By Kevin Gillmann
University of Newcastle
kevin.gillmann(a)wanadoo.fr

“Is it legal for employment to be refused as a result of the outcome of a 3 station OSCE devised by a Trust when a 5 year programme, quality assured by the GMC has provided evidence that the applicant is fit for purpose?” [1]

Such was Professor Tony Weetman, Chair of the Medical Schools Council’s comment, reflecting on the pitfalls underlying the British Government decision to reform the medical career pathway.
Medical Career Pathway in the UK

Since the introduction of the Modernising Medical Careers programme, in 2005, British medical careers are made up of 4 steps. The medical degree, typically consists of 5 years of study in one of the 32 medical schools of  United Kingdom. After graduating, junior doctors enter a 2-year multidisciplinary clinical training called the foundation program. Once they have completed this, doctors can apply for specialty registrar positions, and train to a specialty. This training varies  in length depending on the chosen specialty, and gives access to hospital consultancy or general practice.

Figure 1: Modernising Medical Careers’ organisation with average duration of each step.

A flawed selection process?

While the Modernising Medical Careers programme has made transitions between career steps more harmonious, it is now the access to foundation programme positions that is questioned. The issue was raised in 2008, when a NHS study “The Next Stage Review: A High Quality Workforce” stated that “New work needs to be undertaken to develop more reliable and valid selection tools for recruitment”. Following this declaration, the British department of health took immediate action, committing a panel of international experts to analyse and reflect upon the current selection methods. [2]

The current selection is based upon 2 scores. The first one, a knowledge score, is obtained by ranking medical students on the basis of their medical school results. From this sorted list, each medical school divides its own students into four quartiles, and scores are allocated to students of each quartile. Students from the first quartile receive 40 points, and all those from the second, third and fourth quartiles receive 38, 36 and 34 points respectively. This allocating method has been depicted unfair and two crucial issues were highlighted. First, since students from the first quartile of any medical school get the same amount of points, some students may theoretically be lead to choose a less competitive medical school to rank in the first quartile more easily and thus be more likely to obtain the foundation placement of their choice. [3] Then, there are currently enough foundation positions to ensure employment to every junior doctor. However, it may not always be the case, and the day the ever-increasing number of junior doctors will overcome the number of posts available, some will ultimately be refused. And refusing employment on the basis of a selection process, which is not considered as sound, transparent and fair would open the way to a myriad of potential legal challenges. [2, 4]

The second part of the current selection process is a professionalism score. Students’ professional traits are assessed by a series of open-ended ‘white space’ questions they answer during their spare time at the end of their final year. Their answers are marked by a panel of doctor from the applicant’s first choice base unit. The criticisms on this method are numerous. Firstly, it has been identified that the ‘white space’ format for answers compromised the objectivity of the assessment. [4] Then, despite the fact a random selection of 10% of applicants is asked to provide evidences of their answers, this method is said to open the way to cheating and plagiarism. [4, 5] Finally, the panels responsible for the marking of the forms complain about the time-consuming aspect of the task. [6]

Options study

During the 9 months following these findings, the panel of experts assessed various selection methods, and proposed the “Improving Selection to the Foundation Programme Project”. In order to define the ideal selection criteria, they firstly raised the crucial question of what expectations hospitals have of ‘good doctors’. Three attributes were retained: clinical knowledge, clinical skills and professional traits. [7] They then considered the traditional options available to assess such criteria: structured interviews, multiple-mini interviews, a national examination of clinical skills and knowledge, a national test of professional traits, and a standardised score from medical schools. All these selection methods were assessed upon several criteria, ranging from transparency to fairness and cost. As a result of this feasibility study, interviews were dismissed for their inherent lack of objectiveness and their cost, just like national examinations of which the OSCE component was considered to be too expensive, and the assessment of knowledge too redundant with students’ finals. [8]

Figure 2: Results of the feasibility study showing the cost of every method over five years on the ordinate and their reliability score in arbitrary units on the abscissa. (Adapted from Option Review in Paul O’Neil’s presentation: Pilots for FP Recruitment and Selection 2013)  [8]

Proposed selection process : what is going to change?

At the end of the study, the panel reached a conclusion and proposed a recommendation framework. As other methods to assess clinical knowledge and skills had been ruled out, experts decided that medical school should keep the responsibility of this assessment. However, the quartile distribution would be replaced by a more granular process allowing standardisation of every student’s grades in a fair and reliable way: the Educational Performance Measure (EPM).

As far as ‘white space’ questions are concerned, they would be replaced by another professionalism assessment, which would this time be a national computer-marked test: the Situational Judgement Test (SJT). The Medical Schools Council describes it as “similar to GP short-listing tests”, and it is very likely to be on the form of small scenarios and identifying the most appropriate action to take. It should also put an emphasis on solving ethical and professional dilemma rather than focusing on students’ extra-curricular achievements. The rest of the process should on the whole not be reformed. [8] In practical terms, for students this reform would mainly replace the professionalism “take-home essays” by a National Situational Test, and change the way their medical school achievements are converted into a standardised score.

Figure 3: Proposed Selection Process. (Adapted from «Proposed Selection Process» in Denis Shaughnessy’s presentation: Improving the Selection Process) (7)

Figure 4:  Situational Judgement Test, sample question. A suggested answer to the above question is: A-D-C-B-E. (2)

This new selection process is currently in its stage of development and still has to be tested, legally reviewed and approved by the ministry before it can go live.

Dr Richard Price, careers coordinator at Newcastle University adds: “All we know currently is that the planned changes will be piloted  in selected medical schools alongside the existing system for the next two years, and  will  be  thoroughly evaluated prior to their full introduction.”

These trials are to start in October 2010 on a sample of a few hundred applicants, before expanding to a few thousand by March 2011. These pilots will be followed by a legal review, an approval, and a preparation phase that could last until autumn 2012. This last stage is an unavoidable part of the process since it is during this preparation that will be decided how to combine the EPM and SJT to produce a representative overall score.

Thereby, the new selection process should not go live until the academic year 2012-2013, at the earliest. However, experts recommend to continue with the current method unless the pilots show sound reasons for change. [8]

Figure 5: Introducing the changes: a timing overview. (Adapted from “Timing Overview” in Denis Shaughnessy’s presentation: Improving the Selection Process) [7]

So how do other countries sort the matter?

Generally, four main methods are broadly accepted internationally to determine selection of junior doctors’ first placements after graduation. Most countries opt for one of these solutions, or a close alternatives.

