Editorial

The Future of Academic Medicine

Ana Marušić

Croatian Medical Journal Note: This editorial was prepared from the published articles Zagreb University School of Medicine, on ICRAM activities and the Power Point presentation on Zagreb, Croatia the five scenarios of futures of academic medicine in 2025, prepared by Dr Jocalyn Clark, British Medical Journal. The presentation of the scenarios was used by the author of this editorial for lectures on several occasions, including the Sym- Corresponding author: posium on “Gefährdung der univerisitären Medizin”, Neue Ana Marušić Universität Heidelberg, 22 July 2005; 10th “Grazer Konferenz” Salata 3 on “Curriculum Development as an Ongoing Process” in Vi- 10000 Zagreb enna, 11-13 May 2006; and the Symposium on “Ethics and Croatia Medicine: Today and Tomorrow” in Zagreb, 24 November e-mail: [email protected] 2006.

Received: 05. 09. 2006 Key words: Education, Medical; Schools, Medical; Biomedical Accepted: 25. 09. 2006 Research; Evidence-Based Medicine; Bosnia-Herzegovina.

Academic medicine is usually defined as a cal Sciences in the UK, published in 2002 triad of teaching, research and practice in its report “Clinical Academic Medicine in medicine (1, 2). More broadly, it can be de- Jeopardy: Recommendations for Change”; fined as the “capacity of the health-care sys- and the American Association of Medical tem to think, study, research, discover, eval- Colleges released in 2004 their analysis of uate, innovate, teach, learn, and improve” medical education system in the USA, en- (3). Although these attributes of academic titled “Educating Doctors to Provide High medicine make it crucial for the improve- Quality Medical Care: A Vision for Medical ment of health, there are many voices in the Education in the United States” (3). academic medical community that worry Editors of medical journals, which are about the future of academic medicine (3). an important part of academic medicine, Many national and professional bodies in have also become aware of the problems in medicine discussed this problem and es- academic medicine, and decided to promote pecially the many deterrents to pursuing a the discussion about the future of academic clinical academic career for young physi- medicine at the beginning of the new mil- cians. For example, the Academy of Medi- lennium. BMJ, Lancet, and 40 other jour-

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nals, including the Croatian Medical Journal the ICRAM Working Party used different (1, 4), in 2003 launched a global initiative methodology: a) systematic reviews of the to develop a new vision for the place of aca- research on different aspects of academic demic medicine in the global community. medicine, b) regional meetings with aca- The first result o this initiative was the for- demics from different areas to assess local mation of the ICRAM – the International specificities and needs, c) consultations with Campaign to Revitalize Academic Medicine all stakeholders in academic medicine, and (5, 6). The goal of this campaign was to offer d) discussing and developing vision and val- young medical academics an opportunity to ues of academic medicine in future. think about the future of academic medicine So far, four systematic reviews were con- in a novel way and globally. ducted by the ICRAM members (Sharon ICRAM is run by a working party of 20 Strauss from Canada, John Ioannidis from medical academics (Table 1), nominated by Greece, and I from Croatia) and their col- colleagues from their academic communi- laborators: 1) patient outcomes in academic ties. They represent 14 countries, half of vs. non-academic health institutions (16); 2) the members are women, and half of them role of mentoring in academic medicine (17); come from medium or low income coun- 3) career choices in academic medicine (18); tries. The ICRAM Working Party is chaired and 4) funding of clinical research (19). by the Leader of the Campaign, Prof. Peter To increase awareness of medical students Tugwell from the Centre for Global Health and young physicians about possible careers at the University of Ottawa, Canada; and the in academic medicine, Gretchen Purcell, Campaign Coordinator is Dr Jocalyn Clark, ICRAM Working Party member from the Assistant Editor at the BMJ. (Table 1.) USA, published a series of articles in the BMJ As the contribution to the ICRAM, the Career Focus (http://careerfocus.bmjjournals. Croatian Medical Journal published a series com/), presenting exceptional individuals of 23 essays on academic medicine, both who chose careers in academic medicine from the developed countries (7, 8) and and their advice to aspiring academics. developing and newly emerging countries Members of the ICRAM Working Party (9-14). These challenging and thought-pro- also convened advisory groups of different voking articles from experts coming from 20 stakeholders, as well as seven regional meet- different countries all over the world were ings, modeled after the regions of the World published as a separate book (15). Health Organization.

