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Rapid Responses: Rapid Responses published:
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ACADEMIC MEDICINE INCLUDES PRIMARY CARE
- Blair H Smith, Deborah Sharp, Tony Kendrick, Graham Watt (8 October 2004)
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Ways to respond Global Health Challenges
- Anil Pandit (8 October 2004)
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Academic Medicine; Time for Burial not Resurrection
- Neil Watson (14 October 2004)
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Academic Medicine Who cares? We at least need to care and promote.
- Dr.Hanamaraddi.T Gangal (20 October 2004)
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Academic Career in family medicne in Mediterranean setting
- Francesco Carelli, Christos Lionis School of Medicine - University of Crete,JK Soler - The Family Practice- Malta (26 October 2004)
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Five Rescue Remedies for Academic Medicine
- William House, David Peters (27 October 2004)
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The Student Advisory Group to the Working Party for the International Campaign to Revitalise Academic Medicine
- Andrew G N Robertson, Crispin Hiley (28 October 2004)
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A Growing Funding Gap Between Clinical and Basic Science Publications
- Benjamin G. Druss, Steven C. Marcus (4 November 2004)
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Blair H Smith, Treasurer, Society for Academic Primary Care Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre,, Deborah Sharp, Tony Kendrick, Graham Watt
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The main conflicts between patients’ welfare and academic freedom arise, say Wright and Wedge [1], because of divergent objectives held by universities and hospital clinicians. However their subsequent description of academic centres as combinations of university, medical school and hospital is incomplete. Teaching and research are increasingly conducted outwith these environments, in primary care [2], and the need for investment in academic primary care is, if anything, more acute than in the secondary care sector [3,4]. The proportion of the undergraduate medical curriculum taught through general practices in the UK has been steadily increasing over the last 20 years and is now more than 10% on average, with some medical schools teaching up to 20% of their curriculum in this setting [3]. In addition, since 1999 there has been a significant increase in the number of students admitted to UK medical schools. We estimate from our national surveys that between a quarter and a third of general practices are now involved in teaching medical students [3]. Primary care research is also extremely important, given that many conditions are now treated entirely outside hospitals: 90% of NHS contacts take place in primary care and most of the common public health problems, including hypertension, diabetes, and mental health disorders, are managed almost entirely within primary care. Yet academic general practitioners represent only about 7% of the clinical academic workforce, and 0.5% of the clinical general practice workforce. In contrast, in most hospital specialties, senior academics represent at least 9% of the clinical workforce [5]. Academic primary care physicians, like their hospital colleagues, face the “triple jeopardy” [6] of a multi-professional challenge. Unlike their colleagues, however, they must often do this as independent practitioners, and may not be covered by indemnity arrangements when, for example, patients’ welfare and academic freedom are in conflict. Also unlike their hospital colleagues, they do not suffer from an insecure career structure – currently there is no established career structure for primary care academics. In most other countries, the need for more academic input into primary care is even more acute than in the UK which, despite the problems listed above, leads the world in this area. We wish the International Working Party every success in their campaign to promote and revitalise academic medicine, and urge them to include academic primary care under their umbrella, as Wright and Wedge specifically did not [1]. The Society for Academic Primary Care is happy to offer its support. Yours faithfully, Blair H. Smith, Treasurer,
Society for Academic Primary Care C/o Dr Blair Smith, Department of General Practice and Primary Care,
University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY
References 1. Wright JG, Wedge JH Clinicians and patients’ welfare: where does academic freedom fit in? BMJ 2004 329 795-6 2. Howe A, Baker M, Field S, Pringle M. Special non-clinical interests – GPs in education, research and management. Br J Gen Pract 2003 53 438-40. 3. Heads of Departments of General Practice and Primary Care in the Medical Schools of the United Kingdom. New Century, New Challenges. Report from Society for Academic Primary Care, 2002. 4. Mant D. National Working Group on R&D in Primary Care: Final Report. London: NHS Executive, 1997. 5. Watt GMC. Academic general practice and primary care in Scotland. Hoolet 2004 41 4-5. 6. Researcher, clinician, or teacher? [editorial] Lancet 2001 357 1543. Competing interests: We are all academic general practitioners who would benefit from increased investment in academic primary care and the establishment of a primary care academic career structure. |
