Series: Volume 7, Issue 1 2016

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Letters

Student surgical societies in Australia and New Zealand: do they play a role in early surgical exposure and streaming?

In recent years, there has been an increase in the number and activity of student surgical societies and interest groups in Australian and New Zealand medical schools. To remain competitive, the modern medical student seeks out opportunities for additional surgical research and takes on extra-curricular activities, in addition to their medical studies. This has occurred in the context of increasingly busy curricula and concerns about the reduction in time devoted to structured surgical teaching in medical schools. [1] Most recently the introduction of Doctor of Medicine (MD) programs at several Australian universities, where the qualification of the medical graduate no longer includes a Bachelor of Surgery, reflects a transition whereby surgical teaching now takes place largely in expensive postgraduate courses. Medical training in general is lengthening whilst the number of graduates is increasing and the competition for jobs continues to heighten. In this setting, student surgical societies are becoming more active, and will likely play an increasingly important role in facilitating early exposure to surgery during medical school. [2]

Discussion about the length of general medical and specialty training in Australia and New Zealand continues and several authors suggest there is room for reduction. [3,4,5] It has been proposed that early streaming of general practitioners and specialists from the senior medical student level, as seen in the US, should be considered as a way to potentially reduce the length of training without compromising its quality. [3,6,7] Development and implementation of change to training requires coordination and compromise between the various stakeholders, including universities, teaching hospitals, and medical colleges, which makes formal career streaming seem unlikely in the foreseeable future. But does this already happen informally at our medical schools? Throughout Australia, student surgical societies and interest groups help to facilitate early medical student exposure to both academic and clinical surgery. Already, medical students with an interest in surgery enrol in higher degrees by research in surgical areas, develop technical skills from an early level, complete extra professional courses, and take on leadership and advocacy roles in which they liaise with university faculties, Health Education and Training Institute (HETI), Royal Australasian College of Surgeons (RACS), and other professional bodies. Although there are no guarantees for these surgical-hopefuls, our surgical societies do help to facilitate early streaming albeit in an informal way and at the initiative of the student.

The Sydney University Surgical Society (SUSS) was established in 2006 with the aims of promoting the development of the nine surgical competencies outlined by the Royal Australasian College of Surgeons, facilitating communication between students and surgeons, and providing educational opportunities for students. [8] These goals are achieved by organising student grand rounds, surgical skills tutorials, a journal club, advocating at faculty meetings and working with academic surgeons to facilitate student research. SUSS attempts to ensure early exposure for all students by running surgical career events targeted particularly at students in years one and two, such as the annual ‘Introduction to Surgery: SET & Beyond’ lecture which consistently attracts over 200 students. Many students are enrolled in concurrent honours, masters, and PhDs programs in surgical areas and the academic output is high. Academic surgery is encouraged through a monthly journal club meeting and our relationship with the new Institute of Academic Surgery at Royal Prince Alfred Hospital, where the SUSS President sits on the advisory board. A RACS-accredited eight week intensive anatomy by whole body dissection course is run in the elective period at Sydney Medical School and has become an important way for surgically-inclined students to identify themselves and develop their skills at an early stage. [9] Most importantly, medical students who have been involved with SUSS and related activities can progress through medical school and graduate with a competitive set of skills, knowledge, and insight into the training that lies ahead.

The Surgical Interest Network (SurgIN) is a subcommittee of the Australian Medical Students’ Association that coordinates student surgical societies and interest groups across Australasia. Broadly most of these groups have a similar focus on extra-curricular skills sessions and seminars in clinical surgery, although approaches and philosophies vary. In addition to SUSS, other student surgical groups in New South Wales include the UNSW Surgical Society, Surgical Society of Notre Dame Sydney, Surgical Association of Western Sydney, University of Wollongong Surgical Interest Group, University of New England Surgical Society, and Newcastle University Surgical Society. There has been increasing cooperation and shared events between these NSW groups, most recently coming together to organise and compete in the Golden Scalpel Games Student Edition (previously the NSW Students’ Surgical Skills Competition) with sponsorship from RACS and HETI. [10] Organisational structure or models will necessarily vary, as surgical societies must be run within the confines of their University’s bylaws and regulations; particularly regarding whether they are part of their university’s student union, a sub-division of their medical society, or a stand-alone entity. However, communication and cooperation between surgical societies across Australasia has allowed them to learn from each other and gain access to innumerable opportunities such as conferences, seminars, skills workshops, and networking events to maximise engagement and exposure.

In the face of reduced surgical teaching at medical schools, surgical societies in Australia and New Zealand will play an increasingly important role in promoting and fostering surgery and it is critical that they are well run. A society must present themselves as a professionally oriented and academically productive group of students to ensure support from their medical faculty and input from surgeons.

