Medical research funding may have over-expanded and be due for collapse

Reporting of medical research costs. Improving transparency and reproducibility of medical research

Increasing numbers of research reporting guidelines are being published. These guidelines facilitate rigorous and complete reporting, and presentation of published studies. However, current reporting guidelines do not address issues related to costs of research methods. We propose to publish costs of research in order to increase transparency, efficiency, quality and ultimately reproducibility of scientific studies.

After science: has the tradition been broken?

The majority of professional scientists make use of the artefacts of science but lack understanding of what these mean; raising the question: has the tradition of science been broken? Explicit knowledge is only a selective summary but practical capability derives from implicit, traditional or 'tacit' knowledge that is handed on between- and across-generations by slow, assimilative processes requiring extended human contact through a wide range of situations. This was achieved mainly by prolonged apprenticeship to a Master. Such methods recognize the gulf between being able to do something and knowing how you have done it; and the further gap between knowing how you have done something and being able to teach it by explicit instructions. Yet the 'Master-apprentice' model of education has been almost discarded from science over recent decades and replaced with bureaucratic regulation. The main reason is probably that scientific manpower has expanded so rapidly and over such a long period as to overwhelm the slow, sure and thorough traditional methods. In their innocence of scientific culture, the younger generation of scientists are like children who have been raised by wolves; they do not talk science but spout bureaucratic procedures. It has now become accepted among the mass of professional 'scientists' that the decisions which matter most in science are those imposed upon science by outside forces: for example by employers, funders, publishers, regulators, and the law courts. It is these bureaucratic mechanisms that now constitute the 'bottom line' for scientific practice. Most of modern science is therefore apparently in the post-holocaust situation described in A canticle for Liebowitz and After Virtue, but the catastrophe was bureaucratic, rather than violent. So, the tradition has indeed been broken. However, for as long as the fact is known that the tradition has been broken, and living representatives of the tradition are still alive and active, there still exists a remote possibility that the tradition could be revived.

Institutional operating figures in basic and applied sciences: scientometric analysis of quantitative output benchmarking

Background

Institutional operating figures and benchmarking systems are important features for the implementation of efficacy in basic and applied sciences. They are needed for research evaluation and funding policy. However, the current policy settings for research evaluation urgently need review since there may be imbalances present in many areas.

Methods

The present study assessed benchmarking of research output. By the use of large data bases research output was categorized and analyzed. Specific areas of major research activity were identified by comparing publication density on different organ systems and inter- and intrafield comparison was performed for selected countries.

Results

Novel density-equalizing mappings were constructed that illustrate trends of publication activity and identify subsets of major interest in a total of 5,527,558 published items. A dichotomy was present between Western countries such as the US, UK or Germany and Asian countries such as Japan, China or South Korea concerning research focuses.

Conclusion

The present study is the first large scale analysis of global research activity and output over the last 50 years. The presently described assessment of operating figures at the national and international level can be used to identify single areas of research that are heavily focused. Further research on qualitative output benchmarking is needed to improve current policy settings for research evaluation.

Down-shifting among top UK scientists? - the decline of 'revolutionary science' and the rise of 'normal science' in the UK compared with the USA

It is sometimes asserted that UK science is thriving, at other times that it has declined. We suggest that both assertions are partly true because the UK is thriving with respect to the volume of 'normal' science production but at the same time declining in the highest level of 'revolutionary' science. Revolutionary science may be distinguished from normal science in that revolutionary science aims at generating qualitative advances which change the direction of established science, while 'normal' science aims at incremental progress extrapolating from established science. Revolutionary science has been measured by counting national numbers of science Nobel laureates and ISI Highly Cited (HiCi) scientists; normal science has been measured using the total volume of scientific publications and citations at both national and institutional levels. By these criteria the UK has been progressively catching-up with the USA in terms of normal science since the 1990s. At the same time the UK has declined in revolutionary science over recent decades by a significant brain drain of future Nobel laureates and HiCi scientists, and a sharply reduced success (both in absolute and compared with the USA) at winning science Nobel prizes. One possible cause for this pattern could be a time-lag, such that the UK's improved science production since about 1990 may eventually work-through into improved UK performance in revolutionary science. More pessimistically, this pattern may reflect a strategic down-shift of the best UK-resident scientists away from revolutionary science and towards less-ambitious and safer normal science which is more productive in the short term.

Analysis of arterial intimal hyperplasia: review and hypothesis

BACKGROUND

Despite a prodigious investment of funds, we cannot treat or prevent arteriosclerosis and restenosis, particularly its major pathology, arterial intimal hyperplasia. A cornerstone question lies behind all approaches to the disease: what causes the pathology?

