Careers in academic forensic psychiatryBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39420.527731.CE (Published 05 January 2008) Cite this as: BMJ 2008;336:s3
- Simon Gibbon, clinical lecturer in forensic psychiatry ()1,
- Conor Duggan, professor of forensic mental health1,
- Matthew Langley, foundation year doctor1,
- Najat Khalifa, clinical lecturer in forensic psychiatry2
Simon Gibbon and colleagues give an overview
Forensic psychiatry is a subspecialty of psychiatry that deals with the assessment, treatment, and rehabilitation of mentally disordered offenders.1 Academic forensic psychiatrists combine clinical work with an academic role. One of the main attractions of this specialty is successfully combining a caseload of complex patients with high quality research and teaching.
There are few academic forensic psychiatrists, with seven professorial posts (in London, Nottingham, Manchester, Cardiff, and Newcastle) and eight lecturer posts in the United Kingdom. Other senior academic posts (reader and senior lecturer) are available elsewhere in the UK. In addition there are single senior academic posts in forensic psychotherapy, forensic child and adolescent psychiatry, and forensic learning disability.2
Although a strong case exists for the development of academic psychiatry, there have been concerns about the difficulty in attracting and retaining good candidates. A recent policy document from the Faculty of Forensic Psychiatry of the Royal College of Psychiatrists stated: “Demands for training new clinical specialists, for evidence for service provision and for skills to evaluate service delivery are at an all time high, but there is a crisis in academic forensic psychiatry. There is particular concern about the small and reducing number of specialist academic trainees.”2
In common with most other branches of academic medicine, training in academic forensic psychiatry has been affected by the research assessment exercise and Modernising Medical Careers. The research assessment exercise is a system of “payment by results” whereby university departments are partly funded according to the amount of research funding that they can attract and their research output, with publications in “high impact” journals scoring more credit. This system has been criticised for undervaluing clinical research and disadvantaging specialised research work.3 It may have a special impact on “orphan specialties” such as academic forensic psychiatry because research may have reduced impact for generalists. The government has now announced that the research assessment exercise will be abolished.4
The relatively small size of the specialty means that much current research is descriptive rather than hypothesis based. Relative lack of a basic knowledge base makes it much harder to develop methodologically sound studies (for example, it is difficult to estimate effect size or perform a power calculation). This impacts on funding as funding bodies are disinclined to support less theoretically driven research. Lack of funding makes it harder to develop a basic knowledge base, and so the situation perpetuates itself. Without funding from the drug industry or patient charities, a substantial portion comes from central government. This money, although welcome, is subject to politics and may be given for pursuing public protection rather than patient treatment.
Complex ethical issues are often associated with research on patients who are detained in secure hospitals or at risk of harming others. Our patient group tends to be complex, with a history of serious offending combined with substantial comorbidity (such as schizophrenia in combination with personality disorder and substance misuse), making it harder to isolate independent variables. Trials of treatment may also be constrained by legal, political, and risk management issues.
Most forensic psychiatrists have the opportunity to earn extra income (so called category II payments) by doing medicolegal work. Academics are less able to do this work because of other commitments and find themselves earning less than their full time clinical counterparts. This may constitute a disincentive to pursuing an academic career.
Such difficulties led Grounds to comment that “if history is any guide, substantial development of services may be dependent on scandals, and substantial academic developments may be dependent on generosity of spirit.”5
Modernising Medical Careers and the Walport report67 have outlined a new integrated academic training pathway with four complementary stages. In the first stage new medical graduates can gain general research experience in a year 2 foundation academic programme. After completion of the foundation years aspiring academic forensic psychiatrists undergo basic psychiatry training as an academic clinical fellow. This post lasts up to three years. Seventy five per cent of the trainee's time is spent in clinical training, and the remainder on academic work, with an emphasis on successfully securing research funding to do a full time research degree (doctor of philosophy (PhD) or doctor of medicine (MD)). Trainees who do not secure funding return to full time clinical training.