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Anil Pandit, Physician Patan Hospital, GPO 252, Kathmandu, Nepal
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To respond to global health challenges, Academic medicine should be dedicated to improving and sustaining the health and well being of the an individuals by doing partnersip with National Health Services of each country - important and a major step. It is seen that major bulk of diseases and ill health is borne by developing countries, but much of academic activities are done in developed countries. More opportunities for training in re-knowned academic centers should be provided for academicians in low-income countries. We need to focus our attention on developing countries. We need to create a global work force- preferrably at local levels. Medical educationist should really spread out to different parts of the world, like missionary, with the vision and mission envisaged to promote academic medicine throughout the world. One of the ways of doing it would be -by establishing the network in all parts of the medical centers in world, for bilateral exchage of technical and academic supports which ever side is in need. This could be easily done through emails and internet. There are enough talents in academic medicines while limited financial resources are flowing in. The academic institution in the 21st century should be self-sufficient, rather than looking for financial grants from the organizations who have commercial interests. Financial incentives seeems to be least important ethically but, it is most important practically and one of the major decision influencing factors regarding career choice. So can't be neglected. Competing interests: None declared |
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Neil Watson, Artist and Writer California 94801
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Late in 2003 I responded to Richard Smith’s proposition that academic medicine was in need of resuscitation, by pointing out that it had already been dead for some time, and elaborated on the reasons why that was the case. No-one contacted me in response to my analysis of the situation, which I believe was accurate if perhaps rather outspoken, except Michael O’Donnell, who kindly said that it was one of the best pieces of writing about medical matters that he had read for some time. Now we’re faced with a whole barrage of new gobbledegook as to why academic medicine should be resuscitated. It can’t be, because it has already been dead for too long! One of the key requirements of becoming a really successful artist is to be able to recognise and accept failure. Serious art is a mirror of life, a reflection of the collective subconscious. Why is it so difficult to accept the utter failure of academic medicine? Answer; Because many big names in medicine have got their hands deeply into the ‘till’ and are not about to take them out! Moreover they are syphoning off many of the necessarily limited resources which are available for the care of patients. In that sense the whole thing can be seen as a protection racket. And I don’t really think that many of them care about what happens in the Third World. It would not be inappropriate to add that many, perhaps even most, of the major advances in the practice of surgery in the last century came not from Academic Medicine/Surgery but, rather, from busy and conscientious clinicians with good hands and enquiring minds who have, when necessary, collaborated with other disciplines, for example Engineering. There is Medicine and there is Academia. The marriage between the two, Academic Medicine, has not worked out. Time for a Divorce! Medicine, like the Fine Arts of Drawing, Painting and Sculpture, is something that you DO. In the world of art it has become very clear that the abandonment of basic practical skills, which took place in the second half of the twentieth century, was a terrible mistake. It seems to me that Academic Medicine is similar in many ways to an art school faculty, in which few of the members have any real skill or ability, sit around talking about it in a language that no ordinary person can understand, and, as a consequence, have presided over the graduation of at least two generations of students who have emerged, at great cost, who have almost nothing to say, and would not know how to articulate it in Drawing, Painting and Sculpture, even if they did. Look at the Contemporary Arts ‘Scene’ and it will not be difficult for you to see what I’m driving at. Those who enter the practice of medicine who have innovative and enquiring minds, who care deeply about the global issues in medicine, will find ways, within their own lives and practices, to be themselves and to effect change. That is the nature of the human condition. You can’t legislate for this sort of change. Rebuilding Academic Medicine is simply not the right way to go. Put flowers on its grave and move on! Neil Watson, MA, MD, FRCS Artist and Writer Formerly Consultant Hand Surgeon Competing interests: None declared |
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Dr.Hanamaraddi.T Gangal, practicing surgeon Hubli - 580021, Ka, India
