Category: Articles

Categories
Letters

Amidst ovarian cancer screening challenges, there is hope

I am writing in response to the review article by McMullen (AMSJ Volume 1, Issue 1). [1]

The major cause of gynaecologic-related cancer mortality in women in developed settings is ovarian cancer. [2] Recent research findings in this field provide hope in relation to both screening and early treatment – even though randomised controlled trial evidence in most screening techniques is still not available.

Serum CA125, which is the most commonly used tumour marker for ovarian cancer, is not suitable for population-based screening as it has been found to be elevated in only five to six out of ten women with stage I epithelial ovarian cancer. [3] Screening and diagnosis may therefore have to incorporate a variety of other tools. Primary prevention also needs to be considered.

Primary prevention is aimed at risk factors for ovarian cancer. A study of Australian women found an increased ovarian cancer risk related to high dietary intake of red and processed meat and fat. [4]

A meta-analysis found that smoking may increase the risk of developing mucinous ovarian cancer twofold. [5] Other studies have shown reduced serous ovarian cancer risk with hormonal contraceptive use, breastfeeding duration and increasing parity. [6] Health care workers could contribute to primary prevention by encouraging patients to quit smoking, change dietary habits and breastfeed their babies.

Screening is a type of secondary prevention. Screening will have a higher yield if it is targeted at people at increased risk. Multiple primary cancer links were found in an assessment of South Australian Cancer Registry data which suggested screening for ovarian cancers in patients with colon cancer or cancer of the uterus. [7]

Genetic counselling and testing is a good screening tool in persons at high risk of ovarian cancer and persons with familial ovarian cancer history. [8] Carriers of BRCA1 and BRCA2 mutations account for up to 15% of ovarian tumours. [9] Genetic advances have also identified GTF2A1 and GTF2A1 plus HAAO as principal markers in ovarian cancer diagnosis. [10]

As for the actual screening test to be used, urine angiostatin levels are elevated in patients with epithelial ovarian cancer and have been shown to be a superior marker in detection of epithelial ovarian cancer as compared to CA125. [11] Differentiation of cancer from healthy controls had a sensitivity of 88% and specificity of 92%; while differentiation of benign from neoplastic lesions had a sensitivity of 84% and specificity of 84%. When used in combination with CA125, 91% of ovarian cancers were identified.

Transvaginal ultrasonography has also been shown to be of use in diagnosis, especially in augmentation of CA125 screening. [12] Multimodal screening, on the other hand, involving CA125 and ultrasonography in a pilot randomised trial has a positive predictive value of 21% with prolonged survival rates. [13]

In conclusion, serum CA125 is an inadequate solitary predictor in the diagnosis of ovarian cancer. Upcoming diagnostic methods provide an unprecedented opportunity to combine methods and thus improve diagnosis in Australia.

References

[1] McMullen D. Ovarian carcinoma: Classification and screening challenges. Australian Medical Student Journal 2010;1(1):35-7.

[2] Costi M, Zeillinger R. Drug resistance in ovarian cancer: Biomarkers and treatments. Highlights from the DROC meeting held in Modena (Italy) on the 19th and 20th of February 2009. Scientific topics discussed at the meeting are reported in the present issue. Gynecol Oncol 2010;117(2):149-51.

[3] Moore R, MacLaughlan S, Bast Jr. R. Current state of biomarker development for clinical application in epithelial ovarian cancer. Gynecol Oncol 2010;116(2):240-5.

[4] Kolahdooz F, Ibiebele T, Van Der Pols J, Webb P. Dietary patterns and ovarian cancer risk. Am J Clin Nutr 2009;89(1):297-304.

[5] Jordan S, Whiteman D, Purdie D, Green A, Webb P. Does smoking increase risk of ovarian cancer? A systematic review. Gynecol Oncol 2006;103(3):1122-9.

[6] Jordan S, Green A, Whiteman D, Moore S, Bain C, Gertig D, et al. Serous ovarian, fallopian tube and primary peritoneal cancers: A comparative epidemiological analysis. Int J Cancer 2007;122(7):1598-603.

[7] Heard A, Roder D, Luke C. Multiple primary cancers of separate organ sites: Implications for research and cancer control (Australia). Cancer Causes and Control 2005;16(5):475-81.

[8] Petrucelli N, Daly M, Feldman G. Hereditary breast and ovarian cancer due to mutations in BRCA1 and BRCA2. Genet Med 2010;12(5):245-59.

[9] Despierre E, Lambrechts D, Neven P, Amant F, Lambrechts S, Vergote I. The molecular genetic basis of ovarian cancer and its roadmap towards a better treatment. Gynecol Oncol 2010;117(2):358-65.

