British Journal of Rheumatology 1992;31:797-«00

POSTGRADUATE EDUCATION

ARTHRITIS AND RHEUMATISM COUNCIL FELLOWSHIPS BY DAVID R. KATZ University College London School of Medicine, London W1P 7PN

after the project has been vetted by the same expert referees! 2. More seriously, and crucially, my own view is that the charity (the ARC) must not switch completely either way: the key is to find the balance between the two kinds of funding, the personal and the goal-oriented. CLINICAL RESEARCH FELLOWSHIPS The fellowships that undoubtedly arouse most passion in the wider rheumatological community are those that are awarded to clinicians who already have a commitment to the discipline, and who want to do intensive research as part of their training. Trainee clinical rheumatologists should not expect an ARC-funded research period by right. Firstly, there is insufficient financial resource, and secondly the Council has an obligation to our donors to see that only suitable candidates are supported. The UK does not have an unlimited supply of front rank candidates at any one time. Once appointed, fellows have to do something, and this is where the project that the fellow is going to undertake becomes important, blurring the simplistic distinctions between the person and the science that have been suggested. Therefore, there must a a simple rule of thumb which one has to apply to any request for support. I believe strongly that ARC clinical research fellowship projects must have an objective. Whether this objective is to study a topic classified broadly as basic science, epidemiology, psychosocial, or clinical, there must be some evidence that the fellow has formulated a testable hypothesis, has a framework for collecting the necessary information to test the hypothesis, and furthermore has a desire to report the outcome to the wider academic environment in a peer-reviewed form. The weaknesses and strengths of any such clinical fellowship scheme can only be a reflection of deepseated underlying trends in medical environments, where highly intelligent young students get their introductory exposure to rheumatology. The problems of rehabilitation, mobility and even of quality of life—all so crucial in this discipline—were not necessarily perceived as the most dynamic and intellectually challenging areas during the 1970s. As a consequence, few trainees were attracted by these questions, and fewer still wished to pursue them at an academic level. The contrast was particularly clear with immunology—the stuff of Nobel prizes, many of them won from the UK—which had a dramatic appeal, and attracted the most enthusiastic recruits, who in turn had the most

Accepted 28 July 1992.

© 1992 British Society for Rheumatology

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are no simple rules to guide a charity how to go about its duties with regard to research funding. Even a relatively straightforward question, whether to give priority to the individual applicants who will best fulfil the aims of the charity, or to the projects that have the same objective in mind, is not an easy one to answer. As a result of this confusion, some two years ago the Arthritis and Rheumatism Council (ARC) was faced with the situation that there were a significant but idiosyncratically appointed and poorly monitored group of ARC Research Fellows in post. There were many ways that the Chairman of the newly-established Arthritis and Rheumatism Council Fellowship Committee, created to oversee this programme, might be expected to tackle the task—at least as many as there are professors of rheumatology in the UK, if not, perhaps, as many as there are consultant rheumatologists. What follows is an attempt to explore how I have attempted to. apply Ezekiel's theory to the problem. Broadly speaking, when I undertook the task, experience had already taught me that biases in research funding often reflect fixed vantage points such as: 1. The project is good, but leave it to the periphery to choose the worker—perhaps an early example of the doctrine of subsidiarity. 2. The candidate is good and deserves a personal stamp of approval rather than being merely an employee, so forget about the project which is actually useless. 3. No project is any good unless the worker doing it is any good; so the worker is always more important than the science. 4. Academic excellence must remain paramount, irrespective of project or person. (This last view is often espoused by distinguished academics, irregardless of the question that we have no idea how one assesses it. Is peer review beforehand the only requirement to salve the conscience? Surely outcome is equally important, and we do not know how to measure it except crudely in publication and citation/impact factor indices? With fellows perhaps it would be easier because in theory we can measure where they go in the future job market—but at present, of course, there is precious little of that around!) To confound the problems which faced me, there are several confusing issues which make it more difficult: 1. The same people/projects often end up in front of several different research charity interview panels, THERE

