Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A strong tree needs many roots
- Woody Caan (7 July 2005)
-
Follow the Money Trail
- Mark G. Perlroth (8 July 2005)
-
The gap between practice and theory
- Graeme M Mackenzie (11 July 2005)
-
Designer v Darwinian Future Academic Medicine Leaders
- Ali M Ghanem (12 July 2005)
-
Re: The gap between practice and theory
- Ellen C G Grant (12 July 2005)
-
The need for a specialized professional research system of ‘pure’ medical science
- Bruce G Charlton (12 July 2005)
-
The Future of Academic Medicine
- E Malcolm Symons, Sir Peter Bell and Jangu Banatvala (14 July 2005)
-
Re: The Future of Academic Medicine
- Jocalyn P Clark, on behalf of the ICRAM working party (15 July 2005)
-
Re: Re: The Future of Academic Medicine
- Woody Caan (19 July 2005)
-
close the gap of academics and the practice of medicine.
- Vijayashankara. Nanjegowda (20 July 2005)
-
Eliminating the silos
- Jean D Gray (20 July 2005)
-
Global Responsibilities
- Ian D. Coulter (21 July 2005)
-
Changing medical curricula & bridging the gap between researchers and academics
- Manique Wijesinghe (22 July 2005)
-
The wording of the scenarios
- David L Simel (25 July 2005)
-
A different way
- M Justin S Zaman (28 July 2005)
-
Leading clinical academic medicine into the 21st century
- Dr Sarah Edwards, Dr Jan Walmsley, Assistant Director (12 August 2005)
-
The ICRAM Scenarios: ridiculus mus
- Tom Madden MD FRCGP FAAFP, Donna C Bergen MD (22 August 2005)
-
Re: The ICRAM Scenarios: ridiculus mus
- Jocalyn Clark (25 August 2005)
-
Education The Final Frontier
- Wayne Pearce (25 August 2005)
|
|
|||
|
Woody Caan, Professor of public health APU, Chelmsford CM1 1SQ, UK
Send response to journal:
|
The five scenarios proposed by ICRAM certainly provide food for thought, but I worry that each could produce very lopsided branches of the wider family of medical science and education. Academic Inc would be unlikely, on precedents elsewhere, to develop clinicians for necessary but low-profit-margin areas like Learning Disabilities, and one can imagine what the Ronald Macdonald School of Public Health would produce. In The Public Eye would mean that services seen as "for those other people" or inherently "distasteful" would lose their academic funding pronto: just look at what happened in some parts of the USA to public sector Psychiatry when newly elected Republicans wanted to cut local taxes. It takes a long time to build up a discipline and to match training and new research to workforce and practice demands. The Reformation is much the most appealing scenario to me, because teaching in/for/through practice is the most memorable sort - but Higher Education offers a degree of scope for independent and innovative thought that a purely service-based academia cannot. Fully Engaged brings professional leaders in close contact with politicians and media spin: wasn't this Margaret Thatchers' rationale for the quondam NHS Management Executive? Under Tony Blair hasn't the post of Chief Medical Officer become so widely engaged it is now polygamous? The price these political spins have produced is a worrying split between primary medical care (most patients know the name of 'their GP' and some represent them in Parliament) - and those faceless, uncaring hospital doctors just waiting to give you MRSA - when what good professional training needs is to foster seemless integration of patient care across all settings. The Global Academic Partnership has an appealing, catholic, feel to it, but where will the Medical Pope reside and how will schisms and heresies be resolved, without fierce factional fights.... I predict a breakaway Council of Medical England within a few years. Strange as it may seem in the 21st Century, the historic compromise arrived at in the UK between the Medical Royal Colleges, Higher Education and a Health Service that encourages joint service/teaching contracts is probably the best way of producing a balanced and sustainable medical workforce. The challenge is how to graft in new branches of this family tree, for example the long term educational needs to match new national developments like the Health Protection Agency. Competing interests: Currently involved in projects on workforce planning |
|||
|
|
|||
|
Mark G. Perlroth, Professor of Medicine Stanford University, USA 94305
Send response to journal:
|
I was intrigued by the article. Certainly brainstorming over the future of academic medicine is a fascinating exercise. But aside from revealing facets of the interaction of medicine-in-general with (global) society it is sterile. Academic medicine -meaning the entirety of academic institutions globally- is quite heterogeneous and will certainly evolve differently in different societies as a function of local issues and cultures. But, most importantly, in any given location it will evolve in response to its sources of revenue, which are quite varied. In the large private universities of the USA major funding comes from research grants (Federal, pharmaceutical and philanthropic) and only a small fraction (5-10%) from student tuition. As donors' budget priorities change, so will academic priorities, as will the direction of the academic enterprise. Certainly, medical schools will remain committed to a basic curriculum of human biology and clinical experience. But they will do this by using faculty hired for other purposes (i.e. clinically remunerative procedures and grant-generating enterprises)since tuition alone cannot satisfactorily reimburse the faculty. So, if you wish to see academic medicine's direction in any given situation, look upstream to see where the money is coming from, not downstream, into the babble of salon conversation. Competing interests: None declared |
|||
|
|
|||
|
Graeme M Mackenzie, gp Whitehaven CA28 7RG
Send response to journal:
|
