Dauphinée, Dale MD; Martin, Joseph B. MD, PhD
Section Editor(s): Guest Editors: THE COUNCIL OF ACADEMIC SOCIETIES TASK FORCE ON SCHOLARSHIP
Ten years ago, the Carnegie Foundation for the Advancement of Teaching published a report by Ernest L. Boyer entitled Scholarship Reconsidered: Priorities of the Professoriate.1 The report proffered a more inclusive vision of university scholarship that embraces, yet moves beyond, its traditional role of advancing knowledge through original research. The latter activity Boyer termed the scholarship of discovery, to which he proposed adding three separate but overlapping components of scholarship: integration, application, and teaching.
We have arrived at a critical time to embrace and put into practice the broader view of scholarship envisioned in the Carnegie report. In this article, we focus on the scholarship of integration, and use the biosciences as the basis of our comments.
THE SCHOLARSHIP OF INTEGRATION
With the explosion of communication technologies, academia has never been in a better position to improve the ways new scientific information is managed and shared. The traditional model—scholars conduct discovery research and convey it to colleagues through publications and to students through classroom teaching—is based on a hierarchical, linear model of knowledge development that ignores its bidirectionality. Theory can inform practice, but practice can inform theory as well.
Boyer describes the scholarship of integration as asking “What do the findings mean?” and as “making connections across the disciplines, placing the specialties in a larger context, illuminating data in a revealing way, often educating nonspecialists, too.” It would be unrealistic to try and resurrect the gentleman scholar or Renaissance man of past eras, who was learned in all fields of science and the arts. There is simply too much knowledge for any one person to absorb. Instead, we need to encourage the work of bringing diverse fields together and bringing new perspectives and new insight to bear on research findings.
Boyer suggests that it is through such connectedness that research is ultimately “authenticated” and made to live in society. To promote connectedness requires that scholars place their own research and that of others in broader and larger patterns. Integration means moving beyond disciplinary boundaries. And it means moving interdisciplinary work from the margins into the mainstream of academia.
Let us look at some examples. Physicist and medical educator Geoffery Norman identified four major discoveries that made possible the compact disc, an invention with broad application in information technology, education, and entertainment.2 Three of these discoveries led to Nobel Prizes. Charles Townes' work in quantum electronics, the basis for his 1964 Nobel Prize, led to the invention of lasers, which read the pits in the compact disc and bring alive the beauty of Renée Fleming's voice recorded there. The photoelectric effect allows reflected laser pulses to be converted to electric current, a discovery for which Albert Einstein won a Nobel Prize in 1921. Research in semiconductors, which brought William Shockley a 1956 Nobel Prize, led to transistors, which in turn led to the integrated circuits that carry the electronic signal. But even with these seminal 20th-century discoveries, another problem had to be over-come before CDs could play accurately: with the overwhelming amount of information coded on them, a thousand or more errors per second would occur. Fortunately, a redundant coding system derived from set theory solved the problem. Set theory was an invention of the 18th-century French mathematician Gauloise—who, as Norman points out, had the misfortune to die before Nobel was born!
Dependence of Biomedical Science on Other Sciences
A recent report on federal budget priorities from the national Committee on Science, Engineering, and Public Policy3 underscores the dependence of biomedical science on other scientific disciplines. “Research in the life sciences is motivated by a need to improve health,” the committee writes. “Yet many of the improvements seen in the past decades are due to advancement of knowledge that comes from other fields. Examples would include magnetic resonance imaging, positron emission tomography, and miniaturization in arthroscopic surgery. As Harold Varmus, former director of the National Institutes of Health (NIH), has often explained, discoveries in biology and medicine depend on progress in physics, chemistry, engineering, and many allied fields.”
Dill4 similarly makes a case for greater support of the sciences underpinning biomedicine. He outlines the innovations in these fields that led to advances in biomedical science, pointing out that it is often a long and arduous road from initial discovery to practical application. For example, nuclear magnetic resonance “was originated by I. I. Rabi in 1938, combined with Fourier transform methods by R. R. Ernst and W. A. Anderson in 1966, and first used to obtain a protein structure in 1985,” Dill writes. “Now, 60 years after its discovery, it is a central tool of structural biology” as well as an important clinical diagnostic tool.
These stories illustrate two key points. One is the far-reaching effects, both conceptual and temporal, of basic research. The second is the importance of awareness and interconnectivity between research fields. Cross-pollination, even between seemingly far-flung disciplines, can optimize the chance of integrating the discoveries of disparate fields and ultimately, solving problems that appear intractable from the perspective of one isolated field. These examples are not simply serendipity—good luck frequenting the laboratories of good people—but the result of understanding and integrating new concepts and applying them to challenges, old or new, in another field.
