The 2003 Institute of Medicine (IOM) report on research training in psychiatry residency warned, " … the number of psychiatrist-researchers does not appear to be keeping pace with the unparalleled needs that currently exist in clinical brain and behavioral medicine" (1). The IOM report identified several important factors that influence research training during psychiatry residency and recommended specific changes to address these needs. Over the past 10 years, our department at the University of Pittsburg has implemented changes in psychiatry residency-training, especially in the context of our residency research track (RT) (t1 and t2), which address many of the challenges and recommendations of the IOM report. In this article, we describe our developmental approach to the needs of residents. We believe that our residency RT model can overcome barriers to effective research education and training and can serve as a useful model for other programs to consider.
The IOM report emphasized a need to consider residency training as part of a developmental research training continuum, and it concluded that barriers to effective research training during residency included regulatory, institutional, and personal factors. The report noted significant regulatory barriers to the incorporation of research experiences into residency training, together with a limited research presence on the Psychiatry Residency Review Committee (RRC) and the American Board of Psychiatry and Neurology (ABPN). Significant institutional deficiencies in the funding of resident research, the mentoring of residents, and psychiatry training infrastructure were underscored. Finally, the report noted several personal factors related to perceptions of income, lifestyle, and culture of academic psychiatry careers.
The University of Pittsburgh Department of Psychiatry has long been committed to research training in psychiatry. The education of psychiatrists-in-training was recognized very early on as an important opportunity for the recruitment and training of young investigators. Ten years ago, the academic leadership of the department created a RT for their residents. The goals of the RT have been to develop a community of young psychiatrist researchers, incorporate research and mentoring into their residency, and prepare residents for postresidency research fellowships. The RT has continued to evolve into a structured and well-integrated extension of the residency-training program, much like our combined adult/child and adolescent track. Throughout its history, the RT has gone through many changes, including faculty leaders, schedules, requirements, and, most importantly, resident participation. Today, the RT has increased the number of faculty leaders, appointed a chief resident, increased administrative and financial support, adopted new guidelines and procedures consistent with the recommendations of the IOM report, employed a more prescriptive and less permissive style of training and has become an important source of data for understanding and improving research training during psychiatry residency.
The IOM report highlighted the importance of including psychiatry residencies in the research training developmental pathway. Our department has incorporated research training into its residency program for many years and was cited by the IOM report as a model for other residency programs (1). There remain, however, many challenges to understanding the specific mechanisms behind successful residency research training and how to make this success "exportable" to other programs, especially to those who do not have the type of extensive research funding and infrastructure available at the University of Pittsburgh.
Consistent with the recommendations of the IOM, we have approached the delivery of research training as a "pipeline" that is incorporated into medical training as early as possible (2). Our experiences have suggested that a flexible and nurturing system allows residents time to explore the field, develop their identities as psychiatrists, and define their areas of interest. We have also learned that too much flexibility provides insufficient guidance for residents who are "on the fence" or uncertain about their research career interests. From a developmental perspective, we have attempted to provide a safe home base for young researchers and a prescriptive parenting/mentoring style (3). We think that a combination of structure, discipline, and flexibility will provide the healthiest environment for young researchers to develop secure attachments with the field and with their mentors, build self-confidence, and separate as well as individuate. We believe that, although research infrastructure and funding will differ between residency training programs, this "parenting" style is truly "exportable."
The establishment of a safe and secure home base begins early in our recruitment and training of researchers. During their psychiatry clerkships, medical students are introduced to the rich academic psychiatry environment at Western Psychiatric Institute and Clinic (WPIC) via neuroscience courses, grand rounds lectures, and brown-bag research talks. Medical students who express an interest in research are strongly encouraged to interact with researchers, become involved in projects, and establish relationships with potential mentors. Medical students with an interest in academic psychiatry are highly recruited to the residency program. When applying to our residency program, students who are already prepared to commit to research may also apply to our RT (much like those students who apply to our 5-year combined adult/child and adolescent psychiatry track).
Our prescriptive approach to the recruitment and training of residents begins immediately. Once accepted into the residency program, interns and residents have the opportunity to apply to the RT during residency, but no later than Spring of their PGY-2 year (applications are accepted in January and May). Each applicant is required to create a portfolio, consisting of their curriculum vitae (CV), a specific research proposal, an academic schedule, a list of short-term and long-term research goals, a letter of good standing from the office of residency training (ORT), and a letter from their mentor outlining their project and responsibilities. The faculty leaders make a consensus, final decision on who is admitted to the RT. Applicants who are not accepted to the RT meet with an RT faculty member to discuss how the application could be improved and are encouraged to revise and resubmit their application throughout the year.
