Mandatory publication in India: setting quotas for research output could encourage scientific fraud
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i5002 (Published 15 September 2016) Cite this as: BMJ 2016;354:i5002All rapid responses
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Basic purpose of research is to provide a new insight into what is already known. Hence everybody should and is being (rightly) promoted to provide one's own point-of-vision in patient care. And collectively this knowledge is supposed to lead us to a brave-new-world where management of illnesses is simple, affordable and human suffering is reduced.
But fixing a quota for research poses new challenges and raises new questions. Last year Dr. Rakesh Aggarwal, Professor at SGPGIMS Lucknow, penned an editorial on this issue and that was published simultaneously in almost all the journals of repute. BMJ too covered the theme (1). Several points raised by Prof. Dhastagir Sheriff on this webpage are already covered in that editorial. What we want to highlight is that sometimes it becomes difficult even for top scientists/artists/thinkers to convince the world about their views, and judging that too demands another level of understanding. If everything is pulped to a single lump, there may (rightly) be question-marks about our intellect.
Charles Darwin, proponent of famous Theory-of-Evolution by Natural Selection, made his observations while he was on a voyage in a ship. His theory provides us one-of-the-most fundamental insights into animal (including human) biology (2). Now MCI wants everybody to be trialists. If Darwin were to present his great theory to present day MCI inspectors, they may place the great observer at the end of the promotion-list, as he simply did not conduct a trial. Observational studies, as per our understanding, are uncommonly published as original articles, and original article are the trump cards to get promotions as per existing (funny and impugned) rules.
Ignaz Semmelweis, a physician, more than 150 years ago made an observation that puerperal-fever is common among mothers whose delivery is conducted by doctors, as compared to those made by midwives. Based on the observation he promoted hand washing technique. This is still one-of-the-most fundamental principles of safe motherhood (3). If Semmelweis were to present his observation in front of MCI inspectors today, they would gently tap him on the knuckles, and perhaps advise the astute observer to conduct some trial, if he wishes to get promotion.
Werner Forssmann, a daring doc, inserted a wire into his own heart and then got himself X Rayed. This was for the first time in known human history in a living body. The wire was found inside his heart and the finding challenged the then prevalent theories. After getting to know about the experiment, senior professors banned his entry to the lab, yet the discovery put the foundations for current day cardiac catheterization and interventional cardiology. Later on Forssmann was awarded the Nobel Prize for the discovery in 1956 (4). If he were to present his experiment to present day MCI inspectors, after that groundbreaking X Ray, he will simply be asked to do what everybody is doing - a worthless clinical trial or two, and then get promotion.
When Galileo Galilei directed his telescope towards Jupiter and saw its moons and then shook the very foundation of the then dogma, he was not conducting some sophisticated scientific trial. Religious bodies then used to preach that this world was Earth-centric and everything revolved around the Earth. When Galileo saw moons revolving Jupiter, he put that theory upside down (5). No credit was given to him in his lifetime, he was jailed and lost his eyesight there. Alas, if he were to present his observation to present day MCI inspectors, they again will label that observation as a mere ordinary case report, and he will not be promoted. We shudder to think that how many such fundamental observations have been relegated to a corner, and how many times such honest medical observers have been asked to do something useful as per standards of our MCI inspectors.
LIGO experiment is being conducted to listen to gravitational waves (tweets) of collision of distant stars (6). As per some accounts, this is the biggest endeavor in scale and scope of mankind tio date to unravel the mysteries of the universe, which all of us share. If MCI were to assess the data generated in the mammoth tunnels, quickly they will provide credit to the first 2 researchers, as that is the existing rule. As per existing promotion rules of MCI, only the first 2 researchers get the credit howsoever large or small the study is. Therefore LIGO researchers , to some extent are fortunate that they are not under the direct scrutiny of MCI. If that were the case, instead of putting their brains to analyse the data and interpreting its results, and then designing even a better experiment, the researchers would have been reduced to squabbling about deciding the first 2 authors. This is the way we in India treat the hardworking scientist, whose work has the potential to change the future of all of us.
Nowhere we intend to belittle the importance of clinical trials, or the significance of the data generated by that tedious process. What we want to point out by citing these geniuses and those historical moments which changed the history, is that that is not the only way that science progresses. There is an urgent need to relook and revisit existing MCI rules. Yesterday while throwing open its new National Museum, President Barack Obama says that America is a constant work-in-progress (7). We believe that same principle of work-in-progress is also true for another circumstances -- aligning promotion rules for existing evidences and realities in India too. If in the name of conducting and promoting clinical trials, creativity is suppressed, free opinion is bulldozed and original ideas are scorned; all of us will gradually drift towards a world where all the top positions in all the top academic universities will be occupied by duplicates.
