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<jats:p> The author is university professor and senior vice president at the University of Virginia, Charlottesville, VA. E-mail: <jats:email xmlns:xlink="http://www.w3.org/1999/xlink" xlink:type="simple">ded2x@virginia.edu</jats:email> . Theories about the nature of knowledge and methods of education have been debated since the days of ancient Greece. Is knowledge a mountain of fact for the learner to conquer or is it an ever-changing stream of theories and new conceptions through which one must learn to swim? Should students master facts or develop problem-solving skills? Today, medical and graduate education in the biomedical sciences is failing to balance these two approaches. Unless we begin to confront this imbalance soon, our future physicians and researchers will not be adequately trained for the emerging health care environment. </jats:p> <jats:p>Far too much medical and graduate education imprisons students in dark rooms to be force-fed lumps of information. At varying intervals, after students have digested mountains of facts and the occasional abstract intellectual morsel, they are asked to pass examinations standardized to reflect a consensus of current knowledge. This process encourages students to observe rather than engage the world. In my view, the professional education produced by this method is not only too static and too passive, it is too narrow and too arrogant, lulling our future leaders into a false sense of wisdom.</jats:p> <jats:p>Medicine, like all branches of science, needs scholars who are able to develop appropriate “rules of evidence” and then apply those rules to the continuously flowing stream of new data to determine what is relevant. Successful professionals will need to be able to use information technology to access critical information quickly and integrate it into their constantly changing perception of the world. They will be committed to staying in the stream, despite its fast current, in order to grasp the rare informative nutrients as they flow by. In the basic biomedical sciences and in clinical disciplines, we also need far more individuals who are capable of synthesizing concepts across streams of data from many different disciplines. Their quest must be to acquire insights that transcend individual data streams to capture the whole of a problem and its potential solutions.</jats:p> <jats:p>Our academic health centers are white-knuckled in fear that their historic missions of education, service, and research are threatened from the outside. One major concern is the rise of managed health care and its accompanying decreases in clinical earnings, which have traditionally helped to subsidize the costs of medical education. Yet I believe that a greater threat may lie within the halls of academe. If we remain dedicated to minor revisions of past educational approaches, our prospects will be dim indeed. In addition, education, research, and patient care are all increasingly relying on a new set of evaluative disciplines: biomedical and biotechnical ethics, clinical epidemiology, informatics, health services research, outcomes analysis, and value management. These emerging knowledge bases must become part of a constantly evolving biomedical curriculum.</jats:p> <jats:p>If we survey the current curriculum and look toward future needs, a strong argument can be made for turning our lecture halls into learning laboratories that are focused on the most serious issues in health care, including health care delivery. We all learn most easily when the learning experience is directed toward solving a real everyday problem and uses a rigorous approach in which the effectiveness of an intervention can be readily measured. Multidisciplinary teams of faculty and students can thus pursue, as legitimate educational projects, some of the real problems facing our clinicians and our health care and health education institutions. Solutions found in one location can be shared with neighboring institutions, so that all will be able to learn from each other.</jats:p> <jats:p>Tackling real problems will require searching the data streams with tenacity, nimbleness, and a sense of humor. The initial attempts at integrative stream-based education will most likely be messy. But when a few classes achieve the first amazing successes, more and better strategies for data streaming and integration will emerge. Such successes in the health sciences could prove useful to the entire university.</jats:p>

<jats:p> Recent letters ( <jats:related-article xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="doi" page="1593a" related-article-type="in-this-issue" vol="275" xlink:href="10.1126/science.275.5306.1593" xlink:type="simple">6 Dec., p. 1593</jats:related-article> ; <jats:related-article xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="doi" page="461a" related-article-type="in-this-issue" vol="275" xlink:href="10.1126/science.275.5299.461a" xlink:type="simple">24 Jan., p. 461</jats:related-article> ) have proposed strict rules for co-authorship of scientific publications. I wholeheartedly agree that to put one's name on a paper is an assurance to the scientific community that one has contributed to the work and that one stands behind the work reported. However, one aspect of the co-authorship problem that I have not seen discussed in this forum is that of finding one's name as a co-author on a publication of which one has no knowledge. This recently happened to a colleague and me when we found a paper in a journal listing our names as co-authors, although neither of us had ever contributed to the work, seen the manuscript, or been notified of its submission or publication. </jats:p> <jats:p>I felt victimized by this event and by the use of my name in an inappropriate manner. Integrity and reputation are among our major assets as scientists. I agree with previous letter writers that every reputable journal should secure a written statement from each author listed on a manuscript assuring that a contribution to the work was made and accepting responsibility for the work. Such a requirement will protect both the integrity of the literature from bogus authorship and the integrity of researchers whose names may be usurped.</jats:p>

