Category: Articles

Medical students in Aboriginal Community Controlled Health Services: identifying the factors involved in successful placements for staff and students

Post author By Website Publications Officer
Post date April 15, 2018

Abstract

Background: To identify the facilitators and barriers to positive medical student placements at Aboriginal Community Controlled Health Services (ACCHSs).

Materials and Methods: A total of 15 focused interviews were conducted with medical students from Victorian universities and staff from two Victorian ACCHSs. Staff and students were asked about their expectations of students’ placements; the learning outcomes for students; the structural elements that have an influence on student placements; and the overall benefits and challenges of placements within these settings. This data was then thematically analysed.

Results: The study found that student placements in ACCHSs were of benefit to both the student and the organisation. However, areas for improvement were identified, including avenues for administrative assistance from universities in managing placements and clarifying expectations with regard to learning objectives. Overall, it was the opinion of participants that placements in this setting should be encouraged as a means of medical and cultural education.

Conclusion: The study contributes to building an understanding of the elements that lead to good practice in student placement design, and developing relationships between medical schools and ACCHSs. The study provides grounding for further research into the development of a framework for assisting successful student placements in the ACCHS setting.

Introduction

Medical education can be a powerful tool for social reform [1]. The teaching that occurs within medical schools, and the manner and context in which it is delivered, has the potential to influence the practice of future doctors and have an effect on addressing social inequities. One of the greatest heath inequities in Australia is between Indigenous and non-Indigenous Australians [2].

In an effort to address this health disparity, there has been increasing emphasis on the teaching and learning of Indigenous health issues in medical schools within Australia, with a range of initiatives guiding the development and improvement of the medical curriculum and associated activities [3,4]. One of the most significant is the inclusion in 2006 of Indigenous health in the Australian Medical Council’s guidelines for Assessment and Accreditation of Medical Schools [5]. An important element of the Standards for Accreditation is the emphasis on offering student placements in Aboriginal Community Controlled settings and the development of relationships between medical schools and Aboriginal Community Controlled Health Services (ACCHSs) to facilitate this (see Standards 1.6.2 (regarding effective community partnerships) and 8.3.3 (regarding exposure to culturally competent healthcare) [6].

Student placements in such a setting offer an opportunity for students to develop cultural competency in the area of Indigenous health. This was outlined in the National Best Practice Framework for Indigenous Cultural Competency in Australian Universities as a critical area of need, and defined as:

“Student and staff knowledge and understanding of Indigenous Australian cultures, histories and contemporary realities and awareness of Indigenous protocols, combined with the proficiency to engage and work effectively in Indigenous contexts congruent to the expectations of Indigenous Australian peoples [7]”.

While ACCHSs have played host to medical students for some time, there has been little formal research regarding ACCHS as a setting for student placements, locally or at other universities across Australia [8-11]. The purpose of this study is to investigate the key facilitators and barriers to positive medical student placements in this sector.

Methods and analysis

Participants for this research included Victorian medical students who had completed a placement at an ACCHS and staff members of Victorians ACCHSs who had been involved in medical student placements. Students were recruited on a voluntary basis by responding to an electronic noticeboard announcement. ‘Snowball’ sampling was also employed. A total of seven student interviews were recorded. Of these, six had been involved in placements in ACCHSs, and one in a remote Aboriginal community government-run health service. The duration of placements ranged from one to six weeks, and were conducted in ACCHSs located across Australia in Queensland, Victoria, New South Wales, Western Australia, and the Northern Territory.

The ACCHSs involved in this study were all located in Victoria and selected on the basis of having a pre-existing relationship with the University of Melbourne. Each organisation provided approval for involvement in the research following internal protocols, and staff members were nominated by the ACCHSs on the basis of their direct involvement in medical student placements. A total of eight interviews were conducted with the staff members from Victorian ACCHSs.

Data for this project was collected through a series of one-on-one semi-structured interviews with participants, conducted by the first author, either in workplaces of participants or university campus interview rooms. Interviewees understood the context and purpose of the research, as explained prior to interviews. Interview questions focused on the benefits and challenges both groups experienced during student placements at the services. Transcripts were returned to participants for comment and correction.

The data gathered from the transcribed interviews was arranged according to questions asked, and then further under thematic headings. Shared themes were derived from the data, without use of supportive software.

This project was conducted as part of the Scholarly Selective program of the University of Melbourne Doctor of Medicine. The first author at time of writing was a fourth-year postgraduate medical student, supervised by two experienced researchers. Ethics approval for this project was obtained through School of Population and Global Health Human Ethics Advisory Group of the University of Melbourne (approval no. 1443395).

Results

In total, 15 interviews were recorded for this research. All students were studying medicine at universities in Victoria. The ACCHS placements were undertaken as either GP placements or electives. Staff from the ACCHSs had a variety of roles including general practitioner, nurse, Aboriginal health worker, medical director, clinical director, and executive director of health services. Points of discussion arising from the data fell largely under six major themes:

Student exposure
Burden on health services
Interpersonal value
Community benefits
Educational value
Student engagement

All participants, on direct questioning, agreed that medical student placements in ACCHSs are important. The data was, therefore, considered on the basis that there is strong support from both students and staff to make these placements a positive and constructive experience for all.

Student exposure

A strong theme that emerged from the responses of both groups was that these placements offered medical students practical exposure to Indigenous health, culture, and community, with several students stating that they offered an important insight into Indigenous health that was not possible through theoretical teachings delivered elsewhere in the curriculum:

“I mean, you hear it, you read it, and so you know it superficially, but when you’re sitting in front of multiple people who can tell you the details of their story, you get a much better understanding as to why these families have had opportunities denied to them” (Student 6).

Students and staff also recognised that placements provided an opportunity to teach students about the ACCHS model of healthcare, which involves not only the delivery of medical services, but also health prevention, social outreach and advocacy programs that address the social determinants of health [12-15]. For one Aboriginal health worker, the value lies in teaching the principles of self-determination upon which ACCHS are founded [15]:

“I just like the fact that they’re in our setting, our community, and learning from us, not being told by someone else that this is how it is” (Staff member 6).

Community benefits

Staff and students cited the potential benefits for Indigenous communities, such as recruiting medical staff and strengthening ties between the medical profession and Indigenous communities, as a primary benefit of student placements:

“… we see it as an opportunity to expose people to what it’s like working in Aboriginal health, and that helps us with recruitment” (Staff member 8).

Several staff and students commented on the role of placements to promote awareness of ACCHSs amongst the medical community, thereby increasing the likelihood of referrals and support for the services:

“… it’s very good for the organisation and the community to see that students come here to learn because it gives them the message that this is a place of excellence … I think that builds confidence on their part in the service” (Staff member 8).

In addition, placements provided ACCHSs and their patients the opportunity to engage in the medical education process:

“… it makes medical education more transparent for Aboriginal people … and in turn I think that has the potential to create more trust between the patient and the doctor in Aboriginal health centres” (Student 6).

Participants also saw that placements could have a broader impact on the healthcare system outside of the ACCHS setting, in that the students who have had this experience would go on to work in practices and hospitals across the country in a more culturally appropriate way. As such, these placements are “… seeding the medical workforce with people who have some understanding and experience in Aboriginal health” (Staff member 4).

Burden on health services

Participants recognised that the administrative and organisational duties required for placements were very time-consuming, and that supervising students put pressure on practitioners’ time, increasing delays for patients and overall demand on the practice. The administrative duties for ACCHS staff include scheduling time for teaching, co-ordinating the student’s timetable to allow them to spend time in various parts of the organisation, and working through requests for placements from different universities and faculties.

Many of the challenges that students experienced in their placements related to how well the organisation was able to handle these tasks. This was, as several students noted, a feature of clinical placements that is not unique to the ACCHS setting. Challenges for some students included an apparent lack of structure to the placement, staff being unaware in advance of the student’s arrival, finding the clinic to be underprepared for the student or understaffed, or doctors simply not having the time available to teach the student. As one student commented, the service was, “… definitely very welcoming … but they were very space-limited and time-limited in terms of how much attention they can pay to students” (Student 6).

Several students mentioned the value of a careful introduction and orientation to the practice as a way of helping students to feel comfortable in the new environment, and as a result, improving student engagement and relieving some of the administrative stress on the organisation:

“If the host organisation gives a good introduction to the student, it will be easier for them right the way through the placement because the student will know what they’re doing and where they fit, so they won’t be constantly having to direct them” (Student 6).

Educational value

Responses in regards to the education value of the placement varied both between and within the two groups. Most staff at the ACCHSs were generally very happy with the educational experience they provided, not only in terms of general practice knowledge, but also holistic care, community medicine, and Aboriginal culture. Several staff, however, recognised that the emphasis placed on cultural and holistic care may not have been in line with what students expected from placements:

“… I don’t know if they come with that same perspective of the holistic model of care … yes, the clinical side is important, but that’s not the whole reason why they’re coming to [ACCHS]s” (Staff member 2).

Conversely, some of the staff interviewed said that some students were surprised by the degree of emphasis placed on the general practice aspect of the placement.

While all students reported that the placement had been a valuable learning experience, more than half of those interviewed commented that in terms of examinable material for a general practice rotation, the ACCHS placement was perhaps not as rewarding as a placement in a ‘mainstream’ practice:

“I don’t think I learned a lot of examinable material” (Student 3).

One student noted the fact that the longer consultations, which staff regarded as a virtue, meant fewer patients were seen, and the opportunity for learning through repetition was diminished on a purely quantitative basis.

In contrast to the opinions of some of their peers, several students stated explicitly that they believed the educational experience was better for being in an ACCHS setting, and many said that the cultural and community teachings had enriched their learning.

“I can only say that I think if anything it was an advantage because not only did I get the clinical experience I also got the community, social aspect of it as well which might be harder to grasp if you hadn’t done that” (Student 1).

This discrepancy in opinions to some extent reflects a differing of expectations both within the student group and between the students and staff.

Student engagement

Participants were asked what they defined as a ‘successful’ placement. Responses from students varied, and largely focused on basic principles of medical education such as patient contact and fulfilling the curriculum requirements, but also included having clear expectations and an orientation to the ACCHS.

While staff responses also varied, the majority of comments related to student engagement—with the staff, the service as a whole, and with the community:

“If … I get a sense that they’re starting to integrate with the broader team … that sort of marrying in with the team well, I think, is a very good sign” (Staff member 8).

Several staff commented that students who were confident in the ACCHS and able to seek out their own learning opportunities were ‘easier’, more engaged and more likely to be active learners:

“Some of them are much easier and more outgoing. Whereas some of them you have to spend a bit of time engaging and making them feel confident…that’s not a bad thing but it’s harder work” (Staff member 5).

Interpersonal value

The value of the human interactions that arose from placements emerged as a common theme in the interviews. Several students spoke of the relationships with staff, and the trust that developed with community members returning to the clinic, as particularly rewarding experiences:

“I got to see a number of patients quite a few times so that made it a very good learning experience, and a lot of the patients were very trusting, and so I got to do a lot in terms of their care. That … was really rewarding” (Student 6).

Staff from the ACCHSs spoke enthusiastically of having engaged students around the clinics and the organisations more broadly:

“It’s enjoyable, honestly, to see someone who wants to come here and work with Aboriginal people” (Staff member 7).

They cited the benefits of a fresh perspective on health, a new skill set, at times a helping hand, and importantly, a sense of goodwill toward the Indigenous community and the health organisation in the form of a demonstration of interest in Indigenous people and their health.

Discussion

Major benefits and challenges

This study highlights strong support for student placements in ACCHSs. The most commonly cited reasons for this support centre on the ability to offer students first-hand experience in an Aboriginal community health setting, and the reciprocal benefit to the community in creating a more culturally educated workforce.

The challenges reported by staff and students emphasise areas in need of improvement in the placement process, and provide a foundation for refinement. The foremost of these is the administrative and organisational burden on the health services, how the co-ordination of placements can be improved, and what the implications are for the relationships between universities and ACCHS in this process. Nelson et al [10] suggest that there is a role to be played by university-appointed administrators to assist ACCHSs in the processes required to ensure students and the ACCHSs themselves are adequately prepared for placements. Their study highlights the positive feedback received when such appointments have been made, and the interviews here reinforce the message that good preparation and coordination improves the experience of both staff and students [10].

Orientation

Ensuring that students feel both socially and culturally oriented in the placement environment is an important element of a successful experience for both staff and students. Students who feel at ease, or more confident in the environment, tend to be more proactive with their learning, and less demanding on the organisation. An important way of fostering this is through a formal orientation.

