The future of academic medicine: five scenarios to 2025

Academic medicine might be defined as the capacity of the system for health and health care to think, study, research, discover, evaluate, innovate, teach, learn, and improve. But can academic medicine lead the way into the twenty-first century?|Several UK and US focused reports suggest that this prospect may be in doubt and critics are becoming increasingly concerned that academic medicine is in crisis around the world. Indeed, the lack of basic infrastructure in many countries has meant that academic medicine is floundering, if not absent. Even the current funding in industrialised countries will be wasted if structural changes are not made to allow academic medicine to capitalise on new investments. At a time when the health burden, poverty, globalisation, and innovation all are growing, academic medicine seems to be failing to realise its potential and its global social responsibility.|This report analyses the reasons for the current instabilities in academic medicine, and looks at 5 scenarios for possible development:

• Academic Inc.: Academic Medicine Flourishes in the Private Sector
  Slowly but surely the public sector around the world realises that it cannot support the costs of academic medicine. Because medical students earn a lot of money during their professional lifetime, why shouldn’t they pay for their education? And if researchers are doing something valuable, why shouldn’t they be able to find a market for their product, accepting that sometimes the public sector will pay?
  • Medical schools become private, with many providing niche training
  • Fees and staff salaries are raised, and facilities and technology are cutting edge
  • Competition and pressure to reduce costs and improve quality are intense.
  • Research is taken over by private companies
  • Successful companies are responsive to customers’ needs (governments, researchers, patients).
  • Many training and research companies fail.
  • Overall efficiency and effectiveness of academic medicine improves, but equity suffers.
  • A two-tier system results; the 10:90 gap persists; and the brain drain accelerates.
  • Innovation often suffers because of the immediate accountability to shareholders.
• Reformation: "All Teach, Learn, Research, and Improve
  The gap between academic medicine and practice causes increasing concern, with important research results not being implemented, too much irrelevant research, bored students, and practitioners who stopped learning. The response is not to try to strengthen academic medicine but to abolish it and instead to bring teaching, learning, and researching into the mainstream of health care. This innovative response, although not welcomed at first, proves to be highly successful and is copied everywhere. A century of separate academic medicine ends, and professors disappear. “Academic medicine” is gone, a phenomenon like the destruction of the monasteries, and so it becomes known as the reformation of academic medicine.
  • Education, research, and quality are improved in the practice setting
  • A medical academic no longer is a “jack of all trades” (teach, research, practice).
  • A team approach is adopted, supported by advanced learning and communication technologies.
  • Teams are made up of patients, multidisciplinary practitioners, students, and professional researchers (basic and clinical science).
  • Research questions come from interactions between professionals and patients, and a national question-answering service provides evidence-based responses.
  • Leadership comes from diverse specialist societies, which organize in an international academy that can influence world leaders.
  • Medical students first learn how to learn and then learn by doing.
  • Teamwork fosters learning, but not all teams have the same values, which threatens stability, consensus, and decision making.
  • Brilliant individuals have difficulty shining as leaders.
• In the Public Eye: Success Comes from Delighting Patients and the Public and Using the Media
  Academic medicine is slow to recognize the rise of global media, “celebrity culture,” and the use of public relations (or spin) to drive the political process, but once it does, it responds dramatically. Whereas it once was suspicious of the media and public appeal and rather patronizing to patients, academic medicine realizes that to succeed, it must delight patients and the public and learn to use the media. The most successful academics are those who are very responsive to patients and the public, capturing their imaginations and appearing regularly on their television screens. Some medical academics become as well known as film and rock stars and are feted by politicians.
  • Academic institutions become dominated by citizens and patients, with their public relations department the most important.
  • Grants and prizes are awarded on academic game and reality shows.
  • Citizens’ juries also make decisions about research priorities and funding.
  • Students receive most of their training from expert patients.
  • The form and size of institutions range widely; competition is intense to hire the best teachers and researchers.
  • Academic institutions have strong links with consumer movements and local NGOs.
  • Academics are more anxious about their job security and ability to succeed.
  • Because scientific advances are shaped by popular appeal, they are subject to fads.
  • Health information is essentially unregulated.
• GAP (Global Academic Partnership): Academic Medicine for Global Health Equity
  The world begins to find the growing gap between the rich and poor to be unacceptable. This concern is driven partly by the media and global travel, bringing the plight of the poor to the attention of the rich, but it also is driven by anxieties about global security. Terrorism is recognized as fueled by the obscene disparities between rich and poor. Global policymakers also understand better that investment in health produces some of the richest returns in economic and social development. Health care becomes a “must have,” not a “nice to have.”
  • The primary concerns and resources of academic medicine are to improve global health.
  • The focus on global health offers intellectual stimulation and prestige to academics.
  • Academics champion human rights, economics, and the environment as key determinants of health.
  • Basic science remains important because of emerging global diseases.
  • The G-8 governments sign an accord prohibiting the recruitment of academic health professionals from developing countries.
  • Universities in the Northern Hemisphere commit 10 percent of their faculties’ time to the Southern Hemisphere.
  • North—North and South—South academic partnerships and networks flourish.
  • The 90:10 gap narrows rapidly
  • GAP is idealistic and suffers because political will and global cooperation are often lacking
• Fully Engaged: Academic Medicine Engages Energetically with all Stakeholders
  Academic medicine realizes that most of its relationships with its stakeholders are poor. The public has little or no understanding of what academic medicine is or why it matters. Indeed, its very name implies irrelevance to many. Patients often feel patronized by academics, and many practitioners, including doctors, are not convinced of the value of academic medicine. Policymakers find that academics don’t understand their problems and that the studies they produce come too late to be useful. Some leading academics do have good relationships with politicians, who recognize that biotechnology may be very important to creating future wealth, but the public profile of academic medicine is both low and clouded.
  • Medical academics worry that they are misunderstood, underappreciated, and seen as irrelevant.
  • The main goal is to engage fully with the stakeholders of academic medicine: patients, practitioners, policymakers, and the public.
  • New organizations are created, and existing ones are reshaped, embracing openness.
  • The media are used to interacting with the public.
  • Governance involves all stakeholders; sometimes the academy president is a prominent patient, journalist, or community leader.
  • Medical students drive medical education rather than simply being its consumers
  • Medical academics diversify, and intellectual fiefdoms are breached.
  • Critics worry about “dumbing down” and popularizing academic medicine.
  • Academic medicine fights to remain truly original and independent.

The 5 scenarios share the following features:

• In all the scenarios, academic medicine puts more effort into relating to its stakeholders (the public, patients, practitioners, politicians, and policymakers) which may necessitate the creation of new institutions that involve all these groups.
• academic institutions must be more globally minded.
• Teaching, researching, improving, leading, and providing service will continue to be important, but expecting individuals to be competent in all of these will become increasingly impractical.
• Although teamwork will become more important, individuals also must be allowed to shine and flourish.
• Competition among academic institutions is likely to increase and to become more international.
• In all the scenarios, academic institutions need to become more "businesslike" and more adept at using the media.
• Teaching and learning will become even more important, with one reason being that dissatisfied students may go elsewhere. Learning will be lifelong and depend heavily on information technology.
• It will be even more important to combine research, both basic and applied, with implementation and improvement. The gap between knowledge and practice will become increasingly intolerable.
• The range of types of academic institutions is likely to become more diverse, with medical schools or academic centers being just one of these types.
• The thinking and skills of academic medicine must become broader, combining with and learning from other disciplines like economics, law, ecology, and humanities.
• Thinking about the future will become both increasingly important and increasingly difficult for academic institutions.