In 1997, Joseph Goldstein and Michael Brown, in an article entitled "The Clinical Investigator: Bewitched, Bothered, and Bewildered - But Still Beloved"(1) , analysed the causes of the progressive decline of clinician-researchers in the USA – "an endangered species", as they had been called sixteen years earlier by James Wyngaarden in a famous editorial in the New England Journal of Medicine (2). The increasing divorce between the clinical practitioner and research seems to result mainly from the convergence of two other phenomena that can be observed in all developed countries: the extraordinary development of fundamental biomedical science from the nineteen sixties on (carried out by “professionals” of science) and the increasing complexity and demands involved in modern clinical practice at a time of strong financial restrictions. The solutions proposed, as well as the recommendations made to the National Institute of Health and academic institutions, all pointed towards the need for concerted “systemic” strategies capable of stimulating, compensating and protecting the practice of research by the clinician. Recommendations, indeed, which would be implemented by the NIH in partnership with public and private institutions over the years that followed(3).
Also, it was not by chance that Goldstein and Brown included the adjective "beloved" in their description of the clinician-researcher. In fact, during the first half of the XX century the clinician, for whom the patient is the ultimate aim of his research activity, had been the fundamental agent of transposing science discoveries into clinical practice and the real driving force of a medical research agenda that was truly useful for the patient. Indeed, societal perception of the importance of medical research is in itself very significant, judging by the results in recent population surveys: for example, in the USA over 90% of the population considers health research a national priority (along with national security, social security, health and safety, and education); 82% state that they prefer hospitals where health professionals are actively involved in medical research and in teaching(4). In another field, that of health policy, countries such as Finland, for example, currently include scientific productivity (in terms of quantity and quality) among the criteria for differentiation among hospitals for state financing.
L research carried out by doctors is unique in many aspects. The country’s progress over the last twenty years in the biomedical sciences has been remarkable on all levels, not only due to the exponential increase in highly qualified human resources (in the vast majority non-doctor scientists) but also due to the creation of laboratories of excellence devoted to research into matters of the utmost importance to medicine(5). In other words Portuguese doctors have never had such favourable ecologies for the establishing of fruitful partnerships between clinical practice and basic biomedical science. On the other hand, albeit being late, science policies specifically aimed at stimulating research by doctors are starting to emerge in Portugal – examples of this are the regulations for the PhD-Intern, created in 2008, as well as the opening of competitions (only one to date!) for financing medical research by the Foundation for Science and Technology. Added to these initiatives are others from private foundations and universities, who are seeking to provide advanced scientific qualification for the new generations of doctors in Portugal.
The times are thus of opportunity. Yet operational obstacles to the involvement of the clinician in the daily practice of innovative and internationally competitive research are real and demand an urgent solution.
This was the theme for the first of a series of debates that the Lisbon Society of Medical Sciences is dedicating to the subject "Medical Research in Portugal". The aim of this first debate was to informally collect first-hand accounts of people who through their own institutional or personal experience have “on the ground” knowledge of the difficulties of practising medical research by doctors, asking their opinions about possible solutions for these difficulties. So on the 21st of June 2010, in the Cid dos Santos Amphitheatre in the Faculty of Medicine of the University of Lisbon, in front of an audience made up of interns, young specialists, medicine students, biomedical scientists and several invited guests, João Sentiero, President of the Foundation for Science and Technology (FCT), and Maria do Céu Machado, High Commissioner for Health, heard and commented on the interventions by Rui Victorino, President of the Scientific Council of the Faculty of Medicine of the University of Lisbon and member of the FCT Scientific Council for Health Sciences, João Correia da Cunha, President of the Board of the North Lisbon Hospital Centre, Ana Isabel Lopes, Head of the Paediatrics Service and Nuno Figueiredo, a young General Surgery PhD-Intern.
Rui Victorino made a brief summary of the development of biomedical science in Portugal, and reminded the audience that the vast majority of applications for PhD or post-doctorate grants in the field of Health Sciences approved by the FCT over the last 20 years correspond to basic biomedicine research projects, not involving studies of patients or of human material. This fact justifies that after 20 years of priority investment in fundamental biomedical science it is time to introduce sustained policies to support quality clinical research. He also pointed out that several recommendations on this matter had been included in the book Governação dos Hospitais (6) published in 2009 , of which he stressed:
1. The need to increase financing for quality clinical research projects, not forgetting the areas of outcomes research and clinical epidemiology, meaning that the FCT should regularly hold competitions similar to that in 2007, in which sixty partnership projects between doctors and basic scientists were approved, in a total of 360 applications.
