Academic medicine: the evidence base
http://www.100md.com
《英国医生杂志》
Correspondence to: J P A Ioannidis, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina 45110, Greece jioannid@cc.uoi.gr
The International Campaign to Revitalise Academic Medicine recognises that an evidence based approach is important in discussing the problems of academic medicine. A preliminary exploration of the evidence on academic medicine has led to a research agenda for examining and proposing realistic solutions
Introduction
The Oxford English Reference Dictionary defines academe as "the world of learning," and academic as "scholarly: to do with learning." Scholarship is encountered as a key principle of academic medicine,w1 and it entails the discovery, integration, and application of knowledge, and teaching.w2 Academic medicine practitioners are expected to demonstrate systematic and sustained scholarly effort, with recognisable outputs valued by peers.
Many doctors teach (for example, over 40% of UK general practitioners host medical trainees2) or participate in research sporadically, and the role of such practitioners in the academic enterprise requires more study. Patients are also increasingly involved in clinical research,3 education,4 and service5 and are important academic allies. Finally, scholarship in fields related to health care and medicine is often pursued by non-physicians (nurses or laboratory scientists, for example) who may also encounter the "triple jeopardy" of trying to excel simultaneously in teaching, research, and clinical practice.6 However, policies addressing academic medicine careers typically do not expand the definition to include these scholars.7 Differing (or even conflicting) professional perspectives may prohibit recognition of common issues and lead to different groups fighting over available funds.8 Moreover, social and public health responsibilities and priorities of academic medicine may be different in affluent societies and in those with poor health systems.
Situation analyses are useful to identify barriers, failures, and successful applications in different settings. Most literature to date has selectively focused on developed Western countries, a minority in the global scale. We conducted an illustrative situation analysis for China (available from corresponding author). China has 2.2 million doctors, a third of the world's total number. Problems include the need for an increased academic workforce and structures to support continuing medical education and the production of high quality, licensed doctors; disproportionately low funding for clinical science research; the poor visibility of most domestic research; and an uncertain role for academic medicine in the changing finances of the Chinese health system.
Academic medicine has an uncertain role in the Chinese health system
Credit: STUART FRANKLIN/MAGNUM PHOTOS
Box 1: Analysing the evidence on academic medicine: types of evidence for preliminary themes
Definition and problems of academic medicine: based on qualitative analysis of the previous expert literature and illustrative situation analyses
Capacity: based on systematic review of quantitative non-randomised studies
Research indicators: based on quantitative data from the Institute for Scientific Information (ISI)
Impact of industry: based on ISI data and systematic reviews
Patient outcomes: based on systematic review of controlled studies
Capacity
Medical research is disproportionately dominated by a few wealthy countries. There is a strong correlation between the number of papers indexed by the Institute for Scientific Information (ISI)18 and the gross domestic product,w11 and between the number of citations and GDP (fig 1). No country with an adjusted GDP under $70bn received more than 15 000 citations to clinical medicine papers in the past decade (less than a thousandth of the total number of citations). The same picture applies in related life sciences (data available from contributing author). These indicators are objective, but provide a partial picture. Lack of research infrastructure and funding, publication bias, lack of recognition for some applied research disciplines, and poor access to information in the developing world must be considered. Much research outside Western countries appears in domestic journals available only locally. For the top 10 academic hospitals in China, 18 articles appear in domestic journals for every one in a journal indexed by ISI.
Fig 1 (top) Relation between the number of clinical medicine papers indexed by the Institute for Scientific Information (ISI) 1994-2004 and the gross domestic product (GDP) adjusted for purchasing power parity; (bottom) relation between the number of citations to these papers listed by ISI and GDP adjusted for purchasing power parity18
Although most burden of disease is carried by developing countries, clinical research is done where the money is, not where the investigation should be done.w12 An estimated 94% of the high impact scientific potential of humankind is lost because of various global inequities and squandered opportunities.w13 w14 Brain drain further diminishes the academic potential of poor countries. Brain drain consists of both external migration and internal migration of academics to organisations that fail public health priorities in host countries.
Furthermore, doctors have a shrinking presence in the broader life sciences. Analysis of the most cited scientists in the past two decades in life sciences shows that the representation of doctors among those who are currently 55 or younger has decreased sharply compared with older generations.w15 They still represent approximately 90% of most cited scientists in clinical medicine, the last domain where their research influence remains strong (fig 2).