[10] Huang Y, Jansen R, Fabbri E, Potter D, Liyanarachchi S, Chan M, et al. Identification of candidate epigenetic biomarkers for ovarian cancer detection. Oncol Rep 2009;22(4):853-61.

[11] Drenberg C, Saunders B, Wilbanks G, Chen R, Nicosia R, Kruk P, et al. Urinary angiostatin levels are elevated in patients with epithelial ovarian cancer. Gynecol Oncol 2010;117(1):117-24.

[12] Hennessy B, Coleman R, Markman M. Ovarian Cancer. Lancet 2009;374(9698):1371-82.

[13] Jacobs I, Skates S, MacDonald N, Menon U, Rosenthal A, Davies A, et al. Screening for ovarian cancer: A pilot randomised controlled trial. Lancet 1999;353(9160):1207- 10.

Categories
Letters

Gifts between pharmaceutical companies and medical students: Benefits and/or bribes?

It was with some interest that I read the Review Article ‘What do medical students think about pharmaceutical promotion?’ by Carmody and Mansfield, published in AMSJ Volume 1, Issue 1. [1]

As the article reports, there is a conspicuous lack of solid data investigating the relationship between pharmaceutical companies and medical students, particularly in Australia. Clearly there are both positive and negative aspects to this relationship, and I think the main concern many students hold is, at its roots, an ethical one. Can these companies exert an influence over our opinions about drugs, and subsequently affect our future prescribing practices? More importantly, does this have any relationship at all to accepting free gifts which might benefit our education?

The ethics regarding this issue is a veritable maze of should, should-sometimes and should-nots, and as with many issues, ethics often takes a second place to convenience, and sometimes even third place behind convenience and greed. Naturally, this is not to say that medical students are either indolent or opportunistic, but the importance of this issue is undeniable, with many Australian medical students uncertain about how to deal with pharmaceutical gifts and promotions.

From ethical principles, all moral individuals are bound by the Law of Reciprocity, which unequivocally states that we are disposed, as a matter of moral obligation, “to return good in proportion to the good we receive” – but how does this fit into the situation today? [2] Can a moral person, regardless of whether they are a medical student, accept a gift, be it a pen, mug, lanyard or free sandwich, and not feel a sense of ethical obligation towards the giver?

Carmody and Mansfield report that both doctors and students believe they possess a certain ‘invulnerability’ to any such nefarious ploys of inducing a reciprocal obligation, and as such feel free to accept small gifts without fear. Yet this is acting in direct opposition to the moral law of reciprocity, and consequently, does this mean we are acting unethically?

While medical students may think that getting something for free is an obvious win-win situation, in reality nothing could be further from the truth. If anything, it’s one of those infuriating lose-lose situations. Accepting a gift means the beneficiary takes on a debt which may lead to a conflict of interest in the future, and in doing so acts unethically, something which is frowned upon quite seriously within the medical profession.

Some might argue that medical principlist ethics is not dictated by the moral law of reciprocity, but we all know that few things in this world come free, and in all seriousness, what are the odds that pharmaceutical companies are spending money on gifts for purely altruistic reasons? The Review Article mentions that each doctor in Australia is subjected to an estimated $21,000 worth of pharmaceutical company promotion each year. [1] Certainly, this is a pittance when compared to the US $11 billion that are spent on pharmaceutical marketing and promotions each year in the United States; yet the implications remain clear. [3]

With that said, there are positive sides to an early association between those studying medicine and the pharmaceutical industry. Disregarding the free pens, free food and other little (or not so little) gifts, pharmaceutical companies sponsor educational seminars, social outings and even travel costs to conferences. Surely this can only have a beneficial effect on our medical education. Or, should these too be considered ‘gifts’ of a different kind – gifts that will enrich us intellectually rather than materialistically? If nothing else, such an early relationship will help to prepare medical students for how to deal with the pharmaceutical industry after they graduate.

The path ahead is not clear, for the relationship between pharmaceutical companies and medical students has both positive and negative effects. Barack Obama is reputed to have said that “If you’re walking down the right path and you’re willing to keep walking, eventually you’ll make progress”; yet how can we know where to place our feet if the ‘right’ path is hidden from us within a murky quagmire of ethical principles? Carmody and Mansfield suggest more research studies on this issue regarding Australian medical schools, and while I am not convinced this will make a pronounced change in clearing the fog obscuring the way forward, surely it cannot be a bad place to start.

References

[1] Carmody D, Mansfield P. What do medical students think about pharmaceutical promotion? Australian Medical Student Journal 2010;1(1):54-7.

[2] Becker L. Reciprocity. 2nd ed. Chicago: Routledge & Kegan Paul; 1990.

[3] Wolfe S. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? Characteristics of materials distributed by drug companies: four points of view. JGI Med 1996;11:637-9.