Conflicts of Interest

None declared.

References

[1] Truskett P. Surgeons of the future: where will they come from? ANZ J Surg 2014; 84: 399–400

[2] Dolan-Evans E, Rogers GD. Barriers for students pursuing a surgical career and where the Surgical Interest Association can intervene. ANZ J Surg 2014; 84: 406–11.

[3] Dowton SB. Imperatives in medical education and training in response to demands for a sustainable workforce. MJA 2005; 183: 595-598

[4] McNamara S. Does it take too long to become a doctor? Part 1: Medical school and prevocational training. MJA 2012; 196: 528-530

[5] McNamara S. Does it take too long to become a doctor? Part 2: Vocational training. MJA 2012; 196: 595-597

[6] Taylor TKF. Changes to the University of Sydney medical curriculum. MJA 2008; 189: 414-415.

[7] Taylor TKF. Training doctors – too long in the cellar? MJA 2012;197 (6):328-329

[8] Sydney University Surgical Society (SUSS). About Us [Internet]. NSW (Australia) 2015. Available from: http://surgsoc.org.au/about-suss/

[9] Ramsey-Stewart G, Burgess A, Hill D. Back to the future. Teaching anatomy by whole body dissection. MJA 2010; 193: 668-671

[10] Golden Scalpel Games Student Edition [Internet]. NSW (Australia) 2015. Available from: http://www.ssscomp.org

Categories
Letters

Why should students write a global health case report?

We often see a case report about something absolutely fascinating – that one condition found on that page of Robbins [1] that we vaguely remember – but we don’t often hear about a global health case report. In this short piece, we offer a tangible definition of global health, discuss the concept of a global health case report, [2] and make the case for why we, as medical students, should be writing these.

Defining Global Health

Most medical students find global health quite nebulous and so overarching that it does not necessarily fit with our idea of treating the individual patient in front of us. Global health seems to be for health policy makers rather than doctors. It seems far-fetched that as medical students we could have any effect on how patients live and the determinants of health, especially when we hear that global health concerns only low-income countries. There are two main reasons for this perception: one, a single definition of global health is not universally accepted; and two, worldwide, there remain profound differences in global health education. [3,4]

We propose that the ‘global’ in global health does not refer so much to ‘overseas’ or ‘over there’, as it refers to ‘over here’; indeed, the real definition of ‘global’ in global health is ‘health everywhere’. Even if a doctor, or any health professional, trains and works in their home town, never travelling beyond the limits of what they see every day, they will inexorably meet and treat someone of a different socioeconomic group, ethnicity, religion, race or language. Dealing at an individual level with patients who have become ill because they do not have a safe and clean environment in which to live, have nowhere to sleep, are exploited at work, or vulnerable at home means that those international problems over there for doctors without borders who travel all over the world, are right here for all doctors whose routine practice is right at home. Global health has much in common with public health in that aspects of global health address populations and changes may be implemented at population levels through local, national, and international governments. However, ‘global’ also refers to all aspects of health, i.e. a holistic approach essential to exploring and taking on the real causes of disease, the social determinants of health. This focuses our attention and intervention on the patient in front of us and what we need to do to prevent them from becoming ill again. [5] Global health is, therefore, health that affects every patient we treat, and their families, at a very personal and individual level.

The British Medical Journal Case Reports has published several global health case reports. Here we summarise two examples. In one case, a 2 year-old boy with 40% burns to his head and arms presented to an eye clinic in Turkey one month after his injury. By then, he was blind. [6] The author was moved to write because of the severity of the burns, the preventable causes of house fires, the dire need for equitable access to medical care, and the devastating consequences for the child. Perhaps on their own, each of these global health problems is too large to contemplate and tempting to ignore, but no one can ignore the clinical history of this child, and the authors were moved to investigate the lack of health resources and the social circumstances responsible for this lamentable outcome. The authors offer solutions in healthcare that seem very practical. Certainly, they provide the evidence that these changes are necessary.

Another case report explores the link between HIV/AIDS and Jogini culture of sexual exploitation. [7] The case is of a 32 year-old woman who, since the age of seven, has worked as a Jogini. It’s a powerful story. We read of her first sexual encounter, teenage pregnancy, and total isolation. The global health issues discussed by the authors include the consequences to health of profound social inequalities, gender inequality, criminal prostitution, and the scourge of HIV/AIDS amongst the most vulnerable of society. The author remains focussed on the patient’s life and we read with dismay about her relationship with her son and the likelihood that his life will also be in poverty, without the education or opportunities to change a course that seems bitterly unfair. These global health problems, overwhelming and pervasive, are poignantly real and move us to act. The doctors and medical students submitting global health case reports are describing the lives of patients they see every day, and are moved to write because tackling these problems head-on is essential to making their patients healthy again, keeping them healthy, and helping people just like them.  Enormous, ethereal global health problems are now individual and personal; indeed, they are tangible and very much inside our consulting room or hospital ward.

