Editorial
Academic Medicine:
Can We Afford to Ignore this Ailing Entity?
Faculties and Institutes at the University of Malta face
student population, the ratio of students to patients, so essential
unprecedented challenges imposed by severe budgetary
for the maintenance of quality in clinical training, has decreased.
restrictions, diminishing human resources and a constantly
Clinical tutors now face a situation where patients, exhausted
burgeoning student population. Academic members of staff and
from repeated examination by third, fourth and fifth year
administrators have been asked to cut recurrent expenditure
medical students, not to mention students in various fields of
by approximately 50% but are expected to guarantee the same
healthcare, and candidates for the membership examinations
high standards of tertiary education as in the past. Staff
of the various Colleges, ask to be spared further interaction
recruitment and career progression have also been affected by
with students for the duration of their inpatient stay, a request
these economic realities with vacated posts often left empty and
that must be respected. Given this scenario, how is it going to
staff development and career progression put on hold.
Does the dire financial status of our alma mater constitute
prove possible to continue to develop clinical skills in our future
doctors? Some medical schools already use actors to teach
a real or an imaginary threat to continuing tertiary education
history-taking and communication skills. Learning to elicit
in our country? What are the long term consequences of
physical signs, a crucial hurdle to be overcome in the education
decisions taken by short-sighted financial planners to the
of medical students, however necessitates interaction with
University and the country? Is it conceivable that the resultant
patients. It is naive to expect that standards of teaching are
restrictions could lead to inadequate delivery of tertiary
maintained as the most valuable resource, the patients
education and a lowering of standards, destruction of research
themselves, decide and often justifiably so, to withdraw co-
initiatives, demoralization of staff with a forseeable brain drain,
operation.
and finally unavailability of local expertise and knowledge so
The student-patient quota however is not the sole problem
essential to drive progress and improvement in our country?
plaguing scientific medicine at this level. New developments
Are we heading towards a time when Faculties and Institutes
now dictate that undergraduate students undergo training and
will be unable to provide the required services and will therefore
be versed in problem-based interactive learning, community
of necessity cease to function? Is it time for decentralization of
based training (that is, in the milieu where the majority of
certain administrative procedures and the introduction of a
graduates will practice) and more inclusive of learning related
serious autonomous financial plan as well as the implementation
to the social sciences. Medical schools around the world are
of strategies to make the University economically viable? At this
moving away from didactic teaching techniques to more
time in particular, we should be investing resources in
interactive, hands-on teaching, a move to be lauded but one
propagating education and research locally and in collaboration
that stretches resources (both human and material) even
with centers of excellence on an international basis. I intend to
further. Curricula cannot be expanded indefinitely. The onus
focus on academic medicine in particular but I strongly suspect
falls therefore on medical educators to move beyond the
that what applies to the Faculty of Medicine and Surgery in
boundaries of medical school and into the realm of provision of
principle holds true for other Faculties and Institutes. Indeed,
continuing medical education throughout the lifetime of
in this issue of the Malta Medical Journal, the Faculty of Dental
practicing clinicians. Are medical educators finding the requisite
Surgery in no uncertain terms outlines its concerns for the
infrastructural and personal support to implement the change
future.
necessary in the traditional educational system to meet these
Academic medicine is under siege. At the undergraduate
challenges? Clinical researchers and clinicians who would make
level, the Faculty of Medicine and Surgery now has an annual
excellent teachers and could contribute significantly to medical
intake of students, which since the removal of the numerus
education, whilst serving as catalysts for changing the face of
clausus, has doubled. Whilst the expansion of the honorary
health care provision, are demoralized and since EU accession,
lecturer/senior lecturer pool has partially counteracted the
can now seek employment in other countries where prospects
shortage of teaching staff caused by this mushrooming of the
regarding career progression and working conditions are better
Malta Medical Journal Volume 16 Issue 02 July 2004
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than here. In certain instances clinical scientists and educators
other countries to our local population. Effecting change and
move out of the educational sector into service provision or
improvement in healthcare is dependent on critical evaluation
private enterprise again lured by better conditions.
of new diagnostic and therapeutic interventions, traditionally
Furthermore, a substantial proportion of medical educators are
the remit of academic medicine. A department of postgraduate
being pushed more towards service provision and away from
studies could help facilitate processes for the recruitment and
academic medicine as a result of the re-organisation of
support of post graduate students whilst co-ordinating research
healthcare with a focus on improving and expanding service
and development locally and as part of international networks.
provision geared to increasing patient throughput. This in itself
Academic medicine therefore needs to be revitalised. This
is a worthwhile goal to achieve as long as the process is patient
is a state of affairs that is extant in other countries and
centered and the quality of healthcare provision is ascertained
institutions. In an attempt to raise awareness and to tackle the
and maintained. The latter however requires input from
issues inherent to this problem, a campaign was launched by
academic medicine and currently in the long term under these
the British Medial Journal in collaboration with a number of
conditions, academic medicine will slowly but surely decline to
partners and co-ordinated by Professor Peter Tugwell3 to analyse
the point where it will fail to have a significant impact on clinical
what ails academic medicine and to propose strategies to
practice and healthcare. Central to the problems that plague
overcome these shortcomings. The broad goals of this project
academic medicine lie lack of support (financial and
are to define the roles of academic medicine, assess how well
infrastructural) for education and research, lack of appropriate
these roles are fulfilled and if not, find out why, and finally to
career structures to support recruitment and training of clinical
propose solutions. Undoubtedly, scientific, economic, ethical
scientists, and miserable working conditions.