Categories
Letters

Ensuring pathways for junior doctors

Prof. James Angus
Prof. James Angus

It appears that all the students who graduated at the end of 2010 and are now doing their intern year did find a place. But that is unlikely to be the case for all students finishing this year, and in the immediate future.

All medical students who qualify in Australia must be guaranteed access to an intern place, irrespective of how their study was funded or, indeed, which country they are from. This is a critical element to ensuring the ultimate goal for our medical workforce: that it be selfsustaining by 2025. [1]

Medical Deans, which represents all eighteen medical schools in Australia and the two New Zealand medical schools, has been actively seeking a commitment from governments over the past two to three years that there be sufficient and quality intern places available for all medical school graduates.

Unfortunately, while the significant increase in medical student places since 2005 has been well-publicised, it would seem State and Federal governments have only recently undertaken forward planning to accommodate the impact of these increased numbers as students graduate into the intern year, or indeed, move into later post-graduate training.

The increase in the graduating group began to be felt in 2009, but the real pressures on the health system will be in the next two to three years with 3,786 graduates projected for 2014, 1,400 more than in 2009. About 17% of these graduates are likely to be international fee paying students.

A year ago, Federal and State government Health Ministers met and guaranteed places only for Commonwealth-funded students, leaving about one-quarter of our medical students without certainty. By far the significant majority of these are international fee paying students.

International students must continue to be seen as an integral component of Australian medical schools. They are part of the longer term goal of self-sustainability. The impact of not guaranteeing an internship on both the individual student as well as the Australian higher education sector has already been summarised in the first edition of this journal. [2] For Medical Deans, while that impact will be significant on each medical school, it will be felt far beyond: a significant downturn in the number of international students will compromise the wonderful diversity these students bring to our broader community, the value-add they can make to the Australian health care system by already knowing how the system works, and the ability of these students to take their place in the increasing global workforce.

Medical Deans acknowledges that it needs to work in partnership with government and the newly established Health Workforce Australia (HWA) to ensure that there is an agreed national training plan in place as soon as possible to underpin the self-sustainability goal for 2025. Without reliable data, no systematic planning can be undertaken. As Deans we recognise that a national plan will assist us to establish our enrolment targets, particularly with respect to international students, with a level of certainty able to be provided to each student surrounding their internship. We are encouraged that HWA will soon commence the development of that training plan and look forward to working with them.

This current bottleneck at the intern year will of course replicate itself through to vocational training over the next five to ten years. It is critically important therefore that every point across the medical education continuum is addressed through the training plan and sufficient resources for training allocated at each point. Setting targets at each point will enable each level of training to be prepared.

The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) will be most useful in informing the national training plan. This very successful project of Medical Deans will provide much-needed data on whether first year medical students act on their intentions with respect to type and location of future practice, and whether particular initiatives or programs undertaken during their studies have influenced the student’s eventual choice. The data will greatly benefit the targeting of government resources and provide much-needed understanding of future areas of likely workforce gaps.

The Australian Government’s national health reform agenda, to be implemented through the National Health and Hospitals Network, provides a timely opportunity for a number of critical issues in medical education to be addressed. These include the recognition of the true cost of teaching and clinical supervision, the need for better planning and co-ordination of medical education across the whole spectrum of training, ensuring quality teaching continues to be delivered and the current high quality of our graduates is not diminished, and the importance of embedding translational educational research.

These are issues that Medical Deans will continue to address with vigour. In our view, they are critical to ensuring a self-sustaining workforce by 2025 and one which we can continue to proudly promote as outstanding.

References

[1] National Health Workforce Taskforce. Health Professions Entry Requirements, 2009-2025: Macro Supply and Demand Report. Melbourne: National Health Workforce Taskforce; 2009.
[2] Schiller M, Yang T. International medical students: Interned by degrees. Australian Medical Student Journal. 2010;1(1):10.
Categories
Editorials

Forging Ahead

The first copies being distributed at the launch

It is a pleasure to welcome you to this issue of the Australian Medical Student Journal (AMSJ).

After the very successful launch of the AMSJ’s inaugural issue in 2010, it has been decided that the journal will now operate on a biannual basis from this year.

It has been almost a year since the AMSJ’s launch function, which was held on the 29th of April 2010 at the new Lowy Cancer Research Centre in Sydney. A sizeable crowd of medical students, clinicians and academics from across Australia were present for the event, including many of the authors published in the inaugural issue. Among the guests was AMA President, Dr. Andrew Pesce, who cut the ribbon from the first box of copies. Also present were many of the generous sponsors of the inaugural issue.

