tag:theconversation.com,2011:/us/topics/medical-training-2966/articlesMedical training – The Conversation2024-01-08T13:34:33Ztag:theconversation.com,2011:article/2189912024-01-08T13:34:33Z2024-01-08T13:34:33ZEmergency medicine residencies more likely to go unfilled at for-profit and newly accredited programs<p>The number of unfilled positions in emergency medicine residency programs surged in 2022 and 2023, with the trend most pronounced at programs that were recently accredited or under for-profit ownership. That’s the key finding of <a href="https://doi.org/10.1002/aet2.10902">my team’s recent study</a> of the past two match cycles.</p>
<p>A match cycle is when medical students choose a specialty and learn where they will train. It starts when fourth-year medical students interview at residency programs at hospitals around the country. Then, the students rank their preferred training programs, and the programs rank the students. An <a href="https://www.nrmp.org/intro-to-the-match/#:%7E:text=NRMP%20uses%20a%20mathematical%20algorithm,possible%20match%20for%20all%20participants.">algorithm makes matches</a>.</p>
<p>The proportion of medical students applying for emergency medicine residencies dropped by <a href="https://www.acep.org/news/acep-newsroom-articles/joint-statement-match-2023">16.8% from 2021 to 2022</a> and declined another 18.1% from 2022 to 2023. This abrupt decline may degrade the three-to-four-year clinical training experience of emergency medicine residents and affect how the health care system provides emergency care in the future.</p>
<p>But this waning in demand is only half of the story. Deepening the problem is the fact that the number of emergency medicine residency programs has grown at the same time. </p>
<h2>No checks on the for-profit sector</h2>
<p>Over the past five to eight years, <a href="https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors">more for-profit and private capital-backed firms</a> have bought emergency medicine facilities, taken over staffing contracts in existing hospitals and <a href="https://doi.org/10.1001/jamanetworkopen.2023.12457">created emergency residency programs</a>.</p>
<p>Since they are for-profit entities, these companies have a responsibility to return money to investors. They have been shown to achieve this by <a href="https://doi.org/10.1002/aet2.10786">paying residents less</a> and charging <a href="https://www.bmj.com/content/382/bmj-2023-075244">higher prices</a> on services like imaging and hospitalization.</p>
<p>Currently, there are no limits on the number of residency programs or positions in emergency medicine. The Review Committee for Emergency Medicine <a href="https://www.acgme.org/specialties/emergency-medicine/overview/">automatically approves all proposals for new residency programs</a> that meet requirements. Despite the fact that positions are already going unfilled, <a href="https://apps.acgme.org/ads/Public/Reports/Report/1">eight new emergency medicine residency programs were accredited</a> during the 2022-23 academic year. This accreditation system is currently under review, but any changes will take years to go into effect.</p>
<h2>More positions, lower demand</h2>
<p>I am a physician <a href="https://scholar.google.com/citations?user=KVEHBakAAAAJ&hl=en&oi=ao">who studies the state of emergency care</a>. In our recent paper, my team and I calculated the number of emergency medicine residency programs that filled all positions in the past two match cycles. </p>
<p>Our <a href="https://doi.org/10.1002/aet2.10902">study shows that</a> in 2022, 277 emergency medicine residency programs offered 2,921 positions and had 219 unfilled positions. In 2023, 287 emergency medicine programs offered 3,010 positions and 554 went unfilled. In each of these years, about 30 programs had primary clinical training sites under for-profit ownership. </p>
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<p>The drop in interest in emergency medicine may be driven by well-circulated <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">forecasts predicting a surplus</a> in the emergency physician workforce by 2030 and <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">escalating levels of burnout</a> among emergency physicians. </p>
<p>By examining where residents chose to go when there were more than enough programs to choose from, we learned three things. </p>
<p>First, more established programs did better. Emergency medicine residency programs accredited within the past five years had more than double the likelihood of not filling all positions compared with those accredited for more than five years.</p>
<p>Second, in 2023, more opportunities were offered in several metropolitan areas, including Detroit, Miami and Philadelphia, but these programs ended up with many unfilled positions.</p>
<p>Third, emergency medicine residency programs with for-profit clinical sites were less likely to fill all residency positions. These programs had a 50% greater chance of not filling all positions when compared with nonprofit or government-run sites. </p>
<h2>Possible solutions</h2>
<p>It’s not clear whether these trends will continue. In 1996, <a href="https://www.nrmp.org/match-data-analytics/archives/">the anesthesiology specialty</a> saw the proportion of filled residency positions drop to 45%, an all-time low. Yet the specialty rebounded to fill nearly 100% of available positions by 2002.</p>
<p>While it is possible the past two years for emergency medicine are part of the natural ebb and flow of specialty interest among medical students, our findings, the historical literature and the recent <a href="https://www.wsj.com/articles/kkr-backed-envision-healthcare-plans-chapter-11-bankruptcy-filing-2fff4382">bankruptcy filing of Envision</a> – a large, for-profit emergency medicine group that staffs <a href="https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine">several clinical sites and residency programs</a> – all suggest medical students may be recognizing the disadvantages of for-profit emergency medicine residency programs. </p>
<p>There is little data on the quality of these programs. No research yet has evaluated board exam pass rates of emergency medicine residents graduating from newly accredited or for-profit clinic sites. However, <a href="https://doi.org/10.4300/JGME-D-21-01097.1">residents in pediatric programs</a> with a corporate affiliation had lower board exam pass rates.</p>
<p>In addition to reconsidering the persistent opening of new programs, now may be the time for organizations like the <a href="https://www.emra.org/">Emergency Medicine Residents’ Association</a> and the <a href="https://www.acep.org/">American College of Emergency Physicians</a> to address issues that affect recruitment of emergency medicine residents. </p>
<p>Physician burnout could be addressed by reviewing hospital policies designed to maximize profits. For example, many patients are admitted to the hospital, yet <a href="https://www.acep.org/patient-care/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department">“board”</a> in the hallway of an emergency department for hours. These patients have routinely been shown to have <a href="http://doi.org/10.1001/jamainternmed.2023.5961">worse outcomes</a>, yet hospital leadership frequently attempts to <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217">prioritize revenue-generating</a> surgeries and procedures in lieu of assigning beds for admitted patients from the emergency department.</p>
<p>Loan forgiveness and increased salaries could draw more residents to emergency medicine, especially in rural areas where distinct physician shortages exist. And more female residents would be drawn into emergency medicine if disparities in pay and concerns over violence in emergency rooms were systematically resolved.</p><img src="https://counter.theconversation.com/content/218991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cameron Gettel receives funding from the National Institute on Aging (NIA) of the National Institutes of Health and the American Board of Emergency Medicine / National Academy of Medicine Fellowship. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript.</span></em></p>A new study finds more emergency medicine residencies are available, but hundreds of the positions are going unfilled.Cameron Gettel, Assistant Professor of Emergency Medicine, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2144242023-10-05T16:36:02Z2023-10-05T16:36:02ZPhysician associates: a solution for healthcare staff shortages or a colonial throwback?<figure><img src="https://images.theconversation.com/files/552150/original/file-20231004-27-tr5u8y.jpg?ixlib=rb-1.1.0&rect=25%2C0%2C5628%2C3771&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/multiethnic-group-people-wearing-lab-coats-1926462233">SeventyFour/Shutterstock</a></span></figcaption></figure><p>Before the COVID pandemic, the global health workforce needed as many as <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00532-3/fulltext">6.4 million more medical doctors</a>, and the gap between demand for health workers and supply is growing. As you might expect, the shortage is most acutely felt in low- and middle-income countries. </p>
<p>The latest <a href="https://www.who.int/data/gho/data/themes/topics/health-workforce">World Health Organization (WHO) statistics</a> show that 30 countries have fewer than two doctors for every 10,000 people. Twenty-seven of these are in Africa, while the remaining three are Pacific Island nations.</p>
<p>Wealthier countries are notorious for plugging gaps in their health workforce by recruiting overseas doctors and nurses. “Medical brain drain” is a complex phenomenon, driven by <a href="https://books.google.co.uk/books/about/A_Heart_for_the_Work.html?id=czX-cS9aDgQC&redir_esc=y">more than money</a>. Yet some commentators consider it yet another instance of the west “looting” human capital from Africa and other formerly colonised regions.</p>
<p>In England, the <a href="https://www.nhsemployers.org/publications/nhs-long-term-workforce-plan-2023-what-employers-need-know">government</a> has chosen to address the health worker shortage by investing in new roles. One role that will be significantly expanded is that of “physician associate”. These medics work in GP surgeries and in hospitals.</p>
<h2>Not quite doctors</h2>
<p>A physician associate is someone trained to a standard below that of a doctor. Though a recent title and qualification <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044953/">in the UK</a>, the concept of a physician associate is not new. There is plenty of historical data about the use of medical assistants or auxiliaries to run health services on the cheap. </p>
<p>Much of the historical evidence about the benefits and pitfalls of “not quite” doctors comes from world regions most affected by health worker shortages today. </p>
<p>When European colonial powers decided to offer health services to colonised populations, especially in rural areas, they could not recruit nearly enough European doctors. Instead of improving employment conditions or expanding education for local people, colonial states opted to create subprofessional medical schools and qualifications. </p>
<p>They were known as “African” doctors in <a href="https://doi.org/10.2307/j.ctv2s0jd98.12">Senegal</a>. Assistant medical officers in Sudan. So-called “native” medical auxiliaries in <a href="https://eprints.gla.ac.uk/147771/">Algeria</a>, <a href="https://doi.org/10.2307/j.ctv2s0jd98.12">Cameroon</a>, Congo, Madagascar, <a href="https://www.jstor.org/stable/43305135">Tanzania</a>, Uganda and <a href="https://doi.org/10.1080/17531050701218841">Zambia</a>. The list goes on. </p>
<p>Colonial states typically restricted recruitment into subordinate medical roles to racialised men. Training varied, but usually offered an abridged university curriculum oriented towards infectious diseases (especially diseases stigmatised as “native” or “tropical”, like <a href="https://eprints.gla.ac.uk/147736/">syphilis</a>), manual tasks and administrative skills.</p>
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Read more:
<a href="https://theconversation.com/could-super-nurses-make-up-for-the-shortfall-in-doctors-74933">Could super nurses make up for the shortfall in doctors?</a>
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<p>Locally trained medical assistants often became linchpins of colonial health services, but they were not always accepted by patients or other medical professionals. In the 1950s, <a href="https://iris.who.int/handle/10665/38944?&locale-attribute=zh">the WHO recognised their usefulness</a> for expanding the health workforce. Yet most subprofessional medical schools closed with decolonisation. </p>
<p>Newly independent states aspired to physician-led health services. Medical assistant roles were seen as “<a href="https://doi.org/10.1016/S0140-6736(73)90986-0">a colonial invention</a>” designed to restrict opportunities for non-Europeans. Some of the professionals steering postcolonial health services had once been auxiliaries themselves and understood the challenges experienced by this category of health worker.</p>
<h2>Deep concern</h2>
<p>We are a historian and a medical consultant with an interest in postgraduate education. We work with very different kinds of data, but share a deep concern with how healthcare works. </p>
<p>Across our different contexts, past and present, we find similar unsettled questions. These have nothing to do with the calibre or dedication of individual physician associates. They have everything to do with fairness.</p>
<p>Histories of colonial medicine suggest that when you create two-tier systems for accessing careers in medicine, the “lesser” track will map onto existing inequalities in the surrounding society. In the UK today, this may mean people from economically disadvantaged backgrounds and school leavers affected by the regional awarding gap are more likely to train as physician associates.</p>
<figure class="align-center ">
<img alt="A black female medical professional" src="https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552336/original/file-20231005-27-r8wzzx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&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 physician associate role could embed existing inequalities in healthcare systems.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/african-american-nurse-holding-digital-tablet-2056112471">DC Studio/Shutterstock</a></span>
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<p>Are physician associates an extra pair of hands assisting the doctor, or are they a substitute for the doctor? Historically and today, the line between associate and doctor has been difficult for managers and professionals to define, let alone for patients to understand. </p>
<p>In Algeria under French colonial occupation, patients were often unaware that the medical auxiliary treating them was not a real medical doctor. Although French officials touted medical auxiliaries as a means of reducing healthcare inequalities, the result was <a href="https://doi.org/10.1080/13507486.2021.1990867">a two-tier healthcare system</a>, with restricted services in rural and neglected areas. </p>
<p>Colonial-era medical auxiliaries in Algeria and elsewhere confronted a limited career ladder and inferior employment conditions. Their qualifications were not recognised internationally. They were locked into subordinate roles and faced workplace harassment.</p>
<p>Medical training and roles in colonial states are different from that being proposed in the UK today, but inequalities have not gone away. </p>
<p>How will physician associates’ status, responsibilities, and remuneration relate to other health workers such as nurses and junior doctors? How will they cope with negativity or confusion surrounding their position? Does career progression include filling all the roles of a doctor? </p>
<p>To mitigate the issues associated with changes to the health workforce, we must first acknowledge them. In the UK, at least, there is little sign that this is happening.</p>
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Read more:
<a href="https://theconversation.com/gp-crisis-how-did-things-go-so-wrong-and-what-needs-to-change-208197">GP crisis: how did things go so wrong, and what needs to change?</a>
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<p>When US government officials and medical faculties considered a new auxiliary role from the 1960s, they <a href="https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.57.9.1663">learned</a> from models in formerly colonised states. Today, physician assistants in the US are a significant and more established part of the workforce, but interprofessional conflicts and difficulties occur. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121704/">It has not been shown</a> that the US model would meet the needs of the UK.</p>
<p>Without an open, transparent, evidence-led approach to new professional roles, we risk damaging the trust of patients and frontline health workers. As policymakers in the UK and other nations affirm their commitment to investing in the health workforce, they should look to colonial experiences as a bellwether.</p><img src="https://counter.theconversation.com/content/214424/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>‘The doctor will see you now.’ Except they probably won’t.Hannah-Louise Clark, Senior Lecturer, Global Economic and Social History, University of GlasgowMark Toshner, Associate Professor, Respiratory Medicine, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130572023-10-01T15:12:23Z2023-10-01T15:12:23ZFamily doctor shortage: Medical education reform can help address critical gaps, starting with a specialized program<figure><img src="https://images.theconversation.com/files/551040/original/file-20230928-25-8o9ec7.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5689%2C3386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A program offers training and education specifically on family medicine from the start of medical school, while bypassing administrative hurdles to residency.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/family-doctor-shortage-medical-education-reform-can-help-address-critical-gaps-starting-with-a-specialized-program" width="100%" height="400"></iframe>
<p>Recent reports indicate that <a href="https://doi.org/10.25318/1310048401-eng">over six million Canadians are without a family doctor</a>. This not only has a massive impact for those individuals, <a href="https://doi.org/10.1136%2Ffmch-2023-002236">but also for the entire health-care system</a>. Given current caseloads, about 4,000 family doctors would be required to address the current shortfall.</p>
<p>Education reform is part of the solution to this crisis. A new family medicine program in Ontario is designed to ensure that candidates who are the most qualified and motivated to pursue a community-based family practice get appropriate and comprehensive training. </p>
<p>The <a href="https://meds.queensu.ca/academics/queens-lakeridge-health-md-family-medicine-program">Queen’s-Lakeridge Health MD Family Medicine Program</a> focuses training and education on family medicine from the start of medical school, then advancing directly to residency. We were both involved in the conception and development of the program, Anthony Sanfilippo as senior advisor for educational expansion and innovation, and Jane Philpott as dean.</p>
<h2>Current medical education</h2>
<p>Under the existing system, medical schools across <a href="https://doi.org/10.12927%2Fhcpol.2021.26429">Canada welcomed about 3,100 young people</a> in September. They are eager, academically accomplished and committed. They have succeeded (some would say survived) a gruelling and competitive process that left the other 80 per cent of their similarly accomplished and committed co-applicants disappointed.</p>
<p>Given the <a href="https://doi.org/10.1503/cmaj.109-5704">minuscule attrition rate</a> after medical school admission and availability of postgraduate training positions, they are essentially assured of a career in medicine. That career, in today’s expanded world of specialization and sub-specialization, could be in any of well over 100 distinct areas of medical practice. Some of those fields are in desperate need of new recruits, particularly family medicine. </p>
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<img alt="A group of people in white coats listening to a colleague" src="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551041/original/file-20230928-19-4jgzhn.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">
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<span class="caption">The program is designed deliberately to prepare them for a career in community-based family medicine, and will include early clinical learning in family practice settings.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Despite these pressing needs, students enter medical school with no commitment to any particular area of practice. Given <a href="https://www.carms.ca/pdfs/carms-forum-2023.pdf">current patterns of career selection</a>, it may be as few as 700 medical graduates per year who will be taking up the <a href="https://www.cfpc.ca/CFPC/media/Resources/Research/FM-Longitudinal-Survey-T1-entry-2021-Aggregate-Report.pdf">comprehensive, continuing family practices</a> that would address the needs of those patients.</p>
<p>In fact, much of their next three or (usually) four years in medical school will involve exploring various career options and engaging in yet <a href="https://doi.org/10.1503%2Fcmaj.170791">another highly competitive and arduous process</a> at the end of medical school to obtain a postgraduate training position. </p>
<p>In order to accomplish all this, their curricula will provide, in addition to scientific and professional skills common to all physicians, a broad sampling of specialties. This sampling will include learning, performance and clinical engagement in many areas of practice that they will never actually undertake or, if they do, will need to relearn and refine in their postgraduate training program.</p>
<p>What’s clear is that, without significant reform, modest expansion and even opening new schools will not come close to addressing our needs within the current training paradigm. </p>
<h2>A program specific to family medicine</h2>
<p>This year, for the first time, things will be different for the 20 students entering the new Queen’s-Lakeridge Health MD Family Medicine Program. Their admission was based not only on exemplary academic and personal credentials, but also on their commitment to a career in family medicine.</p>
<p>The program they are about to undertake is designed deliberately to prepare them for those careers, will include early clinical learning in family practice settings and will be taught predominantly by family physicians who are in active clinical practice providing the comprehensive, continuing, community-based care so desperately needed in our country.</p>
<figure class="align-center ">
<img alt="A doctor in an examining room with a woman and child" src="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551038/original/file-20230928-29-z7n11g.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">
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<span class="caption">The program will be taught predominantly by physicians who are in active clinical practice as family physicians providing comprehensive, continuing, community-based care.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>It began as a partnership between <a href="https://meds.queensu.ca/">Queen’s University School of Medicine</a> and <a href="https://www.lakeridgehealth.on.ca/">Lakeridge Health</a>, an integrated organization of five hospitals and over 20 community health locations providing care to the residents of Durham region. It was based on a shared recognition that medical schools have a role in addressing the critical shortage of family physicians impacting so many Canadians, and that this shortage can, in part, be addressed by providing specialized admission opportunities and more purpose-driven education to motivated applicants. </p>
<p>It also seeks to develop models of medical education that address the real needs of contemporary society, evolving in response to the expansion and diversification of medical practice. Medical problems that were previously treated exclusively in hospital or required only palliative management are now very effectively managed chronically with medication and regular followup in the community.</p>