At the post graduate level, the dearth of MD, PhD graduates
and moral issues do play a part. The establishment of networks
for clinical research both on a national and an international basis
is testimony to the laissez-faire attitude of politicians and
is essential to co-ordinate funding and research programmes,
administrators who fail to appreciate the vital role academic
with re-allocation of certain funds depending on appropriate
medicine plays in the transition of knowledge and development
prioritization and for example avoiding duplication of effort.
from the bench to the bedside. Academic medicine has
Creativity and vision is called for to obtain funding from new
traditionally been regarded as bridging the gap between research
sources but restrictions imposed by bureaucracy and centralised
in the basic sciences and clinical medicine. Teaching at
administrative procedures hinder efforts to obtain funding, and
undergraduate and postgraduate level constitutes an essential
negatively affect utilization of resources by undermining sense
function of all academic institutions but has to be complemented
of ownership of various projects. Whilst regulatory procedures
by research into the physiology and pathophysiology of disease.
are to a certain extent essential, over-regulation brings its own
The development of methods to investigate the molecular and
problems to the detriment of healthcare provision in the long
genetic basis of disease has shifted research away from the bed
run, stifling innovation. Team work is essential to ensure that
to the bench on an international level. Funding for research in
such problems are tackled properly as the involvement not
experimental medicine is on the decline as is that for clinical
purely of healthcare professionals but also of scientists,
1
2
trials even in countries such as the UK and the USA which
administrators, financial and legal advisors can contribute to
traditionally have been at the forefront in these areas. However
development plans.
it is well established that interindividual variability in
On a global aspect, health care provision to countries with
susceptibility to disease and in response to management have a
high and low incomes facing different political and economic
significant impact on the response to diagnostic and therapeutic
constraints is similarly an issue that has to be faced. Increasing
research and development. Gender and age differences play a
awareness of areas that merit further analyses or intervention,
definite role as do genetic factors. Recognition of this has led
disseminating that information and protecting the guiding
institutions such as the National Institute of Health, the Food
principle that should ultimately underlie scientific endeavour,
and Drugs Administration in the United States and various
that of effectively improving the quality of life of individuals
prominent European research funding bodies to insist that
regardless of origin, race, religion or political beliefs take
studies include individuals from different ethnic minorities and
priority. A clear example of the difficulties to be encountered
races where genetic, cultural and environmental differences can
on a global level in academia was recently highlighted by a series
further modify disease processes, their management and the
of events precipitated by political decisions that infringed on
response to treatment. Even a country the size of Malta can be
editorial freedom to assess and publish scientific articles
expected to face certain problems inherent to its indigenous
regardless of the country of origin of that work. It is essential
population. We cannot therefore sit back and simply graft
that leaders in the process of change be ready to clearly state
findings, methodologies and treatment options established in
their opposition to interference from political and biased
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Malta Medical Journal Volume 16 Issue 02 July 2004
stakeholder entities and to present a united front to oppose
The Malta Medical Journal supports and endorses both the
attempts to curb scientific advancement. Confrontation may be
campaign to revitalize academic medicine and the WAME
necessary in instances where views are diametrically opposite.
statement on Geopolitical Intrusion in Editorial Matters. It will
The World Association of Medical Editors recently formulated
continue to strive to promote academic medicine as part of its
and published a policy statement on “Geopolitical Intrusion on
remit and to provide a forum for the dissemination of
Editorial Decisions” The spirit of the statement (shown below)
information of relevance to the scientific and clinical
is one that needs to be present in the campaign to revitalise
communities as well as the public whilst working to foster
academic medicine.
interaction with institutions, organisations and networks locally
and overseas. Meanwhile it may be worthwhile to remember
Geopolitical Intrusion on Editorial Decisions
Posted March 23, 2003
that:
Decisions to edit and publish manuscripts submitted
to biomedical journals should be based on characteristics
of the manuscripts themselves and how they relate to the
journal’s purposes and readers.
Among these characteristics are importance of the
topic, originality, scientific strength, clarity and
completeness of written expression, and potential interest
to readers. Editors should also take into account whether
studies are ethical and whether their publication might
cause harm to readers or to the public interest.
Editorial decisions should not be affected by the
origins of the manuscript, including the nationality,
ethnicity, political beliefs, race, or religion of the authors.
Decisions to edit and publish should not be determined by
the policies of governments or other agencies outside of
the journal itself.
Editors should defend this principle, as they do other
principles of sound editorial practice, and enlist their
colleagues’ support in this effort if necessary.
Wame
same level of thinking we were at when we created them.”
“The significant problems we face cannot be solved at the
Albert Einstein (1879-1955)
Josanne Vassallo
Editor
References
1. Bell J Resucitating clinical research in the United Kingdom. BMJ
2003;327:1041-1043.
2. Harding A European and US groups draw up standards for CME
BMJ 2004;328:1279.
3. Tugwell P Campaign to revitalize academic medicine kicks off BMJ
2004;328:597.
Errata Corrige
In the article: “Cigarette Smoking across Three Maltese Generations", one of the authors should have read:
Mary Ann Sant Fournier B Pharm, M Phil
Department of Pharmacology, University of Malta
Email: mary-ann.sant-fournier@um.edu.mt
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