In this issue of the Australian Medical Student Journal, we are fortunate to interview Professor Alicia Jenkins, a Clinical Endocrinologist at St Vincent’s Hospital Melbourne, Director of Diabetes and Vascular Medicine at NHMRC Clinical Trials Centre and President of Insulin for Life. She was also recently awarded the prestigious ADS Kellion Award, which acknowledges an outstanding contribution to diabetes research, clinical or service areas. Prof. Jenkins provides us with an insight into the field of diabetes and endocrinology, the benefits of undertaking research, as well as her charity work for Insulin for Life.
Dinesh was the first quadriplegic medical intern in Queensland and the second person to graduate medical school with quadriplegia in Australia. Dinesh earned a Bachelor of Laws (LLB) prior to completing his Doctor of Medicine (MD) at Griffith University. He has completed an Advanced Clerkship in Radiology at Harvard University. Halfway through medical school, he was involved in a catastrophic motor vehicle accident that caused a cervical spinal cord injury. As a result of his injury and experiences, Dinesh has been an advocate for inclusivity in medicine and the general workplace. He is a founding member of Doctors with Disabilities Australia. Dinesh is currently a resident medical officer at the Gold Coast University Hospital. He is a lecturer at the Griffith University and adjunct research fellow at the Menzies Health Institute of Queensland. He has a research interest in spinal cord injury, particularly in novel rehabilitation techniques. Dinesh is the Gold Coast University Hospital’s representative in the Australian Medical Association Queensland’s Council of Doctors in Training. He is a member of the scientific advisory committee of the Perry Cross Spinal Research Foundation, disability advisory council at Griffith University, and the Ambassador Council at the Hopkins Centre. Dinesh was the Gold Coast Hospital and Health Service’s Junior Doctor of the Year in 2018. He was awarded the Medal of the Order of Australia in 2019.
In the most recent edition of AMSJ I discussed the concepts of intellectual humility, growth mindset, and situational awareness, and their roles in the development of a person’s professionalism and professional identity. In this edition of AMSJ I will discuss some theories of reflection and reflective practice, which are required to utilise the concepts previously discussed, and enable the optimal development of your learning and professional development. In doing this I will discuss the competency matrix, which is a learning development theory that is referred to frequently in healthcare learning, especially in the context of simulated learning environments. I will also discuss some of the flaws in the current theory that are preventing the recognition of optimal reflective practice.
“In the most recent edition of AMSJ, I discussed the concepts of professionalism and professional identity, and encouraged medical students to consider what they understood by them, and how they might influence their future practice. In this edition of AMSJ, I will discuss some of the other concepts that were mentioned: intellectual humility, growth mindset, and situational awareness. These concepts are integral to how students and doctors develop their beliefs and attitudes towards professionalism and professional identity, and I will outline in this article how they relate to clinical decision making, life-long learning, and working relationships.”
It is a pleasure to contribute to the Australian Medical Student Journal, and to be involved in the work and the thinking of the next generation of medical professionals.
Medical education and training are at the core of Australian Medical Association (AMA) policy and advocacy. Without a quality future medical workforce, the health policies and reforms of government cannot succeed. The AMA keeps reminding governments at all levels of this important fact.
But the concerns of medical students and young doctors extend well beyond the medical and the professional. You want to help build a better society. You want to empower people and communities.
You have strong views on issues like climate change and marriage equality. Like the AMA, you want to make a difference – a real difference.
AMA advocacy is very broad and very deep; it has to be. No other medical or health organisation in the country can even come close to our success in initiating or influencing change across the health system and society.
Single-issue or narrow focus groups, like Doctors for the Environment and Doctors for Refugees, do great work, as do the learned Colleges, Societies, and Associations. The other health professions, the public health groups, consumer representatives, and other groups all do their jobs and also do them well.
But the AMA’s mission goes so much further.
If you look at the AMA website, we have around 150 Position Statements, which include:
· Climate Change and Health;
· Workplace Bullying and Harassment;
· Indigenous Health;
· Sexual and Reproductive Health;
· Women’s Health;
· Men’s Health;
· Obesity;
· Human Cloning;
· End of Life Care;
· Family and Domestic Violence;
· Female Genital Mutilation;
· Concussion in Sport; and
· Firearms.
These issues cover many facets of society and many ideologies. Some are regarded as progressive, some are conservative, but most are controversial — and therefore potentially divisive.
We do this on top of our other core business — Medicare, the Pharmaceutical Benefits Scheme (PBS), public hospital funding, the Professional Services Review (PSR), medical workforce, private health, rural health, doctors’ health, and a broad range of public health issues.