Trainees who are successful in gaining funding spend three years doing a research degree. Once they have completed their degree they are eligible to apply for a clinical lectureship post. This stage allows trainees to split time between higher specialist training (leading to the award of a certificate of completion of training in forensic psychiatry) and postdoctoral academic work. It is anticipated that this stage will last four years and will lead to a senior academic post (such as senior lecturer in forensic psychiatry) or the award of further research grants (such as a clinician scientist award). If a trainee decides not to continue with academic work they may take up a full time consultant post after they have gained their certificate of completion of training.
Medical students with an interest in academic forensic psychiatry should aim for experience in both academic medicine and forensic psychiatry. This can be achieved in a number of ways, such as special study modules, elective periods, or an intercalated bachelor of science degree. Aspiring academics should aim for a placement in a forensic unit which also has strong academic links. Students might also consider entering an essay in the Faculty of Forensic Psychiatry's annual essay competition, which offers both a cash prize and the opportunity to attend the faculty's conference (details are published annually in the student BMJ).
Life as a trainee
Time is split between research, teaching, and clinical work, with the balance between these areas being determined by the trainee's stage of training. Academic trainees have access to the same range of placements as other specialist trainees. These include working in secure hospital settings, prisons, and the community and working with criminal justice agencies such as the police, courts, and probation services. On-call commitments are likely to be similar to those of non-academic forensic specialist trainee colleagues.
Trainees are expected to gain experience in attracting funding from external sources and publishing in high impact journals. Depending on their stage of training they will be working up a funding proposal for a PhD or MD, completing a PhD or MD, or doing further postdoctoral research. Successful completion of a higher research degree is an essential requirement for a senior academic post, and there is therefore substantial pressure on aspiring academics to complete this, with inevitable consequences on their clinical working.
In addition trainees participate in teaching undergraduate and postgraduate students. Trainees are increasingly expected to gain a formal teaching qualification (such as the postgraduate certificate in higher education).
Box 1: Person specification for a job as a trainee in academic forensic psychiatry
Essential qualifications and experience
Full registration with the General Medical Council
Appropriate experience of psychiatry
Interest in research as indicated by peer reviewed publications and involvement in research
Evidence of an interest and ability in teaching undergraduates and postgraduates
Excellent communication skills (written and verbal)
Experience of forensic psychiatry
Good time management skills and ability to maintain a balance between academic and clinical commitments
Enthusiasm and passion for academic work
Ability to work with difficult, challenging people in a professional but compassionate wayAbility to work as part of a multidisciplinary team
Box 2: Advantages and disadvantages of a career in academic forensic psychiatry
Opportunity to develop research interests
Opportunity to develop teaching skills
Good opportunities for interdisciplinary research
Rapidly developing specialty in which future research has a potential to influence treatment and even public policy
Challenging and demanding
Pressure to publish in high impact journals
Less time to earn extra cash from medicolegal work
Relatively new and small specialty
Subject to academic, clinical, and criminal justice system politics
Box 3: Tips on surviving as a trainee in academic forensic psychiatry
Be strict with time management
Make sure that your academic time is protected—you can easily end up using most of your academic sessions doing clinical work, especially in a busy unit
Aim to complete your postgraduate degree within the time limit of your contract
Meet regularly with your academic and clinical supervisors
Aim for two to three high impact publications during your time as a lecturer
Try not to miss out on your family or social life
Don't stretch yourself over too many research projects as you may end up completing none of them
Choose your area of academic interest and develop it
Decide at an early stage what you want to do long term. If you want to pursue an academic career, be aware that your work will be scrutinised when you apply for senior academic posts
Learn how to obtain funding grants
Build networks with academics in forensic psychiatry at both national and international levels
Box 4: Further information and reading
Forensic Psychiatry Research Society www.fprs.org
Royal College of Psychiatrists Forensic Faculty www.rcpsych.ac.uk/college/faculties/forensic.aspx
British Medical Association information on academic career pathways http://bma.org.uk/ap.nsf/Content/Hubmoderisingmedicalacademiccareers