Academic medicine: time for reinvention
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7430.49-a (Published 01 January 2004) Cite this as: BMJ 2004;328:49All rapid responses
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Rosario (Argentina), January 4th. 2004
EDITOR - In the British Medical Journal(BMJ)of 1 November Clark and
Smith focus their editorial in the collapse of “Medicine's capacity to
research, think, and teach." (1). Subsequently, in the BMJ of 3 January,
Clark summarizes the commentaries sent by several readers about the above
mentioned viewpoint (2). In this regard, we intend to rescue preliminarily
some aspects about research and teaching, apt to become of relevance in
the above mentioned crisis.
Firstly, we are persuaded that the standing of medical schools clearly
depends, among others, on the prestige of their teachers and researchers
since they determine the fortitude of each undergraduate and postgraduate
endeavor. Consequently, we are also convinced that this assertion joined
to the resources for achieving a suitable teaching and research should
prevail over any other consideration in academic planning.
In a near hierarchic stage, we place the process of evaluation agreeing
with Miller about the importance of this academic procedure (3). In this
sense, we visualize a conspicuous difference between research and teaching
when applying it specifically to both activities. Thus, research shows a
determined grade of objectivity and a reduced number of biases because of
the certainness provided by publications, grants and patents for
evaluating creativity and efficiency. In contrast, teaching offers a high
grade of subjectivity and complexity as well as a higher number of biases.
Here the challenge consists not only in determining what a good medical
teacher is but in establishing standards the more objective the better for
evaluating it. Furthermore, in both activities the role of a continuously
changing society cannot be discarded.
Then, the improvement of research and teaching, including critical
thinking and making emphasis in teaching, should be academically
considered and debated in developing countries as ours, particularly if,
as supported by Clark and Smith, a collapse of defined Medicine's
capacities is at sight in the developed world.
REFERENCES
1 Clark J, Smith R: BMJ Publishing Group to launch an international
campaign to promote academic medicine. BMJ 2003; 327: 1001-2. (1 November)
2 Clark, J: Academic medicine: time for reinvention: Summary of responses.
BMJ 2004; 328; 49 (3 January)
3 Miller G: Los principios en la práctica. En Miller G & Fulop T:
Estrategias educativas para las profesiones de la salud. Cuadernos de
Salud Pública OMS, Ginebra (Suiza) [The principles in the practice. In
Miller G & Fulop T: Educative strategies for health professions.
Public Health Memorandum Books, WHO, Genevre (Switzerland)] 1975; 61; 101-
103
Larisa Ivón Carrera, MD, Instructor of Histology and Embryology,
Rosario University School of Medicine, Argentina
Tomás Eduardo Tellez, PhD, Professor of Histology and Embryology, Rosario
University School of Medicine, Argentina
Alberto Enrique D’Ottavio, PhD, Professor of Histology and Embryology,
Rosario University School of Medicine, Researcher of the Rosario
University Scientific Researcher Career and Chairman of the Rosario
University Research Council, Argentina
Competing interests:
None declared
Competing interests: No competing interests
Random Thoughts on Academic Medicine
In your letter of invitation to potential members of the working
party, you had asked two questions. Here are some of my thoughts.
1. What is the biggest single problem with Academic Medicine?
The question automatically suggests two sets of answers one in
reference to medicine in general and one in particular to academic
medicine. Instead of choosing one major problem, I wish to list three
major changes leading us to this point.
The next step is the definition of academic medicine. In my
definition, academic medicine is primarily concerned with education of
future doctors and acquisition of scientific knowledge. The Flexner report
set the stage for establishment of the profession and teaching of medicine
on a scientific footing. The consequences of developments since then in
biomedical research and several changes in the society force us to review
the role of practice, teaching and research in medicine within the
framework of changed socioeconomic and political conditions.
