Académie royale de Médecine de Belgique

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Texte Robert Casteels et A. Vermeulen, membres titulaires (KAGB)

(Séance du samedi 28 septembre 1985)

THE MEDICAL FACULTY AND MEDICAL RESEARCH

par Robert CASTEELS and A. VERMEULEN, membres titulaires de la « Koninklijke Academie voor Geneeskunde van België », Doyens respectifs des Facultés de Médecine de la « Katholieke Universiteit te Leuven » et de la « Rijkuniversiteit te Gent ».  

Belgian medical faculties have contributed substantially to the progress of biological sciences during the last decades.  This contribution consists not only in the promotion of fundamental research but also in the efficient transfer of new research data to the care of patients.  At the same time our faculties have been responsible for the high quality of medical care and the stimulation of scientific interest in the Belgian regional hospitals.  As a consequence, clinical research is being performed in some of these institutions. The pioneering tasks were achieved in the post-war period by expanding the quality and number of scientific staff in the faculties of medicine.  This first post-war generation of medical scientists was enthusiastic, believed strongly in the progress of science and was, by his training abroad, integrated in the international scientific community.

Those responsible for the faculties of medicine are sincerely worried about the future of research and scientific activity in the medical faculties, not only because this would mean a heavy loss for the eminence of Belgian science, but also because a decline of research in the medical faculties would be extremely deleterious for the quality of patient care.

We will first describe and analyse the reasons and the warning signs that already foreshadow a decline of research activity in the medical faculties.  It is obvious that a sufficient funding of research is an essential condition for its progress, but there are other negative influences as well.

A first causative factor is the impact on some young students of the critical attitude of part of the post-1968 student generation against technology in general and against medical science and technology in particular.  For example, there is the interest in the ideas of Illich and the widespread belief that social sciences should have a larger share in the medical curriculum at the expenses of basic sciences.  According to this view medical science should be softened.

In addition there is no doubt that for a large part of our society and its policy-makers, science only becomes acceptable and worth funding if it is applied science or technology.

This unfortunate trend is killing fundamental science, but it Wii soon kill applied science also.  In addition this attitude defers medical students from the scientific basis of medicine.

A second factor that is turning medical students away from the medical sciences is the excessive burden of our medical curriculum.  Our present curriculum makes any direct contact with laboratory research almost impossible during the whole undergraduate training.  In addition some faculties abroad have even introduced socalled patient-oriented teaching before sufficient insight is acquired in physiology and biochemistry.  Such teaching procedures are not compatible with the precision and logic of a scientific approach.

A third element reducing the attraction of research for our medicals students is the low number of available research careers, compared with the brighter future for those entering medical specialty training.  The requirement for up to six years full-time training as specialist makes it impossible to get research experience before the age of 30.  These very stringent rules of the specialty-certifying boards have, by excluding research training, greatly impeded the development of clinical research.  How can one expect even a bright M.D. to have a creative research career if he cannot start it before the age of 30 ?  In addition this delay in obtaining a permanent career position has a serious impact on financial, social and family status which further discourages our brightest candidates form careers in research.

Conversely starting research immediately after graduation makes it more difficult to become a medical specialist.  Thus, maintaining such rigid rules in the specialty-certifying boards, that separate research and clinical training, would be disastrous for science in general in the faculties and for clinical science in particular.

The integration of research and clinical training is not an esoteric idea : for example, at the Mayo Graduate School of Medicine there is a clinical investigator program in internal medicine, which consists of 1 ½ year of clinical training in general internal medicine, two years of research training, and 1 ½ year of clinical subspecialty training.

A fourth factor making research difficult for young M.D.S. is the growing complexity of science and its experimental procedures.  If is therefore essential to get engaged in research at young age and under proper guidance.  It is misleading to make young people believe that in the present state of science, good research can still be done after finishing a clinical job at 7 p.m. or over the week-end.  In addition it should be understood that the present medical curriculum does not prepare people at all for a research career : the amount of basic science is limited and the teaching of modern research procedures at the age of 25.

The fifth factor is the attitude of the faculty members.  I sometimes wonder whether our present medical teachers are making a sufficient effort to create an attractive and efficient research environment for young research candidates.  Young research workers have to be motivated.  They must also be initiated, guided and taught by discussing their research plans, successes and failures.  They must be introduced to other scientists, and made to feel part of the active research community.  Ideally we ourselves have to remain engaged in research at the bench, so that, by being a living example of the life-long enjoyment of science, we will be essential factors in motivating young people.  Such an environment requires a well-structured laboratory unit and cannot depend on a one-man show.

Finally, the cutback in financial support for science is a major threat to research.  The decrease of funding is even worse than might appear from the poor absolute values of the amount, because some political authorities have been combining support for technology, applied science and basic science.  It is important to mention that the shift of the science policy-makers towards applied science and technology, with a concomitant negative attitude to basic science, has it roots in the American experience on military research during the Johnson administration.  In that case it was rightly concluded that scientists would contribute most in the least time lag when the research was clearly targeted and integrated into a specific purpose.  The same approach was then extended by policians to the much more complex case of biomedical research, with the adage “Turn research to the service of men”.  But the approach that is logical for technological development has on very amateuristic grounds been promoted to the leitmotiv for biomedical research.  Not only has the recent experience with this approach been very negative, but in addition it is misguiding investigators and young M.D.S.  The medical scientist are diverted from investigating answerable questions to striving for the solution of what is currently impossible : cures for cancer, arteriosclerosis.  The young investigator is more attracted by treating patients in a technologically well-equiped environment rather than pursuing the solution of well-defined scientific problems.

