tag:theconversation.com,2011:/africa/topics/medical-schools-13830/articlesMedical schools – The Conversation2024-02-01T13:30:51Ztag:theconversation.com,2011:article/2166032024-02-01T13:30:51Z2024-02-01T13:30:51ZSuicide has reached epidemic proportions in the US − yet medical students still don’t receive adequate training to treat suicidal patients<figure><img src="https://images.theconversation.com/files/562904/original/file-20231201-17-ssns1k.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5982%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every year, more than 12 million Americans have suicidal thoughts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/tired-and-downcast-man-holding-head-with-hands-royalty-free-image/1472116942?phrase=suicide&searchscope=image%2Cfilm&adppopup=true">Djavan Rodriguez/Moment via Getty Images</a></span></figcaption></figure><p>Suicide in the U.S. is <a href="https://www.mentalhealthfirstaid.org/">a societal epidemic</a> and a <a href="https://www.kff.org/mental-health/issue-brief/a-look-at-the-latest-suicide-data-and-change-over-the-last-decade/">staggering public health crisis</a> that demands attention from medical experts.</p>
<p>In 2021, <a href="https://www.cdc.gov/suicide/suicide-data-statistics.html">someone in the U.S. died by suicide every 11 minutes</a>, according to the Centers for Disease Control and Prevention. That rate equates to nearly 50,000 Americans every year. Another 1.7 million people in the U.S. attempted suicide in 2021, and over 12 million more had suicidal thoughts. </p>
<p>And the numbers appear to be getting worse: Preliminary numbers for 2022 show a <a href="https://www.nytimes.com/2023/08/11/well/mind/suicide-deaths-2022-cdc.html">2.6% increase in suicide deaths from 2021</a>. </p>
<p>Suicide particularly affects younger people – it remains one of the top three causes of death for those between ages 10-34. High school students identifying as lesbian, gay, bisexual, transgender, queer and questioning, or LGBTQ+, attempt suicide <a href="https://www.thetrevorproject.org/resources/article/facts-about-lgbtq-youth-suicide/">four times more often than heterosexual students</a>. </p>
<p>These statistics make it clear that far more attention needs to be given to how to talk about suicide, both with loved ones and in medical and other professional settings. </p>
<p>As <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/office-of-medical-education/rbonnin.html">a team of experts</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/gralnikl.html">who educate medical students</a> <a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/ndesmara.html">on how to identify</a> and treat suicidal patients, we are well aware that most medical schools <a href="https://doi.org/10.1097/ACM.0000000000004008">do not yet adequately address the topic of suicide</a>. </p>
<p>In turn, many of their students, once they become physicians, are not adequately equipped to identify, assess and refer suicidal patients. Yet, these health care providers are expected to <a href="https://doi.org/10.3389/fmed.2022.892205">play a key role</a> in the battle to prevent suicide. But as the numbers make clear, this approach is not enough.</p>
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<figcaption><span class="caption">The signs of someone considering suicide include giving away possessions and abusing drugs or alcohol.</span></figcaption>
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<h2>Destigmatizing suicide</h2>
<p>Suicide has a long history of stigma, made worse by how it’s <a href="https://theactionalliance.org/messaging/entertainment-messaging/national-recommendations">portrayed in the media</a>. Often, when someone dies by suicide, the media uses euphemistic phrases such as “no foul play suspected,” rather than clear and accurate language describing the death as a suicide. This type of coded language implies the subject of suicide should not be addressed directly and <a href="https://link.springer.com/chapter/10.1007/978-3-030-26840-4_1">leaves questions about what actually happened</a>. </p>
<p>When a person takes their own life, the phrase <a href="https://www.dailymail.co.uk/news/article-12856353/Emily-Matson-Pennsylvania-suicide-train.html">“committed suicide” is often used</a>, as if it were a sin or a crime. This is partly because, historically, most religions have considered suicide to be sinful and as a result it is <a href="https://doi.org/10.1111/1467-9566.12224">treated as taboo</a>. Although laws against suicide have been <a href="https://ethics.journalism.wisc.edu/2023/03/10/a-guide-to-responsible-reporting-on-suicide/">repealed in the United States and many other places</a>, attempted suicide is still <a href="https://www.law.cornell.edu/wex/suicide">considered a crime in some states</a>. </p>
<p>The verb “commit” in the context of suicide can <a href="https://twitter.com/APStylebook/status/1160941325073731584">suggest a criminal act</a>. In contrast, using language such as “died from suicide” or “took her own life” is less stigmatizing and more neutral, which is why these phrases are <a href="https://www.hse.ie/eng/services/list/4/mental-health-services/nosp/resources/language-and-suicide/">recommended by advocates of mental health</a> as best practices. Consistent with this approach, many media organizations have developed specific guidelines for reporting about suicide. For example, the Associated Press Stylebook recommends <a href="https://www.apstylebook.com/ap_stylebook/suicide">avoiding use of the phrase “committed suicide</a>.” </p>
<p>Similarly – largely because of the societal and historical stigma surrounding suicide, which medical education is not immune to – medical schools do not equip up-and-coming doctors with the language and skills needed to recognize it and properly address it with their patients.</p>
<h2>Shortage of mental health care</h2>
<p>The first point of contact for patients seeking treatment for mental health conditions is usually their primary care physician. About 44% of those who died by suicide worldwide between 2000 and 2017 had visited their primary care provider <a href="https://doi.org/10.1177/1403494817746274">within one month of their death</a>. </p>
<p>This could be due to a combination of factors, including the continued stigma of mental health, <a href="https://theconversation.com/as-the-mental-health-crisis-in-children-and-teens-worsens-the-dire-shortage-of-mental-health-providers-is-preventing-young-people-from-getting-the-help-they-need-207476">limited access to mental health professionals</a> and ease of access to and comfort with their primary care practitioner as a first step. Research shows that gaps between general medical services and specialty mental health options are preventing adults and kids from <a href="https://doi.org/10.1016/j.apnu.2019.08.001">getting the mental health care</a> they need.</p>
<p>In addition, the vast majority of patients with depression are treated by their primary care physicians rather than psychiatrists. </p>
<p>The shortage of available psychiatrists means that primary care physicians provide treatment and prescribe mental health care by default, especially for children, adolescents and geriatric patients. In fact, primary care providers – in other words, practitioners who are not psychiatrists – prescribe more than half of all psychiatric medication. And a 2023 study found that approximately one-third of patients received <a href="https://doi.org/10.1007/s10488-023-01290-x">mental health care from their primary care provider</a>. </p>
<p>Finally, many psychiatrists in private practice do not accept insurance, including Medicare and Medicaid, leading to <a href="https://doi.org/10.1001%2Fjamapsychiatry.2013.2862">reduced availability of psychiatric care</a>. </p>
<p>Thousands of additional lives might be saved if primary care physicians and other practitioners who are not psychiatrists were better trained to ask the vitally important questions about suicide. In addition, better recognition of the warning signs of suicide, readily available psychiatric care and the elimination of stigma of mental illness would facilitate better quality of care. </p>
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<figcaption><span class="caption">Psychiatry and behavioral health professors Rodolfo Bonnin and Nathaly Shoua-Desmarais talk about the urgent need for suicide education for all doctors, not just psychiatrists.</span></figcaption>
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<h2>Training the next generation of doctors</h2>
<p>Why do so many Americans take their lives shortly after seeing a primary care provider? </p>
<p>It may be because many doctors are <a href="https://doi.org/10.1027/0227-5910/a000555">unprepared or uncomfortable discussing suicide</a> or don’t pick up on the signs of <a href="https://pubmed.ncbi.nlm.nih.gov/33351435/">suicidal ideation</a>. It’s also possible that the doctors simply don’t have the necessary time to spend with the patients, even when intervention is needed. </p>
<p><a href="https://medicine.fiu.edu/about/departments/psychiatry-and-behavioral-health/">At Florida International University</a>, we train all medical students, beginning in the first year, on how to discuss suicide with patients. This helps to normalize the topic as just another part of their medical training, which, in turn, destigmatizes it. </p>
<p>We then emphasize the need for comfort and familiarity with the topic, as well as the many myths surrounding it. For example, there’s a false belief that asking a patient about suicide will increase the likelihood they will act upon the suicide. <a href="https://doi.org/10.1080/13811118.2020.1793857">Research indicates otherwise</a>. </p>
<p>Finally, students are told that doctors must create a safe environment for their patients to be open about discussing sensitive topics. In short, doctors must ask questions about suicide in a way that’s not pejorative or dismissive. They must not apologize to the patient or shy away from the subject.</p>
<p>Statements like “I’m sorry to have to bring this up” or “I’m sorry if this question seems too personal” can be an indication of discomfort or uneasiness. Instead, doctors should ask direct and specific questions like “Have you had any thoughts about ending your life” or “Are you having any thoughts of suicide?” </p>
<p>After a risk assessment is completed, then a patient would be hospitalized if they are at risk – there is no mandate for doctors to report on or act on depression.</p>
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<figcaption><span class="caption">Suicidal ideation is an emergency.</span></figcaption>
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<h2>The need for universal suicide screening</h2>
<p>Although universal suicide screening has yet to be made the best practice nationally, there are multiple reasons why a standard screening process would be beneficial. Training in suicide assessment and prevention can be made mandatory for medical license renewal, which would include universal screening practices. </p>
<p>For example, <a href="https://www.pewtrusts.org/en/research-and-analysis/articles/2023/04/19/health-care-providers-laud-universal-screenings-to-help-reduce-suicide-risk">adopting best practices</a> could include offering suicide screening during routine health care visits to identify people at risk who might not otherwise be identified. </p>
<p>Another example: More than half of 15,000 children and adolescents who were seen in a pediatric hospital emergency room for nonpsychiatric reasons between March 18, 2013, and Dec. 31, 2018, were also <a href="https://doi.org/10.1176/appi.ps.202100625">experiencing suicidal ideation and behaviors</a>. These examples emphasize the critical need to train doctors in suicide assessment and prevention. Currently there are fewer than 10 states that <a href="https://www.datocms-assets.com/12810/1577013724-afsphealthprofessionaltrainingissuebrief6-7-19.pdf">require any training on suicide assessment and prevention</a> for doctors to renew their medical license.</p>
<p>In addition, doctors can use empathy, compassion and a nonjudgmental approach, rather than making the patient feel like they are being cross-examined by a lawyer. Interacting empathically leaves the patient feeling more understood and comfortable disclosing sensitive information. </p>
<p>There is a growing movement <a href="https://doi.org/10.1097/ACM.0000000000004008">toward addressing mental health issues</a> in medical schools. Our program prioritizes training a new crop of physicians who will be prepared and motivated <a href="https://doi.org/10.1007/s40596-021-01485-0">to discuss suicide with their patients</a>. </p>
<p><em>If you or someone you know is considering suicide, please <a href="https://988lifeline.org/">call or text 9-8-8 for confidential, free support</a>.</em></p><img src="https://counter.theconversation.com/content/216603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Close to half of those who die by suicide saw a primary care doctor within a month of their death.Rodolfo Bonnin, Assistant Dean for Institutional Knowledge Management and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLeonard M. Gralnik, Chief of Education and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityNathaly Shoua-Desmarais, Assistant Dean for Student Success and Well-Being and Associate Professor of Psychiatry and Behavioral Health, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2105292023-10-25T12:31:23Z2023-10-25T12:31:23ZFrom morgue to medical school: Cadavers of the poor, Black and vulnerable can be dissected without consent<figure><img src="https://images.theconversation.com/files/555053/original/file-20231020-25-57ohdr.jpg?ixlib=rb-1.1.0&rect=8%2C5%2C1964%2C1302&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical students look at cadaver parts being used for demonstration.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/meley-bekele-can-hardly-stand-to-look-at-the-cadaver-parts-news-photo/165288427?adppopup=true">Rick Madonik/Toronto Star via Getty Images</a></span></figcaption></figure><p>Every year, first-year medical students approach their human cadavers with a mixture of awe and trepidation. They will come to know their assigned cadaver intimately. During the course of their studies, they will carefully pull back layers of skin, muscle and tissue as they learn the fundamentals of human anatomy.</p>
<p>When the long process of dissection is complete, the cadavers are cremated, <a href="https://theconversation.com/medical-students-honor-body-donors-through-words-deeds-and-ceremonies-208168">with the remains</a> returned to family, interred in a dedicated plot, scattered in a memorial garden or sometimes buried at sea.</p>
<p>Historically, anatomy laboratories relied on unclaimed bodies or executed prisoners, and even resorted to grave-robbing <a href="https://theconversation.com/from-grave-robbing-to-giving-your-own-body-to-science-a-short-history-of-where-medical-schools-get-cadavers-199947">to meet the growing demand for cadavers</a>. Today, while we’d like to believe every cadaver on the slab has been donated knowingly – and indeed, <a href="https://www.nationalgeographic.com/science/article/body-donation-cadavers-anatomy-medical-education">thousands of Americans will leave their bodies to science every year</a> – the reality is more complicated. </p>
<p>In the United States, when a deceased person’s assets are insufficient to cover the cost of burial or cremation, and next of kin are unable or unwilling to shoulder the financial burden, it falls to the state or county in which the person died to arrange for the disposal of their remains. </p>
<p>In most parts of the country, government officials are permitted to donate these unclaimed bodies to institutions of higher education, with no legal requirement for prior consent from the deceased or their next of kin. In 2019, <a href="https://doi.org/10.1002/ase.1853">12.4% of surveyed U.S. medical schools</a> indicated possible use of unclaimed bodies at their institutions. </p>
<p>As <a href="https://www.uta.edu/academics/faculty/profile?username=shupee">a professional medical ethicist</a>, I was surprised when I learned in 2021 about the continuing use of unclaimed bodies in medical teaching, and I set out to discover the extent to which the practice occurred in Texas, where I live and work. Those efforts culminated in <a href="https://doi.org/10.1001/jama.2023.15132">a peer-reviewed, comprehensive study</a> on cadaver procurement trends within a single state, and what our research team found was alarming.</p>
<p>Between 2017 and 2021, the number of unclaimed bodies accepted by Texas medical schools increased nearly sevenfold. It rose from 64 to 446 – going from 2.27% of all donations to 14.12% – over five years.</p>
<h2>Money plays a role</h2>
<p>Budgetary pressures have likely played some role in driving these trends. In the United States, <a href="https://choicemutual.com/blog/cremation-cost/">the average cost of a no-frills cremation is currently around US$2,000</a>. Some states or counties offer burial for unclaimed bodies if there is reason to believe the deceased wouldn’t want cremation, such as for religious reasons, but it is a more expensive option, with the money coming from the county or state budget. </p>
<p>Not only do medical schools cremate the bodies they accept without charge, but many also offer discount-rate cremation for bodies that are offered but do not meet their requirements for human cadavers. </p>
<p>In densely populated areas with a greater number of unclaimed bodies, these savings can add up. Tarrant County, Texas – home to the city of Fort Worth – has <a href="https://fortworthreport.org/2022/04/03/cadavers-help-students-prepare-for-professions-in-medicine-but-some-are-donated-without-consent/">saved hundreds of thousands of dollars each year</a> through its agreement with a local medical school. </p>
<h2>Ethical controversies</h2>
<p>Concerningly, medical students are sometimes <a href="https://anatomypubs.onlinelibrary.wiley.com/doi/10.1002/ase.1853">kept in the dark</a> about the use of unclaimed bodies at their own institutions.</p>
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<a href="https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C2116%2C1851&q=45&auto=format&w=1000&fit=clip"><img alt="Two medical students, intently looking down, with one covering her mouth with one hand." src="https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C2116%2C1851&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=529&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=529&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=529&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=665&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=665&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555051/original/file-20231020-23-zytvm6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=665&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">First-year medical students at their first anatomy class.</span>
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<p>Mary Peeler, who graduated from the Johns Hopkins University School of Medicine, learned from a teaching assistant that her cadaver had been an unclaimed body only after she had already begun the process of dissection. </p>
<p>“I still grapple,” <a href="https://pubmed.ncbi.nlm.nih.gov/33207091/">she wrote</a> in the New England Journal of Medicine, “with the guilt of having dissected a man who may have wanted to rest in peace.”</p>
<p>What little we know about the demographics of unclaimed bodies suggests that they are <a href="https://doi.org/10.1371/journal.pone.0238348">more likely to be male, more likely to be African American and more likely to have been poor or unemployed prior to death</a> than bodies that are claimed by next of kin. Some who have <a href="https://doi.org/10.1002/ca.21223">spoken out</a> have emphasized that it is disproportionately society’s most vulnerable members who may be dissected without consent.</p>
<p>The International Federation of Associations of Anatomists has released <a href="https://ifaa.net/recommendations/">professional guidelines</a> calling for anatomists to stop using unclaimed bodies, and a handful of medical schools have independently decided to no longer accept them. Oregon Health & Science University, for example, <a href="https://www.oregonlive.com/portland/2009/01/ohsu_stops_taking_bodies_of_in.html">stopped taking unclaimed bodies</a> in 2009 after the sister of a man whose remains were mistakenly donated to the university came forward.</p>
<h2>Bans on the use of unclaimed bodies</h2>
<p>If the use of unclaimed bodies is on the rise in Texas, is the same thing happening elsewhere? For now, we simply do not know. The donation of unclaimed bodies remains legal in the majority of U.S. states, although there are some outliers.</p>
<p>In 2016, <a href="https://www.nytimes.com/2016/08/20/nyregion/law-bans-the-use-of-unclaimed-dead-as-cadavers-without-consent.html">New York banned</a> the use of unclaimed bodies without written consent from the deceased or their next of kin, a move that faced strong opposition from the state’s consortium of 16 medical schools. A few other states, <a href="https://legiscan.com/HI/bill/SB2818/2012">including Hawaii</a> in 2012 and <a href="https://legislature.vermont.gov/bill/status/2014/H.178">Vermont in 2014</a>, have passed similar pieces of legislation.</p>
<p>In 2021, I chose to donate my own body to science. Signing the paperwork attesting that I was of sound mind and fully informed about my decision required a half-hour of my time and the presence of two witnesses. It is unsettling that many Americans may have made that exact “donation” without ever having had to put a pen to paper. Instead, all they needed to do was die poor and alone.</p><img src="https://counter.theconversation.com/content/210529/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eli Shupe does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most states permit government officials to donate unclaimed bodies to medical schools, with no legal requirement for prior approval from the deceased or their next of kin.Eli Shupe, Assistant Professor of Philosophy and Co-Director of Medical Humanities and Bioethics, University of Texas at ArlingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2081682023-06-28T12:34:48Z2023-06-28T12:34:48ZMedical students honor body donors through words, deeds and ceremonies<figure><img src="https://images.theconversation.com/files/534396/original/file-20230627-27-sd4cd.jpg?ixlib=rb-1.1.0&rect=0%2C4%2C1024%2C677&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Donors' bodies lie covered in an anatomy lab at the Justus Liebig University in Giessen, Germany.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/march-2023-hesse-gie%C3%9Fen-couch-with-covered-body-donations-news-photo/1249666093?adppopup=true">Sebastian Gollnow/picture alliance via Getty Images</a></span></figcaption></figure><p><a href="https://www.justice.gov/usao-mdpa/pr/six-charged-trafficking-stolen-human-remains">Six people were charged</a> on June 14, 2023, with buying and selling human remains stolen from the Harvard Medical School morgue and from an Arkansas mortuary. The macabre story <a href="https://apnews.com/article/stolen-human-body-parts-harvard-medical-school-a33afcd82908dda340f4c1df18e7b43f">made national headlines</a>, particularly the indictment of Cedric Lodge: a morgue manager at Harvard from 1995 until earlier this year.</p>
<p>As <a href="https://chaplaincyinnovation.org/team/amy-lawton-phd">a scholar in the sociology of religion</a>, <a href="http://hdl.handle.net/11134/20002:860685608">my research</a> explores practices related to whole-body donation in medical schools across the United States. While these accusations against Lodge are deeply troubling, they are an aberration: Medical school communities go to incredible lengths to respect and honor the people who donate their bodies to science.</p>
<p>Much of this happens behind closed doors. The serious scientific work of anatomical study is undergirded by practices that promote the donors’ dignity, including memorial ceremonies to honor their gift. I conducted <a href="http://hdl.handle.net/11134/20002:860685608">a census of allopathic medical schools</a> – schools that grant the M.D. degree – and analyzed recordings of 60 donor memorial ceremonies, as well as other materials.</p>
<h2>Foundation of learning</h2>
<p>Despite advances made in technology, including virtual reality and 3D anatomy software, dissecting a real human body is generally considered irreplaceable in Western medical education. Substitutions result in <a href="https://doi.org/10.1002/ase.1859">less effective instruction</a>, leading to lower scores on practical and written examinations. One benefit is that <a href="https://doi.org/10.1002/ase.1758">students who learn from dissection</a> see normal bodies, with diversity, variations and imperfections that would not be evident on models. Faculty <a href="http://hdl.handle.net/11134/20002:860685608">views donor bodies as essential</a> because they are always accurate and up to date, which cannot always be said about books or software. </p>
<p>In the U.S., medical schools <a href="https://www.statnews.com/2016/08/17/body-donations-medical-school/">accept bodies from donors</a> and next of kin. A minority of institutions <a href="https://doi.org/10.1002/ase.1853">accept unclaimed bodies</a>, but their use is controversial.</p>
<p>Bodies’ importance goes beyond their effectiveness as a teaching tool. Anatomy lab marks the students’ <a href="https://doi.org/10.1002/ar.b.20117">initiation into the medical profession</a>. It teaches not only anatomy but the value of the human person, professionalism, ethics and clinical skills such as diagnosis. </p>
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<a href="https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A young brunette woman wearing gloves rinses a human heart in a sink in an anatomy lab." src="https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534397/original/file-20230627-35262-9zpqxh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The lessons medical students learn from donor bodies go beyond anatomy.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/liz-harkin-uses-a-running-tap-to-clean-out-a-human-heart-news-photo/145376204?adppopup=true">Bill O'Leary/The Washington Post via Getty Images</a></span>
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<p>From day one, medical students studying gross anatomy are encouraged to think of the donor body as <a href="https://www.nytimes.com/2023/05/31/science/donor-bodies-medical-school-appreciation.html">their “first patient</a>,” someone for whom they will care and from whom they will learn. Medical students are responsible for preserving the body, performing dissections correctly so as not to cause unnecessary mutilation, and speaking of the body and the donor respectfully. </p>
<p>Students work in teams, each of which is usually responsible for dissecting one body. Many also feel a sense of responsibility toward their donors – a duty to learn as much as they can, taking full advantage of the gift they have been given.</p>
<h2>Reflection and respect</h2>
<p>At the end of the semester, students say goodbye to the donors. My research found that more than nine out of 10 allopathic medical schools mark this occasion with a memorial ceremony. <a href="https://thedo.osteopathic.org/2018/03/acom-honors-anatomical-donors-memorial-space-reflection/">Ceremonies also take place</a> at schools for other branches of health care, such as <a href="https://www.liberty.edu/lucom/news/lucom-class-of-2024-hosts-annual-symbolic-memorial-honoring-first-patients/">osteopathy</a> and <a href="https://blogs.chapman.edu/crean/2015/04/08/honoring-those-who-give-life-to-science-donor-memorial-ceremony/">physical therapy</a>. Wherever students learn from body donors, they gather together to express their gratitude for a gift that can never be reciprocated.</p>
<p>Some ceremonies are conducted before an audience that includes the friends and families of all body donors used that year. Some are open to the medical school community, and others are for the students alone. For many, these donors have played a transformative role in their lives. It is common to hear students refer to their donors as a friend or mentor. </p>
<p>At the 2018 University of Iowa ceremony, a student reflected: “I know her hands, her feet, what parts of her may have ached towards the end of life, which organs let her down. I spent countless hours as her pupil. She taught me things about life that no living person ever could. When I was confused and needed time to think, she was patient. My donor entrusted me with the intimate gift of her body to learn about the topics that make my heart race.” </p>
<p>Learning in the anatomy lab and participating in a donor memorial ceremony have something important in common. Both experiences <a href="https://www.britannica.com/topic/sacred">stand apart from everyday life</a>, making them, in a sense, sacred. These ceremonies set aside a special time and space for <a href="https://doi.org/10.1002/ar.10188">reflection and remembrance</a> – time and space that busy medical students do not usually have.</p>
