Research as part of the career of a psychiatrist entering clinical practice

Summary

This article reviews the literature on research as part of the career of a psychiatrist. Many of the reviewed articles emphasised an interest among psychiatry trainees for conducting psychiatric research. A number of reviewed articles discussed the aspects of research training experiences that lead to a career with a major research emphasis. A few articles described the percentage of time dedicated to research by academic psychiatrists. for those trainees completing their training and who plan to pursue a career as a clinician, there are still ways to incorporate research into clinical practice and continue to maintain some of the research skills that were learned as a psychiatry trainee.

Psychiatry is a rich and interesting discipline that offers individuals many areas in which one can specialise. Also, even within a particular subspecialty, there are often different ways that one can offer treatment. A recent survey of 72 consultant psychiatrists in London in the UK asked about the reasons for their career choice of specialising in psychiatry. The top four reasons for choosing psychiatry were: their empathy for individuals with a mental disorder (36.1%); the interface of psychiatry with neuroscience (25.0%); the better working conditions in psychiatry than in other medical specialties (20.8%); and that the psychiatric teaching received as a medical student influenced them to choose psychiatry (19.4%). ¹

As with any discipline, tradition is important. However, assessment and treatment should be guided by some type of research evidence rather than exclusively on tradition or anecdotal evidence. Research and appropriate research training is very necessary to help determine this evidence. Over 25 years ago in 1982, the National Academy of Sciences in the USA found that 34% of medical faculty members from a number of medical specialties had at least 1 year of postdoctoral research training, whereas only 12% of psychiatry faculty members had at least 1 year of postdoctoral research training. ² It was suggested by the authors quoting that report that there may be a greater focus on clinical services in psychiatry fellowships as compared with other medical disciplines. They also wrote that a focus on pressure for clinical services exists in many academic psychiatry departments in both the USA and UK and research becomes neglected. ² Over 20 years later, in 2003, a report by the Institute of Medicine in the USA concluded that there does not appear to be a sufficient number of psychiatry researchers. ³

This paper has two goals. First, the limited literature on research as part of a career as a psychiatrist is reviewed. Second, the paper concludes with some suggestions for the psychiatry trainee and trainer to assist trainees in incorporating research into a career predominately focused on clinical work.

Literature review

There appears to be limited content in the peer-reviewed literature about research as part of the career of a psychiatrist. This brief literature review is based upon searching PubMed and PsycINFO from the years of 1986 to 2007 on 1 January 2008 with three separate searches using the search terms of ‘psychiatry AND career’, ‘psychiatry AND career AND research’, and ‘psychiatry AND career AND academic’. Also, all references in the articles used were reviewed for additional relevant references. Articles focusing only on psychiatry subspecialties (e.g. child psychiatry) were not reviewed. The more specific terms of ‘psychiatry AND research’ were not used as this results in an overwhelming number of abstracts. For example, a search of PubMed for articles published from January 1986 to December 2007 retrieved 79 013 abstracts. A search of the first 100 abstracts retrieved with this unused search approach did not retrieve any relevant abstracts.

Medical student

In one study of 11 048 graduating medical students in the USA in 1985, there was a greater percentage for those pursuing psychiatry than those pursuing other medical specialties to plan to be involved in research during their career. ⁴ This included plans to be ‘significantly involved’ of 17.3% v. 13.9% and for ‘somewhat involved’ of 45.3% v. 37.9%. Also, with regard to career plans there was a similar greater interest of 34.6% for those pursuing psychiatry than other medical specialties of 27.8% for a first preference of career plans including an academic faculty appointment with a combination of research, teaching and basic sciences. However, there was an overall lower percentage for those pursuing psychiatry than other medical specialties for plans to do a postgraduate research fellowship (15.4% v. 20.7%). This lower percentage was even lower among those with a first choice of a career in research or academia (29.9% v. 51.8%).

Haviland et al ⁴ also conducted a number of analyses to understand what variables were associated with the above topics among those pursuing psychiatry (n = 532). With regard to a career in research or academia, the variables of research investigator while in medical school and also attendance at a medical school with a designated psychiatric research centre were both associated with that goal. With regard to exclusive or significant planned research involvement, the variables of author or co-author of an article while in medical school, less adequate research training while in medical school, and research investigator while in medical school were all associated with that goal. With regard to plans to pursue a research fellowship, authorship of a research paper while in medical school, research investigator while in medical school and attendance at a medical school with a research orientation were all associated with that goal. ⁴ In a different study of 484 graduating medical students in the USA in 1986 who planned to pursue psychiatry as a career, having authored or co-authored a research paper while in medical school was the strongest predictor of planning to pursue an academic or research career v. clinical practice. ⁵ Also, attending a private medical school, being an investigator in a research project while in medical school, having received a non-federal scholarship (whether medical or pre-medical), and attending a medical school with research intensity were also associated with planning to pursue an academic or research career.