At the sites where an orientation was undertaken and involved specific cultural awareness training, students felt more confident and engaged. While this responsibility sat with the ACCHS, several participants noted that cultural awareness training should be a core part of medical education in the university environment. Preliminary training would then be the basis for, and be complementary to, the localised and more specific learning provided once students are in the ACCHS setting. Improved coordination between the universities and the ACCHSs is therefore important to ensure that appropriate training and orientation is completed before the student begins their work in the clinical environment.

Educational value of placements in ACCHSs

A successful placement requires that all parties have a clear understanding of the nature and purpose of the placement, with shared expectations of learning objectives. Most placements are either part of general practice rotations or student-initiated electives. While the interviews included positive accounts of both types of placements, the flexibility of student-initiated electives was noted as an advantage in the ACCHS context. Electives, as distinct from other in-semester rotations, are not intended to fulfil precise curriculum requirements, and allow students to engage more freely in learning about Indigenous health and culture and the broader healthcare delivery services provided by ACCHS. However, participants also noted the importance of ACCHSs being included in general practice rotations. It must also be recognised that the medical curriculum is not limited to clinical decision-making, and the educational value of these placements should not be restricted to these domains.

Selection of students

The administrative burden and over-demand for student placements in ACCHSs raises the issue of whether students should be required to demonstrate an interest in Indigenous health to be granted a placement, a requirement that already exists in some ACCHSs. The interview data clearly identified that the burden on the heath service was greater if students were unenthusiastic, disinterested, and unable to self-manage. Approximately half the respondents agreed that an expression of interest should be requisite. The remainder of respondents suggested that those students who do not express an interest in Indigenous health placements might have the most to gain from the experience. Adequate orientation may provide a solution in terms of familiarising the student, managing expectations, and facilitating a positive experience for the student and health service.

Limitations

This study was limited in its breadth by the nature of the research as a University of Melbourne Scholarly Selective project. The study therefore had limited scope and a small sample size, and while strongly-shared themes arose from the data, the interviews did not reach saturation. The authors also acknowledge that students interviewed had all voluntarily selected Aboriginal health placements, and therefore a selection bias may exist with regard to their views of the value of these placements. The authors further acknowledge that while students interviewed were placed in ACCHSs across Australia, the ACCHS staff were from Victorian ACCHSs only, and therefore the placements they describe are not necessarily shared experiences. No community members visiting the ACCHSs were interviewed. Their opinions on the presence of students in the organisations may form a basis for further research.

For ACCHSs to continue to be an active part of medical education, as mandated by the AMC, it is important to ensure that they have the resources to provide a good learning environment, and that the presence of students is not an impediment to the organisations. Placements should contribute to cultivating trust between Indigenous communities and the medical profession, and this is more likely with careful planning and co-ordination of placements. It is hoped that the findings of this research will help guide student placements into the future and contribute to ensuring a mutually beneficial system. Further research and larger trials in this area may include investigation of the perspectives of community members on the presence and engagement of students in ACCHSs, as well as a deeper exploration of the effects of student placements in other settings, including remote areas.

Conflict of interest
None declared.

Abbreviations and notes

ACCHS- Aboriginal Community Controlled Health Service

* Note: the term ‘Indigenous’ is used in this article to refer to the Aboriginal and Torres Strait Islander peoples of Australia.

St x– student no. x

Sf x– staff member no. x

References

[1] Murray RB, Larkins S, Russell H, Ewen S, Prideaux D. Medical schools as agents of change: socially accountable medical education. Med J Aust. 2012;196(10):653.

[2] Australian Bureau Of Statistics. Experimental life tables for Aboriginal and Torres Strait Islander Australians [Internet]. 2007 [updated 2013; cited 2015 October 10]. Available from:

[3] Mackean T, Mokak R, Carmichael A, Phillips GL, Prideaux D, Walters TR. Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential. Med J Aust. 2007;186(10):544-6.

[4] Phillips G. CDAMS Indigenous health curriculum framework [Internet]. Melbourne: VicHealth Koori Health Research and Community Development Unit; 2004 [cited 2015 Jan 5]. Available from: http://www.limenetwork.net.au/files/lime/cdamsframeworkreport.pdf

[5] Australian Medical Council. Assessment and accreditation of medical schools: standards and procedures [Internet]. 2006 [cited 2011 Nov 10]. Available from: http://www.amc.org.au/forms/Guide2006toCouncil.pdf

[6] Australian Medical Council. Standards for assessment and accreditation of primary medical programs by the Australian Medical Council [Internet]. 2012 [cited 2015 Jan 6]. Available from: https://www.amc.org.au/files/d0ffcecda9608cf49c66c93a79a4ad549638bea0_original.pdf

[7] National best practice framework for Indigenous cultural competency in Australian universities [Internet]. Universities Australia Indigenous Higher Education Advisory Council (IHEAC); 2011 [cited 2015 Jan 6]. Available from https://www.universitiesaustralia.edu.au/uni-participation-quality/Indigenous-Higher-Education/Indigenous-Cultural-Compet

[8] Weightman, M. The role of aboriginal community controlled health services in Indigenous health. Australian Medical Student Journal. 2013;4(1).

[9] Ross S, Whaleboat D, Duffy G, Woolley T, Sivamalai S, Solomon. S. A successful engagement between a medical school and a remote North Queensland Indigenous community: process and impact. LIME Good Practice Case Studies. 2013;2:39-43.

[10] Nelson A, Shannon C, Carson A. Developing health student placements in partnerships with urban Aboriginal and Torres Strait Islander Community Controlled Health Services. LIME Good Practice Case Studies. 2013;2:29-34.

[11] Patel A, Underwood P, Nguyen HT, Vigants M. Safeguard or mollycoddle? An exploratory study describing potentially harmful incidents during medical student placements in Aboriginal communities in Central Australia. Med J Aust. 2011;194:497-500.

[12] Marles E, Frame C, Royce M. The Aboriginal Medical Service Redfern – improving access to primary care for over 40 years. Aust Fam Physician. 2012;41(6):433-6.

[13] Panaretto KS, Wenitong M, Button S, Ring IT. Aboriginal community controlled health services: leading the way in primary care. Med J Aust. 2014;200(11):649-52.

[14] Bartlett B, Boffa J. Aboriginal Community Controlled comprehensive primary health care: the Central Australian Aboriginal Congress. Aust J Prim Health. 2001;7(3):74-82.

[15] Davis, M. Community control and the work of the national aboriginal community controlled health organisation: putting meat on the bones of the ‘UNDRIP’. Indigenous Law Bulletin. 2013;8(7):11.

Tags Aboriginal Community Controlled Health Services, placement, In-digenous, student, medical education

Original Research Articles

Mistreatment in Australian medical education: a student-led scoping of experiences

Post author By Website Publications Officer
Post date April 15, 2018

Abstract

Background:
Evidence of bullying and harassment of medical students and junior doctors has existed for over 30 years. However, there has been little attempt to explore the dimensions of this issue in Australia to date. Given the evidence which indicates that experiencing abusive behaviour has a detrimental effect on professional identity formation and on mental health, the Australian Medical Students’ Association (AMSA) undertook a national scoping study to better understand the experiences of Australian medical students.

Methods:
We conducted a mixed methods survey of the 16,959 students enrolled in a medical degree at an Australian university in 2015. An anonymous, voluntary online questionnaire was distributed through AMSA’s social media, email newsletter and website, and medical students’ societies.

Results:
We received 519 responses, including 194 (37%) detailing at least one incident of bullying or harassment. 335 (65%) survey respondents were women and 345 (67%) were in the clinical years of their training. 60% of all respondents reported experiencing or witnessing mistreatment during their medical education. The most common theme in the free text was belittlement of the student’s competence and capacity to be a good doctor. Some gave details about how universities failed to prevent or appropriately respond to students’ experiences of bullying and harassment.

Conclusion:
In line with international data, this study shows that many Australian medical students perceive mistreatment as an important problem that is not always managed well by faculties. Multi-pronged policy and practice responses are needed to instigate cultural change in Australian medical education.

Introduction

“How can we care for our patients, man, if nobody cares for us?”
— Chuck the Intern, The House of God, Samuel Shem [1].

Evidence of bullying of medical students and junior doctors has existed for over 30 years in the United States and the United Kingdom [2-7]. In Australia over the past two years, the topics of bullying, teaching by humiliation, and sexual harassment in Australian medical training have attracted attention both from the mainstream news media and within the profession. There is also some formal evidence about the extent of this problem nationally. A recent local study of “teaching by humiliation” found 74% of medical students reported experiencing this practice and 84% witnessed it [5].

Worldwide, similar studies have shown that any student can be affected, regardless of gender or race [8-10]. The most common form of mistreatment reported is covert, mostly in the form of belittling, exclusion or humiliation, rather than overt yelling or violence [4-6,11]. Sexual harassment is the most common form of documented incident [12-14]. The perpetrators of bullying are most commonly senior male clinicians [4,15]. Under-reporting is the norm, especially when the perpetrator of mistreatment is the student’s clinical supervisor, due to fears about the possible impact on career progression [4,10].

There is evidence that experiencing abusive behaviour causes harm both to the student and later, potentially, to their patients (and colleagues). Other research has demonstrated how a student’s developing identity affects their subsequent career progress, employability, and performance [17-19].

Mistreatment may be a contributor to the high levels of psychological distress found among medical students. Studies have shown that rates of such distress are three times higher among medical students than the general population (9.2% and 3.1% respectively), and that female medical students were more likely than male students to have considered suicide in the past twelve months, with 4.5% having attempted suicide. In particular, Indigenous students found bullying to be a substantial source of stress [16].

The exact nature of bullying and discrimination can be difficult to define. Through this research, we determined which incidents students found distressing, and what they considered to be bullying or discriminatory behaviour.

Prompted by an increase in reports of mistreatment from Australian medical students following media attention to the issue, the Australian Medical Students’ Association (AMSA), in association with the Sydney School of Public Health (SSPH), undertook scoping research to better understand the experiences of Australian medical students.

Rather than confirm the prevalence of abuse, demonstrated by previous research and by the Report of the Senate Inquiry into Medical Complaints Processes (2016) [20], we aimed to explore aspects of students’ experiences and their responses.

Methods

Study design and sample
As the only other previous survey of this issue in Australia was distributed to students from two medical schools only [5], our study aimed to reach a wide variety of students from all Australian medical schools and to confirm that previously published findings were generalisable nationally. For this reason, a survey was chosen as the medium for this research as it could be easily disseminated nationally online.

Medical students aged 18 and older who were enrolled in an Australian University between the 25th of August and the 5th of November 2015 were surveyed. The survey was an anonymous, voluntary online questionnaire using REDCap survey software (Vanderbilt University, Tennessee, USA) (see Supplementary Materials online).

The survey link and description were distributed through AMSA’s official Facebook page, Twitter account, website, and email newsletter (“Embolus”). Some medical schools’ student societies, as well as individual participants also shared the survey link.

The questionnaire contained four parts. Part one collected demographic information. In part two, respondents rated their perception of the extent of five categories of mistreatment — “general bullying”, “sexism”, “disability discrimination” (including mental illness), “racism”, and “homophobia” — in Australian medical education, by moving a pointer on a scale from 0 to 100. In part three, respondents rated the attributes of incidents they had witnessed or experienced and were then invited to use free text boxes to describe these incidents. They were also asked about their response to these incidents. In part four, students could describe what actions they felt AMSA could take in response.

The project received ethics approval from the Human Research Ethics Committee (HREC) of the University of Sydney [Protocol number 2015/642].

Data and statistical analysis
Basic demographic information about the respondents was reported, along with the proportions who reported experiencing or witnessing mistreatment. We tested whether experiencing or witnessing mistreatment was associated with gender, age, enrolment, sexuality, and training stage using Fisher’s exact test and Pearson’s chi-squared test. Boxplots were created based on the levels of agreement scales in part two. Differences in levels of agreement between subgroups of respondents were tested using two-sided exact Wilcoxon rank sum tests (gender, enrolment, and sexuality) and Kruskal-Wallis test (age), as the data were negatively skewed (Figure 2). These analyses were performed in R version 3.2.4 [21]. No adjustment has been made for multiple statistical comparisons.

Authors A-KS, EB and KI independently conducted an initial close coding of the open text responses with advice from CH. The taxonomies and categories developed in this process were then reviewed by the research team for comparison and reliability, and a primarily taxonomic thematic coding structure was agreed upon [22,23]. This was then applied to the free text data.