The formal application process has brought more clarity and structure to the RT and is important for several reasons. 1) It enables the faculty "metamentors" to anticipate problems in the proposed project and address them early (e.g., the project is ill-defined, too advanced for the resident’s experience level, or perhaps the resident has not established enough of a relationship with the mentor). 2) Once a resident is accepted into the RT, they are officially considered a part of the pipeline, and their progress will be tracked regardless of their ultimate decision to pursue a full-time research career.
The departmental leadership has also introduced several other changes to the RT in an effort to increase its cohesion, structure, and identity. Past residents had frequently reported that they were uncertain "who was in and who was not in the RT." Before 2003, the RT had a more permissive style of leadership than it does presently. There were no requirements regarding meeting attendance or participation; the goals and expectations of RT residents were unclear; and there was an absence of resident leadership. Residents were invited to a faculty leader’s home for informal monthly dinners and round table discussions regarding individual research projects and objectives. These meetings were often characterized by low attendance and inconsistent participation. Residents struggled with balancing and prioritizing their dual interests in clinical and academic psychiatry in the face of a structured clinical training schedule and a supportive but laissez-faire RT. The department concluded that increased structure, integration, and discipline were necessary and, after systematically assessing the problems, laid out a process for change. The process for change continues to be supported regularly by the academic leadership of the department in monthly meetings of the Academic Council. For example, in addressing the need for a more structured approach, the Council decided to appoint an RT faculty adviser and to mandate an application focused on mentoring and accomplishment of a project, and participation by residents in the annual research day. Above all, we sought to communicate how RT activities constitute an important bridge in the continuum of development leading to appointment in a postdoctoral research fellowship.
Currently consisting of 13 residents (approximately 26% of total residents) and four primary faculty leaders ("metamentors"), the RT is a diverse group of residents at various levels of training, who are seriously considering an academic career. As part of the effort to refine the RT, the departmental leadership, in 2003, decided to appoint a chief resident to the RT (RT chief). As a senior resident, with established research interests and achievements, the RT chief has already become an important liaison between RT residents and faculty. One of the RT chief’s most important roles is to assist residents with clarifying their goals and expectations and to create a pragmatic short- and long-term plan for residency, including the challenge of balancing clinical requirements with research interests. The RT chief also assists the faculty leaders in helping individual residents locate a primary mentor and junior residents with selecting an initial research project.
In addition to creating a chief resident position and modifying the application process, the departmental leadership has also initiated several new rules and procedures. If accepted to the RT, residents must comply with specific guidelines, including bimonthly meeting attendance, participation in meetings and scheduled activities, and consistent communication with the RT leadership. For those who have not yet established projects and/or relationships with mentors, RT residents are immediately encouraged to outline their goals and expectations and meet with the chief resident and faculty leaders. RT meetings are modeled after postdoctoral research training classes, teaching research literacy via literature review, biostatistics, and grant and manuscript writing. PGY-1 RT residents (during the psychiatry branch of their internship) and PGY-2 RT residents are provided protected time in order to attend the bimonthly RT meetings.
Due to the extensive clinical requirements in the first 2 years of residency training and frequent periods where clinical training demands may delay the development of mentor/mentee collaborations, the departmental leadership has encouraged the RT to function as a "matchmaker" and liaison between residents and mentors. By facilitating "best fit" mentor/mentee pairs early on in the RT resident selection process, and with subsequent bimonthly RT meetings and regular 1:1 chief resident "check-ins," the RT supports ongoing effective collaboration. In the first 2 years, prospective RT residents meet regularly with the RT chief resident, and at least once annually with RT faculty leaders, to identify a mentor with whom they can collaborate on specific projects in the later years of residency.
