Rapid Responses to:

Peter Tugwell
Campaign to revitalise academic medicine kicks off
BMJ 2004; 328: 597 [Full text]
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Rapid Responses published:

[Read Rapid Response] From Socrates to Tugwell
Michael D Goodyear   (12 March 2004)
[Read Rapid Response] Academic Medicine
T L Chambers   (12 March 2004)
[Read Rapid Response] The education and research dichotomy
Martin R Turner   (14 March 2004)
[Read Rapid Response] A Task From Hell
Lawrence J. O'Brien, Arlington, Virginia 22209 USA   (14 March 2004)
[Read Rapid Response] Is academic medicine answering those questions which most need answering ?
Stephen T. Green   (14 March 2004)
[Read Rapid Response] Academic Medicine Has Become Too Academic.
WCS Smith   (17 March 2004)
[Read Rapid Response] Industrial control of academic medicine
Paul A Dieppe   (18 March 2004)
[Read Rapid Response] Is revitalisation required?
Martin W McNicol   (18 March 2004)
[Read Rapid Response] Academic Medicine is failing
Thein H Oo, MD, MRCP(UK)   (18 March 2004)
[Read Rapid Response] Revitalise using the disease mechanism?
Fernando Elijovich   (18 March 2004)
[Read Rapid Response] The isolation of academic medicine
Basil Porter, Southern Region, Israel 84895   (19 March 2004)
[Read Rapid Response] Exciting times for academic medicine.
Alexander SD Spiers   (20 March 2004)
[Read Rapid Response] How should we measure academic success?
David A Cameron   (29 March 2004)
[Read Rapid Response] Concerns for the direction of academic medicine
Margaret S. Terpenning   (31 March 2004)
[Read Rapid Response] Educating the next generation
Dan Kerley   (31 March 2004)
[Read Rapid Response] Creating a roadmap for academic medicine
Jean D Gray   (1 April 2004)
Kerr White   (12 April 2004)
[Read Rapid Response] Bringing academia into clinical practice
Paddy A Phillips   (15 April 2004)
[Read Rapid Response] Non-Academic Science : An Oxymoron
Jacob M. Puliyel   (29 April 2004)
[Read Rapid Response] Don't believe us !
David L. Sackett   (11 June 2004)
[Read Rapid Response] Revitalizing Academic Medicine: Facing Some Harsh Realities
Roy M Poses   (18 June 2004)
[Read Rapid Response] Are our undergraduates engaging with academic medicine? Fewer are publishing letters
Bayanne Olabi   (4 February 2009)

From Socrates to Tugwell 12 March 2004
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Michael D Goodyear,
Assistant Professor
Department of Medicine, Dalhousie University, Halifax NS, Canada B3H 2Y9

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Re: From Socrates to Tugwell

Tugwell (1) raises many interesting points regarding the revitalisation of academic medicine. Amongst these are even whether the name should be retained or changed. Before we embark on such a radical image metamorphosis, we need to very carefully ask ourselves what academic medicine is, and how it got to where it is from where it originated.

It is perhaps telling that the very word �academic� appears to have taken on a pejorative context, meaning irrelevant, and perhaps detached from the reality of everyday practice, perhaps in conjunction with �ivory tower�. The literary roots of �Academic� are perhaps worth a glance being often attributed to Milton�s �Paradise Regained� (2), referring to Plato�s (427-347 BC) garden, purchased from Academos, and where he taught from 387 BC. Even the Oxford Dictionary provides some rather negative attributes such as abstract, and unpractical.

Of course, there are many academics who would feel that their role is not to be main stream but to be a catalyst, to raise issues, and to ask awkward questions like Plato�s mentor Socrates (469-399 BC). On these grounds, then, �academic� should be retained. Plato was not, after all, renowned for his tact and diplomacy.

The second aspect is whether academic medicine has lost its roots in a modern trend whereby anyone involved in a teaching hospital�s function automatically receives a university position. This is in sharp contrast to the traditional �academic unit� within a teaching hospital in which a core of physicians identify themselves primarily with clinical research and teaching and place their primary loyalty to gown rather than town. While the former model risks diluting the �academic� and losing sight of the roles and functions of the academic purpose, the latter also runs the risk of isolation, and a failure to influence (3).

A compromise position that maximises resources is where an academic core is deliberately positioned to provide a framework for placing the practice of medicine on a sound evidence-based and question-asking footing. Tugwell, like many of us, has practised in an environment in which this was the design. At McMaster University in Hamilton, Ontario, the Department of Clinical Epidemiology and Biostatistics acts as a hub within the health sciences framework, linking to all of the clinical and teaching areas and placing people with expertise in asking and answering questions within reach of active clinicians.

The third aspect that Tugwell alludes to, is not to repeat the mistakes of the past and devise a system that ignores the needs and views of those for whom it was created in the first place, the people we joined our profession to serve.

It is good that we revisit our roots, but in doing so we should take some pride in a lasting tradition (4). Let us hope that academic medicine does not suffer the fate of Socrates.

(1) Tugwell P: Campaign to revitalise academic medicine kicks off. BMJ 13 Mar 2004; 328:597

(2) �See there the olive grove of Academe, Plato's retirement, where the Attic bird Trills her thick-warbled notes the summer long�. Milton J (1671): Paradise Regained IV, 244

(3) Sackett D: The sins of expertness and a proposal for redemption. BMJ 2000; 320: 1283

(4) Guyot B: From Socrates to Sackett. BMJ 25 Sep 2000. http://bmj.com/cgi/eletters/320/7244/1283#9896

Competing interests: Academic

Academic Medicine 12 March 2004
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T L Chambers,
Consultant paediatrician
The Consulting Rooms, 2, Clifton Park, Bristol BS8 3BS

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Re: Academic Medicine

Three prior questions: in the 21st century what is academic medicine and its purpose and what distinguishes it from non-academic medicine?

Competing interests: None declared

The education and research dichotomy 14 March 2004
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Martin R Turner,
Wellcome Trust Clinical Research Training Fellow in Neurology

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Re: The education and research dichotomy

Professor Tugwell's editorial and this campaign are timely and welcome. I would suggest that what he describes as the �unnecessary dichotomy between education and research� is a critical issue within this debate. I am at an early stage in my academic career, about to submit my PhD thesis and return to clinical training in neurology, where I hope to apply for a Clinician Scientist Fellowship as the next step. Like many of my peers, I wonder what the future holds in terms of academic training opportunities, incentives and, most importantly, job security. I have an interest in academic neuroscience but also take an active role in education (through teaching), including a wider interest in the communication of scientific ideas to the lay population. Teaching within Medicine is rarely valued or specifically acknowledged (heaven forbid actually rewarded), in the UK. Meanwhile, the public that I meet seem to feel increasingly let down by the �great white hope� of modern Medicine as described to them by the media; science in general continues to be an unattractive prospect for school-leavers; and academic medicine becomes a daunting prospect for medical students, who can earn three times the salary as primary care physicians, and within only a few years of qualification. We need primary care physicians, and of course money isn�t everything. Who or what inspired me I wonder? Simplistically, it was probably educators who were enthusiastic as well as knowledgeable. In the current atmosphere, with tenure the realm of the privileged few, the lecturer�s enthusiasm seems to be eroded by constantly looking over the shoulder for the letter from personnel (P45 enclosed).

