Editor’s Welcome

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

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

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

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

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

R Park:


Guest Articles

The wide world of medicine

It is a pleasure to contribute to the Australian Medical Student Journal, and to be involved in the work and the thinking of the next generation of medical professionals.

Medical education and training are at the core of Australian Medical Association (AMA) policy and advocacy. Without a quality future medical workforce, the health policies and reforms of government cannot succeed. The AMA keeps reminding governments at all levels of this important fact.

But the concerns of medical students and young doctors extend well beyond the medical and the professional. You want to help build a better society. You want to empower people and communities.

You have strong views on issues like climate change and marriage equality. Like the AMA, you want to make a difference – a real difference.

AMA advocacy is very broad and very deep; it has to be. No other medical or health organisation in the country can even come close to our success in initiating or influencing change across the health system and society.

Single-issue or narrow focus groups, like Doctors for the Environment and Doctors for Refugees, do great work, as do the learned Colleges, Societies, and Associations. The other health professions, the public health groups, consumer representatives, and other groups all do their jobs and also do them well.

But the AMA’s mission goes so much further.

If you look at the AMA website, we have around 150 Position Statements, which include:
· Climate Change and Health;
· Workplace Bullying and Harassment;
· Indigenous Health;
· Sexual and Reproductive Health;
· Women’s Health;
· Men’s Health;
· Obesity;
· Human Cloning;
· End of Life Care;
· Family and Domestic Violence;
· Female Genital Mutilation;
· Concussion in Sport; and
· Firearms.

These issues cover many facets of society and many ideologies. Some are regarded as progressive, some are conservative, but most are controversial — and therefore potentially divisive.

We do this on top of our other core business — Medicare, the Pharmaceutical Benefits Scheme (PBS), public hospital funding, the Professional Services Review (PSR), medical workforce, private health, rural health, doctors’ health, and a broad range of public health issues.

The AMA has to always tread a fine line, and we do that willingly, as with recent topical issues like climate change, pollution, air quality, and renewable energy.

The AMA believes that climate change poses a significant worldwide threat to health and urgent action is required to reduce this potential harm.

We have been vocal about the need for urgent government action, and have repeatedly called for the development of a National Strategy for Health and Climate Change.

The AMA Position Statement, Climate Change and Human Health 2015, is a very strong document. It was developed from the ground up, with input from AMA members at grassroots level around the country.

The AMA wants to see a national strategic approach to climate change and health, and we want health professionals to play an active and leading role in educating the public about the impacts and health issues associated with climate change.

Human health is ultimately dependent on the health of the planet, and the AMA lobbies governments for urgent measures to mitigate the evolving effects of climate change, including the transition to non-combustion energy sources.

The evidence is clear — we cannot sit back and do nothing.

There is considerable evidence to encourage governments around the world to plan for the major impacts of climate change, which include extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.

Our stance is not limited to the Position Statement. We are actively engaged in advocacy on climate change and health. We attended the Health Leaders Roundtable at Parliament House in 2016, where health advocacy bodies met with Members of Parliament to discuss the health impacts of climate change and the need for urgent action.

We make regular submissions to relevant Parliamentary inquiries, where we take every opportunity to highlight the connection between climate change and human health.

We adopt this approach across the broad range of policies we, as the peak medical organisation in the country, embrace. We take this role very seriously.

You are the future of the medical profession. It is my job — and that of all AMA leaders — to pass on to you a strong policy platform, and an even stronger advocacy agenda, to help you achieve your ambitions in medicine and to make the world a better place in which to live. We will not let you down.

Guest Articles

Professionalism and professional identity: what are they, and what are they to you?

The terms, profession, professional, professional identity, and professionalism, are quoted many times in medical student teaching, and often used interchangeably. This can lead to confusion as to what the concepts really are, and we therefore need to be careful what we mean when we quote them, and more importantly what we understand about how they relate to our personal clinical practice. Medical students are constantly being told in lectures, tutorials, and workshops, that they need to demonstrate professionalism in their future careers, so what is vital in their professional development is that they understand not only how everybody else defines professionalism, but most importantly what it means to them, that they have got it right, and that they keep getting it right throughout their careers.