1. A national examination ranks applicants according to their results and allocates everyone to his first available choice, starting from the top of the list. [9]
2. Applicants get systematically appointed to the university hospital the graduated from. [10]
3. The government decides where junior doctors are appointed to, depending on current needs. [11]
4. Applicants are scored against various criteria before an algorithm matches them with to their most highly ranked choice. [12]

In France, students do not graduate until they have finished their internship. But the 6-years lecture-based studies are separated from the clinical internship by an examination. This latter is a national examination after which students are ranked upon their score. Students may then choose their positions in the order of their ranking.  There are generally more positions than applicants, however applicants with the lowest scores may not have the choice of their specialty. [9]

In Italy, after graduation junior doctors complete a three-month unpaid supervised placement. It consists of two months in the university hospital they graduated from and a month shadowing a general practitioner in a local surgery. After they successfully complete these, a national examination must be passed to obtain full license to practise. [10]

India : Compulsory Rural Service

In India, the degree of Bachelor of Medicine and Bachelor of Surgery (MBBS) is awarded to students once they have completed five years and a half at medical school. However, in an attempt to improve health care standards in the most rural communities, some states have decreed that junior doctors should, as a priority, be appointed to tribal areas. Thereby, young doctors are now bound to practice medicine in rural settings for a year after graduation, before they can apply to any other post. [11]

During their last year of medical school, American students apply to residency programmes via the online Electronic Residency Application Service (ERAS). These programmes then short-list the applicants they want to interview. Criteria used for such a selection can vary widely. A study undertaken in 2000 shows these variations as 94% residency programmes reported to base their selection on examination scores, 87% on potential letters from deans, 85% on application forms, and only 61% on personal statements. [13] After the interview stage, programmes rank their interviewee by order of preference, and applicants similarly rank the programmes they applied to. An algorithm, the National Residency Matching Program, is then responsible to match programmes and applicants with their most highly ranked choice. In 2008, of the almost 36,000 applicants, 20,940 matched. [14] For the unmatched applicants, it is during a period known as the ‘Scramble’, during which the applicants who did not match try to secure a remaining available position. But this process is barely structured and offers minimal chances of success. Dr. Freedman, an American leader in medical education, describes the situation: “Jammed fax machines and lines of communication make this process challenging. […] In 2008 by 6pm the day after the Scramble, only 179 positions of the 1,388 positions remained open.” The Association of American Medical Colleges has, however, acknowledged the issue and is currently leading a study to give a more defined structure to the Scramble. [12]

References

1- Pr. Weetman T., Written Evidence Submission – The Evaluation Of the Foundation Programme, Medical Education England.

2- Improving Selection to Foundation Programme Briefing Pack – Stage 2 of Project, Medical Schools Council: 2010.

3- Kelly C., Should UK Medical Students Sit a National Qualifying Exam?, Student BMJ: 2008 – 16:184|17.

4- Pr. Paice E., Dr. Rainsberry A., House of Commons, Health Committee, Modernising Medical Careers, Volume II, Written evidence: October 2007 – p127.

5- Medical Schools Council, Characteristics of the Current System for Selection into the Foundation Programme, Appendix B.

6- KSS FP Evaluation Final Report from KSS Deanery: 2006 – p25-28.

7- Shaughnessy D., Improving The Selection Process, Presentation: March 2010.

8- O’Neill P., Pilots For FP Recruitment and Selection 2013, Presentation, UKFPO: 2010.

9- Postes et Rangs Pour l’Examen National Classant, Journal Officiel, Direction de l’Information Légale et Administrative: 2009.

10-Pr. Torre G.C., Corso di Laurea in Medicina e Chirurgia, Facoltà di Medicina e Chirurgia, Università degli Studi di Genova.

11- Sai Gopal M., Opinion Divided Over Compulsory Rural Service, The Hindu: February 2010.

12- Freedman J. MD, The Residency Scramble: How It Works and How It Can Be Improved,  The Student Doctor Network: March 2009.

13- Adams L. J. MSW, Brandenburg S. MD, Blake M. MS, Factors Influencing Internal Medicine Program Directors’ Decisions about Applicants, Academic Medicine: May 2000 – Volume 75 – Issue 5 – p 542-543.

14- Advance Data Tables For The 2008 Main Residency Match, National Residency Matching Program, March 2008 – p3.

In this article, Sirina Keesara discusses the issue of misinformation as a barrier to use of family planning and slowing of population growth in Ghana.

From the invention of the birth control pill in 1960, and the subsequent proliferation of family planning programmes, access to contraception has expanded incredibly (1). Knowledge of at least one method of contraception is now nearly universal in almost all areas of the world, with pills, injectables, and male condoms as the most cited examples (2). Unfortunately, this improvement in knowledge has not been accompanied by an increase in contraceptive use. Use is especially low in Sub-Saharan Africa (2). The juxtaposition of these two findings seems to indicate that people who know about contraception don’t want to use it, probably because they want more children. However, this conclusion is inconsistent with the finding that more than 137 million women throughout the developing world do not want another child but are not using anything to prevent pregnancy (3). So why aren’t they using contraception if they know about contraception, but do not want to continue growing their families?

Researchers who have worked on this question for the past half century, have created a theory of fertility behaviour that attributes this gap in knowledge and practice to factors such as cultural traditions, low education rate, high mortality rate, and lack of women’s autonomy (4). The video at girleffect.org is one of the best popular culture products of this accepted theory. Using only animated words the video conveys a simple and powerful message: empower girls, change the world. At the start of the video, we see the word “girl” associated with the burdens of “child”, “husband,” “HIV”, and “hunger.” Then, with the introduction of “education”, all the burdens fall off, the music changes from gloomy to hopeful and the video rushes full force into the solution of education, micro-loans, and opportunity for girls to fix the world. The viewer is so elated by an elegant solution to complex problems, that many don’t notice one key omission: the family planning factor.

Rewind and click pause to the point when all the burdens fall off. How exactly are these burdens supposed to magically fall away? Giving a girl education prevents babies? No, not directly- only a condom or a set of pills (or any other form of contraception) can do that. Well, a girl will be able to obtain contraception if she has the opportunity for an education and a career… correct? Not necesarily!

