Categories
Editorials

Editor’s welcome: healthcare leaders of tomorrow

v6_i1_a1It  is  with  great  pleasure  that  I  welcome you to Volume 6, Issue 1 of the Australian Medical Student Journal (AMSJ); the  national  peer-reviewed  journal  for medical students. The AMSJ serves two purposes: firstly, to provide a stepping-stone for medical students wishing to advance their skills  in  academic  writing  and  publication; and secondly, to inform Australian medical students of important news relating to medical education and changes in medical care. This issue of the AMSJ showcases an array   of   research,   reviews,   and   opinions that address a wide range of contemporary subjects. In particular, there is a trend for articles on translational research and national healthcare matters.

Australia’s healthcare system is evolving rapidly to accommodate an ageing demographic, growing epidemics of chronic disease, and the introduction of new and often expensive medical technology. We are concurrently faced with major challenges including declining economic growth and considerable budget cuts in an attempt control national debt. The coming decades will be particularly challenging for our healthcare system, but also for us as future doctors. We will have to make difficult decisions to limit healthcare spending whilst ensuring that Australia maintains a leading world-class healthcare system. More than ever, doctors will be required to be leaders in the national healthcare arena, and it will be up to you and your colleagues to direct our ever-changing healthcare system.

In light of this, I am pleased to introduce this issue with a guest article by Professor Brian Owler,  President of  the  Australian  Medical Association. Professor Owler discusses the potential threat of university fee deregulation to Australia’s future medical profession. The AMA and others will be launching a social media and public campaign in February to discourage senators from passing a reformed bill.

This issue of the AMSJ has a record number of original research articles, reflecting some of the best research conducted by medical students across Australia. Not only have the authors written excellent papers, they have spent months, even years conducting these extensive projects. Mr Edward Teo reports a large study comparing specialty choices and rural intentions of students graduating from a private medical program compared to those from other Australian medical schools. Ms Skye MacLeod reports on the adequacy of anticoagulation according to the CHADS2 score in patients with atrial fibrillation. Another two studies address the impact of language and literacy respectively on hospital care.

The reviews and feature articles in this issue cover a diverse array of topics. In particular, there  are  several articles  addressing   the role of novel oral anticoagulants in the management of atrial fibrillation and venous thromboembolism. This is a large area of interest and transition and we are pleased to inform medical students of the latest evidence and guidelines in this field. It is interesting to observe a growing trend in the publication of systematic reviews in our journal. Systematic literature appraisal  and assessment of  bias are highly  useful  skills,  which  are not  only vital for advancing research, but also facilitate the delivery of evidence-based medical care. We encourage students to learn about these methods and consider writing a systematic review during their medical education.

The AMSJ is staffed by a large team of volunteer medical students from almost every medical school in the country. This issue we received a record number of submissions, with all staff increasing their workload to review and manage each manuscript. I would like to commend the editorial team that have worked tirelessly over the last year. I also acknowledge  the  new  proof-editing  team that have been swift at proof-reading all manuscripts and assisting in the development of the new AMSJ style guide. The printed copies of the AMSJ and the AMSJ website would not be possible without help from the print-layout team, IT officers, and sponsorship officers, together led by Miss Biyi Chen. Our Director  Mr  Christopher  Foerster  has  given his heart and soul to ensure that the AMSJ is of the highest possible standard. Finally, I thank our readers, authors, peer-reviewers, and sponsors who continue to support our journal.

On behalf of the staff of the AMSJ, I hope you enjoy this issue.

Thank you to AMSJ Peer Reviewers:

  • Emeritus Prof Francis Billson
  • Prof Richard Murray
  • Prof Ajay Rane
  • Prof Andrew Bonney
  • Prof Andrew Somogyi
  • Prof Andy Jones
  • Prof Anne Tonkin
  • Prof Jan Radford
  • Prof Jon Emery
  • Prof Louise Baur
  • Prof Lyn Gilbert
  • Prof Mark Harris
  • Prof Michael Chapman
  • Prof Nicholas Zwar
  • Prof Paul Thomas
  • Prof Rakesh Kumar
  • Prof Sarah Larkins
  • Prof Tomas Corcoran
  • A/Prof Anthony Harris
  • A/Prof David Baines
  • A/Prof Janette Vardy
  • A/Prof Roslyn Poulos
  • A/Prof Sabe Sabesan
  • A/Prof William Sewell
  • A/Prof Peter Gonski
  • A/Prof Debbie Wilson
  • Dr Adam Parr
  • Dr Andrew Chang
  • Dr Andrew Henderson
  • Dr Anna Johnston
  • Dr Cristan Herbert
  • Dr Dan Hernandez
  • Dr Danforn Lim
  • Dr Danielle Ni Chroinin
  • Dr Darren Gold
  • Dr Despina Kotsanas
  • Dr Freda Passam
  • Dr Greg Jenkins
  • Dr Haryana Dhillon
  • Dr John Reilly
  • Dr Justin Burke
  • Dr Justin Skowno
  • Dr Kathryn Weston
  • Dr Lynnette Wray
  • Dr Mark Donaldson
  • Dr Mark Reeves
  • Dr Matthew Fasnacht
  • Dr Mike Beamish
  • Dr Nolan McDonnell
  • Dr Nollaig Bourke
  • Dr Nuala Helsby
  • Dr Peter Baade
  • Dr Pooria Sarrami Foroushani
  • Dr Rachel Thompson
  • Dr Ross Grant
  • Dr Sal Salvatore
  • Dr Shir-Jing Ho
  • Dr Sid Selva-Nayagam
  • Dr Stephen Rogerson
  • Dr Sue Hookey
  • Dr Sue Lawrence
  • Dr Sue Thomas
  • Dr Susan Smith
  • Dr Venkat Vangaveti
  • Ms Dianna Messum
  • Ms Margaret Evans
Categories
Editorials

Recapturing compassion

Recapturing compassionJohn was wheeled into hospital on a Friday of a long weekend. He was elderly and frail, with severe Parkinson’s disease. Many
hospital staff attended to him – prescribing medications, delivering meals, and changing his sheets. Unfortunately, no one realised that John’s limited mobility meant that he could not reach his drinking cup. Although the staff had performed their duties, the absence of compassion led John to become dehydrated and develop acute kidney injury.

