A Sign of True Innovation in Psychiatry: Success Beyond Academic Centers

While attending this year’s annual Neuropsychiatric Association meeting, I decided to attend the neuromodulation special interest group. At clinical conferences, there are usually opportunities to get involved with colleagues who share more niche interests—things like TBI, early career neuropsychiatry, or neuromodulation.

When I walked into the room there were about 20 men and 3 women. As we went around introducing ourselves, I realized that everyone except me was affiliated with an academic institution, and most were trainees (residents or fellows).

As a rural psychiatrist, I don’t often find myself in environments like this. Most of my work happens with my nursing and social work colleagues on a 10-bed unit in a town of about 5,000 people - far removed from the academic medical centers where much of this research happens.

One of the participants, a resident in a combined neurology/psychiatry program (a five-year residency after four years of medical school), asked about the necessity of a formal one-year fellowship in brain stimulation that was being announced to the group. The interdisciplinary fellowship would be available for physicians who had completed neurosurgery, psychiatry, or neurology residency and wanted additional training in emerging neuromodulation treatments—deep brain stimulation, vagus nerve stimulation, transcranial magnetic stimulation, electroconvulsive therapy, and +/- ketamine.

What I found most interesting was the resident’s concern that another fellowship might create more siloed care and potentially limit access if only fellowship-trained clinicians were able to offer these treatments.

The neuropsychiatrist presenting the fellowship responded that it isn’t ideal for clinicians to learn TMS in a three day course. His argument was that a fellowship allows trainees to develop expertise across multiple neuromodulation modalities rather than just learning one tool.

I can see the merits of a fellowship like this, and it makes sense for certain career paths. But what struck me was how the conversation framed things in somewhat black-and-white terms: either someone is fellowship trained at an academic center, or they take a three-day TMS course.

The reality is that most psychiatry isn’t practiced in academic centers.

Many of us learn about neuromodulation after residency. We read, attend conferences, talk with colleagues, and gradually expand our skill sets over time.

It made me wonder what it would look like if we created more informal, longitudinal learning opportunities for psychiatrists, neuropsychiatrists, and behavioral neurologists who want to continue developing skills in neuromodulation while practicing in the real world.

What if special interest groups weren’t primarily focused on trainees, but also welcomed practicing clinicians who want to stay engaged as the evidence for these treatments continues to grow?

My goal isn’t to offer deep brain stimulation. But I do want to understand what is being studied, how these treatments are used at academic centers, and when I should be referring my patients for them.

What felt important to me in that moment was simply being in the room.

That trainees could see that psychiatrists practicing outside of academic centers - sometimes in small rural hospitals - are still learning and expanding their toolkits.

Medical training is already long and demanding. For many physicians, adding another fellowship after residency isn’t always realistic, especially if the goal isn’t to become the leading expert in a very narrow area.

Innovation in psychiatry doesn’t belong only in academic centers. If these treatments are going to reach patients, clinicians practicing in community hospitals and rural settings will have to stay engaged with the science and keep expanding their toolkits.