HYPOTHESIS

I argue that the question itself is misplaced because it implies that intimal hyperplasia is a novel pathological phenomenon caused by new mechanisms. A simple inquiry into arterial morphology shows the opposite is true. The normal multi-layer cellular organization of the tunica intima is identical to that of diseased hyperplasia; it is the standard arterial system design in all placentals at least as large as rabbits, including humans. Formed initially as one-layer endothelium lining, this phenotype can either be maintained or differentiate into a normal multi-layer cellular lining, so striking in its resemblance to diseased hyperplasia that we have to name it "benign intimal hyperplasia". However, normal or "benign" intimal hyperplasia, although microscopically identical to pathology, is a controllable phenotype that rarely compromises blood supply. It is remarkable that each human heart has coronary arteries in which a single-layer endothelium differentiates early in life to form a multi-layer intimal hyperplasia and then continues to self-renew in a controlled manner throughout life, relatively rarely compromising the blood supply to the heart, causing complications requiring intervention only in a small fraction of the population, while all humans are carriers of benign hyperplasia. Unfortunately, this fundamental fact has not been widely appreciated in arteriosclerosis research and medical education, which continue to operate on the assumption that the normal arterial intima is always an "ideal" single-layer endothelium. As a result, the disease is perceived and studied as a new pathological event caused by new mechanisms. The discovery that normal coronary arteries are morphologically indistinguishable from deadly coronary arteriosclerosis continues to elicit surprise.

CONCLUSION

Two questions should inform the priorities of our research: (1) what controls switch the single cell-layer intimal phenotype into normal hyperplasia? (2) how is normal (benign) hyperplasia maintained? We would be hard-pressed to gain practical insights without scrutinizing our premises.

Mega-prizes in medicine: big cash awards may stimulate useful and rapid therapeutic innovation

Following Horrobin's suggestion of 1986, I argue that offering very large prizes (tens of millions of US dollars, or more) for solving specific therapeutic problems, would be an excellent strategy for promoting the rapid development of effective new treatments. The two mainstream ways of paying for medical research are funding the process with grants or funding the outcome via patent protection. When grants are used to fund the process of research the result tends to be 'pure' science, guided by intrinsic scientific objectives. Practical results, such as useful therapeutic advances, are a by-product. Patent-seeking research, by contrast, is more focused on technology than science. It seeks practical results; and aims to pay for itself (and make a profit) in the long term by generating a patentable product or procedure. Prize-seeking research is subject to different incentives and applicable to different situations than either process-funded or patent-seeking research. Prize seeking researchers have a strong incentive to solve the specified problem as rapidly as possible, but the problem may be solved using old ideas that are scientifically mundane or unpatentable technologies and methods. Prizes therefore seem to generate solutions which are incremental extensions, new applications or novel combinations of already-existing technologies. The main use of mega-prizes in medicine would be to accelerate therapeutic progress in stagnant fields of research and to address urgent problems. For example, medical charities focused on specific diseases should consider accumulating their resources until they can offer a mega-prize for solving a clinical problem of special concern to their patients. Prize money should be big enough to pay for the research and development, the evaluation of the new treatment in a clinical trial, and with a large profit left-over to compensate for the intrinsic risk of competing. Sufficiently large amounts of money, and the prestige and publicity derived from winning a mega-prize, could rapidly mobilize research efforts to discover a whole range of scientifically un-glamorous but clinically-useful therapeutic breakthroughs.

Contemporary (post-Wills) survey of the views of Australian medical researchers: importance of funding, infrastructure and motivators for a research career

OBJECTIVES

To investigate the perceptions of Australian health and medical researchers 4 years after the Wills Report recommended and led to a substantial increase in health and medical research funding in Australia.

DESIGN, SETTING AND PARTICIPANTS

A telephone poll of 501 active health and medical researchers, conducted between 28 April and 5 May, 2003.

MAIN OUTCOME MEASURES

Researchers' views on the adequacy of funding, infrastructure and support, salary, community recognition, the excitement of discovery and research outcomes such as publication and patenting in research.

RESULTS

Research funding was the most important concern: 91% of researchers (455/498) viewed funding as "very" or "extremely" important to their role, but only 10% (52/500) were "very" or "extremely" satisfied with the level of funding. Research infrastructure and support were seen as "very" or "extremely" important by 90% of researchers (449/501), while only 21% (104/501) were "very" or "extremely" satisfied. Researchers in medical research institutes were significantly more likely to be satisfied (27% [56/205] "very" or "extremely" satisfied) with the level of infrastructure and support than those working in universities (15% [41/268] "very" or "extremely" satisfied; P = 0.001). Among the factors that motivate researchers, the excitement of discovery stood out in terms of both high importance and satisfaction. Publications were viewed as more important research outcomes than patenting or commercial ventures.

CONCLUSIONS

Funding and infrastructure support remain overwhelmingly researchers' greatest concerns. University-based researchers were less satisfied with infrastructure and support than those in independent medical research institutes.

