Academic medicine in crisis

At the end of 2003, an editorial in the British Medical Journal (BMJ) announced that academic medicine is in crisis across the world1 and a recent editorial in this journal has described the severe pressures on the United Kingdom system.2 The BMJ has joined forces with a number of other influential medical journals including The Lancet and Canadian Medical Journal to try to help to resuscitate it. Does it matter that academic medicine is in such a poor state? An argument could be made that clinical research should be carried out in research institutions and medical student teaching undertaken by professional educationalists leaving doctors to get on with the job they have been trained for – looking after patients. We think it does matter. Clinical academics have responsibility for educating students at both undergraduate and postgraduate levels and for pursuing research; additionally many take on major leadership roles in healthcare delivery. A culture within healthcare institutions that values and rewards careful and thoughtful evaluation of a range of clinical practices inevitably raises the standard of patient care.3 The advances in basic medical sciences that have taken place over the last two decades, particularly in molecular biology, genetics and proteomics and in the development of new functional imaging technologies, offer exciting opportunities for therapeutics and clinical practice. Clinical academics are uniquely placed to develop translational research whereby these basic discoveries can be converted into health benefits for the population. The need for experimental medicine followed by appropriately designed clinical trials has never been greater. We believe that medical education thrives in an environment where evidence-based practice and critical evaluation are valued and where students can observe advances in biomedical, psychological and social sciences being put into action. Finally, clinical academics can and should take a lead in debate over the ethical, moral and philosophical dilemmas constantly posed by advances in research and technology. So, given exciting developments in both teaching and research, why is academic medicine currently in such a poor state? The challenges to recruitment recognised in the Saville report of 20004 remain, and since that date there has been a further 30% decline in Clinical Lecturer numbers and 17% reduction in the number of Clinical Researchers. A recent report by the Academy of Medical Sciences in the UK5 highlights the following problems: lack of appropriate facilities and infrastructure lack of appropriately trained clinical scientists and a career structure to support them inadequate funding failure to use the opportunity provided by the National Health Service (NHS) in the UK to generate high quality clinical data for studies the increasingly complex legal and ethical governance framework. The UK is not alone in facing a decline in research. Many countries face similar problems but the report argues that the NHS is more dependent on a healthy research environment than other healthcare systems. Where healthcare is free at the point of access and organised according to nationally agreed standards, patients' access to new interventions needs to be based on independent evidence. From the point of view of UK medical education, the major advances of the last few years and the expansion of medical student numbers have taken place in the absence of increased clinical academic numbers and on the assumption that the greater need for teaching would be met by NHS staff. The solutions to the problems of academic medicine include more funding, better career and reward structures and rethinking restrictive governance frameworks.6 Research and development within the NHS needs to be critically reviewed, their links with basic science enhanced and the research ethos revitalised to ensure that scientific development is translated into optimal patient care. From the point of view of medical education, it is vital that teaching and educational scholarship are valued and rewarded. The challenge for any one person to produce high quality research, teaching and clinical care must be acknowledged and individuals encouraged to focus on areas of strength. Teaching is still viewed by most academics as the poor relation of research; this must be addressed through changes to academic promotion and reward schemes in the universities. We believe that academics mainly interested in research and those mainly interested in teaching should join forces as equals to protect and promote academic medicine. This partnership must also involve nonclinical research staff and educationalists. Researchers should draw on the expertise of educationalists to disseminate and promote their findings. Educationalists should develop a critical approach to their work using research-based evidence in teaching content and critically researching and evaluating learning methods. Those clinical academics who continue to carry out both research and teaching at a high level should be valued and supported. We need to work together to produce the next generation of academics in our medical schools; otherwise academic medicine will no longer be in crisis, it will be completely moribund.

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