Academic medicineBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39576.631238.CE (Published 17 May 2008) Cite this as: BMJ 2008;336:s172
Olivia Kingston and Sam Behjati describe the new integrated pathway for academic medicine
Academic medicine is a loosely defined term which describes the branch of medicine pursued by doctors who engage in a variety of scholarly activities. While the traditional role of clinical academics is to provide clinical care, do research, and teach, academics today may also spend some of their time in managerial and representative roles. The clinical workload varies, and a few academics may choose to abandon clinical medicine altogether. Every academic has a different work description, which is one of the many attractions of an academic career.
Why do it?
Academic medicine can be an uncertain business. Competition for research grants is fierce, and there is constant pressure for innovative ideas. On the other hand, an academic career provides lifelong intellectual stimulation, variety, and autonomy. One of the key motivators for many is the opportunity to make discoveries which may be linked directly to improvements in patient care. A common belief is that academics are poorly rewarded financially. This is not true. Apart from private practice, academics are now paid on the same pay scale as their clinical colleagues. Additional benefits include the opportunity to travel and to work with colleagues internationally. However, unless you are willing to commit yourself to your career and to put in those extra hours, academic medicine is not for you.
Academic career pathway: the history
Until now, there has not been a clear route of entry and a transparent career structure in academic medicine.1 The senior academics of today have carved their own, often perilous pathways. They have endured periods of unemployment while constructing research proposals, they have risked criticism for being clinically deskilled, and they have ultimately fought to create their own tailored research role. With the perception that job insecurity was compounded by poor pay parity with clinical colleagues, and the shortage of posts on completion of training,1 it is understandable why academic medicine faced a worrying decline.
The United Kingdom has the potential to offer excellent research opportunities, and clearly this was forgone as a result of poor workforce planning. Urgent action was needed. In 2004 the government created the UK Clinical Research Collaboration, which aims to bring together key stakeholders in the field of clinical research in the UK. With the spotlight on academic medicine and the vogue for “modernising medical careers,” it was the UK Clinical Research Collaboration, in partnership with the academic careers subcommittee of Modernising Medical Careers, which took the opportunity to recommend and then implement a new, more structured academic career pathway.1
What is Walport?
Walport posts are scattered (albeit sparingly) throughout the pages of BMJ Careers. But what are they, and how do they differ from a standard academic post? The simple answer is that they have been created by employing institutions with the new integrated clinical academic career pathway in mind. Walport refers to Mark Walport, chair of the academic careers subcommittee of Modernising Medical Careers and the UK Clinical Research Collaboration. The committee identified and sought to resolve three major issues faced by academic trainees1:
(1) Lack of both a clear route of entry and a transparent career structure
(2) Lack of flexibility in the balance of clinical and academic training and in geographical mobility, and
(3) Shortage of structured and supported posts on completion of training.
Integrated clinical academic pathway
The figure illustrates the new, integrated pathway.⇑ Essentially, the first opportunity for research arises in foundation year 2. The idea of this four month standalone or integrated period is to “explore an interest” in academia rather than do in-depth research. This can then be followed by an academic clinical fellowship during specialist training, in which 25% of time is devoted to research with the aim of generating a research proposal to secure funding for a PhD (doctorate of philosophy) or MD (medical doctorate), usually after specialty training (ST) year 3. After completing the PhD the trainee would return to clinical training at ST4 as a clinical lecturer for postdoctoral research and completion of clinical training, aiming to progress into a senior academic role thereafter.
A key aspect of this scheme is the proposed flexibility. Academic clinical fellows are allocated an academic national training number (NTN(A)), the “A” part of which can be dropped at any point should the trainee wish to leave academic training. There are also multiple entry points.
To tackle the shortage of higher level academic positions 100 new clinical lecturer posts will be created each year until 2010,2 and funding has been secured for roughly 200 more senior lecturer posts over the next five years.3 A further benefit of this scheme is that the funding for lecturer posts may follow the trainees should they relocate to another part of the country.