2. The need for the creating of condition to allow health institutions to contribute towards the flourishing of quality clinical and translational research.
3. The importance of identifying those in hospitals who have shown the capacity to head initiatives orientated towards research on patients, providing them with the conditions necessary to develop their research activity.
4. The importance of the creating of clinical translational centres in quality hospitals, as well as a fellowships programme for doctors who carry out clinical or translational research activities.
5. The creation of scientific qualification opportunities for young specialists similar to the spirit of the PhD-Intern regulation.
João Correia da Cunha started out by mentioning the confusion that generally exists between clinical research and clinical tests, and the need to recognise the respective differences. The latter, in the main headed by the pharmaceutical industry, which remunerates the institution and the researchers, has been developed without any special problems in many hospitals in Portugal (for example, in 2009, seventy-five clinical tests were held just in the North Lisbon Hospital Centre). The same thing does not take place with other types of clinical, pure or translational research. He stressed the enormous importance of quality clinical research in the operating of health units themselves, particularly in the major teaching hospitals, and pointed out the following as the main constraints on the practice of research by doctors:
1. The reduced importance granted to the scientific curriculum in competitions for hospital positions, considering it indispensable for there to be a rapid change in this aspect.
2. Hospital activity undergoing strong budgetary restrictions, without there being any valorisation of research, even in university hospitals, a situation which it is necessary to alter.
3. Deficient articulation in the functioning of the different services in the Portuguese NHS.
4. Difficult articulation between clinicians and biomedical scientists, a situation which he hopes to see altered in the case of Santa Maria Hospital (HSM) through the establishing of a formal partnership between the Hospital, the Faculty of Medicine and the Institute of Molecular Medicine at the time of the creation of the Lisbon Academic Medical Centre.
Ana Isabel Lopes described her research career as a doctor who never interrupted her clinical activity, considering it to be illustrative of what the scientific development of a clinician-researcher should not be. She graduated in 1980 at the FMUL, and then continued hospital activity at the HSM, always having a special interest for research, which led her to begin collaboration with the Institute of Microbiology during her undergraduate days. She was later confronted with the difficulty of conciliating the demanding training of the internship period in the specialty of paediatrics with the practice of research. This would only become possible after the conclusion of the training period of the specialty, beginning her research project related to infection by H. pilorii, for which she obtained small financing from the Ministry of Health and the hospital itself and having established international collaborations. She would conclude her PhD thesis twenty-six years after her first degree and sixteen years after receiving the degree as a specialist. In her personal experience she lived through the difficulties of obtaining a significant collection of biological material (7-8 years for the acquisition of sufficient data), as well as the non-existence of time reserved for research. She concluded that a career of this type, similar to that of many other clinicians, is unacceptably long, and is incompatible with the development of internationally competitive research projects.
Nuno Figueiredo, graduated in 2001, intern in the 6th year of General Surgery, gave an account of his experience as a PhD-Intern since he was accepted on the 1st edition of the Advanced Medical Training Programme created by the Gulbenkian Foundation in 2008 in partnership with the Champalimaud Foundation and the FCT. He stated the importance of the curricular component of the programme in his scientific training, stressing the advantage of having benefited from a Gulbenkian Foundation grant, which allowed him to be exposed full time for six months to a great diversity of training contents, as well as having daily contact with high level Portuguese and international scientists. He stressed the importance of the support received from the Director of the Service, but also the resistance he felt from other colleagues to adapting his clinical activities to the regime of a PhD-Intern after six months interrupting his internship. On the other hand he considered that the collaboration of the group of biomedical scientists with whom he began his research project was instrumental. He called attention to the need for a better juridical framing of the regulations for the PhD-Interns in order to mitigate the disparity by means of which they are obliged to practice in different hospitals. He also stressed that the present doubt, now that there are programmes for the protection for interns/PhD students, is whether there will be subsequent programmes to support specialists/post-docs.
