The psychiatrist of the future—the very near future—will need to be fluent in the language of genetics. Already, advances in psychiatric genetic research have demonstrated that all common mental disorders have a significant heritable component and that the etiology of psychiatric disorders involves multiple genes and interactions of genes and environment (1). As researchers identify genes that affect risk for specific disorders (or disease spectra), it may become possible to offer more precise risk assessments based on genetic testing (2). Bioinformatics technologies, capitalizing on the growth in understanding of genomics and proteomics, may yield the ability to develop individualized profiles of patients for diagnosis and treatment (3, 4). Genetic research advances also hold the potential to illuminate disease mechanisms, point toward new therapeutic targets, enable earlier and more accurate diagnoses, and allow for more individually tailored treatments (3, 5).
Psychiatrists increasingly will be called upon to make informed use of genetic research advances, because the numbers of medical geneticists or genetic counselors are projected to be inadequate to meet the demand for genetic services (6, 7). However, empirical data suggest that many psychiatrists may not be adequately prepared to take on this new role (8, 9).
Thus, educating the next generation of psychiatrists in genetics has been identified as a major challenge for academic psychiatry (10). To meet this challenge, we must first understand the current state of psychiatric genetics education and identify factors that promote or limit the strengthening of curricula to help psychiatrists of the future to be competent in the emerging area of psychiatric genetics. To our knowledge, no published empirical studies have examined the extent of genetics education in the psychiatric residency training curricula, nor have there been any published assessments of the attitudes and preferences of psychiatric residents and educators on this subject.
To begin mapping the existing landscape of psychiatric genetics education, we developed an Internet-based survey of psychiatric educators and trainees. We hypothesized that psychiatric genetics would receive less curricular emphasis than most other subjects and that respondents would identify specific areas of need in trainees’ genetics knowledge and skills.
A voluntary, anonymous survey of U.S. psychiatry educators and residents was conducted during 2006 and 2007. The survey protocol conformed to institutional requirements for human studies and was evaluated or deemed exempt from review by the institutional review boards at the University of Chicago; the University of California, San Diego; and the Medical College of Wisconsin.
The sample of educators was ascertained through the electronic address listing of the American Association of Directors of Psychiatric Residency Training (AADPRT). At the time of the survey, this listing included 509 psychiatric residency training directors, associate or assistant training directors, and other faculty engaged in residency education. Members of the listing were sent an e-mail invitation to participate by following an electronic hyperlink.
The sample of psychiatric residents was ascertained in two ways. First, the e-mail invitation sent to the AADPRT membership asked recipients to forward the invitation to their senior residents. Residents at earlier stages of training were specifically not approached for participation, because they would be less able to comment on the genetics instruction during the entire training period.
To increase the size of the sample, we subsequently sent e-mail invitations to the 207 members of APA’s electronic listing for chief residents. Recipients were directed not to complete the survey a second time if they had completed it previously. To enhance response rates, a second e-mail invitation was sent a week after the first.
We developed a 45-item questionnaire for educators and a 38-item questionnaire for residents. The questionnaires were based in part on surveys previously administered to practicing psychiatrists and other physicians (8, 9, 11), and they were critically reviewed for content validity by a psychiatric residency training director, associate training director, psychiatry department chair, psychiatric genetics fellow, and experienced survey researchers. To reduce nonresponse bias and avoid skewing results toward positive attitudes regarding genetics education, the invitation e-mail and title of the survey did not identify genetics as the topic of the survey. Each questionnaire consisted of Likert-scale items, agree/disagree items, categorical response items, and an open-ended item asking for additional comments on genetics education during psychiatric residency training. Here we report survey items concerning perceptions of the current status of genetics training in the residency curriculum.
