Why academic psychiatry is endangered

Across the developed world, recruitment into all areas of academic medicine has declined, not least psychiatry. For Australia and New Zealand, this will have a serious impact on undergraduate teaching, on postgraduate training and on our continuing contribution to research. In the UK, the Academy of Medical Sciences became sufficiently concerned about the situation in academic psychiatry to deploy a high-level working group to find ways of strengthening it. In America, the National Institute of Mental Health concluded that a decline in the psychiatrist-researcher workforce was ‘harming public needs’ (Institute of Medicine, 2005). It subsequently appointed a National Psychiatry Training Council to seek ways to improve the situation. In Australia and New Zealand, recruitment into academic psychiatry is in the same precarious state, although paradoxically this is occurring at a time when the knowledge base is undergoing unprecedented expansion. We believe that the specialty suffers from an unfavourable image among young graduates who see it as remote from the main body of medicine and as dealing with unrewarding patients, views often endorsed by their clinical teachers in other areas of medicine. In 2013, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) admitted 150 new Fellows. It is from within this modest annual denominator that future academic psychiatrists will be derived. We asked heads of psychiatry departments in Australian and New Zealand medical schools and senior academics with an interest in training and teaching whether they think there is a scarcity of future academics. Their response has amply confirmed our concern and encouraged us to seek far-reaching changes.

Present career opportunities

Confronted as we are with this situation, it is useful to examine the larger context. For some clinicians, treating patients is not itself sufficiently engaging as a full-time career. By contrast, working in a university offers a rich variety of professional activity. It allows teaching and research to be combined with clinical work. Contact with medical students and registrars can be highly stimulating and personally fulfilling. In addition, there is the privileged opportunity to investigate what is unknown but potentially useful. Research can become exhilarating and even addictive, characterised as it is by only intermittent success. In time, participation in a small international group having a common research interest becomes a special privilege, leading to sharing of information for the enrichment of everyone’s efforts. Occasionally, the research progress achieved by one fortunate individual becomes recognised internationally as a major contribution. How do such careers develop?

The first stage is when a trainee becomes aware of an interest in research. This may take place spontaneously but is much more likely in a setting where there are senior clinicians themselves active in research. Trainees at this point are exquisitely susceptible to such an exposure, as many of us know from personal experience. The availability of appropriate role models and mentors seems to be crucial (Kupfer et al., 2002; Levinson, 1978). For psychiatry, as in the rest of medicine, it has to be borne in mind that the career situation is unlike law, business or indeed other areas of science. Our trainees are by then in their late 20s or older, have graduated in medicine, worked 1 or 2 years as an intern, then completed the obligatory 5 years of training for the Fellowship. They often have a partner and dependents and will probably have accrued substantial debts and a mortgage. A few recognise that they are strongly attracted to research, but have little understanding of how to get started. Concurrently, the alternatives of well-paid salaried appointments or the autonomy of private practice are compelling attractions, while the alternative of a path in academic psychiatry offers the prospect of a relatively poorly paid training post, followed by a disparity in pay and conditions compared with fully clinical posts for the remainder of the career.

In both our countries, it is at this critical stage that the present academic career path is both uninviting and unhelpful. The National Health and Medical Research Council (NHMRC) ¹ offers Clinical Research Postgraduate Scholarships for medical graduates at a salary of AUD40,057. For the single applicant who is ranked highest, there is the special Gustav Nossal Stipend of AUD47,008. For trainees in general medicine, the Royal Australasian College of Physicians has 14 ‘Research Establishment Awards’ for its trainees to gain a foothold in research, offering supplementary stipends from AUD20,000 to AUD70,000 for 1 year. Our own College offers New Investigator Grants of up to AUD6000, a Research Scholarship of AUD50,000 over 2 years and a number of smaller awards. For more formal research training, an alternative entry point is an NHMRC Early Career Fellowship. These have been established ‘to foster career development at the postdoctoral level by encouraging the beneficial experience of a different research environment’. They are offered ‘to a limited number of persons of outstanding ability who wish to make research a significant component of their career’. ² The salary is about AUD70,000 plus a AUD15,000 loading for medical graduates. A successful applicant typically starts a Fellowship already with a PhD, an average of 12 publications, has had previous NHMRC funding, has presented at international conferences and has more than once been interviewed or written for the media. The success rate for applicants is around 25%. A newly minted FRANZCP would have little possibility of obtaining such an appointment, even if they found the stipend acceptable. NHMRC also offers Career Development Fellowships, with a starting salary of AUD101,000. But these are for people who have ‘a sustained track record of significant output as demonstrated in peer reviewed literature’. In New Zealand, the only specific research training posts are Health Research Council Clinical Training Fellowships which offer a maximum of NZ$80,000 per annum to cover salary and university fees. There are a small number of these shared between all medical, dental and allied health professionals across all specialties. In short, the current prospects for someone starting an academic career in psychiatry are seriously unfavourable.

