Time for a revolution in academic medicine?
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2508 (Published 28 November 2024) Cite this as: BMJ 2024;387:q2508
- 1Faculty of Medicine, University of Chile, Santiago, Chile
- 2School for Public Health, Imperial College London, London, UK
- 3Stretton Health Equity, University of Adelaide, Adelaide, Australia
- Correspondence to: M L O’Ryan moryan{at}uchile.cl
Academic medicine remains under scrutiny. Despite various attempts to tackle its problems, including a global initiative in 2003, TheBMJ’s editor in chief recentlyconcluded it is “broken.”12 At the centre of the “crisis” are historical power imbalances that have led to broken career structures, perverse incentives for academic reward and research funding, and a widening rift within medical institutions between research and education.1 A crisis in evidence based medicine is also part of the problem.3 In addition, workforce shortages and growing health service demands are putting strain on health system budgets, leaving little room for governments to direct public funds into research rather than service delivery.
To respond to the growing crisis, TheBMJ has launched a Commission on the Future of Academic Medicine, which aims to revive academic medicine and redefine its role for the rest of the century. The commission seeks to trigger a global conversation to build on what is working, to fix what is not, and to realign the role and function of academic medicine to ensure its relevance for the future.
What is meant by academic medicine? Broadly, we mean “academia” and “healthcare.” Its overarching goal should be to train medical professionals and advance knowledge, with the central aim of improving health and wellbeing of the population and planet in an equitable manner. Fundamental principles of academic medicine are that it should serve both academia and medicine, combining science, ethics, and humanities, and promote lifelong learning. Without the rudder of science and ethical thinking, ignorance or misinformation can dominate, making societies vulnerable to populism, poor decision making, and power play. Recent history has shown us how this can exacerbate conflicts, mismanagement of pandemics, and poverty.
Academic medicine has many stakeholders, including the academic community, health organisations, policy makers, the medical workforce, and medical students, with different perspectives. All these groups need to have their say and take responsibility for creating a better future. Other important voices are those supporting medical research, including funders from public and private sectors and industry, and scientific and medical societies and journals.
Global conversation
As a first step, we as co-chairs have identified misalignments in goals and drivers of scientific agendas, and gaps in academic capacity that need fixing in academic medicine (box 1). This broad non-prioritised list is intended to encourage global discussion, including the active participation of The BMJ’s regional advisory boards.
Challenges for academic medicine
Misalignments between academic and healthcare institutions
Widening rift between universities and health systems
o Universities’ performance indicators are focused on individual gain, and reputations are built on academic publication in peer reviewed science journals
o The increasing corporatisation of universities (university enterprises for profit) hinders academic development
o Insufficient interactions and common goals between the higher education and healthcare systems
Medical graduates and specialists today are not necessarily aligned with current and future societal healthcare needs
o Insufficient training of primary healthcare physicians willing to work in community settings where there are high levels of disadvantage
o Insufficient interdisciplinary and transdisciplinary training
o Insufficient training on social and commercial determinants of health and the importance of public health
Misalignments in drivers of scientific agendas and knowledge generation
Financial pressures and constraints in higher education negatively affect research and education
o Funding of research is extraordinarily inequitable globally
o Insufficient public and private funding for research that expands beyond illness management to considerations of health, wellbeing, and prevention
o A focus on individual performance drives unhealthy competition and cultures
o “Perverse incentives” such as excessive valuing of impact factors or citations in determining the quality of research initiatives affecting academic careers and decisions
Decrease in relevance of research to healthcare needs
o Avoidable waste in medical research is fuelled by scientists pressed for funding, who consistently conclude more research (and funds) are needed
o Science that is celebrated in academic circles lacks application or is perceived as irrelevant to practice and not adopted
Disengagement between teaching, clinical, and research activities in medical faculties
o Scientists pressured for academic and financial rewards have little time for teaching resulting in patchy learning and poor pastoral care
Gaps and glass ceilings in academic careers
Lack of incentives and rewards to pursue an academic career
Discrimination and inequities within and among institutions
o Institutional processes are discriminatory and designed to reinforce and widen gender and racial inequalities (eg, Royal Society, Academy of Medical Science require existing fellows to nominate their peers)
o Colonialism has affected academic medicine, diminishing the role of knowledge generated by local communities in previously colonised countries
The BMJ will advance the work by commissioning articles on cross-cutting themes deemed relevant globally, assuring broad and inclusive representation. In addition, each regional advisory board will be invited to reflect on priorities and future perspectives for academic medicine, providing concrete actions within their own realities. We hope to obtain innovative proposals to reshape the current situation and re-establish academic medicine on a firm footing. The key questions include: what is the vision for academic medicine in an era of rapid change? How healthy is academic medicine currently, and is it getting better or worse? Which challenges do we need to tackle first? What strategies, policies, or other actions are needed for urgent or progressive reform? We also seek your submissions and contributions for publication, which will be considered by The BMJ in the usual way.
This reflective process is not only timely but crucial in a world that is dominated by immediacy, superficial exchange of ideas, and increasing acceptance of incomplete or bluntly false information. A deep reflection on what we are doing and achieving in academic medicine is long overdue. Our ambition for this commission is that it leads to root and branch reform of academic medicine so that it is fit to meet the challenges of a world facing polycrises, including the existential threats from climate change. We aim for no less than academic medicine becoming one of the forces for the good of human and planetary health.
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.