Research Training in Psychiatry Residency Strategies for Reform (2003) / Chapter Skim
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4 Institutional Factors
4 Institutional Factors
Pages 91-132
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From page 91... ...
The chapter ends with conclusions and recommendations that include a theoretical framework for evaluating institutions that aim to offer research education to psychiatry trainees. FUNDING ISSUES IN GRADUATE MEDICAL EDUCATION The General Funding Stream Graduate medical education (GME)
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in 1999 and that has the strong support of the Association of American Medical Colleges (AAMC, 2001~. TABLE 4-1 Sources of Graduate Medical Education Funding Source Amount (billions of dollars)
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for reimbursement calculation purposes, the reimbursement is based on an institution's Medicare utilization, an index that reduces the reimbursement rate for institutions with a high pediatric caseload. Additionally, in child and adolescent psychiatry, as with all Accreditation Council for Graduate Medical Education (ACGME)
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A further and important consideration is the institutional flow of GME dollars. These funds usually are directed to hospitals rather than to departmental residency programs, and federal legislation dating back to 1986 prevents expanding the numbers of medical residents funded by Medicare (Knapp, 20024.24 Given the variability in institutional and departrnental needs, GME funding for psychiatry training programs may or may not be proportional to the size of those programs.
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residency training programs, including those that train psychiatrists. General Research Funding Layered over the GME funding constraints described above are the general financial challenges imposed by the emergence of managed care.
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Psychiatric research, like other biomedical research, relies on a multidisciplinary team approach (Beresin, 1997; Institute of Medicine [IOM] , 2000; Meador-Woodruff, 2002; Meyer and McLaughlin, 1998; Roberts and Bogenschutz, 2001~.
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Nevertheless, the ideal of research and research training can be at odds with the immediate needs of patients and the financial bottom line of departments. Accordingly, the committee believes a specific business case for research and research training should be aggressively pursued by psychiatry departments and should be formalized as part of a department's financial plan.
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The current reality is that some institutions receive considerable federal binding, whereas the rest receive little or none (Brainard, 20021. Psychiatry is no exception in this regard, as most psychiatric research funding is concentrated in the top 10 to 15 percent of psychiatry departments nationwide (Pincus, 20021.
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Accordingly, these mechanisms may be models for the establishment of research infrastructure at institutions with less resourceintensive departments of psychiatry. The BRIN and COBRE grants are designed to build local biomedical research infrastructure, including personnel recruitment and training efforts, in regions having the greatest need for resource expansion.
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. Several GCRCs across the country have behavioral assessment cores that can assist with psychiatric research efforts (N]
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An alternative way for small programs to tap available clinical research resources is to seek out opportunities for interdepartmental or interinstitutional coliaboration. A recent AAMC task force made the following recommendation: To enhance clinical research programs and iniias~ucture development, medical schools and teaching hospitals
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also advocate a broad collaborative approach: As individual clinical departments become less able to fund their own essential research infrastructure, medical schools will need to develop institution-wide collaborative efforts to assure access to cutting-edge technology relevant to research on clinical disorders. In this regard, research in psychiatry may be linked to other efforts in clinical and basic neuroscience, human genetics, health services research, clinical trials, and treatment and prevention research relative to general and mental health issues.
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Additionally, the literature contains numerous references to the importance of leadership to the research endeavor, psychiatric research, and research training (KaterndahI, 1996; Meyer and McLaughlin, 1998; Pardes and Pincus, 1983; Rosenberg, 1999~. Leaders who value research will likely promote research and research training in the following ways: .
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Although based largely on presentations to the committee by chairs and resident training directors of psychiatry departments, our strong view is that when hospital executives and department chairs view research as a high priority, there is an increased likelihood that research and research training programs including research-focused didactics, biostatistical and data management support, research options for residents, department-sponsored research fellowships, effective mentorship, and funding for travel to attend national research meetings will flourish. Empirical support for the importance of leadership is difficult to obtain, but at least one recent study offers validation of the notion that proactive leadership can promote research activity.
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And a survey of 20 psychiatry residency training directors found that "the one point on which there was general agreement was that the most important way of interesting a resident in
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spoke of the importance of mentors and the scarcity of time for researchers to serve in that role. Martin Drell of Louisiana State University (former president of the American Association of Directors of Psychiatry Residency Training [AADPRT]
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Special efforts must be made to address mentorship in child and adolescent psychiatry programs. Moreover, given the shortage of child and adolescent psychiatrists serving as research mentors, departments should develop mentoring arrangements between child and adolescent trainees and faculty in other divisions and departments.
