Research-Track Programs for Residents in Psychiatry: A Review of Literature and a Report of 3 Canadian Experiences

Abstract

Objectives:

Clinician-scientists occupy an interesting position at the interface between science and care, and have a role to play in bridging the 2 valleys between fundamental and clinical research, and between clinical research and clinical practice. However, research training during medical residency for future clinician scientists is an important but challenging process. Our article, written by residents and directors of research-track (RT) programs, aimed at reviewing literature on RT programs for residents, and describing the organization of RT programs at 3 Canadian universities (the University of British Columbia, the University of Toronto, and McGill University).

Methods:

A systematic MEDLINE search was conducted for the review section. Psychiatry program directors in Canada were also contacted to provide information about potential RT programs.

Results:

Twenty articles were related to resident RT programs in medicine, including 6 in psychiatry. Moreover, 5 out of 16 Canadian programs were found to offer a formal RT program, of which 3 are described here. Most reviewed articles described the program organization, while only one provided an outcome assessment with evidence of increased scholarly activity following RT implementation.

Conclusions:

Our article sheds light on postgraduate programs aiming at facilitating the dual training of future clinician-scientists, and developed during the last 10 years. It also highlights the lack of outcome assessment, and the paucity of guidelines to organize these programs in relation to the national requirements.

Medical research includes a vast array of domains, from basic science to clinical research and health services organization, in addition to a vast number of topics and methods. Training students in both medical care and research, the so-called future clinician-scientists, has proved to be challenging. As clinicians, they have to acquire a wide range of skills, from “what to know” to “how to do” and “how to be.” Students interested in research need supplementary training. In addition to the fundamentals of research that all physicians should acquire (for example, the ability to critically read and evaluate scientific papers), clinician-scientists need to develop skills to conduct research, including synthesizing the scientific literature and generating new hypotheses, writing protocols, obtaining ethics approval, collecting data, analyzing results, and disseminating findings through publications and presentations to peers, both to researchers and practitioners, and to the public, media, and patients.¹ Students will also have to learn how to run a laboratory, obtain and manage grants and financial accounts, select and manage students and personnel, improve visibility, and collaborate with other research groups similar to the chief executive officer of a small company. Finally, clinician-scientists must also deal with both the hospital and university to secure an academic position.

This dual training lasts many years (actually, an entire lifetime) and is a full-time effort. Therefore, it is important for all concerned stakeholders (not only clinician-scientists but also universities, hospitals, and funding agencies) to discuss the benefits of partaking in this time- and energy-consuming specialized training. This leads to the seminal question: Do we really need clinician-scientists instead of full-time clinicians plus full-time scientists? We believe the answer to be affirmative.

Clinical Implications

• Clinician-scientists help bridge the gap between fundamental and clinical research, and between clinical research and clinical practice.

• Training in both research and clinical care during residency is challenging.

• RT programs have been created in the United States and Canada to facilitate research during the early stages of training and to avoid gaps in research training.

Limitations

• No robust data exist on how RT programs should be organized and their long-term outcome.

• Our study was limited to literature in English, thus additional reports on RT programs may have been published elsewhere.

Clinician-scientists appear to be important for 3 reasons: their expertise in clinical research, per se, their experience with clinical work, and their position to do research translation. As underlined above, research in general necessitates knowledge both on the topic investigated and the methods used, and keeping up with the fast-growing literature. Conducting quality research on a given domain cannot be improvised and requires specific expertise and time. Clinician-scientists have been specifically trained to conduct clinical research and usually have protected time dedicated to research.

Moreover, clinician-scientists, compared with researchers conducting only clinical research, can investigate research questions raised in their clinical practice and observed during regular encounters with patients and families. The history of psychiatry is filled with many examples of insightful advances coming from clinical practice, such as John Cade and lithium, Donald Klein and the use of antidepressants in panic disorder, Jean Delay and Pierre Deniker and the use of chlorpromazine, or Roland Kuhn and the use of imipramine as an antidepressant.

