By any measure, research over the past two decades has yielded revolutionary leaps in understanding the human genome and how the brain functions, two areas of science fundamental to psychiatry. Recent discoveries have transformed our understanding of the brain, demonstrating how neurogenesis continues throughout adult life, mapping the dynamic nature of cortical connectivity that can change in response to experience, and identifying some of the categorical rules by which information is processed in the brain. Yet, during this same period, clinical psychiatry has remained relatively unchanged.
Psychiatry today, much like psychiatry of the past two decades, lacks valid diagnostic tests, innovative treatments, and an understanding of the basic pathophysiology of any of its major disorders. Genomics and neuroimaging have resulted in hundreds of findings, but none have yet changed how clinicians diagnose or treat patients with mental disorders. Additionally, we are still unable to predict with much precision which of our patients will respond robustly to a therapeutic intervention or, alternatively, who is likely to experience serious treatment-emergent side effects. To a substantial degree, the stunning advances we have seen in basic neuroscience have yet to be translated into innovations in clinical care.
The mission of the National Institute of Mental Health (NIMH) is to reduce the burden of mental illness through research on mind, brain, and behavior. To achieve this mission, NIMH must ensure that two types of "translation" occur: 1) the translation of insights from neuroscience into better approaches to the diagnosis and treatment of psychiatric illness; and 2) the translation of what we have already learned about effective science-based treatment into the routine fabric of medical care delivery. An American public willing to invest tax dollars in biomedical research expects returns in the form of new treatments, effective strategies for prevention, and better health care.
Attaining these public health goals requires the efforts of physician-scientists capable of bridging the worlds of basic science and clinical care. Yet, across all medical specialties, the physician-scientist has become an endangered species (1, 2), following a trajectory toward extinction that may be even more rapid in psychiatry than other branches of medicine (3). Based on data from the American Psychiatric Association’s Directory of Research Fellowship Opportunities, the number of psychiatrists pursuing research fellowship training dropped nearly 40% (from 342 to 210 individuals) between 1992 and 2001 (4). The potential impact of these trends is well summarized in a 2000 National Academy of Science Report (5):
Because those who interact with patients often bring great understanding and awareness of the health needs of the public to clinical research, the diminishing role played by physicians affects the capacity of the clinical research workforce to sustain a program of research that addresses the nation’s needs. (5)
Alarmed that the progressive decline of psychiatrist-researchers would soon become (or in the case of child and adolescent psychiatrist-researchers already had become) a significant barrier to reducing the nation’s burden of mental illness, the NIMH, in 2001, commissioned the Institute of Medicine (IOM) to convene an expert committee to review the goals of psychiatry residency training and consider strategies for enhancing research training opportunities. The IOM panel was asked to review the following issues in the context of adult as well as child and adolescent psychiatry residency: 1) the goals of psychiatric residency training, 2) programs that train researchers successfully, 3) obstacles to efficient research training, and 4) strategies for overcoming those obstacles.
Why focus on residency training in isolation when it is clear that the problem of the clinician scientist spans the entire developmental pipeline from undergraduate science education, medical school exposure to outstanding psychiatrist role models, trainee debt, mentoring and support for junior faculty, support for senior faculty to engage in mentoring, and of other structural and economic issues (3)? In our view, many of these pipeline issues were well understood and relatively noncontroversial. In contrast, questions about residency training and the time and effort required to achieve a wide range of competencies appeared contentious and complex. For constituencies within psychiatry, the time allocated within residency seemed to be guarded fiercely as a measure of the value of competing areas of knowledge in a program of clinical training that had become very broad. Furthermore, as the domains of knowledge potentially relevant to the treatment of mental illness will likely continue to expand, we anticipate that the tension between achieving an appropriate balance between breadth and depth of knowledge related to understanding disease and optimizing patient care will become even more acute. In this context, an objective outside body such as the IOM seemed best suited to the challenge of recommending reforms to remove barriers to careers in patient-oriented research.
The IOM Committee’s deliberations and recommendations are summarized in the report: "Research Training in Psychiatry Residency: Strategies for Reform" (6). This report identifies three broad sets of issues bearing on the training of future physician-scientists: regulatory factors (e.g. Residency Review Committee, Accreditation Council for Graduate Medical Education, American Board of Psychiatry and Neurology), institutional factors (academic institutions and their residency training programs), and personal factors (perceived options, competing opportunities, financial issues). An overarching recommendation is that NIMH establish a national coordinating body that will bring together key stakeholders in psychiatry and related disciplines to develop and implement strategies to address barriers operating in each of these domains.