Clearly, the best teachers are not necessarily �academics� (in the sense of full-time researchers), and academics may equally be poor teachers, some having little interest in this role. Non-academic hospital consultants are already over-stretched with their clinical workload, and understandably medical student teaching sometimes pays the price by being the first expendable extra task. Teaching used to be seen as part of the �privilege� of employment within a teaching hospital, but good will starts to disappear when individuals feel over-stretched and undervalued. Teaching unfortunately seems to have little currency within the current framework of academic medicine either, where the �impact factor� and the Research Assessment Exercise rule. �Those who can, do; those who can�t, teach� � we still hear that awful phrase echoing from the overbooked outpatient clinic of the non-academic, as well as from the office of the academic bemoaning the lack of research publications from the department�s lecturers, and the impact on future funding. Meanwhile teaching continues to be squeezed, and ultimately falls, between the two.

Competing interests: None declared

A Task From Hell 14 March 2004
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Lawrence J. O'Brien,
1200 N. Nash Street - Ste. 535,
Arlington, Virginia 22209 USA

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Re: A Task From Hell

Any effort to "revitalise� medical education ought to begin at the beginning, i.e., with the question, why do we educate people to function as physicians? A long while ago in the United States, a federal officer named Charles M. Croner said this:

�For a nation the function of the health care system is to optimize the prevalence of good health and to minimize the toll of ill health among its citizens.�

This is the beginning.

In 1910, a renowned educator named Abraham Flexner was retained by the Carnegie Foundation to study medical education in the United States and Canada and to recommend reforms. At the time, Flexner said this:

�In modern life the medical profession is an organ differentiated by society for its own highest purposes, not a business to be exploited by individuals according to their own fancy. [The physician] is a social instrument [and the medical school] is a public service corporation.�

This must be a starting place for any sincere effort to revitalise medical education.

During the balance of the twentieth century, as sweeping changes in medical education and the practice of medicine were brought about, the US medical profession chose pathways that absolutely contradicted the key principles set forth by Flexner. As a result, the wholesale reconstruction of medical education, of the hierarchy of medicine, and of the patterns and style of medical practice that was launched during the early decades of the twentieth century, propelled by the Carnegie Foundation�s publication of Abraham Flexner�s famous Report, has produced many perhaps unintended but nonetheless fatal structural and conceptual defects in contemporary medical education. The result is that an unholy mess must now be dealt with. It may not be possible to �revitalise� what exists before the house of medicine comes tumbling down as a result of its inherent structural flaws. Too harsh a judgment, you think? Consider just a few of the insights that Catherine McKegney, MD provided for us in 1988, upon completion of her residency training.

Skillfully, and with chilling effect, McKegney has described ingrained structural and behavioral patterns that remain readily observable in America�s medical academies today as being directly analogous to structures and behaviors commonly found at play in neglectful and abusive families:

�Neglectful and abusive families are often characterized by their unrealistic expectations, denial, indirect communication patterns, rigidity, and isolation. The medical education system has similar patterns of behavior that contribute to problems at all levels of the training process and include practicing physicians. The communication patterns within the teaching hospital reinforce trainees� strivings for perfectionism and devalue the contributions of non-physician staff to the supervision-in-training. Excluding the potentially healing influence of �outsiders� contributes to the rigidity within the system. Like parents who raise their children as they themselves were raised, each generation teaches as they were taught, and the patterns are loyally perpetuated. Teachers will need to address their own training experiences, acknowledging the dysfunctional behavior patterns learned and the pain those behaviors cause. Then educators can begin to change how they teach and break the cycle of physical neglect and emotional abuse that has been inherited.�

McKegney�s keen observations about the dominant mind-set in academic medicine in the US have had no noticeable impact to date. Her peer- reviewed paper �fell stillborn from the press.� The society would therefore be well advised not to expect the kind of pivotal changes in medical education she has called for to occur on a voluntary basis any time soon. The very teaching hospitals that the American Medical Association and many political leaders tout as �centers of medical excellence� are, to the contrary, worlds of physical neglect, emotional abuse, and the abnormal rearing of generation after generation of people who are supposed to be trained as healers. McKegney has had more to say about what has been going on in the training of residents and interns:

�[B]y the time they finish training, many have adopted the unrealistic expectations of the medical education system, unskilled at admitting human needs or human mistakes. ...[R]esidency training, particularly internship, is unnecessarily arduous. It is certainly painful, resulting from neglect of physical and emotional needs. The basic human needs to eat and sleep somehow seem shameful disruptions of the work of saving lives. Students and house officers eat hurriedly, at odd hours, consuming excessive amounts of unhealthy convenience foods. They are expected, and come to expect themselves, to remain awake, stay upright, and perform responsibly for 24 to 36 hours at a time. To the rest of the world, this sounds outrageous, but the members of this family actually consider it a matter of some pride. Studies on sleep deprivation demonstrate more severe impairments of psychological measures than physiologic parameters: Mood, judgment, and attentiveness are all affected. The awareness that they are becoming less competent as the night progresses contributes further to the interns� distress. Nevertheless, by the time they finish training, many have adopted the unrealistic expectations of the medical education system, unskilled at admitting human needs or human mistakes.�

McKegney takes note of the fact that, in medical school as well as in the abusive family, silence is golden:

�[In abusive families] the rule of silence is so strong that siblings may not talk to each other about their experiences, and stories which are never told are easier to forget. ...Out of loyalty to their [medical] �family,� even interns find it hard to acknowledge the pain of their ordeal. ...[A]dmitting to feelings of pain, uncertainty, abandonment, and depression, even to themselves, seems intensely disloyal and threatens their sense of membership in the medical family. Secrets are a dominant and critical element of the dysfunctional patterns of communication in abusive families, including the abusive medical family. Hiding significant negative experiences from the outside world serves as the cement in the high wall erected to separate what goes on within the family from the prying eyes of outsiders. When problems cannot be addressed directly because the family has rules about mistakes and secrets, blaming and punishing replace nurturing feedback. These families share the basic assumption that if something is going wrong, someone must be at fault, and they confuse finding fault with solving problems. ...Negative judgment is common at all levels of medical education; direct feedback, which cites specifics and offers suggestions for improvement, is rare. ...Because clear feedback is rare and correction is more common than affirmation, the medical trainee has difficulty feeling competent. Receiving punishing comments about mistakes teaches trainees to hide errors, by lying if necessary. Like emotionally abused children, residents become unwilling to risk the pain they have come to associate with close observation and eventually learn to avoid supervision. The absence of honest constructive feedback and the overabundance of placing blame in medical education perpetuate physicians� perfectionism and leave them at risk for impairment. ...Forced to hide their uncertainties and errors, the trainees' self-esteem never matures. Because students and residents know they have not revealed themselves, they cannot respect either the praise or the criticism they receive.�

This awful conclusion may explain why US physicians always exhibit such difficulty in coping with any criticism of their profession. McKegney�s conclusion also signals the fact that the capacity of a person trained in this system to grow, in either professional or personal terms, has often been fatally stunted by their experiences in medical academia. Can it be any wonder that so many American physicians in practice today are telling opinion surveyors that they find little personal satisfaction in their work? Things have gotten so far off track in some medical schools that a former professor of pediatrics has told about a top student of his who, upon successfully completing his residency, confided that he intended to heal himself after the shattering experiences he had undergone in training. The young man assured his professor that he was firmly committed to recovering his normalcy, and that he was determined to eventually get well.