The AMA has to always tread a fine line, and we do that willingly, as with recent topical issues like climate change, pollution, air quality, and renewable energy.
The AMA believes that climate change poses a significant worldwide threat to health and urgent action is required to reduce this potential harm.
We have been vocal about the need for urgent government action, and have repeatedly called for the development of a National Strategy for Health and Climate Change.
The AMA Position Statement, Climate Change and Human Health 2015, is a very strong document. It was developed from the ground up, with input from AMA members at grassroots level around the country.
The AMA wants to see a national strategic approach to climate change and health, and we want health professionals to play an active and leading role in educating the public about the impacts and health issues associated with climate change.
Human health is ultimately dependent on the health of the planet, and the AMA lobbies governments for urgent measures to mitigate the evolving effects of climate change, including the transition to non-combustion energy sources.
The evidence is clear — we cannot sit back and do nothing.
There is considerable evidence to encourage governments around the world to plan for the major impacts of climate change, which include extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.
Our stance is not limited to the Position Statement. We are actively engaged in advocacy on climate change and health. We attended the Health Leaders Roundtable at Parliament House in 2016, where health advocacy bodies met with Members of Parliament to discuss the health impacts of climate change and the need for urgent action.
We make regular submissions to relevant Parliamentary inquiries, where we take every opportunity to highlight the connection between climate change and human health.
We adopt this approach across the broad range of policies we, as the peak medical organisation in the country, embrace. We take this role very seriously.
You are the future of the medical profession. It is my job — and that of all AMA leaders — to pass on to you a strong policy platform, and an even stronger advocacy agenda, to help you achieve your ambitions in medicine and to make the world a better place in which to live. We will not let you down.
On the Australia Day 26/01/14 Professor George Ramsay-Stewart was awarded OAM for his services to surgical education, in the Australia Day Honours list.Professor Ramsay Stuart joined the Discipline after the review of the Medical Program to assist in increasing the teaching of anatomy to SMP students. He instituted the whole body dissection program for stage 3 students which has been a tremendous success, and highly effective in ensuring good anatomical knowledge in Sydney graduates. He has also forged strong links between our discipline, with the discipline of Surgery which has resulted in the expansion of anatomy teaching into postgraduate surgical education.
On the Australia Day 26/01/14 Professor George Ramsay-Stewart was awarded OAM for his services to surgical education, in the Australia Day Honours list.Professor Ramsay Stuart joined the Discipline after the review of the Medical Program to assist in increasing the teaching of anatomy to SMP students. He instituted the whole body dissection program for stage 3 students which has been a tremendous success, and highly effective in ensuring good anatomical knowledge in Sydney graduates. He has also forged strong links between our discipline, with the discipline of Surgery which has resulted in the expansion of anatomy teaching into postgraduate surgical education.
Rembrandt’s painting “The Anatomy Lesson of Doctor Nicolaes Tulp” in 1632 makes it clear that human anatomical dissection had become one of the spectacles and symbols of the age. Anatomy had become accepted as a portal into the human condition [1]. In many ways, it can be viewed as part of the cultural movement of the Renaissance, despite human dissection existing primarily as a procedure of medicine [2].
Wide-ranging circumstances influenced the revival and unfolding of human anatomy. Anatomical dissection became the cutting edge of medical investigation and the essence of a doctor’s training. This anatomical revolution brought about a paradigm shift away from the traditional thinking of the body and its relationship with the mind and soul, which had so dominated medieval thinking [3].
Human cadaveric dissection was first introduced during the third century BC at the School of Greek Medicine in Alexandria, championed by Herophilus, but this was subsequently not allowed under Roman rule [4]. Galen, in the second century AD, became the anatomical authority; however, all his dissections were on animals, and the extrapolation of his findings to humans resulted in inaccuracies not corrected until the time of Vesalius [5]. His huge collection of work was written in Attic Greek, the contemporaneous language of science, and was largely lost with the fall of Rome [6].
Medieval medical practice [7], carried out mainly in monasteries with small charity hospitals, was dominated by religious values to an extraordinary degree. The declaration of Pope Innocence the Third in 1215 forbade clergy from engaging in any activities likely to cause bloodshed [3]. This prevented clerics from practicing surgery or studying anatomy. Surgery was left to layman practitioners, who were mostly uneducated manual workers, degraded by their contact with blood [2].
With the beginnings of vernacular literature and the founding of the first universities, a more humanistic approach to medicine developed [5]. This coincided with a revival of Greek culture, science, and mathematics, together with advances in industrialisation. The city of Salerno was famous as a health centre since Roman times, and it developed an orientation around Greek medicine when its archbishop, Alphanus, travelled to Constantinople in 1063 [5]. As well as introducing Byzantine and Islamic medicine, a crucial advance came with the re-discovery and translation of Galen’s anatomical texts from Arabic into Latin [2]. This allowed the sharing of medical thinking, and a specialised vocabulary was generated, which provided a framework for medical teaching [5]. A foundation medical text called The Articella was created, and this was used throughout the newly-established medical schools of Europe by the mid-12th century [2].
