International Review of Psychiatry, June 2013; 25(3): 284–290

Stepping stones for psychiatry residents who pursue scientific

research careers

JOYCE CHUNG & MARYLAND PAO

Office of the Clinical Director, Division of Intramural Research Programs, National Institute of Mental Health,
Bethesda, Maryland, USA
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Abstract
Advances in areas of neuroscience are highly relevant to psychiatric disorders but there exists a gap between discoveries in
neuroscience and the practice of clinical psychiatry. Psychiatry is a field in need of high impact research conducted by
physician-scientists who have first-hand experience treating patients with mental illness and who use this clinical knowledge
to improve and discover better or novel interventions. This paper focuses primarily on the training of psychiatry residents
for successful scientific research careers and what residency programmes and others can do to help them succeed. Changes
also need to be made at a regulatory level to enhance the research training and literacy of psychiatry residents. The short-
age of psychiatrists who are well trained in basic and translational research can only be remedied if the path to becoming
an independent investigator is lined with stepping stones that support success, including during the residency years.
Partnerships among funding agencies, professional societies and training institutions can lay the groundwork for our
psychiatric trainees to stay on the path to rewarding scientific research careers.
For personal use only.

Introduction
Psychiatry is a field in need of fruitful and high
impact research conducted by physician-scientists
who have first-hand experience treating patients with
mental illness and who use this clinical knowledge to
improve and discover better or novel interventions
(Bullmore et al., 2009; Fenton et al., 2004). Advances
in areas of science, such as basic neuroscience and
genomics, are highly relevant to psychiatric disorders
but there exists a gap between discoveries in neuro-
science and the practice of clinical psychiatry. Experts
have explained that this gap is due to the fact that
many of these basic scientific discoveries have yet to
be successfully translated to the clinical problems
seen in psychiatry. This translation is emerging and
promising, but has yet to be attained (Roffman et al.,
2006; Rubin & Zorumski, 2012). Others have pointed
out that there is increasing scientific evidence that
the customary approach taken by psychiatrists to
categorize and diagnose disorders as clusters of
observable behaviours and clinical symptoms, i.e.
Diagnostic and Statistical Manual (DSM) method,
does not necessarily align with the underlying
pathophysiology. This mismatch could further
obscure the relationship between scientific findings
and the diagnostic categories commonly used by psy-
chiatrists (Insel et al., 2010; Insel & Wang, 2010;
Morris & Cuthbert, 2012). Because few psychiatry
programmes provide a solid education in clinically
relevant neuroscience for their residents, the literacy
and cultural gap between basic science and clinical
practice will continue to widen if nothing is done to
bridge it (Lehner & Insel, 2010; Rubin & Zorumski,
2012). Physician-scientists who are dually trained in
clinical psychiatry and neuroscience are the logical
connectors between these fields.
Sensing the importance of keeping the fields of
psychiatry and neuroscience connected, Thomas
Insel, Institute Director of the National Institute of
Mental Health (NIMH), has proposed that psychia-
try recast itself as a clinical neuroscience discipline in
order to harness the promise of science to treat the
most devastating mental illnesses (Insel & Quirion,
2005; Martin, 2002). According to Insel, clinical neu-
roscientists would apply ‘the revolutionary insights
from neuroscience to the care of those with brain
disorders’ (Insel & Quirion, 2005, p. 2223). Neuro-
science can be regarded as the basic science of
psychiatry, and aspects of clinical neurology and psy-
chiatry training would be integrated as well, such as
epidemiology, psychological and behavioral theories
and treatments, pharmacology, for example. His vision
builds upon the tremendous growth and interest
in neuroscience fields as demonstrated by active

Correspondence: Joyce Chung MD, Office of the Clinical Director, Division of Intramural Research Programs, National Institute of Mental Health, NIH, 10
Center Drive MSC 1276, Bethesda, MD 20892-1276, USA. Tel: 301–443-8466. Fax: 301-402-2588. E-mail: chungj@mail.nih.gov
ISSN 0954–0261 print/ISSN 1369–1627 online © 2013 Institute of Psychiatry
DOI: 10.3109/09540261.2013.800027

university departments and faculty members,
fascinated students at all levels seeking new oppor-
tunities to learn, and greater public engagement
and advocacy. Insel is interested in developing the
‘next generation’ of clinical neuroscience leaders in
psychiatry who can integrate the numerous exciting
neuroscience findings emerging daily with their
clinical training to address public mental health
needs (Insel & Quirion, 2005; Reynolds et al.,
2009). This goal can only be reached if sufficient
numbers of talented and well-trained psychiatrists
receive the support they need across the span of
their lengthy undergraduate and graduate medical
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education.
