How to Succeed in Psychiatry E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 593

Veröffentlichungsjahr: 2012

Beschreibung

Aimed at recently qualified psychiatrists or those looking to qualify soon, How to Succeed in Psychiatry is not a source of clinical information but a survival guide to help you through the first years practising psychiatry. This book covers the topics you won't find in standard textbooks. It deals with daily problems and practical solutions for young psychiatrists. Psychiatric training is less team based than other specialties, so there is less opportunity for learning from colleagues than one would expect: this book helps to fill that gap.

The book opens with an overview of psychiatry training, describing the similarities and differences among various countries. Subsequent chapters address the opportunities for research and how to publish the results. Psychotherapy and community psychiatry each merit their own chapter on training.

Next, the book guides you through the transition phase into a job, discussing opportunities in both the public and private sectors and considering how to choose the best career for you. It reviews important general considerations, such as ethics, professionalism, leadership and management, how to avoid stress and burn out, and how to liaise with other specialties. The book closes with an account of the role of psychiatry associations and continuing professional development.

Written by early career psychiatrists from around the world, this book provides invaluable first-hand experience to all those wishing to embark on a career in this exciting discipline.

• Practical tips for young psychiatrists starting their careers on the wards or in private practice
• Advice on the transition phase at the end of training, career choice and job opportunities

Leseprobe

Table of Contents

Title Page

Copyright

List of contributors

Preface

Chapter 1: Training in Psychiatry Today: European and US Perspectives

Introduction

Psychiatric Training in Europe

Psychiatric Training in the USA

State of the Art of Psychiatric Training in Europe

State of the Art of Psychiatric Training in the USA

Conclusions and Future Perspectives

References

Chapter 2: How to Start a Research Career in Psychiatry

Introduction

How to Get Started: Choosing a Career in Research

How to Conduct a Research Project: The Phases

Working in Research: Settings and Stages

Recommendations for Early Career Psychiatrists Interested in Research

Conclusions

Chapter 3: Publications in Psychiatry: How to Do and What to Do

Introduction

Planning a Paper

Engaging the Next Generation: Junior Trainees and Students

Conclusions

Chapter 4: Training in Psychotherapy: Where are We Now?

Introduction

Psychotherapeutic Models

Current Perspectives

Assessment of Psychotherapeutic Competencies

What are the Challenges in Training in Psychotherapy?

Future Directions

Conclusions

Chapter 5: Training in Community Psychiatry

Introduction

What is Community Psychiatry?

Planning Community Mental Health Services Delivery: The First Step for Education and Training

Tasks and Roles in Community Psychiatry

Core Skills in Community Psychiatry

Characteristics of Community Psychiatry Training Programmes

A Practical Working Model: The Public Psychiatry Fellowship of New York State Psychiatric Institute at the Columbia University Medical Center

Conclusions

Chapter 6: Why, What and How Should Early Career Psychiatrists Learn About Phenomenological Psychopathology?

Introduction

Objective or Subjective Psychiatry?

The Risks of Neglecting Psychopathology for Psychiatric Training

The Risks of Neglecting Psychopathology for Psychiatry as a Whole

What Training in Psychopathology?

Why Psychopathology is Still Relevant for Psychiatric Training

Some Clinical Examples

Where is Psychiatry Going Without Psychopathology?

A New Era for Psychopathology in Psychiatric Training

Conclusions

Chapter 7: The Psychiatrist in the Digital Era: New Opportunities and New Challenges for Early Career Psychiatrists

Introduction

Digital Tools in Psychiatry: Who Needs Them?

Digital Treatments

Information Technology and Psychiatry

Conclusions

Chapter 8: Portrayals of Mental Illness in Different Cultures: Influence on Training

Introduction

The Anthropology of Psychiatry

Cultural Psychiatry in the Context of Globalization

Migration in the Context of Psychiatry

Classifications Around the World

Examples of Culturally Specific Syndromes

Generalized Effects of Culture on Psychopathology

Culture in Clinical Practice

Cultural Case Formulation/Explanatory Models

Treatment

Conclusions: Is there a Role for Training in Cultural Psychiatry for Young Psychiatrists?

Chapter 9: Recruitment of Medical Students into Psychiatry

Recruitment Issues

Why is Psychiatry Facing Recruitment Problems?

How to Improve Recruitment into Psychiatry?

Who is Responsible for Recruitment?

Conclusions

Chapter 10: Not Quite There Yet? The Transition from Psychiatric Training to Practice as a Psychiatric Specialist

Introduction

The Final Years of Training

The Initial Period as a Specialist in Psychiatry

Recommendations for a Better Transition

Conclusions

Chapter 11: When Things go Wrong: Errors, Negligence, Misconduct, Complaints and Litigation

Introduction

Error

Negligence

Misconduct

Complaints

Litigation

Prevention

Conclusions

Chapter 12: New Ways of Working: Innovative Cross-Sector Care in a Competitive Mental Health Environment

Introduction

History of Change

Dehospitalization

Managed Care and Integrated Care Provision

Management of Integrated Care Programmes

Service Quality, Customer Processes and Patient Relationships

Economic and Financial Management of Integrated Care Contracts

Implementation of Professional Management

Information Technology (IT) Infrastructure: Optimizing Transfer of Information

Voluntary Inscription and Data Protection

Innovation Management in Future Psychiatric Outpatient Care Models

An Outlook for Early Career Psychiatrists

Conclusions

Chapter 13: Choosing a Career in Psychiatry and Setting Priorities

Introduction

Choosing Medicine

Setting Priorities in Psychiatry

Setting Priorities in Own Life

Balance Between Work and Life

Job Satisfaction and Prevention of Burnout

Conclusions

Chapter 14: How to Collaborate with Other Specialties

Introduction

Main Reasons and Examples of Collaboration

Medically Unexplained Physical Symptoms (MUPS)

Practical Suggestions for Improving Collaboration

Two Examples of Collaboration

Conclusions

Chapter 15: Where They Need Us… Opportunities for Young Psychiatrists to Help in Developing Countries

Introduction

The Public Image of Psychiatry

Economic Influences

Where do they Need Us?

Conclusions

Chapter 16: Professional Responsibility in Mental Health: What Early Career Psychiatrists Really Need to Know

Professional Responsibility

Professional Responsibility and Humanism

Professional Responsibility in Psychiatry

Core Professional Responsibilities

Threats to Professional Responsibility

Challenges for Early Career Psychiatrists

Teaching Professional Responsibility in Psychiatry

Conclusions

Acknowledgement

Chapter 17: The Role of Ethics in Psychiatric Training and Practice

Introduction

Ethical Principles and the Therapeutic Relationship: From Paternalism to Autonomy?

Beneficence or Non-Maleficence?