When we first entered medicine, we pledged ourselves as model medical students. We spoke of our compassion for the sick and a
dedication to helping our community. But as we progress through our studies into full time clinical work, putting such aspirations into actions becomes more challenging.

There are checklists for assessing practical skills – be it history taking and examination, inserting cannulas, or writing discharge summaries. Medical schools are honed to teach us to be competent; but do they teach us how to be compassionate?

Why should we care about compassion?

Compassion is derived from the Latin, ‘compati’, meaning ‘to suffer with’ other people. It also involves an active concern for
and effort to alleviate that suffering.

Whilst as students we may initially see the best way to alleviate suffering is to ‘cure’ our patients with medicine, we soon come to realise that we cannot ‘cure’ all our patients. Indeed, over 7 million Australians suffer from chronic disease, which cannot be ‘cured’ completely. [1] But it is not just for these patients that the ‘care’ is just as, if not more important than the ‘cure’. As Sir William Osler explains, ‘The good physician treats the disease; the great physician treats the patient
who has the disease.’

Patients want compassionate doctors. [2] Being compassionate can improve patient wellbeing and care. Compassionate doctors
also help reduce patient anxiety. [3] A positive patient mindset is important, as several studies have linked optimism with better health outcomes. [4] When compassion enters the patient-physician relationship, it builds trust, aiding more accurate diagnosis and understanding of patient problems. [5] Through compassion, care is optimised. It transforms healthcare from being a system to a service.

Why do we struggle with being compassionate?

Although we may begin work with a good understanding of the necessity of compassion, stressors such as heavy workloads and limited time can harden our hearts towards our patients. [6] Bureaucracy and red tape takes time away from direct patient contact. We start to become wary as the list of people needing attention expands. It is possible to let faces blur and details melt away until we are treating ‘the man with the ankle fracture’ or ‘bed 5’s dehydration’. While we never intend to lack compassion, the current reality of medicine means that we are often preoccupied with treating the patient, rather than caring for them.

In many instances, acting with compassion to a patient can be a challenge. In medicine, we see humanity at its best, but also at its worst. Patients are not always polite or easily satisfied. Sometimes, the most difficult keep coming back again and again. ‘Frequent flyers’ is a term applied to patients who commonly represent to hospital. Last year, 1,200 of these patients accounted for over 22,000 presentations to Victorian casualty wards between them. [7] One patient managed to visit Royal Melbourne Hospital 144 times alone. [7] Whilst some of these patients have legitimate health problems, others may be drug seeking, homeless, or hypochondriacs.

It is not surprising then that doctors are at high risk of ‘compassion fatigue’, resulting from the constant demand of caring for others. Compassion fatigue can lead to burn-out and compromise our ability to provide safe and effective patient care. It is concerning to look at the results of the 2008 Australian Health and Wellbeing Survey of junior doctors which found that 54 percent of respondents were at risk of secondary trauma or ‘compassion fatigue’. [8]

How can we recapture compassion?

Perhaps we must begin by remembering to treat ourselves with compassion.

Having enough time for oneself is important in continuing to be a kind and functioning human being capable of showing others
compassion. This includes addressing basic needs such as getting enough sleep, eating regular meals, and making time to refresh our bodies and souls. Unfortunately, it is common to see doctors neglecting on these things and more. There are doctors who have abstained from drinking water to avoid bathroom breaks, and others who have even performed ward rounds with drips in their arms. Such exploits have been boasted about as personal achievements or as self-sacrifice for the sake of having more time with patients. But this is a misperception that is likely to do more harm to ourselves and our patients, as we are prone to make mistakes when tired and stressed. [9]

In fact, being compassionate does not necessarily require large amounts of time. One study compared two interviews in which
the diagnosis of breast cancer was presented. In the second interview, the doctor was more compassionate and added two statements, which acknowledged the patient’s difficulty of receiving such a diagnosis and expressing support. [3] Study participants evaluated the doctor as significantly more compassionate and they also had a reduced anxiety state compared to those exposed to the standard interview. Interestingly, the time difference between the two interviews was only 40 seconds. In the time that we might wait for a lift, it is possible to improve patient wellbeing by showing compassion.

Sometimes it seems difficult to know where we should start with being compassionate to our patients. It does not have to be a
dramatic act, but may begin with pulling up a chair and four simple words, “Hello my name is…”. This is the potent thought that Dr Kate Granger triggered across the world in her viral hashtag #hellomynameis. It was a call to address what she saw as an important gap in communication and patient care within the healthcare system. [10]

Dr Granger is a geriatrician. She is also a longterm patient diagnosed with sarcoma in 2011. During her illness she was startled to find that many of the healthcare workers examining, treating, and looking after her went about nameless. They had missed an essential step to building relationship and trust – the introduction. [10] These experiences inspired her to start sharing her stories and encouraged reforms in Britain’s National Health Service (NHS).

