Reviving the ethos of scientific research in psychiatric practice

We present an argument for revival of the ethos of scientific research in psychiatry in the form of practical wisdom, known in ancient Greek philosophy as phronesis. In his Nicomachean Ethics, Aristotle describes several states of knowledge. These include: craft expertise (techne) or the knowledge derived from skilful practice; science (episteme) or the knowledge derived from deduction; intuition (nous) or the knowledge derived from experience; theoretical wisdom (sophia) or the understanding of universals; and practical wisdom (phronesis) or the understanding of particulars (Aristotle, 1934). While each of these modes of knowledge can be observed within psychiatry to some extent, it is phronesis in the guise of sound clinical judgement that defines not just competence (enkrateia), but excellence (arete), in the practice of psychiatry.

Following on from Aristotle’s observations, good clinical judgement may be said to have its basis in the conjunction of both knowledge and experience (Looi, 2007; Montgomery, 2005; Schwartz and Sharpe, 2010). Consider, for example, an elderly man consulting a psychiatrist with a moderate melancholic depression, who has had minimal response to a series of selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants. Based upon clinical experience and consideration of the evidence base, the psychiatrist considers treatment with a tricyclic antidepressant (TCA) or monoamine oxidase inhibitor (MAOI), measures the patient’s blood pressure and orders an electrocardiogram (ECG). Given the difficulties the psychiatrist knows patients often experience with the dietary restrictions of a MAOI, clinical experience favours the selection of a TCA; pharmacological science prompts the recommendation of an ECG to exclude arrhythmia. The proposed course of action is then explained in a manner understandable to the elderly man and his wife, as well as the concerned eldest daughter. This is a small sketch of the dialogue between knowledge and experience that is wisely synthesised to form a clinical outcome in the practice of psychiatry.

What has become clear in the centuries since Aristotle is how profoundly the methods by which skill and knowledge are generated can influence their content, and also their meaning in developing a skilled practitioner (Crawford, 2009; Sennett, 2008, 2012), or in our case, a psychiatrist. In other words, science in its modern form cannot be equated with episteme; rather, it is a complex product of techne, episteme and nous that may be best regarded as a fully fledged field of practical wisdom in its own right. We therefore advocate strategies to develop a phronetic appreciation of science in psychiatric training, as well as discussing proximal and distal processes that may be implemented to this end.

Currently, the epistemic element of science is retained in psychiatric training, in the form of didactic scientific knowledge. However, the practicalities of generating scientific knowledge must be understood for a comprehensive scientific phronesis. For a full understanding, this necessitates training in, and production of, scholarly research to allow practical experience in the science relevant to psychiatry. Against an environment of resource shortfalls and increasing workloads, there has been pressure to jettison any aspect of psychiatric training not immediately related to provision of care. Thus, scientific training and scholarship have been neglected. A narrow focus on training for clinical practice, and neglect of the ethos and praxis of scientific research, threatens to stunt the future scientific advance of psychiatry, and thus the development of improved care for our patients and their families.

Presently, there is a dearth of scientific training and, subsequently, psychiatric research in Australia and New Zealand, outside of core academic centres at major universities. The contrast with our specialist physician colleagues could not be starker. This speaks to the ethos of specialist medical training. The Royal Australasian College of Physicians (RACP) (2012) facilitates medical research through extensive grants schemes for new researchers and thus the provision of opportunities to conduct research. The Fellowships and Scholarships are available to Fellows and Advanced Trainees of the College, its divisions, faculties and chapters. The majority of awards are designed for Fellows or Advanced Trainees at an early stage of their careers and strong preference is given to these applicants. The RACP Foundation is supported by a wide range of funding sources (Royal Australasian College of Physicians, 2012). These include Fellows and Trainees who contribute by way of an ‘opt out’ donation at the time of their membership renewal. There are also corporate donors, including pharmaceutical companies, but also non- pharmaceutical, such as Australia Post. Institutional donors include foundations that focus on specific diseases such as the Australian Rheumatology Association, Diabetes Australia, or Osteoporosis Australia. Finally, there are individual bequests. Although donations may be targeted at specific illnesses, settings or purposes, all the proposals are investigator-initiated (as opposed to drug company trials) and assessed by the College’s Research Advisory Committee with no input or influence from donors, including pharmaceutical companies.

Medical research is also strongly encouraged in RACP training in general, and research degree enrolment is favourably viewed. In the appointment of new specialist physicians to health services, there is preference given to those having completed a research degree, particularly those done overseas, as a sign of the calibre of the medical phronesis that the physician will contribute. That the RACP has established charitable foundations to fund medical research, under its aegis, demonstrates that the College recognises a key role in developing and supporting its physicians as researchers; part of a broader phronesis. This support suitably prepares specialist physicians to be eligible to apply for major research grants to conduct larger scale research, such as National Health and Medical Research Council of Australia grants.