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BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 12 equally for the fellow to put his newly-honed clinical intelligence to challenge the appropriateness of some of the work in the hosting unit? This means, inevitably, that ARC funding may well always be a little biased towards the more complex problems in rheumatology—and in turn to the oft-repeated and ill-founded charge that only studies of esoteric minutiae are welcome. Obviously the fellowship panel must not be too involved in writing projects for fellows, and supervisors must also walk a delicate path, but there is one aspect which is so recurrent a problem that it is worthy of mention. Clear guidance in epidemiology and statistics— sampling, controls, etc.—are crucial to any proposal, particularly one that aims more towards patient samples directly. It would be inappropriate for the ARC to run such a scheme without giving some thought to the more distant future, and making some commitment of funds on this time scale. This commitment is the rationale for our intercalated studentship programme. Our fellows are only as good as the best of our applicants, and increasing the profile of arthritis amongst undergraduate medical students is the one way we can try to increase the size and quality of the cadre in the longer term. It will be a long while yet before we can gauge outcome, but the scheme is relatively inexpensive, and provides that extra impetus for the enthusiastic recruit. POST-DOCTORAL FELLOWSHIPS If life is tough for the aspirant junior hospital doctor and clinical academic rheumatologist, spare a thought for the non-clinical scientist who has launched on a research career. At a post-doctoral level, when these scientists should be at the most productive stage of their careers, developing new diagnostic avenues and therapeutic strategies, there are virtually no permanent posts available. The unfortunate researcher lurches from one short-term project to another, doing a project written by someone else, without any real chance of individual acknowledgement. Against this background, the ARC has chosen to take its own initiative. We are, of course, not alone: every large medical research charity has tried to grapple with this problem; and if we had decided not to try, there is no doubt that the long term effect would have been for the UK to lag disastrously behind in the rheumatology research field. It is unproven but generally considered correct that the strength of a subject area is more closely correlated with the fundamental research in a given field than it is with the clinical pattern, and one suspects that within a small research community such as the UK this may well be a self-fulfilling prophecy. The ad hominem post-doctoral fellowships are earmarked for candidates with excellent track records, who can be kept within (or attracted into) rheumatological research; and who have proposed a research programme with the kind of objectives that, if they can be achieved, are likely to make a significant impact on how we view rheumatological disease in the future.

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drive and initiative, and who then became the clinical academics of the 1990s. Rheumatology in the UK has benefited from this and the status of the speciality has risen accordingly; it would be naive to ignore this pattern when we explore current trends in research funding. The fellowship committee must always try to facilitate the activities of young talent across a broad spectrum. It is interesting to speculate whether the future promise is that 'pure' molecular biology will have offered the same kind of spark as did immunology 20 years ago. Although molecular methods are clearly already important tools for primary investigation (for example, in cystic fibrosis) it is not yet clear whether in multigene disorders, such as the common rheumatological problems, it will be easy for individual clinical fellows to define many new questions that are sufficiently focused to warrant investigation at the population level. This is likely to be the case at least for the next few years. In contrast, however, there are many new opportunities for the application of molecular methods to biological problems—this is already an immediate issue, and one of the challenges that fellows are beginning to grasp. Thus one may be excused for speculating further: will gene therapy, using molecular methods to regulate the immunological mediators which modify inflammatory processes—hence 'son (or daughter) of immunology'—prove the wave of the future? Possibly this is a nett but unexpected gain of any undue previous emphasis in ARC commitment? And possibly it is only by immersing some of the fellows in these types of question that we will train the rheumatologist(s) who will be able to design the appropriate molecular probes and clinical trials, asking the right question(s), in the future? One point does seem clear from the past two years— the overwhelming evidence suggests that it would be very foolhardy for the ARC to try to straightjacket too tightly the kinds of clinical fellowship application that come before it. There is scope for different types of approach; and even for some variation in the notional discipline to which the clinician wishes to be attached. We have neurosurgical and orthopaedic fellows as well as rheumatological, and hope that this will add hybrid vigour to future progress. An issue that does often arise in the review of fellowship applications is the precise nature of the tasks which the fellow will undertake. A collective view is beginning to emerge, shared by clinical and non-clinical members of interview and review panels. This is that there are lots of opportunities for a future clinician to be a collector and source of samples for the basic science laboratory (or for the professional epidemiologist, social scientist, image analyser. . .). We like to believe that the aim of the fellowship must be something more than that. This is not to decry the value of such activities; but surely the ARC would be failing in its job if it did not create the opportunity for new hypotheses to be tested; for the fellow to have a chance to look behind the scenes and realize what might be done with some of the newer tools available; and