Results

We received 531 completed surveys. Twelve surveys (2%) were excluded as they contained demonstrably unreliable answers or answers unrelated to medical education, leaving a sample of 519 surveys (Figure 1). The respondents were predominantly female (65%), young (median age of 24 years), local students (90%), and at the clinical stage of their training (67%) (Table 1). Each Australian medical school was represented.

**Figure 1.** Number of surveys included and number of incidents of mistreatment described in check box responses or free text.

It was reported by 60% of all respondents that they had witnessed or experienced adverse treatment (Table 1). Adverse treatment was more likely to be reported by: female than male students (64% vs 53%), older than younger students (79% for 35 years and older vs 55% for 20-24 years), non-heterosexual than heterosexual students (75% vs 58%), and clinical than pre-clinical students (70% vs 40%).

For the five categories of mistreatment (general bullying, sexism, disability discrimination including mental illness, racism, and homophobia), females reported greater problems in medical education than males (p≤0.004) (Figure 2). Non-heterosexuals tended to report greater problems than heterosexuals, particularly regarding homophobia (p<0.001). International students believed mistreatment was less of an issue in medical education than local students for all categories, except racism, though differences were small (p>0.05), and there were no consistent patterns with age (data not presented).

**Figure 2.** Boxplots of responses of 519 medical students to statements that general bullying, sexism, disability discrimination, racism and homophobia are a problem in medical education.

Information about 301 incidents involving mistreatment was given by 194 students (Figure 1). In 92% of incidents, the victim was a student (Table 2). The respondents nominated consultants as the primary instigator in 46% of the incidents. Belittlement, condescension or humiliation were present in 65% of the incidents. Most students (68%) reported they did not react (that is, take action in response) to the event. Two major reasons for not reacting were not knowing what to do, and fear of repercussions. Most students were bothered by the incident, with only 4% moving the slider scale from “a little” bothered to “not at all”. Over a third moved the slider to the lowest tenth of the scale, described as “very much”.

**Table 1. Demographics of 519 survey respondents and the proportion who witnessed or experienced mistreatment in medical education.**
Reported p values are for tests of independence between experiencing/witnessing mistreatment and gender, age, enrolment, sexuality and training. Fisher’s exact test was used for gender and training, and Pearson’s chi-squared test for enrolment, sexuality and training.
*There is 1 missing value.

Of the 519 respondents, 168 submitted text descriptions of individual events (Figure 1). Of these, 41 described two events, 14 described three events, and ten described four events. In total, 267 events were described. Themes captured by coding the text responses included the type of event, the perpetrator, the situation and context, aspects that compounded the situation, and any potential outcomes of the event.

The most common theme was the denigration of the student’s competence and capacity to be a good doctor.

“The senior registrar in this instance verbally abused the student regularly, claiming that it was inconceivable that she would one day be a doctor and would cause great harm to potentially anyone she would treat.”

A commonly used framing motif was that the recipient was unworthy, should not have been allowed entry into medical school, or should make way for those who are actually fit to be doctors. The stories included examples of discrimination in all the social categories we investigated. One of the most common was the perceived incompetence or unworthiness of women.

“When we got it wrong, he would tell us we were stupid, we should drop out of medicine because we’d never make a good doctor, or there was no point trying, because we’d quit later to have babies like women should.”

“I was a new mother… and was told by another student I should be at home looking after my child instead of wasting a place at medical school that would have been better off given to someone else.”

A minority of the comments were on non-medical themes such as attractiveness, racial stereotypes, or perceived promiscuousness of the student.
“I would hear jibes about ‘Indians taking over the healthcare system of Australia’ and how ‘No one could understand their curry accent so they shouldn’t be able to work in this country.”

“All the women in our class [were] being scaled on ‘crazy versus hot.’ [The respondent was] followed into a women’s toilet and told to get down on my knees and ‘suck my dick’ while [a male medical student] grabbed his crotch.”

The more the abuse was related to medical practice or competence, the more respondents constructed it as acceptable or understandable.
“The taunts were often unrelated to medicine which made it even more unprofessional.”

Harm and suffering
Implicitly or explicitly, almost all of the 267 free text stories indicated that the recipient(s) of mistreatment were negatively affected as a result. Some accounts directly indicated that teaching by humiliation inhibited rather than enhanced medical learning, decreasing confidence and stopping the student from seeking out further educational opportunities from medical staff.
“Instead of attempting to teach the student in any way, she would harangue the student with increasingly difficult questions — lambasting her further with every question she answered incorrectly… this destroyed the confidence of the student in question quite quickly, to the point where she was afraid and unwilling to go to her clinical placement and learn for fear of the treatment she would receive the next day.”

“I understand that his motivation is to encourage us to be thorough, safe doctors. However, I was so scared at being yelled at for getting an answer wrong in his tutorials that I didn’t learn anything.”

Perpetrators

Students
Of the 38 responses indicating students as perpetrators, the same frame of medical incompetence and unworthiness was common.
“A fellow student kept on telling me that I was stupid and inept and kept saying things like if you don’t know this that (sic) you [don’t] belong in medicine … he threatened to hit me if I continue (sic) doing idiotic things.”

Faculty
We did not include the faculty as perpetrators in our questionnaire. Nevertheless, we received 22 responses citing medical school faculty (including both non-clinical staff and clinical staff in non-clinical roles) as reported perpetrators. These most often related to mishandling of reports of bullying, refusal, or inability to make reasonable allowances for mental illness or disability, and instances of discrimination against students.
“I was told that I was at risk of failing, had my depression called ‘your condition’ the whole time, making me think it was dirty or bad since it couldn’t even be addressed … They said to ask them any questions and the school of medicine would do everything it could to support me, but when I directly asked what they could offer they had nothing.”

Some respondents expressed disappointment and frustration at feeling unsupported by staff.
“The direct inaction by my university nearly led to my suicide … For me the only way I thought the Uni would notice my problem would be if I was to kill myself. Thankfully I pulled myself out of it and am still fighting week in week out to keep myself going.”

Often, students reported faculty promising support to the student, but providing no support or enacting no change. Other responses cited direct bullying or discriminatory action from the faculty towards the student.
“We get mistreated by the very people that are in control of our assessment/progression. How can you complain against the very person that controls your future? It’s just easier to endure it.”

**Table 2. Details of 301 incidents of mistreatment reported by 194 medical students.**
*The number of incidents with this question answered. **More than one response could be selected therefore the percentages do not sum to 100. *** “Other” includes (from most to least frequently reported) intrusive/unwanted questions, refusal to make reasonable allowance for the needs of others, threatening failure/low grade, receiving lower evaluations/grades, asking to perform personal/inappropriate tasks, spreading malicious rumours, being coerced into unprofessional behaviour, other, and actual/threatened physical punishment. **** “Other” includes (from most to least frequently reported) not there at the time, other, chalked it up to experience, told not to respond, it wasn’t that bad, didn’t have the time, my fault, didn’t care, not intentional, not important, and the data field not being filled in.

Discussion

Our study indicates that a significant proportion of medical students across the country experience or witness mistreatment, extending existing evidence of this issue, which had been previously confined to only two Australian medical schools. In line with other studies [4,11,24], our study shows that bullying and discrimination are commonly “medically themed”, in ways that belittle a student’s core identity and competency. This fits with sociologies of medicine that have shown that surviving humiliating treatment is often a ritual of socialisation into the profession [25]. Our study also extends our understanding of which students are affected and identifies a wider range of perpetrators than had earlier studies [5,14], including professional and support staff in their clinical schools and other students.

A limitation of our study was the sliding response scale for which the default setting was in the middle of the scale. If the respondent did not touch the slider, we could not be sure if they had elected to forego answering the question entirely (because they did not have an opinion or they did not want to answer) or if they were agreeing with the default mid-range answer.
While our low response rate and methods of recruitment mean that our results cannot be regarded as necessarily representative of the whole Australian medical student population, our data strengthen worldwide trends and provides confirmation that Australian medical students often experience serious mistreatment. It also reflects the findings of the Inquiry into Medical Complaints Processes, released in December 2016 [20,26].

Our study underscored that these behaviours can be damaging to students’ mental health. Our data also confirmed the widespread reluctance to disclose, report, or confront mistreatment as students fear direct educational and professional disadvantage as a result.

This research demonstrates that mistreatment is justified by the idea of upholding professional competence in medical students. It has also shown that, for some students, the mistreatment has a negative effect on their mental health and their willingness to perform. While there will be no single intervention solution for this problem, the authors suggest that clinical teaching staff may find an evidence-based short course on adult education and effective and constructive criticism, useful training for teaching medical students. This could include clear guidelines for both staff and students on the difference between effective teaching and bullying. Indeed, as teaching is often considered an integral part of clinical medicine, targeted preparation for this could commence in medical school. This should be paired with effective policies ensuring that staff who have been reported repeatedly for bullying behaviours are removed from teaching positions and receive appropriate training to improve their skills before resuming work.

We also saw that under-reporting is often due to fear of educational and professional disadvantage. We can address this by encouraging the production of university and hospital policies ensuring anonymity and protection for those who report, and providing alternatives such as switching the student to a different rotation.

Another finding was how some students felt that universities were failing to take action to support them. This was particularly linked to students with a disability or mental health conditions. The reports detail either a perceived choice by the university to not support the student or the admission that university staff did not have the ability or resources to support the student.

The authors suggest that universities enact stronger policies with safety nets available for struggling students (such as changing rotations, alternate exam arrangements, or taking time off) and ensure they have the necessary resources to do so. We also suggest the creation of policies that monitor how many students are struggling, detailing the issues, and taking steps to ensure the problem does not continue. The authors suggest that medical school accreditation processes should include a more rigorous examination of institutional performance on this issue.

These recommendations run alongside those handed down by the Inquiry into Medical Complaints Processes, which specifically identified the government, hospitals, colleges, and universities as parties with responsibility for addressing bullying and harassment in the medical profession [26].

Changes in policy and training educators on effective criticism would be strengthened by slowly incorporating cultural change through encouraging positive professionalism training. Such programs use creative techniques such as acting skills to build core professional values and behaviours. They can also reveal the impact of bullying on others without directly shaming perpetrators or exposing victims [27-29].

Further research is required to determine the effectiveness of these approaches to change. It is as yet unknown whether a pre-emptive educational approach or more capacity to remove perpetrators from teaching roles would be most effective in reducing mistreatment. Further qualitative research would better capture the dimensions and effects of mistreatment, which may be experienced differently by male and female students, on the basis of mental health status, or with respect to sexuality or ethnicity. Such research could assist in identifying institutional barriers to managing poor behaviour among teaching and non-clinical staff, and identify the best strategies by which the effects of mistreatment in medical education can be ameliorated.

Acknowledgements
We thank Rita Shackel for her assistance with the ethics approval process.

Conflict of interest
None declared.