Fig 2 Proportion with medical degree among the 250 most cited scientists in clinical medicine, immunology, microbiology, molecular biology, and pharmacology, 1981-2000w15
Impact of industry
There also seems to be a need to examine whether patients' outcomes are improved by academic medicine. Subjective outcomes (satisfaction, preferences, perceptions, and roles) as well as objective outcomes (disease) are important. Preliminary searches indicate that most evidence is non-randomised, and confounding is a major problem. The available evidence pertains to diverse conditions, such as general care, acute and chronic critical care, surgery, and obstetrics,19-23 but most data again seem to come from developed countries.
These questions may be provocative, but they are appropriate:
What is the evidence that academic medicine benefits patients?
Is there evidence that academic medicine may harm patients?
Could all health care be done in non-academic clinical settings?
Is academic medicine useful for patient outcomes globally, under select circumstances, for specific healthcare problems, in specific countries, or never?
Does academic medicine work?
Conclusion
International Working Party to Promote and Revitalise Academic Medicine. ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting. BMJ 2004;329: 787-9.
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.
Boote J, Telford R, Cooper C. Consumer involvement in health research: a review and research agenda. Health Policy 2002;61: 213-36.
Spencer J, Blackmore D, Heard S, McCrorie P, McHaffie D, Scherpbier A, et al. Patient oriented learning: a review of the role of the patient in the education of medical students. Med Educ 2000;34: 851-7.
Department of Health. Involving patients and the public in healthcare: a discussion document. London: DoH, 2001.
Researcher, clinician, or teacher? Lancet 2001;357: 1543.
Academy of Medical Sciences. Implementing the clinician scientist scheme. TAMS: London, 2002.
Gross CP, Anderson GF, Powe NR. The relation between funding by the National Institutes of Health and the burden of disease. N Engl J Med 1999;340: 1881-7.
Gray J, Armstrong P. Academic health leadership: looking to the future. Clin Invest Med 2003;26: 315-26.
Council of Heads of Medical Schools. A survey of clinical academic staffing levels in UK medical and dental schools. London: CHMS, 2001. www.chms.ac.uk/chms.pdf (accessed 14 Sep 2004).
Barer M, Kazanjian A, Pagliaccia N, Ruedy J, Webber WA. A profile of academic physicians in British Columbia. Acad Med 1989;64: 524-32.
Phillipson EA. Enhancing faculty renewal and development to address the shortage of physician supply. Medinews 2001;13: 1-5.
Danic A, Hadzibegovic I, Loparic M. Status of women in small academic medical communities: case study of the Zagreb University School of Medicine. Croat Med J 2003;44: 32-5.
DeAngelis C. Professors not professing. JAMA 2004;292: 1060-1.
Ash AS, Carr PL, Goldstein R, Friedman RH. Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med 2004;141: 205-12.
Ioannidis JP. Materializing research promises: opportunities, priorities and conflicts in translational medicine. J Transl Med 2004;2: 5.
Simpson DE, Rediske VA, Beecher A, Bower D, Meuer L, Lawrence S, et al. Understanding the careers of physician educators in family medicine. Acad Med 2001;76: 259-65.
Institute for Scientific Information. Web of knowledge: essential science indicators. http://www.isinet.net (accessed 6 July 2004).
Garber AM, Fuchs VR, Silverman JF. Case mix, costs, and outcomes. Differences between faculty and community services in a university hospital. N Engl J Med 1984;310: 1231-7.
Cooper GS, Chak A, Harper DL, Pine M, Rosenthal GE. Care of patients with upper gastrointestinal hemorrhage in academic medical centers: a community-based comparison. Gastroenterology 1996;111: 385-90.
Bach PB, Carson SS, Leff A. Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998;158: 1410-5.
Dimick JB, Cowan JA Jr, Colletti LM, Upchurch GR Jr. Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg 2004;139: 137-41.
Garcia FA, Miller HB, Huggins GR, Gordon TA. Effect of academic affiliation and obstetric volume on clinical outcome and cost of childbirth. Obstet Gynecol 2001;97: 567-76.