<p>Durham Region provides an ideal location for this program given its increasing and highly diversified population. It’s also home to multiple, well developed medical practice settings (including acute care hospitals, chronic care and mental health facilities, ambulatory clinics, and both group and individual practices) as well as committed medical and administrative communities who have longstanding associations with Queen’s. </p>
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<img alt="A group of health professionals, some wearing scrubs and white coats" src="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/551037/original/file-20230928-27-x3a3l6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&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">Family doctors often practise in primary care teams along with multidisciplinary health-care workers such as nurse practitioners, dietitians and social workers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Queen’s School of Medicine and Lakeridge Health jointly proposed, and were supported by the Ontario Ministry of Health, in the development of this continuous six-year program that would prepare students to become qualified family physicians focused on providing comprehensive, continuing, community-based care.</p>
<h2>Themes specific to family medicine</h2>
<p>A joint Queen’s-Lakeridge Health Working Group was established to explore and implement the program based on four key themes:</p>
<p><strong>Admissions</strong> – After identifying attributes appropriate to a successful career in family practice, a novel admission process was developed that assesses academic aptitude for medicine as well as personal qualities and commitment that will promote both practice satisfaction and retention within communities.</p>
<p><strong>Curriculum</strong> – A novel curriculum was developed focused on fundamental and clinical training relevant to family medicine, with early and continuing placements in community practice settings. The curriculum incorporates key components of the undergraduate MD program and postgraduate family medicine program into an integrated program without the necessity for a secondary application process. The concept is that students will learn how to provide care to patients of all ages, in the types of settings in which they will eventually practise.</p>
<p><strong>Faculty Engagement</strong> – The faculty team blends Queen’s instructors based in Kingston with newly recruited faculty members in the Durham Region medical community. New faculty are welcomed into the Queen’s teaching community with an orientation and instruction process. Students will be learning from doctors who are actively involved in the type of practice in which they are training.</p>
<p><strong>Community Engagement</strong> – The new program is located in Durham Region. Together with Lakeridge Health administration and medical staff, facilities for teaching, housing and community placements have been established. In addition, student support and counselling have been developed locally, with strong support and integration with Kingston-based services.</p>
<h2>Addressing a critical gap</h2>
<p>These students will be able to undertake studies and training that will prepare them for their intended career, in the sort of settings in which they will eventually practise, and with guidance and mentorship of practising faculty. Their learning will be focused on family medicine. They will not be required to undertake any secondary application process, and will have considerable flexibility to tailor their training to the requirements of their eventual practice destination. </p>
<p>The aim is for them to emerge from the program prepared to qualify and practise as family physicians. </p>
<p>Importantly, this approach, although designed at this point for family medicine, could serve as a model for other medical specialties to address current and future medical workforce requirements.</p><img src="https://counter.theconversation.com/content/213057/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>Education has a role to play in addressing the shortage of family doctors. A new program is designed specifically for comprehensive, community-based family practice.Anthony Sanfilippo, Professor of Medicine (Cardiology), Queen's University, OntarioJane Philpott, Dean, Queen's Health Sciences, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2104252023-09-13T18:40:20Z2023-09-13T18:40:20ZSolving Canada’s shortage of health professionals means training more of them, and patients have a key role in their education<figure><img src="https://images.theconversation.com/files/547848/original/file-20230912-7671-ly0s9f.jpg?ixlib=rb-1.1.0&rect=131%2C186%2C5013%2C3523&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A fundamental component for training health-care professionals is interacting with patients and families.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/solving-canadas-shortage-of-health-professionals-means-training-more-of-them-and-patients-have-a-key-role-in-their-education" width="100%" height="400"></iframe>
<p><a href="https://www.ctvnews.ca/health/canadians-worried-about-the-state-of-provincial-health-systems-poll-1.6248713">Eighty-six per cent of Canadians</a> are worried about their health-care systems. Health-care professional organizations like the <a href="https://www.cma.ca/about-us/what-we-do/press-room/health-care-groups-call-premiers-make-canadas-collapsing-health-system-their-top-priority#:%7E:text=%22Canada%27s%20health%20care%20system%20is%20in%20crisis.%20While,only%20added%20fuel%20to%20an%20already%20raging%20fire.">Canadian Medical Association</a> and the <a href="https://www.casn.ca/2022/11/casn-releases-nurses-education-in-canada-statistics-report-2020-2021/">Canadian Association of Schools of Nursing</a> are sounding the alarm about the severe shortage of health-care providers. This shortage is contributing to Canada’s health-care crisis. </p>
<p>Canada urgently needs more trained health-care professionals. While they may not know it, everyone in Canada can play a key role in educating future health-care providers. </p>
<p>Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</p>
<h2>Canada’s shortage of health-care workers</h2>
<p>The House of Commons Standing Committee on Health’s March 2023 report titled <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">Addressing Canada’s Health Workforce Crisis</a> explored and substantiated this shortage of health-care professionals. This report primarily focused on physicians and nurses. Canada anticipates a shortfall of <a href="https://www.canada.ca/en/employment-social-development/news/2023/06/canada-is-addressing-current-and-emerging-labour-demands-in-health-care.html">78,000 physicians</a> by 2031, and <a href="https://www.canadian-nurse.com/blogs/cn-content/2023/04/17/solutions-to-tackle-nursing-shortage#:%7E:text=A%202019%20analysis%20predicted%20a,care%20(OECD%2C%202022).">117,600 nurses</a> by 2030. </p>
<p>Other professions are also sounding the alarm of practitioner shortages, including <a href="https://www.ourcommons.ca/Content/Committee/441/HESA/Reports/RP12260300/hesarp10/hesarp10-e.pdf">dental professionals, medical laboratory specialists, occupational therapists</a> and <a href="https://www.longwoods.com/audio-video/longwoods-breakfast-series/Youtube/9588">pharmacists</a>. </p>
<p>In addition to these predictions, there are significant concerns about keeping the care providers we currently have. A 2022 report from the <a href="https://nursesunions.ca/wp-content/uploads/2022/11/CHWN-CFNU-Report_-Sustaining-Nursing-in-Canada2022_web.pdf">Canadian Federation of Nurses Unions</a> found that 94 per cent of nurse respondents showed signs of burnout, and over half wanted to leave their current job. Other health professions have raised similar concerns. </p>
<h2>Addressing the shortage</h2>
<p>There is no quick fix to these complex problems, and Canada is responding in a variety of ways. This includes recruiting <a href="https://www.canada.ca/en/employment-social-development/news/2022/12/government-of-canada-launches-call-for-proposals-to-help-internationally-educated-professionals-work-in-canadian-healthcare.html">internationally trained</a> practitioners, funding strategies to improve <a href="https://www.canada.ca/en/health-canada/news/2023/04/government-of-canada-announces-support-to-help-address-workforce-challenges-and-retention-in-nursing-field.html">retention</a> and increasing <a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">educational seats</a> to train more future health-care providers. </p>
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<img alt="A woman in scrubs shakes hands with a man using a wheelchair in front of two other people in scrubs" src="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547868/original/file-20230912-5779-i19k0y.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">
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<span class="caption">Each encounter that health-care students have with patients, families and communities helps them develop real-world understanding of the various needs of the diverse Canadian population.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>These responses are being created from <a href="https://www.canada.ca/en/health-canada/news/2022/11/health-canada-announces-coalition-for-action-for-health-workers.html">federal</a>, provincial (such as <a href="https://novascotia.ca/news/release/?id=20221114001">Nova Scotia</a>) and local levels. However, these strategies are not quick fixes and efforts may not be successful. </p>
<p><a href="https://www.cbc.ca/news/health/financial-perks-doctor-recruitment-1.6548194">Retention efforts</a> have not been as effective as anticipated, as financial incentives do not appear to have the same influence they might have had in the past. International recruitment is fraught with <a href="https://theconversation.com/the-ethics-of-recruiting-international-health-care-workers-canadas-gains-could-mean-another-countrys-pain-208542">ethical concerns</a> and complex processes applicants need to work through in order to become licensed to practice.</p>
<h2>Education investments</h2>
<p>Significant provincial investments are being announced to create more seats in education programs for health-care professional students. The <a href="https://edmontonjournal.com/news/politics/alberta-to-expand-seats-in-health-care-education-with-200-million-over-three-years">Alberta government</a> is investing $72 million for 3,400 new seats in a variety of health-related training programs and $20 million for the creation of 120 new physician seats. </p>
<p><a href="https://globalnews.ca/news/9448757/additional-seats-saskatchewan-health-care-training-programs/">Saskatchewan</a> is adding 550 health-care provider education seats. <a href="https://news.umanitoba.ca/manitoba-government-announces-80-physician-training-seats-to-be-added/">Manitoba</a> announced an investment of $200 million for 2,000 health-care professionals, including 80 new physician seats and four <a href="https://news.gov.mb.ca/news/index.html?item=56297">respiratory therapy</a> students. </p>
<p><a href="https://www.universityaffairs.ca/news/news-article/provincial-budget-round-up-2023-highlights-for-the-university-sector/">Other provinces</a> are also investing in a variety of ways such as educational program grants to expand enrolment in Ontario, and student financial support in Prince Edward Island.</p>
<p>While increased training opportunities can increase the future workforce, having more students also requires additional resources and learning opportunities. Education for health-care professionals varies by the type of provider, and can range from certificate programs to graduate degrees. </p>
<h2>How Canadians can help</h2>
<p>We are a team of interdisciplinary researchers who teach health-care professionals in their foundational training. We know that despite significant differences in health-care education programs, one fundamental component for all learners is interacting with patients and families. </p>
<p>That means all Canadians play an essential part in educating future health-care providers. With more students enrolling, Canadians will have even more engagement with students in health-care settings.</p>
<p>Most health-care education programs include public interaction. Some public members purposefully engage. For example, some become guest speakers in classes, and share personal experiences with illness and health care. But more commonly, people engage with health-care professional students while looking after their health needs. </p>
<p>Canadians can anticipate interacting with students in common health-care spaces such as pharmacies, physiotherapy clinics, dental clinics, public health clinics, doctor’s offices, hospitals or outpatient clinics. But students may also be found in less expected places such as food banks, non-profit community organizations, schools and community settings. </p>
<p>Members of the public may feel less inclined to interact with students. This can be due to the perceived increased time it takes, worries about students’ knowledge or abilities, or because they might feel that they <a href="https://doi.org/10.1016/j.ijnurstu.2018.04.010">don’t have anything to contribute</a>. However, it is important for Canadians to know about the benefits of these interactions for both students and patients.</p>
<h2>What Canadians can teach health-care professional students</h2>
<p>Research has identified that student encounters with public patients and family members contributed to the development of their <a href="https://doi.org/10.1007/s10459-022-10137-3">communication</a>, <a href="https://doi.org/10.1080/0142159X.2019.1652731">compassion and empathy skills</a>. It also helped decrease stigma towards traditionally stigmatized groups and conditions, such as those with <a href="https://doi.org/10.1111/1440-1630.12205">mental illness</a>. </p>
<p>Interacting with the Canadian public also increased students’ ability to <a href="https://doi.org/10.1111/j.1365-2850.2011.01858.x">use appropriate language</a> and <a href="https://doi.org/10.1111/j.1365-2850.2012.01955.x">work with patients</a>. It enhanced their <a href="http://dx.doi.org/10.1136/bmjopen-2020-037217">self-confidence</a> and their motivation in caring for the public.</p>
<h2>How does this impact Canadians?</h2>
<p>While these interactions benefit student learning and will help contribute to a larger health workforce, they have also been found to benefit the public. </p>
<p>Research has found that student encounters can increase a patient’s <a href="https://doi.org/10.1111/inm.12021">sense of empowerment</a> to participate in their own health with shared decision-making. Additionally, there is a potential for the improvement of overall <a href="https://doi.org/10.1007/s10459-022-10137-3">health outcomes</a> of patients. One study found patients were more knowledgeable and better able to <a href="https://doi.org/10.1016/j.japh.2021.08.014">manage their own medications</a> after engaging with student practitioners.</p>
<p>The shortage of health professionals in Canada, and globally, is of sincere concern. To address this, it is essential that we increase the number of professionals being trained. This requires the Canadian public’s assistance as they encounter more health-care professional students. </p>
<p>Investing your time in interacting with students has benefits for the students and for you. Canadians can all play a part in building the future health workforce we desperately need. As health-care professionals, we thank you for the important role you play in educating and shaping our students and future health workforce. </p>
<p><em>Bryn Keogh co-authored this article. She is an undergraduate student at the University of Calgary in communication and media studies and received an Alberta Innovates Summer Research Studentship.</em></p><img src="https://counter.theconversation.com/content/210425/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>Each encounter that health-care students have with patients and families helps them understand real-world patient needs. That means all Canadians have a role in educating future health-care providers.Lisa McKendrick Calder, Associate Professor, Nursing, MacEwan UniversityEleftheria Laios, Educational Developer, Queen's University, OntarioKerry Wilbur, Associate Professor and Executive Director, Entry-to-Practice Education, Faculty of Pharmaceutical Sciences, University of British ColumbiaLorelli Nowell, Associate Professor and Assistant Dean of Graduate Programs, Faculty of Nursing, University of CalgaryWhitney Lucas Molitor, Associate Professor and Program Director, Occupational Therapy Department, University of South DakotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2046682023-05-15T19:02:24Z2023-05-15T19:02:24ZNew Zealand’s reliance on foreign doctors to plug gaps highlights the need for another medical school<figure><img src="https://images.theconversation.com/files/526084/original/file-20230515-202058-50hj2p.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5599%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>The New Zealand health system is currently in the throes of its <a href="https://www.stuff.co.nz/national/explained/300626364/explained-the-reforms-that-will-turn-the-health-system-from-an-npc-to-a-super-rugby-of-healthcare">biggest reorganisation</a> in more than 20 years. The aim is to provide more efficiency and equity. </p>
<p>But while it is acknowledged New Zealand has under-invested in health infrastructure, more damaging has been the under-investment in people. </p>
<p>This lack of planning for the future health workforce is directly responsible for the staffing shortages now being experienced. These shortages are being patched up with short-term solutions such as attracting overseas-trained health workers with promises of quick pathways to citizenship. </p>
<p>So as well as structural reform of the health services, the vision for those services and subsequent workforce demands needs to be articulated. Ideally this would include a budget that invests in training more – and more diverse – New Zealand doctors. </p>
<h2>Relentless demand</h2>
<p>We know the demand for more doctors is relentless – fuelled by a growing and ageing population. At the same time, we have an ageing medical workforce, with many doctors planning to retire in the next decade. </p>
<p>There has been a 40% increase in the number of doctors registered with the Medical Council over the past decade, from 13,880 in 2012 to 19,623 in 2023 – a year-on-year increase of 3%. </p>
<p>To sustain this modest growth each year, we will need to increase the total medical workforce by 590 annually. We will also need an additional 300 doctors a year to replace those who are retiring or leaving to work in Australia and elsewhere. </p>
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Read more:
<a href="https://theconversation.com/critically-understaffed-and-with-omicron-looming-why-isnt-nz-employing-more-of-its-foreign-trained-doctors-175914">Critically understaffed and with Omicron looming, why isn't NZ employing more of its foreign-trained doctors?</a>
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<p>Yet we currently only have two medical schools training 550 doctors a year between them. So we continue to rely on importing doctors from other countries. </p>
<p>Out of the OECD, New Zealand has the <a href="https://asms.org.nz/wp-content/uploads/2022/05/IMG-Research-Brief_167359.5.pdf">highest dependency</a> on overseas-trained doctors, with 42% of the workforce being international medical graduates (IMGs). </p>
<p>The regions with the lowest percentages of IMGs are Auckland (31%), Capital & Coast (34%), and Canterbury (36%). But this can climb to 60% in many rural regions. Last year, 1,232 IMGs were registered to practice here, reflecting the high demand for doctors not being met through local training and retention. </p>
<p>Paradoxically, one of Health New Zealand’s goals is to increase the number of Māori and Pacific doctors, which is hard to do when we rely on importing twice as many doctors as we train. </p>
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<h2>Our missing GPs</h2>
<p>Doctor shortages are not evenly spread. There are particular problems in the less wealthy regions, and in particular specialities such as general practice. GPs are the backbone of the health system, with 90% of health consultations occurring in primary care. </p>
<p>Yet while we have increased the number of doctors by 5,000 over the past ten years, the number of GPs has only increased by 260. This means we have GP shortages, resulting in increasing demand on hospitals, increasing waiting times in the emergency departments, and a growing problem of late diagnosis and poorer health outcomes. </p>
<p>The Royal New Zealand College of General Practitioners has called for these shortages to be <a href="https://www.rnzcgp.org.nz/news/college/gp-future-workforce-requirements-report-highlights/">urgently addressed</a> by increasing the number of junior doctors training in general practice to 300 per year. This is hardly possible with only two existing medical schools – it would mean more than half their total output of graduates going into the GP training programme. </p>
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Read more:
<a href="https://theconversation.com/new-zealands-health-restructure-is-doomed-to-fall-short-unless-its-funding-model-is-tackled-first-179935">New Zealand's health restructure is doomed to fall short unless its funding model is tackled first</a>
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<p>Currently, just 25% of the 550 medical school graduates (130-140 doctors a year) choose to go into general practice. To achieve a goal of 300 we would need to double the number of doctors training or take a substantial number of junior doctors out of the other speciality training schemes.</p>
<p>There are geographical differences in where doctors are working, too. New Zealand graduates tend to choose to practice in the major centres where they have trained, while high needs communities and regional centres have to rely even more heavily on attracting IMGs. </p>
<p>Thus the Te Manawa Taki region – serving a predominantly rural population of over a million people across the central North Island, including 25% Maori – has 7% fewer doctors than the other regions (or 265 fewer doctors than would be expected). </p>
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<h2>Investing in training</h2>
<p>The United Kingdom recently opened <a href="https://www.themedicportal.com/application-guide/medical-school-interview/nhs-hot-topics/the-five-new-medical-schools/?v=8e3eb2c69a18">five new medical schools</a>, while Canada is <a href="https://www.cbc.ca/player/play/2198370371725#">set to open three</a>. In both countries, research showed doctors tended to stay and work in the area where they trained. The new medical schools are located in regions with high needs and recruitment difficulties. </p>
<p>There is no doubt New Zealand should be following suit. </p>
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Read more:
<a href="https://theconversation.com/no-one-is-mourning-the-end-of-district-health-boards-but-rebuilding-trust-in-the-system-wont-be-easy-159545">No one is mourning the end of district health boards, but rebuilding trust in the system won't be easy</a>
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<p>The New Zealand Resident Doctors’ Association is calling for another 200 medical students a year to be trained. This should be just the start, with ongoing commitments to increase student numbers in line with the growing medical workforce. </p>
<p>But simply increasing the number of students going to Auckland and Otago medical schools will not work. We cannot expect different health workforce outcomes by doing the same thing again and again. </p>
<p>We need more doctors in training, we need to attract students from a wider range of backgrounds, we need to place these students in the regions they are needed, and we need a new curriculum that will prepare for a workforce consistent with the future demands of the New Zealand health system. </p>
<p>That can only be achieved with a new and more socially accountable medical school, and significant investment. It is said the best time to plant a tree is 20 years ago. The next best time is now.</p><img src="https://counter.theconversation.com/content/204668/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross Lawrenson works for the University of Waikato which has a strategic goal of having a medical school. He has received grants in the past from Health Workforce New Zealand for training doctors and researching workforce needs.
He is a member of the National party.