The pattern of indirect communication is endemic in US medical schools, and it serves to reinforce the rigid, often indirect discipline that the medical guild consistently imposes on all licensed physicians throughout their years of medical practice. The persistent notion that mistakes bring shame to the medical family and must therefore be shrewdly hidden from �outsiders� produces a hideous variety of loyalties within the medical guild, rooted in patterns of professional anxiety, and in plain old fear. Here can be seen the origins of what the late Superior Court Judge B. Abbott Goldberg has termed medicine�s �conspiracy of silence.� In July 1998, Judge Goldberg commented as follows on his feelings about the folly of many legislatures in the nation establishing peer review privileges for physicians to hide behind:

�The fact is [peer review] privileges that are supposed to protect patients� privacy and encourage patients� and physicians� candor and thus promote public health can and have operated to encourage the �conspiracy of silence� which insulates physicians and institutions from liability. Medicine uses the law to help greed masquerade as benevolence.�

The task of revitalising medical education is an overwhelming one, and the effort to attempt this on an international level must be celebrated and admired. It is important that the work begin at the beginning, and that sight never be lost of the fundamental reasons for having a professional health care system. Lawrence J. O�Brien

Competing interests: None declared

Is academic medicine answering those questions which most need answering ? 14 March 2004
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Stephen T. Green,
Consultant Physician in Infectious Diseases and Tropical Medicine
Royal Hallamshire Hospital, Sheffield S10 2JF

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Re: Is academic medicine answering those questions which most need answering ?

I have always believed that when it comes to performing research which will be of any value to man or beast, the critical issue at the outset is �what is the question that we need to answer ?�. So, are we picking the right questions ? Or do we just go along with the mob, and keep prioritising those things that people are most happy spending their time working on ? When it comes to academic medicine, never has this been more necessary then now.

For example, all too often, UK academic medicine appears a little obsessed with the Research Assessment Exercise and associated issues. In such a culture the only academic activities (and individuals) to be encouraged and supported will be those which bring in the most �kudos�, that is those which are associated with the most papers (all placed in high impact journals of course) and the most research money (ideally coming from the most prestigious sources, whatever they are deemed to be at that particular moment in time) in their CV. This seems to be the only game that many senior academic medics are able to play, and the system self-perpetuates as the people who rise to the top of the greasy pole are usually similar in sentiment to those who came before them. In fact, the idea of �academic healthcare�, as opposed to "academic medicine", is an attractive one as medics do not, and never will, have all the answers, and the harnessing the skills and insights of colleagues in health ans social care coming from other backgrounds is essential, albeit challenging.

To choose an example, what about HIV medicine ? So much of the medical world�s efforts are merrily targeting virological, immunological, genetic and therapeutic avenues, and yet there is still nothing better than a condom and the knowledge of how to use it properly when it comes to minimising the spread, and hence the impact, of this lethal infectious agent (which is exactly what it is, if you are not fortunate enough to live somewhere on the planet where the resources and expertise exist to manage and treat your disease). On the other hand, areas such as prevention, attention to social issues, and attention to international and travel medicine, come a very poor and distant second, as they would seem to possess less �kudos�. And yet, it is surely inarguable that this is where the greatest potential for uncovering the right approaches to take when it come to dealing with the rapid world-wide spread of a germ which already has probably 50 million human beings in its grip and is, incidentally and worryingly, reinvigorating the spread of another appalling infectious disease, tuberculosis. By way of illustration, ask oneself how much effort is being spent on a HIV vaccine ?, and will this solve the problem ? I think this is doubtful - for example, we have had effective hepatitis B vaccines for donkey�s years, yet we haven�t got rid of the hepatitis B virus, and even when we have a good vaccine, such as MMR, it doesn�t take much to wreck that vaccine�s reputation and reduce its uptake to levels close to useless (when seen from the population standpoint).

A good example of a question in medicine that needs answering is does advertising work in health care ? - and if it does, how do you do it well ?. It seems logical that it should work, if you have enough resources to spend on doing it well, otherwise why would Coca Cola, Microsoft and the Ford Motor Company bother spending zillions on promoting their wares ? Do we do enough research on the medical and other healthcare dimensions of advertising ? For example, what about the impact of the internet on health care ? I think it comes back round to condoms and well-placed advice � overall, immunisation by high-quality well-targeted well- delivered information and education (�infonisation�) may well be more effective than immunisation by antigens. Infact, education and teaching, both of the professions and of the public, should surely be prioritised, subjected to research in their own right, and given higher priority and status within the academic world.

So, I would plead with Professor Tugwell and his colleagues to seek out for the questions in health care which are most in need of answering, and to be imaginative about uncovering the best ways to answer those questions. For example, don�t just stick with molecular medicine because it is �sexy� (and the research councils like it and give out money to look at it), and if you do stick with it try to harness it more effectively (that certainly merits some thought !). Don�t mark down social and behavioural research into prevention simply because it is not deemed sexy.

People of talent from all relevant professional backgrounds, be they medical, nursing, educational, social work etc etc etc, must be included in this process if we are going to make progress. We all need to put our collective shoulders to the same wheels if we are going to get anywhere with answering the questions in health and social care most in need of answering.

Competing interests: None declared

Academic Medicine Has Become Too Academic. 17 March 2004
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WCS Smith,
Clinical professor of public health
Department of Public Health, Medical School, Aberdeen AB25 2ZD

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Re: Academic Medicine Has Become Too Academic.

Academic Medicine has become too academic. It has become excessively concerned with its own intellectual matters and lacking experience in practical affairs according to the one dictionary definition of academic. The discussion pieces by Peter Tugwell (1) highlight a global problem that is not new but that remains largely unresolved. I have experience of working in Medical Schools in Europe and in Asia and in my view the source of problem is basically quite simple. The solution does not demand a massive intellectually endeavour but rather that we face up to the issues and take the necessary, if somewhat drastic, action as Tugwell suggests.

The Problem

It is no longer feasible or acceptable for clinical academics to attempt to be excellent in clinical practice, medical research, and clinical teaching, not to mention trying to be experts in management. Medical practice has progressively become specialist rather than generalist, patients demand it and the professional requires it. It is no longer acceptable for clinicians to dabble in research. Funding agencies, research ethics, and research governance by institutions ensure that patients are protected from poor research. This does not mean that clinicians cannot participate in research and help formulate the research questions. Similarly it is becoming increasingly difficult for clinical academics to practice clinical medicine without undertaking continuing professional development, clinical audit and appraisal that can take up more time than the actual time spent in clinical practice. The same individuals also attempt to be leaders in teaching and training, curriculum development, and assessment. This no longer tenable, so why do we do it?