Increasing Need for the Scholarship of Integration
Perhaps because it requires the crossing of once-sacrosanct boundaries and the breaking down of longstanding institutional walls, the scholarship of integration has been slower than other forms of scholarship to gain acceptance as an integral activity of the professoriate. “Of the several forms of scholarly work, the scholarship of integration has received the least attention,” according to the American Association for Higher Education.5 “It is this kind of intellectual work, however,” the association adds, “that is most needed in the effort to improve undergraduate education, to make connections to the community, and, ultimately, to ensure the quality of research.”
Dill4 argues that for interdisciplinary cooperation to succeed, researchers in different fields need to respect each other's differing “scientific cultures.” The imperative to find more effective treatments for disease and improve human life drives medical science to a great extent, and this is typically expressed in a sense of urgency to move discoveries in the quickest way possible from bench to bedside. However, writes Dill,
physicists, engineers, computer scientists and mathematicians working on the development of computational models have certain standards of rigor, with attention paid to the number of parameters per prediction, measures of uncertainty, and systematic approximations. Such standards are essential if we are to progress towards a base of knowledge that rests on a well-understood hierarchy of concepts, models, and assumptions. Bolder models that pay less attention to standards may appear attractive, but can turn out to be expensive dead ends.
He cautions that the underpinning research can be distant from the biomedical payoffs. “And, unlike biomedicine, some of it cannot easily capture the public's imagination and compassion.”
Charles Glassick of the Carnegie Foundation, who worked with Boyer on Scholarship Reconsidered, observed that, particularly at large universities, the isolation of disciplines from one another is one of the major forces hampering integration. “We are finding that at small and medium-sized institutions, the scholarship of integration is prospering much faster,” he said in an interview.6 “They can have the conversations much easier because their boundaries are permeable and they can talk through them…. [I]solation within departments does inhibit integration, and we have to find ways to break that down.”
Further, Glassick pointed out, scholars engaged in inter-disciplinary work often feel they are going out on a limb, which is viewed as risky to one's academic career. In particular, he said, “There is lack of collaboration in those areas where people developed quantitative measures for promotion and tenure; that is, ten points for a book and so on. The scholars told us that this led to short, safe research projects. They weren't willing to take any chances, and they certainly didn't want to mess around with other people….”7
In the 1950s, the British scientist-turned-writer C. P. Snow wrote a trenchant and influential book entitled The Two Cultures, in which he observed how scientists and literary intellectuals misunderstand, mistrust, and miscommunicate with each other.8 One of his aims was to promote cooperation between these two cultures in spite of their different perspectives and values. Forty years later, when molecular biology has come to full fruition and molecular medicine has begun to blossom, it is not too much of an exaggeration to speak in a similar way of the “two cultures” of doctors and laboratory scientists, MDs and PhDs.
An important and unfortunate corollary to this alienation of basic science and clinical medicine is the decline in the number of physician-scientists over the past few decades. Wyngaarden9 was one of the first to call attention to the problem. In a 1977 article he declared the clinical researcher an “endangered species.” His concern was based on an analysis of NIH grant applications, which revealed a decline in the number of MD applicants at a time when the number of PhD applicants was rapidly increasing. In 1984, Gill10 published a provocative article entitled “The End of the Physician-Scientist.” In 1989, Cadman11 emphasized the decline in the number of physicians entering clinical research. These difficulties are well summarized by Goldstein and Brown.12 Their title, “Bewitched, Bothered, and Bewildered—but Still Beloved” is a take-off on a song from the musical Pal Joey. Bewitched by the thrills of science and medicine, bothered by the need to choose one over the other, and bewildered because he or she can't decide between the two. Nevertheless, patient-oriented researchers are beloved—and essential.
Goldstein13 offered a new diagnosis for this malady, which he called PAIDS for “paralyzed academic investigator's disease syndrome.” He lamented the fact that it has become difficult, if not impossible, for one person to be an intense and able clinician on the one hand, and to be an intense researcher on the other hand, practicing both in one career. The reasons are complex and manifold. Thirty years ago, the knowledge gap between medical school and a research career was much easier to bridge, and it was easier to combine research with medical practice. Today, with the rapid pace and complexity of research, particularly in molecular medicine, that gap has become a chasm. Basic research is technically sophisticated and is not learned easily or quickly. It has become more difficult for an MD to take a break from a clinical career to spend four or five years training for research. Those who manage it then find it increasingly difficult to manage full-scale research projects while keeping up with the demands of patient care.
Economic disincentives are also high on the list. Faced with a debt that now averages $80,000, even the most brilliant research-oriented medical student might be understandably reluctant to embark on a research career that is likely to be less lucrative and more unstable than a clinical post. But we must find ways to reverse this decline, because losing the physician-scientist would mean losing a vital link between basic science and its application in clinical medicine.
