Andrey Ostrovsky writes on the challenges involved in training students and professionals for work in global health.

My girlfriend writes for a fashion magazine. She makes it seem as though there is a new trend every week: pumps are “the new heels,” clutches are “the new shoulder bag,” and pink is “the new red.” While I don’t know what most of those words mean, I do know that medicine, like fashion, has its trends. In medicine, global health is “the new pink.”

With globalization quickly escalating, more and more doctors-in-training are trying to pursue work in global health. “Trying” is the operative word. There appear to be endless options available for medical students and doctors to “go international.” There are week-long volunteer clinics in almost any country of one’s choosing. There are MPH programs in international health. There are certificate courses on “Global Medicine Made Simple.” However, there is nothing simple about global medicine, nor the path to practicing it. (more…)

Sarah Shore and Claire Spolton Dean discuss the benefits of a broader medical education.   

Modernising Medical Careers (MMC) was designed to nationalise and increase the efficacy of postgraduate training via the implementation of the Foundation Programme in 2005 and a revised Specialist Training programme in 2007. Consequently from 2007 there have been two competitive entry points, both to the Foundation Programme and for Specialist Training posts. Additionally, the Department of Health’s stated policy since 1997 has been to increase the number of undergraduate medical school places to sustain the future demands of the NHS. Since the Tooke Report has highlighted a number of concerns regarding MMC, medical students must remain competitive in this unstable period of educational reform.

What can undergraduates do to remain competitive?

The General Medical Council’s pivotal document, Tomorrow’s Doctors, states that ‘factual information must be kept to the essential minimum that students need at this stage of medical education. Learning opportunities must help students explore knowledge, and evaluate and integrate (bring together) evidence critically. The curriculum must motivate students and help them develop the skills for self-directed learning’. (1) These skills are of paramount importance to successful clinical practice, providing invaluable skills that will be applicable throughout not only the remainder of your undergraduate medical course but also your professional career. Whilst the GMC recognises the limitations of the undergraduate medical courses in encouraging autonomous study and the ability to critically appraise information, an intercalated degree programme develops these skills. Moreover, a prospective longitudinal study by McManus and colleagues[iv] found that students that pursue an intercalated degree often find that their approach to independent study is enhanced.

What do I need to consider?

It can be a difficult and daunting process to decide if intercalating is the best choice for you and to find the most suitable course. As with any decision, there are many factors to consider. These differ with personal circumstances and with the wide variety of courses available nationally (summarised in Box 1).

For many UK medical schools, intercalated programmes comprise a mandatory component of the undergraduate curriculum. Even where such courses are not obligatory, some schools provide comprehensive information on the programmes available. Others, however, do not, and students without this impetus to intercalate or the appropriate support to research relevant information may therefore be at a disadvantage, and indeed many students have found sourcing information to aid their decision time-consuming and frustrating. These perceived obstacles may discourage many prospective students from intercalating despite the ease with which they may be overcome. This phenomenon may also impact upon dental and veterinary students.

Where is this information available?

As a result of our own experiences in making this important decision and the difficulties that we have encountered, we have been involved with the development of a project that brings together details of every intercalated course that is available nationally, both at BSc and MSc (or equivalent) level. This web-based resource has been designed to facilitate the decision to intercalate, and help you find a course that is most suitable for you quickly and effectively.  This website does not require registration or subscription and is available here. 

Reflections on intercalating

In our experience, early research was a significant help in making the best decision regarding intercalating and we found that finding information on funding and scholarships was fundamental in making our choice. Initially this information was difficult to find, but prolonged investigation yielded a number of organisations that provided generous funding to intercalating medical students, which have been detailed on the aforementioned website along with information on the points listed in Box 1.

Although it was more difficult to overcome these hurdles than we had anticipated, now considerably easier since this project has been launched, our experiences from intercalation have only been positive. Although we undertook different degree courses, the transferable skills that we have acquired in the past year are already apparent. We feel confident that when we recommence our medical studies the knowledge that we have gleaned will complement our clinical practice and ease the transition into postgraduate medical education.

Sarah Shore, third year HYMS medical student, BSc (Hons) in Medical Sciences shore.sarah@gmail.com

Claire Spolton Dean, third year HYMS medical student, BSc (Hons) in Medical Sciences

(1) McManus, IC, Richards P, Winder BC (1999) Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students. British Medical Journal, 319: 542-546

Dianna Louie and Shafik Dharamsi discuss the role of health workers as health advocates and use Dianna’s experiences in Uganda to illustrate their points

“We are the first generation in history that can end extreme poverty.
That’s our good fortune, our challenge and our responsibility.” Jeffrey Sachs

Many students spend the summer between first and second year conducting medical research in order to improve their resume for entry into postgraduate medical training. Others shadow different specialists in an attempt to figure out what type of medicine they want to practice at the end of their four year program.