We do it because of the incentives to be involved in all three activities. Academic medics want to be clinicians because that is their original training; there is the short-term satisfaction of working with sick patients, and the linkage to the salaries of clinicians. Academic medics also want to be involved in research because research it intellectually stimulating, it is rewarding in the long-term, and important. And clinical academics want to be involved with teaching because it is a major function of medical schools, there is satisfaction in seeing student progress and develop, and teaching is the major source of funding for most Universities. Good teachers enjoy the lasting respect for students and peers.

The Solution

Academic clinicians need to choose what they want to be experts in; medical practice, research or teaching? They can no longer pretend to be experts in all three � that is not possible or desirable. It is not an attractive career for young clinicians to spend long hours trying to achieve the impossible, academics are seen as sad people with no lives, who delude themselves into thinking they are experts in all these areas. We then would have two distinct tracks � teaching and research. We would have better research with greater potential to address the big questions. We would have better quality teaching programmes developed and managed by educational experts producing better doctors.

There are a number of fundamental components to this solution. Teaching and research must be equally valued. Each stream needs to have its own dedicated training programmes. Both groups need to work closely with clinicians, to listen to them and have clinicians on board in the conduct and delivery of both research and teaching.

Finally we need to drop the title �academic� and shed the image that we have become irrelevant. Some will be �clinical scientists� working with clinicians but not pretending to be practising clinicians with some involvement in teaching but not as educational experts. Others should become �clinical teachers or professors�, again working with clinicians to develop high quality teaching programmes. Both groups need to have a specialist training programme and both need to be equally valued and recognised. This may be simple but it requires radical action � we will not re-vitalise academic medicine until we act. It will take at least a decade to fully implement these changes so be should start soon.

Tugwell P. Campaign to revitalise academic medicine kicks off. Br Med J 2004;328:597.

Competing interests: I am employed by the Univeristy of Aberdeen as a clinical academic professor of public health

Industrial control of academic medicine 18 March 2004
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Paul A Dieppe,
Director, MRC HSRC
Dept Social Medicine, Univeristy of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8, 2PR

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Re: Industrial control of academic medicine

I strongly support the campaign to revitalise academic medicine, advertised in Peter Tugwell's editorial of the 13th of March. However, I was disappointed to see that the leader of the campaign is compromised by support from the pharmaceutical industry.

In my view, one of the most fundamental problems with academic medicine today is the degree of control that this industry has over it. Much of our bench research is done with the aim of drug discovery, and nearly all senior clinical researchers and opinion leaders are in bed with the drug companies. We now ask investigators to declare their interests, as Dr Tugwell has had to do, but it is hard to see how that helps. The BMJ has shown strong leadership in revealing the extent of this industrial control over medical research, with a previous themed issue on the subject. Articles in that and other editions of the BMJ have clearly demonstrated the deleterious effects that sponsorship can have on research and research publication. And yet, the journal's current campaign to revitalise research appears to suffer from the very same problem.

May I suggest the formation of a fifth advisory group within your campaign? We need to examine the whole issue of vested interests in academic medicine, and their influences on the research agenda as well as on the publication and dissemination of research findings. Members of such a group would have to declare any conflicts of interest, and would be ruled out if they had any.

Competing interests: None declared

Is revitalisation required? 18 March 2004
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Martin W McNicol,
Cirencester GL7 1FA

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Re: Is revitalisation required?

The Presidents of all three Royal Colleges with which I am associated are all academics, as are a very significant proportion of their councils. In so far as can be determined from their web-sites the medical colleges are more "academic" than the rest, but they all seem to show very substantial academic representation on their governing bodies. The GMC is led by an academic. Are these signs of crisis?

Martin W. McNicol F.R.C.P. (London and Edinburgh) F.R.C.P.& S. (Glasgow)
Retired consultant physician
Cirencester GL7 1FA

Competing interests: None declared

Academic Medicine is failing 18 March 2004
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Thein H Oo, MD, MRCP(UK),
Assistant Professor of Medicine, Attending Physician ( Hematology and Medical Oncology )
St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA 02135, USA

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Re: Academic Medicine is failing

I was reading this article with great interest. It is not surprising to see why academic medicine is failing.

I am a junior clinical faculty member at a medical school in Boston, Massachusetts which is considered a medical mecca in USA. But I am seeing a sorry state of academic medicine here and elsewhere.

The academic medicine has become too rigid and is not able to adapt to the everchanging environment. Even the smallest bacteria can mutate depending on the environment. Why can't man-made institutions ?

Here in Boston, junior clinical academics are expected to earn their own salaries by seeing more and more patients and at the same time are required to teach medical students and train residents and fellows ( subspecialty residents ). They are also expected to join and attend university committees whether they are interested in or not. At the same time, they are expected to draw in grants from National Institute of Health ( NIH ) or from pharmaceutical industries. They are also expected to publish. However, their salaries are 30-40% lower than the private Consultants. Some big institutions have this attitude " you must be willing to sacrifice as you are working with us " Big Names", "Your CV will be polished with us" etc .

Universities have also created stringent rules on promotions for junior faculty members while very occasionally the rules were broken in order to secure someone who they consider important. ( e.g. a spouse of a world renowned person being promoted for no apparent reason but just to keep the world renowned person at their institution )

In academic circles, publications have been valued well above the clinical skills and patient care. I have seen some academics who have many publications but terrible clinical acumen and skills. They may be speaking at national and international meetings but when it comes to patient care, they do terrible things.

All those little things slowly disappoint us and made us wonder why we should go out and work elsewhere where the grass is greener and the water more clear.

Recently, I have come to accept the fact that good medicine can be practised and that good research can be done outside a university setting. Academic credentials such as Professors, Associate Professors do not matter to me anymore. If I do a good and thorough job, patients will like me and come to me.

Remember Albert Einstein was not an academic while he proposed the relativity theory in 1905. Kary Mullis who invented Polymerase Chain Reaction in the mid-1980s was not an academic either. Both were Noble Prize winners and those developments took place outside the university settings. Computer was invented in the University but they were perfected in the industry and business world. Bill Gate never completed a university degree but he was the greatest enterprenuer and industrialist of our time.

We, junior faculty members, talk about this whenever we meet and joked about the rigid and inflexible nature of the academic setting.

Eventually, the nature will win. The dinosaurs could not survive because they could not adapt to the everchanging environment. Bacteira do survive because they can mutate at any time. If the academic circle does not adapt, then it will be put into the historic rubbish bin like dinosaurs. It is time that current academics adapt to the everchanging environent or they will be historic dinosaurs.

Competing interests: None declared

Revitalise using the disease mechanism? 18 March 2004
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Fernando Elijovich,
Center for Hypertension and Cardiovascular Medicine
Lenox Hill Hospital, New York 10021

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Re: Revitalise using the disease mechanism?

I am encouraged by the BMJ and partners effort to try to revitalise and redefine academic medicine for the 21st century. I was somewhat disappointed, however, at the statement that deals with how to address current failures. A specific point is made about "working within current economic constraints" and giving preference to "strategies that call for no additional funding".

It can be argued that a false entrepreneurial approach, by which the output of health care and medical science is measured in monetary units driven by immediate clinical productivity, is actually the cause of many of the problems of academic medicine. The need to keep academic institutions above the short-term red line has diverted the efforts of their faculty away from research and teaching and weakened their capacity to continue delivering them with high quality. I call this approach "false entrepreneurial" because it neglects to account for the benefits to society that accrue by the training and successful careers of the "endangered species" of physician scientists.

