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Out of order: Clinicians must return to basics
I had the good fortune to earn my master of science degree at the University of Toronto, which sits in one of the great centers of biomedical understanding in North America with no fewer than four teaching hospitals within blocks and many more a subway ride away. Thus, while I plied my trade as a protein biochemist, I rubbed labcoat-ed elbows with medical students and clinicians of all stripes, including many students undertaking an M.D./Ph.D. program.
One facet that immediately stood out with the M.D./Ph.D. students compared to the M.D. soloists was their understanding of the basic science underlying their medical training. All of the medical students could name the major nerve pathways, but only the double-dose cohort could really explain how nerves work.
Local investment in biomedical research seemed to suggest new opportunities for learning, and perhaps I was dazzled by the shiny new lab gear lining the hallways of Toronto’s University Health Network, Mt. Sinai Hospital and Hospital for Sick Children. I believed that if you sat patient-facing clinicians next to lab-facing clinical scientists, you’d end up with a better understanding of human health and disease.
Based on recent research from clinicians at Toronto’s St. Michael’s Hospital, however, the clinician and researcher may be seated together, but they’re not looking in the same direction.
Over the last several years, Warren Lee and colleagues sensed a marked decline in the number of basic research papers in the major medical journals, a trend they found at odds with the opportunities rapidly arising in molecular biology and informatics, citing the Precision Medicine Initiative as an example.
“This ambitious vision will require an exceptionally integrated understanding of genomic, biochemical and bioinformatics information,” they wrote in The FASEB Journal (Steinberg et al. FASEB J. 2016;30:515-518. www.fasebj.org). “Because it is ultimately clinicians who will be tasked with delivering personalized medicine, it is reasonable to expect medical journals to keep them abreast of advances in our understanding of the mechanisms of disease and of human biology.”
But exactly the opposite seemed true.
Thus, the clinicians analyzed the top medical specialty journals, surveying their content from 1994 to 2013 to determine the true incidence of basic research articles. As controls, they also looked at three major non-medical journals as well as the incidence of clinical trial papers in the medical journals.
Of the eight high-impact medical journals they surveyed, all showed an average 30-percent decline in the incidence of basic research papers, and in six, the declines ranged from 40 to 60 percent. During the same period, however, the proportion of articles dealing with clinical trials showed no change, nor did the proportion of basic research articles in the non-medical journals.
“The decline in basic science in the specialty journals reflects both an increase in non-basic science content and an absolute decline in the number of basic science articles in some of the journals,” they reported.
The authors were unable to ascribe reasons for this trend, but suggested it may reflect an editorial preference toward articles that offer higher citation frequency and therefore improve the journal’s impact factor—a journal’s key marketing metric.
They also acknowledged the decline may be the result of the proliferation of basic science journals, with some medical editors assigning the articles to sister publications. But even if this is true, the authors worried, clinicians may miss out.
“These basic science specialty journals are less likely to be read by medical trainees and by practicing clinicians than medical journals, even if published by clinical societies,” they decried, suggesting dire consequences.
“One possibility is that clinicians have diminished experience with the pathogenesis of disease and mechanisms of therapy, and thus will have less understanding of or interest in these concepts,” they pressed. “The paucity of basic science in the top medical specialty journals may send a subconscious message to trainees and practitioners that basic science research is either irrelevant to clinical medicine or simply uninteresting.”
If this is true, then it is no exaggeration to suggest that any hope for precision medicine is faint or that such initiatives will be crippled out of the gate.
“The modern medical journal ... has a critical role to play in helping clinicians make sense of ongoing advances in human biology and pathophysiology, which represent the cornerstone of knowledge required by physicians,” the authors argued.
Without this understanding, clinicians run the risk of being little more than algorithm-following pill-prescribers. And ultimately, patients will suffer.
Randall C Willis can be reached by email at firstname.lastname@example.org