Many medical students who enter psychiatry res-
idency programmes express an interest in academic
careers. They aspire to be a ‘triple threat’ physician,
and thus treat patients, teach in their chosen field,
and conduct research to advance knowledge. We
know that psychiatry residency programmes are
required to provide their trainees with the opportu-
nity to learn a wide variety of clinical skills. In addi-
tion, most programmes expect residents to teach
using the traditional ladder model of medical edu-
cation, in which knowledge is passed down the
For personal use only.
rungs to those more junior. But preparing residents
for successful research careers is a different kind of
endeavour, and one that is not formally dictated by
the US accrediting body, the Accreditation Council
for Graduate Medical Education (ACGME). At the
same time, the residency period can be a critical
period for consolidating interest in a scientific
research career because of direct experiences treat-
ing mentally ill patients, formation of sustaining
mentoring relationships, and pivotal career develop-
ment guidance by informed programme directors.
Concurrently, the scientific basis of medical knowl-
edge has continued to expand exponentially which
makes it necessary for physicians who conduct sci-
entific research to become increasingly specialized
and more highly trained. A successful research
career, in any medical subfield, requires a passion
for scientific pursuit that is carried out in a rigorous,
hypothesis-testing manner, as well as perseverance,
mentorship, and perhaps, serendipity. In this paper
we focus primarily on issues that affect the training
of psychiatry residents for successful scientific
careers in basic and translational research and what
residency programmes and others can do to help
them succeed. Thus, while research in epidemiol-
ogy, clinical trials, and services research, among
others, is important to psychiatry, we will not spe-
cifically address training in these areas. In addi-
tion, we will not discuss broader activities in
academic psychiatry, which encompasses pursuits
in general clinical, didactic teaching and training
activities.
Psychiatry residents – scientific research careers 285
A workforce shortage – the need for more
psychiatrist researchers
The challenges of recruitment and retention of
physician-scientists in mental health have been previ-
ously documented (Balon et al., 2011a; Fenton et al.,
2004; Kupfer et al., 2002). These articles describe
the need to (1) identify and recruit mental health
physician-researchers as early as college and medical
school, (2) recruit more diverse trainees to reflect the
diversity of patients with mental health problems, and
(3) develop strategies to mentor these individuals
through particularly vulnerable times such as the end
of fellowship and at initial junior faculty appointment
(Kupfer et al., 2002). The shortage of psychiatrist
researchers mirrors that of physician scientists in
general as reported by an advisory committee to the
National Institutes of Health (NIH) Director (Work-
ing Group of the Advisory Committee to the Director,
2012). This report looked across the entire biomedi-
cal workforce but recognized that the training and
career paths of physician scientists have different ‘eco-
nomic and educational drivers’ (p. 41). Furthermore,
they note a ‘growing decline in the pool of physician
scientists who are sufficiently trained to become aca-
demic, independent, tenure-track scientists address-
ing basic and/or translational questions’ (p. 41).
About 10 years ago, the National Institute of Men-
tal Health asked the Institute of Medicine (IOM) to
study research training during psychiatry residency
because of the anticipated shortage of psychiatrist
researchers. The committee that was convened on
this topic focused on four areas: the goals of research
training, successful training programmes, obstacles
to research training, and strategies to overcome
obstacles. The report highlighted regulatory, institu-
tional and personal factors that affect the training of
psychiatry residents in research and made a set of
recommendations for changes at each of these levels
to remedy the shortage issue (Abrams et al., 2003).
One finding from the IOM report that is relevant
to this current review is that while the residency
period is a time of intense clinical training, it is also
a ‘pivotal interval’ (p. 5) during which an interest in
a research career can be solidified (Abrams et al.,
2003;Yager et al., 2004). The IOM report on research
training during psychiatry residency was published
in 2003, but there have not been changes made to
date at the regulatory level, for example residency
programme standards by the Psychiatry Residency
Review Committee or specialist certification by the
American Board of Psychiatry and Neurology
(ABPN), to enhance the research training and liter-
acy of psychiatry residents.