That is, if society agrees that medical progress it to its benefit, the mechanisms for the funding of its infrastructure need to be on the table for discussion. Staying away from this issue is tantamount to deluding ourselves, in believing that we will cure the disease with the microbe that produced it. I am not blind to the fact that figuring out a mechanism for funding of the academic enterprise will entail political posturing and political argument. Perhaps it is time for academic physicians and scientists to take a stand beyond the one we have gotten used to, i.e., finagling within the constraints of available resources to deliver an increasingly mediocre product.

I would be delighted to participate in this initiative if it were to redefine and reframe the enterprise of academic medicine, budget its cost and devise the mechanisms to fight for its appropriate funding.

Competing interests: Lecturer and Consultant for several pharmaceuticals

The isolation of academic medicine 19 March 2004
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Basil Porter,
Medical Director
Maccabi Health Services,
Southern Region, Israel 84895

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Re: The isolation of academic medicine

I spent thirty years in an academic experiment devoted to promoting "community-oriented medicine",and saw that changing the direction of academic medicine was not going to happen if left in the hands of the academics (1). I then moved to health service management, which has allowed much room for thought about the role of academic medicine today.

My reflections would include:

1) In the main, academic medicine is controlled by groups needing to replicate themselves.

2) Nobody asks the "consumers" of health care what they would expect academic medicine to be doing.

3) Academic reward is usually unrelated to relevant needs of medicine and health care (number of papers and quality of methodology are the determinants).

4) A true alliance of academicians, politicians, economists and consumers should look at where academic medicine needs to go.


Basil Porter MD MPH

1) Porter B and Seidelman W: The Politics of Reform in Medical Education and Health Services. Springer Publishing Company,1992.

Competing interests: None declared

Exciting times for academic medicine. 20 March 2004
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Alexander SD Spiers,
Professor of Medicine

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Re: Exciting times for academic medicine.

The launching of a multidisciplinary international project to revitalise academic medicine is exciting news. Surely everyone should wish it success and appreciate the opportunity to offer constructive suggestions.

First, we should seriously consider dropping the term "academic". In modern usage this adjective frequently means something that is irrelevant to real life or merely pedantic. A better terminology would be the Medical Service, Surgical Service, Paediatric Service, and so on. The concept of a service would be a constant reminder to us (and our patients) of our function and our aims. Further, it would remove the false and elitist distinction between "academic" doctors and other doctors.

Second, it must be accepted that a medical service has four principal functions: Administration, Education, Patient Care, and Research. Each of these components is essential and therefore they are of equal merit. It must also be recognised that very few individuals are skilled in all of these functions. It should be possible for a doctor to focus on his or her particular strengths; this will benefit the individual and medicine as a whole.

Third, academic snobbery must go. For example, it is wrong to consider that the researcher is superior to the excellent teacher, or to the skilled clinician who delivers superb patient care, or to the talented administrator who can manage personnel, space, finances and priorities in a way that results in a happy and productive service. In some quarters there is still a belief that clinical research is inferior to that done at the bench, and that researchers who work with patients are not the equal of those who work with rodents, viruses, or molecules. It is time to kill off these outmoded beliefs.

Professor Tugwell correctly states that to revitalise academic medicine "more of the same is not enough". But when we consider finance, a great deal more is desirable. Salaried posts, buildings, equipment, supplies, administration, and technical and secretarial support are the foundations of research effort. Further, the financial rewards of a career commitment to academic medicine should be satisfactory - no one wishes to subsist principally on their dedication. In the United States, and other countries where private practice is prevalent and lucrative, promising young researchers are frequently lost to the private sector. This is especially true of the high-earning specialties, for example surgery and invasive cardiology.

Finally, the relationship between academic medicine and the pharmaceutical industry needs better regulation. Funding of research by industry is certain to continue and this is desirable. It is necessary to ensure that such research is as well-conducted and as well-respected as work that is funded from more traditional sources.

Competing interests: None declared

How should we measure academic success? 29 March 2004
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David A Cameron,
Consultant and part-time Senior Lecturer

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Re: How should we measure academic success?

It seems to me that universities, and probably grant-giving bodies, have succumbed to what in the UK we might have called "post-Thatcherism". Measuring performance by simple indicators of financial income and short- term output, and encouraging inherent competition between universities. I think this has led to a predominance of molecular medical academics to the detriment of collaborative cross-institutional programmes and academic-led large scale clinical trials/ interventions.

One of the things for which we need to argue is a recognition of the success of an academic medicine department/programme by what really matters: does the work lead to a change in diagnosis/therapy that results in improved survival for patients, less morbidity/improved health, reduced incidence, or more efficient use of scarce health esources. Grant income and Research Assessment exercises rarely measure these sort of outcomes.

How we do that is the hard bit - and there your campaign to develop a working party to lobby governments and grant giving institutions will have a lot of work to do!

Competing interests: Medical Oncologist with an interest in translational Clinical Trials!

Concerns for the direction of academic medicine 31 March 2004
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Margaret S. Terpenning,
Associate Professor, Internal Med
University of Michigan

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Re: Concerns for the direction of academic medicine

Three areas greatly concern me in terms of the direction of academic medicine.

First, there seems to be no coordination of global concerns within academic medicine. Diverse groups advocate for their causes, but there is no central organization. For instance, is there a central group trying to keep track of sanitation and public health data for various areas of the world? Does academic medicine leave this to the U.N. or does the academic community try to help the U.N. organize the data? Is anyone keeping track of whether there is net progress or not? When people want to volunteer to help, either as physicians or as teachers, has academic medicine provided a central clearing house to help match volunteers with needs? There seem to be People to People programs and Doctors Without Borders, but these are not central organizations. Are all these concerns addressed within academic public health, or are the clinician-academicians involved?

Second, there are trends in teaching which concern me. The pressure of research keeps us away from our students and our patients. The impact on time spent rounding is critical. If we are not to have old-fashioned rounds, what is replacing that time? I have been especially concerned with computer workups and computerized grading. At times I am asked to evaluate students based on computerized writeups on patients I have not always seen. Is this a general trend, and how can it be opposed?

Lastly, the pressures on physicians and patients to use ever-more- expensive drugs seem unrelenting. Patients and their insurance companies will rebel and must rebel. This rebellion will collide with the desire of the drug companies for more profits. The academic physician will be caught in the middle, but will be inclined to side with the patients. Yet drug companies and academic centers have had an alliance, not entirely a holy alliance, which will now be strained and produce polarization between doctors and drug companies, and between doctors and patients.

Competing interests: None declared

Educating the next generation 31 March 2004
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Dan Kerley,
Biochemistry Student, Prospective Medical Student
University of Bath, BA2 7AY

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Re: Educating the next generation

I was reading your article about academic medicine with great interest, and commend the concept of four advisory groups and the perspectives forum. However I couldn't help noticing that students are not considered an important part of the process. Can you expect to engage the next generation of doctors if their voice cannot be heard? It seems to me especially important that medical students are taught to value the contributions of, and actively engage with, academic medicine in order to encourage the transfer of knowledge from one field to another.

