Over the past decade, influential psychiatrists in academic, federal, and other policy making settings have become increasingly concerned about small numbers and declining trends in general and child and adolescent psychiatrists devoted to careers in federally funded patient-oriented research needed to address important questions regarding public mental health policy (1). For example, projecting the declining numbers of federally funded research psychiatrists in the pipeline, especially in child and adolescent psychiatry, the National Institute of Mental Health (NIMH) planners feared that important nonindustry funded research studies requiring multisite designs to answer pressing questions in clinical psychopharmacology might not be feasible due to the dearth of trained psychiatric investigators. The NIMH commissioned the Institute of Medicine (IOM), a subdivision of the nongovernmental National Academy of Sciences often asked to consider important policy issues, to study the problem and offer recommendations to the NIMH and the psychiatric profession as a whole. Following input provided by a large number of stakeholders at an NIMH-sponsored conference in November 2001, committee work on the study began in early 2002.
To conduct this review, the IOM established a Committee on Incorporating Research into Psychiatric Residency Training under the direction of Thomas Boat, M.D., Chair of Pediatrics at the University of Cincinnati. The Committee included general and child and adolescent psychiatrists; a medical school dean; a Ph.D. neuroscientist; a research neurologist; a clinical and research psychologist whose primary appointment has been within a department of psychiatry; and a health economist. The Committee was asked to review current research training practices across typical and exemplary residency programs known for their devotion to research training, the detailed training requirements mandated by the Accreditation Council on Graduate Medical Education’s Residency Review Committees (ACGME RRC), eligibility requirements for certification by the American Board of Psychiatry and Neurology (ABPN), and other related issues. Based on extensive literature reviews, consultations with a large array of outside experts and informed deliberation, the IOM published the Committee’s final report Research Training in Psychiatry Residency: Strategies for Reform (2). The Committee was well aware that issues related to residency training, per se, account for only a portion of the difficulties related to recruiting and retaining a suitable and adequate workforce of psychiatric researchers. While focusing primarily on residency training, the career phase that constituted the Committee’s primary charge, the final report also touched on some of the other critical points in the career pipeline such as attracting research-oriented medical students to psychiatry and sustaining postresidency research interests and careers.
The Committee developed 14 recommendations linked to specific obstacles to research training and targeted to matters related to five domains: longitudinal factors; the continuum of education; regulatory factors; personal factors; and an overarching recommendation for coordination, follow-through, and monitoring of these recommendations by key stakeholders. The key stakeholders identified are: the National Institutes of Health, the American Psychiatric Association, the General Psychiatry and the Child and Adolescent Psychiatry RRCs, the ABPN, the American Academy of Child and Adolescent Psychiatry, the American Association of Chairmen of Departments of Psychiatry, the American Association of Directors of Psychiatric Residency Training, and other professional psychiatric organizations and patient advocacy groups. a1 lists a summary of the obstacles identified and the recommendations made by the IOM Committee in each of the five domains. Copies of their report may be obtained via http://www.nap.edu/catalog/10823.html. At the same time, it should be noted that the Committee had trouble finding data on the number of psychiatric researchers there actually are and how increases or decreases in these numbers would impact on better psychiatric care for society as a whole. Even the claim that too few child psychiatrists exist to conduct clinical trials requires firm documentation. As such, more sound tracking data is needed to established a baseline and to monitor interventions.
Those who commissioned and who authored the IOM report were well aware that without significant, organized, and sustained follow-up, this IOM report and its recommendations might suffer the fate of several previous seemingly ineffective IOM reports published in the previous decades and also addressed problems of recruiting and retaining adequate workforces of academic physician-scientists, which are problems facing virtually all specialties and subspecialties in medicine as a whole (3, 4). Recognizing the complexity of these problems and of implementing the recommendations, Thomas R. Insel, M.D., the Director of NIMH, has appointed a National Psychiatry Training Council (NTPC), co-chaired by Drs. John Greden and James Leckman, charged with planning and providing follow-up to assist in the implementation of recommendations outlined in the IOM report. The NPTC was commissioned for 2 years and met for the first time in April 2004. Its major focus is aimed at efforts to increase the training of psychiatrists who can conduct clinical and translational investigations and to improve research literacy of all graduating psychiatry residents. One central thrust of the report, specifically emphasized in Dr. Insel’s charge to the NPTC, is to develop a detailed vision for reforming psychiatric residency training to include more flexible core training requirements designed to ensure clinical competency while fostering earlier specialization and in-depth training in areas such as patient-oriented research, child and adolescent psychiatry, geriatric psychiatry, and community psychiatry. The NPTC began its work by emphasizing that many groups and constituencies, including hospital administrators, the RRC, educators, third-party payers, patients and families, and proponents of various clinical approaches should have a stake in psychiatric training, and collaboration among all of the key stakeholders working together in partnerships is necessary in order for changes to occur and be meaningfully implemented by the field. The NPTC has been asked to plan and organize these efforts and to develop specific strategies and timelines for accomplishing these steps.