Debate
Diogo Lucena, Administrator of the Calouste Gulbenkian Foundation Science Service, expressed institutional concern about the return of investment made in the training of doctors admitted to the programme supported by the foundation. He considered that the investment will be wasted if there is no continuity to this effort on the part of the institutions, and called attention to the importance of an adequate response by the Portuguese National Health System. He stated the current difference that academic hospitals have in guaranteeing quality clinical research, fearing that even greater difficulties will be felt in other hospitals. He also mentioned that the experience accumulated in this and in other incentive measures for advanced scientific training for clinical doctors raises a problem of the scalability of the intervention. The foundation currently supports 10 doctors a year, but it is likely that the country will need many more (70 per year?) if it wishes to avoid their dilution/neutralization within the health system itself. He also stressed the absolute need to support the quality of programmes of this kind.
José Ducla Soares, Professor at the Faculty of Medicine of the University of Lisbon, called attention to two problems related to the development of clinical research in hospitals: the fact that recruiting interns by hospital sis carried out completely unbeknown to the services where they will be working, which therefore does not take their aims into account, a situation that prevents the choice of interns with a vocation for research. On the other hand, the fact that the hospital institutions do not possess incentives to lead them to stimulate research activity, which leads to it not being valorised in the respective contract-programmes.
João Correia da Cunha reminded the group that there are already indexes of clinical complexity that allow differentiation of financing for health units, admitting that in the future there may be economic incentives for clinical research activities.
José Miguel Caldas de Almeida, Director of the Faculty of Medical Sciences, drew attention to the need not to waste the current opportunities for the development of clinical research and the urgency of granting the directors of clinical services with conditions of institutional flexibility that allows them not to waste vocations, given that in the current structure of hospital functioning it is difficult for a director to release a doctor for one or two days a week for activities other than care. He also reinforced the need not to neglect research into Outcomes Research, as an instrument for improving the health system itself.
Fernando Martins Vale, Professor at the Faculty of Medicine of the University of Lisbon, insisted on the need to reformulate the hospital and teaching careers in order to grant greater importance to research activities.
Jorge Soares, Director of the Gulbenkian Foundation Health and Development Service, drew attention to the several difficulties concerning research by doctors in hospitals: conflicts of interest between the researcher and his own research team; the fact that the institutions are not duly rewarded for the research they carry out; the lack of an effective valorisation of research activities in medical careers; the absence of flexibility in the structure of hospital functioning; and the existence of juridical difficulties in the use of patient data in research by the National Data Protection Commission. He also warned about the banalisation of PhD programmes for doctors in universities, leading to a lowering of the levels of demand.
Rui Victorino, in the same line of thought, stressed that it would be a dreadful service for medical research if grants are awarded to PhD programmes that do not guarantee high quality.
Maria Gomes da Silva, Professor at the Faculty of Medical Sciences and Specialist in Haematology at the Lisbon IPO, stated that discussing the practice of clinical research does not end with, nor should it centre on, the discussion of PhD programmes, but rather on the creating of conditions to allow the practice of research in hospitals, with it being essential to invest in organised and efficient structures that support quality clinical research in health units.
Leonor Parreira reinforced this idea, adding that another indispensable measure without which clinical research cannot flourish, even if there are research centres in hospitals, is the creation of well-structured network-linked clinical databases and biobanks, which have long been promised but still do not exist in Portugal.
António Oliveira, a student at the Faculty of Medicine of the University of Lisbon, expressed his concern about the fact that there is no system to allow the development of a clinical research career, noting that at the moment the clinician-researcher’s individual success still depends on a “chance” factor – the clinician meeting the “right person” at the “right time”.
João Sentieiro, President of the Foundation for Science and Technology, declared that he had particularly appreciated the accounts given by Ana Isabel Lopes and Nuno Figueiredobecause they had shown him the difficulties experienced by clinicians who wish to reconcile research activities with clinical practice – a reality of which he had not been fully aware. He declared the FCT’s interest in contributing towards the development of clinical research, recalling the initiatives of the Harvard-Portugal Programme, as well as the 2007 FCT Competition, specifically for clinical research. Acknowledging that Portugal is facing a quantitative problem of critical mass, he stressed that the FCT is concerned about the quality of the initiatives it supports. Specifically in relation to the status of the PhD-intern, he informed the meeting that modifications had been introduced and had been forwarded for publication in the Republican Diary as Law, leading to a possibility to monitor the quality of the candidates’ research projects. He also informed those present that the FCT will be opening a new competition for clinical research projects by the end of 2010.
