RAE2015 OF THE UNIVERSITY OF TURKUPEER-EVALUATION REPORT

DEPARTMENT OFCLINICAL MEDICINEFaculty of Medicine

RAE2015 OF THE UNIVERSITY OF TURKU PEER-EVALUATION REPORT

DEPARTMENT OF CLINICAL MEDICINE Faculty of Medicine

Panel: Jukka Meurman (chair), Ellen Frandsen Lau, Annette Grüters-Kieslich, Ulf Haglund, Beat Imhof, Alice Lichtenstein, Karina Lovell, Lars Nordsletten, Elaine Ostrander, Ole-Petter Ottersen, Anne Ridley, Klas Wiman

1. OVERALL RATING OF THE UNIT – RATING: Excellent/Sufficient

2. Description of the research activity during the evaluation period 2010–2013 – RATING: Excellent/Sufficient

Describe the panel’s view on the scientific quality and innovativeness of the research activity. How do you see the main achievements in relation to the main resources (for personnel, see 3, for funding, see 4, and for infrastructure, see 5) invested in the research activities of the unit? Indicate strengths, weaknesses and other remarks.

GENERAL COMMENTS AND RECOMMENDATIONS:

The panel’s conclusion is based on two sources of information, namely: 1) The self-assessment report from the Department of Clinical Medicine, and 2) The interviews made with three different constellations from the Department. The interviews provided much new information. The unit’s self-evaluation was mainly focussed on epidemiology and surprisingly little on clinical research and clinical trials of patients, which is the foundation of clinical medicine. The two first interview sections also focused on epidemiology and neuroscience research without much patient oriented research involved.

The self-assessment report on the remaining entire field of clinical medicine including cancer is naturally brief with up to 28 different clinical specialities, and 53 professors in the unit. Many subunits/specialities were mentioned only very briefly in the self-assessment report. At interview, however, they presented very high quality research involving clinical research. Not all units/specialities were mentioned, and thus it is difficult to assess that those absent specialities have any scientific activity. The self-assessment leads us to understand that there are large differences between different units/disciplines according to the quantity and quality of research output.

Description of research activity:

The strongest field of research seems to be the unique and long-term epidemiological studies where they have followed cohorts from the 1970s until present. They have described this activity under the heading “Early Life Events and Risk of Disease” in the self-assessment.

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During the interview they also focused on the same studies, which clearly are of very high quality. In addition several of these studies had been presented before from other departments. In the time period between the sending of the self-assessment in October and the review-week, the Turku Institute for Child and Youth Research had been incorporated into the Department of Clinical Medicine. In the interview, we learned that only one study, the STEPS study, will be part of the department, while the three other studies, which were part of the interdisciplinary center will be continued by other institutions than the University of Turku. It was stated that the experiment of the umbrella structure was regarded as “unsuccessful” and action was taken by integrating the Institute into the Department of Clinical Medicine to reallocate the university funds. No strategy how the Steps Study or the interdisciplinary concept of the former interdisciplinary center will be continued was provided during the interview.

It was also very disturbing that the Strip and LASERI studies, which had been presented by the cardiovascular research center as their major projects and achievements and the DIPP project, which had been presented as a major project of the Institute of Biomedicine were claimed as projects of this research area. Also the FinnBrain project was listed, although it was also presented in detail by the second research area of the Department of Clinical Medicine, the Turku Brain and Mind Center. The clinical focus was not clarified for this epidemiological activity. Findings from epidemiology usually need implementation. An interesting example was the cohort of new-borns followed until the age of 15 years to identify the risk factors of developing diabetes type 1. The prevention arm (DIPP Type 1 Diabetes Prediction and Prevention Study) of this study could have been highlighted. During interview the Public health was presented here. They presented a large national cohort study on health changes around retirement age. The quality of this whole research area is high, but the faculty should consider whether it is best organized under the Department of Clinical Medicine.

