A system ‘alone’ is unable to produce an explanation of itself, is incomplete and it needs the ‘other’ systems to gain a sufficient level of intelligibility” (1)

Since caregivers are often faced with the suffering of others, especially early in their careers, they may wonder whether enough is being done, and whether they are really taking care of the person in front of them. Inexperience, as well as the fear of failure may lead them to focus more on the disease than on the person.

What can I do to better understand my patients’ suffering?

This is the main question I would like to ask this young anthropologist. Herein are her answers to this and other questions I asked her in an attempt to explore and explain the boundaries where biomedical science and humanistic disciplines meet.

What is cultural anthropology?

Cultural anthropology is a discipline whose origins conventionally date back to the late eighteenth century (when Société des Observateurs de l’homme was founded in Paris) and that, with the publication of the first works by Malinowski and Radcliffe-Brown in the Twenties, saw the blossoming of its “classics”. Its aims are to study the dimensions of human sociality, and especially the variety and the diversity of cultures drawn from communities in different times and places.

What does “culture” mean?

The concept of “culture” is clearly central to this subject: “culture”, which has recently undergone continuous, critical re-elaboration, is described as being very close to the definition of cultural anthropology itself. Currently, we may define culture as “a fluid and shifting boundary set of manifestations and symbolic creative practices, related to social institutions and to interactive relationships that form the social fabric of a given human community”(2).

Can you explain it in other words? How can the society in which a subject lives influence his/her way of looking at the world, especially with regards to suffering?

Since the beginnings of cultural anthropology, its interest turned to how (practically and symbolically) members of human societies organise and confront life experiences, which then led anthropologists to study how different populations, especially those once considered “primitive”, manage the phenomena of disorder and suffering. The study by Evans-Pritchard among the Azande is emblematic, and the resulting publication dated 1937 is now considered the first text in medical anthropology (3).

From cultural to medical anthropology: what do these classifications mean? And what happened when anthropology met bioscience?

Medical anthropology (a particular area of cultural anthropology) initially involved heterogeneous phenomena ranging from the indigenous interpretations of the disorder to the links between culture and psyche, rituals and therapeutic healing; however, the encounter with biomedicine represented a turning point. Until then, in fact, allopathic medicine was not seen as comparable to other medical systems. On the contrary, it was considered a type of knowledge that could provide an empirical description of objective reality and, as such, it seemed to be a useful tool for the interpretation and evaluation of other models. Soon, however, this position was questioned. Kleinman, among others, noted that biomedicine, as well as systems developed elsewhere, provide an interpretation of reality (4).

What is the key point of the different way of looking at this issue?

Biomedical interpretation – as well as interpretations pertaining to other medical systems – is characterised by a particular way of looking at the world and at experiential phenomena, and it is the result of a peculiar historical process. It also uses certain patterns, cuts out certain perspectives and proposes specific value systems by excluding other possible representations of the phenomena that are being investigated.

Pain, suffering, sorrow: how can we enclose them in this model?

The biomedical model provides a specific interpretation of suffering (though hardly exhaustive of the many possibilities of interpretation), and therefore it sometimes contrasts with other models. This different way of seeing life can create communicative and relational barriers, thus leading to situations of non-compliance and to the lack of therapeutic efficacy.

How can I incorporate your message into my daily routine? How can I put it into practice?

This takes on great significance in clinical practice. Indeed, when a person is suffering he/she tries to weave a complex web of different cultural perspectives in an attempt to make sense of his/her suffering. In part, the subject appropriates him/herself of a biomedical prospective, but at the same time, popular representations, familiar conceptions and social experiences will superimpose, thus creating a particular horizon of meaning. The person then orients his practices in relation to this meaning, and either accepts – or does not accept – the solutions proposed by the therapists. This is why an analysis that takes into account the diverse cultural perspectives (among other things, in a social space traversed daily by multicultural trajectories) – will prove to be very useful.

In other words, from your point of view, anyone could live and interpret their disease in their own way by drawing from a web of social and culturally shared representations, is that right?

Yes, by simplifying the concept, we can say so. Consequently, understanding how the sick persons experience their own illness and how they represent it becomes crucial: which etiologies do they attribute the onset of symptoms to? How do they read them, and how do they live them? In other words, in which way are they able to render them intelligible when called to make sense of them?

Try to explain this to me. Why would it be so important?

An analysis of this kind is essential if we consider that symbolic representations are always intrinsically related to the practices enabled by individuals: depending on how a person interprets a phenomenon, we expect that he/she will act in a certain way and not in another. This is of great importance in case of a disorder because the interpretation a person gives to a phenomenon will influence the care that is provided, the health professionals themselves, and the solutions they propose. Therefore, the evolution of the disease itself will also prove to be very different, even compared with apparently similar physiological conditions.

Taking care of the socio-cultural dimension could therefore be very important: one might expect to detect any possible correlations between the clinical condition of the patients, some of the interpretative models they propose, and the ability to share such interpretations with the health care professionals. Mutual exchange of biomedical and non biomedical models – each willing to corrupt their own integrity – could also lead to the co-construction of a shared (and therefore more effective) therapy. Still, for the benefit of the patient, bringing the signs carried in the body into their own personal world view in order to acknowledge them as being more understandable, and therefore acceptable, may be a key point.