At the end of the day, we do not always need to feel compassionate or have vast time or strength for it. Instead, we choose
compassion in the little things and persevere in the remembrance that everyone has intrinsic worth. That is when we discover
the simple truth – that what makes a compassionate doctor is the same as what makes a compassionate human being.

At the Australian Medical Student Journal, we provide a stepping-stone for medical student research and writing. We also hope to inspire not only more competent clinicians, but more compassionate ones too.

Acknowledgements

I would like to thank May Whitbourn, Peggy Kuo, Linda Wu, Dr Michelle Johnston, Dr Natalie May and Dr Matthew Leung for their
invaluable feedback and encouragement.

Conflict of Interest

None declared.

Correspondence

G Leo: gracesyleo@gmail.com

References

[1] Australian Institute of Health and Welfare. Chronic Diseases. Accessed online August 2014: http://www.aihw.gov.au/chronic-diseases/.

[2] Puchalski CM. The Role of Spirituality in Health Care. Proc (Bayl Univ Med Cent). 2001. 14(4) 352-7.

[3] Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 Seconds of Compassion Reduce Patient Anxiety? American Society of Clinical Oncology. 1999. 17(1) p371.

[4] Diener E, Chan MY. Happy People Live Longer: Subjective Well-Being Contributes to Health and Longevity. Applied Psychology: Health and Well-Being. 3(1) p1-43.

[5] Post SG. Compassionate care enhancement: benefits and outcomes. The International Journal of Person Centred Medicine. 1(4) pp808-13

[6] Ahrweiler F, Neumann M, Goldblatt H, Hahn EG, Scheffer C. Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians. BMC Med Educ. 2014 Jun 22;14:122. doi: 10.1186/1472-6920-14-122.

[7] Mickelburough P. Frequent Flyer Patients Clog Hospital Queues by Visiting Up to Twice a Week. Herald Sun. June 8th 2014. Accessed online August 2014: http://www.heraldsun.com.au/news/victoria/frequent-flyer-patientsclog-hospital-queues-by-visiting-up-to-twice-a-week/story-fni0fit3-1226946988588?nk=36a2799f847320fe295b5ca863f5418b.

[8] Australian Medical Association. AMA Survey Report on Junior Doctor Health and Wellbeing. 2008. Accessed online August 2014: https://ama.com.au/system/files/node/4217/JDHS_report_FINAL.pdf.

[9] Helmreich RL, Merritt AC. Culture at work: national, organizational and professional influences. Aldershot: Ashgate, 1998.

[10] Granger K. #hellomynameis. Accessed online July 2014: http://drkategranger.wordpress.com/2013/09/04/hellomynameis/.

Categories
Editorials

Appraising laboratory-based cancer research for the medical student

Increasingly clinicians are being asked to participate in translational research–working closely with laboratory scientists to help guide research goals and projects. The work that is done in the laboratory setting can sometimes fall outside the scientific grounding that most medical students and clinicians receive at university, making it difficult to assess the quality of techniques described in journal articles. This article aims to explore some of the most frequently utilised models and technologies in laboratory-based cancer research to ease the appraisal of such scientific papers for the budding clinician.

Statistical significance and biological significance

A recent publication in Nature demonstrating the limitations of the p value has highlighted how research results can be unintentionally misleading, [1] yet many studies still rely simply on this measure. Beyond the limitations of statistics, it is important to consider what a meaningful outcome is in the context of cancer treatment. A treatment may lead to a significant reduction in the levels of a certain protein or RNA transcript, but it is more important to measure how this ultimately affects an in situ tumour. Depending on the way these levels are measured, a small reduction in expression levels can appear statistically significant, but may not represent a large enough change to actually alter the behaviour of tumour cells. Small quantities of stimuli such as cytokines can sometimes have no effect on cancer cells. [2] Similarly, systems can reach an optimal concentration at which point even increasing doses by 10-fold will have no additional effect on cell growth. [2] It is therefore pertinent to consider not only whether a change can pass statistical tests, but also whether this change is altering the tumour environment through more functional experiments that can quantify proliferation, angiogenesis, cell death or apoptosis.

Culturing cancer cells

Many studies utilise in vitro cell culture work. It is a convenient way to look closely at the behaviour of cancer cells in response to various stimuli and treatments. There are, however, a number of limitations to this model. Human cancer cell lines originate from human tumours (the most famous being the HeLa cell lines – isolated from Henrietta Lacks, a cervical cancer patient from the 1950s [3]). Many are not sourced from primary tumours, but rather originate from metastases, commonly from surrounding lymph nodes, but sometimes from such unusual and distal sites as a brachial muscle metastasis. [4] Cancer cells that metastasise are known to have different properties to primary tumours, [5] and although studying metastasis themselves is a valuable pursuit, applying the properties of these cells to a whole disease is flawed.

Furthermore, in order to culture cancer cells, an immortalisation process must be undertaken to allow continued growth outside of the body. [6] Although many cancer cells have already developed a way to avoid normal cell cycle regulation, this process inevitably introduces more oncogenic mutations that may not have been present originally. [7] It is also clear that over time in culture, these cells develop further mutations, leading to variability in results. The product of this is conflicting scientific articles: for example, eight years later and in a different laboratory, pancreatic cancer cells showed the opposite expression of a key oncogenic transcription factor. [8, 9]

Despite allowing scientists to look closely at the behaviour of cancer cells, in vitro studies have limited application to in vivo disease, demonstrating the need for in vitro studies to be confirmed with compelling disease models.