Descriptive and inferential statistical analyses were conducted with SPSS (version 12.0, 2003). To compare views of educators and residents’ views regarding the importance of teaching about specific research topics, we used Mann-Whitney U nonparametric tests (Table 1), because the data were categorical. A Mann-Whitney U test was also used to examine whether there were differences in the proportions of educators and residents who believed that their program placed “a great deal of,” “moderate,” “some,” “a little,” or “no” emphasis on teaching residents about research advances in psychiatric genetics, as opposed to other types of psychiatric research. Chi-square analyses were used to examine differences between educators and residents in yes or no responses to six statements regarding the role of psychiatrists’ and residents’ competency in genetics-related skills (Table 2). Wilcoxon signed-ranks test were used to examine the combined sample’s (i.e., educators’ and residents’) views of faculty expertise in various subject areas (Table 3).
Characteristics of Respondents
We received 101 responses to the educator portion of the survey, yielding an estimated response rate of 20% (Table 4). One respondent self-identified as a fellow and was therefore excluded from further analysis. Because our survey was anonymous, we could not identify which training programs were represented by respondents. A total of 56 educators voluntarily provided their e-mail addresses to receive the results of the survey. A review of these addresses suggests that this subset of respondents was affiliated with at least 39 different U.S. psychiatric residency training programs, including programs in the Northeast, Southeast, Midwest, and far West.
We received 60 survey responses from residents based on e-mail invitations forwarded from faculty and 75 responses to the invitation sent directly to the APA chief residents’ listing, for a total of 135 resident participants. The response rate for the first portion of the sample could not be calculated, because we do not know how many educators forwarded e-mails to residents. For the second portion of the sample, the response rate was 36%. Of the 135 resident participants, 65 voluntarily provided e-mail addresses; those addresses were associated with at least 16 training programs other than those represented by the educators.
Thus, at least one individual participated from at least 55 U.S. psychiatric residency training programs. The group of respondents represented training programs in a variety of settings, including medical schools and universities, public and private hospitals or clinics, and the military.
Training Programs’ Emphasis on Genetics Education
Participants were asked to rate on a 5-point scale (1=a great deal, 2=moderate, 3=some, 4=a little, 5=none) how much emphasis their program placed on teaching residents about research advances in psychiatric genetics, as opposed to other types of psychiatric research. In the educator group, 20% (n=19, out of the 94 educators who answered this question) answered a great deal of or moderate emphasis; 40% (n=38) reported some emphasis; and 39% (n=37) reported little or no emphasis. Among trainees, 16% (n=21) reported a great deal of or moderate emphasis; 30% (n=40) reported some; and 55% (n=74) reported little or no emphasis. Differences between educators and residents in the proportion answering “a great deal,” “moderate,” “some,” “little,” or “no” emphasis were significant, with trainees more likely to report little or no emphasis on genetics education (Mann-Whitney U test: z=−2.45, p=0.013).
Relative Importance of Teaching About Genetic Research Advances
Respondents were asked to rate the importance of teaching residents about research advances in seven subject areas (Table 1). Educators were also asked if they believed some aspects of the curriculum could be eliminated to include more training on genetics, with responses categorized as yes, no, or not sure. A majority of respondents answered no or not sure (38% and 36%, respectively) (data not shown).
Genetics-Related Skills of Residents
Participants responded yes or no to six statements regarding the role of psychiatrists’ and residents’ competency in genetics-related skills (Table 2). Both educators and residents overwhelmingly agreed that residents routinely took detailed family histories of psychiatric illness. A significantly smaller proportion of residents (28%) than educators (38%) reported that residents were competent to interpret papers on psychiatric genetics in the medical literature (χ2=4.03, df=1, p=0.045).
Educators’ Ratings of Faculty Expertise in Curricular Areas
Educators were asked to rate their faculty’s level of expertise in various subject areas (Table 3). Wilcoxon signed-ranks analyses of educators’ average ratings of faculty expertise indicated that they rated their faculty’s level of expertise as significantly lower in genetics and genomics, compared with their perceived expertise in diagnosis (z=−7.28, p<0.001), causes (z=−6.53, p<0.001), treatment (z=−7.60, p<0.001), and prevention of mental illness and behavioral disorders (z=−2.31, p=0.021) and basic behavioral science (z=−3.305, p=0.001).