<p>Unlike most memorial services, these students have no personal memories of the deceased. In fact, some are not even told their donor’s first name, which is often concealed to preserve privacy.</p>
<p>Yet they know at least one fact: This person cared about medicine and other people’s health. Students reflect on how generous and principled the donors must have been – as well as their families, who were willing to carry out loved ones’ wishes in their time of grief. Though students did not witness donors’ lives, they can still <a href="http://hdl.handle.net/11134/20002:860685608">celebrate and honor them</a>. </p>
<p>A student at the University of Cincinnati’s 2019 service shared: “I am overwhelmed with respect and gratitude for all our donors. … As we gather here today, let’s remember the legacy that all of these donors and family members have left in all of us, and celebrate the legacy that they continue to forge even after death.” </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Rows of young people in white medical coats stand respectfully outside at a ceremony." src="https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=448&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=448&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534452/original/file-20230627-27-jgyme6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=448&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Medical students at the University of Mississippi Medical Center attend the Ceremony of Thanksgiving in Memory of Anatomical Donors in 2018.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HonoringTheirGifts/57639ee975e143e6b8acc8d0048f069b/photo?Query=donor%20body%20ceremony&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=41&currentItemNo=7">AP Photo/Rogelio V. Solis</a></span>
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</figure>
<p>A donor body’s gift cannot be “paid back,” but medical students can try to pay it forward. Many describe ways they will try to serve others, as the donor did. Some doctors-to-be express a sense that the donors will forever guide their hands.</p>
<p>There is no foolproof way to prevent bad actors in any institution. Yet research into donor memorial ceremonies shows that no one takes the gift of body donation more seriously than the recipients.</p><img src="https://counter.theconversation.com/content/208168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Lawton received funding from the Templeton Religion Trust administered through the Issachar Fund.</span></em></p>The lessons students learn from dissecting donor bodies go beyond anatomy – and they try to pay that gift forward.Amy Lawton, Research Manager, Chaplaincy Innovation Lab, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1999472023-03-10T13:40:22Z2023-03-10T13:40:22ZFrom grave robbing to giving your own body to science – a short history of where medical schools get cadavers<figure><img src="https://images.theconversation.com/files/514518/original/file-20230309-22-axut7p.jpg?ixlib=rb-1.1.0&rect=42%2C404%2C1903%2C1444&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">These Georgetown University medical students used donated cadavers in their anatomy class in 2011.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/liz-harkin-uses-a-running-tap-to-clean-out-a-human-heart-news-photo/145376204">Bill O'Leary/The Washington Post via Getty Images</a></span></figcaption></figure><p>In 1956, <a href="https://www.newspapers.com/clip/120516087/alma-merrick-helms-1958/">Alma Merrick Helms</a> announced that she was bound for Stanford University. But she would not be attending classes. Upon learning that there was a “special shortage of women’s bodies” for medical students, this semiretired actress had filled out forms to <a href="https://catalog.loc.gov/vwebv/search?searchCode=LCCN&searchArg=25011667&searchType=1&permalink=y">donate her corpse</a> to the medical college upon her death. </p>
<p>As <a href="https://history.utk.edu/people/susan-lawrence/">historians</a> <a href="https://history.wisc.edu/people/lederer-susan-e/">of medicine</a>, we had long been familiar with the tragic tales of 18th- and 19th-century grave robbing. Medical students had to snatch unearthed bodies if they wanted corpses to dissect. </p>
<p>But there was <a href="https://www.technologyreview.com/2022/10/12/1060924/donating-your-body-science-body-farm/#">little to no discussion of the thousands</a> of Americans in the 20th century who wanted an alternative to traditional burial – those men and women who gave their bodies to medical education and research.</p>
<p>So we decided to research this especially physical form of philanthropy: people who <a href="http://doi.org/10.1353/bhm.2022.0020">literally give themselves away</a>. We are now writing a book on this topic.</p>
<h2>Grave robbing and executed criminals</h2>
<p>As more and <a href="https://www.press.jhu.edu/books/title/1862/learning-heal">more medical schools opened</a> before the Civil War, the profession faced a dilemma. Doctors needed to cut open dead bodies to learn anatomy because no one wanted to be operated on by a surgeon who had only been trained by studying books.</p>
<p>But <a href="https://yalebooks.yale.edu/book/9780300078688/the-sacred-remains/">for most Americans</a>, cutting up dead human beings was sacrilegious, disrespectful and disgusting. </p>
<p>According to the ethos of the day, only criminals deserved such a fate after death, and judges intensified murderers’ death sentences by adding the <a href="https://www.jstor.org/stable/20092326?seq=1">insult of dissection</a> after their executions. As in life, the <a href="http://www.beacon.org/The-Price-for-Their-Pound-of-Flesh-P1227.aspx">bodies of enslaved people were also exploited in death</a>, either consigned for dissection by their masters or robbed from their graves.</p>
<p>Yet there were never enough legally available bodies, so <a href="https://www.smithsonianmag.com/history/in-need-cadavers-19th-century-medical-students-raided-baltimores-graves-180970629/">grave robbing flourished</a>. </p>
<h2>The unclaimed poor</h2>
<p>To meet the medical professon’s growing demand for cadavers, Massachusetts enacted the <a href="https://collections.countway.harvard.edu/onview/exhibits/show/nature-of-every-member">first anatomy law</a>. This measure, passed in 1831, made the bodies of the unclaimed poor available for dissection in medical schools and hospitals. </p>
<p>With more medical schools opening and grave-robbing scandals pushing politicians to act, similar legislation eventually took effect across the United States.</p>
<p>One of the most visible incidents occurred when the body of former Rep. John Scott Harrison, both the son and the father of U.S. presidents, involuntarily <a href="https://www.mentalfloss.com/article/64221/body-snatching-horror-john-scott-harrison">turned up on an Ohio dissecting table in 1878</a>.</p>
<p>In many states, kin and friends could claim a body that would otherwise be destined for dissection, but only if they could pay burial costs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Women embrace each other at a grave strewn with flowers." src="https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/514279/original/file-20230308-26-wolhb3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Monuments to honor those who have donated their bodies to science like this one can offer opportunities for their loved ones to mourn and remember them.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/bodies-photos-by-michael-williamson-neg-6-19-06-burial-news-photo/97103197">Michael Williamson/The Washington Post via Getty Images</a></span>
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<h2>Donated bodies</h2>
<p>Yet not everyone shared the horror at the very idea of being dissected.</p>
<p>By the late 19th century a growing number of Americans were willing to <a href="http://doi.org/10.1353/bhm.2022.0020">let medical students cut up their bodies</a> before eventual burial or cremation. It did not apparently frighten or disgust them. </p>
<p>Doctors volunteered, but so did nurses, store owners, actors, academics, factory workers and freethinkers – even prisoners about to be executed. Some were people who simply sought to avoid funeral expenses. </p>
<p>Other Americans hoped that doctors would use their bodies to research their diseases, while others wanted to enable “medical science to enlarge its knowledge for the <a href="https://www.newspapers.com/clip/103849794/1901-young-george/">good of mankind</a>,” as George Young, a former wagon-maker, requested before he died in 1901.</p>
<h2>Cornea transplants</h2>
<p>By the late 1930s, <a href="https://www.google.com/books/edition/Flesh_and_Blood/6Q4TDAAAQBAJ?hl=en&gbpv=1&dq=susan+lederer+%22dawn+society%22&pg=PA199&printsec=frontcover">advances in cornea transplant surgery</a> made it possible for Americans to gift their eyes to restore the sight of blind and visually impaired men, women and children.</p>
<p>Along with <a href="https://www.smithsonianmag.com/science-nature/again-and-again-in-world-war-ii-blood-made-the-difference-1-32174495/">World War II blood drives</a>, heartwarming stories about corneal transplants spread a radically new understanding of corporeal generosity. </p>
<p>As efforts to attract donors who would <a href="https://doi.org/10.1016/0039-6257(82)90151-5">pledge their eyes at death spread in the 1940s</a> and early 1950s, so too did a new problem for anatomists: a decline in the number of unclaimed bodies. </p>
<p>Anatomists blamed a <a href="https://archive.org/details/humandissectioni00lassrich/page/n269/mode/2up">host of factors</a>: <a href="https://www.loc.gov/classroom-materials/united-states-history-primary-source-timeline/post-war-united-states-1945-1968/overview/">rising prosperity in the postwar years</a>; new laws that allowed county, city and state welfare departments to bury the unclaimed; veterans’ death benefits; Social Security death benefits; and outreach by church groups and fraternal orders to take care of their poverty-stricken members. </p>
<h2>Dear Abby and Reader’s Digest</h2>
<p>By the mid-1950s concerns arose about <a href="https://archive.org/details/humandissectioni00lassrich/page/n267/mode/2up">cadaver shortages for anatomy classes</a>. But media coverage of people who had chosen to donate their bodies started to sway others to follow suit. Good examples include a <a href="https://worldcat.org/identities/lccn-n81-103052/">Dear Abby</a> advice column published in 1958 and a <a href="https://bookriot.com/history-of-readers-digest/">Reader’s Digest</a> article in 1961.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&rect=0%2C633%2C1429%2C1105&q=45&auto=format&w=1000&fit=clip"><img alt="Black and white photo of a woman in a suit sitting in a mausoleum" src="https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&rect=0%2C633%2C1429%2C1105&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=860&fit=crop&dpr=1 600w, https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=860&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=860&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1081&fit=crop&dpr=1 754w, https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1081&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/514276/original/file-20230308-626-l2rde3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1081&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In her exposé of the funeral industry’s problems, author Jessica Mitford endorsed donating bodies to science.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/author-jessica-mitford-sitting-in-a-mausoleum-in-sunset-news-photo/50439405">Ted Streshinsky/Getty Images</a></span>
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<p>In 1962, Unitarian advocate Ernest Morgan published “<a href="https://search.library.wisc.edu/catalog/999526260202121">A Manual of Simple Burial</a>,” which promoted memorial services as alternatives to lavish funerals. He included a directory of medical schools and dental schools that accepted whole-body donations.</p>
<p>Journalist Jessica Mitford, in her wildly popular 1963 book that condemned the funeral industry, “<a href="https://archive.org/details/americanwayofdeamitf00mitf">The American Way of Death</a>,” also endorsed that practice. She helped make giving your body to science a respectable, even noble, alternative to expensive conventional burials.</p>
<p>In the early 1960s, <a href="https://www.nejm.org/doi/full/10.1056/NEJM196201252660406">Protestant, Catholic and Reform Jewish</a> leaders also came out in favor of donating bodies to science. </p>
<p>By the late 1960s and early 1970s, some anatomy departments began to organize <a href="https://www.newspapers.com/image/305525888/?terms=%22Their%20service%20to%20mankind%20continued%20after%20death%22&match=1">memorial services</a> to acknowledge donors and provide some closure for their loved ones.</p>
<p>Word of such efforts further encouraged whole-body donation. </p>
<h2>Letters of encouragement</h2>
<p>We reviewed <a href="http://doi.org/10.1353/bhm.2022.0020">dozens of unpublished letters</a> to and from donors in the 1950s to the early 1970s, in which anatomy professors encouraged potential whole-body donors to see themselves as heroically giving to medical science. Early donors frequently expressed this altruistic vision, wanting their mortal shells to participate in advancing knowledge. </p>
<p>By the mid-1980s, most medical and dental schools relied on donated bodies to teach anatomy, although a <a href="https://doi.org/10.1097%2FACM.0000000000002227">few unclaimed bodies</a> still make their way today to medical schools. <a href="https://doi.org/10.1111%2Fjoa.12056">Technology has revolutionized</a> anatomy teaching, as with the National Library of Medicine’s <a href="https://www.nlm.nih.gov/research/visible/visible_human.html">Visible Human Project</a>, but <a href="https://doi.org/10.1002/ase.1649">cadavers are still needed</a>.</p>
<p>Images and models cannot replace hands-on experience with the human body. </p>
<p>Where many Americans once <a href="https://www.newspapers.com/clip/120453623/her-scalpel-in-hand/">regarded medical students as “butchers</a>” for exploiting their beloved dead, contemporary students honor what some of these future doctors call their “<a href="https://doi.org/10.7812/tpp/07-145">first patients</a>” for the precious gift they have been given.</p><img src="https://counter.theconversation.com/content/199947/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This particularly physical kind of philanthropy caught on in the mid-20th century.Susan Lawrence, Profesor of History, University of TennesseeSusan E. Lederer, Professor of Medical History and Bioethics, University of Wisconsin-MadisonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1843772022-06-29T12:05:17Z2022-06-29T12:05:17ZAn online life coaching program for female physicians decreases burnout, increases self-compassion and cures impostor syndrome, according to a new study<figure><img src="https://images.theconversation.com/files/470120/original/file-20220621-15-eoobjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Physician burnout is more prevalent in women than men. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/asian-female-medical-professional-sitting-in-chair-royalty-free-image/91497435?adppopup=true">ER Productions Limited/DigitalVision via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>An online group coaching program that normalizes vulnerability and emotional processing can help fix burnout in female physicians, <a href="https://doi.org/10.1001/jamanetworkopen.2022.10752">our study found</a>. The doctors who participated in this program went from highly to only mildly burned out, while their peers who were not in the program became even more burned out.</p>
<p><a href="https://www.massmed.org/Publications/Research,-Studies,-and-Reports/Physician-Burnout-Report-2018/">Physician burnout</a> happens when doctors lose satisfaction and a sense of efficacy at work and become exhausted instead of fulfilled. </p>
<p>We wanted to address the experiences that negatively affect medical training and begin healing the culture. So we created an online life coaching program: <a href="https://bettertogetherphysiciancoaching.com/">Better Together Physician Coaching</a>, or simply Better Together, as we call it.</p>
<p>Better Together involves twice-weekly live group coaching calls facilitated by either one of us, who are both <a href="https://coachadriennemannmd.com/">certified life coaches</a> <a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/30649">and physicians</a>. The program also includes unlimited anonymous written coaching on the website’s forum as well as weekly worksheets and webinars. The content centers around topics that matter to female doctors such as career decisions, receiving critical feedback and dealing with perfectionism. It also focuses on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571643/#">impostor syndrome</a> – the feeling of doubt about one’s skills despite ample evidence to the contrary – and practicing <a href="https://doi.org/10.4236/psych.2019.103021">self-compassion</a>. </p>
<p>In late 2020, 101 female resident doctors at the University of Colorado volunteered to participate in Better Together and were randomized to either receive the coaching program, or not to, from January to June 2021. Using a scale called the <a href="https://www.mindgarden.com/117-maslach-burnout-inventory-mbi">Maslach Burnout Inventory</a>, we measured participants’ emotional exhaustion. We also measured depersonalization – meaning the extent to which they had an unfeeling or impersonal response to their work – and their sense of professional accomplishment. </p>
<p>Our study also assessed the participants’ levels of impostor syndrome, self-compassion and “moral injury,” which is the accumulation of negative effects by continued exposure to morally distressing situations. </p>
<p>Participants in the coaching program reported significantly lower levels of emotional exhaustion – the primary facet of burnout. They also reported significantly less impostor syndrome and increased levels of self-compassion. The magnitudes of improvement were higher than most <a href="https://doi.org/10.1007/s11606-021-06903-5">other interventions</a> aimed at <a href="https://doi.org/10.1371/journal.pone.0250104">improving well-being among residents</a>. </p>
<h2>Why it matters</h2>
<p>A 2018 Harvard report called physician burnout a <a href="https://www.massmed.org/Publications/Research,-Studies,-and-Reports/Physician-Burnout-Report-2018/">“public health crisis” that urgently demands action</a>. And a systematic review of research found that <a href="https://doi.org/10.1001/jama.2018.12777">up to 80% of physicians experience burnout</a>. </p>
<p>It impacts <a href="https://meridian.allenpress.com/jgme/article/1/2/236/33694/Burnout-During-Residency-Training-A-Literature">a majority of medical trainees and doctors</a> and disproportionately <a href="https://doi.org/10.1016/j.eclinm.2021.100879">affects women and those who are underrepresented in medicine</a>. Physician burnout <a href="https://doi.org/10.4300/jgme-d-09-00054.1">begins early in training</a> and is associated with <a href="https://doi.org/10.1016/s0140-6736(09)61424-0">more errors, higher patient mortality rates, depression, suicidal thoughts</a> and <a href="https://hbr.org/2022/01/why-so-many-women-physicians-are-quitting">high job turnover</a>. </p>
<p>What many medical educators refer to as the <a href="https://doi.org/10.1136%2Fbmj.329.7469.770">hidden curriculum of medical training</a> has historically promoted a culture <a href="https://doi.org/10.1001/jama.2022.10006">where doctors place all other needs above their own</a>, a belief that reinforces perfectionism, isolation and overwork. </p>
<p>Institutions often try to improve physician well-being with offerings like free yoga, more time off or extra snacks instead of addressing the hidden curriculum and resultant toxic culture that drives burnout. At best, <a href="https://doi.org/10.1371/journal.pone.0250104">these offerings</a> have <a href="https://doi.org/10.4300/jgme-d-17-00440.1">little sustainable impact</a> on physician well-being. At worst, doctors see them as attempts to placate or gaslight. </p>
<p>This is the culture that Better Together aims to change. </p>
<h2>What still isn’t known</h2>
<p>The doctors in this pilot test of Better Together were predominantly white, heterosexual, female and cisgender. Additional studies are needed to explore this coaching program in other gender identities, diverse racial identities, career stages and at other institutions.</p>
<p>We plan to scale up and further evaluate Better Together at multiple geographically and culturally diverse sites across the U.S. in the fall of 2022.</p><img src="https://counter.theconversation.com/content/184377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Tyra Fainstad is a professional life coach. She coaches clients (including physicians) outside of her academic roles in an independently owned and operated LLC; in that capacity, she does not recruit or coach medical trainees. She received funding for Better Together Physician Coaching through an internal grant from the Department of Medicine at the University of Colorado, the institution she is affiliated with. </span></em></p><p class="fine-print"><em><span>Dr. Adrienne Mann is a professional life coach. She provides coaching and consulting to individuals (including physicians) and groups outside of her academic role through an independently owned and operated LLC. In that capacity, she does not recruit or coach medical trainees. She received grant funding from the University of Colorado Department of Medicine for the development and Study of Better Together Physician Coaching. </span></em></p>Physician burnout is a severe problem in the medical field, made much worse by the COVID-19 pandemic. But an online coaching program that could be scaled up had dramatic results for participants.Tyra Fainstad, Associate Professor of Internal Medicine, University of Colorado Anschutz Medical CampusAdrienne Mann, Assistant Professor of Hospital Medicine, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1582802021-04-07T21:49:27Z2021-04-07T21:49:27ZMedical schools need to prepare doctors for revolutionary advances in genetics<figure><img src="https://images.theconversation.com/files/393358/original/file-20210405-15-105n7n5.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C5117%2C3427&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical education needs to include understanding how genetic conditions can occur.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Human diversity did not appear to matter to modern medicine. At the time, the state of medical practice <a href="https://dx.doi.org/10.1038/embor.2012.87">ignored the differences between individuals and between men and women</a>. </p>
<p>This practice was reflected in how doctors were trained. They took courses in basic biology, biochemistry, anatomy and physiology. But genetics, the science of variation, was not a required course until recently.</p>
<p>Advances in genetics research have <a href="https://dx.doi.org/10.3399/bjgp12X629955">slowly transformed the practice of medicine</a>. There has been a slow accumulation of <a href="https://dx.doi.org/10.1086/514346">a long list of diseases caused by variations in a single gene</a>. Since the disease-causing variants generally occurred — with some exception — in low frequency, these diseases did not occupy the mainstream concern of the medical profession.</p>
<p>All this changed with <a href="https://www.genome.gov/human-genome-project/What">the Human Genome Project (HGP)</a>. Completed in 2003, the <a href="https://www.genome.gov/25520492/online-education-kit-2003-human-genome-project-completed">sequencing of human genome</a> pushed us into a new era of how genetic diseases would be defined, and how future health services would be delivered.</p>
<p>Medical schools need to do a lot better preparing future physicians and health professionals if the dreams of personalized medicine are to be realized. </p>
<h2>Personalizing medicine</h2>
<p>Personalized medicine means treating patients based on the individual characteristics of their DNA. The information can be used either in direct intervention, as in cancer treatment, or in predictive medicine. </p>
<p>Different specializations would require varying levels of proficiency: for example, family physicians would need a sufficient background in genetics, while oncologists would need in-depth education.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A doctor shows a patient information on a tablet" src="https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393882/original/file-20210407-23-f76x9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Family physicians will have increasing access to data and more detailed genetic information about their patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The HGP made two big promises. First, it promised personalized predictive medicine <a href="https://doi.org/10.1016/S0140-6736(16)00176-8">based on an individual’s genome sequences</a>. Disease-causing mutations at different locations on a gene would be identified, and an overall personalized risk score would be calculated that <a href="https://doi.org/10.1109/tbme.2017.2698602">would tell the individual his or her chances of developing that disease</a>.</p>
<p>The second promise was to develop a better and faster cures for complex diseases such as cancer.</p>
<p>The letdown came when genomic studies showed that genes affecting complex diseases were potentially large in number and individually of small effect, and worse still, <a href="https://dx.doi.org/10.1038/nrg2809">only a small number of all potential genes affecting a given disease could be identified</a>.</p>
<p>Even more problematic, it turned out that all individuals sharing the same risk factor for a given disease did not develop the disease. This creates a problem for predictive medicine if scientists cannot link a disease to a gene with any certainty.</p>
<h2>Evolution and genetic complexity</h2>
<p>The uncovered genomic complexity of diseases was contrary to expectations of the Mendelian model, which did not account for genetic variations beyond “<a href="https://doi.org/10.1161/CIRCULATIONAHA.118.035954">one gene — one disease</a>.”</p>
<p>This is where the work my collaborators and I carried out in our labs comes in. Our work in population genetics and evolutionary genomics relates to how these characteristics are calculated and combined into an overall score used in predictive medicine.</p>
<p>My lab specializes in the evolution of molecular complexity and its impact on precision medicine. We also study variation and evolution of sex and reproduction related genes and their role in the evolution of sexual dimorphism in complex diseases and mental disorders. We reviewed three decades of relevant work in genetics, genomics and molecular evolution and <a href="https://doi.org/10.1038/s41525-020-0128-1">drew the following conclusions</a>.</p>
<p>First, we showed that because of the blind nature of evolutionary forces and the role of chance in evolution in humans, many combinations of genes can lead to the same disease. This implies the existence of a considerable amount of redundancy in the molecular machinery of the organism.</p>
<p>Second, we showed that genes do not work alone: gene-gene and gene-environment interactions are a major part of any organism’s functional biology. This would explain, for example, <a href="https://dx.doi.org/10.1093/annonc/mdv022">why some women with breast cancer genes develop breast or ovarian cancer and some do not</a>.</p>
<p>Third, we showed that since males fight for mates and early reproduction, this would lead to an evolution of male-benefitting mutations even at the cost of them being harmful later, making males vulnerable to diseases in their old age. Male-benefitting mutations harmful to females would trigger a female-driven response leading to the evolution of increased female immunity, and possibly evolution of higher thresholds for complex diseases and mental disorders. </p>
<p>This would explain why many diseases such as <a href="https://doi.org/10.1007/s00239-021-09999-9">autism are more common in boys than girls</a>. In addition, some differences in disease prevalence, such as depression in women, is theorized to be the result of <a href="https://dx.doi.org/10.1007/s00213-019-05326-9">interaction between hormone fluctuation and social stress factors</a>.</p>
<h2>Physicians and personalized medicine</h2>
<p>If you have sought medical attention, it’s likely that your doctor may have asked you about your parents and your siblings. Your physician is interested in knowing if there are any health conditions, such as cardiovascular disease, diabetes or high blood pressure that run in the family and that might affect your health.</p>
<p>Future physicians will need to know <a href="https://dx.doi.org/10.1016/j.ccell.2008.01.004">a lot more than their patients’ family history</a>.</p>
