Five futures for academic medicine: the ICRAM scenarios

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::

i) Academic medicine today: ‘Health care systems’ are not in the habit, as
claimed, of thinking, studying, researching, discovering, evaluating,
teaching, learning and improving (p. 101).

ii) In the same paragraph, is the ‘health burden’ to be read as the
disease burden, or is the reference to rising costs?

iii) The UNAIDS conjectures for Africa, described as scenarios, are not
scenarios at all but population projections, based upon statistical
constructs, as has been common in public health planning over many
decades, whether in calculating population growth or future service need.
They are not of the same species as the ICRAM scenarios!

iv) Short of a revolution, it is impossible for any institution to evolve
or change except from where it is to where it wants to be. Thus, starting
from scratch, simple ‘reinvention’ is no more possible than it would be
for an alcoholic.

v) We found particularly offensive the second paragraph of Scenario 3 (the
‘game show’ scenario). Was this to be taken seriously? It sounded as
though ‘The Weakest Link’ had taken over the Dean’s office. We found
this, in such a serious context, truly ludicrous.
Having read her summary of the scenarios, we cannot say that we and other
faculty members have felt enabled "to think more deeply about the present
and the future", as advertised. On the contrary, our reaction has been
that the alternatives proposed muddied rather than cleared the waters.
None of us is disposed to read the full report.
Enter ‘the drivers of the future’! Unaccountably, these are undefined,
although they would seem to be important! Perhaps we should have stopped
reading when the cliched ‘stakeholder’ (elsewhere ‘player’) appeared on
the first page; and almost certainly we should have abandoned the reading
of the Journal when the word ‘equity’ never put in a single appearance.

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:

i) The ever growing information burden placed upon the novice necessitates
an emphasis on ‘learning to learn’ over information overload. How slowly
we change! This was an issue raised by the G.M.C. in 1864 (not a misprint)
and reaffirmed by the same body in 1980: "the factual burden imposed upon
the student must be reduced."

ii) The locus of training has already changed. With ever briefer
admissions of increasingly sick patients to the ‘teaching hospital’,
acceptable length of stay no longer affords a leisurely opportunity for
observation and teaching. Bedside instruction has become a luxury; and
teaching in out-patient and office settings is becoming the rule. Again,
how slowly we change. In this, we were twenty years behind our U.K.
colleagues.

iii) We, and those who come after us, have too little understanding of the
larger medical world in which we work, of the systems in which we work;
and of those other individuals, members of the public, with whom we are
engaged in a common enterprise, the public weal. This must be changed. The
increasing sophistication and knowledge base of a large part of the public
today in all countries requires no less.

The above may be pertinent to other readers of the B.M.J.

Competing interests:
None declared

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

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

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