Just some thoughts as a non teaching, full time GP I have enjoyed and exploited the easy access to academic medicine through the internet. I sometimes wonder why people like me do not contribute more. Practitoners are in a fast moving, pragmatic world where hundreds of decisions are taken every day. The academic world seems slow and plodding by comparison, even though I know it has to be that way. Vocational, busy GPs have many ideas which just remain active within their own small worlds. I find I use my ideas by making risk assessments in patient situations where the usual treatments have failed. However it is very unscientific and not that amenable to scrutiny. Generally when I have tried to progress ideas, you find enough conservative opposition or disinterest to put you off. Sometimes the speed of progress of an idea is just too slow for me and I lose interest. Usually an idea means trying something "outside the box" and since in some ways my "line manager" is secondary care, one finds that they do not support that sort of behaviour because I suppose in some ways they maybe feel they should have thought about it first themselves. Competing interests: None declared |
|||
|
|
|||
|
Ali M Ghanem, MSc Surgical Science student at UCL Department of Anatomy and Developmental Biology, UCL, London, WC1E 6BT
Send response to journal:
|
Having arrived in the UK from the ‘third world’ witnessing first hand the tremendous 0.1:99.9 gap in medical practice, political practice, legal practice, media and research (not to mention the aetiological gap in fund, revenue and differing social priorities and values) I find the article and the responses most fascinating. Due to the very issues the article and the work behind it is attempting to solve, I regret very much the fact that many colleagues across the globe are already excluded from participating in the debate. Thirsty to development and committed to a future in academic medicine, I realise the costly path of such future made the DIY way (time primarily and resources secondarily). Studying (Distance Learning) law and ethics of modern medicine at the celebrated McLean school in Glasgow highlighted to me the badly needed application of knowledge and critical thinking of lawyers, atheist and religious ethicists and patients alike to dilemmas encountered in every day practice – In deed generalising such application globally will not only produce better researchers and practitioners across the 10:90 gap but also cut down the litigation bill of a publicly funded health care (and the malpractice insurance fees in the privately funded one).Alas, understanding the ethical and legal issues of the ‘molecular era’ validated by an academic ‘M.Phil’ does not provide adequate insight into signalling pathways. Another ‘M.Sc.’ is needed to learn the new alphabet of a rapidly advancing medical knowledge, and rather a ‘Ph. D.’ to hope for participating in the global competitive research field. With a dozen letters after one’s name the patient and the medical student are yet to benefit from the academic process. Naturally, the end of successful clinical careers forces an interest in academic medicine as a means to overcome the bottle neck. However, utilitarian self-seeking motivation rarely produces good teachers and researchers in medicine. The luring private practice of nip-tuck can reasonably be associated with a leak of young and old medics into the ‘market’. Academic medicine is not only alienated from the patients and the public, it is an ambiguous term for young health care workers as well. The lack of a system with a political will to produce leaders in health care able to deliver the advantages of all five scenarios combined in practice, research and teaching will never be able to block the production of such leaders altogether- altruistic and perseverant individuals will always come to rescue. Rather, it will keep the nature and leadership of academic medicine in its controversial state governed by math; (laws of prediction and chance measurement) geography (North-South flow charts) and/or politics (democratic favouritism) in a strict Darwinian selection. Competing interests: None declared |
|||
|
|
|||
|
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
Send response to journal:
|
GP Dr Graeme M Mackenzie is not alone in finding that ideas born of practical experience are not welcomed. The results of your questionaire already shows the dislike of profit based academic medicine and yet drug trials continue to dictate "Evidence-based" medical practice, no matter how flawed they are under closer scrutiny. Can anyone believe that castor oil was used as a placebo for pregant women in the largest trial of IM progestogen during pregnacy? More than half of the "control" women had preterm births. bmj.com has helped to provide easy access to academic medicine through the internet. Rapid responses are an excellent facility for reporting helpful ideas about investigating and treating complicated clinical patient situations. Many usual drug treatments fail because they are unscientific and harmful and have not been adequately scrutinised in drug company-funded or politically- biased trials. Those unable or unwilling for career or financial interests to think "outside the box" must find the freedoms offered, almost uniquely by bmj.com, very irritating. Dr Mackenzie is not alone in trying to progress ideas and finding enough conservative opposition or disinterest to put him off. Even if they feel they should have thought about it first themselves, they are capable of resisting basic scientific facts for decades. Long may the courageous BMA staff value freedom. Competing interests: None declared |
|||
|
|
|||
|
Bruce G Charlton, Editor-in-Chief Medical Hypotheses Henry Wellcome Building, University of Newcastle, NE1 7RU, UK
Send response to journal:
|