The second topic in the interview was “Turku Brain and Mind Center”, which in the self-assessment was headed as “Brain and Mind” which focused protection of the newborn brain and a multidisciplinary approach to traumatic brain injury. The clinical side of brain and mind were barely covered. In the self-assessment their work on very early detection of Alzheimer’s was mentioned. This included basic models of transgenic mice overexpressing amyloid. In psychiatry they look for aetiology of psychotic disorders combining clinical and imaging methods as well as genetics and metabolomics. At interview they presented a study on disruptive behaviour.

The umbrella organization “Turku Brain and Mind Center” is an impressive collaboration of research groups, but the presentation did not convince us that it is best organized under the Department of Clinical Medicine when presented with so little clinical focus.

The second main topic in the self-assessment was “Cancer” which at interview was presented together with the fourth topic grouped under the heading “Selected research projects from different units in the Department of Clinical Medicine”. In the self-assessment international cooperation in the children of cancer survivors, HPV in families, prostate cancer and skin

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cancer were the main topics. At interview they highlighted studies on ovarian and prostate cancer, both treatment and diagnostics were studied. Recently a EU grant was awarded for a consortium on ovarian cancer with participation of the Turku research group. From Turku Neurofibromatosis Centre several ways of studying rare diseases were presented. The Orthopaedic department presented two recently finished RCTs on bone and prosthesis fixation. In the self-assessment treatment studies included: simultaneous breast and lymphatic reconstruction in patients with lymphedema after mastectomy and axillary dissection. RCTs were described in bariatric surgery, other endoscopic surgery of the gastro-intestinal system and in orthopaedics. No RCTSs were described for internal medicine.

This third part of the interview clearly belongs to the Department of Clinical Medicine, and with many good studies with high clinical relevance we grade them as excellent.

3. Organization and personnel during the evaluation period 2010–2013 – RATING: Good

Describe your view on the following points: 1. The unit’s recruiting policy of researchers at various career stages. 2. Possibilities for researchers to proceed in their career. 3. Are the teachers and the researchers also actively involved in research and teaching, respectively? How do you see the balance between teaching and research? 4. Gender and equality issues: pay attention e.g. i) to good gender balance as well as the proportion of foreign personnel in the personnel groups in Appendix A, and ii) to the parental leave issues and gender balance in Appendix B.

GENERAL COMMENTS AND RECOMMENDATIONS:

Both the University and the University Hospital have adopted the tenure track system, which means that researchers can move upwards through the system without having to take other intermediate positions. Hence researchers can advance to Professorship without competition with others for the final position. The department uses this system to recruit and retain young, talented researchers. At interview we got the impression that this system was in its start up.

The departments policy is that everyone should teach and engage in research i.e. all teachers should do research, and that all researchers should teach. This is not the best way to develop excellence in research and education.

The clinical professors usually have a split post i.e. 50% research-50–70% clinical work (but clinical work may include treating trial patients?).

The details of the recruitment strategy were not specified, but they describe that students are recruited at the beginning of their degree (that must then be clinical). During interview all groups were satisfied with the possibility to recruit good young researchers into the PhD programs.

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There is the problem to develop career paths for postdoc physician scientists. Short-term leaves with protected time for research can be offered in some but not all specialties. A structured education in research and career paths with protected time for research for physicians who want to continue research and pursue their subspecialty education at the same time should be developed.

In general teaching, research and clinical work are in balance for advanced faculty.

The professorships are divided 33–36 males vs 7–9 females. This is not satisfactorily, but similar to the situation in other comparable universities. For teaching and research personnel there is much better gender equality. There are no professors from abroad and few among the other personnel as well.

4. Research funding during the evaluation period 2010–2013 – RATING: Excellent/Sufficient

Describe your view on the following points: A. The success and strategy of the unit in the competition for funding. B. Is the division of external funding into the different categories as shown in Appendix C appropriate?

GENERAL COMMENTS AND RECOMMENDATIONS:

The basic funding has increased by 1 million € during 2011–13, which is very good. Also all other sources have increased during the 2 year period evaluated, except for “Funding not through UTU”. Their self-evaluation is: “The success of the units has been good or satisfactory”. They have had problems funding the follow-up of their epidemiological studies, in addition they state that EVO (Government) research funding has been decreasing. In appendix C the “Funding not through UTU” was nearly 5 million € higher in 2012 than in 2011 and 2013. The reason for this is not explained. As this was the largest proportion of research support the change from 2012 to 2013 is large. During interview it was mixed information concerning funding. Some seemed to have good funding while others had to close activity

5. Infrastructure during the evaluation period 2010–2013 – RATING: Excellent/Insufficient

Describe the panel’s view on the following points: A. Major strengths and weaknesses in the unit’s infrastructure. B. Development of the infrastructure 2010–2013 in relation to research needs. C. Possible impact of the unit in developing research infrastructures.