Narrative Data Concerning Genetics Education
Nineteen educators and 12 residents provided narrative responses to an open-ended item encouraging any additional comments. The comments were categorized into three major thematic groups:
Importance of Genetics Training and Concern About Lack of Genetics Education:
“This is an important area of psychiatric training that has been neglected in my residency.” —Resident
Competing Demands on Residents’ Time and Attention:
“I believe that the residents are more concerned with practical matters (diagnose and treat, community resources, etc.) and are interested in the “practical” part of genetics—i.e., what they could use in their practice.” —Educator
Skepticism About the “Practical” Applications of Genetics in Psychiatry:
“I am sure genetics are quite important regarding predisposition of mental illness. But I am left with the question ‘So what?’ Is gene therapy for mental disorders likely—or even desirable? Are you going to counsel two parents with histories of depression not to have children, because the child might be at [risk] for a mood disorder?” —Resident
To our knowledge, this study provides the first empirical data on the state of genetics education in psychiatric residency training programs. Data were gathered from individuals affiliated with at least 55 geographically dispersed programs representing diverse educational settings, suggesting that the findings may be generalizable. The results support our hypotheses that genetics receives less emphasis than many other topics in psychiatric training and that educators and residents could identify specific areas of need in genetics-related skills and knowledge.
As a whole, these findings present a sobering picture of the state of genetics education in psychiatric residency training. Although respondents rated research advances in genetics and genomics as “somewhat important” topics of study, when genetics was compared with other subjects, it appeared near the bottom of the list. Program directors and psychiatrists-in-training also expressed a lack of confidence in the trainees’ skills in key areas—interpreting and ordering genetic tests and understanding papers on genetics in the medical literature.
This study also identified potential barriers to future curricular innovation to increase residents’ exposure to information about psychiatric genetics. First are competing demands of other curricular topics in residency training, especially those that may be more strongly perceived to have immediate practical applications. Second is the lack of faculty with expertise in psychiatric genetics who can serve as intellectual resources for training programs.
The major limitations of this novel study include the use of self-report data and the lower than ideal response rates. However, response rates less than 40% are common in the published literature for Internet-based surveys (12). Furthermore, the likely generalizability of these data are enhanced by the large size of our samples and the inclusion of respondents from at least 55 geographically dispersed programs and a variety of training settings.
Conclusion and Future Directions
We hope this preliminary work will encourage future study of emerging topics in psychiatric genetics education. First, longitudinal surveys are needed to monitor changes in genetics knowledge and skills among psychiatrists and trainees. Empirical and conceptual work is also needed to identify key topics for study (e.g., clinically specific areas such as pharmacogenetic testing and genetic counseling, as well as broad fields of study such as evolutionary and population genetics). Lastly, research in curriculum development, including educational intervention studies, is clearly warranted.
If the findings of the current study are replicated, their implications may extend far beyond the walls of residency training offices. For psychiatric genetic research to be appropriately translated, the medical and psychiatric professions must ensure that clinical care is provided by appropriately trained practitioners. Many programs will need to consider how to develop or recruit the faculty needed to educate the next generation of psychiatrists. Clinical educators may need to be cultivated for this specific task—teaching about a rapidly evolving field of research for which the translation into practice could generate considerable controversy. Specific curricular innovations may also be required to help researchers and educators work together to translate genetic research advances. Training researchers alone may have the unintended consequence of further widening the gap between the knowledge presented in journals and at scientific meetings and the actual practice of psychiatry in the community. Bridging this gap may become one of the most important tasks for psychiatry in the genomic era.
At the time of submission, Drs. Hoop, Savla, and Dunn declared no competing interests. Disclosures of editors are published in each January issue.