How to attract,retain and nurture young academic clinicians

Abstract

Introduction

The announcement of a new UK Centre for Medical Research and Innovation (UKCMRI), which will concentrate on attracting scientists in their mid-30s who are eager to try new ideas, 1 recognizes, although it may be too late for some, the need to make academic careers more attractive and to ensure that trainees, the specialists of the future, are bred in such a way as to be able to practise their discipline most efficiently. We therefore need to consider how those young scientists should best be encouraged.

For at least 15 years there has been a crisis in academic medicine, which has been extensively discussed in the UK and the USA. 2, 3 For example, the number of academic clinicians in the UK has been falling. Since this trend was first highlighted, 4 there have been various initiatives to try to reverse it. Here I review the measures that have been instituted in the UK, enumerate the problems that handicap academic recruitment and retention, and suggest remedies, inspired by Peter Medawar's Advice to a Young Scientist and James Watson's Avoid Boring People. Although my comments are formulated from a UK perspective, the problems that I discuss, of how to attract, retain and nurture academic clinicians, are universal, and recent UK initiatives are relevant to academic medicine wherever it is practised.

Recent UK initiatives

In 2000 the Savill Report of the Academy of Medical Sciences, ‘The tenured track clinician scientist: a new career pathway to promote recruitment into academic medicine’, 5 recommended the introduction of a clinician–scientist scheme, supplementing existing junior medical posts (specialist registrars and clinical lecturers). The National Clinician Scientist Fellowship Award Scheme was launched in April 2001 by the Health Foundation and the Academy of Medical Sciences. The awards are funded by governmental bodies, private charities, and pharmaceutical companies.

In 2005, a joint subcommittee of Modernising Medical Careers (MMC) and the UK Clinical Research Collaboration (UKCRC), chaired by the Director of The Wellcome Trust, in a wide-ranging report,⁶ proposed introducing academic posts into clinical training programmes during the second year after graduation (enabling trainees to explore their potential for an academic career) and academic training programmes (academic clinical fellowships followed by clinical lectureships) in partnerships of Universities with National Health Service (NHS) Trusts and University Deans. Such posts have been introduced. 7

Since then there has been a small upturn. The number of UK clinical academics increased by 2.28% from 2930 full-time equivalents in 2006 to 2997 in 2007.⁸ However, related to the total number of clinicians there was a fall of 0.45%, from 6.42% to 5.97% (the proportion in 2000 having been 7.94%). The number of full-time equivalents reached 3032 in 2008 and 3087 in 2009,⁹ annual increases of only 1–2%. The number of lecturers increased by 5.47% in 2006–2007, 6.13% in 2007–2008, and 5.97% in 2008–2009, presumably mainly due to the MMC/UKCRC scheme. But currently, at least 6.2% of clinical academic posts are unfilled and the 2009 staffing level was 12% lower than in 2000.⁹ My own subject, clinical pharmacology, has started to benefit from increased interest; 10 the Wellcome Trust has instituted research lectureships in translational medicine and therapeutics,^11,12 and the Medical Research Council has announced funding for new clinical training posts. 13 However, much more expansion, including more permanent consultant posts in Universities and the NHS, is needed if teaching and training in safe prescribing and the avoidance of medication errors is to be improved and maintained. 14, 15, 16 The need has been recognized, but recent financial cuts are not encouraging.

One would expect NHS research funding, such as the Department of Health's 2006 initiative, ‘Best Research for Best Health’, 17 to affect numbers of clinical academics. Although an extensive review of the impact of the Health Technology Assessment programme on UK research did not mention academic recruitment, 18 it would be surprising if it has not had some positive effect, perhaps mitigating the fall in numbers that might otherwise have occurred.