The key, but faulty, assumption here is that women and couples will rationally weigh the costs (money or education lost, time that could be spent working, effort) and benefits of having a child and then will take necessary precautions to prevent any unwanted pregnancies (5). The first problem with this assumption is that, many times, children do not come as a product of rational decisions, but rather as a product of the passion of one moment. Therefore, because we have sex for reasons other than reproduction, we will produce babies without consistent contraceptive use. The second problem with the cost-benefit rationale is that it sets the cost of obtaining and using contraceptives very low. However, barriers to contraceptives are far greater than cost and distance to a family planning clinic. As revealed by interviews I conducted in Ghana, we have been successful in giving couples access to family planning, but we have failed to address other less tangible barriers.

Among the wide variety of barriers that exist in the field (6) many programmes have done little to explore or address issues such as misinformation surrounding contraceptives. Through interviews I conducted with women in Ghana, where the unmet need is s among the highest in the world at 34% (7), I found that the key element which holds women back from using contraception is misinformation; rumors, myths, and other pieces of faulty information prevent women, and especially young girls, from using contraception. If they believed that birth control will harm their body, health, or future fertility, they would not use it, even if a pack is placed directly into their hands. For example, the following woman working in a marketplace in the capital city, Accra said:

Sirina: you are afraid of the medicine. Okay, but what do you think will happen if you take it?
Woman: It will disturb you. Because if they say that if you use the medicine, it will destroy the womb. Because I am afraid of not having birth. If you don’t have birth, you won’t feel well in your self
Sirina: you don’t feel well as a woman.
Woman: yes! you are not feeling well. Some of them, they insult you if you don’t have births

Some even believed that abortion was safer than contraceptive pills because “it happened only once”, whereas contraception stifled fertility for an extended time. Abortions in Ghana, though legal, are highly restricted and largely unsafe.

Contrastingly, when the fear of infertility was taken away, many women jumped at the possibility to use family planning and limit their fertility. For example, one woman, who had thirteen children, was adamantly against the use of family planning because it went against God’s will. However, when she was asked, “would you use family planning if you were sure it was safe and it wouldn’t endanger your fertility?,” she answered: “oh of course.” This response was astounding because she seemed to have abandoned her religious reasons within a matter of seconds. When this question was included in all the subsequent interviews, the answer was almost always an emphatic “Yes!”

Furthermore, I found that women are badly in need of a method to control their fertility. One women was pregnant with her fifth child and had decided that she was going to take the “risk” of using family planning because she was so desparate to stop having children:

Interpreter: Well, she knew someone who had a problem with the family planning and they were trying to discourage her from it.
Sirina: But then why did she end up using it? I don’t understand why she would go for it.
I: That’s what I said that she wanted to give it a try and take the risk.
S: but if she took the risk she might not have been able to have babies again?
I: And she would have blamed herself for that. But she didn’t mind, she wanted to do it because she didn’t want any more [babies].

This widely found “intangible barrier” of misinformation meant that women had an ingrained belief that family planning was bad for fertility, and this belief played a large role in women’s reluctance to use it even when they wanted to control their fertility. Furthermore, it seems that when misinformation is removed women will act on their desire to have fewer children and will make a quick reversal of attitudes towards family planning. This can happen even without improvement in formal education or socioeconomic status. Other intangible barriers have a similar effect on women. For example, fear of maltreatment in clinics is potentially a huge hurdle. Despite Ghana’s Ministry of Health’s effort to train nurses and create youth-friendly clinics, these clinics are few and far between. For example, when I worked in a Family Planning Clinic, I witnessed the nurses “counselling” (scolding) a young client who wasn’t married before “getting into those things”. The girl was then forced to change her preferred method of contraception from the injection to the pill, because according to the nurse, that injection could make her sterile (it can’t), and she was sent away thoroughly embarrassed (8). Therefore, we can see that intangible barriers can be as significant or more than physicial availability of contraceptives.

Although intangible barriers are elusive to tackle, they are not insurmountable. For example, Iran, Bangladesh, and Thailand have all been able to ensure access to contraception for many women through community based distribution systems (10). In Iran, the increased governmental attention to family planning access and sexual education dropped the fertility levels (9) from 6.0 children/woman over her lifetime in the 1970s to 4.3 in the 1990s and then 2.1 in 2005 (10) – and inside a traditional culture. Case studies such as these raise questions about the validity of the accepted fertility behaviour theory; they show that fertility levels can drop and population growth can slow without improvement of other socio-economic variables. Therefore, it seems to imply that some factor, other than development, must influence fertility behaviours.

A newer theory of fertility decline, the opportunity model (11), says that women and couples will use contraception if they understand fertility regulation is an imaginable possibility. That is, if they believe they can use contraception without harmful side effects, they will want to use it and demand its availability! Think about it this way, before the internet we didn’t demand a connected web of information through which we could communicate almost instaneously. This demand was created by making such technology an imaginable possibility. Now that it is in our realm of possibility, almost nobody can live without it. In the early years of the internet, skeptics claimed that people would have to learn too many new skills to make use of it. However, Marc Andreesen, the creator of the first browser, replied “People will change their habits quickly when there is a strong reason to do so, and people have the innate urge to connect with other people- when you give them a new way to connect with other people, they will find it objectionable not to be able to”(12). Similarly, many academics have said that people would not adopt family planning because it would require too much behaviour change. However, I would argue that family planning opens doors to new options for women, and when they have access to contraceptive methods, along with correct information backed up with safe abortion, they will find it objectionable not be able to control their family size. In our work studying fertility preference and behaviours in Ghana, this pattern was clear; it seemed that women who learned that family planning was safe and easy to use, in other words who believed family planning was an imaginable possibility, would demand it and start to use it. Considering this theory we assume that the number quoted for unmet need is grossly underestimated because women with many intangible barriers may not realise that they have an option to control their fertility and thus may not express this desire.

This sheds new light on why family planning programmes in the past have not been as successful as expected. We need to redefine the way we think about barriers and tailor programmes to address these issues. If we are able to do this, we will be able to give women control over their own fertility, and by doing so slow rapid population growth. We cannot afford to ignore rapid population growth as this sole factor can ruin all our plans for the Millenium Development Goals and exhaust our world’s resources (13). If we ignore this issue, we are ignoring women’s rights and the rights of the future generations to come. We should encourage the international community to re-direct their attention towards family planning and understand its relevance in the underlying issues of health and development.

Sirina Keesara
Sirina.Keesara(a)ucsf.edu

References
1. Robinson WC; Ross JA. The global family planning revolution: three decades of population policies and programs. Washington, D.C., World Bank, 2007

2. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. Contraceptive Trends in Developing Countries. Calverton, Maryland, USA: Macro International Inc. 2007. DHS Comparative Reports No. 16.

