Dr Mabel Leow MD, PhD | Editor-in-Chief, AMSJ

Welcome to Volume 10, Issue 2 of the Australian Medical Student Journal.
This has been and unprecedented year with Covid-19.

In this issue, we have included a Covid-19 section for medical students to share their thoughts on issues associated with the pandemic. This is in addition to our usual wide range of medical and surgical topics. Of mention are two papers which will be relevant to all medical students. One is a case-based discussion on oxygen delivery, as it is commonly prescribed therapy. The second is a research study on microbial contamination in medical students, a problem which all of us face with in our everyday work.

Over the last 12 months, the AMSJ has taken steps to raise the standards of our editorial team to ensure that we publish quality studies. We have started an Understudy team to provide a platform to train pre-clinical medical students with minimal research experience, but aspire to be editors. As part of being a student journal, it is our mission to train medical students. Hence, if you have an interest in being an editor but lack the experience, please do join our team!

Last but not least, I would like to express my gratitude to various parties who have made this issue possible. First, the editorial team is grateful to the authors who have chosen to publish their work to AMSJ. We are privileged to be part of your research journey, in which you have put in many hours and months of hard work. At a personal level, I am thankful to my entire editorial and proofreading team who have been the backstage workers making this issue possible. To acknowledge their work this year,
we have included the names of the editors and proofreaders who have been working on the manuscripts.

Moving forward, we want to increase the visibility of AMSJ. This would take in the form of advertising our manuscripts on Facebook and Twitter. We would greatly appreciate if authors and readers could also share your articles with your friends and colleagues.

Correspondence: mabelleowqihe@yahoo.com

Welcome to Volume 8, Issue 2 of the Australian Medical Student Journal (AMSJ). The AMSJ is a national peer-reviewed journal serving as a publication platform for all medical students in Australia. Our aim is to showcase medical students’ perspectives on current issues in medicine. The editorial theme of this issue is shaping our future of medicine together as medical students.

Several original and feature articles in this issue clearly show medical students taking ownership of the future of medicine. This includes proposals for better delivery methods of medical education and policy. Dr Timothy Wittick and colleagues highlight the importance of community engagement activities on medical students’ personal and professional development. Dr Nicholas Wilson and colleagues emphasise the significant educational and cultural value for students participating in Aboriginal community placements. In addition, Mr Benjamin Bravery shares his personal experience as a cancer survivor, and discusses potential improvements in delivering oncology education in medical schools. Dr Anna-Kristen Szubert and colleagues address the issue of mistreatment in Australian medical education, and provide recommendations to better shape the future of medical culture and professionalism.

In this issue, we are honoured to feature the voice of influential leaders across the medical field as guest articles. They have generously shared their insights on shaping the future of medicine. Dr Michael Gannon, President of Australian Medical Association (AMA), states that while AMA policy and advocacy address many issues for building a better society, its core lies in the medical education and training for the next generation of medical professionals. A/Prof Stuart Lane defines and explains the core of professionalism and professional behaviour; an essential component in our medical careers as highlighted in many articles in this issue. Prof Michael Besser AM highlights human anatomy as the basis of medicine and states that “human cadaveric dissection represents a profound rite of passage into the medical profession”. Furthermore, invaluable advice on making career decisions is given by Prof Catriona McLean and A/Prof Steven Lane from perspectives of a mother-pathologist-scientist and a physician-scientist, respectively.

Also in this issue, we are excited to present the winning abstract by Manon Audigé from the 3-Minute-Thesis Competition at AMSA Convention 2017, in collaboration with Australian Medical Students’ Association (AMSA).

The AMSJ is run by medical students in Australia. This issue would not be possible without commitment from many individual medical students, led by executive members, who volunteered their time to work in the editorial teams, and in the roles of publication, publicity, sponsorship, finance and university representatives. On behalf of the AMSJ, I would like to show my appreciation to all our authors, peer reviewers and sponsors. Their expertise, time and support have largely contributed to the successful publication of this issue. In addition, I would like to gratefully acknowledge the Medical Journal of Australia (MJA) for their invaluable support in the professional development of our editorial team. Finally, on behalf of the AMSJ, I would like to thank our readers and I hope we, as medical students, continue taking ownership of shaping our future of medicine together!