It is encouraging that solutions are being sought. However, it appears that progress is very slow and limited to prestigious schemes. Furthermore, we need to attract young clinicians to careers in academic medicine outside of such schemes, and to retain them. I have found few specific recommendations about how this might be achieved. For example, in 2003 the Academy of Medical Sciences, discussing how clinical research in the UK might be resuscitated, 19 recommended that ‘better career and reward structures are needed for clinical researchers’, but without explicit discussion about how academics could be attracted, retained and nurtured.

Problems and aspirations

In 2003 the BMJ and 40 other partners launched ICRAM (the International Campaign to Revitalise Academic Medicine). 2, 3 The campaign was led by a working party of 20 medical academics from 14 countries, with associated groups representing academia, business and industry, government and policymakers, journal editors, patients, professional associations, and students and trainees. They gave themselves the challenging task of re-inventing academic medicine, but in 2004 confessed that the task had ‘proved difficult’. 3 ‘The members of the group often couldn’t agree [and] to break the deadlock we decided on scenario planning.' This resulted in five theoretical scenarios (‘futures’) that might inform the debate, although the members of the group admitted that the scenarios were unlikely to come about. 20, 21 This disappointing outcome prompted others to comment that ‘the scenarios give limited reassurance that the current crisis is understood’ and to point out some of the major problems that needed to be addressed: 22

Research assessment exercises. Although the UK Research Assessment Exercise (RAE) has been defended, 23, 24 it has been thoroughly and repeatedly criticized, 25, 26, 27 as has the scheme that will replace it, the Research Excellence Framework (REF). 28, 29, 30 The need for such exercises has been questioned, 31 and the harm they can do has been reviewed; 32, 33

Bureaucratic research governance. Academic medicine in the UK has suffered from neo-puritanical regulatory structures, including draconian ethics procedures and the EU Clinical Trials Directive; 34, 35, 36

The demands of working for two masters (University and, in the UK, the NHS);

The difficulties of animal experimentation: Threats from activists can discourage academics. 37, 38

Box 1

Advice to a Young Scientist and Avoid Boring People

Advice to a Young Scientist, according to its author, is ‘the kind of book I myself should have liked to have read when I began research’. It consists of a series of simple messages about various aspects of the conduct of science, seen from the point of view of a non-clinical scientist.

Avoid Boring People by James D Watson, who ‘nurtured and inspired legions of younger scientists’,⁵⁴ is his latest set of memoirs. Like Enduring Love, Ian McEwan's exploration of the problem of tolerating (enduring) a particular kind of persistent (enduring) love, Watson's title is ambiguous. An early part of his text suggests that ‘boring’ is an adjective: ‘Reading the New York Times at breakfast will expose you to many more facts and ideas than you are ever likely to acquire during evenings with individuals who in most instances haven’t had to think differently since getting tenure' (p. 92). However, he later uses ‘boring’ as a verb: ‘Not boring others requires that you take pains not to become boring, as often happens when you begin to bore yourself’ (p. 311).

Watson's book has two unusual features. Each chapter has a title of the form ‘Manners acquired/learned/etc [in some capacity or other]’; Chapter 6, for example, is titled ‘Manners needed for important science’. And each chapter ends with a set of up to 12 ‘remembered lessons’, such as ‘avoid boring people’. These lessons, which lift the book above the ordinary, range from the frivolous (‘buy, don’t rent, a suit of tails [for the Nobel ceremony]') and banal (‘schedule as few appointments as possible’) to the profound (‘exaggerations do not void basic truths’).

There are other problems:

The over-emphasis in recent years on bench science at the expense of clinical science, 19 coupled with a reduced ability of the NHS to support clinical research; 39

Reduced numbers of individuals to act as role models for clinical academics. This has a multiplicative effect – there are fewer senior academics, who consequently have more administrative duties to carry out, locally and nationally, and less time to train and inspire young clinicians;

Lack of administrative support for academics, diverting them from scholastic pursuits;

The increasingly international outlook of UK medical journals, which commission more authors from abroad, giving UK researchers fewer opportunities to air their expertise to national and international audiences. Some universities now also encourage their staff to publish in the journals with the highest impact factors, a misguided policy 40 which disadvantages UK journals and hence UK science, an effect that will be exacerbated by the REF;