How can we collocate the signs (or the symptoms) within this model?

With regards to this concept, the theories regarding embodiment that were proposed in the late eighties in medical anthropology (5) emphasised that the symptoms (or their perpetuation despite treatment) express, through “body language”, a problematic relationship of the subject with the external environment. An environment in which (necessarily) other human beings live, in which they have their own way of relating and interacting i.e., the socio-cultural environment. In order to cure (or to take care of) a disorder, the social relations inscribed in it cannot be ignored: indeed, they might prove to be one of the causes supporting the affliction itself.

It is perhaps worth recalling a precious gift of anthropology, namely the recognition of the inherent “biological incompleteness of the human being” (6): by his own “nature”, man must make use of cultural and symbolic practices, as well as of a network of social relations in order to survive. His instinctual apparatus is not sufficiently defined, he is a “naturally” open entity – just an incomplete one – that society structures. The individual bases his existence on these social frames, and through them he is able to respond to adversity, including disorders and afflictions. The same health apparatus is a socio-cultural construction in itself. A crisis within a similar apparatus, the non-sharing of its operation, immediately makes the effectiveness of such practices problematic.

In conclusion, what is the take home message that an anthropologist may leave a young doctor?

The modeling approach to multifactorial disorders (models created to analyse how the social frame and cultural dynamics interact with the biological and biomedical practices, since they do influence each other) could be extremely useful for proposing a broader understanding of the disease processes and for extending the potential of care within clinical practice.

Savino Sciascia is a medical intern and a TLS Regional Advisor. Ilaria Lesmo is a second year anthropology post-graduate student. They both attend CMID, Interregional Centre of Coordination of Rare Diseases of Piedmont and Aosta Valley, Giovanni Bosco Hospital in Turin, Italy.
sciascia.savino(at)gmail.com

References

1. Remotti F, 2005 “Sull’incompletezza” in Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie. Editions de la Maison des Sciences de l’Homme, Paris).

2. Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie . Editions de la Maison des Sciences de l’Homme, Paris).

3. Evans-Pritchard E., 1937, Witchcraft, Oracles and Magic Among the Azande, Oxford, Oxford University Press.

4. Kleinman A., 1878, “Concepts and a model for the comparison of medical systems as cultural systems” in Social Science and Medicine, vol.12, 85-93.

5. Scheper-Hughes N. and Lock M. 1987, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology” in Medical Anthropology Quarterly (1): 6-41.

6. Geertz C., 1973, The Interpretation of Cultures, New York, Basic Books.

Introduction

Over the past ten years the field of Global Health has expanded rapidly. Departments, Centres and Institutes of Global Health have been established in universities across the globe, and funding for large-scale collaborative projects to tackle the worlds most pressing health concerns has increased dramatically [1]. In an increasingly connected world, with greater international travel and trade, governments are recognising the importance of Global Health for the health, economic and national security of their domestic populations. From HIV/AIDS, TB, Malaria and pandemic flu, to rising levels of heart disease, respiratory disease, diabetes and depression, the effects are of global concern and need to be addressed by the global community [2].

Global Health encompasses many of the principles of public health (primarily prevention programmes for populations of a particular community or country) and international health (health issues of countries other than one’s own, often low and middle-income countries). However, Global Health recognises the erosion of geographical barriers to disease and seeks to promote better partnerships and the two-way flow of knowledge and experience between rich and poor countries [3]. Global Health is concerned with diseases of global importance; this includes addressing domestic health disparities as well as cross-border health problems. Global Health is also highly multi-disciplinary, aiming to bring the expertise of researchers and practitioners from many different disciplines together, to take technologies and interventions from the laboratory to the field.

When looking at the diversity of people involved in Global Health, it seems that every discipline or sector can play a part. From basic biomedical, environmental and social scientists, mathematical modellers, epidemiologists and engineers, to economists, policy makers, lawyers, business people and politicians. Clinical practitioners, public health specialists, educationalists and community leaders help put interventions into practice. The challenge is thus to bring these different people together in a multi-disciplinary environment, maximising the transfer of ideas and skills, to more efficiently reach the common goal.

Cross-Discipline Collaboration in Research

The breadth of expertise drawn together under the umbrella of Global Health research is extensive. In practise however, researchers in different disciplines work on very specialised areas, taking a specific approach to a problem. For example, a molecular biologist might look at the cellular pathways and proteins involved in a disease process, whereas an epidemiologist would investigate the prevalence and incidence of a particular disease to investigate transmission dynamics or the environmental cause. With such different skills, how can work from one field inform another? Although cross-talk between fields has its difficulties, confounded by the lack of common language and methods [4], there are in fact many examples of interaction between fields.