Correspondence
R Park: editorinchief@amsj.org

 

In this issue of the AMSJ, we talk to Associate Professor Steven Lane about life as a physician-scientist. Associate Professor Lane is a clinical haematologist at Royal Brisbane and Women’s Hospital (RBWH) and head of the Gordon and Jessie Gilmour Leukaemia Research Laboratory at the QIMR Berghofer Medical Research Institute. He has recently been awarded a prestigious CSL Centenary Fellowship.

His lab researches myeloid blood cancers such as acute myeloid leukaemia (AML), myelodysplastic syndrome (MDS) and the myeloproliferative neoplasms (MPN). These are very aggressive and rapidly fatal blood cancers that are among the most common types of cancer affecting Australians.

 

Q: What is the current focus of your research?

A: We are a cell biology laboratory researching leukaemia and other blood cancers. We try to understand at the cellular level how leukaemia forms from normal blood cells, what are the pathways that turn it from being a normal cell into a leukaemic cell, and how it is that treatments can reverse that process or target the cancer cells.

 

Q: What drew you to specialise in haematology?

A: I was initially drawn to haematology mostly because of the patients. The patients are often young people. These are very unlucky people who have very severe illnesses but have a possibility for cure. There’s a lot at stake, but it’s very rewarding because of that.

Additionally, the science and clinical trials are right on the cutting edge of the latest developments.

Finally, in any career you look for good examples and mentors. Haematology at RBWH and PA Hospital in Brisbane are very lucky to have some excellent people working there. I guess they were very inspiring to work around and you want to be like those senior doctors. I think those aspects make haematology a very attractive specialty and lead to a lifetime of challenges and rewards.

 

Q: When did you first become interested in research?

A: Actually, I was never interested in research when I was a medical student. When I started my advanced training in haematology I realised that research was a very necessary part of what we do and I really wanted to get involved in clinical research. I found clinical research at some levels rewarding and some levels frustrating because we are really limited by the fact that we have rare diseases, small numbers of patients, and a lot of conflicting priorities with funding, drug companies, and investigator-initiated research.

That experience motivated me to look at translational research and understanding the fundamental biology as to why things happen. You realise as you become more exposed to a certain field that the big breakthroughs do not happen at the clinical trial end but happen at the very basic biology end. It is those massive discoveries that change medicine. For example, imatinib (Gleevec) which is used for chronic myeloid leukaemia, comes from the basic laboratory from an understanding of how a disease process works.

I also felt that other people had a strong aptitude for clinical research whereas there was an opportunity for me to get involved in the other preclinical side of it.

 

Q: Medical students often ask when the best time is to do a PhD in their training. When in your career did you complete your PhD and how did you find it?

A: I did my PhD after I completed my speciality training.

One of the advantages of doing it later is that you have to maintain momentum in a research career. If you do some research, then leave research for few years and try to come back, you have to start back from square one.

Completing a PhD also resets your career so that you are eligible for young investigator funding, so if you do it later it has other advantages as well.

I think what is important is to get exposure to research but not on a full time basis at the early points. You need to get involved in reading journal articles and writing papers.

A downside to research is that it can be more financially challenging to step out of your career later and it can be challenging if you are married with kids. For all the talk from government and hospitals, they still don’t know how to appropriately manage and fund clinician researchers, and this is an ongoing challenge for the entire field.

 

Q: You completed an overseas fellowship in Boston as a part of your haematology training. Do you recommend heading overseas for a fellowship?

A: I don’t think it matters if you head overseas or stay locally, what matters is that you give yourself the best opportunity. You may be lucky enough to be interested in an area of research where there are experts locally and in that case you should absolutely study with them.

If you get the opportunity to go to a great international centre, I think you should take it, but there is a very substantial financial penalty to doing it. In real dollars it costs an enormous amount of money. In opportunity cost it costs about three times that because you are not earning money here, but you really shouldn’t worry about that now!

 

Q: When you returned from the overseas research fellowship, how did you find establishing yourself as a physician-scientist in Brisbane?

