Concerns about the declining numbers of physician-scientists have existed for several decades. The ‘clinical investigator as an endangered species’ was first mentioned in 1979 in the eponymous paper by future NIH director James Wyngaarden . Twenty years later, Leon Rosenberg aptly called physician-scientists as both ‘endangered and essential’ and continued to identify some of the underlying challenges and possible solutions . In 2016 the National Institutes of Health (NIH) convened a series of workshops to update programmatic, system-wide solutions to the enduring challenge of clinician-investigator recruitment and retention . The percentage of US physicians engaged in patient-oriented research has steadily declined for the past 30 years, from a peak 4.7% in the 1980s to 1.5% as of 2012 [5, 6]. A variety of reasons have been posited for this decline, including: an increasing portion of students with a large academic debt, an increase in the amount of time required to prepare for a research career; and the perception by physicians that they may not be competitive with PhDs.
For psychiatry, the decreasing number of physician-scientists is especially problematic. Viewed in light of challenges such as the public health costs of mental illness, addiction and an aging population, as well as opportunities to utilize scientific advances to improve prevention, early intervention and treatment of psychiatric disorders, the need for psychiatrist-researchers is particularly urgent. In addition to the common concerns about personal economic disincentives and long duration of training, medical students and psychiatry residents face limitations in the availability of appropriate research education and training opportunities.
The need in the area of child mental health is particularly great given the shortage of child and adolescent psychiatrists (CAPs), the prevalence and diversity of child and adolescent mental disorders, their public health costs, and their potential long-term impact on society. One quarter of the U.S. population is under the age of 18, and at least 13% of these children and adolescents (some 15 million individuals) have diagnosable psychiatric disorders [7,8,9]. Nine to 13% of U.S. children and adolescents meet the definition of a ‘serious emotional disturbance’ . However, in 2017, only about one in nine emotionally disturbed U.S. children and adolescents received any mental health services . It is estimated that there is only one CAP per 1807 children and adolescents who are in need of mental healthcare . As of 2016, no state in the US has what professional groups would deem a sufficient number of CAPs to serve children in need .
Mental illness in childhood is costly and a burden to society, especially when the costs associated with human services, educational interventions and juvenile justice interventions are added to those of psychiatric and mental health services. For example, the estimated 1998 annual expenditures for mental health services (specialty mental health and general health sectors) was $11.8 billion, or about $173 per child. This is nearly a threefold increase from the 1986 estimate of $3.5 billion (not accounting for inflation). However, a recent analysis that encompassed youth overall (ages 0–24) and not just mental health service costs, but also health, productivity, and crime costs associated with mental illness in youth, estimated the annual expenditures in 2007 at closer to 247 billion . Although early diagnosis and treatment can help to defray societal costs of mental illness among children, many go undiagnosed  due to lack of access to mental healthcare services, and instead end up in the juvenile justice system . Of the 2 million children arrested each year, an estimated 50–75% have a mental health disorder .
More physician-scientists are needed to pursue research careers to understand the pathogenesis, treatment, and prevention of this costly set of disorders. Future progress depends on the recruitment, training and support of: (1) CAPs, pediatricians, and psychologists who are conversant with advances in genetics and the clinical neurosciences; and (2) basic scientists in the neurosciences and human genetics who are familiar with the phenomenology of childhood-onset neuropsychiatric disorders and who can utilize this knowledge as they approach potentially relevant basic science problems. Research educational programs are needed that can introduce scientific advances and prepare physician-scientists for interdisciplinary careers through the acquisition of advanced degrees and working collaborations with scientists in related fields.
The traditional model of training in psychiatry provides only limited opportunities for medical students and residents to participate in child and adolescent clinical services. That approach also does not typically encourage trainees to pursue formal training in research. As a result, promising medical students who have both a passion for research as well as a commitment to the wellbeing of children and adolescents have few opportunities to pursue these goals immediately following their graduation from medical school. There certainly have been laudable and varied approaches to enhance research literacy and training during psychiatric residency [17,18,19,20] and CAP fellowship , but it is not clear that such interventions have had a long-term impact in the number of independently funded researchers, and particularly in the clinician-scientist tradition. There are inadequate numbers of medical students pursuing specialty careers in academic psychiatry; there is insufficient mentoring at all career levels; and there are far too few institutional and departmental resources devoted to this enterprise. In fact, only about 25% of medical students have a clinical experience in CAP during their psychiatry rotation, leaving them largely unaware of the field and resulting in a large gap in the recruitment and education of future child and adolescent psychiatrists overall , including CAP physician-scientists. Although the majority of medical schools have CAP electives, fewer than 5% of medical students participate in them and the required medical student didactics in CAP are minimal . Innovative approaches to increase the exposure of CAP during medical school have proven effective in raising awareness about the field , including its research opportunities, and in enhancing recruitment into psychiatry .
To address these educational challenges in psychiatric residency, we crafted, with the assistance of a national task force appointed by the American Academy of Child and Adolescent Psychiatry (AACAP), a model curriculum aimed at providing newly graduated physicians with an integrated program that combines training in child and adult psychiatry with early and ongoing formal and ‘hands on’ training in research. [25, 26] The enrollment of a sixteenth cohort into this program provides an opportune time to evaluate the outcomes of its trainees and graduates.
We hypothesized that graduating medical students enrolled into this integrated training program, when compared to peers who were similarly ranked in our original match lists but ultimately pursued residency programs elsewere, would result in a higher rate of clinician-scientists dedicated to careers in child and adolescent psychiatry, and in higher metrics of academic productivity and scientific independence.