</span></em></p>The 2023 budget is unlikely to do the one thing our health system needs: provide the funding for a new medical school to meet our growing need for locally trained doctors.Ross Lawrenson, Professor of Population Health, University of WaikatoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2043272023-04-26T14:24:48Z2023-04-26T14:24:48ZMedical students lose their empathy – here’s what can be done about it<figure><img src="https://images.theconversation.com/files/522565/original/file-20230424-26-kun9w7.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5035%2C3349&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Empathy can save lives.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-male-patient-consultation-doctor-sitting-1393876184">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>A lack of empathy in healthcare can be disastrous. In the UK, between 2005 and 2009, hundreds of avoidable deaths occurred at the Mid Staffordshire NHS Foundation Trust. <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf">The Francis report</a>, which investigated the causes of the failings, concluded that a lack of empathy contributed to the catastrophe.</p>
<p>More recently, dozens of tragic, unnecessary infant and maternal deaths occurred at the Shrewsbury and Telford Hospitals. <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf">The Ockenden Report</a>, which investigated the causes of these deaths, stated that lack of empathy exacerbated the problem.</p>
<p>Meanwhile, research suggests empathy in doctors may even <a href="https://pubmed.ncbi.nlm.nih.gov/31285208/">reduce premature death</a> in patients with type 2 diabetes.</p>
<p>Empathy is a core skill that medical students require. The General Medical Council, which sets the standards and outcomes for medical student education and training in the UK, says that <a href="https://www.gmc-uk.org/-/media/gmc-site/about/how-we-work/corporate-strategy/corporate_strategy_document_final_en_04122020.pdf">empathy is central to their strategy</a>. </p>
<p>However, a “hidden curriculum” in medical school can <a href="https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1964-5">reduce medical student empathy</a>. A new study, published in <a href="https://doi.org/10.1186/s12909-023-04165-9">BMC Medical Education</a>, is the first to systematically demonstrate why empathy declines during medical training and raises important questions about the priorities of current medical education.</p>
<p>Empathy is known to <a href="https://journals.sagepub.com/doi/full/10.1177/0141076818769477">reduce patient pain and improve their satisfaction with care</a>, and <a href="https://pubmed.ncbi.nlm.nih.gov/28868237/">protects against doctor burnout</a>. It’s also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916534/">cost-effective</a> according to a study that compared longer, empathic consultations with standard consultations.</p>
<p>Based on its importance, you might hope that empathy increases throughout medical school. Yet levels of empathy in medical students often <a href="https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1964-5">decline as their training progresses</a>. </p>
<p>In a recently published systematic review, my colleagues and I analysed data from 16 qualitative studies and 771 medical students. Our review included any qualitative study that investigated why empathy might change during medical school.</p>
<p>We found that when medical students transition from the first phase of medical school which is mostly lecture based, to the second phase of medical school which is more clinical and patient-facing, they are met with a <a href="https://pubmed.ncbi.nlm.nih.gov/7945681/">“hidden” informal curriculum</a>. </p>
<p>This curriculum includes <a href="https://www.bmj.com/content/329/7469/770">subtle, non-formal influences over students</a>. For example, there is often an unbalanced focus on the biomedical model of disease, which focuses on the body as a machine, over the “<a href="https://en.wikipedia.org/wiki/Biopsychosocial_model">biopsychosocial</a>” model of disease, which includes biological, psychological and social factors. </p>
<p>But also the way that the curriculum is structured to create a stressful workload, and to promote the influence of role models (who may show little empathy themselves) has an effect. Students, who are likely to have little experience of what being a patient is like, often adapt to this hidden curriculum by developing cynicism and becoming emotionally distanced and desensitised. This, in turn, lowers empathy.</p>
<p>Like all studies, our review has some limitations. The studies included in the review were small, very few were from outside Europe or North America, and many were of limited quality. However, the remarkable consistency of the identified themes warrants rigorous efforts to reverse the empathy decline.</p>
<h2>How to fix the problem</h2>
<p>By bringing the cause of empathy decline to light, our study paves the way for educational programmes that foster, maintain and even enhance empathy in medical students. These interventions are described briefly below.</p>
<ol>
<li><p>Having students “<a href="https://link.springer.com/article/10.1007/s40670-020-01101-0">walk a mile in patients’ shoes</a>”, for example by having them spend the night in the emergency room, or wearing <a href="https://news.mit.edu/2023/unique-mit-suit-helps-people-better-understand-aging-experience-0120">age simulation suits</a>. Providing students with the experience of what it is like to be a patient will provide them with a more empathic perspective.</p></li>
<li><p>Balancing the focus on the biomedical model with education on the more holistic biopsychosocial model of disease. Patients <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1733-2">are increasingly complex</a> and come to see their doctors with intertwined physical, psychological and social problems. The biopsychosocial model is better suited to understand and treat these patients.</p></li>
<li><p>Getting <a href="https://blogs.bmj.com/bmj/2018/09/06/putting-patient-centred-care-at-the-core-of-medical-education/">real patients into the classroom</a> when students are learning facts about the body. By combining patient stories with facts about the human body, their subsequent transition from the lecture theatre to clinical placements is less of a shock.</p></li>
<li><p><a href="https://pubmed.ncbi.nlm.nih.gov/32978187/">Evidence-based and effective</a> empathic communication training. While all medical schools teach communication skills, the <a href="https://pubmed.ncbi.nlm.nih.gov/30562180/">effectiveness of the training varies</a>. Empathic communication skills <a href="https://link.springer.com/article/10.1007/s11606-020-05994-w">have been shown</a> to be effective and include expressing understanding, non-verbal behaviour (nodding, leaning forward) and optimism.</p></li>
<li><p><a href="https://www.med.qub.ac.uk/ClinEd/mod1/assessment/role_modelling_meded.pdf">Role-model training</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9027875/">peer support</a>. Role models are known to have a <a href="https://journalofethics.ama-assn.org/article/role-models-influence-medical-students-professional-development/2015-02">strong influence on medical student behaviour</a>, yet the extent to which doctors display empathy <a href="https://pubmed.ncbi.nlm.nih.gov/28823250/">varies</a>. Enhancing the empathy of the doctors that students meet will therefore promote medical students’ empathy.</p></li>
</ol>
<p>Implementing these empathy interventions is difficult given the pressures on the tightly packed medical school curriculum. But it is possible. The <a href="https://le.ac.uk/empathy">Stoneygate Centre for Empathic Healthcare at the University of Leicester</a> is currently developing and piloting all of them.</p>
<p>Empathy benefits patients and practitioners, yet it declines throughout medical school. Now that we have identified the causes of its deterioration, medical schools can focus on curriculum interventions that enhance it.</p><img src="https://counter.theconversation.com/content/204327/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Howick receives funding from the Medical Research Council, and the National Institute for Health and Care Research. He is the Director of the Stoneygate Centre for Empathic Healthcare, who are funded by the Stoneygate Trust. The Stoneygate Trust had no role in the conceptualisation, design, conduct, or any other aspect of the study upon which this article is based.</span></em></p>A new study finds that medical students lose their empathy, to everyone’s detriment.Jeremy Howick, Professor and Director of the Stoneygate Centre for Excellence in Empathic Healthcare, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004962023-03-31T12:23:01Z2023-03-31T12:23:01ZUnconscious biases continue to hold back women in medicine, but research shows how to fight them and get closer to true equity and inclusion<figure><img src="https://images.theconversation.com/files/518544/original/file-20230330-1798-cyxmdb.jpg?ixlib=rb-1.1.0&rect=1155%2C396%2C4595%2C3190&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women face much higher levels of discrimination in hiring and promotions compared to male medical professionals.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctors-discussing-while-walking-in-hospital-royalty-free-image/961012938?phrase=medical%20team%20diverse&adppopup=true">Cavan Images/Getty Images</a></span></figcaption></figure><p>If you work at a company, university or large organization, you’ve probably sat through a required training session meant to fight gender and racial discrimination in the workplace. Employers increasingly invest in efforts to promote diversity, equity and inclusion – commonly referred to as DEI policies. Yet research shows these efforts often <a href="https://doi.org/10.1037/pspa0000160">fail to address the implicit biases</a> that often lead to discrimination.</p>
<p><a href="https://scholar.google.com/citations?user=10vXfYgAAAAJ&hl=en&oi=ao">I am a professor and a physician</a> who has been working in university settings for over 30 years. I also study and speak about discrimination in medicine and science. Like <a href="https://nap.nationalacademies.org/catalog/24994/sexual-harassment-of-women-climate-culture-and-consequences-in-academic">most of my female colleagues</a>, I have personally seen and experienced gender discrimination on many occasions throughout my career.</p>
<p>However, two things seem to have changed in recent years. First, modern training programs are <a href="https://pubmed.ncbi.nlm.nih.gov/36937456/">starting to reflect decades of research</a> on effective interventions. Second, I am noticing a gradual shift with people now more interested in actively addressing discrimination and harassment than ever before. Taken together, these changes give me hope that the medical profession is finally making progress on efforts to fight discrimination.</p>
<h2>Existing policies haven’t worked</h2>
<p>Many institutional policies <a href="https://ss-usa.s3.amazonaws.com/c/308463326/media/27436024f0b84dfd274918375735238/202102%20-%20DEI%20Report.pdf">outline anti-racist and anti-sexist goals</a>, but research shows results have <a href="https://doi.org/10.1073/pnas.1706255114">been slow in coming</a>.</p>
<p>In a study I conducted to understand what continues to <a href="https://doi.org/10.1001/jamanetworkopen.2021.25843">hold women back in their careers</a>, I interviewed more than 100 men and women in academic medicine, including many in high-powered positions. In my study, dozens of interviewees told me stories of DEI policies that, even with the right intentions, failed to produce good results.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man sitting at the head of a table." src="https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518545/original/file-20230330-26-u00thy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Research shows that despite policies to promote diversity, equity and inclusion, men still fare better in medical careers.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/businessman-at-conference-table-portrait-royalty-free-image/BA60388?phrase=board%20room&adppopup=true">Darren Robb/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<p>For example, frequently search committees are encouraged to broaden and <a href="https://haas.berkeley.edu/wp-content/uploads/EGAL_DEIChecklist.pdf">diversify the pool of candidates</a> for a position. In my study, I found that hiring committees often associate attempts to hire or promote a woman or member of an underrepresented group as “meeting a quota” or “affirmative action,” which the hiring committee sees as an imposition on their ability to choose the best candidates.</p>
<p>A male faculty member I interviewed claimed that a new colleague was hired “because she’s a woman,” even though she was as qualified for the position as other male candidates. Such reactions are part of why this approach, though commonly employed, has not fixed the problem of <a href="https://doi.org/10.1056/nejmsa1916935">women getting fewer promotions than men</a>.</p>
<p>It is also clear that <a href="https://pubmed.ncbi.nlm.nih.gov/31513467/">blatant sexism is still present</a>. For a study I published in 2021, I was told stories of a male department chair putting a dog leash on the desk of a female co-worker, and a female candidate for a leadership position being criticized by the chair of the search committee for <a href="https://doi.org/10.1001/jamanetworkopen.2021.25843">not being “warm and fuzzy”</a>. </p>
<h2>Trainings fail to address implicit bias</h2>
<p>Implicit bias is any unconscious negative attitude a person holds <a href="https://www.apa.org/topics/implicit-bias">against a specific social group</a>. These unconscious biases can affect judgment, decision making and behavior. Implicit bias is often one of the <a href="https://www.statnews.com/2023/01/23/conversations-unconscious-bias-stop-discrimination-in-hiring/">underlying issues</a> that leads to discriminatory practices or harassment that DEI policies are meant to address.</p>
<p>Employee trainings are a staple of organizations’ efforts to meet diversity, equity and inclusion goals. Trainings can take various forms and cover a variety of topics, including implicit bias. These trainings, frequently done online, often “talk at” employees by simply offering information and directives rather than actively engaging them in discussion and analysis. </p>
<p>Trainings that fail to engage participants aren’t very effective in <a href="https://doi.org/10.1177%2F15291006211070781">lessening imlicit bias</a>. In fact, research has shown that some trainings suggest unconscious bias is an unchangeable fact of life and imply it <a href="https://hbr.org/2021/09/unconscious-bias-training-that-works">can therefore be ignored</a>.</p>
<h2>Effective ways to mitigate unconscious bias</h2>
<p>Describing how bias works and how it influences individuals is an important step in addressing discrimination. </p>
<p>Researchers have been studying <a href="https://theconversation.com/measuring-the-implicit-biases-we-may-not-even-be-aware-we-have-74912">how unconscious bias works and how to mitigate it</a> since the 1980s. These studies show that unconscious bias is a <a href="https://doi.org/10.1016/j.jesp.2017.04.009">habit that can be broken over time</a> with a clear, consistent and respectful series of evaluations, feedback and follow-ups. During this process, employees become more aware of bias in others, more likely to judge such bias as problematic and more able to mitigate bias in their own behavior. This type of intervention has been shown to produce measurable increases in the <a href="https://doi.org/10.1016/j.jesp.2017.07.002">number of female faculty in science and medicine</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of people sitting in a semi-circle watching a woman give a presentation." src="https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518546/original/file-20230330-1797-8tm80s.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">Many diversity, equity and inclusion policies rely on trainings that don’t do a good job of engaging employees.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/businesswoman-explaining-strategy-over-a-flip-chart-royalty-free-image/1166085818?phrase=professional%20training&adppopup=true">Luis Alvarez/Digital Vision via Getty Images</a></span>
</figcaption>
</figure>
<p>The question is whether the mandatory trainings and public messaging that are the staples of many DEI policies today can produce similar results to these intensive interventions. </p>
<p>Creating situations or a culture where people can and do share their experiences with harassment and discrimination – without risk of retaliation – can lead to increased awareness of bias in others and clear communication of the negative aspects of this bias.</p>
<p>One interviewee in my study talked about an exercise in which the women wrote down their experiences of discrimination and harassment and then the men read the women’s stories out loud. This woman felt that the men, by reciting the experiences of their female colleagues, finally began to understand how practices that seemed to be inclusive and fair were actively harming others.</p>
<h2>A changing social environment</h2>
<p>Sharing personal experiences of harassment or discrimination with people who have biases is an understandably scary or intimidating thing to do – especially given the <a href="https://doi.org/10.1007/s00268-021-06432-6">history of retaliation or shaming</a>. But my recent experiences seem to suggest that the culture in medicine is shifting from one of avoidance to one of engagement.</p>
<p>I recently gave a talk on gender discrimination at <a href="https://www.cancer.org/research/we-fund-cancer-research/eds-research-programs/jiler-professors-and-fellows-conference/2022-jiler-conference-the-feedback.html">a major cancer conference</a> that brought together researchers from all across the U.S. I shared the results of my study as well as my personal experiences with the audience. At the end of my presentation, the crowd of men and women stood and applauded – a response I have rarely, if ever, seen in my 30 years of attending medical conferences. </p>
<p>This enthusiastic response may suggest that people are broadly becoming more open to and supportive of women and other underrepresented people sharing their own stories of facing discrimination. With a large body of research showing that sharing personal experiences with people who are actively listening and engaging is one of the most effective ways to combat unconscious bias, this standing ovation seemed to me a hopeful sign of things to come.</p><img src="https://counter.theconversation.com/content/200496/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer R. Grandis 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>After decades of effort to reduce discrimination in the workplace, a cultural change may be happening that will enable people to move past their unconscious biases.Jennifer R. Grandis, Distinguished Professor of Otolaryngology-Head and Neck Surgery, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2022262023-03-24T12:36:40Z2023-03-24T12:36:40Z3D-printing the brain’s blood vessels with silicone could improve and personalize neurosurgery – new technique shows how<figure><img src="https://images.theconversation.com/files/517257/original/file-20230323-28-w03xh4.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1864%2C1604&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">3D printers can lay down more than just layers of melted plastic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/realistic-3d-paper-cut-human-brain-royalty-free-illustration/1391832014">Dedraw Studio/iStock via Getty Images Plus</a></span></figcaption></figure><p>A new 3D-printing technique using silicone can make accurate models of the blood vessels in your brain, enabling neurosurgeons to train with more realistic simulations before they operate, according to our <a href="https://doi.org/10.1126/science.ade4441">recently published research</a>.</p>
<p>Many neurosurgeons practice each surgery before they get into the operating room <a href="https://doi.org/10.3390%2Fbioengineering7010007">based on models</a> of what they know about the patient’s brain. But the current models neurosurgeons use for training <a href="https://doi.org/10.1093/neuros/nyaa217">don’t mimic real blood vessels well</a>. They provide unrealistic tactile feedback, lack small but important structural details and often exclude entire anatomical components that determine how each procedure will be performed. Realistic and personalized replicas of patient brains during pre-surgery simulations could reduce error in real surgical procedures. </p>
<p>3D printing, however, could make replicas with the soft feel and the structural accuracy surgeons need.</p>
<p>3D printing is typically thought of as a process that involves laying down layer after layer of melted plastic that solidifies as a self-supporting structure is built. Unfortunately, many soft materials do not melt and re-solidify the way the plastic filament that 3D printers typically employ do. Users only get one shot with soft materials like silicone – they have to be printed while in a liquid state and then irreversibly solidified.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uHbn7wLN_3k?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Researchers are exploring 3D-printing organs using living cells.</span></figcaption>
</figure>
<h2>Shaping liquids in 3D</h2>
<p>How do you make a complex 3D shape out of a liquid without ending up with a puddle or a slumping blob?</p>
<p>Researchers developed a broad approach called <a href="https://doi.org/10.1002/adma.201004625">embedded 3D printing</a> for this purpose. With this technique, the “ink” is deposited inside a bath of a second supporting material designed to flow around the printing nozzle and trap the ink in the place right after the nozzle moves away. This allows users to create complex shapes out of liquids by holding them trapped in three-dimensional space until the time comes to solidify the printed structure. Embedded 3D printing has been effective for structuring <a href="https://doi.org/10.1126/sciadv.1500655">a variety of soft materials</a> like hydrogels, microparticles and even living cells. </p>
<p>However, printing with silicone has remained challenging. Liquid silicone is an oil, while most support materials are water-based. Oil and water have a high <a href="https://doi.org/10.1039/D0SM01971B">interfacial tension</a>, which is the driving force behind why oil droplets take on circular shapes in water. This force also causes 3D-printed silicone structures to deform, even in a support medium.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of oil droplets on water" src="https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517272/original/file-20230323-26-beetje.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">Interfacial tension is what causes oil droplets to form on water and silicone to deform.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/abstract-art-oil-in-water-royalty-free-image/1251006239">Baac3nes/Moment via Getty Images</a></span>
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<p>Even worse, these interfacial forces drive small-diameter silicone features to break into droplets as they are being printed. A lot of research has gone into making silicone materials that can be printed <a href="https://doi.org/10.1016/j.addma.2018.10.002">without a support</a>, but these heavy modifications also modify the properties that users care about, like how soft and stretchy the silicone is.</p>
<h2>3D-printing silicone with AMULIT</h2>
<p>As researchers working at the interface of <a href="https://scholar.google.com/citations?user=PYnyFvsAAAAJ&hl=en">soft matter physics, mechanical engineering</a> and <a href="https://scholar.google.com/citations?user=rVFU5coAAAAJ&hl=en">materials science</a>, we decided to tackle the problem of interfacial tension by developing a <a href="https://doi.org/10.1126/science.ade4441">support material made from silicone oil</a>.</p>
