BMJ No 7108 Volume 315
Education and debate Saturday 6 September 1997
Clinical academic medicine: a Socratic dialogue
D G Grahame-SmithSee Editorial by Chaudhry p 560 and Personal view p 612
As in all walks of life, clinical academic medicine has many vested interests, some acting for the greater good, some not. Socrates has a penchant for sniffing out pretension and sectional interest. Hippocrates is a thoughtful, gentlemanly physician unaccustomed to ensnarement by Socratic wiles, and when he and Socrates meet one day in the marketplace in Athens the following conversation about the state of clinical academic medicine ensues. It is not a dialogue for the timid.
| Summary points |
| Hippocrates: Never has the potential of medical research to discover the molecular causes of disease and design effective new treatments been so great |
| Socrates: So why so down in the mouth? |
| Hippocrates: It is becoming impossible to perform as a competent clinician and promote really original research with full understanding of the molecular sciences |
| Socrates: Cannot clinical academics and basic biological scientists work side by side, each contributing their complementary skills? |
| Hippocrates: Indeed, but our universities do not seem ready to meet this challenge |
| Socrates: How do the young see it? |
| Hippocrates: Their hero is the busy clinician with his keyholes and imaging machines, not the scientific Colossi of yesteryear. There is a problem with the relative charismas of service and academic medicine |
Socrates: Hippocrates, you are looking rather down in the mouth. What's up?
Hippocrates: I am having a sabbatical from my clinical labours to spend time thinking about medical academic and scientific matters.
Socrates: How interesting. I had always thought of you as a proper doctor, not an academic one.
Hippocrates: Sometimes, Socrates, you can be so wounding. How can I explain to you the difference between an everyday hardworking physician in service and one who, while active in clinical work, also has an obligation to teach and by original research to forward his subject?
Socrates: Are not research and practice compatible?
Hippocrates: To some extent they are. Indeed, those who are not labelled "clinical academics," if they are enthusiastic clinicians with a love of order, can and do study their patients and make important and useful contributions to practice.
Socrates: How does that differ from the sort of research you do?
Hippocrates: I have always been interested in the molecular causes of disease.
Socrates: What use is that?
Hippocrates: Without such understanding, there can be no rational progress towards treatments and cures as yet undiscovered.
Socrates: Do you use the word molecular in the same way as the disciples of Watson and Crick?
Prepared minds seeking innovation
Hippocrates: Not entirely. Although their special science of molecular biology is justifiably all pervading in medical research at present, there are other studies of a reductionist nature which are very important for putting that science into the context of disease, and these studies will come into their own when the functional role of obscure genes needs to be defined.
Socrates: So where does all this directed science leave serendipity, which I have been led to believe is one of the most important methods of advance in therapeutics? Were not digitalis, penicillin, and lithium discovered in this way?
Hippocrates: Take care Socrates, not to join the chattering classes in their glibness. Most unlike you. You know very well that those treatments were discovered by prepared minds seeking innovation and developed by imaginative and painstaking clinical experiments. To dismiss this activity as pure serendipity is a travesty.
Socrates: All right, don't get upset. You know my method. Tell me how your reductionist probing of the molecular causes of disease can lead to effective new treatments, and how this differs from previous empirical methods.
Hippocrates: I would give as important broad examples of the benefits of the reductionist approach levodopa in Parkinson's disease, many antiviral drugs, H2 blockers and proton pump inhibitors in peptic ulceration, angiotensin converting enzyme inhibitors in hypertension, and allopurinol in gout, and these are important advances made before the advent of the new molecular medicine.
Socrates: Very impressive, so why so down in the mouth?
Hippocrates: Well, never in my lifetime has the potential of medical research to discover the molecular causes of disease and design new effective treatments been so great. However, I am worried about the serious problems which face clinical academic medicine as it attempts to realise that potential. Molecular medical science is burgeoning at such a pace that it has become impossible to perform as a fully competent physician and promote really original research with full understanding of the molecular sciences. The sheer volume of scientific research is overwhelming, and the proper practice of clinical medicine now so demanding that he who purports to be both a proper doctor and a proper scientist is deluded.
Socrates: Wow! Is that why the senate was so reluctant to pay clinical academics the same as their health service colleagues? Just a joke Hippocrates! Is it not possible to organise a system for medical scientific research in which clinical academics and basic biological scientists work side by side, each of them contributing their complementary skills.
Hippocrates: Indeed that is possible and there are a few medical research institutes where this happens, but our universities do not as a matter of policy seem ready to meet this particular challenge of medical science.
Socrates: Why is that do you think?
Venality in academe
Hippocrates: This is difficult. Universities are egalitarian places, praise the Gods, and as such regard the department of byzantine studies to have equality with medicine. University medical schools are "cuckoos in the nest" - large, arrogant, loud, vocationally successful, clearly practical, and well regarded professionally and culturally by the populace. But they are very expensive. Senior clinical academic staff are paid more than anyone else in the university, medical research is well funded compared with many other subjects, and, although the universities are fortresses of liberty, all this sometimes grates with the rest of academe.
Socrates: I had no idea that such venality existed in the glades of academe. But tell me, the future is in the hands of the young. How do they see it?
