Category: Blog

Volume 2, Issue 2 of the Australian Medical Student Journal (AMSJ) is scheduled to be distributed in the coming weeks. This being the journal’s third issue, it is a timely juncture to take stock of the articles published to date, stratifying by factors such as article type, article topic, and author university.

The AMSJ has published 86 articles in total: 27 in the inaugural issue, 31 in the second issue, and 28 in the third. The most common article types were review articles (20), feature articles (17), and letters (14) (Figure 1). Figure 2 shows how the proportions of each article type have changed over the three issues.

The most common categories of article topic were medical education (13) and general and internal medicine (11) (Figure 3).

Articles have been published by students spanning 18 of Australia’s 20 medical schools (Figures 4 and 5). 14 universities were represented in the inaugural issue, 13 in the second issue, and 14 in the third. Eight universities have been published in all three issues, six have been published in two issues, and four have been published in one issue only. Of the eight universities published in all three issues, six are Group of Eight (Go8) universities.

Table 1 ranks the universities by number of articles published. The University of New South Wales (UNSW) has the most number of publications (14), followed by James Cook University (9), Monash University (8), and the University of Queensland (7). Deakin University and the University of Western Sydney are the only not to have been published. The UNSW dominance may be partly explained by the fact that the AMSJ organisation originated from UNSW and may have developed greater brand awareness at that institution. Four of the 14 UNSW articles were editorials. Of the eight universities with the highest tallies, six were Go8 universities (all Go8 universities except the Australian National University and the University of Western Australia).

Australia’s 20 medical schools span all six States plus the Australian Capital Territory. On a State and Territory basis, Queensland has the highest average number of articles published per university (mean 4.75), followed by Victoria (mean 4.67) and New South Wales (mean 4.14). Western Australia has the lowest average (mean 1.5) (Figure 6).

During AMSJ editorial screening and peer-review processes, editors and reviewers are blinded to the identity of the author(s), including their university. The number of articles published from any one university is likely a factor of both the number and quality of submissions received from that university. It is likely that the number of submissions received by any one university relates to factors such the awareness of the AMSJ at that university and the size of that university’s medical student cohort. It is likely that the quality of submissions relates to factors such as the research intensity of the university or medical school. We can test some of these assumptions using publically available data. [1-5]

In 2011, there are 16,553 medical students enrolled across the 20 medical schools. [1] The AMSJ has published 0.005 articles per student enrolled in 2011, or one article per 192 students. The schools have enrolments ranging from 1797 students (Monash University) to 60 students (University of New England). [1,2] Figure 7 shows the relationship between enrolment and number of articles published in the AMSJ. The relationship is highly significant by ANOVA (F_1,18, 20.008; p=0.001). It would appear from this that the size of a medical school influences the likelihood that its students will be published in the AMSJ. The number of articles published per capita for each university is shown in Figure 8.

The Australian Research Council publishes research ratings in eight disciplines for each university. These scores can be averaged for each university to produce an Australian University Research Ranking. [3] Figure 9 shows the relationship between the 2011 ranking scores and the number of articles published in the AMSJ. The relationship is significant by ANOVA (F1,18, 6.193; p=0.023). It would appear from this that the research intensity of a university influences the likelihood that its medical students will be published in the AMSJ.

The years in which the medical schools accepted their first cohorts of student span from 1862 (University of Melbourne) to 2008 (Deakin University, Notre Dame University Sydney, and University of New England). [4,5] Figure 10 shows the relationship between medical school age and the number of articles published in the AMSJ. The relationship is significant by ANOVA (F1,18, 4.667; p=0.044). It would appear from this that the age of establishment of a medical school influences the likelihood that its students will be published in the AMSJ.

110 authors have been published in the AMSJ. Eight of these have published two articles (including four AMSJ editors), while the remaining 102 have published one.