Why are these case reports useful? Why should we write these?

  1. To look at the root causes of the illness. Let’s think about why our patient is really ill. While a discussion of the social determinants of health may switch off an audience overawed by the magnitude of these issues, with a patient in front of them no doctor or medical student can ignore the causes of illness and the factors limiting the effectiveness of medical therapy for that patient.
  2. To learn about society, economics, politics, cultures, and how they affect our patients. These help us understand our patients better and facilitate all contact with them. These case reports show how individuals deal with illness, how they seek out medical assistance, and what is available for them. By writing these case reports, we also understand better how healthcare priorities are set and decided.
  3. Global health is an in depth analysis of the causes of ill-health, perceptions of health and disease and how healthcare is provided. This is relevant not simply to general practice or public health, but to all medical specialties.
  4. To learn global health. Global health case reports help both the students and faculty discover together the global burdens of disease, the social determinants of health, and factors essential to equity in access to healthcare.
  5. To publish and share patient cases. Publishing an excellent piece of work that speaks for your patient and the general society, and promotes peer discussion of these issues.
  6. To create an evidence base. Every time a global health case is published, we provide more evidence of what our patients need, the reality of their lives, and the care that they received. No one is closer to patients than we are in the medical profession [3]; we have a responsibility to advocate for our patients, and we can do this by writing their stories. This builds evidence that these problems are real and that they cannot be neglected.
  7. To create change. We publish and keep publishing in order for the medical community and the public to read and demand change. Change is possible – doctors are responsible for seat-belts, helmets, and much legislation that has saved millions of lives. [8, 9]

For the audience reading these case reports, global health becomes personal and individual. The case reports are a call to action to work for our patients, and an inspiration to look beyond a pharmacological prescription to the underlying social determinants of health and disease. Ultimately, we must look through the global health lens because, as Virchow famously said:

Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution. [10]

References

[1] Robbins SL, Kumar V, Abbas AK, Fausto N, Cotran RS. Robbins and Cotran pathologic basis of disease. Philadelphia: Elsevier Saunders; 2005.

[2] BMJ case reports; (Journal, Electronic). http://www.bmjcasereports.com

[3] Liu Y, Zhang Y, Liu Z, Wang J. Gaps in studies of global health education: an empirical literature review. Glob Health Action 2015;8(1):25709.

[4] Rowson M, Willott C, Hughes R, Maini A, Martin S, Miranda JJ, et al. Conceptualising global health: theoretical issues and their relevance for teaching. Global Health. 2012;8(36).

[5] Marmot MG. Status syndrome: a challenge to medicine. JAMA. 2006;295(11):1304-7.

[6] Istek, Ş. The devastating effects a fire burn in a child. BMJ Case Rep. 2015 Jun 8;2015. doi: 10.1136/bcr-2014-206663

[7] Borick J. HIV in India: the Jogini culture. BMJ Case Rep. 2014 Jul 11;2014. doi: 10.1136/bcr-2014-204635

[8] Bike helmets a no-brainer, say surgeons. The Australian Doctor [Internet]. 2015 Aug 13 [cited 2015 Oct 09]; Available from: http://www.australiandoctor.com.au/news/latest-news/bike-helmets-a-no-brainer-say-surgeons.

[9] Children’s doctors urge national 20mph limit in built-up areas. The Guardian [Internet]. 2014 Nov 19 [cited 2015 Oct 09]; Available from: http://www.theguardian.com/uk-news/2014/nov/18/children-doctors-20mph-speed-limit.

[10] Virchow R. Die medizinische reform 2. Medicine and Human Welfare. 1949.

Categories
Book Reviews

The Digital Doctor

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age
Robert Wachter
New York: McGraw-Hill Education, 2015

Modern medicine in the 21st century is an evolving enterprise of knowledge and v7i1p14f1technology. In The Digital Doctor, Dr. Robert Wachter, one of America’s 50 most influential physician- executives, discusses the wiring of the healthcare system in the form of electronic health records and ‘big data’ today. While there is hope digitised healthcare will increase the efficiency of practitioners and improve clinical practice, Wachter reports less than optimal experiences – interrupted work flows in the clinic to attend to electronic databases, decreased opportunities for the practitioner to establish healthy doctor-patient relationships, and occasionally, fatal consequences when the technology we so heavily rely on fails us. Indeed, Wachter succinctly summarises today’s epoch of computerised healthcare in his title – “hope, hype and harm.”

