May 7, 1999

BY STEVEN E. HYMAN, M.D.

We have the good fortune of working in psychiatry at a time of unprecedented scientific opportunity. The human genome project and burgeoning genetic technologies will permit us finally to discover genes that produce vulnerability to mental disorders. A panoply of noninvasive imaging technologies has given us the opportunity to see the human brain at work. Basic neuroscience is progressing at an accelerating rate and, indeed, is one of the most exciting frontiers in all of science.

These and other developments make it imperative for us to think creatively about how best to translate findings from basic research into the arena of clinical investigation. With the development of novel treatments and the hoped-for discovery of genes that will permit us to classify mental disorders in a new way, careers in patient-oriented research have become an extremely exciting prospect. Given the state of the science and the urgent public health need to find better ways to treat our patients, it is both ironic and alarming that the clinician-investigator in psychiatry remains an endangered species.

Many hypotheses have been put forward to explain the mismatch between opportunities and investigators. A prime suspect is managed care, which clearly has had a less-than-salutary impact on the choice of a research career. It is considerably more difficult now for psychiatrists, in their early years after residency, to support their salaries by seeing patients while reserving adequate time to learn their chosen research discipline. Diminished opportunities to generate income are put in stark relief by increasing debt burdens carried by medical school graduates that make additional research training years very difficult for the majority of psychiatry's early postresidency graduates.

The requirement for an additional intensive period of training following four years of medical school and four years of residency is, perhaps, the major hurdle-or obstacle-one will encounter in attempting to enter successfully into a scientific career. Some believe that residency requirements in psychiatry, compared with other disciplines, are relatively burdensome and discourage individuals who might want research careers in clinical neuroscience. Compounding this perceived problem, science in fact has grown more and more complex and more and more distant from the skills gleaned in a clinical residency. As real as these obstacles may be, there's no getting around the fact that an independent, effective research career requires substantial professional training beyond residency.

I believe that, as a field, we must ensure that our graduates have the opportunities to train in research. Rather than being viewed as a burden, these training years can and should be among the most exciting and productive in a person's life. If we were to make possible, as we should, a nearly full-time focus on research training, young investigators could essentially immerse themselves in an exciting, intellectual endeavor, and perhaps have time-unprecedented in the prior course of training-for contemplation and the pursuit of knowledge. Should we fail to ensure such opportunities, dangerously few young psychiatrists will undertake research training and, of those who do, many will continue to undertrain.

The absolute minimum protected time required by research trainees is two years, although in almost every instance, we must ensure more time-four or more years. We also must ensure that training occurs in the proper setting, recognizing that this often may not be within the trainee's home psychiatry department. Psychiatrists who would plan to undertake genetics studies should involve themselves with the very best genetics groups regardless of whether the focus of their training experience, at least initially, is on mental disorders. The same is true of trainees who would dedicate their research careers to clinical trials. A career that uses the tools of functional imaging to study mental disorders requires additional training in such areas as neuroanatomy and cognitive neuroscience, as well as immersion in the complex issues of analyzing data that emanate, for example, from an fMRI experiment. The genetics of mental disorders, no less the study of biostatistics and research design issues relevant to clinical trials, are highly complex professional disciplines, requiring intensive study and excellent mentorship. Those who undertrain or fail to gain adequate depth and professionalism will have an increasingly difficult time maintaining funding and productivity in the world of modern science.

During the past two years, NIMH has recommitted itself to the support of early careers. We have a variety of early career awards, including a new series of awards for both trainees in the early period after residency and for midcareer clinical investigators who will serve as mentors. The Mentored Patient-Oriented Research Career Development Award (K23) provides support to young investigators who want to devote substantial parts of their careers to clinical research. This award is complemented by the Mid-Career Investigator Award in Patient-Oriented Research (K24) that will provide support to outstanding clinical scientists within 15 years of specialty training. The grant will underwrite a period of intensive research to enhance needed skills and support an expressed commitment on the part of awardees to mentor others in patient-oriented research.

In addition, the Clinical Research Curriculum Award (K30) is a new institutional grant to foster multidisciplinary didactic training in settings where significant clinical training already is under way. All NIH institutes are chipping in to fund this Heart, Lung, and Blood Institute-administered program. The support is for the institution per se and for clinical research mentors, not for any disease or institute-specific training interests.

There is no question but that research training creates new and serious hurdles at the end of residency when many feel that it is time to capitalize on their long educational investment. Nonetheless, the research tools that we have in our hands as we enter the new millennium confer enormous power to do good and to lead to an extraordinarily gratifying career. Without clinically trained investigators who are absolutely committed to the area of mental illness, all of our patients-and, indeed, the whole field-will suffer.

I urge psychiatrists with an interest in pursuing a research career to contact NIMH at the e-mail address nimh-od@ngmsmtp.nimh.nih.gov.

Dr. Hyman is director of the National Institute of Mental Health.