I decided to do something different. (more…)

James Matheson interviews some experts on the potential of this exciting new specialty

In May 2006 the American Board of Physician Specialties announced board-certification in Disaster Medicine and, in the United States, a new specialty was born. The Florida hurricanes and a heightened awareness of the terrorist threat in the wake of 9/11 had demonstrated America’s vulnerability to disaster and concerns were high about the ability to respond.

Dr Maurice A. Ramirez, founder-chairman of the American Board of Disaster Medicine (ABODM) explains why: “The most ominous words ever uttered by a disaster preparedness expert were that given the current state of hospital preparedness and the rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital.

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  Anna Shore presents the benefits of a more global attitude to health education

Ease of travel, the impact of the internet, large multinational corporations, population migration - all good examples that we live in an increasingly globalised society. The need for health is common to the whole of the world’s population, and it is unsurprising that medicine too is starting to become more global in its outlook.

Many areas of medicine bear evidence of this change, including undergraduate education. (1) Medical schools in the UK and overseas are starting to respond (2), and it is possible to spend a year studying for an intercalated degree in International Health at selected universities. (more…)

  Johnny Boylan discusses what is happening in the UK and beyond

There is clear evidence that, throughout the world, people from ethnic and cultural minorities experience inferior health care compared to the majority, dominant population. In the United States this applies to African-Americans,  the Hispanic population and American Indians; in France to people of North African descent; in Germany to Turkish migrant workers; in Turkey to the Kurds; in Israel to Jews from Ethiopian, North African and Russian backgrounds; and in the United Kingdom to people of Indian, Pakistani and West Indian origin.(1)

This international healthcare issue has led to an increased awareness of the need to educate medical undergraduates in equality and diversity issues (2): for example in Britain in 2007 when the BMA produced their guidelines on Equality and Diversity Education. (3) In addition there is evidence that such educational programmes have positive outcomes and that participant attitudes changed over the period of the teaching. (2) (more…)

Whether you are a new medical student or not, this letter from Daniel Sokol hits the mark

Congratulations!  How many others would love to be in your shoes, tracing the footsteps of Hippocrates, Jenner, Lister, Osler, Fleming and other greats of medicine. (1) The path ahead is indeed long, but was it not Confucius who reminded us that even a journey of a thousand miles begins with a single step? (2) (3)Why this letter?  I have some advice which you may find helpful.  A secret?  Not really.  The talking fox, in The Little Prince, had a real secret: “It is only with the heart that one can see rightly; what is essential is invisible to the eye”. (4)

My simple message concerns the moral dimension of medicine.  Medicine is fundamentally about human beings and, whenever humanity is involved, so too is morality.  Why?  Because, as social creatures, we have duties to each other.  I have a duty to treat you in a particular way.  I shouldn’t lie to you, or steal from you, or insult you for no good reason.  And we also have duties to ourselves.  We must treat ourselves with respect and dignity.  As a medical student, and later as a doctor, you will be dealing with patients, relatives and colleagues.  More specifically, you will strive to help patients who are by nature sick and vulnerable.  For the patient, the awkward shift from health to illness is not the only change.  The clinical environment itself can be impersonal, unfamiliar and often confusing. (5)

The task is all the more complicated because whenever we try to help patients, whether through words, drugs or procedures, we risk harming them.  An aspirin tablet can trigger an anaphylactic reaction; a caesarian uncontrollable bleeding.  The sharp sword of Damocles hangs precariously over doctors and their patients. (6)   As time is limited and resources scarce, you may also deprive others of needed assistance.  If you decide to drain Mr Smith’s abscess now, the injured Mr Jones will have to wait in pain a while longer.  More dramatically, giving a heart to a patient with severe cardiomyopathy (an abnormality of the heart muscle) may entail the death of another patient in desperate need of the organ.  For all these reasons, medicine is a deeply moral endeavour, often involving conflicting moral principles. 

Throughout your training, you will be exposed to the scientific and technical components of medicine.  You will wonder at, and on occasion curse, the sheer volume of medical and biochemical knowledge acquired over the centuries.  We have come a long way from the days of supernatural explanations of disease, and Galen’s long-standing belief that illness was caused by an imbalance of four humours.  The ethical aspect will not feature as much as the technical and the temptation will be to dismiss ethics as irrelevant, unimportant or inconvenient to the immediate task of helping the patient. 

