As far as my research experience, it played a major role in impacting what I decided to do, i.e., psychiatry, and what my interests are within the field. Having a research experience as a medical student is important because it exposes us to what is currently going on within the field and also allows us to participate in the potential future of psychiatry, which is very fulfilling and exciting. It also allows us to become more proficient at deciding which studies are most meaningful. I think that even if it is not something that you would want to continue, the experience itself is very important because it helps to encourage students to ask questions and to hopefully move the field forward. It is an experience unlike anything else in medical school and it can really help to get students interested in different areas. I had no previous research experience and I did not know what to expect. It was a constant learning process which I really liked, and I also enjoyed the creative and academic nature of designing projects and then how many other studies become possible because of the results. For me, it really made psychiatry come to life in a different way from my rotations, and feeling like you are hopefully contributing to the future of how different disorders are treated is very exciting. Then, as a result of presenting the poster/paper, you can attend meetings which are really great experiences to have as a student. It allows us to see what other institutions are doing and to discuss our research with others and then come up with more questions. It was a great experience for me to discuss the ideas other researchers and clinicians had about our research. —Sara Bobak, M.D., Wayne State University School of Medicine, Class 2005
Many, if not all, would argue that the future of psychiatry depends on research advances, and such advances are dependent upon an adequate number of psychiatric investigators (1). At the same time, psychiatry, along with other medical specialties, faces the crisis of a decline in the numbers of clinical researchers. The proportion of physician investigators applying for clinical research grants is steadily declining and was down to 25% in 1998 (2). There are various reasons for this decline, including increasing demands of an academic career in the form of growing clinical and teaching loads among young physicians, large indebtedness after graduating from medical school, lack of research training during medical school and residency, and lack of research funding. The decrease in the numbers of clinical researchers presents a great challenge to the national clinical research enterprise (3). This challenge is not limited to any particular specialty (4, 5), but it does present serious challenges for psychiatry and its subspecialties (6, 7).
Additionally, the clinical research workforce is growing older. Only 8% of principal investigators conducting industry-sponsored clinical trials are younger than 40 years, and less than 4% of competing research grants awarded by the National Institutes of Health (NIH) in 2001 was awarded to investigators age 35 or younger [cited in (3)]. The lack of research experience may be a factor among younger physicians on a personal level.
According to one small study (8), integration of research with clinical practice was correlated with greater job satisfaction and personal satisfaction with a career in psychiatry for Canadian psychiatrists.
There has also been a significant decrease of psychiatrists in postgraduate training during the 1990s. Only time will tell whether the recent increase in the number of students entering psychiatric residency is a sign of an improving trend or a delay in a permanent decline. Further, the field of psychiatry is not attracting enough top students (9). The reasons for the lack of medical students’ attraction to psychiatry are complex and poorly understood (10).
The statement of a medical student, cited earlier in this article, clearly documents that research experience during medical school can be an important and "guiding" one, at least for some students. Interestingly, medical school applicants frequently ask about the availability of research experience during their interview (11). It seems obvious that training in research makes sense in the framework of national research enterprise (3), on a specialty level (6, 7) and possibly on a personal level (8).
As training of future clinical researchers clearly becomes a critical issue for the future of medicine and psychiatry, we may start to ask specific questions. Whom, what, how, where and when to train? Residency training is considered by many "a key crossroads in the career path of many M.D.s" (12, p 43). However, it represents but "one step toward a research career" (12, p 43). The question "How early does the research pipeline issue begin?" has also been raised by many (4). It is possible that the optimal time to decide on a research career is before residency. Research training is inadequate in the majority of residency training programs in the United States (13). In addition, some experts question considering residency training during residency in isolation, and not as a part of the entire developmental pipeline (14). Medical student training is another part of the research pipeline (though perhaps not the earliest one anyway, as some try to introduce biomedical research to high school students). And, as Nathan pointed out (2), "If clinical research is to flourish, medical students must become interested in the field. Today, medical students have multiple opportunities to gain experience in basic research but few to engage in clinical research." Nathan (2) also emphasizes that "The NIH cannot solve the problem of clinical investigation alone because it is only one of several contributors to the discipline." Early experience in research, as in other parts of medical education (15), "could strengthen and deepen cognitively, broaden affectively, contextualize, and integrate early medical education."
Medical student research experience in psychiatry seems to make sense. But how do we do it, and do we have any experience in training medical students in psychiatric research?
The available literature on research training in psychiatry suggests the existence of at least six possible models of research training. These are: the Columbia Model (16), the Michigan Model (17), the Pittsburgh Model (18), the Wayne State Model (19), the University of California San Diego Model (20, 21), and the Yale Model (22).