Models of disease

As a way of contextualising results seen in cells cultured in the laboratory, animal models of cancer are widely used to examine pathogenesis and management options.

Mice with genetic mutations

Specific augmentation of genes can lead to spontaneous development of tumours without other stimuli. [10] These models can be excellent for studying a range of disease processes, looking at specific oncogenes and other events (such as inflammation) that may result in the development of tumours. [10] Their relevance can sometimes be limited by this single mutation, as very rarely do endogenous or naturally occurring human tumours result from one single mutation. Additionally, tumours do not always mimic the disease course in humans, with atypical metastatic processes. [11]

Mice with inducible cancers

As gene modulation developed, a number of systems that allows organ- or cell-type-specific genetic mutation have allowed more detailed study into the roles of specific proteins in the development of tumours.

A common inducible model is the Kras model. Kras is a gene that is mutated in approximately 90% of lung cancers. [12] This gene can be utilised to generate lung tumours in mice. Removal of a stop codon in the K-ras gene allows for expression and development of tumours, which can be done by administering a viral effector, AdenoCre. [12] Similar to mice with specific genetic mutations, this sort of targeted induction of mutation is not wholly representative of human disease.

Other forms of treatment can also be used to provoke dysplasia in animal models. An extremely widely used model for mimicking inflammation-associated colorectal cancer is the DSS-AOM model. This model has been highly variable, especially in regards to the role of the immune system in worsening or alleviating disease. [13-18] Much of this variation has been attributed to resident gut flora variation, highlighting its role in the development of inflammation-associated cancer, [16] but not assisting in providing a robust answer to the scientific questions posed in these individual studies.

Xenografts

An alternative to endogenous cancers, animals can be used to investigate the response of human tumours to therapies. The process of removing a tumour from a patient, and inserting it into an immunocompromised mouse is called xenografting. These can be very effective models for assessing, in vivo, the penetrance and effects of cancer therapy. [19-22] Unfortunately, these too have limitations. Many studies insert tumours in the subcutaneous tissue of the mouse flank – making tumour size easy to measure, both for ethical and research outcomes. However, the limitations of this location are clear, as the tumour is not located in a place it would usually physiologically be able to access. Recently, an effort to establish xenografts in a most physiologically appropriate location has been made. [23, 24] This may yield more accurate results and improve the efficiency of translated treatments in clinical trials.

Xenografts could also potentially play a role in advancing personalised medicine. Studies have implanted an individual patient’s tumour into a colony of mice, who are then administered a range of chemotherapeutic agents to determine which regime leads to the greatest reduction in tumour burden. [25] This is an exciting frontier in personalised medicine that will hopefully lead to more effective treatment in the future.

Conclusion

Despite limitations in laboratory research, the future for cancer therapy lies, at least partially, in these laboratories. When paired with a clear clinical goal and active attempts to translate ideas both from the bed to the bench and back again, promising breakthroughs can be made that will be valuable for researcher, clinician and most importantly, patient.

Conflict of interest

None declared.

Correspondence

A Browning: afbro1@student.monash.edu.au

References

[1] Nuzzo R. Scientific method: statistical errors. Nature 2014;506(7487):150-2. Epub 2014/02/14.

[2] Beales IL. Effect of interlukin-1beta on proliferation of gastric epithelial cells in culture. BMC gastroenterology 2002;2:7. Epub 2002/04/09.

[3] Callaway E. Deal done over HeLa cell line. Nature 2013;500(7461):132-3. Epub 2013/08/09.

[4] Akiyama S, Amo H, Watanabe T, Matsuyama M,Sakamoto J, Imaizumi M, et al. Characteristics of three human gastric cancer cell lines, NU-GC-2, NU-GC-3 and NUGC-4. The Japanese journal of surgery 1988;18(4):438-46. Epub 1988/07/01.

[5] Bidwell BN, Slaney CY, Withana NP, Forster S, Cao Y, Loi S, et al. Silencing of Irf7 pathways in breast cancer cells promotes bone metastasis through immune escape. Nature medicine 2012;18(8):1224-31. Epub 2012/07/24.

[6] Maqsood MI, Matin MM, Bahrami AR, Ghasroldasht MM. Immortality of cell lines: challenges and advantages of establishment. Cell biology international 2013;37(10):1038- 45. Epub 2013/06/01.

[7] Lehman TA, Modali R, Boukamp P, Stanek J, Bennett WP, Welsh JA, et al. P53 mutations in human immortalized epithelial cell lines. Carcinogenesis 1993;14(5):833-9. Epub 1993/05/01.

[8] Corcoran RB, Contino G, Deshpande V, Tzatsos A, Conrad C, Benes CH, et al. STAT3 plays a critical role in KRAS-induced pancreatic tumorigenesis. Cancer research 2011;71(14):5020-9. Epub 2011/05/19.

[9] Scholz A, Heinze S, Detjen KM, Peters M, Welzel M, Hauff P, et al. Activated signal transducer and activator of transcription 3 [STAT3] supports the malignant phenotype of human pancreatic cancer. Gastroenterology 2003;125(3):891-905. Epub 2003/09/02.