Following the launch, 2,500 hard copies of the journal were distributed to students Australia-wide via the twenty university medical societies. In early July, through a partnership with the Australian Medical Students’ Association (AMSA) Global Health Conference (GHC) in Hobart, copies were distributed to all 500 delegates. The new AMSJ website also proved to be a huge success, receiving around several thousand visits in the week after the launch, and over 15,000 visits in the months that followed.

The second half of 2010 saw the roll-out of the first major phase in expanding the AMSJ’s staff structure. A national recruitment campaign has seen the AMSJ take on staff from all twenty Australian medical schools, giving the journal a tremendous presence in the student community within a short period of time. Check our staff list to find out who is the AMSJ Representative at your university.

Continuing in the footsteps of the inaugural issue, this issue contains a broad range of high-quality student research, reviews and opinion pieces. Women’s and children’s health are particularly well represented in this issue, with articles covering the acute abdomen in pregnancy, causes of neonatal death, ovarian conditions, vertical Hepatitis B transmission, and the confidentiality rights of minors. Medical hygiene also comes under the spotlight with articles on alcohol-based hand rubs, and stethoscopes as vectors of infection. We have also published articles from an interesting range of guest authors, this time with a little more of an educational slant. Among others, John Murtagh (author of Murtagh’s General Practice) offers some advice on how to deal with baffling patient presentations, while Murray Longmore (author of the Oxford Handbook of Clinical Medicine) shares some tips on how to enjoy one’s patients more! Nobel Laureate, Peter Doherty, and outgoing editor of the Medical Journal of Australia, Martin Van Der Weyden, offer some reflections on their interesting career paths.

We are also pleased to announce that we will be partnering with the AMSA Convention 2011 to present the 2011 NHMRC Student Research Competitions (see page 14). If you are in Sydney in July for the Convention, look out for us there.

Once again, I offer a huge thank you to everyone who has made this publication possible, including the authors, staff, sponsors, and most importantly, our readers.

I would encourage you to think of how you may like to contribute to the next issue of the AMSJ. Submissions are already open for the next issue, which is due to come out in September. Also, stay tuned for updates about our next round of national recruitment.

Categories
Feature Articles

So you think you can research?

I had always considered myself an exceptional dancer. In my mind, my dance moves were unparalleled. However, in reflection, I must admit that the majority of my moves were employed to impress the scrub-nurses by turning my gown in tune to the bopping background beat of the theatre iPod. However, my delusions of dancing grandeur were shattered after watching a number of the popular dance-based shows on television. I realised it took far more than genetic talent, which I still choose to believe I have in abundance, to make a dancer. It requires hours of practice combined with fitness, good music, choreography and originality to succeed. Research, it appears, is not too dissimilar.

I had never been the most proactive student and my CV was barer than a middle-aged German tourist holidaying in Thailand. I had reached a stage in my career where it was time to contribute to medical research. Those who partake in evidence-based medicine know how important research is to the field of medicine.

If you have ever considered undertaking some formal research yourself, here are a few lessons I learnt the hard way:

What do you need?

So, you want to research? Not sure where to begin?

In dance, you need to start with either good music or a good choreographer. In research, your music is your idea, question or inspiration, and your choreographer is your supervisor.

The music (idea)

The chances are that someone, somewhere, has already attempted to adapt “the sprinkler” to your chosen music. As in research, if you think you have a good idea, someone else may have had it before you. To find out, the next step is to conduct a literature review. Medline is a good place to start.

Don’t be disheartened if someone has already researched your hypothesis. In medicine, most people can only answer very specific questions. So, if your good idea has already been partially covered, then read a few articles and find a more specific, unanswered question similar to your original one.

For example, if your question was “How effective is heparin in preventing DVT?” then refine your question to “How effective is low molecular weigh heparin in preventing DVT in male patients aged between 80 and 81 with a past history of smoking 22 cigarettes a day who have just undergone a knee replacement and whose favourite colour is light blue, when compared to Aspirin?” and believe you me, it is unlikely anyone else has researched that topic! Also, if someone has attempted to answer your question, it is worthwhile reading their article. If you find that their methodology is lacking, then you may decide to investigate that topic regardless, albeit with more watertight…

Categories
Feature Articles

A very good iDEA: The inaugural gathering of the student division of Doctors for the Environment Australia

The result of one attendee’s bright iDEA.

In early December 2009, just prior to the much-hyped COP15 round of United Nations climate negotiations in Copenhagen, 40 medical students, representing six states and eleven medical schools, descended upon Melbourne for iDEA, the inaugural gathering for the student division of Doctors for the Environment (DEA). Attendees were encouraged to be mindful of their carbon footprints whilst travelling to the conference, with many students opting for train or coach rather than air travel. Most impressively, three Tasmanians cycled for three days from Hobart to Melbourne University (with the assistance of the Bass Strait ferry).

