September 2003
Volume 16, Number 9
The Many Roles of a Research Psychologist in a Medical School
For more than 10 years I have worked as a non-clinical psychologist in a medical school department of family medicine. My colleagues are 15 physicians (many with master's degrees in epidemiology), six physician associates, and faculty with a variety of auxiliary degrees (anthropology, clinical, cognitive, and educational psychology, home economics, gerontology, clinical social work, library science, physiology, anatomy, pharmacology). They run a clinic and an academic department, train medical students, residents, and physician associates, and perform research.
My research and teaching are about medical decision-making - specifically, decision analysis and the psychology of particular decisions made by physicians and patients. In informal settings, I also teach clinicians research methodology and the interpretation of research, codified as "evidence based medicine."
A psychologist considering working at a medical school should read the analysis by Fang and Meyer (2003) that shows the increasing role of PhD scientists in medical schools, particularly in clinical departments. The study attributes this not only to our applicable research training, but also to the pressure on MD faculty to bring in clinical income, which limits the time they can devote to research. The study also discusses the possible status differences between MDs and PhDs, though it has no data on salaries.
The authors were surprised at the number of psychology PhDs in clinical departments. They note that psychological training in quantitative analysis and research methods can easily be transferred to clinical research, but still find it hard to account for. Therefore I want to give a sense of what this psychologist does - not only the content of my research and teaching, but also the relationship I have with my colleagues around those activities.
My psychology field is judgment and decision-making. My central role here in the medical school is to study how physicians should correctly make decisions versus how physicians and patients actually make decisions (e.g., Hamm & Smith, 1998). My projects have studied patient decision-making about particular economically important decisions concerning cervical, breast, and prostate cancer screening. How should the advantages and disadvantages of screening be communicated (McFall & Hamm, 2003)? How do patients perceive the communications, change their behavior, or react when they get a positive screening test result? To incorporate my abiding research interests, I include questions on people's perceptions of probabilities and other decision relevant information.
My identity as a psychologist is brought into play in many ways besides the research projects. As a teacher, I am a small group discussion leader in a second year medical student course on ethics that uses, in part, the Problem Based Learning approach. Socratic discussion of particular cases that present difficult dilemmas, such as "which of these imperfect patients should get the life saving transplant, and by what principles?" gives me an opportunity to engage students with the concepts of my field. I also run a 10-week summer research program involving medical students (and others) in clinical research, which examines questionnaires and other research methods, as well as statistics and research design. This is probably the only experience in clinical or behavioral research methods that they'll get during medical school.
A disadvantage for a psychologist teaching in a medical school is that you have no intellectual children; that is, people getting the same degree, focused on learning fundamentally the same field as you. In Europe the male dissertation advisor is called the "doctor father;" the psychologist in a medical school is more like an aunt or uncle. Among my many research assistants there have been a few psychology graduate students. I take pleasure as any of them move on, whether to medical school, physician associate school, jobs in epidemiology, or even clinical research in other (better paying) departments on campus.
My family medicine department offers a very collaborative role. Some of my colleagues are research amateurs, motivated by their interest in particular diseases; others are very methodologically sophisticated, but they have little time. To many of them, I represent all of psychology (including clinical, personality, educational), all of statistics, and all of research methodology. Gaps in my knowledge become their gaps. If I don't talk about it, they may not use it.
My most cited paper is one of these collaborations (Hamm, Hicks, & Bemben, 1996). Hicks had a passionate objection to the pharmaceutical sales force-driven use of antibiotics for patients with viral colds. The treatment doesn't work - in fact it promotes drug resistance - but doctors give antibiotics because they think patients want them. Our study asked patients with colds what they had wanted before they saw the doctor, then asked the doctor what the patient had wanted, what had been diagnosed, and what had been prescribed. Then we revisited the patients, asking how satisfied they were, whether they got what they wanted, how much time the doctor spent explaining the disease, and what prescription they would expect next time. We found that physicians don't guess patient expectations very accurately, patient expectations are rather malleable, patients are more satisfied when the physician explains things than when the physician prescribes antibiotics, and if the physician prescribes an antibiotic, the patient will expect one next time. As a result, I continue to be invited to review papers on physicians' treatment of colds. This shows that you don't know which application of your psychological methodology is going to gain you recognition.
A side effect of playing the helper role is that it draws attention from my central research interests. Recently I reviewed the promotion package of a psychologist in a department similar to mine. Her CV had an incredible variety of work, but where was the focus? Understanding and identifying with her situation, I read the papers and found the unifying theme, the common questions and methodological approach. This dispersion of focus is a disadvantage of the psychology career in the clinical medical school department, but it seems to come with the territory.
Given all this, I was surprised by a recent conversation with a friend who has been a full professor in a psychology department for decades. He wanted to shift to a job like mine! He spoke of the burdens of repeating the same courses for younger and younger students, the triviality of the behavior that is accessible in the psychology lab, as well as a lack of collaboration with colleagues. Maybe we should switch places for a sabbatical! I would probably be very happy to return home. But with luck, maybe he would want to stay and work in my department! Though not perfect, mine is still a pretty good academic life.
References
Abernathy, C M, & Hamm, R M. (1995). Surgical Intuition. Philadelphia, PA: Hanley and Belfus.
Fang, D, & Meyer, R E. (2003). PhD faculty in clinical departments of U.S. medical schools, 1981-1999: their widening presence and roles in research. Academic Medicine, 78(2), 167-176.
Hamm, R M, Hicks, R J, & Bemben, D A. (1996). Antibiotics ande respiratory infections: Are patients more satisfied when expectations are met? Journal of Family Practice, 43, 56-62.
Hamm, R M, Loemker, V, Reilly, K L, Johnson, G, Dubois, P, Staveley-O'Carroll, K, Brand, J, Owens, T, & Smith, K. (1998). A clinical decision analysis of cryotherapy compared with expectant managagement for cervical dysplasia. Journal of Family Practice, 47, 193-201.
Hamm, R M, Scheid, D C, Smith, W R, & Tape, T G. (2000). Opportunities for applying psychological theory to improve medical decision making: Two case histories. In G B Chapman & F A Sonnenberg (Eds), Decision Making in Health Care: Theory, Psychology, and Applications (pp. 386-421). New York: Cambridge University Press.
Hamm, R M, & Smith, S L. (1998). The accuracy of patients' judgments of disease probability and test sensitivity and specificity. Journal of Family Practice, 47(1), 44-52.
McFall, S L, & Hamm, R M. (2003). Interpretation of prostate cancer screening events and outcomes: a focus group study. Patient Education and Counseling, 49(3), 207-218.