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It might also ignite research careers among some talented trainees. Despite the widely acknowledged importance of good mentoring, there are strong financial and time obstacles to faculty members' mentoring of residents, fellows, and junior colleagues.
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Second, it describes five illustrative training models, drawing on a combination of the published literature and communications between the committee and program faculty. Third, it presents the views of eight department chairs whose programs the committee believes can be characterized as emerging with regard to their overall research effort and exemplify various strategies and ideas for enhancing research training options in residency training.
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, a part-time masters degrees, or "time out" from residency options. An important mode} descnbed by the AAMC task force is the NIH Clinical Research Curriculum Development Award (or K30 grant)
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found only a single program designed to produce academic physicians, suggesting that most programs are directing their research training efforts to all residents rather than to the training of independent physician-investigators. The authors further note that evaluation procedures are used infrequently: only 12 percent of the publications include some objective measures of pre- and postintervention research skills or accomplishments, and none include long-te~ follow-up.
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(1993) describe a weekly 2-hour research seminar, during which child and adolescent psychiatry residents reviewed case vignette modules that included a list of pertinent research questions.
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These arrangements included a research training option that provided at least 1 half-day of protected research time and 1 hour of supervision per week. The department also established a standing committee of faculty representatives, including the residency training director, to oversee residency-based research activities and to review residents and faculty involved in these research training arrangements.
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Research training exists within psychiatric residency, but intensive research training in the form of research tracks appears to attract fewer than 9 percent of residents (Baron and Singh, 20011. For the successful programs that do exist, only limited data are available on the Tong-term effectiveness of their efforts (i.e., the career research productivity of their trainees)
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These residency program components suggest an implicit research track for at least some residents, although it is notable that Columbia recently (liscontinuecl its formal research track in favor of encouraging all residents to pursue research experiences (persona] communication, R
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. It is also notable that female and minority graduates from these fellowships have been successful in sustaining research careers at rates comparable to those for men and nonminorities (Rieder, 2003)
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According to the vice chair for research at the University of Michigan, James Meador-Woodruff, as of November 2001, 90 percent of all graduates of this research track had moved on to research careers (Meador-Woodruff, 2001~. Additional outcome data have not been obtained.
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Residents may pursue training in the 4-year adult residency program, subspecialty training in the 5-year child and aclolescent psychiatry program, and/or a I-year fellowship in clinical addiction psychiatry (begun in 1999 with funding from the National Institute on Alcohol Abuse and Alcoholism [NIAAAl) or a 2-year fellowship in psychopharmacology (begun in 2000)
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. ~ 2002, six adult and two child and adolescent psychiatry residents participated in the program.
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chairs said that the shortage of child and adolescent psychiatry researchers was especially acute. A majority (six)
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. SPCAP is a professional society composed of directors of child and adolescent psychiatry programs, many of whom have research experience.
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through seminars, Sterner sites, and other outreach methods. As briefly mentioned in Chapter 3, the principle professional society for child psychiatrists, the American Academy of Child and Adolescent Psychiatry (AACAP)
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Nevertheless, these data are presented in Table 4-2 to offer a summary view of research training rates across core residency programs (i.e., not a specialized research track)
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SOURCE: Data were derived from various sources, including correspondence with training directors, website and literature reviews, and eight focused interviews with department chairs. Appendix C offers additional details regarding the programs listed.
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Research is not generally considered part of core residency training. As a result, funding for research activity needs to be justified independently and obtained either from extramural grants or from discretionary internal funds (e.g., endowments, profits from practice plans)
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. Department chairs and other leaders can promote psychiatric research by developing and financing a long-te~m business plan that considers the monetary, marketing, and societal benefits likely to result from mental health research.
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Academic institutions and their psychiatry residency training programs should reward the Involvement of patient-or~ented research faculty in the residency training process. The National Institute of Mental Health should take the lead in identifying funding mechanisms to support such incentives.
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The National Institute of Mental Health, foundations, and other funding agencies should provide resources to support efforts to create competency-based curricula for research literacy and more comprehensive research training in psychiatry that are applicable across the spectrum of adult (general) and child and adolescent residency training programs.
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that can be used to implement the following recommendations Recommendation 4.4. The National Institute of Mental Health should support those departments that are poised to improve their residency-based research training to achieve measurable increases in patientoriented research careers among their trainees.
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Initiate pilot andior short-term research activities for residents. Educate adult and child and adolescent residency training directors and other faculty in how to promote and guide research career planning.
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Models at NIMH already exist in the form of seminars for K awardees (Tuma et al., 19871. Similar "retreats" for residency training directors and/or vice chairs of research could facilitate the flow of information on research training grants and other relevant matters to those most responsible for training residents.
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