The American philosopher Mortimer J. Adler defined a professional as “a man or woman who does skilled work to achieve a useful social goal. In other words, the essential characteristic of a profession is the dedication of its members to the service they perform [1].” So, if professionals belong to a profession, what does it take to be part of one? In the early 20th century E. P. Scarlett defined what he believed were the seven pillars of a profession: (1) technical skill and craftsmanship, renewed by continuing education; (2) a sense of social responsibility; (3) a knowledge of history; (4) a knowledge of literature and the arts; (5) personal integrity; (6) faith in the meaning and value of life; and (7) the grace of humility [2].  This ‘list’ of attributes, as to what defines a person or a concept has become common amongst modern society, and just as humans have a ‘tick-box’ of what they may desire in a future partner, healthcare organisations have ‘tick-boxes’ as to what they expect of their members. For example, the Accreditation Council for Graduate Medical Education (ACGME) in another seven-point list defined the core competencies of a doctor as respect, compassion, integrity, responsiveness to needs, altruism, accountability, commitment to excellence, sound ethics, and sensitivity to culture, age, gender, and disabilities [3]. We can see that professionalism is an expected attribute for a member of the medical profession, but it also seems to align with old-fashioned values considered to be core properties of a profession, and the people who define these pillars are not just the profession themselves, but society as well. The profession has a contract with society, that society grants them self-determination and awards them an elevated status, in return for civic responsibility, community leadership, and this professionalism.

So, what is the connection between professional identity and professionalism? Burke states that “identities are the meanings that individuals hold for themselves, what it means to be who they are. These identities have bases in being members of groups (social identity), having certain roles (role identities) or being the unique biological entities that they are (personal identities) [4].” This is important for medical students as they develop their identity during their time at medical school. Tajfel and Turner [5] proposed that people tend to categorise themselves into one or more in-groups, deriving their identity from the group and forming boundaries with other groups. This group identification promotes self-esteem within the group and leads to greater commitment to the group, even if the group’s status is low. They believed the three major components of social identity are: (1) categorisation: putting others or ourselves into categories, labelling the person as a way of defining the person; (2) identification: the way in which we define our self-image through association with a group, in-groups being the ones with which we identify and out-groups those which we do not; and (3) comparison: we compare our own groups to others and create favourable biases towards our own. This process is very strong within people’s minds and leads to stereotyping. If doctors are stereotyped as being caring, altruistic individuals by one person, they may now be stereotyped in another person’s mind as greedy and arrogant. Ultimately, once these stereotypes are formed they can become rigid.

Coulehan [6] distinguishes three types of professional identity in medicine: (1) technical identity: the doctor abandons traditional values, becoming cynical about duty and integrity, and narrows the sphere of responsibility to the technical arena; (2) non-reflective identity: the doctor espouses and consciously adheres to traditional medical values whilst subconsciously basing behaviour, or some of it, on opposing values, thus being self-deluded and detached; and (3) compassionate and responsive identity: the doctor overcomes conflicts between tacit and explicit socialisation, internalises the virtues and values professed, and manifests these in behaviour. What is worrying is that Coulehan [6] demonstrated that a large percentage of medical graduates can be classed as having a non-reflective professional identity, maintaining that this outcome is most likely where there are conflicting values in the learning environment. The inability to reflect appropriately was demonstrated by the participants when there were deficits in their clinical reasoning, and this highlighted the need for expert facilitation and education. With poor supervision and mentorship, new doctors may internalise beliefs that certain ‘unvirtuous’ behaviours are virtuous, since that is ‘the way things are in medicine’; that is to say, it is the cultural norm. However, the development of a person’s professional identity is strongly influenced by another concept, the notion of ‘belongingness’. Belongingness is the human emotional need to be an accepted member of a group. Whether it is family, friends, co-workers, or a sports team, humans have an inherent desire to belong, and be an important part of something greater than themselves. This implies a relationship that is greater than simple acquaintance or familiarity. The need to belong is the need to give and receive affection from others [7]. Without belonging, a person cannot identify oneself as clearly, thus having difficulties communicating with and relating to one’s surroundings. This implies that belongingness is related to identity. However, there is a danger with belongingness in that the desire to belong can lead to conformity, which can lead to lack of self-regulation. And this is what brings us back to the notion of professionalism.

