Who cares about academic medicine?
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7469.751 (Published 30 September 2004) Cite this as: BMJ 2004;329:751All rapid responses
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Dear Editor,
We are writing on behalf of the Student Advisory Group to the Working
Party for the International Campaign to Revitalise Academic Medicine(1).
The Student Advisory Group was set up this month and we had our first
meeting last week in London, at the BMA House.
Our aims are to express the views of students world-wide on academic
medicine and use these to help define the future of academic medicine and
also to promote academic medicine to students and to others. To do this we
hope to involve students world-wide and establish ourselves in every
university world-wide.
We are writing:
(i) To inform readers about who we are.
(ii) To inform readers about our aims and goals.
(iii) To increase support and encourage students from all countries to get
involved with this campaign.
(iv) To show that students are interested in academic medicine and the
campaign.
(v) To recruit students from as many countries as possible to act as
representatives for their respective medical school/country- either
directly or by appealing to academics/deans within an institution to
encourage suitable students to contact us.
If anyone is interested in the Student Advisory Group, please contact
us at sag_icram@yahoo.co.uk.
Yours sincerely,
Andrew G N Robertson
Crispin Hiley
On behalf of the Committee Members of the Student Advisory Group to
the Working Party for the International Campaign to Revitalise Academic
Medicine.
1: ICRAM (the International Campaign to Revitalise Academic
Medicine): agenda setting. International Working Party to Promote and
Revitalise Academic Medicine BMJ 2004 329: 787-789.
Competing interests:
None declared
Competing interests: No competing interests
The big problem for academic medicine is irrelevance. Sewankambo (1)
and others rightly call for relevant research for irrelevance creeps in at
every stage of research and teaching, from identifying health problems,
conceptualising them, designing ethical research projects, securing
funding, and interpreting findings . When the outcome filters back to
clinicians and would-be clinicians it is stamped with the hallmarks of
ambitious politicians and academics, the avarice of shareholders and
corporations, the tired ideas of bastioned, venerable institutions, the
bureaucratic dead hand of committees and the blindness of science. Then
comes the righteous indignation that Luddite clinicians ignore these
expensive, erudite fruits and that students fall asleep. The brutal fact
is that academic medicine’s understanding will always lag behind the doing
of good clinical practice, just as literary scholarship follows good
creative writing and natural science follows nature. Even transformative
technical innovations betray a mechanistic view of humanity that often
misses the point of being alive. Nevertheless, it suits the games of
politicians and corporations to keep academia alive to supply credibility
and commodities.
What is to be done?
1) Devolve more clinical research and teaching away from institutions
towards the coalface at home and abroad.
2) Encourage more jobbing practitioners to do research and teaching.
3) Revive responsive research funding, and put research commissioning in
the hands of a mix of patients, clinicians (including public health
clinicians) and global thinkers (not politicians or medical academics).
4) Publicly funded institutions to be limited to an agreed percentage of
industry-initiated research.
5) Use more conceptual approaches based on values and systems such as
creative arts, complexity and philosophy. The art of medicine and the
human predicament will not be understood by science alone.
(1) Sewamkambo N. Academic medicine and global health
responsibilities BMJ 2004;329:752-3
Competing interests:
None declared
Competing interests: No competing interests
In many parts of the world developments in teaching and research in
the domain of family medicine have contributed to its recognition as an
academic discipline.
However, the discipline is still developing and would benefit from
better support to increase capacity.
In addition, family medicine also seeks full academic recognition in
several European Countries, and this seems to be more evident in the
Mediterranean setting.
Colleges, teaching - educational amd research networks in Southern Europe
are struggling to attract the necessary support and resources to flourish
and to see family mediicne develop as an independent academic discipline.
This is in contrast to Western and Northern Europe, where teaching -
educational and research capacity has been developing for several decades.
The development of academic career structure, including academic training,
deserves high priority.
It is necessary to make the discipline more attractive for the best
medical students and young physicians.. This may then deliver new
knowledge in education and research methods, and offer new ideas and
innovative proposals about effective clinical care.