ICRAM Goals and Activities Scenarios on the Future of Academic Medicine The goal of the ICRAM Working Party was to produce a series of evidence-based recom- Working on the visions and values of aca- mendations for reform in global academic demic medicine, revealed many differences medicine by developing a vision and values in opinions among the members of the of academic medicine, discuss strategies for Working Party (3). We could not agree on building capacity of academic medicine, in- the values of academic medicine: was it to cluding better career paths, and proposing compete (to earn more) or to provide public how academic medicine could improve its service. We also disagreed on the role of the relationships with other stakeholders – pa- private sector, especially the pharmaceutical tients, policy makers, funders, and health industry, and its importance for academic practitioners (5, 6). To reach these goals, medicine of today and tomorrow – would

 Ana Marušić: Future of Academic Medicine

Table 1 . Members of the International Campaign to Revitalize Academic Medicine, ICRAM (4)

Peter Tugwell, University of Ottawa, Institute of Population Health, Ottawa, Canada Leader of the Campaign

Jocalyn Clark, Assistant Editor, BMJ, London, UK Campaign Coordinator

ICRAM Working Party Members: Tahmeed Ahmed Clinical Sciences Division, ICDDR, Dhaka, Bangladesh Shally Awasthi Department of Paediatrics, King George’s Medical University Lucknow, India Mark Clarfield Department of Geriatrics, Soroko Hospital, Ben Gurion University, Beersheva, Israel Lalit Dandona Centre for Public Health Research, Administrative Staff College, Hyderabad, India Amanda Howe School of Medicine, University of East Anglia, Norfolk, UK John Ioannidis Department of Hygiene and Epidemiology, University of Ioannina, Ioannina, Greece Edwin Jesudason Department of Child Health, University of Liverpool, Liverpool, UK Juan Manuel Lozano Department of Pediatrics and Clinical Epidemiology, Javeriana University, Bogota, Colombia Youping Li Chinese Cochrane Centre, West China Hospital, Chengdu, China Ana Marušić Department of Anatomy and Croatian Medical Journal, Zagreb University School of Medicine, Zagreb, Croatia Idris Mohammed Department of Immunology and Infectious Diseases, University of Maiduguri, Maiduguri, Nigeria Gretchen Purcell Department of Surgery, Pittsburgh Children’s Hospital, Pittsburgh, IL, USA Karen Sliwa-Hähnle CH Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa Sharon Straus Department of Medicine, Toronto General Hospital, Toronto, Canada Tessa Tan-Torres Edejer Department of Health Systems Financing, Expenditure and Resource Allocation, WHO, Geneva, Switzerland Tim Underwood Cancer Sciences Division, University of Southampton, Southampton, UK Robyn Ward Department of Medical Oncology, St Vicent’s Hospital, Darlinghurst, Australia Michael Wilkes School of Medicine, University of California Davis, Davis, CA, USA David Wilkinson Mayne Medical School, University of Queensland, Brisbane, Australia

business interests threaten or save academic moil about the Future of South Africa (16), medicine? the vision of AIDS problem in 2025 by UN- In such a deadlock, we decided to use the AIDS (17), or the future of patient-centered methodology of scenario building, which care in 2015 by Picker Institute (18). is often used by commercial companies for When several ICRAM Working Party short-term decision making and long-term members met in London on the 7th to the strategic planning. In the process of scenario 9th February 2005 to work on the scenarios, building, alternative futures are developed I thought that we would do our job very as credible stories which are not predictive quickly – we would sit down and write how but are plausible. Building such scenarios we imagine the future. However, we soon helps to stretch thinking about the future, learned that scenario building is structured allows richer conversations, and addresses process, requiring team work and exploring conflicts, disagreements, dilemmas and di- different perspectives, including the consid- vergent opinions. erations of instabilities of the present and Scenario building has proven useful not the drivers for the future. Among the main only for planning business strategies but instabilities we identified in the present aca- also in different situations and settings, such demic medicine (3, 23), the most prominent as the Mont Fleur scenarios undertaken in were the unsustainability of the “teaching- South Africa during the post apartheid tur- research-practice” triad of academic medi-