The need for a specialized professional research system of ‘pure’ medical science One different way to consider the future of academic medicine is to look at the future of scientific specialisms. It has been noticeable that over recent decades, medical research has become mostly an ‘applied’ science which implicitly aims at steady progress by an accumulation of small improvements, each increment having a high probability of validity. However, the need for predictability makes modern medical science risk- averse and this is leading to a decline in major therapeutic breakthroughs where new treatments for new diseases are required [1]. There is now a need for the evolution of a specialized professional research system of ‘pure’ medial science, whose role would be to generate and critically-evaluate radically novel and potentially important theories, techniques, therapies and technologies [2]. Such ideas typically have a lower probability of being valid, but the possibility of much greater benefit if they turn out to be true [3]. At present there is no formal mechanism by which pure science publications may be received, critiqued, evaluated and extended to become suitable for ‘application’. Indeed, the domination of medical research by ‘applied’ criteria means that potentially fruitful ideas are often ignored or summarily rejected as being too speculative [2]. Pure medical science needs to evolve to constitute a typical specialized scientific system of formal communications among a professional community [2]. The members of this putative profession would interact via close research groupings, journals, meetings, electronic and web communications –like any other science. Pure medical science units might arise as elite grouping linked to existing world-class applied medical research institutions. However, the pure medical science system would have its own separate aims, procedures for scientific evaluation, institutional organization, funding and support arrangements; and a separate higher-professional career path with distinctive selection criteria. Pure medical science would work most effectively and efficiently if practiced in many independent and competing institutions in several different countries. The main ‘market’ for pure medical science would be the applied medical scientists, who need radical strategies to solve problems which are not yielding to established methods. The stimulus to create elite pure medical science institutions might come from the leadership of academic ‘entrepreneurs’ (for instance, imaginative patrons in the major funding foundations), or be triggered by a widespread public recognition of the probable exhaustion of existing applied medical science approaches to solving major therapeutic challenges [1]. 1.Charlton BG, Andras P. Medical research funding may have over- expanded and be due for collapse. QJM. 2005; 98:53-5. 2.Charlton BG, Andras P. The future of ‘pure’ medical science: the need for a new specialist professional research system. Medical Hypotheses. 2005; 65: 419-425. 3.Charlton BG. Inaugural editorial. Medical Hypotheses. 2004; 62: 1- 2. Competing interests: None declared |
|||
|
|
|||
|
E Malcolm Symons, Emeritus Professor Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham, UK, Sir Peter Bell and Jangu Banatvala
Send response to journal:
|
The failure of academic medicine in recent years can be directly ascribed to four factors. The first of these is the Research Assessment Exercise (RAE) which, surprisingly, was not discussed in the IRCAM Scenarios (1). The second is the difficulties that have been put in the way of clinical research in the form of the draconian regulations now applied by ethics committees and the third is the huge problem faced by anyone wishing to work with animals. Finally, there is the old problem of having to work for two masters-the Universities and the NHS. These problems have been exacerbated by the introduction of job plans and clinical targets that have to be met. It is good that IRCAM has contributed to a wide ranging consideration of Academic Medicine but the IRCAM scenarios seem to take singularly little account of the models of clinical academic departments that have been successful in the past and that have made important contributions to advances in medical science as well as promoting high standards of medical education. No one questions the fact that it is almost impossible for an individual to be an expert clinician and teacher whilst maintaining a high profile as a bench scientist. There are not enough hours in the day. Nevertheless, a good clinical academic department will include a group of staff who can fulfil all of these functions. The need is for a department to have staff that have a range of individual skills, be they in surgical techniques, teaching or molecular biology. The real strength of academic medicine is the interaction between these disparate but interlinked functions combined in such a way that they draw good clinical practice together with good basic science. The current divisive approach in many undergraduate medical schools whereby clinical practice is separated from research is not in the best interests of clinical research or patient care. The RAE is inappropriate for the craft specialities because it essentially demeans those staff with teaching and surgical skills and concentrates only on the type of research that draws in large research funds (2). Scenario 4 draws attention to the issues of global academic partnerships. Perhaps the members of IRCAM did not realise that this was very much the nature of clinical academic departments up to the time of the introduction of the RAE. The fixation on research excellence, as worthy as this may be, has forced academic staff to withdraw from many of their external commitments. Some decisions need to be made soon or decisions will be made by attrition. As mentioned by Davies (3), the disappearance during the last four years of 42% of clinical lecturer posts has removed the seed corn of future leaders in Academic Medicine. In the craft disciplines, these posts have virtually disappeared. Where they still do exist, the applicant rates are low and largely inappropriate as judged by RAE criteria. They do not rest well with the RAE as they are trainee posts of limited tenure. With the persistence of the RAE and the present governance of Universities, there has to be a strong case for the creation of separate Universities of Health Sciences that are not subject to the inappropriate structures driving the destruction of academic medicine. Is there no one out there that understands how far advanced is the destruction of medical schools in the UK and the importance of these issues to the future of medicine in the UK? The IRCAM scenarios give limited reassurance that this is the case, painting as they do a global commercial structure whilst ignoring many of the obvious local problems that currently exist. The schemes they outline do remind one of the orchestra playing music on the stern of the Titanic. Unless immediate corrective measures are taken to halt the erosion of academic medicine, it faces a bleak future. The sufferers will be our patients. 