GENERAL COMMENTS AND RECOMMENDATIONS:

The department stated, in the self-assessment “The hospital premises are old, overcrowding and poorly suitable for modern clinical work, and by no means suitable for research work”.

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This was only true for paediatrics and obstetrics and gynaecology, the others had moved into brand new facilities and were very happy. Paediatrics and Turku Brain and Mind Center rented housing outside the campus to compensate for the situation in the old hospital. Besides they use various facilities including MediCity, Turku PET Centre, Turku Brain and Mind Center and Turku Centre for Biotechnology. Recent organisational changes have led to increased access to MRI for brain injuries.

6. Scientific quality of research during 2010–2013 – RATING: Excellent/Good

How would you evaluate the scientific quality of the unit’s research in relation to top national/international research?

GENERAL COMMENTS AND RECOMMENDATIONS:

Their epidemiological studies are of high quality, however it was unclear as to which extent they had implemented the findings of these studies. Studies of different treatment (RCTs) were described in orthopaedics and gastroenterological surgery, but were surprisingly few in the self-assessment. As RCTs on different treatment are the basis of Evidence based medicine, this must be seen as the main topic for clinical medicine. At interview there were presented several planned and ongoing RCTs, and several ones , which have been published.

7. Publications 2010–2013 – RATING: Outstanding/Excellent

How would you evaluate the publication policy and quality based on the examples of publications in the self-evaluation report and Appendixes D and E? Estimate the overall quality of the publications that the unit estimates as its most important ones.

GENERAL COMMENTS AND RECOMMENDATIONS:

The list of the selected 25 papers contains a high number of publications with a very high impact factor including the New England J Med (3), Cell, Lancet, J Clin Oncol, etc. Of the selected papers 16 are within the research areas "Early life events and risk for disease" and "Cancer" and "Brain and mind". The remainder are focused on 5 additional fields of research such as treatment of infectious diseases in the young, osteoporosis, brown fat tissue in man, gene changes in infants with respiratory infections and in inflammation, and environmental factors such as retirement and job strain as risk factors. Many sections of the department are not represented at all in the publication list and it is difficult to determine how much the excellent publication and other scientific activity are shared throughout the department.

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8. Doctoral training 2010–2013 as part of the scientific activity in the unit – RATING: Good

How would you estimate the organisation and success of doctoral training in the unit?

GENERAL COMMENTS AND RECOMMENDATIONS:

The department follows the policies and procedures of the University of Turku. It is stated that the department offers doctorial training in 48 main subjects; i.e. about one subject per professor in the department. It is unclear how the department ensures that they are adequately trained and experiences teachers in all these subjects since the report did not cover all areas. During the 4-year period 104 doctorands have passed their examinations with an equal gender balance. The trends do not indicate any ongoing shifts. The number of doctors with a clinical background is not stated. Provided this proportion is high the average age of the doctor, which is 40 years, is what would be expected in a clinical department. In the self-assessment if is not stated which research areas provided these thesis and it is therefore not possible to evaluate to what extent the scientific activity in the different parts of the department have contributed.

9. Researcher mobility – RATING: Sufficient

A. How would you evaluate researcher mobility in the unit? B. Has the unit succeeded in attracting international researchers?

GENERAL COMMENTS AND RECOMMENDATIONS:

Trainee investigators have presented in international meetings, post-docs have studied abroad (5 well known universities in Germany and USA are mentioned) and professors have been abroad to visit research fellows. Considering the high number of professors and post-docs in this department the mobility was expected to be at a higher level.

10. International co-operation and partners 2010–2013 – RATING: Excellent

Describe the panel’s view on the following points: A. Success and extent of international co-operation B. Has international co-operation provided clear extra value for the research?