Once a mentoring relationship has been established, the selection of an appropriate initial project is critical. An important element of RT "metamentoring" is helping junior residents identify projects with a high likelihood for success and publication. It is the RT faculty’s belief that such projects should be relatively small in scope (preferably a secondary data analysis or review paper) and can be completed in the time frame of one or two semesters. So long as the data are broadly related to the resident’s interests, this is acceptable. The major goal of the report is to enhance skills in writing, data analysis, study design, and mentor/mentee collaboration—developing the "toolbox" of skills needed as an investigator. Ideally, all residents are encouraged to have at least one first-authored, peer-reviewed publication to show for their efforts by the completion of the PGY-4 year.
Consistent with the IOM’s recommendation for changes in program and curriculum infrastructure, the departmental leaders have designed the RT to resemble several effective research training models and programs already in place in the department of psychiatry. For example, the "Research Survival Skills" practicum, a weekly, problem-based learning seminar aimed primarily at helping postdoctoral fellows learn manuscript preparation, grant-writing, platform presentations, and other research survival skills, has served as one template for the RT (4). The seminar, now in its thirteenth year, is a supportive and friendly peer environment, during which postdocs engage in peer review and discuss issues regarding mentorship, manuscript writing, and other critical elements of academic careers. The practicum is itself modeled after National Institutes of Health (NIH) study sections and promotes constructive criticism and practice for the "real world" of research. Like the RT, the seminar also includes experienced researchers who present their own scientific autobiographies and serve as faculty guides and "metamentors."
The RT borrows these elements from the postdoctoral training and research skills programs and imparts their virtues to residents in a stepwise fashion. In the early years, the guidance of the RT faculty leadership and chief resident tends to be highly prescriptive: interested junior residents are told to meet with one of the RT faculty members and the RT chief to discuss their general areas of interest. They are then directed to meet with one or more senior investigators within the institution that have a strong track record of mentoring students, residents, and fellows. Early on, this "curriculum within a curriculum" (meetings with prospective mentors, regular RT meetings, designation of a discrete initial project) is highly prescriptive for a reason. Much of clinical training in medical school and residency involves being told where to go and what to do. The process of developing one’s own ideas and direction is one of the larger challenges for physicians adjusting to the life of a postdoctoral research fellow. Taking junior residents by the hand early on may reduce growing pains until they have established at least one major success. Furthermore, taking on a project already designed by a seasoned investigator is much less threatening than generating and defending the merits of one’s own original idea.
The RT chief resident works with the clinical chief resident to schedule time for RT residents to engage in these projects. By forgiving one required clinic each semester, and arranging clinic schedules so that at least 1 day per week is blocked off for research time, the resident has an easier time shifting into "research mode" and focusing energy on a scholarly project.
Currently, all four PGY-3 RT residents are collaborating with a mentor on a secondary data analysis or review paper as a central component to their PGY-3 RT experience. WPIC requires third year (non-RT residents) to complete nine half-year clinics (six required and three elective), in addition to formal didactics, psychodynamic psychotherapy cases, and faculty supervision. PGY-3 RT residents are excused from two of the elective clinic experiences during the year, amounting to a 20% reduction in total clinical duties carried by non-RT PGY-3 residents. All RT residents PGY-3 and above are required to present their findings as a poster or paper presentation at the annual WPIC Research Day at the end of the academic year. Since adopting this more proactive stance in encouraging RT residents to present their work, RT resident participation in Research Day has more than tripled in the past 4 years (from 0—2 resident participants each year from 2001—2003, to 7 residents in 2004). Though this is not required, we have seen a similar increase in participation in the annual Resident Research Night of our local American Psychiatric Association chapter, among both RT and non-RT residents. Another RT requirement is that all senior RT residents present their current research project for discussion with peers during an RT meeting. This not only provides opportunities for junior residents to look forward, it fosters critical appraisal skills and places the senior resident in the role of a teacher and role model to junior residents.
Later in the RT residency experience, during the PGY-4 or PGY-5 years (child and adolescent and geriatric psychiatry fellows), residents are encouraged to prepare for a postdoctoral fellowship. PGY-4 adult-track RT residents, during this flexible elective year, can devote up to 75% of their time to research endeavors. During these years, the supervision of the RT resident shifts from the RT to identified mentors. In these years, the role of the RT shifts from direct, hands-on supervision to the advancement of practical skills, such as collaborations with biostatisticians, and the preparation and presentation of research projects and ideas to peers and senior investigators. Child and adolescent-track RT residents can devote up to 50% of their time in the PGY-4 and PGY-5 year to research endeavors and still meet the clinical requirements of the child psychiatry fellowship. A recent analysis of our current psychiatry residents revealed that, despite the amount of RT-related research activity during residency, there were no significant differences between RT and non-RT resident Psychiatry Residency In-Training Examination (PRITE) scores, with the exception of our PGY-3 RT residents, who had statistically higher scores than the non-RT residents [t = 2.55, p=0.013] (1, 18).