Consent

Bioethics

Ethics in Psychiatric Research

Designing Psychiatric Research Trials

Informed Consent in Psychiatric Research

Protecting Private Information in Research

Confidentiality

Forensic Psychiatry

Anticipated Directives and Ulysses' Contract

Boundary Violations

Conclusions

Chapter 18: Coercive Measures and Involuntary Hospital Admissions in Psychiatry

Introduction

Coercive Measures

Involuntary Hospital Admissions

Conclusions

Chapter 19: Mental Health Problems of Early Career Psychiatrists: From Diagnosis to Treatment Strategies

Introduction

Early Career Psychiatrists: A High-Risk Group for Developing Mental Health Problems

Burnout Syndrome

Suicide

Global Perspective on Early Career Psychiatrists' Mental Health Problems

Prevention and Treatment

Conclusions

Chapter 20: Leadership, Management and Administrative Issues for Early Career Psychiatrists

Introduction

Leadership vs Management

Organizational Values and The Concept of Morality in Leadership

The Need for Leadership, Management and Administrative Skills

Psychiatrists as Leaders

Leadership and Management Competencies

Team-Working and Team-Building

Targets for Improvement

How the Needs can be Addressed

Conclusions

Chapter 21: Why Should I Pay for It? The Importance of Being Members of Psychiatric Associations

Introduction

World Psychiatric Association (WPA)—Early Career Psychiatrists Council (ECPC)

European Psychiatric Association—Early Career Psychiatrists Committee (ECPC)

European Federation of Psychiatric Trainees

National Associations

Index

This edition first published 2012 2012 by John Wiley & Sons, Ltd.

Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley's global Scientific, Technical and Medical business with Blackwell Publishing.

Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

How to succeed in psychiatry : a guide to training and practice / edited by Andrea Fiorillo, Iris Calliess, and Henning Sass.

p. ; cm.

Based on: Professione psichiatra / a cura di Andrea Fiorillo, Mariano Bassi, Alberto Siracusano. 1. ed. 2009.

Includes bibliographical references and index.

ISBN 978-1-119-99866-2 (cloth)

I. Fiorillo, Andrea. II. Calliess, Iris Tatjana. III. Sass, Henning. IV. Professione psichiatra.

[DNLM: 1. Psychiatry. 2. Professional Practice. 3. Psychiatry–education. 4. Vocational Guidance. WM 21]

616.89–dc23

2011043614

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

List of contributors

Olivier Andlauer

Department of Psychiatry, University Hospital, Besançon, France

Julian Beezhold

Norfolk and Waveney Mental Health NHS Foundation Trust, United Kingdom, University of East Anglia, Norwich, UK

Joshua Blum

Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA

Stavroula Boukouvala

Norfolk and Waveney Mental Health Care NHS Foundation Trust, Norwich, UK

Emma Brandon

Norfolk and Waveney Mental Health NHS Foundation Trust, Norwich, UK

Otilia Butiu

Psychiatric Department, University of Medicine and Pharmacy Tg Mures, Romania

Victor Buwalda

Altrecht ggz, Utrecht/Den Dolder and Department of Psychiatry, Free University of Amsterdam, The Netherlands

Iris Tatjana Calliess

Department of Psychiatry, Social Psychiatry and Psychotherapy, Institute for Standardized and Applied Hospital Management, Hannover School of Medicine, Germany.

Giuseppe Carrà

Department of Mental Health Sciences, University College Medical School, London, UK;

Department of Neurosciences and Biomedical Technologies, University of Milano Bicocca Medical School, Monza, Italy

Massimo Clerici

Department of Neurosciences and Biomedical Technologies, University of Milano Bicocca Medical School, Monza, Italy

Stephanie Colin

AP-HP, Hôpital Avicenne, Service de psychopathologie de l'enfant, de l'adolescent, psychiatrie générale et addictions, Bobigny, France

Michael Davis

Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California Los Angeles (UCLA), Los Angeles, CA, USA

Valeria Del Vecchio

Department of Psychiatry, University of Naples SUN, Naples, Italy

Corrado De Rosa

Department of Psychiatry, University of Naples SUN, Naples, Italy

Abigail L. Donovan

Harvard University, Massachusetts General Hospital, Boston, MA, USA

Defne Eraslan

Department of Psychiatry, Faculty of Medicine, Acibadem University, Istanbul, Turkey

Silvia Ferrari

Department of Mental Health, University of Modena and Reggio Emilia, Policlinico di Modena, Italy

Andrea Fiorillo

Department of Psychiatry, University of Naples SUN, Naples, Italy

Domenico Giacco

Department of Psychiatry, University of Naples SUN, Naples, Italy

Cecile Hanon

EPS Erasme, Antony, France

Sameer Jauhar

Sackler Institute of Psychobiological Research, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK

Sarah Johnson

Department of Psychiatry, University of Louisville, KY, USA

Nikolina Jovanovi

Department of Psychiatry, University Hospital Centre and Zagreb School of Medicine, Croatia

Marianne Kastrup

Centre Transcultural Psychiatry, Psychiatric Centre Copenhagen, Denmark

Patrick Kelly

Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA

Mario Luciano

Department of Psychiatry, University of Naples SUN, Naples, Italy

Gregory Lydall

Castel Hospital, La Neuve Rue, Guernsey; University College London, London, UK

Amit Malik

Southern Health NHS Foundation Trust, Aerodrome House, Gosport, UK

Kate Manley

Norfolk and Waveney Mental Health Care NHS Foundation Trust, Norwich, UK

Dominique Mathis

Institut Paul Sivadon, Hôpital de l'Elan Retrouvé, Paris, France

Nya Maughn

Norfolk and Waveney Mental Health Care NHS Foundation Trust, Hellesdon Hospital, Norwich, UK

Molly McVoy

University Hospitals of Cleveland/Case Western Reserve, Cleveland, OH, USA

Adriana Mihai

Psychiatric Department, University of Medicine and Pharmacy Tg Mures, Romania

Davor Mucic

Psychiatric Centre “Little Prince”, Copenhagen, Denmark

Alexander Nawka

Department of Psychiatry, First Faculty of Medicine, Charles University, Prague, Czech Republic

Fiona Nolan

Centre for Outcomes Research and Effectiveness (CORE), Sub Department of Clinical Health Psychology, University College London, London, UK

Kajsa B. Norstrom

Psychiatric Unit Angered, Capio Lundby Hospital, Goteborg, Sweden

Clare Oakley

St Andrew's Academic Centre, Institute of Psychiatry, King's College London, London, UK

Paul J. O'Leary

Department of Psychiatry, Emory University, Atlanta, Georgia, USA

Magdalena Peckskamp

Department of Psychology, University of Vienna, Austria

Felipe Picon

Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil

Florian Riese

Psychiatric University Hospital Zurich, Switzerland

Martina Rojnic Kuzman

Department of Psychiatry, Zagreb University Hospital Centre and Zagreb School of Medicine, Zagreb, Croatia