Based on the IOM recommendations, some of the stakeholder groups are already moving ahead. The American Psychiatric Association has appointed Charles F. Reynolds III, M.D., Professor of Psychiatry, Neurology and Neuroscience, University of Pittsburgh School of Medicine to the Residency Review Committee for General Psychiatry. Michael H. Ebert, M.D., Chair of the Residency Review Committee, has already made plans for the group to consider proposals from residency programs to incorporate more flexible programming that may foster psychiatric research training during residency for select individuals. Many innovative suggestions are expected to emerge. The American Association of Chairs of Departments of Psychiatry (AACDP) had endorsed the anticipated IOM recommendations during a meeting attended by most of the key stakeholders held in Washington, D.C. in November 2003, and they recently held another retreat planning meeting in Sonoma in July 2004 to sustain momentum. This was attended by Dr. Insel and representative leaders of other relevant NIH Institutes and SAMHSA, the American Psychiatric Directors of Psychiatry Residency Training (AADPRT), and medical student educators.
The NPTC has established a group of action-oriented, implementation-focused task forces. Each task force is to compile creative, future-oriented and, most of all, feasible recommendations for implementation within the next 5—10 years. Task force membership, comprised of more than 90 leading psychiatrists, includes but is not limited to members of the NPTC. Many others are also being asked to participate, based on specific areas of expertise and stakeholder membership. Each task force is expected to "cross-talk" and integrate their ideas and recommendations. In this way each recommendation will have to be considered in relation to regulatory modifications that might involve the NIH, ACGME, ABPN and/or other institutions and agencies, each of which has to be considered in relation to each recommendation (i.e., "impact statements"). Task force recommendations are expected to be as explicit as possible, designating the exact steps that various stakeholder groups will be expected to implement if improvements are to occur. The specific NPTC Task Forces and the issues they have been asked to address appear in a2
No one expects these tasks to be easy. Prior IOM reports that tackled difficulties of recruiting and retraining physician-researchers across the broad domain of academic medical specialties have been thorough and thoughtful conceptual documents with strong consensus recommendations. However, the IOM is primarily a "think tank." Ultimately, it is up to leaders in medicine as a whole, psychiatry in particular, to act on those recommendations if change is to occur. Although the 1994 report is well respected and physician-investigators remain an endangered species, the recommendations of the report and those of other similar documents have gone largely unaddressed, and these reports now serve primarily as dust-gatherers on library shelves. There are several reasons for this unfortunate outcome. First, the problems contributing to difficulties in recruiting and retaining academic physician-scientists are formidable, complex and systemic, originating at multiple levels in the culture of medicine and society as a whole. Furthermore, experts across the board acknowledge that estimating societal need for the medical professional workforce has been extremely challenging. The recommended solutions require highly involved bureaucratic interventions as well as financial support. Specific recommendations regarding research training must vie with numerous other resource and attention-seeking agendas that compete at each federal health policy level. Furthermore, specific health initiatives are often swamped and lost as larger federal priorities adjust with subsequent changes in funding priorities (e.g. consider the impact of the War on Terror.)
Nevertheless, efforts by the NIMH, NTPC, and all other stakeholder organizations designed to assure organized, practical, and sustained follow-up promise that our field will stay focused and on-track, with respect to implementing whatever feasible actions might contribute to increasing the number of psychiatrists training for and remaining in research careers. The overall health of scientific and academic psychiatry, our profession, and the public at large are linked to the outcomes.