Academic general practice should also strive to develop measurement
of equity in health and health care, as an important subject of the GP /
Family Medicine educational and research agenda.
More senior posts are required in order to fulfil the task of
academic leadership within the countries whose situation has been
described above.
GPs are at times perceived as being at the bottom of the academic
scale. Measures should be taken towards the establishment of a national
career structure for academic general practice in Southern Europe.
This is because of the importance for a surviving connection between
academic activity and clinical work, and because many NHS doctors have
significant teaching and research and managemnt responsibilities, without
being exactly academics.
Mainly in General Practice discipline, we have GPs with really
increasing service delivery committmens, but, at the same time, we are
seeing a great development in GP teaching and research and new Countries
are opening or are at least thinking to open finally the acamedic door to
General Practice.
Differently from Northern Countries, we see Countries where the
contracts are not looking at flexiblity on work and nothing is devoted to
career development and protected time for academic teaching, research and
management.
Developing the Mediterranean family practice educational and research
agenda is a unique chance to bridge the figurative academic chasm betwen
Northwestern and Southern Europe and should be a priority for the European
Union.
References
1 Jones R. Academic family practice. Fam Pract 2003; 20: 359.
2 Lionis C. General Practitioners need more route acquiring
recognition from other
specialties. E-BMJ: 2 March 2000.
3 Carelli F. Undergraduate Teaching of Family Medicine in Italy: the
Modena Model.
Eur J Gen Pract 2003; 9: 121.
4 EURACT Statement on Selection of Teachers and Practices –
www.euract.org.
5 Carelli F. Special non clinical interests as career development –
Br J Gen Pract 2003; 53: 569.
6 Carelli F. European Agenda for Departments of GP in each
University. E-BMJ: 15 July 2003.
7 Soler J K, Lionis C, Carelli F., et al. Developing a Mediterranean
family medicine group – The Malta consensus. Eur Gen J Pract 2002; 8: 69-
70, 74.
8 Rodnick J. International Family Medicine Education. Fam Med 2003;
35: 222-223.
9 Lionis C, Stoffers ΕJΗ, Hummers-Pradier E,
Rotar Pavlič D, Griffiths F, Rethans JJ. Towards a Strategy for
General Practice Research in Europe: setting priorities
and identifying barriers. FamilyPractice,Vol.21,5,October 2004.
10. Lionis c., Carelli F., Soler JK - Developing academic careers in
family medicine within the Mediterranean setting - Family Practice, Vol.
21, 5, Octobers 2004, Editorial
Competing interests:
None declared
Competing interests: No competing interests
Academic Medicine Who cares? We at least need to care and promote.
To achieve rational method of treating patient is the object of
academic medicine.This will necessarily involve various aspects. As I
have stated in my rapid response 1, to “BMJ Publishing Group at the launch
of "an international campaign to promote academic medicine” “Please join
us”2, we need to appreciate the situation is part of the general malady in
the society world over.In the present situation the society and the
profession are at loggerheads due to mistrust in each other. This is
partly perpetuated by the serving profession by its blind participation
by adopting drugs and technologies in which it had no active role to
develop.We need to make the professional colleagues and society to appreciate this situation and to participate to facilitate the change in
general,in their attitude towards better for every ones good. This will
enable the present movement initiated BMJ to work towards it.
The movement certainly needs every participant to be honest,
knowledgeable, fair in out look, open minded to achieve the adoptable
grounds to promote it.In the present state the biotechnology,industry,
business, and media make rosy pictures of the developments even before
they are tried in the humans with an aim to make immediate impact on the
(stock) market. This results in high and imaginative expectations by the
(society) patients from the profession. This is not a practical
feasibility in the present situation.
To make these expected results utilizable in clinical practice, the
developments need to under go clinical trial to conclude their worthiness
in humans. This aspect of trial is
the major link between the biotechnology/drug, technology developing
laboratory promoted by the industry / business and the profession. It is
getting disrupted for reasons, which are primarily the financial gains
rather than social good. This outlook is encouraged by the government’s
entire world over.