When you look at the definitions of medical professionalism, there are numerous differing statements. For example, the University of Ottawa states that professionalism embodies the relationship between medicine and society as it forms the basis of patient-physician trust [8]. It attempts to make tangible certain attitudes, behaviours, and characteristics that are desirable among the medical profession [8]. The Medical Protection Society in the UK has a whole page on it, but does not give a definition [9]. The Australian Medical Association (AMA) makes a statement on it: “while the expression medical professionalism is used in different ways, for the purposes of this position statement we are using it to refer to the values and skills that the profession and society expects of doctors, encapsulating both the individual doctor-patient relationship and the wider social ‘contract’ between the profession and society [10].” Despite this, professionalism remains very vague as a concept.

The previous discussion and statements suggest that professional identity is constructed at the level of the individual, whereas professionalism is constructed by the community and medical profession as a whole. These community and societal ideals are articulated in professional codes, institutional frameworks, and formal medical curricula, which may or may not reflect reality. However, professional identity is a reality that might not correspond to the ideal, for reasons that can be valid or not. It is based on one’s beliefs about what it means to be professional, and a doctor’s beliefs may differ from those of the community or other health professionals. It therefore follows that a responsive and reflective professional identity is more likely to develop where there is alignment between the understandings and expectations of others, self-identity and personal values, the social identity of the professional group, and the cultural milieu of the working environment. Since identity implies values and goals, it will also determine motivation; thus it has important educational implications for self-regulated learning. This means that professionalism must be defined by the individual, and they have to ensure that their personal beliefs and concept of what professionalism means resonates with the organisations and society in which they operate.

Ensuring that you define professionalism to yourself in the correct manner necessitates critical reflection. Reflection can occur at either a superficial, moderate, or deep level [11], and it is this deeper level of reflection that makes it critical. Superficial reflection is purely descriptive, and whilst it might make reference to existing knowledge it does not critique it. With moderate reflection, often called dialogic reflection, the person takes a step back and starts to explore thoughts, feeling, assumptions, and gaps in knowledge. The reflector makes sense of what has been learnt from the experience, and what future action might need to take place. Deep or critical reflection leads to a change due to the experience. To achieve this, the learner needs to be aware of the relevance of multiple perspectives from contexts beyond the chosen incident, and how the learning from the chosen incident will impact on other situations.

So how does this translate to me, a practicing clinician? After all, if I am to suggest that you should practice in a certain manner, then I should lead by example. Professionalism as defined by myself to myself is based on ‘3 rights’: (1) I know what the patient has a right to; (2) I know what the right thing to do is, and I will do it; and (3) I know the right manner to do it in. This conveniently for me encompasses the legal, ethical, and moral aspects of my clinical practice, and I believe it is summarised by the concept of integrity: integrity for me is what defines professionalism. To translate this into a clinical concept, consider the delivery of open disclosure. I know the patient has a right to an apology, I am aware of need to apologise, and I want to apologise. To ensure that I hopefully continue to practice in this way, I reflect with the right people, at the right time, in the right manner, meaning I don’t seek out those who will always agree with me, and I ask them for them an opinion before I state my beliefs, whilst I am ready to listen to their suggestions.