As a medical student, The Digital Doctor has been thought provoking. My generation of medical students are digital natives who, having grown up with technology, are comfortable with it. Yet, as Wachter points out in his book, by being too comfortable with computerised healthcare, we are less critical of its shortcomings. It is hence imperative to reflect on the importance of striking a balance between being technologically-competent and being vigilant in the age of digitised healthcare.

Through interviews with prominent health professionals and vivid anecdotes, the picture Wachter paints is realistic but solemn. When patient history, drug doses, and investigations are electronically recorded, bedside treatment shifts to the computer. Electronic health records and digital monitoring of the patient, which may come in the form of electronically updated investigation results, introduces the concept of the ‘iPatient’. The iPatient is monitored online, and only attended to when the electronic healthcare system sends out reminders. The fundamental concern is that less time is spent taking a history or physically examining the patient. The end result being that we might overlook diagnoses and unnecessarily invest in costly technological interventions. When these amount to hastened patient interactions and increased billing costs, the patient’s experience with the healthcare system will be an unsatisfactory one.

Digitised healthcare may have also fallen short of the areas in which it has sought to improve. Although digitised healthcare was designed for convenience, electronic documentation is burdensome when one must adhere to strict formatting when recording data. Additionally, the availability of patient information at the click of a mouse means that any data stored online is just as easily lost, possibly through software malfunction or accidental deletion. Furthermore, there is the possibility that digitised healthcare undermines the skill of practitioners, where practitioners are too trusting on the computer to speak up when in doubt. The Digital Doctor draws up a real incident whereby a computer error led to a teenager being prescribed an overdose of 38.5 antibiotic tablets. The error, despite raising suspicions amongst the nurses, was not corrected, and resulted in the patient taking the prescribed medication overdose. This raises the concern of the quality of education students receive to prepare them for transitioning to practitioners. Are we adequately trained to confidently apply our knowledge in real life situations where the patient is more than an illness defined by exam buzzwords? Is there the possibility that we give ourselves room for mistakes because we trust that computerised healthcare will always correct us when we are wrong? As current medical students undergoing traditional medical school teaching methods, are we sufficiently prepared to become future doctors competent both in our practice, and in the technology that accompanies it?

It is crucial to note that this narrative is set in America. While there are differences between the American and Australian healthcare system, we too practice digitised healthcare, and there are lessons to learn. We should accept that this technology is inevitable alongside advancements in diagnostic and therapeutic equipment. We need to understand that technology is an aid to improve our practice. It is not an alternative or a distraction. We must remember that it is still our patients we are treating, not digital data presented to us.

The Digital Doctor is a cautionary narrative that is highly relevant, albeit critical. We need to accept that the interface of medicine, as The Digital Doctor rightfully highlighted, is changing. The future of technology in healthcare is dynamic and promising – it can be our Mecca if we are adaptive practitioners in using this technology. While we are never fully prepared for what lies ahead of us in our medical careers, we are at the very least, enlightened by the age of computerised medicine and what it has in store for us, both good and bad.

Conflict of Interest

None declared.

References

[1] Wachter R. The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age. United States of America: McGraw- Hill Education; 2015.

Categories
Guest Articles

Why all medical students need to experience research

Prof Christine Bennett AO

Medical students are very busy. The demands of studying medicine are extraordinary. Why then is it so important, on top of all there is to learn, to bother engaging in health and medical research? It is particularly important to consider this question at a time when, nationally and internationally, medical schools are including a research project as either a requirement of their program or a highly encouraged option. In fact, the Australian government is now supporting research by medical students with a specific category of scholarship funding from the National Health and Medical Research Council (NHMRC) available to students undertaking in a combined MBBS/PhD or MD/PhD program. [1]

As a Dean of Medicine, and passionate advocate of health and medical research (HMR) in Australia, I support the inclusion of research in medical programs. Research training and experience are not just ‘nice to have’ but a ‘must’ for our doctors of the future. Increased research training in medical programs is beneficial for a student’s professional pathway, their evolving practice and, most importantly, for the health of the patients and communities they serve. [2,3]

Demonstrated research experience at medical school is increasingly important in obtaining positions in training programs post-graduation. [4] Recognition of the importance of HMR in developing and applying the skills and knowledge acquired in their medical studies has seen many of the specialist colleges including research training and productivity (for example publications) in their approach to selection of trainees. Competition for vocational and advanced training places is fierce, and a professional resume that includes research productivity and qualifications is and will continue to be important. Some colleges may even move to requiring a PhD for entry into advanced training.