The profession is becoming alert to its own obligation to check and
verify the justification of its blind participation. This enables avoiding to getting entangled in law suits
of unknown consequences. With vast developments in all allied branches of
science having applicability in medical science making head way as are
seen today trying to convey though not true the rude feasibility of the
redundancy of the profession, its skill and decisions in attending to the
pat-ients needs. All these are at a cost even the developed countries are
feeling their inability to meet this cost of treating most of its
society.However the subsequent adverse outcomes in clinical trials of the
propagated developments
mainly based on the commercial outlooks has created distrust between the
profession and the drug / technology developing industry. This is now
obviously evidenced by events of withdrawals of quite a few drugs and
techniques from marketing and use.This development has left the
profession at the mercy of many with no advantage to many but added problems to very many. This has also created enormous scope to convey openly
the distrust in the form of filing of many lawsuits in many forms.
Such situations has made the profession to mandate its obligatory
need to be aware of the developments into urges to keep itself abreast to
provide heath needs of the society.
The profession is trying to get involved in clinical resea-rch. It tries
to evaluate the rationality and applicability to participate.Thus it has
realized the importance of Academic Medicine.Large-scale appreciation of
this has enabled adoption of resolution in 1999,by the Association of
American Medical Colleges(AAMC) stating Academic Medicine forms the bases
for future developments to keep abreast with the needs of the patients.
Developments in science have provided vast scope to think of
feasibility to utilize clinically applicable information to improve our
results. To make academic medicine work effectively, needs interested
professionals, this is to be supported by the profession /an
organization/the local Government. Similarly it needs to be promoted and
utilized to enable the benefits to be gained to the society. This action
will make positive impact about the movement and facilitate to strengthen
it and will also dissuade the glorification of lab oriented results.
As can be observed from the editorials in BMJ the benefits achieved
in Brazil 3 and Uganda 4 from utilization of the available knowledge do
help in promoting the movement. Both are not developed countries.This is
indicative that financially less affordable are likely to contribute to
the development of Academic Medicine.The Editorial article 5 summarizing
the International working party’s feelings to promote and to revitalize
the Academic Medicine, one of the ways suggested is to extend academic
medicine, traditionally focused on tertiary hospitals,into primary care
and public health.Similarly the developments in clinical care even by
individuals need attention of promotion. This will enable their large
scale utilization by the serving profession to the good of the society.
The Editorial article 6 appreciating the failure of provi-ding health
for all by 2000AD as declared in 1981 by the Government of India and
taking into consideration the distrust the public has shown in the
Medical profession, the Central Working Committee,the leaders of the
Indian Medical Association (IMA.HQ),New Delhi,has decided to fight it out
to create a better image.It has launched a programme prono-unced by a
slogan in Hindi “Aao Gaon Chalay” an equivalent of it in English is “come,
let us go villages” and serve.It has called upon the Government of India
to provide assistance to make the programme a success,and thus enable it
to regain the trust of the society and the credibility.
There is an expression of anxiety about the feasibility to reduce the
gap between the Academic Medicine and the achievable in clinical
practice.To me there is hardly any gap to exist.If it is there,it is
beyond rectification in the present circumstance.Most of the time the gap
perceived is due to non-applicability of the Academic out look in clinical
practice to find the actual problem, try to rationalize to find academic
solutions.This is to a large extent feasible, and enables to reduces the
presumed gap to an acceptable level for a particular point of time. This
also has to be evaluated in the context of other available remedies worth
consideration.
Failure to appreciate these backgrounds,the present efforts to
revitalize will mean, we concede Academic medicine has no ground in
medical science to meet the present needs of the society. This may
definitely create other way effect.