<p>We reasoned that most silicone inks would be chemically similar to our silicone support material, thus dramatically reducing interfacial tension, but also different enough to remain separated when put together for 3D printing. We created many candidate support materials but found that the best approach was to make a dense emulsion of silicone oil and water. One can think about it like crystal clear mayonnaise, made from packed microdroplets of water in a continuum of silicone oil. We call this method <a href="https://doi.org/10.1126/science.ade4441">additive manufacturing at ultra-low interfacial tension, or AMULIT</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of AMULIT technique printing the bronchi of a lung model within a bath of supporting material, with a close-up of the needle depositing layers of silicone to make the tissue." src="https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517288/original/file-20230323-22-p3hiok.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&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">This diagram shows the AMULIT technique printing the bronchi of a lung model within a bath of supporting material. At right is a close-up of the needle depositing layers of silicone to make the tissue.</span>
<span class="attribution"><a class="source" href="https://www.science.org/doi/10.1126/science.ade4441">Senthilkumar Duraivel/Angelini Lab</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>With our AMULIT support medium, we were able to print off-the-shelf silicone at high resolution, creating features as small as 8 micrometers (around 0.0003 inches) in diameter. The printed structures are as stretchy and durable as their traditionally molded counterparts. </p>
<p>These capabilities enabled us to 3D-print accurate models of a patient’s brain blood vessels based on a 3D scan as well as a functioning heart valve model based on average human anatomy.</p>
<h2>3D silicone printing in health care</h2>
<p>Silicone is a <a href="https://doi.org/10.1002/14356007.a24_057">critical component of innumerable products</a>, from everyday consumer goods like cookware and toys to advanced technologies in the electronics, aerospace and health care industries. </p>
<p>Silicone products are typically made by pouring or injecting liquid silicone into a mold and removing the cast after solidification. The expense and difficulty of manufacturing high-precision molds limits manufacturers to products with only a few predetermined sizes, shapes and designs. Removing delicate silicone structures from molds without damage is an additional barrier, and manufacturing defects increase when molding highly intricate structures. </p>
<p>Overcoming these challenges could allow for the development of advanced silicone-based technologies in the health care industry, where personalized implants or patient-specific mimics of physiological structures could transform care.</p><img src="https://counter.theconversation.com/content/202226/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>Organ models that more accurately capture finer details could reduce surgical error and lead to personalized implants.Senthilkumar Duraivel, Ph.D. Candidate in Materials Science and Engineering, University of FloridaThomas Angelini, Associate Professor of Mechanical and Aerospace Engineering, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2021362023-03-21T19:11:55Z2023-03-21T19:11:55ZDoctors may soon get official ‘endorsements’ to practise cosmetic surgery – but will that protect patients?<figure><img src="https://images.theconversation.com/files/516551/original/file-20230321-16-ypoa6u.jpg?ixlib=rb-1.1.0&rect=15%2C117%2C3537%2C3186&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1551601651-09492b5468b6?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1213&q=80">Unsplash/Olga Guryanova</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Disturbing reports about botched cosmetic surgeries and injuries in Australia – from breast augmentations causing chronic pain to liposuction leaving patients with lifelong injuries – have <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">sparked concerns in recent years</a>. Several high-profile cosmetic surgeons alleged to have fallen short of expected professional standards have been <a href="https://www.medicalboard.gov.au/News/2022-09-01-Ahpra-MBA-CSR-reply.aspx">disciplined</a>. </p>
<p>Last year, <a href="https://www.supremecourt.vic.gov.au/sites/default/files/2022-08/Group%20Proceeding%20Summary%20Statement%20%289%20March%202022%29.pdf">a class action</a> was commenced against one clinic in the Victorian Supreme Court.</p>
<p>People who are interested in exploring whether cosmetic surgery is appropriate for them are right to feel wary and confused. Now, the introduction of a scheme to officially endorse doctors who practise in the area of cosmetic surgery promises to allay patients’ doubts. But the idea <a href="https://www.smh.com.au/politics/federal/legitimises-the-activities-of-unscrupulous-operators-cosmetic-surgery-safety-fears-20230313-p5crnq.html">remains contentious</a> for those in the field.</p>
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Read more:
<a href="https://theconversation.com/thinking-about-cosmetic-surgery-at-last-some-clarity-on-who-can-call-themselves-a-surgeon-196947">Thinking about cosmetic surgery? At last, some clarity on who can call themselves a surgeon</a>
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<h2>The story so far</h2>
<p>In the wake of cosmetic surgery controversies, two significant but separate responses have been adopted by medical regulators. First, the country’s health ministers began a <a href="https://pubmed.ncbi.nlm.nih.gov/35338692/">consultation</a> to decide whether to stop doctors promoting themselves as “surgeons”.</p>
<p>The consultation acknowledged a gap or “loophole” that allows any registered medical practitioner to call themselves a surgeon in Australia, even with <a href="https://www.sydney.edu.au/news-opinion/news/2016/05/12/call-yourself-a-cosmetic-surgeon--new-guidelines-fix-only-half-t.html">no specialist training</a> beyond their medical degree.</p>
<p>The second response was initiated in December 2021, by AHPRA, which accredits and registers doctors, and the Medical Board of Australia, which regulates the practices of registered medical practitioners. Together, they commissioned an <a href="https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-surgery-review.aspx">independent review</a> into the regulation of medical practitioners who perform cosmetic surgery in Australia. </p>
<p>Although informed by each other, these separate initiatives wrought distinct solutions. While one has been embraced, the other remains controversial.</p>
<h2>Ministerial reforms</h2>
<p>After nearly two years of consultation, the health ministers decided <a href="https://www.health.gov.au/sites/default/files/2022-12/health-ministers-meeting-communique-14-december-2022_0.pdf">last December</a> to restrict the use of the title “surgeon”. Soon, only medical practitioners holding a specialist registration, such as ophthalmology, will be permitted to use the title.</p>
<p>In a meeting late last month, health ministers approved <a href="https://www.health.gov.au/sites/default/files/2023-02/health-ministers-meeting-communique-24-february-2023.pdf">a draft bill</a> to give effect to this decision. While the draft remains unpublished, no stakeholders in the health sector appear to have criticised the change. </p>
<p>But the health ministers approved another, more controversial, reform as well. They welcomed a new model of accrediting cosmetic surgery practitioners known as an “endorsement of registration”. This proposal came from the AHPRA and Medical Board review.</p>
<h2>AHPRA and the Medical Board’s ‘endorsement model’</h2>
<p>Among its 16 recommendations (all of them accepted by AHPRA and the Medical Board), <a href="https://theabic.org.au/storage/app/media/BLOG/Ahpra---Report---Cosmetic-surgery-independent-review---Final-report---August-2022.pdf">the independent review’s</a> first and most significant reform proposal was to establish an “area of practice endorsement” for cosmetic surgery. </p>
<p>The technical language of “<a href="https://www.legislation.qld.gov.au/view/html/inforce/current/act-2009-hprnlq#sec.98">endorsement</a>” comes from <a href="https://www.ahpra.gov.au/About-Ahpra/What-We-Do/Legislation.aspx">consistent national laws</a> enacted, with minor variations, in each state and territory.</p>
<p>In a nutshell, “area of practice endorsement” would introduce new minimum standards for the education, training and qualification of Australian medical practitioners seeking to practise as cosmetic surgeons. </p>
<p>Currently, the Medical Board uses <a href="https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx">codes of conduct</a> and <a href="https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Advertising-a-regulated-health-service/Guidelines-for-advertising-regulated-health-services.aspx">guidelines</a> to regulate most doctors’ practices. </p>
<p>But these “soft law” instruments permit doctors to decide for themselves whether they are competent enough to perform procedures like brow lifts or tummy tucks.</p>
<p>The new endorsement model would require doctors to apply to the Medical Board to qualify to practice in the area of cosmetic surgery. To be approved, the doctor-applicant would need to furnish evidence of their qualifications. Such an endorsement arrangement already exists for <a href="https://legislation.nsw.gov.au/view/whole/html/inforce/current/act-2009-86a#pt.7-div.8-sdiv.4">acupuncture</a>.</p>
<p>Together with restricting the title “surgeon” and some other reforms (such as improved information campaigns), it is now hoped the endorsement model would manage risky cosmetic surgeries by requiring practitioners to be endorsed by the Medical Board. But not everyone thinks it’s the way to go. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/whos-the-best-doctor-for-a-tummy-tuck-or-eyelid-surgery-the-latest-review-doesnt-actually-say-189700">Who's the best doctor for a tummy tuck or eyelid surgery? The latest review doesn't actually say</a>
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<h2>What’s the problem with endorsement?</h2>
<p>Fresh forms of old tensions have arisen, based on how endorsement will be designed. At the core of these tensions is a debate about how the Australian Medical Council, which is responsible for setting the accreditation, training and education standards for the medical profession, will determine the curriculum and assessment regimes for cosmetic surgery study programs. </p>
<p>What was once a debate about an unregulated area of practice is now about what kind of training cosmetic surgeons should have before wielding their instruments.</p>
<p>Some experts suggest <a href="https://researchnow-admin.flinders.edu.au/ws/portalfiles/portal/21121551/Dean_Defining_P2018.pdf">defining cosmetic surgery</a> could help regulation and safety discussions. Meanwhile, the Royal Australasian College of Surgeons says it will <a href="https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/advocacy/20221212-Consultation-cosmetic-surgery-registration-standards.pdf?rev=a997d89161cf4abc8c7b405f1e7a5ccb&hash=F4DFEE1BC200732360B2976ACE6E1D4F">oppose</a> any study program of a lesser standard than that required of specialist surgeons. </p>
<p>Although the Australian Medical Council has not yet published its education standards for cosmetic surgery, it has proposed <a href="https://www.amc.org.au/wp-content/uploads/2023/01/Attachment-B-Draft-Accreditation-standards-for-cosmetic-surgery-programs.pdf">six draft qualification standards</a> and is consulting with the profession. </p>
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<h2>What this could mean for patient safety</h2>
<p>On the one hand, the proposed changes are a continuation of a long-running turf war. On one side are the surgeons with special accreditation, approved by the Royal Australasian College of Surgeons and typically engaged in reconstructive plastic surgeries. On the other, stand the so-called “non-surgeons” or “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8795651/">wannabees</a>”.</p>
<p>The debate is also about protecting patients and <a href="https://www.legislation.qld.gov.au/view/html/asmade/act-2022-022#ch.3-pt.2">legislative reform</a>. </p>
<p>It is too early to determine whether the Australian Medical Council’s endorsement standards will improve patient safety. But the slow process of reforming the cosmetic surgery “industry” – in the face of explosive increases in demand, fuelled in part by <a href="https://doi.org/10.1177/07488068221105360">seductive social media claims</a> – illustrates how complex medical regulation is in Australia. With so many regulatory actors involved in our <a href="https://eprints.qut.edu.au/127800/">polycentric system</a>, feuds over governance are unsurprising. </p>
<p>Today, the cosmetic surgery industry is estimated to be worth <a href="https://www.afr.com/life-and-luxury/health-and-wellness/cosmetic-surgery-boom-is-new-face-of-covid-19-20200821-p55o0u">more than one billion dollars a year</a>. It is crucial regulators ensure the public is protected from unscrupulous – or unqualified – operators.</p><img src="https://counter.theconversation.com/content/202136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rudge was previously a researcher at the Medical Council of New South Wales. He is a chief invstigator on a project concerning patient decision-making about stem cell treatments funded by the Australian government's Medical Research Future Fund.</span></em></p>A new proposal is reigniting an old debate about cosmetic surgery. Now it’s focused on what kind of training cosmetic surgeons should have before wielding their instruments.Christopher Rudge, Law lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1956062022-12-05T16:34:16Z2022-12-05T16:34:16ZMedical jargon is often misunderstood by the general public – new study<p>Students learning medicine must learn a whole new language to allow them to express their clinical impressions to others accurately. In time, this becomes second nature and soon they can be heard babbling away confidently and sounding quite the part. Communication skills are a standard part of medical education and the teachers take great care to ensure that these newly found linguistic skills do not impinge on their communication with patients. Most seem to take this on board and do their utmost not to confuse patients.</p>
<p>With all of this good education going on, why is it that we hear of misunderstandings between doctors and patients? Do doctors really throw up verbal smokescreens to confound others? A <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2799079">recent paper</a> from the University of Minnesota would suggest so. </p>
<p>A survey of 215 members of the public examined their understanding of some common phases used by doctors in their consultations. Words such as “your cancer screening test came back and the results were negative” were correctly interpreted by 97.7% of the people. However, only 21% correctly understood that a doctor saying their radiography was “impressive” was generally bad news. And “Have you been febrile?” was understood by just 9.3%. </p>
<p>The researchers concluded that medical jargon is alive and well and living in consulting rooms in Minnesota – and presumably a lot of other places as well.</p>
<p>Before we all take the view that doctors need yet more browbeating about their communication skills, let us look at this paper in context. The study participants were members of the public visiting the Minnesota State Fair. Presumably, they were looking forward to a day of candyfloss and helter-skelter rides rather than being accosted by researchers offering university-branded backpacks as inducements to participate. They were not expecting to be patients that day and may even have been there to get away from worries about health. </p>
<p>The questions were multiple choice, with no opportunity to ask for clarification. Medically qualified readers will all be familiar with patients who ask for immediate explanations of terms and most, I hope, will understand the power of the phrase: “By which I mean … ” </p>
<p>Somehow, the study methods used by these researchers seem not to accurately replicate the conditions found in your average clinic and, in fairness, they acknowledge this.</p>
<h2>Don’t infantilise</h2>
<p>Why use certain terms and phrases in the first place? Oddly, the answer is not wholly straightforward. Today’s internet-enabled patient is better informed than ever. Popular TV programmes show doctors and patients in action, using copious quantities of medical jargon for realism and artistic effect. The public lap it up. </p>
<p>In the clinic, patients like to be treated as adults and communicated with accordingly. They don’t want to be infantilised or patronised – and they certainly let doctors know if they are made to feel that way. Skilled doctors know this and will introduce terms followed (hopefully) by immediate explanations to ensure understanding. Too slow with an explanation and the wily patient will ask: “Can I have that in English please?”</p>
<p>Whatever the words used and however they are put, some patients are not in a position to take it all in. Fear and anxiety cloud the comprehension of messages in any consultation, and this must be accounted for. There should be adequate adjuncts, such as information leaflets, web links, and that all-important opportunity to ask questions at the time or on a subsequent occasion.</p>
<p>Nobody should leave a healthcare consultation confused and none the wiser because of the use of medical jargon, and none should be spoken down to or patronised. The skill of the doctor is to find the happy medium and make patients feel informed and respected – even if they can’t always offer a cure.</p><img src="https://counter.theconversation.com/content/195606/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Hughes 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>Most people don’t know that when a doctor says your X-ray is impressive, it’s generally bad news.Stephen Hughes, Senior Lecturer in Medicine, Anglia Ruskin UniversityLicensed 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/1812512022-05-11T15:25:49Z2022-05-11T15:25:49ZHow rural Canada can attract and retain international health-care providers: Address discrimination, provide support<figure><img src="https://images.theconversation.com/files/461820/original/file-20220506-14-71w1ww.jpg?ixlib=rb-1.1.0&rect=353%2C43%2C5113%2C3785&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Common approaches used to encourage internationally educated health-care professionals to work in smaller communities often focus primarily on attraction, but do not address the reasons why they tend to leave.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Smaller communities in Canada, particularly those located in rural areas, find it difficult to attract and especially retain health-care professionals, <a href="https://www150.statcan.gc.ca/n1/pub/82-003-x/2019005/article/00001-eng.htm">leading to poorer health outcomes</a>. </p>
<p>For example, <a href="https://www.cbc.ca/news/canada/thunder-bay/red-lake-er-closure-1.6399514">in March 2022, the physician shortage in Northern Ontario forced the emergency department in Red Lake to close for 24 hours</a>, and those with medical emergencies had to drive over 200 kilometres to the nearest hospital. In the same region, <a href="https://www.cbc.ca/news/canada/thunder-bay/northern-ontario-nursing-shortage-toll-1.6290814">staffing shortages of nurses and personal support workers</a> are exacerbated by recruitment and retention challenges. Similar situations <a href="https://doi.org/10.1002/hpm.2712">exist in many small communities across Canada</a>.</p>
<p>It’s no surprise then that all five Northern Ontario cities participating in the Rural and Northern Immigration Pilot, designed to bring more immigrants to smaller communities, <a href="https://www.northernontariobusiness.com/regional-news/northeastern-ontario/newcomers-to-the-north-needed-to-fill-health-care-skilled-trades-positions-3903442">are prioritizing health-care professionals</a>. But can they keep them? </p>
<p>Recruiting internationally educated health-care professionals (IEHPs) to work in underserved communities is not new. However, challenges in keeping them in these communities persist. As immigration researchers, we have documented the challenges of retaining newcomers in Canada’s small communities, <a href="https://www.ryerson.ca/content/dam/cerc-migration/Policy/CERCMigration_PolicyBrief06_JAN2022.pdf">with a recent focus on IEHPs</a>. </p>
<h2>Why popular approaches don’t work</h2>
<p>Common approaches used to encourage IEHPs to work in smaller communities often include “return of service” contracts requiring that IEHPs work in underserved areas for several years as a pathway to licensure to practise within the province or territory. For example, the <a href="https://mcc.ca/assessments/practice-ready-assessment/">National Assessment Collaboration’s Practice-Ready Assessment programs</a> for international physicians, offered in seven provinces, require a return-of-service commitment in a rural area of the province. </p>
<p>These somewhat coercive strategies <a href="https://www.hhr-rhs.ca/en/?option=com_content&view=article&id=401:chhrn-chfi-mythbuster-imgs-a">tend to be ineffective in the long term</a> because they focus primarily on attracting IEHPs to smaller communities and do not address the reasons why they tend to leave. These reasons include social and professional isolation.</p>
<figure class="align-center ">
<img alt="A man in a white coat with a stethoscope around his neck handing a piece of paper to a woman seen from behind" src="https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462363/original/file-20220511-26-7xzfbq.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">Internationally educated health-care professionals in smaller communities may experience long work hours and limited time off for vacation due to the small size of the health-care team, and have limited opportunities for professional development and advancement within a cohort of peers.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p><a href="http://p2pcanada.ca/wp-content/blogs.dir/1/files/2019/08/Beyond-The-Big-City-Report.pdf">The factors driving social isolation</a> for IEHPs in smaller communities include distance from family members and social connections, limited access to settlement services that can facilitate connections to the community, the lack of a large immigrant population and access to cultural and religious supports, limited employment and educational opportunities for family members, and experiences of racism and discrimination. </p>
<p><a href="https://www.srpc.ca/resources/Documents/CJRM/vol23n1/pg15.pdf">The factors driving professional isolation</a> in smaller communities include long work hours and limited time off for vacation due to the small size of the health-care team, and limited opportunities for professional development and advancement within a cohort of peers. IEHPs may also find that they lack the generalist skill sets required for practising in smaller communities, which can differ considerably from urban health care.</p>
<p>While several of these factors apply to all health-care professionals, whether Canadian-born or internationally trained, others tend to be unique to IEHPs, compounding their sense of isolation and their motivation to move to a large urban centre.</p>
<h2>Reasons to stay</h2>
<p>Several strategies can be used to support the retention of IEHPs, including training and experience in small community health care. As an example of the importance of training and experience, <a href="https://www.cbc.ca/news/canada/sudbury/nosm-doctors-northern-ontario-1.4354750">the Northern Ontario School of Medicine (NOSM) has increased the number of physicians and dietitians who practise in smaller communities in Northern Ontario</a>. </p>
<p>NOSM graduates are familiar with the needs of these communities and, due to their specialized training, are prepared to serve them long-term. Once established in a community, professional networks and professional development opportunities can also help IEHPs to overcome professional isolation. </p>
<figure class="align-center ">
<img alt="A man and a woman and a child potting plants on a green lawn in front of a house" src="https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462362/original/file-20220511-12-ro9psh.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">
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<span class="caption">Internationally educated health-care professionals will be more likely to stay in small communities if their families are happily settled in the community and they feel socially connected.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In addition, IEHPs will be more likely to stay in small communities <a href="https://med-fom-crhr.sites.olt.ubc.ca/files/2019/09/Rural-Evidence-Review-Community-Level-Recruitment-and-Retention-Scoping-Review-FINAL-reduced-file-size.pdf">if their families are happily settled in the community and they feel socially connected</a>. Addressing <a href="https://www.northernpolicy.ca/upload/documents/publications/commentaries-new/nac-slip-case-studies_total_en-2022-02-1001.pdf">racism and discrimination in the community is a first step</a>. Also, the spouses of IEHPs may require special assistance to find employment related to their field of study. The children of IEHPs may benefit from connections to educational and extracurricular activities. </p>