Correspondence
A Szubert: anna.szubert64@gmail.com

References

[1] Shem S. The House of God. New York: Dell Publishing Company; 1978.
[2] Baldwin Jr D, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harassment during medical school: a survey of ten United States schools. West J Med. 1991;155(2):140.
[3] Neville AJ. In the age of professionalism, student harassment is alive and well. Med Educ. 2008;42(5):447-8. doi:10.1111/j.1365-2923.2008.03033.x
[4] Rees CE, Monrouxe LV. A morning since eight of just pure grill: a multischool qualitative study of student abuse. Acad Med. 2011;86(11):1374-82. doi:10.1097/ACM.0b013e3182303c4c
[5] Scott K, Caldwell P, Barnes E, Barrett J. Teaching by humiliation and mistreatment of medical students in clinical rotations: a pilot study. Med J Aust. 2015;203(4):185. doi:10.5694/mja15.00189
[6] Silver HK. Medical students and medical school. JAMA. 1982;247(3):309-10.
[7] Ulusoy H, Swigart V, Erdemir F. Think globally, act locally: understanding sexual harassment from a cross-cultural perspective. Med Educ. 2011;45(6):603-12. doi:10.1111/j.1365-2923.2010.03918.x
[8] Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89(5):817-27. doi:10.1097/ACM.0000000000000200
[9] Wear D, Aultman JM, Borges NJ. Retheorizing sexual harassment in medical education: women students’ perceptions at five U.S. medical schools. Teach Learn Med. 2007;19(1):20-9. doi:10.1080/10401330709336619
[10] Babaria P, Abedin S, Berg D, Nunez-Smith M. I’m too used to it: a longitudinal qualitative study of third year female medical students’ experiences of gendered encounters in medical education. Soc Sci Med. 2012;74(7):1013-20. doi:10.1016/j.socscimed.2011.11.043
[11] Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC. A pilot study of medical student ‘abuse’: student perceptions of mistreatment and misconduct in medical school. JAMA. 1990;263(4):533-7.
[12] McDonald P. Workplace sexual harassment 30 years on: a review of the literature. Int J Manag Rev. 2012;14(1):1-17. doi:10.1111/j.1468-2370.2011.00300.x
[13] Nora LM, McLaughlin MA, Fosson SE, Stratton TD, Murphy-Spencer A, Fincher R-ME, et al. Gender discrimination and sexual harassment in medical education: perspectives gained by a 14‐school study. Acad Med. 2002;77(12, Part 1):1226-34.
[14] White GE. Sexual harassment during medical training: the perceptions of medical students at a university medical school in Australia. Med Educ. 2000;34(12):980-6. doi:10.1097/ACM.0b013e3181d27fd0
[15] Crebbin W, Campbell G, Hillis DA, Watters DA. Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia. ANZ J Surg. 2015;85(12):905-9. doi:10.1111/ans.13363
[16] Wu F, Ireland M, Hafekost K, Lawrence D; National mental health survey of doctors and medical students [Internet]. Beyond Blue; 2013 [cited 2015 Aug 25]. Available from: https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmss-full-report_web
[17] Foster C. Factors influencing notions of professionalism: insights from established practitioner narratives [dissertation]. Sydney (NSW): University of Sydney; 2012.
[18] Frost H, Regehr G. I am a doctor: negotiating the discourses of standardization and diversity in professional identity construction. Acad Med. 2013;88(10):1570-7. doi:10.1097/ACM.0b013e3182a34b05
[19] Monrouxe LV. Identity, identification and medical education: why should we care? Med Educ. 2010;44(1):40-9. doi:10.1111/j.1365-2923.2009.03440.x
[20] Medical complaints process in Australia [Internet]. Canberra: Community Affairs References Committee; 2016 Nov [cited 2017 Jan 16]. Available from
[21] R: A language and environment for statistical computing [Internet]. R Foundation for Statistical Computing: 2014 [cited 2015 Aug 25]. Available from: http://www.R-project.org/
[22] Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-72. doi:10.12691/ajnr-1-1-2
[23] Creswell, JW. Research design – qualitative, quantitative and mixed methods approaches. 4th ed. California: SAGE Publications; 2014.
[24] Gan R, Snell L. When the learning environment is suboptimal: exploring medical students’ perceptions of mistreatment. Acad Med. 2014;89(4):608-17. doi:10.1097/ACM.0000000000000172
[25] Timm A. It would not be tolerated in any other profession except medicine: survey reporting on undergraduates’ exposure to bullying and harassment in their first placement year. BMJ Open. 2014;4(7). doi:10.1136/bmjopen-2014-005140
[26] Buisson E. We know the way, but is there the will to stop bullying? [Internet]. MJA Insight; 2017 Jan 21 [cited 2017 Jun 10]. Available from: https://www.doctorportal.com.au/mjainsight/2017/1/we-know-the-way-but-is-there-the-will-to-stop-bullying/
[27] Scott KM, Berlec Š, Nash L, Hooker C, Dwyer P, Macneill P, et al. Grace under pressure: a drama-based approach to tackling mistreatment of medical students. Med Humanit. 2017. 43(1):68-70. doi:10.1136/medhum-2016-011031
[28] Heru AM. Using role playing to increase residents’ awareness of medical student mistreatment. Acad Med. 2003;78(1):35-8. doi:10.1097/00001888-200301000-00008
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Tags education, student, Medical, mistreatment, bullying

Original Research Articles

Knowledge needs and coping with atopic dermatitis: perspectives of patients and healthcare professionals in Singapore

Post author By Website Publications Officer
Post date April 15, 2018

Abstract

Background: Atopic dermatitis (AD) is a common chronic skin condition which has significant disease burden. Hence, it is important to understand the knowledge needs and coping of patients with AD.

Materials and Methods: This study was conducted in a dermatology outpatient clinic in Singapore. Qualitative, semi-structured interviews were conducted with patients, dermatologists, dermatology nurses, and a medical social worker (MSW). A sample of patients with AD was recruited. Dermatologists and dermatology nurses who regularly worked with patients with AD were selected. Interviews were recorded and transcribed verbatim. The framework method was employed for data analysis.

Results:
A total of 22 participants were recruited, comprising of eight patients with AD, eight dermatologists, five dermatology nurses, and one MSW. The main needs of patients that were identified were: knowledge about AD and coping with psychosocial aspects of the disease. Regarding knowledge about AD, patients wanted to know more about the underlying causes and management of AD. On coping with psychosocial aspects, patients expressed their appreciation for both the concern shown by their healthcare professionals and the opportunity to share their experiences. Some patients had difficulties coping with the rashes on the visible areas of their body.

Conclusion: It is essential to include education surrounding AD pathophysiology and the psychosocial aspects of coping with AD during counselling of these patients. Itch management, knowledge of possible triggers, and discussion on complementary and alternative medicine should be included as components of counselling. With respect to psychosocial counselling, patients could be given strategies to cope with both the changes in appearance and the frustration associated with undesired outcomes.

Introduction

Atopic dermatitis (AD), also known as atopic eczema, is a common chronic skin condition prevalent in people who have a family history of atopy, including asthma, eczema, or allergic rhinitis [1]. In the United States, the prevalence of AD has been reported to be 10.7% in children and 10.2% in adults [2]. AD is also the most common skin disease in the Asian population [3,4]. In Singapore alone, 20.8% of children between the ages of seven and 16 have been diagnosed with AD [4].

AD is characterised by intermittent periods of exacerbation and remission. Patients with AD have pruritic rashes, erythema, lichenified patches, and excoriations due to scratching of the skin. These symptoms often affect the patient’s sleep and mood, resulting in a decreased overall quality of life [5,6].

Due to its significant disease burden, understanding the education needs of patients is important for developing a holistic program to help patients manage their condition. From a review of the literature, the education needs of AD patients and their caregivers include disease pathophysiology, awareness of trigger factors, skin care (including application of topical creams such as steroids, moisturisers, and wet wraps), a range of treatment modalities, management of symptoms such as itch and sleep disturbances, nutritional aspects, and coping strategies [7,8]. A good education program has been found to result in a significantly lower dermatitis severity index, increased use of emollients and wet wraps, decreased use of steroids, reduced itching and irritability, and improved sleep [7,9].

It is important to understand the knowledge needs and coping mechanisms from both the patient’s and healthcare professional’s perspectives. Studies to understand the education needs of AD patients were mainly conducted in Western countries. Conducting such a study in an Asian context will enable us to tailor AD education programmes for these populations [10]. This study aims to achieve an understanding of these issues through group interviews with patients and their multidisciplinary healthcare team.

Materials and Methods

**Table 1.** The guide used to focus the group discussions on atopic dermatitis for patients and healthcare professionals.

Design
This study was conducted in a tertiary dermatological centre in Singapore between June and December 2015 after obtaining ethical approval from the Domain Specific Review Board (DSRB) by the National Healthcare Group (NHG), study reference 2015/00236. Qualitative semi-structured interviews were conducted with AD patients and healthcare professionals. Both patients and healthcare professionals were included to obtain the perspectives from both groups, and to identify any conflicts. In a semi-structured interview, an interview guide with broad questions was used to focus the discussion (Table 1). Patients and nurses were interviewed in groups of three to five participants, while dermatologists and a medical social worker (MSW) were interviewed individually. All interviews were conducted in English, by the same primary investigator to ensure consistency.

Participants
A purposive sample of patients with AD was recruited for the focus group interviews. Recruited patients had AD for at least twelve months and were all older than 21. Dermatologists and dermatology nurses, who regularly worked with patients with AD, were selected for the interviews.

Data collection
Patients who met the inclusion criteria and had clinic visits during the study period were recruited and written consent was obtained. Demographic data obtained from the patients included age, gender, race, level of education, occupation, smoking and drinking status, areas of skin affected by AD, age of onset, disease duration, previous treatments, and history of inpatient admission due to their skin condition.

The demographic data obtained for dermatologists and nurses included age, position, number of years practicing, and academic qualifications. The focus group interviews lasted around 60 minutes, and the individual interviews lasted 20-45 minutes. Data was collected until saturation was achieved, which meant that no new information was obtained from subsequent interviews.

Data analysis
Recorded interviews were transcribed verbatim. The framework method was employed for data analysis. Briefly, this included the analysers familiarising themselves with the interview content, coding of transcripts, and categorising the data into themes [11]. Trustworthiness was achieved using strategies suggested by Lincoln and Guba [12], which included credibility, transferability, dependability, and confirmability. Credibility was achieved through triangulation and critical self-reflection. Triangulation, which was used to ensure validity through exploring multiple perspectives, was achieved through interviewing both patients and their healthcare professionals [13]. Critical self-reflection (the reflection of one’s viewpoints) was used in data collection and analysis to reduce bias from self-imposed viewpoints [14]. Transferability (generalisability of results) was achieved through transcription of the entire interview to provide context and meaning [15]. Dependability (the reliability of the results) was ensured by developing an audit trail which consisted of raw data, audio recordings, products of data analysis and synthesis, and interview guides, to increase overall transparency of the research process [14]. Finally, confirmability was achieved when the criteria of credibility, transferability, and dependability were established [12]. The preliminary analysis was completed by a single researcher, who then presented the selected pre-codes and themes to the other team members.

Results

A total of 22 participants were recruited: eight patients with AD, eight doctors, five nurses, and one MSW. Two focus groups were conducted for the patients, and one for the nurses. There were nine face-to-face interviews with the doctors and MSW.

Patient demographics and clinical data
The mean age of the patients was 30.9±7.8, and there was equal gender distribution (11 (50%) males, 11 (50%) females). AD affected numerous body regions, including the scalp (n=4, 18%), face (n=4, 18%), trunk (n=5, 23%), upper limbs (n=6, 27%), and lower limbs (n=8, 36%). The mean age of onset of AD was 13.9±12.1 years, and the mean duration since AD diagnosis was 17.0±9.1 years. Topical steroids (n=8), prednisolone (n=6), and phototherapy (n=7) were common treatments received.

Healthcare professional demographics
The mean age of the healthcare professionals was 42.1±12.2 years. The mean duration of specialisation in dermatology was 12.1±10.4 years.

Themes
The main needs of patients could be broadly divided into two themes: knowledge about AD and coping with the psychosocial aspects of the disease (Table 2).

Table 2. Themes, sub-themes and codes arising from the patient and healthcare professional interviews on atopic dermatitis.

Knowledge about AD
This theme includes the knowledge needs of patients with AD comprising the underlying pathophysiology of AD and management of the disease.

Pathophysiology of ADMost healthcare professionals believed that most patients required only the most basic information on the nature of AD so as not to overwhelm them with too much information. However, some patients were interested to know the various subtypes of eczema, and important tips to help them identify the severity and status of their condition.

“They just need to know two or three key points of information. Otherwise they forget everything which is said. Firstly, I tell them the genetic causes. The gene makes good skin that’s why they have poor skin. Because of the poor skin, they have poor skin barrier. Water is lost and a lot of allergens or infectious agents can come in. [This is] good enough.” (Healthcare professional 3)

“Personally I will like (sic) to have more information. But I can see how sometimes more information gets you more worried especially if they tell you some eczema are more dangerous and it can last forever (sic), for example. It would have been nice if I knew ‘here are different severities of eczema’ for example. Not just types, but more serious, less serious and some kind of sense of where you are along the spectrum. That will be useful.” (Focus group 2)

Management of AD
Healthcare professionals felt that the importance of the use of moisturisers and topical steroids could not be overemphasised among patients with AD. Patients were often very concerned with their itch, and wanted better strategies to alleviate their symptoms. They were also very keen to discuss the role of complementary and alternative medicines (CAMs) as part of their overall management, however, these options were often not addressed or quickly dismissed.