The fact that Association of American Medical Colleges (AAMC) has
adopted Academic Medicine to form the bases for future developments should
provide enough ground on the rationality of its decision on the future of
the academic
medicine for some time to come. Similarly now the move by BMJ in the same
direction and seeking world wide participation to claim support to spear
head in promoting it indicates the long delayed appreciation of its place
in the present day,it to be rational in all our outlook. The valid rational clinical benefits will enable its promotion,should lead for better
remuneration.All these efforts need to be clubbed with healthy cooperation
and competition to enable achieve at least a part of the intended
developments in academic medicine.
The Author feels there many requirements for any individual in
private practice in small areas to participate in Academic Medicine.To
develop research will be a farfetched desire and to pursue will be a
Herculean Task. Though it appeared
a workable programme with some difficulties as long as he was teaching the
postgraduates. The works were gaining ground.This was further
facilitated by the stalwarts in the field heading the professional
organizations. The present situation needs to regain such ground.It
needs to be pursued by an organization intending to do so.
The organization needs to be associated with people beyond
self,knowledgeable,receptive and open minded to accept and promote the
valid ones.As can be seen from the responses enough suggestions are
provided,quite a few backgrounds have been considered for action.These may
require further work on their implementation,propagation, and to think on
how to combat the consequences of adverse outcomes, and measures to safe
guard on any such events needs attention.
The author has research contributions covering variety of clinical
conditions. They are published.These have been tried and are proved to be
reproducible.In fact on many occasions they can provide better and
acceptable than are available in the tertiary referable hospital.They are
very well suited to provide health care at primary health care center at a
considerably reduced cost, with minimum trauma, reduced risk, loss of
working and earning time, more significant is they provide holistic
benefits, reduce the needs of major surgery to a large extent. They have
proved to be effective when conventional treatments were not able to
treat. These works need to be promoted. In the present days of sponsored
programmes and research activities these works though can be utilized by
the profession are not getting the deserved grounds. We will be achieving
possibly
more than planned in case there is a scope to utilize these concepts. Thus
we are in a position to provide the academic needs of the programme to a
good extent.
Dr.H.T.Gangal.
1 Rapid Responses to: EDITORIALS:Jocalyn Clark and Richard Smith BMJ
Publishing Group to launch an international campaign to promote academic
medicine BMJ 2003; 327: 1001-1002 [Full text] The situation in Academic
Medicine is a systemic manifestation of major illness of the general
health of the of the society world over
Dr.Hanamaraddi.T Gangal, -------- (7 November 2003)
2 BMJ2003;327:1001-1002 (1 November) Editorial BMJ Publishing Group
to launch an international campaign to promote academic medicine Please
join us
3BMJ2004;329:753-754(2October ),oi:10.1136/bmj.329.7469.753
Editorial A academic medicine as a resource for global health: the case of
Brazil
4.BMJ 2004;329:752-753 (2 October), doi:10.1136/bmj.329.7469.752
Editorial.Academic medicine and global health responsibilities Academic
medicine can contribute in four ways
5. BMJ 2004;329:787-789 (2 October), doi:10.1136/bmj.329.7469.787
ICRAM (the International Campaign to Revitalise Academic Medicine): agenda
setting
6.Editorial, Doctors Day. IMA’s Concern for Rural Health and NPH for
BPL People.JIMA, Vol 102, No 7, Jul 2004, Page 347.
Competing interests:
None declared
Competing interests: No competing interests
Late in 2003 I responded to Richard Smith’s
proposition that academic medicine was in need of
resuscitation, by pointing out that it had already been
dead for some time, and elaborated on the reasons
why that was the case. No-one contacted me in
response to my analysis of the situation, which I believe
was accurate if perhaps rather outspoken, except
Michael O’Donnell, who kindly said that it was one of
the best pieces of writing about medical matters that he
had read for some time.
Now we’re faced with a whole barrage of new
gobbledegook as to why academic medicine should be
resuscitated. It can’t be, because it has already been
dead for too long!
One of the key requirements of becoming a really
successful artist is to be able to recognise and accept
failure. Serious art is a mirror of life, a reflection of the
collective subconscious. Why is it so difficult to accept
the utter failure of academic medicine?