Of particular relevence to this point is the difficulty in accessing relevent research papers when a student. The fledgling open access scheme is one of the most important steps forward in recent years, though tragically seems in danger of going the way of other pay-per-view services. If students cannot access the relevent research they are stuck with what they can find elsewhere-which is all too often outdated and outmoded. In my view all scientific papers should be open-access from 3 years post-publishing. By this stage most are only useful for educational purposes anyway, as research has already moved on.

I am a final year biochemistry student and have applied to study medicine in 2004, so I have some insight into being a student in a research based discipline and recognise the importance of knowledge transfer from the lab to the clinic. Journal articles on recent medical advances need to be freely available to those in a position to implement them, and their importance as an educational tool needs to be recognised. I believe that this is something medical students must become familiar with early on, as they are unlikely to learn it after graduation.

Competing interests: None declared

Creating a roadmap for academic medicine 1 April 2004
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Jean D Gray,
Professor Emeritus, Dalhousie University
Halifax, NS B3M 2B3

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Re: Creating a roadmap for academic medicine

The international effort to revise and/or reform academic medicine is both timely and appropriate. Arguably, the process of health professional education and research is currently at a crossroads that requires new approaches and guidance to forge a new path. Flexner's report was, in its time, useful to create a roadmap for the development of the science of medicine and the creation of the "teaching hospital". But almost a century has passed and we are still very dependent on the Flexnerian model.

What has changed in the last century? The science of medicine has become a massive enterprise, fueled by both government and industry dollars. But growth has also resulted in a separation of that science from the practitioner of the discipline. Most of today's major scientific health advances are created not by practicing physicians, but by individuals whose entire career is based in the laboratory. Disciplinary boundaries within healthcare have become blurred so that many health professionals perform (and perform well) in roles previously felt to be medical roles. Several major reports have resulted in transformation in the processes of medical education so that curricula are now more student- centred (e.g. problem-based learning), more community-based (to provide training in the milieu where practice will subsequently occur), and more inclusive of the social sciences than was the case in the past.

The 21st century calls out for new reforms. Scientific medicine must incorporate the contributions not just of the "basic" scientist and, where available, the clinical investigator, but must also build teams of many skills to address contemporary health problems. Both the student and the practitioner of medicine must see the relevance of the research to their own work and possibly even contribute in an appropriate fashion. Globalization requires that the fortunate medical schools in the first world must partner with their colleagues in the less developed parts of the globe to assure that educational standards and basic health care delivery are assured for all. Instead of lengthening the medical school and residency curricula to encompass new developments, medical educators must accept responsibility for the continuum of health education, moving beyond the initial four years of medical school and encompassing the entire learning lifetime of the practicing clinician. And if health professionals work in teams then they should also learn in teams, if real change in health care is the objective of the learning experience. The reward system for faculty members engaged in team activities does not exist at the moment but must arise out of the new approaches to research and education.

The time for reform is now. I applaud the BMJ and its international partners for leading the mapping process necessary for transformation. Jean Gray

Competing interests: None declared

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Kerr White,
Retired (Former Deputy Director for Health Sciences, the Rockefeller Foundation)
250 Pantops Mountain Rd, #5328, Charlottesville, Virginia, USA, 22911

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� There is more than adequate evidence to expand medicine�s worldview beyond the useful but unduly narrow biomedical model to include social, environmental, familial, occupational and emotional factors on health disease and to substantially expand its educational venues beyond the hospital to include physicians� offices, patients� homes, nursing homes, rehabilitation facilities, and hospices.

� The notion of single �causes� for the majority of diseases should be abandoned and the concept of predisposing, precipitating, and perpetuating factors adopted by recognizing that most illnesses require clusters or sequence of several elements to evoke biological or behavioral changes, e.g. genes, diet, and sedentary life-style for diabetes; strong coffee, aging, and �stress� for atrial fibrillation; relative poverty, depression, and the tubercle bacillus for tuberculosis; climatological change, �stress/depression� and a virus for the common cold etc.

� Everybody needs a compassionate Personal, Generalist Physician (or Nurse Practitioner or even Aide) who listens to the patient, uses efficacious and cost-effective interventions, refers judiciously, works in a group practice, and is sensitive and knowledgeable about the demographic, cultural, social, biological, and other environments surrounding the practice and its geopolitical jurisdiction.

� Students should be required to prepare a paper describing briefly the clinical features, incidence/prevalence, and costs of individual and population-based therapeutic and preventiveinterventions for the ten commonest problems in their own jurisdictions, in their country, and in three developing countries.

� Referrals to specialists and super-specialists should be made by generalists with substantially decreased differential physician re- imbursement for self-referred patients they treat.

� At graduation all physicians should be thoroughly knowledgeable about the clinical, biomedical, behavioral, and population perspectives in medicine and healthcare � their current concepts, methods, contributions and limitations.

� Courses in anatomy, molecular biology, biochemistry, and immunology should be shortened and their principles incorporated into longer courses that focus on knowledge and skills in recognizing and counseling individuals and populations about genetic, familial, and occupational influences on susceptibility to illness and disease and on the rationales for pharmacological, procedural, and behavioral interventions with emphasis on their relative efficacy and costs.

� For each patient assigned, the student should turn in a report of the charges for the admission and a statement of the costs of the treatments prescribed on discharge for the next year or fraction thereof.

� A short (1-3 months) course should be given by a safety engineer from the aviation industry explaining how �near misses�, errors, and catastrophes are reported and managed.

� All medical curricula should include a substantial required lecture/reading/study/essay course on both the history of the scientific method and the history of medicine.

� All medical curricula should include a substantial required lecture/reading/study/essay course based on the humanities that bear on pain, suffering, deprivation, medical interactions, and living with disability, and that includes works by physicians and nurses.

� All medical students should be required to spend at least two three -month electives working as a generalist in a deprived area or in a developing country � one each in urban and rural settings.

� Specialization should not start until after graduation and the numbers of residents in an institution should be limited to those who can be effectively mentored and supervised; the wisdom of the practice of letting the residents/house staff �run the place� and �learn by doing� should be reconsidered.

� The Health Information System should be based on patients� presenting symptoms, complaints, problems, or questions using the International Classification of Primary Care which can then be mapped to the International Classification of Diseases as required in order that episodes of care and the natural history of illness can be investigated and monitored.

� The first year should include a substantial (6-12 months) exercise where two patients, one with a chronic illness and another with an acute disease, are presented and discussed or alternatively each student is assigned such patients with the charge to write a paper using medical journal standards that discusses how the illness was first labeled, what the diagnostic criteria are, how it is coded, how many such patients there are in the relevant city, county, state, and nation and how this information is known by the health departments, what interventions are used and the evidence for their efficacy, the costs of treatment those afflicted individually and collectively in the relevant the jurisdiction, who pays, and finally what is beingdone to limit the spread, deterioration, and prevention of the condition and who is responsible for each of these, etc.

� Starting in first year and continuing throughout the curriculum, each student should be assigned one patient with a chronic disease/disability who is followed regularly at home, and elsewhere if indicated, and for whom a brief monthly status report is prepared.

� Curiosity should be stimulated by having each student submit a brief annual essay discussing some facet of a disease, patient care, intervention, health policy etc. for which no adequate explanation, justification, or resolution could be found.