<jats:p> <jats:bold>Letters from:</jats:bold> </jats:p> <jats:p>Although medical schools might appear to be robust enterprises, with aggregate annual expenditures in 1995 of more than $30 billion, the fact is that on average only about 10 to 20% of their annual revenues comes from such secure sources as tuition and fees, endowment earnings and gifts, or (mainly for the public schools) state support. About 20% of their annual revenues comes from the NIH (National Institutes of Health), nearly 35% from fees generated by the faculty physicians' practice of medicine, and another roughly 15% in direct payments from teaching hospital partners. In other words, about 50% of the schools' aggregate revenues is derived from the provision of medical care; these revenues have provided surpluses that have been used by the medical schools as flexible funds for academic investments. In fiscal year 1994, the Association of American Medical Colleges survey indicated that revenues from the faculty physicians' practice alone contributed $2.4 billion to medical schools for support of education and research. Although the majority of the funds were expended for clinical education and research, not all of them were, and the fact that the funds were discretionary is their critically important feature. It is these clinical surpluses that are being wrung out of the health care system by a managed care enterprise that has demonstrated little willingness to contribute to the costs of education and research. And just as the teaching hospitals are threatened by this new environment and require additional stabilization funds, so, too, are the medical schools.</jats:p> <jats:p> The purpose of a new Medical School Fund (K. I. Shine, Editorial, <jats:related-article xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="doi" page="9" related-article-type="in-this-issue" vol="275" xlink:href="10.1126/science.275.5296.9" xlink:type="simple">3 Jan., p. 9</jats:related-article> ) is to replace these clinical revenues and provide the schools with flexible funds for the support of their academic objectives. Some of the new funds would go toward the support of curricular innovation, others to the support of the research infrastructure (or capacity) that enables the medical schools to partner with NIH in sharing the costs of sustaining the world's leading biomedical research enterprise. A good fraction of the funds would undoubtedly go to the support of clinical research, but that should be by choice and not by mandate. The schools must certainly be held accountable for the expenditure of any monies that might be received from a new public fund, but the overriding need of the medical schools at this time of convulsive change is for new monies that are flexible, not earmarked by prescription to overly specific applications. </jats:p> <jats:p>There is an old adage in medical school lore which says that any policy that would gratuitously restrict a previously unrestricted source of funds is bad policy. From this perspective, and with deeper understanding of the schools' historic dependence on flexible clinical revenues to support a broad array of educational and research objectives, one should oppose the suggestion by Shine that funds to be raised from a new all-payer assessment be restricted by policy to support clinical investigation.</jats:p>

<jats:p> In Eliot Marshall's News &amp; Comment article of 7 February ( <jats:related-article xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="doi" page="777" related-article-type="in-this-issue" vol="275" xlink:href="10.1126/science.275.5301.777" xlink:type="simple">p. 777</jats:related-article> ), it is suggested that the National Institutes of Health's (NIH's) insistence on rapid release of gene sequence information arising from their large-scale sequencing programs and avoidance of patent filing on such information is in violation of the Bayh-Dole Act. This is not correct. </jats:p> <jats:p> Sequence fragments of unknown utility, although important starting points for further research, are likely not to be inventions, and hence not within the Bayh-Doyle purview. NIH's early applications to patent such sequences, as discussed clearly in Marshall's companion article (News &amp; Comment, <jats:related-article xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="doi" page="780" related-article-type="in-this-issue" vol="275" xlink:href="10.1126/science.275.5301.780" xlink:type="simple">7 Feb., p. 780</jats:related-article> ), were considered unpatentable by the U.S. Patent and Trademark Office (PTO), and although there was no appeal to trigger a more final decision, few if any patents of a similar nature have since been issued. </jats:p> <jats:p> Furthermore, it is not likely that commercialization will be thwarted by publication of a sequence, as confirmed by the decision <jats:italic>In re Deuel</jats:italic> ( <jats:xref ref-type="bibr">1</jats:xref> ) (patentability of partially published protein sequence). Instead of wasting PTO and applicant time and money on trying to patent the unpatentable, the focus should be on protecting the commercially important invention. Most often, that invention will be the identification of how a particular sequence can be used and patent coverage for a diagnostic or therapeutic modality that can actually be incorporated into a product useful to the public. NIH and the universities have no reluctance to file for patents and encourage commercialization of inventions such as these. </jats:p> <jats:p>The record is clear that we recognize the role of patents in advancing the health and welfare of the communities we serve and in encouraging economic competitiveness. It is perfectly consistent with the Bayh-Dole Act to encourage more dissemination of sequence information, so that the actual inventions can be made.</jats:p>