The title is not a non sequitur. It is possible to be both a psychiatrist and researcher. However, it is not easy. This article provides some information and advice for medical students, residents, research fellows, and junior faculty who have such an ambition, or need to respond to an expectation to do research by, for example, a departmental chair or promotions committee. We describe the financial and other rewards for those doing research, the skills that are required to conduct research, the opportunities for obtaining research funding or training that are available at various stages of a psychiatrist's career, the obstacles to success in this endeavor, and some strategies for overcoming those obstacles.
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The Nature and Finance of Research Careers
To embark on any career path, one should know how success is obtained, including financial rewards. Being a researcher is an unusual job, in that few such positions are advertised and paid, as opposed to jobs such as being a staff psychiatrist on an inpatient unit with clinical care and teaching responsibilities. Most researchers do have a salary, via a University, but the funds for that salary are usually obtained by the researcher herself, from a source like the National Institute of Mental Health (NIMH), or a pharmaceutical company interested in doing research on its product. Such researcher-generated funding is especially the case for full-time researchers; part-time work on a research project might be funded via someone else's grant, and thus resembles a regular job. For example, someone might be hired to be the treating psychiatrist in a clinical trial, or to help diagnose patients entering a study focused on brain imaging or genetics.
Given that for many years full-time researchers generated their own salaries by writing successful grant applications, it can be stressful and precarious—reasons why many choose not to pursue this career. However, there are important rewards. A researcher gets a chance to work in an independent, self-directed way, studying exactly his or her own interest, and there is the possibility of becoming well known in the field. Also, the most successful researchers are sometimes granted "hard-money" support, a university or research institute salary with the job security most often called tenure.
This renown and financial security may be the outcome of a fruitful career in research, but this is not what the beginning researcher encounters. In the early stages, research is not usually supported by one's own grants. Medical students might or might not be paid for assisting in studies, residents are paid by their hospital programs with some elective time available for research, postresidency research fellows usually receive a "stipend" that could be defined as a skimpy salary with no or few benefits attached, and junior faculty usually have a salary for doing clinical duties with the possibility of part-time (paid or unpaid) research. All of these are excellent ways of learning what it feels like to be doing research. However, they do not fully convey both the excitement and perils of being a full-time researcher. A student thinking of this path should talk to researchers who are further along on it. He or she would probably report that a period of full-time research training is necessary for a successful career as a full-time researcher. The goals of training (the research skill set), and ways of doing both part-time and full-time research training at various levels of one's career, are discussed below.
Putting aside the skills for basic science laboratory work, we focus on clinical research skills—those involved in doing clinical trials or psychobiological studies. First, there are diagnostic skills, using rigorous diagnostic methodology such as structured interviewing. Residents and junior faculty who have had clinical training can easily develop these abilities and can also serve as reviewers of diagnoses that are developed by nonprofessional interviewers. Next, there are the skills involved in recruiting and managing patients who are volunteering to be part of a study. Residents and junior faculty can employ their psychotherapeutic training to assuage fears in volunteers and help them stay committed to the study. The number of patients who complete a study can be the most important, rate-limiting step in the whole process, and those who can help this happen are very appreciated. Residents and junior faculty may be trained to deliver patient care in a clinical trial of a medication or specific psychotherapy. Here, their clinical skills may be both a help and a hindrance. Residents may feel discomfort responding to the needs of a patient by increasing the dose of medication when it might actually be a placebo. Or, think of how, in a trial of CBT exposure therapy, you might want to discuss a transference comment made by the patient but feel you cannot do so because it will be caught on the videotape that is reviewed by the project's therapy monitor.
In addition, other skills are necessary for a career in research:
Many medical schools offer opportunities to do research. The most substantial of these are the combined M.D./Ph.D. programs, which may not only pay for tuition, but offer a living stipend over 7 or so years. What is not well known is that many of these programs can be entered as late as the second year of medical school; students who find that neuroscience, for example, is exciting should think of finding a research lab and mentor and applying.