Larissa Ryan

Warneford Hospital, Oxford, UK

Virginio Salvi

Mood and Anxiety Disorders Unit, Department of Psychiatry, University of Turin, Italy

Henning Sass

Department of Psychiatry, University of Technology RWTH, Aachen, Germany

Paola Sciarini

Department of Neurosciences and Biomedical Technologies, University of Milano Bicocca Medical School, Monza, Italy;

Department of Health Sciences, Section of Medical Statistics and Epidemiology, University of Pavia Medical School, Pavia, Italy

Joseph Stoklosa

Harvard Medical School, McLean Hospital, Boston, MA, USA

Kai C. Treichel

Medical Center Friedrichshain Berlin, Germany

Umberto Volpe

Department of Psychiatry, University of Naples SUN, Naples, Italy

Preface

What does it take to become a psychiatrist today? What are the training and educational needs for modern psychiatrists? What does it mean to be a psychiatrist today? What are the professional responsibilities of psychiatrists and of other mental health workers? And what will be their perspectives in the future? These are only some of the questions we have tried to address in this book, promoted by the EPA Early Career Psychiatrists Committee and the European Federation of Psychiatric Trainees, which includes 21 chapters by 50 authors from 16 different countries.

The book “How to succeed in psychiatry: a guide to training and practice” is not a source of clinical information, but rather a survival guide to help young colleagues through the first years of practice. A “survival” kit seems to be particularly needed by young psychiatrists in our days, who are very different from colleagues starting their career only a few years ago. The clinical choices of young psychiatrists today seem to be driven predominantly by the need to avoid professional errors rather than the wish to find the best and most effective therapeutic treatment. In clinical practice, young psychiatrists quite often adopt “defensive” medical styles in order to avoid complaints and litigation with patients, family members, stakeholders and also with managers. More often than in the past, young psychiatrists report not being able to bear stressful working situations and experiencing high levels of burn-out, with anxiety and depressive symptoms. Belonging to scientific and professional associations is one way to prevent these feelings and to improve young doctors' skills. Other ways to overcome these possible difficulties are reported in this book; they include setting the correct priorities for one's own life and career or choosing the “right” career among the various possibilities (e.g. private practice, community or hospital settings, academic career).

The volume is organized as an ideal path from training to employment, presenting all the relevant difficulties of being a psychiatrist today, as well as possible solutions, being represented. The book opens with an overview of psychiatric training, describing the similarities and differences among various countries. Subsequent chapters address the opportunities for research studies and for getting the results published. Chapters 4 and 5 describe training in psychotherapy and in community psychiatry, both of which are particularly relevant for young psychiatrists, as they represent two of the most frequent possible working scenarios. In chapter 7 the importance of telecommunication resources for the psychiatric profession and the risks associated with the use of new technologies are described. Chapter 8 addresses cultural factors that can influence psychiatric training. Chapter 9 deals with the problem of the shortage of psychiatrists, focusing on the transition from medical school to training in psychiatry.

Next, the book guides the reader through the transition phase into a job, discussing job opportunities in both the public and private sectors and suggesting how to choose the best career. Chapter 12 deals with job opportunities in the private sector; this is an ever-expanding sector and often represents one of the first employment opportunities after specialization. In chapter 19 the topics of mental health, work stress and burnout, to which mental health professionals seem to be particularly vulnerable, are addressed. Authors report data from the literature showing an increased risk of stress in younger colleagues and provide, at the same time, practical advice that we should all learn to follow.

The following section of the book reviews important general and legal considerations, such as ethics, professionalism, leadership and management, and how to liaise with other specialties. Professional responsibility in medicine today is a “hot” issue, and the emphasis given to this topic reflects the sensitivity of young psychiatrists to these issues. What the authors of this volume have not lost is the ethics of medical work. Chapter 17 is a useful discussion of the most significant ethical and deontological aspects of medicine in general, not only of psychiatry. In chapter 18 practical suggestions regarding compulsory hospital treatments and the use of coercive measures are offered. Again, this is a hotly-debated issue in clinical psychiatry, for which early career psychiatrists do not seem to have all the necessary information, being too often overlooked in the curricula of psychiatrists. The book closes with an account of the role of psychiatric associations and continuing professional development.

Although this book is aimed mainly at recently qualified psychiatrists or those looking to qualify soon, we believe it will be useful for all psychiatrists, including more experienced colleagues: while reading the book, they will go back in time to when they were young psychiatrists and re-experience the curious and exploratory approach to life, which is—in our opinion—the true essence of being a psychiatrist today. We hope that young psychiatrists worldwide will succeed in their aims and careers, but will never lose this attitude of “curious determination” that brought them to choose psychiatry.

We are grateful to a number of people. It is almost impossible to name all of them. Basically, we want to thank here our contributors, who have provided excellent chapters and who have enthusiastically joined this initiative; the leadership of the European Psychiatric Association, which has supported us throughout the preparation of the book; Professors Bhugra and Sartorius, for their valuable advice in selecting chapters and authors; Joan Marsh and her team at Wiley-Blackwell. We are greatly indebted and grateful to all of them.

Andrea Fiorillo, Iris Tatjana Calliess, Henning Sass

Chapter 1

Training in Psychiatry Today: European and US Perspectives

Martina Rojnic Kuzman,1 Kajsa B. Norstrom, 2 Stephanie Colin, 3 Clare Oakley4 and Joseph Stoklosa5

1 Department of Psychiatry, Zagreb University Hospital Centre and Zagreb School of Medicine, Zagreb, Croatia

2 Psychiatric Unit Angered, Capio Lundby Hospital, Goteborg, Sweden

3 AP-HP, Hôpital Avicenne, Service de psychopathologie de l'enfant, de l'adolescent, psychiatrie générale et addictions, Bobigny, France

4 St Andrew's Academic Centre, Institute of Psychiatry, King's College London, UK

5 Harvard Medical School, McLean Hospital, Boston, MA, USA

Introduction

The last few decades have brought rapid social changes, which have greatly influenced health, communication, ethics, politics and economics. Psychiatry, as a significant component of the health-care system, has also been affected by these changes. Nowadays, trainees and early career psychiatrists worldwide are facing several challenges, quite different from those faced previously. Young psychiatrists acquire the competencies requisite of a mental health professional through medical schools and postgraduate residency trainings, and this formative stage is crucial for the development of competent mental health professionals.

