Not enough hours in the day

A long, long time ago, I was sitting in the biochemistry coffee room in the medical school in Newcastle. Roger Paine, a professor of biochemistry came and sat next to me. I knew of him, but he didn’t know me. He was a FRS, I was a dermatology research registrar taking my first steps in learning some wet bench science in the Medical Molecular Biology Group there. Coffee rooms work, as do Aeron chairs. Sometimes you need to talk, and ramble around what interests you; and sometimes you have to sit alone, and dream. If you don’t, you will do ‘kit’ science, or act out being an administrator by conducting randomised controlled trials.
We got chatting—we shared a mutual colleague—and he expressed his puzzlement to me about how medics managed to do any research. He pointed out what with seeing patients, and some undergraduate teaching and postgraduate training, how on earth could you hope to do any meaningful research. I listened, not wanting to hear what he said. And I should point out, he was a keen collaborator with medics,  nor stand-offish in any way.

Many years later, in another setting, I was talking to another successful scientist, a geneticist, also a FRS. We knew each other reasonably well, and by this stage I had been working in wet-bench science for a dozen years or more. Some modest successes, and plenty of failures. He told me that because he knew the details of many clinical medics research careers very well, he would be loathe to ever approach any of them if he needed medical care. He had the highest regard for them as academics, and researchers, but he too couldn’t see how they could carry on all the various activities expected on them. (And no doubt be able to go to the cinema once in a while: Steven Rosenberg, a one time Chief of Surgery at NIH, in his autobiography, describes how he would struggle to leave Sunday evening free of lab and clinical duties, so that he could go to the cinema with his wife).

This all came back to me a couple of weeks back when I was preparing a talk for Atrium. My former colleague, and friend Peter Friedmann, many years ago introduced me to the writings of Joe Goldstein and Michael Brown on clinical science. One of their articles, made a big impression on me, not least because it was a tale of academic failure and lack of nerve, with a character we only knew as JR (the initials, need I remind you, of yours truly). The piece deserves to be read in full, rather than precised, but in brief Godstein and Brown argue that most clinical researchers end up doing ‘kit’ bench science, without ever making fundamental clinical or scientific insights. They end up in some fast moving area of science without the skills or the time to make deep discoveries. (Of course I would add they later end up as suited lab chief executives, never to be seen at the bench , sifting applications from the next wave of clinical academics).

Goldstein and Brown argue that cloning genes in the morning and seeing patients in the afternoon is a mugs game. Perhaps you can collaborate, or be a member of a small team, but it is rarely possible to make major contributions within the constraints of this workload. I read all their stuff, quoted it widely, but was reluctant to accept it until much later.
I think Goldstein and Browns insights are near the mark. I also do not know of anybody who comes close to them in terms of scientific prowess, and insight into how advance in clinical medicine occurs. What they also point out is that there are other paths that those interested in real clinical discovery can follow. There are of course hybrid areas, such as the sort of work I once did where knowledge of patient phenotypes and clinical presentation gives you an edge in terms of where to look when you are in the lab. In my view much of genetic dermatology was in this vein for at least a decade or so. If you knew something about phenotypes, and patient presentations, and some rudimentary technology, you could make robust contributions. Not Nobel prize stuff, but work that was solid and placed another brick in the wall. It was satisfying, and had a reasonable degree of intellectual honesty about it.

Some other types of clinical discovery require an even greater familiarity with disease and patients. Doing this sort of work seems to me to demand day-to-day immersion in clinical medicine, but coupled with imagination and often courage and belligerence. Examples would include the development of in vitro fertilisation (a collaboration, and impossible without great surgical skill and courage), and the work of people like Roy Calne, Kurt Semm, and Barry Marshall. In my own area, I would suggest Sam Shuster’s elucidation of the pathogenesis of seborrhoeic dermatitis; Fiztpatrick’s development and championing of PUVA; and the work that led to the discovery that systemic retinoids could near cure acne. I have written about some of this here and here.
The problem with these latter patient-orientated research contributions is that they are usually high risk, cannot be predicted, and usually do not fall in the 3 or 5 year project grant paradigm, that universities now demand. They do not always (but sometime do) rely on clinicians who necessarily see lots of patients themselves, but they do require minds that are immersed in disease and patients. And with time to dream a little. This sort activity is not encouraged by universities, nor in the UK by those with contracts —whether honorary or not–with the NHS. It is one of the reasons that advance in medicine is slower than it once was, despite the volume of research increasing.
So why does all this belong on a blog about medical education? Well, of course educating the next generation of researchers is an important role for any university. In medicine this is particularly difficult because, as I have implied, the really big discoveries are sometimes made by those who are not career scientists. (Sometimes all some of us academics can do is to try and rail again the establishment that wants to constrain genuine out-of-the box thinkers and careers. The monomaniacs are indeed often those with most to contribute. Once you suck the kool-aid of equipoise, you are doomed).
But that this is not the main reason for writing. The principal reason behind this post, is that almost everything I have said about research is also true of teaching and learning. If we think about the triad of activities that clinical academics pretend to pursue, we have clinical practice, research and teaching. Of course universities / multiversities do other things too— commercialisation, outreach and so on—but for a clinical academic these are the three core activities. Of the three, teaching and learning receives the least institutional attention. Clinical work is ever more policed, and research drives most academic appointments and activity. Teaching is fitted into what is left or, almost without shame, universities assume that it is done by NHS staff. It is longer sensible to imagine that all these three activities can be performed to a high level by the same individual all the time. We will only seriously reform and improve undergraduate medical education when we accept this. A number of changes are needed. Let me sketch some of them.

First, it is not necessary to perform clinical work across a broad area of clinical practice, to undertake research or teaching at the undergraduate level. Postgraduate training may be a different matter. Research is focussed on small areas, and clinical practice is only necessary to the extent that it is needed to support research. Clinical academics should only perform the clinical work that is necessary for their research or teaching duties. This is why the universities pay their salaries. This is why students pay fees: fees are not a way of subsidising the NHS. A university (should) command respect because of its research and teaching. In some parts of the world, clinical service dovetails into this. This is no longer true in the UK, as clinical service is the responsibility of the NHS. This is of course a major structural weakness for some areas of clinical research, because it undermines the purpose of some research, and limits the types of innovation that might contribute greatly to important health care problems. In some areas, the UK does not provide a suitable environment for some clinical research or clinical training.
Second, it will be hard enough to combine 2 of the 3 duties, so it should be the norm to allow people to focus on any 2—but not 3 of the duties. Some good researchers are great teachers, and we must not lose their influence on undergraduates. They will have undertaken clinical training, but they may not practice long term.
Third, evidence from around the world suggests that many (in Goldstein’s words) disease orientated researchers do not practice clinical medicine routinely. Ditto, I would suggest for teaching, in that continued clinical practice is not always necessary. I am not suggesting that undergraduate teachers have not previously had to practice medicine in a particular discipline, but only that the demands of teaching or research limit what individuals can and should do during heir career.
The big winner from this will be  teaching and learning. No longer will it be ‘there is not enough time to provide student teaching’ but rather it will be clear that teaching or research is what gets filled in first in the timetable, before clinical work or work for the wider NHS. The unpicking of the collegiate NHS and the academy began a long time ago, it is time to start building something to replace it.