Shapiro, Eugene D. MD; Coleman, David L. MD
Section Editor(s): Guest Editors: THE COUNCIL OF ACADEMIC SOCIETIES TASK FORCE ON SCHOLARSHIP
The application of knowledge to consequential problems of individuals or of society is the domain of the scholarship of application, one of the four types of scholarship envisioned by Boyer1: discovery, integration, application, and teaching. The scholarship of application encompasses a broad range of different types of scholarship, some quite traditional, others less well recognized and more difficult to define. (Some idea of this range is indicated later in this article.) We discuss scholarship of application broadly, but also focus on how it applies to patient-oriented research such as clinical trials and to service performed by physicians; we try to define scholarship in each of these areas. We also discuss the importance of the scholarship of application, incentives and disincentives to the conduct of this form of scholarship, and how it should be evaluated, rewarded, and nurtured.
WHAT IS SCHOLARSHIP OF APPLICATION?
The scholarship of application can be understood by reviewing its function in many types of patient-oriented research, which include clinical trials of either a drug or another intervention (e.g., physical therapy or acupuncture) and observational studies, such as either case-control studies or cohort studies of the effectiveness of an intervention (e.g., a licensed vaccine or a drug). In essence, the investigator is assessing how an intervention works when it is applied to humans.
Epidemiologic studies of risk factors for the development of certain diseases (e.g., a case-control study of the association between smoking and lung cancer) or of the association between malnutrition and life expectancy in a developing country represent other types of applied research. What these types of scholarship have in common is the fact that the investigators are trying to answer a question (presumably one of either clinical or epidemiologic importance): How efficacious is the intervention? Which intervention works better? What are the most important risk factors associated with a certain disease? What is the magnitude of the association between a risk factor and an outcome (such as a disease, death, or disability)?
What constitutes scholarship in the application of clinical expertise? The clinician who sees many patients and becomes expert in clinical evaluation, in differential diagnosis, and in the management of patients with complex problems clearly is applying knowledge and is a valuable asset to an academic department, but his or her application of expertise does not constitute scholarship. However, if that same clinician systematically assesses the effectiveness of different techniques and communicates the findings in a way that allows others to benefit from his or her expertise, that is scholarship. The quality of the scholarship may be determined, in part, by how carefully the clinician defines the elements of the different techniques as well as how well he or she is able to assess differences in their effects. A clinician also might perform a scholarly project by assessing his or her effectiveness in communicating a prognosis using different techniques, or may assess the effectiveness of different techniques to get patients to comply with management plans (e.g., taking medications or exercising).
The element that is common to all of these examples is that the academician is trying to answer a question (or to test a hypothesis). The quality of the scholarship (as with other types of scholarship) will depend on the clarity and importance of the question, whether the methods used are appropriate, the validity and generalizability of the conclusions, and the effectiveness with which each of these elements is communicated.
Can the academician perform scholarly work without testing a hypothesis? We believe that the answer is a qualified yes. A clinician can develop a thesis or model that can become a subject for scholarly study that can assess, criticize, and ultimately modify the model. This is in some ways analogous to a thesis put forward by a scholar in the humanities. For example, a Shakespearean scholar might promulgate a certain interpretation of a play (or parts of a play), using examples from the work to support the thesis. Once published (or in some other way communicated), other scholars could support or criticize the thesis, which might lead to modification of the original interpretation. In clinical medicine the model might be a systematic approach to treatment of some disorder or symptom complex (e.g., chronic fatigue) or an approach to the diagnostic evaluation of certain symptoms (e.g., abdominal pain). The clinician might devise a model to approach such problems that is believed to be effective. The clinician could make a scholarly contribution if he or she is able effectively to describe both the rationale and the elements of the model and communicate these in a way that can be assessed and criticized.
Similar standards can be applied to service performed by physicians, either in practice or in the community. Again, simply performing useful service, while valuable and important, does not constitute scholarship. However, if the skilled clinician tries to assess patients' satisfaction with the care that is being rendered, and assesses which aspects of care are well received and which are not (and can communicate this to others in a presentation or, ideally, in a publication), that is scholarship. Similarly, committees that establish policy are useful and necessary, but scholarship can best be defined by seeking answers to meaningful questions arising from committee deliberations (e.g., Is this the most effective way to deliver care? What are the determinants of physician satisfaction in a health maintenance organization?) and then communicating the results to others. The common aspect of the many forms of scholarship of application is the dissemination of useful, testable, and reproducible information to others.