� Every student should be present for at least 3-5 encounters when �good� news and 3-5 when �bad� news is given to the patient and/or relatives.

� �Common� diseases are very common� and �Rare� diseases are very rare.

� For the vast majority of diseases �caring� (more than the �placebo� effect�) is at least half of the �cure�.

Kerr L. White M.D., klw2j@virginia.edu

Competing interests: None declared

Bringing academia into clinical practice 15 April 2004
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Paddy A Phillips,
Head of Medicine
Flinders University, Adelaide 5042

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Re: Bringing academia into clinical practice

I would be keen to be involved in any program to revitalise academic medicine.

I have a firm belief that many academic leaders are not necessarily the role models or even the clinical leaders they should be. In particular, whilst many are outstanding scientists in a branch of the biomedical or even clinical sciences, it is rare for us to bring a truly academic perspective to our clinical work. By this I mean we rarely apply the rigorous principles of science to our clinical work through questioning established dogma, by testing new ways of doing things or even evaluating our clinical practices. Without providing leadership in our clinical work in these ways I believe that academic medicine is doomed to becoming increasingly less relevant to health care and more focussed on biomedical science. Obviously biomedical science is important but I question whether biomedical scientists should be the academic medical leaders with their attention elsewhere and not more directly involved in improving health and health care and teaching others how to do this.

Competing interests: None declared

Non-Academic Science : An Oxymoron 29 April 2004
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Jacob M. Puliyel,
Consultant Pediatrician and Head of Department
St Stephens Hospital, Tis Hazari, Delhi 110054

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Re: Non-Academic Science : An Oxymoron

I have been following the discussion on academic medicine, and have been impressed by your global approach. Thus you seem, not to be attempting to revitalize academic medicine in the UK but internationally, and such an approach is most likely to promote the science and health in general.

In India research is an essential component of post-graduate training. For the MD, or MS and the DNB (Diplomate of the National Board) it is mandatory to submit a research dissertation or thesis, besides appearing for written and clinical examinations. This research need not be PhD level seminal work, but it is in place to familiarize the candidate with research methodology, and the process of analysis and presentation of research.

I find that specialists-in-training are keen researchers, but they need mentoring and also the confidence that their mentor has the tenacity to carry the project through, up to publication. Research funding is not such a big issue, if research-data-collection and computation is done by volunteer-junior-doctors, who are keen on the experience and the glory of publication. This is not part of the MRCP requirements in the UK and I feel you forgo a unique opportunity to impart training in research skills.

We have of late become overly concerned about applying research to practice. The modern fad of producing CATs (Clinically appraised Topics) is axiomatic of this. (Jacob M. Puliyel, Noopur Baijal, Dherain Narula Evidence-Based Investigation into The Relation Between Sexual Intercourse And Pregnancy Electronic Letters Archives of Disease in Childhood 15 March 2004;742 ) The true measure of the impact of academic medicine is not how many people in the community utilize the research results, but the effect research has on the researcher and how it modifies his or her understanding and responses in medical practice. Academic medicine is far deeper and more involved than doing a CAT � it in fact provides the grist for the mills that churn out CATs

To my mind all science is scholarly and the concept of non-academic medicine is a contradiction in terms and akin to quackery. It is a sad commentary on our times that the term �academic� has now acquired the connotation; �not being of practical relevance�. The effort to revitalize academic medicine is to revitalize medicine itself. I hope you succeed in your effort to raise the profile of academic medicine and thereby that of the science as a whole. I will willingly volunteer time and energy to this noble effort

Competing interests: None declared

Don't believe us ! 11 June 2004
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David L. Sackett,
Trout Centre at Irish Lake, Markdale ON Canada N0C 1H0

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Re: Don't believe us !

Don�t believe us

I write this open letter not (strangely, for someone at my age and stage) to offer any advice to the magnificent, international group of young people who are coming together to propose improvements for the academic medicine of tomorrow. Rather, I pose a question to them: �Why, on earth, should you take any advice from any of us old farts who (through inattention, greed, or simple incompetence) got academic medicine into the simply awful mess in which you find it today?�

Although our confessions and academic autopsies might be informative, do you really think that our prescriptions for the future of academic medicine will be anything but self-serving and stultifying?

My academic autopsy, for example, includes glaring failures: I failed to convince the granting bodies here in Canada to adequately fund applied and health care research (1). I also failed to convince them of the immorality of handing the responsibility for clinical trials over to the profiteers, and I have been reduced to merely mocking the dreadful system my incompetence helped to create (2).

And I am the rule, not the exception. As academic clinicians, we have rejected the provision of continuous, comprehensive care and middling incomes in favor of huge waiting lists, unethical self-referral for costly diagnostic tests, and industry-consultantships that pervert our science as profoundly as they line our pockets. We used to tend the sick and poor for public good; now we write guidelines for personal profit.

As medical educators, we continue to apply curricula that value memory above thought, promote study by fear rather than reason, and sentence post-graduates to years of servitude in the educationally �lost- generation.� Our nomenclature reveals our true priorities: there are research �challenges,� but only teaching �loads.�

As medical scientists, we value the study of adenine, thymine, cytosine and guanine far above the study of childhood diarrhea, Chagas disease, community health, and patient decision-making. The issue is not the potential usefulness of basic research at some distant future date (although you might even dare question whether it is being oversold). The issue is that basic medical scientists have hijacked the granting bodies and have erected research policies that place greater value in serving their own personal curiosities than in serving the sick.

Fifty years ago, Jonas Salk was asked, �Who owns the patent on this [polio] vaccine?� He replied, �Well, the people, I would say. There is no patent. Could you patent the sun?(3)� Academic medicine can (4). By this spring, U.S.-based universities alone had already taken out over 4,500 DNA -based patents, often licensing them to a single firm, despite the "detrimental short-term and long-term effects on both the quantity and quality" of health care (5).

Finally, in setting the rules for career advancement in academic medicine, we not only reward selfishness (e.g., solo publication, lead authorship, the non-sharing and commercial exploitation of techniques or early results). We demand it. Educational contributions receive short shrift at promotion time, and exemplary clinical care close to none.

We who pontificate on how to improve academic medicine have failed even to sustain it ourselves. Why, on earth, should you accept any of the advice we�ll try to force on you?