In the wake of the Tooke report and following the launch of the new integrated pathway, academics tentatively awaited the recommendations for academic careers. The outcome is encouraging. Sir John Tooke’s recommendations largely support clinical academic training as it now stands.4 In terms of the academic career pathway, the major change arises at foundation year 2 level, since the report advocates abolishing this level altogether. Consequently the academic foundation year 2 may now be undertaken within core training, which will maintain research opportunities at junior level. What will happen to the academic clinical fellowship programmes is less clear at this stage, but the report is unequivocal about its support for these. Academic clinical fellowship programmes are likely to be integrated within core specialist training (ST1 to ST3 level). The report emphasises the need for a diversity of programmes that reflect local academic strengths and service requirements. Modular masters programmes during this period are encouraged, and again, the need for flexibility in terms of entry into and exit from academia is highlighted.
Will it work?
So the pathway is there, the funding is in place, but will the integrated clinical academic pathway work? On paper, yes; in practice this is debatable.
It is questionable how flexible the scheme really is. While dropping the academic component of an NTN(A) may be relatively straightforward, attainment of an “A” is not quite as easy. Academic clinical fellowship posts are currently limited (there were 238 across the UK this year),2 and the recent selection for posts starting in August 2008 was highly competitive, with an average of 9.5 applications for each place across the UK.2 The scheme aims to attract “the brightest candidates with the greatest evidence for future potential academic development.”1 Candidates will therefore be expected to hold a verifiable record of exceptional academic achievement.
Furthermore, the scheme clearly disadvantages clinicians who at a later stage in their careers, say during subspecialty training, realise their academic desire. Would they be able to compete against those who have been fortunate enough to progress through the Walport pathway from the outset?
Finally, as the Tooke report highlights, a “binary divide” exists between clinicians with no research involvement on the one hand and academic doctors on the other. The integrated clinical academic pathway may deepen this divide as it does not provide opportunities for trainees who pursue full time clinical training but have an interest in research.
What if I have missed the boat?
Worry not. It is the successful completion of a higher research degree, ideally a PhD, which remains the key entry point for doctors into academia. While the academic clinical fellowship, for example, provides trainees with the luxury of protected time during which a PhD grant proposal can be developed, any doctor who is keen to pursue an academic career can apply for funding for a PhD or MD. Not being part of the integrated clinical academic pathway does not preclude academic work; the senior academics of today did not have Walport to guide them. Indeed, carving one’s own pathway will be hard graft but it will also be highly rewarding.
Fyeza Hasan is an academic clinical fellow in paediatrics at University College London Institute of Child Health and Great Ormond Street Hospital for Children. She graduated from Bristol University in 2003, where she also completed an intercalated BSc (bachelor of science) degree involving experimental research. After doing house jobs she started training in paediatrics. One of her senior house officer jobs was based in the haematology-oncology department of Great Ormond Street Hospital for Children, where she developed her academic and clinical interest in this subspecialty. As an aspiring academic paediatric oncologist, she is using the academic clinical fellowship as an entry point into academia. Her schedule is busy, and in addition to doing experimental work she is writing a PhD grant proposal and is enrolled in a masters programme in clinical paediatrics at the Institute of Child Health. What she likes about academia is the intellectual stimulation it provides. And the downside? Well, the fact that a day has only 24 hours.
Geraint Rees is a professor of cognitive neurology and Wellcome senior clinical fellow at University College London and an honorary consultant at the National Hospital for Neurology and Neurosurgery. He also has an active role as joint deputy chair for the BMA’s Medical Academic Staff Committee, where he has contributed significantly to the evolution of the integrated academic training pathway. As a medical undergraduate at Cambridge Professor Rees did a degree in experimental psychology and neurophysiology. The combination of inspirational teachers and a captivating subject matter resulted in a highly addictive recipe that led to his development of a lifelong fascination with neuroscience. Professor Rees’s career pathway is highly idiosyncratic and untypical. After senior house officer training he did a PhD at University College London followed by postdoctoral training at the California Institute of Technology. Having negotiated funding from the London Deanery to complete further specialist training in cognitive neurology, he went on to secure a Wellcome senior fellowship and was appointed senior lecturer while at specialist registrar level. He gained entry to the specialist register through the academic and research group and was promoted to professor after just two years as a consultant. Professor Rees could not be more enthusiastic about his job and the possibilities within academic medicine: “It is a fantastically flexible job which allows me to fit a demanding career around family life, with a high degree of personal autonomy and responsibility which is extremely rewarding. Every day is different and being paid to find out how the brain works is a privilege and a pleasure.”
We thank Professor Geraint Rees for his help in writing this article.