Context

For more than a decade it has been widely stated that there is ‘a crisis in academic medicine’.  For example, in 1989 the Academic Medicine Group, based in the Royal College of Physicians of London published a paper entitled ‘Academic Medicine: The Problems and Solutions’ which stated ‘the health of academic medicine is in serious jeopardy’ (1). The problems it identified included reduction in staffing in clinical academic departments, increased dependence on short term support from outside, constraints imposed by ‘achieving a balance’, problems of recruitment to academic medicine, problems for teaching and decline in clinical research.  It produced a list of 26 separate recommendations, which included ‘each medical school should define a limited number of areas in which it perceives it can mount internationally competitive research’, ‘funds for research should be allocated by medical schools to the multidisciplinary departmental research groups concerned with selected subjects’, and ‘a proper career structure is needed for particularly talented medical research workers’.

In 1995 the House of Lords Select Committee on Science and Technology (2) expressed concern that the recruitment of clinical academics might become severely compromised, particularly in relation to the changes proposed for specialist medical training (the Calman Report) and for the organisation of NHS research.  The Select Committee said ‘we consider that the disincentives to a clinical academic career are now so great as to warrant an immediate enquiry in their own rights’. The Department of Health declined to set up an enquiry but subsequently the Committee of Vice Chancellors and Principals (CVCP) – now Universities UK - invited an independent task force to investigate these matters.  This task force, under the chairmanship of Sir Rex Richards, reported in June 1997 (3). In summary the task force was convinced that there is a potentially serious problem and made a number of recommendations to prevent the problem from developing significantly. 

Currently, according to the BMA, there are 79 vacant chairs, 145 vacant senior lecturer and 177 vacant lecturer posts in clinical departments in the United Kingdom (4).  Recruitment is difficult in all specialties; there are often very few applicants for posts and little opportunity for appointments panels to choose. In England entry to medical school has been increased by 2000 students per year, the equivalent of 10 average sized medical schools, and there are four new medical schools established or about to be established.  Thus at a time of shortage of clinical academics, many more will be needed. 

The cause of the problem is multiple.  Clinical academics have three main duties – teaching, research and clinical practice, and have usually to be involved in at least some administration in all three of these.  Although the contractual arrangements vary, they work for two employers, a university and a health service trust, both of which are increasingly concerned with measures of performance.  The agendas of the university and the health service do not always coincide.  One example of this is the fate of clinical lectureships, which are important for both clinical and academic training.  Because they are part of the complement of academic staff in the universities, they have to be returned in the Research Assessment Exercise (RAE).  However, because clinical lecturers do not usually have significant research performance as they are still training, the posts are tending to disappear.  This leaves a gap in career progression for potential clinical academics.  The new arrangements for postgraduate training (Calman) are also perceived to disadvantage those wishing to undertake research or prepare for an academic career.  For some specialties, particularly the surgical specialties, there is also a financial disincentive to an academic career.

While many NHS consultants contribute to both teaching and research, academics have to manage teaching programmes, run examinations and assessments, and lead in teaching quality assessments.  They are also more heavily involved in research (it is a contractual obligation).  They often develop and lead specialised NHS services and are heavily represented on local, national and international committees and organisations.

Universities and the health service will have to work increasingly closely together to manage academic medicine and to ensure that clinical academics are not subject to intolerable pressures.  A number of initiatives in this regard (5) have taken place, including an important document from the Nuffield Trust (6). Appraisal, long established in universities, is being introduced into the NHS and joint appraisal between universities and trusts has been recommended by the report of the committee, chaired by Sir Brian Follett, on the management and accountability of consultants with joint contracts with universities and trusts, which followed the report of the Alder Hey Inquiry (7).

In response to the Richard’s Report, a working party of the the Academy of Medical Sciences (8), and the Academic Medicine Committee of the Royal College of Physicians of London (9), have considered training in academic medicine.  Both reported in March 2000.  The Academy of Medical Sciences group, chaired by Professor John Saville, made recommendations to allow trainees to accomplish both clinical training to consultant level and pre- and post-doctoral research experience.  This would prolong the period of training and they recommended that 50 clinical scientist posts per year, additional to existing specialist registrar posts, should be established, with a competitive entry scheme and special national training numbers.  They also recommended that clinical lectureships should be retained.  The Royal College of Physicians produced similar proposals with what they termed ‘phase 1 and phase 2 training’.  Both proposals involved the phase 2 training schemes having tenure and leading automatically to a post at senior lecturer or higher level and with a consultant salary being paid at a time when the trainee had achieved clinical training at consultant level.  In March 2001 the Department of Health in London announced the National Clinical Scientist Scheme (10) which largely implements the recommendations of the Saville Report. The response to the scheme was disappointing.

Academic Geriatric Medicine

The term Geriatric Medicine will be used although different terminology is used in both hospitals and universities.  Geriatric Medicine as a clinical specialty developed with the onset of the National Health Service in 1948. The first chair of Geriatric Medicine in the world, the David Cargill Chair in the University of Glasgow, was established in 1965 and filled by the late Professor Sir Ferguson Anderson.  There are now chairs of Geriatric Medicine in every university in the UK, although not all of them are currently filled.  Three professors of Geriatric Medicine are Deans of Faculties of Medicine in the UK and Professors of Geriatric Medicine have also been Deans of Medical Schools in the University of Dublin and the University of Otago.  In recent years Professors of Geriatric Medicine have held high office in the Royal College of Physicians.  In some respects therefore academic Geriatric Medicine is well established. 