Education and networking were the focus of this three day gathering at Newman College within the University of Melbourne, where a plethora of distinguished speakers presented talks and interactive workshops to enlighten the receptive minds in attendance: academics, environmental activists, clinicians and all combinations of the three.

All present agreed that it was long overdue that medical students gathered to discuss environmental issues relevant to health; issues that for various reasons have been sidelined by the medical fraternity. These issues often traverse traditional subject boundaries, implying a perceived or real lack of academic expertise. Additionally, the lack of confidence in using one’s ‘authority’ as a medical professional plays a part. Climate change, for instance, is often seen as a political or economic concern rather than a threat to health. Being too busy, self-preservation, fear over allegations of hypocrisy, ignorance, inertia and ‘donor fatigue’ all contribute to the reluctance of doctors to speak up.

According to Costello et al., climate change “is the biggest global health threat of the 21st century” and the repercussions to health will be global in reach, but with a disproportionately large impact falling on the developing world. [1] Matthew Wright, co-founder of Beyond Zero Emissions, a Melbourne-based organisation promoting the rapid transition to a zero carbon future, raised the interesting point that planning for a zero-carbon future is different to planning for a low emissions future, which, in turn, is different to planning for a doubtful emission reduction trading scheme in which concessions are made to big polluters. Although it seems paradoxical, government inaction in the short term could thus be preferable to legislating a hurried, binding scheme, that is in fact ineffectual in preventing an unsafe average global warming of two or more degrees.

Richard Di Natale, a former GP and Public Health physician, provided insight into how one might make the transition from clinician to environmental activist and politician. His non-linear career trajectory has seen him transition through positions in primary care, HIV programme development, Government Health Department bureaucracy and community-building. Most recently, he is persuading Victorian voters to give him the job of a Greens Senator at the next Federal election…

Categories
Feature Articles

Applying the retrospectoscope to an elective: Reflecting on six weeks in Timor-Leste

Timorese girls from the Gleno Orphanage, located about 40km or a two hour drive from Dili in the Emera Mountains. The mobile clinic from Bairo Pite Medical Clinic visited the orphanage monthly.

The medical elective is notorious for being an excuse for taking a holiday in an exotic corner of the world. Like many of my colleagues, I also travelled to one such corner, Bairo Pite Clinic in Timor-Leste (the official name of East Timor), in search of an adventure with some medical experience thrown in. In retrospect, those six weeks were without doubt the steepest learning curve of my medical training. However, there are a number of things I wish I had known and a great number I would have done differently. Therefore please let me share some insights I have gained with use of the retrospectoscope – the device in medicine which enables the viewer to judge past events or actions with the aid of knowledge obtained since they occurred. This is in the hope of equipping you with some knowledge to make your elective experience the time of your life.

Language

I arrived in Dili, the hot, dusty capital of Timor-Leste after an almost sleepless night in Darwin airport and with a four-word vocabulary of Tetun, the local language. Nevertheless, I was almost immediately loaded onto the clinic’s four-wheel drive ambulance to embark on my first of many mobile clinics into the mountains. For such clinics the four-wheel drive is loaded up with a box of very basic medications, and a driver, a doctor or medical student and a medications dispenser drive up to six hours on a road resembling a goat track to a remote village. There, they see a queue of patients – some waiting, some materialising from the surrounding forest- and drive back, often with acutely ill patients. And thus was the experience from which stems my first insight – learn some of the language.

Despite having an ‘interpreter’ – she spoke as much English as I spoke Tetun – I was luckily armed with the Lonely Planet Tetun phrasebook, which I think saved more lives than I did that morning. Daily Tetun lessons, jotting phrases on the back of my hand and the phrasebook ensured I quickly picked up enough language to hold a reasonable medical consultation. Despite this, I wished countless times I knew some Tetun before I arrived in-country. If you are planning on travelling to a non-English speaking country, do try and learn some local language before you depart. Being able to communicate with your patients makes a world of difference.

Pre-Read

After my mobile clinic baptism of fire, I returned to the Bairo Pite clinic in Dili to be confronted with the afternoon ward round, and a lady in the final stages of labour. Prior to my elective I had seen one patient with tuberculosis (TB) and delivered five babies. Score at the end of the first ward round: 67 TB patients and eight babies delivered. I vividly recall returning to my room that night acutely aware of how much I did not know. I sincerely wished then that I had taken the time to read up on the common problems experienced in Timor: tuberculosis, malaria, labour and its common complications and gastroenteritis. A basic understanding of how to identify and manage these conditions in resource poor countries is essential to getting the most out of your elective. The World Health Organisation (WHO) has some great articles on managing these and other health issues specific to the developing world. [1-4] I thoroughly recommend utilising these prior to and during your elective. Along with the Lonely Planet phrasebook these articles saved a number of lives.