1. Clark J. International Campaign to Revitalise Academic Medicine. Five futures for academic medicine: the IRCAM scenarios. BMJ 2005;331:101- 4 2. Banatvala J, Bell P, Symonds,M. The Research Assessment Exercise is bad for UK Medicine. Lancet. 2005 ;365:458-9 3. Davies S. Commentary: Universities have a vital role. BMJ 2005; 331:105 E Malcolm Symonds. Emeritus Professor and Former Dean, Faculty of Medicine and Health Sciences, School of Human Development and Midwifery, Queen’s Medical Centre, Nottingham.UK Sir Peter Bell. Emeritus Professor,Department of Surgery. Leicester Royal Infirmary, Leicester. UK Jangu Banatvala. Emeritus Professor, Guy’s, King’s and St Thomas’ School of Medicine and Dentistry, London UK Profems@aol.com We declare we have no conflict of interest. Competing interests: None declared |
|||
|
|
|||
|
Jocalyn P Clark, Associate editor BMJ WC1H 9JR, on behalf of the ICRAM working party
Send response to journal:
|
To Drs Symons, Bell, and Banatvala, we thank you for your incisive comments in response to the summary of the ICRAM scenarios published in BMJ. During our scenario building process the RAE in the UK (and other such mechanisms in other countries) was indeed identified as a threat to the values and future of academic medicine. We discuss RAEs, along with many other uncertainties facing academic medicine, in much more detail in the accompanying long report on the Scenarios published by the Milbank Memorial Fund. The report, entitled "The Future of Academic Medicine: Five Scenarios to 2025" can be accessed at www.milbank.org. The main article on the scenarios can be accessed at www.plosmedicine.org.
Competing interests: I am the project manager of ICRAM |
|||
|
|
|||
|
Woody Caan, Professor of public health APU, Chelmsford, Essex CM1 1SQ.
Send response to journal:
|
In considering the Global dimension of future ICRAM developments, the project team may find a Swiss report by the agency La KFPE helpful, especially the collaborative case studies (for example the response of international academic medicine to researching diabetes within Bangladesh) [1]. [1] Maselli D, Lys J-A, Scmid J. Improving Impacts of Research Partnerships. Swiss Commission for Research Partnerships with Developing Countries, KFPE. Berne: Geographica Bernensia, 2004. (English language version edited by T. Wachs and A. Zimmerman) Competing interests: None declared |
|||
|
|
|||
|
Vijayashankara. Nanjegowda, Professor of Pediatrics SDUMC, Kolar, India. 567103
Send response to journal:
|
Sir, Academics all through the years have been only academics and have immersed themselves in various research projects without bothering about what and how their research affects the consumer, the patient. I think the future of academics and researchers lies in the area where the evidence is integrated with the actual practice of medicine. Competing interests: None declared |
|||
|
|
|||
|
Jean D Gray, Professor Emeritus, Dalhousie University Halifax, NS B3M 2B3, Canada
Send response to journal:
|
The discussion that will hopefully ensue throughout the world following the publication of the five scenarios concerning the future of academic medicine should be very helpful in reducing (although probably not eliminating) some of the very prominent silos that exist in academic medicine today. Just a few examples include the silos of basic science and clinical care, the silos of care in the developed world and care in the developing world, the silos of publically-funded research and industry -funded research, the silos of medicine and the other health professions, the silos of research and education, and so on. Our value system in academic medicine has grown out of concepts that have been overtaken by developments that do not reflect the mission statements and value systems of the very organizations in which these developments have occurred. Opportunities for meaningful discussion between laboratory scientists and social scientists, between physicians and other academics (including other academic health professionals), between bedside clinicians and those who develop and implement health policy are few and far between. These scenarios clearly indicate the need to break down these invisible barriers, demolish the silos, and begin a new dialogue that will bring academic health care (not academic medicine) into the 21st century with a clear vision of the future. Thanks to the International Campaign to Revitalize Academic Medicine for initiating this dialogue, both globally and locally. Competing interests: None declared |
|||
|
|
|||
|
Ian D. Coulter, Professor UCLA/RAND CA 90272
Send response to journal:
|
While the current terrorist threats have bought home how global our probems have become, the HIV epidemic should have also by now have convinced us all that the distribution of disease and the inequities of care transcend all national boundaries. These inequities are not separate they are all a piece of the glaring disparities that exist between the developed world and the developing (so called) nations. The plight of Africa is the shame of the Western World both in terms of their contribution to the plight as the initial colonial powers but also in terms of their miserly contribution to the solution. An academic medicine not engaged in global issues and the issues of disparities even within individual countries is a morally bankrupt medicine. It is difficult to see how such a medicine will produce doctors more concerned with service and vocation than with money. Evidence based practice, problem based learning and the other so called transformations of contemporary medicine are rather secondary to actually caring for people and in fact to the extent they accrue to the already substantial advantage of the well off, are morally problematic as well. Whie it may seem overly simplistic, medicine needs to get back to what it was, a profession where service to humanity was considered the paramount virtue and where the patient's interest came first over all other interests and where the rewards were not measured in monetary terms. Without this, medicine is a job like any other with customers instead of patients and where the public would be wise to assume the position of caveat emptor and its educational institutions might just as well become proprietary. All the educational innovation in the world will not help medicine unless it first reclaims its "soul". Those who do not wish to see medicine as a calling should perhaps not be invited to join the profession. Those public educational institutions that do not wish to serve all the public should perhaps not be publicly supported. Competing interests: None declared |