The AMSJ only accepts articles where the primary author is a current university student or medical intern, or where the primary author’s research was largely conducted whilst a university student. The exceptions to this rule are letters and solicited articles. 83 (75.5%) of the AMSJ’s authors were classified as students, while 27 (24.5%) were non-students. Of the non-student authors, eight were letter authors, seven were co-authors with a student as the primary author, and twelve were solicited by the AMSJ. These include three Australians of the Year (Patrick McGorry, Fiona Stanley, and Ian Frazer), a Nobel laureate (Peter Doherty), two Australian federal politicians (Kevin Rudd and Nicola Roxon), and three prominent medical authors (Nicholas Talley, John Murtagh, and Murray Longmore).

What is the purpose of analysing all of this data? As the national journal for medical students, the AMSJ would like to see representation and contribution from all of our medical schools. Hopefully, we can encourage a friendly rivalry between schools and in doing so, increase awareness of the AMSJ and the number and quality of submissions.

Since its establishment in mid-2009 and the release of its inaugural issue in April 2010, the AMSJ has become a truly national publication. It has a staff of around 50 students, spanning all 20 medical schools. [6] It has published articles by students from 18 medical schools and distributes to more than 10,000 students per issue via both print and electronic editions. This is an impressive presence that the AMSJ will try to build upon going forward.

References
[1] Medical Deans Australia New Zealand. 2011 Medical Student Statistics. Table 2 (a): Total student enrolments 2011 by year of course (Australia) [Online]. 2011 Sep 16 [cited 2011 Sep 28]. Available from: URL: http://www.medicaldeans.org.au/wp-content/uploads/Table-2-Website-Stats-2011.pdf

[2] University of Newcastle and University of New England. Bachelor of Medicine Joint Medical Program 2011 [Online]. 2010 May 25 [cited 2011 Sep 28]. Available from: URL: http://www.une.edu.au/rural-medicine/resources/pdfs/jmp-bmed-brochure.pdf

[3] Australian Education Network. Rankings of Australian Universities [Online]. 2011 [cited 2011 Sep 28]. Available from: URL: http://www.australian-universities.com/rankings/
[4] Lawson KA, Armstrong RM, Van Der Weyden MB. A sea change in Australian medical education. Med J Aust 1998;169(11/12):653-8.

[5] Lawson KA, Chew M, Van Der Weyden MB. The new Australian medical schools: daring to be different. Med J Aust 2004;181(11/12):662-6.

[6] Australian Medical Student Journal. Staff List [Online]. 2011 [cited 2011 Sep 28]. Available from: URL: https://www.amsj.org/about/staff-list

Have you thought about how tough medicine is and whether it’s worth staying in it for the long run?  Have you thought of doing other things with your medical degree such as those suggested in Part 1?

So you may have, but what are the reasons for why medical students get disillusioned? Let’s take a closer look…

“As an intern, nothing you do matters”

In final year, you’re striving to reach the light at the end of a tunnel, only to realise that the light is just illuminating the entrance of another tunnel. This might seem the case when you are comparing interns to registrars and consultants, but what if you compare interns to other people in society?

I remember a conversation with Rob, someone I no longer know. Last I heard he was roaming Australia in a van, driving anywhere that was away from Sydney. On the bus one evening, he tells me: ‘I don’t know what I’m doing in life. My job is meaningless. I have no stories to tell. I wish I was you.’ Even after one day in a hospital, we have a story to tell. Some of life’s most incredible stories are medical. Everyone knows it, especially television producers.

The TV producer might focus on the boy born without limbs or the horribly disfigured trauma victim, but what about the significance of everyday ward tasks. One of my current patients was hospitalised for an inguinal hernia repair – one of the most common surgical procedures. He now has an enterocutaneous fistula, feces draining from his abdominal wound, and has been in hospital for nearly two months. He was the victim of several medical and nursing errors and during my term, I saw this once jolly old man who even managed to enjoy his hospital food, transformed into one who is depressed, apathetic and is fed via a nasogastric tube.

It’s dreadful for the patient,  but you can still squeeze something positive out the awful situation – even when you are doing the ‘nothing’ tasks of an intern, the blood forms, discharge summaries, consults and others, if you do them well, you are preventing another patient from a similar fate.

One thing that keeps me going is knowing I won’t end up with the same complaints as Rob.

“There’s just too much to learn”

What are the fourteen branches of the maxillary artery?¹ What are the fifteen eponymous signs of aortic regurgitation?² One of the worst things about being a student is constantly being reminded, usually by your consultant, that there is so much left to learn.