The clinician-scientist’s contribution to basic science is evidenced by the large proportion of MDs receiving Nobel prizes (101/172) since the award’s inception in 1901.² Clinician-scientists are also important in translating basic research into diagnoses and therapies by bridging the gap between laboratory science and the clinic.^3,4 Recently, the CIHR, the main medical research funding agency in Canada, has acknowledged a problem in the research-to-practice continuum.⁵ Notably they have defined 2 valleys between basic biomedical research and clinical research, and between clinical research and clinical practice.⁵ Importantly, patient-oriented research has become a priority, as witnessed through funding opportunities in Canada^5,6 and the National Center for Advancing Translational Sciences initiative by the NIH in the United States.⁷ There is also a renewed focus on training researchers to be able to do knowledge translation activities. More specifically, psychiatry as a discipline currently faces an accumulating number of discoveries and findings, both in biomedical (for example, neuroimaging, genetics, and neurophysiology) and in psychological and psychosocial fields, but limited clinical applicability. Clinician-scientists can help in expanding these areas and orienting them toward their preventative and therapeutic use.

While there are benefits to train clinician-scientists and while there are numerous examples of effective clinician-scientists, statistics also show that they face numerous challenges. In the United States, the number of physicians has increased during the past years, while the number of clinician-scientists during the same time span has stagnated or decreased.^8,9 Moreover, the number of MD-PhD first-NIH grantees, when compared with that of PhD first-NIH grantees, has decreased during the past several decades.¹⁰ Less than 25% of NIH research grants are awarded to MDs or MD-PhDs in comparison with more than 40% in the 1960s,¹¹ and only one-fifth of first applicants to NIH grants are MDs.¹⁰ Canadian statistics show similar findings. From 1985 to 2001, a decreasing proportion of behavioural sciences grant applications were submitted to CIHR by MD applicants, compared with PhD applicants, and consequently fewer MD grants were funded.¹² Of note, clinician-scientists may be shifting from biomedical research to other areas of health research, such as health services or population-based studies.¹³ These tendencies are likely related to the difficulties in becoming and remaining a clinician-scientist.¹⁴ It is important to highlight that the lack of clinician-scientists is not specific to psychiatry. Specialties, such as hematology and dermatology, struggle with the same recruitment issues.^15,16

These data necessitate identifying obstacles in the clinician-scientist’s career path and intervening appropriately, beginning at the level of the trainee.¹ A first obstacle is that research training during medical school and residency training is suboptimal.¹⁷ For example, one must not forget that clinician-scientists eventually have to compete scientifically against PhD grant applicants, who are more intensely trained in grantsmanship.¹⁷ The large salary drop in being a clinician-scientist, high levels of debt, the long time horizon, absence of mentoring and institutional salary support, and lifestyle issues pertaining to having time for family and other activities additionally corrode the appeal of the clinician-scientist’s career.¹⁸ Time constraint is frequently mentioned as a challenge to holding a dual career as a clinician-scientist. In fact, many clinician-scientists are faced with the difficult task of ensuring adequate patient care while being academically productive.¹⁹ In addition, the beginning of an academic career as a clinician-scientist usually occurs at an age when one would consider starting a family. It is important to highlight that this may partly contribute to the lower rate of female clinician-scientists.²⁰ The prospect of lower income and the limited availability of academic positions can additionally be problematic and may discourage some people from pursuing a career as a clinician-scientist.¹ Importantly, junior faculty may have accumulated financial debts over the course of their studies.¹ While clinical work is more lucrative than research, more clinical duties translate into limited time for research.

To address these issues and the need to avoid a gap in research training during residency for those with a clinician-scientist career prospect, several universities have started programs combining clinical and research training. RT programs have been introduced at different stages of medical training, beginning in medical school and the combined MD–PhD programs in some universities. During residency, RT programs could be defined as programs for residents, integrated into or in parallel to the residency programs, with the aim to train and support some residents to conduct good quality research. Specific objectives usually include gaining a research mentor, acquiring research experience, executing a research protocol, publishing papers, presenting findings at conferences, obtaining a graduate degree (for example, Master of Science or PhD), and preparing the candidate for a career in academia.

While physicians have incentives to abandon research career pursuits as discussed above, evidence indicates that this often happens because of insufficient institutional support, a perceived lack of available mentors and role models, and discouragement.²¹ It has been suggested that the ingredients of academic success as a clinician-scientist has less to do with one’s academic abilities, but more critically determined by good mentoring, having priority lists, and good time management.²² Of note, medical students have shown increasing interest in research since 1997.⁸ The development of clinician-scientist programs is a potential way to foster the maturation of nascent research physicians while providing a fertile training milieu. In the United States, several programs have RTs, often supported by NIH grants.²³ Cleveland Clinic, for instance, has established an innovative approach to training clinician-scientists by selecting appropriate students and then introducing them to an RT program during medical school even prior to residency. Investments in early research career training and support programs in the United States led to greater success at obtaining initial grant funding and at a younger age than usual.²⁴ Medical student training programs have seen a record number of applicants in the United States,²⁵ and this has led to the formation of a trainee section in clinical investigative medicine.²⁶

In our article, we first aimed to review literature on RT programs for residents with a particular focus on psychiatry, and present 3 experiences in Canada. We were particularly interested in investigating the organization of these programs. We then aimed to understand the impact of these RT programs on residents in psychiatry.