The situation in psychiatry is considerably different. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) does offer New Investigator grants and a Trainee Presentation Award at the College congress to encourage research by Trainees and new Fellows. However, the teaching hospitals and community health services, where we train and work as psychiatrists, are inimical to the conduct of research because of clinical workload and resource shortfalls. Thus, trainee psychiatrists, even with the availability of small stipends, lack time in which to conduct research. Most extant psychiatric research is based in university departments of psychiatry affiliated with established medical schools, and conducted by academic psychiatrists. As a result of the limited opportunity for research, it is difficult for psychiatrists to develop a sufficient research profile to compete for grants. Consequently, in contrast to internal medicine physicians, there are few academically qualified psychiatrists in health services to mentor and foster research. Whilst the RANZCP also recognises a key role in developing and supporting its psychiatrists as researchers, practically our Fellows lack opportunity (particularly time) and grant support relative to physicians.

The National Health and Medical Research Council of Australia (NHMRC) spends approximately $60 million dollars per year on mental health research. It is therefore ranked fifth behind cancer (c. $180 million), prevention (c. $150 million), cardiovascular (c. $110 million) and diabetes (c.$70 million) – and yet mental health is termed a priority (NHMRC, 2011b). Where additional funds have been made available, these have focused primarily on the prevention of, and early intervention in, mental illness in children and young people (NHMRC, 2011a); and yet mental illness in adults and older persons and other contexts also warrants similar funding. The success rate for all grant applications in 2010 was only 23%. In New Zealand, while mental health is a government priority, it is not yet a specific priority for the country’s Health Research Council, and the proportion of research funding in psychiatry is less than in Australia (Ministry of Health, New Zealand, 2005). Without scientific training, psychiatrists will continue to lack the experience, track record and research degrees that are necessary for major grants.

The practical implications of a dearth of scientific training for clinical practice are manifold. Advancement of medical science is predicated on basic and applied research. As clinicians, psychiatrists can contribute a unique perspective, based on both broad and specific training, to medical research. Without the lived experience, or nous, of psychiatric research, a sophisticated understanding of scientific research relevant to psychiatry is not possible. Without the involvement of psychiatrists in research, the science underlying our clinical practice will not be able to advance. In addition, with a lack of in-depth understanding of the scientific method, psychiatrists will not have the skills to consider the scientific literature critically, and will not be able to make good judgements about clinical practice. It is imperative for psychiatrists, their patients and patients’ families that psychiatry does not fall behind other fields of medicine in its ability to deliver the best possible care. Scientific training, scholarship and increased psychiatric research are essential.

To revivify psychiatric phronesis, we advocate the re-integration of scientific training in the vocational training of psychiatrists, so that the development of scientific skills and experience parallel the acquisition of clinical skills and experience. The grounding of education in the CanMEDS competency of scholar (Royal College of Physicians and Surgeons of Canada, 2011), adopted by the RANZCP (2012) as part of the Competency Based Fellowship Program, is a start. However, good scientific research requires resources. We advocate for an increased number of New Investigator grants to fund research by trainee psychiatrists whilst developing experience and skill. For those trainees and psychiatrists inspired by such research experience to contribute further, we advocate for the funding of Early Career Fellowships. These Fellowships should be of sufficient number and duration to allow for the completion of research degrees, such as masters or doctorates. Additionally, the stipend for such scholarships should adequately reflect the opportunity cost in forgoing, temporarily, full-time specialist practice.

To bridge the gap to major grant eligibility for trainees and psychiatrists, the RANZCP has a Research and Education Foundation. This currently funds the Trainee Presentation Award at the RANZCP congress, and New Investigator and Block Family grants. The capacity of the foundation could expand if the RANZCP would actively seek donations for psychiatric research. The RACP provides one model of how this might be achieved in practice. The RANZCP, as an advocate of consumer and carer representation in specialist medical training, is well placed to partner with the community in fund-raising to support psychiatric research by psychiatrists, in collaboration with those affected by mental illness. The lesson from the experience of the RACP is also that this should form part of a range of funding sources that should also include institutional and corporate donors. Conflicts of interest can be managed by the assessment of applications at arms length by independent experts. The example of Australia Post’s sponsorship of research into melanoma, as well as breast and prostate cancer, shows that this need not be limited to the pharmaceutical industry.

In conclusion, we advocate for the re-integration of clinical experience with scientific nous and episteme as a foundation of psychiatric phronesis. Knowledge of the science of psychiatry is developed partly didactically (episteme), but only through practical participation in research and scholarship can the full extent of that knowledge (nous) be assimilated. Practical participation in the production of scientific knowledge, leavened by clinical experience, is crucial for the application of science (techne) in the exercise of wise clinical judgement (phronesis). These aims can be achieved by inclusion of scholarship in practice at all levels of psychiatric training and continuing education, together with developmental funding for scholarship and research, towards the development of excellence (arete) in care of the community. Our science is long in complexity and wise clinical judgement is hard-won, requiring dedicated didactic and practical learning – as it has been since the origins of medicine, when Hippocrates observed:

Life is short, science is long; opportunity is elusive, experiment is dangerous, judgment is difficult. It is not enough for the doctor to do what is necessary, but patients and attendants must do their part as well, and circumstances must be favourable.

(Hippocrates, 1983, p.206)