One of the best is realising how much you already know, across such a wide field. Exams only seem to test the knowledge we lack, but take a second to consider how much you know about psychiatry, surgery, paediatrics, obstetrics, basic sciences and much more – although most of us won’t admit it. Many registrars have said to us final year students: “you will never be as smart as you are now…unless you do BPT.”

We grumble that it takes at least a decade to become a consultant. But then, in what profession can you walk straight out of uni and be a boss? It’s a long ladder, but the view from the top is worth it.

“We work too hard, and for little reward”

I guess to appreciate this, you need to find some perspective. You can often get perspective from your patients, seeing the suffering they have to deal with, and being thankful you are spared. Often though, it is hard to appreciate what you can gain from patients when you are focussed on their creatinine, their CT results and their urine output. Sometimes it can be easier to gain perspective from the real world, the one outside the hospital walls, the one where we spend less and less time.

A surgical attachment can begin and end in darkness. I walk to the station in the chilling, gloomy pre-dawn light every morning at 6.00 am. Even then, the station’s little news-stand is open, manned by a solitary middle aged lady. She knows that she’s at the mercy of her product – people will only buy newspapers if the front page is enticing, and she has no control over that. In the evening, she is still there, desperately hoping to sell another magazine, a Herald or perhaps even the Telegraph. Oblivious, commuters bustle past her, screens in their faces and headphones in their ears. She works longer hours than a surgical intern, doing a thankless job just well enough to pay the rent. There’s nowhere for her to go. That stand is not going to get any bigger, she’s not going to establish a successful news-stand franchise. When yesterday and today are the same, the worst thing is knowing tomorrow will be the same too. Suddenly, eleven hours at hospital was nothing for me to complain about.

1. Deep auricular, anterior tympanic, middle meningeal, inferior alveolar, accessory meningeal, massteric, pterygoid branches, deep temporal arteries, buccal , sphenopalatine, descending palatine, infraorbital, posterior superior alveolar, artery of pterygoid canal
2. Austin Flint murmur, Corrigan’s, de Musset’s, Duroziez’s, Quincke’s, Traube’s, Landolfi’s, Becker’s, Muller’s, Mayen’s, Rosenbach’s, Gerhardt’s, Hill’s, Lincoln’s, Chen’s

“So, you are a medical student? And 5^th year as well? Well, well, you must know all of your anatomy by now! Do they still even teach you that nowadays at university? Go scrub in for the next case, I want to quiz you on the anatomy of the abdominal wall and how to operate on inguinal hernias.”

The amount of anatomy teaching delivered by current Australian and New Zealand medical schools has become an area of considerable debate. There has been much criticism indicating that anatomy teaching has become a neglected area of medical education with a reduction in teaching hours compared to previous decades. Adequate anatomical knowledge is undoubtedly critical in almost all medical disciplines; from understanding clinical presentations, performing a competent physical examination, to arriving at an accurate diagnosis with the aid of imaging techniques and initiating appropriate treatment including surgical management. Historical data indicates that there has been a decline in the number of hours of anatomy teaching in medical schools. This prompted a recent survey of 19 Australian and New Zealand medical schools, which identified that the average total anatomy teaching was 171 hours with a large standard deviation of 116.7 hours, with some teaching as few as 56 hours in total and others 560 hours.[1] This study has suggested that with the large discrepancy in numbers of anatomy teaching hours there will also be variability in the knowledge of medical graduates. Hence there have also been calls for a standardised national medical curriculum with an increase in teaching of the basic medical sciences, which has also become an area of recent debate.[2]