The story of Human Papillomavirus (HPV) and cervical cancer is one such example. For decades clinicians and epidemiologists had supposed that cervical cancer might be connected with a sexually transmitted agent (increased sexual partners correlated increased cancer incidence), however, a causative agent remained elusive. A break-through came in the early 1980’s when Harald zur Hausen and colleagues demonstrated the presence of a novel strain of HPV (HPV16) in cervical carcinoma biopsy samples [5]. Building on this work, through collaboration of the virologist Keerti Shah and the epidemiologists, Xavier Bosch and Nubia Muñoz, the link between HPV and cervical cancer was shown on a global scale [6]. Further advances in basic research confirmed the link, and subsequent collaboration between clinicians, epidemiologists and the pharmaceutical industry [7] saw the development of the HPV vaccine – now a major public health intervention (reviewed by [8-10]). Through this example we can see that the journey from bench to the field is a long one. However, by bringing together diverse researchers under one roof ‘Global Health’, it is hoped that this journey could be accelerated.

The involvement of researchers from many diverse fields may even have unexpected benefits for global health problems. A surprising example is the participation of planetary physicists in global health research. Colin Pillinger, notable for his work on the Beagle 2 Mars mission, is hoping that technology developed for use on Mars could be used for the diagnosis of TB in resource poor settings [11]. The use of mass spectrometry for the fast and accurate diagnosis of TB is under investigation [12]. However, it will be the skills of physicists and engineers in designing lightweight, durable, energy efficient and autonomously operating instruments that could take this technology to the field.

HIV/AIDS researchers have highlighted the need for diversity of input. Although there have been many scientific and clinical breakthroughs over the last 28 years, an effective vaccine has not been developed. One initiative designed to bring fresh ideas to the field is the Ragon Institute, established in February 2009. The institute aims to create ‘non-traditional partnerships among experts with different but complementary backgrounds’. For example, bringing engineers and computational biologists together with basic immunologists and clinicians. It is hoped that new people with different expertise could bring fresh perspectives and innovation to the field.

This table illustrates the breadth of specialties involved in academic Global Health research. The universities listed have designated Global Health Institutes, Centres or Departments designed to promote interaction between researchers in different fields. Many other universities do carry out international health research, and may offer courses in Global Health, however only those with specific Global Health centres are shown. The date indicates when the Institutes/Centre/Department was established. The coloured squares show the broad specialties involved in Global Health research for a particular university. This information is subject to change and was obtained in November 2009.

Translation to the Field

Creating mulit-disciplinary research arena’s in academic institutions is one step towards more efficient translation of research into interventions for public health benefit. A move to include business, legal and regulatory expertise within universities, with clinical and basic research should enhance the process [13]. This is being encouraged in the USA and Europe through the launch of ‘Clinical and Translational Science Awards’, the Seventh European Framework and the establishment of Academic Health Science Centres. However, to take a new medical technology or drug into large-scale production and clinical testing also requires the skills and input from industry under the regulation of government bodies. Greater interaction between the three components: academia, industry and government, and an investment in people capable of transcending these boundaries have been proposed as a way forward [13, 14]. Interdisciplinary conferences bringing together scientists, clinicians, industry and lobby groups, supports this endeavour (the Conference on Retroviruses and Opportunistic Infections is a good example of this).

The inclusion of health systems, health delivery and policy research within Global Health departments should aid the translation of public health findings into changes in government policy and legislation. Public health professionals working between academic institutions and government Departments/Ministries of Health, also facilitate this process. Recent years have also seen the unprecedented interest in Global Health on the global political agenda. UNAIDS (launched in 1996) is the first United Nations programme formed to deal with a specific disease. In collaboration with other UN organisations, this committee has successfully lobbied governments for changes in policy for people living with HIV/AIDS and secured massive investments for treatment and prevention programmes. This organisation demonstrates how politicians, scientists, clinicians and campaigners can work together to address health issues of global importance.

Finally, a note of caution: With the recent emphasis on translational medicine, and the move towards large-scale collaborative approaches (e.g. CHAVI, IAVI, CAVD), the importance of investment in basic work should not be over-looked. The recent failure of microbicide and vaccine trials in the HIV/AIDS field has prompted much reflection on the way forward. In the desperate need for an HIV vaccine, large-scale collaborations were set up to reduce duplication of effort, to standardise techniques for better comparison and to promote information exchange. However, could this approach stifle ingenuity? A survey of a number of prominent scientists in the field suggests a lack of investment in individual investigator-initiated projects has contributed to a lack of innovation in the field [15]. Thus in the effort to promote collaboration, and more cohesion between the different aspects of Global Health, care should be taken to insure support for individuals and their ability to pursue new avenues.

The Future of Global Health

The field of Global Health is vast in its encompassment of bench to population work – from academic research to practitioners and policy makers. It may be impossible for an individual to master every facet, however, perhaps a better understanding of the translational process could facilitate its progress. The education and training of a new generation of professionals, with broader skills and an understanding of the over all picture, has been suggested [16]. The emergence of new Masters in Global Health degree courses may support this endeavour (see table). Additionally, a renewed focus on capacity building for health research in developing countries, and greater global collaboration, bodes well for the future of Global Health.