The evolution of a progressive society is dependent upon the application of new knowledge to address its problems and challenges. Scholarship of application should extend knowledge in the sciences or in the humanities that leads to solutions for problems of consequence in society. Examples of the benefits to society include the development and refinement of useful diagnostic and therapeutic medical interventions, establishment of practices for preventive medicine, design of strategies to improve the public's health, and the development of screening practices to identify individuals who are at risk of various health problems. In the social sciences, examples may include the evaluation of fiscal policy in economic growth, or the efficacy of preschool interventions for ensuring educational success among populations at risk. Society clearly benefits from the evaluation of relevant problems based on the scholarly application of new knowledge.
The scholarship of application also benefits academic institutions. Applied scholarship helps academic institutions meet their obligations to serve society. The scholarship also improves political support for academic institutions by allowing a broad range of individuals to understand how academic institutions make meaningful contributions to the quality of their lives. Increased political support also increases the financial support of academic institutions by legislatures, philanthropic organizations, and individuals. As academic health centers face increasing financial pressure, the scholarship of application provides an opportunity to add visible prestige and to improve their positions in the competitive health care marketplace. In addition, academic health centers can benefit from the findings of studies that improve both the efficiency and the effectiveness of their service functions. Just as with basic research, studies of application can also lead to new questions as well as to new methods to address relevant issues. Applied studies can thereby beget new studies, adding further benefit to society and to academia.
The scholarship of application also benefits individual faculty members. Since this form of scholarship can be understood by larger segments of society than is often the case for more laboratory-based research, it is more likely to increase the visibility of faculty. The increased visibility increases the self esteem of individual members of the faculty and also increases the likelihood that they will receive support from the institution (and from outside sources of funding).
In academic health centers, the clinical practice income of faculty may also be stimulated through the increased visibility derived from this form of scholarship. Moreover, the ability of faculty to expand the scope and impact of their studies will be increased by a scholarly record that is both meaningful and understandable.
The aforementioned benefits to society, to academic institutions, and to individual members of faculties provide substantial incentives to perform scholarship of application. The usefulness and visibility of this form of scholarship may enhance the appeal of requests for grants to funding agencies, since they are likely to appreciate the value of studies that are directly applicable and relevant to the problems of individuals or of society.
The benefits of scholarship of application in a clinical setting may be particularly compelling. For example, clinicians are under considerable pressure to improve both the effectiveness and the efficiency of their clinical operations. Scholarship that critically examines clinical strategies is likely to be particularly useful to clinicians. Clinicians are also in an ideal position to conduct observational studies in their clinical practices. Consequently, this form of scholarship may be quite practical while it meets the needs of both the individual academician and the institution.
The successful completion of meaningful scholarship of application is hindered by a number of factors. Despite compelling goals, this form of scholarship is often held in lower esteem within academic peer groups. While few would dispute that teaching, caring for patients, and serving the community have value, scholarly efforts to classify and evaluate the approaches to and effects of these areas are problematic, which has contributed to the under-recognition that has been associated with such scholarship. In addition, short-comings in the methods of scholarly studies may limit both the value and the prestige of this form of scholarship. The methodologic challenges are often formidable. In a clinical trial, for example, the investigator must overcome problems such as inadequate compliance, heterogeneity of populations, obtaining informed consent, interobserver variability in the data, and inadequacy of the size of the sample. Consequently, clinical trials infrequently provide definitive information and may yield conflicting results. Scholarship in the social sciences may also be confounded by substantial practical methodologic challenges. The methodologic short-comings generally reflect the practical difficulties of executing these studies rather than lower standards of the scholars.
The individuals who are most likely to conduct applied scholarship in academic health centers may not have sufficient protected time to pursue such scholarship in a rigorous and thoughtful manner. Demanding clinical or administrative responsibilities may detract from the ability of faculty to overcome the considerable methodologic and technical challenges inherent in the scholarship of application. In addition, many clinical scholars have not received adequate training in how to conduct high-quality, patient-oriented research. These shortcomings further add to the perception that applied research is less rigorous than laboratory-based research, which also may reduce the academic credit derived from this form of scholarship.