Gamulin S. Academic approach to academic medicine. Croat Med J 2004;45: 245-7.
The International Campaign to Revitalise Academic Medicine recognises that an evidence based approach is important in discussing the problems of academic medicine. A preliminary exploration of the evidence on academic medicine has led to a research agenda for examining and proposing realistic solutions
Introduction
The Oxford English Reference Dictionary defines academe as "the world of learning," and academic as "scholarly: to do with learning." Scholarship is encountered as a key principle of academic medicine,w1 and it entails the discovery, integration, and application of knowledge, and teaching.w2 Academic medicine practitioners are expected to demonstrate systematic and sustained scholarly effort, with recognisable outputs valued by peers.
Many doctors teach (for example, over 40% of UK general practitioners host medical trainees2) or participate in research sporadically, and the role of such practitioners in the academic enterprise requires more study. Patients are also increasingly involved in clinical research,3 education,4 and service5 and are important academic allies. Finally, scholarship in fields related to health care and medicine is often pursued by non-physicians (nurses or laboratory scientists, for example) who may also encounter the "triple jeopardy" of trying to excel simultaneously in teaching, research, and clinical practice.6 However, policies addressing academic medicine careers typically do not expand the definition to include these scholars.7 Differing (or even conflicting) professional perspectives may prohibit recognition of common issues and lead to different groups fighting over available funds.8 Moreover, social and public health responsibilities and priorities of academic medicine may be different in affluent societies and in those with poor health systems.
Situation analyses are useful to identify barriers, failures, and successful applications in different settings. Most literature to date has selectively focused on developed Western countries, a minority in the global scale. We conducted an illustrative situation analysis for China (available from corresponding author). China has 2.2 million doctors, a third of the world's total number. Problems include the need for an increased academic workforce and structures to support continuing medical education and the production of high quality, licensed doctors; disproportionately low funding for clinical science research; the poor visibility of most domestic research; and an uncertain role for academic medicine in the changing finances of the Chinese health system.
Academic medicine has an uncertain role in the Chinese health system
Credit: STUART FRANKLIN/MAGNUM PHOTOS
Box 1: Analysing the evidence on academic medicine: types of evidence for preliminary themes
Definition and problems of academic medicine: based on qualitative analysis of the previous expert literature and illustrative situation analyses
Capacity: based on systematic review of quantitative non-randomised studies
Research indicators: based on quantitative data from the Institute for Scientific Information (ISI)
Impact of industry: based on ISI data and systematic reviews
Patient outcomes: based on systematic review of controlled studies
Capacity
Medical research is disproportionately dominated by a few wealthy countries. There is a strong correlation between the number of papers indexed by the Institute for Scientific Information (ISI)18 and the gross domestic product,w11 and between the number of citations and GDP (fig 1). No country with an adjusted GDP under $70bn received more than 15 000 citations to clinical medicine papers in the past decade (less than a thousandth of the total number of citations). The same picture applies in related life sciences (data available from contributing author). These indicators are objective, but provide a partial picture. Lack of research infrastructure and funding, publication bias, lack of recognition for some applied research disciplines, and poor access to information in the developing world must be considered. Much research outside Western countries appears in domestic journals available only locally. For the top 10 academic hospitals in China, 18 articles appear in domestic journals for every one in a journal indexed by ISI.
Fig 1 (top) Relation between the number of clinical medicine papers indexed by the Institute for Scientific Information (ISI) 1994-2004 and the gross domestic product (GDP) adjusted for purchasing power parity; (bottom) relation between the number of citations to these papers listed by ISI and GDP adjusted for purchasing power parity18
Although most burden of disease is carried by developing countries, clinical research is done where the money is, not where the investigation should be done.w12 An estimated 94% of the high impact scientific potential of humankind is lost because of various global inequities and squandered opportunities.w13 w14 Brain drain further diminishes the academic potential of poor countries. Brain drain consists of both external migration and internal migration of academics to organisations that fail public health priorities in host countries.
Furthermore, doctors have a shrinking presence in the broader life sciences. Analysis of the most cited scientists in the past two decades in life sciences shows that the representation of doctors among those who are currently 55 or younger has decreased sharply compared with older generations.w15 They still represent approximately 90% of most cited scientists in clinical medicine, the last domain where their research influence remains strong (fig 2).
