Psychiatric residency programs provide comprehensive training in diagnostic procedures and therapeutic modalities that inform the clinical practice of psychiatry. Although all psychiatric residencies are regularly reviewed to ensure that they provide training in the essential competencies, this report provides objective evidence that training in clinical genomics is inadequately provided.

Demonstrating the genomic variability of individual patients is becoming increasingly important in all fields of medicine, and nearly all major psychiatric illnesses have been demonstrated to have a genetic component. Furthermore, clinical psychiatric pharmacogenomics has expanded rapidly since the FDA approved a methodology to genotype two cytochrome P450 genes in 2004. For the past 5 years, clinicians have had increasingly greater access to genomic tools designed to clarify patients' specific metabolic capacities.

The number of clinically trained medical geneticists is insufficient to provide adequate consultation to primary care providers and medical specialists (1). Thus, medical specialists are increasingly expected to develop greater competence in the expanding clinical applications of genomic research (2, 3). Although psychiatrists are interested in learning about psychiatric genomics, many do not feel well prepared to use genomic test results (4).

Medical undergraduate training in genomics has expanded dramatically, and guidelines specify the curricular content. Reigert-Johnson et al. (5) developed a genomic component for the resident training curriculum in internal medicine, and Finn (6) proposed a similar plan for genomic training in psychiatry.

The Residency Review Committee recently revised the essential requirements for psychiatric training to state that the didactic curriculum must include biological, genetic, and psychological factors that significantly influence physical and psychological development (7). However, concern is increasing that residency programs are not fully compliant in providing broad training in genetics and specific training in genomics. This survey provides data that address this question from the perspective of chief residents.

Chief residents in U.S. and Canadian psychiatry programs were asked via email to participate in a survey of their perceptions of their psychiatric genetics and genomics competencies. Chief residents were chosen because they were highly likely to be familiar with the current content of the curricula in their programs yet reasonably objective about the curricula because they were not personally responsible for the structure of their programs.

The survey was created by considering components of Finn’s (6) proposed curriculum for genetic education of psychiatric residents, the American Society of Human Genetics guidelines for Medical School Core Curriculum, and a new genetics curriculum for internal medicine residents (5). Respondents were asked to report the number of hours that had been devoted to genetics in their didactic curricula over the entire course of their residency training and to respond to a series of statements using a 5-point scale. Institutional Review Board approval was obtained for this study.

The survey was delivered to participants using an APA e-mail list of the 217 psychiatry chief residents in the spring of 2008. The initial response rate was only 9%, so we sent three follow-up e-mails to the 178 chief residents who provided their e-mail addresses while attending the APA Chief Resident Executive Training Retreat. Verbal confirmation was subsequently obtained from the APA list administrator that those residents were a subset of the initial residents on the list. To increase participation, a $5.00 gift certificate from an online retailer was provided to chief residents who completed the survey. The investigators verified that there were no repeat e-mail surveys from respondents by ensuring each e-mail address was surveyed only once.

Three cohorts of residents were designated on the basis of their reported number of hours dedicated to psychiatric genomics over the course of their residency training (3 or fewer hours=“least time trained” group; 6 or more hours=“most time trained” group; between 3 and 6 hours=“average time trained” group). Using analysis of variance, the differences between the groups were assessed and post hoc analyses were conducted using the Student-Newman-Keuls statistic.

Ultimately, 80 chief residents responded for an overall response rate of 37%. Figure 1 shows the distribution of educational and clinical experiences devoted to genetics or genomics, 15% of respondents stated that they had no training in genomics, and another 35% reported receiving between 1 and 3 hours of training.

The concept of genetic predisposition to disease was reported to be understood by 67% of 77 respondents. However, only 6% of the 80 chief residents stated that they understood the components of a comprehensive genetic examination. Only 18% of 80 respondents reported that they knew how to make an appropriate genetics referral, and only 8% had actually participated as a member of a multidisciplinary team that used genetic/genomic specialists (Table 1).

Residents who stated that they did not recognize the growing importance of genetics on pharmacologic choices were more likely to be in the least time trained group than the two groups of residents with more extensive training (F=8.58, df=2, 76, p<0.001). Chief residents in the least time trained group were also less likely to acknowledge that they recognized the current clinical status of testing for P450 genotyping polymorphisms than the rest of the sample (F=5.25, df=2, 76, p=0.007). Significant differences were found between the least time trained group and the other chief residents for 17 of the 21 probe statements.

Respondents with the least training in genomics indicated that they had less knowledge about the clinical utility of genomics. Respondents who had received 3 or fewer hours of training on clinical psychiatric genomics reported that qualified faculty were lacking in rounds and conferences. A lack of faculty with adequate training in genomics and a lack of understanding of the implications of genomics testing have been identified as two barriers to improving genomic education (5).

Many indicated that they had not worked with either medical geneticists or genetic counselors. This is unfortunate because such professionals can help residents to better understand basic genetic principles, interpret traditional genotyping results, and appreciate the importance of patient education in genetic risk.

Limitations include the modest response rate of 37%, which does not allow generalization of the results of this survey to all psychiatric residency programs. Also, the survey documented the perceptions of chief residents rather than testing the factual extent of genomic medical knowledge. Information was not collected regarding the individual programs of respondents to ensure anonymity and to improve the response of residents to the survey, so more than one chief resident from a program may have responded and the data may not represent 80 distinct programs. However, the data present the reports of 80 different chief residents. Although survey response rates have been reported to be lower using web-based technologies than telephone or mail surveys (8), our rate of response is comparable to other published national samples (9). Although this survey does not comprehensively assess all residency programs, it documents limitations on the exposure of some residents to important genetic aspects of psychiatric illnesses.

More objective testing of the working knowledge of clinical genomics that has been achieved by psychiatric residents is clearly needed to define the extent of this problem. However, this first report will hopefully stimulate more comprehensive investigations of this important component of psychiatric training.

The development of a genomic curriculum for psychiatric residency programs should become a higher priority for psychiatric educators. Table 2 presents a set of proposed learning objectives for such a curriculum.

Teaching methodologies could include sessions designed to ensure that residents are able to evaluate current scientific reports that address new findings in psychiatric genomics. Ideally these sessions would include small-group discussions to clarify benefits and limitations of new research findings. Whenever possible, the inclusion of case discussions that focus on pharmacogenomic evaluation and treatment management should be included to provide a clinical approach to achieving mastery of the application of new genomic technology.

A team of researchers, including Dr. Mrazek, has developed intellectual property that has been exclusively licensed by AssureRx. Dr. Winner is a consultant for AssureRx, a personalized medicine company. At the time of submission, Drs. Matsu and Goebert declared no competing interests.