“I think they need to know the importance of moisturiser. I think when you ask the patients if they put (sic) moisturiser, most of them will say, ‘maybe once’ or sometimes, ‘forget’. They always think that steroid is the main thing. So moisturiser is very important for eczema because you want to resolve the barrier function. So most of the time I spend quite a long time telling them how important the moisturiser is as a maintenance.” (Healthcare professional 6)

“Maybe for them [healthcare professionals] to be more open to alternative treatment. You [another participant] mentioned is (sic) gut health and all that. Things like having more holistic treatment options instead of just dismissing it as, ‘Ah, doesn’t work’. They need to be able to discuss with you.” (Focus group 1)

Patients had variable preferences with respect to the amount and types of treatment related information they received. Some preferred to know all the possible types of treatment options, while others believed that the doctors would make the best decision for them.

“[The doctors can] outline the different treatment methods and what are the pros and cons of each.” (Focus group 1)

“I think I will put myself in the hands of the doctor. Because they know our condition better. They have seen a lot of patients with similar conditions. So maybe they know what is the best for us.” (Focus group 1)

Coping with the psychosocial aspects of AD
Patients expressed feeling frustrated and stressed by the supposedly well-intended opinions of relatives, friends, and strangers who did not understand that there was no cure for their eczema, yet still continued to provide advice. Patients also expressed that they appreciated the concern shown by their healthcare professionals, and also the opportunity to talk about their eczema exacerbations and how to prevent them. Some patients had difficulties coping with the unsightly rashes on visible areas of the body, such as the face, arms and legs.

“Some uncles and aunties will say, ‘you must do this, do that’. But I think sometimes these kind (sic) of things make us feel a bit down. As I mentioned, my friend’s son has severe eczema on his face. So she also has people coming up to her and telling her things. She feels very upset about it. So I feel that, it’s a kind of a stress in a way.” (Focus group 1)

“I think it’s showing concern for you. Because when you come up for your routine check-ups, it is good that they give you a chance to share about any flare ups that you experienced, and discuss what might have caused it, and what you can do to prevent it.” (Focus group 1)

Both patients and healthcare professionals agreed that having support groups for AD patients is essential for enabling them to share their challenges and provide support for one another.

“I do think such support groups are good for patients to come together and share. Because they [patients] do trial and errors for different kind of remedies (sic). So sharing experience will help different patients to spot each other needs (sic).” (Focus group 2)

“Showing them support groups. So it’s just not the nurses [only], but you organising a good support group. I think that is very critical for them.” (Healthcare professional 7)

Discussion

Due to the chronic nature and impact of AD on patients’ physical and psychosocial health, education is critical to ensure successful long-term management of the disease and adherence to treatment. Barbarot and colleagues [10] emphasised the importance of tailoring AD education programmes to the sociocultural context of the patient. In this study, we have explored the education needs of patients with AD in an Asian context. Both patients and healthcare professionals expressed two main components pertinent in AD counselling, which were knowledge about AD, and coping with the psychosocial aspects of the disease.

Knowledge about AD
Although both patients and healthcare professionals agreed that providing knowledge on the pathophysiology of AD was important, patients wanted to know more about the different subtypes of AD and severities, which contrasted with healthcare professionals believing that providing only basic information relating to AD was sufficient. Patients felt that this knowledge could help them manage an impending exacerbation when, for example, they noticed subtle changes in their skin condition. Although the majority of patients in this study felt that they wanted more information on their disease, one patient also acknowledged that having more knowledge might generate unnecessary worry and could therefore have a negative impact. Hence, it is important to tailor the amount and type of information provided to the needs of the patient.

Healthcare professionals tend to emphasise the use of moisturisers and topical steroids in the management of AD, which plays a large role in nurse-led eczema counselling programmes [7,9]. However, patients did not feel that they needed more information on the use of topical treatments, possibly indicating that sufficient information is already being provided in this respect.

Regarding medical treatments, patients expressed that they wanted healthcare professionals to be more open to discussions surrounding CAMs, and not simply discount them as unscientific or ineffective. A recent study also described that the majority of patients rated it as being important that healthcare professionals know about CAMs for the treatment of AD [16]. Education and counselling regarding CAMs may prove to be an important part of patient counselling, particularly when considering the chronic nature of AD and the limitations of current therapies [17]. It has also been found that in addition to their prescribed therapies, patients who were more familiar with the Internet were likely to search for alternative complementary therapies online, including homoeopathy, ingestion of essential fatty acids, Chinese herbal therapy, phytotherapy, acupuncture, autologous blood therapy, and bioresonance [18]. Small trials have shown that these therapies may have some positive effects, but the evidence is not yet sufficient to support their use [19]. Despite the lack of scientific and clinical evidence supporting the effectiveness of CAMs, healthcare professionals need to be able to address these issues with their patients.

Symptomatic itch was a major concern for all patients included in this study, and they expressed a desire for more information relating to its management. Although patients knew that they should not scratch their skin as it would worsen their AD, many found this hard to avoid. This highlights the importance of including itch management as an important component in AD counselling. Besides antihistamines, the current first-line therapy for controlling itch (which is often unsuccessful), patients could be taught to use distraction and habit reversal techniques [20].

Coping with the psychosocial aspects of AD
Both healthcare professionals and patients agreed that having a support group could be a platform for patients to share their AD coping methods. Weber and colleagues [21] found that support groups helped improve patients’ quality of life, personal relationships, and participation in leisure activities. The impact of AD on body image has been documented in the literature [6]. As a result of impaired socialisation secondary to changes in body image, support groups could provide a platform for overcoming these issues.

Participants also found it stressful and frustrating to receive advice from relatives and friends who did not have much knowledge relating to AD. It was reported by the study participants that most people believed that the rashes were caused by a food allergy, and told them to avoid certain foods, or tried to provide suggestions to cure their AD which did not have any effect. The participants in this study were all adults above 21 years of age, which meant that they were now unlikely to outgrow their disease. On a community level, there could be more education on the various types of skin rashes and the possibility of AD continuing into adulthood.

Study limitations
A cross-sectional study was conducted, and therefore we do not know the changes in the needs and coping of patients over time. Also, the experiences of the participants relating to their initial diagnosis was based on recall, which may be inaccurate or subject to bias.

Practical implications
Itch management and management of exacerbations are essential for helping AD patients cope with their disease. AD is a chronic skin condition with no cure. Hence, it is common for patients to seek alternate methods of treatment, and therefore CAMs are widely used. Furthermore, people who are more familiar with the Internet could search for information on these therapies online [18]. Healthcare professionals need to be able to discuss the use of these therapies with patients, including explaining that while there may not be any evidence to support their use, CAMs may be used if the components of the therapy are identified and not known to cause any serious adverse effects.

Support groups could be used to help patients cope with the psychosocial aspects of their disease. Patients may also benefit from support in managing the stress and frustration arising from well-intentioned, but unhelpful comments from family members and friends.

Potential future directions
This study highlighted some conflicts in the perceived information requirements of AD patients and healthcare professionals. Most patients wanted more information on the nature of AD, which healthcare professionals believed was unnecessary. For treatments, besides the use of topical steroids and moisturisers, patients wanted more information on CAMs, which healthcare professionals did not believe were beneficial or useful. Despite the lack of scientific and clinical evidence to support the effectiveness of CAMs, healthcare professionals need to have a basic knowledge on these therapies as the discussion of such therapies was important to patients. With respect to psychosocial issues, patients could be taught how to cope with the changes in appearance associated with AD, and the stress and frustration arising from the advice given by their family and friends. A counselling programme should be developed to address these patient needs.

Acknowledgements
The study was funded by National Healthcare Group – Health Outcomes and Medical Education Research (NHG-HOMER) grant (FY15/A02). The authors would like to thank the participants in the study for their time and input.

Conflict of interest

None declared.

References

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[8] Jackson K, Ersser S, Dennis H, Farasat H, More A. The eczema education programme: intervention development and model feasibility. J Eur Acad Dermatol Venereol. 2014;28(7):949-56. doi:10.1111/jdv.12221

[9] Cork M, Britton J, Butler L, Young S, Murphy R, Keohane S. Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. Br J Dermatol. 2003;149(3):582-9. doi:10.1046/j.1365-2133.2003.05595.x

[10] Barbarot S, Bernier C, Deleuran M, Raeve L, Eichenfield L, El Hachem M, et al. Therapeutic patient education in children with atopic dermatitis: position paper on objectives and recommendations. Pediatr Dermatol. 2013; 30(2):199-20. doi:10.1111/pde.12045

[11] Gale N, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. doi:10.1186/1471-2288-13-117

[12] Lincoln Y, Guba E. Naturalistic inquiry (Vol. 75). Beverly Hills, CA: Sage; 1984.

[13] Polit D, Beck C. Essentials of nursing research: appraising evidence for nursing practice. United States: Lippincott Williams & Wilkins; 2013.

[14] Macnee C, McCabe S. Understanding nursing research: using research in evidence-based practice. United States: Lippincott Williams & Wilkins; 2008.

[15] Shenton A. Strategies for ensuring trustworthiness in qualitative research projects. Edu Info. 2004;22(2):63-75. doi:10.3233/EFI-2004-22201

[16] Munidasa D, Lloyd-Lavery A, Burge S, McPherson T. What should general practice trainees learn about atopic eczema? J Clin Med. 2015;4(2):360-8. doi:10.3390/jcm4020360

[17] Lim M, Sadarangani P, Chan H, Heng J. Complementary and alternative medicine use in multiracial Singapore. Complement Ther Med. 2005;13(1):16-24. doi:10.1016/j.ctim.2004.11.002

[18] Ring J, Alomar A, Bieber T, Deleuran M, Fink‐Wagner A, Gelmetti C, et al. Guidelines for treatment of atopic eczema (atopic dermatitis) part II. J Eur Acad Dermatol Venereol. 2012;26(9):1176-93. doi:10.1111/j.1468-3083.2012.04636.x

[19] Vieira BL, Lim NR, Lohman ME, Lio PA. Complementary and alternative medicine for atopic dermatitis: an evidence-based review. Am J Clin Dermatol. 2016;17(6):557-81. doi:10.1007/s40257-016-0209-1

[20] Mochizuki H, Kakigi R. Itch and brain. J Dermatol. 2015;42(8):761-7. doi:10.1111/1346-8138.12956

[21] Weber MB, Prati C, Soirefman M, Mazzotti NG, Barzenski B, Cestari T. Improvement of pruritus and quality of life of children with atopic dermatitis and their families after joining support groups. J Eur Acad Dermatol Venereol. 2008;22(8):992-7. doi:10.1111/j.1468-3083.2008.02697.x

Tags atopic dermatitis, counseling; eczema, patient education

Original Research Articles

Routine blood tests in hospital patients: a survey of junior doctor’s cost awareness and appropriate ordering

Post author By Website Publications Officer
Post date April 15, 2018

Abstract

Background: Excessive and redundant ordering of pathology tests contributes to increasing healthcare costs. Common blood tests, such as full blood counts, liver function tests, serum electrolytes, and C-reactive protein are frequently ordered with little consideration of purpose or intent. Most commonly the ordering of ‘routine’ blood tests is the responsibility of the most junior member of the medical team (the intern). We hypothesise that overutilisation of pathology tests exists due to an under-appreciation of the costs of testing.

Materials and Methods: We surveyed 50 interns regarding their comprehension of the cost of four commonly ordered pathology tests. We also identified the proportion of participants that had ordered an investigation inappropriately.

Results: Full blood counts, serum electrolytes, liver function tests and C-reactive protein were, on average, overestimated in cost by 9%, 32%, 36%, and 71% respectively. Costs for each test were underestimated in only a minority of cases, 32% for full blood counts, 14% for serum electrolytes, 16% for liver function tests, and 18% for C-reactive protein. All participants recall circumstances in which they inappropriately ordered an investigation.

Conclusion: Junior doctors did, on the whole, not underestimate the cost of pathology tests. Junior doctors are poorly informed about the cost of tests, however, this does not appear to influence their ordering, with 100% of participants reporting that they had inappropriately ordered investigations.

Introduction

The use of diagnostic testing is essential in the accurate diagnosis, monitoring, and screening of various diseases [1], with an estimated 70% of clinical decisions being substantially based on the results of such investigations [2]. Over the past 20 years, the number of laboratory tests available to clinicians has more than doubled [3], with most clinical laboratories in Australia reporting a 5-10% increase in their annual workload [4]. Similar to biochemical investigations, the uptake of imaging based diagnostics has growth at a rate of 9% annually [5]. Laboratory medicine is the single highest volume activity in healthcare, with demand increasing disproportionally to other medical activities [6].