The loss, following the adoption of the new UK consultant contract in 2003, of parity between some clinical academic and NHS salaries;⁶ there may also be related resentment among clinical academics, who generally work longer hours than contracted.⁴¹

There is a further concern. Thomas S Kuhn, in The Structure of Scientific Revolutions 42 distinguished ‘normal’ science (‘research firmly based upon one or more past scientific achievements, achievements that some particular scientific community acknowledges for a time as supplying the foundation for its further practice’, p. 10) and ‘revolutionary’ science (‘transformations of paradigms’, p. 12). We are excellent at normal science, but not so successful, it has been suggested, at revolutionary science. 43 Incidentally, although it is often assumed that revolutionary science is always basic science, that is not so; 44 the Nobel prizes to Barry Marshall in 2005 for his work on Helicobacter pylori and to Robert Edwards in 2010 for his work on in vitro fertilization emphasize that clinical research can be revolutionary too.

Table 1

Twelve suggested precepts for attracting and retaining academic clinicians and encouraging them to be scientifically revolutionary

Precept	Relevant comment from Peter Medawar's Advice to a Young Scientist ⁴²	Relevant comment from James D Watson's Avoid Boring People ⁴³
1. Inculcate curiosity in [undergraduate and graduate] students as early as possible, starting in school, or at least in University	‘Most able scientists I know have something for which “exploratory compulsion” is not too grand a description’ [Medawar decries the word ‘curiosity’ as inadequate] (p. 7)	‘Keep your intellectual curiosity much broader than your thesis objective’ (Chapter 3, lesson 7)
2. Expose them to research early on, preferably before they achieve their first degree	‘By far the best way to become proficient in research is to get on with it’ (p. 17)	‘Encourage undergraduate research experience’ (Chapter 8, lesson 4)
3. Expose them to prize-winning scientists; encourage established scientists to act as role models	‘Inbreeding is often the way in which a great school of research is built up’ (p. 13)‘Isolation is disagreeable and bad for graduate students. The need to avoid it is one of the best arguments for joining some intellectually bustling concern’ (p. 14)	‘Never be the brightest person in a room’ (Chapter 6, lesson 3)
4. Encourage them to develop interdisciplinary scientific interests (and to study humanities)	‘Young scientists … should have more than one string to their bow’ (p. 6) ‘Many successful scientists try their hands at a great many different things before they settle upon a main line of investigation’ (p. 14) ‘An indifference to the history of ideas is widely interpreted as a sign of cultural barbarism – and rightly, too, I should say, because a person who is not interested in the growth and flux of ideas is probably not interested in the life of the mind’ (p. 30)	‘Our discovery [of the structure of DNA] was done using the methods of physics and chemistry to understand biology’ (p. 188)‘A subscription to the Times Literary Supplement made me more interesting to sit beside than someone whose diet was limited to Time, Newsweek, or The Economist—or Nature for that matter’ (p. 311)
5. Give researchers the courage to tackle difficult problems and allow them to take risks	‘It can be said with complete confidence that any scientist of any age who wants to make important discoveries must study important problems’ [italics in original] (p. 13)	‘Have a big objective that makes you feel special’ (Chapter 5, lesson 1)‘Choose an objective apparently ahead of its time’ (Chapter 6, lesson 1)
6. Teach researchers how to communicate their results most effectively and to persist in the face of skepticism	‘Most scientists do not know how to write’ (p. 63)‘Young scientists … should be willing to take no for an answer if the evidence points that way’ (p. 6)‘A young scientist must beware of following fashion’ (p. 15)‘It is better by far to have the reputation for being querulous and unwilling to be convinced than to give reason to be gullible’ (p. 94)	‘Immediately write up big discoveries’ (Chapter 8, lesson 7)‘Irreproducible results can be blessings in disguise’ (Chapter 5, lesson 3)‘Intellectuals who break new ground inevitably threaten minds continuing in old ways’ (p. 50)
