Editorial
Boom or bubble? Is medical research thriving or about to crash?
Bruce G. Charlton
Medical Hypotheses 2006; 66: 1-2
Summary
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.
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A recent issue of JAMA (2005; vol. 294) was full of good news and optimistic forecasts about medical research – not least that funding in the USA had doubled over a decade [1]. The portrait was of a booming enterprise. By contrast I have suggested that medical research is a speculative bubble due to burst [2]. How can two such different predictions be compatible?
It is a matter of perspective. Modern society is constituted by complex social systems, each with a distinctive function and with specific rules of internal processing appropriate to that function [3]. Different social systems generate different evaluations of what is going on in the world. From inside the expanding world of medical research – at least to those successful people who are asked to write articles for JAMA – 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.
Inside the medical research system, personal success is evaluated by highly professional and objective criteria such as a large volume of publications in tightly refereed and high status journals, pulling-in large grants, running a large team and having one’s work heavily cited. Outside the system people tend to ask: what have you discovered? The result is a perspectival mismatch – since very successful medical scientists may not have ‘discovered’ anything very much. Essentially, the work of a successful medical researcher may consist of doing much the same as everyone else but more of it; and probably doing it a bit better, or using a new method. This kind of thing is what the medical research system values, and this is what it generates.
The point is that professional criteria of success are not the same as the outsider’s view of success. Outsiders do not really care how many papers are published or where – they want the medical research system to generate therapeutic progress. That is its job. Furthermore, outsiders want therapeutic progress to be achieved as efficiently as possible: the most progress for the least resources, because medical research is not the only good way of spending money.
The medical research system is in competition with other social systems. Clearly, while funding can potentially increase indefinitely (due to growth of the economy) the proportion of resources devoted to medical research cannot long continue to double every decade or so. 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 such as extra health care provision, education, legal aid, defence capability or tax cuts.
The coming shift of funding away from medical research will not happen because the research system says ‘stop – we have enough!’. Neither will it depend on convincing the government by rational argument that medical research is well into an era of diminishing returns. Cuts in medical research funding 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 effect, as medical research funding gets too big and too inefficient, the other social systems will inevitably ‘gang-up’ against medical research, and since they are more numerous, powerful and influential they will (somehow or another – but somehow) cut it down to size.
Even so, it is true that things from inside medical research currently look fine – and they will continue to look fine until quite rapidly they become not-fine. Medical research has become dependent on rapid and continuous funding growth over several decades – and when this slows, ceases and cuts begin to bit, the system will collapse very quickly down to a smaller size. In the short term there will inevitably be a quantitative decline of research production [4]. But in the longer term the medical research system will re-grow in a more efficient form – because, of course medical research is vital and will continue.
Overall, this will be to the good. Looking back on the current era, observers are unlikely to regard it as a ‘golden age’ of therapeutic progress – that came much earlier, in the mid-20th century [2]. Instead, future commentators will probably see the past few decades as something of a ‘silver age’ of scholasticism, rather like the late medieval period of highly-professional logic-chopping and commentaries written on commentaries. This activity was not without its value, philosophical progress was made – but academia needed rationalizing to yield the more rapid advances characteristic of The Renaissance. Let us hope a renaissance of medical research lies not too many years in the future.
References
[1] H. Moses, E.R. Dorsey, D.H.M. Matheson and S.O. Thier, Financial anatomy of biomedical research, JAMA 294 (2005), pp. 1333–1342. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
[2] B.G. Charlton and P. Andras, Medical research funding may have over-expanded and be due for collapse, QJM 98 (2005), pp. 53–55. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
[3] B. Charlton and P. Andras, The modernization imperative, Imprint Academic, Exeter, UK (2003).
[4] B.G. Charlton and P. Andras, Modernizing UK health services, J Eval Clin Pract 11 (2005), pp. 111–119.