POSTGRADUATE EDUCATION

SENIOR FELLOWSHIPS The apex of the fellowship scheme are the senior ARC fellows, who are chosen for excellence, and may or may not be clinically qualified. They are expected to be leaders in their branch of rheumatology research, and to be able to address broad major questions, which therefore implies the development and leadership of their own research group. In the recent past, the objective of all such senior fellowship schemes, including the ARC one, was to hire someone under 40, and to give them a boost, free of teaching and administration, that would place them on the short list for every professional selection panel. Reality has intruded in several ways, and the rheumatological community needs to be aware of how competitive the senior fellowships are in 1992. Furthermore, the consequences of the launch of this scheme have been that the ARC has now become the the chief support of some of the most important groups in connective tissue biology in the UK. The dearth of posts in the university sector as well as at high level in industry has forced the Scientific Co-ordinating Committee to mandate the Fellowship Committee Chair-

man to allow the possibility that senior fellows re-apply, and then again undergo the intense scrutiny and competition. This step has been necessary in order to avoid very valuable and distinguished researchers, who are already leading groups of their own, being lost to research. There are inevitable queries raised by the critics about this scheme, too. The senior fellows are all at large centres, which is probably inevitable given the requirement for interdisciplinary collaboration in most top rank enterprises today. Although some of the fellows are clinically qualified, a practising bedside, rather than benchside, senior appointment has yet to be made: again probably reflecting the complexity and full-time commitment required for research in the 1990s. It does depend on where one is standing when addressing the question: if one regards ARC professorships within the same general pool of resource, then of course there are far more clinical posts than fellowships available in the pool. Taking a longer term view, the objective would be to see someone pass through the ranks of post-doctoral fellow to the senior level; and even further down the line one can anticipate PhD students following the same trajectory. Hopefully there will still be sufficient flexibility in the system at that stage to ensure that the successful ARC worker will have moved laboratory during this cycle, to be exposed to different vantage points; but we should pride ourselves that our selection is sufficiently stringent that we can create a career path without sacrificing quality in any way. WORKINGS OF THE ARC FELLOWSHIP COMMITTEE The mythology about what happens when an application arrives and is screened appears to be limitless. One is constantly surprised at the rumoured methods that we adopt to ensure that someone's favourite candidate is eliminated. It is virtually invariable for applications to be sent for review. At least one reviewer is a clinical rheumatologist; at least one is chosen as UK expert in the discipline; and one other reviewer is a leader in the field. We try to make use of European and American authorities as well as locals; it would be unheard of for a senior fellowship to be awarded without this being done, and increasingly the same applies at the more junior levels as well. Short listing is avoided as much as possible, but where the review is obviously very adverse, exclusions do have to be made. More than one day of interviewing, and more than 12 interviews per day seems to me to be too much of a strain even for those with the stamina of the UK academic community. The papers relating to the exclusions are always made available to the interview panel when it meets, along with those who are attending. The panel is selected to avoid including anyone from the place where the applicants are working, and where they plan to work. We also eliminate referees and reviewers, and have to ensure that there are at least