A: I currently have two separate part-time appointments: 70% as a researcher (QIMR) and 30% as a clinician (RBWH). At the moment in Brisbane they do not have combined physician-scientist positions, so you need to get a clinical job and a laboratory job and put them together to make a full-time position. Some hospitals in other cities such as Melbourne do have combined roles.

For my clinical appointment, I have regular clinic days each week and also do ward service, on call, and other clinical meetings.

 

Q: Lastly, what advice and tips would you give a medical student interested in a career as a physician-scientist?

A: You have to be self-motivated, proactive and have self-discipline. Do not expect too much too quickly. If you show you are interested and spend time on it, opportunities will present themselves. Keep an open mind and follow those opportunities. If you do the right things and do them for the right reasons, it will work out in the end.

 

A comprehensive literature review is one of the first steps in the research process. It is important to contextualise any study in terms of what is currently known, and identify knowledge gaps that need to be filled. A well-conducted literature review, particularly when performed with a systematic methodology, can be an important contribution to a field of research in its own right. This article will summarise the aims and methodological differences between the most common types of review articles. This article does not provide step-by-step instructions for the completion of a literature review. As such, readers are encouraged to review the referenced articles for further information [1,2].

 

Is this review necessary?

The key aim of a literature review, in terms of the research process, is to orient the researcher to the current scholarship on a certain topic, and to guide the development of research questions. Another key aim is to answer a specific research question or present key findings in a field, based on the entirety of the accumulated evidence. A sufficiently comprehensive search of the literature needs to be performed to develop an integrated answer to this question.

The review may not be necessary if:

1. A previous review article has been published that answers your question, and there is insufficient new evidence to warrant a replication or expansion of the review; or
2. Answering the research question will not expand the current base of knowledge, or help to guide further research.

 

Types of review articles

There are many types of literature reviews, which can be broadly grouped into three  categories based on the rigorousness of the methodology used: systematic reviews, scoping reviews, and narrative reviews.

 

Systematic review

Systematic reviews are designed to comprehensively review all of the available evidence relating to a specific and narrow research question. Systematic reviews are both systematic and comprehensive: they have a detailed methodology and aim to capture all, or the vast majority of, the available literature in answer to a specific question. Meta-analyses are similar to systematic reviews, but also include a quantitative synthesis, by which they synthesise an overall estimate of effect based on all of the accumulated data within individual studies [3].

Systematic reviews are performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [4]. Important components of a systematic review include:

1. A comprehensive literature search using broad, relevant search terms across multiple databases, such as PubMed and Embase.
2. Pre-specified inclusion and exclusion criteria for studies, and a study selection process conforming to these criteria.
3. Synthesis of evidence to answer narrow research questions.
4. An assessment of study quality, usually using validated quality assessment scales such as the Jadad scale for randomised controlled trials and the Newcastle-Ottawa scale for observational studies [5,6]. It is worth noting that there have been some concerns raised about the validity of the Newcastle-Ottawa scale, despite its relatively frequent use [7].

Systematic reviews typically require significant effort on the behalf of the authors to execute, but along with meta-analyses, provide the highest level of evidence available in answer to a research question [8,9]. This is particularly the case when the included studies are randomised controlled trials. It is important to note that poorly-conducted systematic reviews and meta-analyses of low quality studies may result in biased conclusions [9]. The editorial staff at the AMSJ strongly encourage medical students to attempt systematic reviews to both learn about methodological processes in research and to elevate the quality of their review.

 

Scoping review

Scoping reviews have been labelled in a variety of ways in the past: rapid review, mini-review, scoping study, and literature mapping. A scoping review is less strictly defined than a systematic review because it does not have its own set of standardised guidelines. Instead, the general guidelines proposed by Arksey and O’Malley [10], and further developed by Levac et al [11], can be used for guidance on how to complete reviews of this type.

In brief, a scoping review differs from a systematic review in that:

1. It is typically addressing a broad rather than a narrow research question, in order to map knowledge in a particular field.
2. It is usually, but not always, performed in a shorter time span and hence may utilise fewer databases or a more limited search.
3. It does not typically include extensive bias and quality assessments required in systematic reviews.