Answer; Because many big names in medicine have
got their hands deeply into the ‘till’ and are not about to
take them out! Moreover they are syphoning off many of
the necessarily limited resources which are available
for the care of patients. In that sense the whole thing
can be seen as a protection racket.
And I don’t really think that many of them care about
what happens in the Third World.
It would not be inappropriate to add that many, perhaps
even most, of the major advances in the practice of
surgery in the last century came not from Academic
Medicine/Surgery but, rather, from busy and
conscientious clinicians with good hands and
enquiring minds who have, when necessary,
collaborated with other disciplines, for example
Engineering.
There is Medicine and there is Academia. The marriage
between the two, Academic Medicine, has not worked
out. Time for a Divorce! Medicine, like the Fine Arts of
Drawing, Painting and Sculpture, is something that you
DO. In the world of art it has become very clear that the
abandonment of basic practical skills, which took place
in the second half of the twentieth century, was a
terrible mistake.
It seems to me that Academic Medicine is similar in
many ways to an art school faculty, in which few of the
members have any real skill or ability, sit around talking
about it in a language that no ordinary person can
understand, and, as a consequence, have presided
over the graduation of at least two generations of
students who have emerged, at great cost, who have
almost nothing to say, and would not know how to
articulate it in Drawing, Painting and Sculpture, even if
they did. Look at the Contemporary Arts ‘Scene’ and it
will not be difficult for you to see what I’m driving at.
Those who enter the practice of medicine who have
innovative and enquiring minds, who care deeply about
the global issues in medicine, will find ways, within
their own lives and practices, to be themselves and to
effect change. That is the nature of the human
condition. You can’t legislate for this sort of change.
Rebuilding Academic Medicine is simply not the right
way to go.
Put flowers on its grave and move on!
Neil Watson, MA, MD, FRCS
Artist and Writer
Formerly Consultant Hand Surgeon
Competing interests:
None declared
Competing interests: No competing interests
To respond to global health challenges, Academic medicine should be
dedicated to improving and sustaining the health and well being of the an
individuals by doing partnersip with National Health Services of each
country - important and a major step.
It is seen that major bulk of diseases and ill health is borne by
developing countries, but much of academic activities are done in
developed countries. More opportunities for training in re-knowned
academic centers should be provided for academicians in low-income
countries. We need to focus our attention on developing countries.
We need to create a global work force- preferrably at local levels.
Medical educationist should really spread out to different parts of the
world, like missionary, with the vision and mission envisaged to promote
academic medicine throughout the world. One of the ways of doing it would
be -by establishing the network in all parts of the medical centers in
world, for bilateral exchage of technical and academic supports which ever
side is in need. This could be easily done through emails and internet.
There are enough talents in academic medicines while limited
financial resources are flowing in. The academic institution in the 21st
century should be self-sufficient, rather than looking for financial
grants from the organizations who have commercial interests. Financial
incentives seeems to be least important ethically but, it is most
important practically and one of the major decision influencing factors
regarding career choice. So can't be neglected.
Competing interests:
None declared
Competing interests: No competing interests
The main conflicts between patients’ welfare and academic freedom
arise, say Wright and Wedge [1], because of divergent objectives held by
universities and hospital clinicians. However their subsequent
description of academic centres as combinations of university, medical
school and hospital is incomplete. Teaching and research are increasingly
conducted outwith these environments, in primary care [2], and the need
for investment in academic primary care is, if anything, more acute than
in the secondary care sector [3,4].
The proportion of the undergraduate medical curriculum taught through
general practices in the UK has been steadily increasing over the last 20
years and is now more than 10% on average, with some medical schools
teaching up to 20% of their curriculum in this setting [3]. In addition,
since 1999 there has been a significant increase in the number of students
admitted to UK medical schools. We estimate from our national surveys that
between a quarter and a third of general practices are now involved in
teaching medical students [3]. Primary care research is also extremely
important, given that many conditions are now treated entirely outside
hospitals: 90% of NHS contacts take place in primary care and most of the
common public health problems, including hypertension, diabetes, and
mental health disorders, are managed almost entirely within primary care.
