The widening gap between clinical, teaching and research work

The roles of clinician, educator and researcher have traditionally been central pillars of the discipline of medicine. The synergy created by combining these roles adds value to all three, facilitating high-quality teaching, clinically relevant research and evidence-based practice.1-3 However, current trends in Australia are placing pressure on the sustainability of academic medicine, and on the traditional ways of delivering medical education and undertaking medical research.

The need for greater resources to meet student demand extends beyond universities. Medical practitioners whose primary role is clinical have always played a significant part in teaching and research. In 2006, 20% of medical practitioners with a primary clinical occupation reported providing some medical education.12 Over a third of specialists were involved in education (36%), along with 18% of specialists-in-training, 10% of primary care clinicians and 8% of hospital non-specialists. For clinicians who provided medical education, the average time spent was 4.7 hours per week.8

Because the clinical medical workforce is much larger than the medical education workforce, the contribution of clinicians to medical education in terms of total time spent is substantial. In 2006, clinicians provided almost three-quarters of total medical teaching hours — specialists provided almost half (47%), and primary care clinicians provided 14% (Box 1). Available data do not indicate the stage of education provided (student, intern or registrar), but this probably varies between specific clinical and non-clinical medical occupations. Many clinicians involved in education have honorary appointments. Yet, the system of adjunct or honorary appointments, which has been an important contributor to university medical programs, is highly variable and often lacks transparency and clear expectations.13

However, with greater numbers of students needing clinical placements, clinicians are struggling to cope. Furthermore, many sectors of the Australian medical workforce, such as general practice, are currently experiencing workforce shortages, which are expected to continue.14,15 These shortages strain the capacity of clinicians to meet the demand — pressured clinicians are likely to prioritise provision of clinical services over the less urgent demands of teaching and, particularly, research.16

Training no longer takes place exclusively, or even predominantly, in the public hospital sector. This shift is a result of both lack of capacity within traditional settings and changing patterns of clinical service delivery. As the burden of disease shifts to chronic conditions,17 and length of stay in acute settings decreases,18 primary care and ambulatory settings become increasingly prominent. Private-sector settings are being used more for training, but the mechanisms to support and recognise teaching by clinicians vary significantly across these settings.

Teaching functions in public hospitals are funded by a complex mix of sources, including general state government hospital funding, state and federal government funding for vocational trainee positions, and specific funding agreements with individual universities for medical students. General practitioners are eligible for teaching activity payments through the Practice Incentives Program, and about one in five Australian general practices currently claim this incentive.19 Medical specialists have no equivalent program to support teaching activities within their own private practices. The interim report of the National Health and Hospitals Reform Commission (NHHRC) noted that many contributions to medical education receive little explicit resourcing or acknowledgement.16

Support for research is even more limited, and medical research is more divorced from clinical settings than medical education. The core medical research workforce, which in 2006 comprised 1149 medical practitioners,8 was responsible for just over half of all estimated research time in that year.12 Only 7% of clinicians reported undertaking research in 2006.12 Specialists had the highest proportion involved (15%), compared with 8% of specialists-in-training, and negligible numbers of primary care clinicians (1%) and hospital non-specialists (2%). The average time spent in medical research by clinicians who undertook this work was 6.6 hours per week in 2006.

The demands of service delivery and changed funding models in public hospitals are straining the capacity of clinicians to undertake education and research.20 Data from the Australian Institute of Health and Welfare suggest that both the teaching hours and research hours of clinicians are decreasing. Total teaching hours for clinicians, which increased between 2000 and 2005 due to increased numbers of clinicians and slight increases in average hours per week, dropped in 2006, when lower proportions of all clinical occupations reported involvement in education compared with 2005 (Box 2). Total research hours for clinicians changed little between 2000 and 2005, and then decreased slightly in 2006, again attributable to lower proportions of clinicians involved. Although these data raise the possibility of a downward trend in the amount of academic work being done by clinicians, more detailed data collection and analysis are warranted.

The changes described above are putting pressure on the traditional model for educating successive generations of doctors and the sustainability of academic medicine. Although the consequences of deteriorating academic capacity within the medical workforce may be less immediately obvious than deficits in clinical capacity, they are still important. Ongoing programs of clinically relevant research are essential for continued improvements in the quality, efficacy and efficiency of health service delivery.16,20 More broadly, a strong and productive academic sector is at the core of maintaining and developing all disciplines in medicine.

We have identified a range of strategies that could be implemented by universities, health providers and governments to ensure an adequate medical academic workforce and a sustainable, quality medical education system (Box 3). The importance of a coordinated approach cannot be overemphasised, given the current lack of integration between stages of medical education; the multiplicity of funding sources, accreditation authorities, and individual arrangements within and between institutions such as universities and hospitals; and the lack of career pathways for medical researchers and educators.13,27

1 Proportion of total time spent on medical education in Australia, by main occupation, 2006*

* Total time spent on medical education was calculated from national medical labour force survey data as follows: the average number of hours per week spent in medical education (stratified by main occupation)8 was multiplied by the estimated number of medical practitioners in each occupation group who provided at least 1 hour per week of education (the latter calculated from the proportion in each occupation who reported undertaking medical education12 and the benchmark medical workforce numbers for 20068).

2 Total time spent on medical teaching and research by academics (medical educators and researchers) and clinicians in Australia, 2000–2006*

* Data were derived from references 8, 12 and 21–25. See also footnote to Box 1.