Maria de Belém Roseira, Vice-president of the Socialist Party Parliamentary Group, stressed the importance of the sustainability of the policies for supporting the scientific training of doctors. She stated that even if there is no capacity for quality programmes in the nine medical schools in Portugal it is probable for each one’s best critical mass to be involved in quality training programmes. She also reinforced the importance of co-opting the interest of civil society to the problem of medical research, namely through patients’ associations.
Maria do Céu Machado, High Commissioner for Health, commented on the several different accounts, recalling that the participation of the clinician in research may take place at any moment in their professional careers, and stressing the importance of clinical maturity for the developing of research projects that are relevant to patients. She reminded the group of the importance of role models in the doctor’s professional preparation, considering that the classic model of the freelance clinician-researcher has not come to an end, and wondered about the advantage of interrupting clinical activity for the doctor to gain scientific qualifications. She also considered that a good deal of the hospital constraints on research practices may be the consequence of the running of hospitals nowadays being given over to managers who base themselves solely on indexes of care productivity. In her opinion the problem is made worse by the fact that the directors of services are forced to respond to clinical productivity, often they themselves not having had the opportunity to do research. This may explain why they are less willing to facilitate the development of clinical research in their services. In relation to the national clinical database, she stated that it did not exist and that she did not know when it would be possible to create it, referring to difficulties on the organisational level of the health system itself, such as incompatibilities between computer systems between health units, the non-uniform organisation of the clinical system in different hospitals, the waste of information resulting from the lack of systemic coordination and the rigidity of the current legislation, which prevents even the National Institute of Statistics from providing data relative to medical research when requested by the High Commission for Health in order to prepare the National Health Plan.
Conclusion and Recommendations
The obstacles to a consistent research practice by clinical practitioners in Portugal are many, although it has been clear in the several talks given that most of them are a result of the organisational and functional structure of the units of the National Health System (SNS). Modification of the current system, like that which is practised in other countries, needs, 1) the adopting of incentives aimed at health institutions; 2) the reinforcing of the current initiatives aimed at post-graduate scientific training for clinicians; 3) reinforcing and regularity in financing patient-focused research projects; 4) nationwide creation of the instruments essential for quality medical research: clinical databases and biobanks.
1 – Modification of the institutional culture of the health units in the SNS:
a) Political initiatives providing incentives for practising patient-focused research, including criteria of scientific production in differentiation between health units.
b) Incentives for creating ecologies fertile for the involvement of the doctor in research, creating quality clinical translational research centres in the hospitals of reference.
c) Significant valorisation of the scientific curriculum of the medical career, particularly in the field of recruiting for positions in academic hospitals.
2 – Continuation of investment in the scientific qualification of the clinician-practitioner:
a) Improvement in political initiatives to support scientific training for young interns.
b) Introduction of similar measures but specifically aimed at young specialists, with the creation of clinical/translational research fellowships for specialists.
3. Reinforcement and continuity for the financial support for clinical research:
a) Regular opening of FCT competitions specifically aimed at the financing of quality clinical research projects.
b) Involvement of civil society in this aim, namely by co-opting the participation of the Patients’ Association.
4. Databases and Biobanks:
When one takes into account the operational difficulties involved in the Portuguese National Health System itself in relation to recording clinical data in its health units, it shows that there is a situation that is not only prejudicial to the working of the system itself but also makes it difficult to create national data registers for research purposes. On the other hand, the time allowed was not enough to discuss the ongoing measures for the creating of a national network-structured Biobank linked to similar structures in different countries. These issues will thus be those that the Lisbon Society of Medical Sciences will try to air in the next debate on “Medical Research in Portugal”, to be held in the 1st term of 2011.
Leonor Parreira
President, Lisbon Society of Medical Sciences
vandaoliveira@fm.ul.pt
_____________
(1) Joseph oldstein & Michael Brown. "The Clinical Investigator: Bewitched, Bothered, and Bewildered - But Still Beloved". J. Clin. Invest. 99:2803-2812,1997.
(2) James Wyngaarden. The clinical investigator as an endangered species. N. Engl. J. Med. 301:1254–1259., 1981.
(3) Varki A, Rosenberg LE. Emerging opportunities and career paths for the young physician-scientist. Nat. Med. 8:437-439, 2002.
(4) Woolley M & Propst SM. Public attitudes and perceptions about health-related research. JAMA, 294:1380-1384, 2005.