Self-management of psychiatric symptoms using over-the-counter (OTC) psychopharmacology: the S-DTM therapeutic model--Self-diagnosis, self-treatment, self-monitoring

Pharmacological self-management is becoming more widespread in modernizing societies, as part of a general expansion of health care. This may exert a vital corrective balance to the professionalization of health by ensuring that the individual perspective of patients is not neglected. There are many 'good ideas' for new treatments being published which have a plausible scientific rationale for effectiveness and a low likelihood of harm, yet are essentially ignored by mainstream medical research. The most likely avenue for progress is probably the spread of self-management, together with increased sharing of experience via the internet. There is considerable scope for self-management of psychiatric symptoms with psychoactive medication purchased 'over-the-counter' (OTC) and without prescription. A surprisingly wide range of effective psychoactive agents are available with the potential to self-treat many of the common psychiatric problems. These include 'medical' psychopharmacological agents such as analgesics and antihistamines, a plant extract called St. John's Wort (Hypericum), and physical treatments such as early morning bright light therapy. But self-management currently lacks an explicit therapeutic model. A three stage process of S-DTM - self-diagnosis, self-treatment and self-monitoring is proposed and described in relation to psychiatric symptoms. Self-diagnosis describes the skill of introspection to develop awareness of inner bodily states and emotions. A specific sensation is identified and isolated as the 'focal symptom' for subsequent treatment and monitoring. Self-treatment involves choosing a drug (or other therapy) which is intended to alleviate the focal symptom. Self-monitoring entails a continued awareness of the focal system and of general well-being in order to evaluate effect of therapy. Self-monitoring could involve repeated cycles of dose-adjustment, and on-off ('challenge-dechallenge-rechallenge') therapeutic trials. An example of S-DTM applied to psychiatry might include the attempt to alleviate the fatigue and malaise symptoms underlying a 'depressed' mood by using OTC analgesics such as aspirin, paracetamol/acetaminophen, ibuprofen or codeine. Anxiety symptoms might be self-managed either using an 'unofficial SSRI' (selective serotonin-reuptake inhibitor) such as the antihistamines diphenhydramine or chlorpheniramine; or with St John's Wort/hypericum.

Boom or bubble? Is medical research thriving or about to crash?

A recent issue of JAMA (2005; vol. 294) presented a portrait of medical research as a booming enterprise. By contrast I have suggested that medical research is a speculative bubble due to burst. How can two such different predictions be compatible? From inside the expanding world of medical research everything seems fine and getting better. But to people outside the system, it seems like there is an awful lot of money going in, and not much coming out. Professional criteria of success (publications, impact factors, citations, grant income, large teams, etc.) are not the same as the outsider's view of success. Outsiders want the medical research system to generate therapeutic progress as efficiently as possible: the most progress for the least resources. Medical research is not the only good way of spending money and is in competition with other social systems. As funding increases, diminishing returns will set-in, opportunity costs will begin to bite, and there will be more and more social benefit to be gained from spending the extra research money on something else. Therefore, future cuts in medical research will happen because of pressure from outside the system - specifically pressure from other powerful social systems which will press their alternative claims for funding. In the short term, there will be a quantitative decline of research production. But in the longer term the medical research system will re-grow in a more efficient form. After a 'golden age of therapeutic progress in the mid-20th century, recent decades have seen a 'silver age' of scholasticism which is due to end soon. Perhaps a renaissance of medical research lies not too many years in the future.

The future of ‘pure’ medical science: The need for a new specialist professional research system

Over recent decades, medical research has become mostly an 'applied' science which implicitly aims at steady progress by an accumulation of small improvements, each increment having a high probability of validity. Applied medical science is, therefore, a social system of communications for generating pre-publication peer-reviewed knowledge that is ready for implementation. However, the need for predictability makes modern medical science risk-averse and this is leading to a decline in major therapeutic breakthroughs where new treatments for new diseases are required. There is need for the evolution of a specialized professional research system of pure medial science, whose role would be to generate and critically evaluate radically novel and potentially important theories, techniques, therapies and technologies. Pure science ideas typically have a lower probability of being valid, but the possibility of much greater benefit if they turn out to be true. The domination of medical research by applied criteria means that even good ideas from pure medical science are typically ignored or summarily rejected as being too speculative. Of course, radical and potentially important ideas may currently be published, but at present there is no formal mechanism by which pure science publications may be received, critiqued, evaluated and extended to become suitable for 'application'. Pure medical science needs to evolve to constitute a typical specialized scientific system of formal communications among a professional community. The members of this putative profession would interact via close research groupings, journals, meetings, electronic and web communications--like any other science. Pure medical science units might arise as elite grouping linked to existing world-class applied medical research institutions. However, the pure medical science system would have its own separate aims, procedures for scientific evaluation, institutional organization, funding and support arrangements; and a separate higher-professional career path with distinctive selection criteria. For instance, future leaders of pure medical science institutions would need to be selected on the basis of their specialized cognitive aptitudes and their record of having generated science-transforming ideas, as well as their research management skills. Pure medical science would work most effectively and efficiently if practiced in many independent and competing institutions in several different countries. The main 'market' for pure medical science would be the applied medical scientists, who need radical strategies to solve problems which are not yielding to established methods. The stimulus to create such elite pure medical science institutions might come from the leadership of academic 'entrepreneurs' (for instance, imaginative patrons in the major funding foundations), or be triggered by a widespread public recognition of the probable exhaustion of existing applied medical science approaches to solving major therapeutic challenges.