7. Give long-term contracts (7–10 years) to postdoctoral academic clinicians (‘post-docs’) and tenure to researchers who have proved themselves	‘[The] postdoctoral revolution is an unqualifiedly good thing, and it is very much to be hoped that the patrons and benefactors of science will not allow it to languish’ (p. 15)	‘Promote key scientists faster than they expect’ (Chapter 14, lesson 7)
8. Abandon minimum target standards for all researchers; encourage diversity and an environment in which revolutionary scientists can flourish, supported by both high-class normative scientists and academics who are not necessarily research active but whose talents lie in other scholastic areas	‘The great incentive to learning a new skill is an urgent need to use it. … very many scientists … do not learn new skills or master new disciplines until the pressure is upon them to do so’ (p. 16)	‘Manage your scientists like a baseball team’ (Chapter 13, lesson 3)‘Teaching can make your mind move on to big problems’ (Chapter 8, lesson 1)‘Join the editorial board of a new journal’ (Chapter 8, lesson 6)‘A wise editor matters more than a big advance’ (Chapter 12, lesson 2)‘Become the chairman’ (Chapter 11, lesson 6)
9. Change current methods of funding (return to the old formulae or find another way of distributing funds); re-establish baseline funding (the ‘well-founded laboratory’), including the restoration of administrative help for academics)	‘To be creative, scientists need libraries and laboratories and the company of other scientists’ (p. 40)	‘Be prepared to resign over inadequate space’ (Chapter 11, lesson 3)[On learning that Harvard proposed to give only $1m to all science departments for supplies and equipment]: ‘the miserly way Oxford was being run toward insignificance [in 2001] was no way for Harvard to keep pace with MIT’ (p. 323)‘Research grants, no matter how much overhead they cover, are never enough to meet immediate needs’ (p. 313)
10. Employ professional grant writers	‘It is the administrator’s job to get money and the scientist's to spend it' (p. 58)	‘Under normal funding circumstances, those who have remained successful invariably get adequate research grants to cover themselves and then some’ (p. 284)
11. Reduce regulatory bureaucracy; abandon research assessment exercises; abandon compulsory appraisal	‘A scientist’s work is in no way deepened or made more cogent by privation, anxiety, distress, or emotional harassment' (p. 40)	‘Scientists do their jobs best when left alone to do them, freed of the irksome impression of simply carrying out someone else’s will' (p. 311)
12. Pay clinical academics the same as their non-academic counterparts	‘[Do not] treat a graduate student … as a disposable colleague’ (p. 14)	‘Success should demand a premium’ (Chapter 11, lesson 1)‘Much bunk is peddled about money not being a prime motive of the academic’ (p. 210)

I consider it axiomatic that academic medicine matters. 45 That being so, there is a spectrum of aims to which we should aspire: to attract young clinicians to academic careers; to retain and nurture them; and to encourage them to be scientifically innovative and revolutionary. To do this we should break down these barriers to academic progress.

Lessons from PB Medawar and JD Watson

Where better to seek advice on all this, and particularly on how to be a revolutionary scientist, than in the writings of revolutionary scientists themselves. The texts I have chosen are by UK and US scientists, both Nobel prize winners: Advice to a Young Scientist by Peter B Medawar 46 and Avoid Boring People by James D Watson 47 (Box 1). It is beyond my scope here to discuss in detail matters such as research assessment exercises and the bureaucracy of research ethics, which others have discussed widely (see above).

