Academic medicine: a faltering engine

“Oh let me lead an academicke life”

B Hall, Virgidem 1599;IV:83

Arecent report for the council of heads of medical schools for the United Kingdom has concluded that 1000 more clinical academic posts will be needed by 2006 to train 2500 more medical students—a 60% increase in the number of students since 1998.¹ Clinical research is also under threat: the number of clinical academics active in research in British universities fell by 12% between the 1996 and 2001 research assessment exercises (from 2813 to 2469 full time equivalents).² Despite this, there is a crisis in recruitment and retention of clinical academics within the United Kingdom such that over 10% of posts are unfilled.¹ This is not a new problem. In 1995 a House of Lords select committee drew attention to recruitment problems in academic medicine. In 1997 the Richards report made 35 recommendations to prevent a threat to academic medicine, yet few of these were acted on.³ Why has this crisis occurred and what can be done about it?

Unfortunately there is no single culprit. The uncertain career structure for clinical academics remains a major disincentive. Although the specialist registrar training programme provides a structured and accelerated approach to training junior doctors, it lacks flexibility in accommodating the training of academics, which involves a postdoctoral research fellowship. Undertaking a period of protected research remains a competitive process. The Medical Research Council and Wellcome Trust, for example, fund only one in five of all applications for clinical training fellowships. But competition may be healthy for the development of academic medicine. Few students entering medical school plan a career in academic medicine, but the need to do research to be competitive at an interview stimulates many into such a career. Increased competition for national specialty training posts will, it is hoped, increase our recruitment for research. The Medical Research Council and Wellcome Trust have increased their clinical training fellowships by 100% over the past five years and other charities have followed suit.

Thereafter academic trainees still switch to a career in the NHS, and two factors contribute to this lack of retention.⁴ The first is the perceived inability of the trainees to achieve competitiveness in funding future research aspirations. This is intricately linked to career structure. Pressures from research assessment exercises in some universities have eroded clinical lecturer posts, an important stepping stone in the development of an academic. A comparable non-clinical post is usually more competitive in terms of research output and value for money. Senior academics have had to respond to increased demands from the NHS and teaching responsibilities, leaving less time for research. Universities must take some blame here.

Academic promotion is biased towards research output rather than teaching—largely because funding is also biased that way. Most medical schools receive two thirds of their income on the basis of the numbers of students taught, but until recently there was no assessment of quality of teaching. The recent teaching quality assessment exercise⁵ did grade the quality of teaching, but it has no implications for funding. By contrast, the remaining third of the funding depends on the amount and quality of research as determined by scores achieved in the research assessment exercise.² This emphasis on research as opposed to teaching may undermine the expansion of the medical profession, particularly if new posts funded by taking in more medical students are prioritised to research driven appointments.

Here the relationship with the local NHS is important. The NHS relies heavily on clinical academics for providing patient care, but medical schools increasingly depend on NHS colleagues and premises to deliver the clinical curriculum. However, the funding underpinning this relationship varies across the United Kingdom. In Cambridge nearly 60% of clinical academic posts are funded by the NHS, but in Southampton only 14% are. The mean across the United Kingdom is 37%.¹

The second factor that deters progression in an academic career is lack of parity of income with a clinical career, due both to earnings lost during training and the inability to earn from private practice. The latter probably accounts for the current discrepancy in academic training in different specialties. In a recent survey 67% of research training fellows planned a career in the subdisciplines of internal medicine, but only 7% in surgery. Only one individual aspired to be an academic anaesthetist, yet anaesthetists comprise the largest group of consultants in the United Kingdom.⁴ Parity of income may further worsen as the government, in the absence of additional NHS resources, seems content to foster private practice. Parity of income has been a major threat to academic medicine in the United States also.

The career structure for clinical academics is being improved. A strong message from the Academy of Medical Sciences and council of heads of medical schools to all deans is to preserve the post of clinical lecturer in spite of internal pressures. In addition to more training fellowships, charity and council funded fellowships are being recognised as an important step to enable an established academic trainee to gain further experience. The development of 50 clinician-scientist posts in the United Kingdom as a result of the recent Savill report is an important advance.⁶

These posts are aimed at research-led clinical academics with outstanding research potential demonstrated during their first period of research. They can enter a five year post that enables them to complete clinical training while simultaneously extending their research training and base. Medical schools are encouraged to view these posts as a tenure track leading to a strategic senior appointment in the school after the fellowship. This is a major innovation but one which must see an exponential expansion over the next five years to make a significant impact on career development. An improved environment for clinical academics will be facilitated through the Wellcome Trust Clinical research facilities—five purpose built research institutes across the United Kingdom dedicated to patient oriented clinical research and based on the general clinical research centres in the United States. Improvements in infrastructure are expected through successful government and Wellcome Trust funding awards.

So there remain many obstacles before one can “lead an academicke life.” We need to reward excellence in teaching if the government wishes to train more competent doctors. Equally important are issues surrounding career structures and parity of pay. However, we should also undertake a public relations exercise to improve recruitment and retention, and here the Academy of Medical Sciences could play a major part. The professional rewards for success in academic medicine are immense. We rely heavily on clinical academics for national and international leadership in medical affairs. In an era of manager-driven health provision, academic clinicians have the luxury of a varied workload—still a commitment to clinical practice—but importantly the ability to control their destiny through excellence in research and education. Despite a current crisis the future remains bright for academic medicine.

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