GENERAL COMMENTS AND RECOMMENDATIONS:

In some areas, international co-operation has without any doubt provided clear extra values, in terms of international funding and also in terms of creating important networks and providing larger patient materials. Other areas of the department do not seem to have any international co-operation.

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11. National co-operation partners 2010–2013 – RATING: Excellent

Describe the panel’s view on the following points: A. Success and extent of national co-operation. B. Has the national co-operation provided clear extra value for the research?

GENERAL COMMENTS AND RECOMMENDATIONS:

The department demonstrates a high level of activity in co-operation with a range of national groups, institutes, and departments.

In some areas the national co-operation has been a prerequisite for providing high class research and co-operation has for instance ensured that the patient material has sufficient numbers.

12. Wide-range impact of research during 2010–2013 – RATING: Excellent/Good

How would you estimate the impact of the unit’s research on basic and applied research?

GENERAL COMMENTS AND RECOMMENDATIONS:

Research in some of the areas included in the department has had a significant impact on medical practice and on society. MRI at term for identifying those at risk for later neurodevelopmental impairment, information about risk for later psychological problems in international adoptions, probiotic research and improved treatment of respiratory virus infections in children are important examples. Further evaluation of changing practice from open surgical treatment to minimally invasive procedures or conservative treatment is ongoing and could have significant impact on individuals and society. Furthermore, techniques for breast reconstruction and lymphatic surgery, to prevent lymph stasis following node excisions, could prove to be a very important step forward for women operated upon for breast cancer.

13. Innovations – RATING: Outstanding

How would you evaluate the innovations (e.g. social innovations, co-operation with companies and TEKES projects, established companies, patents, innovation announcements) described in the unit’s self-evaluation report?

GENERAL COMMENTS AND RECOMMENDATIONS:

Some parts of the department have been very active in applying for patents on products with a potentially very important effect on the care of patients. This is true for diabetes in the young, in allergology, dermatology, ophthalmology, anesthesiology and Ob-Gyn. The activity in the orthopedic research unit has resulted in the start up of two companies - one is sold to the Netherlands and the other continues as one of the internationally leading companies.

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14. Special impact on the national and international scientific community 2010–2013 – RATING: Excellent/Good

How would you evaluate the unit’s impact on scientific leadership as well as on the national and international scientific community?

GENERAL COMMENTS AND RECOMMENDATIONS:

Most parts of this large department have researchers that have played important roles in international and national committees and evaluations processes.

15. Research activity plan 2015–2018 – RATING: Good

Describe the panel’s view on the future success of the unit, paying particular attention to the following points:

A. Is the research activity plan feasible? How do you see the ratio of the planned investments and the aimed outcomes and impacts? Does the unit describe potential weaknesses that may affect reaching these aims? How are alternative approaches being considered?

The research plan is fairly superficial and not well prepared. It is therefore difficult to follow and several parts of the department is not mentioned at all. It is true the new hospital building probably will provide better working conditions. The Biobank will be an important asset. How funding can be maintained in a more challenging financial climate is not discussed.

B. Estimate the potential of this research activity plan for significant new outcomes, scientific breakthroughs, scientific progress in this field, as well as its potential outcomes and impacts.

The research plan is good for those parts of the department mentioned.

C. Can the panel foresee any potential scientific breakthroughs not considered by the unit itself? Not really. See A and B.

D. Estimate the planned national and international co-operation and networks in light of the aimed outcomes and impacts.

The networks and co-operation activities are good to excellent.

E. Estimate the potential of the described strategy for success in competition for funding. Probably sufficient. Difficult to judge. See A.

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GENERAL COMMENTS AND RECOMMENDATIONS:

The self-assessment and the interviews demonstrated very good scientific levels within certain parts of this huge department, while others were not really mentioned to that extent that they could be evaluated. These parts could therefore not be assessed.

Based on our experience from the self-assessment and the interviews we have to question if the organization of these units into one very large department is functional and provides the best opportunities for them to develop their research. Instead, it is suggested the department is split into 3 – 5 separate thematic oriented research groups/areas based on scientific similarities and mutual needs as well as patient’s need.