Yet academic general practitioners represent only about 7% of the clinical
academic workforce, and 0.5% of the clinical general practice workforce.
In contrast, in most hospital specialties, senior academics represent at
least 9% of the clinical workforce [5].
Academic primary care physicians, like their hospital colleagues,
face the “triple jeopardy” [6] of a multi-professional challenge. Unlike
their colleagues, however, they must often do this as independent
practitioners, and may not be covered by indemnity arrangements when, for
example, patients’ welfare and academic freedom are in conflict. Also
unlike their hospital colleagues, they do not suffer from an insecure
career structure – currently there is no established career structure for
primary care academics.
In most other countries, the need for more academic input into
primary care is even more acute than in the UK which, despite the problems
listed above, leads the world in this area. We wish the International
Working Party every success in their campaign to promote and revitalise
academic medicine, and urge them to include academic primary care under
their umbrella, as Wright and Wedge specifically did not [1]. The Society
for Academic Primary Care is happy to offer its support.
Yours faithfully,
Blair H. Smith, Treasurer,
Deborah Sharp, Chair,
Tony Kendrick, Chair, Heads of Department Group,
Graham Watt, Past Chair, Heads of Department Group.
Society for Academic Primary Care
C/o Dr Blair Smith, Department of General Practice and Primary Care,
University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY
blairsmith@abdn.ac.uk
References
1. Wright JG, Wedge JH Clinicians and patients’ welfare: where does
academic freedom fit in? BMJ 2004 329 795-6
2. Howe A, Baker M, Field S, Pringle M. Special non-clinical interests –
GPs in education, research and management. Br J Gen Pract 2003 53 438-40.
3. Heads of Departments of General Practice and Primary Care in the
Medical Schools of the United Kingdom. New Century, New Challenges.
Report from Society for Academic Primary Care, 2002.
4. Mant D. National Working Group on R&D in Primary Care: Final
Report. London: NHS Executive, 1997.
5. Watt GMC. Academic general practice and primary care in Scotland.
Hoolet 2004 41 4-5.
6. Researcher, clinician, or teacher? [editorial] Lancet 2001 357 1543.
Competing interests:
We are all academic general practitioners who would benefit from increased investment in academic primary care and the establishment of a primary care academic career structure.
Competing interests: No competing interests
A Growing Funding Gap Between Clinical and Basic Science Publications
The campaign to promote academic medicine represents an important
effort to address the many challenges facing the international clinical
research enterprise.(1) Particularly since this campaign is led by a
group of academic publishers, it is worthwhile to ask if or how these
challenges have been reflected in the biomedical literature. To
investigate this issue, we examined all 8.1 million articles indexed in
MEDLINE between 1994 and 2001, comparing three eras: 1978-85, 1986-93, and
1994-2001.
The proportion of studies involving human subjects (the most common
proxy for clinical research) increased during the study period from 62.6%
to 68.8%. There was a shift in the most common Medical Subject Headings,
with the topics of public health, quality of care, and epidemiological
methods supplanting headings for pathological processes and mammals. The
study period saw a tripling in the proportion of randomized clinical
trials from 1.9% to 6.2% of all articles.
While absolute rates of funding rose over time for both types of
research, they rose more rapidly for studies not involving human subjects,
leading to a widening funding gap between these papers and clinical
manuscripts. By the final study era (1994-2001), 66.8% of clinical
publications reported no funding source, compared with only 32.1% of basic
science articles. Both this absolute difference and the change over time
were highly statistically significant. (p<0.001)
This analysis provides a mixed prognosis on the health of clinical
research as reflected in the biomedical literature. On the one hand,
there are indications of a robust and expanding body of clinical
publications. On the other hand, there appears to be a large and growing
funding gap between clinical and basic research. If we are to preserve
the vitality of the clinical research enterprise, we must work to ensure
that funding keeps pace with the need for high-quality clinical evidence
(2, 3).
Competing interests:
None declared
Competing interests: No competing interests