A scoping review is usually still “systematic” in that it is performed according to a pre-defined methodology, but this methodology is often less prescriptive and may capture fewer articles. Hence it may be labelled semi-systematic or systematic, but not comprehensive. While scoping studies can be limited in terms of the level of evidence they provide, it is often a more practical method by which the literature can be reviewed before completing a research study. See the referenced studies by Arksey and O’Malley [10] and Levac et al [11] for a description of methodologies for completing a scoping review.

 

Narrative review

A narrative review is a non-systematic exploration of the literature performed to explore the key findings in a field [1]. The word “narrative” in the name is telling because these types of reviews are normally written in an eminently readable narrative style, which makes them suitable for communicating the key points on a particular topic. If readability is a major strength of narrative reviews, then a lack of comprehensiveness is their fundamental weakness. It is typical for reviewers conforming to this methodology to select studies at their own discretion for inclusion, leaving out any they believe to be non-vital.

This approach is particularly suitable when the writer is an expert in the field who is very familiar with the literature and can use their knowledge to select only the most pertinent studies for their time-pressed readers. Students employing this review style should take caution to avoid omission of important studies and ideas by first reading widely on the topic area to be reviewed.

 

Review articles at the AMSJ

At the AMSJ, we take a more flexible approach as we aim to be a platform by which students can get their first experiences at publishing good quality research, but also to be a source of articles containing information that a typical medical student would find useful and engaging. Aligning with these values, we will accept submissions of any of the review types mentioned above.

We strongly encourage students to attempt to use the framework for a scoping review. This type of review is particularly suitable for medical students and submissions to the AMSJ, as it involves a more rigorous methodology than a narrative review but is far quicker and more practical to complete than a full systematic review. It is often possible to convert a narrative review completed for an essay or assignment to a scoping review by performing a systematic search of at least one comprehensive database such as PubMed, MEDLINE, or Embase and ensuring all relevant articles are included.

A narrative review should not simply be a rehashed assignment. These assignments are typically not written in the style and to the level of rigour necessary for a peer-reviewed publication. A well-composed narrative review should be detailed and well-referenced with primary studies (rather than just other review articles), and the information contained should be current. Please ensure that the research question or topic to be addressed is well defined.

 

Conclusion

Writing a literature review is a vital part of the early research process, in both orienting an individual to the current state of knowledge in a particular field, and aiding with the development of research questions for investigation. It is hence a particularly important skill for medical students to develop early in their careers, and at the AMSJ we strongly encourage students to prepare and submit these types of articles. The use of systematic methodology enhances articles of this type, and can be a valuable experience in learning about the critical evaluation of evidence.

 

Conflict of interest

None declared.

 

References

 

[1] Cronin P, Ryan F, Coughlan M. Undertaking a literature review: a step-by-step approach. Br J Nurs. 2008;17(1):38-43.

[2] Randolph JJ. A guide to writing the dissertation literature review. Practical Assessment, Research & Evaluation. 2009;14(13).

[3] DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177-88.

[4] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-41.

[5] Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, et al. Clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1-12.

[6] Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. Canada: The Ottawa Hospital; 2009 [cited 2017 Aug 1]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

[7] Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603-5.

[8] Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128(1):305-10.

[9] Merlin T, Weston A, Tooher R. Extending an evidence hierarcy to include topics other than treatment: revising the Australian ‘levels of evidence’. BMC Med Res Methodol. 2009;9(34).

[10] Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32.

[11] Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5(69).

 

 

 

Death in a paediatric hospital: who, where, and how?

 

Background: In the developed world, most paediatric deaths follow withdrawal or withholding of medical treatment (WWMT), and previous studies have largely focused on an intensive care setting perspective.

Methods: A retrospective review of medical records was conducted for all paediatric inpatient deaths at the Royal Children’s Hospital (RCH) from April 2015 to April 2016. Results were compared with data from January to June 2007. Chi-squared tests were used for comparisons.