3. Sedgh, Gilda et al. Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Alan Guttmacher Institute, 2007: Occasional Report No. 37. Accessible at http://www.guttmacher.org/pubs/2007/07/09/or37.pdf

4. Notestein F.W. Economic problems of population change. Proceedings of the Eighth International Conference of Agricultural Economists. London, Oxford University Press. 1953

5. In Gary Becker’s Nobel Prize winning book, Treatise on the Family, he uses economic principles to explain decisions and actions that pertain to the dynamics of the family. He includes on chapter about the Demand for Children in which he terms children as a high cost commodity and explains childbearing as a parent’s rational decisions about their “consumption” of children. ( cite his book)

6. Campbell, M.M. Sahin-Hodoglugil N. & Potts, M. Barriers to Fertility Regulation: A Review of the Literature. Studies in Family Planning, 2006: 37, 87-98

7. Gribble, Jay. Family Planning in Ghana, Burkina Faso, and Mali. Population Reference Bureau. April 2008. access on December 30th, 2009 at http://www.prb.org/Articles/2008/westafricafamilyplanning2.aspx

8. Keesara, Sirina. Barriers to Fertility Regulation for Ghanaian Women. Presentation at 137th annual APHA conference. Accessible at: http://apha.confex.com/apha/137am/webprogram/Session27587.html

9. Fertility levels are measured by Total Fertility Rate (TFR), the number of children that a woman (women, or a woman – hjave or has) would have in her /or their lifetime if fertility rates are constant. Replacement lvel fertility, in which each woman has the number children only replace the population is 2.1.

10. Gubaju, Bhakta, GUBAJU, BHAKTA. Fertility Decline in Asia: Opportunities and Challenges The Japanese Journal of Population. March 2007; 5:1

11. Campbell M, Bedford K.The theoretical and political framing of the population factor in development Phil. Trans. R. Soc. B 2009 364, 3101-3113.

12. Friedman, Thomas. Chapter 2. The World is Flat: A Brief History of the Twenty-First Century.

13. All Parliamentary Group on Population Development and Reproductive Health, “Return of the population Growth Factor: Its Impact on the Millenium Development Goals” (HMSO, London, 2007). www.appg.popdevrh.org.uk Accessed on December 27th 2009

Leonardo Da Vinci’s Vitruvian Man

‘Conscience without science is weak and ineffective, but science without conscience is dangerous’

I started off as a student of science, enamored by the human ability to think, create, imagine and understand the world around us. Fascinated by the use of scientific tools and technology to demonstrate and answer the why’s and how’s of the way things work.

Our educational edifice is built of bricks of the basic sciences and a smattering of the arts, these subjects are seen as separate as oil and water. But in the initial steps of a career in medicine we are taught that “medicine is an art and a science”. This dichotomy of science-art is hard to comprehend as a raw medical student unexposed to the practice of medicine. Especially as many of us may feel we are about to embark on what we perceive to be a logical, precise journey into the medical sciences.

The Science

Prior to the study of clinical medicine we learn the basic sciences- biology, chemistry and physics which then transcend into the anatomical, physiologic and biochemical realm. Here mechanisms and functions– gross, molecular, biochemical and pharmaceutical interactions are elucidated. We learn through scientific methods about how our bodies generally function and develop a basis for understanding disease alterations in humans.

The ‘scientific method’ refers to the application of scientific techniques for investigating, acquiring new knowledge, or correcting and integrating prior knowledge. To be termed scientific, a method of inquiry must be based on gathering observable, empiric and measurable evidence, which is subjected to specific principles of reasoning. A scientific method consists of the compilation of data through observation and experimentation, with formulation and testing of a hypotheses.[1]

We then move on to acquire clinically relevant knowledge, which is also based on strict scientific observation. Every technique from taking a blood sample, palpating for a spleen, auscultating the heart and lungs, are learned by recognizing specific systematic protocols, using tools and techniques that have been practiced and studied, developed and proved through years of evidence based medicine. Evidence-based medicine aims to apply the best available evidence gained from the scientific method to medical decision making [2] . It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment), refining and validating the information continuously. As not all statistically viable data is clinically relevant and treatment methodology applied on one individual may not be applicable on every other.

Medical science dictates such an impersonal, objective character, which does not relative to personal thoughts and experiences. “Medical practice depends on generalizations that can be reliably applied and scientifically demonstrated. Without understanding people as objects in this way, there can be no such thing as medical science” without which, the practice of medicine would be impossible [4].

The doctor observes signs and symptoms, experiments to improve clinical evaluation, tests for signs, hypothesizes, collects data, and samples and tests them for a conclusive confirmation which concludes in a diagnosis. Then the treatment modalities are initiated and are given similar scrutiny to assess, refine and continue development of advances in the field of medicine. Till this stage the process seems straightforward and well charted out.

The Art

By heading to the clinics often the expectations and experiences flow into a direction diametrically opposite to a logical scientific view.

In art, as understood by artists themselves, the quality of the achievement cannot be measured. It cannot be determined by comparing it against some norm or transforming it into such neutral entities as quantities and figures. Similarly, every case does not present as pictured in the book as patients may present in different stages, after taking some treatment or be unique due to other reasons. Along with the disease aspect, patients are scared, uncomfortable, bored and frequently down right miserable. Understanding the individual patient as encountered in practice and comparing the individual, with himself and not on a broad research perspective is an essential requirement. The art encompasses human skills as well as demonstration of technical clinical skills[5].

The human art lies in knowing that everyone deserves dignity, respect, empathy and care. Empathy is not just sympathy; it implies feeling of deep concern for the overall welfare so as to restore the patients help or mitigate suffering [6].Building the human touch of a physician- patient interaction helps both parties. Ask an unscripted question [7], smile or shake a hand. Good patient care necessitates that the patient actively participates in his own management; without trust this is difficult. Our skill in this regard is to understand and respect individual needs, their socio-economic and familial status and provide a non judgmental environment for them to be able to confide in us. This can only be achieved when we can assure them that our probing questions and examinations will help us help them. The art of medicine is the art of healing, not just treating, not even just curing. Technology will not assuage the mental torment, fear, anxiety that may follow illness.[6]

The need to show care is not just to be a good human being, in today’s litigious society, it is a necessity, patients are less likely to sue if they think you care [8]. The patient needs to be informed and reassured about the tests, procedures and treatment so that, they can understand the pros and cons of therapy and weigh the benefits and risks of complying or not complying with treatment.
Even in end of life care the art of medicine is paramount, palliative care may mean that hope of cure is lost, but the hope of care is still present. Palliation is often a neglected aspect of the medical treatment, at many times due to the inadequacy of the expanse of care which the treating doctor is qualified or capable of providing. A poor prognosis does not call for an abandoning attitude. Acquiring all these skills may sound difficult, some are naturally gifted a friendly gregarious demeanor and others not, but if the determination to master the art of skillful communication is there, the art of medicine can be acquired through observation, study and training by anyone.

