Boom or bubble? Is medical research thriving or about to crash?

A recent issue of JAMA (2005; vol. 294) presented a portrait of medical research as a booming enterprise. By contrast I have suggested that medical research is a speculative bubble due to burst. How can two such different predictions be compatible? From inside the expanding world of medical research everything seems fine and getting better. But to people outside the system, it seems like there is an awful lot of money going in, and not much coming out. Professional criteria of success (publications, impact factors, citations, grant income, large teams, etc.) are not the same as the outsider's view of success. Outsiders want the medical research system to generate therapeutic progress as efficiently as possible: the most progress for the least resources. Medical research is not the only good way of spending money and is in competition with other social systems. As funding increases, diminishing returns will set-in, opportunity costs will begin to bite, and there will be more and more social benefit to be gained from spending the extra research money on something else. Therefore, future cuts in medical research will happen because of pressure from outside the system - specifically pressure from other powerful social systems which will press their alternative claims for funding. In the short term, there will be a quantitative decline of research production. But in the longer term the medical research system will re-grow in a more efficient form. After a 'golden age of therapeutic progress in the mid-20th century, recent decades have seen a 'silver age' of scholasticism which is due to end soon. Perhaps a renaissance of medical research lies not too many years in the future.