Academic Psychiatry 22:47-55, March 1998
© 1998 Academic Psychiatry
Mentoring Psychiatric Trainees' First Paper for Publication
Michael T. Lambert, M.D. and
David L. Garver, M.D.
Dr. Lambert is associate professor, Department of Psychiatry, University of Texas Southwestern Medical School at Dallas (UTSWMSD); and assistant chief, Psychiatry Service, Dallas Veterans Affairs Medical Center (DVAMC), Texas. Dr. Garver is a staff psychiatrist at the DVAMC and professor in the Department of Psychiatry, UTSWMSD. Address reprint requests to Dr. Lambert, Psychiatry Service 116A, DVAMC, 4500 South Lancaster Avenue, Dallas, TX 75216.
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ABSTRACT
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The authors describe their experience supervising and collaborating on projects that led to the first publications of several medical students and psychiatric residents. Rather than mandating a research project of all the residents, the faculty focus effort on the trainees with a sincere interest in writing a scholarly paper for publication. The authors break down the procedure of developing a published project into manageable steps that reflect and teach the scientific process. The mentoring required for these trainee-faculty publications is involved and time consuming, but the process is extremely rewarding. Four successful projects illustrate different levels of publication possibilities for trainees and demonstrate the positive effects the experiences had on their academic aspirations.
Key Words: Mentoring • New Idea • Scholarly Publishing
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INTRODUCTION
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One of the more rewarding experiences in academic life is seeing one's work published in a peer-reviewed journal. This scholarly product is a major focus of academic energy, yet medical students and psychiatry residents considering future academic careers are seldom mentored in the process of developing a project and seeing it through to publication. Collaborating with interested students and residents to develop clinical or research material for publication benefits all parties involved. Students who publish while in medical school often pursue academic careers and continue to publish during the 20 years following their medical school graduation (1).
Some medical schools and residencies require a medical-doctoral thesis or a faculty-mentored scholarly project. In one obstetrics-gynecology residency that required a faculty-mentored research undertaking, only half of the projects were eventually published in peer-reviewed journals (2). Our literature review found no recent descriptions of American psychiatric training programs designed to foster publication skills, but in the early 1980s the psychiatric faculty at Cornell University Medical College developed a curriculum focusing on basic research and manuscript preparation skills (3). Their course offered "shepherding" of projects through the last 3 years of residency and included ongoing "research-in-progress" seminars. The course contents included critical reading of the literature, basic research technique (including service research), data analysis, and manuscript preparation.
Because few of our residents are interested in research or academic careers, psychiatry faculty decided not to establish a specific curriculum aimed at teaching all residents to publish. The level of academic interest is reflected by the fact that about 5 of the 45 residents in our program publish papers each year. The majority of our residents intend to develop private-practice careers. Our faculty had reservations about investing large amounts of time and energy if most of the residents were unenthusiastic about the endeavor. Instead, research electives, training in clinical research areas, and supporting interested trainees to work individually with faculty members on projects were chosen as strategies for encouraging residents to consider research endeavors and careers (4). While no formal publication training program is required, our trainees have opportunities to become involved in projects during regular rotations on our research teaching unit or during electives on this and other units (5). Participation is completely optional and—often but not always—indicates preexisting academic interest.
In this article, we illustrate to other academicians how we involved our students and residents in publishable projects without a formal program or requirement for this in the Psychiatry Department at the University of Texas Southwestern Medical School at Dallas. We believe that developing interested trainees' research and publication skills increases the chance of recruitment into the field and assists future junior faculty to be productive. We have been doing this at our institution since 1992.
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ENGAGING TRAINEES AND SELECTING A PROJECT
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Some trainees identify themselves as interested in research or writing a paper by signing up for a research elective or directly contacting the faculty. Such residents often have a well-known interest in an academic career and are ready to become involved in a project. However, some residents are uncertain about their future interests, and they must be encouraged to consider a project. The authors routinely offer all residents assigned to our supervision the opportunity to write a case report, literature review, or to become involved in ongoing research. The medical students who involve themselves in projects are usually superior students who have already decided to go into psychiatry. We believe building mentoring relationships around research and writing assists with recruitment of these desirable students into the residency program.