Over the next few years of your careers, you will hear it repeated many times from senior clinicians that as your career progresses the knowledge becomes fairly straightforward. This is not entirely true as new advances and techniques are continually being developed, however understanding yourself and those around you to a greater depth is the best piece of armamentarium you can acquire as you begin to forge your medical careers. Your curriculum is extremely busy and you will probably not relish the thought of further background reading, however this will not change throughout your career, so make time to see medicine beyond the facts. Consider concepts such as intellectual humility, growth mindset, situational awareness, and the competency matrix, concepts beyond your basic curriculum, as this will ensure your career is as successful and fulfilling as possible.



[1] Manning PR, DeBakey L. Preserving the passion in the 21st century. 2nd ed. New York: Springer; 2003.

[2] Scarlett EP. The medical jackdaw. Patrick Lewis Papers 1949-1987. Johannesburg: Historical Papers Research Archive; 2016.

[3] Accreditation Council for Graduate Medical Education (ACGME). Outcome Project [Internet]. 2007 [cited 2017 Apr 10].

[4] Burke P. Identities and social structure: the 2003 Cooley-Mead Award address. Soc Psychol Q. 2004;67:5-15.

[5] Tajfel H, Turner J. The social identity theory of intergroup behaviour. In: Worchel S, Austin W. Psychology of intergroup relations. Chicago: Nelson-Hall; 1986.

[6] Coulehan J, Williams P. Conflicting professional values in medical education. Camb Q Healthc Ethics. 2013;12:7-20.

[7] Fiske ST. Social beings: a core motives approach to social psychology. New Jersey: Wiley; 2003.

[8] What is professionalism in medicine? [Internet]. Canada: University of Ottawa [cited 2017 Apr 10]. Available from:

[9] The Medical Protection Society. Chapter 1: Medical professionalism – what do we mean? [Internet]. 2017 [cited 2017 Apr 10].

[10] Medical Professionalism [Internet]. Australian Medical Association; 2010 [updated 2015 Oct; cited 2017 Apr 10].

[11] Reflective practice in health: models of reflection [Internet]. La Trobe University [updated 2017 Apr; cited 2017 Apr 10].

Guest Articles

Human anatomy

On the Australia Day 26/01/14 Professor George Ramsay-Stewart was awarded OAM for his services to surgical education, in the Australia Day Honours list.Professor Ramsay Stuart joined the Discipline after the review of the Medical Program to assist in increasing the teaching of anatomy to SMP students. He instituted the whole body dissection program for stage 3 students which has been a tremendous success, and highly effective in ensuring good anatomical knowledge in Sydney graduates. He has also forged strong links between our discipline, with the discipline of Surgery which has resulted in the expansion of anatomy teaching into postgraduate surgical education.

Rembrandt’s painting “The Anatomy Lesson of Doctor Nicolaes Tulp” in 1632 makes it clear that human anatomical dissection had become one of the spectacles and symbols of the age. Anatomy had become accepted as a portal into the human condition [1]. In many ways, it can be viewed as part of the cultural movement of the Renaissance, despite human dissection existing primarily as a procedure of medicine [2].

Wide-ranging circumstances influenced the revival and unfolding of human anatomy. Anatomical dissection became the cutting edge of medical investigation and the essence of a doctor’s training. This anatomical revolution brought about a paradigm shift away from the traditional thinking of the body and its relationship with the mind and soul, which had so dominated medieval thinking [3].

Human cadaveric dissection was first introduced during the third century BC at the School of Greek Medicine in Alexandria, championed by Herophilus, but this was subsequently not allowed under Roman rule [4]. Galen, in the second century AD, became the anatomical authority; however, all his dissections were on animals, and the extrapolation of his findings to humans resulted in inaccuracies not corrected until the time of Vesalius [5]. His huge collection of work was written in Attic Greek, the contemporaneous language of science, and was largely lost with the fall of Rome [6].