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Academic Medicine Who cares? We at least need to care and promote. To achieve rational method of treating patient is the object of academic medicine.This will necessarily involve various aspects. As I have stated in my rapid response 1, to “BMJ Publishing Group at the launch of "an international campaign to promote academic medicine” “Please join us”2, we need to appreciate the situation is part of the general malady in the society world over.In the present situation the society and the profession are at loggerheads due to mistrust in each other. This is partly perpetuated by the serving profession by its blind participation by adopting drugs and technologies in which it had no active role to develop.We need to make the professional colleagues and society to appreciate this situation and to participate to facilitate the change in general,in their attitude towards better for every ones good. This will enable the present movement initiated BMJ to work towards it. The movement certainly needs every participant to be honest, knowledgeable, fair in out look, open minded to achieve the adoptable grounds to promote it.In the present state the biotechnology,industry, business, and media make rosy pictures of the developments even before they are tried in the humans with an aim to make immediate impact on the (stock) market. This results in high and imaginative expectations by the (society) patients from the profession. This is not a practical feasibility in the present situation. To make these expected results utilizable in clinical practice, the developments need to under go clinical trial to conclude their worthiness in humans. This aspect of trial is the major link between the biotechnology/drug, technology developing laboratory promoted by the industry / business and the profession. It is getting disrupted for reasons, which are primarily the financial gains rather than social good. This outlook is encouraged by the government’s entire world over. The profession is becoming alert to its own obligation to check and verify the justification of its blind participation. This enables avoiding to getting entangled in law suits of unknown consequences. With vast developments in all allied branches of science having applicability in medical science making head way as are seen today trying to convey though not true the rude feasibility of the redundancy of the profession, its skill and decisions in attending to the pat-ients needs. All these are at a cost even the developed countries are feeling their inability to meet this cost of treating most of its society.However the subsequent adverse outcomes in clinical trials of the propagated developments mainly based on the commercial outlooks has created distrust between the profession and the drug / technology developing industry. This is now obviously evidenced by events of withdrawals of quite a few drugs and techniques from marketing and use.This development has left the profession at the mercy of many with no advantage to many but added problems to very many. This has also created enormous scope to convey openly the distrust in the form of filing of many lawsuits in many forms. Such situations has made the profession to mandate its obligatory need to be aware of the developments into urges to keep itself abreast to provide heath needs of the society. The profession is trying to get involved in clinical resea-rch. It tries to evaluate the rationality and applicability to participate.Thus it has realized the importance of Academic Medicine.Large-scale appreciation of this has enabled adoption of resolution in 1999,by the Association of American Medical Colleges(AAMC) stating Academic Medicine forms the bases for future developments to keep abreast with the needs of the patients. Developments in science have provided vast scope to think of feasibility to utilize clinically applicable information to improve our results. To make academic medicine work effectively, needs interested professionals, this is to be supported by the profession /an organization/the local Government. Similarly it needs to be promoted and utilized to enable the benefits to be gained to the society. This action will make positive impact about the movement and facilitate to strengthen it and will also dissuade the glorification of lab oriented results. As can be observed from the editorials in BMJ the benefits achieved in Brazil 3 and Uganda 4 from utilization of the available knowledge do help in promoting the movement. Both are not developed countries.This is indicative that financially less affordable are likely to contribute to the development of Academic Medicine.The Editorial article 5 summarizing the International working party’s feelings to promote and to revitalize the Academic Medicine, one of the ways suggested is to extend academic medicine, traditionally focused on tertiary hospitals,into primary care and public health.Similarly the developments in clinical care even by individuals need attention of promotion. This will enable their large scale utilization by the serving profession to the good of the society. The Editorial article 6 appreciating the failure of provi-ding health for all by 2000AD as declared in 1981 by the Government of India and taking into consideration the distrust the public has shown in the Medical profession, the Central Working Committee,the leaders of the Indian Medical Association (IMA.HQ),New Delhi,has decided to fight it out to create a better image.It has launched a programme prono-unced by a slogan in Hindi “Aao Gaon Chalay” an equivalent of it in English is “come, let us go villages” and serve.It has called upon the Government of India to provide assistance to make the programme a success,and thus enable it to regain the trust of the society and the credibility. There is an expression of anxiety about the feasibility to reduce the gap between the Academic Medicine and the achievable in clinical practice.To me there is hardly any gap to exist.If it is there,it is beyond rectification in the present circumstance.Most of the time the gap perceived is due to non-applicability of the Academic out look in clinical practice to find the actual problem, try to rationalize to find academic solutions.This is to a large extent feasible, and enables to reduces the presumed gap to an acceptable level for a particular point of time. This also has to be evaluated in the context of other available remedies worth consideration. Failure to appreciate these backgrounds,the present efforts to revitalize will mean, we concede Academic medicine has no ground in medical science to meet the present needs of the society. This may definitely create other way effect. The fact that Association of American Medical Colleges (AAMC) has adopted Academic Medicine to form the bases for future developments should provide enough ground on the rationality of its decision on the future of the academic medicine for some time to come. Similarly now the move by BMJ in the same direction and seeking world wide participation to claim support to spear head in promoting it indicates the long delayed appreciation of its place in the present day,it to be rational in all our outlook. The valid rational clinical benefits will enable its promotion,should lead for better remuneration.All these efforts need to be clubbed with healthy cooperation and competition to enable achieve at least a part of the intended developments in academic medicine. The Author feels there many requirements for any individual in private practice in small areas to participate in Academic Medicine.To develop research will be a farfetched desire and to pursue will be a Herculean Task. Though it appeared a workable programme with some difficulties as long as he was teaching the postgraduates. The works were gaining ground.This was further facilitated by the stalwarts in the field heading the professional organizations. The present situation needs to regain such ground.It needs to be pursued by an organization intending to do so. The organization needs to be associated with people beyond self,knowledgeable,receptive and open minded to accept and promote the valid ones.As can be seen from the responses enough suggestions are provided,quite a few backgrounds have been considered for action.These may require further work on their implementation,propagation, and to think on how to combat the consequences of adverse outcomes, and measures to safe guard on any such events needs attention. The author has research contributions covering variety of clinical conditions. They are published.These have been tried and are proved to be reproducible.In fact on many occasions they can provide better and acceptable than are available in the tertiary referable hospital.They are very well suited to provide health care at primary health care center at a considerably reduced cost, with minimum trauma, reduced risk, loss of working and earning time, more significant is they provide holistic benefits, reduce the needs of major surgery to a large extent. They have proved to be effective when conventional treatments were not able to treat. These works need to be promoted. In the present days of sponsored programmes and research activities these works though can be utilized by the profession are not getting the deserved grounds. We will be achieving possibly more than planned in case there is a scope to utilize these concepts. Thus we are in a position to provide the academic needs of the programme to a good extent. Dr.H.T.Gangal. 1 Rapid Responses to: EDITORIALS:Jocalyn Clark and Richard Smith BMJ Publishing Group to launch an international campaign to promote academic medicine BMJ 2003; 327: 1001-1002 [Full text] The situation in Academic Medicine is a systemic manifestation of major illness of the general health of the of the society world over Dr.Hanamaraddi.T Gangal, -------- (7 November 2003) 2 BMJ2003;327:1001-1002 (1 November) Editorial BMJ Publishing Group to launch an international campaign to promote academic medicine Please join us 3BMJ2004;329:753-754(2October ),oi:10.1136/bmj.329.7469.753 Editorial A academic medicine as a resource for global health: the case of Brazil 4.BMJ 2004;329:752-753 (2 October), doi:10.1136/bmj.329.7469.752 Editorial.Academic medicine and global health responsibilities Academic medicine can contribute in four ways 5. BMJ 2004;329:787-789 (2 October), doi:10.1136/bmj.329.7469.787 ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting 6.Editorial, Doctors Day. IMA’s Concern for Rural Health and NPH for BPL People.JIMA, Vol 102, No 7, Jul 2004, Page 347. Competing interests: None declared |
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Francesco Carelli, EURACT Council ,National Representative - Italian College of GP Milan - Italy, Christos Lionis School of Medicine - University of Crete,JK Soler - The Family Practice- Malta