Unfortunately, these increased volumes of testing have not always resulted in clinically relevant or useful patient interventions. Indeed, numerous studies [3,7-9] have attempted to investigate the impact of inappropriate pathology testing. While definitions of inappropriate use vary, it can generally be understood as pathology findings that do not have any impact on the clinical decision-making pathway. Estimating the size of this issue is difficult, but has been explored in numerous studies. Miyakis et al [10] found that 68% of a panel of 25 investigations failed to contribute to a patient’s clinical management. Sarkar et al [11] reviewed the cases of 200 patients with haemostatic disorders, and found that 78% of investigations ordered did not influence patient management. This represented an avoidable cost of $200,000. Rogg et al [12] found that repeat investigations are redundantly ordered in 40% of patients transferred from the emergency department to inpatient wards.

Rates of overuse reported in other studies ranged from 40-65%, depending on how ‘appropriate use’ was defined [13-17]. Walraven et al [19] reported, in a systematic review of laboratory clinical audits, pervasive overuse ranging from 4.5-95%. A more recent meta-analysis by Zhi et al [20] estimates the general prevalence of overuse as 20.6%. In Canada, redundant test ordering is expected to represent an annual cost of $36 million (CAD) [21], finances that could have otherwise been redistributed to other essential areas of healthcare.

The impact of inappropriate testing cannot, however, be qualified simply in terms of monetary cost. Even high-value and high-quality investigations can have limitations. False positive results can lead to unnecessary, anxiety provoking, and costly follow-up investigations [22-24]. Appropriate ordering decreases the likelihood of false positive results, thereby reducing the associated physical and emotional stress associated with these false positive values.

Improving the practice of ordering laboratory diagnostics is a challenging issue, the solution of which has been widely studied with variable levels of success. Consensus between these studies seems to suggest that education, audit, and feedback regarding appropriate investigations can limit the demand for diagnostic investigations. Miyakis et al [10] observed a 20% reduction in avoidable testing after education was provided to clinicians regarding their test ordering behaviours, the costs of ordering, and the factors that contributed to overuse. Feldman et al [25] found that attaching fee data to routinely ordered pathology investigations reported an 8.6% reduction in the number of tests ordered. A similar study by Tierney et al [26] reported a 7.7% reduction in the number of tests ordered. Hampers et al [27] found that listing the individual charges of diagnostic tests at the time of ordering resulted in a 27% reduction in the total ordering of diagnostic tests.

Miyakis et al [10] found that junior medical staff are 20% more likely to order unnecessary investigations when compared to senior staff. This observation is vitally important as in public teaching hospitals, junior medical staff are generally most often responsible for the ordering of relevant investigations, often under a degree of self-direction. It is in this group where education regarding cost awareness would be most impactful in reducing inappropriate ordering. Limited numbers of past studies suggest there is a knowledge gap regarding cost comprehension in junior medical staff. Khromona et al [28] found that 82 (70%) respondents at a single institution felt they needed further education into the ordering of appropriate tests. Stanfliet et al [29] found that all interns interviewed (n=61) across two South African Hospitals reported that they would benefit from further education into the appropriate ordering of investigations.

The aim of this pilot study was to evaluate the awareness that junior medical staff (interns) at the Gold Coast University Hospital have of the costs of various commonly requested blood tests. It was hypothesised that systematic over-ordering may be accounted for by underestimation of cost. If this was confirmed, it would be possible to devise educational interventions designed to manage these deficiencies, which may subsequently promote more cost-effective and appropriate investigation. The efficacy of this process has been suggested in previous studies [10,25-27].

Materials and Methods

Table 1. Example of questions asked of survey participants to gauge their understanding of the costs associated with pathology testing in hospitals

Study design

The study utilised an observational design, with the development of a questionnaire aimed at assessing cost compression of interns at the Gold Coast University Hospital (Table 1). The questionnaire included questions relating to some of the most commonly ordered investigations at the hospital: full blood count (FBC), liver function tests (LFTs), serum electrolytes (UES), and C-reactive protein (CRP). Additionally, we requested that participants report if they had ever requested a pathology test that they felt was not clinically indicated, or was inappropriate.

Ethics approval to perform this survey was granted by the Human Research and Ethics Committee of the Gold Coast University Hospital (HREC//16/QGC/320).

Participant selection and setting

Medical staff of the classification of intern (first year medical graduates) were approached for inclusion. These staff represented the most junior element of their respective medical/surgical teams. The centre in which this project was conducted is the largest facility of the Gold Coast Health district, which, across its Southport and Robina campuses, serves over 750 beds, with over 100,000 emergency presentations annually. Both campuses are major teaching hospitals, and the majority of interns were graduates of Queensland universities.

The questionnaires were completed during mandatory teaching sessions, which all interns were required to attend. Each participant from the study population had an equal likelihood of being involved in the study. A total of 88 interns were present at these education sessions. Participants were approached randomly with requests for their participation until a sample of 50 participants was reached.

To enhance a response rate and ensure reliability, all surveys were completed during face-to-face meetings with the principal investigator, thus ensuring responders could not have advance understanding of the nature of the specific questions and therefore prepare accordingly by accessing reference materials.

Data collection

The actual cost of the four commonly ordered pathology tests (FBC, CRP, UES, LFTs) according to hospital financial records was used as a comparison with participant estimates. These values are represented as a total dollar value without a breakdown of individual costs, and represent the cost of labour, consumables, processing, and reporting.

Questionnaire responses were de-identified, and no personal or identifying information was retained. Participation and completion of the questionnaire was completely voluntary. This process was repeated until a minimum of 50 completed questionnaires had been collected. It was thought that this number would allow for an equal distribution of uncontrolled variables amongst the study sample.

Statistical analysis

Data was collated using Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA, USA) and statistical analysis was performed using SPSS version 23 (SPSS Inc, Chicago, Ill, USA). Continuous data were analysed for normality using the Kolmogorov-Smirnov method. The mean estimated cost provided by participants was compared to the true cost of the relevant test and was analysed using a one-sample T-test, where p<0.05 was considered statistically significant. Simple graphical representations were used to visualise the number of participants that had overestimated or underestimated the cost of the test. Responses within 25% of the actual cost were regarded as accurate, with estimates more than 25% above the true cost being considered an overestimate, and likewise estimates more than 25% below the true cost being considered underestimates. These thresholds were suggested by a previous systemic review which examined physician cost awareness of pathology testing [29].

Results

A total of 50 interns at the Gold Coast University Hospital were included in this study. The mean assumed cost of pathology testing was, for all tests, higher than that of the true cost.

For almost all tests (with the exception of FBC), costs were routinely overestimated. Costs were overestimated by 50% of participants with respect to UES, 56% of participants with respect to LFTs, and 68% of participants with respect to CRP testing (Figure 1, Table 2). The FBC was the most accurately predicted test, with 40% of respondents accurately estimating the true cost.

**Figure 1. Proportion of candidates to overestimate (grey), accurately estimate (orange) or underestimate (blue) the true cost of pathology tests.** Estimates within 25% of the true cost were regarded as accurate. Estimates more than 25% above the true cost were regarded as overestimates. Estimates more than 25% below the true cost were regarded as underestimates

**Figure 2. Comparison of the mean estimates of pathology test costs amongst interns (blue), compared with the actual cost of the test (orange).**

Comparing the mean estimated cost and true value directly, we observed that for LFTs, UES, and CRP testing, there was a statistically significant overestimation of cost. LFTs, UES, and CRP were overestimated by 35.5% ($20.87±10.53, p<0.001), 31.5%, ($19.76±12.55, p=0.001), and 70.6% ($39.97±38.20, p<0.001), respectively when compared to the true costs. FBC testing was overestimated by only 9% ($17.25±13.43, p=0.442).

**Table 2. Proportion of respondents who underestimated costs, accurately predicted costs and overestimated costs of commonly ordered blood tests**. Estimates within 25% of the true cost were regarded as accurate. Estimates more than 25% above the true cost were regarded as overestimates. Estimates more than 25% below the true cost were regarded as underestimates.

**Table 3. Actual and estimated cost of pathology tests**.

Of note is that 100% of responders reported ordering an inappropriate pathology test during their clinical practice. We hypothesised this inappropriate ordering would be explained by an assumption that tests were cheaper than their true value; however, this was not the case as the majority of participants were found to overestimate costs for most investigations (Figure 2, Table 3).

100% of participants reported that they had previously ordered tests inappropriately.

Discussion

The results of this study seem to suggest that the understanding of the cost of common pathology tests is highly variable between individuals, with a clear lack of consensus amongst the study group a whole. Surprisingly on average, the estimated cost of pathology testing was generally more than the true cost of testing. In this study 100% of individuals report having ordered a pathology test inappropriately, and various previous studies [7-11] explore the prevalence of test overordering. This would suggest that other factors other than underappreciation of cost are driving excessive ordering amongst medical staff.

It was not surprising that the majority of interns would admit to ordering unnecessary blood tests. This could be because it is often easier to perform the tests with onsite phlebotomy services. Due to the high workload of interns, ordering “routine blood tests” is convenient, time-efficient, and often an expectation of senior staff.

In agreement with previous studies [29,30] interns at the Gold Coast University Hospital demonstrate a poor understanding of the cost of pathology investigations. They also report knowingly ordering inappropriate or unnecessary investigations. We propose three potential explanations for this. First, some participants may have had prior experience with or knowledge of commercial pathology testing, which tends to carry higher costs than in-house hospital pathology tests. Second, due to clinical inexperience, the perceived clinical value of the unnecessary tests was thought to be greater than the monetary costs of performing the investigation. Finally, it is possible that cost reduction is not perceived to be the responsibility of the most junior member of the management team. One study by Tiburt et al [29] in 2013 found that only 36% of physicians considered themselves responsible for reducing healthcare costs. Simply put, many clinicians do not acknowledge or accept their own role in rationalising healthcare costs.

Miyakis et al [10] found that junior staff will order inappropriate investigations 20% more frequently than senior staff (across a single Australian emergency department). However, the same study did not suggest cost-comprehension as a driving force for this difference. Schilling [31] found that only 28% of Swedish emergency department physicians correctly predicted the cost of investigations used to investigate pulmonary emboli, concluding that level of experience did not imply a better knowledge of the costs of investigation. A systematic review by Allan et al [32] of 14 studies of diagnostic and non-drug therapy cost estimates reported that clinicians of various nationalities estimated costs to within 25% of the tests correct value 33% of the time, and that the year of study, level of training, and specialty did not appear to impact this accuracy. These studies were represented by mixed specialties in various European and American based institutions. Broadwater-Hollifeild et al [33] found that only 20% of emergency physicians correctly predicted the costs of common medical tests (within 25% of true cost) across eleven emergency departments in Utah, USA. For comparison as an aggregate, in our study, interns were able to correctly predict cost (within 25% of true value) in 29.5% of proposed tests. The individual populations and settings varied in these studies and the resounding consensus is that clinicians, in general, will poorly predict the cost of investigations.
While experienced clinicians may have a limited knowledge of the costs of the investigations they order, they may request more relevant investigations, likely to be a consequence of experience and a better understanding of the specific indications and limitations of particular tests [33]. However, in some scenarios seniority does not always correlate with a reduced volume of testing. For example, a recent study by Magin et al [34] found that in Australian GPs, for every 6 months of cumulative training, the number of investigations ordered increased by 11%. This indicates the relationship between ordering and experience may be more complex. This may be because with greater comprehension of potential pathology, registrars in later stages of training have greater concern for potential missed diagnoses, or in general have a lower acceptance of ambiguity.

Although unnecessary testing is often associated with a net detrimental effect, examples do exist where excessive ordering of low yield investigations can result in the capture of significant pathology, allowing for the early management of conditions that may have otherwise led to significant mortality and morbidity. These screening programs usually undergo rigorous cost-benefits analyses, ensuring the net benefits outweigh any risks and costs associated with implementing such a program. Some examples of which include routine screening for breast cancer [35] and colorectal cancer [36,37]. These are examples of tests where despite low pretest probability of disease, the impact of a positive value can significantly alter patient mortality and morbidity to the level that routine testing is justifiable for relevant parties. Another example is routine screening for inborn errors of metabolism, which is performed for every child born in Australia. Although these illnesses are rare, these routine tests have high sensitivity and specificity, allowing for early intervention and leading to substantially better outcomes for affected patients [38]. While we acknowledge that this ‘shotgun’ approach can occasionally have positive outcomes, clinicians face an ethical conundrum. Maximising the use of resources in every patient runs the risk of eroding and diluting the overall effectiveness of the healthcare system, and each investigation ordered for a patient increases the risk of a false positive result or adverse event. We do not advocate compromising patient safety in favour of retaining finances, but as 100% of the junior doctors surveyed in this study have ordered inappropriate tests, some degree of cost containment must be considered.