How to attract, retain and nurture academic clinicians

These two books suggest 12 precepts for attracting, retaining and nurturing academic clinicians and encouraging the emergence of revolutionary science. The supporting lessons from Medawar and Watson are quoted in Table 1:

Inculcate curiosity in [undergraduate and graduate] students as early as possible, starting in school;

Expose them to research early on;

Expose them to prize-winning scientists (prize-winners breed prize-winners 48 ); encourage established scientists to act as role models;

Encourage them to develop interdisciplinary scientific interests (and to study humanities);

Give researchers the courage to tackle difficult problems and allow them to take risks;

Teach researchers how to communicate their results most effectively and to persist in the face of skepticism;

Give long-term contracts (7–10 years) to post-doctoral academic clinicians (post-docs a );

Abandon minimum target standards for all researchers – this breeds [relative] mediocrity; instead, encourage diversity and an environment in which the few really revolutionary scientists can flourish, supported by both high-class normative scientists and academics who are not necessarily research active but whose talents lie in other scholastic areas (e.g. teaching, editing, policy-making; see also below);

Change current methods of funding (return to the old formulae or find another way of distributing funds); re-establish baseline funding (the ‘well-founded laboratory’, including the restoration of administrative help for academics);

Employ professional grant writers; they will teach young researchers the art of writing a grant application, help senior researchers prepare their applications (freeing time for research), and do research on methods of funding (contributing to policy);

Reduce regulatory bureaucracy; 35, 36 abandon research assessment exercises;^25-27,31 abandon compulsory appraisal;

Pay clinical academics the same as their non-academic counterparts. 6

Some of these precepts appear in the MMC/UKCRC report,⁶ and the Academy of Medical Sciences offers successful applicants to its Scientist Award Scheme access to mentoring and professional networks, and connects award holders to peers and senior academic leaders. 5 However, some we could do better. Others we do not do at all, and should.

A model for academic clinicians

Although Medawar's and Watson's remarks are aimed at non-clinical scientists, they also apply to academic clinicians. That academic clinicians cannot fulfil all of the roles that are expected of them – as innovative (revolutionary) researchers, authoritative clinicians (whether in hospital or general practice), and inspiring teachers, setting aside administrative tasks and their contributions to national policy – is not a new idea, although it is one that has been rejected in the past. 49 However, the increasing complexity of clinical medicine, and in particular the advent of new types of therapeutic agents and techniques, and the increasing complexity of research techniques, have made it truly much more difficult for them to excel in all aspects of their profession. We should acknowledge that it is no longer possible for clinical academics to fulfil each of their three expected roles, especially if it is true, as has been suggested, that it takes 10,000 hours of experience to become proficient at anything. 50 Even those who have the capacity do not have the time, especially now that there are fewer of them. We should, therefore, encourage the development of those who excel at any two of these (

Figure 1

A tripartite model for clinical academics. The small central diagram is the traditional model; the three outer diagrams show a proposed model for three interacting types of academic clinicians; policy-making is omitted for the sake of clarity

Figure 1) and formally establish the following categories: 51

researcher–teachers (mainly laboratory-based): innovative researchers, training young academics;

clinician–teachers (mainly clinically-based): authoritative clinicians and inspiring teachers;

clinician–researchers: combining clinical and research skills, bridging the other two groups.

All categories should take part in the development of national and international policy, and some may eventually move into full-time policy roles. There should be freedom to change category during a career, if aptitude allows. 6

The category of researcher–teachers will be relatively small. Truly revolutionary scientists are scarce and it is difficult, if not impossible, to predict at an early stage which will be. We should train and enable all scientists to be élite (in the best sense of the word), but discourage them from behaving in an élite fashion (in the worst), since the revolutionary ones must be prepared to liaise with both normative scientists (as described by Kuhn 42 ) and practising clinicians. We should protect this category from administrative and external duties that divert them from their research. We should nurture them, by giving them unrestricted grants for extended periods, subject to only occasional review. Some enlightened grant-giving bodies have done this in the past.

Describing academics as clinician–teachers and clinician–researchers does not rule out the possibility that the former will do some research and the latter some teaching; however, such duties should not be part of the general expectation, as they currently are. Both groups would, however, be expected to take part in administrative duties and policy development, locally, nationally, and internationally when relevant. Interactions among researcher–teachers, clinician–teachers, clinician–researchers, and non-clinical scientists would stimulate the development of translational medicine.