Medieval medical practice [7], carried out mainly in monasteries with small charity hospitals, was dominated by religious values to an extraordinary degree. The declaration of Pope Innocence the Third in 1215 forbade clergy from engaging in any activities likely to cause bloodshed [3]. This prevented clerics from practicing surgery or studying anatomy. Surgery was left to layman practitioners, who were mostly uneducated manual workers, degraded by their contact with blood [2].

With the beginnings of vernacular literature and the founding of the first universities, a more humanistic approach to medicine developed [5]. This coincided with a revival of Greek culture, science, and mathematics, together with advances in industrialisation. The city of Salerno was famous as a health centre since Roman times, and it developed an orientation around Greek medicine when its archbishop, Alphanus, travelled to Constantinople in 1063 [5]. As well as introducing Byzantine and Islamic medicine, a crucial advance came with the re-discovery and translation of Galen’s anatomical texts from Arabic into Latin [2]. This allowed the sharing of medical thinking, and a specialised vocabulary was generated, which provided a framework for medical teaching [5]. A foundation medical text called The Articella was created, and this was used throughout the newly-established medical schools of Europe by the mid-12th century [2].

Anatomical knowledge was boosted by the discovery of Galen’s text On Anatomical Procedures, which was a treatise on how to carry out a dissection [8]. The first public record of a systematic anatomical dissection was in 1315 on a condemned criminal at the Bologna medical school by Mondino de Luzzi [9]. De Luzzi subsequently wrote the standard anatomical text for the time based on the Galenic model [5]. Dissection based on this model soon became part of medical education in universities across Europe, and authorities began supplying condemned criminals to medical faculties for human anatomical dissection [9].

The anatomical basis of medicine paved the way for its foundation as a rational science [10]. However, the idea that dissection might be used to verify, or even correct, established medical thought was still quite alien [9]. A typical dissection scene consisted of the physician, in his academic robes, sitting high on a throne reading from a Galenic text, whilst a surgeon dissected, aided by a teaching assistant pointing out anatomical details [10]. The goal was not to add to knowledge, but to verify the text in which the knowledge was enclosed [5]. Surgical benefits were rarely mentioned, and surgeons still learned their anatomy by practical apprenticeship [11].

By the 16th century, permanent anatomy theatres were built to accommodate a growing audience, including laymen and artists [4]. University anatomy dissections became somewhat theatrical events lasting many days, followed by banquets in an almost carnival-like atmosphere [1]. Enthusiasts of anatomy included Renaissance artists, such as Leonardo da Vinci [12], and a revival of naturalistic art involved them in not only attending dissections, but in performing their own [2]. The new involvement of artists with anatomy resulted in more realistic medical illustrations, which became increasingly available [13].

Andreus Vesalius, at the University of Padua, not only transformed research in human anatomy, but also, equally profoundly, the teaching of anatomy. Vesalius based his research and teaching on the dissections of cadavers he carried out himself, in contrast to his contemporaries [14]. He rapidly exposed Galen’s anatomical errors, and published his beautifully illustrated seven-volume book De Humani Corporis Fabrica in 1543. This marked a turning point in the understanding of the human body, and Vesalius’ core ideas became the essence of the new anatomy [15].

Over time, cadavers became increasingly difficult to obtain. Clandestine acquisition of bodies, including grave-robbing, together with fear of vivisection in the community, caused increasing public disquiet regarding anatomical practice [11]. A gradual decline in public dissection developed, despite the practice being considered a linchpin of surgical training and an important component of medical education. The dubious morality surrounding the procurement of cadavers was mitigated with the British Anatomy Act of 1832 which allowed for body donations, and excluded the use of executed criminals [9]. This was a paradigm shift in the procurement of human cadavers for anatomical dissection.

The teaching of anatomy by dissection has gradually declined in the modern era, often replaced by virtual and digital imagery to save time and money [16]. Many have reasoned, however, that clarity of understanding regional relational anatomy and construction of a mental three-dimensional representation of the human body, cannot occur without anatomical dissection [17]. Some research has shown that decreased use of dissection as a teaching tool is one of the factors that can have a negative influence on the anatomical skills of medical students and, somewhat paradoxically, leads to a decline in anatomical knowledge [18].