Of note, during this same ten-year interval, the
ABPN has been phasing out the oral and live patient
portions of the psychiatry specialty examinations
 286 J. Chung & M. Pao
and the ACGME has been developing the Next
Accreditation System (NAS) in which training com-
petencies will be assessed using a set of milestone
modules (Nasca, 2012). In light of these active regu-
latory changes, we suggest that it is a prime time to
forge collaborations and dialogue to find opportuni-
ties to gain traction in the areas of neuroscience and
research training of psychiatry residents.
Stepping stones versus pipelines
The development of physician-scientists has often
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been likened to that of a pipeline, harkening the
image of a linear path whereby an individual com-
mits to an academic career at an early stage and
finally emerges as a finished product at the end of a
long training period. However, the pathways taken to
achieve successful scientific careers in medicine and
psychiatry are not always predictable or straightfor-
ward. One example is the case of students who are
accepted into MD-PhD programmes, particularly
those who are accepted into medical scientist train-
ing programmes (MSTP) at the top US medical
schools (Garrison, 2007). It would seem inevitable
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that these individuals with their track record of high
levels of scholarship and exceptionality would all
pursue research careers. MD-PhD students are obvi-
ously well positioned to succeed, but there are often
significant numbers of years between the time that
they finish their dissertation research (usually com-
pleted between second and third years of medical
school) and when they complete their psychiatry
residency (six years or more) which leads to some
attrition. Then, even if they enter specialized research
track residency programmes, these individuals can
lose ground in the rapidly changing world of science
compared to their PhD-only peers. There appears to
be a trend towards more MD-PhDs choosing psy-
chiatry over the past 10 years but they will need sup-
port to transition successfully to scientific research
careers (Insel, 2012). In the end, most, but not all
MD-PhDs wind up in research careers; the NIH Bio-
medical Workforce report states that approximately
75–80% of MD-PhD graduates continue on to
become independent academic faculty members
(Working Group of the Advisory Committee to the
Director, 2012, p. 41). For some residents who con-
sider a research career, the uncertainty and stress
along with the need to ‘publish or perish’ might
appeal less when compared to the more stable and
predictable life of a practising clinician who receives
more tangible and immediate gratification.
Thus it might serve our purpose better if instead
of a ‘pipeline’, we conceptualize the research training
of psychiatrist-researchers as following a series of
stepping stones. This metaphor provides a more
flexible framework for the variable placement and
size of ‘stones’ that are not necessarily arranged in a
straight line and some of which may be skipped and
still lead to the same destination. Stepping stones, or
moments of support, can be a variety of opportuni-
ties or experiences: concrete experiences doing
research, mentor identification and availability, up-
to-date information about funding that can supple-
ment training, opportunities to attend meetings to
present research, or even validation of research aspi-
rations. Likewise, the recruitment and training of
physician-scientists should provide the necessary
footing needed for residents to proceed according to
their stage of training and available resources
(Walaszek & Rieder, 2011). Indeed, the stepping
stones framework also allows for multiple entry
points for physician-scientists who discover a passion
for research only after exposure to a particular
clinical problem or research mentor during their
residency training years.
Early steps: enhancing research experiences
prior to psychiatry residency
When do most individuals who pursue psychiatric
research careers embark upon this path? A recent
survey of senior residents in psychiatry with high
levels of interest in research compared to their peers
with low or moderate levels of interest found that this
interest began well before residency, as early as high
school. Silberman and colleagues found that resi-
dents who plan a research career were more consis-
tently involved in research at each stage of education
or training and were more likely to have a graduate
degree in addition to their medical degree. The study
findings suggest that if psychiatry departments iden-
tify and offer research opportunities to medical stu-
dents who are inclined towards research, they could
possibly steer more of them into scientific careers in
psychiatry (Silberman et al., 2012). Medical schools
increasingly offer research opportunities and some
now require that medical students complete a schol-
arly project prior to graduation (Boninger et al.,
2010). The scholarly project option allows students
considering psychiatry to become involved in self-
directed learning while conducting scientific research
under the close supervision of faculty mentors.