Even for trainees with strong future academic interest, selecting an area of interest and developing material for a paper can be overwhelming. Many trainees believe they must have a research grant and a monumental project to generate a paper. Faculty can help by describing the range of publishable article material that includes letters to the editor, brief reports, case reports, literature reviews, and research reports. Research can be clinically or services-oriented, such as comparing outcomes in different groups of patients, or can involve sophisticated testing of neurochemical hypotheses. Faculty should draw on their own expertise to engage trainees in ongoing projects or to develop spin-off substudies of existing research. Occasionally existing databases can be "mined" for additional publishable data and conclusions. A clinical question related to a patient the student is treating can also be a rewarding beginning of a study. A particularly interesting or challenging patient may be the catalyst for a case study and literature review.
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FROM HYPOTHESIS TO PUBLICATION: TEACHING THE PROCESS
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We attempt to separate the task of developing a project and publishing the results into several manageable steps (Table 1). The basic tasks include 1) choosing a question or topic to explore (hypothesis building), 2) designing an approach to use data to answer the question (study design), 3) data collection ("research"), 4) assessing the results (data analysis), 5) writing the paper (manuscript preparation), and 6) navigating the submission and revision process to final acceptance for publication (publishing skills). Breaking the process into these manageable steps allows students or residents to assimilate the task more readily. This approach teaches the scientific process and is applicable to the whole range of publishable projects.
Step 1: Hypothesis Building
A critical learning issue is turning a clinically relevant question into a testable hypothesis. For some publications, such as case reports and literature reviews, the trainee's curiosity about a certain topic or case suggests the question, such as "what is known about delirious patients with new-onset olfactory hallucinations?" The "hypothesis" to test may be restated as "nothing is known about delirious patients with new-onset olfactory hallucinations." The actual research consists of a literature-information search that examines current knowledge on the topic.
Step 2: Designing a Study
Trainees interested in more formal research often have a question in mind, which allows the faculty mentor to discuss the development of a testable hypothesis and a reasonable study design. The mentor should elucidate the relative merits and weaknesses inherent in various study designs. As a general principle, simple study designs are preferable. Prospective double-blind studies should usually be reserved for the experienced researcher or fellow with a consistent commitment to the research, because considerable time is needed to coordinate blind study procedures and arrange for one or more blind evaluators. Time and resource limitations make a retrospective study more practical for trainees. We discourage involvement in any study that would not allow the trainee to be cited as an author or co-author.
Step 3: Data Collection
The process of data collection begins after identifying a case, topic, or research question. The next step is to conduct a thorough literature review, which at minimum should include published research and reviews in the last 5 years, and older articles when little is written on a topic or important historical literature exists. Trainees may have a rudimentary idea of how to use MEDLINE (6), but the supervisor will need to assist in a search that includes other electronic databases such as PSYCHLIT (7) and Excerpta Medica (8). Students usually need assistance when they first attempt to explore by text words or author, or to limit and combine search-results sets. The supervisor may accompany the student or resident to the library to demonstrate the search process, or the services are available online. Someone on the research team may have the time and expertise to assist. After copies of the articles are available, a systematic and thorough review of the existing research occurs.
Step 4: Data Analysis
We do not recommend a formal course in statistical analysis. Rather, the mentor should begin thinking with the student about data analysis early in the development of the study. Depending on the study, the mentor should review the essence of common statistical procedures such as "t-tests," repeated analyses of variance, and linear correlations. Computer programs such as SigmaStat and InStat (9,10) are helpful because the programs ask the user a series of questions concerning what he or she needs to accomplish. These programs provide summary descriptions of data, statistically compare groups, predict trends, find correlations, and recommend statistical procedures based on the number of subjects or tests in the data. The Help functions of these programs succinctly and clearly explain the tests and terminology to the trainee. Graphics programs, such as SigmaPlot (11) are relatively easy to use and can translate cherished data into visuals (graphs, figures, tables) for presentation or publication. Entering and processing data provide trainees an excellent hands-on learning experience that is preferable to simply presenting the data to a statistician.