References
(1) Travasso C. Indian editors urge Medical Council to rethink publication guidelines for academic promotions 2016 ;352 : i344, available at http://www.bmj.com/content/352/bmj.i344
(2) Natural Selection, on Wikipedia , available at https://en.wikipedia.org/wiki/Natural_selection
(3) Macnerney S , on Big Think . Decision making has its Semmelweis , now it needs a Gawande , available at http://bigthink.com/insights-of-genius/decision-making-has-its-semmelwei... 2015
(4) " Werner Forssmann - Facts " nobelprize.org Nobel Media AB 2014 Web 26 Sep 2016 , available at http://www.nobelprize.org/nobel_prizes/medicine/laureates/1956/forssmann...
(5) Galileo Galilei, on Wikipedia , available at https://en.wikipedia.org/wiki/Galileo_Galilei
(6) Castelvecchi D. LIGO detects whispers of another black- hole merger. Nature 15 June 2016 ;534 : 7608 , available at http://www.nature.com/news/ligo-detects-whispers-of-another-black-hole-m...
(7) "We Are America" : Obama opens National museum of African American history and culture. NBC Washington ,24 Sep 2016 , available at http://www.nbcwashington.com/news/local/Smithsonian-National-Museum-of-A...
Competing interests: No competing interests
It was indeed a pleasure to read the commentary on setting research quotas for promotion in medical college in India (BMJ 2016;354:i5002). The authors have brought to light something that has been discussed in medical circles in India for a couple of years now. I would, however, argue that the publication quotas for promotions in medial institutes in India is a right step and should be continued for the following reasons:
1. The academic publications quota is applicable for promotions of medical teachers in medical colleges. In this fast changing world of medicine where evidence is key to decision making, medical faculties who cannot conduct research would not serve any purpose to create the future cadre of medical doctors. The argument put forth in the commentary about 'research output as an indicator of a doctor' forgets the fact these doctors in medical colleges are also responsible for teaching medical students and are expected to be academics and not just service providers. As the commentary itself acknowledges, "medical knowledge cannot advance without research." How can we expect medical education in India to advance without medical teachers being ability to conduct research? The example given of Mohalla clinic is farcical considering that the so called knowledge of Swasthya Slate has come from medical research and this also needs to be evaluated in future, through research, to see if it is actually working and it is a proper use of resources.
2. There has been a cultural change in the last decade towards stress on research because of this policy by the MCI, and institutions are now more open to facilitating research than previously. A decade back the stress was only on provision of service, and any proposal to conduct research was seen as a headache and something that was unnecessarily being embarked on. Many young and talented doctors have benefited from this policy.
3. I agree that it might increase the chances of research fraud but the demand then should be policies to prevent them and penal measures for those caught rather than scrapping a policy which incentivises research. A whistle blower act along with more robust institutional/ ethical committee oversight needs to be considered.
In the best interests of medicine in India, the MCI needs to continue this policy and combine it with increased investment and capacity building for medical research rather than scrap this policy under popular pressure and allow the gains made through this policy to fall apart.
Competing interests: No competing interests
Pressuring physicians to publish a certain number of papers to be promoted could lead to negative consequences with potential impact on more than one level.
Firstly, such a requirement has the potential to significantly increase physician burnout, by sending a message that focusing on patient care is meaningless and possibly not appreciated as opposed to the number of research publications one produces, and this could shift the attention from a patient-centered care to a paper-centered service delivery, at least for some junior physicians. As a consequence, it is reasonable to expect an increase in the number of medical errors and a decline in physicians' and patients' satisfaction.
Secondly, the pressure to publish is likely to increase unethical medical practices such as enrolling patients in meaningless trials, ordering useless laboratory tests and performing unnecessary experimental procedures, and thus potentially violating patients' rights and draining hospitals' resources.
And, finally, the pressure to publish is likely to lead to unethical publishing practices, including coercive authorship where authorship is conferred to non-contributing senior physicians in response to their real or perceived abuse of power, ghost and guest authorship, further proliferation of the so-called predatory journals and publishers and the evolution of black market publishing houses, where scholarly and biomedical papers are sold to busy doctors who hardly have time to read them.
Competing interests: No competing interests
I institutions like All India Institute of Medical Sciences, New Delhi, Post Graduate Institute of Medical Education and Research, Chandigarh, JIPMER, Puducherry, Christian Medical College, Vellore and Ludhiana, St John's Institute of Medical Sciences and Research Institute, Banglore, Manipal Academy of Medical Education contribute bulk of the publications.