Other possible steps that can be encouraged
during medical school are research electives that can
be done during the fourth year at home or away insti-
tutions. These are particularly helpful for students
who are enrolled in medical schools that have fewer
research faculty staff or funded research programmes.
For instance, the NIH Clinical Center offers a
clinical electives programme (CEP) for fourth-year
medical students which lets them learn about research

at the world’s largest clinical research centre (www.
cc.nih.gov/training/students/clinical_electives.html).
Some highly motivated students opt to extend their
medical school programmes and take a dedicated
research year such as the funded positions offered by
the National Institutes of Health (NIH) (www.cc.
nih.gov/training/mrsp/index.html) or the Howard
Hughes Medical Institute for qualified students
(www.hhmi.org/grants/individuals/medical-fellows/
year-long/about-program.html). These forays into
biomedical research, in addition to other research
experiences prior to medical school, can further
define a path towards a scientific research career.
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Given that only 4% of seniors at US medical schools
choose psychiatry residency programmes (NRMP,
2012), it is imperative that psychiatry departments
do more to identify early and nurture medical
students who have a track record of interest in
research.
In light of Insel’s proposal that psychiatry be con-
ceptualized as a clinical neuroscience field, one
opportunity to reframe our specialty for medical
students is during their core third-year medical stu-
dent psychiatry rotation (Rosenstock, 2011). With
this in mind, NIMH developed two model web-based
For personal use only.
video modules aimed at medical students and psy-
chiatry residents (Kakar et al., 2011). The first mod-
ule, entitled ‘Translating neural circuits into novel
therapeutics’, explores research on cognitive deficits
in schizophrenia and how translational neuroscience
can provide clues for the development of promising
novel therapeutics (NIMH, 2012a). The second
module, ‘Fear/safety, anxiety and anxiety disorders’,
describes animal models of fear that inform human
studies and help shed light on post-traumatic stress
disorder (PTSD) symptoms that led to successful
research studies for anxiety disorders (NIMH,
2012b). These training modules, which animate the
translational steps that start with basic science find-
ings and move through research paradigms that
eventually lead to targeted interventions, is one
example of ready-made online resources that can be
used by course coordinators of psychiatry courses or
rotations. Another example of neuroscience teaching
resources is an online site curated by the Society for
Neuroscience, the Educational Resources in Neuro-
science, which is available for public access and use
(www.erin.sfn.org).
Maintaining footing: stepping stones during
residency training
Despite an impression that psychiatry residency is
not an ideal time to train residents for research
careers, it is the most critical period for developing
their identity as a psychiatrist and for them to
Psychiatry residents – scientific research careers 287
identify the clinical problems that they are most com-
pelled to research. Mentor relationships that develop
during residency can ignite and sustain a research
career. Furthermore, the ability to step back and
appreciate the need for better psychiatric therapeu-
tics is a needed perspective that can only develop
when deeply engaged in clinical care. There is no
question that the residency period can cement a
commitment to a scientific research career and can
also be a time to attract ‘late bloomer’ research-
oriented residents to this pathway.
During psychiatry residency: developing literacy in
clinical neuroscience
One way to better emphasize the need for basic and
translational research in psychiatry is to teach about
the neuroscience connections to mental illnesses at
a more detailed level during the residency years.
However, using the DSM is not as useful here because
its categorical approach does not align well with
modern research approaches that are more dimen-
sional. The NIMH-initiated Research Domain Cri-
teria (RDoC) project, a new classification system for
mental illnesses, provides an alternative framework
for organizing clinically relevant neurobiological
research findings (NIMH, 2008). While RDoC was
developed for research purposes, it naturally lends
itself to teaching about breakthroughs in genetics,
and molecular, cellular and systems neuroscience
(Morris & Cuthbert, 2012; Chung et al., 2013). The
RDoC approach promotes translation of basic sci-
ence findings to mental illnesses because the focus is
on pathophysiology of mental illness, especially neu-
ral circuitry. Clinical neuroscience is a content area
that is currently not well developed among many psy-
chiatry residency programmes and represents an
opportunity for change (Rubin & Zorumski, 2012).