A research experience may be the first time a student has had to write and record what they do, think, and find coherently, concisely and precisely. This can contribute to developing lasting habits of critical thinking. In a landmark and classic essay, C. Wright Mills commented that there was never a time he was not thinking, reflecting, analysing, and writing – he was always working on an idea. [5] This is the mindset that research can build up, and this is surely the mindset we want in clinical medicine and population health, where continuing critical appraisal of new evidence and engagement with new ideas is vital. In addition to stimulating ongoing interest in learning, this intellectually curious mindset contributes to a sense of personal satisfaction and eagerness to engage in discovery and learning as part of a team. [3,6] Research achievements are rarely made by individuals in isolation. Developing a mindset of critical inquiry in individuals and teams clearly encourages research productivity in grants and publications in the longer term, [3] which can ‘future-proof’ careers at a time when research performance is important in professional esteem and progression. Even more importantly, involvement in research appears to improve clinical practice. Research-active healthcare providers appear to provide better care and achieve better patient outcomes, [7] making the investment of time in research training for medical students potentially very important to building a healthier society in the long term. Given the potential benefits to early career clinicians and to patients, it is important to expose recent medical graduates to research as well, and successful postgraduate training programs are also taking steps to include research training. [3,8]

So, what is the best way for medical schools and postgraduate training programs to provide research training that maximises these benefits? It is clear from the literature that the most important thing is to have protected time to pursue research. Whether the research is a programmed experience as part of a course (as is increasingly the case), or something pursued independently by the individual student or trainee, giving as much time as possible is key to getting the best quality outcomes. For recent graduates, hospitals need to allow time to do research. [8] For students, time should be set aside within the program. [4] Students and trainees also need to be mentored by experienced researchers to get the best results. [3] Research experiences for students and trainees that combine mentorship and protected time can deliver the biggest benefits to our future clinical leaders and society as they are most likely to result in high quality outputs that are published and improve knowledge and practice. Where possible, trainees without research degrees should try to enrol in these at the same time as pursuing their research experiences, through a university that offers flexible research training and options to submit theses by publication, as earning a research degree such as a PhD is increasingly becoming a prerequisite for obtaining research funding that can support a clinical research career.

In summary, more than ever before, being a doctor in the 21st century is a career of lifelong learning. The combination of continued, rapid growth in knowledge and advancing technology bringing that information to your fingertips, have brought both a richness to the practice of medicine as well as a challenge. There is a growing appreciation that researchers make better clinicians. Research exposure increases understanding of clinical medicine; facilitates critical thinking and critical appraisal; improves prospects of successful application for post graduate training, grants, and high impact publications; develops teamwork skills; and increases exposure to the best clinical minds. The government is lifting its investment in health and medical researchers like never before. The establishment of the Medical Research Future Fund by the Australian Government, for example, offers the promise of continued durable investment in HMR and innovation, and the NHMRC’s substantial investment in research training scholarships for current students and recent graduates signals the Government’s commitment to developing clinician researchers for the future.

I encourage all students to make the most of research opportunities in medical school and beyond, not only for the personal and professional benefits, but in contributing to the health of their patients and to the Australian community.

References

[1] NHMRC Funding Rules 2015: Postgraduate Scholarships – 6 Categories of Award – 6.2. Clinical Postgraduate Scholarship. 2015. https://www.nhmrc.gov.au/book/6-categories-award-3 (accessed Nov 2015).

[2] Laidlaw A, Aiton L, Struthers J, Guild S. Developing research skills in medical students: AMEE guide no. 69. Med Teach. 2012;34:754–71.

[3] Lawson PJ, Smith S, Mason MJ, Zyzanski SJ, Stange KC, Werner JJ, Flocke SA. Creating a culture of inquiry in family medicine. Fam Med. 2014;46(7):515–521.

[4] Collier AC. Medical school hotline: importance of research in medical education. Hawai’i Journal Med Public Health. 2012;71(2):53-6.

[5] Mills, CW. On intellectual craftsmanship. In: Seale, C. Editor. Social research methods: A reader. London: Routledge, 2004.

[6] von Strumm S, Hell B, Chamorro-Premuzic T. The hungry mind: intellectual curiosity is the third pillar of academic performance of university. Perspect Psychol Sci. 2011;6(6):574-88.

[7] Selby P, Autier P. The impact of the process of clinical research on health service outcomes. Ann Oncol 2011;22(Suppl 7):vii5-vii9.

[8] Chen JX, Kozin ED, Sethi RKV, Remenschneider AK, Emerick KS, Gray ST. Increased resident research over an 18-year period – a single institution’s experience. Otolaryngol Head Neck Surg. 2015;153(3):350-6.

Categories
Guest Articles

Looking to the future – students and academics leading the charge in publishing innovation

Dr Virginia Barbour
Dr Virginia Barbour

As a medical student (a long time ago, admittedly), peering into the far future to wonder what publishing was going to look like when I graduated and practiced was very far down my list of priorities, if it ever crossed it.

