Publish or perish: It’s survival of the fittest

Ever since the first invocation of the dogma “publish or perish” in the 1930s, modern medical practice seems to have followed in the ways of Darwinian evolution: It’s survival of the fittest. This doctrine, concise yet striking, refers to the competitive nature of the academic profession in which we have been raised and continue to grow. Although obtaining a medical degree reflects many years of effort, discipline, and camaraderie, to be part of this prestigious profession often implies survival in a hostile professional environment, where training and employment prospects, financial opportunities, and publishing possibilities are increasingly limited and difficult to access.

To publish or perish reinforces the misconception that research is but a means to an end: A way of survival, and a means to gain respect, prestige, recognition, and professional opportunities that would not otherwise be achieved. Such philosophy seems to suggest that the aforementioned elements are essential to be valued and respected in our profession. It implies that the acquisition and development of other interests and skills to advance the science and the provision of care, such as aptitudes in health management, health policy, and medical education, would be less valuable to attain desirable positions, and of less benefit to our patients and careers. Above all, this principle seems to imply that the main objective of embarking upon the scientific method is to gain a reputation suitable enough to persist, when in reality, the idea of “professional survival” figures nowhere in the process of observation-hypothesis-experimentation-results-interpretation.

Abraham Flexner subscribed to the motto, “Think much; publish little.” Indeed, to the great American educator, research was not an end in its own right; it was important because it led to better teaching and patient care. It follows, therefore, that not in the spirit of productivity, but rather in the spirit of helping our patients and advancing our collective cause should medical research be undertaken. If throughout this process, our findings are recognized and our career plans are advanced, we have a moral and professional responsibility to accept it as a secondary benefit and not as a primary motivation to continue in our research efforts.

Indeed, although the effects of clinical research on our professional status seem obvious and desirable, the consequences upon our personal growth far outrank them. Beyond encouraging the study of clinical problems, the solutions of which are essential to the provision of quality evidence-based care, research inevitably leads to the ultimate transformation of the clinician, from a reader to a writer; from an obedient being, to a critical being; from an intelligent individual, to a scholar. Indeed, from a clinician to a clinician-scientist.

Once embarked upon the process of the scientific method, the quest for an answer, seemingly concrete at first sight, becomes an abstract amalgam of infinite possibilities and permutations. In this transition, we often find ourselves lost, more knowledgeable and more ignorant at the same time. It is in this particular state that we grow both as professional and critical beings, more adept to evaluate, and better suited to appreciate the natural world around us. Certainly, beyond a publication in a medical journal, the reception of a grant, or an invitation to an international conference, developing a sense of criticism and curiosity will undoubtedly bring us a greater sense of satisfaction, and connection to the natural world. This process and way of thinking can begin as early as medical school and may very well be career-long.

Although some of us may be graduates, we are forever students in training. Akin to a surgical skill, one of the goals of our own continuing medical education should be the mastery of curiosity as an automatic reflex: It is learned after multiple failures, but once acquired, it is hardly forgotten. More than a title, the clinician-scientist is the quiet person within each of us, often veiled by the fear of facing the obstacles to conducting research: research funds on the decline, the long delays for IRB’s approval, the non-standardized coding of medical archives, the lack of systematic electronic health records, the overloaded schedules of epidemiologists and biostatisticians, and the increasingly competitive printing space in medical journals, to name a few.

These barriers may exist, but their impact depends largely on the willingness and the desire we have to create an infrastructure, even theoretically, to put our ideas into place. With the now increasingly accessible medical literature, our medical generation finds itself in a never-before, privileged position, with the latest medical advances at our disposal, allowing us to develop our interests and curiosity at the greatest rate.

Traditionally, the clinician-scientist title is reserved for clinicians holding a masters or doctorate degree, for whom time is privileged outside of clinical duties to conduct research. For department heads and recruiters, to go to the hunt for the clinician-scientist means to hire clinicians with the greatest number of experiences, degrees, and publications.

To the individual clinician, however, the hunt for the clinician-scientist means to accept the very real possibility that concealed within our own daily experience are ideas that could potentially change the lives of our patients, and the future of medical practice. Such experiences should be explored for precisely those reasons, and not because we risk perishing otherwise. After all, the discovery of the clinician-scientist does not require a specialized degree. Rather, it requires tasks undoubtedly more difficult and less scientific: introspection and motivation.

We live in a time where the medical field is advancing at a greater pace than natural evolution. We are immediate consequences of a medical revolution led by our ancestors, and as such, we have a moral responsibility to contribute to this progress as well, and pass on the challenge to future generations. It is increasingly clear that those of us at the bedside are all in some way clinician-scientists with the potential to blossom.

As Newton did, we must stand on the shoulders of giants from whom we have learned, and using the tools they have bestowed upon us, look beyond their vision. Given that at the core of scientific discovery lies curiosity, whether barriers exist or not, whether we publish or not, let us cultivate our curiosity and when faced with uncertainty, learn to ask, “Why is it like that?” The benefit for our patients will undoubtedly follow.

Jacques Balayla is an obstetrics-gynecology resident.

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