Dear Editor,

I have greatly enjoyed reading Dr. Praga’s editorial regarding independent clinical research.1 Aside from being written with clarity and grace, it includes a serious analysis of the multiple ailments that the “independent” clinical researcher suffers from in our country. Although I have been away from the hospital environment for some time now,2 I have not stopped appreciating and admiring the service, teaching and research activities that are carried out daily in Spanish hospitals. However, some of the affirmations/reflections found in the editorial have provoked me into sharing my comments. First of all, I believe that Dr. Praga effectively demonstrates that the brilliant clinical research in our country is not efficiently supported thus not providing a trajectory of successful projects. Without a doubt, I agree with him that the achievement of good scientific research per se without good publications is poor evaluation criteria The problem, however, does not reside in “glorifying” the project but in correctly evaluating its development and final results. In Spain, evaluation is frequently carried out «ex ante»; that is, in the moment that a new project is applied for, and, in theory, a good part of its viability depends on the curricular trajectory of the applicant. Thus, if Dr. Praga applied for funding from an agency with sound evaluation systems, he would have a good chance of obtaining it. On the other hand, the evaluation should also be carried out «ex post», a trend that is progressively being incorporated into certain funding agencies. An additional perversion derives from the argument proposed in the editorial: the conceptual separation between research and project. Research projects in hospitals (basic or clinical) should serve to make the intellectual life of the departments more dynamic and integrate different areas of the hospital, besides financing the personnel and materials to carry out the projects. Therefore, projects should always be carried out, as clearly defined by the editor, with rigorous follow-up and evaluation of the results. Asecond aspect that I would like to emphasise is the permanent divorce between clinical and basic research, a loss that would be significantly reduced not only if the basic researchers in the hospitals were to consider the clinical researchers, but also if the clinical researchers, reasonably motivated, dedicated time and effort to get close to the laboratory. This leads me to comment on his thoughts concerning the programme to intensify research proposed by the Carlos III Health Institute (ISCIII). Although my laboratory has been funded only on rare occasions by this organization, and thus I can speak with certain independence, it is only fair to recognize its effort in the last few years to carry out rigorous evaluations and to try to improve the research environment in hospitals. The “protected time” initiative for clinicians with research interest is not copied from basic research but is inspired by the American system where hospitals with this profile are partially or totally freed from their health-care responsibilities in order to focus on the development of their projects. This initiative, although still needing much improvement according to that proposed by Dr. Praga, implies that the system is, at least, taking it into account. However, the true revolution will not arrive until the curricular researcher does not suppose an implicit commercial benefit. As Dr. Praga notes, the assessment of the professional development of hospitals in the public sector system of many Autonomous Communities suffers from obsolete criteria whatever the perspective. Returning to the subject of independent clinical research, there is no doubt that case-by-case review and meta-analysis are powerful tools for good clinical research. However, they do not allow for the establishment of causal evidence in the majority of cases and thus it is necessary to resort to clinical trials with intervention phases and other approximations. The same thing happens in the laboratory and, basically, at the back of function loss or gain strategies, only an asymptotic approximation to the truth is obtained. That said, this independent clinical research is not only praiseworthy but necessary to allow, among other things, the consideration of more ambitious projects than those with which it should be a part. We will not forget the primary consideration of research is that, like medicine, it should be of good quality regardless of being basic or clinical. As an example, I would like to point out the minimum advances in the treatment of glomerular diseases during the last 30 years and, moreover, it is likely that the future will come from the knowledge of an abstruse and complex pathway discovered in a fly, the Notch pathway.3 I wonder how many Spanish nephrologists know about and think about this pathway. The same nephrologists who within 10 years will present communications about the drugs based on its regulation. Would it not be interesting if some of them started right now to integrate it in the realm of their worries and if they would actively participate in the understanding of their role in glomerular pathology? I will conclude with a comment for my much appreciated and admired clinical researcher. A hundred and fifty years ago, Darwin put the human species where it belonged, and at the speed at which we are living, it does not seem that his moral genome has reached such high evolutionary levels. Dr. Praga says that “research is carried out for the love of truth... for our profession and for our patients”. Beyond getting into an irresolvable discussion about the existence or not of authentic altruism, there is little real motivation for our species beyond glory, power, sex and money. Although I am willing to get excited about the possibility that Dr. Praga forms an exception, it would be a good thing if the scientific policy managers would take into account these ideas and, above all, the proposals of the editorial, to slowly transform the reality of research in the majority of Spanish hospitals.