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cine; “brain drain”; poor career incentives; and cost-reducing companies flourished, poor translation of research, both from basic and those less competitive failed. With such science into clinical studies and from clini- competitiveness, overall efficiency and ef- cal studies into medical practice and health fectiveness of academic medicine improved, decisions; and poor relationships with stake- but equity suffered – with the rich easily cre- holders. Globalization and feminization of ating careers in academic medicine and the medicine, as well as new internet and com- poor becoming increasingly disadvantaged munication technologies were identified as to enter the profession. Also, “brain drain” important drivers for the future. accelerated, and innovation in research of- We then imagined the future after a span ten suffered because the shareholders were of 20 years and wrote up five scenarios, some more interested in financial outcomes than less and some more futuristic from the per- in exploring novel but high-risk ideas. spective of 2025 (3, 23). Second Scenario: Reformation First Scenario: Academic Inc. In this scenario, all members of academic In this scenario, academic medicine flour- medicine teach, learn, research, and improve, ished in the private sector (3): “Slowly but following “the death of academic medicine” surely the public sector around the world (3): “There was increasing concern about realized that it could not support the costs the gap between academic medicine and of academic medicine. Medical students had practice with important research results not high earnings during a professional lifetime: being implemented, too much irrelevant why shouldn’t they pay for their education? research, bored students, and practitioners And if researchers were doing something who stopped learning. The response was valuable then shouldn’t they be able to find not to try and strengthen academic medi- a market for their product – accepting that cine but to abolish it and instead to bring sometimes payment would come from the the processes of teaching, learning, and re- public sector?” searching into the main stream of health Medical schools became private, with care. This innovative—though not initially deans acting rather like Chief Executive Of- welcomed—response proved to be highly ficers (CEO) of a company than academics. successful and was copied everywhere. A Many schools targeted specific populations century of separation of academic medicine and provided niche training, such as for older was ended. Professors disappeared. The en- students, or in community medicine, or sur- tity “academic medicine” was dead. It was gery. Schools asked high fees from students, akin to the destruction of the monasteries and used the resources for high staff salaries and so became known as the reformation of as well as for purchase of cutting edge facili- academic medicine.” ties and technology. There was intense com- In this scenario, medical schools ceased petition and pressure to reduce costs and to exist as entities, and education, research, improve quality, and research took place in and quality improvement took place in the range of private companies. Successful com- practice setting. The triad of teaching, re- panies-medical schools were responsive to search and practice was not any more a re- the needs of their customers – governments, quirement for an academic – team approach researchers, or patients. Academic medicine was adopted, supported by advanced learn- became a great market field, where innova- ing and communication technologies. Team tive, flexible, responsive, and cost-conscious members were health practitioners, stu-

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dents, researchers in basic or clinical medi- medicine. The most important department cine, and patients. Research questions arose at medical schools became that for public in professional-patient interactions and and media relations because the school’s pri- special national services provided evidence orities and activities became dominated by based responses. Leadership came from the public, i.e. the patients. Students received diverse specialist societies, which joined most of their training not from medical aca- together in an international academy with demics but from expert patients. There was great social and political influence. Medical a great diversity in the form and size of insti- students spent the first six moths learning tutions, and the competition was intense for how to learn, then learned by working in a the best teachers and researchers. Academic team, starting with a round in general prac- institutions had strong links with consumer tice. Some students specialized early, some movements and local non-governmental or- becoming competent specialists within five ganizations. Financial support for research years, as there was no distinction among came from media “interest”, similar to TV undergraduate, specialist, and continuing games and reality shows. The downsides of education. this scenario were manifold, including in- Team work fostered learning, but the creased anxiety of academics about their failings of this approach were in the fact job security and ability to succeed, because that not all teams held shared values, which scientific advances and clinical practice were threatened stability, consensus, and decision shaped by popular appeal, so subject to fash- making. Team structure also often prevented ion and not evidence. Also, there was very brilliant individuals to shine as leaders. little regulation of health information.

Third Scenario: In the Public Eye Fourth scenario: Global Academic Partnerships In this scenario, success in academic medi- cine comes from delighting patients and the This scenario described how academic med- public, and using the media (3): “Academic icine contributed to global health equity (3): medicine was slow to recognize the rise of “The world began to find the growing gap global media, “celebrity culture,” and the use between the rich and poor unacceptable. The of public relations (or spin) to drive the po- concern was driven partly by the media and litical process, but once it did it responded global travel bringing the plight of the poor dramatically. Whereas it had once been sus- in front of the eyes of the rich, but it was also picious of the media and public appeal and driven by anxieties over global security. Ter- rather patronizing to patients, academic rorism was recognized to be fuelled by the medicine realized that to succeed it must de- obscene disparities between rich and poor. light patients and the public and learn to use Global policy makers also understood better the media. The most successful academics that investment in health produced some of became those who were very responsive to the richest returns in economic and social patients and the public, capturing their imag- development. Health care was a “must have” inations, and appearing regularly on their not a “nice to have.” television screens. Some medical academics The primary concern and goals of aca- became as well known as film and rock stars demic medicine were to improve global and were feted by politicians.” health. A global health focus offered aca- In this scenario, the patients and the demics intellectual stimulation and prestige, public became the center force of academic and Academics championed human rights,