(5) Nos últimos 20 anos, as duas áreas científicas que mais contribuíram para a internacionalização da ciência portuguesa foram, precisamente, as "Ciências da Saúde" e a "Biologia" (21% e 43% das publicações em revistas internacionais, respectivamente). Resultados tanto mais impressionantes quanto a parcela que lhes coube do investimento total em I&D, no mesmo período, foi apenas de 24% (10% no caso específico das Ciências da Saúde), um valor substancialmente inferior ao de outras áreas, em particular as Ciências da Engenharia e Sociais [ver: Produção Científica Portuguesa, 1990 - 2009: Séries Estatísticas (http://www.gpeari.mctes.pt/?idc=103)].
(6) Victorino RMM. A investigação no Hospital. in Governação dos Hospitais. Ed. Luís Campos, M. Borges e R. Portugal. Casa das Letras, 2009.
Also, it was not by chance that Goldstein and Brown included the adjective "beloved" in their description of the clinician-researcher. In fact, during the first half of the XX century the clinician, for whom the patient is the ultimate aim of his research activity, had been the fundamental agent of transposing science discoveries into clinical practice and the real driving force of a medical research agenda that was truly useful for the patient. Indeed, societal perception of the importance of medical research is in itself very significant, judging by the results in recent population surveys: for example, in the USA over 90% of the population considers health research a national priority (along with national security, social security, health and safety, and education); 82% state that they prefer hospitals where health professionals are actively involved in medical research and in teaching(4). In another field, that of health policy, countries such as Finland, for example, currently include scientific productivity (in terms of quantity and quality) among the criteria for differentiation among hospitals for state financing.
L research carried out by doctors is unique in many aspects. The country’s progress over the last twenty years in the biomedical sciences has been remarkable on all levels, not only due to the exponential increase in highly qualified human resources (in the vast majority non-doctor scientists) but also due to the creation of laboratories of excellence devoted to research into matters of the utmost importance to medicine(5). In other words Portuguese doctors have never had such favourable ecologies for the establishing of fruitful partnerships between clinical practice and basic biomedical science. On the other hand, albeit being late, science policies specifically aimed at stimulating research by doctors are starting to emerge in Portugal – examples of this are the regulations for the PhD-Intern, created in 2008, as well as the opening of competitions (only one to date!) for financing medical research by the Foundation for Science and Technology. Added to these initiatives are others from private foundations and universities, who are seeking to provide advanced scientific qualification for the new generations of doctors in Portugal.
The times are thus of opportunity. Yet operational obstacles to the involvement of the clinician in the daily practice of innovative and internationally competitive research are real and demand an urgent solution.
This was the theme for the first of a series of debates that the Lisbon Society of Medical Sciences is dedicating to the subject "Medical Research in Portugal". The aim of this first debate was to informally collect first-hand accounts of people who through their own institutional or personal experience have “on the ground” knowledge of the difficulties of practising medical research by doctors, asking their opinions about possible solutions for these difficulties. So on the 21st of June 2010, in the Cid dos Santos Amphitheatre in the Faculty of Medicine of the University of Lisbon, in front of an audience made up of interns, young specialists, medicine students, biomedical scientists and several invited guests, João Sentiero, President of the Foundation for Science and Technology (FCT), and Maria do Céu Machado, High Commissioner for Health, heard and commented on the interventions by Rui Victorino, President of the Scientific Council of the Faculty of Medicine of the University of Lisbon and member of the FCT Scientific Council for Health Sciences, João Correia da Cunha, President of the Board of the North Lisbon Hospital Centre, Ana Isabel Lopes, Head of the Paediatrics Service and Nuno Figueiredo, a young General Surgery PhD-Intern.
Rui Victorino made a brief summary of the development of biomedical science in Portugal, and reminded the audience that the vast majority of applications for PhD or post-doctorate grants in the field of Health Sciences approved by the FCT over the last 20 years correspond to basic biomedicine research projects, not involving studies of patients or of human material. This fact justifies that after 20 years of priority investment in fundamental biomedical science it is time to introduce sustained policies to support quality clinical research. He also pointed out that several recommendations on this matter had been included in the book Governação dos Hospitais (6) published in 2009 , of which he stressed:
1. The need to increase financing for quality clinical research projects, not forgetting the areas of outcomes research and clinical epidemiology, meaning that the FCT should regularly hold competitions similar to that in 2007, in which sixty partnership projects between doctors and basic scientists were approved, in a total of 360 applications.