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They have already had some post-doctoral experience, and are now beginning to develop their own status. The interviewing panel has the discretion to make these appointments for up to five years. At this stage in a non-clinical career the prospective fellow should certainly be a master/mistress of their chosen field, and willing to withstand intensive critique, both by reviewers and by a panel which has to include at least one expert in a closely related field. For example, if the applicant is in the field of biochemistry, we would always try to have a professor of biochemistry not only among the anonymous reviewers but also on the panel itself. The ARC operates the scheme in order to provide some career stability for non-clinical workers, and our remit does therefore include the possibility of appointing a fellow via this scheme who is a person that is considered to play a pivotal role within a particular research group, even if the candidate is not quite the acknowledged authority on the topic of his choice. However, such appointments are inevitably going to be relatively less common. Again, the ARC has had to ask itself: where do these fellows come from? and has concluded that PhD training is the key target time to interest young researchers in questions about arthritis. Therefore, we have introduced a studentship scheme which is now much in demand. For this scheme, rather than try and match potential students to laboratories ourselves, we have chosen to ask for proposals from the research community, and have selected the eight top applications, using a simple scoring system and then adding weightings for geography, the number of studentships in that discipline, and the track record of the applying unit as a training group. We have been more than pleasantly surprised by the calibre of those who have applied to the selected supervisors for these places.

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BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 12 get it right and justify the expenditure, when neither the senior rheumatologists themselves nor the health care planners have yet laid the appropriate foundations. The Fellowship Committee is taking a keen interest in quality control: how do we plan to measure outcome? The simple short term measures—achieving a higher degree, and refereed publications—are obvious. But what is the follow-up of fellows in career terms? Are we doing better than an an hoc system? What major advances in rheumatology have been a consequence of the work of the ARC fellows? It is too soon to judge these issues on a system that has only been fully operational for 18 months. Probably it will take at least five years, and even then changes may be intangible—how does one measure a difference in attitudes and perspective? One way to assess progress is by site visits, and it is now policy that at least one such visit must take place in the third year of a five-year award. It is also our intention to initiate annual meetings where fellows can gather, talk to each other, give a brief seminar on their work, and feel part of a community of excellence. As Chairman, and in presenting the report of our activities to the higher committees, one has always to bear in mind our responsibilities. Unlike the impersonality of other forms of research support, this is where the human side of the ARC is clearly visible, where face to face confrontation occurs with high stakes, and where there are acute human sensitivities, and human careers, directly at stake. It is always humbling to remember that we are making major decisions, judging our peers, controlling other peoples' lives. I am sure sometimes we are going to get it wrong, but we do try hard not to do so!

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four members in addition to the Chairman and Scientific Secretary. The most open face of the committee is the exhaustive interview process—not less than 30 minutes a candidate, followed by a brief exchange of views between the panellists. By the end of the day it is surprising how often unanimity has been achieved, so that the selections made can be recommended immediately to the Scientific Co-ordinating Committee. The unsuccessful candidates are notified, usually with very detailed feedback. This is widely praised as almost as good as a review of a paper, only with the advantage that it is before the work is done rather than after the mistakes have been made! Many rheumatologists have suggested that there is already a strong case for collaboration between the ARC fellowship scheme and the new Health Services Research initiative, in order to ensure that studies are designed which can aim to evaluate and reduce the human cost of inadequate and poorly defined care. There is also scope for links with commerce and industry, and not only those that are health care productrelated: lost productivity due to rheumatological conditions is a sufficient economic burden to justify considerable investment. But good clinical research of this type is not easy to define and not easy to do. Once the 'good' questions have been defined, strategies for answering them could be put forward; but probably these would involve long-term following of patients in ways that are not really suitable for a 3-year fellow. This area represents a far broader issue currently challenging the rheumatology community: i .e. to tease out, in an answerable form, questions about the effectiveness and value of conventional rheumatological care, or its absence. Perhaps at present it may be unfair on the prospective fellow, clinical or non-clinical, to try to

Arthritis and rheumatism council fellowships.

British Journal of Rheumatology 1992;31:797-«00 POSTGRADUATE EDUCATION ARTHRITIS AND RHEUMATISM COUNCIL FELLOWSHIPS BY DAVID R. KATZ University Coll...
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