Methods

Data Sources and Search Strategy

A systematic review of studies published until November 31, 2013, was conducted using PubMed. The search was done by 2 authors working independently. The initial search strategy, followed by the inclusion and exclusion criteria, were agreed on before starting the search process. The initial search was kept broad and included the following order of MESH terms: internship and residency or psychiatry/education and research or translational medical research. The retained articles were then reviewed together, and the final list of articles retained for synthesis and analysis. Article references were also checked.

Study Selection

Studies that met the following 3 inclusion criteria were included in this review: published in an English-language, peer-reviewed journal; the main topic was about research training during residency; and in medicine and more specifically in psychiatry.

In addition to the review process, program directors from the 16 postgraduate psychiatry programs offered in Canada were contacted by email to provide details regarding integration of research in the residency program.

Results

The initial search yielded 5400 articles. The titles and abstracts were then reviewed for research and residency, which yielded 216 articles. Among the 216 articles, there were 107 dealing specifically with medicine, 20 with psychiatry, and only 6 specifically on RT in psychiatry.^27–32 There appear to be more RT programs during psychiatry residency in the United States (supported by funding from private or government sources), but the program details have not been published.

Regarding our poll in Canada, responses were received from 12 programs, 5 of which (the 3 described below and the universities of Ottawa and Montreal) could be considered to have a formal RT program. Of note, all acknowledged that they aim at supporting research training for motivated residents, and many programs offer integrated research training based on the Royal College Clinician Investigator Program.

Organization

The 6 specific articles on RT in psychiatry describe objectives and organization of specific programs including 5 programs in psychiatry at Columbia University,³² University of Pittsburgh,²⁸ University of South Carolina,²⁹ Beth Israel Medical Center Program,³¹ Veteran Affairs,³⁰ and an additional program in child and adolescent psychiatry at Children’s Hospital Boston.²⁷ Table 1 summarizes details about the organization of 3 RT programs at U of T, UBC, and McGill University. Below, we will summarize specific aspects of organization provided by these programs.

Table 1.

Summary of organization of RT programs at 3 Canadian universities

Characteristic	University of Toronto	University of Bristish Columbia (UBC)	McGill University
Date of creation	2001	2008	2011
Specificity	2-stage program: CSS from PGY1 to PGY4 CSP in PGY5 and 1-year fellowship (application required)	Dedicated resident positions and a separate match within the CaRMS Two positions per year since 2010	Long-standing graduate program in the department of psychiatry Connection with the graduate program in psychiatry
Selection criteria and process	Students with an interest in pursuing a career in research are invited to apply prior to matriculation in their PGY1 year, or any year thereafter Files are removed by the RT program director	Students with previous experience in research and a clear interest in pursuing an academic career Selection during CaRMS by an RT steering committee consisting of the RT program director, a panel of clinician scientists, and a current RT resident	Students with clear interest in research and in pursuing an academic career Some students are met during CaRMS by a research committee Written application after CaRMS results and selection by RT director
Start of the program	PGY1 and PGY2	PGY1	PGY1 and PGY2
Protected time for research:
PGY1	2 months	Up to 12 weeks	2 months
PGY2	One-half day per week	Up to 1 day per week for 9 months, up to 3 days per week for 3 months	One-half day per week
PGY3	One-half day per week	Similar to PGY2	One-half day per week
PGY4	One-half day per week	Similar to PGY2	One-half day per week
PGY5	Full time	Up to 4 days per week	Full time if needed Possible to take it earlier during PGY if needed by research
Seminars	Monthly for CSS and CSP residents	6 hours of lectures during PGY1 and PGY2 years in statistics and research methodology	Monthly during PGY1
Graduation	MSc or PhD expected during CSP	Possibility to complete a master’s degree within the 5-year program. A PhD degree program can be started during the residency and completed during PGY6 and PGY7 funded by a competitive grant from UBC and the CIP.	Encouraged to complete a master’s degree within the 5-year residency Organization of ad hoc PhD in discussion
Follow-up	Supervisor progress report and resident progress report, biannually	Monitored by the RT program director, PGE director, and the RT steering committee Written objectives, expectations, and milestones	Monitored by the RT program director and PGE director Two meetings per year
Diverse	Reimbursement for travel expenses for presentations at scientific meetings	Website44 Several networking events Resident research forum for brief resident presentations on their research projects Events are planned and organized by research-engaged residents, as is BrainTalks, a monthly lecture series on cutting edge clinical neuroscience topics	Annual psychiatry research day Application to various department awards Pilot grant in discussion
Total number of residents in program in 2013/2014	26	8	10

