CORRESPONDENCE

Private practice-driven research

To the Editor: When working in private practice, we all come across questions we are curious to explore, but clinical research has long been viewed as the domain of tertiary medical institutions, or so-called ivory towers. Research does not need to be relegated to academics alone, as integrating clinical research within private practice can be intellectually stimulating and rewarding on many levels. As research funding and grants become increasingly scarce, there will be an increasing need for private practitioners to participate in clinical research,^[1] both in cohort studies and in the further testing and development of new therapies.

The purpose of this letter is to encourage colleagues in the private sector to participate in clinical research, which can transform the way they practise; however, the demands of doing research should not be underestimated. Those of us who work in the private sector see our main priority as the care and treatment of our patients, so we have significant time constraints with regard to conducting research. The simplest way to get started in clinical research is to look at your own practice and think of a difficult or interesting clinical conundrum that you would like to answer. This could be as simple as analysing data on your patients' outcomes or their pathways to care. The outcomes range from simple yet important events such as relapse or hospitalisations to more complex phenomena such as quality of life. In fact, you may already be collecting these data on your patients during routine clinical practice in order to improve the quality of your service.

Challenges

Private practice settings have unique features that make it challenging to conduct research. Most colleagues worry when they enter private practice that they will not have time to engage in clinical research or other educational activities that drew them to specialise in the first place. Colleagues are busy with high patient loads, managing their business and personnel, and time-consuming administrative duties. In addition, most of us are not affiliated to an academic or training institution, where most research is traditionally carried out, and therefore feel that we do not have access to supervision and mentorship from our senior colleagues in academia.

Some important ethical issues also need to be explored. For example, conducting research on your own patients may require careful consideration of patient autonomy and informed consent.^[2] Concerns have been raised regarding the practice of recruiting one's own patients into clinical trials and clinical research, but to exclude such subjects would result in the effective exclusion of private practice as a viable environment in which to conduct such research. Following proper ethical guidelines when one is involved in clinical trials or clinical research in the private setting will be of paramount importance. The general requirement is to obtain ethical clearance from the hospital review board. If the hospital does not have an ethics review board, one would have to seek a central ethics committee. However, we can all strive to be scientist-practitioners, and to both consume and contribute to research literature.

Benefits

The patient population, treatment needs and availability of resources differ substantially between private and public healthcare patients, but in both sectors there is new knowledge to be learned and shared with the medical community. There are many private practitioners who have presented very interesting cases at continuing medical education meetings. Many of these cases deserve to be written up and shared more widely with other colleagues. Intellectual stimulation and adding variety to the daily task of seeing patients can be rewarding. The opportunity to travel to academic meetings and conferences to present one's work is very gratifying. Making contributions to the understanding of disease processes and development of new therapies helps fulfil our own intellectual curiosity, as well as leading to improved patient outcomes and assisting colleagues who may have challenges with similar cases.

Clinical trials can also build up your practice in two ways: bringing new patients to your practice and increasing community awareness of your practice. Industry-sponsored trials relieve you of the task of having to create a study design or clinical protocol. They also provide training and some remuneration for the time spent participating in the trial. The training can be particularly helpful in building up the confidence one needs to pursue one's own research. Clinical research conducted in the private setting can potentially strengthen the clinical skills of any clinician.

The patient pool available to clinicians in private practice is considerably smaller than that in state institutions. As waiting periods are often shorter in private practice, clinicians may see a different patient population (e.g. at an earlier stage of the illness). Including these patients in research will add valuable information that may ultimately improve delivery of care to patients. Recently, research conducted by colleagues in academic settings has been criticised as detached from the common issues faced by ordinary clinicians.

Lastly, we need data to support some of our unique clinical practices. It is clear that a large number of our psychiatric patients need more than one psychotropic agent in order for them to do well, yet we were taught simple pharmacological practices of monotherapy that did not take complex comorbidities into account.^[3] Data from private practices could help us argue for increased funding from medical insurance companies, ultimately leading to better patient care.

Conclusion

The practice of medicine today is driven by evidence. Although clinicians based in public health services have access to a wider population base, private practice-based research will be extremely useful as it will supply data that can increase the speed of implementation of new evidence-based practices into direct patient care. Private practice is a viable environment for conducting research, and clinical research should no longer be relegated to the halls of academia.

Sibongile Mashaphu

Department of Psychiatry, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. mashaphus@hotmail.com

Bonginkosi Chiliza

Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa

REFERENCE

1. Gevers W. Clinical research in South Africa: A core asset under pressure. Lancet 2009;374(9692):760-762. DOI:10.1016/S0140-6736(09)61119-3        [ Links ]

2. Kass NE, Sugarman J, Faden R, Schoch-Spana M. Trust, the fragile foundation of contemporary biomedical research. Hastings Cent Rep 1996;26(5):25-29 DOI: 10.2307/3528467        [ Links ]

3. Correll CU, Gallego JA. Antipsychotic polypharmacy: A comprehensive evaluation of relevant correlates of a long-standing clinical practice. Psychiatr Clin North Am 2012;35(3):661-681. DOI:10.1016/j.psc.2012.06.007        [ Links ]