<h2>The right fit</h2>
<p>Efforts should also be made to attract IEHPs with characteristics that make them more likely to stay. <a href="https://doi.org/10.1093/pubmed/fdaa031">IEHPs who are from small or rural communities</a> may find it easier to adapt to living and working in smaller Canadian communities, making them much more likely to stay. </p>
<p><a href="https://doi.org/10.1186/s12960-020-00502-x">Communities should also communicate what kind of lifestyle they can offer to IEHPs, and IEHPs should know what to expect</a>, improving fit. IEHPs may be attracted to smaller communities because of the housing, educational and outdoor leisure opportunities on offer, or because of the sense of safety and community that some smaller centres can provide. Importantly, these location attributes may appeal more to IEHPs who are at a certain point in their lives. <a href="http://p2pcanada.ca/wp-content/blogs.dir/1/files/2019/08/Beyond-The-Big-City-Report.pdf">Those prioritizing homeownership or raising children may be more likely to have their needs met in a smaller community</a>. </p>
<p>For the upcoming <a href="https://www.canada.ca/en/immigration-refugees-citizenship/corporate/transparency/consultations/2020-consultations-immigration-levels-and-municipal-nominee-program/discussion-guide.html#mnp">Municipal Nominee Program</a>, in which communities will have more say in the selection of new immigrants, a key measure of success will be how the program addresses labour shortages and retention in key sectors such as health care. The ability of small communities to make the right matches and address professional and social isolation for IEHPs will be essential.</p><img src="https://counter.theconversation.com/content/181251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalya Brown receives funding from PhiLab - the Canadian Philanthropy Partnership Network. She volunteers with the North Bay and District Multicultural Centre and the Nipissing-Timiskaming Federal NDP Electoral District Association. </span></em></p><p class="fine-print"><em><span>Victoria Esses receives funding from Immigration, Refugees and Citizenship Canada.. </span></em></p><p class="fine-print"><em><span>Melissa Kelly 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>Small communities struggle to retain needed internationally educated health-care professionals. Challenges will persist until the compounding effects of social and professional isolation are addressed.Natalya Brown, Associate Professor of Economics, Nipissing UniversityMelissa Kelly, Research fellow, Canada Excellence Research Chair (CERC) in Migration and Integration, Toronto Metropolitan UniversityVictoria Esses, Professor, Department of Psychology, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1731862022-03-06T12:15:21Z2022-03-06T12:15:21ZEquitable medical education can be achieved with efforts toward real change<figure><img src="https://images.theconversation.com/files/444433/original/file-20220203-27-1y3us7.jpg?ixlib=rb-1.1.0&rect=0%2C53%2C7054%2C4006&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Going beyond window dressing is crticial in promoting equitable medical education. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>There is evidence of ongoing anti-Black and anti-Indigenous racism in Canadian health care. In 2020, the Toronto Board of Health declared <a href="https://doi.org/10.1503%2Fcmaj.201579">anti-Black racism a public health crisis</a>, acknowledging that race-based health inequities disproportionately affect Black and racialized communities. </p>
<p>Anti-Indigenous racism remains present in Canadian health care, as demonstrated by appalling and tragic events like Joyce Echaquan experiencing <a href="https://www.cbc.ca/news/canada/montreal/joyce-echaquan-systemic-racism-quebec-government-1.6196038">in-hospital racism that contributed to her death</a> — and persisting poor health outcomes for Indigenous people.</p>
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Read more:
<a href="https://theconversation.com/as-an-indigenous-doctor-i-see-the-legacy-of-residential-schools-and-ongoing-racism-in-todays-health-care-162048">As an Indigenous doctor, I see the legacy of residential schools and ongoing racism in today's health care</a>
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<p>Some medical educators have <a href="https://doi.org/10.1097%2FACM.0000000000004017">urged medical schools</a> to produce physicians who not only represent the communities they serve, but who are also trained to address racism and health inequity. This appeal for more equitable and inclusive medical education is an important part of educating a next generation of medical practitioners, and has been present for years. Yet, as we witness persisting inequities in health care and their harms, a sense of urgency remains. </p>
<h2>Need for diverse physician workforce</h2>
<p>Researchers highlight that a diverse physician workforce can help decrease health inequities, and that establishing such a workforce requires <a href="https://doi.org/10.1097%2FACM.0000000000004017">establishing a just and equitable system of medical training</a>.</p>
<p>In the United States, researchers note that <a href="https://doi.org/10.1001/jamanetworkopen.2019.10490">Black, Hispanic and Indigenous students continue to be underrepresented in medical schools</a>, and this underrepresentation has not changed significantly since 2009. In Canada, <a href="https://doi.org/10.1503/cmaj.141502">data regarding diversity in medical education remains scarce</a>. </p>
<h2>Avoiding false sense of of progress</h2>
<p>In today’s world, if an institution posts a statement declaring that it has become more inclusive while it still preserves discriminatory practices in the background, the false reassurance that the problem has been solved <a href="https://doi.org/10.1097%2FACM.0000000000002388">could shut down ongoing conversations around race</a>.</p>
<p>The appearance of an inclusive academic environment could initially attract underrepresented applicants, but in fact give them a false sense of security until they experience discrimination. This, once made public, would lead to an institution not only being known as one that stifles diversity and inclusion, but also as one that is inauthentic. </p>
<figure class="align-center ">
<img alt="A Black and South Asian student sit in lab coats poring over medical books." src="https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447114/original/file-20220217-1111-1glngmi.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">
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<span class="caption">To truly become known as a place that fosters inclusive learning environments, institutions must ‘walk the walk’ of eliminating discriminatory practices.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Profound change in medical education will be visible only after years of sustained effort. Diversity is necessary at all levels in medicine, and attention must be given not just to recruiting a diverse workforce but to <a href="https://doi.org/10.1056/NEJMp2105578">retaining and promoting a diverse group of faculty and leaders</a>. </p>
<h2>Towards comprehensive solutions</h2>
<p>Potential solutions will need to be comprehensive and thoughtful and could include the following:</p>
<p>Institutions must examine themselves deeply and thoroughly. Leaders in medical education need to listen closely to students, faculty and the communities they serve to understand what is truly happening and <a href="https://theconversation.com/universities-must-open-their-archives-and-share-their-oppressive-pasts-125539">what has happened in the past in their learning environments</a>. Whatever is found needs to be acknowledged and dealt with so the institution can move forward and improve.</p>
<p>Institutions must actively avoid mismatch between their statements and their actions. Learning about social justice must be paired with the unlearning and undoing of past processes and biases. <a href="https://doi.org/10.1503/cmaj.201684">Adopting an anti-racist framework</a> that includes accountability measures has the potential to help with this.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/4-ways-white-people-can-be-accountable-for-addressing-anti-black-racism-at-universities-164983">4 ways white people can be accountable for addressing anti-Black racism at universities</a>
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<h2>What meaningful change looks like</h2>
<p>Institutions, if they are to achieve it, must have an idea of what meaningful, comprehensive change looks like. In an institution that is truly inclusive there will be:</p>
<ol>
<li><p>Inclusive and localized planning. When forging and implementing equity plans that reflect institutions’ visions, and take into account their legacies and pasts, listening to the lived experiences of current racialized faculty and students matters.</p></li>
<li><p>Accountability. Actions by faculty or students that go against principles of exclusion can be reported and schools are prepared to take counteraction.</p></li>
<li><p>Support for underrepresented students. Students from underrepresented groups will not think twice about applying or attending, as they are guaranteed support and mentorship. Those who are let in through the door must be supported, <a href="https://doi.org/10.1007%2Fs11606-020-06478-7">mentored and promoted for success</a>. </p></li>
<li><p>Curricular change. Students from underrepresented communities see their own communities represented in the cases and images presented in teaching.</p></li>
<li><p>Representative leadership and faculty. Students from underrepresented communities will see themselves in their role models, faculty and leaders at every level.</p></li>
</ol>
<p>Meaningful change cannot occur unless the efforts made toward equitable medical education go beyond window dressing. The good news is that authentic changes in structures and practices are possible and an inclusive medical education is an achievable goal. </p>
<p>Superficial efforts that only improve appearances, but actually overlook deeply entrenched systemic racism in medical schools, are only going to set us back.</p><img src="https://counter.theconversation.com/content/173186/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mala Joneja 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>Medical schools need long-term equity planning and built-in accountability measures in order to help realize a larger vision of anti-racist and inclusive health care.Mala Joneja, Associate Professor, Division Chair for the Division of Rheumatology, Department of Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1719422021-12-13T01:17:51Z2021-12-13T01:17:51ZDoctors are trained to be kind and empathetic – but a ‘hidden curriculum’ makes them forget on the job<figure><img src="https://images.theconversation.com/files/434324/original/file-20211129-17-1kae8gu.jpg?ixlib=rb-1.1.0&rect=20%2C30%2C6669%2C4365&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/thank-you-doctor-smiling-thankful-600w-1971114932.jpg">Shutterstock</a></span></figcaption></figure><p>Health-care professionals are often idealised, especially in recent times, as heroes. But meeting a physician can be an underwhelming experience. </p>
<p>Patients and families can find themselves on the receiving end of curt communications or seemingly uncaring attitudes. This is understandably disappointing. A worried, scared patient looks to the doctor not just as the person who will take the lead of the situation, but as someone who can understand their feelings and emotions. </p>
<p>The good news is doctors are trained to provide care and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494899/">empathy</a>. The bad news is the training doesn’t always make a difference in the long run: a “hidden curriculum” of medical education can explain this.</p>
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Read more:
<a href="https://theconversation.com/hospital-emergency-departments-are-under-intense-pressure-what-to-know-before-you-go-169098">Hospital emergency departments are under intense pressure. What to know before you go</a>
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<h2>Teaching students empathy and communication</h2>
<p>In the 1990s, medical educators realised students’ training was too focused on biomedical sciences and did not take into account the experience of patients and their families. Most medical schools now invest considerable effort to make sure future doctors are well equipped to support their patients and be empathetic practitioners. </p>
<p>In the words of <a href="https://www.britannica.com/biography/Sir-William-Osler-Baronet">William Osler</a> – who created the first residency program to get aspiring physicians out of the lecture theatre and bring them to the bedside: </p>
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<p>The good physician treats the disease; the great physician treats the patient who has the disease. </p>
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<p>This idea underpins most modern medical school curricula, with a focus on <a href="https://www.safetyandquality.gov.au/our-work/partnering-consumers/person-centred-care">person-centred care</a>. In our medical school we deliver an extensive communication skills curriculum across the five-year program. In the first two years, the training covers verbal communication and body language, making decisions with the patient, not for the patient, and listening actively. At the end of this initial training, we are confident that students are sensitive, empathetic, and caring. </p>
<p>The patient-centred approach has been a feature of medical training for several decades, so we should be seeing a system dominated by those trained in this way. But we’re not and unfortunately, it isn’t just veteran medicos who are the problem. </p>
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<figcaption><span class="caption">Don’t be like Doctor House.</span></figcaption>
</figure>
<h2>Learning to fit in</h2>
<p>Young and vibrant <a href="https://pubmed.ncbi.nlm.nih.gov/20636585/">new graduates lose at least some of their empathy</a> as they progress through medical school and postgraduate training. A series of unwritten and often unintended consequences of education, the “hidden curriculum” is what students learn without anyone teaching them. </p>
<p>First coined in 1968 for school settings by educational scholar <a href="https://news.uchicago.edu/story/philip-w-jackson-education-scholar-committed-childrens-flourishing-1928-2015">Philip Jackson</a>, the phenomenon went on to be identified in all areas of education, <a href="https://pubmed.ncbi.nlm.nih.gov/9580717/">including medical training</a>. </p>
<p>After medical school, learners who enter a new environment start changing their views and their behaviours to align with those of the more senior members of the profession and “become part of the team”. Students who learn the unofficial rules of a clinical environment might be more easily accepted within the social group. But there are also negative consequences.</p>
<p>In the classroom, our students learn to pick up on cues from their patients, to use reflective listening and ask about their patients’ concerns. In the clinical environment, <a href="https://pubmed.ncbi.nlm.nih.gov/33128262/">research shows</a> students do not see these skills used by the more experienced clinicians around them or the supervisors they look up to and want to impress. Soon, <a href="https://pubmed.ncbi.nlm.nih.gov/19707055/">good habits can be replaced by poorer behaviours</a>. And, when the students become supervisors and mentors themselves, the cycle can continue. </p>
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<figcaption><span class="caption">We are in the middle of a compassion crisis says this ICU doctor.</span></figcaption>
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<h2>Making empathy the norm</h2>
<p>Empathetic, warm clinicians definitely exist. The challenge is to make these clinicians the norm rather than the exception and to change the environment so the hidden curriculum has a positive influence on students and graduates. </p>
<p>Researchers, educational institutions, health-care institutions and patients can create and maintain a clear cultural and organisational expectation for doctors to meet a minimum standard of communication skills. </p>
<p>Firstly, researchers can challenge assumptions about the way the health system prevents doctors from being empathetic. Time pressure is often cited as an excuse to cut short on human connection, but the evidence tells us meaningful, <a href="https://pubmed.ncbi.nlm.nih.gov/27777231/">person-centred communication doesn’t take more time</a> than doctor-centred communication in a consultation. And strong empathetic connections can not only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529296/">improve patient outcomes</a> but also give doctors <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960200/">greater job satisfaction</a>.</p>
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Read more:
<a href="https://theconversation.com/true-grit-we-measured-it-and-found-it-protected-doctors-from-career-burnout-170628">True grit – we measured it and found it protected doctors from career burnout</a>
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<h2>Rewarding the good</h2>
<p>Academic health-care institutions such as teaching hospitals should improve their programs to support the doctors’ communication skills, and flood the system with empathetic doctors. They should also support new doctors so that work and study stress don’t cause burnout that can block empathy. </p>
<p>Patients should be encouraged to provide <a href="https://www.karger.com/Article/Abstract/288551">reviews of their doctors’ communication</a>, and identify both positive and negative examples of care. This feedback should be kept in consideration by the health-care system and professional organisations such as the Australian Medical Council. Good communication and empathy should be explicitly rewarded, recognised in employment and promotion processes.</p>
<p>It is each doctor’s responsibility to be the best doctor they can be – but they can’t do it alone. We can all contribute to make the environment better, and help medical students <a href="https://jamanetwork.com/journals/jama/fullarticle/200456">hold onto their empathy</a> as they become doctors.</p>
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<strong>
Read more:
<a href="https://theconversation.com/you-should-care-about-your-doctors-health-because-it-matters-to-yours-78039">You should care about your doctor's health, because it matters to yours</a>
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<img src="https://counter.theconversation.com/content/171942/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>It’s time to make caring doctors the norm, not the exception.Eleonora Leopardi, Lecturer in Clinical Education, University of NewcastleConor Gilligan, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706282021-11-02T19:06:49Z2021-11-02T19:06:49ZTrue grit – we measured it and found it protected doctors from career burnout<figure><img src="https://images.theconversation.com/files/429295/original/file-20211029-23-1b3sz8c.jpg?ixlib=rb-1.1.0&rect=43%2C8%2C5708%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/exhausted-doctor-indoors-stress-health-600w-1834874182.jpg">Shutterstock</a></span></figcaption></figure><p>Doctors are under increased pressure today – with hospitals and health settings <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">under strain</a>, extra COVID safety protocols in place, and patients fraught with worry. </p>
<p>Many doctors will be <a href="https://www.theguardian.com/australia-news/2021/nov/01/i-desperately-want-to-quit-the-often-unbearable-burden-on-australias-junior-doctors">working long hours under stressful conditions</a>, after years of gruelling training and groundwork. Some will suffer from extreme exhaustion and, at worst, burn out and leave the profession. </p>
<p><a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/ajo.13427">We studied</a> 751 Obstetrics and Gynaecology doctors working in Australia and New Zealand and used an established test of “grit”. </p>
<p>We found those who had it were less likely to suffer burnout. Our findings might help other doctors or those outside the medical field altogether.</p>
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Read more:
<a href="https://theconversation.com/hospital-emergency-departments-are-under-intense-pressure-what-to-know-before-you-go-169098">Hospital emergency departments are under intense pressure. What to know before you go</a>
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<h2>Measuring grit and burnout</h2>
<p>For our survey we recruited members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). We divided them into three groups: core trainees (in the early years of their training placements), advanced trainees (in their penultimate years of training) and fellows (fully qualified specialists). </p>
<p>Grit is defined as passion and sustained persistence for long-term achievement. It combines resilience, ambition and self-control. </p>
<p>We measured grit using the Short Grit Scale, and burnout using the Oldenburg Burnout Inventory – two of the most recognised and widely validated tools in this field of psychological assessment.</p>
<p>The <a href="https://angeladuckworth.com/grit-scale/">Grit Scale</a> was developed by <a href="https://www.goodreads.com/book/show/27213329-grit">Angela Duckworth</a>, a professor of psychology at the University of Pennsylvania. Duckworth’s GRIT score consists of ten self-assessment questionnaires with multiple-choice answers ranging from “very much like me” through to “not like me at all”. Prompt statements include: “My interests change from year to year”, and “Setbacks don’t discourage me. I don’t give up easily”. </p>
<p>We used the <a href="https://www.mdapp.co/oldenburg-burnout-inventory-olbi-calculator-606/">Oldenburg Burnout Inventory</a> to assess burnout in terms of disengagement and exhaustion. Like the Grit Scale, the Oldenberg Inventory asks respondents to rate themselves on a scale from “Strongly disagree” to “Strongly agree”. Statements include: “I always find new and interesting aspects in my work”, and “During my work, I often feel emotionally drained.”</p>
<p>In 2017, American College of Obstetricians and Gynaecologists <a href="https://www.acog.org/news/news-articles/2019/10/why-ob-gyns-are-burning-out">reported</a> up to 75% of Obstetrics and Gynaecology doctors experience some form of professional burnout during their career. </p>
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<a href="https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="boy tries monkey bars" src="https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/429299/original/file-20211029-23-142l3j6.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">Grit has been studied in other contexts including children’s learning and sporting achievement.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/determined-boy-exercising-on-monkey-bar-661021753">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/you-should-care-about-your-doctors-health-because-it-matters-to-yours-78039">You should care about your doctor's health, because it matters to yours</a>
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<h2>True grit and gynaecology</h2>
<p>In our study, the level of seniority and grit were the only two factors that significantly predicted the level of burnout among obstetricians and gynaecologists. </p>
<p>Specialists scored higher on the grit scale and experience less burnout than the training doctors. This isn’t surprising, given they’ve already shown they can power their way through the tough training years to achieve the senior rank of specialist. </p>
<p>But doctors across the spectrum with higher grit scores are also less likely to report burnout. This is consistent across age, gender, location of practice and seniority level. It shows the amount of grit a doctor has, can protect their well-being and predict success.</p>
<p>In Australia, our research paper is the first study investigating the concept of grit and burnout in medical speciality training. The relationship between grit and burnout has been studied in other fields of medical training across the world, including <a href="https://pubmed.ncbi.nlm.nih.gov/27864350/">ear, nose and throat specialists in the United Kingdom</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/31629138/">neurosurgery and orthopaedics in the United States</a>, and <a href="https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-02187-1">medical students in Slovenia</a>. </p>