Much of the research that is currently funded by NIMH is termed "translational research"—extending basic science findings to study psychiatric disorders, and there is no training that qualifies a psychiatrist more for such studies than having a Ph.D. in a basic science area such as genetics or neuroscience. However, some students might not want to do laboratory research for one or more years but are attracted to doing clinical research with patients. There are usually opportunities to do this as well. Many medical schools support students doing such research in the summer after the first year, and brief training experiences in aging research have been specifically designed (1). Balon et al. (2) review this and many other programs available for medical students.
External agencies offer substantial and desirable research training programs for medical students. The Doris Duke Clinical Research Fellowship supports 1 year of clinical research, including coursework and a stipend of $27,000, at 12 different sites (3). The Howard Hughes Medical Institute Medical Fellows Program also supports 1 year of research (with stipend, personal allowance, and research funds) (4) and the Howard Hughes/NIH Research Scholars program offers 9—12 months of research experience on NIH campus, including salary and benefits (5).
Medical students interested in careers in academic psychiatry should consider the research resources available in the psychiatric residency programs at which they interview. It would be rare for any residency program director to say that she could not offer such opportunities. However, the essential mentorship and research infrastructure that is actually necessary is in no way spread equally across different departments of psychiatry. Students may begin with the most recent list of NIH funding for departments of psychiatry, available online via the Blue Ridge Institute for Medical Research (6). Those departments at the top of the list will have the most research resources.
Then, students should discuss research training with the residency program director and residents in the program. See if there is a research track that offers time for research. Determine if there are specific researchers who might serve as a mentor and provide lab space or a clinical population to study. Ask if any funds for presenting at or attending research meetings might be available. Ask how residents with research interests can be funded as research fellows after graduation. However, also ask carefully about the quality of the clinical experiences and education; the primary focus of the 4 years should be on your learning about psychiatric illness and its treatments (including psychotherapy). There should be time to do research and learn some new research skills, especially those used in clinical research. However, students should not expect, or want, a 4-year laboratory postdoctoral fellowship. Students should consider, as they develop their NRMP rank lists, how well residency programs will be able to support their current and potential research interests.
Those who did research during medical school and wanted to continue research in addition to obtaining clinical training in psychiatry will likely pick a residency program that can provide both opportunities. However, it is not too late for those residents who have not done research but find themselves dreaming of causes and cures.
Residents are usually told what to do—where to work each month, when they must be on call, what forms they must complete for each patient, and so on. Also, they are very busy with their assigned duties, especially in the early years of residency training. Thus, it is understandable that they often do not see how they can pursue their own research interests if they are not in a research track. However, all residents should know that in the department of psychiatry (or related clinical and basic science departments such as neurology, psychology, and neuroscience), there are investigators who would be happy to meet and engage them. For example, this might come in the form of a discussion surrounding a research article, or it might be designing a project that could be done on a part-time basis. Sometimes residency training directors will give time off for research to residents who have a plan and a faculty member backing them. Residents usually have a substantial amount of elective time in the last year of training, but if they have not made these connections earlier, they tend to pick clinical rather than research electives and thus never develop any research skills or find an area of academic interest. Given the longitudinal nature of clinical research, it is especially important that residents consider their options early in the course of residency.
Residents should maintain an inquisitive and scholarly approach to their clinical experience. Any time a literature search does not uncover a satisfactory answer to a clinical question, the resident should ask, "How would I design a study to answer that question?" Residencies should have available in their curricula courses on research methodology and biostatistics that will help residents answer such questions. If those resources are unavailable in the department, residents should ask program directors where else on campus they could receive such training. There are excellent articles on research training during psychiatric residency (7—10). We recommend that residents interested in research apply for the numerous national awards and fellowship programs available to provide funding for research or to support travel to research meetings to obtain assistance with research career development (see Table 1).