Bethan McDonald is studying for a PhD in Infecious Diseases at King’s College London School of Medicine in the UK
Bethmcdonald2000(at)yahoo.com

References

1. Ravishankar, N., et al., Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet, 2009. 373(9681): p. 2113-24.

2. Piot, P. and G. Garnett, Health is global. Lancet, 2009. 374(9696): p. 1122-3.

3. Koplan, J.P., et al., Towards a common definition of global health. Lancet, 2009. 373(9679): p. 1993-5.

4. Robertson, D.W., D.K. Martin, and P.A. Singer, Interdisciplinary research: putting the methods under the microscope. BMC Med Res Methodol, 2003. 3: p. 20.

5. Durst, M., et al., A papillomavirus DNA from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions. Proc Natl Acad Sci U S A, 1983. 80(12): p. 3812-5.

6. Bosch, F.X., et al., Prevalence of human papillomavirus in cervical cancer: a worldwide perspective. International biological study on cervical cancer (IBSCC) Study Group. J Natl Cancer Inst, 1995. 87(11): p. 796-802.

7. Harper, D.M., et al., Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet, 2004. 364(9447): p. 1757-65.

8. Koutsky, L., The epidemiology behind the HPV vaccine discovery. Ann Epidemiol, 2009. 19(4): p. 239-44.

9. Schiller, J.T. and D.R. Lowy, Prospects for cervical cancer prevention by human papillomavirus vaccination. Cancer Res, 2006. 66(21): p. 10229-32.

10. zur Hausen, H., Papillomaviruses in the causation of human cancers – a brief historical account. Virology, 2009. 384(2): p. 260-5.

11. Pillinger, C., http://colinpillinger.com/barnstormpr.co.uk/research.htm. Open University, UK., Site accessed in November 2009.

12. Kaal, E., et al., A fast method for the identification of Mycobacterium tuberculosis in sputum and cultures based on thermally assisted hydrolysis and methylation followed by gas chromatography-mass spectrometry. J Chromatogr A, 2009. 1216(35): p. 6319-25.

13. Albani, S. and B. Prakken, The advancement of translational medicine-from regional challenges to global solutions. Nat Med, 2009. 15(9): p. 1006-9.

14. Andrews, N., et al., Translational careers. Science, 2009. 324(5929): p. 855.

15. Thomas, C., Roadblocks in HIV research: five questions. Nat Med, 2009. 15(8): p. 855-9.

16. Maclachlan, M., Rethinking global health research: towards integrative expertise. Global Health, 2009. 5: p. 6.

Many medical students and doctors will recognise the age-old criticisms of medical specialties bandied about from the ward and operating theatre to parties, lecture theatres and even the mass media. Is the geriatrician really a ‘weedy, slow-moving no-hope[r]’ as one gastroenterologist observed, and as a consultant surgeon suggested, an obstetrician simply a ‘midwife with a scalpel’? How much of this condemnation of other specialties within hospital medicine can be put down to being ‘friendly banter’ and how much detrimentally undermines the professionalism between sub-sectors of physicians and surgeons? Does this ultimately filter down to affect the medical student and even the public perception of the role of certain types of doctor?

Specialty ‘Bashing’; A Global Problem

A study published in Family Medicine suggests that the ‘exposure to non-constructive criticism of medical specialties’ is a global phenomenon experienced by most students on their clinical attachments. Discussing studies from America and Australia, it is said that inter-specialty bashing influences career selection to the extent that trainee doctors are more likely to change their specialty choice when hearing a negative comment than a positive one (1).

Having heard derogatory remarks from doctors on the wards from ‘haematologists are boring sods’ to ‘A and E doctors just refer everyone on’, I too found that specialty biases mentioned, subliminally affected the way I perceived my own career path. I wondered whether this was a universal issue for students and if these negative stereotypes were as significant for physicians within the hospital.

This consequently led me to think about the magnitude to which specialty typecasting may have manipulated the general public’s opinion. Perhaps television programmes such as House, E.R and Scrubs which cater to an international audience could encourage the idea, if it exists, of a hierarchal medical framework.

I gathered perspectives from twenty acquaintances comprising of other students, physicians and the public to consider the implications of medical specialty bashing.

Students’ Experiences; Truth or Teasing?

Colleagues I questioned on this topic mentioned a variety of derogatory remarks heard on their specialist rotations from ‘never trust radiologists’ to ‘a psychiatrist is someone who knows nothing and does nothing’ and ‘orthopaedic surgeons are incompetent Neanderthals.’

Some were outraged and disillusioned by their encounters either from the fact that the doctor in that particular specialty felt able to make the derogatory comments or from the off-putting characterisations made of other specialties. Student responses to this heard ‘bashing’ ranged from ‘come to think of it they’re all bullies’ to ‘I’ve been put off from choosing surgery now’. However, others qualified it by surmising that ‘each speciality is valued in its own right’, and thus the criticisms only represent friendly teasing that is ‘fun to join in’ on. Interestingly, all student respondents requested to remain anonymous, even those who approved the inter-specialty mockery. This suggests that perhaps the rivalry is not quite as genial as they may like to believe.