Step 5: Preparing the Manuscript
After developing a hypothesis and a study design and then researching and analyzing data, the actual writing begins. Awareness of journal style is important. We familiarize trainees with the two predominant style approaches, which are thoroughly described in the two APAs' (American Psychiatric Association and American Psychological Association) style manuals (12,13). Most journals follow one of these styles, although some have minor variations. We explain the basic template of a manuscript, starting with an abstract containing a summary of the project's objectives, methods, results, and conclusions. Some trainees find it helpful to receive a computer diskette with the major sections (typically Introduction, Methods, Results, Discussion, Conclusions) already outlined. The last paragraph of the introduction should explain the purpose of the project. Trainees need help with computer word-processing packages, setting up sections of a paper, page formatting, headers, cover page, and figure preparations. Some universities have academic support services that will assist with manuscript preparation.
Among the many books on medical writing, one by Weiss-Lambrou is especially suitable for neophyte authors (14). Most students and residents overuse passive voice. To improve the clarity and readability of their work, we encourage trainees to set a target that 85% of the sentences in their manuscript be in the active voice. The grammar checkers in good word-processing applications help this process. To meet the word-count requirements of the section of the journal chosen for submission, the manuscript may have to be expanded or condensed without substantially changing content. A colleague in the faculty should review a near-final draft of the manuscript.
Step 6: Navigating the Submission and Revision Process
The type of paper influences the choice of journals. For example, many journals do not accept case reports, but some do. Properly matching the journal's purview and manuscript topic enhances the chances of ultimate acceptance of the work. The faculty mentor's familiarity with different journals' publication practices is helpful to beginning authors. We keep a file of instructions to contributors from different psychiatric journals for trainees to peruse. In 1993 the Psychiatric Research Report published an extensive 2-part review of the focus and type of papers sought by a wide variety of psychiatric journals, as well as the name and address of the editor of each journal (15,16). The Jefferson Journal of Psychiatry specifically solicits psychiatric residents' publications.
Young authors are exquisitely sensitive to the criticism inherent in the review process. To prepare trainees for this feedback, we use a "mock review." This is essentially a game in which the attending physician or a colleague anticipates and simulates the critique of a manuscript in a somewhat exaggerated way, hopefully illustrating to the trainee something about the thought that goes into the review process and how reviewers communicate their opinions. Because the mock review is written by a "third person," it is less deflating to the trainee than the mentor directly communicating a project's weaknesses. Trainees can also write their own mock reviews. Trainees prepared by this exercise react to the actual reviews as valuable feedback. Lessons commonly learned from this exercise include writing in a succinct, direct style; clearly stating both the weaknesses and implications of a study; and justifying conclusions.
Developing a revision accompanied by a thorough, nondefensive letter of response further emphasizes the constructive nature of the feedback from journal reviewers. The letter of response should very carefully address each point or concern made by the reviewers. Faculty members' own experience as reviewers of manuscripts for journals is a great asset in facilitating this aspect of the mentoring.
While navigating the submission, review, revision, and rejection/acceptance process, mentors must not allow the trainee to become discouraged. Trainees should know that many good papers are not accepted at the first journal to which they are submitted. Editors often couch revision invitations in guarded, almost negative language for fear of conveying a guarantee of ultimate acceptance. By accurately interpreting these messages for the trainee, experienced faculty can encourage the trainee to persevere with the project at this critical stage.
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RESULTS: EXAMPLES OF MENTORED PROJECTS
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About half of the projects the authors have mentored are initiated on regular 2- to 3-month inpatient rotations and finished over the next year. The other half come from research electives that can be tailored in length from 3 to 9 months. As other interested faculty have become aware of the rewards of this type of effort, the number of resident publications appears to be increasing, from an average of 4 to 5 per year, to 8 papers by 8 different residents or students in 1995. The trainees were generally pleased to see their collaborations described and their papers referenced for this paper. The following examples illustrate the spectrum of projects our trainees attempted and the mentoring style the authors used in teaching the process.