Targeted interventions to curtail unnecessary investigations may assist in this regard. Given the overestimation of costs found in this study, it is unlikely that providing fee data for investigations would impact ordering behaviours significantly. A better approach would be to try and understand what factors are taken into consideration when ordering tests by more senior clinicians, given their tendency to order less inappropriate investigations than interns. Further studies would benefit from comparisons between interns and more senior medical staff, to establish what behaviours in senior staff result in more appropriate test ordering. Targeted education of these concepts may produce a reduction in inappropriate test ordering.

Study limitations and future directions

Our study analysed only awareness of costs, but did not demonstrate or attempt to ascertain the degree of inappropriate usage. Based on our current results we could not provide an opportunity for a cost reduction through education of true cost, as participants generally overestimate rather than underestimate test values.

In future studies, it may be beneficial to include additional questions incorporating a Likert scale in which participants rank the factors most important to them when ordering a blood test (for example, including factors such the cost of the test, expectations from a superior, desire for completeness, and expectations from patients). This would allow for identification of the traits most likely to lead to excessive ordering. Consequently, future interventions could be developed to address factors most likely to contribute to these behaviours. As discussed, it may be beneficial to compare groups of interns to more senior clinicians to establish the behaviours that most strongly correlate with rational test ordering.

Another limitation of this study was that we did not ascertain the degree of previous education regarding pathology testing costs that each participant had received. Previous studies [26,27] suggest that this may be a widespread phenomenon. It would also be valuable to ascertain how many tests participants are ordering to establish if participants who routinely underestimate the cost of tests tend to order more frequently, or vice versa. Such data could be linked to administrative data to assess for clustering and to determine if ordering behaviours vary between departments.

Conclusion

Junior doctors frequently report ordering inappropriate tests and in general, overestimate the costs of these pathology tests. This has a financial impact on the health system. We advocate that pathology services develop educational strategies for reducing inappropriate testing. Cost awareness does not appear to be a highly relevant factor in test ordering. Further study is needed to recognise the specific factors that contribute to systematic over-ordering.

Acknowledgements

I would like to extend my thanks to both Robert Ellis and Miranda Rue-Duffy, who have both been invaluable in providing advice on producing appropriate statistics.

Conflict of interest

None declared.

References

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[6] Freedman DB. Towards better test utilisation – strategies to improve physician ordering and their impact on patient outcome. EJIFCC. 2015;26(1):15-30.

[7] Hogg W, Baskerville N, Lemelin J. Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost consequences analysis. BMC Health Serv Res. 2005;5:20.

[8] Hicker JM, Fernald DH, Harris DM, Poon EG, Elder NC, Mold JW. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005;31:81-9.

[9] Weydert J A, Nobbs N D, Feld R, Kemp JD. A simple, focused, computerized query to detect overutilization of laboratory tests. Arch Pathol Lab Med. 2005;129(9):1141-3

[10] Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82:823-9.

[11] Sarkar MK, Botz CM, Laposata M. An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time. Diagnosis. 2017;4(1):21-6.

[13] Rogg JG, Rubin JT, Hansen P, Liu SW. The frequency and cost of redundant laboratory testing for transferred ED patients. Am J Emerg Med. 2013;31(7):1121-3.

[14] Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-2.

[15] Institute of Medicine Roundtable on Evidence-Based Medicine. The National Academies Collection: reports funded by National Institutes of Health. In: Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: lowering costs and improving outcomes: workshop series summary. Washington: National Academies Press; 2010.

[16] Bates DW, Boyle DL, Rittenberg E, Kuperman GJ, Ma’Luf N, Menkin V, et al. What proportion of common diagnostic tests appear redundant? Am J Med. 1998;10(4);361-8

[17] Spiegel J S, Shapiro M F, Berman B, Greenfield S. Changing physician test ordering in a university hospital. An intervention of physician participation, explicit criteria, and feedback. Arch Intern Med. 1989;149(3);9549-53.

[18] Schroeder S A, Myers L P, McPhee S J, Showstack JA, Simborg DW, Chapman SA, et al. The failure of physician education as a cost containment strategy. Report of a prospective controlled trial at a university hospital. JAMA. 1984;252(2):225-30.

[19] Van Walraven C, Naylor CD. Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. JAMA. 1998;280(6):550-8.

[20] Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8(11):e78962.

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[22] Moynihan R, Doust J, Henry D. Preventing over diagnosis: how to stop harming the healthy. BMJ. 2012;344:e3502.

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[26] Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;322(21):1499-1504.

[27] Hampers LC, Cha S, Gutglass DJ, Krug SE, Binns HJ. The effect of price information on test-ordering behaviour and patient outcomes in a paediatric emergency department. Paediatrics. 1999;103(4 pt 2):877-82.

[28] Khromova V, Gray T. Learning needs in clinical biochemistry for doctors in foundation years. Ann Clin Biochem. 2008;45:33-8.

[29] Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310(4):380-8.

[30] Stanfliet JC, Macauley J, Pillay TS. Quality of teaching in chemical pathology: ability of interns to order and interpret laboratory tests. J Clin Pathol. 2009;62:664-6.

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[33] Broadwater-Hollifield C, Gren LH, Porucznik CA. Emergency physician knowledge of reimbursement rates associated with emergency medical care. Am J Emerg Med. 2014;32(6):498-506.

[34] Margin PJ, Tapley A, Morgan S. Changes in pathology test ordering by early career general practitioners, a longitudinal study. Med J Aust. 2017;207(2):70-4.

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[37] Lin JS, Piper MA, Perdue LA, Rutter CM, Webber EM, O’Connor E, et al. Screening for colorectal cancer: updated evidence report and systemic review for the US preventative services task force. JAMA. 2016;315(23):2576-94.

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Tags Cost Containment, medical education, Junior Doctor, Pathology tests, Health Economics

Original Research Articles

Combined epiretinal membrane and cataract surgery: visual outcomes

Post author By Website Publications Officer
Post date April 15, 2018

Abstract

Introduction: This study compares visual outcomes between patients undergoing a single surgery combining cataract and epiretinal membrane (ERM) peel versus cataract surgery preceding ERM surgery as separate procedures.

Materials and Methods: A retrospective review was undertaken of electronic medical records for patients undergoing ERM surgery by vitrectomy, performed by a single surgeon. Peri-operative, three month, and twelve month follow-up visual data were collected. Three groups were identified: 1) Cataract surgery prior to ERM peel; 2) Combined ERM and cataract surgery; and 3) Cataract surgery post-ERM peel. Post-operative complications and mean change in visual acuity (VA) were investigated in the cataract surgery prior to ERM group compared to the combined surgery group.

Results: A total of 271 eyes underwent ERM peel either before or after cataract surgery, or combined with cataract surgery. 62 eyes were excluded as they did not have follow-up data available. Of the 209 included eyes, 62 had cataract surgery prior to ERM peel, 105 had combined ERM peel and cataract surgery, and 28 had cataract surgery post-ERM peel. Analysis of outcomes in the cataract surgery pre-ERM versus combined surgery group found improvements in both groups’ VA at three months (mean logMAR (logarithm of minimum angle of resolution) improvement -0.10 vs. -0.08, p=0.87) and twelve months post-operative follow-up (mean -0.18 vs. -0.22 p=0.54), with no significant difference between the groups. There was no difference in the proportion of eyes in either group that had peri-operative (9.5% vs. 4.8%, p=0.28) or post-operative complications (5.9% vs.1.8%, p=0.42).

Conclusion: Combined cataract and ERM vitrectomy is as effective as consecutive operations for improving VA, whilst reducing patient exposure to the risks associated with two separate procedures.

Introduction

The epiretinal membrane (ERM), also referred to as macular pucker or cellophane maculopathy, is a sheet of fibrous cells on the surface of the retina. Proliferation of the fibrous cells and the subsequent contraction of the membrane lead to defective visual symptoms, in particular distortion and blurred vision. ERM is a relatively common occurrence with ageing, with the prevalence of ERM ranging from 8.6% to 12.1% amongst various ethnic groups and countries [1-3], and typically affecting patients over 60 years old [3]. Often symptoms are only minimal and ERM requires no intervention unless progression occurs. In some instances however, ERM adversely affects vision and requires treatment through surgical intervention with vitrectomy and an ERM peel procedure. Patients requiring treatment for ERM may have other comorbid eye conditions, such as cataract, which also need to be addressed. Therefore, the question arises if these two problems are best addressed simultaneously or sequentially. The current literature provides only small case series in answering this question and results have been mixed, although most papers have found no significant differences [5-7]. There is also a paucity of literature that compares combined surgery and cataract surgery prior to ERM peel.

Aim

In this study, we sought to identify the number of patients who underwent ERM vitrectomy before or after cataract surgery and the number of patients who received ERM phacovitrectomy combined with cataract surgery at a single site. Secondly, we sought to determine complication rates and visual outcomes in patients who had combined ERM cataract surgery compared to cataract surgery prior to or after ERM vitrectomy.

Materials and Methods

Following approval from the University of Tasmania Human Research Ethics Committee (H0015009), we conducted a retrospective review of the medical records of patients who were diagnosed with ERM and underwent an ERM peel vitrectomy by a single surgeon. The surgeries were conducted in an Australian regional town (Launceston) between July 1, 2005 and May 12, 2014. Inclusion criteria were patients with pre-operative visual data and twelve month post-surgery follow-up visual data.

Information retrieved from patient medical records consisted of:

Baseline demographics
Medical comorbidities (pre-operative and post-operative)
Lens status (phakic or pseudophakic),
Date of cataract surgery (cataract surgery pre-ERM, combined, or cataract surgery post-ERM)
Surgical complications during ERM removal
Best corrected visual acuity (VA) pre-operatively as well as at three months and twelve months post-operatively
Central macular thickness (CMT) (pre-operatively and twelve months post-operatively)

Patients were classified according to the date of cataract surgery in relation to their ERM vitrectomy: cataract surgery before ERM vitrectomy, combined phacovitrectomy, or cataract surgery after ERM vitrectomy. Patients who did not return for twelve month follow-up were excluded.

Snellen acuity measurement of best-corrected visual acuity (BCVA) was performed and the results were converted into a logarithm of the minimal angle of resolution (logMAR) before analysis. To utilise a stable BCVA, the twelve month post-operative follow-up BCVA was used in the final analysis. The surgeries were performed by one surgeon. Details on posterior vitreous detachment (PVD) and peri-operative complications were also collected.

Data from patient records were extracted into an Excel 2010 (Microsoft, Redmond, WA, USA) spreadsheet and imported into Stata 14.1 (StataCorp, College Station, TX, USA) for analysis. Continuous data distributions were investigated and one-way analyses of variance (ANOVA) were used to investigate baseline differences between the three groups (cataract surgery pre-ERM, combined, or cataract surgery post-ERM) with Tukey-Kramer post-hoc tests. For categorical data, crosstabs with Chi-square and Fisher’s exact tests were utilised to investigate differences among the three groups at baseline. These were also used to investigate complications and the proportion of eyes with VA improvements of one chart line or greater at three month and twelve month follow-ups for the cataract surgery pre-ERM group versus the combined surgery group. Independent t-tests were used for the investigation of mean change in VA (logMAR) and mean change in CMT from baseline to three month follow-up, and twelve month follow-up between the pre-ERM group versus the combined surgery group. All tests were two-sided and differences were accepted as significant at p<0.05.

Results

A total of 271 eyes underwent ERM peel either before or after cataract surgery, or combined with cataract surgery. There were 62 eyes excluded as they did not have follow-up data available. Twelve month follow-up data was available for 209 eyes from 199 patients (93 women and 106 men) and these were selected for analysis. There were 108 (51.7%) right eyes and 101 (48.3%) left eyes (Table 1). There were 62 (29.7%) eyes with cataract surgery prior to ERM peel, 28 (13.4%) eyes proceeding to cataract surgery post-ERM peel, 105 (50.2%) eyes with combined ERM peel and cataract surgery, and 14 (6.7%) eyes with solely ERM peel that have not yet required cataract surgery (Table 1).

Table 1. Baseline characteristics of all eyes.