2. The need for the creating of condition to allow health institutions to contribute towards the flourishing of quality clinical and translational research.
3. The importance of identifying those in hospitals who have shown the capacity to head initiatives orientated towards research on patients, providing them with the conditions necessary to develop their research activity.
4. The importance of the creating of clinical translational centres in quality hospitals, as well as a fellowships programme for doctors who carry out clinical or translational research activities.
5. The creation of scientific qualification opportunities for young specialists similar to the spirit of the PhD-Intern regulation.
João Correia da Cunha started out by mentioning the confusion that generally exists between clinical research and clinical tests, and the need to recognise the respective differences. The latter, in the main headed by the pharmaceutical industry, which remunerates the institution and the researchers, has been developed without any special problems in many hospitals in Portugal (for example, in 2009, seventy-five clinical tests were held just in the North Lisbon Hospital Centre). The same thing does not take place with other types of clinical, pure or translational research. He stressed the enormous importance of quality clinical research in the operating of health units themselves, particularly in the major teaching hospitals, and pointed out the following as the main constraints on the practice of research by doctors:
1. The reduced importance granted to the scientific curriculum in competitions for hospital positions, considering it indispensable for there to be a rapid change in this aspect.
2. Hospital activity undergoing strong budgetary restrictions, without there being any valorisation of research, even in university hospitals, a situation which it is necessary to alter.
3. Deficient articulation in the functioning of the different services in the Portuguese NHS.
4. Difficult articulation between clinicians and biomedical scientists, a situation which he hopes to see altered in the case of Santa Maria Hospital (HSM) through the establishing of a formal partnership between the Hospital, the Faculty of Medicine and the Institute of Molecular Medicine at the time of the creation of the Lisbon Academic Medical Centre.
Ana Isabel Lopes described her research career as a doctor who never interrupted her clinical activity, considering it to be illustrative of what the scientific development of a clinician-researcher should not be. She graduated in 1980 at the FMUL, and then continued hospital activity at the HSM, always having a special interest for research, which led her to begin collaboration with the Institute of Microbiology during her undergraduate days. She was later confronted with the difficulty of conciliating the demanding training of the internship period in the specialty of paediatrics with the practice of research. This would only become possible after the conclusion of the training period of the specialty, beginning her research project related to infection by H. pilorii, for which she obtained small financing from the Ministry of Health and the hospital itself and having established international collaborations. She would conclude her PhD thesis twenty-six years after her first degree and sixteen years after receiving the degree as a specialist. In her personal experience she lived through the difficulties of obtaining a significant collection of biological material (7-8 years for the acquisition of sufficient data), as well as the non-existence of time reserved for research. She concluded that a career of this type, similar to that of many other clinicians, is unacceptably long, and is incompatible with the development of internationally competitive research projects.
Nuno Figueiredo, graduated in 2001, intern in the 6th year of General Surgery, gave an account of his experience as a PhD-Intern since he was accepted on the 1st edition of the Advanced Medical Training Programme created by the Gulbenkian Foundation in 2008 in partnership with the Champalimaud Foundation and the FCT. He stated the importance of the curricular component of the programme in his scientific training, stressing the advantage of having benefited from a Gulbenkian Foundation grant, which allowed him to be exposed full time for six months to a great diversity of training contents, as well as having daily contact with high level Portuguese and international scientists. He stressed the importance of the support received from the Director of the Service, but also the resistance he felt from other colleagues to adapting his clinical activities to the regime of a PhD-Intern after six months interrupting his internship. On the other hand he considered that the collaboration of the group of biomedical scientists with whom he began his research project was instrumental. He called attention to the need for a better juridical framing of the regulations for the PhD-Interns in order to mitigate the disparity by means of which they are obliged to practice in different hospitals. He also stressed that the present doubt, now that there are programmes for the protection for interns/PhD students, is whether there will be subsequent programmes to support specialists/post-docs.