<p>The number of situations that involve relevant genetic contributions will continue to increase with advances in molecular insights and precision medication. The medical research establishment is becoming increasingly aware of the importance of individual genetic differences and of sex and gender when assessing diseases and health-care proposals. Health professionals must have sufficient expertise in diversity, genomics and gene-environment (gene-drug) interaction.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Laptop with floating icons related to health care" src="https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393875/original/file-20210407-15-7njvu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medical schools need to develop their curriculums to include advances in genetic research.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Future physicians will be part of health networks involving medical lab technicians, data analysts, disease specialists and the patients and their family members. The physician would need to be knowledgeable about the basic principles of genetics, genomics and evolution to be able to take part in the chain of communication, information sharing and decision-making process. </p>
<p>This would require a more in-depth knowledge of genomics than generally provided in basic genetics courses.</p>
<p>Much has changed in genetics since the discovery of DNA, but much less has changed how genetics and evolution are taught in medical schools.</p>
<p>In 2013-14 a survey of course curriculums in American and Canadian medical schools showed that while most medical schools taught genetics, most respondents felt the amount of time spent was insufficient preparation for clinical practice as it did not provide them with sufficient knowledge base. The survey showed that <a href="https://doi.org/10.1038/gim.2014.208">only 15 per cent of schools covered evolutionary genetics in their programs</a>.</p>
<p>A simple viable solution may require that all medical applicants entering medical schools have completed rigorous courses in genetics and genomics.</p><img src="https://counter.theconversation.com/content/158280/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rama Shankar Singh receives funding from McMaster University. </span></em></p>Medical education has not kept up with genetic discoveries — primary care physicians require more genetics and genomics training.Rama Shankar Singh, Professor of Biology, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1488762020-12-17T20:57:08Z2020-12-17T20:57:08ZHalf of Ontario’s medical schools are now named after wealthy donors<figure><img src="https://images.theconversation.com/files/374231/original/file-20201210-18-1csv5i3.jpg?ixlib=rb-1.1.0&rect=0%2C103%2C4564%2C2862&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Defunding of universities has forced administrators to to seek and secure private donations from wealthy individuals or corporations. Pictured here, the Michael G. De Groote Faculty of Medecine, McMaster University, in Hamilton, Ont. </span> <span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>With the September announcement <a href="https://www.cbc.ca/news/health/u-of-t-donation-1.5737613">of a record $250-million donation</a> <a href="https://www.theglobeandmail.com/canada/article-university-of-toronto-medical-school-to-get-record-250-million/#:%7E:text=James%20and%20Louise%20Temerty%20will,their%20honour%2C%20the%20university%20said">to the University of Toronto’s medical school, renamed</a> the <a href="https://medicine.utoronto.ca/about-faculty-medicine">Temerty Faculty of Medicine</a>, three of the six <a href="https://mdprogram.mcmaster.ca">medical schools</a> <a href="https://www.schulich.uwo.ca">in Ontario</a> are now named after wealthy donors.</p>
<p>Should we simply <a href="https://www.theguardian.com/news/2018/may/24/the-trouble-with-charitable-billionaires-philanthrocapitalism">celebrate philanthropic donations</a> to medical schools — or hospitals for that matter? There are reasons to look closer. As
<a href="https://press.princeton.edu/books/hardcover/9780691183497/just-giving">political scientist Rob Reich</a> of Stanford University notes:</p>
<blockquote>
<p>“<a href="https://news.stanford.edu/2018/12/03/the-problems-with-philanthropy/">Philanthropy is an exercise in power</a> …. In a democratic society, wherever we see the exercise of power in a public setting, the first response it deserves isn’t gratitude but scrutiny.”</p>
</blockquote>
<h2>Public institutions</h2>
<p>All <a href="https://www.royalcollege.ca/rcsite/resources/canadian-medical-schools-e">17 universities with faculties</a> of medicine in Canada are <a href="https://www.educanada.ca/programs-programmes/university-universite.aspx?lang=eng#:%7E:text=The%20case%20for%20university%20in,French%20speaking%20countries%5B3%5D">public universities</a> — part <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/190724/dq190724a-eng.htm">of Canada’s</a> <a href="https://higheredstrategy.com/why-dont-we-have-private-universities-in-canada/">largely public higher education landscape</a>. </p>
<p>Similarly, Canadian hospitals are almost all public institutions, the result of <a href="https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html#a3">policy developments that culminated</a> in the the <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/hcs-sss/alt_formats/pdf/pubs/cha-ics/2015-cha-lcs-ar-ra-eng.pdf">Canada Health Act</a> in 1984.</p>
<p>In Ontario, <a href="http://www.health.gov.on.ca/en/common/system/services/hosp/faq.aspx#hospitals">145 of 155 hospitals in the province are public hospitals</a>. These institutions are funded by taxpayers’ money and work within the rules set forth by the act prohibiting user fees and mandating public administration. </p>
<p>But <a href="https://pressprogress.ca/canadas-universities-and-colleges-are-being-taken-over-by-big-corporations-and-wealthy-donors/">defunding</a> of <a href="https://www.fao-on.org/en/Blog/Publications/Post_Secondary#Figure%204">both higher education</a> and <a href="https://www.oha.com/Documents/Ontario%20Hospitals%20-%20Leaders%20in%20Efficiency.pdf">health</a> has occurred, in the form of direct cuts and indirectly through stagnant budgets in the face of rising costs and yearly inflation starting in the ‘90s onwards. This defunding has presented institutional administrators with significant financial challenges. </p>
<p>In post-secondary institutions, part of the solution has been to seek and secure private donations from wealthy individuals or <a href="https://cupe.ca/sites/cupe/files/backgrounder_3_corporatization_eng.pdf">corporations</a>.</p>
<p>It is not very different in the <a href="https://www.thestar.com/news/gta/2015/12/02/toronto-east-general-renamed-michael-garron-hospital-after-landmark-50m-donation.html">public health-care system</a>, where <a href="https://www.hamiltonhealthsciences.ca/about-us/our-organization/our-locations/juravinski-hospital">entire hospitals</a> or <a href="https://www.uhn.ca/PMCC">important parts</a> including health-care programs are also named after wealthy donors.</p>
<figure class="align-center ">
<img alt="The Labatt Family Heart Centre at Sick Kids hospital." src="https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373608/original/file-20201208-23-1l4em2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Labatt Family Heart Centre at Sick Kids Hospital in Toronto, shown in April 2018.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Doug Ives</span></span>
</figcaption>
</figure>
<p>The <a href="https://academicmatters.ca/the-role-of-governments-in-corporatizing-canadian-universities/">root cause</a> for this pervasive and insidious practice is the lack of adequate government funding. </p>
<p>The practice should be challenged for many reasons, including the transparency and democracy of public institutions, institutional independence and equity in education and health-care delivery.</p>
<p>The rightful owners of a public institution are citizens and taxpayers. Although the share of public funding of universities has been slowly eroded, government funds and student fees still make up the <a href="https://higheredstrategy.com/download/22343">largest proportion of revenue together, at 46 per cent and 30 per cent respectively, while private/corporate funds makeup 24 per cent</a>.</p>
<p>Whether a charitable donation to <a href="https://www.cbc.ca/news/health/u-of-t-donation-1.5737613">a university</a> <a href="https://www.cbc.ca/news/canada/toronto/toronto-east-general-now-michael-garron-hospital-after-family-s-50m-gift-1.3346764">or hospital</a> is large enough to <a href="http://www.planningandbudget.utoronto.ca/Assets/Academic+Operations+Digital+Assets/Planning+$!26+Budget/budget201819.pdf">cover an entire year’s budget</a> <a href="https://www.tehn.ca/sites/default/files/file-browser/toronto_east_health_network_03312019_final_fs.pdf">or not</a>, many many more years of funding post-donation are still needed to run these institutions over the long term.</p>
<p>Even according to the logic of business and shareholders, how is it that the smaller contributor/donor (minor shareholder) gets their name on the front door? </p>
<p>How is it that such important decisions are made without transparent or wide consultation with the people that are the soul of these institutions and that make them what they are?</p>
<p>Here, I mean the nurses, physicians, allied health providers and communities of patients in the case of hospitals or faculty members, students and alumni in the case of universities. Where is institutional transparency when deals are announced as fait accompli after they’ve been signed behind closed doors? </p>
<h2>Institutional independence</h2>
<p>Not uncommonly, large donated funds <a href="https://www.theglobeandmail.com/news/national/time-to-lead/the-tricky-business-of-funding-a-university/article4619883/">are earmarked</a> for specific educational, research or health-care services, as requested by the donor, and potentially set priorities for the recipient university or hospital. </p>
<p>In a publicly funded institution, such priorities should be set independently by the institution itself, informed by societal and community needs. </p>
<p>We should be seriously concerned about potential donor influence in institutional decisions, such as selection of leadership positions. The University of Toronto’s law school recently faced <a href="https://www.thestar.com/opinion/contributors/2020/09/30/u-of-t-law-school-failed-minorities-in-hiring-scandal.html">criticism after allegations that a donor influenced a hiring decision</a>, prompting the Canadian Association of University Teachers <a href="https://www.caut.ca/latest/2020/11/caut-council-passes-motion-censure-against-university-toronto">to pass a motion of censure</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1306980059186638848"}"></div></p>
<h2>Equity in education and health care</h2>
<p>Equity in access to health care and education remains a reason to justify public funding. </p>
<p>Many factors clearly influence medical institutions’ <a href="https://healthydebate.ca/2015/02/topic/politics-of-health-care/philanthropy">ability to garner donations</a>: these include the geographic location of institutions (affluent versus poorer neighbourhoods or cities); <a href="http://healthydebate.ca/2012/10/topic/wait-times-access-to-care/cancer">how some diseases, often those that have captured mainstream attention and affect the more affluent</a>, can more easily attract donors; or what may be deemed the business relevance or marketability of particular specialities or programs. By <a href="https://healthydebate.ca/2015/02/topic/politics-of-health-care/philanthropy">extension, philanthropy can impact inequitable service provision</a>.</p>
<p>When a rich family’s name is on a faculty building and new medical students see this as they arrive on campus — especially those who already experience wealth inequities or other structural barriers such as racism — what kind of message do they receive about exactly who’s in power and what their place may be?</p>
<p>Until adequate funding for medical education and health care is restored, public universities and hospitals will continue to struggle financially. </p>
<p>The solution on a more fundamental level must, at least in part, be in the <a href="https://www.broadbentinstitute.ca/the_case_for_a_wealth_tax_in_canada">taxation of wealth</a>, as supported by a <a href="https://www.huffingtonpost.ca/entry/wealth-tax-canada-poll_ca_5fb7ec50c5b625a2ae66dbda">majority of Canadians</a>, to ensure adequate funds <a href="https://www.thestar.com/news/gta/2014/12/16/gap_between_rich_and_poor_greater_than_most_canadians_think.html">and to level</a> <a href="https://www.nationalobserver.com/2019/01/21/news/obscene-gap-between-rich-and-poor-says-oxfam">wealth inequity</a>, which is a critical <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30571-8/fulltext">determinant of health</a>, <a href="https://www.who.int/news-room/q-a-detail/social-determinants-of-health-key-concepts">among other inequities</a>.</p>
<p>Meanwhile, if we accept that large private and corporate funding is essential to the very sustenance of these institutions, they must ensure contributions are universal, transparent and regulated. </p>
<p>I propose a number of measures to minimize the detrimental impact of large private and corporate donations:</p>
<ol>
<li><p>Ideally, donations would be anonymous (and no, this does <a href="https://www.thestar.com/news/gta/2018/01/11/a-donor-is-giving-a-record-100-million-to-camh-and-doesnt-want-to-be-named.html">not make large donations</a> impossible), so that brand advancement is not a given with philanthropy. Where this is perceived as impossible, a name on a plaque with the prohibition of any naming of whole institutions or part should suffice.</p></li>
<li><p>Donors should strictly deal with the institution’s foundation department. Any direct contact between faculty, deans and physician leaders should be prohibited.</p></li>
<li><p>Agreements regarding major donations should be made public and presented for binding consultation with institutional stakeholders named above. </p></li>
<li><p>There should be a transparent process of vetting the <a href="https://books.google.ca/books?id=wqZRZ9qZCCIC&pg=PA162&lpg=PA162&dq=degroote+and+laidlaw+settles+for+23+million&source=bl&ots=1lcxW_dMNm&sig=ACfU3U3s9H0Zc5wWEFM80SLeeV-5nTk8cw&hl=en&sa=X&ved=2ahUKEwjftKTfv-DsAhVhhOAKHeLuBQsQ6AEwC3oECAwQAg#v=onepage&q=degroote%20and%20laidlaw%20settles%20for%2023%20million&f=false">business practices</a> of major donors on an ethical basis (for example, as related to fair labour practices or how they engage with Indigenous land rights).</p></li>
<li><p>There should be <a href="https://www.thestar.com/opinion/star-columnists/2020/10/14/u-of-t-orders-independent-review-of-human-rights-program-hiring-fiasco.html">a truly independent body</a> to investigate complaints exposing influence and coercion and to protect whistleblowers.</p></li>
</ol>
<p>Scrutiny and strict regulation of corporate funding of public universities and hospitals is essential for maintaining institutional independence and equitable provision of education and health care. Such regulation must be coupled with demands for increased government funding.</p><img src="https://counter.theconversation.com/content/148876/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Najib Safieddine does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We should challenge government defunding of universities, and greater reliance on private donations that can affect the transparency, equity and democracy of public institutions, including hospitals.Najib Safieddine, Assistant Professor, Department of Surgery, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1479872020-10-16T11:02:18Z2020-10-16T11:02:18ZWhat is osteopathic medicine? A D.O. explains<figure><img src="https://images.theconversation.com/files/363792/original/file-20201015-19-1k9z1ap.jpg?ixlib=rb-1.1.0&rect=73%2C5%2C3388%2C2057&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">D.O.s like Sean Conley, physician to the president, can face stigma from people who don't understand the practice.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/white-house-physician-sean-conley-answers-questions-news-photo/1228914747">Saul Loeb/AFP via Getty Images</a></span></figcaption></figure><p><em>When President Trump was diagnosed with COVID-19, many Americans noticed that his physician had the title D.O. stitched onto his white coat. Much confusion ensued about doctors of osteopathic medicine. As of a 2018 census, they made up <a href="https://doi.org/10.30770/2572-1852-105.2.7">9.1% of physicians in the United States</a>. How do they fit into the broader medical field?</em></p>
<p><em>Andrea Amalfitano is a D.O. and dean of the Michigan State University College of Osteopathic Medicine. He explains some of the foundations of the profession and its guiding principle: to use holistic approaches to care for and guide patients. And don’t worry, yes, D.O.s are “real doctors” and have full practice rights across the U.S.</em></p>
<h2>How did osteopathic medicine get started?</h2>
<p>In the years after the Civil War, without antibiotics and vaccines, many clinicians of the day relied on techniques like arsenic, castor oil, mercury and bloodletting to treat the ill. Unsanitary surgical practices were standard. These “treatments” promised cures but often led to more sickness and pain.</p>
<p>In response to that dreadful state of affairs, a group of American physicians <a href="https://www.aacom.org/become-a-doctor/about-osteopathic-medicine/history-of-osteopathic-medicine">founded the osteopathic medical profession</a>. They asserted that maintaining wellness and preventing disease was paramount. They believed that preserving health was best achieved via a holistic medical understanding of the individual patients, their families and their communities in mind, body and spirit. They rejected reductionist interactions meant to rapidly address only acute symptoms or problems.</p>
<p>They also embraced the concept that the human body has an inherent capacity to heal itself – decades before the immune system’s complexities were understood – and called for this ability to be respected and harnessed.</p>
<h2>What do osteopathic doctors do today?</h2>
<p>Doctors of osteopathic medicine – D.O.s, for short – can prescribe medication and practice all medical and surgical specialties just as their M.D. counterparts do. Because of the focus on preserving wellness rather than waiting to treat symptoms as they arise, more than half of D.O.s gravitate to primary care, including family practice and pediatrics, particularly <a href="https://www.healthaffairs.org/do/10.1377/hblog20171023.624111/full/">in rural and underserved areas</a>.</p>
<p>D.O. training embraces the logic that understanding anatomic structures can allow one to better understand how they function. For example, alongside contemporary medical and surgical preventive and treatment knowledge, all osteopathic physicians also learn strategies to treat musculoskeletal pain and disease. These techniques are known as “manual medicine,” or osteopathic manipulative treatment (OMT). They can provide patients an alternative to medications, including opioids, or invasive surgical interventions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman manipulating a man lying on a treatment table" src="https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363793/original/file-20201015-15-wqcgp7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An osteopathic medical student practices an adjustment that is part of osteopathic manipulative treatment.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sarah-fang-a-3rd-year-osteopathic-medical-student-does-a-news-photo/566007125">Gary Friedman/Los Angeles Times via Getty Images</a></span>
</figcaption>
</figure>
<p>D.O.s pride themselves on making sure their patients feel they’re treated as a whole person and not simply reduced to a symptom or blood test to be rapidly dealt with and then dismissed. We say we aspire to care for “people, not patients,” with an empathetic attitude and an emphasis on making sure those closest to those in their care, such as family and loved ones, as well as other social factors, are all taken into account.</p>
<h2>What’s different between a D.O. and an M.D.?</h2>
<p>The osteopathic philosophy around prevention and wellness might seem like common sense today, but it was revolutionary. Aspects of osteopathic medicine, including the use of alternative therapies such as OMT, were originally met with skepticism or outright hostility by some medical doctors who questioned their scientific bases. Indeed, in 1961, the <a href="https://doi.org/10.1001/jama.1961.73040370010008">American Medical Association’s code of ethics declared it “unethical”</a> for an M.D. physician to professionally associate with doctors of osteopathy.</p>
<p>So with the guidance of the American Osteopathic Association, D.O.s created their own D.O. hospitals, residency and fellowship programs, and four-year D.O. degree-granting medical schools. Instruction around the current science of health and illness is similar between D.O.s and M.D.s – it’s the philosophical delivery of that knowledge that’s different.</p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p>
<p>Certainly a holistic approach to health is no longer exclusive to D.O.s. In fact, many M.D., nursing, physician assistant and other health professional schools now embrace parts of it as they deliver care. And now, D.O.s and M.D.s often work side by side in medical settings across the country. More recently, the AMA has recently <a href="https://www.ama-assn.org/residents-students/usmle/comlex-do-matching-and-gme-accreditation-what-you-need-know">recognized the D.O. licensing exams as equivalent</a> to the exams M.D.s take. D.O.s compete for the same training residencies as M.D.s and, eventually, the same jobs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="crowd of D.O. students wearing their white coats" src="https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363796/original/file-20201015-13-1uopo9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Michigan State University College of Osteopathic Medicine students take the osteopathic pledge.</span>
<span class="attribution"><span class="source">Michigan State University</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>How prevalent is osteopathic medicine today?</h2>
<p>Osteopathic medicine is now <a href="https://www.healthaffairs.org/do/10.1377/hblog20171023.624111/full/">one of the fastest-growing health professions</a>, with over 150,000 D.O.s and D.O. medical students practicing in the U.S. and internationally. <a href="https://osteopathic.org/wp-content/uploads/OMP2019-Report_Web_FINAL.pdf">One in four newly minted U.S. physicians</a> <a href="https://www.aamc.org/data-reports/students-residents/interactive-data/2019-facts-enrollment-graduates-and-md-phd-data">in the class of 2019</a> graduated from an osteopathic medical school.</p>
<p>Osteopathic medicine is now a mainstay of contemporary medical practice, with D.O.s active in all aspects of the nation’s health care systems.</p><img src="https://counter.theconversation.com/content/147987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Amalfitano is Dean of the College of Osteopathic Medicine, and the Osteopathic Heritage Foundation Professor of Pediatrics, Microbiology and Molecular Genetics at Michigan State University. Dr Amalfitano also consults for ImmunityBio, Etubics Corp., and Avasure Inc, and has received external funding from a number of government, corporate, foundational, and private sources, including the NIH, MDA, and AMDA.</span></em></p>Almost 10% of physicians in the US are doctors of osteopathic medicine, and that proportion is rising. Their medical knowledge matches that of other doctors; the difference is the philosophy behind it.Andrea Amalfitano, Dean of the MSU College of Osteopathic Medicine and Professor of Pediatrics, Microbiology and Molecular Genetics, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1385892020-05-20T11:35:20Z2020-05-20T11:35:20ZHow stories of success can help increase diversity among medical students<figure><img src="https://images.theconversation.com/files/336386/original/file-20200520-152338-1vli7v3.jpg?ixlib=rb-1.1.0&rect=965%2C60%2C4785%2C3466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-students-learning-professor-university-244565806">wavebreakmedia/Shutterstock</a></span></figcaption></figure><p>At the turn of the century, the majority of students in UK medical schools were white, male and middle-class. Over the past 20 years, though, there has been success for some groups of students in getting through the doors. </p>
<p>Medical schools have made changes to how they admit students, but there are still barriers to success. An increasing number of women and students from black, Asian and minority ethnic (BAME) backgrounds have been admitted to medical school each year. However, there has not been a similar increased representation of students from lower socioeconomic backgrounds, which has remained static at about <a href="https://www.medschools.ac.uk/media/2536/selection-alliance-2018-report.pdf">10% of all admissions</a>. </p>
<p>Our research shows that to create diversity in medical schools, we need to reconsider the ways we measure this diversity. By considering the experiences of individual students as well as statistics, we can learn how to create routes to success. </p>
<p>One reason to <a href="https://www.medschools.ac.uk/our-work/selection/selecting-for-excellence">increase the diversity of students</a> admitted to medical school is to increase fairness and equity in educational opportunities for all applicants. Another key reason is to ensure that the future medical workforce will reflect the wide range of backgrounds in the UK population. This will allow the doctors of the future to better meet the healthcare needs of the population they serve. </p>
<p>Making it through the doors of medical school is only one hurdle. There are still challenges to be overcome for students from certain backgrounds in their journey to become a doctor. For example, students from BAME backgrounds are <a href="https://doi.org/10.1111/j.2044-8279.2011.02060.x">more likely to fail their exams</a> than other students. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.2044-8279.2011.02060.x">These statistics</a> are useful to highlight the differences in admissions and academic achievement between groups of students who can be identified by having specific characteristics, such as a BAME background. But they don’t give more information about the reasons behind the differences. We need to look more closely at the complex factors which lead to student success. This will require research which seeks to understand students’ lives and their experiences of medical school.</p>
<h2>Routes to success</h2>
<p>We have surveyed a range of studies to consider the ways research into this issue is conducted. This has led us to make some important recommendations about how these <a href="https://doi.org/10.15694/mep.2020.000084.1">differences can be reduced</a>.</p>
<p>Most of the studies we looked at continued to classify students into a specific category, such as BAME background. The findings are then presented as though they are typical of all students within the category.</p>
<p>But only three studies looked at the experience of high-achieving students who had been classified into a single category such as BAME. It is essential to understand the various factors that have contributed to the academic success of these students. This information can then be used to inform future policies, as well as practices, for improving the experience of students from specific backgrounds. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336393/original/file-20200520-152284-ru9dbx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Learning about individual students’ routes to success is vital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-female-patient-listening-doctor-explain-1277411626">Rocketclips, Inc./Shutterstock</a></span>
</figcaption>
</figure>
<p>Understanding the factors for success can lead to the development of specific advice services for students from these backgrounds, such as guidance on making medical career choices. The establishment of peer networks and mentors who are students and doctors from a similar background can be very useful.</p>
<h2>Student input</h2>
<p>We also found that only a few studies mentioned that students were actively involved in the research process. Students can be involved in developing questions that are of particular importance to themselves, and can make recommendations for change in how medical schools could improve the learning and support experience of students. A lack of student involvement limits the relevance and value of the findings for future policies and practices. It also restricts the ability of individuals to develop and implement changes that can improve the experiences of all medical school students.</p>
<p>The main findings from our research show that increasing the diversity of students who are accepted to medical school and ensuring their success is still a challenge.</p>
<p>Our recommendations have important implications for all education, including universities, colleges and schools. Each student has their own potential for success and their strengths should be identified and used to improve their own experience, and that of other students. </p>
