My Journey as a Clinical Scientist

John March, M.D.

I am delighted to be asked to contribute a short piece for the DevelopMentor on why to choose a research career in child and adolescent psychiatry.

I came late to research, having hopped around more than a little between molecular biology, epidemiology and family medicine before becoming an academic child and adolescent psychiatrist. My friends and family wondered if I'd ever settle down, but the path I took turned out to have broad application to a career as a clinical scientist in a field where these are exactly the skills that are driving progress in the care of youth with mental illness.

So what makes a researcher and why become one?

First, one must be bitten by the science bug. Clinicians (like their patients) tend to want certainty or, put in practical terms, want to sift quickly through the clinical story to a diagnosis and treatment that will help the patient suffer less. Scientists, who tend to like uncertainty, prefer to wander off beyond the boundaries of what is known, but to do so experimentally so that there is an individual and corporate check on what is thought to be true. Carl Sagan nicely captured the wonder of scientific exploration when he said: "I maintain there is much more wonder in science than in pseudoscience. And in addition, to whatever measure this term has any meaning, science has the additional virtue, and it is not an inconsiderable one, of being true." In practical terms, this means that work (my academic life) doesn't feel any different than play (sea kayaking is my current passion) and, in fact, I'm just as likely to be sitting in my kayak on a 3PM conference call in the middle of Jordan Lake as I am to be writing grants at home at 3 in the morning or seeing patients on clinical trials in my office at Duke. Science isn't a job, it is the best kind of play.

Second, be clear that science is service work. When I was in graduate school in molecular biology at Berkeley my major professor used to scoff at the three P's: power, prestige and profit, any one of which is anathema to good science. In point of fact, academicians generally make less money and spend a lot of time getting rejected. It helps to have a thick skin when your grants get triaged, your papers rejected and your ideas criticized. But then again, the competition among ideas over time is what makes science so exciting and rewarding. Someone once said that advances are made by answering questions, discoveries by asking them. Clinical research is about advances. From a motivational point of view (at least for me), clinical research is service work very much in intention like serving meals at the homeless shelter. The work we do benefits children with whom we work and whom we'll never meet. This opportunity is one for which I'm more than grateful, which I point out when consenting patients for our research projects. It is the relatively few patients who are willing to participate in our research projects who deserve all the merit, not us scientists. Without them, we'd be unable to learn anything.

Third, becoming a scientist requires early career discipline in the interest of long term job satisfaction. It used to be held that one could do clinical psychiatry, raise a family and complete analytic training. Oh, and be a researcher, all at the same time. Not any longer. At a recent NIMH conference on the assessment of depression, I gave a complex talk on sources of measurement error in clinical trials that relied on some fairly sophisticated statistical concepts. In the middle of discoursing on the perils of autoregressive data structures, my computer died causing me to quip that today's researcher needs to be an expert clinician, understand scientific methodology and be a gifted teacher, oh, and yes, it helps to be an accomplished AV technician.

Each of these is a separate skill that takes considerable effort to master. Without clear short- and long-term goals and the dedication and self-discipline to bring them to fruition, it is next to impossible to collect the requisite skills. Most importantly, the aspiring researcher needs to cheerfully make a variety of personal sacrifices in order to gain the long term goal of becoming a clinical scientist. Given that doing science is so rewarding, it actually isn't that hard, but it does take some reminding to do the important, necessary things in preference to frittering away time on urgent but unimportant stuff or time wasting activities like watching TV. If you recognize Steven Covey's Seven Habits, you're on the right track. For me this means that I do science, spend time with my family, meditate regularly and stay fit. Most everything else (birding, reading novels, non-academic travel, among other hobbies) will wait until retirement.

Fourth, your family has to be willing to put up with the sacrifices. Most physicians don't complete residency training knowing much about research. To acquire research skills means a research fellowship or a career development award. Not always easy on top of making a living, growing a family and taking care to meet all the other demands of daily life. Particularly at the beginning, it is important for one's family to fully subscribe to the long-term goal of building an academic life. The payoff: exciting and interesting work, the chance to live in a college town, friendships with colleagues from around the world and the opportunity to travel academically and at the same time to vacation together as a family. Job satisfaction surveys routinely show that academics have higher job satisfaction and, at least in my experience, their spouses and families in the long run are grateful for the opportunities that the academic life provides.

What to do if you're interested in a scientific career? Perhaps the most important thing is to seek out a mentor, someone who is experienced and willing to help nurture you along your chosen path. In addition to my Dad, who as a scientist showed me the joys of science from a very early age, I've been especially fortunately to have three experienced mentors-- John Greist, Keith Conners and Edna Foa-each of whom has become a close personal friend. While John would have liked for me to stay at Wisconsin, he pointed me to Duke as a place where I could develop as a researcher, saying the field needs you more than we do. I know of no better example of what it means to be a mentor than this. Not incidentally, the Academy has a variety of mechanisms for jump-starting medical students, residents and fellows who are interested in research careers. So does the NIMH. Every one of them involves some form of mentorship. I'm particularly excited about the Early Investigator's Group sponsored by the Workgroup on Research, but there are many other opportunities for those interested.

The opportunities in Child and Adolescent Psychiatry to do exciting science and meaningful clinical work are greater now than ever before. Just think about how neuroimaging and genetics as well as the dramatic advances in neuropsychopharmacology and cognitive-behavioral psychotherapy are quickly driving improvements in patient care. Fifteen years ago, my supervisors told me not to bother with OCD-it was untreatable. Today, we have proven cognitive-behavioral and medication treatments and soon we will understand their relative benefit alone and in combination. We're getting ready to move to treatment-addition studies to learn how best to manage partial response and to neuroimaging studies that promise to tell us how the cortico-striatal-thalamo-cortical circuits that mediated the symptoms of OCD respond differentially to drug and psychological treatments. As my teenage daughter would say, "How cool is this!"

You too can be a part of moving our field onto a sound scientific platform. Whether you practice clinical medicine or embark upon a research career, choose science as the foundation of your clinical practice. Best of all, become a scientist yourself. Within medicine, there is no higher calling than to contribute to the body of scientific knowledge that we all rely upon in the care of our patients.