In my view, the three most important changes that have occurred since
the Flexner Report are: 1. Explosion of scientific knowledge with
resultant technologies and specialization. 2. Patient autonomy, patient
rights and the public demand for voice in medical decision making at an
individual level,on allocation of resources and on how physicians are
taught. 3. Cost of care and complicated administrative structure directly
related to items 1 and 2. These three changes must be addressed to refocus
academic medicine for the future
Increase in knowledge has clearly benefited the human kind. It has
created several new technologies and specialties. This has resulted in
better and earlier diagnosis and prolongation of life for those who are
sick and can get access to these specialties and technologies. It has not
necessarily improved overall health and has caused social inequities. As
Odegaard pointed out, the primary goal of medicine is “caring”, not
necessarily “knowing”. That is not to deny the fact that knowing clearly
makes caring better and we absolutely do need to know. But current trend
has tilted too much towards “knowing” and not enough towards “caring”. The
public resents that trend.
The public also resents and complains about the fact that the focus
is on the organ pathology and not the person with the disease. The public
knows that high and effective technologies come out of academic centers
and everyone wants an access to the best technology when he/she is sick!
Since medical education takes place at academic centers dominated by
specialization and technology, and since the public does not understand
what academic medicine does and how important it is to the society,
support for academic medicine is eroding.
Most of the medical education is still hospital-based in the midst of
high technology and rare diseases with rare complications. There are
excellent teachers in these sub-specialties, of course. But the fact is
that academic centers primarily reward and promote researchers and
specialists with narrower focus. Clinician educators and generalists are
undervalued and are treated as second class citizens in a separate
academic track. To survive even in that track, clinical money has to be
generated. Why would any one want to be a clinician/educator? No wonder
that there are very few role models as teachers of medical students and
hospital trainees.
The basic relationship between the physician and patient has also
taken a dramatic and a crucial turn. Patient are better educated and
better informed. In a democratic society the informed public is
increasingly skeptical of authority and power. Patient rights and informed
consent are the norms. Patients do not want to be passive and comply with
doctors “orders” and recommendations. They want to be partners in decision
making. These are positive developments. But this requires different sets
of skills in the physicians of the future. (It is disheartening to learn
that policeman deliver sad news better than physicians!) Academic medicine
has not done a good job in preparing physicians for this task. We need
scientifically trained clinicians with human relation skills more than
ever before as role models.
Cost of care has escalated. There are several causes and several
effects. One of the effects is that department heads are burdened with
financial management and fund raising and are not able to perform their
function as physician role models.In my view this is not healthy since it
leads to cynicism among students. Able scholars and teachers who become
leaders get either bogged down with administrative details or seem to get
into fund raising activities. They either step down in disgust or forget
their clinical roots!
2.What is a realistic and achievable solution to at least a portion
of the problem?
I have 6 general ideas. But they need more reflection,discussion and
analysis.
1. Academic centers should be organized on the model of McMaster
University so that an academic unit in Clinical Epidemiology,
Biostatistics and Health Services Research is the hub. All clinical
departments will work through this hub in answering clinically relevant
questions. All clinicians – generalists and specialists - should be
expected to perform their scholarly activities through this hub.
2. Academic centers should make extra efforts to encourage,
recognize, retain and support clinician/scholars as teachers and role
models in par with research scientists and specialists.
3. The administrators and financial specialists should be under the
direction of clinician/ scholars who develop the vision for “high-tech”
but humane care based on patient needs and clinical realities. Of course,
the clinical leader has to be fiscally responsible.
4. Medical education should help prepare the physician reestablish
the patient-physician dyad in the new environment of patient as a partner
in decision making. The curriculum should reflect the new knowledge in
biomedical sciences and also in human relation skills (particularly for
specialists) – such as listening skills, observational skills,
communication skills, problem-solving skills, decision-making skills and
negotiating skills.
5. The subspecialty departments may be realigned so that the research
core is common and the clinical specialties give continuity of care,
cutting across age and sex related sub-sub specialties (eg: pediatric
orthopedics, geriatric orthopedics).
6. Academic medicine has to do a better job of educating the public
on the value of academic medicine to the society and in making the public
part of the decison making process.
Competing interests:
None declared
Competing interests: No competing interests