Results: A total of 101 deaths in 2015-2016 were reviewed, and compared to 50 deaths in 2007. In both periods, most deaths followed WWMT (84% vs. 87% of deaths) and occurred in children with pre-existing chronic conditions (84% vs. 85% of deaths). From 2007 to 2015-2016, there was a shift to earlier discussions with parents around WWMT. Cases where discussions began prior to the last admission increased from 4% to 19% (p=0.004). There was also increased palliative care involvement (10% vs. 37%, p<0.001), and more children dying outside of intensive care (16% vs. 22%, p=0.253). In 2015-2016, subgroup analysis revealed that children dying on the wards were 76% more likely to have palliative care involved than those dying in intensive care (p<0.001), and 51% more likely to have discussed WWMT with families before the last admission (p<0.001).

Conclusion: The last decade has seen an increase at RCH in paediatric palliative care involvement and advance discussions around WWMT. These are both associated with death outside of intensive care — a world-first finding that warrants further study.

 

Conflict of interest

None declared.

Welcome to Volume 7, Issue 2 of the Australian Medical Student Journal (AMSJ). Here, we have the privilege of publishing the best research, opinions, reviews, and insights from medical students and junior doctors around Australia.

We feature outstanding guest articles from influential leaders across the medical landscape. Dr Alan Finkel AO, Australia’s Chief Scientist, looks optimistically ahead with an incisive commentary about the future landscape of medical research. With the rise of artificial intelligence and robots with far superior decision-making power in patient care, research skills will become increasingly valuable as a clinician, and will help us happily and healthily live to 100 years of age.

Dr Chris Nickson of lifeinthefastlane.com, SMACC, and FoamEd fame provides you with the essential skills to maximise the ever-developing resource of Free Open Access Meducation – a must read to increase the efficiency and effectiveness of your learning and engagement.

Prof. Kingsley Faulkner AM, Chairman of Doctors for the Environment Australia (DEA), writes on climate change, health, and our responsibility to act. Forget whatever government might threaten Medicare – climate change is the greatest crisis for human health and we need to find a voice and translate this into action.

Once again, we have received topical and original articles of excellent standard over a range of topics. Dr Sharna Kulhavy, in her original research article, highlights the deficiencies in knowledge in women taking the oral contraceptive pill in a rural setting. This adds to previously published work by this journal in the area of health literacy and its impact on patient care. Obert Xu reviews the efficacy of, and issues, surrounding the impending implementation of pre-exposure prophylaxis (PrEP) in the Australian setting. Considering the potential effectiveness of PrEP as a public health strategy in combatting HIV infection, this is something all future practitioners should be aware of. In a succinct review, Ronny Schneider evaluates the current and emerging evidence for persistent occiput posterior in labour.

Finally, our feature articles and letters highlight a range of current issues, for example, refugee health, and the health profession’s use of language with patients. It is with exception we publish a letter anonymously, on a student’s experience of harassment in medicine. It is vital to share these stories to confront this scourge that discourages, discriminates against and disillusions our best and brightest.  It is an indictment of our culture that the author feels the need to write incognito for fear of the personal impact of speaking out, however I commend her courage to write at all.

The AMSJ is a national publication staffed by committed volunteers from medical schools throughout the country. Each issue requires many hours of work from editors, proof readers, and publications and IT teams. All this is not possible without the work of a great team of university representatives, publicity, and sponsorship and finance teams, all lead by our capable executive. My thanks to each and every person listed in this journal that has given their time to promote student research and national collaboration.

We thoroughly enjoy working with our authors and peer reviewers – thank you all for your submissions and feedback. Funding for medical research continues to be difficult throughout Australia, but there are exciting times ahead. I would like to thank our readers and sponsors for their ongoing support to provide the environment to encourage and develop the budding leaders in medicine and research with the commitment to submit to this publication. On behalf of the AMSJ, I hope you enjoy this issue.

One of the six key priority areas identified by The United Nations Global Strategy for Women’s and Children’s Health is to develop ‘stronger health systems with sufficient skilled health workers at their core’. [1] Such skilled workers   require   an   awareness   of   global health issues in order to meet the challenges inherent in future practice in the modern globalised world. Early exposure to global health experiences as a medical student is important in promoting future global health leadership, and can also help to optimise practice in the local community.

