Assessment

After a brief moment of silence, another one around the table remarked, “In addition to the grant, clinical professors have very good reasons to hire scientists to do research for them. You know, the substantiation and promotion of a clinical academic staff depend almost entirely on their research output. Service and teaching are practically not considered, and, since basic science journals generally have a higher impact factor than clinical ones, it makes sense for clinical academics to focus on making money and find suitable experts to do the research work.”

“Very true,” my mentor nodded, “That brings us back to the eternal question: How to assess the performance of a clinical academic staff – especially in the situation when we have to compare a clinical professor to a basic scientist?”

My eyebrow rose. The question was certainly not a déjà vu feeling of what I was asked by TL a few days ago.

“My own suggestion is simple,” he explained, “It should be a two-stage process. When a clinical academic staff is applying for substantiation or promotion, the first thing that they have to prove is the amount – and preferably the quality – of the service and student teaching that they provided. If, and only if, this step is passed, they would be further assessed on their research output. If they have sufficient research output – by themselves or by whoever they hire, it doesn’t matter – but do not contribute to service and teaching adequately, they could still be substantiated or promoted, but they should receive the salary of a non-clinical academic staff.”

It sounds a terrific (or horrible?) idea to me.

Behalf

“You see? Many clinical professors do very little clinical service nowadays – and they hardly ever teach either,” the man who used to have a moustache went on, “They put most of their time and effort on private patients, for which they pocket a good sum of money, and a portion of it is used to pay for the salary of one or more scientists to do the research on the professor’s behalf.”

“Oh…!” Some of us gasped. Well, to be honest, we know that much already, but it remains disturbing to have a senior member of the academic hierarchy saying all these openly.

“I must say the government policy is to some extend encouraging all these,” my mentor continued, “You know, competitive grants are more likely to be given to laboratory research – because the assessment panel is dominated by basic scientists. As a clinician, what is the easiest way to prepare a grant proposal – and, logically, to follow on – a research paper on basic science? The obvious answer is to find someone to write it for you. After all, unlike clinical professors, true basic scientists are not expensive to hire.”

We all nodded eagerly.

“The real problem is, since the papers are prepared by someone else, the clinical professor may know very little about what’s going on – actually they may not even understand what’s being written – even though their name is put down as the first or last author!”

I cannot agree more.

PS. I sudden realize for clinical academic staff who avoid service and teaching but focus on research may not be that bad – at least they know what their own research is all about.

Never

For some political reasons, I was summoned to a dinner gathering by the godfather of medicine.

The man who used to have a moustache was also invited but he came late. As usual, he led the conversation around the table as soon as he made the appearance.

“You know, I am busy with some internal audit,” he said.

“And what do you find?” We all asked.

“Alas, I wouldn’t quote specific incidents,” he smiled, “Nonetheless, I see very well that many medical schools are not healthy nowadays.”

We made an inviting grunt – I’m sure he was not pinpointing at the one north to the Lion Rock Tunnel.

“Let me tell you an incident I overheard,” he went on with the following story:

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Shortly before the final MB examination, a final year student told his classmate, “You know what? I met the external examiner in the loo.”

His classmate was surprised, “How do you know that’s the external examiner? How does he look like?”

The student described a formally dressed, serious-looking old man, and added, “After all, I could not recognize who he is.”

“Why!” His classmate yelled, “He is our professor of surgery! We have not seen him because he never teaches any student!”

How

Shortly after the talk on orphan diseases, we held the membership examination in my hospital.

My friend TL was responsible for the organization and everything was absolutely smooth. While we had a brief moment of casual chat during the break, however, the star neurologist caught my arm and asked, “Szeto, there’s something I wish to ask for your opinion – I know you are never short of opinion.”

“What’s that?” I asked; my mind was pondering about his meaningful remark.

“I read your recent blogs. I just want to ask, in your opinion, how could the faculty determine the performance of a clinical academic staff – especially in the situation when we have to compare a clinical professor to a basic scientist?” he said.

It seems that TL is another friend of mine who finds my fancy story on the big toe specialist disturbing.

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I shall not tell you my response to TL’s question – or whether I made any meaningful response at all. To my surprise, I heard shortly afterwards a very good answer from my mentor.

I mean the man who used to have a moustache.

Subsides

A commonly used but seldom recognized means of paying for expensive treatments is government subsides on medical research.

The idea is simple: If government contributes to part of the R&D cost of a new medicine, the final price could be reduced. At least in theory, explicit agreement could be signed to limit the final market price of a new product when the research bears fruitful result.

It sounds great, eh?

The problem is, however, a conflict of local versus international interest. As a government, the aim is to help its own citizens. In other words, a new drug whose development is subsidized by, say, the American government would be affordable for patients in the States but remains astronomically expensive for other countries. After all, why should the government contributes even more for the R&D so that the price could be lower for every other people on earth?

It follows that affluent countries with more resources for R&D would enjoy dual benefit. Their people enjoy cheap technology, and their companies earn a gigantic profit from everywhere in the world.

Alas, you see, this phenomenon does not happen only in medicine, but also computer, mobile phone, and almost all fancy gadgets of our life.

Pay

I don’t think I have to discuss the problem of asking patients who could afford an expensive treatment to pay for themselves, but letting the government to pay for those who do not have the money. Interested visitors may like to read http://ccszeto.blogspot.hk/2008/07/thermodynamics.html and related posts.

How about asking the government to pay for everyone, including those who are rich enough?

No, that would mean absolute communism – a road to serfdom.

Why? Because communism discriminates against the rich. Essentially the policy could be written in this way: If the government cannot afford a treatment and pay for the poor, the rich could not have it either.

There is, however, another indirect way of paying. 

I shall elaborate tomorrow.

Philanthropy

Fans of Milton Friedman may ask: What’s wrong with market economy and let only those who could afford the treatment have it?

No, there’s nothing wrong – just that I’m afraid the actual market would become even smaller and there will be very little incentive for drug companies to develop any new treatment for uncommon diseases – because the stake is high but the chance of making a good profit is slim.

(You may ask when I am so keen on supporting research and development. No, not because I am a fan of science, but, rather, for a worldly and pragmatic reason – I shall leave the discussion on this topic of supreme importance later.)

But, let’s go back to the original question: If many patients could not afford the expensive treatment, who should pay for them?

Some would suggest a somewhat philanthropic approach: For those who have the money, please pay for it so that the company could make a profit. For those who are not that well off, the drug company has an obligation to provide the treatment.

Alas, I should not tell you my comment on this suggestion directly, but I would like to remind you it is a naive idea to believe drug companies are owned by tyrants with morbid obesity living in Miami or Zurich – many of the shareholders are humble ordinary citizens, widows, retired persons, or your mandatory provident fund.