Doctors- ‘We all Bash Psychiatry’

I found that most hospital doctors I approached accepted that ‘bashing’ of other specialties occurred, but were hesitant to support a hypothesis that this repartee may hint at any form of hierarchy. They favoured more politically correct statements such as ‘all specialties in every hospital provide crucial services’ and ‘we consider ourselves to be in equal footing irrespective of what we do, or what kind of patients we care for’. Tellingly, the majority of those same physicians and surgeons were able to list in their opinion, when prompted, the ‘most respected’ and ‘least respected’ specialties in the hospital, whilst denying this represented any form of ranking. Additionally, these doctors all had differing opinions on who was the source of the badmouthing from ‘Intensive care, for some reason they see themselves as the saviours of the hospital’ to ‘general surgeons’ and ‘we all bash psychiatry’.

Only one, an orthopaedic surgeon, went against the trend by emphatically stating his agreement of an unspoken, unofficial hierarchy to the extent that he produced his own league table of specialties from ‘best’, to ‘worst’. He said that although medical branches have their own pecking order, separate to that of surgery, ‘there is no denying that there is one’. In choosing his own specialty, he reminisced that ‘despite being amongst the top students’ in his year, when he elected for orthopaedics, everyone ‘from classmates to professors’ thought he ‘had gone bonkers’. His motivation for bucking the trend was simple love of the job. However, he believed the effect of peer pressure swayed the ‘cleverest’ from joining in him in this self-directed approach.

Everyone Loves A Brain Surgeon

Speaking to people who had no affiliation with the health service I speculated whether I would gain an alternative viewpoint. The consensus was that as the brain and heart represent ‘vital organs of the body’, they were also ‘the most dangerous to operate on’; consequently, doctors working in these specialties demanded ‘the most respect’.

One business student went as far as to say that professionals in these areas had ‘earned the right’ to belittle the ‘less important ones’. A Cambridge University history graduate offered an anecdote which aimed to justify this overwhelming admiration for cardio-thoracic and neurosurgeons by suggesting that her experience of a neurosurgeon’s ‘poor bedside manner’ was a by-product of his ‘talent overriding the need to be civil or comforting’. She believed that ‘brain surgeons spend so long training that you are wasting money and time if you ask them for any information’ and as a patient, you should simply defer to their higher prowess. She mused that ’salary’ should ‘dictate the prestige and how difficult the specialism is’. The most affluent doctors seem, to her, to be those treating the ‘heart and brain’ and therefore it makes sense for them to ‘have the most intellectually difficult training’. They above any other, ‘have to be both technically and academically brilliant’.

The Hypothetical Hierarchy

From the fifteen medical students and doctors I spoke to, ‘care of the elderly’, ‘orthopaedics’, ‘psychiatry’ and ‘pathology’ were most frequently cited as the ‘least respected’ and, ‘general surgery’, ‘cardiothoracic surgery’ and ‘neurosurgery’ as the most. Interestingly this corresponds well with opinion above from the general public about which medical specialties come top in a hypothetical hierarchy, with cardiology and neurology garnering much higher esteem than others.

The Hospital Drama – TV and Reality

Where do these stereotypical views of doctors, by doctors, medical students and the public, come from? They serve to aggravate any inter-specialty rivalry and appear to be partly directed by both personal experience and the media. Medical students are impressionable and it is undeniable that ‘role models, especially amongst medical staff, are very influential’ (2).

One student cited the television programme Green Wing as depicting an environment whereby ‘surgeons are conductors of everything’. Another proposed that their idea of the ‘least respected’ medical specialty was substantiated by Dr Cox in the popular drama Scrubs saying to a patient, ‘Mr. Warner… do you see what you’ve made me do?… You have forced me to [page] the attending dermatologist’ and ‘validate his most ridiculous of career choices.’

A passage in the careers advice book for medical students, ‘So you want to be a brain surgeon?’ addresses the issue of ‘the macho image of the surgical consultant’ enduring in contemporary soap operas. It suggests that they are portrayed as a man who is ‘knife-happy, still offensively rude’ and who ‘exploits a sort of droit de seigneur by bonking nurses and any other willing handmaidens during nights on-call.’ (3)

This image may seem ridiculously outdated but the fascinating thing is that television appears to have a much greater gravitas than one may give it credit for, in ability to subliminally manipulate public and professional attitude (4,5). One fifth year student also quoted Scrubs in stating that when ‘Dr Kelso says to [Doctor Reid] that all women do in medicine’ is go into ‘paed [iatrics] or o[bstetrics] and g[ynaecology]’ this caused her to believe it to ‘be general opinion’ and potentially question her own career path. She also mused that people are ‘brainwashed into wanting to become surgeons’, through the perception of ‘surgeons as the real heroes’ from a ‘glory association’ persevering in newspapers, hospital dramas and films. A study in the Journal of Broadcasting and Electronic Media proposes that television in its depiction of doctors has the ability to control viewers ‘common conceptions of societal facts, norms, and values’ to the extent that it influences their ‘conceptions of reality, standards of judgment, attitudes, thoughts, and behaviour’ (6).