There has been a burgeoning interest in global health amongst medical students. [2] Today’s medical students are increasingly aware of global health issues and feel a strong sense of responsibility towards the global community. This can be attributed to numerous factors, including  the  media,  which  has  forged  a sense of an interconnected global society, and the rise of challenges that do not recognise geographic borders, such as climate change and the spread of infectious diseases. [3-5] This  has  emphasised  that  global  issues  are far less remote than they might have once seemed.

For medical students to make meaningful change in the global health arena, they require skills that may extend beyond those taught by traditional medical curricula. The attributes of a global health leader, according to Rowson et al., include being ‘globalised’, ‘humanised’, and ‘policy-orientated’. [6] Increasing  globalisation  demands  that doctors are culturally sensitive and address determinants of health at global as well as local levels.   Overseas medical experiences can encourage ‘globalised’ thinking, for example  by  encouraging  flexibility  as students witness alternative models of care guided by different cultural values. [7] One of the most important driving forces behind students’ commitment towards contributing to  developing  world  health  is  altruism, which underlies practice as a ‘humanitarian’ doctor. Humanitarianism makes participation in  global  health  rewarding  for  many,  and can foster a lifelong commitment to global health action and leadership. Another less well-recognised  attribute  of  global  leaders is the understanding that doctors can have a   substantial   impact   not   only   through treating individual patients, but also through policy-making  at  a  population  level.  A  key way Australian health professionals have helped in developing countries has been by advocating in partnership with local leaders to effect change.  For example, the TraumAid International organisation established by Dr Jennifer Dawson equips local leaders to run programs in the community on how to deal with trauma experiences. [8] Closer to home, there have been striking examples of doctors utilising their political voices to protect vulnerable populations, such as through advocacy for the rights of asylum seekers. [5,9]

The skills learnt overseas benefit students by not only encouraging them to be global health leaders, but also to be effective doctors back home. Students have reported enhanced clinical and communication skills, lateral thinking, personal awareness and enthusiasm towards training following overseas elective experiences. [10] They are also more likely to seek to serve underprivileged populations, including   in   rural   and   remote   Australia. [11]   Experience   in   low-resource   settings can also help graduates to be more aware of the impact of their clinical decisions. For example, the principles of the rational use of investigations learnt in developing countries can be transferred back to local settings to promote cost-effective practice by minimising the over-ordering of tests in favour of astute clinical assessment. [10]

A number of initiatives have arisen to meet the growing interest of Australian medical students in global health. Largely student- driven,   these   include   the   annual   AMSA Global Health Conference and the formation of university global health interest groups which operate within the AMSA Global Health Network. [4] Being part of a global health group encourages students to develop an early passion in global health and network with like-minded individuals to share ideas. [2] Global health groups have also taken leadership  in  piloting  education  programs that raise awareness of current global health issues. Encouragingly, these programs attract not only medical students, but also students completing a variety of courses at university and even the general public, as has been our experience with the global course facilitated by   the  Medical   Students’  Aid   Project  at UNSW. This underscores a key reality in global health, that solutions in the developing world often require partnership between medical professionals and those outside the medical sphere.

A popular way in which students gain practical experience in global health is through arranging electives in developing countries. The benefits of such electives are numerous. It is important to note, however, that electives can  be  associated  with  potential  harm  to both the student and the local community. Risks include lack of supervision which can lead   to   students   assuming   roles   beyond their capabilities, which can compromise patient care. [7] Trainees may also experience physical harm due to unstable environments or psychological impacts which can be exacerbated  by  limited  support  networks. [7] The potential harm to local communities can include disruption to local practices and disincentives  to  governments  to  invest  in local workforces. It is well-recognised that initiating long-term, continuous partnerships with communities are more effective in optimising health outcomes compared with short-term, “bandaid-approach” medical missions. [3] Further strategies to reduce risks and  promote  ethical  practice are  discussed in guidelines, such as ‘A Guide to Working Abroad for Australian Medical Students and Junior Doctors’ by AMSA and the AMA. [12,13] These   resources   can   encourage   students to be mindful of their potential impact on communities.