The art of medicine also lies in the skillfulness and technique of demonstrating clinical skills, which are acquired after years of practice [5]. Clinical skills are required to elicit knee jerk in an uptight individual, distinguish bronchial from vesicular breathing in a crying scared child etc. Even more important is to know what treatment should be given under which circumstance. Even non- medical issues need to be understood and accounted for, such as understanding patient compliance, factors related to their occupation or economic status. Old people may find it difficult to comply with complicated regimens and those without support systems may need a different treatment approach. Ethnic sensitivity is required in today’s international world, and peoples’ cultural and religious preferences should be accorded respect, to facilitate care. Trousseau, a French physician ended one of his clinical medicine lectures thus ‘For mercy’s sake gentlemen, let us have a little less science and a little more art!’[6]

Fallacies

Modern day medicine is essentially science, however there is good science, bad science and pseudoscience. There is also good, bad and ugly art as art is in the eye of the beholder. Learning the appropriate demeanor for a situation requires sensitivity. A major faux pas would be a silly, joking attitude while breaking a life threatening illness or a stern attitude towards anxious parents before a surgery. Hippocrates himself claimed that they were the real doctors, unlike their opponents or any other ‘idiotes’( the Greek for ‘laymen’ from which we derive the word idiot.) [9]. One may acquire knowledge about a certain condition like obesity and some may come to blame a patient or believe they are ‘idiotes’ for they did not take the proper precautions and their ignorance towards themselves may have led them to you, but this arrogance is uncalled for. A combination of bad science and bad art may lead to unproductive results as exemplified by many medical charlatans, seen through the ages. They claim to possess more knowledge or skill than they really do and have managed to build a large following.

Dr Abrams’, the father of radionics invented a diagnosing machine in 1910 called the “dynamizer”, which was a box with a jungle of wires. One wire ran to an electrical source, and another was attached to the forehead of a health person. A drop of blood from the patient was obtained on filter paper was placed in it. Following this he would percuss the abdomen – and for reasons never made clear was made to face west – by listening he would then diagnose the disease. His logic – the spine has nerves which vibrate, the dynamizer picks the vibrations from the blood sample and transmits them amplified back to the spine and are then sent to various parts of the body where it can be detected. His theory was that every disease has its own “vibratory rate”. He also built an oscilloclast to impart vibrations to drugs, a reflexophone for diagnosing over the phone. Radionics devices contradict principles of biology and physics, and no scientifically plausible mechanism of function is posited. In this sense, they can be described as magical in operation. No plausible biophysical basis for the “putative energy fields” has been proposed, and neither the fields themselves nor their purported therapeutic effects have been convincingly demonstrated. No radionic device has been found efficacious in the diagnosis or treatment of any disease. [9,10,11] Many doctors are also able to “charm” patients into needing hospitalization for minor problems, or assenting for expensive and unnecessary treatment; this ‘art’ is unworthy of the noble profession.

Combining the Two

‘Conscience without science is weak and ineffective, but science without conscience is dangerous’

Good doctors use their personal judgment to affirm what they believe to be true in a particular situation. Their knowledge is not purely subjective, for they cannot believe just anything; and their judgment is made responsibly and with universal intent, i.e. they take it that anyone in the same position should concur. It is practical wisdom -medical practice demands such judgments on a daily basis. The good doctor is able to reflect on diverse evidence and to apply it in a particular context. But this too cannot be anything one imagines by hit and trial. Judgment cannot be reached by logic alone. Here medical practice as art and science merge. [3]

As students we can only learn, however this quest should not be blind or rigid. We need to apply ourselves to attain the goal of assimilating the true essence of both the science and art of our chosen field. We should learn by understanding the scientific basis of all our skills and the significance of how to apply them. Data and methodology should be available for careful peer scrutiny by other researchers and be given the opportunity to verify results by attempting to reproduce them. We should be open to changes and in turn not be complacent in our approach and hope to be spoon fed all knowledge, [13] for no one person possesses all knowledge and right knowledge is dynamic in nature.

As doctors of tomorrow we are bestowed with a huge moral, social and ethical responsibility. We as the palanquin bearers of the world of medicine must strive to uphold the virtues entrusted on us- which is possible only by a balanced amalgamation of both Science and Art in their purest forms.

Bhavna Seth is a second year medical student at Lady Hardinge Medical College, University of Delhi.
bhavna.seth(at)gmail.com

References:

1. Scientific method: Merriam-Webster Dictionary. 11th Edition.

2. Elstein AS. “On the origins and development of evidence-based medicine and medical decision making”. Inflamm. Res. 2004 53 Suppl 2: S184–9

3. Saunders J. The practice of clinical medicine as an art and as a science. West J Med. 2001;174(2): 137–141.

4. Guttentag OE. The phrase art and science. California and western medicine 1939; 50(2) : 86-87

5. The Forgotten Art of Healing and Other Essays by Farokh Erach Udwadia Oxford. University Press; 2 edition (Aug 1 2009)

6. Better: A Surgeon’s Notes on Performance by Atul Gawande, Metropolitan Books; 1st edition (April 3, 2007)

7. Wu AW, Huang I, Strokes S et al. Disclosing Medical Errors to Patients: It’s Not What You Say, It’s What They Hear. 2009; 24(9): 1012-1017

8. Eureka! The Birth of Science by Andrew Gregory Publisher: Icon Books Ltd; 1st Edition (5 Nov 2001)

9. National Center for Complementary and Alternative Medicine.”Energy Medicine: an overview”. Retrieved 2008-02-09. “In the aggregate, these approaches are among the most controversial of CAM practices because neither the external energy fields nor their therapeutic effects have been demonstrated convincingly by any biophysical means.”

10. Fads and Fallacies in the name of science, Martin Gardner, Dover Publications, Inc. New York, 1957 ISBN-10: 0486203948 ISBN-13: 978-0486203942

11. Raines K. Quack Cures and Radionic. JW Research Journal. 1996; 3(2).

12. Chan A, Peets A. The student’s perspective. Clin Invest Med 2000;23(1):103-4.

Ever wondered what to do for the summer? If you do not have a temporary job, and the Caribbean is nowhere on the horizon, consider undertaking a short research project for the summer. Not many students are aware of the opportunities available and hence, they are often underapplied for.