Debate
Diogo Lucena, Administrator of the Calouste Gulbenkian Foundation Science Service, expressed institutional concern about the return of investment made in the training of doctors admitted to the programme supported by the foundation. He considered that the investment will be wasted if there is no continuity to this effort on the part of the institutions, and called attention to the importance of an adequate response by the Portuguese National Health System. He stated the current difference that academic hospitals have in guaranteeing quality clinical research, fearing that even greater difficulties will be felt in other hospitals. He also mentioned that the experience accumulated in this and in other incentive measures for advanced scientific training for clinical doctors raises a problem of the scalability of the intervention. The foundation currently supports 10 doctors a year, but it is likely that the country will need many more (70 per year?) if it wishes to avoid their dilution/neutralization within the health system itself. He also stressed the absolute need to support the quality of programmes of this kind.
José Ducla Soares, Professor at the Faculty of Medicine of the University of Lisbon, called attention to two problems related to the development of clinical research in hospitals: the fact that recruiting interns by hospital sis carried out completely unbeknown to the services where they will be working, which therefore does not take their aims into account, a situation that prevents the choice of interns with a vocation for research. On the other hand, the fact that the hospital institutions do not possess incentives to lead them to stimulate research activity, which leads to it not being valorised in the respective contract-programmes.
João Correia da Cunha reminded the group that there are already indexes of clinical complexity that allow differentiation of financing for health units, admitting that in the future there may be economic incentives for clinical research activities.
José Miguel Caldas de Almeida, Director of the Faculty of Medical Sciences, drew attention to the need not to waste the current opportunities for the development of clinical research and the urgency of granting the directors of clinical services with conditions of institutional flexibility that allows them not to waste vocations, given that in the current structure of hospital functioning it is difficult for a director to release a doctor for one or two days a week for activities other than care. He also reinforced the need not to neglect research into Outcomes Research, as an instrument for improving the health system itself.
Fernando Martins Vale, Professor at the Faculty of Medicine of the University of Lisbon, insisted on the need to reformulate the hospital and teaching careers in order to grant greater importance to research activities.
Jorge Soares, Director of the Gulbenkian Foundation Health and Development Service, drew attention to the several difficulties concerning research by doctors in hospitals: conflicts of interest between the researcher and his own research team; the fact that the institutions are not duly rewarded for the research they carry out; the lack of an effective valorisation of research activities in medical careers; the absence of flexibility in the structure of hospital functioning; and the existence of juridical difficulties in the use of patient data in research by the National Data Protection Commission. He also warned about the banalisation of PhD programmes for doctors in universities, leading to a lowering of the levels of demand.
Rui Victorino, in the same line of thought, stressed that it would be a dreadful service for medical research if grants are awarded to PhD programmes that do not guarantee high quality.
Maria Gomes da Silva, Professor at the Faculty of Medical Sciences and Specialist in Haematology at the Lisbon IPO, stated that discussing the practice of clinical research does not end with, nor should it centre on, the discussion of PhD programmes, but rather on the creating of conditions to allow the practice of research in hospitals, with it being essential to invest in organised and efficient structures that support quality clinical research in health units.
Leonor Parreira reinforced this idea, adding that another indispensable measure without which clinical research cannot flourish, even if there are research centres in hospitals, is the creation of well-structured network-linked clinical databases and biobanks, which have long been promised but still do not exist in Portugal.
António Oliveira, a student at the Faculty of Medicine of the University of Lisbon, expressed his concern about the fact that there is no system to allow the development of a clinical research career, noting that at the moment the clinician-researcher’s individual success still depends on a “chance” factor – the clinician meeting the “right person” at the “right time”.
João Sentieiro, President of the Foundation for Science and Technology, declared that he had particularly appreciated the accounts given by Ana Isabel Lopes and Nuno Figueiredobecause they had shown him the difficulties experienced by clinicians who wish to reconcile research activities with clinical practice – a reality of which he had not been fully aware. He declared the FCT’s interest in contributing towards the development of clinical research, recalling the initiatives of the Harvard-Portugal Programme, as well as the 2007 FCT Competition, specifically for clinical research. Acknowledging that Portugal is facing a quantitative problem of critical mass, he stressed that the FCT is concerned about the quality of the initiatives it supports. Specifically in relation to the status of the PhD-intern, he informed the meeting that modifications had been introduced and had been forwarded for publication in the Republican Diary as Law, leading to a possibility to monitor the quality of the candidates’ research projects. He also informed those present that the FCT will be opening a new competition for clinical research projects by the end of 2010.