Psychiatric Training in Europe

In Europe, training programmes in psychiatry are developed and subsequently implemented by educational policy-makers, at national levels in each European country. Accreditation policy as well as quality assurance mechanisms also fall within the remit of authorities at national levels. The need for harmonized postgraduate training in psychiatry has developed in parallel with the development of the European Union. Today, the Section and Board of Psychiatry of the Union Européenne des Médecins Spécialistes (UEMS) play an active part in shaping the future of European psychiatrists. UEMS was established in 1958 as a response to the signing of the Treaty of Rome in 1957, where harmonization and mutual recognition of diplomas was foreseen.1 In 1990, the Section of Psychiatry was formed to deal primarily with general issues related to psychiatric practice and quality assurance of psychiatric care. In 1992 the Board of Psychiatry was formed, focusing on training issues. In 1993 the Treaty of Maastricht was signed on an EU level, which opened up the internal market and free movement of goods, persons, services and capital. Today, 27 European countries benefit from this Treaty, and in the last decade this has been reflected in an increasing migration of psychiatric trainees and psychiatrists across Europe.

Due to the observed huge variations in training standards, training programmes and training facilities in European countries, in 1993 the UEMS published the Charter of specialist training.2 The Section and Board of Psychiatry have drafted and approved numerous reports and guidelines to enhance the speed and recognition of the harmonization process in psychiatric training. These documents concern several areas, such as training in psychotherapy, supervision, quality assurance and accreditation of training schemes in psychiatry, and in 2009 a European framework for competencies in psychiatry was published.3 These documents are considered as guidelines and it is intended that the member countries use them in order to reform their national training programmes. UEMS has no legal authority to enforce changes in any particular country; therefore, it is important to have a continuous process of discussion and to promote a supportive attitude in order to make progress with the harmonization of psychiatric training.

Trainees' perspectives in Europe are represented by the European Federation of Psychiatric Trainees (EFPT), the first and only international organization of national psychiatric trainees' associations. EFPT has full voting rights at the European Board of Psychiatry of the UEMS, contributing significantly to the cooperation between the two organizations. The Federation has grown rapidly over the years and currently encompasses more then 30 member countries across Europe.4

As regards child and adolescent psychiatry (CAP) training in Europe, the UEMS CAP training logbook states that ‘children are not simply small adults’. Nevertheless, the core identity of child and adolescent psychiatry has been at stake for the last few decades. Whereas in most European countries CAP has slowly grown to become an independent specialty, separated from adult psychiatry, in others it is still a subspecialty or is still strongly linked with paediatrics. Hence, there are huge discrepancies in the training programmes in CAP in Europe. Within the UEMS, CAP psychiatrists used to be represented in the Section and Board of Psychiatry, until the establishment of a separate Section and Board in 1992. The ideas behind this initiative to split within the UEMS were to promote high standards of mental health care for children across Europe, both directly and indirectly, by establishing standards and improving the quality of postgraduate CAP training, with a particularly strong emphasis on training in psychotherapy.5

Again, the perspective of European CAP trainees is represented by the EFPT, which now provides a valuable framework for European child and adolescent psychiatry trainees to discuss and exchange ideas. Its inner structure has recently been modified in response to the growing identity claims of CAP trainees, as a new board position for a ‘CAP secretary’ was created, allowing specific representation of CAP trainees in European CAP meetings, and enhanced links with international organizations, such as UEMS-CAP and the European Society for Child and Adolescent Psychiatrists (ESCAP).

Psychiatric Training in the USA

The young psychiatrist training and practising in the USA today faces a different set of challenges than the psychiatrist training just a few decades ago. The structure of psychiatric training itself has shifted from a participation-based into a competency-based model, in response to pressures from government, practitioners and patients to make physicians more accountable to the public. Psychiatric training is regulated by a single governing body for all US residencies, which is a private, non-profit council called the Accreditation Council for Graduate Medical Education (ACGME). The ACGME was established in 1981 from demands in the academic medical community for an independent crediting association with the mission to ‘improve health care by assessing and advancing the quality of resident physicians' education through exemplary accreditation’.6 Comprising 28 specialty-specific Residency Review Committees (RRCs), each RRC is formed by 6–15 volunteer physicians appointed by the American Medical Association (AMA) and individual specialty boards. It is these RRCs that then determine the specific programme requirements for each specialty training programme, including psychiatry. RRCs also have direct oversight on each specific training programme institution to ensure sufficient support within each programme. Each residency training programme submits to a review by its RRC at least every 5 years. During review, each programme provides extensive information on all aspects of training, which is then verified by the site visit to solicit trainee and faculty feedback, and make direct observations on patient care, staff and facilities.7

In 1959, child and adolescent psychiatry was established as an official subspecialty of general psychiatry. Residents wishing to pursue this subspecialty can enter the two-year fellowship after either their third or fourth year of general psychiatry training. The core requirements of child and adolescent specialty training also fall under the purview of the psychiatry RRC.

Around this system of regulation, several unique situations in US culture have evolved that sculpt the modern psychiatry resident's experiences, including the rise of core competency-driven education, the advent of national duty hours regulations, and the US health-care system of managed care.

State of the Art of Psychiatric Training in Europe

For the majority of European countries, curricula for psychiatric training across Europe are set by national authorities. In a significant proportion of European countries, the curricula are developed in accordance with the UEMS requirements for the specialty of psychiatry and standards, as defined in the document called the ‘Charter on training of medical specialists in the EU: requirements for the specialty of psychiatry’.2 A selection of the UEMS recommendations is given in Table 1.1.

Table 1.1 A selection of requirements for the specialty of psychiatry according to charter on training of medical specialists in the EU released by the Union Européenne des Médecins Spécialistes (UEMS)2