Change the World

Before travelling to Timor-Leste, a number of people warned me against thinking I could change the world in six short weeks. And, yes, I completely agree with them, it is not possible. However, do not allow anyone to convince you of the disillusion that you cannot make a difference, but, like chocolate cake, there is a delicate balance between too much and too little. During my time in Timor-Leste, I fluctuated between strategising how to revolutionise their health system and becoming exasperated with the staff, the patients and the system itself.

I only found this happy medium after many discussions with long-serving expatriates, my supervisor, the famous Dr Dan Murphy and a 24 hour flight using the almighty retrospectoscope. Be aware that revolutionising the local health care system includes ensuring nurses actually take observations rather than just filling in normal results; it is amazing how your patient can be saturating at 99% when the clinic does not have a working saturation probe! The work ethic in Timor is much more relaxed than the Australian system, and it is worth remembering that the way you are used to is not necessarily superior and you are the visitor, so embrace and work along with their system. And remember, change on a big scale, if you want it to last, takes time, dedication and education. So if you are planning a revolution, be prepared for your elective to go for six years rather than six weeks.

However, it is also worth noting that you can make a difference for…

Addendum

The arrow head was lodged in the young man’s right atrium. In order to remove it we did a transverse thoracotomy and made a pericardial window. After placing a purse-string around the arrow shaft we removed it, although we had to extend the entry site a small amount in order to remove the barb. Then, we pulled the purse sting taught and oversowed the pericardium (i.e. when repairing the pericardial window you overlap the edges to prevent tamponade in the event of leakage). He made a remarkable post-operative recovery. He was demanding food in an hour and asking when he could go home in two hours! Thankfully he didn’t develop any infections, and because we didn’t open the pleura at all, he didn’t require a post-operative chest-tube. All of this meant he was discharged home after three days. I saw him again about four weeks later and you never would have guessed he had been in hospital, let alone had an arrow pierce his chest!

Categories
Feature Articles

What’s wrong with the Nobel Prize?

Introduction

The Nobel Prize is the single greatest honour that can be bestowed upon a scientist, and yet it has received its fair share of criticism. Even Nobel Laureate, Max Dulbrück, has criticised the Prize stating “by some random selection procedure, you pick out a person and make them the object of a personality cult. After all, what does it amount to?” [1] Recently, there have been calls to reform the Nobel Prizes with ten scientists writing an open letter to the executive director of the Nobel Foundation. [2] This article presents a critical analysis of the Nobel Prize and its role in science, showing that whilst flawed the Prize is still valuable.

The origin of the Nobel Prize

The Nobel Prize is named after Alfred Nobel, who made a fortune in the munitions industry after inventing dynamite. When he died in 1896, Nobel’s estate was worth more than 33 million kronor with one year’s interest from the fortune equal to the annual budget of Sweden’s greatest university. [1] Nobel’s will, written in 1895, dedicated the majority of this estate to prizes for those who had “conferred the greatest benefit on mankind” by making “the most important discovery or invention” in the fields of physics, chemistry and physiology or medicine. In just one short paragraph, Nobel directed how the Prizes should be awarded: the Swedish Academy of Sciences was appointed to award the Physics and Chemistry Prizes and the Karolinska Institute was given responsibility for the Prize for Physiology or Medicine. [3] Nobel also included Prizes in Literature and Peace, but these will not be discussed in detail in this article. For various reasons, Nobel’s will remained in legal peril until 1898 when the Nobel Foundation was finally established as the legal legatee. [4] In 1901, five years after Nobel’s death, the first Nobel Prizes were awarded.

The role of the Nobel Prize in recognising and rewarding great discoveries

The purpose which Alfred Nobel intended his Prizes to serve remains their primary role: to recognise and reward great scientific discoveries. [5] Indeed, one of the reasons that the Nobel Science Prizes now demand so much respect is that their histories give testimony to many of science’s most significant discoveries. Only on a few occasions has a Nobel Prize in Science been awarded for an undeserving discovery. Most notably, Johannes Fibiger won the 1926 Nobel Prize for Medicine for discovering that parasites caused cancer, a discovery which later turned out to be completely unfounded. [1,6] There have also been instances in which outstanding advances in scientific thinking have gone unrecognised by the Nobel Prize. Albert Einstein, although awarded a Nobel Prize for the discovery of the photoelectric effect, received no recognition for his most important achievement, the theory of special relativity. On the whole however, the Nobel Prizes for Science have been awarded for great scientific discoveries. The prizes have found their value in the calibre of their recipients. [5]

The Nobel Prizes for Peace, and in particular Literature, have not fared as well. [1,4] In the early years the Nobel Committee for Literature favoured conventional authors and failed to recognise greats such as Tolstoy. Consequently, the reputation of the Literature Prize was damaged and still suffers. Some suggest that the Science Prizes have enjoyed more success because science is objective, and the selection of Prize winners is less arbitrary than in the subjective fields of literature and peace. This is not the case. The selection process for the science awards is also subjective and may be influenced by the bias of the decision-makers.