It is clear that an awareness of global health is vital for preparing future doctors to meet diverse future health challenges. Although numerous   student-run   opportunities   exist for students to engage in global health, there has been a call to also integrate global health into the formal university curricula, with over 90% of students believing that global health should  be  a  component  of  medical  school programs.   [7,11]   This   could   complement overseas  medical  experiences  by  providing a conceptual framework of the global health environment,  which  can  be  reinforced  by practical experience.

In our ever-changing environment, it is vital that students and junior health professionals are  offered  all  of  the  opportunities  they require    to    lead    meaningful    change    in tomorrow’s world.

Acknowledgements

None.

Conflict of interest

None declared.

Correspondence

N Jain: n.jain@amsj.org

S Jain: s.jain@amsj.org

References

[1] Ki-Moon B. Global Strategy for Women’s and Children’s Health. The Partnership for Maternal, Newborn and Child Health, 2010.

[2] Leow J, Cheng D, Burkle Jr F. Doctors and global health: tips for medical students and junior doctors. Med J Aust. 2011;195(11):657-9.

[3] Panosian C, Coates TJ. The New Medical “Missionaries” —   Grooming   the   Next   Generation   of   Global   Health Workers. N Engl J Med 2006;354(17):1771-3.

[4]  Fox  G,  Thompson  J,  Bourke V,  Moloney  G.  Medical students, medical schools and international health. Med J Aust. 2007;187(9):536-9.

[5] Australian Medical Association. Speech to AMSA Global Health  Conference  2014  ‘Changing  Dynamics  in  Global Health Issues, priorities, and leadership’ by AMA President A/Prof Brian Owler’ [Internet]. Canberra ACT: Australian Medical Association; 2014 Sep 8 [cited 2015 30 June]. https://ama.com.au/media/speech-amsa-global-health- conference-2014].

[6] Rowson M, Smith A, Hughes R, Johnson O, Maini A, Martin S, et al. The evolution of global health teaching in   undergraduate   medical   curricula.   Global   Health. 2012;8:35-.

[7] Mitchell R, Jamieson J, Parker J, Hersch F, Wainer Z, Moodie A. Global health training and postgraduate medical education in  Australia:  the  case  for  greater  integration. Med J Aust. 2013;198(6):316-9.

[8] TraumAid International. TraumAid International 2015 [cited 2015 23 June]. Available from: http://www.traumaid.org/home.

[9] Talley N, Zwi K. Let the children go — advocacy for children in detention by the Royal Australasian College of Physicians. Med J Aust. 2015;202(11):555-7.

[10]  Bateman  C,  Baker  T,  Hoornenborg  E,  Ericsson  U. Bringing   global   issues   to   medical   teaching.   Lancet. 2001;358(9292):1539-42.

[11] Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: a call for more training and opportunities. Academic medicine : journal of the Association of American Medical Colleges. 2007;82(3):226-30.

[12]   Parker   J,   Mitchell   R,   Mansfield   S,   Jamieson   J, Humphreys D, Hersch F, et al. A Guide to Working Abroad for Australian Medical Students and Junior Doctors. Med J Aust. 2011;194(12):1-95.

[13]  Pinto  AD,  Upshur  REG.  Global  health  ethics  for students. Dev World Bioeth. 2009;9(1):1-10.

“Medicine is pathology” declares The Royal College of Pathologists of Australasia (RCPA) [1] – a motto that has driven many to delve into this esoteric medical discipline. The legendary Robbins and Cotran textbook elegantly summarises pathology as the study of disease. [2] However, the discipline entails more than just studying disease, since it is firmly integrated in modern medicine through the diagnosis, prognosis, investigation, and management of medical conditions.