But, as the Australian Medical Student Journal’s Editor in Chief recently described in the Australian Open Access Support Group (AOASG) blog [1], medical students today are already immersed in a rapidly evolving world of publishing, which is changing the way that they access and publish information, via journals such as the Australian Medical Student Journal. [2]

There is even more profound change going on and unlike for much of the recent history of publishing, which has been led by publishers, many for profit, the next wave is being led by academics, even students.

How has this happened? The underlying technology driving all this is, not surprisingly, the Internet. The Internet is 25 years old [3] and for most university students and younger, it was essentially always there. Even for academics in their 30s and 40s, it was there while they grew up. As well as the technology, the Internet signalled a change in mindset – academics were not just consumers of the scholarly literature, they were generators of it even in ways that could lie outside the scholarly publishing system.

So in my mind, this enabling technology also led to a profound shift in immediate behaviour, such as blogging, but also to changes in behaviour for solving problems.

What has this behaviour change led to in scholarly publishing? Several examples illustrate this well.

First, Open Access (OA) publishers such as Public Library of Science (PLOS) [4] came about as a result of academics seeing a need to make the research literature open – that is, free and shareable [5] – and starting their own publishing houses.

A second example came about when an academic needed to have a place to deposit and share his figures and data, but was not yet ready to incorporate them into a full paper. Hence, Figshare [6] was founded.

Third was when a group of medical students saw the need to get access to papers that were not OA and also to catalogue the extent of this need. Thus, the OA button [7] came into being.

Fourth, two separate groups of academics, one in New Zealand and one in Australia, saw a problem with researchers not getting credit for peer review. Publons [8] and Academic Karma [9] took up this challenge.

Fifth, and even more relevant to medical publishing, innovation has been used to specifically improve the reliability of the medical literature. This move started in the 1990s when editors and trialists began to explore how to better report research with low-tech solutions, such as checklists, to improve trial reporting. [10] Two developments have led on from that. One of these developments is known as a ‘threaded publication’ and aims to link all parts of a medical study, from protocol to trial report, to post marketing surveillance. [11] The other, following on from the AllTrials [12] initiative to get all trials registered and all results reported, is Open Trials [13], which will have a fully linked and searchable database of all trials, linked to their authors, institutions, and funders.

This growth of innovation – of academics seeing a need, designing a solution, and then building it, is now, I believe, fundamentally woven into the structure of new publishing, so much so that there is now a site that is cataloguing all these innovations [14] (not all of which are researcher-led) and this is a movement that can only grow.

What underpins the successful publishing enterprises now is, I believe, three things. First, they are built on the principle of openness – the data around the innovation itself, as well as the content is openly available, as is, increasingly, the code. Second, is the need for solid principles to build the innovation into something that works – the equivalent of making sure a revolution has functional water systems and drains. The third is the notion of interoperability – of seamless linking of all parts of the innovation with other innovations, for example, people through their ORCiD identifiers [15], trials through their registration numbers, [16] and papers [17] and funders [18] through their own unique identifiers.

In the end, all these innovations are working in one direction – to a more open, transparent and reproducible academic literature. It is not going to be perfect at every step but at least if there are novel ideas, built on transparent infrastructure, we can ensure that what is built will allow the next generation of innovation to be built upon them in turn.

Prepared for the AMSJ, © 2015 Barbour. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] http://aoasg.org.au/2015/11/24/open-access-and-why-it-matters-to-medical-students/

[2] https://www.amsj.org/

[3] http://www.ft.com/cms/s/2/f3fe9c4a-4bd1-11da-997b-0000779e2340.html

[4] https://www.plos.org/

[5] http://aoasg.org.au/what-is-open-access/

[6] http://figshare.com/

[7] https://openaccessbutton.org/

[8] https://publons.com/

[9] http://academickarma.org/

[10] http://www.equator-network.org/

[11] http://www.trialsjournal.com/content/15/1/369

[12] http://www.alltrials.net/

[13] http://opentrials.net/

[14] https://innoscholcomm.silk.co/

[15] http://orcid.org/

[16] http://www.anzctr.org.au/

[17] https://www.doi.org/

[18] http://www.crossref.org/fundref/

 

Categories
Guest Articles

Mental health in the medical profession: Support for students

Dr Stuart Dorney

Much has been reported about the prevalence of mental health concerns amongst medical students and doctors, both internationally and in Australia.