ArticleContentCENTRAL MONITORING AUTHORITY FOR PSYCHIATRY (defines the requirements for the monitoring Authority, the recognition of teachers and training Institutions, quality assurance mechanisms and recognition of quality)GENERAL ASPECTS OF TRAINING IN PSYCHIATRY (in addition, it defines the selection and access to the training, the circumstances of the interruption of training, training abroad and funding)Training duration    The minimum duration of training will be 5 years in psychiatry; can take place in different institutions if they are recognized nationally as training institutions; part-time training should be possible in every EU member state    Definition of common trunk    Within the national training programme in psychiatry there is a common trunk of fundamental knowledge and skills that is required of all candidates. The common trunk is compulsory. This common trunk includes training in inpatient psychiatry (short, medium and long stay), outpatient psychiatry (community psychiatry, day-hospital), liaison and consultation psychiatry, and emergency psychiatry. Psychotherapy training is also part of the common trunk. Training should cover general adult psychiatry, old age psychiatry, psychiatric aspects of substance misuse, developmental psychiatry (child and adolescent psychiatry, learning difficulties and mental handicap) and forensic psychiatry. The training programme can include not more than one year of flexible training (e.g. research or other related subjects to be approved by the head of training)    Practical training    Practical training should evolve around routine clinical work under supervision. As training progresses there should be an increasing level of responsibility. During the period of training rotation within different sections of an institution should be compulsory. Rotation to different institutions should be facilitatedSupervision    Clinical supervision should be available on a daily basis. In addition to clinical supervision and psychotherapy supervision, individual educational supervision (dealing with such subjects as attitude, growth in the profession, etc.) is compulsory for a minimum of 1 hour per week, at least 40 weeks per year    Implementation of training programme/training logbook    The theoretical and practical training will follow an established programme approved by the national authorities in accordance with national rules and EU legislation as well as with the requirements and recommendations of the European Board of Psychiatry. The different stages and the activities of training and the activities of trainees should be recorded in a training logbook    APPENDIX 1: Theoretical training    Training should include a structured training (lectures, seminars, etc.) over 4 years, on average for 4 hours per week. The subjects to be covered are the scientific basis of psychiatry, psychopathology, examination of a psychiatric patient, diagnosis and classification, psychological tests and laboratory investigations, specific disorders and syndromes, child and adolescent psychiatry, mental handicap, psychiatric aspects of substance misuse, old age psychiatry, diversity in psychiatry, legal, ethical and human rights issues in psychiatry, psychotherapies, psychopharmacology and other biological treatments, multidimensional clinical management, community psychiatry, social psychiatric interventions, research methodology, epidemiology of mental disorders, psychiatric aspects of public health and prevention, medical informatics and telemedicine, leadership, administration, management, economicsAPPENDIX 2: Training in psychotherapy    Psychotherapy is an integral part of training in psychiatry. The content that is considered essential for training in psychotherapy include a mandatory part of the training curriculum that takes place within working hours, practical application of psychotherapy in a defined number of cases, theory of psychotherapy over at least 120 hours, supervision provided on a regular basis for at least 100 hours, individual (at least 50 hours) but preferably also group supervision. Experience should be gained with a broad range of diagnostic categories, including assessment and evaluation of outcome. Experience in psychotherapy should be gained with individuals as well as families and groups. As a minimum, psychodynamic, cognitive behavioural therapy (CBT), and systemic theory and methods should be applied, but integrative psychotherapies are highly recommended. Personal therapeutic experience/feedback on personal style is highly recommended. Research methodology should be included    Training should if possible take place within different parts of mental health services. Supervisors should be qualified. Training should be publicly fundedREQUIREMENTS FOR TRAINING INSTITUTIONS (defines the criteria for the recognition of training institutions, their size and the quality assurance of training institutions)REQUIREMENTS FOR TEACHERS (defines the qualification of the chief of training and the training programme)REQUIREMENTS FOR TRAINEES (defines the required experience, language skills and specialization for trainees)

While in most European countries the structures of training programmes are reasonably compatible with standards set by the UEMS, the duration of different placements, as well as the duration of training as a whole, varies across Europe. This is more pronounced in some parts of Europe—the shorter duration of training is seen in some parts of Eastern and southeastern European countries, but not in all countries. There are great differences in the psychiatric trainees' assessment before they become specialists: some countries have neither examinations nor other methods of assessment, while other countries employ a range of assessment methods, including different types of examination, workplace-based assessments, portfolios and supervisor's reports.8 An overview of the structure of training programmes in Europe is given in Table 1.2.

Table 1.2 Training programmes for adult psychiatry across Europe

Recently, a UEMS survey aiming to find out whether the UEMS directives had an impact on the conditions of psychiatry training across Europe was conducted.9 The authors concluded that while there were great differences between the training centres in different countries, progress towards developing high standards had been made. The parts of the training programmes that display major variations and that show little coherence even within a country seem to be supervision (especially educational supervision) and psychotherapy training.9 These findings are compatible with recent EFPT data, where the most important problems faced by postgraduate psychiatric trainees across countries were implementation of postgraduate curricula, psychotherapy training and lack of supervision.10 Problems with the implementation of training programmes are related to the implementation of newly developed programmes in some countries, while in others there is a significant gap between the conception of the training systems that are prescribed by the national educational bodies and their delivery at a local level. This issue might be related to the overall shortage of psychiatrists,11 leaving the trainees without proper educational and clinical supervision, but also leaving the trainees to engage in the tasks of fully trained specialists, which they are not yet competent to do. It may also be due to the lack of accredited or high quality facilities in many parts of Europe (especially in eastern and southern countries) and to the heterogeneity of standards of training in different centres, even within the same country, with a consequent relative overload of trainees in some placements and thus long waiting lists for some rotations. Another reason for explaining implementation problems of training programmes might be the lack of adherence to the recommended quality assurance mechanisms at the national and international levels.

In recent years, a significant shift in the philosophy of training has occurred. As the result of the work of the UEMS and of national authorities in several European countries, a competency-based framework for training, including a competency-based curriculum and assessment programmes ranging from workplace-based assessments to exit examinations, was designed and it is now being implemented in several European countries.12 Whilst this introduction of competency-based training represents a major shift in medical education, new challenges arise with this transition, due to the high demands on trainers to deliver this relatively intensive method of providing postgraduate training and to the new regulations for residents. Nevertheless, the benefits of the new programme are clear and, thus, it is firmly supported by both the UEMS and the EFPT.

Although European child and adolescent psychiatry has undergone impressive development over the past 50 years, there is still a huge variability in the structure of CAP training across Europe, and a long way to go for full harmonization in the programs. CAP is now an independent specialty in more then 20 countries and a subspecialty in the rest of them, but some countries still do not have any structured CAP training curriculum (Table 1.2).13 One of the main achievements of the UEMS CAP Board was to publish a training logbook, which has been implemented at least partially in two-thirds of the countries.14 It specifically states that the minimum duration of postgraduate training should be 5 years, of which 4 years should be pure CAP. Training differences are marked even within the EU member countries, and not only in terms of content of training programmes, but also of duration, trainee selection and graduation procedures. Moreover, a lack of detailed information regarding training curricula in several countries has also to be acknowledged. While the UEMS-CAP logbook emphasizes training in psychotherapy as being mandatory, only half of the countries have integrated structured psychotherapy training as a full component of CAP training. Interestingly, trainees in almost all countries have to pay with their personal funds for their psychotherapeutic education within CAP training. In virtually all European countries, experience in psychiatry with adults of working age is a necessary component of training in CAP. Similarly, experience in paediatrics is welcome, or required, in many countries. Training in research, however, is integrated as a structured part of the training only in one-third of the countries.

Leaving the tradition of any particular country aside, and devising an adequate yet realistic training schedule that would incorporate such experiences, the UEMS CAP Board recommended a 12-month minimum time for training in adult psychiatry. Similar rotations in paediatrics or neurology are recommended, but they are optional. The logbook has already proven to be important in helping new EU member countries to develop their own training programme in CAP.15 However, standards set in the logbook are high and may well exceed those set by relevant authorities in each country: they should therefore be inspirational.

