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What is the Future for Academic Medicine?: A Global Perspective

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Title: What is the Future for Academic Medicine?: A Global Perspective


1
What is the Future for Academic Medicine? A
Global Perspective
  • ACAHO presentation 4 Nov 2005
  • Jocalyn Clark
  • Associate editor, BMJ
  • On behalf of the International Campaign to
    Revitalise Academic Medicine (ICRAM)

2
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3
ICRAM
  • Campaign launched by BMJ, Lancet, and partners
    (journals, organisations) in late 2003
  • Initiated by BMJ editorial board
  • Lets stop complaining about academic medicine
    and do something about it
  • Search committee for our Leader
  • Peter Tugwell
  • Funding from BMJPG, Milbank Memorial Fund,
    Nuffield Trust, The Health Foundation

4
Call for ideas
  • The need for a global, problem based campaign
  • Credibility Establish process for improving
    relationships with customers, including
    patients, policy makers, practitioners, and
    others
  • Recruitment/ Retention How to encourage the best
    and brightest students to go into academic
    medicine, and how to keep them
  • Values Base Determine with customers and
    academics on what should be the values of
    academic medicine
  • Future Aspirations Develop a vision for the
    future of academic medicine

5
ICRAM
  • Led by an international working party of young
    medical academics
  • Nominated by members of the establishment
  • 20 members, representing 14 countries
  • Talented, junior colleagues 50 women, 50
    from LMICs
  • Facilitating committee
  • Peter Tugwell, chair/leader

6
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7
ICRAM
  • Stakeholder groups
  • Academia
  • Business industry
  • Government policy makers
  • Journal editors
  • Patients
  • Professional associations
  • Students trainees
  • Regional networks covering the world

8
Rationale
  • Concern that academic medicine around the world
    is in crisis, or decline
  • Several consultations/blue ribbon panels have
    gone before but mostly Canada, US, UK
  • Journals have unique insider-outsider status
  • We are beneficiaries of academic medicine
  • We can cast a critical gaze on institutions
  • Global outlook
  • Reinvention is needed

9
Goals
  • To produce a series of recommendations
    actionable choices for reform in global
    academic medicine, including
  • Develop a vision and values for AM
  • Strategies for building capacity, including
    better career paths
  • Proposing how AM could improve its relationships
    with its customers

10
Activities
  • Evidence reviews
  • Impact of AM on health outcomes (Ioannidis et
    al.)
  • Funding of top cited clinical research (Ioannidis
    et al.)
  • Factors influencing career choice (Straus et al.)
  • Impact of mentoring and leadership on career
    progression (Marusic et al.)
  • Consultations
  • Regional meetings
  • Stakeholder groups
  • Journalistic pieces
  • My Path series (Purcell et al.)
  • Editorials
  • Visions and Values
  • Future Scenarios

11
Deadlock
  • What are the values of academic medicine?
  • Disagreement about role and importance of private
    sector (especially pharma)
  • Would business interests enhance or destroy
    academic medicine?
  • Lack of clarity about the roles academic medicine
    need to assume
  • What added value does academic medicine bring to
  • the health care system and
  • society?
  • Does academic medicine have a responsibility to
    the global health burden?

12
What are scenarios?
  • Alternative futures
  • Not predictive, but plausible
  • Creative, credible stories
  • Aim to
  • Stretch thinking about the future
  • Enable richer conversations
  • Address conflict, dilemmas, and divergent opinion
    or values

13
Why scenarios?
  • Future is uncertain and complex
  • Change and learning comes from instability
  • While we cant control, we can try to influence
  • open a path to deeper understanding of the
    trends, forces and trade-offs that drive change
    and development.
  • www.shell.com/scenarios

14
Scenarios
  • Pioneered by Shell in the 1970s
  • Used in range of contexts and settings
  • The Mont Fleur scenarios for future of South
    Africa
  • UNAIDS on AIDS at 2025
  • Picker Institute on Patient-Centered Care 2015
  • Short term decision making and long term
    strategic planning
  • Tools not ends
  • Regional and context modification

15
The scenario building process
  • Team based and diverse perspectives
  • Considers instabilities of the present
  • Unsustainability of triad
  • Brain drain
  • Poor career incentives
  • Considers drivers of the future
  • Globalisation
  • Feminisation of medicine
  • New internet and communication technologies
  • Wide survey and consultations fed into process