[10] Judd LM, Bredin K, Kalantzis A, Jenkins BJ, Ernst M, Giraud AS. STAT3 activation regulates growth, inflammation, and vascularization in a mouse model of gastric tumorigenesis. Gastroenterology 2006;131(4):1073-85. Epub 2006/10/13.

[11] Judd LM, Alderman BM, Howlett M, Shulkes A, Dow C, Moverley J, et al. Gastric cancer development in mice lacking the SHP2 binding site on the IL-6 family co-receptor gp130. Gastroenterology 2004;126(1):196-207. Epub 2003/12/31.

[12] Jackson EL, Willis N, Mercer K, Bronson RT, Crowley D, Montoya R, et al. Analysis of lung tumor initiation and progression using conditional expression of oncogenic K-ras. Genes & development 2001;15(24):3243-8. Epub 2001/12/26.

[13] Allen IC, TeKippe EM, Woodford RM, Uronis JM, Holl EK, Rogers AB, et al. The NLRP3 inflammasome functions as a negative regulator of tumorigenesis during colitisassociated cancer. J Exp Med 2010;207(5):1045-56. Epub 2010/04/14.

[14] Bauer C, Duewell P, Mayer C, Lehr HA, Fitzgerald KA, Dauer M, et al. Colitis induced in mice with dextran sulphate sodium [DSS] is mediated by the NLRP3 inflammasome. Gut 2010;59(9):1192-9. Epub 2010/05/06.

[15] Dupaul-Chicoine J, Yeretssian G, Doiron K, Bergstrom KS, McIntire CR, LeBlanc PM, et al. Control of intestinal homeostasis, colitis, and colitis-associated colorectal cancer by the inflammatory caspases. Immunity 2010;32(3):367-78. Epub 2010/03/17.

[16] Elinav E, Strowig T, Kau AL, Henao-Mejia J, Thaiss CA, Booth CJ, et al. NLRP6 inflammasome regulates colonic microbial ecology and risk for colitis. Cell 2011;145(5):745-57. Epub 2011/05/14.

[17] Takagi H, Kanai T, Okazawa A, Kishi Y, Sato T, Takaishi H, et al. Contrasting action of IL-12 and IL-18 in the development of dextran sodium sulphate colitis in mice. Scand J Gastroenterol 2003;38(8):837-44. Epub 2003/08/28.

[18] Zaki MH, Boyd KL, Vogel P, Kastan MB, Lamkanfi M, Kanneganti TD. The NLRP3 inflammasome protects against loss of epithelial integrity and mortality during experimental colitis. Immunity 2010;32(3):379-91. Epub 2010/03/23.
[19] Yagi Y, Fushida S, Harada S, Tsukada T, Kinoshita J, Oyama K, et al. Biodistribution of humanized anti-VEGF monoclonal antibody/bevacizumab on peritoneal metastatic models with subcutaneous xenograft of gastric cancer in mice. Cancer chemotherapy and pharmacology 2010;66(4):745-53. Epub 2009/12/25.

[20] Stoeltzing O, McCarty MF, Wey JS, Fan F, Liu W, Belcheva A, et al. Role of hypoxia-inducible factor 1alpha in gastric cancer cell growth, angiogenesis, and vessel maturation. Journal of the National Cancer Institute 2004;96(12):946- 56. Epub 2004/06/17.

[21] Fujimoto-Ouchi K, Sekiguchi F, Yasuno H, Moriya Y, Mori K, Tanaka Y. Antitumor activity of trastuzumab in combination with chemotherapy in human gastric cancer xenograft models. Cancer chemotherapy and pharmacology 2007;59(6):795-805. Epub 2006/10/13. [22] Min Y, Adachi Y, Yamamoto H, Imsumran A, Arimura Y, Endo T, et al. Insulin-like growth factor I receptor blockade enhances chemotherapy and radiation responses and inhibits tumour growth in human gastric cancer xenografts. Gut 2005;54(5):591-600. Epub 2005/04/16.

[23] Jones-Bolin S, Ruggeri B. Orthotopic models of human gastric carcinoma in nude mice: applications for study of tumor growth and progression. Curr Protoc Pharmacol 2007;Chapter 14:Unit 14 4. Epub 2007/06/01.

[24] Bhullar JS, Makarawo T, Subhas G, Alomari A, Silberberg B, Tilak J, et al. A true orthotopic gastric cancer murine model using electrocoagulation. Journal of the American College of Surgeons 2013;217(1):64-70; discussion -1. Epub 2013/04/16.

[25] Villarroel MC, Rajeshkumar NV, Garrido-Laguna I, De Jesus-Acosta A, Jones S, Maitra A, et al. Personalizing cancer treatment in the age of global genomic analyses: PALB2 gene mutations and the response to DNA damaging agents in pancreatic cancer. Molecular cancer therapeutics 2011;10(1):3-8. Epub 2010/12/08.

Categories
Editorials

A platform for research and endeavour

Welcome to Volume 5, Issue 1 of the Australian Medical Student Journal (AMSJ). The latest issue continues to showcase the vast breadth of medical student and junior doctor research, reviews, and opinions in a wide range of relevant and compelling articles.

This issue includes the latest trends in laboratory-based cancer research, covered in an editorial by Alison Browning, and provides a timely overview of this rapidly growing field. Grace Leo’s editorial shifts our attention to the waning practice of compassion during patient care and ways in which this can be addressed.