Psychiatry resident/trainee

In a study following up nine psychiatry trainees doing a 6-month research experience in the UK, all those who participated continued to do research. ⁶ More than half (n = 5) had full-time academic or research positions. The main criticism that they had about the research training experience was the lack of structure. ⁶ In another study of 20 individuals completing a research rotation as part of their psychiatry training, almost all (90%) were currently actively involved in some aspect of research. ⁷ Some reported that this experience helped them decide to pursue an academic career although others reported that this experience helped them decide that they did not want to to pursue an academic career.

One limitation of the above two studies is the non-specified range of years of follow-up with the possibly of some individuals only having a few months of follow-up. This very short range of follow-up could possibly suggest that over a long period of time some individuals may have had their enthusiasm for research diminish. In a third study conducted in 1987 in the UK of those completing psychiatry training between 1965 and 1975 (n = 161), participation in research during training predicted an academic career. ⁸ However, research experience before starting psychiatry training and having published scientific publications before starting psychiatry training did not predict an academic career.

Three studies report the attitudes of psychiatry trainees towards research training. One study in the UK of 69 psychiatry trainees reported that only 9% were strongly encouraged by their supervisors to participate in research projects. ⁹ Also, 35% did not receive any encouragement by their supervisors to participate in research projects. Of trainees in very busy posts, 56% reported that their supervisors ignored or discouraged research participation. Also, 30% were able to take a half day each week to engage in research, although 44% never had free time for research. ⁹

Another study in the UK of 66 psychiatry trainees indicated that approximately 90% from the three different subgroups expressed interest in doing research. ¹⁰ With regard to actually doing research, 86% of the post-membership trainees were doing research whereas only 20% of the pre-membership trainees were doing research. ¹⁰

In a study of 60 psychiatry trainees and 24 consultants in the UK, approximately half indicated that the best time for research was after Part 1 of the MRCPsych examination. ¹¹ When asked about the problems relating to carrying out research, the main reasons were: lack of time; difficulty choosing a project that would not conflict with the demands of clinical work; not having a designated advisor for research; and obtaining a large enough sample. The consultants had similar responses with the additional reason that there was a lack of interest among trainees for research. ¹¹

Besides the studies above with responses from trainees or trainees and supervisors, one study surveyed 20 residency programme directors in the USA. ¹² This study found that the most important way to encourage a psychiatry resident to participate in research was to provide a research mentor. It also found that the only factor for psychiatric research not being viewed as a necessity was when there was a large amount of clinical work. The author of this study emphasised that a research mentor is not someone who just provides ‘research direction’. This mentor should be generous about authorship, assist with local and conference presentations, and help the resident interact with members of the research community.

Lastly, one study describes a research track approach for psychiatry residency training at a programme in the USA. ³ This programme has protected time to attend trainee meetings on research literacy, biostatistics, grant writing and manuscript writing. All residents in this track are encouraged to have at least one first-authored peer-reviewed paper by the completion of the fourth year of training. The authors also emphasised that one benefit of a research mentor is to identify which research idea has a probability of success. The authors reported that even with all this time devoted towards research training, the scores on the Psychiatry Residency In-Training Examination (PRITE) did not significantly differ between those who were in this research track and those who were not.

Psychiatry fellow/postdoctoral

A survey of 3107 psychiatry faculty members in the USA in 1989 found that for those with an MD degree, 39.7% had postdoctoral research training of 12-23 months, 21.9% had from 24 to 35 months, and 18% had greater or equal to 36 months. ¹³ Although 20.4% had less than 12 months of training, it is not clear why lack of training is grouped together with those who may have had training of less than 1 year duration. The main reason for doing postdoctoral training was having an outstanding professor or mentor. Also, among all the faculty (whether MD, MD/PhD, or PhD), the three most important aspects of postdoctoral research training were time with a mentor (94.8%), maths and statistical coursework (83.3%) and length of training period (81.9%).