16
Instabilities
  • Status Quo not sustainable in the majority of
    countries
  • Consumerism ignored Lack of patient
    centeredness
  • International collaboration to work on the 10-90
    gap not funded or rewarded
  • Lack of a systems approach eg patient safety,
    malaria bed nets
  • Triple threat (stellar researcher, educator,
    clinician) fine for top 1 - for rest means no
    family priority
  • Triad Imbalance Exceptional in teaching,
    service, or management is still inferior to
    researcher with high impact factor publications
  • MD Scientists lose to PhDs in research grant
    competitions (bias toward basic science over
    clinical research)
  • Policy makers and funders do not see academic
    medicine as relevant or a priority - researchers
    being asked to see patients to fund themselves
  • Career structure and security the pits. Student
    loan burden a major disincentive.
  • Gender imbalance More women students than men
    but vanishingly few senior women full professors
    pay inequity
  • Brain Drain

17
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18
Five Scenarios to 2025
19
Academic Inc.
  • Academic medicine flourishes in the private sector

20
Academic Inc.
  • Academic medicine flourishes in the private
    sector
  • Slowly but surely the public sector around the
    world realised that it could not support the
    costs of academic medicine. Medical students had
    high earnings during a professional lifetime why
    shouldnt they pay for their education? And if
    researchers were doing something valuable then
    shouldnt they be able to find a market for their
    productaccepting that sometimes payment would
    come from the public sector?

21
Academic Inc
  • Medical schools became private many provided
    niche training
  • High fees and staff salaries, cutting edge
    facilities and technology
  • Intense competition and pressure to reduce costs
    and improve quality
  • Research took place in range of private companies
  • Successful companies were responsive to
    customers needs (governments, researchers,
    patients)

22
Academic Inc
  • Many training and research companies failed
  • Overall efficiency and effectiveness of academic
    medicine improved, but equity suffered
  • A two tier system resulted, the 1090 gap
    persisted, and brain drain accelerated
  • Innovation often suffered because of immediate
    accountability to shareholders
  • ACAHO Suitable business models? Research vs
    education clinical care. Implications for
    costs, efficiency, equity, innovation.

23
Reformation
  • All teach, learn, research, and improve (The
    death of academic medicine)

24
Reformation
  • All teach, learn, research, and improve (The
    death of academic medicine)
  • There was increasing concern about the gap
    between academic medicine and practice with
    important research results not being implemented,
    too much irrelevant research, bored students, and
    practitioners who stopped learning. The response
    was not to try and strengthen academic medicine
    but to abolish it and instead to bring the
    processes of teaching, learning, and researching
    into the main stream of health care. This
    innovativethough not initially welcomedresponse
    proved to be highly successful and was copied
    everywhere. A century of separation of academic
    medicine was ended. Professors disappeared. The
    entity academic medicine was dead. It was akin
    to the destruction of the monasteries and so
    became known as the reformation of academic
    medicine.

25
Reformation
  • Education, research, and quality improvement took
    place in the practice setting
  • A medical academic was no longer a jack of all
    trades (teach, research, practice)
  • Team approach was adopted, supported by advanced
    learning and communication technologies
  • Teams comprised patients, multidisciplinary
    practitioners, students, and professional
    researchers (basic and clinical science)

26
Reformation
  • Research questions arose in professional-patient
    interactions and a national question answering
    service provided evidence based responses
  • Leadership came from diverse specialist
    societies, which organized in an international
    academy that had influence on world leaders

27
Reformation
  • Medical students first learned how to learn, then
    learned by doing
  • Team work fostered learning, but not all teams
    held shared values which threatened stability,
    consensus, and decision making
  • It was hard for brilliant individuals to shine as
    leaders
  • ACAHO Do CEOs prefer or fear reformation?
    De-institutionalisation of health care.
    Dismantling of universities.

28
In the public eye
  • Success comes from delighting patients and the
    public, and using the media

29
In the public eye
  • Success comes from delighting patients and the
    public, and using the media
  • Academic medicine was slow to recognise the rise
    of global media, celebrity culture, and the use
    of public relations (or spin) to drive the
    political process, but once it did it responded
    dramatically. Whereas it had once been suspicious
    of the media and public appeal and rather
    patronising to patients, academic medicine
    realised that to succeed it must delight patients
    and the public and learn to use the media. The
    most successful academics became those who were
    very responsive to patients and the public,
    capturing their imaginations, and appearing
    regularly on their television screens. Some
    medical academics became as well known as film
    and rock stars and were feted by politicians.