Some medical schools have adopted a self-directed or “problem-based” approach towards teaching,[3] whereby the student’s themselves are responsible for identifying deficiencies in their knowledge in order to pass exams and ultimately, to use this to become competent clinicians. As a student I have found that it requires much more self-motivation to keep studying in this way especially in the latter years of my program when we have relatively fewer exams and more focus on clinical experiences, although it is something that one should become used to for continual professional development. There is also a general consensus amongst most students that teaching of biomedical sciences has been reduced and replaced with teaching of communication and interpersonal skills, which are difficult to teach and assess objectively and are also dependent on individual student personality and life experiences developed through “living, seeing and doing”.[4] For some students, self-directed learning can also be a burden for study and it makes it difficult to identify how much to focus on a particular topic or how much to study. The scenario above highlights one case of a style of teaching employed- or rather “grilling” that we may receive during our clinical years of medical school, which can be beneficial in motivating some students to study to avoid embarrassment or showing-off how much they know to a consultant. However, it is the general lack of specific anatomical knowledge by some medical students reflected in these scenarios that has been identified by surgeons and radiologists which has become a recent area of criticism. The culprit for this has become some of the newer medical programs which have less formal teaching in anatomy compared to previous decades. At the end of the day, however, I believe that it is the responsibility of the students themselves to identify major gaps in their knowledge and address these.

Some criticism has also arisen from a deficiency in assessment of anatomical knowledge during exams. It is true that with major study “cramming” sessions, anatomy tends to be left out by some students based on the assumption that the material is unlikely to be examined, or will not form a major part of integrated basic sciences in applied case-based exams. Additionally, as most universities do not have a specific exam for anatomy, there is no specified minimum level of achievement for gross anatomy and as such, some students can do poorly in gross anatomy questions, although perform well overall and still progress and graduate from their degree.[1] This does appear to be a major problem in the knowledge of graduates, although it is also important to realise, that without adequate understanding of function, disease processes, pharmacology and drug prescription, there is no point in merely knowing human structure. Junior medical officers would be at much greater risk at putting themselves and their patients at danger.

But what does this all mean for graduates? As a fifth year medical student, I still have thousands of hours of study remaining till I graduate from my six year degree and to be honest, I am not sure where most of my current knowledge will eventually take me after graduation and internship. I also realise that if I intend to become a surgeon, there will be much more detailed knowledge expected from me in all the basic science disciplines, especially anatomy. It is clearly evident that for most contemporary post-graduates entering into training programmes, they will not have sufficient anatomical knowledge to practice in a surgical specialty.[3] Additionally, with increasing numbers of medical students it has become difficult for logistical reasons to have career anatomists, retiring surgeons or surgical registrars teaching gross anatomy to hundreds of students and dissection of cadavers for teaching is virtually unheard of. The focus now seems to have shifted towards the introduction of graduate diplomas and master’s degrees in surgical anatomy delivered by Australian and New Zealand universities for those interested in surgical specialties.[1] This does seem to be a suitable method of filtering graduates with a greater interest in anatomy and favouring those with a photographic memory for rote learning and remembering millions of small anatomical details; skills which are suitable for proceduralist practice. However, at the university level, teaching methods are also being revised and recently, the University of Sydney have started an anatomy dissection course as an elective, which was greeted with positive enthusiasm by students.[5] Re-introduction of dissection may prove useful for students to gain beneficial hands-on anatomical knowledge rather than rote learning structures from anatomy picture atlases. However, this would prove difficult, as it is extremely resource intensive and difficult at some universities with low ratios of experienced anatomy tutors to students.

Further studies and debate is warranted to compare older teaching methods with current methods and to assess for a standardised national teaching curriculum in conjunction with, or replacing medical school assessment. With the boom in numbers of medical students in recent years, this is becoming increasingly important to ensure the maximal effectiveness of student teaching in the basic sciences. This will hopefully boost student confidence and application of knowledge that will be essential for future junior medical practitioners.

 

References

[1] Craig S, Tait N, Boers D, McAndrew D. Review of anatomy education in Australian and New Zealand medical schools. ANZ J Surg 2010;80(4):212-6.

[2] Schiller M, Lucewicz A, Yang T. National standards in medical education. AMSJ 2011;2(1):10-1.

[3] Smith JA. Can anatomy teaching make a comeback? ANZ J Surg 2005;75(3):93.

[4] Linacre J. Wither anatomy teaching?: a student perspective. ANZ J Surg 2005;75(3):96-7.