|||
|
|
|||
|
Manique Wijesinghe, Third year medical student University of Southampton, SO17 1BJ
Send response to journal:
|
ICRAM has brought to our attention that Academic Medicine is ailing and in need of an injection of adrenaline; and we’ve got to do something NOW. And it’s got to start at medical school level, so that tomorrow’s doctors – those who will be shaping the world of Medicine come 2025 and beyond – will be better prepared to make positive moves which will encourage the resurrection of Academic Medicine. A medical qualification can lead to work in numerous areas outside of traditional hospital or general practice – working in global health organisations & NGOs, the army, industry, and of course, research. However, I believe it is fair to say that our training does not sufficiently prepare, or expose us to the different facets of medical work. As far as Academic Medicine is concerned, students need to be presented with far more options and information concerning getting involved in research, and the opportunity to carry out projects should be easily available to all. Alternative pathways should be created for students who decide, midway through their medical course, that their interests lie primarily in academic medicine. Currently, some medical school courses contain a compulsory intercalated BSc, and of these, only a few provide an opportunity for students who perform exceptionally well to progress onto a PhD program. However, I suggest that even in schools where intercalating is not compulsory, all students should be given some form of research experience, and motivated students encouraged to go further, perhaps opting for a BSc and more, if they wish. Giving everyone some form of research experience is likely to instil a respect for academic medicine, even in those who decide that they would like to work in a clinical setting. Hopefully, this would help bridge the divide between clinicians and academics. We need to breed a new generation of clinicians and academics who have mutual respect for each other’s work, and recognise that each plays an important and complementary role in providing healthcare to the global community. For this, as ICRAM suggests, it is extremely important that a clear path of career progression in Academic Medicine is elucidated and communicated to medical students early on, so that they can make informed choices when considering future career options. Importantly, respect and acknowledgement for the principles of research should be discernible in every part of the medical curriculum – for example, by getting students to find out how the mechanisms of a chosen disease were first elucidated, and how drugs and other methods were found to treat it – so that students recognise the indispensable role of research in changing clinical practice and outcomes at the bedside. This should highlight something important – it was observations made by clinicians at the bedside that first led to the identification of the signs and symptoms of particular diseases, and forms of treatment. As GP Dr Graeme Mackenzie points out in his response to the ICRAM article in the BMJ, practitioners make many observations and have many ideas which ought to be made use of in improving health care. Thus clinicians too, are researchers, albeit working in a different environment to ‘pure’ academics – provided their inputs are acknowledged and made use of! All medical professionals have important contributions to make in improving healthcare, be they academics or GPs; it is up to every one of us to ensure that all voices are heard. Recognising, encouraging and rewarding the contributions of clinicians to academic work should lead to better integration between the two disciplines in the future. Changing medical school curricula to acknowledge the importance of research to clinical work, and vice versa, is just as important. I believe these are two of the many possible ways by which to ensure that Academic Medicine continues to thrive. Competing interests: None declared |
|||
|
|
|||
|
David L Simel, Professor of Medicine Durham VA Medical Center, Durham, NC USA 27705
Send response to journal:
|
While the scenarios are interesting to read, they are interesting to me primarily because they seem loaded with emotional words and phrases, making me infer that they were not developed with equal balance. I surmise that readers all over the world will infer different things from each scenario, but my hunch is that there is a suggestion of some underlying "political correctness" in the scenarios and the wording of the questions. I do not, in any way, suggest that the writers and group of participants who must have worked hard to develop these had a conscious agenda, but neither do I dismiss an unconscious desire to create a bit of unbalance. At face value, sitting at my desk, the titles of the scenarios "fully engaged" and "global academic partnership" seem much more 'correct' than "academic inc", "reformation" and "in the public eye". Are we respondents giving "expected answers", "desirable answers", or what we truly believe the future holds? Competing interests: None declared |
|||
|
|
|||
|
M Justin S Zaman, British Heart Foundation Research Fellow in Cardiovascular Epidemiology University College London Medical School, London WC1
Send response to journal:
|