1. Sackett DL. Time to put the Canadian Institutes of Health Research on trial. CMAJ 1999;161:1414-5.

2. Sackett DL, Oxman AD. HARLOT plc: an amalgamation of the world�s two oldest professions. BMJ 2003;327:1442-5.

3. Smith JS. Patenting the Sun: Polio and the Salk Vaccine. Anchor Books, Doubleday, 1990.

4. Horton R. The dawn of McScience. New York Review of Books 2004;51:

5. Malakoff D. INTELLECTUAL PROPERTY: NIH Roils Academe With Advice on Licensing DNA Patents. Science 2004;303:1757-8.

Competing interests: Already on your website at: http://bmj.com/cgi/content/full/324/7336/539/DC1

Revitalizing Academic Medicine: Facing Some Harsh Realities 18 June 2004
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Roy M Poses,
Director of Research General Internal Medicine
Brown University Center for Primary Care and Prevention, 111 Brewster St., Pawtucket, RI, 02860, USA

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Re: Revitalizing Academic Medicine: Facing Some Harsh Realities

Efforts to reform academic medicine may tend to turn inward, leading physicians and health care faculty to blame themselves for academic medicine's malaise. Although physicians deserve plenty of the blame for what has gone wrong with health care, paradoxically we may also have been too timid about challenging external threats to our core values. More physicians now may realize that our core values are progressively threatened not only by our own failure to adhere to them, but also by external threats, particularly from increasing concentration and abuse of power in health care.(1)

In 1988, Alain C. Enthoven, an architect of "managed competition" in the US, writing for a European audience, blamed a supposedly tight-knit physicians' "guild" for many of the problems in health care, and suggested that improving health care would require a strategy of increasing the power of managers and bureaucrats to "break up the guild."(2) (Enthoven, of course, put on a more physician friendly face when writing for medical journals in the US.) (3) The main opposition to "managed competition" in the years before the failed Clinton health care reform efforts came from those who wanted the government to take over all payments for health care, i.e., in a nationalized "single payer" system.(4)

Thus many who argued for health care reform wanted to give more power to bureaucrats and managers, a strategy which seems to be increasingly popular in the developed and developing world. This has lead to the domination of health care by large organizations. Just which organizations are dominant varies from country to country, but in the US we have the corporate employers and government agencies which finance health care (with other peoples' money); insurers and managed care organizations which pay those who actually care for patients; hospitals, often organized into ever larger health care systems; device, pharmaceutical, and information technology corporations; brokers, consultants, and providers of out-sourced services; etc., etc. These organizations' actions may conflict with physicians core values, sometimes despite these organizations' proclaimed missions. For example, just this week, simultaneous lawsuits were launched in a dozen major US cities that alleged not-for-profit hospitals charged patients without health insurance, and who were therefore likely poor, far more than the discounted rates they charged insurance companies.(5)

Furthermore, as power in health care is concentrated within such organizations, it is more prone to abuse. There are numerous anecdotes of such abuse, including instances in which physicians and patients have been subject to perverse incentives and have been caught in cross-fires between competing interests.(1) Most extreme were examples of physicians punished for speaking out about health care quality, and researchers punished for reporting research that offended vested interests.(1,6)

Although many of the people who work for large health care organizations are doubtless well-intentioned, there are numerous anecdotes reported in the press of leaders who were ill-informed, who put their self -interest ahead of their organizations' mission, and who were even corrupt. Governance structures that are often not representative of key constituencies, secretive, unconstrained by clear codes of ethics, and not accountable may fail to guard against the corrupting effects of power on health care leaders. One dramatic example was that of Allegheny Health Education and Research Foundation, once the largest health care system in Pennsylvania. The system eventually collapsed into bankruptcy. Its Chief Executive Officer was sentenced for up to 23 months for misusing $30 million of Allegheny's charitable endowments to conceal operating losses. The institutions that made up Allegheny, including several major teaching hospitals, were left in chaos.(6) Although many such incidents have been reported in the media, they have been largely ignored in the medical and health care literature.

Academic medicine must work within such a dysfunctional health care milieu. Furthermore, some academic physicians and medical faculty may work for organizations whose governance structures are liable to abuse, and a few may work for leaders who misuse their power. To be successful, a campaign to revitalize academic medicine must face these realities.


(1) Poses RM. A cautionary tale: The dysfunction of American health care. Eur J Int Med 2003; 14: 123-130.

(2) Entoven AC. Theory and Practice of Managed Competition in Health Care Finance. Amsterdam: North Holland, 1988. P. 122.

(3) Enthoven A, Kronick R. A consumer-choice health plan for the 1990s: universal health insurance in a system designed to promote quality and economy. N Engl J Med 1989; 320: 29-37, 94-101.

(4) Himmelstein DU, Woolhandler S, and the Writing Committee of the Working Group on Program Design, Physicians for National Health Program. A national health program for the United States: a physicians' proposal. N Engl J Med 1989; 320: 102-108.

(5) Abelson R, Glater JD. Nonprofit hospitals said to overcharge uninsured. New York Times, June 17, 2004. http://www.nytimes.com/2004/06/17/business/17suit.html

(6) Poses RM. The US health care system: dysfunction and hope. Lancet Oncology, in press.

Competing interests: None declared

Are our undergraduates engaging with academic medicine? Fewer are publishing letters 4 February 2009
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Bayanne Olabi,
Intercalating medical student
Edinburgh, EH89HP

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Re: Are our undergraduates engaging with academic medicine? Fewer are publishing letters

EDITOR - The revitalisation of academic medicine discussed by the International Campaign to Revitalise Academic Medicine(1) should begin at medical school. Encouraging students to critically appraise and publish work is an excellent opportunity to engage in this field, and with the increasing emphasis on evidence-based-medicine in the NHS, these skills will soon be as important for doctors as clinical competence, effective communication and teamwork. Is the motivation and support amongst the undergraduate student body currently present to develop these skills?

To investigate this, and extending the study by Hanratty et al.(2) conducted almost 10 years ago, I examined letters to the BMJ over eight years and quantified the extent of medical student authorship. An internationally renowned journal, with substantial student readership, the BMJ serves as an ideal resource to determine whether undergraduates are involved in reviewing and publishing original work.

I examined the letters sections of the BMJ from January 2000 to December 2007 (volumes 320-335) and recorded the total number of letters and the number with at least one medical student author. These letters were categorised into four types: author's reply; critical appraisal of a published paper; original work, which included case reports, surveys and other results of research; and viewpoint, which offered an opinion on any topic or article but without critical appraisal of the work.

Over this eight year period, the BMJ has published 3247 sets of letters, each corresponding to a particular article or topical area of discussion. 69 (2.1%) of these sets of letters had at least one medical student author. When looking more closely at the number of letters published each year, it was found that medical student authorship had progressively fallen after 2003 (graph 1).

Medical students from overseas have contributed significantly to the letters section (26% of letters studied), primarily by providing their viewpoints, and 33 (48%) of these letters were written by students alone, without coauthors in the specialty. Interestingly, when analysing the type of letter written by year, before December 2007, the last student critical appraisal was written in October 2003, whereas 18 viewpoints were published throughout this time.

Although it is difficult to quantify the extent to which the undergraduate medical curriculum today trains students to become competent in research and academic medicine, publication of letters by medical students has merit as an informal measure. The decline in the number of letters, and particularly critical appraisals, written by medical students is perhaps something which could be rectified by providing more opportunities for undergraduates to carry out and appraise current research. For example, at the University of Edinburgh, all students undertake a research project in fourth year, and intercalating is optional. This year, a new student society ATRIUM (Academic TRaining In Undergraduate Medicine) has also provided students with information and resources to develop these skills, even running a �how to write letters to the editor� session, which returned excellent feedback from students. In my opinion, changing medical school curriculums to acknowledge the importance of research to clinical work is a step in the right direction.

(1) Tugwell P. Campaign to revitalise academic medicine kicks off. BMJ. 2004;328:597.

(2) Hanratty B, Lawlor D. Getting letters published in journals is good aim for medical students. BMJ. 1999;319:1198.

Competing interests: None declared