Anatomical knowledge was boosted by the discovery of Galen’s text On Anatomical Procedures, which was a treatise on how to carry out a dissection [8]. The first public record of a systematic anatomical dissection was in 1315 on a condemned criminal at the Bologna medical school by Mondino de Luzzi [9]. De Luzzi subsequently wrote the standard anatomical text for the time based on the Galenic model [5]. Dissection based on this model soon became part of medical education in universities across Europe, and authorities began supplying condemned criminals to medical faculties for human anatomical dissection [9].
The anatomical basis of medicine paved the way for its foundation as a rational science [10]. However, the idea that dissection might be used to verify, or even correct, established medical thought was still quite alien [9]. A typical dissection scene consisted of the physician, in his academic robes, sitting high on a throne reading from a Galenic text, whilst a surgeon dissected, aided by a teaching assistant pointing out anatomical details [10]. The goal was not to add to knowledge, but to verify the text in which the knowledge was enclosed [5]. Surgical benefits were rarely mentioned, and surgeons still learned their anatomy by practical apprenticeship [11].
By the 16th century, permanent anatomy theatres were built to accommodate a growing audience, including laymen and artists [4]. University anatomy dissections became somewhat theatrical events lasting many days, followed by banquets in an almost carnival-like atmosphere [1]. Enthusiasts of anatomy included Renaissance artists, such as Leonardo da Vinci [12], and a revival of naturalistic art involved them in not only attending dissections, but in performing their own [2]. The new involvement of artists with anatomy resulted in more realistic medical illustrations, which became increasingly available [13].
Andreus Vesalius, at the University of Padua, not only transformed research in human anatomy, but also, equally profoundly, the teaching of anatomy. Vesalius based his research and teaching on the dissections of cadavers he carried out himself, in contrast to his contemporaries [14]. He rapidly exposed Galen’s anatomical errors, and published his beautifully illustrated seven-volume book De Humani Corporis Fabrica in 1543. This marked a turning point in the understanding of the human body, and Vesalius’ core ideas became the essence of the new anatomy [15].
Over time, cadavers became increasingly difficult to obtain. Clandestine acquisition of bodies, including grave-robbing, together with fear of vivisection in the community, caused increasing public disquiet regarding anatomical practice [11]. A gradual decline in public dissection developed, despite the practice being considered a linchpin of surgical training and an important component of medical education. The dubious morality surrounding the procurement of cadavers was mitigated with the British Anatomy Act of 1832 which allowed for body donations, and excluded the use of executed criminals [9]. This was a paradigm shift in the procurement of human cadavers for anatomical dissection.
The teaching of anatomy by dissection has gradually declined in the modern era, often replaced by virtual and digital imagery to save time and money [16]. Many have reasoned, however, that clarity of understanding regional relational anatomy and construction of a mental three-dimensional representation of the human body, cannot occur without anatomical dissection [17]. Some research has shown that decreased use of dissection as a teaching tool is one of the factors that can have a negative influence on the anatomical skills of medical students and, somewhat paradoxically, leads to a decline in anatomical knowledge [18].
The lack of anatomical knowledge in students reaching their clinical years, and by extension surgical trainees, led to a review of the University of Sydney Medical School program and re-introduction of a whole-body dissection course in 2009 [19]. Subsequently, the pass rate in anatomy for the Generic Surgical Sciences Examination (GSSE) went from 57% in 2007 to 92% in 2015 for graduates of the university.
There are also other considerations. The handling of a human cadaver encourages humanistic qualities in medical students, and provides some insight into the meaning of human embodiment and mortality [20]. Indeed, some would argue that human cadaveric dissection represents a profound rite of passage into the medical profession [21].
Vesalius was a pioneer of medical illustration in medical teaching, but he saw this only as an aid to learning [22]. He insisted that anatomy could only be studied and understood by inspection of the human body through dissection [23]. Despite the passage of 500 years since his birth, this principle still remains of enduring relevance today.
References
[1] Sawday J. The body emblazoned: dissection and the human body in Renaissance culture. London and New York: Routledge; 1995.
[2] Porter R. The greatest benefit to mankind. Harper Collins London: Fontana Press; 1997.
[3] Alston M. The attitude of the church towards dissection before 1500. Bulletin Hist Med. 1944;16(3):221-38.