<p>In schools and colleges, <a href="https://www.ucu.org.uk/media/10385/Transformative_teaching_and_learning_in_further_education_july_2019/pdf/transformativeteachingandlearninginfurthereducationjuly2019">transformational teaching and learning</a> which focuses on the individual aspirations of each student can increase the chances of success for diverse students entering professions like medicine. Once at medical school, students can be supported by mentoring and meeting role models that have successfully navigated the journey through the educational system and beyond.</p><img src="https://counter.theconversation.com/content/138589/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Sandars receives funding from Health Education England North West. </span></em></p><p class="fine-print"><em><span>Jayne Garner receives funding from the Medical Schools Council.. </span></em></p><p class="fine-print"><em><span>Prof Jeremy Brown receives funding from Health Education England North West . </span></em></p><p class="fine-print"><em><span>Vicky Duckworth does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To achieve diversity in medical schools, we need to look at the stories behind the numbers.John Sandars, Professor of Medical Education, Edge Hill UniversityJayne Garner, Senior Lecturer in Medical Education, Edge Hill UniversityJeremy Brown, Professor of Clinical Education, Edge Hill UniversityVicky Duckworth, Professor of Education, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1156132019-04-17T23:13:12Z2019-04-17T23:13:12ZFive strategies to improve medical training – to reduce stress and boost expertise<figure><img src="https://images.theconversation.com/files/269683/original/file-20190416-147525-on5ndx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Canadian medical students graduate with up to $200,000 in debt, and burnout rates are high. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Recent changes in undergraduate medical education and postgraduate residency training in Canada are <a href="http://www.cmaj.ca/content/189/50/E1569">stressing trainee doctors</a>, increasing their debt load and reducing their experiential learning. </p>
<p>Such changes include a perceived shortage of residency positions, a premature requirement to choose a career path early in medical school and a growing fixation on exam preparation. </p>
<p>Older doctors are largely unaware of these new challenges. For trainees, on the other hand, this is the only system they know. Patients simply expect us to produce “triple A” doctors — available, affable and able. </p>
<p>As a cardiologist and head of medicine at Queen’s University, I offer several suggestions to reduce trainee stress, debt and burnout. I believe these suggestions will also enhance the expertise of Canada’s newly minted doctors.</p>
<p>For a start, we should increase residency training positions to meet Canada’s medical needs, and simplify the <a href="https://www.carms.ca/">Canadian Resident Matching Service (CaRMS)</a> process for allocating residency positions. We should also constrain the time trainees spend studying for qualifying exams, delay the selection of medical career tracks until internship and restore the rotating internship.</p>
<h2>Loss of empathy and self-worth</h2>
<p>Nearly half of medical residents report burnout — <a href="https://www.cfms.org/news/2018/05/02/press-release-cfms-launches-the-national-wellness-program-and-commits-to-working-with-the-afmc-to-create-health-promoting-learning-environments.html">defined as a loss of empathy and sense of self-worth</a>. Burnout is reported ever earlier in residents, despite legislated restrictions on work hours and increased pay. </p>
<p>A contributing factor is the increasing time residents spend studying for the <a href="http://www.royalcollege.ca/rcsite/home-e">Royal College of Physicians and Surgeons of Canada (RCPSC) qualifying exams</a>. Trainees are also impacted by funding decisions of provincial governments, which limit the size of medical schools and residency programs, and by hospital congestion, which impairs the learning environment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/doctor-wellness-is-a-marathon-effort-and-training-should-start-in-medical-school-113704">Doctor wellness is a marathon effort and training should start in medical school</a>
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</em>
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<p>The reasons medical students experience burnout are complex. They include worries about whether they will match to a residency program and about which career track to select during their second year. Students also worry about debt — the <a href="https://meds.queensu.ca/ugme-blog/archives/1807">average medical school debt was over $70,000 in 2014</a>. This number <a href="https://www.doctorsofbc.ca/news/facts-cost-becoming-doctor">increased to over $158,000 in 2017</a> (and many students borrow up to $200,000).</p>
<p>While tuition (at around $20,000 per year) is an important source of debt, a new and avoidable expense relates to the cost of off-site electives and CaRMS interviews incurred in their search for future residency positions.</p>
<h2>1. Increase residency positions</h2>
<p>So, what if we increased residency positions 10 per cent while reducing off-site medical school electives? </p>
<p>Medical students and residency training programs rank each other through an online system, called <a href="https://www.carms.ca/">CaRMS</a>. Recently, <a href="https://healthydebate.ca/2017/05/topic/medical-residency-match">the number of unmatched Canadian graduates has been increasing</a> — from 11 in 2009 to 68 in 2017. While 68 unmatched students (from a national total of 3000) may sound like a small problem, it can have tragic consequences.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"877270014021296129"}"></div></p>
<p><a href="https://www.thestar.com/news/canada/2017/06/17/tragic-case-of-robert-chu-shows-plight-of-canadian-medical-school-grads.html">Medical school graduate Robert Chu ended his life in 2016</a>, after twice failing to match. He wrote:</p>
<blockquote>
<p>“Without a residency position, my degree … is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with patients and my student debt in excess of $100,000 on this pursuit have all been for naught.”</p>
</blockquote>
<p>Of course, we should only create more residency positions if we need more doctors. Provincial governments tend to believe there are too many doctors; however, OECD data show Canada (with two MDs per 1,000 population) ranks near the bottom of the pack.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/269840/original/file-20190417-139107-10t47u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>In 2017, there were 2,967 residency positions available in Canada and <a href="https://healthydebate.ca/2017/05/topic/medical-residency-match">2,810 residents in the hunt</a>. This scarcity is exacerbated by <a href="https://caper.ca/sites/default/files/pdf/fact-sheets/FactSheet-NationalIMGDatabase_en.pdf">an influx of international medical graduates</a>, many of <a href="https://deptmed.queensu.ca/dept-blog/land-opportunity-canadian-medical-student-wannabes-scotland">whom are Canadian citizens</a>, a net <a href="https://www.macleans.ca/education/uniandcollege/most-quebec-medical-grads-are-leaving-the-province/">outflow of students from Quebec</a> and fewer available positions in “popular” specialty programs, such as dermatology, emergency medicine and plastic surgery. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=323&fit=crop&dpr=1 600w, https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=323&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=323&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=406&fit=crop&dpr=1 754w, https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=406&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/269841/original/file-20190417-139113-aftvlr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=406&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>This means that there is just two per cent wiggle room between positions required and positions available, complicated by student geographic and specialty preferences. </p>
<h2>2. Develop a ‘learn local’ strategy</h2>
<p>To reduce the risk of being unmatched, medical students spend their time criss-crossing Canada performing electives to demonstrate their interest in a program, while serving as their own travel agent and paying for travel and accommodations. </p>
<p>This adds to their debt and stress and these brief sojourns often yield superficial clinical experiences. One budding dermatologist told me: </p>
<blockquote>
<p>“I did six electives in dermatology (12 weeks total), and two electives in internal medicine… If I was to do it again, I probably wouldn’t have done so many dermatology electives - it’s just that I didn’t get the ones I really wanted until the end. I’m not sure I necessarily needed to do this many dermatology electives in order to match….I definitely felt the pressure to do the majority of my electives in this specialty to show my interest and build relationships at the programs I was interested in. … I can’t say exactly how much I spent. Certainly, in the thousands of dollars.”</p>
</blockquote>
<p>Another student toured 12 universities across Canada to interview for surgery residencies. She ended up with her first choice of residency and stayed at her home university. Between external electives and the CaRMS interviews, medical students lose around four months of local clinical exposure.</p>
<p>A “learn local” strategy combined with a 10 per cent increase in residency positions would reduce expense, travel and stress and allow students to extend rotations at their own centres. The proposed changes would also right-size our medical work-force.</p>
<h2>3. Delay specialty selection</h2>
<p>What if we delayed the choice of career track until internship? </p>
<p>Some students struggle to choose a speciality. Family physician, internist, surgeon, pediatrician, obstetrician, radiologist, ophthalmologist, pathologist… there are many options. How can an informed choice be made after two years of relatively superficial exposure to the options? </p>
<p>A Queen’s student noted: </p>
<blockquote>
<p>“It felt like there was an abrupt change when we went from exploring disciplines in medical school to when we needed to decide on our specialization. In first year, we were required to do observerships to promote variety. But midway through second year we needed to select our clerkship stream and then all of a sudden it seemed like decisions had to be made…. Midway through second year, by picking my stream, I had to decide that I was not going to pursue emergency medicine, anesthesia or a subspecialty surgery.”</p>
</blockquote>
<p>By delaying specialty selection until internship, trainees could make more informed choices.</p>
<h2>4. Reinstate the rotating internship</h2>
<p>What if we reinstated the rotating internship? </p>
<p>A rotating internship gave doctors a broad experience. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2145314/pdf/canfamphys00133-0070.pdf">We abandoned the rotating internship</a> in favour of a two-year family medicine residency in around 1990. However, rotating internships did not just train GPs, they also trained many future specialists. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/doctors-in-training-nervous-about-lack-of-opportunities-89220">Doctors-in-training nervous about lack of opportunities</a>
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</em>
</p>
<hr>
<p>During my rotating internship at Royal Columbian Hospital in New Westminster, British Columbia, from 1981 to 1982, I spent time in obstetrics (delivering more than 100 babies), pediatrics (caring for sick and premature babies), surgery (as first assist on all operations and primary surgeon for hernias and appendectomies), intensive care (placing arterial lines and managing ventilators) and internal medicine (running the ward). </p>
<p>I learned respect for each specialty by walking a mile in their shoes. These practical experiences alter the medical DNA of a young physician in a way no clerkship experience can. Re-establishing a rotating internship as the first year of residency would result in Canada’s doctors being more broadly trained.</p>
<h2>5. Reduce preparation time for exams</h2>
<p>Exams consume a trainee’s after-hours life for one month of medical school and nine months of residency, engendering stress and contributing to burnout. Studying too much may also distract trainees from clinical learning opportunities.</p>
<p>Objectively however, the <a href="http://www.royalcollege.ca/rcsite/credentials-exams/writing-exams/results/exam-pass-rate-percentages-e">success in the RCPSC exam has long been 95 per cent</a> for Canadian graduates (likewise the LMCC exam for medical students). </p>
<p>Let’s recast medical school and residency as programs for adult learners and reset expectations for how much time a trainee can or should study to some reasonable duration — say one month for medical students and two months for residents.</p>
<p>The training of doctors is a joint responsibility of universities, provincial agencies, accrediting agencies and society. Together we should refocus medical school and residency training with the goal of producing triple A doctors who are more clinically experienced, less stressed and owe less money.</p><img src="https://counter.theconversation.com/content/115613/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Archer receives funding from the Canadian Institutes of Health Research (CIHR).</span></em></p>A ‘learn local’ strategy, along with increased residency positions and the return of a rotating internship could go a long way towards improving Canada’s system of medical training.Stephen L Archer, Professor, Head of Department of Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1071252018-11-19T11:36:39Z2018-11-19T11:36:39ZAccelerating health care innovation by connecting engineering and medicine<figure><img src="https://images.theconversation.com/files/246000/original/file-20181116-194488-1j3swrk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A robot's hand holds an artificial heart.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/robots-hand-holds-robotic-heart-191590598?src=7-Mj8QI2tjl5pFq-ivy76A-1-59">Ociacia / Shutterstock.com</a></span></figcaption></figure><p>Artificial heart valves, prosthetic hips, bedside monitors, MRI machines – these and so many other innovations that we now take for granted emerged at the interface of engineering and medicine. </p>
<p>In an era of big data, personalized medicine and artificial intelligence, the importance of engineering, especially in medicine, is increasing. In my own field of cardiovascular bioengineering, engineers now routinely build and run sophisticated, patient-specific computer models of blood flow in just a few hours, helping doctors diagnose and treat heart disease. These groundbreaking inventions are possible only through the contributions of multidisciplinary teams of researchers, clinicians and engineers. </p>
<h2>The rise of biomedical engineering</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/246002/original/file-20181116-194519-1foaca.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The electroencephalogram (EEG) head cap with flat metal discs (electrodes) attached to a white plastic model’s head shown in a science exhibition.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/electroencephalogram-eeg-head-cap-flat-metal-602845433?src=iuFRoDmdBuElMFzRC-cXfQ-1-50">Min Jing/Shutterstock.com</a></span>
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<p>Engineering schools are preparing for this future in part through the growth of biomedical engineering, where students learn not only the tools and concepts of engineering but also how to apply those ideas to today’s medical challenges. Many aspects of modern healthcare – from designing implants that survive for decades in the body to constructing secure medical records systems – are driving the demand for biomedical engineers.</p>
<p>In 1974 only three engineering schools offered <a href="http://main.abet.org/aps/Accreditedprogramsearch.aspx">accredited biomedical engineering programs</a>. Forty years later, in 2014, more than 100 accredited programs granted bachelor of science degrees in biomedical engineering or bioengineering. In line with broader trends in engineering education, these programs prepare students to collaborate by challenging them with team-based projects. </p>
<p>As a result, our nation’s young biomedical engineers have the engineering expertise, appreciation for collaboration and at least some of the medical vocabulary they need to communicate effectively with physicians.</p>
<h2>A gap in medical training</h2>
<p>Yet, nothing in my medical school curriculum was designed to help physicians develop a complementary skill set. Every physician now uses advanced technology during the course of their daily work. But only a handful have the technical vocabulary or training required to help develop it. Several medical schools have recognized the need for engineering-literate physicians, building new <a href="https://medicine.illinois.edu">campuses</a> and launching new <a href="https://enmed.tamu.edu">programs</a> that blend medical and engineering education. Yet, many of these efforts are employing an outdated, physician-centric model that envisions training one person in two disciplines, rather than preparing them to collaborate in multidisciplinary teams.</p>
<p>This one-person, two-discipline approach has a long history at medical schools, exemplified by prestigious M.D.-Ph.D. programs that seek to train physician-scientists who split their time between caring for patients and conducting research. </p>
<p>While these M.D.-Ph.D. programs have been successful in some respects, they train only a small number of doctors. As recently <a href="https://news.aamc.org/press-releases/article/md-phd-career-trends-report/">reported</a> by the American Association of Medical Colleges (AAMC), M.D. and Ph.D. programs are producing approximately 600 graduates per year, a number that is limited in part by financial resources; these students represent only 3 percent of medical school graduates but receive 17 percent of non-need based medical school scholarships. Joint programs that incorporate graduate engineering degrees will be further limited by the pool of applicants qualified for both medical and graduate engineering study.</p>
<h2>Collaboration: A proven, scalable approach</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/246008/original/file-20181116-194491-tcuaoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Side view of sportsman with artificial leg limb training in gym and doing push-ups on a bosu ball.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/side-view-sportsman-artificial-leg-limb-1198894903?src=uVLdKBt6hdZn08wwVE0OSg-1-2">TENphoto</a></span>
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<p>That is why we need a new approach: a proven, scalable approach at the engineering-medicine interface that teaches engineers and health care professionals to work together in teams. </p>
<p>At the University of Virginia, our <a href="https://engineering.virginia.edu/research/centers-institutes/center-engineering-medicine">Center for Engineering in Medicine</a> promotes innovation by embedding engineering students into clinical environments and nursing and medical trainees into engineering laboratories. Embedded students acquire the technical vocabulary, cultural literacy and experience working in multidisciplinary teams that provide a foundation for careers in health care innovation.</p>
<p>Teaching engineers and health care professionals to collaborate is faster, cheaper, and more feasible than building specialty programs to train physician-engineers or launching more biomedical engineering programs. Teaching engineers and healthcare professionals to collaborate is faster, cheaper, and more feasible than
building specialty programs to train physician-engineers or launching more biomedical engineering programs. This approach builds on the experience of successful programs like <a href="http://biodesign.stanford.edu">Stanford Biodesign</a>
and the <a href="http://whcf.org/coulter-foundation-programs/translational-research/coulter-translational-partnership-tp-and-research-awards-ctra/">Coulter Translational Partners Program</a>, and is especially attractive at institutions like UVA, where engineering and medical schools
are located on the same campus. </p>
<h2>Overcoming distance</h2>
<p>However, many universities in America are not built to promote collaboration between the fields of engineering and medicine. In part, that is because schools devoted to agriculture and engineering are often miles from those focused on liberal arts and medicine. In situations where physical proximity is not possible, workshops, conferences, continuing medical education courses and cross-disciplinary events can spark the cross talk that catalyzes innovation.</p>
<p>Finding ways to reduce literal, and disciplinary, separation between engineering and medicine is essential for cultivating and expanding innovation at the interface. While new specialized training programs may play a role in this effort, promoting collaboration within the existing workforce has the potential to make a much bigger impact. </p>
<p>The leaders in the next wave of health care innovation will be the universities, health systems, and companies that find ways to train engineers, doctors, nurses and others to work together effectively in teams to solve tomorrow’s complex health care challenges.</p><img src="https://counter.theconversation.com/content/107125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey W. Holmes has received research grants from the National Institutes of Health, the National Science Foundation, the American Heart Association, and the Paul G. Allen Frontiers Group. He trained in a joint MD/PhD program with scholarship support from the National Institutes of Health.</span></em></p>Health care relies on increasingly sophisticated devices for implanting into the body or monitoring it. Yet most med school graduates are not versed in engineering. That needs to change.Jeffrey W. Holmes, Professor of Biomedical Engineering and Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043902018-11-15T22:38:24Z2018-11-15T22:38:24ZExercise is medicine, and doctors are starting to prescribe it<figure><img src="https://images.theconversation.com/files/245662/original/file-20181114-194509-4nat10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clinical research has established exercise as a safe and effective intervention to counteract the adverse physical and psychological effects of cancer and its treatment. The Clinical Oncology Society of Australia is the first to recommend exercise as part of regular cancer care. </span> <span class="attribution"><span class="source">(Unsplash/curtis macnewton)</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>There is a movement afoot (pun intended) to get more people exercising by involving their family doctors. </p>
<p>In the United Kingdom, the government recently released <a href="https://movingmedicine.ac.uk/"><em>Moving Medicine</em></a> — an online resource to help doctors talk to their patients about the importance of exercise in relation to conditions as diverse as cancer and dementia. This is a welcome initiative given that <a href="http://dx.doi.org/10.1136/bjsports-2012-091810">physical inactivity is the fourth leading cause of death in the world</a>, according to the World Health Organization.</p>
<p>The benefits of exercise have been proven over and over again: Exercise reduces risk of <a href="https://doi.org/10.1176/appi.ajp.2018.17111194">depression</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26092138">type 2 diabetes</a>, <a href="https://doi.org/10.1016/S0140-6736(17)31634-3">heart disease</a>, <a href="https://www.ahajournals.org/doi/abs/10.1161/STROKEAHA.110.584300?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">stroke</a> and many <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2521826">cancers</a>, and prevents early death. </p>
<p>If it was a pill, exercise would be a trillion-dollar money-maker prescribed to everyone. </p>
<p>Exercise as a therapy is mentioned in almost all prevention and treatment guidelines, which are written by doctors themselves. Still, most patients never hear their doctor talk about it. And <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2015001/article/14135-eng.htm">fewer than one in four Canadians</a> meet <a href="http://www.who.int/dietphysicalactivity/factsheet_adults/en/">current guidelines for physical activity</a>, which recommend that people participate in moderate (such as brisk walking) and vigorous (such as jogging, swimming or running) activity for at least 150 minutes per week. </p>
<p>Part of the reason is that most doctors in practice today received little, if any, training on the role of exercise in managing disease. Years ago I taught a 30-minute lecture on the topic at a Canadian medical school and this was all the students got over their four-year program. </p>
<p>This is about to change.</p>
<h2>Free gym prescriptions</h2>
<p>In recent years, Canadian medical schools — such as the Cumming School of Medicine at the University of Calgary — have <a href="https://calgaryherald.com/health/diet-fitness/u-of-c-med-school-beefs-up-nutrition-and-lifestyle-education">revised their curricula</a> to incorporate aspects of exercise in the prevention and treatment of disease.</p>
<p>This is one part of growing initiatives like <em><a href="http://exerciseismedicine.org/canada/">Exercise is Medicine</a></em> that advocate for the role of exercise and encourage doctors to prescribe it. </p>
<p>Similarly, the <a href="https://www.prescriptiontogetactive.com/"><em>Prescription to Get Active</em></a> program in Alberta allows doctors to prescribe free 30-day gym memberships to patients. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/245630/original/file-20181114-172710-f6vspx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctors who exercise themselves are more likely to recommend exercise to their patients.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>A grassroots program called <em><a href="https://walkwithadoc.org/">Walk with a Doc</a></em> has local doctors walking with their patients. The program was begun by Dr. David Sabgir, a cardiologist in Columbus, Ohio, who was frustrated with his inability to affect behaviour change in the clinical setting and invited his patients to go for a walk with him in a local park one Saturday morning. More than 100 people showed up, and there are now 400 chapters worldwide.</p>
<p>There have also been calls for exercise to be considered a vital sign, much like blood pressure and heart rate. Health insurance provider Kaiser Permanente requires doctors in the United States to <a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000559">record how much physical activity a patient does</a>. </p>
<p>Patients who receive exercise prescriptions and counselling from their doctors are <a href="https://doi.org/10.1136/bmj.e1389">more likely to be active</a>, so these initiatives are a good start. </p>
<p>More needs to be done, however, when <a href="http://cjgim.ca/index.php/csim/article/view/22/26">only one-third of doctors talk to their patients about exercise</a>. </p>
<h2>Reactionary health-care system</h2>
<p>Not surprisingly, <a href="https://bjsm.bmj.com/content/43/2/89">doctors who exercise themselves are more likely to counsel their patients</a> about physical activity. Therefore, targeting doctors to be more active may provide a substantial population effect.</p>
<p>At the same time, <a href="https://bjsm.bmj.com/content/51/8/624.2">doctors say they need more and better training</a> with respect to the benefits of exercise and how to counsel patients. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/245629/original/file-20181114-194497-3gyv1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Exercise is an effective medicine for many patients dealing with heart disease, dementia, depression, stroke and cancer.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>The need for this change in approaching health and disease comes from two key realizations. One is that there are a growing number of people with preventable chronic illness, and our health-care system is not adequately prepared to deal with all these patients. </p>
<p>Our system is reactionary; it is designed to wait until someone has a disease instead of preventing it. But chronic illnesses are not like diseases of old. They cannot be cured, although many can be prevented. Exercise is increasingly recognized as important to this change.</p>
<h2>Exercise for cancer care</h2>
<p>Second, we have greater knowledge about the benefits of exercise in treating disease in addition to preventing it. Exercise is used for <a href="https://doi.org/10.1016/j.jacc.2015.10.044">cardiac rehabilitation</a>, after a heart attack. </p>
<p>Exercise works as well as drugs that lower cholesterol and blood pressure in preventing early death. And diabetics who exercise require less medication to manage their blood sugar. </p>