Funding

Joint funding streams would enable such posts, sharing costs among universities, grant-giving bodies, healthcare services (such as the NHS in the UK), and industry (e.g. pharmaceutical companies)

Figure 2

Possible joint funding streams for the different types of clinicians outlined in Figure 1; the illustrated possibilities are not comprehensive

(Figure 2).

Such schemes could be instituted universally.

Table 2

Examples of joint funding schemes in clinical pharmacology

Source of funding	UK examples
University + drug company	Company contract work in departments of clinical pharmacology; clinical trials of new agents
University + NHS	Traditional academic clinicians (‘A+B’ posts)
University + grant-giving body	Traditional research grants (now eroded by full economic costing)
Grant-giving body + drug company	Wellcome Trust Research Programmes in Translational Medicine and Therapeutics
Grant-giving body + NHS	MRC Clinical Pharmacology and Pathology Fellowship Programmes
Drug company + NHS	ABPI/NHS training scheme for clinical pharmacology; clinical trials of new agents

Table 2 shows UK examples of joint sources of funding in clinical pharmacology; clinicians in other disciplines and other countries will be able to give examples from their own experience. Clinician–teachers have for many years been jointly funded by UK Universities and the NHS (in what used to be called ‘A+B’ posts). Schemes for joint funding of researcher–teachers, by, for example, grant-giving bodies and pharmaceutical companies, have a long history, a recent example being the Wellcome Trust's programmes in translational medicine and therapeutics. 52 A scheme run jointly by the Association of the British Pharmaceutical Industry and the NHS a few years ago 53 was an excellent example of joint funding of training posts for clinician–researchers by drug companies and a healthcare provider. The Medical Research Council's Clinical Pharmacology and Pathology Fellowship Programmes 13 exemplify how a grant-giving body and a healthcare provider can jointly fund clinician–researchers.

Conclusions

If we are to stimulate academic medicine we must make academic careers more attractive and ensure that our trainees, the specialists of the future, are bred in such a way as to be able to practise their discipline most efficiently. We should provide them with role models. Current demands on clinical academics are excessive; we should lighten the burden of expectation, increase their efficiency, and give them more freedom to pursue the art and science of being an academic clinician.

Interactions among different types of clinicians (researcher–teachers, clinician–teachers and clinician–researchers), and with non-clinical scientists, would stimulate the development of translational medicine.

Joint funding streams would enable such posts, sharing the costs among universities, grant-giving bodies, healthcare providers, and industry (e.g. pharmaceutical companies).

Lessons from the writings of a UK scientist, Peter Medawar, and a US scientist, James Watson, both Nobel prize winners, suggest 12 precepts for attracting, retaining and nurturing academic clinicians. To these I add a 13th: study the autobiographies of revolutionary scientists.

Footnotes

DECLARATIONS

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor JKA

Contributorship JKA is the sole contributor

Footnotes

Acknowledgements

None

a

In a medical context this term implies a doctor who has received a research degree such as PhD or MD (the latter being a postgraduate research degree in the UK) after achieving a primary medical qualification, such as MBChB or MBBS (in the UK) or MD (in the USA and elsewhere).

References

. London's ‘somewhat unusual’ new research centre. Nature 2010 June 18. See http://www.nature.com/news/2010/180610/full/news.2010.307.html (last checked 20 June 2010)

Clark

Smith

. BMJ Publishing Group to launch an international campaign to promote academic medicine BMJ 2003; 327: 1001–2

International Working Party to Promote and Revitalise Academic Medicine. ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting. BMJ 2004;329:787–9

College of Vice Chancellors and Principals. Clinical academic careers. Report of an independent task force. London: CVCP; 1997

The Academy of Medical Sciences. National Clinician Scientist scheme. See http://www.acmedsci.ac.uk/p57.html (last checked 26 July 2010)

