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SOME FACTORS TO BE CONSIDERED FOR FACING THE REINVENTION
- Alberto E D'Ottavio, Tomás E. Tellez and Larisa I. Carrera (6 January 2004)
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Random Thoughts on Academic Medicine
- Balu H. Athreya (22 April 2004)
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Alberto E D'Ottavio, Professor - Researcher Rosario University School of Medicine, 2000 Rosario, Argentina, Tomás E. Tellez and Larisa I. Carrera
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Rosario (Argentina), January 4th. 2004 EDITOR - In the British Medical Journal(BMJ)of 1 November Clark and Smith focus their editorial in the collapse of “Medicine's capacity to research, think, and teach." (1). Subsequently, in the BMJ of 3 January, Clark summarizes the commentaries sent by several readers about the above mentioned viewpoint (2). In this regard, we intend to rescue preliminarily some aspects about research and teaching, apt to become of relevance in the above mentioned crisis. Firstly, we are persuaded that the standing of medical schools clearly depends, among others, on the prestige of their teachers and researchers since they determine the fortitude of each undergraduate and postgraduate endeavor. Consequently, we are also convinced that this assertion joined to the resources for achieving a suitable teaching and research should prevail over any other consideration in academic planning. In a near hierarchic stage, we place the process of evaluation agreeing with Miller about the importance of this academic procedure (3). In this sense, we visualize a conspicuous difference between research and teaching when applying it specifically to both activities. Thus, research shows a determined grade of objectivity and a reduced number of biases because of the certainness provided by publications, grants and patents for evaluating creativity and efficiency. In contrast, teaching offers a high grade of subjectivity and complexity as well as a higher number of biases. Here the challenge consists not only in determining what a good medical teacher is but in establishing standards the more objective the better for evaluating it. Furthermore, in both activities the role of a continuously changing society cannot be discarded. Then, the improvement of research and teaching, including critical thinking and making emphasis in teaching, should be academically considered and debated in developing countries as ours, particularly if, as supported by Clark and Smith, a collapse of defined Medicine's capacities is at sight in the developed world. REFERENCES 1 Clark J, Smith R: BMJ Publishing Group to launch an international campaign to promote academic medicine. BMJ 2003; 327: 1001-2. (1 November) 2 Clark, J: Academic medicine: time for reinvention: Summary of responses. BMJ 2004; 328; 49 (3 January) 3 Miller G: Los principios en la práctica. En Miller G & Fulop T: Estrategias educativas para las profesiones de la salud. Cuadernos de Salud Pública OMS, Ginebra (Suiza) [The principles in the practice. In Miller G & Fulop T: Educative strategies for health professions. Public Health Memorandum Books, WHO, Genevre (Switzerland)] 1975; 61; 101- 103 Larisa Ivón Carrera, MD, Instructor of Histology and Embryology, Rosario University School of Medicine, Argentina Tomás Eduardo Tellez, PhD, Professor of Histology and Embryology, Rosario University School of Medicine, Argentina Alberto Enrique D’Ottavio, PhD, Professor of Histology and Embryology, Rosario University School of Medicine, Researcher of the Rosario University Scientific Researcher Career and Chairman of the Rosario University Research Council, Argentina Competing interests: None declared |
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Balu H. Athreya, Professor of Pediatrics, Thomas Jefferson University/Jefferson Medical College A I Dupont Hospital for Children, Wilmington DE USA 19899
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In your letter of invitation to potential members of the working party, you had asked two questions. Here are some of my thoughts. 1. What is the biggest single problem with Academic Medicine? The question automatically suggests two sets of answers one in reference to medicine in general and one in particular to academic medicine. Instead of choosing one major problem, I wish to list three major changes leading us to this point. The next step is the definition of academic medicine. In my definition, academic medicine is primarily concerned with education of future doctors and acquisition of scientific knowledge. The Flexner report set the stage for establishment of the profession and teaching of medicine on a scientific footing. The consequences of developments since then in biomedical research and several changes in the society force us to review the role of practice, teaching and research in medicine within the framework of changed socioeconomic and political conditions. In my view, the three most important changes that have occurred since the Flexner Report are: 1. Explosion of scientific knowledge with resultant technologies and specialization. 2. Patient autonomy, patient rights and the public demand for voice in medical decision making at an individual level,on allocation of resources and on how physicians are taught. 