<p>The grit concept has been studied outside the medical field too, in military academies for training, among teachers for academic engagement and learning outcomes for students and within sporting teams. </p>
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Read more:
<a href="https://theconversation.com/grit-matters-when-a-child-is-learning-to-read-even-in-poor-south-african-schools-157982">Grit matters when a child is learning to read, even in poor South African schools</a>
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<p>Duckworth suggests grit is a useful concept for reflection and research, but <a href="https://angeladuckworth.com/qa/#faq-152">cautions</a> against using it as a decision-making tool for “selecting employees, admitting students to college, gauging the performance of teachers, or comparing schools or countries to each other”. She adds researchers have yet to find significant grit score differences between the sexes. </p>
<p>There have been <a href="https://phys.org/news/2017-09-validity-psychological-grit-scale.html">critics</a> of the Grit Scale, who say it measures two constructs – perseverance plus consistency of interests – as one. </p>
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<figcaption><span class="caption">Researcher Angela Duckworth explains it isn’t good looks or IQ that determines success – it’s grit.</span></figcaption>
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<h2>Can we foster grit for doctors and others?</h2>
<p>There is understandable interest in fostering grit among doctors. However, little is known about how to foster the development of these traits within individuals. </p>
<p>Grit is likely to develop over time and be learnt through challenges, rather than being taught. </p>
<p>A “<a href="https://theconversation.com/you-can-do-it-a-growth-mindset-helps-us-learn-127710">growth mindset</a>” – a belief capability can be developed with effort over time – rather than a fixed mind-set has been <a href="https://www.abc.net.au/news/2018-07-31/growth-mindset-grit-and-resilience-key-to-success/10055608">associated</a> with the presence of grit in individuals. This might prove a useful approach.</p>
<p>Our surveys show grit has a protective role in combating burnout among doctors. Assessing doctors’ grit could become a standard test to minimise the likelihood of burnout or be useful for them – indeed anyone – to reflect on their goals and monitor risks to their well-being. Incorporating the concept of grit may have the potential to identify doctors intrinsically more susceptible to workplace stress and burnout and its consequences.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-to-avoid-toxic-positivity-and-take-the-less-direct-route-to-happiness-170260">How to avoid 'toxic positivity' and take the less direct route to happiness</a>
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<img src="https://counter.theconversation.com/content/170628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Donald Angstetra is a consultant obstetrician and gynaecologist at Gold Coast University and Gold Coast Private Hospitals</span></em></p>The quality of grit – passion and sustained persistence – is a useful predictor of burnout and exhaustion for doctors and maybe the rest of us too.Donald Angstetra, Adjunct Associate Professor, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1676312021-09-21T23:56:26Z2021-09-21T23:56:26ZHow Cuban medical training has helped Pacific nations face the pandemic challenge<figure><img src="https://images.theconversation.com/files/422039/original/file-20210920-19-yftgrv.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C3785%2C2620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kiribati President Taneti Maamau (rear middle) watches the country's vaccination campaign roll out in early September.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>With the COVID-19 pandemic stretching health systems worldwide, Pacific countries have capitalised on their relative isolation to avoid the worst. Border closures and other measures have slowed and stopped the spread of the virus to the point some nations have <a href="https://www.spc.int/updates/blog/2021/09/covid-19-pacific-community-updates#CurrentStatus">recorded no cases</a> at all.</p>
<p>Even where the virus has not spread, however, establishing screening, quarantine and mass vaccination programmes has <a href="https://www.adb.org/sites/default/files/linked-documents/50282-003-dc.pdf">stretched already limited health systems</a>. Where community transmission has occurred, as in <a href="https://www.stuff.co.nz/world/south-pacific/300368608/covid19-fiji-health-system-is-collapsing-under-pressure-doctor-warns">Fiji</a> and <a href="https://www.rnz.co.nz/international/pacific-news/449434/is-png-sleepwalking-through-the-pandemic">Papua New Guinea</a>, it has severely tested national health systems. </p>
<p>The good news is that these small nations have been more resilient than they might otherwise have been due to a dramatic increase in the number of doctors employed in the Pacific in the past decade.</p>
<p>In some countries this has seen a <a href="https://www.tandfonline.com/doi/abs/10.1080/09512748.2020.1808053">doubling or more</a> of doctor numbers. For example, from 2012 to 2019, the number of <a href="https://devnet.org.nz/wp-content/uploads/Cristine-Werle-Policy-Brief-The-gift-of-health_Cuban-medical-cooperation-in-Kiribati.pdf">doctors in Kiribati</a> increased from 18 to 51. Remarkable increases have also been recorded in the Solomon Islands (79 to 170), Tonga (44 to 80), Vanuatu (27 to 67) and Tuvalu (7 to 27).</p>
<p>Where these doctors come from may surprise you. Most are new graduates of the Latin American School of Medicine (<a href="https://instituciones.sld.cu/elam/">ELAM</a>) in Cuba. Over the past decade, more than 250 Pacific students have travelled to Cuba, learned Spanish, and completed six years of medical training on full scholarships from the Cuban government.</p>
<figure class="align-center ">
<img alt="teacher in white coat teaching students in a medical class" src="https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422022/original/file-20210920-31825-16clzd7.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">A long history of international cooperation: a class at the Latin American School of Medical Sciences in Havana, Cuba.</span>
<span class="attribution"><span class="source">GettyImages</span></span>
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</figure>
<h2>Solidarity and compassion</h2>
<p>Cuba has a long history of international medical cooperation and Cuban doctors have served in over 150 countries. In the Pacific, approximately 50 Cuban doctors have served in <a href="https://www.rnz.co.nz/international/pacific-news/365327/cuban-medical-team-travels-to-nauru">Nauru</a>, <a href="https://mro.massey.ac.nz/bitstream/handle/10179/15899/WerleMPhilThesis.pdf?sequence=3">Kiribati</a> and Vanuatu since 2006. </p>
<p>But Cuba has also recognised that having foreign doctors staff health systems indefinitely is <a href="https://scielosp.org/article/medicc/2019.v21n4/83-92/en/">unsustainable</a>, and that “the ideal provider is a well trained, homegrown health professional”. </p>
<p>The purpose of ELAM is therefore to train students from lower income and medically under-resourced communities who will go on to serve their countries. Training doctors is an act of solidarity and compassion built on Cuba’s commitment to health as a human right.</p>
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Read more:
<a href="https://theconversation.com/pacific-nations-grapple-with-covids-terrible-toll-and-the-desperate-need-for-vaccines-164769">Pacific nations grapple with COVID's terrible toll and the desperate need for vaccines</a>
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<p>While the programme began long before the COVID-19 pandemic, its impact on health system resilience and crisis response has been crucial. Without skilled professionals as a first line of defence, there can be no effective <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30598-0/fulltext">health security or pandemic response</a>. </p>
<p>Cuban medicine and medical training also emphasises prevention, public health and community care. It’s a model designed for low-resource environments, well matched to the <a href="https://thediplomat.com/2015/03/a-rare-opportunity-for-pacific-islands-health-care/">needs of the Pacific</a>. As one Cuban-trained graduate in Tuvalu said:</p>
<blockquote>
<p>Cuban-trained doctors have a sense for preventive medicine […] I think our best contribution in the health services would be to apply what we learned in Cuba and to adapt it to our health system in Tuvalu. </p>
<p>As a result of this pandemic our resources have become even more limited than before. So, prevention and good health promotion would be the main goals to achieve to limit the use of already scarce resources. </p>
</blockquote>
<figure class="align-center ">
<img alt="mural on a wall in Italy thanking Cuban doctors" src="https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422275/original/file-20210921-17-1bvyuqu.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">
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<span class="caption">A history of medical diplomacy: mural in Turin, Italy, thanking Cuban doctors who helped during the first wave of the pandemic.</span>
<span class="attribution"><span class="source">GettyImages</span></span>
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<h2>Problems persist</h2>
<p>At the same time, the return of these graduates and their integration into local practice hasn’t always been smooth. Their initial integration has been threatened by a lack of places in medical internship programmes in the region. These had to be rapidly created or upscaled in the Solomon Islands, Vanuatu and Kiribati. </p>
<p>While they demonstrated good basic medical knowledge and strong foundations in preventative health, many Cuban graduates did <a href="https://www.solomonstarnews.com/trainee-doctors-fail-exam/">poorly on their entry exams</a> for internship training.</p>
<p>In particular, they <a href="https://www.abc.net.au/radio-australia/programs/pacificbeat/van-cuba-drs/9790010">struggled with basic procedures</a> and also with <a href="https://www.abc.net.au/news/2015-02-09/cuban-trained-doctors-struggle-with-language-skills-in-pacific/6081278">medical English</a>, having studied in Spanish. </p>
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<strong>
Read more:
<a href="https://theconversation.com/cuban-compassion-training-doctors-for-a-pacific-island-nation-running-out-of-time-119986">Cuban compassion: Training doctors for a Pacific island nation running out of time</a>
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<p>Partly, though, problems have been the <a href="https://mro.massey.ac.nz/bitstream/handle/10179/15899/WerleMPhilThesis.pdf?sequence=3">result of differences</a> between Cuban and Pacific health systems and needs. Many <a href="https://www.who.int/westernpacific/activities/combatting-communicable-diseases-in-the-pacific">diseases prevalent in the Pacific</a> have been eradicated in Cuba, which also has a much higher <a href="https://www.who.int/data/gho/data/indicators/indicator-details/GHO/medical-doctors-(per-10-000-population)">doctor to population ratio</a> and therefore more defined professional roles within the health sector. As a medical trainer noted:</p>
<blockquote>
<p>The Cuban-trained interns said that in Cuba you would never take your own blood samples […] You wouldn’t interpret the X-rays. You’d have lots of other people to do that for you. So they’d never learn any of those skills. But they were keen to. They were so keen to learn.</p>
</blockquote>
<h2>Sustaining front line workers</h2>
<p><a href="https://www1.racgp.org.au/newsgp/professional/exciting-and-worthwhile-medical-life-in-the-solomo">Bridging courses</a> and successful intern training have addressed these differences. Concerns have eased as graduates have moved into jobs, with some also undertaking post-graduate training in Fiji, New Zealand and elsewhere. </p>
<p>Cuba’s direct Pacific contribution has slowed due to the pandemic and changes in regional governments, with only one Cuban doctor still in the region (in Kiribati). </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/by-sending-doctors-to-italy-cuba-continues-its-long-campaign-of-medical-diplomacy-134429">By sending doctors to Italy, Cuba continues its long campaign of medical diplomacy</a>
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<p>But <a href="http://misiones.minrex.gob.cu/en/articulo/cuba-takes-part-virtual-work-session-convened-pif-secretariat-address-regional-response">a virtual meeting</a> last year between Cuban experts and representatives from seven Pacific countries did address regional responses to the pandemic. Cuba has also offered post-pandemic support to Nauru and <a href="https://www.rnz.co.nz/international/pacific-news/415945/cuba-offers-doctors-to-palau-helps-stranded-palauan-students">Palau</a>, and remains open to cooperation with other Pacific countries.</p>
<p>It’s safe to say, however, that many Pacific nations have been able to respond well to the challenges of COVID-19 because of Cuba’s past assistance. In particular, the strong sense of service, community and solidarity built into Cuban medical training has sustained and motivated Pacific health workers on the front lines.</p>
<hr>
<p><em>Thanks to Dr Helen Leslie and Assoc. Prof Robert Huish for their advice and support early in this research, and to Cristine Werle for her master’s thesis work in Kiribati.</em></p><img src="https://counter.theconversation.com/content/167631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon McLennan received funding for this research from the Royal Society of New Zealand's Marsden Fund.</span></em></p>COVID-19 might have hit Pacific nations harder had it not been for Cuba’s long-standing policy of international medical diplomacy and cooperation.Sharon McLennan, Senior Lecturer in Development Studies, Massey UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1502892020-11-24T18:59:03Z2020-11-24T18:59:03ZWhen health workers came up against COVID it laid bare gaps in their training<figure><img src="https://images.theconversation.com/files/370913/original/file-20201123-21-1avsxf3.jpg?ixlib=rb-1.1.0&rect=0%2C49%2C6609%2C4343&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/nurses-assisting-elderly-people-retirement-home-1423975322">New Africa/Shutterstock</a></span></figcaption></figure><p>COVID-19 turned 2020 on its head for all healthcare workers, particularly those at the <a href="https://theconversation.com/rising-coronavirus-cases-among-victorian-health-workers-could-threaten-our-pandemic-response-142375">front line of the pandemic response</a>.</p>
<p>Unexpectedly, the need to control the spread of the coronavirus has consumed healthcare systems. The healthcare workforce’s pivotal role in our pandemic response has been in the public spotlight. The experience has exposed knowledge gaps in curriculums, bringing to the fore questions about the education and training of front line healthcare workers.</p>
<p>The pandemic has highlighted the importance of including infection control, mental healthcare and ageing and aged care in all educational programs for health professions.</p>
<h2>Infection control</h2>
<p>All healthcare disciplines are expected to include infection control contents and principles in the curriculum. However, the teaching of this content was not designed to address a pandemic of historic proportions. Nor are healthcare workers specifically taught to apply infection controls in their workplaces with a pandemic in mind. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rising-coronavirus-cases-among-victorian-health-workers-could-threaten-our-pandemic-response-142375">Rising coronavirus cases among Victorian health workers could threaten our pandemic response</a>
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</em>
</p>
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<p><a href="https://www.safetyandquality.gov.au/covid-19">Infection control protocol</a> during this pandemic requires all front-line healthcare workers to wear protective personal equipment, observe strict hand hygiene and adhere to contact-tracing measures. </p>
<p>In addition to including the classic “<a href="https://www.safetyandquality.gov.au/sites/default/files/2020-05/break_the_chain_poster_a3.pdf">chain of infection</a>” in teaching healthcare, we need to ensure students can apply these concepts in specific clinical settings. For example, aged care homes have a different set of infection control challenges from hospitals. These include potential breaches of isolation and infection containment measures by COVID-positive residents visiting other residents, a lack of dedicated isolation rooms and staff with limited training.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-all-aged-care-residents-with-covid-19-be-moved-to-hospital-probably-but-there-are-drawbacks-too-143826">Should all aged-care residents with COVID-19 be moved to hospital? Probably, but there are drawbacks too</a>
</strong>
</em>
</p>
<hr>
<p>Infection control goes beyond competence in the use of protective gear and isolation measures. Management skills are needed to ensure everyone follows recommended infection control practices within their organisations. </p>
<p>For example, <a href="https://www.healio.com/nursing/journals/jgn/2017-10-43-11/%7B49699924-3ec3-4df9-8d2b-b5756b1ca864%7D/nursing-work-in-long-term-care-an-integrative-review">registered nurses in aged care</a> must oversee and manage staff adherence to infection control protocols with their facility. These workers include students, cooks and cleaners, so they too must have the essential infection control knowledge and training.</p>
<figure class="align-center ">
<img alt="Aged care residents smiling as they exercise" src="https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370915/original/file-20201123-23-cm1xc8.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">Aged care homes that acted decisively to implement measures appropriate for a pandemic protected their residents from COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-four-smiling-senior-women-toning-367740032">belushi/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Ageing and aged care</h2>
<p>Older people are unquestionably at greater risk of serious illness or death from COVID-19. To protect them, visits by family and friends are often curtailed, particularly in residential aged care facilities. Not surprisingly, <a href="https://theconversation.com/social-isolation-the-covid-19-pandemics-hidden-health-risk-for-older-adults-and-how-to-manage-it-141277">loneliness and social isolation</a> are increasing among older people. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/social-isolation-the-covid-19-pandemics-hidden-health-risk-for-older-adults-and-how-to-manage-it-141277">Social isolation: The COVID-19 pandemic's hidden health risk for older adults, and how to manage it</a>
</strong>
</em>
</p>
<hr>
<p>Psychosocial issues like these underscore the importance of a focus on ageing and aged care in healthcare curriculums. In Australia, <a href="https://onlinelibrary.wiley.com/doi/10.1111/ajag.12775">pre-pandemic evidence</a> indicated a lack of ageing-related education for health professionals. This was highlighted by the <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2020-10/RCD.9999.0541.0001_1.pdf">Aged Care Royal Commission recommendation to integrate age-related conditions and aged care into healthcare curriculums</a> as an accreditation requirement. </p>
<p>In the context of the COVID-19 pandemic, it is crucial that healthcare students are well prepared to provide optimal care for our most vulnerable age group. </p>
<h2>Mental health</h2>
<p>The <a href="https://www.sciencedirect.com/science/article/pii/S0165032720325891?casa_token=-wkCQmsHTN4AAAAA:ug6b8ROvuo58APOPYLlxS_KKM7n2qijLURC28glKDirZAJLq6y-LOeDnsF0jA2T3_0c92s8h">mental health impacts</a> of COVID-19 have affected all population groups. <a href="https://theconversation.com/we-cant-ignore-mental-illness-prevention-in-a-covid-19-world-145686">Preventing further mental health issues is now the main goal</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-cant-ignore-mental-illness-prevention-in-a-covid-19-world-145686">We can't ignore mental illness prevention in a COVID-19 world</a>
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</em>
</p>
<hr>
<p>However, not all healthcare programs include content that incorporates approaches to psychological distress and a potential mental health crisis. COVID-19 has exposed this gap in the education of healthcare workers who have had to attend to patients’ <a href="http://pu.edu.pk/MHH-COVID-19/Articles/Article19.pdf">mental health needs</a> during the pandemic. </p>
<figure class="align-center ">
<img alt="Lonely older man looking out of window" src="https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=458&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=458&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370921/original/file-20201123-15-1xugfig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=458&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The lack of social contacts under COVID-19 restrictions has been challenging for people’s mental health.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/disabled-man-suffering-loneliness-old-age-262066235">Photographee.eu/Shutterstock</a></span>
</figcaption>
</figure>
<p>Education and training are essential as complex challenges can arise when <a href="https://doi.org/10.1111/j.1742-6723.2011.01472.x">non-expert healthcare workers</a> manage mental health issues. There’s a need to consider the inclusion in healthcare curriculums of mental health education encompassing the lifespan and life transitions – for example, <a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2768028">maternal mental health with pregnancy and childbirth during a pandemic</a>.</p>
<h2>Building in pandemic preparedness</h2>
<p>The emergence of COVID-19 has highlighted the need for healthcare curriculums to include pandemic preparedness. </p>
<p>Preparedness of course includes clinical competence of healthcare workers. However, a successful pandemic response also requires <a href="https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/COVID-19-BuildingWorkplaceResilience.pdf">building resilience</a> at a time of change in health systems. Students need to be prepared for changes in health-service delivery such as the use of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320687/">telehealth and digital platforms</a>. </p>
<p>Access to healthcare <a href="https://theconversation.com/even-in-a-pandemic-continue-with-routine-health-care-and-dont-ignore-a-medical-emergency-136246">must be maintained</a> even in the midst of a pandemic.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/even-in-a-pandemic-continue-with-routine-health-care-and-dont-ignore-a-medical-emergency-136246">Even in a pandemic, continue with routine health care and don't ignore a medical emergency</a>
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<h2>Upholding human rights</h2>
<p>COVID-19 has raised ethical and moral issues relating to the rights of every individual to health. The pandemic has <a href="https://theconversation.com/how-californias-covid-19-surge-widens-health-inequalities-for-black-latino-and-low-income-residents-143243">exposed inequalities</a> at every level – for example, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16539">rationing healthcare resources</a> for <a href="https://www.independent.co.uk/news/health/coronavirus-italy-hospitals-doctor-lockdown-quarantine-intensive-care-a9401186.html">older people</a>. It’s vital that healthcare curriculums integrate content on upholding human rights during a pandemic. </p>
<p>Understanding the <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30234-4/fulltext">social determinants of health</a> in a pandemic also helps provide contexts for infection control, care for vulnerable groups and prevention of mental health issues. </p>