Is the decision-making process arbitrary?

The statutes of the Nobel Foundation dictate rules for selecting Prize winners, adding several criteria to those stipulated by Nobel. These can be summarised as follows: [7]

  • Prizes may only be awarded for work that “by expert scrutiny has been found to be of … outstanding importance” and of great benefit to mankind.
  • “The awards shall be made for the most recent achievements in the fields of culture referred to in the will and only for older works if their significance has not become apparent until recently.”
  • “To be eligible to be considered for a Prize, a written work shall have been issued in print or have been published in another form.”
  • Prizes may not be awarded posthumously but a Prize may still be presented if the Prize winner dies before the presentation ceremony.
  • Prizes may be shared between two or three co-workers or between two discoveries but not between more than three people.

The Foundation’s statutes also provide guidelines for nominations and adjudication of the awards. Nominations are not open to the public and to be considered for an award, a written nomination must be received from “a person competent to make such a nomination.” This includes all Nobel Laureates, members of the Prize-awarding bodies (the Swedish Academy of Sciences and the Karolinska Institute) and those invited to submit nominations. [6] Each Prize-awarding body sends out thousands of invitations every year to scientists world-wide, and a rotation system is used to include as many people as possible. Nominations for an award are then considered by a subset of the Prize-awarding body, the Nobel Committee, which consists of three to five persons appointed by the Prize-awarding body. After careful deliberation, the Nobel Committee votes to determine which candidate should be recommended for the award. Although the final…

Categories
Medical Careers

Nicholas Talley: A career of reinvention

Prof. Nicholas Talley

I finished medical school at the University of New South Wales at the end of 1978 wrapping up my course with an inspiring elective at Addenbrookes Hospital in Cambridge, England; they invited me to stay on, but I returned to Australia eager to start my internship, although I had no clear idea of how my career path would progress. I have now been a practicing clinician, researcher and educator for about 30 years; I still love it. Everyone’s personal journey is different, and will be influenced by all sorts of external as well as internal forces, some of which are not under one’s control. However, we all learn lessons from others and perhaps a few pieces of advice will prove instructive.

Plan to periodically reinvent your career

Re-invention and renewal is the course I have chosen. I spent four years as a resident and medical registrar learning how to become a competent hospital based clinician from 1979 to 1982. I then decided I wanted a break; I was offered a research position with an outstanding academic (Prof. Douglas Piper) and decided to give it a go. I spent three very happy years from 1983 to 1985 undertaking a PhD at Royal North Shore Hospital in Sydney, then a further year as the Professorial Registrar at the hospital, years when I wrote the first editions of my most popular books, as I’ll describe later.

I developed a passion for generating new knowledge and publishing it, so I next decided to move to the United States (US) to join an outstanding expatriate Australian (Prof. Sidney Phillips) for further mentorship and training. I expected to stay a year but instead spent seven years in Rochester, Minnesota, initially as a Research Fellow at Mayo Clinic for 18 months and then as a junior faculty member (first as Assistant Professor, then Associate Professor – if you are productive, you can rise very rapidly in the academic ranks in the US).

In 1993, I returned to Australia to take up a new post as Foundation Professor of Medicine at Nepean Hospital, which had just been designated a new Teaching Hospital of the University of Sydney; I was 37 years old, had virtually no administrative experience and was charged with the daunting task of developing teaching and research plus new clinical departments in a hospital that didn’t even yet have a physicians training program. I spent nine exciting years developing a fresh dynamic Division of Medicine, introducing the new graduate medical program and actively engaging in research, education and clinical practice.

At the end of 2001 I was offered an opportunity to return to Mayo Clinic in Rochester for a period to pursue a new research passion; I wanted to focus on gene hunting in the functional bowel diseases. As I really knew little about how to do this, I initially undertook a Masters degree in genetic and molecular epidemiology at the University of Newcastle online; I learnt a lot about medical education trends being a virtual student! I had planned to be away about a year, but again was enticed to stay, even though returning to Mayo Clinic in 2002 required me to re-start my research program from scratch once again. I spent four years focused on building my research team and program.