The Academic Sub-Committee of UKCRC and Modernising Medical Careers. Medically and Dentally Qualified Staff: Recommendations for Training the Researchers and Educators of the Future. London: Modernising Medical Careers, 2005. See http://www.ukcrc.org/PDF/Medically_and_Dentally-qualified_Academic_Staff_Report.pdf (last checked 26 December 2008)

UK Clinical Research Collaboration. Clinical Academic Careers for Doctors and Dentists. See http://www.ukcrc.org/workforcetraining/doctorsanddentists (last checked 26 July 2010)

Fitzpatrick

. Staffing Levels of Clinical Academics in UK Medical Schools as at 31 July 2008. London: Medical Schools Council, 2009. See http://www.medschools.ac.uk/SiteCollectionDocuments/MSC%20Clinical%20Academic%20Staff%20Survey%20July%202008.pdf (last checked 26 July 2010)

Fitzpatrick

. A Survey of Staffing Levels of Clinical Academics in UK Medical Schools as at 31 July 2009. London: Medical Schools Council, 2010. See http://www.medschools.ac.uk/AboutUs/Projects/Documents/Clinical%20Academic%20Staff%20Survey%202010.pdf (last checked 26 July 2010)

10.

Aronson

. Clinical pharmacology and therapeutics in the UK – a great instauration. Br J Clin Pharmacol 2010;69:111–17

11.

Wellcome Trust. Interdisciplinary Training Programmes for Clinicians in Translational Medicine and Therapeutics. See http://www.wellcome.ac.uk/node2165.html (last checked 4 January 2008)

12.

Aronson

Cohen

Lewis

. Clinical pharmacology – providing tools and expertise for translational medicine. Br J Clin Pharmacol 2008;65:154–7

13.

MRC Clinical Pharmacology and Pathology Fellowship Programmes. See http://www.mrc.ac.uk/Fundingopportunities/Fellowships/Clinicalpharmacologypathology/index.htm (last checked 29 December 2009)

14.

Maxwell

Webb

. Clinical pharmacology – too young to die? Lancet 2006;367:799–800

15.

Aronson

. A prescription for better prescribing. Br J Clin Pharmacol 2006;61:487–91

16.

Aronson

Henderson

Webb

Rawlins

. A prescription for better prescribing. BMJ 2006;333:459–60

17.

Department of Health. Best Research for Best Health – a National Health Research Strategy. London: Department of Health; 2006. See http://www.dh.gov.uk/en/Researchanddevelopment/Researchanddevelopmentstrategy/index.htm (last checked 26 July 2010)

18.

Hanney

Buxton

Green

Coulson

Raftery

. An assessment of the impact of the NHS Health Technology Assessment Programme. Health Technol Assess 2007;11:iii–iv, ix–xi, 1–180

19.

Bell

, on behalf of the working group of Academy of Medical Sciences. Resuscitating clinical research in the United Kingdom. BMJ 2003;327:1041–3

20.

Clark

, for the International Campaign to Revitalise Academic Medicine. Five futures for academic medicine: the ICRAM scenarios. BMJ 2005;331:101–4

21.

Awasthi

Beardmore

Clark

.; International Campaign to Revitalise Academic Medicine. Five futures for academic medicine. PLoS Med 2005;2:e207

22.

Symonds

Bell

Banatvala

. Five futures for academic medicine: future of academic medicine looks bleak. BMJ 2005;331:694

23.

Gordon

. UK's Research Assessment Exercise. Lancet 2005;365:1025

24.

Hillhouse

Noble

. UK's Research Assessment Exercise. Lancet 2005;365:1025–6

25.

Williams

. Misleading, unscientific, and unjust: the United Kingdom's research assessment exercise. BMJ 1998;316:1079–82

26.

Tomlinson

. The research assessment exercise and medical research. BMJ 2000;320:636–9

27.