State of the Art of Psychiatric Training in the USA

The Accreditation Council for Graduate Medical Education policy defines a set of specific requirements for psychiatric training programmes that are seeking accreditation. Currently, residency education in psychiatry requires 4 years of training.16 Thus, the newly graduated doctor, having just completed medical school, must undertake an additional 4 years of training prior to practising as an independent physician. The first year of training includes 4 months in a primary care setting (internal medicine, family medicine and/or paediatrics), and 2 months in neurology. The second 6 months can comprise additional medical training or introductory psychiatry training. The second year of residency marks the true beginning of psychiatry training; this includes at least 9 months of inpatient psychiatry and 12 months of continuous outpatient psychiatry that uses both psychotherapy and biological therapies. Additional requirements exist to ensure diversity of experience within the inpatient and outpatient training, including at least 2 months of child and adolescent psychiatry, 1 month of geriatric psychiatry, 1 month of addiction psychiatry, and 2 months of consultation/liaison psychiatry. Residents must also have clinical experience in the following areas: forensic psychiatry, emergency psychiatry, community/public sector psychiatry, group, couples and family therapy, and psychological testing. Residents must participate in a didactic curriculum that includes neurobiology, psychopharmacology, major theories of psychotherapy, child development and cultural issues in psychiatry. Training must encompass a wide variety of clinical experiences with different patient populations. The ACGME is committed to achieving a balance between psychodynamic and biological psychiatry, in both education and clinical care.

Beyond the specific educational components, the ACGME also sets recommendations on the hierarchical structure of programmes and specific monitoring parameters. These various requirements include regulations for necessary programme personnel, faculty qualifications, educational resources, specific competencies, scholarly activities' participation, resident and faculty evaluations, and duty hours. In order to meet ACGME certification, these requirements must all be met during RRC review.

The ACGME previously guided psychiatric training by a set of ‘minimum standards’ that needed to be met by each trainee in order to complete training. These ‘minimum standards’ were met through completion of the required rotations and clinical experiences; thus, the model was largely participation-based.17 Each training programme was responsible for defining and implementing its own system to assess satisfactory performance on these required rotations. However, in 2000 the ACGME dramatically changed the requirements for education assessment from merely participation-based to competency-based. The idea of measuring competence grew out of a culture in the USA that prized directly measurable outcomes. This ‘outcomes movement’ began in the 1980s in a variety of non-medical industries, such as aviation and business, with great success.17 In medicine, this movement followed society's shift toward research and evidence-based outcomes and away from traditional physician judgment and intuition. This was soon embodied nationally with the establishment in 1989 of the Agency for Health Care Policy and Research. The outcomes movement reached educational programmes when the Department of Education mandated that graduate educational institutions shift to an outcomes model. In the 1990s, this model reached residency training when the ACGME endorsed its own definition of outcomes-based competence by defining a set of basic skills necessary for residents to practise medicine. In 2000, the ACGME formalized its recommendations as the ‘six core competencies’, which now define the specific abilities and skills that comprise residency training and drive the focus for resident education. Residents must now demonstrate competency in the following six areas: patient care (including clinical reasoning), medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and system-based practice.6 While each programme may use individual models of assessment for each competency, these universal core competencies have changed the focus and face of psychiatric training on a national level.

A second major shift in US residency training is the advent of strict duty hours limitations. The days of residents working 36-hour shifts, and up to 120 hours per week, are no more. In 2003 the ACGME passed its own work hours regulations for residents, which include: (i) weekly duty hours must be no more than 80 hours per week; (ii) no shift longer than 24 hours, with an additional 6 hours for transfer of care; (iii) at least 10 hours off between shifts; (iv) call every third night or less frequently; and (v) one day off in seven.18 There is a debate regarding the merits of duty hour regulations. Supporting duty hours regulation, studies show that residents make more serious medical errors, medication errors and diagnostic errors after long shifts in the intensive care unit.19 Given that psychiatric evaluation requires a high level of attentiveness to the patient and empathic responsiveness, it is felt by supporters that these regulations protect residents and patients alike from poor quality therapy, consultations or evaluations.20 Furthermore, for the increasing numbers of physicians choosing specialties based on lifestyle, shorter work hours allow for a new kind of professionalism and life balance to emerge.

However, duty hour regulations also have a number of drawbacks. More frequent pass offs (handovers or transfer of care) may also lead to a decrease in alliance and connection with patients, which are central to effective psychiatric care. There are worries that limited duty hours are leading to less overall training per resident, less exposure to patient diversity, and less direct patient contact.21 Given that early estimates showed 86% of all psychiatry residencies had some duty hour violations, more work must be done to understand better the harms and benefits of this new system.22

Another major shift in training followed the dramatic changes of the health-care system in the USA over the last several decades. In the 1990s, costs for medical care rose dramatically.23 The government and insurance companies supported ‘managed care’ as a way to decrease these costs. ‘Managed care’ requires that medical services be approved by a patient's primary care physician or an insurance reviewer. It exists in several different forms, including health maintenance organizations, point of service, or preferred provider organizations, differing in fee structure and ‘in network’ versus ‘out of network’ coverage. The goal of this system was to reduce unnecessary medical costs in order to preserve basic care for the largest number of people. This theoretical construct has merit; however, managed care in the USA has led to challenges in providing appropriate services to psychiatric patients. Practically speaking, managed care has created challenges in both the practice of psychiatry and patients' access to care, leaving only the most ill patients admitted to hospitals and shortening the length of hospitalizations. That in turn, besides leading to reduced cost, may also represent cost shifting of those with severe mental illness to the criminal justice system.23 The criminal justice system becomes involved because many patients who do not qualify for an inpatient level of care, or who are discharged too quickly, may end up committing crimes as a result of their largely untreated mental illness, resulting in their imprisonment. Furthermore, many medications and most long-term therapies also require prior authorization. Outpatient care has now shifted to a focus on psychopharmacology and brief therapy, as managed care considers these more cost-effective treatments and will approve payment for them more readily. Thus, briefer ‘15-minute’ medication visits are becoming more prevalent in standard outpatient practice, with an increase in prescribing psychotropic medication and decrease in psychiatrists providing psychotherapy themselves. Because of this change, early career psychiatrists in the USA must now become skilful at short-term therapy and psychopharmacological management under strict time constraints, become familiar with which types of services are authorized by which insurers, and learn how to advocate effectively for their patients' needs with an insurance reviewer. Lastly, they must know how to accurately and effectively fill out insurance paperwork that sometimes requires hours of extra work.

