TO THE EDITOR: The Spring 2001 Special Issue of Academic Psychiatry presented interesting ideas about research training in the United States and underscored the importance of well organized, structured research training. We would like to share an experience with research training in another country, the Czech Republic. Research training in the Czech Republic has been reconceptualized and revamped during the last decade, since the fall of communism. Similar to the training in the United States, research training in the Czech Republic is conceived at two main levels, undergraduate and graduate. Research training is not mandatory at either level.
Undergraduate research training is poorly organized. Medical students usually work for free in research labs, where they join someone's research project. They focus on a small, specific problem. Students present the results of their research at various student conferences and/or specialty society meetings. They rarely conduct their own project from the very beginning to completion. Thus, the research training experience of medical students in the Czech Republic is similar to the research experience of most medical students in the United States. The M.D./Ph.D. programs are just starting at some medical schools.
Postgraduate research training (PGRT) is offered along two pathways, internal and external. Trainees applying for either pathway have to take an entrance examination or have an interview in their chosen discipline, such as psychiatry/neurosciences, endocrinology, or biochemistry.
The internal research pathway is a full-time research job. The trainee may enter this pathway after medical school without any residency training. This pathway was originally (and still is) conceived as basic science PGRT. Thus the choices of disciplines include, for instance, biochemistry, molecular genetics, physiology, and neurosciences. The length should be 3 years, but it is usually extended to 5 years or occasionally even more. Each trainee chooses a mentor and has an individual curriculum plan. Mentors have to be accredited; that is, have a faculty rank of professor or associate professor and a research track record. Trainees select their own project, write a proposal, realize it, and defend it before a nationally accredited dissertation committee. The required structure of the written dissertation includes introduction, aims, methods and statistics, results, discussion, conclusion, summary, and references. In addition, trainees have to take various mandatory classes and seminars in methodology and their specific discipline, plus a foreign language examination (TOEFL accepted as an equivalent of the English exam). The successful graduate receives a Ph.D. degree in a particular discipline.
The trainee receives a stipend (the equivalent of U.S. $110 to $220 per month), plus various "medical student" discounts for public transportation, meals, and the right to stay at dormitories. As the stipend is fairly low, many trainees in this pathway moonlight, work part-time in hospitals, or are involved as raters or co-investigators in pharmaceutical company—sponsored investigational drug trials.
The external research pathway is usually a clinically oriented PGRT. Interested individuals undergo this research education during postgraduate training in a particular clinical specialty (similar to residency training), or even as junior faculty after finishing their clinical training program. This pathway is usually about 2 years longer than the internal PGRT, and thus it lasts beyond residency training; according to the regulations, the maximum length of PGRT is 8 years. The trainees again have to choose an accredited mentor and their individual curriculum plan under the mentor's guidance. Similarly, they take mandatory classes, seminars, and examinations, including the foreign language examination. They are guaranteed protected time for their class attendance. The final oral examination in a particular field (e.g., neurosciences, endocrinology) is before a special multidisciplinary committee comprising at least 5 members, of whom at least 2 are professors or associate professors and at least 2 are from a different university or from abroad; the trainee's mentor is present, but cannot ask questions. The trainees again select their own project, write a proposal, realize it, and defend it before a nationally accredited dissertation committee. The dissertation has the same required structure as the internal-pathway dissertation. Upon successful graduation, the trainees in this pathway also receive a Ph.D. degree in a particular discipline. Trainees in this research pathway receive a full residency or junior faculty salary and do not receive any medical student discounts. There is no tuition fee for either pathway.
PGRT in the Czech Republic is centrally governed by the laws and regulations of higher education, which are issued by the Department of Education. However, there has been no uniformity among the universities in biomedical PGRT requirements and in outcome. This is probably because the government requirements are not uniformly interpreted and applied. One of the differences is in what is considered to be research and/or science. Some universities do not consider clinical work and clinical research to be "real science" and require laboratory-based research during both PGRT pathways. Graduation requirements also differ. Some universities are satisfied with completion of a thesis. Others require, in addition to thesis completion, three publications, including at least one with the trainee as first author, in peer-reviewed international journals with an impact factor. (This requirement could be quite difficult for some trainees, considering the language barrier and the fact that, right or wrong, many non-U.S. authors whose mother tongue is not English feel that U.S. journals look upon their submissions unfavorably.) Thus, as everywhere else, the quality of PGRT graduates may vary significantly from institution to institution.