In 2013, beyondblue released the results from its national survey of Australian medical students and doctors. Among the survey’s key objectives was to better understand the issues associated with the mental health of Australian medical students and doctors, and to increase awareness of these issues across the profession and the wider community. [1]

The survey included questions about general mental health status, substance use, suicidal ideation and self-harm, workplace and life stressors, levels of burnout, impact of mental health symptoms, treatment and coping strategies employed to address mental health symptoms, barriers to seeking treatment and support, and attitudes regarding doctors with mental health conditions. The survey was completed by 1,811 (27%) of the 6,658 students and 12,252 (28.5%) of 42,942 doctors sampled. [2] Most of the students who participated were aged 22-25 years old (45.1%), female (62.6%), non-Indigenous (98.8%), located in a metropolitan region (66.5%), and worked part-time on average 12 hours per week (50%). [2] The responses from the survey were compared with the responses from the National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics in 1997. [2]

Dr Greg Kesby

beyondblue found that very high levels of psychological distress was three times higher in medical students than in the general population (9.2% and 3.1% respectively), and two times higher than levels reported by interns (9.2% and 4.4% respectively). [2] Students also reported higher rates of burnout and emotional exhaustion, with the highest rates being reported by females. [2]

When it came to perceptions about mental health within the medical profession, a high proportion of respondents held the view that doctors who had a mental health issue were stigmatised as a consequence, a finding particularly prevalent amongst those respondents who had been diagnosed with a mental illness themselves. Students with a current mental health diagnosis, compared with those not currently diagnosed, were more likely to report they felt doctors with a history of mental illness were less competent (52.4% and 38.2% respectively). Furthermore, 42% of students with a current mental health diagnosis felt that doctors tended to advise colleagues not to divulge their history of depression or anxiety disorders, compared to 22.6% of students who were not currently diagnosed with depression or anxiety. [2] This finding is particularly disturbing and probably explains the considerable reluctance of some medical students and members of the medical profession to seek independent help for mental health issues, and instead pursue a pathway of self-diagnosis and self-treatment with its associated risks. Too often we see students and medical practitioners only first presenting for appropriate independent care when they are acutely unwell or in crisis. This is unnecessary and needs to change.

The Medical Council of New South Wales has published a guideline for self-treatment and treating family members, which encourages all medical practitioners (and students) to have their own, independent general practitioner and advises practitioners against self-diagnosis or initiating treatment for themselves or their family members. [3] The Medical Board of Australia’s Good medical practice: a code of conduct for doctors in Australia also advises medical practitioners who know or suspect they have a health condition or impairment that could adversely affect their judgement, performance, or patients’ health not to rely on their own assessment of the risk they pose to patients and to instead consult their doctor about whether, and in what ways, they may need to modify their practice. [4]

Just as we would recommend to patients, it is important for medical students and doctors to adopt a healthy lifestyle through a balanced diet and regular exercise. It is also vital to ensure that immunisations are kept up to date, alcohol is consumed within the National Health and Medical Research Council guidelines, and that illicit drug use and prescription drug misuse is avoided. It is also helpful to have a strong personal support network and develop interests outside of medicine.

Key to addressing health issues, including mental illness, is early intervention. Medical students should feel comfortable and be encouraged to seek independent, objective advice from a general practitioner as early as possible when mental health issues arise, and in providing care medical practitioners must endeavour to provide a non-judgemental and supportive environment that good medical practice dictates for all patients. In addition to seeking advice and treatment from a general practitioner, psychologist, or psychiatrist, there are a range of early intervention services and supports available to promote optimal care, including the various university health services, university medical facilities, beyondblue, Headspace, Lifeline, and the Doctor’s Health Advisory Service, available in each state and territory.

Under the Health Practitioner Regulation National Law (NSW) (the National Law), impairment is one of the grounds under which a complaint or notification can be made about a student or practitioner. This often generates fear amongst students as to whether their mental health issues will exclude them from graduating and practising as a medical practitioner. However, it needs to be appreciated that the term “impairment” has a specific meaning under the National Law. It refers to a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that is linked to a student’s capacity to undertake clinical training, or a doctor’s capacity to practise medicine. [5] In some instances notification is mandatory.