The RCPA is responsible for training medical doctors, scientists, and dentists in pathology in Australasia. There are currently nine overarching disciplines that, perhaps unknowingly to medical students, have been covered at various times in medical school: anatomical pathology, chemical pathology, clinical pathology, forensic pathology, general pathology, genetic pathology, haematology, immunopathology, and microbiology. [3] Training to become a pathologist typically takes at least 13 years, including medical school.    Some    pathology    disciplines    can also be combined with internal medicine disciplines under the supervision of The Royal Australasian College of Physicians. Because pathologists  have  medical  training,  they work closely with both medical practitioners and scientists to provide answers and advice for patients’ diagnoses, investigations and management. In addition, as medicine becomes  more  personalised  and  predictive at the genetic and molecular levels, [4] pathology   will   play   a   more   prominent role in patient care.   Moreover, pathology laboratories  must  correspondingly adapt  to cater for the analyses of substantial amounts of data. [5] This makes a pathology career a dynamic, fast-paced and challenging area to study and work in.

However,   pathology   is   one   of   the   least popular choices for specialisation, with one survey of Australian trainees showing that only   approximately  3%  of   trainees  enter this discipline. [6] Another Australian study found that immunology, as a sub-specialty of pathology, was considered in the top three career choices of only 6% of surveyed final- year medical students. [7] But what makes pathology such an unpopular discipline amongst medical students?

There have been several reports in the literature looking at this very phenomenon. An early study found that medical students tend to regard pathology with less prestige than other disciplines. [8] Medical students also remarked that pathology was clinically invisible, it was a mere basic science with little clinical applications, and they highlighted negative stereotypes of pathologists, including being “introverts”. [9,10] Interestingly, there may be some unfortunate truth to the latter – at least at the student level. A number of studies using standardised psychometric tests found  that  students  who  were  interested in the hospital-based disciplines (including pathology) scored lower on sociability measures than other disciplines. [11,12]

However, the attractive lifestyle of pathologists appears to be a major advantage, and is well recognised by medical students. [9] But how significant is an attractive lifestyle in influencing one’s future career? The limited research suggests that it has become a more dominant   factor   over   the   years.   [13,14] An early study of United States medical students over a decade found an increasing proportion of the top academic medical students were entering a “controllable- lifestyle” career, including pathology. [15] Resneck has analysed this trend in medical specialty selection and found that this trend reflected a societal shift in people opting for work with more flexibility, and placing more emphasis on friends and family. [16] Thus it appears that external factors are becoming more prominent in dictating ultimate future careers.

Medical students’ intended careers are also influenced  by   their   own   expectations   of future practice, own clinical experiences, influences from peers and mentors, and the exclusion of other disciplines. [9] The impact of role models, too, has a dominating effect on influencing future careers. [17] This influence is certainly important in the field of pathology, where the discipline may not be such an obvious choice for students. [18] Although role models can be junior and senior doctors, the latter (especially consultants) tend to have a bigger influence on future careers, according to one survey of medical students. [19]

One author has even argued that medical schools have a duty to expose students to the field of pathology, since a survey of Canadian residents found many stated that they receive little pathology teaching as a student, and therefore had several misconceptions about the   discipline.   [20]   This   suggests   that   a way for engaging more students and junior doctors in pathology is adequate exposure to the field during medical school. This may be through a stronger emphasis on role models or mentors, or medical school societies that promote interest in the area. Teachers/ clinicians  may  also  foster  interest  through the encouragement of research, by supplying research projects for medical students. [21] As a fast-advancing medical discipline, pathology is an ideal area for students to engage in.

In conclusion, there appears to be a multitude of reasons why people enter or avoid pathology, ranging across internal to external influences. Although it may not be the most popular medical discipline, pathology offers practitioners a challenging career that is advancing quickly as the understanding of genetic, molecular and cellular aspects of medicine are unravelled. So medical students may create an informed evaluation, teachers or role models should ensure adequate exposure  of  this  discipline  during  medical school.

Acknowledgements

None.

Conflict of interest

None declared.

Correspondence

A YS Lee: a.lee@amsj.org

References

[1] The Royal College of Pathologists of Australasia. What is pathology? 2013 [cited 2015 21 Jun]. Available from: https://www.rcpa.edu.au/Prospective-Trainees/What-is- Pathology.

[2] Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. 9th ed. Philadelphia, United States: Elsevier; 2015.

[3]  The  Royal  College  of  Pathologists  of  Australasia. Disciplines 2013 [cited 2015 June]. Available from: https://www.rcpa.edu.au/Prospective-Trainees/Disciplines.

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