Undertaking a short research project over the summer can be fun and challenging and can give you an insight into research. Working with a research team will enable you to gain a whole range of essential and transferable skills that will help you through whatever career path you choose. Research plays a vital role in medicine and enables doctors to treat patients more effectively. [1] Katie Foy has accurately identified the role research plays in the NHS: It provides a basis of evidence that enables practitioners to institute the best medical and social care for the patient to improve overall outcomes. The NHS and Department of Health have set out new objectives with aims to be an internationally recognised centre for research excellence through the ‘Best research for Best Health’ scheme. This will undoubtedly create new and favourable opportunities for academic research staff in the near future. [2] Therefore, students considering an academic career are recommended to gain more exposure in order to decide if they want to be a part of this exciting and expanding field.

However, a common problem encountered by students is the question: ‘But where do I find a research project that recruits students for the summer?’

As Ryan-Lee and Tso [2] have indicated, there are several organisations based in the UK that run vacation research programmes and, on top of that, grant studentships or bursaries to support them in their work. The financial remuneration aims to cover students’ personal expenses and can be up to £180 per week. [3]

Research Placements
Some of the organisations that run vacation research placements are listed in Table 1. These organisations offer applicants a choice of research projects that are ongoing in their institutions. [4,5,6] Since the research project has been designed and planned beforehand, it provides students with the advantages of getting straight into work and a clear picture of the objective and outcome of the project. The disadvantage, however, is that you miss out on the opportunity to experience the planning and brain-storming of ideas involved in research projects.

Undergraduate Student Funding Organisations
The other option is to search for research projects yourself. This is a trickier and lengthy process, but equally worthwhile. The advantage is that you can select a project in a field that interests you, with a supervisor of your choice at a location of your choice. Universities across the UK have ongoing research in various fields and any senior member of a research team is a potential supervisor! Doing a summer project in a field of your interest simply requires writing to members of a university’s appropriate research team to ask if they are willing to take you on for the summer period. However, you will have to be flexible in your choice of supervisor, as not all are able to take in students or offer short projects.
A problem with doing a research project during the summer is that this is often unpaid, and many students use their summer holidays to earn money.
One solution is working on a part-time basis in casual employment. However, this may not always be possible as time commitments on the project may not allow it. Fortunately, several organisations award bursaries to students who show academic potential and request funding for work on innovative projects. These bursaries are purely designed to support students with their personal expenses and range from £140 to £190 per week.

Applying for Funding
Competition for these bursaries is high and there are always strings attached. Some of the organisations that offer bursaries to undergraduate students for vacation projects are listed in table 2. Some organisations are aimed at bioscience or life-science students, but medical students are also eligible to apply, and the course the applicant is enrolled in does not usually determine allocation of the award. However, note that awards are subject to certain requirements. For example, many awards require you to submit a written report at the end of the project; some awards are only open to students whose supervisors are members of the organisation providing the funds or funding is only available for a specific research field.

*Many institutions award grants directly to universities, who then advertise within their departments and invite applicants directly. Keep an eye out for these awards on university notice boards.

The basic requirement for any bursary is doing a project which is well-planned and has a defined set of objectives. Support from a supervisor is also a prerequisite.

*Applications for bursaries open as early as February, and so preparation and planning in advance is essential.

Academic exposure is often limited to students who intercalate, but vacation projects offer students to get a ‘flavour’ of research. An academic career is long and challenging, but the rewards are numerous. With the changes introduced by Modernising Medical Careers in the UK [13], it has become increasingly important to plan your career early and partake in activities to form a strong and well-structured CV, especially since the career path for an academic is becoming increasingly competitive. Vacation projects can offer you the skills and experience to pursue a career in academics and also show your determination and enthusiasm to employers.

Getting started
The career services at universities often offer a comprehensive list of organisations running studentships or bursary awards and are a good starting point.

Also, talk to lecturers and tutors, who are often involved in ongoing research in their department. They may also be aware of other staff who offer projects in the fields that you may be interested in. However, it is important to note that many supervisors may not be aware of undergraduate placements, and so you may have to pitch a convincing proposal to generate interest.

If you are currently in clinical training in a hospital, then asking the local research and development department about clinical research or is helpful, especially if you are interested in clinical research.

In order to get accepted into a vacation project, you will need to put in a lot of effort. Expect that your application may be rejected and that you may need to redraft a proposal, but remember: the more thorough you are, the better are your chances to get into a project.

During the project, there will be numerous opportunities to learn new skills and network with other researchers, and there may be the opportunity to present your project in a publication or on a poster. The more work you put into it, the more you will get out of it.

And beyond…
Remember, there are several other opportunities in addition to these. As P. Alexander [14] has mentioned, there is innumerable research funding for student projects overseas, especially in the USA. If you fancy a break from all the bio-science, then similar bursaries are also available for subjects such as astronomy, physics or engineering…

Remember there are numerous opportunities which if well exploited can offer a whole different experience of the summer vacation!

Vinit K Shah
vinit.shah@student.manchester.ac.uk

Vinit is a medical student at the University of Manchester, and was awarded a Welcome Trust undergraduate vacation studentship to fund a project with the Maternal and Fetal Health Research Group at St Mary’s Hospital in Manchester.

1. Katie Foy (2009). Research and Me – a viewpoint. The Lancet Student online Journal. http://www.thelancetstudent.com/2009/02/19/research-and-me

2. Department of Health, Research and Development directorate. Best research forbest health: A new national health research strategy.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4127225

3. WK Ryan Lee and S. Tso. Working Summer. sBMJ 2007; 15: 257

4. University College London institute of Child Health: CHRAT Studentships. http://www.ich.ucl.ac.uk/education/vacation_studentships/chrat.html

5. London Research Institute: Summer studentships. http://www.london-research-institute.co.uk/jobs/summer_student/?version=5

6. Imprerial College Undergraduate Research Opportunities Programme (UROP) http://www3.imperial.ac.uk/urop

7. Wellcome Trust Undergraduate support grants http://www.wellcome.ac.uk/Funding/Biomedical-science/Grants/Undergraduate-support/

8. Nuffield Foundation Undergraduate Research Bursaries
http://www.nuffieldfoundation.org/go/grants/nsbur/page_412.html

9. Biochemical Society Undergraduate Studentships
http://www.biochemistry.org/Grants/EducationalGrants

10. Society for General Microbiology Undergraduate Studentships
http://www.sgm.org.uk/grants/vs.cfm

11. The Genetics Society: Genes and Development studentships

http://www.genetics.org.uk/genetics_society_summer_studentships

12. Psychology Society: Undergraduate research bursary
http://www.eps.ac.uk/index.php/undergraduate-research-bursary-scheme

13. Modernising Medical Careers: Specialty Training England. http://www.mmc.nhs.uk

14. P. Alexander. Working summer. sBMJ 2002; 10: 353

Student participation across clinical specialities and situations is an essential component of medical education. A balance must be sought between patient care and student education.[1] In most specialities, patient comfort with medical student involvement is generally high.[2] However, concordance of patients with medical students, particularly males, in obstetrics and gynaecology is lower than in other specialities due to the unique, intimate nature of the speciality.[1] This article assesses how medical student participation differs on labour wards, investigates the factors behind any difference and outlines methods of maximising important learning opportunities.