There was no significant difference between the groups for pre-operative CMT or cystoid macular oedema (CMO). There was a significant difference in mean age between the groups (F_2,192=7.8, p=0.001) with the Tukey-Kramer post-hoc test indicating a significant difference between the cataract surgery prior to ERM peel group and the cataract surgery post-ERM peel group (p<0.0001) and the combined group and the post-ERM peel group (p=0.02), but not between the cataract surgery prior to ERM peel group and the combined group (p=0.13). The combined surgery group had better mean VA (logMAR) pre-operatively compared to the cataract surgery prior to ERM or post-ERM groups (p=0.04). In the cataract surgery pre-ERM group, there was a mean of 1347±1179 days between cataract surgery and ERM peel.

**Table 2. Baseline characteristics of cataract surgery pre-ERM, combined surgery and cataract surgery post-ERM groups.**
*Unable to calculate due to small expected cell sizes. ns: not significant.

Overall there were 18 peri-operative complications: 17 retinal tears or breaks (8.1%) and one lens touch (0.48%) There was no difference in the proportion of eyes that had peri-operative complications in the cataract surgery pre-ERM group compared to the combined group (4.8% vs. 9.5%, p=0.38) or in the proportion of eyes with postoperative complications (1.8% vs. 5.9%, p=0.42).

In the post-operative period, CMO developed in five eyes that had combined surgery and three eyes that had cataract surgery after ERM peel. No eyes that had cataract surgery pre-ERM developed CMO post-operatively (Table 3). Comparing the cataract surgery after ERM peel versus combined surgery group, there was a trend for a larger proportion of eyes receiving cataract surgery after ERM to have CMO post-operatively, although this was not statistically significant (11.1% vs. 4.8%, p=0.36).

There were improvements in both the cataract surgery pre-ERM group and the combined group at three month and twelve month post-operative follow-up appointments (Table 3). There was no difference between the groups for mean change in VA (logMAR) from baseline to three month (p=0.87) or twelve month follow-ups (p=0.54). There was also no significant difference in mean change in CMT from baseline to three month follow-up (p=0.07) or twelve month follow-up (p=0.20) between the groups.

Table 3. Visual acuity at three month and twelve month follow-up in pre-ERM versus combined surgery group.
*Note: Five pre-ERM eyes and ten combined eyes did not have three month follow-up data available. †Three eyes with missing twelve month follow-up VA excluded.
‡There were 41 eyes with twelve month follow-up PVD information not available.
ns: not significant.

Discussion

BCVA is our main tool for predicting visual outcomes in ERM vitrectomy. It is a widely used and reliable prognostic factor to measure visual outcomes [4]. Our study utilised results from a single vitreoretinal surgeon and one centre, which provided consistency for this study, and reduced variation. We investigated outcomes in the combined surgery and the cataract surgery prior to ERM peel groups, due to the limited published research comparing these groups. For these outcome analyses, we excluded the cataract surgery post-ERM group.

Dawson et al [10] found pre-operative VA may predict visual improvements at follow-up. Our results confirm Dawson et al’s [10] research for both groups, with the strongest prediction being for the consecutive surgery group (pre-surgery VA is a stronger predictor of follow-up VA in consecutive versus combined surgery). In our study, the combined surgery group had better mean (logMAR) pre-operative BCVA, due to a greater proportion of eyes within the 6/15 to 6/24 range. To control for greater baseline visual acuity in the combined group, we analysed change in BCVA (logMAR) at follow-up between the two groups.

Our finding of no significant difference in mean VA improvement between the cataract surgery pre-ERM group and the combined group is similar to previous research. In a 2010 study by Dugas et al [5], 174 eyes were compared for surgical outcomes between combined and consecutive cataract extraction and ERM vitrectomy. At twelve months follow-up, the groups did not demonstrate a statistically significant difference in VA improvements [5]. In another similar study conducted by Yiu et al [6] in 2013, 81 eyes from 79 patients were grouped into combined cataract and ERM vitrectomy and ERM vitrectomy alone. Yiu et al [6] found no statistically significant differences between the groups on VA improvements at six month and twelve month follow-up. We also found no significant difference in mean improvement in CMT between the cataract surgery pre-ERM group and the combined group. This finding is also consistent with both Dugas et al [5] and Yiu et al [6].

Eyes that had cataract surgery after ERM peel had approximately double the incidence of post-operative CMO compared to the combined surgery group. While this finding was not statistically significant, this may be explained by the small number of eyes that developed CMO in each group, resulting in a lack of power to detect a significant difference between the groups. Among the combined group in our study, 5.0% developed CMO. This concurs with previous studies that reported incidences of 3.6% to 8.1% in combined surgical cases [7,8]. A separate study also concluded no difference in the incidence of CMO between combined surgery and pre-ERM groups [9]. Due to the small sample size, and no eyes in the cataract surgery pre-ERM group developing CMO post-operatively, we were unable to determine if the incidence of CMO would have improved if consecutive surgery (either cataract surgery before or after ERM peel) was conducted. Perhaps a further study with larger population sizes would allow for a clearer understanding of this.

ERM peel is known to be a safe and effective procedure. Our study indicated that there was no statistically significant difference in the proportion of patients in the combined or sequential groups who had peri-operative or post-operative complications. Peri-operative complications included retinal tears and lens touch. Post-operative complications included CMO and posterior capsule opacification. The rate of complications we observed was also consistent with similar studies. As such, we would conclude that there was no evidence to demonstrate that combined surgery would be safer in terms of complications. The benefits of a combined operation include the reduced risks of two separate operations, reduced costs, and increased convenience for the patient. Furthermore, a cataract operation after an ERM peel might be more challenging for the surgeon, due to the lack of vitreous support and increased difficulty of intraocular lens placement, thus increasing peri-operative complications [11]. Both ERM and cataract affect vision, so conducting a cataract operation alone might not provide optimal VA improvement, as there may be progression of ERM. Considerations against combined surgery include an increased post-operative inflammatory response, CMO, and increased rates of posterior capsule opacification and posterior synaechiae formation [12].

Limitations of this study include its retrospective design. Unfortunately, this was necessary to identify a substantial number of patients for inclusion (this required an eight year study inclusion period), as the study recruited patients from the only cataract and vitreoretinal surgeon in the region. A prospective study including patients from several surgeons would have less bias and the results would have greater generalisability. We excluded patients from the study if they did not return for post-surgery follow-up. This resulted in 29 combined surgery eyes and 33 pre-ERM eyes being excluded. If these eyes were included in the study, 21.6% of the combined surgery group and 34.7% of the pre-ERM would have been categorised as lost to follow-up. It is probable that patients lost to follow-up may have had better improvements in their VA. However, it is unknown to what extent the exclusion of these eyes may have introduced bias to the study results, particularly when comparing the two groups. The patients who underwent combined phacovitrectomy had a better mean (logMAR) VA and a greater proportion had a pre-operative VA of 6/24 or better. Given the presence of both pathologies, these patients underwent combined surgical procedures. However, some of these patients with both pathologies (ERM and cataract) may have had an acceptable VA improvement from cataract surgery alone, such that they would not have ordinarily proceeded to epiretinal surgery. In contrast, the patients in the cataract surgery prior to ERM peel group had already selected themselves into that group requiring ERM surgery as they were sufficiently affected by ERM. Thus, the patients in the consecutive surgery group potentially would not present for surgery unless already having a worse pre-operative VA than the combined surgery cohort.

We acknowledge that an analysis of a twelve month follow-up BCVA would include various confounders, such as new ophthalmic pathologies or worsening of pre-existing pathologies. Those factors were not taken into account during our analysis. As post-operative conditions tend to stabilise by three months following operation, we also analysed our patients at the three month follow-up period. The results were similar at three and twelve month follow-up intervals. Whilst we made an assumption that the patients were stable at three months, they appeared to continue improving after this time, as demonstrated by the twelve month follow-up results. Additionally, our comparison did not include patients who were diagnosed with ERM but only underwent cataract surgery, as they might not present for ERM peel secondary to acceptable visual improvements. Our consecutive group involved patients who underwent cataract operation then ERM peel. Some of these patients might have developed ERM only after the cataract surgery. Finally, our study is limited by the absence of baseline comorbidity data. As such, we were unable to assess the impact, if any, of comorbidities on VA improvements.

Conclusion

This study has shown that combined cataract and ERM vitrectomy is at least as effective as consecutive operations, if not better, for improving VA. As such, it may be prudent to conduct combined surgery, as it reduces patient exposure to the risks of two separate operations, as well as being more convenient for the patient.
Acknowledgements

We would like to thank the staff at the Launceston Eye Institute for their technical assistance in obtaining the dataset required for this research.

Conflict of interest

None declared.

References

[1] Cheung N, Tan S, Lee S, Cheung G, Tan G, Kumar N, et al. Prevalence and risk factors for epiretinal membrane: the Singapore epidemiology of eye disease study. Br J Ophthalmol. 2017;101:371-6.

[2] Noda Y, Yamazaki S, Kawano M, Goto Y, Otsuka S, Ogura Y. Prevalence of epiretinal membrane using optical coherence tomography. Nippon Ganka Gakkai Zasshi. 2016;119(7):445-50.

[3] Aung K, Makeyeva G, Adams M, Chong E, Busija L, Giles G, et al. The prevalence and risk factors of epiretinal membranes. Retina. 2013;33(5):1026-34.

[4] Kauffmann Y, Ramel JC, Lefebvre A, Isaico R, De Lazzer A, Bonnabel A, et al. Preoperative prognostic factors and predictive score in patients operated on for combined cataract and idiopathic epiretinal membrane. Am J Ophthalmol. 2015;160(1):185-92.

[5] Dugas B, Ouled-Moussa R, Lafontaine PO, Guillaubey A, Berrod JP, Hubert I, et al. Idiopathic epiretinal macular membrane and cataract extraction: combined versus consecutive surgery. Am J Ophthalmol. 2010;149(2):302-6.

[6] Yiu G, Marra KV, Wagley S, Krishnan S, Sandhu H, Kovacs K, et al. Surgical outcomes after epiretinal membrane peeling combined with cataract surgery. Br J Ophthalmol. 2013;97(9):1197-201.

[7] Kim KN, Lee HJ, Heo DW, Jo YJ, Kim JY. Combined cataract extraction and vitrectomy for macula-sparing retinal detachment: visual outcomes and complications. Korean J Ophthalmol. 2015;29(3):147-54.

[8] Wensheng L, Wu R, Wang X, Xu M, Sun G, Sun C. Clinical complications of combined phacoemulsification and vitrectomy for eyes with coexisting cataract and vitreoretinal diseases. Eur J Ophthalmol. 2009;19(1):37-45.

[9] Savastano A, Savastano MC, Barca F, Petrarchini F, Mariotti C, Rizzo S. Combining cataract surgery with 25-gauge high-speed pars plana vitrectomy: results from a retrospective study. Ophthalmology. 2014;121(1):299-304.

[10] Dawson SR, Shunmugam M, Williamson TH. Visual acuity outcomes following surgery for idiopathic epiretinal membrane: an analysis of data from 2001 to 2011. Eye (Lond). 2014;28(2):219-24.

[11] Cole CJ, Charteris DG. Cataract extraction after retinal detachment repair by vitrectomy: visual outcome and complications. Eye (Lond). 2009;23(6):1377-81.

[12] Smith M, Raman SV, Pappas G, Simcock P, Ling R, Shaw S. Phacovitrectomy for primary retinal detachment repair in presbyopes. Retina. 2007;27:462-7.

Tags epiretinal membrane, cataract surgery, vitrectomy

Editorials

Editor’s Welcome

Post author By Website Publications Officer
Post date April 14, 2018

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

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

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

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

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

Correspondence
R Park: editorinchief@amsj.org

Editorials

A balancing act: life as a physician-scientist

Post author By Website Publications Officer
Post date April 14, 2018

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

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

Q: What is the current focus of your research?

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

Q: What drew you to specialise in haematology?

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

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

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

Q: When did you first become interested in research?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Guest Articles

The wide world of medicine

Post author By Website Publications Officer
Post date April 14, 2018

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.

Editorials

Designing a literature review: critical considerations

Post author By Website Publications Officer
Post date April 14, 2018

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

Is this review necessary?

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

The review may not be necessary if:

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

Types of review articles

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

Systematic review

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

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

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

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

Scoping review

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

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

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

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

Narrative review

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

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

Review articles at the AMSJ

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

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

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

Conclusion

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

Conflict of interest

None declared.

References

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

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

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

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

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

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

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

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

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

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

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

Guest Articles

Human anatomy

Post author By Website Publications Officer
Post date April 14, 2018

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 21^st 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.