Additionally, there are other models of medical student research training available that are not psychiatry-specific, such as the Duke University School of Medicine Model (23) and the Mt. Sinai School of Medicine Model (24). These models describe various structures, funding, mentoring, and other aspects of research training. They emphasize the importance of longitudinal experience. However, only three (19—22) present any research experience or research training for medical students, and only two (20—22) seem to have a possible widespread application at present. Interestingly, the author of the description of one of these models (17) not focused on medical student training describes his own dilemma about entering a psychiatry residency. At the time of his third-year psychiatry clerkship, he did not believe (mistakenly) that "there were any good psychiatric research opportunities" (at the University of Michigan).
The Columbia Model flourishes in a department that has nine separately funded NIH T32 institutional research training programs in various areas (e.g., child psychiatry, psychobiology, neurobiology). These programs/fellowships are developed and funded for psychiatrists who wish to obtain research training. The University of Michigan Department of Psychiatry offers a residency research track, which provides a longitudinal research experience. It is a 5-year program with up to 18 months of protected research time during PGY-2 through PGY-5 residency training years (17). The Pittsburgh Model of research career development (18) offers moderately structured training consisting of monthly meetings and an increasing percentage of time spent on research activities as research progresses (more intensely in PGY-3 and PGY-4 years).
These three models (16—18) focus mostly on the residency and fellowship stages of the research pipeline, although some of them (16, 18) also deal with postresidency/postfellowship (junior faculty) research career development. They do not seem to be developed and very useful for research training of medical students in their present form.
The Wayne State Experience
The Wayne State Model entertains two possible exposures to research in neuroscience for medical students: specific medical student summer programs (the Summer Neuroscience Research Fellowship and clinical elective programs) and the Master of Science in psychiatry program. The summer research fellowship allows medical students to pursue a research project over the summer between their first and second years of medical school. The fellowship lasts 8—10 weeks and is administered by the graduate program’s office at the school of medicine. It is sponsored by funding from the Wayne State University School of Medicine Alumni Association (stipends up to $2,400), and the costs incurred by the department are only those of promoting the program and the time and energy put in by the mentors. The clinical elective programs are 1—2 month research electives within year 3 and/or year 4 of medical school. Students usually participate in established research projects (time limitation) "to learn and participate in the approach to medical research," though students’ own projects are also possible.
The Master of Science in psychiatry program (20) was specifically developed to train residents, fellows and medical students in clinical research. The medical student track requires taking at least a 1-year break from medical school, either between years 2 and 3 or 3 and 4. Each trainee has an individual curriculum developed. This curriculum involves classes, seminars and presentation of a thesis on a research problem. Students must complete 30 credit hours in required and elective subjects (e.g., neurobiology, statistics, thesis direction) and design, complete, and write up a research project in the form of a thesis. Three medical students have completed the Master of Science in psychiatry program thus far. Examples of projects include proton spectroscopic imaging of the thalamus in treatment-naive pediatric obsessive-compulsive disorder, or effect of nicotine on mood and performance in nonsmokers. Master of Science in psychiatry has its limits, such as resources (e.g., funding for tuition of various classes provided by the department), availability of research faculty, and interest and commitment among students to name a few.
The University of California, San Diego Model
This model focuses on early career research training in geriatric psychiatry. The authors (20, 21) established the Summer Research Institute (SRI) in Geriatric Psychiatry, which was intended for research training of "promising postresidency and postdoctoral fellows as well as junior faculty members." However, a few medical students (5) participated in its first year, and the number of medical student applicants for the second year increased dramatically. The program is supported by NIMH and pays stipends to the trainees ($5,000 for undergraduate, and $6,500 for graduate and medical students) so that they would not need to work at other summer jobs during the period of research training (21).
The information about this summer program was disseminated via a brochure sent to principal investigators on NIMH grants related to aging and to members of several professional organizations (such as the American Psychiatric Association [APA] and the American Association for Geriatric Psychiatry) and also via a website (http://startmh.ucsd.edu). In its first year (21), 30 trainees (from 22 institutions) were selected from 85 applicants, and 34 mentors (from 21 different institutions) were selected from 38 applicants. The trainees spent 10 weeks during the summer working on the research projects under an established research mentor (if a student chooses to apply with his or her mentor, then they may develop a research project with the investigator; however, if a student is matched with a mentor, he or she will most likely work on an already existing project (23). Seventeen students trained at their "home" institutions, and 13 elsewhere. At the end, a workshop brought together all the trainees who presented research posters (students from other institutions flew to San Diego, CA, for the 2-day workshop; the program covered all the travel expenses—these did not come from the stipends)(23).