[4] Singer AJ. A short history of anatomy and physiology from the Greeks to Harvey. New York: Cambridge University Press; 1957.
[5] French R. The anatomic tradition. In: Bynum WF, Porter R, editors. Companion Encyclopaedia of the History of Medicine. London and New York: Routledge; 1993.
[6] Besser M. Galen and the origins of experimental neurosurgery. Austin J Surg. 2014;1(2):1-5.
[7] Pouchelle MC. The body and surgery in the middle ages. New Jersey: Rutgers University Press; 1990.
[8] Johnston IJ. Galen on diseases and symptoms. Cambridge: Cambridge University Press; 2006.
[9] Park K. The criminal and the saintly body: autopsy and dissection in Renaissance Italy. Renaiss Q. 1994;47(1):1-33.
[10] Rawcliffe C. Medicine and society in later medieval England. Phoenix Mill: Alan Sutton Publishing Ltd; 1995.
[11] Magee R. Art macabre: resurrectionists and anatomists. ANZ J Surg. 2001;71(6):377-80.
[12] Keele KD. Leonardo da Vinci and anatomical demonstration. Med Biol Illus. 1952;2(4):226-32.
[13] Choulant L. History and bibliography of anatomic illustration. New York: Hafner Pub Co; 1962.
[14] Huisman F, Warner JH, editors. Locating medical history. Baltimore and London: The Johns Hopkins University Press; 2004.
[15] Strkalj G. Remembering Vesalius. Med J Aust. 2014;201(11):690-2.
[16] Sugand K, Abrahams P, Khurana A. The anatomy of anatomy: a review for its modernization. Anat Sci Educ. 2010;3(2):83-93.
[17] Korf HW, Wicht H, Snipes RL, Timmermans JP, Paulsen F, Rune G, et al. The dissection course – necessary and indispensible for teaching anatomy to medical students. Ann Anat. 2008;190(1):16-22.
[18] Ellis H. Medico-legal consequences in surgery due to inadequate training in anatomy (editorial). Int J Clin Skills. 2007;1(1):8-9.
[19] Ramsey-Stewart G, Burgess AW, Hill DA. Back to the future: teaching anatomy by whole body dissection. Med J Aust. 2010;193(11):668-71.
[20] Educational Affairs Committee of the American Association of Clinical Anatomists. A clinical anatomy curriculum for the medical student of the 21st century: gross anatomy. Clin Anat. 1996;9(2):71-99.
[21] Peck D, Skandalakis JE. The anatomy of teaching and the teaching of anatomy. Am Surg. 2004;70(4):366-8.
[22] Pearce JMS. Andreus Vesalius: the origins of anatomy. Fragments of Neurological History. London: Imperial College Press; 2003.
[23] Gogainiceanu P, O’Connor EF, Raftery A. Undergraduate anatomy teaching in the UK. Bull R Coll Surg Engl. 2009;91(3):102-6.
The terms, profession, professional, professional identity, and professionalism, are quoted many times in medical student teaching, and often used interchangeably. This can lead to confusion as to what the concepts really are, and we therefore need to be careful what we mean when we quote them, and more importantly what we understand about how they relate to our personal clinical practice. Medical students are constantly being told in lectures, tutorials, and workshops, that they need to demonstrate professionalism in their future careers, so what is vital in their professional development is that they understand not only how everybody else defines professionalism, but most importantly what it means to them, that they have got it right, and that they keep getting it right throughout their careers.
The American philosopher Mortimer J. Adler defined a professional as “a man or woman who does skilled work to achieve a useful social goal. In other words, the essential characteristic of a profession is the dedication of its members to the service they perform [1].” So, if professionals belong to a profession, what does it take to be part of one? In the early 20th century E. P. Scarlett defined what he believed were the seven pillars of a profession: (1) technical skill and craftsmanship, renewed by continuing education; (2) a sense of social responsibility; (3) a knowledge of history; (4) a knowledge of literature and the arts; (5) personal integrity; (6) faith in the meaning and value of life; and (7) the grace of humility [2]. This ‘list’ of attributes, as to what defines a person or a concept has become common amongst modern society, and just as humans have a ‘tick-box’ of what they may desire in a future partner, healthcare organisations have ‘tick-boxes’ as to what they expect of their members. For example, the Accreditation Council for Graduate Medical Education (ACGME) in another seven-point list defined the core competencies of a doctor as respect, compassion, integrity, responsiveness to needs, altruism, accountability, commitment to excellence, sound ethics, and sensitivity to culture, age, gender, and disabilities [3]. We can see that professionalism is an expected attribute for a member of the medical profession, but it also seems to align with old-fashioned values considered to be core properties of a profession, and the people who define these pillars are not just the profession themselves, but society as well. The profession has a contract with society, that society grants them self-determination and awards them an elevated status, in return for civic responsibility, community leadership, and this professionalism.