Factors in Choosing a Medical Specialty

If the media can influence both the public and some medical students (even in their final year when they have completed most of their specialist rotations), I wonder whether students are being exposed to specialties in an appropriate way. Certainly, in selecting specialties the ‘reasons are many, various and complex’ as stated by the Royal College of Physicians. Yet, it has become apparent through research and clinical experience, that ‘bashing’ of specialties by physicians themselves and in the public arena through the media, can play a realistic part in medical student preference. Amongst both the students and the doctors I spoke to, all were aware that the motivation in choosing a specialty is made such as on ‘the basis of an individual team’ as well as ‘gender expectations for family planning’ and the opinion of ‘other medical students’ yet concurred that it is ‘the consultants’ views’ that act as a key factor.

Reasons For Specialty Badmouthing

As for why this inter-specialty ‘bashing’ still exists, in which radiologists are belittled to a ‘bunch of switch flickers’ and respiratory physicians ‘sputum loving pedants’, there are mixed views amongst students and doctors. Some see it as old-fashioned prejudices that are ‘ingrained’ in the health system and in this changing cultural environment can only be aired through criticisms disguised as jest. The gastroenterology registrar believes the badmouthing to infiltrate within specialties as well as between owing to the innate natural ‘competitive[ness]’ between doctors which allowed people to enter ‘into medical school in the first place’. Others blame certain doctors in each specialty for having ‘that personality’ to criticise others and a ‘misplaced ego.’ Either way, there is no escaping that ‘the superficial and demeaning comments that students hear about particular career choices’ can act as a ‘hidden curriculum’ (7). This equally, can affect graduates until their specialty choices are made. Dr Foxton in Confessions of a Junior Doctor reminisces about a registrar’s condemnation of Foxton’s psychiatric ambition, by saying ‘they’re a bunch of boring, pretentious weirdos with no life who never answer their bleeps’ (8).

How To Improve Ward Life

Sweeping generalisations such as ‘the medics are the clever geeks and the surgeons are the cool heroes’ may masquerade in jest but both health professionals and the media have a huge obligation to project a positive image of their own specialty rather than badmouthing others, as careers advice as an undergraduate is inevitably coloured and conditioned by staff and their specialties (3). Although it is little spoken about and downplayed by both doctors and some students, it is through an attitude of arrogance and disregard for others choices, whether intentional or not, that a universal hierarchy of specialties has been allowed to persist. Additionally, a review collating medical literature on differences in assumed prestige of hospitals specialties from the 1950s onward, concluded that such a chain of command may eventually influence the priority level of various specialties within healthcare and thus impinge upon patient treatment (9).

With these serious implications in mind, I deem a re-evaluation in the delivery of specialty information to students to be essential, and inter-specialty respect fostered from entry into medical school. Otherwise, students are left floundering in a sea of career choices with little guidance but the opinion and experiences they have clinically to guide them. Nurturing a tolerant attitude on the wards and educating the public is fundamental to redress thoughtless ignorance in the medical system. This will finally allow us to come to the sincere conclusion that all services play a crucial role in national health.

Priya Garg is a 5th year medical student at Imperial College, London
priya.garg05(at)imperial.ac.uk

References:

1. Holmes D, Tumiel-Berhalter L M, Zayas L E, Watkins R. “Bashing” of Medical Specialties: Students’ Experiences and Recommendations. Fam Med 2008; 40 (6): 400-406.

2. Wilkinson T J, Gill D J, Fitzjohn J, Palmer C L, Mulder R T. The impact on students of adverse experiences during medical school. Med Teach 2006; 28 (2): 129-135.

3. Ward C, Eccles S. So you want to be a brain surgeon? A Medical Careers Guide. Second Edition. Oxford: Oxford University Press, 2001.

4. O’Connor M M. The role of the television drama ER in Medical Student Life: Entertainment or Socialization? J Am Med Assoc 1998; 280:854-855

5. Ornelos J, Parikh N. Medical Students Take Heed, They’ll Be Expecting Dr. Carter. American Medical Association Journal of Ethics 2007; 9 (3): 237-240. http://virtualmentor.ama-assn.org/2007/03/mhum2-0703.html (accessed 9 Aug 2009)

6. Chory-Assad R M, Tamborini R. Television Doctors: An Analysis of Physicians in Fictional and Non-Fictional Television Programs. Journal of Broadcasting and Electronic Media 2001; 45: 499–522.

7. Hunt D D, Scott C, Zhong S, Golstein E. Frequency and effect of negative comments (”badmouthing”) on medical students’ career choices. Acad Med 1996; 71 (6): 665-669.

8. Foxton M. Bedside Stories. Confessions of a Junior Doctor. London: Atlantic Books, 2003.

9. Norredam M, Album D. Review Article: Prestige and its significance for medical specialties and diseases. Scand J Public Health 2007; 35: 655-661.

Imagine being asked this question at a job interview, as a male or female candidate. To answer ‘yes’ is to acknowledge that there are more female than male doctors, and to assume that such a disparity is detrimental to medical education, clinical practice and research.

Consider this question from the perspective of clinical students in their penultimate year of undergraduate study, with job applications imminent; approaching the crossroad between education and employment. This is the position I find myself in, staring at a computer screen in the library. Upon receiving the Medical Women’s Federation essay poster via the university intranet, like many colleagues I read this question with initial apathy. I close the file and press ‘play’ on an audio e-lecture. Listening to the male professor speak about his enthusiasm for his specialty I feel an undeniable sense of curiosity about the question. I begin to realise I don’t have any definite opinions on the issues it raises and can’t help but wonder why. After all, I am a woman in medicine.