Engelberg and Bosomworth14 point out that integrative study presents a special challenge for academic health centers: developing an understanding of how the “myriad of parts (molecules, cells, organisms) can form stable complex living wholes.” But they also argue that the academic health center is “the natural and ideal home for the study of complex systems” because the very nature and imperative of medical care demand that its faculty, students, and staff use integrative patterns of thought and analysis, because their very raison d'être—caring for the sick, the injured, and the dying—encompasses the disciplines of biology, ethics, law, psychology, and spirituality, among others.
A decade ago Sir Francis Crick, co-discoverer of the DNA double helix, wrote that “almost all aspects of life are engineered at the molecular level, and without understanding molecules we can only have a very sketchy understanding of life itself.”15 In the short time since Crick wrote those words, our understanding of molecules—including DNA—and the roles they play has grown considerably. Within the last ten years, technologic advances have put in our hands the tools to peer into life's genetic foundation. As the 21st century unfolds, the post-genomics age has begun. We now have the ability to decipher the functions of each of the soon-to-be-identified one hundred thousand proteins that determine the structure and function of each cell in the human body, whether bone or brain. This knowledge will allow us to pin-point the molecular basis of disease, a process that has already begun and that will continue to pick up speed. Novel proteins are identified weekly, and with the astonishing progress in the sequencing of the human genome, the backlog of genes continues to pile up, their functions waiting to be discovered.
But the products of our genes, the proteins that make up the structure and function of each cell in our bodies, do not act alone. The reductionist approach to biomedical research has been a powerful and enormously fruitful one. But in the 21st century, we must focus on putting Humpty-Dumpty back together again, which will require the collaboration of scientists from diverse disciplines.
Closer integration of the biomedical and behavioral sciences will be particularly crucial to further advances in our understanding of the vast complexities of the human brain and its functions. The abiding tendency—even among scientifically trained persons—to see in human beings a dichotomy between mind and brain has frequently led these two (in fact inseparable) entities to be considered and treated as though they occupied different worlds. Neurology and psychiatry have historically moved closer or drifted apart, depending on their reigning paradigms. Until the mid-20th century, medical schools frequently combined these disciplines in one department. But as psychoanalytic theory and practice came to dominate psychiatry, its concerns began to seem remote from those of neurology and neuroscience, and a wide chasm opened between the fields. As Price and colleagues16 note,
until the recent past, a limited number of disorders were of mutual collaborative interest to neurologists and psychiatrists…. The “organic versus functional” approach was perpetuated by both groups. Neurologists acknowledged that psychiatrists knew about the mind but not about the brain. Psychiatrists acknowledged that neurologists knew about the brain but not about the mind…. Neither group recognized the advantages of using the methods of neuropsychology in planning the study of cerebral diseases.
Given these biases … little common ground was perceived. As a residual testament to this great divide, we could identify no major specialty journal widely read by both disciplines. The relationship could be characterized by the shared sentiment, “We get along fine as long as we don't meddle in each other's business.”
Those authors are encouraged, however, by recent developments that “make it not only possible but necessary to emphasize the integration of neurology and psychiatry,” such as the ability to study the brain with advanced imaging technologies and the realization that many mental illnesses have biological and genetic components to their etiology.
Koch and Laurent17 likewise argue that further progress in neuroscience will depend on the integration of a number of distinct and complementary approaches to studying the brain and behavior. “Advances in the neurosciences have revealed the staggering complexity of even `simple' nervous systems,” they write. “This is reflected in their function, their evolutionary history, their structure, and the coding schemes they use to represent information. These four viewpoints need all play a role in any future science of `brain complexity.”' They conclude that “perhaps the most obvious thing to say about brain function from a `complex systems' perspective is that continued reductionism and atomization will probably not, on its own, lead to fundamental understanding. Each brain is a tremendously heterogeneous patch-work. Understanding the function of any of its parts requires a precise knowledge of its constituents but also of the context in which this part operates.”
In a recent newspaper article,18 Shaywitz and Ausiello argue that “translational medicine” is an emerging discipline unto itself, and that integration of basic and clinical science might best be accomplished by academic health centers through the careful grooming of specialists in this “border-line” field. They write:
In our excitement about the progress of science, we cannot forget that determining the DNA sequence of a gene, or understanding how two proteins bind to each other in a test tube, or learning how a particular type of cell grows in a petri dish, is not equivalent to developing treatments and cures for complex human disease…. We train biologists to study life's fundamental questions, generally by focusing on highly simplified models in the laboratory, and we train physicians to manage illness and treat patients—with all their wonderful complexity and maddening unpredictability. Now, academic medical centers and the pharmaceutical and biotechnology industry must work together to develop approaches for educating a cadre of investigators who will focus exclusively on this region between the bench and the bedside and can translate promising biological advances into real clinical progress.
