Do you think medical research is fast paced? People suffering from terminal illnesses would not agree if you answered yes. Neither would Donald R. Forsdyke, a biomedical researcher at Queen's University, Kingston, Ontario. Forsdyke critiques our current system for funding health research in a provocative book called Tomorrow's Cures Today? How to Reform the Health Research System. In this collection of short essays, most of which have been published previously, Forsdyke analyzes the funding system and proposes reforms. It is written for the layperson and scientist alike, although two of the 14 chapters are fairly technical and would be difficult reading for outsiders.

The funding process, Forsdyke asserts, determines who will conduct biomedical research, what that research will be, how it will be conducted, and how rapidly it will be completed. Unfunded projects die, and large numbers of excellent proposals are not funded.

In the current funding system, scientists submit research proposals (many scientists spend four months or more per year doing only this) to a granting agency such as the National Institutes of Health (NIH). After a lag of about 6 months, the proposals are assessed by scientists selected by NIH officials from the general population of researchers at universities and hospitals. These scientists are the colleagues or peers of the grant applicants. A peer review scientist may be a judge in one session while her own proposal may be judged by others in the next session. At NIH, half of the proposals are rejected without evaluation. The rest are assigned ranks or grades. The proposals are funded starting with the "best" and going down the ranked list until the money runs out (usually at the 15th to the 25th percentile). The remaining 75 to 85 percent of the proposals are not funded.

What is wrong with this procedure? Quite a lot, according to Forsdyke, whose writing provides a stimulus for those discontented with the pace of research to propose improvements. He argues that although it is comforting to listen to reports of scientific breakthroughs in the media each week, "if the talents, energies and enthusiasms of members of the biomedical research community had been deployed more effectively, there might have been many more breakthroughs . . . a train proceeding towards its destination at 20 miles per hour sounds great, unless you happen to know that trains are capable of much greater speeds."

The first chapter cogently describes a major flaw in the current system. It rewards salesmanship as much as or more than innovative research. If you cannot sell your ideas to the reviewers who score your proposal, you will not get funded. Unfortunately, an excellent scientist may be a poor salesman and vice versa. This problem is compounded by the fact that your colleagues who review your proposal probably know less about your research area than you do.

In a chapter entitled "Alas We Are No Longer at School," Forsdyke likens peer review to an eighth grade class in which the students grade each other's exams and rank order the scores. If a teacher had graded the papers, the grades and the rank order would be quite different. However, there is no teacher in the real world. Why should one assume that the scientist who rates a proposal knows more than the scientist who wrote it? Are the committees who evaluate proposals really "experts" on each proposal they review? Probably not. Overdependence on a committee of "experts" can have tragic consequences. Forsdyke gives the example of an "expert committee's" delay in initiating vaccination against diphtheria in the United Kingdom, an action (or inaction) that may have resulted in millions of deaths.

In the more technical chapters, Forsdyke details the misevaluations given to prominent scientists during the 1800s and 1900s. These interesting examples amply illustrate a phenomenon Forsdyke calls "peer resistance to novel ideas." New ideas in science are often regarded with suspicion when they should be embraced or at least given a chance. Another problem is the emotional damage done to scientists whose proposals are rejected by reviewers. This is often the first taste of failure for scientists who had been at the top in high school, college, and graduate school. Moreover, universities, departments, and individuals are ranked for the most part by the number of research dollars they pull in. Having your grant proposal rejected has severe consequences. At most universities, junior faculty are fired if they do not obtain grant funding in three to four years. The frantic drive to obtain grants discourages long-term planning and encourages short-term studies that give immediate results. Moreover, it dramatically discourages collaboration and the sharing of data. It may even discourage honesty.

What should be done? Forsdyke recommends a system of "bicameral review" coupled with a sliding funding scale. Research proposals would be given two reviews: a retrospective review and a prospective review. Peers would conduct only the retrospective review and would base their evaluations on the applicant's past work. Importantly, the evaluation would take into account the relationship between the research accomplished and the amount of funding used to do it. This would encourage economy (the current system rewards scientists who spend the most money). Forsdyke points out that it would be easier (i.e., more objective) for peers to evaluate past progress than to assess a research plan for the future (as in the current system). New scientists would receive modest funding until their track records become established. Financial officers at the funding agency would rate the "prospective" portion of the research proposal and determine whether the budget was justified. Top-rated proposals would receive all the funds requested, the next tier down might receive 90 percent, and the lowest rated proposals might receive only 10 percent of the requested funds. Because there would be no sharp cutoff line for funding of approved proposals, researchers could keep their labs going even if the rate of their research slowed.

These reforms are interesting, radical, and certainly worthy of consideration. The critique of the current system will hit home for those involved in research. The solutions to funding problems suggested in this book, however, raise many questions. For example, could someone who has only 10 percent of the requested budget really conduct meaningful research? Wouldn't the clever applicants submit huge grants so that even a 10 percent award would be a goodly amount? What about a scientist who has an unremarkable research record, but comes up with a fantastic new idea? Would this researcher be refused funding and essentially disbarred from research forever? How would a bicameral system reduce secrecy and competitiveness? And isn't it actually difficult to judge performance in the recent past? (There is, for example, usually a marked delay in awarding Nobel prizes because it is difficult to tell at first whether someone's work is critically important.)

Despite these questions, this small book raises big issues and attempts to improve the system. It is not just scientists who should care about it. As Forsdyke concludes: "Based on the premise that those who are most motivated are the most likely to be successful, the author points to the friends of patients (perhaps including you dear reader), as most likely to bring about reform."