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In many parts of the world developments in teaching and research in the domain of family medicine have contributed to its recognition as an academic discipline. However, the discipline is still developing and would benefit from better support to increase capacity. In addition, family medicine also seeks full academic recognition in several European Countries, and this seems to be more evident in the Mediterranean setting. Colleges, teaching - educational amd research networks in Southern Europe are struggling to attract the necessary support and resources to flourish and to see family mediicne develop as an independent academic discipline. This is in contrast to Western and Northern Europe, where teaching - educational and research capacity has been developing for several decades. The development of academic career structure, including academic training, deserves high priority. It is necessary to make the discipline more attractive for the best medical students and young physicians.. This may then deliver new knowledge in education and research methods, and offer new ideas and innovative proposals about effective clinical care. Academic general practice should also strive to develop measurement of equity in health and health care, as an important subject of the GP / Family Medicine educational and research agenda. More senior posts are required in order to fulfil the task of academic leadership within the countries whose situation has been described above. GPs are at times perceived as being at the bottom of the academic scale. Measures should be taken towards the establishment of a national career structure for academic general practice in Southern Europe. This is because of the importance for a surviving connection between academic activity and clinical work, and because many NHS doctors have significant teaching and research and managemnt responsibilities, without being exactly academics. Mainly in General Practice discipline, we have GPs with really increasing service delivery committmens, but, at the same time, we are seeing a great development in GP teaching and research and new Countries are opening or are at least thinking to open finally the acamedic door to General Practice. Differently from Northern Countries, we see Countries where the contracts are not looking at flexiblity on work and nothing is devoted to career development and protected time for academic teaching, research and management. Developing the Mediterranean family practice educational and research agenda is a unique chance to bridge the figurative academic chasm betwen Northwestern and Southern Europe and should be a priority for the European Union. References 1 Jones R. Academic family practice. Fam Pract 2003; 20: 359. 2 Lionis C. General Practitioners need more route acquiring recognition from other specialties. E-BMJ: 2 March 2000. 3 Carelli F. Undergraduate Teaching of Family Medicine in Italy: the Modena Model. Eur J Gen Pract 2003; 9: 121. 4 EURACT Statement on Selection of Teachers and Practices – www.euract.org. 5 Carelli F. Special non clinical interests as career development – Br J Gen Pract 2003; 53: 569. 6 Carelli F. European Agenda for Departments of GP in each University. E-BMJ: 15 July 2003. 7 Soler J K, Lionis C, Carelli F., et al. Developing a Mediterranean family medicine group – The Malta consensus. Eur Gen J Pract 2002; 8: 69- 70, 74. 8 Rodnick J. International Family Medicine Education. Fam Med 2003; 35: 222-223. 9 Lionis C, Stoffers ΕJΗ, Hummers-Pradier E, Rotar Pavlič D, Griffiths F, Rethans JJ. Towards a Strategy for General Practice Research in Europe: setting priorities and identifying barriers. FamilyPractice,Vol.21,5,October 2004. 10. Lionis c., Carelli F., Soler JK - Developing academic careers in family medicine within the Mediterranean setting - Family Practice, Vol. 21, 5, Octobers 2004, Editorial Competing interests: None declared |
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William House, general practitioner St Augustine's Practice, 4 Station Rd,Keynsham, Bristol, BS31 2BN, David Peters
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The big problem for academic medicine is irrelevance. Sewankambo (1) and others rightly call for relevant research for irrelevance creeps in at every stage of research and teaching, from identifying health problems, conceptualising them, designing ethical research projects, securing funding, and interpreting findings . When the outcome filters back to clinicians and would-be clinicians it is stamped with the hallmarks of ambitious politicians and academics, the avarice of shareholders and corporations, the tired ideas of bastioned, venerable institutions, the bureaucratic dead hand of committees and the blindness of science. Then comes the righteous indignation that Luddite clinicians ignore these expensive, erudite fruits and that students fall asleep. The brutal fact is that academic medicine’s understanding will always lag behind the doing of good clinical practice, just as literary scholarship follows good creative writing and natural science follows nature. Even transformative technical innovations betray a mechanistic view of humanity that often misses the point of being alive. Nevertheless, it suits the games of politicians and corporations to keep academia alive to supply credibility and commodities. What is to be done? 1) Devolve more clinical research and teaching away from institutions
towards the coalface at home and abroad.