Other institutions take time to establish the basic requirements of running a standard Medical College. Many of the colleges are run by administrators who have no clue or vision to run such colleges. Government colleges run on meager funding allocated for education and research by the government. They lack facilities or Research Professors to guide and develop research both basic and applied. There are no collaboration between University Departments of research and medical colleges. Medical Universities who control state-wise medical colleges lay emphasis on administration rather than research. They have very few departments who could conduct standard research. These Medical Universities administer, control and co-ordinate medical colleges in the State with a uniform pattern of examinations as well as Board of Studies related to various pre-clinical, para-clinical and clinical departments. Administrative Bodies like Syndicate and Senate take care of the administrative aspect of medical education with fewer voices for research. There are many Deemed Universities that conduct medical undergraduate (UG) and PG programs under University Grants Commission granting them deemed university status. Therefore, in the absence of basic facilities or guidance or support many of the private medical colleges including the government medical colleges are not able to promote research. Basic research which is the foundation stone is grossly neglected and the government allocation for such research is below 2% of the total budget. But the governing council of medical education stipulates that research publications are necessary for promotion,. The Body insists it must not be digital form of publication, it must be in pub-med or any other international citation index. This has resulted in journals who get few citation index and promote publications with a price. We have therefore publications of various standards which cannot be equated with publications of high impact journals. One must understand that with all these limitations faculty members try their must to write research papers and send them for publication. The refereed journals will definitely guide them with their short comings and suggest ways to improve their presentations. Yet there is a growing interest among the Faculty to do research. Then we have the problem of writing a research paper, getting approval from the Ethics committee and research body of the institution. Many of the members of the body act as critics and dampen the interest of the research workers. Therefore, medical council of India is in the process of revamping with a possibility of being replaced by another body to control medical education.
Whatever may be the regulating bodies:
They need to understand the institutions are of different categories. The newly started institutes are struggling to establish their college to produce physicians to meet the demands of the society. Such institutions must be classified as Basic Medical colleges which will train to promote undergraduate education. Postgraduate institutions with PG programs will be responsible for UG and PG education and promote research. We need more funding and we need encouragement. We need to bring about an understanding between basic scientists teachers and clinical teachers. We must not fight for divisions but for unification. We have immense potential to benefit our medical faculty. Only there must be an encouragement, economic freedom and access to research facilities for promoting research. Indian journals could be encouraged to publish the articles.That will be the learning experience to make the faculty to improve their research and develop findings to publish in better journals. Change must come but it must not come as a shock.
We are a unique country with lots of potential and there are great teachers, doctors and educationists. We need to bring about good collaboration between the university to provide guidance for promoting research in colleges affiliated to them.
I find it difficult to digest very harsh remarks or criticisms without giving credit to age-old institution of Medical Education of India which has served the cause of medicine commendably as well as globally,
Research is a living creative activity which kindles the examining minds of physicians. Once it lights up the canvas of research and publications will highlight the contribution towards excellent research that serves the community, the patient and the nation. The nation must understand that it has to encourage basic and fundamental research with more funding without any strings attached with a freedom for the researcher mind to develop the inquisitive mind for opening the gates of future research for the benefit of the patient.
Competing interests: No competing interests
This is yet another edition of Campbell's law: any indicator, once it becomes a target, ceases to become an indicator (sometimes called Goodhart's law in the UK). (paper here: http://www.sciencedirect.com/science/article/pii/014971897990048X). Once publication becomes a specific target, it ceases to be a useful indicator of research excellence. Instead it starts to be gamed.
The alternative for quality improvement- in academia as elsewhere- is to have standards but not make them too prescriptive. That means loose but agreed standards for reward held by evaluators, underpinned by professionalism (so the standards are agreed without making them too prescriptive ) and, usually, some kind of competition (e.g. US universities) or external incentive (e.g. the UK REF). That's hard, since neither professionalism nor healthy competition is all that easy to induce, but if you want to avoid stupid gaming of indicators, that's the way to go.
Competing interests: No competing interests
Re: Mandatory publication in India: setting quotas for research output could encourage scientific fraud
Fixing the quota for publication in promotion for faculty posts in medical institutes by the MCI is indeed not a logical decision. Forcing papers for research would ultimately degrade its value and lead to fraudulent publications. It would have been better if there were a separate incentive for publishing quality research. Further, without upgrading the research potentials of the faculties, it is not justifiable to expect from them quality publications. Without it, this step of fixing the quota for promotion would do more harm than any good to the already poor state of medical research in India...
Competing interests: No competing interests