<p>Even in treating cancer, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008465.pub2/full">exercise can reduce the side-effects of treatment</a>, such as anxiety, depression and fatigue. This has prompted the <a href="https://www.mja.com.au/journal/2018/209/4/clinical-oncology-society-australia-position-statement-exercise-cancer-care">Clinical Oncology Society of Australia</a> to release a position statement recommending exercise as part of regular cancer care. It is believed to be the first of its kind in the world, but hopefully not the last.</p>
<p>Doctors would benefit from additional incentives such as specific billing codes that allow for prescribing of exercise as well as more continuing medical education sessions on how to do so. </p>
<p>Educating current and future doctors that exercise is as good, if not better, than many medications will be essential to prevent the increasing burden of chronic illnesses.</p>
<p><em>Scott Lear writes the weekly blog <a href="https://drscottlear.com/">Feel healthy with Dr. Scott Lear</a></em>.</p><img src="https://counter.theconversation.com/content/104390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Scott Lear receives funding from the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, and the Robert Wood Johnson Foundation.</span></em></p>From weekend walks with your doctor to free gym memberships, there is a global movement afoot.Scott Lear, Professor of Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/896462018-01-09T11:15:21Z2018-01-09T11:15:21ZYoung doctors struggle to learn robotic surgery – so they are practicing in the shadows<figure><img src="https://images.theconversation.com/files/200962/original/file-20180105-26139-952nox.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surgeons in Switzerland use the robot da Vinci to aid a hernia operation. Over a third of US hospitals have at least one surgical robot.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Switzerland-Robotic-Surgery/b25d6d98375c408aa9de47c5c82b62e0/17/0">AP Photo/Keystone, Salvatore Di Nolfi</a></span></figcaption></figure><p>Artificial intelligence and robotics spell massive changes to the world of work. These technologies can automate new tasks, and we are making more of them, faster, better and cheaper than ever before. </p>
<p>Surgery was early to the robotics party: Over a third of U.S. hospitals <a href="http://phx.corporate-ir.net/phoenix.zhtml?c=122359&p=irol-irhome">have at least one surgical robot</a>. Such robots have been in widespread use by a growing variety of surgical disciplines, including urology and gynecology, for over a decade. That means the technology has been around for least two generations of surgeons and surgical staff.</p>
<p>I studied robotic surgery for over two years to understand how surgeons are adapting. I observed hundreds of robotic and “traditional” procedures at five hospitals and interviewed surgeons and surgical trainees at another 13 hospitals around the country. I found that robotic surgery disrupted approved approaches surgical training. Only a minority of residents found effective alternatives. </p>
<p>Like the surgeons I studied, we’re all going to have to adapt to AI and robotics. Old hands and new recruits will have to learn new ways to do their jobs, whether in construction, lawyering, retail, finance, warfare or childcare – no one is immune. How will we do this? And what will happen when we try?</p>
<h2>A shift in surgery</h2>
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<a href="https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/200863/original/file-20180104-26154-1v53p1q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The da Vinci Surgical Robot at a hospital in Pittsburgh.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Robotic-Hysterectomies/3701ec7c21d74497ab84e6ecd710de84/2/0">AP Photo/Keith Srakocic</a></span>
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<p>In <a href="http://journals.sagepub.com/doi/full/10.1177/0001839217751692">my new paper</a>, published January 8, I specifically focus on how surgical trainees, known as residents, learned to use the 800-pound gorilla: Intuitive Surgical’s da Vinci surgical system. This is a four-armed robot that holds sticklike surgical instruments, controlled by a surgeon sitting at a console 15 or so feet away from the patient. </p>
<p>Robotic surgery presented a radically different work scenario for residents. In traditional (open) surgery, the senior surgeon literally couldn’t do most of the work without constant hands-in-the-patient cooperation from the resident. So residents could learn by sticking to strong “see one, do one, teach one” norms for surgical training. </p>
<p>This broke down in robotic surgery. Residents were stuck either “sucking” at the bedside – using a laparoscopic tool to remove smoke and fluids from the patient – or sitting in a second trainee console, watching the surgical action and waiting for a chance to operate. </p>
<p>In either case, surgeons didn’t need residents’ help, so they granted residents a lot less practice operating than they did in open procedures. The practice residents did get was lower-quality because surgeons “helicopter taught” – giving frequent and very public feedback to residents at the console and intermittently taking control of the robot away from them. </p>
<p>As one resident said: “If you’re on the robot and [control is] taken away, it’s completely taken away and you’re just left to think about exactly what you did wrong, like a kid sitting in the corner with a dunce cap. Whereas in open surgery, you’re still working.” </p>
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<h2>Shadow learning</h2>
<p>Very few residents overcame these barriers to effectively learn how to perform this kind of surgery. The rest struggled – yet all were legally and professionally empowered to perform robotic surgeries when they finished their residencies. </p>
<p>Successful learners made progress through three norm-bending practices. Some focused on robotic surgery in the midst of medical school at the expense of generalist medical training. Others practiced extensively via simulators and watched recorded surgeries on YouTube when learning in real procedures was prized. Many learned through undersupervised struggle – performing robotic surgical work close to the edge of their capacity with little expert supervision. </p>
<p>Put together, I called these practices “shadow learning,” because they ran counter to norms and residents engaged in them out of the limelight. Also, none of this was openly discussed, let alone punished or forbidden. </p>
<p>Shadow learning came at a serious cost to successful residents, their peers and their profession. Shadow learners became hyperspecialized in robotic surgery, but most were destined for jobs that required generalist skills. They learned at the expense of their struggling peers, because they got more “console time” when senior surgeons saw they could operate well. The profession has been slow to adapt to all this practically invisible trouble. And these dynamics have restricted the supply of expert robotic surgeons. </p>
<p>As one senior surgeon told me, robotics has had an “opposite effect” on learning. Surgeons from top programs are graduating without sufficient skill with robotic tools, he said. “I mean these guys can’t do it. They haven’t had any experience doing it. They watched it happen. Watching a movie doesn’t make you an actor, you know what I’m saying?”</p>
<h2>The working world</h2>
<p>These insights are relevant for surgery, but can also help us all think more clearly about the implications of AI and robotics for the broader world of work. Businesses are buying <a href="https://www.businesswire.com/news/home/20171207005539/en/Global-Robotics-Market---Expected-Grow-CAGR">robots</a> and <a href="https://www.prnewswire.com/news-releases/artificial-intelligence-market-to-experience-massive-growth-of-629-cagr-by-2022-657227263.html">AI technologies</a> at a breakneck pace, based on the promise of improved productivity and the threat of being left behind.</p>
<p>Early on, journalists, social scientists and politicians focused on how these technologies would destroy or create jobs. These are important issues, but the global conversation has recently turned to a much bigger one: job change. According to one <a href="https://www.mckinsey.com/global-themes/digital-disruption/harnessing-automation-for-a-future-that-works">analysis from McKinsey</a>, 30 percent of the tasks in the average U.S. job could soon be profitably automated.</p>
<p>It’s often costly – in dollars, time and errors – to allow trainees to work with experts. In our quest for productivity, we are deploying many technologies and techniques that make trainee involvement optional. Wherever we do this, shadow learning may become more prevalent, with similar, troubling implications: a shrinking, hyperspecialized minority; a majority that is losing the skill to do the work effectively; and organizations that don’t know how learning is actually happening. </p>
<p>If we’re not careful, we may unwittingly improve our way out of the skill we need to meet the needs of a changing world.</p><img src="https://counter.theconversation.com/content/89646/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matt Beane does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are more robots than ever in the operating room – but that’s led to fewer opportunities for surgical trainees. Now, some new doctors are teaching themselves in secret.Matt Beane, Project Scientist, Incoming Assistant Professor, University of California, Santa BarbaraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/844292017-10-22T19:01:59Z2017-10-22T19:01:59ZHow doctors are taught to deal with death<figure><img src="https://images.theconversation.com/files/186963/original/file-20170921-8194-1whg8re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have to deal with death every day. It's not easy to come to terms with it. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>As a society we’re pretty removed from death. We don’t really talk about it. Yet when medical students start their training, it suddenly becomes something they’re intimately acquainted with. So how are young doctors taught to deal with death?</p>
<p>The teaching of medicine has traditionally been one of apprenticeship. A student is equipped with basic knowledge and then, through experience in “the clinic”, is guided by a trusted senior into a medical career. The teaching of students around one of the key skills they will require in their career, care of the dying, requires specific skills that the student may not encounter in their ordinary clinical teaching.</p>
<p>So it’s necessary to ensure all aspects of this vital topic are covered in the curriculum, and any extra clinical experience is a bonus to help cement the knowledge and understanding for the students.</p>
<h2>What medical schools teach students about death</h2>
<p>The most important skills medical schools need to teach students is to develop an understanding of the broad impact of chronic illness on patients and their communities; to understand patients’ (and their families’) responses and priorities; to understand their own emotions; and to be able to do all of this while ensuring the patient has all of the relevant medical information.</p>
<p>Most medical students, like many young Australians, have had no personal experience with death. They are part of a “death-free generation” that may not encounter the death of a close family member until later in life. </p>
<p>In many medical degrees, death is introduced in a theoretical way in the first year of study, with lectures on the ethics of body donation for anatomy dissection, and deaths of hypothetical patients. Some universities even have commemorative services to thank those who donated their bodies to be used in anatomy classes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/medical-schools-are-shaking-off-a-dark-past-by-honouring-people-who-donate-their-bodies-to-science-80752">Medical schools are shaking off a dark past by honouring people who donate their bodies to science</a>
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<p>Using these methods, the moral and social dimensions of dying and death are explicitly highlighted alongside the physical dimensions.</p>
<p>In addition to visiting patients on wards during clinical experience, students spend time following one patient through in-hospital care and to their follow-up appointments with different health care providers. This gives them unique insights into the patient experience, communication exchanges, decision-making, and the dynamics of receiving care in the setting of serious illness.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186964/original/file-20170921-8218-gxfsib.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Students need to learn in practice and theory what dealing with death encompasses.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<h2>Student experiences of death</h2>
<p>Most medical students will also have practical experience at a palliative care facility or acute hospital setting, caring for dying patients. The experience includes ward rounds, patient consultations, family meetings, home visits, discussions with social workers and pastoral care workers.</p>
<p>Teaching in this area covers pain and symptom management, with a focus on nausea and constipation, which are very common for patients at the end of life. This palliative care module allows them to cover the psychological, existential and spiritual issues, and discuss these with palliative and pastoral care staff.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/palliative-care-should-be-embraced-not-feared-59162">Palliative care should be embraced, not feared</a>
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</em>
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<p>In reflecting on these experiences, students are helped by relationships with trusted senior doctors or counsellors to talk through dealing with uncertainty and end of life care issues. </p>
<p>All medical schools have staff whose role is to provide appropriate student support. Many medical schools also build a mentor role into the curriculum, providing a regular safe space for students to discuss concerns. <a href="https://www.ncbi.nlm.nih.gov/pubmed/15980079">Research shows students may</a>, in turn, adopt the negative mindset of doctors who consider any patient death to be a personal failure. This issue is directly discussed in these individual or group support settings.</p>
<h2>Junior doctor experiences of death</h2>
<p>All Victorian hospitals with interns (first year medical graduates) have a designated senior doctor as the intern supervisor. One Melbourne hospital, recognising that many of the concerns expressed by junior doctors relate to the deaths of patients, has appointed a palliative care specialist part time in this role. </p>
<p>Junior doctors, informally and in formal teaching sessions, find it very helpful to have a doctor who is comfortable speaking about death, able to answer their questions and support them to accept that patients will die. A <a href="https://www.ncbi.nlm.nih.gov/pubmed/17908112">UK study found</a> 90% of doctors considered they coped well with deaths by using available informal and formal supports. </p>
<p>Any student or junior doctor who is struggling with any aspect of the course or work is encouraged to seek help from their medical school, university or hospital support services. Other organisations such as Doctors’ Health Services, Medical Defence Organisations and the Australian Medical Association also offer support.</p>
<p>Many students and junior doctors find it difficult to ask for help. Collegiate support through information, mentoring, and guided experiential learning is an important part of improving the care of patients with advanced illness and their families, and at the same time, improving the health and professional satisfaction of the doctors providing such care. </p>
<hr>
<p><em>If you or someone you know needs help contact Lifeline’s 24-hour helpline on 13 11 14, SANE Australia on 1800 18 7263 or the Beyondblue Info Line 1300 22 4636.</em></p><img src="https://counter.theconversation.com/content/84429/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Philip receives funding from Victorian Cancer Agency, Bethlehem Griffiths Research Foundation for peer reviewed funded grants. </span></em></p><p class="fine-print"><em><span>Eleanor Flynn does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Teaching students to care for the dying requires specific skills that the student may not encounter in their ordinary clinical teaching.Eleanor Flynn, Associate Professor in Medical Education, The University of MelbourneJennifer Philip, Professor, VCCC Chair of Palliative Medicine, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/846622017-10-04T22:09:54Z2017-10-04T22:09:54ZHow to improve the skills of tomorrow’s doctors<figure><img src="https://images.theconversation.com/files/188714/original/file-20171004-6713-1v44l96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new model of 'competency based' medical education is gaining popularity globally, in which trainees are assessed on skill rather than mere time invested.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine you’re inside an ambulance racing to the emergency room with the lights and sirens blaring. You and your nine-year-old daughter were in a car accident; she is unconscious and bleeding. The paramedic has initiated an IV, placed cardiac monitors and an oxygen mask on her. </p>
<p>Minutes later, you arrive at the hospital. You need the best doctors available to take care of your child. You are at the mercy of their skills and expertise.</p>
<p>This scenario happens multiple times every day in my role as an emergency room physician. Patients and their family members place their trust in our team to care for them in a way that is competent, compassionate and patient-centred. As a clinical faculty supervisor, I also guide physician trainees to take on this leadership role. As a leader in medical education at Queen’s University’s medical school, I help create, refine and optimize physician training for the doctors of tomorrow. </p>
<p>This is why we have recently launched something called <a href="http://www.queensu.ca/gazette/stories/better-training-better-care">competency-based medical education (CBME)</a> at Queen’s. With this new model, trainees progress to the next stage of their education only once they have achieved required competency in clinical tasks — and not before. In the old system, they progressed when they had completed a set number of hours in a rotation, with no flexibility to slow down, or speed up, their path to independent practice. </p>
<p>The Royal College of Physicians and Surgeons of Canada recommended adopting competency-based medical education (CBME) several years ago. Many medical schools and teaching hospitals across Canada are slowly shifting their curriculum, specialty by specialty. In launching CBME all at once, Queen’s University’s medical school is <a href="https://beta.theglobeandmail.com/news/national/queens-university-to-revamp-medical-training-to-focus-on-skills/article28253206/?ref=http://www.theglobeandmail.com&">the first in North America</a> to fully adopt this innovative new approach to medical education across all of its residency education programs.</p>
<h2>Training that uses time as a resource</h2>
<p>The traditional model of apprenticeship-style, time-based medical training, introduced in the last century, has served us well for many years. Yet we are now at a tipping point for physician training in Canada. Health care is far more complicated today and a number of opposing forces are challenging the status quo. </p>
<p>How do we reconcile the need to decrease trainee hours — to optimize physician wellness and improve patient safety — with developments in new technology, diagnostic tests, therapeutic drugs and procedures, end-of-life care options and overall medical progress? </p>
<p>One might wonder — is CBME really necessary? Such a large-scale transformation of medical training has huge implications for universities, hospitals, accreditation bodies and government funding structures. It’s normal, perhaps necessary, to be skeptical.</p>
<p>But the term “resident” doctor comes from decades ago when 100- to 120-hour work weeks were common. You lived in the hospital for prolonged periods of time while you cared for patients and developed your skills as a physician. You had little direct supervision, practised many skills for the first time on real patients and learned from your mistakes at the patient’s expense. </p>
<p>For years, everyone has recognised this “traditional” way of training is more than outdated — it is unacceptable — and only a transformative approach will take us to where we need to go moving forward. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/188850/original/file-20171004-32388-1w5eb9o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">With CMBE, trainees can progress through their education faster, but only if they achieve the competencies to function effectively in their speciality.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If we continue in a time-based system, where time spent on numerous clinical rotations is the standard to become competent as a doctor, it will take even longer than the current average of 13 to 15 years at university to graduate as a specialist physician. This cannot be. There must be a better approach to training that uses time as a resource.</p>
<h2>Promotion based on competence</h2>
<p>Competency based education (CBE) is not a new concept. It has been part of adult learning methods for many decades. Only recently has it become <a href="http://macyfoundation.org/docs/macy_pubs/JMF_CBTVHPE_Summary_web_JMF.pdf">integrated into medicine</a>. </p>
<p>At its root, competency based medical education (CBME) is very simple. It reduces the emphasis of learning in clinical rotations based on “units of time” and instead <a href="https://www.researchgate.net/publication/45387545_Competency-based_medical_education_in_postgraduate_medical_education">shifts the basis of trainee promotion to the demonstration of competence</a>. </p>
<p>A trainee is directly supervised and is promoted only once skills (competencies) can be performed independently. In a CBME system, there is not a fixed time frame. The time to promotion may be longer for slower development, or may be quicker if a trainee demonstrates early mastery.</p>
<p>In the drive to transform how doctors are trained, CBME is an idea worth sharing with everyone. Depending on who you are as a stakeholder, CBME means different things. For a resident trainee, CBME offers a more flexible curriculum, greater individualized learning plans, more frequent assessment and better overall preparedness for practice — through the attainment of “entrustable professional activities (EPAs).” </p>
<p>For the patient, it is more focused on patient-centred care, allows direct feedback on residency assessment and provides greater physician accountability. Faculty in a CBME system provide enhanced learner driven instruction, focus assessments on real-time observable competencies and use well-defined learning outcomes. For society, CBME tightens the gap between medical education, health care delivery and societal health needs.</p>
<h2>Canada can lead medical education globally</h2>
<p>Canada has a world-class reputation in medical education and is well-positioned to be at the cutting edge of the transition to CBME. Our country has been a leader for decades, since launching <a href="http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf">the seven essential “CanMeds” roles of a physician</a> (communicator, collaborator, health advocate, leader, medical expert, professional, scholar). Many countries have implemented pioneering work from Canada.</p>
<p>More recently in 2010, the College of Family Physicians of Canada (CFPC) launched a transformational competency framework — <a href="http://www.cfpc.ca/Triple_C/">The Triple C</a> — to optimize how family physicians are trained across the country. </p>
<p>And the Royal College of Physicians and Surgeons of Canada announced in 2015 the creation of a new <a href="http://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e">Competency by Design (CBD)</a> framework that will transform residency education across more than 60 specialties at all 17 universities with medical schools in Canada. </p>
<h2>Strong institutional leadership needed</h2>
<p>So what are the next steps to make training better for our future doctors? To be successful, the following changes to our medical training models must occur:</p>
<ol>
<li><p>All sides of the patient care interaction need to become engaged with CBME. This includes universities, hospital and government leadership, as well as students, residents, faculty, allied health care providers and patients and their families. </p></li>
<li><p>Strong institutional leadership is needed — to implement change in a strategic, collaborative and meaningful manner.</p></li>
<li><p>Barriers within government funding models must be broken down to become more fluid in all stages of medical training — medical school, residency training and continuing career development.</p></li>
</ol>
<p>Ultimately, every patient, parent and family member must have confidence that all doctors involved in their care are competent, compassionate and have the prerequisite expertise required. </p>
<p>Arriving in the emergency room, the operating room, the intensive-care unit, a hospital ward environment or clinic can be a frightening situation. As a parent myself, I know I need the next generation of physicians to be competent to care for my family too.</p><img src="https://counter.theconversation.com/content/84662/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J Damon Dagnone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A radical new model of “competency based” medical education emphasizes trainee skill over time invested. Queen’s University is the first in Canada to fully embrace this shift.J Damon Dagnone, Associate Professor of Emergency Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/807522017-09-06T20:07:42Z2017-09-06T20:07:42ZMedical schools are shaking off a dark past by honouring people who donate their bodies to science<figure><img src="https://images.theconversation.com/files/182023/original/file-20170814-12098-1aqq2w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Commemorations to honour those who have donated their bodies for the study of anatomy not only contain symbolic objects like candles and flowers, but also song and online tributes.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/572233663?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Donating your body to science could give you two send-offs, not one. Not only do family and friends say goodbye at your funeral, you could have a second ceremony when medical students say “thank you” for your generous gift.</p>
<p>This second ceremony takes place at universities across the world in a commemoration of donors – an act of honouring the people who have donated their bodies for the study of human anatomy.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/passed-away-kicked-the-bucket-pushing-up-daisies-the-many-ways-we-dont-talk-about-death-77085">Passed away, kicked the bucket, pushing up daisies – the many ways we don't talk about death</a>
</strong>
</em>
</p>
<hr>
<p>Ceremonies can be religious or secular. They often include artistic or ritualistic performances, reading of reflective texts, prayers and pledges, and symbolic objects such as flowers and candles.</p>
<p>And in recent years, <a href="https://books.google.com.au/books?id=YPAnDwAAQBAJ&pg=PR4&lpg=PR4&dq=Commemorations+and+Memorials:+Exploring+the+Human+Face+of+Anatomy.+Hackensack:+World+Scientific&source=bl&ots=77yd1wdP46&sig=LEpgnMNIOevOzylpqmu2vpWD6xM&hl=en&sa=X&ved=0ahUKEwiuub7xss7VAhXMybwKHYHeBhsQ6AEILTAC#v=onepage&q=Commemorations%20and%20Memorials%3A%20Exploring%20the%20Human%20Face%20of%20Anatomy.%20Hackensack%3A%20World%20Scientific&f=false">electronic resources, the internet and social media</a> are also used to <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.198/full">perform, record and communicate</a> these ceremonies.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z5SNdV4EgNo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Anatomy students at Oakland University in the US commemorate those who have donated their bodies to science.</span></figcaption>
</figure>
<p>We don’t know exactly how widespread these ceremonies are. But in Germany, <a href="http://onlinelibrary.wiley.com/doi/10.1002/ar.10012/full">81% of 36 anatomy departments</a> commemorate donors; and in the USA, out of 84 departments (68.2%) responding to a survey, <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1413/full">95.5% carried out ceremonies</a>.</p>