<p>Attention to the most vulnerable groups, people and their families who experienced COVID-19 deaths, and an understanding of <a href="https://news.un.org/en/story/2020/10/1075002">universal health coverage</a> are fundamental for healthcare students during this pandemic and beyond.</p><img src="https://counter.theconversation.com/content/150289/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>Health education curriculums need to specifically prepare healthcare professionals to respond to a pandemic when it comes to aspects like infection control, aged care and mental health.Jed Montayre, Senior Lecturer (Nursing), Western Sydney UniversityYenna Salamonson, Professor in Nursing, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1498162020-11-19T22:48:51Z2020-11-19T22:48:51ZWhy the way we approach transgender and non-binary healthcare needs to change<p>Demand for healthcare for transgender people is <a href="https://www.nzma.org.nz/journal-articles/increasing-rates-of-people-identifying-as-transgender-presenting-to-endocrine-services-in-the-wellington-region">on the rise</a> in New Zealand but training for health professionals to develop basic competencies is lagging behind. </p>
<p>There is little teaching on gender and sexuality at either of <a href="https://www.nzma.org.nz/journal-articles/sexuality-and-gender-identity-teaching-within-preclinical-medical-training-in-new-zealand-content-attitudes-and-barriers">New Zealand’s medical schools</a>. It’s partly due to lack of time, but also lack of <a href="https://www.nzma.org.nz/journal-articles/advancing-transgender-healthcare-teaching-in-aotearoa-new-zealand">confidence and knowledge</a> to teach the topic. </p>
<p>Medical education needs to change urgently to prepare doctors to adequately care for their transgender and non-binary patients.</p>
<h2>Transgender and non-binary health</h2>
<p>We use the term transgender (or trans) to refer to people who identify with a gender different to that assigned to them at birth. The term non-binary describes people who don’t identify with the male/female gender binary. </p>
<p>There are other gender identities such as <a href="https://takatapui.nz/#home">takatāpui</a>, a traditional Māori term which has been reclaimed to embrace all Māori who identify with diverse genders and sexualities. Not everyone will identify with these umbrella descriptors. </p>
<p>Transgender identities are not an illness or a mental health problem. They are a variation of human experience. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/supporting-trans-people-3-simple-things-teachers-and-researchers-can-do-149832">Supporting trans people: 3 simple things teachers and researchers can do</a>
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<p>Problems arise because of negative societal attitudes. Trans and non-binary people still face <a href="https://www.hrc.co.nz/news/human-rights-commission-issues-report-rainbow-human-rights-aotearoa-new-zealand/">discrimination, stigmatisation and marginalisation</a>. These experiences can lead to <a href="https://www.liebertpub.com/doi/full/10.1089/trgh.2016.0012">psychological distress</a>.</p>
<p>In the <a href="https://www.fmhs.auckland.ac.nz/assets/fmhs/faculty/ahrg/docs/Youth12-transgender-young-people-fact-sheet.pdf">Youth’12</a> survey of 8,500 high school students carried out in 2012, almost half of the transgender students reported experiencing depressive symptoms. One in five had attempted suicide in the year prior to the survey. </p>
<p>The <a href="https://countingourselves.nz/">Counting Ourselves</a> survey in 2018 also showed high rates of mental health problems and a higher risk of suicide and substance abuse. </p>
<p>It highlighted the difficulty many transgender and non-binary people face in accessing gender-affirming healthcare. Many already had negative experiences and said they avoided seeing a doctor because they were worried about being disrespected. </p>
<p>Not all trans people will require access to hormone therapy or surgery, but many do. Removing barriers to healthcare is essential. Trans and non-binary people have specific health needs to affirm their gender identity and to reduce <a href="https://www.healthnavigator.org.nz/health-a-z/g/gender-dysphoria/">gender dysphoria</a> — the distress that can occur when someone’s gender identity differs from the sex assigned to them at birth. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/informed-consent-individual-care-vital-to-ensure-reproductive-rights-of-transgender-australians-99589">Informed consent, individual care vital to ensure reproductive rights of transgender Australians</a>
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<h2>Changing medical education and training</h2>
<p>Case studies used to teach medical students rarely show diversity of sexuality or gender identity. When you don’t see yourself or the population reflected in your learning, it can send a message that this isn’t important or relevant to future practice. </p>
<p>Just as we want our <a href="https://www.otago.ac.nz/healthsciences/students/professional/otago686979.html#:%7E:text=The%20Mirror%20on%20Society%20Selection,have%20applied%20via%20the%20application">future doctors</a> to reflect the population they will treat, the <a href="https://www.bmj.com/content/364/bmj.l300.full">medical curriculum</a> should evolve to do so, too.</p>
<p>Transgender healthcare teaching needs to be part of all medical speciality, nursing and allied health training, so that trans and non-binary patients can expect some basic cultural competence in all areas of our health service. Care and sensitivity are required in certain specialities — including endocrinology, obstetrics, gynaecology, sexual health, mental health, urology and breast surgery. But it is most important in general practice where we receive most of our healthcare.</p>
<h2>From dysphoria to celebration</h2>
<p>While some care requires hospital specialists, general practitioners (GPs) can provide much gender-affirming care. </p>
<p>GPs are experts in supporting people with normal life issues, as well as addressing physical and psychological needs in a holistic manner. </p>
<p>GPs who wish to provide gender-affirming care based on an <a href="https://www.transhub.org.au/clinicians/informed-consent">informed consent</a> model, should be supported and encouraged to do so. This aligns with <a href="https://www.nzma.org.nz/journal-articles/guidelines-for-gender-affirming-healthcare-for-gender-diverse-and-transgender-children-young-people-and-adults-in-aotearoa-new-zealand">best practice models</a> that view the patient as the expert in their identity and recognise them as a competent adult who can make choices about their own healthcare. </p>
<p>A multidisciplinary approach with the GP at the centre, supported by other specialists where necessary, is an ideal model. Financial and educational support for primary care to take the lead in this area would increase patients’ access to care and reduce the need for referrals to secondary care, freeing up appointments for people who need them. </p>
<p>There are simple steps health providers can take to make transgender and non-binary patients feel more welcome and respected, including:</p>
<ul>
<li>Outward signs of acceptance in the practice environment, such as a rainbow flag, relevant posters and pamphlets</li>
<li>gender-neutral toilets</li>
<li>enrolment forms with appropriate questions around gender identity, names and pronouns.</li>
</ul>
<p>These things in themselves can make a difference, but need to be backed up by staff who use people’s correct names and pronouns and do not make assumptions around gender or sexuality. </p>
<p>Healthcare providers who treat their transgender and non-binary patients with respect and support them to affirm their individual gender identity contribute to making them comfortable attending appointments. The result is improved health and well-being.</p>
<p>Better medical training and practice also require changes in societal attitudes, and that’s where we all have a role to play.</p><img src="https://counter.theconversation.com/content/149816/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Rona Carroll is a general practitioner affiliated with PATHA (Professional Association for Transgender Health Aotearoa).</span></em></p>Trans and non-binary people often avoid seeing a doctor because they fear discrimination. Health professionals need better training to provide gender-affirming care.Rona Carroll, Senior Lecturer, Department of Primary Health Care and General Practice, University of OtagoLicensed 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>
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<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>
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<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>
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<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>
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<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/1379752020-07-07T21:11:29Z2020-07-07T21:11:29ZSimulations with actors prepare nurses for the demands of their profession<figure><img src="https://images.theconversation.com/files/345342/original/file-20200702-111374-1drboia.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C1957&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Training with actors gives nurses the chance to practise caring for a diverse set of patients.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span></figcaption></figure><p>Now more than ever, it is essential that post-secondary nursing programs train students to deal with real-world scenarios. The sudden onset of COVID-19 has further highlighted the critical role nurses play in our health system. What role can professional actors play in preparing nursing students to handle these demands? </p>
<p>At MacEwan University, our nursing science program uses theatre graduates to play standardized patients in clinical simulations. In a typical simulation, the instructor asks the actor to improvise a situation that the nursing students may face in their professional practice. After each simulation, the instructor leads a debriefing session to help nursing students reflect on what worked and what they can improve on.</p>
<h2>Benefits of using actors</h2>
<p>According to Cynthia Gundermann, who co-ordinates theatre graduates in the simulation program, her students benefit greatly from working with the actors. “When our learners can suspend their disbelief and fully engage with the portrayed characters, they are able to gain richer and more meaningful learning from their simulation events.” </p>
<p>To help the students buy into the simulations, the actors use <a href="https://www.penguinrandomhouse.com/books/350929/the-stanislavski-system-by-sonia-moore/">Russian theatre actor Constantin Stanislavski’s psychological realism techniques</a> to create believable patients. “The most important thing is to be authentic,” explained theatre graduate Dempsey Bolton. “Working with actors is the closest students can get to a real-world situation.” </p>
<p>Research demonstrates that role-play with actors enhances the realism of clinical simulations. <a href="https://doi.org/10.1016/j.pec.2014.07.001">One study conducted with the Program to Enhance Relational and Communication Skills (PERCS)</a> noted that 98 per cent of 192 learners and 97 per cent of 33 faculty members described the actors’ portrayals of patients as realistic. In addition, 97 per cent of learners and 100 per cent of faculty agreed that the use of actors was valuable to learning.</p>
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Read more:
<a href="https://theconversation.com/how-theatre-training-can-boost-your-doctors-empathy-102395">How theatre training can boost your doctor's empathy</a>
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<p>The actors also use renowned acting teacher <a href="http://applausebooks.com/books/9781617746192">Stella Adler’s theories</a> on character development to portray patients with a wide range of physical, psychological and socioeconomic characteristics. This helps the students better understand how to treat patients with diverse worldviews, backgrounds and prejudices. Theatre graduate Jarrod Smith said exploring patients’ backstories helps him “put flesh on their bones,” resulting in more truthful performances. “I want to know what my characters ate for lunch,” said Smith jokingly.</p>
<p>In addition, the actors draw on American theatre coach <a href="https://www.penguinrandomhouse.com/books/113022/sanford-meisner-on-acting-by-sanford-meisner-and-dennis-longwell-with-an-introduction-by-sydney-pollack/">Sanford Meisner’s</a> listening and improvisation exercises to interact with nursing students without the need for a scripted text. This helps students develop communications skills and the ability to think on their feet. Similarly, <a href="https://doi.org/10.1016/j.pec.2014.07.001">research by Sigall K. Bell and others found that learners valued the actors’ flexibility in their approach to conversation.</a></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&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">Simulations with actors train nurses to deal with a host of real-world scenarios.</span>
<span class="attribution"><span class="source">(Unsplash/CDC)</span></span>
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<p>The actors also use <a href="https://www.wiley.com/en-ca/Respect+for+Acting%2C+2nd+Edition-p-9780470228487">techniques developed by Uta Hagen</a> to realistically express intense emotions such as grief, fear, anxiety, sadness and anger. Interacting with patients in emotional distress helps nursing student develop empathy and teaches them to balance both the patient’s physical and psychological needs. </p>
<p>Nursing instructors like working with actors because they are able to instantly incorporate feedback in simulations, just as they would a theatre director’s notes in rehearsals. “In theatre school we were encouraged to embrace constructive criticism just as much as praise,” said graduate Kendra Sargeant. “When a director gives me a note, I’m able to integrate it into my performance immediately.” </p>
<p>The use of professional actors in simulations does not only benefit the nursing students. “It’s a beneficial relationship on both ends,” said Smith. “It’s an opportunity to dust off my acting chops between shows.” Working in simulations also gives Smith a sense of purpose, knowing he is contributing to society in a positive way. “It’s rewarding know that you’re helping someone who’s going to be a nurse one day.” </p>
<h2>Challenges of simulation work</h2>
<p>While performing in simulations is gratifying, the actors experience a few challenges. It can be difficult to maintain a sense of spontaneity when acting the same scenario repeatedly, albeit for different students. “Keeping it fresh is definitely a challenge,” said Bolton. </p>
<p>In addition, Sargeant confessed that the repetitive nature of the work can be emotionally taxing. Smith agreed: “Going to extreme emotional places throughout an eight hour day can be pretty draining.” Research indicates that some actors <a href="http://dx.doi.org/10.1016/j.ecns.2016.08.005">depicting mental illnesses, such as depression, have difficulty shaking off such feelings, even days after the simulations</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?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">
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<span class="caption">A mannequin being used for a surgery simulation.</span>
<span class="attribution"><span class="source">(Unsplash/Tim Cooper)</span></span>
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<p>Another challenge is that sometimes the actors are required to act opposite a mannequin. This can elicit understandable giggles from the nursing students. Therefore the actors must rely on their acting chops to help them treat the mannequin as if it were a real human being. “When we’re engaged, it’s easier for the students to be engaged,” said Smith. </p>
<p>This fledgling partnership between MacEwan’s theatre graduates and nursing students has highlighted the striking similarity between the roles of actors and nurses. Both jobs are about being present, listening, thinking on your feet, understanding people, managing intense emotions, working as part of a team, embracing constructive criticism, navigating personal boundaries, fostering empathy and acting authentically. And perhaps most important, both jobs keep us alive — one physically and one spiritually.</p><img src="https://counter.theconversation.com/content/137975/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>Using actors can provide nurses with valuable training dealing with a diverse set of patients.Dawn Sadoway, Assistant Professor, Theatre Department, MacEwan UniversityLeigh Rivenbark, Assistant Professor, Theatre Department, MacEwan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1342422020-04-01T05:16:22Z2020-04-01T05:16:22ZUsing nursing assistants to fill coronavirus gaps brings risks if they’re not up to the job<figure><img src="https://images.theconversation.com/files/324483/original/file-20200401-66109-l7q7hc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7877%2C4443&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Have a nice day Photo</span></span></figcaption></figure><p>The number of people going to hospital with the coronavirus is expected to rise, putting a strain on our health and aged care services and their workforce.</p>
<p><a href="https://www.canberratimes.com.au/story/6701301/student-nurses-to-join-health-ranks-in-the-battle-against-covid-19/">Australian undergraduate student nurses</a> and those <a href="https://www.afr.com/politics/federal/student-nurses-could-be-a-great-asset-when-virus-peaks-20200318-p54bdz">health workers here on visas from overseas</a> are being encouraged to work as nursing assistants during this COVID-19 pandemic.</p>
<p>This is in keeping with the worldwide trend of employing more nursing assistants in health and aged care services.</p>
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Read more:
<a href="https://theconversation.com/supplies-needed-for-coronavirus-healthcare-workers-89-million-masks-30-million-gowns-2-9-million-litres-of-hand-sanitiser-a-month-134786">Supplies needed for coronavirus healthcare workers: 89 million masks, 30 million gowns, 2.9 million litres of hand sanitiser. A month.</a>
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<p>But <a href="https://www.acn.edu.au/wp-content/uploads/white-paper-regulation-unregulated-health-care-workforce-across-health-care-system.pdf">questions remain</a> about the differences in training of nursing assistants compared to regulated nurses (registered and enrolled nurses) and the tasks they are able to undertake.</p>
<h2>An unregulated workforce</h2>
<p>As nursing assistants are unregulated, their training and clinical practice is not controlled by professional bodies or governments.</p>
<p>Training is certainly recommended, but it is not compulsory, and content between training organisations can be different. Therefore, <a href="https://doi.org/10.1111/jan.14354" title="A systematic review of activities undertaken by the unregulated nursing assistant">nursing assistants working in hospitals and residential aged care facilities</a> may have completed an on-line course, a <a href="https://www.aqf.edu.au/aqf-qualifications">Certificate III</a> qualification, completed one year of undergraduate nursing studies or have a nursing qualification from overseas. They may have had no training at all.</p>
<p>Visa holders can work as a nursing assistant while their overseas nursing qualifications are being assessed by the <a href="https://www.nursingmidwiferyboard.gov.au/Registration-and-Endorsement/International.aspx">Nursing and Midwifery Board of Australia</a>.</p>
<p>It is these last two examples, undergraduate nursing students in Australia or overseas trained nurses, that the <a href="https://www.smh.com.au/national/visa-work-restrictions-lifted-on-20-000-international-student-nurses-20200318-p54bfz.html">Prime Minister Scott Morrison recommends</a> organisations seek to recruit.</p>
<h2>What a nursing assistant can do</h2>
<p><a href="https://www.health.nsw.gov.au/workforce/Documents/AIN-acute-care-position-description.pdf">Nursing assistants can work</a> under the supervision of a registered or enrolled nurse to help provide basic nursing care such as showering, hair, skin and mouth care. They can assist with activities essential for daily living including helping people with dressing and feeding. </p>
<p>They may also perform simple wound dressings, transport stable patients or residents between beds or wards, and undertake nursing observations such as pulse, temperature and respiratory rates.</p>
<p>Using student nurses and current visa holders seems like a potential solution to a possible staffing crisis. But is it?</p>
<p>For student nurses, there is considerable variation in the course structure offered by universities, who each write their own curricula within the boundaries of the <a href="https://www.anmac.org.au/about-anmac/about">Australian Nursing and Midwifery Accreditation Council</a>.</p>
<p>This means not all students will have had the same clinical experience or completed the same content by a given point in their course. Therefore they may not have equivalent knowledge or skills before working as a nursing assistant.</p>
<h2>Patients at risk?</h2>
<p>This variation may be a problem and there is a lot of evidence that a higher number of unregulated nurses and a lower number of regulated nurses increases the risk of <a href="https://theconversation.com/replacing-registered-nurses-isnt-the-answer-to-rising-health-costs-25739">patient infections</a> and other <a href="https://www.sciencedirect.com/science/article/pii/S0020748916301559" title="The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data">adverse events in hospitals</a>) and the <a href="https://theconversation.com/our-ailing-aged-care-system-shows-you-cant-skimp-on-nursing-care-115565">aged care</a> sector.</p>
<p>For example, nursing people with an infectious disease requires scrupulous attention to detail and meticulous use of Personal Protective Equipment (PPE) to prevent further spread.</p>
<p>There are <a href="https://theconversation.com/why-singapores-coronavirus-response-worked-and-what-we-can-all-learn-134024">correct ways to apply</a> and remove a mask and gown. A tiny slip-up can put the wearer and others at risk of contamination.</p>
<p>Working as nursing assistants can provide undergraduate students with valuable clinical experience. Our recent <a href="https://doi.org/10.1111/jan.14354" title="A systematic review of activities undertaken by the unregulated nursing assistant">research</a> shows most nursing activities performed by nursing assistants are those personal care activities described above.</p>
<p>But we found around one-third of tasks they performed require a higher level of skill and knowledge and should therefore be performed by regulated nurses.</p>
<p>This may explain why the rate of adverse events increases with more unregulated nurses. With the projected increase in patients who may need intensive care, experienced qualified nurses who can work without supervision will be needed.</p>
<h2>Can retired nurses help?</h2>
<p>Some have recommended recruiting <a href="https://theconversation.com/how-well-avoid-australias-hospitals-being-crippled-by-coronavirus-133920">retired nurses</a> to help staff intensive care units. Again, this is fraught with problems. </p>
<p>Working nurses are ageing – the average age is about 45 – with two out of five aged <a href="https://www.aihw.gov.au/reports/workforce/nursing-and-midwifery-workforce-2015/contents/who-are-nurses-and-midwives">50 and over</a>. So most retired nurses are likely in their 60s or older.</p>
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<a href="https://theconversation.com/in-the-time-of-coronavirus-donating-blood-is-more-essential-than-ever-134541">In the time of coronavirus, donating blood is more essential than ever</a>
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<p>The two age groups – the over 50s and the over 60s – are precisely those at risk of a severe response to the coronavirus, which could make staffing shortages and the demand for beds much worse. </p>
<p>Perhaps a more effective and sustainable solution would be to use Australian Defence Force nurses who are all regulated, presumably fit and who have been prepared to deal with emerging crises at short notice.</p>
<p>Australia is clearly going to need innovative ways to ease pressure on the health workforce over the coming months. If we’re going to recruit student nurses and current visa holders, we need to make sure all have been trained and assessed to the same standard.</p><img src="https://counter.theconversation.com/content/134242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Blay is a member of the Australian College of Nursing </span></em></p><p class="fine-print"><em><span>Christine Duffield receives funding from the Australian Research Council.