CaRMS = Canadian Resident Matching Service; CIP = Clinician Investigator Program; CSP = Clinician Scientist Program; CSS = Clinician Scientist Stream; MSc = Master of Science; PGE = postgraduate education; PGY = postgraduate year; RT = research-track

Selection Criteria and Process

In the United States, most programs offered a specific number of RT positions based on a competitive entry process, the details of which were not made explicit. However, one training program keeps the scholarly track open to all residents.³¹ In Canada, 1 program (UBC) selected residents prior to beginning the first residency year by having dedicated RT positions through the CaRMS, and the other 2 programs remained flexible for entry into RT residents. Programs appear to have paid attention to personal factors (for example, motivation), previous research experience, and productivity in selecting residents for the RT program, and a similar approach was noted in Canada.

Start of the Program

In the United States, the RT programs commenced during residency years 1 and 2. In Canada, 1 program (at UBC) started during residency year 1, and residency year 2 programs started during residency years 1 or 2.

Mentorship

In the United States, all programs placed special emphasis on early and systematic mentoring. Programs attempted to reduce institutional barriers to effective mentoring, attempted to expose residents to research leaders and mentors during residency, and also created RT chief residents. In Canada, similar approaches are seen with the establishment of RT training directors and designated RT resident representatives at the 3 programs. Further, the residents and mentors are proactively matched, and progress is reviewed by the mentor, RT director, and program director.

Protected Time

In the United States, general psychiatry training programs are 4 years in length, and the protected time gradually increased during successive years. For example, in the Columbia University (New York) RT program, residents have protected time during residency years 1 and 2 to attend courses, 40% protected time during residency year 3 for research, and up to 80% protected time during residency year 4.³² In Canada, general psychiatry training programs are 5 years in length. In Canada, all programs had 2 to 3 months of protected time during residency year 1, one-half to 1 day a week during residency years 2 to 4, and the possibility of full-time research during residency year 5.

Courses and Seminars

In the United States, most programs created a seminar series for RT residents, and the frequency varied with the program. Most programs also made courses on biostatistics and evidence-based medicine available. In Canada, similar steps have been taken with the creation of a seminar series and access to relevant available courses at the respective universities.

Graduation

In the United States, there is no stated requirement to complete a graduate degree during the RT program. However, in Canada, enrolment in a graduate training program is encouraged for RT residents unless they have graduate degrees prior to starting the program.

Follow-up

In the United States, specific yearly expectations and benchmarks are assigned to RT residents, and progress reviewed by the RT director and program director. In Canada, similar measures are in place, and progress reviewed through progress reports and periodic meetings with the RT director and program director.

In the United States, some programs received government and private funding to provide access to specialized training, research funds, and pilot grants. Some programs had continued access to research training for a few years following completion of residency and loan repayment programs. In Canada, programs made travel funds available and attempted to align the RT programs with the Royal College Clinician Investigator Programs.

Assessment

Among these 8 programs, only one²⁷ reported an assessment of impact of the RT program. Following RT implementation, the proportion of residents with a previous scholarly experience and continuing research increased from 30% to 36% in the general residency program and from 12.5% to 66.7% in the child and adolescent psychiatry program. This effect was also found in residents from the child and adolescent program in terms of new scholarly activity (0% to 25%) but not in residents from the general program (70% to 64%). Two programs^28,33 reported numerous residents becoming post-doctoral students and obtaining grants based on retrospective surveys without any formal comparison before implementation of the program or with a comparison group outside the RT program.

Discussion

To our knowledge, this is the first article reviewing the literature on RT programs for residents in psychiatry. We also added the description of 3 programs currently conducted in Canada. This is timely as emphasized by the Institute of Medicine, which, in 2003, identified a critical shortage of clinician-scientists and underscored the need for competency-based curricula that foster research training during psychiatry residency as a way to address that shortage.^1,34 In the same year, a systematic literature review³⁵ of 41 publications focusing on residency-based research across different specialties showed that only a single program was 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 clinician-scientists. Since then, several RT programs have been implemented and described in publications. Our review revealed 2 main findings in terms of organization and assessment.