Banatvala

Bell

Symonds

. The Research Assessment Exercise is bad for UK medicine. Lancet 2005;365:458–60

28.

Higher Education Funding Council for England. Research Excellence Framework. See http://www.hefce.ac.uk/Research/ref/ (last checked 26 July 2010)

29.

Mroz

. First, let's find out if it will fly. Times Higher Educ 2009 December 17. See http://www.timeshighereducation.co.uk/story.asp?sectioncode=26&storycode=409630 (last checked 29 December 2009)

30.

Collini

. Impact on humanities. Times Lit Suppl 2009 November 13:18–19

31.

. What next for the UK's Research Assessment Exercise? Lancet 2007;370:1738

32.

Gillies

. Why research assessment exercises are a bad thing. Post-Autistic Econ Rev 2006;37:1

33.

Gillies

. Lessons from the history and philosophy of science regarding the research assessment exercise. Royal Inst Philos Suppl 2007;82:37–73

34.

Aronson

. What is a clinical trial? Br J Clin Pharmacol 2004;58:1–3

35.

Stewart

Stears

Tomlinson

Brown

. Regulation – the real threat to clinical research. BMJ 2008;337:a1732

36.

Godlee

. It's time to change how Europe regulates research. BMJ 2008;337:a2986

37.

Yeoman

. The £1m hate campaign paid for by high street collections. The Times 2008 December 24:6

38.

Yeoman

. Extremists face long jail sentences after blackmail conviction. The Times 2008 December 24:7

39.

Rothwell

. Medical academia is failing patients and clinicians: the neglect of basic observational clinical research. BMJ 2006;332:863–4

40.

Smith

. Commentary: the power of the unrelenting impact factor – is it a force for good or harm? Int J Epidemiol 2006;35:1129–30

41.

Williams

Buchan

. Assessing the new NHS consultant contract. A something for something deal? London: King's Fund; 2006. See http://www.kingsfund.org.uk/applications/research/index.rm?searchstring=Assessing+the+new+NHS+consultant+contract&filter=publications&id=20250&skip=0&sort=date (last checked 26 July 2010)

42.

Kuhn

. The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press; 1970

43.

Charlton

. Oxford University = University of Minnesota. What has the RAE ever done for Oxford University? Improvement in normal science – but decline in revolutionary science. Oxford Magazine 2008;271:3–5. See http://charltonteaching.blogspot.com/2008/01/oxford-university-university-of.html (lst checked 26 December 2008)

44.

Rothwell

. Funding for practice-oriented clinical research. Lancet 2006;368:262–6

45.

Clark

Tugwell

. Does academic medicine matter? PLoS Med 2006;3:e340

46.

Medawar

. Advice to a Young Scientist. New York, NY: Harper & Row; 1979

47.

Watson

. Avoid Boring People. Lessons From a Life in Science. Oxford: Oxford University Press; 2007

48.

Zuckerman

. The sociology of the Nobel prizes. Sci Am 1967;217:25–33

49.

Williams

. The clinical investigator and his role in teaching, administration, and the care of the patient. JAMA 1954;156:127–36

50.

Gladwell

. Outliers. The Story of Success. New York, NY: Little, Brown and Company; 2008

51.

Aronson

. Fitzpatrick Lecture. Clinical Pharmacology – A Suitable Case for Treatment. Royal College of Physicians, London, 2 April 2007. See https://admin.emea.acrobat.com/_a45839050/p74648562/

52.

Wellcome Trust brings academia and industry together to share clinical and research expertise. See http://www.wellcome.ac.uk/News/Media-office/Press-releases/2008/WTX049865.htm (last checked 29 December 2009)

53.

Baber

Brown

. A new opportunity for training in clinical pharmacology. Br J Clin Pharmacol 1996;41: 365–8

54.

Coyne

. Review of James D Watson's Avoid Boring People. And Other Lessons From a Life in Science . Times Lit Suppl 2008;5463:22–3