Maria de Belém Roseira, Vice-president of the Socialist Party Parliamentary Group, stressed the importance of the sustainability of the policies for supporting the scientific training of doctors. She stated that even if there is no capacity for quality programmes in the nine medical schools in Portugal it is probable for each one’s best critical mass to be involved in quality training programmes. She also reinforced the importance of co-opting the interest of civil society to the problem of medical research, namely through patients’ associations.
Maria do Céu Machado, High Commissioner for Health, commented on the several different accounts, recalling that the participation of the clinician in research may take place at any moment in their professional careers, and stressing the importance of clinical maturity for the developing of research projects that are relevant to patients. She reminded the group of the importance of role models in the doctor’s professional preparation, considering that the classic model of the freelance clinician-researcher has not come to an end, and wondered about the advantage of interrupting clinical activity for the doctor to gain scientific qualifications. She also considered that a good deal of the hospital constraints on research practices may be the consequence of the running of hospitals nowadays being given over to managers who base themselves solely on indexes of care productivity. In her opinion the problem is made worse by the fact that the directors of services are forced to respond to clinical productivity, often they themselves not having had the opportunity to do research. This may explain why they are less willing to facilitate the development of clinical research in their services. In relation to the national clinical database, she stated that it did not exist and that she did not know when it would be possible to create it, referring to difficulties on the organisational level of the health system itself, such as incompatibilities between computer systems between health units, the non-uniform organisation of the clinical system in different hospitals, the waste of information resulting from the lack of systemic coordination and the rigidity of the current legislation, which prevents even the National Institute of Statistics from providing data relative to medical research when requested by the High Commission for Health in order to prepare the National Health Plan.
Conclusion and Recommendations
The obstacles to a consistent research practice by clinical practitioners in Portugal are many, although it has been clear in the several talks given that most of them are a result of the organisational and functional structure of the units of the National Health System (SNS). Modification of the current system, like that which is practised in other countries, needs, 1) the adopting of incentives aimed at health institutions; 2) the reinforcing of the current initiatives aimed at post-graduate scientific training for clinicians; 3) reinforcing and regularity in financing patient-focused research projects; 4) nationwide creation of the instruments essential for quality medical research: clinical databases and biobanks.
1 – Modification of the institutional culture of the health units in the SNS:
a) Political initiatives providing incentives for practising patient-focused research, including criteria of scientific production in differentiation between health units.
b) Incentives for creating ecologies fertile for the involvement of the doctor in research, creating quality clinical translational research centres in the hospitals of reference.
c) Significant valorisation of the scientific curriculum of the medical career, particularly in the field of recruiting for positions in academic hospitals.
2 – Continuation of investment in the scientific qualification of the clinician-practitioner:
a) Improvement in political initiatives to support scientific training for young interns.
b) Introduction of similar measures but specifically aimed at young specialists, with the creation of clinical/translational research fellowships for specialists.
3. Reinforcement and continuity for the financial support for clinical research:
a) Regular opening of FCT competitions specifically aimed at the financing of quality clinical research projects.
b) Involvement of civil society in this aim, namely by co-opting the participation of the Patients’ Association.
4. Databases and Biobanks:
When one takes into account the operational difficulties involved in the Portuguese National Health System itself in relation to recording clinical data in its health units, it shows that there is a situation that is not only prejudicial to the working of the system itself but also makes it difficult to create national data registers for research purposes. On the other hand, the time allowed was not enough to discuss the ongoing measures for the creating of a national network-structured Biobank linked to similar structures in different countries. These issues will thus be those that the Lisbon Society of Medical Sciences will try to air in the next debate on “Medical Research in Portugal”, to be held in the 1st term of 2011.
Leonor Parreira
President, Lisbon Society of Medical Sciences
vandaoliveira@fm.ul.pt
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(5) Nos últimos 20 anos, as duas áreas científicas que mais contribuíram para a internacionalização da ciência portuguesa foram, precisamente, as "Ciências da Saúde" e a "Biologia" (21% e 43% das publicações em revistas internacionais, respectivamente). Resultados tanto mais impressionantes quanto a parcela que lhes coube do investimento total em I&D, no mesmo período, foi apenas de 24% (10% no caso específico das Ciências da Saúde), um valor substancialmente inferior ao de outras áreas, em particular as Ciências da Engenharia e Sociais [ver: Produção Científica Portuguesa, 1990 - 2009: Séries Estatísticas (http://www.gpeari.mctes.pt/?idc=103)].
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