Does research make for better doctors?

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EDITOR AL

Does research make for better doctors? In many research"

of medical

practice "doing some is actively encouraged; in some professional training schemes a period of research has become compulsory. Pro-research enthusiasts continually have to counter the sceptic’s question: areas

"What evidence do we have that a burst of research makes a better doctor?" The short answer may be none, but a moment’s reflection will reveal the misleading simplicity of the query. Perhaps some doctors benefit from research training more than others; future academics are obvious candidates, but a little research experience may help their nonacademic counterparts too. These issues are aired in a thoughtful document from the Royal College of Physicians of London, UK, on the role of research in National Health Service consultants’ training. A year of research is strongly advocated, not only as an option for future academics or for those who are unsure about their future pathway, but also for all who are intent on a purely clinical career. The benefits of research, according to the report, go beyond the advancing of medical knowledge to of and encompass acquisition analytical communication skills that are useful in any future career.

We should begin by thinking about the role of science in medicine. A good start is McCormick’s dictum: "Medicine is not science, and it is certainly not art" ,2meaning that the daily practice of medicine is not a scientific activity but a practical craft to ease the many transitions in our lives, from birth to senescence, and to postpone or alleviate some of the worst. However, the progress of medicine is a scientific activity, rooted in both basic and clinical science; medical practice derives its sounder part from a scientific basis, and the terms in which a practitioner reasons about a patient are taken directly from science. In such a context, medical training, from undergraduate to postgraduate, must serve two October 30, 1993

purposes. First there is transmission of the tools of the trade. This is usually done very conservatively: only

clinical knowledge is taught. However, since medicine is in constant evolution, a future doctor should also be educated to understand scientific advances. This does not mean that every practising physician should be capable of evaluating

"proven"

published item pertaining to might be dangers in such an undertaking, even if it were practicable. Postgraduate training of practising physicians is more often done by academic gurus who have attended international congresses and who thereafter spread the news at local meetings. Still, this presupposes that every physician has sufficient scientific background to understand and recognise sound scientific arguments for changing a medical practice. So, do we admit that science does not make doctors more empathic or better skilled as diagnosticians, but that science is needed as a general background to ensure they keep up with medical progress? Not quite. The picture of a few academics devoting critically

every

medicine-there

themselves to innovative research while the rest of the medical workforce sits back to watch is too crude. People who have conducted a good piece of research and who do not stay in academia still tend to become local or regional leaders of the profession. Why? Partly because they have learned to speak "standing on their feet"; partly because they have acquired analytical skills; and partly because their inside knowledge of research enables them to read between the lines of a research report. Instead of a dichotomy, there is a smooth transition between the very few who do innovative research and the medical workforce who put the new lessons into practice. In between the innovative top and medical there are ever-broadening layers containing all shades of innovativeness and commitment to research. These act as sieves in the transmission of

practice

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knowledge from the stage of innovation to the stage of practice. Within this pyramid of medical knowledge, whose base represents universally accepted truths, the middle layers are just as vital as

new

the innovative top. Even a country that does not have top innovative research in a certain area still needs a large "middle class" of researchers who can understand and catch up with the newest developments. Second, innovative top research does not exist in a vacuum, nor is it nailed down for ever in one place. Innovation eventually emerges from the masses of talented young clinical and basic science investigators who do hundreds of thousands of small research studies-the "seeds" of progress.3 Third, when innovation comes from basic science we will always need clinical researchers who can integrate the information at different levels of biological

complexity. Most physicians practising in university hospitals belong to the large middle class of researchers, who predominantly sift out the theories of others, and only occasionally dig up a nugget of their own. The gurus who attend the international conferences and disseminate what they have learned should reflect critically on what they have heard, then try things out; they are able to do so because they are in the same line of research. Specialists who left academia after having had their turn at research may reflect on what they hear at postgraduate meetings and may also try out a few ideas. Thus there is no sharp dividing line between the middle-of-the-road academic and the astute consultant. We cannot return to the days when a clinical consultant could compete with the laboratory bench researcher, but the consultant has available a wealth of material suitable for clinical research on common conditions. Overall, therefore, we should have as many future consultants doing research as possible. There is one caveat, also made by the Royal College. All too often research becomes a dreary unmotivated activity because it was not started well. Even in areas very distant from medicine such as sociology or literature, writers of all languages have emphasised the importance of careful thinking about the research question.4,5 In the mid-1800s Claude Bernard described how every inquiry starts with a clearly preconceived idea;6 at the turn of the century Clifford Allbutt advised about the difficult choice of subject.7 The need for careful phrasing of the research question was echoed for basic science in Medawar’s "art of the soluble"8 and has been similarly emphasised for clinical research and epidemiology. 9,10 Every young physician embarking on a research project would benefit from the opportunity to discuss the focus and feasibility of the work with someone with a good track record in research. Lastly, when should a future clinician do research, 1064

long, and who will pay? Professional organisations often warn against the allocation of too much time to academic fancies; after all, there is a trade to learn. The drawback of doctors’ starting research projects immediately after leaving medical school and before specialisation is that they have little idea what medicine is about, and cannot provide basic scientists with any feedback from clinical reasoning. Moreover, juniors who enter clinical training after a successful research period often find it hard to adapt: suddenly they are back at the beginning, and may even be denied the right to think for themselves. The drawback of starting research after clinical training is the big financial penalty. Taking some time off halfway through medical specialisation would be best, when people already know what medicine is for how

about and

motivated to return to the clinic. Moreover, at this point in a career a shorter time might be spent on research more profitably-a year might suffice. And we should not forget that in future more than half of the medical workforce might consist of women, many of whom want to raise a family and might be unwilling to combine clinical and research duties that lengthen their training. Clinical training might be shortened if combined with clinical research. Whatever the scheme, one year of research during a five-year training period means that for every ten doctors in training two are set free from clinical duties. So, who will pay? In the UK the Royal College suggests the new NHS research and development budget, since much of the research by clinicians in training might fall under those terms. We should never lose sight of the purpose of research in medical training. While most such activities will have little immediate clinical effect, research advances medicine’s body of knowledge for the future, and secures the existence of a large class of doctors, both inside and outside academia, who are able to follow the course of medicine critically, thereby enhancing all aspects of medical practice. are

The Lancet

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Turnberg LA. The place of research in the training of NHS consultant physicians. J R Coll Physicians Lond 1993; 27: 403-04. McCormick J. The contribution of science to medicine. Persp Biol Med 1993; 36: 315-22. Rahimtoola SH. Control of scientific research. In: Brugada P, Wellens HJJ. Cardiac arrhythmias: where to go from here? Mt Kisco, NY: Futura Publishing, 1987: 689-98. Mills CW. The sociological imagination (appendix: on intellectual craftsmanship). London: Oxford University Press, 1959. Eco U. Come si fa una tesi di laurea. Milano: Bompiani, 1977. Bernard C. Introduction à l’étude de la médecine expérimentale (1865). Paris: Garnier-Flammarion, 1966. Allbutt TC. Notes on the composition of scientific papers (1904). London: Keynes Press, 1984. Medawar PB. Advice to a young scientist. New York: Harper and

Row, 1979. Vandenbroucke JP. On the new clinical fashion in epidemiology. Epidemiol Infect 1989; 102: 191-98. 10 Feinstein AR. Clinical epidemiology, the architecture of clinical research. Philadelphia: Saunders, 1985.

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