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If Swedish clinical research were a patient, its condition might be described as critical. The predicament is twofold: too little money and time available for clinicians who want to do research, and a younger generation of doctors that is reluctant to embark on research at all.

No one doubts the value of clinicians doing research. Clinicians play a vital role bridging the worlds of health care and academic research. Their firsthand experience enables them to develop research questions that are highly relevant to clinical practice. And through their contact with the academic world, new research findings and methods may be more quickly transferred from lab to hospital.

As the song says, money makes the world go around, and lack of funding is one of the main reasons for the clinical research crisis. Government funding for research in general has decreased sharply in the last decade, but medicine has been harder hit than other areas. And within medicine, clinical research has fared worse than the trendier basic biomedical field. Recognizing this, the government recently raised the amount allotted to clinical research--SKr 25 million (?2.8 million) will be available in 2005--although the small size of the increase makes its value symbolic rather than practical.

But it's not just the funding to do research that is in short supply. Motivation, too, is lacking. Medical doctors who take time out to get a PhD often find that their colleagues who stick with their MDs shoot far ahead in their careers in the meantime. Whereas once a PhD was a prerequisite for senior medical posts ( överläkare), this is no longer the case. This has proved to be a clear disincentive for young would-be clinical researchers. At least two of Sweden's big university hospitals, the Akademiska Sjukhuset in Uppsala and Karolinska Sjukhuset in Stockholm, have, however, now reintroduced this requirement.

Beside money and status, changing attitudes also play a part, believes Per Bengtsson, who was appointed by the government to investigate the situation of specialized medical care and clinical research. Whereas the medical scientists of yesterday were often willing to sacrifice family and leisure for their work, today's young people aren't.

Emilia Leffler, a primary care physician in Borås in western Sweden, is a case in point. "I would like to do clinical research as a part of my ordinary workload--not added on to my normal MD hours. Even if I like science, it should not be allowed to interfere with my family and other important things in life," she says. The health care system must find ways to accommodate this change, asserts Bengtsson.

A survey last year of medical students by the Swedish Research Council found that 'too much work' and 'too slight economic rewards' were the reasons most frequently given for not wanting to pursue research. Asked about the main reasons for doing research, the majority put down 'intellectual curiosity and inspiration' and 'being both a clinician and a researcher gives a varied experience.'

The word 'both' seems to be an important one here. Although few of the respondents wanted to devote the bulk of their time to research, many of them would like to do research part time. In fact, the interest in such a mix seems to grow throughout the course of training, being highest among the students who were in their final internship before qualifying. The council believes this trend towards an increasing interest in research means that "there should therefore be a sufficient number of persons with a clinical background to do clinical research in the future," but notes that organisational and structural changes nonetheless need to be made to ensure that the interest is followed up.

The six Swedish universities with a faculty of medicine are doing their best to further increase the appeal of research. Their efforts take various forms, from having prominent scientists as occasional teachers on their medical courses, to encouraging students to do scientific projects during their MD studies, to setting up summer research schools.

Not only clinical but also preclinical research is being promoted by the universities. Although there is no 'preclinical crisis' in the sense of too few postgraduate students, the scarcity of MDs in preclinical research (now dominated by science graduates) is lamented. If too few MDs go into preclinical research, this field will lose valuable input, many believe.

Swedish MDs who do choose to pursue a research career often find themselves in a potentially dubious situation.

"Many of our postgraduates are MDs," says Elisabeth Grundström, dean in charge of postgraduate studies at the medical university Karolinska Institutet. "They start out doing research in their spare time and don't mind not being registered until later, when their results start appearing." But in fact it is illegal for departments to take on such unregistered students--known as "shadow postgraduate" ( skuggdoktorand).

Universities may not accept a higher number of postgraduates than can be given a minimum level of financial support, but according to a recent survey more than 80% of Karolinska's postgraduates started their studies before being formally accepted onto a PhD programme.

Swedish institutions are usually strictly law-abiding, but the "shadow postgraduate" condition has benefits for both sides. The university department may truly want to take on a certain person as postgraduate but lack the means to do so at the time. The "shadow" role gives these research trainees a chance to try out PhD studies with no strings attached, and--if everything goes well--get a head start on their thesis work.

Nonetheless, the Swedish National Union of Students is highly critical of departments that allow this irregular system to continue. Because they don't officially exist, shadow postgraduates have no insurance or social benefits. And they can never be sure of being accepted into the PhD programme at all. Should they fall out with their supervisor, or should he or she find another more talented postgraduate-to-be, they might not get accepted even when a vacancy in the programme arises.

The cards are stacked against Swedish clinicians turning to research. It seems that a better solution to the issues of work-life balance and training needs to be found, and soon.