<p>Ceremonies are also beginning to <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.171/full">take</a> <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1335/full">place</a> <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1422/full">in</a> <a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1525/full">other</a> <a href="https://books.google.com.au/books?id=YPAnDwAAQBAJ&pg=PR4&lpg=PR4&dq=Commemorations+and+Memorials:+Exploring+the+Human+Face+of+Anatomy.+Hackensack:+World+Scientific&source=bl&ots=77yd1wdP46&sig=LEpgnMNIOevOzylpqmu2vpWD6xM&hl=en&sa=X&ved=0ahUKEwiuub7xss7VAhXMybwKHYHeBhsQ6AEILTAC#v=onepage&q=Commemorations%20and%20Memorials%3A%20Exploring%20the%20Human%20Face%20of%20Anatomy.%20Hackensack%3A%20World%20Scientific&f=false">countries</a>, each reflecting the relevant context and culture.</p>
<h2>A short history of body donation</h2>
<p>The acquisition of bodies for dissection is one of the <a href="https://books.google.com.au/books?id=vbfSoAEACAAJ&dq=Persaud+TVN,+A+History+of+Human+Anatomy.&hl=en&sa=X&ved=0ahUKEwjhr4vz6NfVAhXBTLwKHXMzCdgQ6AEIMDAC">darkest chapters</a> in the history of medicine. Bodies for anatomy were often stolen from the graveyards, or sent from the workhouses, asylums and hospitals if not claimed by relatives or friends. No wonder anatomy was often perceived as suspicious and a “dark art”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-donate-your-body-to-science-you-die-what-happens-next-1481">You donate your body to science, you die ... what happens next?</a>
</strong>
</em>
</p>
<hr>
<p>So today’s commemoration ceremonies act, in part, to shake off anatomy’s dubious history. They demonstrate to the <a href="http://www.smh.com.au/national/health/donating-a-body-to-science-not-just-altruistic-but-saves-money-too-20110912-1k61h.html#ixzz3FVbionYb">wider community</a> that bodies (cadavers) in universities are treated not only legally, but with moral integrity.</p>
<p>These ceremonies also provide donors with a final farewell. Some keep donors’ names anonymous while others reveal their identity with consent of the donor and family.</p>
<p>And for the ceremonies that include relatives and friends of the body donors, ceremonies can help in the grieving process. As one family <a href="http://www.worldscientific.com/worldscibooks/10.1142/10118">commented</a>:</p>
<blockquote>
<p>The way in which our mother was acknowledged allowed us to see how this donation was valued and valuable to students and faculty alike. This was a great
encouragement to us.</p>
</blockquote>
<h2>Ceremonies around the world</h2>
<p>Our <a href="https://books.google.com.au/books?id=YPAnDwAAQBAJ&pg=PR4&lpg=PR4&dq=Commemorations+and+Memorials:+Exploring+the+Human+Face+of+Anatomy.+Hackensack:+World+Scientific&source=bl&ots=77yd1wdP46&sig=LEpgnMNIOevOzylpqmu2vpWD6xM&hl=en&sa=X&ved=0ahUKEwiuub7xss7VAhXMybwKHYHeBhsQ6AEILTAC#v=onepage&q=Commemorations%20and%20Memorials%3A%20Exploring%20the%20Human%20Face%20of%20Anatomy.%20Hackensack%3A%20World%20Scientific&f=false">recent book</a> describes the many and varied ceremonies and memorials around the world.</p>
<p><strong>New Zealand</strong></p>
<p>New Zealand researchers describe the practice at the <a href="http://www.otago.ac.nz/medical-school/about/bequest-of-bodies/">University of Otago</a>, which reflects Māori cultural beliefs, when the dead body is recognised as tapu (sacred or restricted).</p>
<p>The university holds a <a href="http://www.otago.ac.nz/anatomy/about/bequests/how/">“clearing of the way” ceremony (whakawātea)</a> at the beginning of each academic year, which allows Māori students to enter and work in the dissecting room without transgressing cultural norms and customs. Non-Māori students can also take part.</p>
<p><strong>China</strong></p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1422/full">In China</a>, there are body donation monuments, memorial parks, public memorial activities, <a href="http://www.sixthtone.com/news/2136/cadavers-are-the-silent-teachers-of-tomorrows-doctors">online memorial sites</a>, and thanksgiving ceremonies included as part of anatomy teaching.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=288&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=288&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=288&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=362&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=362&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184454/original/file-20170904-8521-1c24xmw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=362&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An example of a Chinese online memorial.</span>
<span class="attribution"><a class="source" href="http://www.sixthtone.com/news/2136/cadavers-are-the-silent-teachers-of-tomorrows-doctors">Screen shot</a></span>
</figcaption>
</figure>
<p>These were established to address traditionally low levels of body donation in China.</p>
<p><strong>Brazil</strong></p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/ase.1335/full">In Brazil</a>, a course at one university ends with a temporary exhibition of dissected specimens open to the public called the “Museum of Anatomy”.</p>
<p><strong>Germany</strong></p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=803&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=803&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=803&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1009&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1009&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184463/original/file-20170904-8504-zfrqvq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1009&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People whose bodies were sent to medical schools in Nazi Germany without consent are finally commemorated.</span>
<span class="attribution"><a class="source" href="http://www.berghahnbooks.com/title/HildebrandtAnatomy">Screenshot</a></span>
</figcaption>
</figure>
<p><a href="http://ghsm.hms.harvard.edu/person/faculty/sabine-hildebrandt">One US-based researcher</a> highlights the role played not only by doctors and biomedical researchers but also anatomists in the atrocities of the Nazi regime in Germany in 1933-1945.</p>
<p>This is when bodies from jails and concentration camps, including those of political prisoners and those imprisoned for their racial and ethnic origins, were sent without consent to medical schools. </p>
<p><a href="https://books.google.com.au/books?id=9ynfCQAAQBAJ&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false">Research</a> focuses on identifying and restoring the names and biographies of these victims, who have remained unnamed over many decades. This has included publishing <a href="http://www.berghahnbooks.com/title/HildebrandtAnatomy">victims’ stories</a>.</p>
<p>While not a traditional ceremony as such, these biographies nevertheless act as lasting commemorations. And as these are public, this means victims’ biographies are shared beyond immediate families and friends.</p>
<p><strong>USA</strong></p>
<p>“Body companies” provide donor bodies to various institutions for surgical training. While they don’t charge for the body, they do charge the institutions for transport and handling. And research shows these companies (some profit, some not-for-profit) <a href="https://umshare.miami.edu/web/wda/ethics/Champney-2016-Clinical_Anatomy.pdf">rarely commemorate donors</a>, while university and state-based body donation programs do.</p>
<p><strong>Australia</strong></p>
<p>The <a href="http://www.npr.org/templates/story/story.php?storyId=16678816">Calcutta bone trade</a>, which operated 1930–85, is estimated to have shipped more than two million skeletons obtained without consent to countries across the world, including Australia, for teaching anatomy. No-one knows the names of these donors.</p>
<p>Once the University of Queensland <a href="https://www.researchgate.net/publication/316924308_COMPLEXITIES_AND_REMEDIES_OF_UNKNOWN-PROVENANCE_OSTEOLOGY_Exploring_the_Human_Face_of_Anatomy">confirmed it had some of these skeletons</a>, it removed these remains to a memorial to pay respect to those whose skeletons were traded without consent. </p>
<h2>Ceremonies are about the future too</h2>
<p>For society as a whole, commemorations and memorials are an encouragement that the <a href="https://medicalsciences.med.unsw.edu.au/community/bequeathal-program">selfless act of donating a body</a> can be celebrated and that knowledge can be gained through studying it. As such, modern anatomy is not about death, it is about life.</p><img src="https://counter.theconversation.com/content/80752/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We’ve come a long way since the dark days of grave robbing to provide bodies for dissection. Now, there are ceremonies and memorials to honour people who have donated their body to science.Nalini Pather, Associate Professor, Medical Sciences & Director, EPICentre, UNSW Sydney, UNSW SydneyGoran Štrkalj, Associate Professor, biological anthropologist and anatomist, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/788292017-07-04T23:23:27Z2017-07-04T23:23:27ZThe risky lure of Caribbean offshore medical schools<figure><img src="https://images.theconversation.com/files/172607/original/file-20170607-3665-6pdofh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Private medical schools in the Caribbean promise low fees and tropical beach locations, amongst other benefits.</span> <span class="attribution"><span class="source">(Valorie Crooks)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Many Canadians dream of becoming a doctor. The reality is that only a fraction of students who <a href="https://www.ouac.on.ca/statistics/med_app_stats/">apply to Canadian medical schools</a> are admitted. This reality is driving an increasing number of Canadian undergraduates to offshore medical schools in Dominica, Jamaica, Guyana, Aruba and other Caribbean countries.</p>
<p>There are over 50 of these private medical schools throughout the Caribbean, catering to international students. They promise low fees, tropical beach locations and the possibility of practising medicine at home or in the US after graduation. </p>
<p>But an offshore medical education is also risky — for Canadian students and for their host country populations. We know that Canadians graduating from overseas schools face <a href="http://vancouversun.com/news/staff-blogs/odds-stacked-against-canadians-studying-medicine-abroad-if-they-want-to-return-for-residency-training">stiffer competition for residency placements</a> back home. Often, they graduate with <a href="http://www.utpjournals.press/doi/pdf/10.3138/cpp.2014-037">higher debt</a>. </p>
<p>For-profit schools in the Caribbean also fail to meet the traditional social obligations of medical schools. These obligations are defined by the <a href="http://apps.who.int/iris/bitstream/10665/59441/1/WHO_HRH_95.7.pdf">World Health Organization</a> and <a href="https://afmc.ca/pdf/pdf_sa_vision_canadian_medical_schools_en.pdf">Health Canada</a> and they include the duty to train local doctors and to address local health challenges. </p>
<p>Our <a href="http://www.sfu.ca/medicaltourism/">research group</a> at Simon Fraser University is studying offshore Caribbean medical education, as part of a wider research program into the equity and ethical impacts of global health-care mobilities. We focus on international movements of patients or health-care providers that are untracked, untraced, and unregulated. Our established research about <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-0948-3">medical tourism in the Caribbean</a> is what first introduced us to the growing number of offshore medical schools in the region. </p>
<h2>Graduation gifts: higher debt and stiffer competition</h2>
<p>We have visited offshore medical schools in <a href="https://www.mona.uwi.edu/wimjopen/article/1645">St. Lucia</a>, Grenada, Cayman Islands and Barbados. We have attended information sessions put on by recruiters from some of these schools in our home city of Vancouver. We see posters advertising these schools throughout our university. And we are frequently targeted by ads on social media encouraging us to apply. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172610/original/file-20170607-3668-1fsbnae.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The skills laboratory of an offshore medical school located on the south coast of Barbados.</span>
<span class="attribution"><span class="source">(Valorie Crooks)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We recently published an <a href="https://www.dx.doi.org/10.1186/s12909-017-0936-x">analysis of the promotional messages</a> Caribbean medical schools use on their websites. We found that they encourage students to attend so they can help with physician shortages at home. They also commonly advertise low tuition rates and the possibility of practising medicine at home after graduation. Many Canadians who study medicine abroad at these schools <a href="http://socasma.com">hope to return to Canada to practise</a>. </p>
<p>What is most interesting is what such promotional messages do not communicate. They do not explain that Canadian graduates will need to <a href="http://vancouversun.com/news/staff-blogs/odds-stacked-against-canadians-studying-medicine-abroad-if-they-want-to-return-for-residency-training">compete for residency placements</a> as international medical graduates. In <a href="http://www.carms.ca/assets/upload/pdfs/2013R1_MatchResults/Master_PDF_En.pdf">2013</a> only 499 of the 2,962 international medical graduates who applied were successfully matched to residencies. Nor is it explained that Canadians who study medicine abroad often graduate with <a href="http://www.utpjournals.press/doi/pdf/10.3138/cpp.2014-037">significantly higher debt levels</a>.</p>
<h2>Medical schools: public institutions with social obligations</h2>
<p>Caribbean offshore medical schools train international students for international practice. Students are taught so that they will succeed in American medical licensing examinations. Success in these American licensing examinations is so important that pass rates are frequently reported on school <a href="https://www.dx.doi.org/10.1186/s12909-017-0936-x">websites</a> and promotional posters. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=685&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=685&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=685&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=860&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=860&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172614/original/file-20170607-3707-1p59s3r.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=860&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A sponsored advertisement that has appeared in Valorie’s Facebook feed many times. Note the reference to graduates’ pass rates on the American medical licensing exam.</span>
<span class="attribution"><span class="source">(Valorie Crooks)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Traditionally though, medical schools are public institutions. Not only do they typically receive public funds, but they also train physicians who will treat local people. It is suggested that they have social obligations due in part to their public nature.</p>
<p>The <a href="http://apps.who.int/iris/bitstream/10665/59441/1/WHO_HRH_95.7.pdf">World Health Organization</a> says that medical schools have a social obligation to focus research, clinical and training activities on local health priorities. This obligation has led Canada to produce a <a href="https://afmc.ca/pdf/pdf_sa_vision_canadian_medical_schools_en.pdf">statement </a> about how social values can be incorporated in medical education. It has also led to the development of a <a href="http://healthsocialaccountability.org">global consensus statement on medical education</a>. </p>
<p>Medical schools should be integrated into local communities. Instructors should practice in local clinics and draw on community-based knowledge when teaching. Administrators should incorporate local public health priorities into the curriculum. Research should address local problems in addition to global ones. Many students should be local and want to work locally. They should know how to identify pressing local health challenges. </p>
<p>Caribbean offshore medical schools typically do not meet such social obligations. They train international students to practice elsewhere. Their organizational structures rely heavily on international lecturers and foreign investment. This makes it very unclear who they are accountable to. </p>
<p>What is lost when students are trained at medical schools without strong social mandates or accountability to local populations? Do these schools contribute to local health system inequities and shortages of trained medical personnel? </p>
<p>These are important questions. Given the growing number of Canadians enrolling at Caribbean offshore medical schools who want to practice in Canada and the value placed on social accountability in medical education here, we believe these are questions worth grappling with.</p><img src="https://counter.theconversation.com/content/78829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Valorie A. Crooks holds the Canada Research Chair in Health Service Geographies and a Scholar Award from the Michael Smith Foundation for Health Research. She has received research funding from the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Jeffrey Morgan is funded by a Canada Graduate Scholarship from the Canadian Institutes for Health Research.</span></em></p>Competition for spaces is driving Canadian undergraduates to medical school in the tropics. And there are risks - for student career prospects and Caribbean health systems.Valorie A. Crooks, Full Professor, Simon Fraser UniversityJeffrey Morgan, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/785352017-06-04T20:25:05Z2017-06-04T20:25:05ZHow can Australia have too many doctors, but still not meet patient needs?<figure><img src="https://images.theconversation.com/files/171944/original/file-20170602-25664-qdxhuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you live in a rural area, you would never think Australia had too many doctors.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same - statistically at least. </p>
<p>With <a href="http://www.oecd.org/health/health-data.htm">3.5 practising doctors</a> for every 1,000 people in 2014 (<a href="http://www.aihw.gov.au/workforce/medical/how-many-medical-practitioners/">4.4 per 1,000 in major cities</a>) we’ve never had so many. In 2003, there were 2.6 doctors for every <a href="http://www.oecd.org/health/health-data.htm">1,000 people in Australia</a>, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).</p>
<p>Yet at 2.6 per 1,000 was when <a href="https://www.mja.com.au/journal/2003/179/4/medical-workforce-issues-australia-tomorrow-s-doctors-too-few-too-far">we decided we were “short”</a> and went on to <a href="https://www.mja.com.au/">double the number</a> of medical schools and almost triple the number of medical graduates in a little over a decade. </p>
<p>And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pubs-mtrp">granted 2,820 temporary work visas</a> to overseas-trained doctors in 2014-15. In the same year, Australian <a href="http://www.medicaldeans.org.au/statistics/annualtables/">medical schools graduated</a> another 3,547.</p>
<p>This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only <a href="http://www.oecd.org/health/health-data.htm">Denmark and Ireland</a> in the same league of doctor-production for population.</p>
<p>So why do we have too many doctors, but think we have too few?</p>
<h2>Our approach to medical training</h2>
<p>In a <a href="https://www.mja.com.au/">Medical Journal of Australia</a> editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.</p>
<p>To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?</p>
<p>There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.</p>
<h2>1. Production</h2>
<p>Back in the early 2000s, the biggest issue relating to the <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BN/%7E/link.aspx?_id=4FB58821DB2B49F58743E7802D1C4ED3&_z=z">training of Australia’s medical workforce</a> was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas. </p>
<p>While <a href="http://www.rrh.org.au/publishedarticles/article_print_2991.pdf">results of these policies</a> have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school. </p>
<p>That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a <a href="https://ama.com.au/ausmed/trainee-doctors-face-uncertain-future">fierce competition</a> for ever-more sub-specialised training jobs. </p>
<p>Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the <a href="http://www.abc.net.au/news/2017-04-13/government-bid-to-keep-medical-specialists-in-rural-areas/8440474">recently announced</a> funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.</p>
<h2>2. Excessive specialisation</h2>
<p>There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/F3F2910B39DF55FDCA257D94007862F9/%24File/AFHW%20-%20Doctors%20report.pdf">there’s now an imbalance</a> between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field. </p>
<p>Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.</p>
<h2>3. Financing and models of care</h2>
<p>Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs. </p>
<p>Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments. </p>
<p>However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to <a href="https://www.safetyandquality.gov.au/atlas/">inappropriate medical care</a>, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions. </p>
<p>An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can <a href="http://www.pc.gov.au/research/supporting/supplier-induced-medical-demand">lead to higher rates</a> of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.</p>
<h2>Time for action</h2>
<p>Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate. </p>
<p>Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.</p>
<p>Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved. </p>
<p>We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres. </p>
<p>And we especially need to expand the number of broadly-skilled <a href="http://www.abc.net.au/news/rural/2016-06-24/rural-health-election-promises/7540768">rural generalists</a> and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession - and the time to act is now.</p><img src="https://counter.theconversation.com/content/78535/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Murray is Dean of a medical school and President of the peak body representing Australian and New Zealand medical schools. He is a past President of the Australian College of Rural and Remote Medicine.</span></em></p><p class="fine-print"><em><span>Andrew Wilson is a professor the University of Sydney Medical School. In 2015 he conducted a national review of medical internships for the Australian Health Ministers Advisory Committee. He is chair of the Pharmacuetical Benefits Advisory Committee. </span></em></p>Australia has more doctors per population than most comparable countries, yet many living in rural and remote areas don’t receive the care they need. Changing the way we train doctors will fix this.Richard Murray, Dean of Medicine & Dentistry, James Cook UniversityAndrew Wilson, Co-Director, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/701932016-12-12T18:58:19Z2016-12-12T18:58:19ZWe don’t know enough about mental health in Australian medical students<figure><img src="https://images.theconversation.com/files/149602/original/image-20161212-31379-19bk7vv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long term monitoring of mental health in medical trainees is urgently required. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/usarmyafrica/10571666614/in/photolist-h7byb3-fjP9B8-693cYz-do1n1Y-9WQFVG-q92HqQ-hhZB71-d7tCQ3-akizqU-do1noY-akizyN-o5Pqpe-rjmutb-d4ZwLW-do1fGH-dfs78G-duHCeh-do1mnu-dfs6ff-q92JUw-do1g5Z-otsmWE-dfs5zo-do1ni5-9WMQy6-do1ndQ-do1h6T-cJYHpN-cJYP1Y-do1nsU-do1mL9-cLUFFA-cJYP8o-fhkLKb-dA4GiV-bqka8W-8y32yB-8rqoqG-8JVvBf-7ZetsF-gJ592Y-7ZeuSt-692TCP-psRTAN-h7by4j-34TJZ-7eqpcQ-6PwVhK-gJ4UBu-8rmYr8">usarmyafrica/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The highly regarded Journal of the American Medical Association has published a <a href="http://jamanetwork.com/journals/jama/article-abstract/2589340">comprehensive review</a> examining the prevalence of depression, depressive symptoms and suicidal thoughts among medical students.</p>
<p>The pooled findings of 195 studies from 47 countries demonstrated that the mental health of medical students is a significant global problem. Overall, around a quarter of students screened positive for symptoms of depression, and one in ten reported suicidal thoughts. The authors said that these estimates are around two to five times higher than those reported in the general population.</p>
<h2>Depression, exhaustion and anxiety in junior doctors</h2>
<p>While this <a href="http://jamanetwork.com/journals/jama/article-abstract/2589340">report</a> has caused a notable stir in the medical academic community, sadly it adds to a body of existing evidence. Concerns about unacceptable levels of mental health problems in medical trainees have been voiced for <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/610073">decades</a>. The current study follows a <a href="http://jamanetwork.com/journals/jama/fullarticle/2474424">2015 publication</a> by the same group, in which they reported prevalence of depressive symptoms in trainee resident physicians of almost 29%.</p>
<p>Recent evidence shows that Australian medical students also face mental health problems. <a href="https://www.beyondblue.org.au/">Beyond Blue</a> conducted the <a href="http://resources.beyondblue.org.au/prism/file?token=BL/1132">first nation-wide study</a> in 2013. Of 1,811 medical students surveyed, one in five reported suicidal thoughts over the previous year, and 40-50% experienced emotional exhaustion and symptoms of depression and/or anxiety above case level (as measured by the <a href="http://occmed.oxfordjournals.org/content/57/1/79.full">General Health Questionnaire</a>). The documented rates of distress and suicidal thoughts were significantly higher than those of the Australian population and other professional groups.</p>
<h2>Serious problems not being addressed</h2>
<p>Collectively these findings present serious cause for concern. It is clear that training to become a doctor is associated with a high personal burden of mental health problems. But there are ramifications beyond the personal level, with research documenting significant links between the <a href="http://bjp.rcpsych.org/content/190/3/268">mental health</a> of medical professionals and the overall effectiveness of health care, including <a href="http://www.rcpe.ac.uk/journal/issue/journal_39_4/editorial.pdf">patient safety</a>. In the medical context, ensuring good mental health in trainees is central to addressing and improving the future health of Australia as a nation.</p>
<p>Why then has this problem remained unaddressed for so long? Perhaps it’s habit. Medical training continues to <a href="http://bmjopen.bmj.com/content/2/5/e001776.full">reinforce the idea</a> that the profession is demanding and that doctors should be invincible and immune from the effects of stress.</p>
<p>Significant <a href="http://bmjopen.bmj.com/content/2/5/e001776.full">stigmatising attitudes of doctors</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/23561490">medical students</a> in regard to the competency of colleagues with known mental health conditions have been documented. These attitudes lead to underreporting of mental health problems and impede appropriate help-seeking behaviours. Notably, this new <a href="http://jamanetwork.com/journals/jama/article-abstract/2589340">systematic review</a> found that only 16% of students who screened positive for depression actually sought professional help.</p>
<h2>The culture of medicine</h2>
<p>In an <a href="http://jamanetwork.com/journals/jama/article-abstract/2589328">editorial</a> that accompanies the newest research, Dr Stuart Slavin agrees that aspects of the culture of medicine are likely to have contributed to the evident inertia in effectively addressing the mental health risks of medical trainees. He criticises the tendency of educators to primarily focus on the student through providing generic resilience-building programs. Dr Slavin suggests evaluation of the culture and teaching environment would be a better focus, particularly given <a href="http://www.doctorportal.com.au/mjainsight/2016/2/training-crisis-means-more-bullying/">reports</a> that bullying and harassment of junior doctors are common.</p>
<p>Even so, unless we understand the spectrum of risks and triggers of student mental health problems, Band-Aid solutions hastily put in place are not likely to offer effective or lasting solutions. Our recent <a href="https://www.ncbi.nlm.nih.gov/pubmed/27541670">research</a> shows that one size rarely fits all in behavioural interventions.</p>
<p>A <a href="http://jamanetwork.com/journals/jama/article-abstract/2589343">review</a> examining the effectiveness of existing interventions aimed at improving medical student wellbeing found the available evidence of such poor quality that no firm conclusion could be reached.</p>
<h2>We need better data, and action</h2>
<p>Clearly, implementation of strategies at the personal, curriculum and medical culture level requires better quality evidence. Research must be of a prospective, longitudinal nature to enable examination of a role for pre-existing risks and vulnerabilities in the development and maintenance of health problems.</p>