A Cross-disciplinary Initiative
We cannot wait for serendipity to bring together the knowledge and tools of diverse fields. We must take deliberate steps to make it happen. An exciting cross-disciplinary initiative at Harvard University exemplifies the scholarship of integration in action in the biomedical arena. This is the Institute of Chemistry and Cell Biology (ICCB), a joint venture between the Medical School and the Faculty of Arts and Sciences. The mission of the institute is to exploit the power of combinatorial chemistry to create and define large sets of biologically active molecules. These novel molecules will allow scientists to characterize protein-protein interactions, which should lead to better understanding of normal cellular structure and function. Most important, the ability to modify such interactions will aid in the identification of compounds that may have therapeutic benefits in diseases such as cancer, atherosclerosis, arthritis, and asthma, where protein-protein interactions go awry.
The work of the institute can be described as “chemical genetics,” a term coined by ICCB co-director Tim Mitchison, who noted that recent developments in drug-design technology, specifically in the area of molecular diversity, have opened up powerful new avenues to identify unknown proteins from complex systems.19 Finding a way to apply this vision to the needs of research laboratories is the central goal of the ICCB. Another way Harvard Medical School is working to foster the integration of research is through a seed grant program to encourage collaboration between basic scientists and clinical researchers at the affiliated hospitals.
LINKING ACADEMIA AND THE COMMUNITY
Moving beyond the academic health center and the university campus to the larger community, Boyer states that “linkages between the campus and contemporary problems must be strengthened.” He quotes Derek Bok, then president of Harvard: “Universities will usually continue to respond weakly [to social problems] unless outside support is available and the subjects involved command prestige in academic circles.”
The interdependence of higher education, including the academic health center, and the outside community has never been greater. Mary Budd Rowe has called science “a special kind of storytelling, with no right or wrong answers, just better and better stories.”20 But are these stories of scientific progress understood and valued in our communities? More important, is medical science having an optimal impact on the ills that plague society and its members? In an era where more people study and believe in astrology than astronomy, there is a huge disconnect between the scientific community and the larger public in the understanding of science. Try explaining scientific ideas to well-educated friends: you may be as surprised as was one of us.21 Further, Rice suggests that a kind of disconnect exists within the scholarly professions, such as medicine: “The academic career, as it is currently arranged, fosters a disconnection from the larger society—its problems and opportunities—and even from the self.”22
Medical students are trained to think scientifically, to form hypotheses, to frame questions that can be answered by collecting data. We must make sure they are equally well prepared to communicate, to tell patients and society about the evidence we can count on as well as the parts that are unsure. What is the mechanism of chronic low back pain? Why do patients with cancer betray our predictions about survival? Have we resolved the ethical issues of letting go so a patient can peaceably depart this life?
The scientific basis of medical practice is secure. We are educated to understand its logic and to approach an understanding of disease by examining the mass of evidence collected by our forebears, and we are prepared to keep abreast of and to assess progress being made while at the same time applying genuine skepticism to the purported effectiveness of the treatments we give our patients.
But there is a persistent and potentially aggravating disconnection between our position of assumed authority in the treatment arena and the patient's perspective and concerns about the communications we give. It is estimated that only half of all pills we prescribe are actually taken; the remainder languish in medicine cabinets, are flushed down toilets, are taken irregularly, or are given with good intentions to friends and relatives for their “similar symptoms.” The need to overcome these disconnects is more than a public relations problem. We need to make real changes, including a different view of our ultimate roles and responsibilities as academics.
How can we in academia work to break down the barriers between disciplines, to remove the obstacles to fuller collaboration and integration? Do we need to improve the ways we relate and communicate ideas and research findings from one academic “silo” to another? Do we need to create more opportunities for true interdisciplinary research? These notions are widely accepted today—in theory. But precisely what are the roadblocks to putting them into practice, and how can we remove them? With regard to the larger community outside academia, how can the sciences and other academic disciplines make more meaningful connections with society?
Leaders in academic medicine and the sciences at each of our institutions—and at national and international levels through organizations such as national medical associations, scientific and professional societies, the National Academy of Sciences, the American Association for the Advancement of Science, and the Association of American Medical Colleges—must assign high priority to developing a long-term strategy to address these questions. We need to cultivate the ability both to respond to current critical needs, such as re-invigorating the integrative role of the physician-scientist in the clinical arena, and to anticipate and exploit emerging opportunities, best exemplified by the genomics revolution's potential to stimulate medical advances. These are the challenges that demand our best, most creative thinking if we are to breathe life into the scholarship of integration.