30
In the public eye
  • Academic institutions became dominated by
    citizens and patients the public relations
    department was the most important
  • Grants and prizes were given on academic game and
    reality shows
  • Citizens juries also made decisions about
    research priorities and funding

31
In the public eye
  • Students received most of their training from
    expert patients
  • Great diversity in the form and size of
    institutions competition was intense for the
    best teachers and researchers
  • Academic institutions had strong links with
    consumer movements and local NGOs

32
In the public eye
  • Academics were more anxious about job security
    and ability to succeed
  • Scientific advances were shaped by popular
    appeal, so subject to fads
  • Little regulation of health information
  • ACAHO Public boards of hospitals. Major shift
    in power. Is this the way forward for AM?

33
Global academic partnership
  • Academic medicine for global health equity

34
Global academic partnership
  • Academic medicine for global health equity
  • The world began to find the growing gap between
    the rich and poor unacceptable. The concern was
    driven partly by the media and global travel
    bringing the plight of the poor in front of the
    eyes of the rich, but it was also driven by
    anxieties over global security. Terrorism was
    recognised to be fuelled by the obscene
    disparities between rich and poor. Global policy
    makers also understood better that investment in
    health produced some of the richest returns in
    economic and social development. Health care was
    a must have not a nice to have.

35
Global academic partnership
  • The primary concern and resources of academic
    medicine were to improve global health
  • A global health focus offered academics
    intellectual stimulation and prestige
  • Academics championed human rights, economics, and
    the environment as key determinants of health
  • Basic science remained important because of
    emerging global diseases

36
Global academic partnership
  • The G8 governments signed an accord that
    prohibited recruitment of academic health
    professionals from developing countries
  • Universities in the North committed 10 of
    faculty time to the South
  • North-South and South-South academic partnerships
    and networks flourished

37
Global academic partnership
  • The 9010 gap narrowed rapidly
  • GAP was idealistic and suffered because political
    will and global cooperation were often lacking
  • ACAHO Many doing overseas partnerships.
    Rural/remote areas. Rich (and necessary) source
    of learning/training.

38
Fully engaged
  • Academic medicine engages energetically with all
    stakeholders

39
Fully engaged
  • Academic medicine engages energetically with all
    stakeholders
  • Academic medicine realized that its relationships
    with its stakeholders were mostly poor. The
    public had little or no understanding of what
    academic medicine was or why it mattered. Its
    very name implied irrelevance to many. Patients
    often felt patronised by academics, and many
    practitionersincluding doctorswere unconvinced
    of the value of academic medicine. Policy makers
    found that academics didnt understand their
    problems and that the studies they produced came
    too late to be useful. Some leading academics did
    have good relationships with politicians, who
    recognised that biotechnology might be very
    important in future wealth creation, but the
    public profile of academic medicine was both low
    and clouded.

40
Fully engaged
  • Medical academics worried that they were
    misunderstood, underappreciated, and seen as
    irrelevant
  • The main goal became to engage fully with the
    stakeholders of academic medicinepatients,
    practitioners, policy makers, the public
  • New organizations were created, and existing ones
    were reshaped, embracing openness
  • The media was used to interact with the public

41
Fully engaged
  • Governance involved all stakeholders sometimes
    the academy president was a prominent patient,
    journalist or community leader
  • Medical students drove medical education, rather
    than simply be its consumers
  • Medical academics diversified and intellectual
    silos were breached

42
Fully engaged
  • Critics worried about dumbing down and
    popularization of academic medicine
  • Academic medicine fought to remain truly original
    and independent
  • ACAHO Patient safety lobby, wait times
    initiatives. How best incorporate all
    perspectives.

43
Lessons from the scenarios
  • None of the scenarios will come to exist
  • But the future is likely to contain elements of
    each
  • We can learn from the common elements of the
    scenarios
  • What decisions do we need to take now to achieved
    our desired future?

44
Common features
  • Relating to stakeholders
  • Globally minded
  • No jack of all trades
  • Teamwork
  • Competition will increase
  • More business-like and better with media
  • New emphasis on teaching and (lifelong) learning

45
Common features
  • Combine research (basic and applied) with quality
    improvement
  • Diversity of academic institutions
  • Broader thinking and skill set
  • Clinical and non
  • Economics, ecology, law, humanities
  • Leadership development
  • Think more about the future

46
Vote for your desired future
47
Looking forward to 2025,which scenario do you
find the most
  • Creative?
  • Liberating?
  • Distasteful?
  • Desirable?
  • Likely?

48
  • What would you do if you woke up in this world?
    If you knew this world was an absolute certainty
    for academic medicine in 20 years time, what
    would you do now?
  • Quit / Change your career
  • Demand more money
  • Lobby government
  • If you want this world to be realised, what would
    you do NOW?