<p>We also need to know about new triggers emerging in response to emotional, existential and work place-related challenges met in clinical training. Data collection must go beyond self-report measures, and include clinical assessments allowing valid estimates of mental conditions.</p>
<p>Further, the full spectrum and comorbidity of mental health complaints likely to be seen in young adults – including eating disorders, substance misuse and anxiety disorders – have yet to be examined prospectively over the course of clinical training.</p>
<p>Mental distress and associated poor coping and health behaviours (including <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-psych-010213-115205?journalCode=psych">sleep</a>) are known to affect the <a href="https://www.ncbi.nlm.nih.gov/pubmed/19424767">function of biological systems</a> linked to adaptation and body integrity, such as the nervous and immune systems. Disturbances in these interconnected systems – which impact dynamically on <a href="http://www.nature.com/nrn/journal/v10/n1/full/nrn2555.html">key neural circuits</a> responsible for emotion and motivation – can perpetuate a vicious cycle of <a href="https://www.ncbi.nlm.nih.gov/pubmed/24056922">ill health</a> and <a href="http://www.internationaljournalofcardiology.com/article/S0167-5273(12)01298-3/abstract">poor functioning</a>. Preliminary data collected at my laboratory clearly shows that this is indeed the case in UNSW medical students (manuscript under review).</p>
<p>To date, no study has included longitudinal monitoring of psychopathology, biological functioning and behaviour in a cohort of medical trainees. Only research of this calibre will elucidate the triggers and mechanisms that put our student doctors at risk of serious mental health problems.</p>
<p>How much longer will we wait before we take this important issue seriously?</p><img src="https://counter.theconversation.com/content/70193/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ute Vollmer-Conna does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>About a quarter of medical students show symptoms of depression, and one in ten report suicidal thoughts.Ute Vollmer-Conna, Associate Professor, School of Psychiatry, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/667692016-10-18T06:45:58Z2016-10-18T06:45:58ZWikipedia is already the world’s ‘Dr Google’ – it’s time for doctors and researchers to make it better<figure><img src="https://images.theconversation.com/files/142101/original/image-20161018-12440-1f759xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that Wikipedia is one of the most read sources of medical information by the general public across the world.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/67272961@N03/6123892769/">jfcherry/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Health professionals have a duty to improve the accuracy of medical entries in Wikipedia, according to a letter published today in <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30254-6/fulltext">Lancet Global Health</a>, because it’s the first port of call for people all over the world seeking medical information.</p>
<p>In our correspondence, a group of international colleagues and I call on medical journals to do more to help experts make Wikipedia more accurate, and for the medical community to make improving its content a top priority. </p>
<h2>Use around the world</h2>
<p>Ranked the <a href="http://www.alexa.com/topsites">fifth most-visited website</a> in the world, Wikipedia is one of the <a href="http://jamia.oxfordjournals.org/content/16/4/471.full">most-read sources of medical information</a> by the general public. It’s also frequently the first port of call for <a href="http://www.jmir.org/2015/3/e62/?trendmd-shared=1">doctors</a>, <a href="http://www.tandfonline.com/doi/full/10.3109/0142159X.2012.737064?scroll=top&needAccess=true">medical students</a>, <a href="http://heinonline.org/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/yjolt12&section=3">lawmakers</a>, and <a href="http://www.pewinternet.org/2013/02/28/how-teachers-are-using-technology-at-home-and-in-their-classrooms/">educators</a>.</p>
<p>Access is provided free of charge on mobile phones in many countries, under the <a href="https://blog.wikimedia.org/c/wikipedia-zero/">Wikipedia Zero scheme</a>. In developing nations, this has helped the site become the main source of information on medical topics. During the <a href="http://www.nytimes.com/2014/10/27/business/media/wikipedia-is-emerging-as-trusted-internet-source-for-information-on-ebola-.html?_r=0">2014 Ebola outbreak</a>, for instance, page views of the <a href="https://en.wikipedia.org/wiki/Ebola_virus_disease">Ebola virus disease</a> peaked at more than <a href="http://www.wikipediatrends.com/Ebola_virus_disease.html">2.5 million per day</a>.</p>
<p>Earlier this year, the site launched the free <a href="https://play.google.com/store/apps/details?id=org.kiwix.kiwixcustomwikimed&hl=en">Medical Wikipedia Offline app</a> in seven languages. The Android app has had nearly 100,000 downloads in its first few months of release. It’s particularly useful in low and middle-income countries, where internet access is typically slow and expensive.</p>
<p>All this makes Wikipedia’s accuracy vital because every medical entry on the collaborative online encyclopedia has the potential for immediate <a href="http://www.who.int/bulletin/volumes/87/4/08-056713/en/">real-world health consequences</a>.</p>
<h2>A question of priorities</h2>
<p>Given its model of allowing anyone to edit entries, Wikipedia is already <a href="http://www.nature.com/nature/journal/v438/n7070/full/438900a.html">surprisingly accurate</a>, famously rivalling Encyclopedia Britannica. But even as the online encyclopedia matures, the accuracy of its medical content remains inconsistent.</p>
<p>The platform has historically <a href="https://www.theguardian.com/education/2011/mar/29/wikipedia-survey-academic-contributions">struggled to attract expert contributions</a> from researchers. Improving Wikipedia entries tends to be low on the list of priorities for doctors and other health professionals. </p>
<p>Finding time to write unpaid content in an unfamiliar format can easily lose out to more immediate career concerns. Doctors consistently work <a href="http://jamanetwork.com/journals/jama/fullarticle/1475198">long hours</a> with patients, and researchers tend to be busy applying for grants and <a href="http://jmi.sagepub.com/content/14/4/321.short">publishing in academic journals</a>. </p>
<p>The <a href="https://en.wikipedia.org/wiki/Stillbirth">entry on stillbirth</a> illustrates well why Wikipedia needs to attract more expert contributors. Every day, there are <a href="http://www.who.int/reproductivehealth/topics/maternal_perinatal/stillbirth/en/">7,000 stillbirths worldwide</a>, but before my colleagues and I updated the Wikipedia page, it was was missing crucial information.</p>
<p>It didn’t mention key causes, such as malaria, and common complications, such as depression. Having the full picture of a medical condition is extremely <a href="https://www.jmir.org/2003/3/e17/?trendmd-shared=1">important for effective health care</a>. And it’s vital for patients as well. Knowing that depression is a normal side effect of stillbirth, for instance, can help women <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2524.2008.00814.x/full">cope with the emotional fallout</a>. </p>
<p>Similarly, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106930">accurate information on medication</a> affects what doctors prescribe, what patients request, and what students learn.</p>
<p>Such important topics quite simply demand accuracy.</p>
<h2>Possible solutions</h2>
<p>While spotting the shortfall is easy, solving it will require the concerted efforts of multiple communities with unique strengths.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142102/original/image-20161018-12440-13bev85.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wikipedia has historically struggled to attract expert contributions from time-poor researchers and doctors.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/youraccount/7839794684/">Garnet/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Doctors and researchers can provide expert knowledge about complex topics; medical journals can leverage their infrastructure for robust peer review and indexing; Wikipedians can provide their experience in encyclopedic writing and technical expertise; and medical schools can encourage student involvement. </p>
<p>Simultaneously publishing peer-reviewed work in academic journals and in Wikipedia could benefit all participants. This would include both putting existing entries through academic peer review, and converting suitable journal articles into Wikipedia entries. Official recognition of authors’ efforts through their citeable publications by scholarly journals is an important reward for time-pressed contributors.</p>
<p>Peer review would ensure the quality of content, and for journals wanting to <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31771-8/fulltext">have an impact on public health</a>, Wikipedia is the among the best outreach tools available.</p>
<p>Several scholarly journals have been exploring academic peer review of Wikipedia entries and more look to soon join them. Examples of joint-publishing include the Wikipedia articles for Dengue fever and the cerebellum, which have been reviewed and published by the medical journals <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787">Open Medicine</a> and the <a href="https://en.wikiversity.org/wiki/WikiJournal_of_Medicine/The_Cerebellum">WikiJournal of Medicine</a> respectively.</p>
<p>PLOS Computational Biology similarly <a href="http://collections.plos.org/topic-pages">joint-publishes review articles</a> in its journal and in Wikipedia for maximum impact. And, the journal RNA Biology requires researchers describing a <a href="http://www.nature.com/news/2008/081216/full/news.2008.1312.html">new RNA family</a> to also write a Wikipedia entry for it.</p>
<h2>Embedding the new approach</h2>
<p>Progress has been slow, but several independent ventures show how the attitudes of major players in the biomedical ecosystem are beginning to shift further, and take Wikipedia more seriously.</p>
<p>Cochrane, which creates medical guidelines after reviewing research data, now finds <a href="http://www.cochranelibrary.com/editorial/10.1002/14651858.ED000069">Wikipedian partners for its Review Groups</a> to help disseminate their information through Wikipedia.</p>
<p>Medical schools are also <a href="http://journals.lww.com/academicmedicine/Abstract/publishahead/Why_Medical_Schools_Should_Embrace_Wikipedia__.98408.aspx">getting involved</a> in improving Wikipedia entries. Medical students at University of California, San Francisco, can <a href="http://www.nytimes.com/2013/09/30/business/media/editing-wikipedia-pages-for-med-school-credit.html?_r=0">gain course credit</a> for supervised editing of Wikipedia articles in need of attention.</p>
<p>These and similar schemes can hopefully normalise Wikipedia editing within future medical community. And patients will ultimately be the winners. When it comes to health content, the deadline is now.</p><img src="https://counter.theconversation.com/content/66769/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Shafee is an active Wikipedian and is on the WikiJournal of Medicine editorial board. </span></em></p>Medical entries on Wikipedia are widely consulted across the world. Doctors and medical researchers need to make efforts to ensure the content on the online collaborative encyclopedia is accurate.Thomas Shafee, Research Fellow in Biochemistry and Evolution, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/638982016-08-15T10:14:27Z2016-08-15T10:14:27ZWhy get a liberal education? It is the life and breath of medicine<figure><img src="https://images.theconversation.com/files/134007/original/image-20160812-31267-tmskur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical student and child at Minnesota Indian Health alternative spring break experience. </span> <span class="attribution"><span class="source">Geisel School of Medicine, Dartmouth</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Hospital <a href="http://www.usnews.com/info/blogs/press-room/articles/2016-08-02/us-news-announces-the-201617-best-hospitals">rankings</a> were released Aug. 2 by U.S. News & World Report. Of the <a href="http://www.usnews.com/info/blogs/press-room/articles/2016-08-02/us-news-announces-the-201617-best-hospitals">top 20</a>, almost every single hospital is affiliated with a medical school. These big academic medical centers treat a large share of our nation’s sickest patients.</p>
<p>Yet <a href="http://www.wsj.com/articles/universities-get-second-opinion-on-their-hospitals-1429725107">academic medical centers</a> across the nation are reeling from economic pressures and questioning one of their core tenets: that institutions of higher education have medical schools because they bring revenue and prestige.</p>
<p>That was true for decades. In recent years, however, this assumption has been challenged. Academic medical centers have faced a financial double whammy: shrinking “<a href="https://www.advisory.com/daily-briefing/2016/05/02/medicare-margins-projected-to-decrease">clinical margins</a>” from changes imposed by the Affordable Care Act and a generally <a href="http://www.sciencemag.org/news/2014/12/within-nih-s-flat-2015-budget-few-favorites">flat research budget</a> from federal granting agencies such as the National Institutes of Health.</p>
<p>In response, medical schools and their teaching hospitals, including <a href="http://ww2.kqed.org/stateofhealth/2016/04/22/budget-cuts-threaten-uc-berkeleys-medical-program/">Berkeley</a>, <a href="http://harvardmagazine.com/2015/01/balanced-budget-benefits-battle">Harvard</a>, <a href="http://www.crainsdetroit.com/article/20150211/NEWS/150219947">Michigan</a>, <a href="http://www.sj-r.com/article/20160310/NEWS/160319948">Southern Illinois</a>, <a href="http://news.vanderbilt.edu/2014/11/myvumc-announce-nov2014/">Vanderbilt</a>, <a href="http://www.detroitnews.com/story/news/local/detroit-city/2015/12/04/wayne-state-medical-school-deficit/76806820/">Wayne State</a>, <a href="http://www.montefiore.org/body.cfm?id=1738&action=detail&ref">Yeshiva</a> and our home institution, <a href="http://thedartmouth.com/2015/09/29/geisel-will-restructure-due-to-financial-constraints/">Dartmouth</a>, have turned to significant restructuring to rein in budgets. <a href="http://www.ktbs.com/story/22385312/pending-budget-cuts-could-f">Some have done so</a> to stave off the threat of closure.</p>
<p>At the same time, as the cost of an undergraduate education skyrockets, <a href="http://www.forbes.com/sites/sergeiklebnikov/2015/06/19/liberal-arts-vs-stem-the-right-degrees-the-wrong-debate/#3d39de5141ec">the validity of a broad-based liberal education</a> has also come increasingly under fire. People question the <a href="https://www.google.com/?gws_rd=ssl#q=wall+street+journal+value+of+liberal+arts+education">value of a liberal arts education in a digital economy</a> compared to the hard, technical skills from the STEM fields in making graduates marketable in today’s world.</p>
<p>The confluence of these two shifts is particularly marked in smaller medical centers like ours at Dartmouth. This raises the question: Does a medical school belong with a liberal arts school? Or are we (as we are sometimes called) an overly expensive trade school that produces “body mechanics” and outside the school’s dedicated mission to <a href="https://www.aacu.org/leap/what-is-a-liberal-education">liberal education</a>?</p>
<p>As medical school faculty members and administrators, we sought to explore this question.</p>
<h2>A need to know how to communicate</h2>
<p>Many may be surprised to learn that liberal education is deeply ingrained in medical school curricula. Yes, medical students learn anatomy, physiology, biochemistry and neuroscience, but they also have required courses in ethics, leadership, policy, economics, sociology and psychology. </p>
<p>To succeed at their trade, doctors not only need to have a sophisticated knowledge of biology, they also must master the complex clinical <a href="http://clinicalmicrosystem.org/">micro-</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2012.00670.x/abstract;jsessionid=F5530400866A3B2AF22B5202275188BE.f04t01">macro-</a>systems in which their patients live and they work.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134009/original/image-20160812-16330-1rcwxuq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical student with migrant workers in New Hampshire.</span>
<span class="attribution"><span class="source">Geisel School of Medicine, Dartmouth College</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Thus, today’s medical curriculum teaches new doctors about culture and communication. It is no longer good enough – and probably never was – for a doctor to simply know the appropriate medication to prescribe or diagnostic test to order. </p>
<p>Physicians must also fully understand <a href="https://books.google.com/books?id=h4KVNX5E2lkC&printsec=frontcover&dq=REinventing+diversity+transforming+organizational+community+to+strengthen+people,+purpose+and+performance&hl=en&sa=X&ved=0ahUKEwjUlYfKnKLMAhVJWD4KHRmCD38Q6AEIHTAA#v=onepa">social constructs</a> such as class, gender and race, explicit and implicit, that mold both how they make medical decisions and how, in turn, patients receive their care. We all know the most science-smart physicians will fail their patients if they aren’t effective communicators with a sense of cultural humility.</p>
<p>On the world stage, understanding culture, politics and economics is crucial to health challenges that range from pandemics to bioterrorism. As the global health expert <a href="https://www.foreignaffairs.com/articles/2007-01-01/challenge-global-health">Laurie Garrett</a> noted recently, culture isn’t just important in these efforts; it’s the whole ballgame.</p>
<p>Medical schools are also often at the forefront in innovations in pedagogy. For example, “experiential learning” as a concept has gained traction in recent years across academic institutions. Yet medical schools have been leading such efforts for centuries where all students spend time “on the wards” learning how to take care of patients. </p>
<h2>Working beyond the wards</h2>
<p>Beyond the wards, medical students also engage in off-campus activities where they learn the realities of providing clinical care within highly diverse human communities. At Dartmouth, we incorporate ethics, economics, global politics, anthropology and sociology into our medical curriculum. We also <a href="https://www.aamc.org/download/249510/data/cipvendordocument.pdf">track and evaluate</a> the impact of these areas of study on student performance.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134008/original/image-20160812-366-12ywd1w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical student with patient in Tanzania.</span>
<span class="attribution"><span class="source">Geisel School of Medicine, Dartmouth College</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>From working with <a href="https://geiselmed.dartmouth.edu/students/programs/ihri/">underserved populations in tribal nations</a> and <a href="https://geiselmed.dartmouth.edu/uhs/about/mission_statement/">inner cities</a> in the U.S., to participation with <a href="http://geiselmed.dartmouth.edu/globalhealth/programs-partners/tanzania-dar-dar/">collaborative HIV/tuberculosis training and treatment programs</a> in Tanzania, these experiential programs teach students the critical <a href="https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health">importance of social determinants of health</a>. They learn that, nationally or internationally, the greatest problems in “health” do not arise from either malaria or atherosclerosis. They arise from the impact of upstream causes such as poverty, malnutrition and lack of access to high-quality education.</p>
<p>Assimilating these social, political, environmental and economic factors into health care delivery has been widely acknowledged by both governments and high-profile nonprofit organizations, such as The <a href="http://www.gatesfoundation.org/What-We-Do" title=") and [Ashoka](https://www.ashoka.org/fields/health "">Bill and Melinda Gates Foundation</a>. </p>
<p>So too, the arts and humanities have long been infused into the medical school curricula. At the turn of the 20th century, <a href="http://journals.lww.com/academicmedicine/Fulltext/2010/02000/Reforming_Medical_Education_in_Ethics_and.34.aspx">Abraham Flexner</a>, called the father of modern medical education, acknowledged the essential nature of ethics and the humanities to the practice of medicine, and the <a href="http://www.tandfonline.com/doi/abs/10.3109/0142159X.2010.519064%3FjournalCode=imte20">liberal arts</a> more broadly have historically been foundational to medical education.</p>
<p><a href="http://avagallery.org/community-programs/art-for-kids/">Dartmouth</a> is far from the only medical school to have long recognized the importance of the arts and humanities in fostering the empathy, compassion and humanity that are cornerstones for effective medical care and to have incorporated them into their curricula. </p>
<p>Schools across the country, including <a href="https://www.aamc.org/newsroom/reporter/may2014/380438/humanities.html">The University of Texas Health Sciences Center at San Antonio</a> and more recently <a href="https://www.statnews.com/2015/11/03/why-medical-schools-are-adding-courses-in-literature-and-dance/">Harvard</a>, have incorporated variations of “Art Rounds” as elective into their educational programs. </p>
<p>And at <a href="http://yalemedicine.yale.edu/spring2014/people/reunion/191342/">Yale</a>, such programs are not only mandatory for students, but are incorporated into their continuing medical education workshops for alumni. Washington University’s medical historian, <a href="https://history.artsci.wustl.edu/ludmerer">Kenneth Ludmerer</a>, has noted that incorporation of the arts and humanities provides a needed counterweight to the ever-increasing load of technical information required of medical studies. This is a sentiment that <a href="https://www.aamc.org/newsroom/reporter/may2014/380438/humanities.html">has been echoed</a> by the governing body for all <a href="https://www.aamc.org/about/membership/378788/medicalschools.html">LCME-accredited</a> U.S. and Canadian medical schools, the Association of American Medical Colleges.</p>
<p>Moreover, the importance of fields of study outside of classical biomedical disciplines is also recognized for medical school faculty. Impact is key in academic advancement, and publication in journals such as The New England Journal of Medicine or Nature still trumps the achievement list for promotions committees. </p>
<p>But promotions committees at medical schools are broadening since “impact” is surely also evident in the 2013 <a href="http://www.cnn.com/2013/05/17/opinion/welch-jolie-mastectomy">op-ed piece on CNN.com</a> by Dr. Gil Welch, which has had more than 3.6 million page views (and still counting). Policy and public understanding about end-of-life care are sculpted as surely by Atul Gawande’s best-seller <a href="https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152">“Being Mortal: Medicine and What Matters in the End”</a> as by well-regarded scientific <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303238?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">reviews of hospice care</a>. </p>
<h2>From cash cow to albatross?</h2>
<p>In short, the wide spectrum of fields in liberal education benefits the faculty as well as the students at medical schools.</p>
<p>Since its early days, medicine has been recognized to be both an art and a science. Despite the explosion in scientific knowledge over the past decades, the art has not been displaced. Rather, medical training is embracing the spectrum of arts, social as well as natural sciences, and humanities.</p>
<p>In an era of tight budgets and doubts about whether that onetime cash cow is now an albatross, administrators ought to consider the true contribution of medical schools to the university, not just as professional training grounds but also as an epitome of true liberal education. </p>
<p>And on the flip side, a society becoming obsessed with how we are wasting valuable dollars in undergraduate liberal arts should recognize how essential these fields are to the training of those who are entrusted with our health and medical care.</p><img src="https://counter.theconversation.com/content/63898/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leslie Henderson received funding from the National Institutes for Health (NIH/NIDA). </span></em></p><p class="fine-print"><em><span>Glenda Shoop and Lisa V. Adams do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The sustainability of academic medical centers and the value of a liberal education have both been under attack. Both are essential and integrated components of our best U.S. institutions.Leslie Henderson, Professor of Physiology and Neurobiology, Dean of Faculty Affairs, Geisel School of Medicine, Dartmouth CollegeGlenda Shoop, Assistant Professor of Medical Education, Dartmouth CollegeLisa V. Adams, Associate Professor of Medicine, Geisel School of Medicine, Dartmouth CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/631092016-08-02T20:13:38Z2016-08-02T20:13:38ZThe hidden curriculum in surgery says it’s not for women<figure><img src="https://images.theconversation.com/files/132109/original/image-20160727-7045-1ctraj1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While medical schools have equal numbers of men and women, few female doctors go on to become surgeons. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Despite more than 15 years of gender parity in Australian medical education, <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-pubs-mtrp-14-toc">women remain underrepresented in surgery</a>. The proportion of female surgical trainees is rising, but more slowly than in other specialties. </p>
<p>Of just over 1,000 surgical trainee applications submitted to the Royal Australasian College of Surgeons in 2015, fewer than 300 were from female applicants. In 2015, <a href="https://www.surgeons.org/media/24007165/RACS040-Activities-Report-2015-LR.PDF">only 28% of active surgical trainees</a> were female. In comparison, <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-pubs-mtrp-14-toc%7Ework-pubs-mtrp-14-4%7Ework-pubs-mtrp-14-4-tre">more than 65% of trainees</a> in obstetrics and gynecology were female in 2010.</p>
<p>So why aren’t many female medical graduates choosing surgical careers?</p>
<h2>It starts at medical school</h2>
<p>Students form some perceptions of specialties even <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1784089/">prior to beginning at medical school</a>, yet <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2517937/">research shows</a> career aspirations change markedly over the course of medical education. Consistently, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575371/">a significant factor</a> influencing career choice in medical graduates is gender.</p>
<p>Perceptions of specialties are developed through personal experience and through cultural messages referred to as the “hidden curriculum”. The hidden curriculum consists of the undercurrents of information, not formally part of the medical curriculum, that filter through from peers, patients and lecturers to budding doctors. It is <a href="http://www.ncbi.nlm.nih.gov/pubmed/25693983">powerful, visible, gendered and discriminatory</a>.</p>
<p>In medicine, these cultural messages perpetuate a distinctly masculine stereotype of a “typical surgeon”. They teach students to anticipate barriers to surgery <a href="http://www.americanjournalofsurgery.com/article/S0002-9610(14)00280-3/abstract">based on their gender</a>. In <a href="http://www.ncbi.nlm.nih.gov/pubmed/22902099">one revealing study</a>, both male and female medical students held a perception that surgery is “not a career welcoming to women”.</p>
<p>Although these messages don’t deter the most certain, committed female students from pursuing a career in surgery, students who are less set on a particular specialty are subtly influenced.</p>
<p>In facilitating positive female exposure to surgery and purposefully challenging the stereotypes perpetuated by the hidden curriculum, medical schools, as well as surgical professional bodies, hospitals and government, can play a role in increasing the number of female medical students considering a career in surgery.</p>
<h2>Negative experiences of surgical rotations</h2>
<p>Medical schools play an important role as the facilitators of the first formal contact of medical students with the surgical profession during hospital-based surgical rotations. This represents a time where gendered perceptions of surgery may be contradicted or reinforced.</p>
<p>Overt discriminatory or sexist comments are the most common predictor of a negative perception of surgery. Rates of gender discrimination, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317470/">measured in US medical schools</a>, revealed almost ubiquitous experience of gender-based discrimination. During their surgical rotations, 87% of women observed or experienced gender-based discrimination. </p>
