Ethicist-Educator Insists Community Must Be Engaged

Laura Roberts, M.D., finished her psychiatry training in the early 1990s just as the ethical challenges of psychiatric research—how to acquire informed consent from individuals with mental illness, the pitfalls and potential of drug “washout” trials, and other questions—were attracting national attention.

As it happened, she emerged from her training with a unique grounding in medical ethics—she had studied with Mark Siegler, M.D., and other prominent thinkers in the field at the University of Chicago, where she went to medical school—and in clinical care with a diverse and underserved rural population served by the University of New Mexico, where she did her residency.

In a field that until then had been traditionally guided by “expert opinion” issuing edicts about an abstract ideal, Roberts brought to medical ethics the new and refreshing perspective of evidence-based research.

“I began writing proposals in this unique area of evidence-based ethics,” Roberts told Psychiatric News. “I didn't approach these topics from the standpoint of 'What is the expert opinion on this question?' Instead, we went out and really talked with people living in the community with mental illnesses and got their perspective about their own experiences in research.

“The idea was to think more systematically and in a more down-to-earth way about complex ethical questions. Expert opinions do not always help resolve dilemmas, and very, very good people can have very different points of view about controversial topics. We took the approach of listening to the people most deeply affected by ethics policies and trying to understand their perspectives, rather than making assumptions about what their motivations or vulnerabilities were.”

So as early as 1996, Roberts (still in her 30s) began publishing evidence-based ethics work on such topics as teaching ethics in psychiatric supervision, attitudes of consultation-liaison psychiatrists toward end-of-life practices, ethical issues around disparities in access to mental health services, and conceptual issues and empirical findings about the ethical bases of psychiatric research.

Her approach to ethics research—focused on real-world problems and their solutions, casting a wide net for maximum input from stakeholders most affected by an issue, and capable of integrating conflicting viewpoints—was one that would serve her well as she rose through the ranks of academic medicine. By 2000 she was named interim chair of the department of psychiatry at the University of New Mexico, where she established the Institute on Ethics, and in 2003 Roberts moved to the Medical College of Wisconsin, where she assumed the chair of the Department of Psychiatry and Behavioral Medicine.

Last November, Roberts reached a new landmark when she was elected the first woman president of the American Association of Chairs of Departments of Psychiatry (AACDP).

Diversity of all kinds is the future in academic medicine, Roberts commented.

“People with very diverse and distinctive pathways to leadership—that's the emerging pattern. Certainly there are a lot of department chairs who are outstanding physician investigators in the traditional mold, and my own reputation is related to that tradition. But many of my colleagues who are coming up through the ranks today have shown superb leadership in nontraditional areas such as community programs, medical education, or executive and economic issues.

“There is no longer only one path to becoming a chair. Today, it's all about demonstrating leadership capacity in diverse areas.”

Psychiatric educators say that in that regard, Roberts is an exemplar.

“I think what the department chairs have recognized in electing [Roberts] is her ability to get people with disparate backgrounds and conflicting priorities to work together,” said immediate past APA President Carolyn Robinowitz, M.D., and a past dean of Georgetown University School of Medicine. “She has a very deft touch, which is really important for a department chair who has to be the interface between the work of the department and the goals of the institution.

“Laura is the kind of department chair a dean likes to have. She's a problem solver who focuses on what can be done, rather than saying, 'No, we can't do that.' And she is able to deal with conflicts and resolve them without becoming enmeshed in them herself.”

Roberts also has responsibilities within APA. She is chair of the Task Force to Update the Ethics Annotations, a member of the editorial board and board of directors of American Psychiatric Publishing Inc., and a member of the Council on Research.

“We Can't Just Sit Around and Be Smart”

As a department chair, Roberts said she has found a place at the center of research, education, clinical care, community outreach, and professional development where she can put her talents to work. “For me, being an academic chair means you can do it all, all at once,” she said.“ That is what I love.”

As for being the first woman president of the AACDP, Roberts acknowledged that it's a landmark: there are few women chairs of departments throughout medicine, she said, and the number of women who are deans of medical school is growing, but lags proportionately far behind their numbers as physicians.

But Roberts said that she believes a more striking divide in academic medicine is the generational and attitudinal one between physicians trained in previous decades and those rising to leadership positions in academic medicine today.

“The task of leadership now is to preserve the strengths of the past, such as a deep commitment to the therapeutic relationship and patient well-being, and to advance a modern model of medicine that will serve society in the future.”

In a “President's Message” on the Web site of the AACDP, Roberts wrote that the mission of academic psychiatry must go beyond the traditional “three-legged stool” of education-research-clinical care to also include what she calls “community engagement” and“ professionalism.”

“We can't just sit around and be smart,” Roberts told Psychiatric News. “We have to demonstrate that we can contribute to society and to the health of future generations.”

Roberts said that is the biggest challenge facing the field of psychiatry today—showing the larger society “what it is that psychiatrists do as physicians that is an invaluable and unique contribution to the care of people living with all kinds of illnesses. We need to be very clear about why psychiatry can and does improve the lives of people who experience devastating diseases.”

At the same time, resources are scarce. “We are undervalued in society, people with mental illness are marginalized, and some in the public doubt even that mental illness exists,” she said. So we have to be innovative, creative, and wise stewards of resources.”

So what are her goals as AACDP president this year?

Roberts said they are threefold: strengthening the skill set of people who are already department chairs, helping to define the ethical basis of the field for the larger society, and supporting the professional development of future department leaders.

This educator-researcher-clinician-ethicist and mother is not deterred by challenges or obstacles. “People have said to me, 'Oh, you can't be a mother and have an academic career' or 'You can't do evidence-based ethics.' But I've never been discouraged by negative messages in my environment.

“At all times,” she said, “I've followed my heart.”▪