[5] Robotham J. Anatomy of a dissection debate. The Sydney Morning Herald; April 14^th 2011. Available from http://www.smh.com.au/world/science/anatomy-of-a-dissection-debate-20110413-1deaf.html

 

Earlier this year the Royal Australasian College of Physicians (RACP) controversially thrust Australian doctors into the climate change debate via a high profile media release commenting on the government’s proposed carbon tax.  The release supported action on climate change, but urged the government to ensure that proposed measures did not impact negatively on the health of socioeconomically disadvantaged populations by driving up the cost of living. Headlines such as ‘Doctors fear health impact of carbon tax’ greeted this announcement and stoked the political conflagration surrounding the proposed tax. In the fallout the chairman of the RACP’s climate change working group resigned in protest at the wording of the statement which was at odds with the recommendations of the working group. A revised statement was released several weeks later softening the wording of the initial release. Outside observers within the medical profession have suggested that this may have significantly dented the credibility of the college.

Internationally, climate change has been framed by prestigious medical journals such as the BMJ and the Lancet as the ‘biggest global health threat of the 21^st century’.  A series of papers in these journals have been at the forefront of the drive for involvement of medical professionals in this debate. Medical colleges and public health groups in Europe and America have begun to weigh in on the debate, however aside from the RACP Australian medical colleges and associations have been relatively quiet on the subject. In contrast, the Australian Medical Student’s Assocation (AMSA) has launched ‘Code Green’, an education and advocacy campaign to encourage medical student participation in the debate. Various universities, most notably Monash University have initiated similar education and advocacy campaigns.

The potential public health impacts of climate change would by definition draw medical professionals into certain aspects of policy and management, however in such a politically loaded and emotive issue is it wise for medical groups to step further into the debate than the health aspects? How do you define the ‘health aspects’ of such a debate? What should the role of Australian medical professionals and students be in this debate? Should AMSJ take an interest? Have your say below!

While this is not the forum to debate the science of climate change, insightful comments or responses to the above questions are welcome. If you feel particularly strongly about the issue, why not submit an article or letter to the next edition of AMSJ?

 

It’s the question that everyone asks you. From fellow medical students to patients, to family and friends, to the random acquaintance you’re meeting for the first time. They all ask, ‘So what do you want to specialise in?’ If you’re like most medical students, it changes by the week. But what if you’ve realised you don’t like any of the specialties, or even medicine in general? What are your options then? You’ve done years of study and you’re determined to graduate with a medical degree, but maybe medicine isn’t the career you want. Well, there are plenty of options outside of clinical medicine that perhaps you are unaware of.

I have a friend who decided fairly early on in medical school that working as a doctor didn’t suit him. He wanted the fame and fortune, without all that annoying patient interaction. He started planning his way out early, and while still at medical school, completed internships with big corporations and applied for various graduate positions. He ended up with a job in management consulting, with one of the most prestigious global management consultancy firms straight out of university, and never even bothered with his intern year or getting registered as a doctor.

I have another friend who, midway through his intern year, decided he wanted to change paths as well. No need to go through all that competition for specialty training positions. He applied to go back to university to study dentistry. The ultimate goal might be to become an oral maxillofacial surgeon, but if that falls through, working as a general dentist with its lifestyle and monetary benefits would suffice.

Personally, I took a few years away from medical school to conduct medical research. While at this point, I don’t see myself working full-time in research in the future, I can definitely see the benefits it would have over clinical practice. Research is a truly international occupation, and the opportunity to live and work overseas is much easier in research than in clinical medicine, especially in non-English speaking countries or countries with different medical systems. Research (for the most part) provides stable working hours, the chance to completely explore an area of personal interest and challenge yourself in different ways.

However, the opportunities don’t end in business or research. Medical administration is another option, and an area to which you can put your knowledge of the healthcare system to good use. Take the RACMA for example – the Royal Australasian College of Medical Administrators. Dozens of doctors have also become politicians, business advisors, journalists and even actors or comedians.

Ultimately, a medicine degree is highly regarded in many industries, not just in health. It proves that you’re intelligent, you can problem solve, you can work in a team, and have many other skills other degrees might not necessarily provide. Studying medicine doesn’t mean you have to become a doctor or even that you are a doctor for life, and the career path you take is only determined by what opportunities you explore.