In the IOM report, support by the RRC in psychiatry and the ABPN for research experiences and scientific literacy training during residency was deemed to be critical. The report also pointed out the lack of experienced psychiatrist-investigator involvement in these influential organizations. The report further identified funding issues, leadership/mentoring, and program/curriculum infrastructure as key institutional factors influencing research training during psychiatry (5).
Consistent with these concerns raised by the IOM report, our residency-training program has continued to strongly encourage the incorporation of research experiences into residency training, and research literacy represents a core training requirement for all residents. During their PGY-3 year, all residents are required to take courses in Evidence-Based Psychiatry and Introduction to Psychiatric Literature. During PGY-4 and PGY-5 years, all child/adolescent psychiatry residents/fellows are required to take the Child Literature Seminar and Child/Adolescent Psychiatry Literature Seminar. All senior residents, both RT and non-RT members, are required to complete a scholarly project (typically a case report, literature review, or poster presentation) and present a grand rounds lecture prior to graduation. Furthermore, in line with the IOM’s recommendations for increasing the presence of academic psychiatrists in influential residency-training organizations, an RT faculty leader (C.F.R.) is currently a member of the RRC-Psychiatry.
The University and its faculty provide continuous support for the RT. The department chairman negotiates on an annual basis with the University of Pittsburgh Medical Center system for psychiatry residency training funding, including allocations for investigative activities in the PGY-3 and PGY-4 years. A senior researcher in the department (C.F.R.) is designated as RT director. The RT director meets with the residency group for 1 hour one to two times per month and with the RT chief as needed (generally one to two times per month) and communicates via e-mail. The group of senior faculty overseeing the track (D.J.K., H.A.P., N.R., C.F.R.) discusses the track at monthly 1 hour meetings of the department’s Academic Council. In addition, individual residents each have mentors with whom they meet regularly; the mentors are invited to the RT meetings to discuss presentations by residents working in their research programs. The oversight or mentoring efforts are generally subsumed under efforts as PI on NIH grants (center or research project awards) or covered through endowed chairs.
Another way that our institution continues to address funding challenges is by supporting the growth of research clinics, where residents have the opportunity to integrate their clinical and research training. Most RT residents participate in one or more research clinics during their training. Many RT residents take advantage of our clinical research settings, such as our late-life mood disorders and adolescent bipolar disorder clinics, as places to learn both clinical and academic psychiatry. The resident’s research mentor can often double as the faculty supervisor in these clinical research settings. In this role, the mentor can provide an "enhanced" clinical training experience, where research principles in study design, recruitment, and other content areas important to clinical research can be taught in parallel with individual patient management skills. Even psychiatry departments with a smaller cadre of research faculty can link residents with useful experiences that are broadly within their field of interest (i.e.- an inexperienced resident interested in pediatric bipolar disorder may benefit from involvement in studies addressing mood disorders research in adults, or a child and adolescent study of a topic other than bipolar disorder).
The IOM report also examined personal factors that influence residents’ decisions to pursue research training, including several innate characteristics, financial issues, and cultural issues affecting the recruitment and retention of young psychiatry researchers.
Supplementing the time dedicated to research literacy, our bimonthly RT meetings include invited junior and senior researchers who are asked to educate and advise the residents about financial and lifestyle issues. Financial topics include moonlighting opportunities and performance incentives that bridge the gap between research and independent practice earning potential. The invited guests also share perspectives on quality of life regarding research careers in an effort to demystify the day-to-day life of researchers. They are asked to address potential misperceptions, noted in the IOM report, such as a negative image of tedious work with delayed gratification and concerns that research careers are incompatible with family and life obligations.
The RT organizes both meetings and activities to address many of the various negative images that were reported by the IOM. Interactions with psychiatrist-investigators are not only an essential component of RT meetings but are also encouraged through several RT activities, including an annual WPIC Research Day, during which senior RT residents are required to submit abstracts for either a poster or oral presentation. One of the many aims of Research Day is to maximize the interaction between residents and other members of the WPIC scientific community.