The lack of anatomical knowledge in students reaching their clinical years, and by extension surgical trainees, led to a review of the University of Sydney Medical School program and re-introduction of a whole-body dissection course in 2009 [19]. Subsequently, the pass rate in anatomy for the Generic Surgical Sciences Examination (GSSE) went from 57% in 2007 to 92% in 2015 for graduates of the university.

There are also other considerations. The handling of a human cadaver encourages humanistic qualities in medical students, and provides some insight into the meaning of human embodiment and mortality [20]. Indeed, some would argue that human cadaveric dissection represents a profound rite of passage into the medical profession [21].

Vesalius was a pioneer of medical illustration in medical teaching, but he saw this only as an aid to learning [22]. He insisted that anatomy could only be studied and understood by inspection of the human body through dissection [23]. Despite the passage of 500 years since his birth, this principle still remains of enduring relevance today.



[1] Sawday J. The body emblazoned: dissection and the human body in Renaissance culture. London and New York: Routledge; 1995.

[2] Porter R. The greatest benefit to mankind. Harper Collins London: Fontana Press; 1997.

[3] Alston M. The attitude of the church towards dissection before 1500. Bulletin Hist Med. 1944;16(3):221-38.
[4] Singer AJ. A short history of anatomy and physiology from the Greeks to Harvey. New York: Cambridge University Press; 1957.
[5] French R. The anatomic tradition. In: Bynum WF, Porter R, editors. Companion Encyclopaedia of the History of Medicine. London and New York: Routledge; 1993.

[6] Besser M. Galen and the origins of experimental neurosurgery. Austin J Surg. 2014;1(2):1-5.
[7] Pouchelle MC. The body and surgery in the middle ages. New Jersey: Rutgers University Press; 1990.
[8] Johnston IJ. Galen on diseases and symptoms. Cambridge: Cambridge University Press; 2006.

[9] Park K. The criminal and the saintly body: autopsy and dissection in Renaissance Italy. Renaiss Q. 1994;47(1):1-33.

[10] Rawcliffe C. Medicine and society in later medieval England. Phoenix Mill: Alan Sutton Publishing Ltd; 1995.

[11] Magee R. Art macabre: resurrectionists and anatomists. ANZ J Surg. 2001;71(6):377-80.

[12] Keele KD. Leonardo da Vinci and anatomical demonstration. Med Biol Illus. 1952;2(4):226-32.

[13] Choulant L. History and bibliography of anatomic illustration. New York: Hafner Pub Co; 1962.

[14] Huisman F, Warner JH, editors. Locating medical history. Baltimore and London: The Johns Hopkins University Press; 2004.

[15] Strkalj G. Remembering Vesalius. Med J Aust. 2014;201(11):690-2.

[16] Sugand K, Abrahams P, Khurana A. The anatomy of anatomy: a review for its modernization. Anat Sci Educ. 2010;3(2):83-93.

[17] Korf HW, Wicht H, Snipes RL, Timmermans JP, Paulsen F, Rune G, et al. The dissection course – necessary and indispensible for teaching anatomy to medical students. Ann Anat. 2008;190(1):16-22.

[18] Ellis H. Medico-legal consequences in surgery due to inadequate training in anatomy (editorial). Int J Clin Skills. 2007;1(1):8-9.
[19] Ramsey-Stewart G, Burgess AW, Hill DA. Back to the future: teaching anatomy by whole body dissection. Med J Aust. 2010;193(11):668-71.
[20] Educational Affairs Committee of the American Association of Clinical Anatomists. A clinical anatomy curriculum for the medical student of the 21st century: gross anatomy. Clin Anat. 1996;9(2):71-99.