Studies of intrapartum care indicate that acceptance of medical students during labour is between 62% and 75%.[1] This is lower than in other specialities and is demonstrated in the obstetrics and gynaecology outpatients department as well as on the labour ward.[5] This is likely to be due to increasingly invasive procedures having lower levels of consent to participation, a factor demonstrated in all parts of medicine.[3] Furthermore, many women are unaware that medical students can perform and assist in deliveries.[3,4]

(more…)

High altitude populations

More than 140 million people live at altitudes over 2,500 m. In certain areas of the world, such as in the highlands of Peru, East Africa and South-Central Asia, some populations live at altitudes over 4,000 m where ambient oxygen availability is a meager 60% of sea-level values (1). By comparison, the peak of the highest mountain in Western Europe, Mont Blanc, is only 4807 m. At these altitudes, even functioning normally is no small feat. Yet for generations these populations have somehow managed to survive in the face of extreme hypoxia, freezing temperatures and low pressure. These three populations, however, have not adapted equally to high-altitude living (3). A theory of migration attempts to solve this disparity by stating that how well populations have adapted to high-altitude is dependent on the time they have been resident there. Understanding the physiology of these populations could therefore yield important implications. Firstly, as many people now ascend to higher altitudes for recreation, determining how the body best copes with hypoxia from populations that have adapted well could help these amateur sojourners cope with the extreme environment. Secondly, understanding the physiology of those populations that do adapt well could help inform treatment on how to help those populations that don’t. Knowing this, a research team of physiologists from Canada, the UK and the USA set their sights on the Ethiopian highlands. As an M.Sc. student studying cardiovascular control at Simon Fraser University in Vancouver, Canada it was difficult to say no to the opportunity to be involved in some field research overseas.

The story so far

Arrival in Bale

The team had experience of similar research amongst native high-altitude residents over the past 6 years and over 3 continents. Results from research amongst Highland Peruvians, Tibetans and Ethiopians had shown a spectrum of hypoxic adaptation between the Peruvians who seemed the least-adapted and the Ethiopians who seemed to be best-adapted to the altitude (3). An underlying theory of human migration has been put forward in an attempt to solve this disparity, in proposing that the Ethiopians’ adaptation may be due to their residence at such a high altitude for longer; Homo sapiens, after all, are considered to have originated from what today would be Kenya-Ethiopia. Peruvians, on the other hand, would have migrated to their resident altitude much later on in an evolutionary timescale and, therefore, would not have adapted so effectively (4). Chronic Mountain Sickness (CMS), related to cerebral autoregulatory dysfunction, is often used as a marker of mal-adaptation to high-altitude (5) and anecdotal reports were beginning to surface of CMS incidence in an Ethiopian population in the southern Bale Mountains. Previous studies performed in the northern Simien Mountains of Ethiopia failed to find any cases of CMS (2). Given the close proximity of these populations, the above theory would suggest they share a similar genetic makeup and adaptation profile to the high altitude. However, if the reported cases of CMS were in fact true, and we could determine that the two populations differed in cardiovascular responses to the altitude, we would discredit the prevailing migration theory for human high-altitude adaptation.

The joys of high altitude

Our research campsite in the Simien Mountains of Ethiopia

Our campsite in the Bale Mountains was desolate. At 4,118 m there wasn’t much wildlife save some small birds and the odd Ethiopian wolf. The high altitude became more than a research topic as it began to have its effect on me personally: with an ambient barometric pressure of approximately 460 mmHg at the campsite, oxygen levels were about 60% of that at sea-level. Consequently, my blood oxygen saturation had dropped to about 70% and my average heart rate floated around 130 beats/min (compared to 60 beats/min at sea level). A huge headache, nausea, fatigue, lack of appetite and wanting to vomit all welcomed me to life at high altitude. Thankfully, I was surrounded by doctors at the campsite who were able to keep an eye out for the more serious symptoms of the deadly pulmonary oedema and cerebral oedema. Often these two problems affect altitude sojourners and as I had never camped above 1,000 m prior to this trip it was a real worry that had to be addressed. Whilst the rest of the team set up, the only thing I could do was try to sleep and get better as soon as possible; the research would need to begin soon.

Researching above the clouds

Field research

Researching on the mountains was hectic. Everyone was up at sunrise and we would be testing continually till sunset. We only had a few days to test eight locals with each test taking about four hours. It was up here that I realized how different field research is to that conducted in labs across the world. All the equipment had to be set up in the morning and taken down at night in fear of animals ruining it. Generators became both our best friends and worst enemies as they often broke down leaving all teams stranded. No power meant there was no way to collect data and out there sticking to deadlines was hard enough as is. Power failures in Bale were a constant problem and oftentimes we would be stranded in the middle of our experiments, already hungry, hypoxic and tired, knowing that we still have another subject before the end of the day. In a makeshift tent on top of an African mountain, maintaining clinical standards became a full-time job. Equipment was constantly being sanitized and cleaned and dirt would somehow find its way into absolutely everything. Up on the mountains it really was machine versus nature. Kicked-up dirt managed to destroy one of the teams’ ultrasound equipment and our laptop and gas analyzer were beginning to show signs of trouble. As the temperatures dropped below zero overnight all equipment would collect condensation and at sunrise we would waste no time in taking out the equipment and drying out the components to prevent them from dying as well. Passing on messages to a subject in Bale had to cross three languages beforehand and given the complexity of the Ethiopian languages, learning to pronounce just “hello”, “thank you” and “how do you feel” properly took a lot of work. Nevertheless, it really was exciting. The idea that we were studying people that have probably never been studied before with the possibility of finding something new must have been enough to excite any medical professional.

