Doctors are expected to perform miracles. But can medical scientists handle the many expectations in science and everyday clinical work while at the same time ensuring high standards in research and patient care?
© Artur Gabrysiak - iStockphoto.comMirroring the development of our science and healthcare system, the image of the physician in academic medicine, which has always been complex, has become even more differentiated over the past decade - driven not least by the spread of the molecular medicine paradigm. The main issue however remains how the physician's personal circumstances can be brought into line with the central tasks of academic medicine. Reconciling highest standards of patient care, research and teaching with an increasingly difficult economic situation and a critical ethical and legal point of view in everyday life is the challenge today.
Pressure on the management of university clinics to be economically self-sufficient is continuing to grow in a manner that appears to threaten their other academic functions. The influence of the Excellence Initiative and other educational policy concepts in research funding is impossible to ignore, as is the resulting pressure to focus on specific areas of research and overspecialise institutionally. Added to this are public demands for improved medical training and to adapt to international standards.
The role of performance incentives and career opportunities, and of course developments in remuneration systems, are further factors whose role in changing the image of doctors must be examined. Clinical academic medicine now has competition. Private clinics working in highly specialised fields have become established in the knowledge that possible risks will be covered by the university clinic. Limited staff coverage means that many clinics require an organisational tour de force to compete because they have to provide superordinate clinical services and training in addition to these specialised institutions. As complete care centres and in view of the complex commitment to further training, university clinics can however not afford to act solely as clusters of equally specialised clinical departments. The dynamics of change in the healthcare system additionally demand economic and administrative consequences that are not necessarily conducive to meeting scientific challenges and fulfilling teaching duties.
Scientific academic medicine is also facing further competition. The extreme demands of the Excellence Initiative will only be met in medicine if it succeeds in spanning the divide between basic research and its application in patients. Scientific policy is intensifying this issue by specifically funding extra-mural application-oriented research institutions designed to focus on the most important health-related topics in collaboration with top clinical researchers.
But this type of top-class research can only become established where openness to basic research and experience of research with patients meet - ideally combined in a single leading personality. The medical faculties have begun to examine student training with a new intensity in recent years. Apart from local curricular pilot projects, the new Federal Regulation on the Licensing of Doctors (Approbationsordnung für Ärzte, ÄAppO) has undeniably created a wave of professionalisation. Today, further training courses in academic teaching are sometimes even mandatory, and performance-related distribution of teaching funds is already established at some faculties.
Teaching duties, previously often sidelined in the clinical field due to the pressures of patient care, have in many places become positively connoted teaching functions. The trend to gradually also introduce separate budgets for teaching and counteract the extreme time demands through methodical professionalisation has doubtless also contributed to this development.
Only a few years ago, a suggestion to distribute the tasks of university medicine, patient care and teaching on the one hand and research on the other hand to different heads was under discussion. The previously described differentiation of the functions of academic medicine allowed a structure of this type to appear as a new way forward. Talk of the "tandem model" for managing university clinics as demanded by the Science Council and the German Research Foundation has however died down again. The idea of taking better advantage of highly specialised individual skills in this way appeared promising only at first sight. The inevitably associated communicative and organisational problems became apparent all too quickly, not to mention issues relating to status and education. Whichever way it is considered, the special status of academic clinical medicine still consists of the indispensable requirement to combine patient care, research and teaching in the person of the physician. Only from this closely interconnected position can it fulfil each of its respective remits. The personal freedom to focus on individual areas of interest has however grown.
This issue must be discussed particularly with respect to its effects on the orientation of young medical scientists. Setting out on such a thorny career path as a young person requires an at least vaguely recognisable guiding image. The haziness of this image and exaggerated expectations have doubtlessly contributed to the fact that today too few young people are embarking on this route to a university career. After years of excessive commitment, many young scientists may additionally find themselves faced with the insecurity of how to evaluate their own career opportunities.
This is what the question of the physician's image in academic medicine seems to me to currently be about: a scientifically oriented pattern of thinking for developing independent questions and clinical research must be acquired through thorough post-graduate scientific activity, and can then become the foundation of any type of scientific co-operation. Only in this way will it be possible to keep abreast of the transition towards a molecular medical paradigm and the rapid progress in biomedical research. Professionalisation in the functions of patient care and teaching must complete this necessarily complex image. That every doctor will of course develop a personal focus within this overall picture does not change the fact that the unity of the physician's image will remain indispensable to ensuring the high standards of clinical academic medicine now and in the future.
From Forschung und Lehre :: April 2010
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