My message is this: do not yield to this temptation, however strong, but take the ethical issues in medicine as seriously as you do the technical ones.  This doesn’t mean devouring textbooks on medical ethics.  It means simply seeing ethics as integral to the proper care of your patients.  Just as you want to increase your understanding of the factual aspects of medicine, so should you want to deepen your moral understanding.  Your ability to perceive moral issues, to reason through ethical problems in search of a solution, and to act upon your decision is inextricably linked to your future success as a doctor.   

I have on occasion heard your peers say that ethics is merely a matter of law.  You should of course consider the law when deciding how to act, but the law is no moral panacea.  While morals may form the basis of law, there is much that the law permits but that morality forbids.  A student who laughs at the misfortune of a dying patient is not acting unlawfully, but may still be morally at fault.  Law often represents the lowest acceptable measure of morality.  As a member of the medical community, you should be striving for a higher standard.  Sometimes, the law is silent, or permits several options.  Should you breach a patient’s confidentiality if you believe your silence may endanger someone else?  The law offers no easy solution.

You will be faced with many diagnostic and therapeutic mysteries in years to come.  Medical journals are replete with case studies involving rare cases of tetanus, typhoid or other diseases whose unusual symptoms stumped the medical team.  Biomedicine is a young discipline and much remains to be found.  You will also encounter ethical puzzles.  What should you do or say if you made a medical error that no one else noticed?  How should you deal with patients’ cultural or religious beliefs at odds with your own?  How should you handle racist or abusive patients?  How should you evaluate a patient’s quality of life or the futility of a given treatment?  Like the medical ones, these problems will need to be diagnosed and resolved, and may require skill, creativity, humility, wisdom and courage.  In ancient times, whether in Greece or China, doctors were philosophers.  Today, a good doctor - and a good medical student - remains a practical philosopher.

So here endeth the lesson.  I’m aware that I haven’t discussed how to resolve moral problems.  This will, I hope, be taught to you in the coming months.  My intention here is more modest: to remind you, at the outset of this lifelong journey, of the profoundly ethical nature of medicine which in this technical age is too easily overlooked.  The ethical aspects are neglected because, unlike physical abnormalities, they are difficult to see.  The fox was right: what is essential is invisible to the eye.

Daniel K. Sokol L
Lecturer in Medical Ethics and Law
St George’s, University of London
Cranmer Terrace
London SW17 0RE
daniel.sokol@talk21.com

 Endnotes

(1) An excellent introduction to the history of medicine is Roy Porter’s Blood and Guts: A Short History of Medicine  (2002), published by W.W. Norton and Co.

(2) Confucius was a Chinese thinker living in the 6^th century BC.  For a concise summary of his life and philosophy, see http://plato.stanford.edu/entries/confucius/

(3) Sir William Osler (1849-1919), while Regius Professor of Medicine at Oxford, addressed medical students as “fellow students”.  For Osler, all doctors, however experienced, were students of medicine, always learning more about the many facets of medicine.

(4) For more on this inspiring little book, see http://en.wikipedia.org/wiki/The_Little_Prince

(5) I have written frankly about my own experience as a patient in the British Medical Journal (2004, 328:471. http://www.bmj.com/cgi/content/full/328/7437/471).

(6) The Roman writer Cicero recounts the story of Damocles.  In the story, king Dionysius allows the envious Damocles to experience, for a short time, the life of a powerful ruler.  As Damocles is enjoying a lavish banquet, he notices, hanging directly above him, a sharp sword suspended by a single horse’s hair.  This was meant to represent the illusory appearance of comfort and the ever-present danger that Dionysius faced as a king.

 Jon Mendelson explains more about this innovate school

It was a jolting ride over the rocky desert to the Bedouin village. A small group of first-year medical students and a family physician trekked off the main roads to visit a local Arab Bedouin patient half an hour from the city limits. Scattered mostly around the northern Negev Desert in Israel, many modern Bedouin retain some of their ancestral nomadic desert lifestyle. Others have moved into towns, leaving much of their old way of life behind. In the rural areas, extended families live in small communities of tents or tin houses, with their flocks of animals corralled by the side of their homes.

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Rupert Major shares some of the experiences of this link which could help to reduce the “brain drain”

Ethiopia has had a bad press.  It is one of the five poorest countries in the world.  You might imagine famine, political unrest, wars around the borders… however, visit one of its major cities, Gondar, in North West Ethiopia and think again.  This former capital of Ethiopia and city of historical importance has a population of 150,000 people.  Its 350-bed university hospital serves a region of more than 3 million people.

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