If the present cohort of senior academics is not replaced, the consequences need to be anticipated. While non-academic clinicians usually make excellent teachers and role models for medical students and registrars, teaching programs are usually led by clinical academics. In addition, clinicians value and rely on the connection with academic centres for their own ongoing professional development and guidance in teaching and assessment. If clinical leadership is lost, then the research-led and evidence-based focus in teaching will be diminished and academic advice on health policy will be diluted. High-quality studies in mental health will continue, but few psychiatrists will be engaged in these, and fewer leading them. Instead, research work will be undertaken by highly trained researchers from other professions, particularly psychology, biomedicine and neuroscience. Many of these staff will not have experienced responsibility for patients. In our own view, the most serious deficiency will be in mentorship and role models because it is that influence on young minds that is so powerful and enduring across generations. There is the added prospect of losing the translation of research to clinical practice, and the noun ‘psychiatry’ will likely be progressively replaced by the term ‘mental health’. This change carries significance.

Action required

The situation requires far-reaching changes, starting with the creation of adequately remunerated career paths in well-resourced institutional settings such as universities, teaching hospitals and academic psychiatry research centres. In Australia and New Zealand, mutually complementary initiatives by key national bodies will be needed, involving the Federal and New Zealand Governments, the universities, NHMRC and HRC (Health Research Council), the Society for Mental Health Research and the Royal Colleges. Such action will require exemplary leadership. It will require the investment of substantial sums over many years because it will take such an interval for any improvement to emerge.

The interventions will need to be positioned at several career stages. The first is to improve recruitment into psychiatry itself among undergraduates. Here, the introduction of electives is known to have an enduring influence (Haviland et al., 1987; Kupfer et al., 2002). Next is fostering interest in interns when they are rotated through psychiatry after graduation. Then, among those who go on to start Fellowship training, what is most effective in recruiting likely researchers is exposure to mentors. It is they who, by their own behaviour, foster an enquiring attitude to everyday clinical issues, so that all trainees, irrespective of their subsequent career, become ‘educated consumers of research findings’ (Burke et al., 1986). From within this pool, our best young minds then need to be identified and offered the scientific environment in which they will flourish. That environment needs to be strong in mentorship, research methodology and biostatistics, a situation that exists in only a small number of centres. For example, one of us (SH) secured a full-time appointment in the MRC Psychiatric Epidemiology Unit at the Royal Edinburgh Hospital, Scotland where, as a member of its scientific staff for 4 years, set in a department with a wide research agenda, he was exposed to a fresh way of thinking and the methods for tackling significant questions, while paid a senior registrar’s salary. It was a profoundly formative experience after being a psychiatry registrar in Sydney in the 1960s. This can be one way towards an academic career after clinical training. But it requires the existence of such appointments in an appropriate scientific environment.

What is required is an academic milieu in which early career researchers and academics can be immersed and coated with academic zeal. This would ensure positive modelling of various styles of academia. It would also provide multiple opportunities to pursue different career pathways within academia – wholly research, partly research and partly teaching, partly academic and partly clinical – which can be either in the public or private sector. It would also provide the necessary support in the early years when academics have yet to establish roots and need to remain more mobile so as to find ‘sunlight’ – in the form of pursuing training, research grant and mentorship opportunities.

In centres where research programs are already in action and high-quality supervision available, appointment as a staff consultant with some time for research is one career option for the aspiring academic, but clinical commitments in such posts inevitably make serious erosions on the working week. We believe that the best path is for the trainee to have a full-time clinical research fellowship in a centre of excellence, with a salary in no way disadvantaged compared to full-time clinicians. There they will acquire some of the attributes Burke et al. have described for the clinician researcher: an intellectual orientation, learning what research questions to ask and how to ask them, technical research skills, the management skills so essential to the survival of a research program and, finally, strategies to maintain motivation in themselves and their colleagues throughout a project. It is in such settings that the next generation of academic psychiatrists has the best chance of evolving. Very much in accord with the above, the UK Academy of Medical Sciences ³ has made recommendations in three areas: to enhance recruitment to academic psychiatry; to increase research opportunities including doctoral research in optimal settings during clinical training; and to integrate psychiatry with other neuroscience disciplines.

Psychiatry shares the same predicament that the rest of medicine is experiencing. In view of the current parlous situation, it is encouraging that there has been sufficient recognition of this problem across the various Australian specialty colleges that a summit has been conducted in 2014 – in conjunction with Medical Deans Australia and the Australian Medical Association (AMA) – to establish an integrated training pathway for clinical academics. It is also to be welcomed that the recently established Australian Academy of Health and Medical Sciences is considering what far-reaching initiatives are now needed. Clearly, the resources and influence necessary for success can be marshalled only through an effective coalition.

A coalition of the willing

1. In universities, we need to ensure that our teaching and student experience is as rewarding and stimulating as possible, and conveys the intrinsically interesting nature of the underpinning science.

2. Our College needs to argue that trainees receive adequate exposure to positive clinical outcomes (i.e. they observe patients getting better and are able to experience a broad range of clinical disorders in a variety of settings). There also needs to be the opportunity for trainees to spend time training in academic activities such as research and teaching of medical students.

3. Our governments (state and federal) need to provide academic psychiatry training and to ensure that mental health is adequately resourced and that research into mental illness becomes a high priority.

4. The funding of academic units must allow for succession planning through appointments at lecturer, senior lecturer and associate professor levels.

5. Finally, all of us need to strive towards destigmatising psychiatric illness and this requires the engagement of consumer groups and the continued prioritising of education about mental health from an early age in schools via programs such as MindMatters and KidsMatter.

If we fail to achieve these goals, no longer will we be endangered but extinct.