In the 16th and 17th centuries, it was believed that the wealth of a nation was dependent upon the amount of gold and treasure piled up in the palace of its ruler. This view was famously challenged in the 18th century by Adam Smith, who asserted that the wealth of a nation was dependent upon the labor of its people. Smith also described how the division of labor would increase productivity, and how the exchange of goods increases the wealth of the nation.
Let us consider, then, the wealth of a particular academic clinical field in reference to these ideas. For example, the strength of the impact factor in any clinical field is clearly related to the number of citations generated: the more the citations, the bigger the impact factor. This does not, however, serve as an indicator of the academic richness of that field. It can, rather, be assumed that the richness of a given academic field will depend on the sum of the work of all the physicians involved, which will include not just research, but also clinical activities as well. Detailed and precise clinical work is the very foundation of academic richness in clinical medicine.
Moreover, just as the division of labor increases industrial productivity, the division of research work greatly enriches the results. This pressure to concentrate on one particular area, however, can lead to over‐specialization and the phenomenon of the so‐called “expert ignoramus”. To avoid falling into this trap, it is important to take a broad and long‐range view of one's chosen field as a whole, always striving to grasp as wide a variety of academic information as possible. It is imperative, therefore, that this be borne in mind in the organization of scientific conferences and the publication of journals.
Metaphysically, scientific meetings and journals can be regarded as an academic marketplace where all types of information are available. Thankfully, all this information can be readily obtained at reasonable expense whenever you attend conferences or read journals. But although such information may be accessed with ease, this says nothing about the richness of the field itself.
So what constitutes the wealth of an academic field? I believe that the answer involves not only the availability of information, but also the exchange of knowledge. It is on this issue that I would like to focus here.
In a clinical setting, “information gain” may be defined as simply obtaining a predetermined answer to a given question. At conferences or in journals, authors present their answers to a particular question, usually framed as a “Question–Answer” set, and thus make this knowledge available to others engaged in that field. If those others accept that answer, they will be able to apply that knowledge in their clinical settings.
This also applies in the case of general information, such as clinical guidelines, for example. Where the clinician finds that a Question–Answer set in the guidelines matches his or her own needs, they can take that information and apply it clinically. This is information gain and it differs from information exchange. So what is information and/or knowledge exchange? It is adding new value to an answer by applying it to another Question–Answer set. The following is an example of such knowledge exchange.
In the 1980s, D.W. Wilmore at Harvard found that patients in critical condition with low levels of glutamine were more likely to die. There appeared to be no pathophysiological explanation of this phenomenon. Meanwhile, H.G. Windmuller at the National Institutes of Health had been studying the intestinal absorption process of a certain drug. Both were working in different academic fields and there was no scientific communication between them. Using a regional perfusion model, Windmuller discovered that glutamine was the key energy source in the intestine. In other words, he realized that glutamine was essential in maintaining the integrity of the intestine. Windmuller's Question–Answer set, then, was “What is essential in maintaining intestinal function?—Glutamine, low levels of which will induce loss of intestinal function”. What Wilmore did was to apply this answer to his own Question–Answer set to arrive at a novel solution to his own problem.
In Wilmore's scenario, glucose would be the main energy source in critical patients receiving parenteral nutrition. However, due to its instability in fluids, no glutamine would be present in the infusion fluid used to provide this parenteral nutrition. Therefore, in critical patients on parenteral nutrition, glutamine in the intestine would be obtained by catalyzing muscle, the main store of glutamine in the body. In such patients, however, this intestinal energy source would eventually dry up as the levels of available glutamine were depleted. This would result in thinning of the intestinal wall and immunological failure, which would induce disruption of intestinal defense mechanisms. Thus, the patient's condition would deteriorate and the probability of death increase. This is the essence of Wilmore's Gut–Glutamine theory.
It should be noted, however, that the basis of this Gut–Glutamine theory is Wilmore's own Question–Answer set, which was “Why are critical patients with low levels of glutamine more likely to die?—Because glutamine is essential for the intestine, and low levels will result in loss of intestinal function (or, in other words, disruption of intestinal defense mechanisms)”. Thus, Wilmore inserted Windmuller's answer to another Question–Answer set to obtain a novel answer to the problem of why such high mortality rates were observed in critical patients with low levels of glutamine. Such creative application of predetermined answers to other problems constitutes knowledge exchange, as it enhances the value of the product of the original Question–Answer set to generate new solutions to formerly intractable problems. Thus, it is clear that this process is essential in utilizing and extrapolating from obtained information and enhancing original values. This directly related to the increase in wealth of that particular academic field. The wealth of an academic field, therefore, needs to be analyzed in these two terms, information gain and knowledge exchange.
Whereas in other branches of clinical medicine an organ‐focused approach might be preferred, in the field of acute medicine and surgery it is best to have a broad overview of the patient's condition. I believe, therefore, that in this particular field it is important not just to focus on information gain of a particular organ and/or research field, but also on knowledge exchange in a wider field of the science market, as this is an area in which there are boundless opportunities for exploiting the potential of answers from one Question–Answer set in another. Therefore, I would assert that employing every available means, including electronic publishing and secondary publication aimed at overcoming the language barrier, can only increase the wealth of the field of acute care.
In closing this editorial, I would like to introduce some lines from The Wealth of Nations by Adam Smith:
… he intends only his own gain; and he is in this, as in many other cases, led by an invisible hand to promote an end which was no part of his intention.
Book IV Chapter II
This Editorial can be read in Japanese in the Journal of Japanese Association for Acute Medicine— click here .