In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was approved by the US government. This act, which went into effect in late 2009 and 2010, requires that insurance-based financial requirements (such as co-pays and deductibles) and treatment limitations (such as visit limits) applicable to mental health and substance use disorders can be no more restrictive than the predominant requirements or limitations for medical and surgical illnesses. The effects of this act on care for patients with psychiatric illness in the USA remain to be seen.

Conclusions and Future Perspectives

The last few decades have brought rapid and important social changes, greatly influencing health, communication, ethics, politics, economics and, consequently, psychiatry. These global changes were also reflected by the shift in requirements that trainees and early career psychiatrists worldwide must fulfil, which are very different from those required only a few decades ago. These social changes also influenced the development of educational programmes worldwide. Although there are globally shared problems for trainees and early career psychiatrists, there are still significant differences between the European and US educational systems, and thus psychiatry training programmes.

In Europe, one of the most challenging tasks for European authorities that develop and implement training programmes is still the harmonization of training programmes. This is one of the major strategies for improving scientific, working and educational activities in all European regions. This task is becoming more and more important now that the expansion of the EU has brought more countries with different historical and socio-cultural backgrounds into the Union. While efforts towards the harmonization of psychiatric training in Europe started a few decades ago, progress in this challenging task is slow, especially for the observed discrepancy between what is happening in respect of training and what occurs in actual practice. The UEMS and the EFPT, as the major players in psychiatric educational policies at the pan-European level, are working together to develop effective strategies that can enhance the full implementation of the harmonization process. The UEMS strategy and aims for the next decade include harmonization of postgraduate medical training to the highest standards, including evaluating performance and proposing changes. This will be achieved by advocating the harmonization of training based upon the published document ‘European framework for competencies in psychiatry’,12 which outlines the competencies and assessments required for psychiatric trainees, and by the development of high-quality assurance mechanisms. In this perspective, developing stronger links with responsible national training authorities and bodies, and providing advice and feedback about the development of high-quality psychiatric training programmes that are nationally driven, are crucial. Moreover, proper executive power should be allocated to the national bodies that are responsible for quality control, while international bodies, such as UEMS, should provide an additional external quality control source by enhancing national clinical visits throughout Europe.

Psychiatric training in the USA needs to embody the ACGME core competencies as caring, informed, up-to-date, professional communicators able to function within the US health-care system. In the USA there are strict limits on duty hours, requiring a mastery of more frequent transfers of care. It is also essential to learn to function within a regulated system of managed care via briefer outpatient visits and shorter inpatient stays; the effect of the Mental Health Parity and Addiction Equity Act remains to be seen. For psychiatrists entering the field today, these new challenges come at a time when psychiatry is rapidly expanding its knowledge base of diagnosis and treatment. European trainees have faced similar challenges with a recent reduction in working hours to 48 hours per week as a result of the European working time directive. A shift to competency-based training is also beginning in many countries, as opposed to the participation-based model.

Despite the still significant differences between the European and US educational and health-care systems, and societal differences, globalization has contributed to the increase in global sharing of challenges among the communities of trainees and early career psychiatrists and to the formation of a ‘global community of young psychiatrists’. This fact is also evident by the formation of international networks of trainees and young psychiatrists aiming to serve as a platform allowing colleagues to share and learn from each others' experiences. In light of the growth of globally shared challenges in psychiatric training, learning from international experiences is crucial to develop more effective training systems. Ultimately, to succeed as psychiatrists, trainees worldwide must remember that their responsibility to their patients is paramount, and they must learn to effectively balance the demands of the health-care industry, training bodies and society.

References

1. Maillet B. The Union of European Medical Specialists. World Med J 2008; 54: 50–54.

2. UEMS Section for Psychiatry. Charter on training of medical specialists in the EU: requirements for the specialty of psychiatry. Eur Arch Psychiatry Clin Neurosci 1997; 247(Suppl.): S45–47.

3. UEMS Section and Board of Psychiatry (http://www.uemspsychiatry.org).

4. European Federation of Psychiatric Trainees (http://www.efpt.eu).

5. Hill P, Rothenberger A. Can we—and should we—have a neuropsychiatry for children and adolescents? The work of the UEMS Section and Board for Child and Adolescent Psychiatry/Psychotherapy. Eur Child Adolesc Psychiatry 2005; 14; 466–470.

6. Beresin E, Mellman L. Competencies in psychiatry: the new outcomes-based approach to medical training and education. Harv Rev Psychiatry 2002; 10: 185–191.

7. Bhatia SK, Bhatia SC. Preparing for a successful residency review committee site visit: A guide for new training directors. Acad Psychiatry 2005; 29: 249–255.

8. Oakley C, Malik A. Psychiatric training in Europe. The Psychiatrist 2010; 34: 447–450.

9. Lotz-Rambaldi W, Schafer I, ten Doesschate R, Hohagen F. Specialist training in psychiatry in Europe—results of the UEMS-survey. Eur Psychiatry 2008; 23: 157–168.

10. Nawka A, Rojnic Kuzman M, Giacco D, Malik A. Challenges of the postgraduate psychiatric training in Europe: a trainee perspective. Psychiatr Serv 2010; 61: 862–864.

11. World Health Organization. MhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. 2008; available at: www.who.int/mental_health/mhgap_final_english.pdf.

12. UEMS Section for Psychiatry—European Board of Psychiatry. European framework for competencies in psychiatry. UEMS, 2009.

13. Karabekiroglu K, Doğangün B, Hergüner S, von Salis T, Rothenberger A. Child and adolescent psychiatry training in Europe: differences and challenges in harmonization. Eur Child Adolesc Psychiatry 2006; 15: 467–475.

14. Rothenberger A. The training logbook of UEMS Section/Board on Child and Adolescent Psychiatry/Psychotherapy (CAPP)—progress concerning European harmonization. Eur Child Adolesc Psychiatry 2001; 10: 211–213.

15. Costello, Jane E. Increasing awareness of child and adolescent mental health. Am J Psychiatry 2010; 167: 1411.

16. Berestin EV. The administration of residency training programs. Child Adolesc Psychiatr N Am 2002; 11: 67–89.

17. Swick S, Hall S, Beresin E. Assessing the ACGME Competencies in Psychiatry Training programs. Acad Psychiatry 2006; 30, 330–351.

18. Sattar SP, Basith F, Madison J, Bhatia SC. New ACGME work-hour guidelines and their impact on current residency training practices. Acad Psychiatry 2005; 29: 279–282.

19. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351: 1838–1848.

20. Rasminsky S, Lomonaco A, Auchincloss E. Work hours regulations for house staff in psychiatry: bad or good for residency training? Acad Psychiatry 2008; 32: 54–60.

21. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does house staff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994; 121: 866–872.

22. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA 2006; 296: 1063–1070.