Despite the compelling nature of scholarship of application, peer-reviewed funding agencies have traditionally not been as supportive of this type of scholarship.2–5 Moreover, both private and public funding agencies often evaluate applied studies with the bias of a pre-existing economic or political agenda. For example, pharmaceutical companies finance studies designed to provide support for use of their products. Public funding agencies are subject to political oversight and must fund a portfolio of studies supported by Congress or other public institutions. Therefore, the stability of public funding may fluctuate according to political rather than scientific imperatives.
The evaluation of scholarship of application presents additional challenges. Peer review is the bedrock of the evaluative process and can best ensure that the quality and standards of the scholarship meet the standards of the academic community. Academicians are most suited to evaluate the validity and the generalizability of the work. Inferior scholarship not only will erode both the quality and the credibility of academic institutions, but may also be injurious to society, to institutions, and to individuals.
The peer-review process must incorporate a range of criteria in assessing scholarship. The reviewers must evaluate the importance of the work, the adequacy of the method, and the impact of the results. The broad implications of some forms of this type of scholarship may not be fully recognized or accurately assessed by the traditional peer-review process. Therefore, a more expansive review process may be necessary. For example, to assess fairly studies of the effectiveness of different approaches to education, it may be necessary to receive input from the students who are subjected to the different techniques. Studies that evaluate new approaches to the delivery of health care should incorporate measures of patient satisfaction. In many areas of application, scholarship of high quality, excellent credibility, and powerful impact is most likely to be recognized when the process incorporates both review by peers and input from the beneficiaries of the scholarship.
REWARDS AND NURTURING
Rewards for scholarship of application should be similar to those for other forms of scholarship. Academic institutions should hire and promote individuals who conduct high-quality scholarship of application. Successful individuals should be granted institutional awards, publicity, and financial rewards that are equivalent to those received by academicians who conduct other types of scholarly work. Public and private organizations also must recognize substantial contributions in the scholarship of application.
Several steps are necessary to induce individuals and institutions to conduct and nurture scholarship of application. First, trainees should receive rigorous instruction in methods that are appropriate for this form of scholarship. Too often, both the importance of and the need for such training are ignored. High standards of inquiry should be taught and enforced among trainees. Both the credibility and the impact of this form of scholarship will be substantially eroded without a sound foundation and reasonable expectations. Faculty can be further encouraged to perform this type of scholarship if highly successful individuals are promoted and receive the recognition that is appropriate for their achievements in this form of scholarship. For example, allocation of tenure slots to individuals with substantial achievements in the scholarship of application sends a powerful message to both faculty and trainees that the institution endorses this form of scholarship.
The performance of scholarship of application requires protected time for members of the faculty who conduct this form of scholarship. In addition, promotion committees should recognize that this type of scholarship may require a long period of time to complete. The “up-or-out” provisions in the academic promotion process must account for constraints on certain types of scholarship of application by utilizing a more flexible timetable for the evaluation process. While it is reasonable to demand evidence of achievement for research that is in progress, institutions must grant faculty sufficient time to perform this scholarship successfully.
Moreover, if academic institutions are convinced that the scholarship of application is an important part of their mission, this goal should be communicated directly to faculty, and confirmed by providing tangible support and rewards to individuals with significant achievements in this type of scholarship. Financial support is a critical component of promoting this form of scholarship. Academic institutions will need to generate this financial support internally as well as by stimulating support through external public and private funding agencies.
The scholarship of application involves the translation of fundamental knowledge to practical applications to help solve problems of individuals and of society. This form of scholarship is vital for both society and academic institutions. Accordingly, academic centers must undertake a variety of strategies to promote this form of scholarship. The methodologic challenges and broad scope of scholarship of application demand rigorous training and may require long periods of time for the successful conduct of such scholarly studies. Evaluation of scholarship of application must utilize peer review as the critical component, but (when appropriate) should also augment the evaluation with input from “consumers” to fully assess both the quality and the impact of the scholarship. The interdependence of academic institutions and society requires that the scholarship of application be conducted with rigor and relevance.