Key guest articles include a piece by Professor Patrick McGorry which builds on the momentum placed on medical student mental health and wellbeing this year, offering new insights in this area in the wake of a 2013 beyondblue survey which highlighted some stark statistics on medical student and junior doctor mental health. Professor Stephen Leeder, the Editor-in-Chief of the Medical Journal of Australia (MJA) which is celebrating its centenary this year, navigates the overload of medical information that faces us now and into the future. The Australian Indigenous Doctor’s Association provide an informative view into the future of Indigenous health in Australia, and draws on the need to train culturally competent doctors to make inroads in this area.

Additionally, this issue has attracted an unprecedented number of original research submissions, testament to the growing popularity of research amongst students and the AMSJ’s ongoing drive to publish early career research. Stephanie Barnes suggests a technique to anatomically localise functionally defined cortical areas using MRI, while a second research article in the field of radiology compares two key methods of identifying adrenal glands on computed tomography (CT). Public health measures to prevent skin cancers amongst men and women are assessed in a study of rural Australians, and the findings suggest that the measures are still not being heeded by some.

The review and feature articles again cover a diverse array of topics, with a spotlight on penicillin allergies, an overview of the history of modern anaesthesia, and reviews of cancer and psychiatric treatments.

The growing calibre of research submissions, as well as our staple review and feature articles, reflect the variety of interests and undertakings of Australian medical students and junior doctors. The AMSJ is currently in the midst of exploring potential partnerships with the Australian Medical Students’ Association (AMSA) and the MJA to bring more opportunities to students, encourage research, and promote medical editing and journalism. Keep an eye out on our website for more announcements. Furthermore, our presence on social media continues to strengthen and has played a strong role in increasing our readership, including to an emerging international audience.

The AMSJ is produced by an expanding team of volunteer staff of medical students which is now well and truly established across all states and medical schools in Australia. This year has been a time of transition at the AMSJ with many staff members completing their terms with us and handing over the reigns to a new team of enthusiastic editors, proof-readers, and other internal staff positions who bring with them a wealth of experience. I would like to thank past executive members and editors who have overseen the development of the AMSJ and to current staff who have worked tirelessly to publish this issue. I would also like to extend our thanks to the peer-reviewers who have provided us with invaluable feedback on articles and are central to the quality and success of the AMSJ.
Finally, I would like to thank our readers, authors and sponsors who continue to support the AMSJ. On behalf of the staff at the AMSJ, we hope you enjoy this issue.

Thank you to AMSJ Peer Reviewers:

  • Dr Karl Friston
  • Dr Shuli Futeran
  • Dr Craig Lewis
  • Dr Saxon Smith
  • Dr Susan Ireland
  • Professor Philip Hazell
  • Dr Matthew Links
  • Dr Himanshu Popat
  • Professor Jennifer Reath
  • Dr Shaun Roman
  • Dr Wai Kit Lee
  • Professor Graham Johnston
  • Dr Tracy Putoczki
  • Dr Joanne Lewohl
  • Professor David Robertson
  • Dr Michael Hornberger
  • Dr Joseph Moxon
  • Dr Tony Lamont
  • Dr Susan Smith
  • Dr Shane Brun
  • Dr Ryan Shum
  • Dr Martin Kroslak
  • Professor Saxby Pridmore
  • Dr Stephen Adelstein
  • Professor Gregory Peterson
  • Mrs Lisa Gilroy
  • Ms Miranda Stephens
  • Dr Andrew Chang
  • Dr William Glasson
  • Professor Philip Mitchell
  • Professor Anthony Harris
  • Dr Matthew Fasnacht
  • Associate Professor Ute Vollmer-Conna
  • Associate Professor Julian Trollor
Categories
Articles Editorials

Thought the ‘bed shortage’ was bad, until the ‘surgeon shortage’ came along

“Make up your mind how many doctors a community needs to keep it well. Do not register more or less than this number.’’ George Bernard Shaw

If you have ever had the opportunity of finding yourself in a surgical theatre, the last thing you want to have on your mind are doubts about the person holding the scalpel. To ensure the highest professional standards are maintained, trainees of the Royal Australasian College of Surgeons (RACS) undergo a rigorous five to six year postgraduate training program prior to final qualification as a surgical consultant. [1] However, such a long and demanding training program has proven to be a double-edged sword for the surgical speciality. Studies have shown that one in four surgeons plan to retire in the next five years and that only sixteen percent of surgeons were under 40 years old. [2] The same study demonstrated that the average retirement age for surgeons has decreased by ten years. [2] These factors place an immense amount of pressure on surgical training programs, particularly in an era where the ageing population is creating more demand for surgical services. [2] While workforce shortage issues are by no means unique to the RACS, and indeed are felt by many medical colleges across Australia, this editorial will focus on the RACS to illustrate the issues affecting a broad range of medical specialities.

Along with many medical colleges around Australia, the RACS faces a looming workforce crisis with an ageing workforce approaching retirement and an ageing population with increasing healthcare needs, combining to create a critical demand for scarce services. The 2011 annual report published by the RACS highlighted that the number of first year surgical trainees across all specialties was 246 [3] compared to the 3000+ medical students graduating from around the country each year. While this represents a relatively small fraction of the available workforce pool, the RACS has taken the initiative to increase the number of surgical trainee positions by twelve percent compared to 2010. [3] Despite these gains, the RACS estimates that at least another 80 surgeons will have to graduate each year in addition to the 184 new surgeons currently graduating each year, in order to begin to redress surgeon workforce shortage. [4,5]