While recent media reports and editorial columns have suggested that mandatory reporting laws in all states and territories excluding Western Australia may be a barrier to medical students and doctors accessing support and treatment for mental health problems, there is no reliable evidence to support such claims and no reason that this should be the case. The purpose of mandatory reporting is to act as a safeguard when medical students and doctors are unwilling or unable to seek help and manage any risk to public safety by compelling practitioners to raise serious concerns with the regulatory authorities. The threshold for making a mandatory notification about an impaired colleague is high. A practitioner treating a medical student or doctor is not automatically required to make a mandatory notification simply because they have a mental health issue. The National Law states it is only when a practitioner has formed a reasonable belief that a fellow practitioner has placed the public at risk of substantial harm in the practice of the profession because of their impairment that they are required to make a mandatory notification. [6]

Education providers also have an obligation to make a mandatory notification if they have formed a reasonable belief that a student undertaking clinical training has a health issue that may place the public at substantial risk of harm. The formation of a reasonable belief may well be influenced by factors such as whether the medical student is receiving appropriate treatment and advice or has made a voluntary notification. [6]

Medical students and doctors who believe they may have an impairment are encouraged to make a voluntary notification to the Australian Health Practitioner Regulation Agency (AHPRA). [6] For individuals with mental health issues who self-notify or who are the subject of a notification to AHPRA, there are remedial, non-disciplinary programs, which differ from state to state, that are designed to support students to remain in study and doctors to remain in practice whilst receiving appropriate treatment, provided it is safe for them to do so.

In NSW, the Medical Council’s Health Program aims to protect the public while at the same time supporting medical students and doctors affected by health issues, including mental illness. Not everyone with a mental health issue who self-notifies or is the subject of a notification to AHPRA enters into the Health Program. Many are assessed as having a psychiatric illness that is under appropriate management, with the student/doctor having appropriate insight and support networks, and are therefore not considered to place the public at a significant risk of harm. That is, they are not considered “impaired” as defined in the National Law. Most of those who do enter the Health Program remain in practice or study, subject to conditions on their registration tailored to address their particular circumstances and designed to ensure public safety while they undertake treatment and rehabilitation. Participants remain under the care of their own treating practitioners, but also undergo independent reassessment by Council-nominated practitioners from time to time. Participants in the Health Program meet with Council delegates, usually at six to 12 monthly intervals, and as they progress in their rehabilitation and recovery, the conditions on their registration are gradually eased, until the Medical Council considers that they no longer require being under the Council’s surveillance and consequently exit the Health Program. Whilst return to unconditional practice is a goal of the Program, some participants, for example those with a recurring psychiatric illness, may remain on the Program indefinitely, albeit with low level conditions and occasional review by the Council.

Many participants have had great success on the Health Program and have found the experience of significant benefit. For example, one participant, who had suffered from depression since his teenage years, found the Program’s impact on his work and personal life to be “only positive”. He said the Program encouraged him to set realistic work schedules, engage in activities outside the workplace, develop insight into the demands that he had previously placed on himself, and establish strong networks of support, both personally and professionally. Upon exiting, he said the Program had assisted him to successfully return to practice and engage in a “full and meaningful life”. Another, who had been self-prescribing and suffering from depression, and by his own assessment entered the Health Program “at a time when I was out of control and rapidly heading towards disaster”, found the Program forced him to confront his problems, encouraged him to maintain engagement with a treating psychiatrist, and enabled him to stop his prescription drug misuse and eventually return to full time work. He attributes his professional survival to his involvement in the Health Program and, at the time of exiting the Program, was receiving consistent feedback that he was excelling in his practice of medicine.

We are a caring profession, and we need to care for ourselves as well as each other. The Medical Council and other regulatory authorities encourage everyone with mental health issues, including medical students and doctors, to seek appropriate care – and seek it early. We recognise that some will be reluctant or unable to do so – through fear, or a lack of insight, or simply due to the lack of energy and initiative that may accompany their illness. You are therefore all encouraged to reach out to your colleagues if you suspect they may be suffering in silence. Offer those who appear to be troubled with life assistance in accessing appropriate support. Help them frame their thinking around whether they should self-notify to AHPRA. You can start by simply asking “Are you okay?”

References

[1] beyondblue. Doctors’ mental health program. https://www.beyondblue.org.au/about-us/programs/workplace-and-workforce-program/programs-resources-and-tools/doctors-mental-health-program (accessed Nov 2015).

[2] beyondblue. National mental health survey of doctors and medical students. 2013. http://www.beyondblue.org.au/docs/default-source/default-document-library/bl1148-report—nmhdmss-exec-summary_web (accessed Nov 2015).

[3] Medical Council of NSW. Guideline for self-treatment and treating family members. 2014. http://www.mcnsw.org.au/resources/1460/Guideline%20for%20self-treatment%20and%20treating%20family%20members%20PDF.pdf (accessed Nov 2015).

[4] Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx (accessed Nov 2015).

[5] Medical Board of Australia, Information on the management of impaired practitioners and students. 2012. http://www.medicalboard.gov.au/documents/default.aspx?record=WD12%2F7049&dbid=AP&chksum=Pzr054PF7tcB6ZQnesHKvA%3D%3D (accessed Nov 2015).

[6] Medical Board of Australia, Guidelines for mandatory notifications, http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Guidelines-for-mandatory-notifications.aspx (accessed Nov 2015).