Research and practice in adolescent medicine: “both-and” not “either-or” for clinicians

Abstract

Abstract The Society for Adolescent Medicine, a multidisciplinary organization, is devoted to the development of comprehensive acute, chronic, and preventive health care delivery to youth and to the institution of imaginative scientific research regarding all aspects of adolescence (1). Thus reads the masthead of the Journal which has been the primary vehicle for disseminating the scientific research to which the Society has committed itself. On this twentieth anniversary of the Journal, it is fitting, as it is with any anniversary, to examine how close the fit is between our principled objectives and our more real products appearing on these pages. Twenty years seems too brief a time span (as any parent at a college graduation will tell you easily enough), but twenty years has been time enough for a fledgling professional society to launch and sustain a journal which has moved from its primary clinical roots to a broad interdisciplinary scope. The last decade has witnessed the publication of both Guidelines for the Participation of Adolescents in Research (2) as well as a Code of Research Ethics in the Journal (3). These policy documents of the Society and its other efforts (4) provide a basis from which to embark on the comprehensive scope of scientific research to which we have pledged ourselves. It is noteworthy that the Society devotes itself to the development of health care delivery and to the institution of research. This dual commitment underscores the conviction that our discipline remains a mosaic of art and science and that a health care professional involved with patients must possess the skills of both healer and scientist. The art of health care is represented by a tradition of empathetic caring historically rooted in priestly duties when healers were invited by people into the troubled times of their lives to aid, to comfort, and to witness. This was, and remains, a sacred duty and a profound honor. The Society understands its obligation to initiate its members into prudent, responsible, and compassionate practice that reveres and preserves this legacy through its active dedication to mentoring. The science of health care is pursued and learned through research, which is both a process and a product. But restricting the process to clinical research units or population-based interventions fails to grasp the dual obligation assumed by clinicians to practice both art and science. Indeed, any therapeutic intervention in any clinical encounter should be conceptualized as a trial with one subject, requiring individualized therapy, a measurable endpoint, monitoring toward that goal, and the patient as an informed partner (5). Anything less weakens the rational basis of therapeutics and erodes the science. Nothing substitutes for the critical eye at the bedside. In fact, traditionally astute clinicians had been the first ones to pose the questions that lead to basic scientific breakthroughs. Sadly, too many clinicians today view themselves as little more than the consumers of clinical research produced by others. It is also disappointing to see so little basic clinical research in adolescents in the Journal of Adolescent Health. Whether this reflects an author preference for publication in other specialty journals or a broader failure to attend to the formal study of pressing clinical questions requires careful examination. Trends in the research activity of the Society and of the Journal have been documented by Cromer (6–7). She notes that study designs in Journal publications have increased in complexity over time. Further, the number of Journal citations by other publications continues to increase. These observations are healthy developmental signs for the Journal. However, Cromer's other findings should give pause. First, the balance between psychosocial and biomedical research continues to erode. Articles on psychosocial issues, mostly related to high-risk behavior in adolescents, continue to increase and currently account for 50% of all publications. Second, the percentage of articles presenting the results from experimental trials has never exceeded 5%. Clinical trials and basic research directly support the evolution of improved heath care. Their paucity in the Journal, coupled with documentation of adolescent under-enrollment in clinical trials themselves (8), should prompt a thoughtful evaluation of how to better nurture such research efforts. Such action is driven as much by the need for balance as it is to ensure the viability of adolescent medicine as an academic discipline within schools of medicine. The words of Antoine de Saint-Exupery hold true: As for the future, your task is not to foresee it, but to enable it. The future we must enable is one that both reveres the fullness of our legacy and bestows the continuing clarity of scientific vision.