Low trainee numbers represent a composite of many factors, including financial limitations, need for skilled supervision and opportunity for practical experience. [6] The public sector has reached its full capacity for surgical training posts as such posts are funded by the State governments hence they are limited by budget provisions. [5] Consequently, underfunding, chronic shortage of nursing staff and lack of resources in public hospitals are seen as some of the main reasons for extended waiting times for surgery. [7] Due to the lack of such resources, it is a common trend now to see surgical lists being limited or procedures being cancelled because of time constraints. [7] Increasing the number of trainee posts will require significant fundamental changes, namely greater resourcing of the public health system. [6] To avoid the looming workforce crisis, governments will have to move quickly to ensure adequate training posts are in place across all medical specialties. [3,5] In Australia, more than 60% of elective surgery is in the private sector. [5] Novel training opportunities, such as those offered by the private sector, should also be considered as clinicians with the appropriate range and depth of experience required to train junior doctors are not limited to the public sector. [5] Lack of resources, funding, safe working hours and reduced clinical exposure are all elements that add to this crisis of looming workforce shortage. [6,8]

While there is a compelling argument to expand the number of trainee positions around Australia, the challenge is to maintain the highest standards for surgical trainees. [7] Emphasis on the number of training positions created is the priority of any college and is a crucial aspect in offering quality treatment in both the public and private hospitals. [7] However, increasing the number of trainees to accommodate and cope with surgeon shortage might result in reduced individual theatre time, which is not acceptable. [4,7] While this may relieve the workforce shortage, however, it would only create more specialists with limited exposure to a wide range of surgical presentations. [7] The aim of surgical training is to ensure that trainees progress through an integrated program that provides them with the highest professional responsibility under appropriate supervision. [9] This not only ensures exceptional quality but also enables trainees to acquire the competencies needed to perform independently as qualified surgeons. There are concerns nonetheless that if there is a large intake of surgeon trainees it may favour ‘quantity’ of trained surgeons over ‘quality’. [7] This is unacceptable, not only for the safety of our patients, but also in a world of increasing medico-legal implications and litigation. [7]

Another challenge affecting the surgical profession and surgical trainees is the issue of safe working hours. Currently, the reported working hours of the surgical workforce on average is 60 hours per week, excluding 25 hours per week on average spent on-call. [5] Although safe working hours are less of an issue in Australia than the rest of the world, it still affects surgical training. [10] Safety and wellbeing of surgical trainees is a top priority of the RACS. [7] Reduced trainee hours have been encouraged by research showing that doctor fatigue compromises patient care, as well as awareness that fatigue hampers learning. [10] Long hours traditionally worked by surgeons may result in concerns regarding safe working hours and the possibility that the next generation of surgeons will seek enhanced work-life balance. [4,7] Adding to the ominous shortage of surgeons, the challenge still remains whether surgical trainees can still assimilate the necessary clinical experience in this reduced timeframe. [7] More and more trainees place increased emphasis on work-life balance [5], making alternate specialisation pathways a real possibility that many consider.

Many, if not all, of the issues felt by the RACS across Australia are rarefied in rural Australia. Rural general surgery, much like its general practice counterpart, is facing an impending crisis of workforce numbers. [11] Despite increasing urbanisation, approximately 25% of Australians still live in rural Australia [12] and it is this portion of the population that is likely to be the first and worst affected by any further constriction in medical workforce numbers. Single or two-man surgical practices provide service to many rural and remote centres. [11] However in many areas where surgical services could be supported, no trainee surgeon is available. [11] Many current rural surgeons are also fast approaching retirement age. [11] In past years retention of surgeons in rural communities has been strong. [13] The lifestyle benefits, challenges and rewards all combined, have ensured that a large amount of rural surgeons are growing old in the country. [13] However, this perception may well be a thing of the past. [13] Younger surgeons are more likely to consider time off on call, annual leave and privacy as lifestyle considerations which compel them back towards the metropolitan area. [13] Such a shift in attitude towards limiting one’s workload combined with the continuing decline in Australian rural practices will apply various additional pressures on the rural surgeon workforce in the near future. [11]

Two main factors that determine if a trainee surgeon is more likely to pursue a rural career are the exposure to good quality rural terms as an undergraduate and having a rural background. [11,13] Selections for rural posts are more common in doctors from a country background who are more likely to return to, and remain in, a rural practice. [12,13] Acknowledging this factor, many Australian medical schools have now incorporated both mandatory and voluntary rural terms as a part of their curriculum. [11] In addition to these undergraduate initiatives, ongoing rural placements during postgraduate years may need to be established and given greater prominence. [11] A trainee being allocated to the same rural location over a period of years increases the possibility of the trainee settling in the same rural location following their training. [13] This may be due to familiarity with the social and cultural setting as well as the desire to provide continuous care for his/her patients. [13] As a result of these undergraduate and/or postgraduate initiatives, we can expect to witness the next generation of advanced surgical trainees with a foundation of rural experience, demonstrating a willingness to undertake rural terms as an accepted and expected component of their general surgery training. [11,13] These trainees may then choose to settle in the same rural location following training, thus decreasing the rural surgeon shortage.

The aim of surgical training is to ensure that trainees progress through an integrated program that provides them with increasing professional responsibility under appropriate supervision. [8] This enables them to acquire the competencies needed to perform independently as qualified surgeons. [9] The RACS has taken major steps to address its workforce shortage. Continuing efforts to provide for trainees and their needs are given place of prominence in the RACS 2011-2015 strategic plan. The RACS’ role in monitoring, coordinating, planning and provisioning of services, as well as obtaining adequate funding for surgical training programs, remains a major responsibility of the College. Emphasis on rural rotations at an undergraduate and early postgraduate level, consideration of the work-life balance of both trainees and surgeons and sufficient staffing of theatres, will help eradicate the surgeon shortage whilst ensuring that the finest surgical education and care is available to Australians into the future.