So, what is the connection between professional identity and professionalism? Burke states that “identities are the meanings that individuals hold for themselves, what it means to be who they are. These identities have bases in being members of groups (social identity), having certain roles (role identities) or being the unique biological entities that they are (personal identities) [4].” This is important for medical students as they develop their identity during their time at medical school. Tajfel and Turner [5] proposed that people tend to categorise themselves into one or more in-groups, deriving their identity from the group and forming boundaries with other groups. This group identification promotes self-esteem within the group and leads to greater commitment to the group, even if the group’s status is low. They believed the three major components of social identity are: (1) categorisation: putting others or ourselves into categories, labelling the person as a way of defining the person; (2) identification: the way in which we define our self-image through association with a group, in-groups being the ones with which we identify and out-groups those which we do not; and (3) comparison: we compare our own groups to others and create favourable biases towards our own. This process is very strong within people’s minds and leads to stereotyping. If doctors are stereotyped as being caring, altruistic individuals by one person, they may now be stereotyped in another person’s mind as greedy and arrogant. Ultimately, once these stereotypes are formed they can become rigid.
Coulehan [6] distinguishes three types of professional identity in medicine: (1) technical identity: the doctor abandons traditional values, becoming cynical about duty and integrity, and narrows the sphere of responsibility to the technical arena; (2) non-reflective identity: the doctor espouses and consciously adheres to traditional medical values whilst subconsciously basing behaviour, or some of it, on opposing values, thus being self-deluded and detached; and (3) compassionate and responsive identity: the doctor overcomes conflicts between tacit and explicit socialisation, internalises the virtues and values professed, and manifests these in behaviour. What is worrying is that Coulehan [6] demonstrated that a large percentage of medical graduates can be classed as having a non-reflective professional identity, maintaining that this outcome is most likely where there are conflicting values in the learning environment. The inability to reflect appropriately was demonstrated by the participants when there were deficits in their clinical reasoning, and this highlighted the need for expert facilitation and education. With poor supervision and mentorship, new doctors may internalise beliefs that certain ‘unvirtuous’ behaviours are virtuous, since that is ‘the way things are in medicine’; that is to say, it is the cultural norm. However, the development of a person’s professional identity is strongly influenced by another concept, the notion of ‘belongingness’. Belongingness is the human emotional need to be an accepted member of a group. Whether it is family, friends, co-workers, or a sports team, humans have an inherent desire to belong, and be an important part of something greater than themselves. This implies a relationship that is greater than simple acquaintance or familiarity. The need to belong is the need to give and receive affection from others [7]. Without belonging, a person cannot identify oneself as clearly, thus having difficulties communicating with and relating to one’s surroundings. This implies that belongingness is related to identity. However, there is a danger with belongingness in that the desire to belong can lead to conformity, which can lead to lack of self-regulation. And this is what brings us back to the notion of professionalism.
When you look at the definitions of medical professionalism, there are numerous differing statements. For example, the University of Ottawa states that professionalism embodies the relationship between medicine and society as it forms the basis of patient-physician trust [8]. It attempts to make tangible certain attitudes, behaviours, and characteristics that are desirable among the medical profession [8]. The Medical Protection Society in the UK has a whole page on it, but does not give a definition [9]. The Australian Medical Association (AMA) makes a statement on it: “while the expression medical professionalism is used in different ways, for the purposes of this position statement we are using it to refer to the values and skills that the profession and society expects of doctors, encapsulating both the individual doctor-patient relationship and the wider social ‘contract’ between the profession and society [10].” Despite this, professionalism remains very vague as a concept.
The previous discussion and statements suggest that professional identity is constructed at the level of the individual, whereas professionalism is constructed by the community and medical profession as a whole. These community and societal ideals are articulated in professional codes, institutional frameworks, and formal medical curricula, which may or may not reflect reality. However, professional identity is a reality that might not correspond to the ideal, for reasons that can be valid or not. It is based on one’s beliefs about what it means to be professional, and a doctor’s beliefs may differ from those of the community or other health professionals. It therefore follows that a responsive and reflective professional identity is more likely to develop where there is alignment between the understandings and expectations of others, self-identity and personal values, the social identity of the professional group, and the cultural milieu of the working environment. Since identity implies values and goals, it will also determine motivation; thus it has important educational implications for self-regulated learning. This means that professionalism must be defined by the individual, and they have to ensure that their personal beliefs and concept of what professionalism means resonates with the organisations and society in which they operate.