In Nottingham University Hospitals NHS Trust, women hold ~31% and ~41% of Board and senior clinical staff positions respectively (1). Female medical students hold 12 of the 26 currently filled positions for BMA Medical Students Committee representation, yet only 2 of the 32 heads of UK medical schools are women (2, 3, 5).

In the last decade women have for the first time come to outnumber men in UK medical school admissions (2, 8), accounting for approximately 60% of the 2006-07 intake (6). The shift in medical school demographics is paralleled by the gender-ratio of doctors. Women are a growing proportion of the workforce, with an 8.7% increase in women consultants in 2007 (9). Increasing numbers of women were expected across all specialties given the number entering and progressing through medical training (11). However, women remain under-represented in several acute hospital specialties (9), in the university sector (6, 7) as clinical researchers, full-time academics, and at senior levels throughout the whole profession, such as department leadership, medical journal editorship, medico-politics (2, 4, 8, 10). In the USA, men outnumber women as associate and full professors in all specialties except social sciences (12).

The Views of Consultants and General Practitioners Amidst Changes in the Demands and Expectations of the Medical Workforce

Women account for 35-44% of doctors in many affluent countries (Australia and most longstanding EU member countries), 45% or more in ex-Soviet countries and Finland, but less than 30% in less affluent African and Asian countries, and a rising proportion in the USA and Japan (currently 16% women) (13). Precise figures for other countries are not easily available (Latin America, India and China) but the general trend of increasing women doctors is relevant worldwide.

I spoke to one of the UK Clinical Directors, a consultant of 10 years. We discussed that as the medical workforce evolves, corresponding developments in clinical practice can be expected (including family-friendly working practices). This impacts on healthcare professionals, patients seeking medical care, and the government. Of the six Clinical Directors in the NHS Trust he works for, one is female.

Failure to recruit and retain senior female staff suggests women still face barriers to pursuing medical careers. In Norway, women in hospital-based specialties requiring longer, condensed training compared with community medicine, delayed the first birth and had fewer children (14). In 2006, based on studies into the attitudes and experiences of women doctors, the UK Chief Medical Officer identified that obstacles faced by women entering the medical profession are directly attributable to gender (10, 11). Actions were taken to redress the gender imbalance, including reinforcement of mentorship schemes with more female role models, increased flexible training opportunities, part-time contracts and provision of workplace childcare or career breaks (10, 11). The Association of American Medical Colleges also reports institutional strategies to support women (12). Norwegian authorities have developed gender-equality and family policies (14).

The Impact of Gender on Medical Knowledge and Practice

International studies indicate that women tend to academically outperform men in certain disciplines, but this is negligible in practical terms (16). Men tend to feel more competent, but may overestimate their clinical skills (16). Controversial criticisms of the influence of women in shaping future medical culture include objectively measured and statistically significant gender differences in hospital activity rates, as well as perceived power and status (15, 16). A recent UK report rebuts concerns that deficits in academic medicine leadership are attributable to increased entry of women (13).

Interpersonal skills may vary with physician gender. A critical review of empirical research has shown that female physicians engage in more active partnership behaviours, counselling and emotionally focussed talk in primary care, associated with patients disclosing more biopsychosocial information (19). So less time-efficient communication styles may reflect positive aspects of patient care and outcome (15, 18). These qualitative benefits might outweigh any perceived negative impact of lower quantitative input. However, differences in patient satisfaction have not been demonstrated.

Professional motivations and attitudes, and patient perceptions and expectations are highly subjective and variable, making it difficult for authors to draw reliable conclusions. Furthermore, gender does not determine how well equipped an individual is for a career in medicine and stereotyping can be a source of contentious misconceptions, prejudice and discrimination.

The complexity of gender-specific processes in professional roles should not deter their evidence-based exploration, to improve healthcare interactions. Further research may substantiate or refute concerns about the ‘productivity’ of women in medicine. Either way, selection processes should be merit-based and the ongoing underlying issues of inequity must be addressed so all doctors can overcome difficulties in balancing work and family life, in order to achieve their full potential and contribute optimally once in employment.

Sunita Deshmukh is a fourth year medical student at the University of Nottingham
mzyzsrd@nottingham.ac.uk

References

1. Nottingham University Hospitals NHS Trust, About the Trust.
http://www.nuh.nhs.uk/about/index.htm
(accessed 16 March 2009).

2. British Medical Association (2006) Encouraging women to work in academic medicine.
http://www.bma.org.uk/employmentandcontracts/equality_diversity/gender/WomenInAcademicMedicine.jsp
(accessed 16 March 2009).

3. British Medical Association (2008) Women in Academic Medicine: Developing equality in governance and management for career progression, Full Report.
http://www.bma.org.uk/images/Womenacademicmedicine_tcm41-178228.pdf
(accessed 16 March 2009).

4. British Medical Association, Medical Student Representation.
http://www.bma.org.uk/representation/local_representation/medical_student_reps/
(accessed 16 March 2009).