(1) Sewamkambo N. Academic medicine and global health responsibilities BMJ 2004;329:752-3 Competing interests: None declared |
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Andrew G N Robertson, Medical Student Medical School, University of Glasgow, University Ave, Glasgow, G12, Crispin Hiley
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Dear Editor, We are writing on behalf of the Student Advisory Group to the Working Party for the International Campaign to Revitalise Academic Medicine(1). The Student Advisory Group was set up this month and we had our first meeting last week in London, at the BMA House. Our aims are to express the views of students world-wide on academic medicine and use these to help define the future of academic medicine and also to promote academic medicine to students and to others. To do this we hope to involve students world-wide and establish ourselves in every university world-wide. We are writing:
If anyone is interested in the Student Advisory Group, please contact us at sag_icram@yahoo.co.uk. Yours sincerely, Andrew G N Robertson Crispin Hiley On behalf of the Committee Members of the Student Advisory Group to the Working Party for the International Campaign to Revitalise Academic Medicine. 1: ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting. International Working Party to Promote and Revitalise Academic Medicine BMJ 2004 329: 787-789. Competing interests: None declared |
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Benjamin G. Druss, Associate Professor of Health Policy Rollins School of Public Health, Emory University, Steven C. Marcus
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The campaign to promote academic medicine represents an important effort to address the many challenges facing the international clinical research enterprise.(1) Particularly since this campaign is led by a group of academic publishers, it is worthwhile to ask if or how these challenges have been reflected in the biomedical literature. To investigate this issue, we examined all 8.1 million articles indexed in MEDLINE between 1994 and 2001, comparing three eras: 1978-85, 1986-93, and 1994-2001. The proportion of studies involving human subjects (the most common proxy for clinical research) increased during the study period from 62.6% to 68.8%. There was a shift in the most common Medical Subject Headings, with the topics of public health, quality of care, and epidemiological methods supplanting headings for pathological processes and mammals. The study period saw a tripling in the proportion of randomized clinical trials from 1.9% to 6.2% of all articles. While absolute rates of funding rose over time for both types of research, they rose more rapidly for studies not involving human subjects, leading to a widening funding gap between these papers and clinical manuscripts. By the final study era (1994-2001), 66.8% of clinical publications reported no funding source, compared with only 32.1% of basic science articles. Both this absolute difference and the change over time were highly statistically significant. (p<0.001) This analysis provides a mixed prognosis on the health of clinical research as reflected in the biomedical literature. On the one hand, there are indications of a robust and expanding body of clinical publications. On the other hand, there appears to be a large and growing funding gap between clinical and basic research. If we are to preserve the vitality of the clinical research enterprise, we must work to ensure that funding keeps pace with the need for high-quality clinical evidence (2, 3). Competing interests: None declared |
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