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economics, and the environment as key de- ated, and existing ones were reshaped, em- terminants of health. Basic science remained bracing openness, and the media were used important because of emerging global dis- to interact with the public. Governance of eases. The richest (G8) governments signed an academic medicine involved all stakehold- accord that prohibited recruitment of academ- ers, so that the leading figures in academic ic health professionals from developing coun- institutions could be patients, journalists, or tries, thus alleviating brain drain from these leaders in the community. Medical students academic setting. Universities in the North were not any more simple consumers of aca- committed 10% of faculty time to the South; demic medicine, but they shaped and drove North-South and South-South academic part- medical education. The downfall of the such nerships and networks were established and fully engaged academic medicine was that worked to the benefit of all partners. it got too “popular” and perhaps “dumbed The 90:10 gap between the developed down”, and academic medicine had to strug- and developing nations narrowed rapidly. gle to stay truly original and independent. GAP was idealistic and suffered because po- litical will and global cooperation were often Lessons from the Scenarios lacking. What we learned from these scenarios was Fifth Scenario: Fully Engaged that none of them would predict the future with certainty, but that the future would In this scenario, academic medicine engaged have elements of each of the five scenarios. energetically with all stakeholders (3): “Aca- There were also some common features to demic medicine realized that its relationships all scenarios. Firstly, academic medicine will with its stakeholders were mostly poor. The need to relate better to other stakeholders public had little or no understanding of what and learn how to use media to relate its im- academic medicine was or why it mattered. portance to the public. It will also have to Its very name implied irrelevance to many. become more business-like in the modern Patients often felt patronized by academ- world, as the competition will increase in ics, and many practitioners—including doc- the global society. Globalization will stim- tors—were unconvinced of the value of aca- ulate academic medicine to be more and demic medicine. Policy makers found that more globally minded and embrace new academics didn’t understand their problems technologies. Medical academics cannot be and that the studies they produced came too any more “jack of all trades” and will have late to be useful. Some leading academics to give up the whole triad of research-teach- did have good relationships with politicians, ing-practice to the teams of professionals. who recognized that biotechnology might The emphasis in academic medicine will be very important in future wealth creation, be teaching and lifelong learning, both in but the public profile of academic medicine clinical and non-clinical areas. Academic was both low and clouded.” institutions will also diversify, offering spe- Medical academics worried that they were cialized expertise. Quality improvement will misunderstood, underappreciated, and seen have to be combined with basic and applied as irrelevant by the public. The main goal of research. Academic medicine will have to academic medicine became to engage fully accept a broader thinking and skill sets, in- with the stakeholders of academic medi- tensively collaborating with other research cine—patients, practitioners, policy makers, and professional fields, such as economics, and the public. New organizations were cre- ecology, law, and humanities. We will also

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have to learn more about developing leader- during and after the war, and established ship skills. And we will have to think more fruitful collaboration in many areas (29), about the future, starting with the decisions contributing to the peace process in the do we need to take now to achieve the de- country (30), and confirming positive ex- sired future. periences from other political conflicts (31). After the publication of five scenarios, All five medical schools in Bosnia and Her- BMJ asked its readers to judge which sce- zegovina joined together to work on medical narios they thought likely and desirable. Ac- curriculum reform under the framework of cording to the poll (24), the most desirable the Trans-European Programme for Co-op- scenario was “Global Academic Partner- eration in Higher Education in Central and ships”, but it was also judged as the least like- Eastern Europe (Tempus project “Design of ly scenario. In contrast, the most likely sce- an Integral Curriculum to Undergraduate nario was “Academic Inc.”, where academic Medical Education in Bosnia and Herze- medicine becomes a full business enterprise, govina – DICTUM”) (25, 27, 28). The Eu- although it was judged least desirable. ropean partners in the project were medical schools from Austria, Belgium, Denmark, Current Activities on Restructuring and Germany. Within the framework of the DICTUM program, all five medical schools of High Education in Bosnia and performed a structured and well planned in- Herzegovina ternal and external assessment of the medi- In Europe, the future of academic medicine cal curricula (25), as an exercise in generat- is related to the ongoing restructuring and ing an objective insight and generate ideas harmonization of higher education, defined for institutional development and joint cur- in the Bologna Joint Declaration of the Eu- riculum reform. ropean Ministers of Education in 1999. Bos- In fact, the activities currently under way nia and Herzegovina, like other Central and at the medical schools in Bosnia and Herze- Eastern European countries in post-com- govina have many elements of the most de- munist transition, have specific problems sirable scenario for global future academic related to the political and socioeconomic medicine – global academic partnership. framework in which their medical curricula Actually, researchers within the framework have been shaped in the past (25). Bosnia of the DICTUM project were the first to pro- and Herzegovina has the additional heavy pose dual commitments of academics from burden of immense war destruction and developed and developing academic com- population migration, which also affected munities as a possible solution to bridging aca- medical education (26, 27). demics and learning from each other (29). Despite these disadvantages and excep- With a new journal dedicated to aca- tionally complex political, ethnic and religious demic medicine, Acta Medica Academica, situation in the country, medical schools in the academic community in Bosnia and Bosnia and Herzegovina were pioneers in Herzegovina is on the best way to make revitalization of academic medicine, not “Global Academic Partnerships” not only only in the region but in the global context most desirable, but also very likely future of (27, 28). The schools functioned normally academic medicine!

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