[21] Peck D, Skandalakis JE. The anatomy of teaching and the teaching of anatomy. Am Surg. 2004;70(4):366-8.

[22] Pearce JMS. Andreus Vesalius: the origins of anatomy. Fragments of Neurological History. London: Imperial College Press; 2003.

[23] Gogainiceanu P, O’Connor EF, Raftery A. Undergraduate anatomy teaching in the UK. Bull R Coll Surg Engl. 2009;91(3):102-6.

Guest Articles

Moments in a mother’s medical career in pathology

Professor Catriona McLean

I am 20. At a social barbecue I talk with an obstetrician about careers in medicine. She tells me that there is no point becoming an obstetrician if I want to have a family. I remain quiet.

I am 22. I compliment my favourite aunt on her new hairstyle. Her look is blank. It is a wig. I am so naïve. She dies the night of my fourth-year final exam. I forget to go to my exam.

I am 24, an intern in my first term. I am looking after Ian, who is having the first bone marrow transplant in my hospital. I am fascinated by the science. I see Ian remain positive and friendly at all times despite what he is going through. He has a lovely family. I don’t want him to die with this brand new treatment. I remain vigilant and work to my capacity; to my great relief, Ian lives.

I am 27, a senior resident medical officer. I have offers to continue training in oncology, cardiology, or neurology. I am unsure which direction I really want to go. I am pregnant. There is no maternity leave in the medical officer award in 1987. I am forced to resign. I let all three physician training offers go. I lose my entitlements. My little boy eclipses medical study.

Choosing what you should do with your medical degree, and balancing this with your personal life may not be clear to you early in your medical career. A single event, person or patient may inspire you in a direction. Your career choice may not evolve as you wish it to. You may need to make compromises. You may face hurdles that you never thought would occur.

After some deliberation about which path I should take I chose to become a pathologist. At the time I also thought it was going to be more practical for me and my young family. I’d always been fascinated in pathology and I remain fascinated by pathology. Whilst there is disease, there is the need to diagnose, understand pathogenesis, and find effective treatments. Even today, I often see something new down the microscope. It could be something I’ve overlooked every other time or an extremely rare disease. I’ve learnt to keep my eyes and my mind open.

Often I get questioned by junior doctors about moving into pathology and moving away from the patient. I do not see it that way. I feel that the patient is very central to our role. We want to make sure their diagnosis is correct, that we offer them accurate information about their disease. We are not disconnected from them.

It has not always been plain sailing trying to juggle fellowship exams, consultancy, and being a mother. I did, however, create a rule for myself very early on. This rule was to never study once I returned home after work. If I could not keep family and work separate it would not work for me in the long run. So, I learnt to concentrate super hard. If I read something once, it had to stick. If I saw something down the microscope, I had to be able to recognise it the next time. I still abide by this rule today.

Once I’d completed my fellowship, there were very few public hospital jobs around so I started a doctorate and received some sessional work. It was a 56 kilometre round trip to the hospital for one of the sessions. Sometime later I was pregnant again. I chose to resign from the distant workplace, took eight weeks off, and continued to work on my thesis at the university. Fifteen months later I was pregnant with twins. I took annual leave. I’d finished my experimental work so I wrote my final thesis when my twins were three months old. They’d sleep and I’d write. They’d wake and I’d feed them. Don’t ask me details about this time of my life.

Following my doctorate, I found a consultant job close to home. I also decided early on that collaboration would offer me more scope for research than trying to juggle full time service work and leading research. Some colleagues choose to become the leaders of research laboratories. I choose to contribute my skills and knowledge to research. Everyone is different.

I am 44. I have four children. I am offered a job as professor and head of anatomical pathology and I take it. The children can all walk to school and I never make or find time to wash my car. Time is of the essence.

I am 57. I am still head of anatomical pathology amongst other new titles and fellowships I’ve gained. My special interest is in brain and muscle pathology, particularly rare diseases. My world-ranked expertise is shared with medical science via more than 350 research papers in which I am a co-author.