Hippocrates: Difficult to give a global answer. Their views are various: some enthusiastic, some not so.(1) No one ever really asks them in an ordered way, so I can give only anecdote. Every head of a clinical academic department is uneasy about the small number of applicants for the clinical academic jobs that are advertised.
Socrates: Why is that?
Hippocrates: The future of top class medical research in this country is uncertain. It is a very expensive enterprise and the outcome is unpredictable if the research is very innovative and creative. Others have bemoaned the straitjacket which is placed on innovation and creativity in research when funding is very restricted, and they fear that the quality of our reductionist research in medicine is becoming prosaic. I have to say I agree. My recent investigations into the effects of drugs on gene expression in tissues shows that the vast majority of studies on this subject come from Gaul or the New World.
Socrates: Does that matter? Is not science a universal activity? Is it necessary to adopt scientific chauvinism?
Hippocrates: My sentiment is not chauvinistic in the way you imply. I believe it is a serious matter, educationally and culturally, when young people cannot get caught up in the enthusiasm of new, creative science. If you fail to maintain an involvement with the cutting edge of science, your application of it at a later stage will be uninformed and unskilled and if the concepts are not well sown it will take a long time to catch up.
Socrates: I do see that. Is then the difficulty in getting support for what you would call creative, innovative, research into the molecular sciences in medicine the main barrier to recruitment of the young into that fold?
Corinthianism is out
Hippocrates: No there are others. You will remember when we were young, Socrates, how we admired the way the academics of Corinth disported themselves. They wore their learning lightly; they were gentlemen rather than players, and their style was one a young man could aspire to. Times have changed. The world is for players, not gentlemen. Where now does the hero worship lie? Not with the Sherringtons, the Watsons or the Cricks, the Flemings, the Blacks, the Vanes, or the Eccleses, the cultural scientific Colossi of yesteryear. The medical students' hero is the busy clinician, the more specialised the better, with his tubes and his optic fibres, his keyholes and his needles and his machines of great imaging intensity.
Socrates: Golly, your disillusionment is deep. You are implying that the type of medical research which interests you is no longer respected by your clinical peers.
Hippocrates: Oddly enough, that is not so. The problem is that the art of my type of research is now so divorced from the bedside that it is difficult for devoted clinicians to relate to it, and this I believe is the same for the medical student, who will soon be the young doctor, who once upon a time might have been looking for a career in clinical academia.
Socrates: Beside this cultural division, what else is there to discourage the youngster from going into a clinical academic career?
Hippocrates: If such a career is to continue as it has in the past the clinical academic has to be fully trained not only in his clinical speciality but also in those aspects of science necessary for his research. Even if he or she works all hours of the day and night at both of these disciplines, it plainly is going to take a very long while to reach that level of proficiency in both, which equally clever people, working equally hard in only one, acheive. You and I remember how quickly one's youth is past and how rapidly the energy for adventurous creativity dissipates. Many young people reject this situation and decide to get on with the job of curing people. So you see there is a problem with the comparative charismas of service and academic medicine today. However strapped for cash service medicine may be, the youngsters perceive it as being immensely effective, while, except for a few centres, dust threatens academe. Did you know that in our city state there are as many clinical professorships vacant in the various fields of medicine as there are varieties of Heinz?
Socrates: Heavens, as bad as that. What are we going to do?
Hippocrates: The city fathers have initiated a number of committees to look into the problem and present their findings to the senate, but whether the senate will do anything about it, or whether it will instruct the universities and the medical profession to sort out their own problems, one cannot tell. It has to be said that within the resources available medical practice is surviving, despite all the grumbles, and keeping up by and large technically, and it is arguable whether putting more money into university medical schools is really going to improve the quality of health care delivered to the populace.
Socrates: Well Hippocrates, why not do away with medical schools in the universities and let the health service run them as sort of medical technical colleges producing "semi-shod" doctors practising medicine based on the discoveries made by medical scientists in other countries and honed here for our own purposes? Do you think patients would be any worse off? And another point while we are about it. Why does every medical school have separate departments of anatomy, physiology, biochemistry, and pharmacology, teaching mainly medical students those basic scientific disciplines? Are not the preclinical departments staffed by the very basic scientists that we would like to have working with clinicians in research? Why not amalgamate preclinical and clinical departments, combine the talents of clinical and basic scientists, and save money on plant and resources? Some basic scientists might gain new inspiration for both teaching and research if they were in a clinical milieu.
Conjuring up the synapse in outpatients
Hippocrates: Such a reorganisation would be very unpopular with my preclinical colleagues, even though it might improve the competitiveness of our national medical research base. The universities might also argue that such an amalgamation may be contrary to the premise that universities exist to pursue knowledge for its own sake. Can you imagine Sherrington conjuring up the concept of the synapse while doing a neurological outpatient clinic?
Socrates: Never forget, Hippocrates, that Albert Einstein conceived the special theory of relativity while working in the Swiss patent office, an environment, one would have thought, almost as uncongenial to creative intellectual activity as a neurological outpatient clinic. However, Einstein himself observed that: "A practical profession is a salvation for a man of my type; an academic career compels a young man to scientific production and only strong characters can resist the temptation of superficial analysis." Think on that Hippocrates.
University Department of Clinical
Pharmacology,
Radcliffe Infimary,
Oxford OX2 6HE
D G
Grahame-Smith,
Rhodes professor of clinical
pharmacology
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