3. Cost of care and complicated administrative structure directly related to items 1 and 2. These three changes must be addressed to refocus academic medicine for the future Increase in knowledge has clearly benefited the human kind. It has created several new technologies and specialties. This has resulted in better and earlier diagnosis and prolongation of life for those who are sick and can get access to these specialties and technologies. It has not necessarily improved overall health and has caused social inequities. As Odegaard pointed out, the primary goal of medicine is “caring”, not necessarily “knowing”. That is not to deny the fact that knowing clearly makes caring better and we absolutely do need to know. But current trend has tilted too much towards “knowing” and not enough towards “caring”. The public resents that trend. The public also resents and complains about the fact that the focus is on the organ pathology and not the person with the disease. The public knows that high and effective technologies come out of academic centers and everyone wants an access to the best technology when he/she is sick! Since medical education takes place at academic centers dominated by specialization and technology, and since the public does not understand what academic medicine does and how important it is to the society, support for academic medicine is eroding. Most of the medical education is still hospital-based in the midst of high technology and rare diseases with rare complications. There are excellent teachers in these sub-specialties, of course. But the fact is that academic centers primarily reward and promote researchers and specialists with narrower focus. Clinician educators and generalists are undervalued and are treated as second class citizens in a separate academic track. To survive even in that track, clinical money has to be generated. Why would any one want to be a clinician/educator? No wonder that there are very few role models as teachers of medical students and hospital trainees. The basic relationship between the physician and patient has also taken a dramatic and a crucial turn. Patient are better educated and better informed. In a democratic society the informed public is increasingly skeptical of authority and power. Patient rights and informed consent are the norms. Patients do not want to be passive and comply with doctors “orders” and recommendations. They want to be partners in decision making. These are positive developments. But this requires different sets of skills in the physicians of the future. (It is disheartening to learn that policeman deliver sad news better than physicians!) Academic medicine has not done a good job in preparing physicians for this task. We need scientifically trained clinicians with human relation skills more than ever before as role models. Cost of care has escalated. There are several causes and several effects. One of the effects is that department heads are burdened with financial management and fund raising and are not able to perform their function as physician role models.In my view this is not healthy since it leads to cynicism among students. Able scholars and teachers who become leaders get either bogged down with administrative details or seem to get into fund raising activities. They either step down in disgust or forget their clinical roots! 2.What is a realistic and achievable solution to at least a portion of the problem? I have 6 general ideas. But they need more reflection,discussion and analysis. 1. Academic centers should be organized on the model of McMaster University so that an academic unit in Clinical Epidemiology, Biostatistics and Health Services Research is the hub. All clinical departments will work through this hub in answering clinically relevant questions. All clinicians – generalists and specialists - should be expected to perform their scholarly activities through this hub. 2. Academic centers should make extra efforts to encourage, recognize, retain and support clinician/scholars as teachers and role models in par with research scientists and specialists. 3. The administrators and financial specialists should be under the direction of clinician/ scholars who develop the vision for “high-tech” but humane care based on patient needs and clinical realities. Of course, the clinical leader has to be fiscally responsible. 4. Medical education should help prepare the physician reestablish the patient-physician dyad in the new environment of patient as a partner in decision making. The curriculum should reflect the new knowledge in biomedical sciences and also in human relation skills (particularly for specialists) – such as listening skills, observational skills, communication skills, problem-solving skills, decision-making skills and negotiating skills. 5. The subspecialty departments may be realigned so that the research core is common and the clinical specialties give continuity of care, cutting across age and sex related sub-sub specialties (eg: pediatric orthopedics, geriatric orthopedics). 6. Academic medicine has to do a better job of educating the public on the value of academic medicine to the society and in making the public part of the decison making process. Competing interests: None declared |
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