The largest PGRT program is organized at Charles University, which has five medical schools (two outside Prague with significantly smaller PGRT programs). This program has been in existence for five years. The PGRT at Charles University admits approximately 300 trainees in all disciplines every year, about 30% to 50% of them to various neuroscience programs (psychiatry, neurophysiology, neurochemistry, neurology). This academic year, neurosciences admitted 150 trainees. The success (completion) rate in all disciplines combined has been quite small so far: about 1% at the end of the first 3-year internal pathway PGRT and about 10% this year. However, because there is a solid tradition of neuroscience research in the Czech Republic, the success rate in neurosciences, including psychiatry, has been about 20%, which is comparable to the success rate in internal medicine disciplines (metabolism, genetics, endocrinology, etc.), and better than in other biomedical sciences.
Clinical research has probably been the weakest area of the PGRT in the Czech Republic. Many young investigators are gaining their core experience in clinical research only by participating as raters or co-investigators in investigational drug trials sponsored by pharmaceutical companies. Although they frequently gain very good clinical research experience, they do not participate in developing and formulating a hypothesis and in planning and conducting statistical analysis. However, this situation is gradually improving, partially because of the wider availability of government-sponsored research grants even for young investigators. Another source of help has come in the form of research training institutes established by grants from pharmaceutical companies (e.g., Lundbeck Psychiatric Institute in Skodsborg, Denmark, funded by Lundbeck International Neuroscience Foundation; or Vienna School of Clinical Research, founded by Eli Lilly initiative and funded by different sources). These institutes train young investigators from Eastern and Central Europe in various research skills, including clinical research, and allow for interaction among young investigators from various countries.
We believe that some of the ideas and goals of research training in the Czech Republic (structure, research project requirement, publication requirement) are interesting and are worth considering for adaptation by training programs in the United States. However, much the same as in the United States, PGRT in the Czech Republic does not address two key issues: how and if to adequately train all trainees/residents in research and how to attract more people to a research career. At the time of essentially uniform incomes under the past system, an academic and research career was considered prestigious. However, with the new opportunities of good earnings in private practice or in a well-paid non-research sales position for a pharmaceutical company (young physicians can and do work as drug sales representatives or detail persons with salaries higher than in academia) some young and talented physicians are not interested in academic and/or research careers any longer. Low-paid prestigious jobs became low-paid jobs without any prestige (1).
Several young Czech investigators have undergone research training in U.S. research institutions (e.g., the Nathan Kline Institute, Vanderbilt University). U.S. research institutions and training programs may be interested in attracting these high-quality candidates to research and academic positions. There are three issues to consider in this process. The first one is attracting their attention. This could be done either by advertising in Czech psychiatric journals or by developing a formal collaboration between U.S. and Czech academic institutions (e.g., Psychiatric Center Prague or First Medical School of Charles University in psychiatry and behavioral sciences; the Academy of Sciences in some other disciplines). Prague's Charles University has already developed collaborative and exchange programs with various academic institutions throughout Europe. The second issue is the identification of a high-quality candidate. This could be done either through the established collaboration among academic institutions or through looking at certain facts in the candidate's curriculum vitae (e.g., publications in journals with a solid impact factor, completed Ph.D. program, TOEFL score, history of clerkship/research stay at a foreign institution). Third and most difficult is the issue of easing the access to various types of visa; this would require institutional help.
All residents should understand how research is done and what research does and does not reveal. However, not all residents want, or should receive, research training. Research is and should be just one of the career options. Nevertheless, the number of physicians applying for research funds has been declining. The number of well-trained clinical researchers may be critically low, possibly because in the first place too few are being trained (2). This could be detrimental to the future of our discipline. Thus, any experience that could help us reverse this decline, including undergraduate and postgraduate training in clinical investigation (3), should be carefully evaluated.