Ensuring that you define professionalism to yourself in the correct manner necessitates critical reflection. Reflection can occur at either a superficial, moderate, or deep level [11], and it is this deeper level of reflection that makes it critical. Superficial reflection is purely descriptive, and whilst it might make reference to existing knowledge it does not critique it. With moderate reflection, often called dialogic reflection, the person takes a step back and starts to explore thoughts, feeling, assumptions, and gaps in knowledge. The reflector makes sense of what has been learnt from the experience, and what future action might need to take place. Deep or critical reflection leads to a change due to the experience. To achieve this, the learner needs to be aware of the relevance of multiple perspectives from contexts beyond the chosen incident, and how the learning from the chosen incident will impact on other situations.
So how does this translate to me, a practicing clinician? After all, if I am to suggest that you should practice in a certain manner, then I should lead by example. Professionalism as defined by myself to myself is based on ‘3 rights’: (1) I know what the patient has a right to; (2) I know what the right thing to do is, and I will do it; and (3) I know the right manner to do it in. This conveniently for me encompasses the legal, ethical, and moral aspects of my clinical practice, and I believe it is summarised by the concept of integrity: integrity for me is what defines professionalism. To translate this into a clinical concept, consider the delivery of open disclosure. I know the patient has a right to an apology, I am aware of need to apologise, and I want to apologise. To ensure that I hopefully continue to practice in this way, I reflect with the right people, at the right time, in the right manner, meaning I don’t seek out those who will always agree with me, and I ask them for them an opinion before I state my beliefs, whilst I am ready to listen to their suggestions.
Over the next few years of your careers, you will hear it repeated many times from senior clinicians that as your career progresses the knowledge becomes fairly straightforward. This is not entirely true as new advances and techniques are continually being developed, however understanding yourself and those around you to a greater depth is the best piece of armamentarium you can acquire as you begin to forge your medical careers. Your curriculum is extremely busy and you will probably not relish the thought of further background reading, however this will not change throughout your career, so make time to see medicine beyond the facts. Consider concepts such as intellectual humility, growth mindset, situational awareness, and the competency matrix, concepts beyond your basic curriculum, as this will ensure your career is as successful and fulfilling as possible.
References
[1] Manning PR, DeBakey L. Preserving the passion in the 21st century. 2nd ed. New York: Springer; 2003.
[2] Scarlett EP. The medical jackdaw. Patrick Lewis Papers 1949-1987. Johannesburg: Historical Papers Research Archive; 2016.
[4] Burke P. Identities and social structure: the 2003 Cooley-Mead Award address. Soc Psychol Q. 2004;67:5-15.
[5] Tajfel H, Turner J. The social identity theory of intergroup behaviour. In: Worchel S, Austin W. Psychology of intergroup relations. Chicago: Nelson-Hall; 1986.
Victoria's brain bank has received more than 1000 brain and spinal cord donations. The bank researches neurological conditions such as dementia, Parkinson's and mental illness. They also ship samples across the world. The banks leader Professor Catriona McLean is pictured in the Brain Bank where parts of donated brains are stored in Formaldehyde.Picture:Ian Currie
Professor Catriona McLean
I am 20. At a social barbecue I talk with an obstetrician about careers in medicine. She tells me that there is no point becoming an obstetrician if I want to have a family. I remain quiet.
I am 22. I compliment my favourite aunt on her new hairstyle. Her look is blank. It is a wig. I am so naïve. She dies the night of my fourth-year final exam. I forget to go to my exam.
I am 24, an intern in my first term. I am looking after Ian, who is having the first bone marrow transplant in my hospital. I am fascinated by the science. I see Ian remain positive and friendly at all times despite what he is going through. He has a lovely family. I don’t want him to die with this brand new treatment. I remain vigilant and work to my capacity; to my great relief, Ian lives.
I am 27, a senior resident medical officer. I have offers to continue training in oncology, cardiology, or neurology. I am unsure which direction I really want to go. I am pregnant. There is no maternity leave in the medical officer award in 1987. I am forced to resign. I let all three physician training offers go. I lose my entitlements. My little boy eclipses medical study.
Choosing what you should do with your medical degree, and balancing this with your personal life may not be clear to you early in your medical career. A single event, person or patient may inspire you in a direction. Your career choice may not evolve as you wish it to. You may need to make compromises. You may face hurdles that you never thought would occur.
After some deliberation about which path I should take I chose to become a pathologist. At the time I also thought it was going to be more practical for me and my young family. I’d always been fascinated in pathology and I remain fascinated by pathology. Whilst there is disease, there is the need to diagnose, understand pathogenesis, and find effective treatments. Even today, I often see something new down the microscope. It could be something I’ve overlooked every other time or an extremely rare disease. I’ve learnt to keep my eyes and my mind open.