The trainees reported that the program enhanced their interest in research and pursuing a career in geriatric mental health research. Several trainees later submitted their work for presentation or publication. The authors intend to contact the participants annually to determine how many continue to be active in research.
As the authors (21) pointed out, the program has its limitations (e.g., short term duration) and its limited usefulness for medical students at the present time—"most second- and third-year medical students have clinical rotations during the summer, and therefore only the first-year medical students can devote the entire summer to other activities" such as research. We believe that there may be solution(s) to this problem—either the medical school would allow students to take PGY-4 electives in a 3-month block to attend a summer research institute, or students at some schools where more time is devoted to research (e.g., Duke University—see below) would let their students participate in a similar national venue.
The Yale Model is probably the best developed, focused, and well thought out program for research training of medical students at present. The program is in its sixth year and is supported by NIMH. The following description of the program is from the article published in Psychiatric Research Report (22).
The creation of the program was stimulated by the fact that many Yale medical students from each class enter a research career in various clinical and basic science areas, but very few Yale medical students went into psychiatric training and less than one student every 3 years entered into clinical neuroscience research in psychiatry. The authors of this program constructed a curriculum that digests, organizes, and presents a vast array of available neuroscience information to medical students in such a way that its relevance to psychiatry is clear. This program includes a curriculum in the "Biology of Behavior" for the first-year medical students and a curriculum in the "Neurobiology of Behavioral Disorders" for the second-year medical students.
Currently, the program has two components designed to attract and engage medical students in translational clinical neuroscience research careers:
1. A modern, Internet-based didactic curriculum that interrelates basic and clinical neuroscience with clinical psychiatry. This curriculum is specifically designed to integrate basic, clinical, and neuroscience disciplines with a focus on understanding psychiatric illness. As part of the lectures and small group activities, case reports, live interviews, and video clips are used to illustrate the clinical relevance of each aspect of basic neuroscience. A unique and novel aspect of the curriculum is the development and use of an extensive interactive, digital, electronic syllabus available on the Yale intranet for all students. It covers all facets of the curriculum: full text journal articles with access to abstracts of references and additional reading; graphics, animation, videotaped patient presentation; and opportunities for self-study and self-evaluation. Each year, aspects of this curriculum are presented in an interactive lecture format to 200 first- and second-year medical students.
The authors of this curriculum plan to make it available first to medical students in the New England area (the Internet-based tutorials are being tested at Brown University and University of Connecticut at present) and later nationally.
2. A structured and mentored clinical neuroscience research training experience. All Yale students are required to write a thesis (research project), but they can choose any field of inquiry within medicine. All students interested in neurosciences enroll in the Yale Neuroscience Research Program and participate in/do a clinical neuroscience project. As the first- and second-year medical students at Yale proceed through the curriculum, they take the next step of actually evaluating and committing to careers in clinical neuroscience research. The program provides financial support for each medical student to spend a 3 to 12 month block of time in "real world" clinical research after the first-, second-, or third-year of medical school. Students participate in a structured mentored clinical neuroscience research experience. This experience involves the student in choosing a topic and an adviser who will sponsor the research. The student then conducts a background literature review, formulates a research question, and designs a study under the adviser’s guidance. The study is then conducted, the research analyzed and written up for possible publication. There is also a more advanced curriculum for trainees participating in the clinical research training experience. This curriculum also relates basic neuroscience to clinical psychiatry but, in addition, covers more advanced topics such as ethics of research involving psychiatric patients, research design, protocol construction, protocol management, data analysis and statistics, and report writing. The trainee is introduced to specific ethical and social issues as well as to specific clinical assessment and evaluation methods. A major focus is on the conceptual and practical bridges between basic and clinical neuroscience and on actual studies with psychiatric patients. The curriculum and mentored clinical research experiences are specifically tailored to the educational level of the participants. The entire program has built-in methods for evaluation with yearly follow up.
The entire Yale Neuroscience Research Program initiative or parts of the model could be relatively easily adopted by medical schools/departments of psychiatry around the country if sufficient resources were made available.
Duke University School of Medicine (24)
The curriculum at Duke University School of Medicine includes a full year of research or scholarly study (year 1: Basic Sciences Classroom; year 2: Core Clinical Rotations; year 3: Research Basic Science, year 4: Clinical Elective Rotations). During the third year, all students conduct research or scholarly activity (some do an MPH; some work toward a J.D. or Master’s in a particular area; etc.). Students choose a mentor in whose lab they complete their project, and they select an area of study referred to as a study track. There is a designated director of the study track who shepherds students throughout the year. Some students complete a year in psychiatry or related areas, including participation in clinical projects. This is subsumed under the behavioral neuroscience study track. There is a wide range of mentors and projects available in this study track. All approved mentors must have sufficient funding to provide the students with the resources they need. Students pay tuition for the year, but this does not go to funding their research projects or the lab they work in. Students have a dissertation requirement as they complete their third year and begin their fourth year.