Fig 2 Proportion with medical degree among the 250 most cited scientists in clinical medicine, immunology, microbiology, molecular biology, and pharmacology, 1981-2000w15
Impact of industry
There also seems to be a need to examine whether patients' outcomes are improved by academic medicine. Subjective outcomes (satisfaction, preferences, perceptions, and roles) as well as objective outcomes (disease) are important. Preliminary searches indicate that most evidence is non-randomised, and confounding is a major problem. The available evidence pertains to diverse conditions, such as general care, acute and chronic critical care, surgery, and obstetrics,19-23 but most data again seem to come from developed countries.
These questions may be provocative, but they are appropriate:
What is the evidence that academic medicine benefits patients?
Is there evidence that academic medicine may harm patients?
Could all health care be done in non-academic clinical settings?
Is academic medicine useful for patient outcomes globally, under select circumstances, for specific healthcare problems, in specific countries, or never?
Does academic medicine work?
Conclusion
International Working Party to Promote and Revitalise Academic Medicine. ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting. BMJ 2004;329: 787-9.
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.
Boote J, Telford R, Cooper C. Consumer involvement in health research: a review and research agenda. Health Policy 2002;61: 213-36.
Spencer J, Blackmore D, Heard S, McCrorie P, McHaffie D, Scherpbier A, et al. Patient oriented learning: a review of the role of the patient in the education of medical students. Med Educ 2000;34: 851-7.
Department of Health. Involving patients and the public in healthcare: a discussion document. London: DoH, 2001.
Researcher, clinician, or teacher? Lancet 2001;357: 1543.
Academy of Medical Sciences. Implementing the clinician scientist scheme. TAMS: London, 2002.
Gross CP, Anderson GF, Powe NR. The relation between funding by the National Institutes of Health and the burden of disease. N Engl J Med 1999;340: 1881-7.
Gray J, Armstrong P. Academic health leadership: looking to the future. Clin Invest Med 2003;26: 315-26.
Council of Heads of Medical Schools. A survey of clinical academic staffing levels in UK medical and dental schools. London: CHMS, 2001. www.chms.ac.uk/chms.pdf (accessed 14 Sep 2004).
Barer M, Kazanjian A, Pagliaccia N, Ruedy J, Webber WA. A profile of academic physicians in British Columbia. Acad Med 1989;64: 524-32.
Phillipson EA. Enhancing faculty renewal and development to address the shortage of physician supply. Medinews 2001;13: 1-5.
Danic A, Hadzibegovic I, Loparic M. Status of women in small academic medical communities: case study of the Zagreb University School of Medicine. Croat Med J 2003;44: 32-5.
DeAngelis C. Professors not professing. JAMA 2004;292: 1060-1.
Ash AS, Carr PL, Goldstein R, Friedman RH. Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med 2004;141: 205-12.
Ioannidis JP. Materializing research promises: opportunities, priorities and conflicts in translational medicine. J Transl Med 2004;2: 5.
Simpson DE, Rediske VA, Beecher A, Bower D, Meuer L, Lawrence S, et al. Understanding the careers of physician educators in family medicine. Acad Med 2001;76: 259-65.
Institute for Scientific Information. Web of knowledge: essential science indicators. http://www.isinet.net (accessed 6 July 2004).
Garber AM, Fuchs VR, Silverman JF. Case mix, costs, and outcomes. Differences between faculty and community services in a university hospital. N Engl J Med 1984;310: 1231-7.
Cooper GS, Chak A, Harper DL, Pine M, Rosenthal GE. Care of patients with upper gastrointestinal hemorrhage in academic medical centers: a community-based comparison. Gastroenterology 1996;111: 385-90.
Bach PB, Carson SS, Leff A. Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998;158: 1410-5.
Dimick JB, Cowan JA Jr, Colletti LM, Upchurch GR Jr. Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg 2004;139: 137-41.
Garcia FA, Miller HB, Huggins GR, Gordon TA. Effect of academic affiliation and obstetric volume on clinical outcome and cost of childbirth. Obstet Gynecol 2001;97: 567-76.
Gamulin S. Academic approach to academic medicine. Croat Med J 2004;45: 245-7.