I spent my first five years after graduating from psychiatric residency in clinical practice, my income solely derived from the act of providing mental health services to patients. The work was challenging yet fulfilling, often anxiety provoking but profoundly meaningful. The personal growth experienced in honing my clinical skills, as an attending physician, was a truly unparalleled feeling.
But, over this time, I also became increasingly aware of gaps and weaknesses in “real world medicine” and nowhere was this more evident than with my sickest patients. Here my role as a psychiatrist providing care seemed most diminished. Factors such as the part of town they lived in, the kind of social support or health insurance coverage they had seemed to engulf my best efforts to help. I would find myself thinking back to the first year of medical school and a lecture slide depicting the “social iceberg” illustrating how traditional healthcare systems treat just the tip of the proverbial iceberg; that those who most need healthcare often live in impoverished areas, have lower levels of resources, education and people advocating for them and, often, don’t make it into healthcare systems until it is too late.
Inadequately Serving the Under-Served
Now, in real life clinical practice, it was becoming painfully obvious to me that the social iceberg theory held water and I was inadequately serving the under-served. Increasingly I felt compelled to record these disparities and document related clinical outcomes in a way that was significantly meaningful and could ultimately provide solutions for the betterment of patient care. It did not take me long to realize that I did not have the necessary skill set to do this properly so I left clinical practice to join a two-year research fellowship.
It has often crossed my mind that there was an alternate decision that I could have made at that juncture of my career, that is, move my practice to an under-served community and spend the next thirty years plugging at least one of the many gaping holes that need to be filled by a psychiatrist. But my choice to pursue a formal research training route was guided by the enormously influential role clinical research plays in the way we practice 21st medicine — even to the extent of how we measure our effectiveness as physicians. Clinical research and the resultant “evidence base” shapes the opinions of thought leaders, clinical practice guidelines recommendations, what health insurance will cover, government policies and hospital procedures. This, in turn, directly impacts the care we provide to patients.
As physicians, a prerequisite of our training is to have sustained exposure to patients, listen to their stories, and witness the course of their illness along with the inevitable setbacks and limitations of the systems they are treated in. Who then, is better equipped to pose scientific questions, shape clinical research agendas and implement the key findings?
Where are the Physician-Scientists?
The problem is physician-scientists are an “endangered species”. Great minds have already offered many an explanation for this, such as, the increase in women physicians (like me) in the workplace, mounting medical school debt and the length of time it takes to receive grant funding to get a successful research career off the ground. But soon after entering the world of research, and much to my dismay, I discovered what I think is another important reason: the physician-scientist who is able to successfully and simultaneously be both active clinician and clinical researcher is indeed hard to find. Embarking upon the competitive and perilous track toward becoming an independent clinical researcher appears to involve a trade off — a sizable, if not total reduction in the amount of time spent in providing direct patient care. Something, I imagine, is hard for many physicians to stomach.
It is not difficult to see why such a trade off is necessary, in an increasingly competitive clinical research environment conducting influential and meaningful research requires tremendous dedication and diligence. Success often requires relocating to academic communities that are hubs of knowledge and resources so you can keep up to date with the latest developments and move in sync with like minded professionals working in the field. Success requires mastery of the completely different language of epidemiology and biostatistics and a sophisticated understanding of pertinent research methodologies. A prerequisite to having an independent research career is the ability to write for grants and effectively navigate the highly complex systems of the associated regulatory bodies and funding agencies. Success in these endeavors is followed by considerable efforts to disseminate findings via peer reviewed publications, presenting at professional conferences and informing relevant healthcare policies and decision makers. These activities are so utterly time consuming that it is easy to see how direct patient care activities can become marginalized.
The Research-Practice Gap
So, soon after starting research training, my unanticipated secondary dilemma became this: committing to conducting serious research appeared to lie in conflict with my desire to be an active clinician. My need to solve important problems in health disparity was, ironically, taking me further from the very patients I wished to serve. Yet even if I could convince myself that this was a worthwhile trade off for a long term, equally important, if different research goal there was another reason I felt compelled to maintain my clinician identity and that was to avoid what has been called by other disciplines the “research-practice gap”.
An unfortunate side effect of the polarization of the physician-scientist identity appears to be an undesirable gap between research and the practice of medicine. Research theory and hypotheses developed by scientists not actively engaged in clinical work risk losing relevance to the physician in clinical practice. Findings from research studies which have strict eligibility criteria and are time limited do not translate well into clinical settings where patients do not present with straightforward problems and a long term patient-physician relationship is the norm. This research-practice gap can mean that the words of physician scientists, who may not be clinically active, don’t hold much clout in real world settings with physicians who spend the totality of their working day at the bedside, tending to patients. This is being realized and appreciated by grant funding agencies who are now placing more emphasis on personalized medicine and effectiveness studies versus an over reliance on efficacy studies. Also, senior physicians are highlighting the imperative need for a new generation of physician-scientists who are active physicians engaged in innovative patient care as well as scientists involved in structured research studies.
Moving from the Bedside to the Laboratory and back to the Bedside Again
So that is what I am trying to do now—attempting to stabilize my professional identity crisis on the traditional “3 legged stool” of patient care, research and medical education– being an active innovative clinician and a cutting edge researcher and moving from the bedside to the laboratory and back to the bedside again. My approach will, no doubt, have a slower trajectory and there will be negative consequences of not having both my feet firmly planted in one camp. But my decision to take such a risk is fueled by a firm belief that, although the worlds of psychiatric research and psychiatric practice have so many competing differences, they also have vital commonalities and by engaging in both worlds regular priceless opportunities for inspiration and richer meaning will arise.
The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.