If Academic medicine is defined as ‘the capacity of the healthcare system to think, study, research, discover, evaluate, teach, learn, and improve, then it itself should do these things. It is a less attractive career option due to factors that stand out against a comparable clinical career among which include a more undefined career progression, less remuneration and perhaps an ill-focused exposure to only certain types of research. Academic medicine as a field is huge, yet exposure to it at medical school seems to be more in what seems to be the ‘in thing’ at the time. All I recall was of genetics and molecular biology. Very little exposure was in fields such as Public Health. Furthermore, research seemed to be long way from the bedside. It is difficult to relate cyclic GMP to a medical scenario. There is also the well-described research-policy gap, where it takes far too long to get important research findings into practice and policy(1). This field of Medicine has the true potential to advance our thinking, and hence it needs to be flexible. I’ll give you my example. As a cardiology registrar, my personal concern is that 80 percent of deaths from cardiovascular disease worldwide and 87 percent of related disability currently occur in low-income and middle-income countries. Surely, if I have the ideas and the drive, I should be able to compete on an equal footing with the geneticists and molecular biologists for research money? Research in the developing world, especially in low-cost, high-yield diagnostic/management strategies will not only be of benefit to those nations but also to the NHS. My vision is to be a UK academic, whose research is shared with academics from the developing world so they can get can published and their populations get focus, whilst I will continue to use what I learn there in an NHS practice back here. If however I get judged simply on my ability to simply publish in numbers, then I’ll go back to being a full- time clinician as I want to spend an equal time in laying down the policies, otherwise the benefits accrued from my research efforts will not fully utilised if they have no impact on the health of populations I study. Students and junior doctors need to be exposed early to the fact that Academic Medicine is all around Medicine, not separate from it, and that it does not mean spending hours in an underground laboratory. 1. Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Organ 2004;82(10):724-31; discussion 732. Competing interests: None declared |
|||
|
|
|||
|
Dr Sarah Edwards, Programme Evaluation Officer The Health Foundation, Dr Jan Walmsley, Assistant Director
Send response to journal:
|
Jocalyn Clark’s recent BMJ paper updating readers on the activities of the International Campaign to Revitalise Academic Medicine (ICRAM) presents us with a timely set of scenarios for the future of academic medicine. (1) The Health Foundation has a strong interest in academic medicine, having funded 13 talented individuals through its £5.4 million Clinician Scientist Fellowship award scheme since 2000. Following an interim evaluation and a wider consultation, we concluded that the future success of clinical academic medicine lies in making explicit the link between research and improvements to the quality of patient care. Such a vision for academic medicine would incorporate elements from each of Clark’s scenarios, namely: • Responsiveness to its customers (i.e. patients within the NHS) and a focus on research which is likely to improve the quality of healthcare. • Closer integration with education and service provision to ensure that research findings are translated into practice. • Involvement of teams of medically and non-medically trained researchers, as well as a range of stakeholders to ensure that “research and quality improvement are simultaneous and translational research is favoured.” (1) Those leaders will draw on the support of patients and practitioners as Clark describes. To test these ideas further, The Health Foundation will soon invite applications to a new Clinician Scientist Fellowships scheme. Launching in September 2005, the scheme will provide five years of full funding and research expenses for up to 11 clinicians with the potential to make an outstanding contribution to patient-oriented clinical academic research and practice. We’re particularly keen to receive applications from those working in disciplines where there is an identified national shortage of expertise, namely radiology, pathology, anaesthesia, surgery, psychiatry and public health. We agree wholeheartedly that academic medicine will have to “put more effort into relating to its stakeholders – the public, patients, practitioners, politicians and policy-makers.” (1) Our new scheme will support fellows in communicating research findings, networking and influencing to help aid the translation of research into clinical practice that will directly benefit patients. The future of academic medicine is reliant on professionals who can not only raise their own profile in their area of expertise but also help to establish centres of excellence and revitalise those areas of academic medicine in crisis. References: 1. Clark, J. Five futures for academic medicine: the ICRAM scenarios, BMJ 2005;331:101-104. Competing interests: None declared |
|||
|
|
|||
|
Tom Madden MD FRCGP FAAFP, Associate Professor of Preventive Medicine Rush University Medical Center, Chicago, Illinois, USA 60612, Donna C Bergen MD
Send response to journal:
|