As an academic discipline Geriatric Medicine is very much younger than the major disciplines of medicine, surgery, pathology etc, although with increasing specialisation, there are now many academic chairs in the medical sub-specialties.  A newly developed academic discipline will inevitably have to go through a period of development and there will be relatively few suitably qualified candidates for senior positions in the early years.  The original professors of Geriatric Medicine were usually distinguished clinicians in the specialty who had pioneered both teaching and research.  Occasionally clinical academics moved from related clinical specialties.  The major deficit in academic Geriatric Medicine now is in the infrastructure.  There is not a large body of senior lecturers committed to an academic career, pursuing research of a high standard and preparing themselves to be the academic leaders of the profession in the future.  Hence when chairs become vacant, there are often no suitable applicants and sometimes no applicants at all. Research activity in academic Geriatric Medicine is under-performing.  It is notable that a significant number of research reports on areas relevant to Geriatric Medicine are published by researchers working in other fields. 

Geriatric Medicine is the single biggest medical specialty and is broadening the scope of its activities.  The opportunities for research in ageing, age related disease, and the care of elderly people are enormous and increasingly research funders are keen to support such research (11-15). It is essential that the specialty has a strong teaching and research base and that the brightest young doctors in the specialty are attracted to academic careers. 

Cause of the Problem

The problems in academic Geriatric Medicine are in some respects a reflection of the problems in academic medicine as a whole but in addition there are special features.

1. The RAE has caused universities to be very stringent in only appointing academics who have strong research records and research potential.  While this should not be a threat to Geriatric Medicine, as its research should be of as high quality as that in any other discipline, it will need a culture change to achieve this and the provision of appropriate research training opportunities and infrastructure.

2. It is increasingly recognised that research has to be undertaken selectively and that only the largest and best endowed medical schools are able to carry out high quality research in a wide variety of clinical areas.  This means that the smaller specialties, if they do not build up very large research teams of their own, have to collaborate with others and to some extent risk losing their identity. This requires a culture change and the ability to recognise and exploit opportunities.  There are many specialties with which collaboration and the building of teams could benefit geriatric research, eg. neurosciences, cardiovascular research, epidemiology, health services research.

3. Some academic Departments of Geriatric Medicine have been perceived by their universities to be under-performing in research and have been threatened with disinvestments or closure.

4. Postgraduate training programmes, while they may allow research, do not necessarily encourage it, and many postgraduates try to keep open their options on whether they wish to have an academic or a clinical career.  This problem is being addressed by the National Clinical Scientists Scheme (10) and it is important that Geriatric Medicine participates in this. It is also important that potential clinical academics in the specialty undertake research training in the best laboratories in the world.

5. Geriatric Medicine is still seen as a ‘new’ specialty. One result of this is that there is still expansion in the numbers of consultant posts and hence young doctors can obtain consultant posts fairly easily.  It is easier to train for and obtain a consultant post than an academic post. 

6. Geriatric Medicine is a very general specialty. There has been a tendency for research to be carried out over a wide area and not in great depth. A recent NHS R&D Strategic Review of research in Ageing and Age-Associated Disease and Disability noted 23 areas of research relevant to the topic (appendix).  Choosing an area and researching it in depth is the only way forward in the academic world and this is not always attractive to those who have entered the specialty because of its general nature.

7. All clinical academics have to balance their clinical responsibilities with their university responsibilities. Inevitably the demands of patients tend to dominate. Clinical academic posts usually have six clinical sessions, of which three should be fixed sessions.  Because of the widespread nature of Geriatric Medicine with service in acute medicine, rehabilitation, day hospital, liaison, perhaps stroke or other special units, it is difficult to confine it to three sessions.  It should be recognised that academic clinicians in Geriatric Medicine will not cover the whole range.  One way of approaching this is for the academic team of a department to share responsibility for the clinical load normally undertaken by a consultant, perhaps on a rotating basis.

8. Some academic departments of Geriatric Medicine are outside the main medical school or teaching hospital campus. This makes it difficult for them to collaborate with colleagues.

Recommendations

Communication

The BGS should communicate the opportunities and attractions of academic medicine to trainees by:

1.  Having ‘surgeries’ at the BCG meetings at which academics would be available to discuss prospects for research with trainees.

2. Highlighting the opportunities and attractions of academic geriatric medicine in the BGS Newsletter.

3. Ensuring that the BGS meetings are showcases for the best research that takes place.

4.  Having a formal link between the BGS and the Association of Professors of Geriatric Medicine so that the academic voice is heard at all deliberations of the BGS and its committees.

Research

5. The BGS should develop a research strategy and in particular highlight areas of research strengths and opportunities within the United Kingdom.

6. Suitable candidates should be encouraged to apply for the National Clinical Scientist Scheme.

7. Potential clinical academics should take research training in the best research centres in the world.

Education

9. Clinical academics should undertake no more than 3 ‘fixed’ clinical sessions per week, except for sessions specifically for research.

Strategic Alliances

10. Departments of Geriatric Medicine should participate fully in the research strategies of their universities and medical schools and seek alliances with their relevant disciplines in order to build a critical mass of researchers in particular areas. Departments of Geriatric Medicine should take a lead in research in age-related topics.

11. The BGS should seek alliances with research funders to ensure that the research opportunities in ageing and age-related disease are fully exploited.

12. Consideration should be given to forming a link with the National Institute of Ageing of the US National Institutes of Health, to allow exchange of trainees and young researchers.

General

13. The BGS should be alert to any threats to individual academic Departments of Geriatric Medicine and lobby the university concerned.

References