5. Medical Schools Council (2008) MSC Members, Executive Committee.
http://www.chms.ac.uk/members.htm
(accessed 17 March 2009).

6. Medical Schools Council (2007) Women in Clinical Academia: Attracting and Developing the Medical and Dental Workforce of the Future.
http://www.medschools.ac.uk/AboutUs/Projects/Documents/WomeninClinicalAcademiaReport2007.pdf
(accessed 17 March 2009).

7. Aldridge J & Fitzpatrick S, (2008) Clinical Academic Staffing Levels in UK Medical Schools, Medical Schools Council.
http://www.chms.ac.uk/documents/ClinicalAcademicStaffSurvey2008Medicinejan09.pdf
(accessed 17 March 2009).

8. Medical Women’s Federation, Campaigns: Women in Academic Medicine.
http://www.medicalwomensfederation.org.uk/Campaigns/WAM.html
(accessed 15 March 2009).

9. Royal College of Physicians (2006 & 2007) Census of Consultant Physicians in the UK.
http://www.rcplondon.ac.uk/news/news_census2006.asp
http://www.rcplondon.ac.uk/professional-Issues/workforce/census/Pages/Headlines.aspx
(accessed 15 March 2009).

10. Donaldson L, (2006) On the state of public health: Annual Report of the Chief Medical Officer 2006, Chapter 7: Women in Medicine: Opportunity Blocks, Department of Health.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_076817
(accessed 15 March 2009).

11. Donaldson L, (2007) On the State of Public Health: Annual Report of the Chief Medical Officer 2007, Chapter 2: Progress Check, Department of Health.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_086176
(accessed 15 March 2009).

12. Association of American Medical Colleges, Women in U.S. Academic Medicine Statistics and Medical School Benchmarking 2007-2008.
http://www.aamc.org/members/wim/statistics/stats08/start.htm
(accessed 11 July 2009).

13. Elston MA, (2009) Women and medicine: the future, Report, Royal College of Physicians.
http://www.rcplondon.ac.uk/pubs/contents/bd2d994a-7d38-465f-904a-21a70cdc7d9c.pdf
(accessed 26 July 2009).

14. Gjerberg E, (2003) Women doctors in Norway: the challenging balance between work and family life, Social Science & Medicine, 57(7): 1327–1341.

15. Bloor K, Freemantle N, Maynard A, (2008) Gender and variation in activity rates of hospital consultants, J R Soc Med. 101(1): 27–33.

16. Hall C, (2004) Influx of women ‘will harm medicine’, Telegraph.
http://www.telegraph.co.uk/news/uknews/1468508/Influx-of-women-doctors-will-harm-medicine.html
(accessed on 18 March 2009).

17. Fleming N, (2008) Women doctors ‘less productive than males’, Telegraph.
http://www.telegraph.co.uk/news/uknews/1576516/Women-doctors-less-productive-than-males.html
(accessed on 18 March 2009).

18. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T, (2007) Women in medicine – is there a problem? A literature review of the changing gender composition, structures and occupational cultures in medicine, Medical Education, 41: 39–49.

19. Roter DL & Hall JA, (2004) Physician Gender and Patient-Centered Communication: A Critical Review of Empirical Research, Annual Review of Public Health, 25: 497–519.

Jenny Hey and Elizabeth Leyland intercalated in History of Medicine at the University of Leeds in 2006­­­-07. With the benefit of hindsight, they decided to share some of the ways in which they feel history relates to modern global practice.

Studying medicine requires understanding of a range of subjects, from anatomy to psychology and epidemiology to pharmacology. There is so much to learn about current local practice that looking beyond the ‘here and now’ could appear to be educationally extravagant. Is there anything to be gained from exploring the ‘bigger picture’? We certainly think so. But how? Considering global health is one way to broaden horizons. Looking at the history of medicine adds another dimension; one that we feel deserves some attention.

Medicine is constantly evolving. Current practice represents a point on its journey, a snapshot in time. Using a few examples, we will attempt to illustrate how ‘old’ gives rise to ‘new’, which in turn quickly becomes ‘old’. History of medicine holds explanations for the names of anatomical parts, surgical tools and techniques, and countless weird and wonderful syndromes. We realise it is not for everyone, but we hope that some will appreciate how inspirational history can be in the bid to make medical advances. (more…)

Nadarevic Amra and Stjepic Tomislav write on the rebuilding of Bosnia and Herzegovina and its medical education. 

This article is about a small country, situated in the heart of Europe, called Bosnia and Herzegovina. It is the one place in the world that we call home. A few years ago we had a chance to read an article, where some people (during 1992-1995) called Bosnia and Herzegovina a “modern hell”; some of them even said that Bosnia and Herzegovina was worse than the infernal circles that Dante Alighieri wrote about. The biggest genocide after World War II had happened just 500km from the Western World; up to 7500 Bosnian men and boys over 13 years of age, were killed in Srebrenica. Prior to this genocide, the United Nation had declared Srebrenica a UN protected “safe zone”, but that didn’t prevent the massacre.  The Olympic city of Sarajevo was bombed every day and every night. (more…)

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.

(more…)