What will the future be for certain specialties in medicine? Will algorithms and robots overtake large aspects of our work? It is important to look to the future but also to remain optimistic and to be prepared to change. One aspect of my field, rare paediatric neuromuscular diseases, has seen a great deal of change in the past five years. Next generation — and now whole exome — sequencing has resulted in many genetic diagnoses being made. What about those children who remain without a genomic resolution? What happens to those in whom a specific mutation has been found? Is there a specific treatment available based on this new information? Not usually. Not yet. What then?

Knowing the gene mutation does not mean that the mechanism of pathogenesis is known. Without a good understanding of pathogenesis, specific treatments remain unknown. It is a group effort to solve these unknowns with input required from multiple specialties. I’ve been involved in several recent cases looking at new gene mutations and how they affect muscle. There has been much for me to learn from using this new information to help interpret future cases and to aid in understanding the pathogenesis of a disease. This new genomic information adds to the new information provided in the seventies by electron microscopy and in the nineties by immunohistochemistry — each of which was revolutionary in its time.

Making each career decision, each medical decision, requires adaptation and use of your knowledge in new ways. At the same time, it is important to remember that your career should always be fun. It should always be challenging. You will always be learning.


A balancing act: life as a physician-scientist

A/Prof Steven Lane

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

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


Q: What is the current focus of your research?

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


Q: What drew you to specialise in haematology?

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

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

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


Q: When did you first become interested in research?

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

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

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


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

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

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

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

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

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


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

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

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


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

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

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


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

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

Craig Coorey



Designing a literature review: critical considerations

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


Is this review necessary?

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

The review may not be necessary if:

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


Types of review articles

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


Systematic review

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

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

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

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


Scoping review

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

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

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

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


Narrative review

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

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


Review articles at the AMSJ

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

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

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



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


Conflict of interest

None declared.




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

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

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

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

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

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

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

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

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

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

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




Original Research Articles

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


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

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

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

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



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

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

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

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

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


Methods and analysis

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

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

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

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

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



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

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

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

Student exposure

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

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

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

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

Community benefits

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

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

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

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

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

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

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

Burden on health services

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

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

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

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

Educational value

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

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

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

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

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

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

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

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

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

Student engagement

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

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

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

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

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

Interpersonal value

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

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

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

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

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



Major benefits and challenges

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

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


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

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

Educational value of placements in ACCHSs

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

Selection of students

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


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

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


Conflict of interest
None declared.

Abbreviations and notes

ACCHS- Aboriginal Community Controlled Health Service

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

St x– student no. x

Sf x– staff member no. x



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Original Research Articles

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


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

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

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

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



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

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

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

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


Materials and Methods

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

Conflict of interest

None declared.


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Original Research Articles

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


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

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

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

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



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

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

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

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

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

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

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


Materials and Methods

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

Study design

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

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


Participant selection and setting

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

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

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

Data collection

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

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

Statistical analysis

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



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

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

Figure 1. Proportion of candidates to overestimate (grey), accurately estimate (orange) or underestimate (blue) the true cost of pathology tests. Estimates within 25% of the true cost were regarded as accurate. Estimates more than 25% above the true cost were regarded as overestimates. Estimates more than 25% below the true cost were regarded as underestimates
Figure 2. Comparison of the mean estimates of pathology test costs amongst interns (blue), compared with the actual cost of the test (orange).

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

Table 2. Proportion of respondents who underestimated costs, accurately predicted costs and overestimated costs of commonly ordered blood tests. Estimates within 25% of the true cost were regarded as accurate. Estimates more than 25% above the true cost were regarded as overestimates. Estimates more than 25% below the true cost were regarded as underestimates.
Table 3. Actual and estimated cost of pathology tests.

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

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


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

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

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

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

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

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

Study limitations and future directions

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

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

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



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


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


Conflict of interest

None declared.



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