Residency can be a good time to gain experience with scholarly writing. Residents should watch vigilantly for clinical cases that they could write up and submit as case reports. For example they may wish to submit manuscripts to the Residents' Journal of The American Journal Psychiatry. Residents may partner with faculty supervisors on writing a review paper or writing or updating a book chapter. Residents involved in educational projects should consider submitting posters or workshops for presentation at the annual meetings of the American Association of Directors of Psychiatric Residency Training (AADPRT), the Association for Academic Psychiatry (AAP), or the Association of Directors of Medical Student Education in Psychiatry (ADMSEP).
Finally, residents should get in the habit of keeping their Curricula Vitae (CVs) updated. While the official formatting of an academic CV varies from institution to institution, residents may refer to a helpful Association of American Medical Colleges (AAMC) website to learn how to prepare a CV (27).
There are many postresidency research fellowships, but few psychiatrists are in them. This may be due to the low compensation, at least relative to the pay of a psychiatrist beginning practice. Some fellowship programs find ways to supplement a fellow's income. Nevertheless, fellowships are the main route for becoming a psychiatrist-researcher. Those residency graduates without prior substantial research training need about 3 years of mentored research to become researchers, and even those with prior research training, such as M.D./Ph.D.s, graduating from residency, need time and training to reestablish their research skills and credentials.
The goal is to obtain independent funding after a few years of fellowship. The importance of this needs to be understood. The assumption is that "good research" will be funded by grants from NIMH or other agencies, so anyone getting such a grant is assumed then to be a "good researcher." The most common aim of a research fellow is thus to get a "K Award" (a Mentored Clinical Scientist Development Award) from NIH or something similar from the Department of Veterans Affairs (VA) or a foundation. There are a variety of different types of K Awards offered by the various institutes (11).
Finally, what about junior faculty, who want to be "academic psychiatrists" and have a faculty title, but also have substantial clinical responsibilities in inpatient, outpatient, ER, or consultation-liaison settings? Publishing is necessary to advance in academic status. They often feel their only choices are to stay in their jobs or leave for independent practice. A number of papers have commented on this situation and have suggested ways that clinical faculty could develop research skills (12—16).
One alternative we recommend is to find research colleagues in the department, or in a nearby institution, and develop a long-term collaboration. A junior faculty member brings all the skills mentioned above that residents bring, and they also often bring something that may be extremely valuable—access to a clinical population out of which might come some research subjects. Examples of this would be collaborating with those who have a biochemical measure that they want to correlate with clinical symptomatology, or those who would like to try a new medication combination in a specific clinical condition.
Junior faculty are often asked to participate in educational activities for residents and medical students. This may be an excellent opportunity to develop an educational research project. Those interested in educational research are referred to two excellent reviews (29, 30).
Junior faculty may also be eligible for loan repayment programs through NIH, which offers a number of different options for those conducting clinical research, pediatric research, and health disparities research, as well as those from disadvantaged backgrounds. Repayment is up to $35,000 per year in exchange for a commitment to conduct qualified research for at least 2 years. In 2008, 35% of new applications and 70% of renewal applications for loan repayment programs for clinical research were funded (28).
Academic promotion requires establishing a regional, then national, reputation. A typical promotion packet includes letters of recommendation from faculty outside one's own institution. Junior faculty can begin to identify extramural mentors and collaborators by attending national meetings or conferences specifically designed to foster career development (Table 1). These may lead to invitations to present on panels at national meetings, be a peer reviewer for a journal, or coauthor on articles or book chapters.
We have focused on the various ways to obtain research training and become involved in research at various stages in a young psychiatrist's career. We end by emphasizing that just participating in research is a way of training in research, especially if it's followed by writing for publication. One thereby reviews all aspects of research—hypothesis, rationale, sample characteristics, intervention, outcome measure, results, statistical analysis, and discussion or interpretation. You will quickly learn that the discussion always concludes that "More research needs to be done on this topic"—and no one is now more qualified to do it than YOU!