This model probably attracts a lot of medical students interested in research to Duke University School of Medicine. However, the impact of this model on interest and recruitment in psychiatry is not clear (24).
Mt. Sinai School of Medicine
According to the article by Zier and Stagnaro-Green (25), Mt. Sinai School of Medicine created its Office of Student Research Opportunities (OSRO) in 1995, "to stimulate students to engage in research." A senior faculty member involved in patient-oriented research was also appointed as a new dean to direct the OSRO. This office was established to inform students about research activities and help them locate mentors. It coordinates all aspects of medical students’ research activities. The Mt. Sinai School of Medicine also offers a 3-week block at the end of the first year to begin projects that continue through the summer intersession (25). This block is followed with a 10-week summer break available for research. The school has also been developing a novel program, called Research and Medicine. This program will offer "research training to students who are committed to obtaining advanced research training and experience, but who do not plan to obtain a Ph.D." (25). These students will complete a number of research blocks during 4 years of medical school, receive special training in research methods, design, analysis, and ethics and be encouraged to take a tuition-free year devoted to research, following their second or third year (25).
As in the case of Duke University School of Medicine initiative, the significance and impact of this program for psychiatry are unclear and unknown.
In response to the Institute of Medicine recommendations on research training in psychiatry (12), which call for fostering the integration of research into training programs nationally, the National Institute of Mental Health (NIMH) appointed the National Psychiatry Training Council (NPTC). The NPTC and its task forces focus on research training of psychiatry residents and junior faculty (26). The APA in collaboration with NIMH may consider establishing a similar body with focus on research training in psychiatry and neurosciences for medical students. This body could be either independent of the NPTC or under the umbrella of the NPTC.
1. The NIMH and/or APA should appoint a national council/committee/task force which would survey the number of medical students involved in psychiatry research across the country and the number and types of programs currently available to foster such research, either independently or within the framework of the NPTC.
2. A nationwide research training of medical students in psychiatry initiative should be established. This initiative should either embrace or adapt the Yale Model of research training for medical students, or expand the University of California San Diego Model to other areas than geriatric psychiatry.
3. Medical schools (those who do not have a special research initiative such as Duke University or Mt. Sinai School of Medicine) should be encouraged to allow students to take a block of electives in year 4 of medical school to participate in an activity akin to the Summer Research Institute.
4. Regional centers for medical student research training in psychiatry and neurosciences should be established. These centers would help to organize the structured and mentored clinical neuroscience research training experience for medical schools lacking the resources, research infrastructure and mentors. For instance, a medical student from a small medical school with a clinically oriented department of psychiatry may be able to obtain a research mentor from a regional research oriented medical school/department of psychiatry (or even NIMH) and possibly spend a research elective in this department (or at NIMH).
5. The APA should establish a research colloquium solely for medical students, either independently or within the framework of the research colloquium organized by APA Corresponding Committee on Research Training. If this research colloquium is organized within the framework of the existing research colloquium, there should be a group solely focused on medical students, not mixed with other groups.
6. Medical students interested in psychiatry should be encouraged to attend APA annual meetings and other national society meetings in psychiatry. It is strongly recommended that mentorship (e.g., arranged by APA) be offered to interested students as part of their participation. Mentorship during the meeting was found useful in other APA sponsored programs for medical students.
7. The APA should reevaluate its existing fellowships (e.g., BMS, GSK, Lilly Products Fellowships) with focus on fostering research training/careers of medical students interested in psychiatry and neurosciences.
8. The APA & NIMH should establish a special research award for medical student research.
9. The nationwide research training curriculum and network should foster specific research training/projects with a focus on psychosocial issues (relatively neglected in the recent research where biologically focused research is overabundant), health services and outcome, and clinical trials.
10. Specific funding resources for research training of medical students should be identified (NIMH, industry, foundations, alumni organizations) and the information should be disseminated to the departments of psychiatry around the country.
11. Facing the increasing number of women graduating from medical schools and entering psychiatry and the relatively low involvement of women psychiatrists in research (20), special attention should be paid to opportunities in research training for women in order to increase the recruitment of women investigators (27).
Some of these recommendations could be coordinated within the framework of the NPTC with the efforts to foster resident research training. We recognize that some of our recommendations may be premature, and most of the recommendations definitely require more systematic study.
We hope that adaptation of all or some of these initiatives would help to increase the number of medical students pursuing a career in psychiatric research.