Often I get questioned by junior doctors about moving into pathology and moving away from the patient. I do not see it that way. I feel that the patient is very central to our role. We want to make sure their diagnosis is correct, that we offer them accurate information about their disease. We are not disconnected from them.
It has not always been plain sailing trying to juggle fellowship exams, consultancy, and being a mother. I did, however, create a rule for myself very early on. This rule was to never study once I returned home after work. If I could not keep family and work separate it would not work for me in the long run. So, I learnt to concentrate super hard. If I read something once, it had to stick. If I saw something down the microscope, I had to be able to recognise it the next time. I still abide by this rule today.
Once I’d completed my fellowship, there were very few public hospital jobs around so I started a doctorate and received some sessional work. It was a 56 kilometre round trip to the hospital for one of the sessions. Sometime later I was pregnant again. I chose to resign from the distant workplace, took eight weeks off, and continued to work on my thesis at the university. Fifteen months later I was pregnant with twins. I took annual leave. I’d finished my experimental work so I wrote my final thesis when my twins were three months old. They’d sleep and I’d write. They’d wake and I’d feed them. Don’t ask me details about this time of my life.
Following my doctorate, I found a consultant job close to home. I also decided early on that collaboration would offer me more scope for research than trying to juggle full time service work and leading research. Some colleagues choose to become the leaders of research laboratories. I choose to contribute my skills and knowledge to research. Everyone is different.
I am 44. I have four children. I am offered a job as professor and head of anatomical pathology and I take it. The children can all walk to school and I never make or find time to wash my car. Time is of the essence.
I am 57. I am still head of anatomical pathology amongst other new titles and fellowships I’ve gained. My special interest is in brain and muscle pathology, particularly rare diseases. My world-ranked expertise is shared with medical science via more than 350 research papers in which I am a co-author.
What will the future be for certain specialties in medicine? Will algorithms and robots overtake large aspects of our work? It is important to look to the future but also to remain optimistic and to be prepared to change. One aspect of my field, rare paediatric neuromuscular diseases, has seen a great deal of change in the past five years. Next generation — and now whole exome — sequencing has resulted in many genetic diagnoses being made. What about those children who remain without a genomic resolution? What happens to those in whom a specific mutation has been found? Is there a specific treatment available based on this new information? Not usually. Not yet. What then?
Knowing the gene mutation does not mean that the mechanism of pathogenesis is known. Without a good understanding of pathogenesis, specific treatments remain unknown. It is a group effort to solve these unknowns with input required from multiple specialties. I’ve been involved in several recent cases looking at new gene mutations and how they affect muscle. There has been much for me to learn from using this new information to help interpret future cases and to aid in understanding the pathogenesis of a disease. This new genomic information adds to the new information provided in the seventies by electron microscopy and in the nineties by immunohistochemistry — each of which was revolutionary in its time.
Making each career decision, each medical decision, requires adaptation and use of your knowledge in new ways. At the same time, it is important to remember that your career should always be fun. It should always be challenging. You will always be learning.
Every senior medical student and young doctor want to be able to keep up with the latest advances in medicine. However, the output of published literature keeps rising, so that we are all in danger of drowning in data. It’s difficult enough to keep up with the latest in clinical practice, let alone in basic research.
To at least some extent, evidence-based medicine can help, because it offers approaches that help to turn the data into knowledge which can actually be applied. Notably, these include systematic reviews and meta-analyses, which yield evidence-based practice guidelines that can inform clinical decision-making. Of course, one must remember that guidelines are only generalisations. Achieving the best outcomes for any given patient requires a combination of:
skilled clinical observation
appropriate investigations
application of knowledge and expertise gained by experience
the best scientific evidence from the literature.
In this article, I will focus on the appropriate use of investigations. This is an important issue with respect to the care of individual patients, because unnecessary and inappropriate investigations may have adverse effects, while false-positive results may prompt further needless investigation. It is also important with respect to utilisation of resources, particularly in Australia where costs to the health care system are substantially borne by the taxpayer. Over the past decade, the use of laboratory tests has seen a modest annual increase of approximately 3% to 6% [1]. At the same time, requests for diagnostic imaging investigations have increased at approximately 9% per year, so that these services now account for approximately 15% of all Medicare outlays [2].
When looking at evidence-based medicine in the context of the rational use of investigations, it is easy to get lost in the arithmetic of predictive values, probabilities and likelihood ratios. An alternative simpler approach is to rely on the maxim “Only request a laboratory test if the result will change the management of the patient” [3]. This may be an oversimplification in that among other things, investigations are relevant to establishing a diagnosis, excluding differential diagnoses, assessing prognosis and guiding management. Nevertheless, focusing on investigations that matter is sound advice, which is unfortunately all too often ignored.