Dear Editor, The ICRAM Scenarios Parturient montes, nascetur ridiculus mus - Horace We keenly favour the reform of Academic Medical Centres, reforms perhaps most essential in defining for them a new societal context. However, it is their role in the professional formation of the future physician which directly concerns us. One of us has been responsible for a specialist clerkship and education of residents and fellows in her department; the other is a member of a faculty group with the current task of integrating. basic science teaching and early clinical exposure in the first two, formerly pre-clinical, years. Aspects of the corporate existence of AMCs, as not-for-profit institutions, are not our immediate concern. It was therefore with excited interest that, prior to reading the summary by Jocalyn Clark, we circulated the series of related articles (pages 101 - 107) from the 9 July Journal. Now, having read and discussed it, we would like to indicate that, in the Association of American Medical Colleges (A.A.M.C.) and a majority of its constituent colleges, there has been, over more than a decade, a continuing discussion and evolution of thinking about the tasks and priorities of medical education. This has been based, in the manner of any scientific enquiry, upon objective assessment of what goes on in lecture halls, and, increasingly, in small group and lab studies; in evaluating programs as to their effective delivery, in expert review of the tests that we administer; in initial steps toward the better preparation and support of teachers (faculty development); in continual dialogue with student class representatives; in the search for resources. This contrasts sharply with the direction adopted by ICRAM. Perhaps surprisingly, considering the U.S. system of health care and those of Europe, where the idea of publicly provided, equitable health care is not viewed as by definition second rate, such enquiries and discussions have been open, untainted by considerations of gain, and relating purely to educational goals and their achievement. A majority of students select R.U.M.C. because of its twenty year record of assisted self-study, early opportunities for patient contact in community settings and a number of widely-supported voluntary community health programs, which they control. In none of these initiatives, whether read about or joined in, is there the merest echo of such deliberations as are recounted in Jocalyn Clark’s report. Her presentation of the approach and conclusions of ICRAM is, to say the least, a singularly awkward ‘read’; although this may reflect a complicated and verbose master text and the host of topics raised. In the interest of dialogue on what we consider important issues of principle, we have refrained from a more comprehensive review of her article, to concentrate our challenge on the procedures chosen and outcome of the ICRAM meeting. We do question a number of her formulations which appear either naive, or
uninformed::
Faced, as was to be expected, with difficulties of communication between participants arriving with different, even irreconcilable philosophies, a solution was sought in games playing with a professional facilitator. And the ‘model’ chosen owed its origin to one of the great corporate polluters of the world; including the criminal contamination and impoverishment of the Niger Delta. There is, admittedly, a great deal wrong with current programs of professional education and formation; but much of what is wrong is already familiar on both sides of the Atlantic. Nothing about this is a mystery requiring the skills of an alchemist or dowser. Some of it relates to conservatism of thought; some to territoriality or vested interest in departments and sections, a universal obstacle. Should it not have been possible to agree on new challenges; on specific known problems and deficiencies; and to develop a broad consensus and enthusiasm around a slate of goals and priorities? A comprehensive look at resources and timetables would also have been useful. In terms of practical help to struggling faculty, might not more have been expected from such a colloquium? Scenario One puts industry in charge of all education and research; while here, in conservative America, some schools and some departments are already restricting ‘the detail man’ and blocking his introducing students and residents (over pizza) to unlisted (unapproved) applications of the product he represents. We wonder who, reading the ICRAM Manifesto, will emerge with a clear view of the need to improve the human and societal relations of medicine as a whole - of which the academic world is a tiny though important part; to respond specifically to the public health challenge of the increasing global burden of infectious and chronic diseases, of specific diseases (AIDS and Alzheimer’s; the scourge of the young and their orphaned children, the scourge of the old and their hard-pressed care-givers); in the U.S. and the so-called ‘developing’ world, to the plight of the un- or under-insured. And, in the context of the medical school, against that background, are there not clear and already familiar directions that we and other A.A.M.C. colleges must follow? From a long list, we mention only:
The above may be pertinent to other readers of the B.M.J. Competing interests: None declared |
|||
|
|
|||
|
Jocalyn Clark, Associate editor, BMJ BMA House, WC1H 9JR
Send response to journal:
|
Dear Dr Madden and colleagues, Thank you for your comments on the ICRAM scenarios. Indeed the association of American medical colleges (AAMC) has been a leader and pioneer in medical education, primarily in the US, and their work has been of great benefit to ICRAM. We urge you to access the full length report of the ICRAM scenarios, published by the Milbank Memorial Fund, at www.milbank.org. In the full report we provide a broader context and background to the scenarios including a discussion of work that's gone before, most of which has been done in the US, UK, and other industralised nations, and its limitations. Best wishes, Jocalyn Clark Competing interests: I am the project manager of ICRAM |
|||
|
|
|||
|
Wayne Pearce, Clinical Manager Morwell Victoria 3840
Send response to journal:
|