In response to this overarching recommendation, the director of NIMH established the National Psychiatry Training Council (NPTC) under the co-leadership of John Greden, M.D. from the University of Michigan and James Leckman, M.D. from the Yale Child Study Center, an adult academic psychiatrist and a child and adolescent academic psychiatrist, respectively. Conceived as a body with an initial 2-year charter, the NPTC’s initial charge are:
Key stakeholder organizations were identified (a1) and nominated one or more members to serve on the training council. Collectively, these are the organizations that define the structure and content of psychiatric education in the United States. We are hopeful that, convened together for the first time with a clear charge and commonality of purpose, they will achieve reforms to meaningfully enhance not only patient-oriented research training opportunities but also training in other areas where critical manpower shortages exist such as public sector, child and adolescent psychiatry, and geriatric psychiatry. The NPTC initially met on April 7, 2004, in Bethesda, Maryland to organize an approach to setting goals and initiating the process of reform. To date, a number of task forces have been formed to address both the Council’s specific charge and related issues, including model programs, pipeline, regulatory revisions, mentorship, research literacy, retention, finance, outcomes, and dissemination.
From the NIMH vantage point, two central concepts should guide the reform of psychiatric residency training: 1) flexibility to permit specialization and 2) grounding in the principles of evidence-based medicine.
In internal medicine, core residency training is 2 years, followed by 2 years of specialization. We believe that as psychiatry matures as a scientific discipline, specialization may become more important, particularly as the assessment and treatment of complex patients will require skills in diverse fields from pharmacogenomics to functional neuroimaging. Notwithstanding the need for generalists, the value of the psychiatrist in both the medical and intellectual "marketplace" may increasingly derive from deeper competency in disorder (psychosis, affective illness), age (child and adolescent, geriatrics), and setting (public psychiatry) based areas of specialization. For capable residents committed to becoming physician-scientists, flexibility should allow the opportunity for earlier specialization and more in-depth training experiences while ensuring the achievement of clinical competency in evidence-based diagnostic and treatment modalities.
The adoption of evidence-based medicine as the organizing focus of training should be the second core principle guiding psychiatric residency reform. As part of a broad shift in medicine from reliance on traditional authority and theory-based standard practices to relying on systematic assessment and compilation of research evidence from clinical trials, evidence-based practice is rapidly becoming the basis for rationally informing treatment decisions in psychiatric disorders. This approach assumes that both individual patient care decisions and health policies should promote access to treatments based on rigorous scientific information concerning the efficacy (outcomes), costs, and cost-effectiveness of alternative treatment approaches. Fully integrating evidence-based medicine into psychiatry training has implications for allocation of scarce training time but also implies that research literacy should be a core competency for all psychiatrists by the end of training.
A major criticism of evidence-based practice is that it ignores intuition, experience, and clinical judgment; de-emphasizes the importance of the physician-patient relationship; and renders the practice of medicine sterile and formulaic. Contrary to these criticisms, most proponents of evidence-based practice agree "that a cookbook is not a cook." Aspects of the "art of medicine" can only be derived from the opinions and experience of exceptional clinicians who have a gift for precise observation, careful diagnosis, and excellent judgment in making complex clinical management decisions. Evidence-based reviews of treatment effectiveness increasingly suggest that for the most severe disorders such as schizophrenia integrated psychosocial and biological treatments yield superior outcomes (7). The psychiatrist’s understanding of human behavior and human experience, derived both from didactic study and supervised clinical work, should place him or her in the unique position of being able to create and monitor treatment plans that integrate both biological and psychosocial perspectives.
The time is now right for a rethinking and reform of psychiatric residency training. The IOM report, convening of the National Psychiatry Training Council, and unprecedented cooperation of diverse stakeholders create what may be a once-in-a generation opportunity to achieve meaningful change. The future of psychiatry as a medical specialty depends critically on our success in training physician-scientists to translate advances in neuroscience into new treatments and cures and research-literate clinicians who can ensure that patients receive the best science-based care.