Academic medicine: resuscitation in progress

Academic medicine is in crisis around the world.1 So begins a call by BMJ editors Jocalyn Clark and Richard Smith to “revitalize—and reinvent—academic medicine.” Their call to action is propelled by a recent report from the Academy of Medical Sciences on the state of experimental medicine in the United Kingdom.2 The UK is losing its attraction as a site for clinical research, the Academy's working group laments, due to a loss of capacity in facilities, personnel and funding, and as a result of organizational, behavioural and regulatory impediments. The working group recommends new funding structures, career incentives, capital investment, “modernization” of the “regulatory environment” and the development of international (i.e., European) clinical research networks. Much of this sounds familiar to us in Canada, where the research climate strikes various commentators as chilly3^,4 (although the working group gives special mention to the “encouraging example” of the Canadian Institutes of Health Research). Canadian researchers tend to view the funding cup as half empty, not half full; hence the immediate and enthusiastic interest within our own editorial board in the BMJ's initiative.

Where does “academic” medicine fit into 21st-century medical practice? The designation “Academy” enjoys a nouveau-classical vogue these days, although Plato's garden is undeniably remote from our modern sensibilities. The word “academic” has come to mean something like theoretical, abstract, impractical and even moot. Ever since Flexner's scientific reform of medical education in the early days of the last century, there has been a tension between the academic and vocational cultures of medicine.5^,6 In 2004, the Zeitgeist of academic medicine reflects a more general phenomenon that we might characterize as technological commercialism. Although academics express a longing for a time when the practice and teaching of medicine were simpler and less rushed, and when, we are told or like to remember, there was time for reflection, they find themselves in countless meetings and committees, continually writing grants and reports and teaching students in an academic garden tangled with competing curriculum requirements and crowded with “industry partners.”

Is this a crisis, or just a longing for a more gracious (and privileged) age? Perhaps the most noticeable change is the transformation of medicine from a private enterprise to a public one. Indeed, Flexner saw the physician as “a social instrument.”5 Today's academics are not the small group of (almost entirely) men who controlled medical schools and hospitals, but part of a larger group of people sitting on governance boards and interdisciplinary committees who report to and are judged by public authorities and, increasingly, by the public itself. Some may conclude that, in adapting to these changes, academic medicine has become weaker, not stronger.

Another change is the result of the success and enormous growth of health sciences research, particularly in molecular genetics. The greater complexity and expense of conducting modern research have forced governments and universities to partner with industrial sponsors. Certainly the movement of research away from clinical applications and toward high-tech bench research, and from public to private funding (and research agendas) is part of the malaise.

Further, the accelerating subspecialization of research has transformed medicine into a Babel of specialties and subspecialties. It is now necessary to speak of “knowledge translation.” The effects on the curriculum are profound. Can we expect medical students or even residents to emerge with the breadth of understanding of science needed to practise “academic” medicine? Or is it enough that young physicians emerge with a cookbook-style command of guidelines and consensus statements?

And then we have the Oslerian problems of the bedside. Physicians now encounter patients who, whether or not they are wiser about health than their parents and grandparents, believe that they are better informed. Armed with information gathered from the unsystematic and limitless Web, today's patients worry that their physicians' information uptake is slower than a modem. And physicians, themselves insecure in the face of the rapid pace of new technology and science, may feel that this is not the medicine they once knew or to which they had aspired.

Academic medicine is threatened by more than withering clinical research opportunities. Clark and Smith call for the creation of an international advisory board and for help from all who are interested in salvaging and strengthening academic medicine. After canvassing our editorial board we've sent several Canadian nominations to BMJ. Naturally, we lend the BMJ campaign our support. — CMAJ