Also in Belgium the new research initiatives made money available largely for applied research, but they did not provide permanent positions for excellent scientists.  Rather, temporary jobs were created for mediocre people who would never have been accepted by the NFWO-FNRS.  We can understand the frustration of the young research worker with excellent credentials, who after six years of research has to choose between unemployment, a non-research job or following the brain-drain to surrounding countries.  This perspective at the beginning of a research venture in a faculty of medicine is not as attractive as a clinical position even in a regional hospital.

The Belgian medical faculties worry about their future as centers of excellence with that special symbiosis between humane and high-quality medical care of patients on the one hand, and fundamental and clinical research on the other.  A bad omen for the faculties of medicine is that their basic and clinical research depends less and less on their own M.D. graduates and more and more on research workers from other faculties who take over their vacancies. We have to be grateful to those people because they help us to maintain the standard of scientific interest.  However it is a symptom of ill health if a faculty cannot attract at least some of its own excellent students to pursue the research that is one of its main activities.

The diagnosis is clear : ten years from now, if nothing is changed in our faculty policy and in the funding system, there will be a decline of basic and clinical research, with inevitably dismal consequences for the level of clinical proficiency.

The necessary are at three levels : 1) the faculty, 2) the young generation, 3) science policy.

1) The medical faculties have the primary responsibility to create the proper research environment for investigator candidates.  Basic and fundamental research require not only adequate instrumentation and financial support, but also a stimulating environment and the close friendly guidance of young investigators.  As stated by the late Sir Hans Krebs, it is essential to have outstanding teachers at the critical early stages of scientific development of young investigators.  Their initial enthusiasm will only yield contributions to the progress of science if the unavoidable frustrations occurring in research are neutralized by the advice and the support of an experienced staff.

We have to make it possible for research to be started at a relatively young age, when the mind is still sufficiently adaptable to acquire new knowledge and skills, when family obligations do not yet prevent the research worker form going abroad or working long days and week-ends.

Unfortunately our present curriculum makes it almost impossible for bright medical students to obtain real research experience form the preclinical years onwards.

We hope that the pathway of student-researcher can be reopened.  It would certainly be worthwhile  to do so and to examine the possibility of funding a research period after the preclinical years.  Our main duty as a faculty is to motivate some of the most gifted graduates to start research at once, preferably as bursaries of the NFWO.  As proposed earlier, these people deserve first a proper research environment and the certainty that, if they wish, they still train as a medical specialist after their four years of research.

In addition it is only equitable and logical that, in view of their mental gifts and their scientific training, the overall duration required for a clinical training (undergraduate and postgraduate) should be less than for those M.D.S., preferring clinical training only.

Such a combined research-clinical training will not only provide the faculties with excellent clinicians, but it will also be possible to recruit out of these people the new generation of clinical investigators.  In addition some of those research-minded M.D.S. will stay in basic research, renewing the faculties of medicine with M.D.S. working and teaching in the basic subjects.     

2) The coming research generation must be actively planned for in this new venture.  While the individual initiative must come from the young investigators themselves, the faculties and the science-policy makers have to provide the environment, the career structure and the financial means for them.  Even those students who are gifted can only reach and maintain the peak of their performance by very hard work.  “Effortless superiorty” does not exist in science, nor anywhere else.

Sir Hans Krebs gave this advice on how to attain distinction in scientific research :

get a post-doctoral Fellowship, which will give you the time and opportunity to test yourself;

attach yourself to a centre of excellence;

work hard and make the fullest use of the time and facilities the Fellowship affords;

from time to time, search your heart critically with the help of objective critics, to find out whether you really possess the right mixture of those qualities – the urge, commitment, imagination, humility – which are the roots of creativity in science.

3) A more dynamic attitude of the faculties and of the younger generation towards research and science will not be of any help unless society supports science to a larger extent.  A particularly important aspect is the impact of this support on the future of the young medical investigator.  Very early in his research career he faces the fierce competition to get one of the very few faculty positions or tenure positions of the NFWO-FGWO. Our society is unwise and unfair if it does not open up opportunities for these very gifted and well-trained people.  The sums required to sustain the steady infusion of young people that our facilities need are really trivial, even when compared to the modest cost of biomedical research.  Even very motivated people expect in the long run a minimum of assurance and a salary which does not bring them to the lowest level of medical society.

The Government bodies should be prepared to invest much more in our bright people and in centers of excellence.  One is doing a disservice to this country by creating a large number of temporary stipends for second-rate people, rather than investing in excellence.  The urgent plea of the faculties is that much larger support should be granted to the NFWO and FGWO, for providing a larger number of permanent or long-term positions at the faculties of medicine in basic and clinical research.

Much larger financial means have to be provided for the good research laboratories in the faculties of medicine in order to provide a sufficient supply of new equipment and to make it possible to start new ventures in basic research.  This is absolutely essential because the financial means of the medical faculties proper will decline as the number of their students decreases.  The Fund for Medical Scientific Research is the adequate institution for the distribution of additional financial means.

Both the NFWO and FGWO are by their tradition, their experience and objectivity the main pillars of Belgian science.  There is no alternative for their role in stimulating the progress of science in our faculties.