Example 1: Case Reports and Literature Review (17)
Early in an inpatient rotation, a second-year resident informed one of the authors that he was considering an academic career and asked for advice. He enthusiastically accepted a suggestion to develop a publication, but he had no time for a research project. He agreed to screen his admissions for unusual or interesting issues worthy of a case report and literature review. Within a month, he identified two schizophrenia patients with the unusual delusion of having an electronic chip implanted in a tooth. The patients were interesting because of the systematized delusion of being controlled by the chip, in the absence of hallucinations.
With faculty assistance, the resident concurrently conducted an extensive literature search and gathered data on treatment response in the cases. Material gathered in the literature search identified several areas for discussion, including the validity of informed consent in delusional patients and the similarity of the cases to monosymptomatic hypochondriasis.
The resident's early drafts were too long and written almost completely in the passive voice. As the work developed, the resident learned about organizing a manuscript and active-voice writing. To meet word-limit requirements, the faculty mentor demonstrated the art of shortening a manuscript without removing important content. The journal accepted the paper after one revision. The positive experience with this early publication reinforced the resident's academic aspirations. As a third-year resident, he collaborated with another faculty member to win a "Young Investigator Award" from the National Alliance for Research on Schizophrenia and Depression.
A classmate, aware of the above resident's publication, requested a similar collaboration during a regular second-year inpatient rotation, resulting in a review of the efficacy of gun-control legislation and its impact on psychiatric populations. Work on this project continued long after the resident rotated off service. The manuscript is currently in press (18).
Example 2: Mining a Database (19)
A third-year medical student interested in a future psychiatric career voiced concern during ward rounds about extrapyramidal side effects in his patients, which led to a discussion of the general principle of using the lowest effective dose to minimize side effects. A literature review, conducted with faculty assistance, suggested that patients on 4-5 mg of haloperidol equivalents per day suffer less extrapyramidal side effects than those on higher doses. This left the question of the antipsychotic efficacy of doses in that lower range. Instead of studying several hundred patients at various fixed doses, the attending physician suggested using a preexisting database from a haloperidol plasma level-response study. The subjects in the original study received fixed doses (4 mg, 10 mg, and 40 mg), so it was possible to reexamine the data for a drug dose-response relationship.
The data showed that patients receiving 4 mg of haloperidol per day had similar psychosis rating scales to those on 10 mg daily, and better than those on 40 mg per day. With the assistance of the mentor, the student presented the question as "Is there a clinically relevant advantage in favor of doses higher than 4 mg per day of haloperidol?" The student operationalized "clinically relevant advantage" as more than three points on the Brief Psychiatric Rating Scale score, favoring the higher doses. Analyzing the data statistically, there was no significant response difference between the dosage-range groups.
Reviewers at a leading journal had several problems with the study, but they indicated that with changes the paper might be reconsidered. Discouraged, the student wondered if another journal would take his "imperfect product" or if he should abandon the project. The mentor recognized the editor's reply as "journal talk" for a probable acceptance predicated on suggested improvements. The journal accepted the revised manuscript (19), and the student learned about developing and testing hypotheses, using statistics, writing a manuscript, and working with a journal's editor. After medical school graduation, our residency program successfully recruited him; he is currently an intern and plans on a future research fellowship.
Example 3: Old Data, New Paper (20)
A third-year psychiatry resident considering an academic career began a brief (6 weeks) rotation on an inpatient research teaching unit (5). Her interest in lithium as a treatment modality coincided with her mentor's one-time focus on the use of lithium in nonaffective psychosis. There was a clinical impression that schizophrenic-like nonbipolar patients who responded to lithium alone (compared with nonresponders) had fewer "negative" symptoms, such as apathy and withdrawal, and family histories with an unusual absence of both mania and psychosis. The mentor had old stored data concerning negative symptoms, family history, and lithium response in nonaffective psychosis that had never been analyzed.
