Clinical research needs a shot in the arm

Concerns are voiced on the future of clinical research, the impact of fees and the need to encourage more students into independent higher education

ALL IS not well with clinical research in this country, or so it would appear from the recently published report of a taskforce on clinical academic careers, chaired by Sir Rex Richards (THES, July 25). Sir Rex's report points out that in the recent research assessment exercise very few of the departments of British undergraduate medical schools were judged to have achieved research of international standing. The fact that the report offers no fewer than 35 recommendations reflects the complexity of the underlying problems. Can they be sorted out, and what will happen if they cannot?

Medical research stretches from the work of the pharmaceutical industry, through the basic biological sciences, to investigations of patients. The British pharmaceutical industry remains highly competitive and the work of many of our basic science departments, underpinning medical research, also has a high international standing. The problem concerns "clinical research", an activity which, though it may involve complex laboratory studies or large-scale epidemiological analyses, always has the prevention or better management of illness as its central goal. It is the decline in standards of this type of work - much of it done in university clinical departments - that is worrying.

University clinical departments have to fulfil three roles: clinical practice, teaching and research. It is not widely appreciated how much clinical work is carried out by university staff. In teaching centres such as my own, university staff support up to 40 per cent of the acute clinical services.

For many years the NHSprovided an ideal vehicle for clinical research. The "knock-for-knock" arrangement, whereby university clinicians looked after patients for the NHS while the NHS provided facilities for teaching and research, worked well. However, endless reform has had a deleterious effect on the role of the NHS as a vehicle for research. In the new marketplace economy, teaching and research, since they do not create wealth, have become low priorities.

The "knock-for-knock" arrangements were taken apart and every item costed. At the same time, pressures on the clinical services of teaching hospitals increased dramatically. Clinical academics, with their NHS colleagues, spent futile hours on committees trying to make the whole thing work. Since they could not neglect patient care and teaching, little wonder their research began to suffer.

These difficulties are not unique to this country. The advent of "managed care" in the United States is having the same effect. A recent paper from HarvardMedical School finds that "the rate of publication for clinical researchers in the three previous years decreased significantly in competitive markets, while the rate of publication for other faculty remained unchanged". But in Britain other factors are exacerbating a similar problem.

The government cuts in the 1980s hit medical schools hard. In addition, the General Medical Council has now asked for an extensive reorganisation of the medical curriculum which, together with the extensive increase in medical student numbers without additional teaching staff, threatens to place further pressures on the time of clinical academics. Even more worrying for the future of medical research, both the GMC and the department of health are encouraging a reduction in the emphasis of some of the basic sciences in medical education, presumably in the belief that this will produce a generation of more caring, socially adaptable and efficient doctors.

The battering that academic medicine has taken over recent years could not have come at a more inopportune time. Following the revolution in biology of the post-DNA era, there has been a change in the emphasis of biomedical research from the study of patients and their organs to the analysis of disease at the level of molecules and cells. While this has remarkable possibilities for the future of medical practice, most medical schools in the UK have had neither facilities nor staff to enable them to take advantage of these new research opportunities.

Coping with NHS reforms, rigid training programmes for young doctors, chronic underfunding, and developing new and complex teaching curricula, has meant many British medical schools have failed to take advantage of therevolution in the basic biological sciences and have found it difficult even to pursue more conventional clinical and epidemiological research.

Medical research is entering the most exciting phase of its development. The long-term possibilities for preventative medicine and improvements in patient care are immense. If we are to take advantage of the current revolution in the biological sciences for the improvement of health care we must train a cadre of young clinician-scientists, not only to staff our university clinical departments but also to augment the work of the pharmaceutical and biotechnology industries. They will need a good grounding in both clinical medicine and the basic sciences to function as the critical link between the two, with sufficient knowledge of both worlds to adapt the potentials of molecular and cell biology and information technology to clinical practice.

In the future, therefore, clinical scientists will have to be verydifferent animals to those of the past. They will have to have sufficient training and time to develop their research skills as well as their clinical competence, so that they can communicate as equals with their basic science andmedical colleagues. At the same time it will be equally important for other clinical academics to improve the standards of bedside and community research, which require an equally demanding training programme. In the present climate it is not easy to see how this will be achieved.

It has recently been announced that an Institute of Medicine is to be established to serve the needs of academic medicine. If it sees the light of day, its first task should be to tackle the problem of clinical research. It will not be easy, requiring as it does the encouragement of completely new attitudes.

Clinical research is not a sport for medical academics, to be fitted into their spare time between the more serious issues of patient care, teaching and administration. Rather, it is a way of life that requires, above all, time. We neglect it at our peril if we are to develop the full potential of modern science for patient care.

Sir David Weatherall is Regius professor of medicine at the University of Oxford.