Fellow of the Australian College of Nursing</span></em></p><p class="fine-print"><em><span>Michael Roche has received funding from the Australian Research Council. He is a member of the Australian College of Nursing. </span></em></p>We need to make sure those brought in to help cope with the pandemic have adequate training to avoid any risks in patient care.Nicole Blay, Research Fellow - workforce, Western Sydney UniversityChristine Duffield, Professor, Nursing and Health Services Management, Faculty of Health, University of Technology SydneyMichael Roche, Associate Professor Mental Health Drug and Alcohol Nursing, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1310772020-02-17T17:18:57Z2020-02-17T17:18:57ZThe number of new doctors continuing their NHS training has plummeted – burnout may be to blame<p>The number of people applying to study medicine has increased by <a href="https://www.gmc-uk.org/-/media/documents/the-state-of-medical-education-and-practice-in-the-uk---workforce-report_pdf-80449007.pdf">over 6%</a> in the last year, with many medical schools receiving over ten applicants for every university place. And so you might think that the UK’s future supply of doctors is in excellent health. </p>
<p>Don’t be so sure. <a href="https://www.gmc-uk.org/-/media/documents/the-state-of-medical-education-and-practice-in-the-uk---workforce-report_pdf-80449007.pdf">Over half</a> of doctors surveyed recently are planning to either retire early or to spend less time in clinical practice. And shockingly, <a href="https://www.foundationprogramme.nhs.uk/wp-content/uploads/sites/2/2019/11/F2-Career-Destinations-Report_FINAL-2018.pdf">recent figures</a> reveal that only 37% of doctors completing their foundation years – the two obligatory first years in work after the five years in medical school – are going straight into training to become the surgeons, radiologists, anaesthetists and GPs of tomorrow.</p>
<p>Many in the medical world saw this coming. There has been a <a href="https://www.foundationprogramme.nhs.uk/wp-content/uploads/sites/2/2019/11/F2-Career-Destinations-Report_FINAL-2018.pdf">steady decline</a> in these numbers since this survey began in 2011, when around 71% of foundation doctors elected to continue into their speciality training. Experience suggests that most doctors avoiding specialisms do return within three years, but a worrying <a href="https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk">5% are lost</a> for good.</p>
<h2>What’s going wrong</h2>
<p>One explanation for this worrying drop off is that young doctors are just not ready to commit to a chosen speciality on completion of their foundation training. Many argue that they need more time to either explore the options available or to contribute to research or voluntary work overseas.</p>
<p>I recognise this motivation: I spent several years as a senior house officer (SHO) – a service doctor not attached to a speciality training programme – in A&E, paediatrics, obstetrics and gynaecology, and anaesthetics before it became clear what I wanted to do, eventually training in anaesthetics and intensive care medicine. </p>
<p>During this time I accumulated a wealth of knowledge and experience and continued to serve the health system I’d trained for. Only around <a href="http://www.asit.org/assets/documents/MMC_FINAL_REPORT_REVD_4jan.pdf">a third</a> of doctors know what they want to do after foundation training, a remarkably similar number to those now dropping off the fast track to specialist training. </p>
<p>Much can be blamed on the <a href="http://1nj5ms2lli5hdggbe3mm7ms5.wpengine.netdna-cdn.com/files/2010/03/pnsuk1.pdf">NHS Plan 2000</a>, which sought to “improve patient care by improving medical education with an efficient career path for doctors” and “modernised” the SHO grade by replacing it with fast-track run-through training. This effectively removed any opportunity to “try before you buy” your eventual career. The chickens are now coming home to roost, with young doctors with little clinical experience having to make big choices too early.</p>
<p>The other explanation for dropping out – burnout – is more worrying. The British Medical Association, along with many of the specialty medical royal colleges, has <a href="https://www.bma.org.uk/news/media-centre/press-releases/2018/november/number-of-junior-doctors-suffering-burnout-is-deeply-concerning">highlighted</a> this as a growing problem among young doctors.</p>
<p>It seems incredible that young doctors could feel burnt out having barely started the career they dreamed of as a student. They are protected by working time directives; they are annually appraised; they work in quality-reviewed environments and are surveyed to within an inch of their lives to determine how satisfactory they find their training programmes. </p>
<p>All of this was alien 25 years ago. Yet despite all the “improvements” imposed on training, today’s young doctors seem to be the unhappiest generation that has ever been. As in most unhappy relationships, I believe both parties are contributing to the problem – the modern trainee doctor and the modern NHS.</p>
<h2>What needs to change</h2>
<p>Millenials and Generation Z (the post-millennials) have different expectations than Generation X, the central one being that they feel entitled to a good <a href="https://www.forbes.com/sites/heidilynnekurter/2018/11/15/5-ways-millennials-are-shaking-up-the-workforce-from-the-bottom-up/">work-life balance</a>. This seems perfectly reasonable. But placed in the context of a career nested in an increasingly bureaucratised, over-regulated, performance-managed, risk-averse NHS, a traumatic collision is inevitable. </p>
<p><a href="https://www.gmc-uk.org/-/media/documents/the-state-of-medical-education-and-practice-in-the-uk---workforce-report_pdf-80449007.pdf">Data shows</a> a year on year decline in graduates feeling prepared for their jobs as foundation doctors, reflecting an increasingly difficult NHS working environment. Doctors’ jobs have always been hard, but the pay-off was that you were made to feel a special part of the NHS and nurtured within caring teams, given on-site accommodation and parking, and were able to cultivate a vibrant social life within your hospital to compensate for the stressful work and long hours. No more. </p>
<p>The disintegration of consultant “firms” – clinical teams under the leadership of a single consultant, which rarely exist now, a wholesale move to shift working, and perks “value-engineered” to non-existence have removed any buoyancy aids that once kept young doctors afloat. </p>
<p>The usual solutions to this growing problem can be reeled off depending on your perspective. Produce more doctors (to pour into the leaky bucket), make working life more flexible (to spend less time at work), improve training (oh Lord, not more inspections). But I guarantee that none of these will stem the outgoing tide.</p>
<p>On the one hand, we need to recapture the humanity of the NHS and make doctors feel more than grinding cogs in a brutal machine. The clinical family needs to be reconstructed to help cushion the stresses of everyday clinical work. On the other hand, doctors need to rediscover the moments of undiluted joy in the work they do. Those indescribable moments of delight when you realise you’ve made a difference to the life of another human being.</p>
<p>These changes are subtle and will not be brought about by governmental think tanks or well meaning educationists. That is what brought us to where we are. Let’s begin to think the unthinkable and chip away at mindless political correctness, impassive administration and litigation-paranoia. Doctors are too focused on the risks of getting it wrong, rather than the rewards of getting it right.</p>
<p>One thing is certain: if we keep doing more of the same we will get more of the same, a disillusioned workforce whose aim is to spend as little time as possible at the clinical coalface.</p><img src="https://counter.theconversation.com/content/131077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Kinnear 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 need to recapture the humanity of the NHS and make doctors feel more than grinding cogs in a brutal machine.John Kinnear, Head of School of Medicine, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1239322019-10-28T15:04:00Z2019-10-28T15:04:00ZHealth professionals and cadavers: the quest for an ethical approach<figure><img src="https://images.theconversation.com/files/298556/original/file-20191024-170481-12xhgvk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cadaver-based teaching prepares students intellectually and emotionally to deal with the challenges they will face in their health sciences careers.</span> <span class="attribution"><span class="source">Dr Tobias Houlton </span></span></figcaption></figure><p>The study of anatomy has been the foundation for the training of students in medical and allied health sciences – dentistry, physiotherapy, occupational therapy, pharmacy, nursing and medical science – for hundreds of years. To most teachers of human structural anatomy, knowledge of this complex subject is inseparably linked to dissection of the human body. Dissection remains a fundamental aspect of anatomy and is considered to be the “gold standard” for teaching human anatomy in many parts of the world.</p>
<p>The reason for this is that cadaver-based teaching prepares students intellectually and emotionally to deal with the challenges they will face in their health sciences careers.</p>
<p>The dissection of the human cadaver guides students in understanding the intricate three-dimensional relationships of the structures underlying the skin. This is important for a number of reasons. For example, it’s vital for doctors performing a clinical examination of a patient, and for a dentist in knowing where to inject or make surgical incisions during procedures in the mouth.</p>
<p>Dissection also allows students to understand the differences between the normal and the abnormal, such as congenital abnormalities or pathologies.</p>
<p>In addition, it’s vital for surgeons. This is because each living person is unique. The variability of structures in the human body seen during dissection prepares surgeons-to-be for any eventuality during surgery. Similarly, knowledge gained from dissection of the body aids radiologists with interpreting shapes and shadows of structures they notice in the scans and images they scrutinise to arrive at a diagnosis.</p>
<p>The importance of dissection has been stressed in relation to other essential learned abilities too. For example, exposure to dissection introduces the health professional student to death. It also provides moral and ethical training, as well as a humanistic approach to patient care.</p>
<p>Given the importance of dissection, acquiring bodies for teaching and basic research is crucial. But what ethical codes should apply? What rules should be followed?</p>
<h2>Early history</h2>
<p>The early history of the acquisition of cadavers causes discomfort for most anatomists. This is because it includes accounts of body snatching, grave robbing and other immoral and unethical means of acquiring bodies.</p>
<p>In the past in South African medical schools, human cadavers were often derived from unclaimed bodies. This is still legal under the <a href="https://www.gov.za/documents/national-health-act">National Health Act</a>. But, with the change in social beliefs in the 20th century, many departments of anatomy around the world initiated body donation programmes. This includes South Africa.</p>
<p>These programmes embraced the religious and cultural beliefs of the communities in which they were based, and are specifically designed to encourage informed consent. This means that the donor should have full knowledge of how their remains will be used for teaching and research. With this knowledge, a person can make an informed decision as to whether or not they will consider donating their remains.</p>
<p>In addition, anatomy departments have been provided with guidelines for the ethical acquisition of cadavers. These guidelines have been drawn up by professional anatomical societies such as the International Federation of Associations of Anatomists and the Trans European Pedagogic Research Group.</p>
<h2>Major changes</h2>
<p>The guidelines, plus a strong commitment to an ethical approach, have led to major changes in the way the School of Anatomical Sciences at the University of the Witwatersrand acquires cadavers.</p>
<p>The school’s population of cadavers has been transformed from an almost totally unclaimed collection to one which consists purely of bequeathed and donated individuals.</p>
<p>However, there is a need to encourage diversity in the cadaver population to ensure it represents the country’s rich variety in population affinity, age and sex. This can only be achieved by informing communities throughout the country of the importance of body donor programmes.</p>
<p>This requires gaining trust which can only be done through ethical practice. The central message is that the bequest of one’s body after death is an altruistic gift.</p>
<p>South Africa isn’t the only country addressing the ethics of its cadaver population. Every year the International Federation of Associations of Anatomists raises awareness about the continuing challenges on World Anatomy Day. This date commemorates the day on which Vesalius, the “father of anatomy”, died in 1564. To mark the day, international departments and schools of anatomy, such as ours, celebrate the generosity of the <a href="https://www.wits.ac.za/anatomicalsciences/become-a-body-donor/">selfless donors</a> who have contributed to the training of many health professionals.</p><img src="https://counter.theconversation.com/content/123932/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brendon Kurt Billings has previously received funding from the National Research Foundation</span></em></p><p class="fine-print"><em><span>Beverley Kramer is Professor Emeritus in the Wits School of Anatomical Sciences which uses cadavers for teaching and research. She has previously received external and government funding for research, but not related to studies on cadavers. She is also currently President of the International Federation of Associations of Anatomists. </span></em></p>Dissection is important for developing a range of skills, as well as moral and ethical training and a humanistic approach to patient care.Brendon Kurt Billings, Lecturer/Curator, University of the WitwatersrandBeverley Kramer, Emeritus Professor, School of Anatomical Sciences, faculty of Health Sciences, University of the WitwatersrandLicensed 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>
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<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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<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>
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<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>
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<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>
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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>
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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>
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<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>
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<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>
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<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>
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<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/1116912019-02-15T12:08:16Z2019-02-15T12:08:16ZHow prisoners and soldiers are preparing student nurses for life on NHS frontline<figure><img src="https://images.theconversation.com/files/258754/original/file-20190213-181623-10gkmuz.jpg?ixlib=rb-1.1.0&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/speeding-ambulance-city-street-zoom-effect-61698112">Shutterstock</a></span></figcaption></figure><p>The NHS is duty bound to provide its patients with a high standard of nursing care. But a range of pressures is making this increasingly difficult for a <a href="https://www.bbc.co.uk/news/uk-scotland-45416421">shrinking nursing workforce</a> to provide. An <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/july2017">ageing population</a> means more people in hospital, often for longer periods. Patients with multiple, complex conditions require round-the-clock care from a team of dedicated nurses. But fewer nurses attempting to treat growing numbers of patients creates the perfect storm for stress and burn-out.</p>
<p>Today’s student nurses must be equipped with a range of strategies if they are to successfully face these challenges. They must be emotionally and physically resilient while also possessing communication, teamwork and leadership skills. It’s a tall order, but one which has been an addressed at Dundee University with the support of local prisoners and soldiers.</p>
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<img alt="" src="https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=310&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=310&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=310&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=390&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=390&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258757/original/file-20190213-181619-vfum80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=390&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Experience of emergency injury scenarios gives students the confidence to deal with the real thing when it happens.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>One element of the undergraduate nursing programme is simulation, which requires public volunteers to role-play the part of the patient in realistic practice scenarios. Students work as a team to achieve a successful outcome for the “patient” who, in turn, gives feedback to students on their performance.</p>
<h2>Prison break</h2>
<p>Attempting to keep the simulated scenarios as real as possible has proved to be a challenge. As with most volunteer groups, members tend to be elderly retirees. Volunteers from marginalised groups were required in order to make the experience more authentic for students. This is where inmates from the nearby <a href="http://www.sps.gov.uk/Corporate/Prisons/CastleHuntly/HMP-Castle-Huntly.aspx">Castle Huntly Prison</a> stepped in to bridge the gap.</p>
<p>Initially, the idea of involving prisoners in an undergraduate nursing programme did raise a few eyebrows but, on closer examination, the rationale for this initiative soon became clear. <a href="https://www.scotpho.org.uk/population-groups/prisoners/data/prisoner-health/">Research</a> shows that prisoners have poor physical, mental and social health. Many have low education and literacy levels, low levels of employment and may have been in care.</p>
<p>The Castle Huntly volunteers were typical of this group, and they proved to have a wealth of knowledge about complex health needs, experience of poor mental and physical health and experience of being in the NHS system. The prison’s main role is to help prepare offenders for reintroduction back into their communities. This is done by encouraging individuals to take personal responsibility for their own actions and offering opportunities to build “job readiness” through work placements.</p>
<p>Participation in simulation activities quickly became a popular placement with more than 60 prisoners taking part. Prisoners’ roles were initially as actors, but they soon became involved in helping design, deliver and evaluate the simulation activities which included diabetes, sexual health and substance misuse.</p>
<p>Not only were the prisoners supporting the education of student nurses, they were developing their own self-esteem and sense of worth, as one prisoner explained:</p>
<blockquote>
<p>When I came back from that session I was on a high. I really enjoyed the day… It’s the first time in years I’ve actually gone out and been a human in that kind of environment … expanding my own knowledge. It’s a good idea.</p>
</blockquote>
<h2>Soldiering on</h2>
<p>But it’s not just prisoners getting in on the nurse education experience in Dundee. The local army barracks has also become involved in an the scheme to help build emotional and physical resilience in nursing students.</p>
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<img alt="" src="https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=304&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=304&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=304&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=382&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=382&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258755/original/file-20190213-181604-162tc1u.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=382&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The 225 Medical Regiment helping students experience an authentic medical emergency.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>The 225 Medical Regiment Scotland partnered the university to develop a series of authentic, real-life scenarios which students may face in their future careers. One activity, “exercise team resilience”, is a day-long, outdoor experience which creates the simulated scenario of an earthquake.</p>
<p>Prisoners, keen to retain their involvement, played the part of locals who had been caught up in the disaster. The day aims to develop nursing students’ teamwork and leadership skills, offering an opportunity to develop physical and emotional resilience in a high-stress situation. <a href="https://stv.tv/news/north/1396348-nursing-students-learn-to-save-lives-after-earthquakes/">Feedback</a> from both students and prisoners was positive.</p>
<p>Further exercises were developed and delivered, including “team spirit” and “team endurance” which focused on team building and clinical skills and have been been well received by students, prisoners and soldiers. </p>
<p>Nursing is a rewarding but challenging career, and all staff face many demands in a job that is unlikely to get easier any time soon. But with a more creative kind of approach that looks for alternative ways to teach and provide experience, student nurses should be better equipped for a long, fulfilling career in healthcare. NHS patients deserve nothing less.</p><img src="https://counter.theconversation.com/content/111691/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom McConnachie previouslyreceived funding from the Scottish Medical Education Research Consortium</span></em></p>Simulating real-life disaster situations helps students develop physical and emotional resilience and leadership skills.Tom McConnachie, Lecturer in Nursing, University of DundeeLicensed as Creative Commons – attribution, no derivatives.