Another paper comments on post-residency research, although it does not provide the results of an empirical study. ¹⁴ The author mentions that some worry that if they prepare for a scientific career, they will not be able to find a job. The author believes that this is not a reasonable worry. The author, based upon personal experience, writes that fellows will often have self-doubt as they realise that they initially have limited research skills. Fellows will often realise that clinical work can have more immediate gratification than research, which often does not. If a fellow is ‘turned on’ to a research project, the period of self-doubt diminishes. The author recommends that it is good practice to introduce general research design but only gently introduce statistics, as individuals can become discouraged by looking at and analysing a lot of numbers.

Psychiatry faculty/attending ^‡ /consultant

Two surveys estimate the percentage of time devoted to research among full-time MD faculty members in psychiatry departments. ^15,16 A ‘researcher’ was defined as someone who spends at least 20% of their professional time in research activity, authored or co-authored an original research article within the past 2 years and has either assigned research space other than office space or external research funding. A ‘limited researcher’ was defined as one who does some research but did not meet at least one of the researcher criteria. In a USA survey conducted in 1989, 33% had no research involvement, 41.2% limited research and 25.8% were researchers. ¹⁶ In a Canadian survey conducted in 1993-1994, 42% had no research involvement, 41% limited research and 16% were researchers. ¹⁵ For both the USA and Canadian studies, separate data were also included for those with MD/PhD degrees.

Recommendations for encouraging research as part of a clinical career

Trainee recommendations

It is quite well understood that many who practice psychiatry intend to be clinicians and not researchers. The articles reviewed earlier emphasise that participating in research when a medical student ^4,5 or psychiatry trainee ^6–8 can influence that individual to pursue a research career. This does not mean that someone who intends to be a clinician should completely ignore research. An understanding of research can allow one to be an educated consumer of research results, ¹⁷ train oneself to think critically and apply this to clinical situations, and even allow a better understanding of patients. As a trainee it is well worth considering dedicating part of the time and/or making time in one's schedule to participate in a research project. This research time is not likely to adversely impact on scores in psychiatry competency examinations such as in-service exams. ³ It will allow instead the individual to decide if research is of interest and importance, and to help influence the individual to consider incorporating some type of part-time research as part of a career as a clinical psychiatrist.

For those trainees completing their training and who definitely plan to pursue a career as a clinician, there are still ways to incorporate research into clinical practice and continue to maintain some of the research skills that were learned when a psychiatry trainee. A grant is not necessarily needed to conduct research. There are many topics that can be done without any funding. Similarly, it isn't always necessary to spend a lot of time each week devoted to research. It is possible to decide how much time to spend, even if it is a small amount of time, collecting data for a research project. Some may decide that personally conducting one's own research is too much of a time commitment. It then may be worth considering asking colleagues or those working at a local hospital or university if they need access to certain types of patients for their research that are treated in one's practice. Consideration needs to be given to the level of involvement. This can range from more labour-intensive work such as conducting interviews or screenings to the less intensive work of administering surveys in the waiting room or even just asking the patient if a particular research project can contact the patient. This approach can help contribute to the scientific evidence in the psychiatry literature, can provide satisfaction seeing an article written about one's research being published, or being a co-presenter at a conference or co-author for a published article, and also by thinking like a researcher one's clinical skills become sharper by evaluating topics in detail with an analytical research approach.

Trainer recommendations

The faculty members of a training programme will have quite varied opinions about research. For those who value research, this belief should be communicated to trainees in an encouraging manner, as trainees often report that they receive little encouragement or even active discouragement from their training faculty regarding psychiatry research. ⁹ For those who are neutral or even dislike conducting research, they should consider that a training programme should offer trainees experiences from all aspects of psychiatry, including a basic component about experiencing how psychiatry research is conducted. It is important to recognise that not all trainers will be able to provide this research experience for trainees. For a trainee to receive a positive experience of research, a research mentor is essential. ^11–13 Trainers should actively encourage trainees to participate in a research project and provide the appropriate support necessary for this to be done properly. This should include allowing some dedicated time for this research, ^9,11 providing appropriate research mentors, ^12,13 and ensuring that there is a biostatistician available to analyse the research data.

Conclusion

Psychiatrists have varying experiences of research as part of their career. The key aspects for a successful experience with research have been reviewed. Recommendations for trainees and trainers have been provided. This approach can provide the tools and experiences for a psychiatrist entering clinical practice to incorporate research into clinical practice.

Declaration of interest

None.