Importantly, leaders in psychiatry organizations,
such as the American Association of Directors of
Psychiatry Residency Training (AADPRT) have
recently been interested in enhancing the neuropsy-
chiatry and neuroscience rigour of psychiatry resi-
dency programmes, and their studies have found
good support among programme directors for such
efforts (Benjamin et al.,. 2012; Dunstone, 2010;
Roffman et al., 2006). Excellent efforts have been
made to develop neuroscience courses and curricula
for psychiatry residents, notably by junior faculty
members with strong neuroscience backgrounds who
are interested in psychiatric education and training.
We are aware of two recent examples, (1) a four-year
neuroscience curriculum that is closely tied to the
stage of residents’ training and culminates in a com-
prehensive case formulation developed by David
Ross, Associate Program Director at Yale (personal
communication), and (2) an integrative neuroscience
 288 J. Chung & M. Pao
course for postgraduate year (PGY3) residents
taught by Amit Etkin at Stanford that is organized
according to constructs in the NIMH RDoC project
(Etkin, 2011). Evaluation of these courses is ongoing
at this time.
A chance to build science opportunities onto
regulatory changes
The ACGME is in the process of rolling out their
New Accreditation System (NAS) using competency
milestones, and psychiatry is scheduled to adopt the
new system in July 2014 (Nasca, 2012). The draft
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psychiatry milestones were distributed for review and
comment in late 2012 and included two milestones
of relevance to this paper. The first was the inclusion
of a set of clinical neuroscience milestones and
the second was a set of milestones on the critical
evaluation of research and clinical evidence. If
adopted in their current form, the psychiatry
milestones will ensure that residency programmes
provide the neuroscience content and research lit-
eracy standards that are lacking at this time. These
milestones constitute residency stepping stones that
can help foster the more robust teaching of the sci-
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entific foundations of psychiatry and the ability for
residents to better understand the scientific literature
and future breakthroughs.
If the residency programme standards are revised
for psychiatry in the NAS, it will also prompt the
revision of the written examinations used by pro-
grammes to evaluate the cognitive knowledge of their
trainees. For example, the Psychiatry Resident in
Training Examination (PRITE) sponsored by the
American College of Psychiatrists (ACP) is adminis-
tered yearly to psychiatry residents and fellows and
provides national norms for individuals and pro-
grammes to assess performance. The current exam
does not include a section devoted to clinical neurosci-
ence and the questions that relate to clinical neurology
would not substitute for this fund of knowledge. Like-
wise, now that the ABPN psychiatry specialist exami-
nation will only be a single written test (after attestation
of clinical competency by the residency programme
using a live patient standardized clinical skills evalua-
tion), this written examination could be revised to
reflect the new research and science content areas
included in the ACGME psychiatry milestones.
Institutional and psychiatry programme
director support
Psychiatry residency programmes are quite diverse
with regard to the departments and settings within
which they are housed, the type of faculty staff and
residents they attract, and the resources available to
support the research training of their residents. Some
of the ways that psychiatry programmes and institu-
tions have offered pathways to achieve research
success for residents include (1) identifying and
encouraging MD-PhD students to choose psychiatry
residency, (2) offering a research track in their resi-
dency programmes (some funded by NIMH R25
grants) (Back et al., 2011; Gilbert et al., 2006), (3)
applying for training or supplementary grants that
support post-residency research training (T32 or
grant supplements), (4) providing protected time
during PGY-4 to conduct research (including discre-
tionary or private funds to help support resident
research time). It is important to note that residency
programmes are required by the ACGME to ‘pro-
mote an atmosphere of scholarly inquiry, including
the provision of access to ongoing research activity
in psychiatry’ as well as ‘the opportunity for deve-
lopment of research skills for residents interested in
conducting research in psychiatry or related fields’
(ACGME, 2008, p. 24).
One of the most important things a programme
director can do for residents who want to pursue a
scientific research career is to be aware of specific
opportunities such as travel awards to scientific meet-
ings, nominations for research awards, funding
announcements for research activities, special paper
sessions or colloquia at meetings for residents, as well
as other career development activities that can keep
the research fire burning during clinical training
(Balon et al., 2011b). For example, there were two
recent funding announcements by NIMH (http://
grants.nih.gov/grants/guide/noticefiles/NOT-MH-
11-014.html and http://grants.nih.gov/grants/guide/
notice-files/NOT-MH-12-019.html) for administra-
tive supplements to support trainee research experi-
ences: one that provides salary support for MD-PhDs
to gain more protected time for research during the
residency or fellowship period (NOT-MH-11-014)
and another for early career physicians (residents and
fellows) and medical students from diverse back-
grounds (NOT-MH-12–019).