First, although the objectives were rather similar across programs and countries, each program brought slightly different responses, emphasizing one aspect or another. One important issue is to know whether RT programs should be restricted to a small number of residents in an elitist fashion, with the risk of generating 2 types of residents within a PGY program, or open to all residents at any point in their training, with the difficulty of organizing training programs. An additional consideration is whether residents should be selected very early (as soon as the end of medical school) and if it should remain open to residents who develop an interest in research later during residency. In a study³⁶ looking at factors that influenced motivation among graduating residents to become researchers, the high-interest group appeared to have more graduate degrees, interest and involvement in research starting before residency, and appeared to have decided to pursue a research career at the time of starting residency. Based on our own experience, we believe that programs should still be open to some residents with late interest in research. Interestingly, having a mandatory research year in general surgery was found to lead to less satisfaction among residents, probably as it included residents with little interest in pursuing research careers.³⁷ Mandating research during residency was seen favourably by most training directors in oral and maxillofacial surgery, but the opposite result was noted on resident surveys.³⁸

RT programs additionally face challenges owing to the variability of each resident’s research background, for example, previous research experience and graduation. The issue here is to know whether the selection criteria should be more restrictive (for instance, only medical students with a research experience) or more open and, consequently, whether to integrate research courses during curriculum to improve basic research training. Some programs may also be interested in addressing the issue of underrepresentation of women, ethnic minorities, and international medical graduates in research, as underlined by the 2003 Institute of Medicine report,¹ by means such as offering specific positions or dedicated funding.

Combining medical program and research is often challenging. For instance, in Canada, many residents feel that the Royal College requirements leave little space for research. Discussion at the national level should be conducted to help find solutions. A related concern is that research during residency could impact attainment of clinical competence.³⁹ This may not be true. In internal medicine, participation in an RT program did not have a significant impact on internal medicine certification status. Moreover, two-thirds continued to work in academic medicine, and one-third spent a substantial amount of their time in medical research 10 years after completing the RT program.⁴⁰ Importantly, involvement in research activity enabled them to have competitive fellowships.⁴¹

Mentorship is, unequivocally, a significant ingredient of success in research.¹ Programs have proposed different ways of selecting mentors (from a reduced list of names to an open system) and organizing mentorship (from free organization to frequent meetings and clear milestones). Another related question is organization of follow-up by the program. Some articles have tried to define and examine the requisite competencies for mentors of clinical and translational researchers. This process has included aspects such as aligning expectations,⁴² availability and accessibility, psychosocial support, career professional, and research development.⁴³

Apart from organization, the second main finding of our review is that the impact of these RT programs has not been formally assessed, with the exception of one program.²⁷ Another 2 programs did a retrospective review^28,33 and more investigations are clearly needed. Indeed, very motivated residents may not need any organized program to become efficient clinician-scientists.³⁶ Therefore, assessment of programs should not only include a pre- and post comparison but also, within the same period, compare the characteristics of successful residents within the RT programs and without. Another issue relates to the outcome variables in the short-and long-term (for example, number of publications, quality of publications, academic position, and grant success). Robust demonstration of the efficacy of these programs may lead to more widespread implementation of this RT model, with a potentially significant impact on research at the national level.

Conclusion

Clinician-scientists are drawn to research by the nature of challenges involved in discovery, their curiosity, intellectual gratification during the process, and potential impact on their patients. They are part of both the research and the medical communities, and, as such, have a role to play on both sides through their dual perspective. However, their training faces numerous challenges.

The RT programs represent a potentially interesting opportunity to facilitate training of future clinician-scientists in psychiatry and address some of the issues raised. However, our review shows that we lack robust data about how these programs should be organized and their real efficacy. Nonetheless, preliminary data suggest they could improve success in research. At a national level, one unresolved issue will be to know how many researchers are needed and if adjusting the number of trained clinician-scientists and needed residents is justified and realistic. This has proved to be a challenging issue in medicine in many countries. More research is definitely needed to improve research training.

Abbreviations

CaRMS

Canadian Resident Matching Service

CIHR

Canadian Institutes of Health Research

MD

Doctor of Medicine

NIH

National Institute of Health

PGY

postgraduate year

PhD

Doctor of Philosophy

RT

research-track

UBC

University of British Columbia

U of T

University of Toronto