The RT has also attempted to address financial issues highlighted in the IOM report, including loan repayment, grant, and travel award opportunities for residents. The RT chief and faculty leaders are responsible for making National Institutes of Mental Health (NIMH) loan-repayment program, grants, and travel awards more accessible and "user-friendly" to RT residents. This not only creates opportunities for residents to engage in research early in their training, but also serves to enhance a sense of camaraderie within the research community.
The IOM report stressed the importance of recruiting more women, international medical graduates (IMGs), and underrepresented minorities into psychiatric research. The RT has implemented several strategies to achieve these important goals, such as creating an "open-door" policy for meetings, such that any resident can attend and observe. Furthermore, we have included IMGs in the RT faculty and have recruited women and minority faculty to participate in and accept leadership positions within the RT. We have also made a point of inviting a diverse group of young researchers (postdoctoral fellows and junior faculty) to meetings in order to share their "scientific autobiographies" with the group and provide feedback regarding various lifestyles in academic psychiatry.
The WPIC RT has three main goals for the future development of the track: 1) improved data gathering on RT outcomes and productivity; 2) better collaboration and communication between RT leaders and individual resident mentors; 3) improved collaborative efforts between the RT and the Office of Residency Training (ORT).
The IOM report identified several overarching recommendations for the future of research training in psychiatry residency. Foremost among them was the need for better data gathering to assess research training and development. A recent review of RT attendance records and correspondence with residency graduates, who had participated in the RT from 1994—2004, revealed that 27 of 33 residents remained in the RT during their residency and 15 of those 33 entered either a postdoctoral research fellowship or remained in research following graduation. Further analysis has demonstrated that 11 of the 33 RT resident graduates have received a Career (K) award and/or an RO1 research grant. The factors that influenced these residents as well as those who dropped out of the RT and/or chose a different career path remain to be fully elucidated. Continued evaluation of our RT residents and non-RT residents is needed.
The RT leadership is currently designing a longitudinal database in collaboration with the residency training office that will track all RT residents for a minimum of 5 years after completion of residency training. The most practical way of obtaining this information may be to request updated CV’s annually, and abstract important data (i.e., practice setting, academic appointments, research grants and publications). Impressing upon current RT members the importance of participation in follow-up efforts, no matter what their ultimate career direction, is a key focus of our current efforts.
We have already underscored the importance of the mentor/mentee relationship in the development of physician-scientists. One of the benefits of a formal RT application process has been that RT faculty leaders were able to identify several resident projects that were either too ambitious to have a high probability of success, or too nebulous to have any quantifiable product. In a recent review of residency research curricula, the authors identified six papers citing lack of faculty experience in supervising residents as a barrier to development (6). If the mentors at a given institution are taking vastly different approaches in their guidance and advice to residents, any attempts to provide a central core curriculum and structure can be very challenging. When individual mentor/mentee pairs are struggling to identify an appropriate scholarly activity, senior RT faculty can intervene to communicate some of the basic expectations of RT residents and guidelines for appropriate projects. The more consistent and coordinated the mentoring efforts at an institution, the easier it should be to establish explicit goals, monitor outcomes, and standardize resident training experience.
Another future RT goal is a more active collaboration between the RT and the Office of Residency Training, in order to facilitate resident research efforts and more flexible training schedules. Regular presentations of RT outcomes by the residency training director and RT chief at national training meetings, such as the American Association of Directors of Psychiatry Residency Training (AADPRT), may stimulate more interprogram collaborative efforts to make research opportunities in residency more mainstream, and help research training occupy a more central role in curriculum development.
As the field of psychiatry attempts to integrate more traditional clinical training with the rapidly advancing neurosciences, research training in residency increases in importance. The critical need to recruit and retain new physician-scientists, as set forth in the recent IOM report, requires significant action by psychiatry training departments on multiple levels, including regulatory, institutional, and personal. Developmentally appropriate research training models are needed for these efforts. Our 10-year RT experience was made possible by our departmental leadership’s willingness to invest time, money, patience, and flexibility into this project. The recent elevated resident participation in the RT may suggest that a developmental approach to training, including a more prescriptive and less permissive style, is a cardinal trait of a successful program. We believe that continued analysis of the RT and its evolving database will better elucidate factors that contribute to residency research training success and resilience.