There are important adjustments that, I feel, researchers need to make when working in these environments. Firstly, never expect anything to go to plan. From problems with getting customs approval for our equipment to constant power failures hindering data collection, stalls are the only things that are guaranteed when conducting field research. Secondly, understand the volunteers who are involved in the tests. It is extremely important to understand local customs and viewpoints so as to not offend people in your interaction with them or question why something that is normal to you is not as normal to somebody else. A lot of this grows out of respect for other people but its importance makes it worth noting in any case. Third and finally, be prepared. Environmental conditions, equipment damage, problems with subject recruitment; there are many factors that cannot be controlled for when operating in the field outside of the laboratory. It is important to be conscious of all the potential challenges and be prepared for them as well as possible.

Cultural issues in overseas field research

Conducting research in a foreign country poses other cultural and ethical issues as well. Informed consent is a particularly important one. Informed consent forms are documents that fully explain the test procedures along with the benefits and possible negative effects the research may have. When conducting human research it is imperative that informed consent is obtained from the volunteers. The problems in Ethiopia were, firstly, the language. The informed consent forms we had for the protocols had to be translated into all of the local languages, which made sense. However, most of the villagers could not read thereby making the informed consent forms largely biased by the way they are interpreted and explained by the researcher. We had independent doctors travel with us to accurately discuss the test protocols in as unbiased a manner as possible, but this is a potentially dangerous loophole that other researchers or medical professionals could exploit as research in these places is not well regulated. Another issue that commonly arose in researching this population was that many locals did not feel comfortable in certain test protocols, notably, giving blood samples. Of course, if locals did not feel comfortable we did not force them and they were welcome to complete certain protocols while leaving others incomplete. The doctors later informed us that many locals see giving blood as giving more than just biological material and that it’s almost viewed as giving away part of something more metaphysical. To many of us this was new but, as always, it was important to respect the wishes of the volunteers and so we happily removed those test protocols for the volunteers that were uncomfortable with it.

The locals we were testing were remarkable people. Almost all of them were subsistence farmers and they seemed taller and more muscular than the average Ethiopians I had seen in Addis Ababa. None of the villagers spoke English and my Orominya (the local language) was virtually non-existent, but through one of the Ethiopian doctors travelling with us I was able to talk to a lot of the locals that came up to the campsite. tThey all confused me for being a Muslim, and being Muslims themselves an occasional salaam would make a lot of the elders happy. The few attempts I did make to explain that I wasn’t Arab and that my grandparents were from India were futile but I must admit, I thoroughly enjoyed my interactions with the people in Bale. We were generally well-received by the local population we studied although there was an element of trust that had to be built before we reached that point. We noticed in the first couple of days of testing that most of the villagers would bring hunting knives with them to the testing campsite. However, towards the middle and end of our stay they no longer brought them. The doctors had spoken to some of the villagers who told them that they had previously brought the knives for protection to make sure we do not harm them! After they had realized we intended to do no harm they started coming without the knives. Although it at first may seem odd to require protection as we normally trust researchers to conduct ethical research, it makes sense that a people who may have never been exposed to the concept of research before would need to make sure we’re not setting out to hurt them. When the locals stopped coming for tests with their knives we took that as a sign that we’re doing something right!

Another thing I learnt in Bale in particular, but Ethiopia in general, was that I brought with me many false preconceptions about the place. Thanks to charity advertisements I’d seen back home I envisioned a drought-stricken and poor Ethiopia where almost everybody was starving and urgent humanitarian interventions were needed. However, what I saw in Ethiopia and in Bale were a proud people who worked hard and a country that seemed to be relatively prosperous. Sure, they have faced hardship in the past and as water is such a precious commodity there remains the possibility they may also have to face it in the future, but I was taken aback by the strength of the Ethiopian people and was left admiring the resolve they showed. I can only hope to convey this message to others to help curb any misconceptions they may have of the country and its people.

Conclusions

Although the results of the experiments are still being disseminated we hope that our research may provide many answers for us. Already high altitude field research like ours has helped identify certain drugs, such as acetazolomide, in helping people with CMS (6). As the results slowly begin to surface we also hope to be able to provide a better anthropological understanding of how some populations are better adapted to high altitude then others. Ultimately though, the research is about helping those high altitude populations that suffer with CMS and through better understanding the different cardiovascular and genetic profiles of well-adapted high altitude populations we may be able to confer better treatment for CMS in less adapted populations.

Inderjeet Sahota is studying for an MSc in cardiovascular physiology at Simon Fraser University in Canada
isahota(at)sfu.ca

References

1. Hainsworth R and Drinkhill MJ. (2007) Cardiovascular adjustments for life at high altitude. Respiratory Physiology & Neurobiology 158, 204-211.

2. Claydon VE, et.al. (2008). Cerebrovascular responses to hypoxia and hypocapnia in Ethiopian high altitude dwellers. Stroke 39, 336-342.

3. Xing G, et al. (2008) Adaptation and Mal-Adaptation to Ambient Hypoxia; Andean, Ethiopian and Himalayan Patterns. PLoS ONE 3(6): e2342.

4. Brugniaux JV, et al. (2007). Cerebrovascular responses to altitude. Respiratory Physiology & Neurobiology 158, 212-223.

5. Hultgren, Herb. (1997) High Altitude Medicine. Stanford, USA: Hultgren Publications.

6. Richalet, Jean-Paul, et al. (2005) Acetazolamide: A Treatment for Chronic Mountain Sickness. American Journal of Respiratory and Critical Care Medicine 172, 1427-1433.

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

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2. British Medical Association (2006) Encouraging women to work in academic medicine.
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3. British Medical Association (2008) Women in Academic Medicine: Developing equality in governance and management for career progression, Full Report.
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4. British Medical Association, Medical Student Representation.
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6. Medical Schools Council (2007) Women in Clinical Academia: Attracting and Developing the Medical and Dental Workforce of the Future.
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7. Aldridge J & Fitzpatrick S, (2008) Clinical Academic Staffing Levels in UK Medical Schools, Medical Schools Council.
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8. Medical Women’s Federation, Campaigns: Women in Academic Medicine.
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9. Royal College of Physicians (2006 & 2007) Census of Consultant Physicians in the UK.
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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.
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13. Elston MA, (2009) Women and medicine: the future, Report, Royal College of Physicians.
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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.
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17. Fleming N, (2008) Women doctors ‘less productive than males’, Telegraph.
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