The twice-yearly individual meetings that pro-
gramme directors hold with residents are an ideal
time to specifically ask about research career devel-
opment. Programme directors can help residents
solidify research career interests by helping to find
suitable mentors within the department or outside,
for example, basic or translational labs. A calendar of
research-related opportunities could be developed by
residency programmes to remind training directors
and residents of upcoming deadlines and help them
plan ahead.
Programme directors should also be aware that
for those who are serious about scientific research
careers, post residency research training is necessary,
even for those with a strong science background
(Abrams et al., 2003). Research fellowships give

young psychiatrists the opportunity to immerse
themselves more fully in doing research, although it
is not uncommon for fellows to also continue sig-
nificant clinical duties during fellowships, sometimes
50% time or more. This dilution of research time
commitment can be due to relatively low stipends
provided by fellowship positions compared to resi-
dency salaries at a time when educational loans need
to be repaid. The fellowship period is usually two to
four years immediately after completion of residency;
some residents might be able to start research train-
ing in PGY-4, for example NIMH Clinical Fellow-
ship in the Intramural Research Programs. Because
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the transition from residency or post-residency fel-
lowship training to faculty appointment is seen as a
‘critical time period’ for physician-scientists, an inno-
vative national resource to intervene at this early
stage, the Career Development Institute (CDI)
was developed by the University of Pittsburgh and
Stanford University in conjunction with the Ameri-
can College of Neuropsychopharmacology (Kupfer
et al., 2009; www.cdipsych.org). Outcomes for the
first 77 participants as reported by Kupfer and col-
leagues included an average of 75% time devoted to
research, 27 NIH grants and 22 NARSAD Young
For personal use only.
Investigator Awards. The more programme directors
know and utilize these and other research training
resources, the more likely their trainees will continue
to pursue scientific research careers.
Some residents opt to complete a sub-specialty
post-residency fellowship that might have an aca-
demic component but often does not prioritize
research training; some fellowship programmes will
offer an additional year of research training after
completion of all clinical requirements. Factors at
play are whether the individual wants the additional
ACGME-accredited specialist status, whether salary
or geographic considerations are an issue, and over-
all time spent in training. Because research training
delays the entry of a fellow into the academic job
market, mechanisms such as the NIH Loan Repay-
ment Program (LRP) can repay up to $35,000 of
qualified student loan debt annually for trainees who
conduct biomedical or behavioural research funded
by a non-profit or government institution. This can
help make the lengthened training period for research
more tolerable for residents who leave medical school
with substantial debt.
Conclusions
Given today’s need to integrate evidence-based
medicine with the explosion of data coming from
neuroscience, genetics, systems biology and other
scientific fields, research literacy must be a core com-
petency for all psychiatrists whether they are practi-
tioners, highly-trained scientists or late converters to
Psychiatry residents – scientific research careers 289
research. Strengthening this competency area will
keep the field of psychiatry connected to the science
that underlies mental illnesses and breakthroughs
that will emerge from clinical neuroscience research.
The shortage of psychiatrists who are well trained
in basic and translational research can only be
remedied if the path to becoming an independent
investigator is lined with stepping stones that sup-
port success, including during the residency years.
While psychiatry residency programmes are pri-
marily focused on fulfilling the clinical training
requirements for their trainees, they should also rec-
ognize their role in identifying, encouraging and
supporting residents to transition to scientific
research careers. Thus, at the same time that pro-
grammes help develop a solid clinical foundation
for future psychiatrist researchers, any opportunity
to provide research experiences, mentoring and
funding will likely determine whether a resident
chooses to pursue a research career or not. The field
of psychiatry needs a new generation of clinically
trained researchers with strong scientific skills who
can keep pace with the rapid advances in science.
The institutions that educate, accredit and fund
psychiatry must value research training and revise
their policies accordingly. Partnerships among fund-
ing agencies, professional societies and training
institutions can lay the groundwork for our psychi-
atric trainees to stay on the path to rewarding
scientific research careers.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
The views expressed are those of Dr. Chung and
Dr. Pao and do not reflect the official position or
views of the US Federal Government, National
Institutes of Health, or the National Institute of
Mental Health
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