Dear Editor:

I would like to thank Drs. Lamas, Rodríguez-Puyol and Cruzado for their comments on my editorial.1-3 Is independent clinical research being supported in Spain?4 As I mentioned, it was not my intention to do an indepth study of hospital research in our country, which would be an undertaking quite beyond my capabilities and available time, but rather, to describe the personal experience of a hospital researcher with many years dedicated to the task. I would like to stress that I am surprised by the wide-ranging response provoked by my letter: I have received numerous e-mails from doctors who felt they saw themselves reflected in the editorial and declared that they share the same opinion. On the other hand, a significant percentage of the messages came from doctors outside the practice of nephrology, which shows that our magazine has a wider distribution than we had thought.

Drs. Lamas, Rodríguez-Puyol and Cruzado raise well-deserved points about my letter, and I essentially agree with them. The three authors have all made a career of high-quality research and divulgation of the needs for research and rigour in scientific evaluation, and their opinions are always valuable and represent the highest authority in the sphere of research. However, some of their statements require amendment in turn. The letters by Rodríguez-Puyol and Cruzado stress the effort that Spanish government agencies have put into supporting hospital research. I agree with this point, which I also noted in the editorial. Likewise, today we have financial resources that would have been unthinkable not so long ago. But our need for the provided institutional support to be effectively reflected in the improvement of the real conditions under which we do research in hospitals is made all the more categorical by these undeniable advances. That is, giving money (which is of course very important) to clinical projects and evaluating research is not enough; rather, mechanisms must be created that would permit clinical projects to be developed and concluded without meaning an excessive effort for doctors. In the editorial, I referred to the huge difference between participating in a clinical treatment study propelled by the industry, in which everything is served on a plate and one can even earn money, and the growing mountain of bureaucratic difficulties that an independent researcher, who receives an official compensation, must face if he or she wishes to finish well. We merely have to count the number of completely independent clinical treatment studies that have been carried out in Spain without the participation of the pharmaceutical industry. As I mentioned in the editorial, in a country such as Spain, which has very complex requirements for authorising a clinical trial, we need official bodies that would do what CROs do to develop studies of the industry and relieve the researcher of a bureaucratic process which at present is nearly unavoidable.

But there are more topics, and therein lies my criticism: I think that very few experienced doctors will deny that the role of the Medical Management in Spanish hospitals has been progressively deteriorating (although there are of course praiseworthy exceptions to this tendency), with the introduction of operating diagrams (clinical management which is neither clinical nor proper management, “quality” departments which have nothing to do with the quality which we can value and recognise, etc.) which grow more autistic and lacking in scientific or moral authority every day. This is a main topic, which deserves all of our thoughts. In this context, attempting to develop a quality clinical study can be a heroic task. I also commented that in many hospitals, we now have the ideal tools for supporting research, such as research institutes and foundations, but it is necessary to instil in them the spirit of intellectual curiosity that is the basis of research. On this topic, it is necessary that doctors struggle in order for those bodies to truly be effective at facilitating and promoting quality investigation, and for them to not be contaminated by the unfortunate schemas that are so common in hospital management. I know that there are still hospital research foundations that develop a model activity by diagnosing problems within the centre and providing real assistance to research groups. And these foundations and institutes should also serve to fuse basic and clinical research: both Rodríguez-Puyol and Cruzado insist on the need for including both types of research together. I agree completely, and I believe that nowhere in my editorial did I state the contrary. But we must take into account, as I stated above, the particular problems that prospective clinical treatment trials suffer from, which require a specific solution.

And lastly, referring to the dejection that my friend José María Cruzado detects in me, this is not the case; the fact that I launch diatribes like this editorial is proof to the contrary. Nevertheless, although the situation is somewhat better than it was a few years ago, we must go on fighting. Furthermore, as I stated in the editorial,  one of the purposes of the same was to stimulate debate on hospital research. I feel that my letter has indeed sparked debate, and therefore, I am satisfied.