A research culture that asks too much

Abstract

The academic clinician combines clinical duties with research and teaching. In the USA the first duty is complicated, even in the best-endowed medical schools, by a need for academic staff to deliver a commercially viable turnover of cases at a time when managed and federally funded care are cutting expenditure. To focus on the clinical academic is not to play down full-time research or teaching and research by non-academic clinicians; nor does it deny the fact that medical research is a collaborative effort and no longer a matter for the medically qualified alone. All the same, there has to be a career path for those who, combining the three major roles of patient care, teaching, and research, choose to be employees of a university. It is hard to find any country—including the United States and Japan, in which relatively, research-minded MDs in clinical departments are in abundance—where this path looks attractive to the younger newcomer in the 1990s. The Lancet's occasional country profiles have illustrated the variety of the challenges within Europe. There are some interesting answers too; not all of them(eg, the Dutch approach to centres of research excellence) will prove popular or practicable. The position in the UK, not yet profiled, is very worrying. To the struggles for funding, the uncertain future of clinical lectureships, and the neglect of research in recent training reforms has to be added another dent in the traditional academic culture. The January, 1997, issue of Archives of Disease in Childhood speaks depressingly of medical schools “advising or even ordering staff to decline invitations” to write material such as review articles and editorials because these tasks do not count in research assessment excercises. Later on, the journal's editors despair at the refusal of senior academics to referee papers (“one told us that that his institution disparaged such work as unproductive for the department”). In the UK a Committee of Vice-Chancellors and Principals task force is looking at disincentives to careers in clinical academic medicine. Back in 1995 the government's view was, in effect, “We see no serious problem”. The CVCP thought otherwise, and the independence of Sir Rex Richards' team, now drafting their report with a target completion date of early May, will give extra force to their verdict. One stumbling block has already been removed: increases in academic pay-scales for doctors will now be linked to recommended increments in the National Health Service. Another obstacle is the reluctance to give credit to years in research. The academic ladder is fitted with slippery rungs and leant against a steep-sided pyramid. More young doctors would be tempted to try a research-based career if they could be confident that it would be easy to move across to a more full-time clinical job, one which will be done all the better for the years spent in a research setting. Is a culture that demands three tasks, all to be well done, asking too much of the academic clinician? We think it is. Prudence demands that young men and women with one foot on the academic ladder work towards some form of specialist accreditation, usually involving examinations, at the very time when the basic tools of research, let alone teaching, have still to be learned. In the UK there is much talk of two types of university, one focusing on teaching and the other on research. Medical schools will, rightly, deplore such a split but they may have to adjust their training programmes and clinical rotas if they are to be guaranteed high-calibre entrants to junior academic posts. The MD means different things in different countries but as a higher degree it should include formal courses on basic research techniques, including clinical epidemiology and medical informatics. The danger in an overmanaged university system is that one skill that a research culture should foster—and it is just as valuable when removed from the ivy-clad walls of a university to the hurly-burly of the clinic—is being neglected. A critical faculty, strongly developed in a postgraduate academic setting, is an invaluable asset to any career in medicine.