I found the article of “Five futures for academic medicine” very refreshing. Finally someone is putting forward a malleable platform, fostering innovation and “out of the square” thought production, rather than simply stating obvious facts. Well done to the members of ICRAM and the BMJ. Recognising that this is a global problem, in my belief, is the first step to breaking down the silo mentality that has prevented progress for so long. The medical fraternity is now in a position to develop and engage global partnerships utilising information technology systems, to allow academic medicine to finally reach its potential. This will only occur if egos are left at the door and minds are opened to new ways of thinking. Communication and collaboration need to be recognised as the new foundations of progress. When I speak of the medical fraternity I am not only speaking of doctors. I speak of the whole medical fraternity. This fraternity is clearly identified in Scenario 5 Fully engaged. Recognition, that all stakeholders have a part to play. Patients, pre-hospital care providers, nurses, allied health professionals, physicians, researchers and policy makers alike. All work towards producing better patient outcomes, but all too often the same fraternity only produce negative prognostical outcomes. Take for example the patient involved in a motor vehicle accident with significant trauma in a rural environment. The patient requires expeditious transport to a major metropolitan trauma facility. The patient is transported to the nearest hospital by the paramedics the aero medical chopper is cancelled. At the receiving hospital the inexperienced medical resident is afraid to call the physician and instead elects to care for the patient. The patient deteriorates rapidly and after much prompting by the nursing staff the resident finally calls the physician. Upon arriving at the hospital the physician recognises immediately that the patient requires a higher level of definitive care and requests urgent transport to the major regional trauma facility. Upon arrival at the regional trauma facility the patient is reviewed by the trauma team who sit on the patient for longer than necessary. The patient is stabilised but continues to further deteriorate. The patient requires immediate surgery and an air evacuation is requested. Elapsed time is 5 hours post incident. The patient dies reroute to the metropolitan trauma facility. Who is at fault? Did the patient have to die? Was the patient potentially salvageable? All members of the relevant medical fraternity were fully engaged. How, were those involved educated. In essence the system let the patient down. Scenario 4 speaks of global academic relationships. How often are studies performed taking up countless hours of an organizations time, only to find that another organization has performed the same study but was reluctant to share their results. Ultimately leading to wasteful utilisation of scant medical resources. If partnerships were open and transparent and leaders encouraged the sharing of information this duplication would hopefully dissolve. Of all the scenarios put forward number 2 Reformation struck the most
resonant chord in particular the first and last points of the scenario;
In my mind quality improvement is an ongoing process that has to be adopted as a shared value throughout the whole organization if it is to be successful. Continued quality improvement in the health arena can only occur if organizations as discussed earlier, break their silo mentalities and begin to form strategic alliances. Organizations can learn together and facilitate pure knowledge management practices. These alliances must not only encapsulate the particular field in question, but also align and adopt the practices of other cutting edge organizations. As was discussed in the American Institute of Medicines 1999 To Err Is Human. The health industry can learn much from industries such as, Chemical, Aviation and Military to improve quality practices. Although there has been much discussion on the topic the health industry is moving very slowly towards adopting the tried and proven practices of the aforementioned organizations. The primary driver being the huge litigation costs and the increased level of knowledge that the Western new age litigious element has brought with it. The public are now wanting to know why things went wrong and are no longer afraid to ask the hard questions. In essence quality improvement in the health setting is being driven by the legal industry. True or false? The final and most relevant point that I wish to highlight is that of education and research. Only through adopting current evidence based medicine practices can we ensure that patients are receiving the best quality of care. Sadly the majority of these cutting edge interventions are extremely costly, policy makers and organizations alike baulk at the fiduciary requirements that evidence based best practice requires for its adoption and implementation in the field. Most practitioners do not have the time or the clinical expertise to research medicine in the field. Most recognise that clinical epidemiology is a specialist field. There is no doubt that research is an integral part of treatment pathways performed on patients. Organizations must engage the services of these specialists to ensure that current practice is appropriate and inline with best practice world trends. In doing this litigation can be minimised and costs incurred by organizations due to high insurance premiums may be influenced. The ability of how to learn and then to learn by doing cannot be understated the members of ICRAM have cited in my mind the most relevant aspect to any health organizations success. This topic alone could take forever to discuss but the principle is beautiful in its simplicity. Western society has become so focussed on university training the most fundamental element for quality care has been lost. Being educated by performing the job. In no way am I denigrating the educational system but if I were to ask you to learn the art of Aikido from reading a book the task would simply be impossible due to the fact that so many of the idiosyncratic traits required of the true martial arts practitioner can only be learnt from actual hands on education. This is usually facilitated by a teacher who has proven significant credentials in the spoken field. Why is it then that in such a dynamic field as medicine that students are expected to learn from books and then implement what they have learnt on patients. Often the students are taught by academics who have no real life experience. If academic medicine is to progress the current system needs to be reviewed completely and a global think-tank needs to be developed so progress can measured and shared by all. Ultimately this is about the patient and many in the fraternity have lost sight of this simple fact. Once again well done for daring to be different and approaching this arena from a completely new perspective. Competing interests: None declared |
|||