The quality of the evidence around overuse of diagnostic investigations is relatively low. In hospital settings, however, it has long been recognised that as many as two-thirds of requests for some common Pathology tests may be avoidable, in that they fail to contribute to diagnosis or management [4]. Senior medical students and junior medical officers need to be especially aware of this, because most hospital Pathology test requests are submitted by junior doctors. Among factors that contribute to the uncritical overuse of investigations by JMOs are inexperience, lack of awareness of the evidence base for using a particular investigation and lack of awareness of the cost of the test. Other significant factors are the desire to anticipate the expectations of one’s supervisor and the fear of missing something important. Perhaps the supervisors of PGY1/2 trainees themselves need to drive cultural change and better model the appropriate use of diagnostic investigations!
Some strategies targeted at the test-requesting behaviour JMOs appear to be effective in at least some settings, for example restricting the range of tests that junior doctors may request in emergency departments [5,6]. More generally, management systems with budgetary controls, as well as online systems with decision support, have been promoted [7]. Importantly, education also has a valuable role to play [8].
With funding support from the Commonwealth Department of Health, my colleagues and I developed an open-access website to educate JMOs about the rational use of diagnostic investigations. As a user, you interact with simulated cases and can request investigations as you attempt to establish a diagnosis, while being presented with a running tally of the costs of the tests sought. At the end of each case, you receive feedback via comparison with what an expert would have done. Try it by self-registering, without cost, at http://investigate.med.unsw.edu.au/. The largest collection of cases is targeted to JMOs, but are also likely to be of interest to senior medical students. In addition, there are cases for trainee GPs, plus a few specifically created for advanced trainees in Respiratory Medicine. However, all cases are accessible to all users.
We have evidence that this educational approach can work: in a trial at a large Sydney hospital, we demonstrated that in the period immediately following active engagement of the cohort of junior doctors with this website, there were significant hospital-wide cost savings and an encouraging reduction in the number of blood samples collected from patients [9]. Unfortunately, in agreement with other studies of educational interventions, these changes in test-requesting behaviour were not sustained over the following months. However, there is additional evidence that routine requests for diagnostic investigations can be reduced if junior doctors are provided with cost data at the time of submitting a request [10]. We think a good case can be made for integrating this information into online systems in hospitals, to provide reinforcement.
Meanwhile, I encourage you to have a look at one of the few collections of guidelines about the use of investigations, available on the Australian Choosing Wisely website at http://www.choosingwisely.org.au/resources/clinicians?displayby=MedicalTest. These guidelines are supported by a number of specialist medical colleges, notably including the Royal College of Pathologists of Australasia and the Royal Australian and New Zealand College of Radiologists. Also well worth reading is a thoughtful reflection on the “big picture” of overuse and the Choosing Wisely initiative, published late last year and targeted specifically to medical students and trainee doctors [11].
References
National Coalition of Public Pathology. Encouraging quality pathology ordering in Australia’s public hospitals – Final Report, 2012 http://www.ncopp.org.au/site/quality_use.php (last accessed January 2017).
Hawkins RC. The Evidence Based Medicine approach to diagnostic testing: practicalities and limitations. Clin Biochem Rev. 2005; 26:7-18.
Hammett RJ, Harris RD. Halting the growth in diagnostic testing. Med J Aust 2002; 177:124-125.
Stuart PJ, Crooks S, Porton M. An interventional program for diagnostic testing in the emergency department. Med J Aust 2002; 177:131-4.
Chu KH, Wagholikar AS, Greenslade JH, O’Dwyer JA, Brown AF. Sustained reductions in emergency department laboratory test orders: impact of a simple intervention. Postgrad Med J 2013; 89:566-71.
Janssens PMW. Managing the demand for laboratory testing: Options and opportunities. Clin Chim Acta 2010; 411:1596-602
Corson AH, Fan VS, White T, Sullivan SD, Asakura K, Myint M, Dale CR. A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs. J Hosp Med. 2015; 10:390-5.
Ritchie A, Jureidini E, Kumar RK. Educating young doctors to reduce requests for laboratory investigations: opportunities and challenges. Med Sci Educ 2014; 24:161-3.
Feldman LS, Shihab HM, Thiemann D, Yeh HC, Ardolino M, Mandell S, Brotman DJ. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med 2013; 173:903-8.
Lakhani A, Lass E, Silverstein WK, Born KB, Levinson W, Wong BM. Choosing Wisely for medical education: six things medical students and trainees should question. Acad Med 2016; 91:1374-8.