<p>The figures for Australian students on surgical rotations are not available. We could assume they have similar experiences.</p>
<p>Students <a href="https://www.mja.com.au/journal/2015/203/4/sexual-equality-discrimination-and-harassment-medicine-it-s-time-act#3">need to be able to report</a> gender discrimination or harassment during clinical rotations and medical schools need to commit to retraining or retrenching teachers who perpetuate gender discrimination.</p>
<h2>Female role models</h2>
<p>Lack of female role models is a key factor discouraging women from selecting a career in surgery. Surgical programs with higher proportions of female role models in faculty <a href="http://www.ncbi.nlm.nih.gov/pubmed/11918878">achieve higher numbers of female trainees</a>.</p>
<p>Medical schools need to expose students to a diverse range of surgical role models, as clinical tutors, lecturers or student mentors.</p>
<p>Surgical training programs are renowned for their highly competitive nature, and choosing surgery may be influenced by a student’s perceived preparedness or likelihood of success. Students lacking in research experience, publications or surgical mentors or networks may be less likely to choose highly competitive surgical training positions.</p>
<p>Research productivity among female American academic surgeons initially lags behind male peers. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7897785">Female surgeons cite</a> lack of time, funding and opportunities for collaboration as barriers to early career research. It is likely gendered patterns of research opportunity and publication are already occurring at the undergraduate student level.</p>
<p>Formalised pathways for research and surgical experience are an alternative strategy to ensure female students gain access to these opportunities which are necessary for a future surgical training application.</p>
<p>Strategies to increase gender equity should be assessed and monitored to make sure they’re working. Transparent reporting of gender data will encourage increased accountability and awareness of ongoing inequalities in surgical education.</p>
<p>Countering cultural messages like those surrounding surgery requires an open commitment by medical schools to improving gender equality in medicine. The message that such disparity is inevitable and intractable needs to be broken down.</p><img src="https://counter.theconversation.com/content/63109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Renae Ryan receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Kirsten Black's affiliations are not relevant to the subject of this piece</span></em></p><p class="fine-print"><em><span>Victoria Cook is affiliated with Level Medicine. </span></em></p>The proportion of female surgical trainees is rising, but at a slower rate than other specialties.Renae Ryan, Associate Professor in Pharmacology, Sydney Medical School and Chair, Sydney Medical School Gender Equity Committee, University of SydneyKirsten Black, Associate Professor & Joint Head of Discipline Obstetrics, Gynaecology and Neonatology, University of SydneyVictoria Cook, Medical Student, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/597082016-05-24T12:04:59Z2016-05-24T12:04:59ZWhy getting medical information from Wikipedia isn’t always a bad idea<figure><img src="https://images.theconversation.com/files/123554/original/image-20160523-11000-6mwr04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More medical experts should contribute to Wikipedia to ensure its health pages are accurate.</span> <span class="attribution"><span class="source">Gary Cameron/Reuters</span></span></figcaption></figure><p>Wikipedia’s detractors will tell you that the site is inaccurate, incomplete and unreliable. Many universities <a href="http://isites.harvard.edu/icb/icb.do?keyword=k70847&pageid=icb.page346376">won’t allow</a> students to use Wikipedia as a reference in essays or assignments. So it may come as a surprise to learn that it’s the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25739399">most commonly used</a> source for obtaining medical information online – even among medical students and doctors.</p>
<p>In fact, research has found that Wikipedia is <a href="http://www.ncbi.nlm.nih.gov/pubmed/25739399">more popular</a> for this kind of information than reputable bodies’ websites – including those belonging to the World Health Organisation and the US’s Centres for Disease Control. In some settings, researchers <a href="http://www.ncbi.nlm.nih.gov/pubmed/25739399">have discovered</a>, more than 90% of medical students and 50% of doctors turn to Wikipedia at some point.</p>
<p>But the academic medical community largely views Wikipedia <a href="http://www.ncbi.nlm.nih.gov/pubmed/26443650">with suspicion</a>. This appears to be because the site doesn’t adhere to traditional peer-review mechanisms. There’s also no reward for a busy academic or medical practitioner who takes the time to improve existing Wikipedia pages and ensure that medical information is accurate. Some traditional journals and medical schools are starting to take Wikipedia more seriously, but we wanted to take things a step further by marrying Wikipedia and a traditional journal model. That’s how the <a href="https://en.wikiversity.org/wiki/Wikiversity_Journal_of_Medicine">Wikiversity Journal of Medicine</a> was born.</p>
<h2>Attitudes starting to shift</h2>
<p>Most journals are expensive, hard to access and considered quite elite. They also <a href="http://www.straitstimes.com/opinion/prof-no-one-is-reading-you">aren’t read</a> by very many people beyond academia and research houses. Research has suggested that medical journals need to increase their <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221335/">social impact</a> by actively promoting knowledge sharing on sites like Wikipedia. This offers scope for people all over the world and from a variety of language groups to get more reliable information about health and medicine.</p>
<p>Some journals have heeded this call. <a href="http://journals.plos.org/ploscompbiol/">PLOS’s Computational Biology</a>, for instance, requires any author it publishes to also write a <a href="http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1002446">Wikipedia page</a> on the topic. The journal article is static, referenced and unchanging. The Wikipedia page is changeable and invites contributions. Another journal, RNA Biology, <a href="http://dx.doi.org/10.1038/news.2008.1312">requires</a> the same approach. </p>
<p>There have also been <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242788/">experiments</a> that have seen a Wikipedia article put through traditional medical journal quality control processes. It is then formally published in the journal and the original Wikipedia article is updated.</p>
<p>A few medical schools are embracing this new approach, too. The University of California San Francisco has <a href="http://www.nytimes.com/2013/09/30/business/media/editing-wikipedia-pages-for-med-school-credit.html?_r=0">introduced a course</a> into its curriculum that teaches medical students how to contribute to Wikipedia.</p>
<p>These are all laudable efforts that point to a growing <a href="https://arxiv.org/ftp/arxiv/papers/1506/1506.07608.pdf">open-access</a> movement in the world of <a href="http://dx.doi.org/10.1161/CIRCOUTCOMES.115.002415">scholarly communication</a>. </p>
<h2>Challenges and successes</h2>
<p>The Wikiversity Journal of Medicine, which was launched in 2014, is hosted directly by the <a href="https://wikimediafoundation.org/wiki/Home">Wikimedia Foundation</a>, the same organisation that hosts Wikipedia. It uses the same <a href="https://en.wikipedia.org/wiki/MediaWiki">software</a>, MediaWiki, which makes editing and processing very easy.</p>
<p>The whole service is free to authors and readers; as with Wikipedia our operating costs are covered by donations from around the world. The Wikiversity Journal of Medicine follows standard international best-practice guidelines for medical journals, drawing from such reputable bodies as the <a href="http://www.icmje.org/icmje-recommendations.pdf">International Committee of Medical Journal Editors</a>. </p>
<p>Submission and acceptance follow the traditional medical journal processes, including peer-review by experts on the topic that’s being written about. One important difference is that authors have the option of submitting their article directly onto the journal’s site. This option was designed to enhance transparency and has been taken up by some authors. Others have been more hesitant, as other journals may consider a paper that’s on Wikiversity to be already publicly available and may reject it as a result.</p>
<p>The editorial board includes people from three continents: Africa, North America and Europe. Among them are the editor-in-chief, Sweden’s Dr Mikael Häggström. He’s made extensive <a href="https://upload.wikimedia.org/wikiversity/en/7/7b/Medical_gallery_of_Mikael_H%C3%A4ggstr%C3%B6m_2014.pdf">image contributions</a> to Wikipedia – for example, the site’s <a href="https://en.wikipedia.org/wiki/Ebola_virus_disease">Ebola</a> page features <a href="https://upload.wikimedia.org/wikipedia/commons/4/4a/Symptoms_of_ebola.png">his images</a>.</p>
<p>Dr James Heilman is another board member. He’s arguably the world’s leading expert on <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=James+Heilman">Wikipedia and medicine</a>.</p>
<p>So far the journal has published 16 articles about diverse medical topics. We believe that the journal’s association with Wikipedia has created the false notion that anyone can edit an accepted journal manuscript. There are two versions of each published article. One is a PDF that cannot be edited and stands as the version of record. The second is a wiki and can be edited by anyone. The board monitors these edits. </p>
<p>The journal’s model has potential, though. A US physics professor, Guy Vandegrift, has established <a href="https://en.wikiversity.org/wiki/Second_Journal_of_Science">a second</a> wiki-based journal. This, along with the broader debate around open access to medical information, suggests that the Wikiversity Journal of Medicine provides a feasible, scalable and sustainable model. Of course, it should not be the only source of information – in the same way that no single article in any format should ever be one’s only source. We hope that even if medical experts and researchers don’t contribute to the journal, they will start to take Wikipedia more seriously and, where necessary, to improve it so that people have access to more reliable information.</p>
<p>Such initiatives can, we believe, help to further address the <a href="https://theconversation.com/its-time-to-redraw-the-worlds-very-unequal-knowledge-map-44206">profound inequities</a> in the global knowledge economy that greatly hamper public health.</p>
<p><em>This article was co-authored with Dr Mikael Häggström, a medical doctor in Sweden who is also the editor-in-chief of the Wikiversity Journal of Medicine.</em></p><img src="https://counter.theconversation.com/content/59708/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gwinyai Masukume is the assistant to the editor-in-chief of the Wikiversity Journal of Medicine and is a Wikipedian.</span></em></p><p class="fine-print"><em><span>James Heilman is affiliated with the Wikiversity Journal of Medicine, Wikipedia, Wiki Project Med Foundation, and the Wikimedia Foundation.</span></em></p>The academic medical community largely views Wikipedia with suspicion. But some traditional journals are starting to take the site more seriously – and some journals work very closely with it.Gwinyai Masukume, Medical Doctor, Epidemiologist and Biostatistician: University College Cork, University of the WitwatersrandJames Heilman, Clinical Associate Professor, Department of Emergency Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/561602016-03-17T04:02:22Z2016-03-17T04:02:22ZPhysiotherapy students have much to learn from the humanities<figure><img src="https://images.theconversation.com/files/114836/original/image-20160311-11288-1ffcvk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A little girl in Sudan gets treated by physiotherapist Fatima Mohamed.</span> <span class="attribution"><span class="source">Reuters/UNAMID/Albert Gonzalez Farran/Handout </span></span></figcaption></figure><p>Undergraduate physiotherapy students spend most of their time learning about the basic and clinical sciences. This has a certain pragmatic appeal, but a person is more than an assemblage of body parts. Our students learn anatomy and biomechanics – the idea of bodies as machines – and then explore what can be done to those bodies in order to “fix” them. Universities pay lip service to the idea that patients require holistic management. But not much in the curriculum signals to students that it <em>really</em> matters.</p>
<p>Research has confirmed what seems intuitively true to many: <a href="http://www.ncbi.nlm.nih.gov/pubmed/15203476">empathy</a> is critical in developing medical students’ professionalism. The humanities, and particularly literature, are considered effective tools for increasing students’ empathy. There is also <a href="http://www.forbes.com/sites/robertglatter/2013/10/20/can-studying-art-help-medical-students-become-better-doctors/#2f0232f51b3f">some evidence</a> that health professionals who are trained in the humanities and liberal arts are better at caring for themselves and their patients.</p>
<p>In addition, a relationship between emotion and learning has been <a href="http://www.ibe.unesco.org/fileadmin/user_upload/Publications/Educational_Practices/EdPractices_24eng.pdf">well established</a>, with findings from multiple domains supporting the idea that emotion is intimately <a href="http://onlinelibrary.wiley.com/doi/10.1111/mbe.12099/pdf">intertwined</a> with cognition, serving to guide learning, behaviour and decision making. This suggests that introducing concepts from the humanities when educating health professionals can do two important things: develop students’ emotional responses and their empathy; and simultaneously improve their overall learning.</p>
<h2>Examples from other disciplines</h2>
<p>The <a href="http://www.hopkinsmedicine.org/medart/">medical</a> disciplines have started <a href="http://my.clevelandclinic.org/services/arts_medicine">to embrace</a> the role that the humanities and the arts can play in developing empathy in their graduates. In the US, Johns Hopkins Medical School has a <a href="http://www.hopkinsmedicine.org/medart/">department</a> of art as applied to medicine and Stanford School of Medicine has a <a href="http://bioethics.stanford.edu/arts/">programme</a> for medical humanities and the arts. These are two of the world’s <a href="http://www.topuniversities.com/university-rankings-articles/university-subject-rankings/top-medical-schools-2015">top</a> medical schools. Elsewhere in the world, South Africa’s University of Cape Town’s medical school chose the theme <a href="https://www.uct.ac.za/dailynews/?id=8957">“Medicine and the Arts”</a> for its first ever Massive Open Online Course.</p>
<p>In an editorial explaining Stanford’s stance, the medical school’s dean, Lloyd B Minor, <a href="http://www.stanforddaily.com/2014/04/06/the-humanities-and-medicine/">wrote</a>:</p>
<blockquote>
<p>The specificity of scientific interventions does not account for the messiness of human life … We as physicians heal best when we listen to and communicate with our patients and seek to understand the challenges they face in their lives. The perspectives on illness, emotions and the human condition we gain from literature, religion and philosophy provide us with important contexts for fulfilling these roles and responsibilities.</p>
</blockquote>
<h2>Physiotherapy lags behind</h2>
<p>There is little evidence that physiotherapy and other health professions are following these medical schools’ innovative approaches in undergraduate education. Some physiotherapy researchers have explored how concepts from the humanities could be <a href="http://www.sciencedirect.com/science/article/pii/S0031940605658658">integrated</a> into clinical practice. But this has tended to focus on the impact on professional practice among qualified therapists, rather than on students and their learning. </p>
<p>The reasons for this are unclear, though several factors may be at play. Physiotherapy is conservative by its nature and tends to privilege <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2009.03418.x/full">positivist methods</a> in general. It favours quantitative measurements of progress as the standard against which impact is measured. Our students are taught how to address physical impairments in a patient’s anatomy and biomechanics, using joint range of motion, strength and fitness as indicators. This is important but also tends to sideline approaches that are more interpretive in nature. For example, it’s good to know how to treat back pain from a purely physiological point of view – but it’s also important to know how to respond to a patient who believes his or her pain is <a href="http://www.bodyinmind.org/wp-content/uploads/Madden-et-al-2013-JCHS.pdf">the result of witchcraft</a>. </p>
<p>These differences in perspective may be what limits the potential for the humanities to have much impact on curriculum change from the point of view of the clinical therapist. My own teaching experience, though, suggests that physiotherapy students benefit hugely from practices and ideas that are influenced by the humanities. </p>
<h2>Putting theory to the test</h2>
<p>About three years ago, as an experiment, I started applying some of these ideas in the professional ethics module I teach at a South African <a href="https://www.uwc.ac.za/Faculties/CHS/physiotherapy/Pages/default.aspx">university</a>. Initially the module’s emphasis was on human rights, but I started foregrounding empathy and the development of empathy instead.</p>
<p>Over the past few years my students have explored the humanities – art, literature, theatre, music and dance – in their assignments for this module. This has helped them to develop a sense of awareness of empathy in the context of clinical education. </p>
<p>Students can interpret the assignment in any way they want as long as they integrate concepts from the ethics module with their own experiences in clinical practice. They must also express their work through “creative” means: they write <a href="http://www.mrowe.co.za/blog/2014/08/eleven-hundred-hours-poem-by-a-student/">poems</a>, draw pictures or cartoons, film video diaries or re-interpret popular songs. Two of my students have even filmed themselves using interpretive dance to try and embody what it might be like to live with a disability. Others have completed <a href="https://photovoice.org/">PhotoVoice</a> assignments (such as the image below). Here, they photograph people in community or clinical contexts, and then reflect on how those experiences and interactions informed their personal and professional development as ethical practitioners.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114834/original/image-20160311-11302-1y2xej7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An example of a photograph taken by a fourth-year student in the author’s professional ethics module.</span>
<span class="attribution"><span class="source">Sarah Manig</span></span>
</figcaption>
</figure>
<h2>Students’ response</h2>
<p>Many students were initially worried about the assignments, telling me they were “not creative” and would prefer to write an essay. I suspect that they were simply feeding off my own hesitation in the early days. Now that I provide literature to support the assignment design, give examples from previous students and am fully committed to the process, far fewer students express these concerns. </p>
<p>They are also starting to open up in much more interesting ways. They draw from their own very deep emotions and personal experiences, and are more willing to share and discuss their work in class.</p>
<h2>Building empathy</h2>
<p>Creativity does not naturally decrease over time. Instead, higher education systems place less and less emphasis on creative expression as students move through the system. If universities want to graduate physiotherapists who have an increased awareness of patient suffering, and an associated empathic response, maybe the key is to provide them with learning tasks that encourage their creative expression through humanities and the arts.</p>
<p><em>This article was adapted from a post that first appeared on the author’s <a href="http://www.mrowe.co.za/blog/">own blog</a>.</em></p><img src="https://counter.theconversation.com/content/56160/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Rowe receives funding from the National Research Foundation. </span></em></p>Many medical disciplines have started encouraging their students to embrace lessons from the arts and humanities. Physiotherapy is lagging behind.Michael Rowe, Senior Lecturer in Physiotherapy, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/411362015-05-14T04:36:48Z2015-05-14T04:36:48ZSouth Africa needs a new way to address the doctor shortage<figure><img src="https://images.theconversation.com/files/81554/original/image-20150513-2497-17pxqx7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is a skewed distribution of skilled staff and an imbalance of skills. </span> <span class="attribution"><span class="source">Andreea Campeanu/Reuters</span></span></figcaption></figure><p>Millions of South Africans are missing out on basic health care because of a skewed system that fails to make use of all the country’s skilled health professionals.</p>
<p>It is public knowledge that there are not enough doctors in the South African <a href="http://www.iol.co.za/dailynews/sa-needs-14-351-doctors-44-780-nurses-1.1456417#.VVMhVvmqqko">public health system</a>. For every 1000 people, the country has less than <a href="http://gamapserver.who.int/gho/interactive_charts/health_workforce/PhysiciansDensity_Total/atlas.html">one doctor</a> available. Brazil, with a similar gross national product per capital to South Africa, has <a href="http://gamapserver.who.int/gho/interactive_charts/health_workforce/PhysiciansDensity_Total/atlas.html">nearly two physicians</a> for every 1000 people. </p>
<p>What is less well known is that if South Africa’s complete health workforce is tallied, there is not a critical shortage of human resources. The combined national average is<a href="http://www.hst.org.za/sites/default/files/Chapter17_Indicators.pdf"> 2.9 doctors, nurses and midwives</a> for every 1000 people. This is similar to Thailand, which has a comparable economic environment and counts <a href="http://ac.els-cdn.com/S0140673610620351/1-s2.0-S0140673610620351-main.pdf?_tid=1ae4c7a0-f97c-11e4-a5e9-00000aacb35d&acdnat=1431527395_8cdf39618458d792383e4b6cb7deb151">2.7 doctors and nurses</a> for same number of people. Both figures are well above the World Health Organisation’s suggested<a href="http://www.who.int/whr/2006/06_chap1_en.pdf"> 2.28 doctors and nurses</a> for every 1000 people as the critical shortage threshold. </p>
<h2>So what’s the problem?</h2>
<p>The challenge with the health workforce in South Africa is two fold: the skewed distribution of skilled staff and an imbalance of skills. Doctors are mostly in private practice located in urban areas and the skills imbalance means that there is limited use of the mid-level health workforce. </p>
<p>Distribution needs urgent intervention. Even if the number of health care workers increases, the urban-rural imbalance may be worsened, particularly with doctors. </p>
<p>There is also a need to shift some tasks from doctors to nurses. This can be done without having a detrimental effect on quality. For every doctor in South Africa, there are just under five nurses, which is higher that the global average of 2.1 nurses for each doctor. This suggests a potential for some efficiency gains in health workforce. </p>
<p>If less reliance is placed on doctors for health care delivery and nurses are given the responsibilities, there would be less shortages in under-serviced areas.</p>
<h2>Why so few doctors</h2>
<p>One of the most common reasons for the shortage of doctors is the fact that not enough are produced annually by the country’s medical schools.
South Africa’s eight medical schools each produce about <a href="http://www.samj.org.za/index.php/samj/article/view/7323/5357">200 doctors a year</a> - but its not enough to serve a population of just over 50 million people. </p>
<p>Cuba, in comparison, with a population of about 11 million people, has <a href="http://www.samj.org.za/index.php/samj/article/view/7323/5357">22 medical schools</a>. </p>
<p>The stumbling block is in the production line. The country’s institutions are unable to produce more doctors. </p>
<p>The government has established a ninth medical school in Limpopo province, which should have its first intake in 2016. It has also continuously encouraged medical schools to increase their intakes. But a significant increase in the intake of medical students would require clearing a number of hurdles. </p>
<p>Medical schools are accredited by the Health Professions Council of South Africa to train only the number of students that their existing infrastructure can accommodate. Any increase in student intake needs the council’s approval.
The council will give the nod only if faculty can guarantee quality training. This would involve expanding facilities such as staff, lecture room seats and hospital facilities. </p>
<p>Approval would also require public hospitals to increase the number of posts for two-year intern training so that there are enough senior staff to supervise. </p>
<p>Universities are caught in a double bind. Expanding teaching facilities requires a significant cash injection. But between 60% - 80% of their funding comes in the form of a major block grant based on the number of full time students they take in two years earlier. This means that even if they increased their student now, the increase in subsidies would only be realised in 2017.</p>
<p>Institutions also need to rethink their admission policies which are skewed towards students from better-off urban areas. Refining the admission criteria to attract more students from rural and under-serviced areas would go some way to lessening this imbalance as doctors in rural areas would be more likely to return home after graduation. The latest <a href="http://www.hpcsa.co.za/uploads/editor/UserFiles/downloads/medical_dental/MDB%20Core%20Competencies%20-%20ENGLISH%20-%20FINAL%202014.pdf">medical training curriculum</a> adopted by the council emphasises this social accountability back home. </p>
<p>Medical school tuition would also have to become cheaper to enable rural students to afford the cost of a medical degree. This remains a challenge despite the government’s intervention through the <a href="http://witsvuvuzela.com/2015/01/22/witsies-face-uncertain-future-without-nsfas/">National Student Financial Aid Scheme</a> (NSFAS).</p>
<h2>Changing the way the system works</h2>
<p>It has been suggested that the shortage of doctors poses a challenge to the South African government’s ambitious plan to create <a href="http://www.sarrahsouthafrica.org/SUPPORTFORHIVANDHEALTH/EQUALACCESSTOHIVANDHEALTHSERVICES/NATIONALHEALTHINSURANCE.aspx">universal access to health care</a> which is to be rolled-out over the next 10 years.</p>
<p>This does not need to be the case. More doctors are needed and sending 1000 students to <a href="http://www.samj.org.za/index.php/samj/article/view/7323/5357">Cuba for medical training </a> every year is helping to fill the gap.</p>
<p>But this needs to be accompanied by a re-engineering of the primary health care system to focus on preventive care. Ward-based teams could be deployed to communities, assigned to a number of households. The teams would be made up of a several community health workers and led by a nurse coordinating the regular visits. This would ensure the maintenance of health, and care would be provided before it requires a doctor’s intervention. </p>
<p>Improving the availability of the health workforce and not just doctors would go a long way, particularly in rural areas. This would require training more mid-level clinicians such as the clinical associates and the providing a policy that reduces the over reliance on doctors and shifting some of the clinical functions and responsibilities to lower cadre of clinical staff.</p><img src="https://counter.theconversation.com/content/41136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prof Lekan Ayo-Yusuf receives funding from the National Research Foundation, Cancer Association of South Africa, USAID and American Cancer Society. He is also a visiting scientist at the Harvard School of Public Health and an extraordinary professor in the School of Health Systems and Public Health at the University of Pretoria.</span></em></p>If South Africa’s complete health workforce is tallied, there is not a critical shortage of human resources to provide health care services.Lekan Ayo-Yusuf, Executive Dean (Interim), Sefako Makgatho Health Sciences UniversityLicensed as Creative Commons – attribution, no derivatives.