In 2006 I was tapped on the shoulder to become the Chair of the Department of Medicine at Mayo Clinic Florida. My charge was to transform the Department into a cohesive academic entity, and I have focused on building teamwork and ensuring financial success while expanding teaching and research. The administrative experience in Florida has been exhilarating; I have learnt more about the science of leading and managing than at any other time in my career. My next (but hopefully not my last) transformation will take place later in 2010; I have decided to move back to Australia to take up the post of Pro Vice Chancellor (Health) at the University of Newcastle, where I will strive to make a positive difference in terms of research and education across the health faculties and in the country.

Strengthen your written and verbal communication skills

Some have asked me how I came to write medical textbooks so early in my career. Frankly, it was the combination of falling upon a good idea, a little luck, and a good team. I saw while having the pleasure of sitting the Fellowship examination for the Royal Australasian College of Physicians (FRACP) that there was an acute need for better guidance on how to prepare for this difficult test. I also recognized many useful clinical examination techniques were poorly discussed in the available textbooks; a detailed systems based approach was largely lacking. At the party celebrating my passing the FRACP exam, I invited Simon O’Connor to join me as a co-author; I knew his wit and style would help add life to the planned manuscript, plus I felt a team would be better equipped to cover the waterfront (and having a co-author…

Categories
Book Reviews

The iPhone: Is it an indispensable tool for medical students?

Technology is always presenting us with new ways of going about our daily lives, and our inability to be separated from our mobile phone, internet or online social networking is growing. Some technology has become obsolete and fallen into obscurity, while some has never caught on. One that definitely has, though, is Apple’s iPhone. As medical students, smartphones have the potential to revolutionise our education and training, and one heavy contributor to this is Apple’s growing library of medical ‘apps’ (applications made specifically for iPhones).

‘Medical’ is a headline category on the iPhone App Store, right next to Utilities, Lifestyle and Games. It is even separate from Healthcare and Fitness – something a good chain bookstore is yet to figure out. Entering this category brings up a multitude of free and paid apps that will be of interest to practicing physicians, medical students or other health care professionals. Finding an app to suit one’s needs is made even easier by using one of several online app directories. Apps can do everything from looking up reference values, differentiating between types of arrhythmias to performing useful calculations. While this article cannot hope to delve very far into the thousands of medical apps available, what follows is an overview of some of the most popular ones, which may prove useful for the uninitiated.

The app ABG, or Arterial Blood Gas, can help in the sometimes complicated world of blood gases; simply type in lab values to determine if an acidosis is respiratory or metabolic in nature. Instant ECG (electrocardiogram) displays rhythm strips of many common arrhythmias to study and then provides a quiz to consolidate learning. General Medical History categorically runs through all the questions one should ask to take a medical history. It is very comprehensive, and could be particularly useful for junior medical students who are still becoming familiar with the basics of history-taking. However, pulling out an iPhone in front of a patient, let alone a clinical supervisor, will no doubt fail to convey the best impression.

Some of the big names in textbooks have already made their way to the iPhone platform. The Netter’s series of texts is available, including very handy anatomy flashcards. These are an ideal way to brush up on anatomical identification skills while commuting or waiting around. However, some may find that the size of the screen does not do justice to Netter’s famous illustrations. The Merck Manual of Diagnosis and Therapy is a guide on the essentials of diagnosis and treatment. Taber’s Medical Dictionary is perfect for a mental block on what Klippel-Trenaunay-Weber Syndrome actually is. The original Gray’s Anatomy is right amongst the lineup in all its pencil-rendered beauty. However, while it does have a search function, it does not have a table of contents, which is a major oversight. Medscape, Epocrates and Skyscape are bundled apps which include medical calculators and continually updated drug and clinical references – a veritable all-in-one reference for clinicians on the go. Epocrates even has a drug identification tool to allow you to identify a patient’s pills.

The Australian-specific content is also increasing. Frank Shann’s Drug Doses promises to end the suffering of those who need a little reminder just how many mg/kg of fentanyl to give a child. Likewise, MIMS Australia now has their product available for the platform, allowing healthcare professionals to look up entire product information. Most of the calculator programs such as MedCalc have the ability to change units, allowing the user to easily modify the program to suit the needs of an Australian medico.

One of the drawbacks is that some apps are just not in an affordable price range for many students (Table 1). Netter’s Anatomy Flashcards is priced at $47.99, MIMS is an explosive $170, and some, such as Frank Shann’s Drug Doses at $23.99, are over double the price of the hardcopy version. However, some of the helpful ones are free, such as Medscape and Skyscape, and there are always useful medical apps on sale. Epocrates has several tiers of its product. The basic version is free, and includes features such as a drug interaction checker and pill identifier. However, to obtain features such as disease images and a medical dictionary, a subscription is required, ranging from US$99 to US$199 depending on the features required.

Another major drawback to some of these apps is that they consume considerable amounts of storage space, such as Gray’s Anatomy at 402…