We have spent over 15 years in Singapore pushing clinicians – and more recently other health professionals – to become more involved in research, to compete for grants, and to publish academic papers (and file for patents). A little “cottage industry” of clinician-scientists has emerged, with their own chapter within Singapore’s Academy of Medicine. They are largely supported by institutional or government/public funds, paid commensurate to their clinical peers, and assessed primarily based on their academic publications and ability to secure research grant funding (very few develop patents).

There are many good arguments to support continued investment in clinician-scientists, some of which were mentioned in this Straits Times article in 2016. However, it is sometimes interesting to explore different aspects of the research environment, and see how these shape the research that is being done (and this applies to research in general, not just biomedical research).

Take academic publishing. After completing a research project, the usual practice is for the researchers to write up their findings in the form of a manuscript, and to submit it to an academic journal, where the work will undergo preliminary assessment by the journal’s editorial board, and sent out for (almost always anonymous) peer review if deemed suitable for the journal. These peer reviews return weeks later, after which the managing editor makes a decision on whether to reject, accept or request for further changes based on the assessments. If the manuscript is rejected, the researchers usually re-format the work for submission to another journal, where the process repeats. Most manuscripts that are not rejected will have to undergo revision, with additional experiments to be performed based on the comments from said peer reviewers. Even if the manuscript is accepted, it takes weeks before the finalized version is available (although many journals now have a section for “accepted manuscripts” where the unedited version is available for download and perusal immediately). 

There is a strong argument that this entire process slows down the rate of information dissemination: some results may take more than a year to reach the light of day – a problem exacerbated by the incentives mentioned below. The solution that has worked well for physicists, and that is increasingly being adopted by biomedical researchers, is preprints – that is, a manuscript that is (usually) publicly available but that has not yet been peer reviewed or published in a peer-reviewed journal. This article at Wired.com describes the pros and cons of preprints in biological research very well (the prevailing concern – although this has not yet been borne out – is that accuracy will be sacrificed for speed, and we will be inundated with bad or fraudulent science). Dr Jordan Anaya tracks preprint statistics on one of his many excellent websites here, and I include a screenshot below – hard to read but shows the rapid adoption of preprints in biomedical research.

There are a number of rewards tied to publishing impactful research for researchers – including clinician-scientists – in academia (basically the old refrain “publish or perish”): better hiring prospects, better annual bonuses, promotion prospects, and tenure for university staff. Some have argued that these incentives/rewards in academia are perverse – they distort science (perhaps a topic for another day). The problem is that there is no easy way to recognize most of the impactful research, especially across diverse fields, at the time of scientific review. This certification of impact or quality then, is largely outsourced to the academic journals. In an illuminating article published in Bloomberg early last year, the author argued that academic journals are better understood as “dispensers of status” rather than “purveyors of information”, an insightful perspective. Publishing in the top journals then (Cell, Nature and Science for basic scientists; NEJM, Lancet and JAMA for clinical researchers; just to name a few) has become something of an obsession for biomedical researchers, and it is easy to understand how the drive for “novelty” coupled with the incentives of academia has affected research perversely, resulting increasingly in work that cannot be reproduced or are outright fraudulent.

The incentives inherent in academia where publishing research work is concerned has also helped create a curious situation that is possibly unique in transactional terms. Researchers submit their work to journals and – for all intents and purposes – sign over their copyright to the journal publishers for free. Other researchers provide peer review for free, and the for-profit journals sell access rights to these works to libraries and independent subscribers for hefty sums. The alternate model – open access publishing – usually results in a hefty (from hundreds to several thousand dollars) upfront article processing charge that is billed to the authors, creating potentially a “pay to play” situation that is too costly for researchers without substantial grant funding. The good part of open access publishing is that the published works are free for all to peruse subsequently. The bad part includes the hundreds to thousands of predatory journals that have arisen to capitalize on this phenomenon. Either way, the profitability of academic publishing is tremendous, according to this recent compelling Guardian piece that also provided a historical perspective of the business of academic publishing.

It is difficult to unknot the tangled web that is academic publishing, but perhaps one place to start would be to re-examine the incentives in academia (and therefore for clinician-scientists). I attach a nice table from Marc Edwards and Siddharta Roy’s 2016 paper below.