23. Hoge MA, Jacobs SC, Belitsky R. Psychiatric residency training, managed care and contemporary clinical practice. Psychiar Serv 2000; 51: 1001–1005.

Chapter 2

How to Start a Research Career in Psychiatry

Domenico Giacco,1 Mario Luciano,1 Sameer Jauhar2 Andrea Fiorillo1

1 Department of Psychiatry, University of Naples SUN, Naples, Italy

2 Sackler Institute of Psychobiological Research, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK

Introduction

Research has always been a source of great interest for young doctors starting a complex and fascinating specialty such as psychiatry, and this is particularly true in recent years.1–3 J.A. Lieberman says that ‘there has never been a better time to go into biomedical research. The science is burgeoning and better than ever. The current funding levels are generous. There are numerous training opportunities. And, finally, the field is eagerly seeking the next generation of psychiatric researchers.’1

Despite several difficulties and obstacles, research in psychiatry is advancing rapidly, and has a diversity that few other medical specialties can rival.2, 3 Acquiring research skills is considered by most university professors as an essential part of training.4 In fact, all psychiatrists, even those not primarily involved in research activities, clearly benefit from an understanding of research methodology and from the ability to think critically about research findings.5–7 The section of psychiatry of the Union Européenne des Médecins Spécialistes (UEMS) has recently produced a document called ‘UEMS Framework for competencies in psychiatry’, which states that psychiatrists have to ‘contribute to research and to the development of new knowledge’, and that they should acquire the following specific research competencies:8

recognize the principles, methodology and ethics of research and scholarly inquiry;formulate a research question and conduct a systematic search for evidence;select and apply appropriate methods to address the question;analyse, interpret and report the results;appropriately disseminate and utilize the findings of a study.

Furthermore, the European Federation of Psychiatric Trainees (EFPT) has also produced a statement on research training, according to which ‘Psychiatric residents should be trained in basic knowledge of research theories and methodologies. They should have basic training in analyzing the quality of research. Trainees should also be encouraged to develop scientific attitudes towards their professional activities and an ability to effectively implement new research evidence into their clinical practice.’9

Despite the increasing emphasis on the importance of research skills for all psychiatrists, early career psychiatrists often meet several difficulties when they try to acquire the skills needed to participate in research activities and to start a research career; these fall into three large categories:6

regulatory factors, such as time in training programmes dedicated to research experiences and to development of research skills;institutional factors, such as lack of mentors and limited technological access, knowledge and resources; andpersonal factors, such as female gender, non-Caucasian ethnic group, lack of motivation and financial difficulties.

This chapter is intended as a practical guide for early career psychiatrists wishing to work in psychiatric research. The different steps to follow to get started in research activities, the international opportunities available for improving research skills, the different phases of a research project, and the different settings and stages of a research career will be outlined. At the end of the chapter, some practical tips will be provided.

How to Get Started: Choosing a Career in Research

Assessing One's Own Research Interests

Before starting a career in research, it is essential to identify the fields of interest. Research in psychiatry is, by its very nature, interdisciplinary and involves several different approaches, which focus on the different aspects of mental disorders.10, 11 The choice should be guided by personal interests and values but, most importantly, by the personal experience of research activities during training.1, 12 It is important to avoid spending energy on too many projects that are not of interest. Nevertheless, maintaining a very narrow focus may also be a mistake. The mind of a prospective psychiatry researcher must be open to different influences and be aware of the ‘big picture’ of mental disorders.12

Reading Scientific Literature

The knowledge acquired from textbooks studied during training is already at least 1 year old, at best, due to the time required for the author to finish the manuscript, and for the publisher to print and circulate the book.13 Therefore, in order to keep up to date on the continuous advances in the field, articles published in scientific peer-reviewed journals are of utmost importance throughout the whole medical career. This is particularly true for researchers: the development of valid research hypotheses requires an in-depth knowledge of the updated literature evidence.

Currently, several online databases exist; to access articles of interest, keywords—and sometimes combination of keywords—must be used. Hundreds of abstracts must be screened, among which only a few need to be identified and read in detail. When one or few articles have been identified, it is advisable to go through the methodology of the study first. If this section seems adequate, suggesting that the results can be trusted, then it is worthwhile reading the results, discussion and introduction sections.13 This process requires experience, which can only be acquired by practice and by the guidance of senior experts. In particular, discussing with professors or senior colleagues how a study has been designed, why a given methodology has been used and, possibly, identifying methodological flaws is a very useful exercise for those wanting to learn research methods and to improve research skills. The so-called ‘journal clubs’ (i.e. groups of individuals who meet regularly to critically evaluate recent articles in scientific literature) help students to become more familiar with the advanced literature in their field. In addition, these journal clubs help to improve students' skills of understanding and debating current topics of active interest in their field. Research laboratories may also organize journal clubs for all researchers in the lab to help them keep up with the literature produced by others who work in the same field.14 A continuing medical education course aimed to provide early career psychiatrists with competencies on how to critically read and review scientific literature, and to write scientific papers, is offered by the European Psychiatric Association; see www.europsy.net for further information.

Joining a Research Group

After the self-assessment of research preferences, the next and crucial step is to join a research group. Learning how to undertake high-quality research requires membership of a group that publishes regularly, and offers a rich learning environment. To be part of a research group, team orientation, team spirit, team management skills and the ability to handle one's own tasks are required.15 It is important to become active in the group and to help experienced researchers as much as possible; in turn these will give guidance, mentorship and feedback to younger researchers.

Choosing a Mentor

As in other walks of life, it is very important to choose a mentor who can be a guide and a teacher for young and inexperienced researchers. The role of a research mentor is to be a constant key-point for the young researcher. In particular, mentors should: (i) provide ‘research directions’; (ii) involve young colleagues in writing scientific papers; (iii) introduce young colleagues to public speaking at conferences; and (iv) help them interact with members of the research community. It has been documented that having a good research mentor is one of the strongest predictive factors for embracing a successful research career.16, 17

Participating in International Scientific Initiatives (Congresses, Fellowships, Courses)

Participation in international scientific initiatives is essential for early career researchers. Attending a congress provides the opportunity to listen to inspiring lectures by prominent experts and, possibly, to meet them in person. This may be an occasion to establish contacts with them, to ask for their advice on research and receive their feedback, or to propose that they act as mentors or advisors of one's own research projects. Furthermore, there are several international fellowship programmes and courses for young psychiatrists who want to improve their research skills. These programmes give the opportunity to establish contacts with different research institutions, to work in research centres with advanced technical facilities for research,1 and to acquire expertise in specific research fields. Box 2.1 presents some recent international initiatives aimed at improving early career psychiatrists' skills in research.

Box 2.1 : International Opportunities for Research Training

World Psychiatric Association (WPA) (www.wpanet.org)