The resident eagerly set about assembling the data into a computerized database. The study design simply tested the hypotheses inherent in the clinical observations by comparing the lithium responsive group to lithium nonresponders using t-tests for negative symptoms and chi-square comparisons for positive vs. negative family history. The statistical program was of great help, suggesting necessary corrections to the t-test for unequal variance in the negative-symptom group. The program recommended a Fisher's Exact Test rather than a chi-square because of low numbers in some cells. Both analyses yielded statistical significance in the hypothesized direction.
Prior to publication, the resident presented the findings at the annual meeting of the American Psychiatric Association. Following the paper's return for relatively minor revisions, the journal accepted the manuscript for publication. The resident is now a faculty member in our University and practices at an affiliated state hospital.
Example 4: A Formal Study (21)
As part of a 9-month research track, a fourth-year resident was interested in affect recognition in schizophrenic patients. Although this was not the mentor's major research interest, he supported the resident in designing the project and anticipating statistical procedures. The resident learned the use of structured clinical interviews as a diagnostic assessment for the study. He purchased classic pictures of persons demonstrating a variety of emotional responses. A group of normal control subjects served as a comparison group to assess the accuracy of the schizophrenic patients' affect recognition. Schizophrenic patients were available to him on his mentor's research unit.
The resident systematically collected data on consenting patients and age- and gender-matched control subjects. Recognizing that persons with paranoid schizophrenia often overinterpret interpersonal cues, the mentor recommended examining paranoid and nonparanoid subgroups for within-schizophrenia comparisons as well as comparisons with the control subjects. Only the persons with nonparanoid schizophrenia had impaired ability to discriminate affect from photographs.
With the considerable block of time made available by the research elective track, this resident was able to design his own project rather than tapping into an ongoing project or preexisting database. He defended the project through the Human Subjects Committee approval, explained the study and obtained informed consent from patients, recruited control subjects; analyzed the data, and prepared the manuscript.
The resident presented his findings at the annual meeting of the national Psychiatric Research Society prior to submission for publication. The manuscript required few alterations before the journal accepted it for publication. The resident has now graduated and is pursuing an academic research career using functional brain imaging to further study the recognition of affect using standardized photographs.
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DISCUSSION
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Mentors must be willing to invest themselves in their trainees' projects. Our experience has been that just giving trainees an idea and some encouragement is not nearly enough. As our process description implies, faculty must extensively involve themselves in each step of the project. While we have been fortunate to get all of our trainees' papers eventually published somewhere, we are aware that a rejection could discourage a trainee's interest in the field. A worthwhile project, properly mentored, is likely to eventually be published—if not in the first rank of journals, at least in some venue. By extensively involving ourselves in the project, we give trainees the message that we share responsibility for the success or failure of the paper.
A formal, mandatory program for research-publication training may not be either necessary or the best approach. Given the pressures on teaching and research time that currently exist in academia, it makes sense to focus effort on trainees who really desire the experience, although a few who have a hidden interest may be missed. Trainee motivation is not the only issue. Many fine academicians in our university indicated that they simply do not have the time or temperament to enjoy this type of mentoring. In a program mandated across the board, these faculty members could be unhappily paired with unmotivated residents or, perhaps worse, with motivated ones.
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CONCLUSION
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Developing a publication is within the reach of motivated psychiatric students and residents when faculty provide sufficient mentoring. Trainees considering such projects are often interested in psychiatric academic careers, and the trainees should have the advantage of early experience in the area of scholarly writing, research, and publication. For faculty mentors, the effort can result in a publication, lead to future collaborations, and may also assist in recruitment.
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ACKNOWLEDGMENTS
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The authors thank Drs. Donald Robert Fowler, Debbie Miller, and Steven Kingsbury for their helpful comments regarding the manuscript.
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ABSTRACT
INTRODUCTION