49
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50
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51
  • The MOST desirable (GAP)
  • ..is judged the least likely
  • The LEAST desirable (Academic Inc)
  • ..is considered the most likely

52
Next steps
  • Reality check with lead customers
  • Patients and advocacy groups
  • Medical Associations BMA, CMA
  • Policymakers and funders
  • Practitioners and Colleges, Academies
  • Industry pharma, device, insurance, hi-tech
  • Regional Consultations- WHO IFME
  • Final report synthesizing the evidence reviews,
    scenarios and their implications for others to
    develop vision statements and blueprints for
    action

53
Publication of scenariosWe want your feedback!
  • Five futures for academic medicine. PLoS
    Medicine 2005 2(7) e207. www.plosmedicine.org
  • The future of academic medicine Five scenarios
    to 2025. Milbank Memorial Fund. www.milbank.org
    long report
  • Five futures for academic medicine the ICRAM
    scenarios commentaries. BMJ 2005 331(7508)
    101-7. www.bmj.com

54
ICRAM working party
  • Tahmeed Ahmed (Scientist, Clinical Sciences
    Division, International Centre for Diarrhoeal
    Disease Research Bangladesh, Dhaka, Bangladesh)
  • Shally Awasthi (Professor, Department of
    Paediatrics, King George's Medical University,
    Lucknow, India)
  • A. Mark Clarfield (Professor, Department of
    Geriatrics, Soroka Hospital, Ben-Gurion
    University of the Negev, Beersheva, Israel)
  • Lalit Dandona (Director, Centre for Public Health
    Research, Administrative Staff College of India,
    Hyderabad, India)
  • Amanda Howe (Professor of Primary Care, School of
    Medicine, University of East Anglia, Norfolk,
    United Kingdom)
  • John P. A. Ioannidis (Chairman, Department of
    Hygiene and Epidemiology, University of Ioannina
    School of Medicine, Ioannina, Greece)

55
ICRAM working party
  • Edwin C. Jesudason (Academy of Medical Sciences
    National Clinician Scientist, Health Foundation
    Leadership Fellow, and Lecturer in Paediatric
    Surgery, School of Reproductive and Developmental
    Health, University of Liverpool, Liverpool,
    United Kingdom)
  • Youping Li (Director, Chinese Cochrane Centre,
    West China Hospital, Sichuan University, Chengdu,
    China)
  • Juan Manuel Lozano (Professor, Department of
    Pediatrics and Clinical Epidemiology, Javeriana
    University School of Medicine, Bogota, Colombia)
  • Hardi Madani (Student, Royal Free and University
    College London medical schools, London, United
    Kingdom)
  • Ana Marusic (Professor, Department of Anatomy,
    Zagreb University School of Medicine, and Editor,
    Croatian Medical Journal, Zagreb, Croatia)

56
ICRAM working party
  • Idris Mohammed (Outgoing Provost, College of
    Medical Sciences, Department of Medicine and
    Clinical Immunology, University of Maiduguri,
    Maiduguri, Nigeria)
  • Gretchen Purcell (Pediatric Surgery Fellow,
    Pittsburgh Children's Hospital, and Adjunct
    Assistant Professor of Medicine, University of
    Pittsburgh, Pittsburgh, Pennsylvania, United
    States)
  • Margaret Rhoads (Medical student, Imperial
    College London, London, United Kingdom)
  • Karen Sliwa-Hähnle (Professor, Department of
    Cardiology, CH Baragwanath Hospital, University
    of the Witwatersrand, Johannesburg, South Africa)
  • Sharon E. Straus (Associate Professor, Department
    of Medicine, Toronto General Hospital, University
    of Toronto, Toronto, Ontario, Canada)

57
ICRAM working party
  • Tessa Tan-Torres Edejer (Scientist, Department of
    Health Systems Financing, World Health
    Organization, Geneva, Switzerland)
  • Timothy Underwood (Medical Research Council/Royal
    College of Surgeons Clinical Research Training
    Fellow, University of Southampton, Southampton,
    United Kingdom)
  • Robyn Ward (Associate Professor, Department of
    Medical Oncology, St Vincent's Hospital and
    School of Medicine, University of New South
    Wales, Darlinghurst, New South Wales, Australia)
  • Michael S. Wilkes (Vice Dean and Professor of
    Medicine, School of Medicine, University of
    California, Davis, California, United States)
  • David Wilkinson (Deputy Head and Professor of
    Primary Care, School of Medicine, University of
    Queensland, Brisbane, Australia)
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