Conflict of interest

None declared.

Correspondence

J Goonawardena: j.goonawardena@amsj.org

References

[1] The College of Physicians and Surgeons of Ontario. Tackling the Doctor Shortage. Ontario: CPSO; 2004. p. 5

[2] Surgeon shortage looms. The Hobart Mercury 2006 March 22:26

[3] The College of Surgeons of Australia and New Zealand. The Royal Australasian College of Surgeons Annual Report 2010. Melbourne: RACS; 2011. p. 9

[4] Royal Australasian College of Surgeons. (2011, October 7). Surgeons warn of looming workforce crisis [Media release]. Retrieved from http://www.surgeons.org/media/293538/MED_2011-10-07_Surgeons_warn_of_looming_workforce_crisis.pdf

[5] Royal Australasian College of Surgeons. RACS 2011: Surgical Workforce Projection to 2025 (for Australia). Melbourne: RACS; 2011. P. 8-57

[6] Amott DH, Hanney RM. The training of the next generation of surgeons in Australia. Ann R Coll Surg Engl 2006; 88:320–322.

[7] Berney CR. Maintaining adequate surgical training in a time of doctor shortages and working time restriction. ANZ J Surg. 2011; 81:495–499.

[8] Australian Medical Association Limited. (2005 April 5). States and territories must stop passing the buck on surgical training [Media Release]. Retrieved from http://ama.com.au/node/1966

[9] Hillis DJ. Managing the complexity of change in postgraduate surgical education and training. ANZ J Surg. 2009; 79: 208–213.

[10] O’Grady G, Loveday B, Harper S, Adams B, Civil ID, Peters M. Working hours and roster structures of surgical trainees in Australia and New Zealand. ANZ J Surg. 2010; 80: 890–895.

[11] Bruening MH, Anthony AA, Madern GJ. Surgical rotations in provincial South Australia: The trainees’ perspective.  ANZ  J Surg. 2003; 73: 65-68.

[12] Green A. Maintaining surgical standards beyond the city in Australia. ANZ  J Surg. 2003; 73: 232-233.

[13] Kiroff G. Training, retraining and retaining rural general surgeons. Aust. N.Z.J. Surg. 1999; 69:413-414.

 

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Freedom of information

Early last year, a David and Goliath battleraged between the most unlikely of foes. The gripes of a single blog post inspired a group of disaffected mathematicians and scientists to join forces and boycott the world’s largest publisher of scientific journals, Elsevier. Their movement, dubbed “Academic Spring”, was in response to the company’s political backing of the Research Works Act, a proposed bill in the United States (US) aimed at denying public access to scientific research funded by the US National Institute of Health (NIH). Drafted solely to benefit the interests of publishing companies, Elsevier reneged on its support for the bill following months of escalating protests and scathing publicity. Though the bill never saw the light of day, the struggle that unfolded was symptomatic of a more deep-seated and pervasive conflict between academics and publishers; a conflict that has been thrown into sharp relief by the rise of online publishing.

Since the publication of the first scholarly journal in 1665, journals have played an integral role in the scientific process. [1] As vanguards of modern day science, journals have been an enduring and authoritative source of the latest scientific research and developments. Academics form a key ingredient in the turnover and success of journals. Not only are they responsible for generating content, but they also volunteer as peer-reviewers for submissions relevant to their field of expertise and as mediators of the editorial process; a peculiar arrangement that plays into the hands of publishers. Before the arrival of the internet, journals facilitated the quick and widespread exchange of information throughout the scientific world. Publishers performed services including proofing, formatting, copyediting, printing, and worldwide distribution. [1] The digital age, however, rendered many of these tasks redundant and allowed publishers to dramatically reduce their costs. [1] Publishers also used the opportunity to offload further responsibilities onto the shoulders of academics, such as formatting and most copyediting, in order to significantly increase profits despite playing a limited role in the journal’s overall production.

The changing landscape of scientific publishing has seen commercial publishing firms acquire a lion’s share of the market from not-for-profit scientific societies in the last few decades. [2] The resulting monopolistic stranglehold has led to exorbitant subscription fees for access to their treasury of knowledge. Profit margins have hovered between 30-40 percent for over a decade, due in part to subscription prices outpacing inflation by seven percent per annum. [3] Moreover, publishers have exploited the practice of offering journals subscriptions in bundles, rather than on an individual needs basis, a crucial ploy underlying their profits. [4] Long-standing price increases, accompanied by dwindling library budgets, have gravely hampered the ability of libraries, universities, and investigators to acquire the most up-todate publications necessary for research and education. [4] The total expenditure on serials by Australian university libraries in 2010 was a staggering AU$180 million. [5] Even the most affluent libraries, such as Harvard, are declaring the situation as untenable and are resorting to subscriptions cuts. [3]

Along with cost, the principle of access for clinicians, scientists, and the general public alike underscores the ensuing debate. There is little argument that the accessibility of scientific findings is critical to the advancement of scientific progress. Consequently, the great paywalls of publishing houses have fostered an environment that stagnates the translation of science to the bedside and stifles medical innovation. Peer-reviewed literature is often funded by taxpayer-supported government grants. In Australia and New Zealand, over 80% of research and development is funded by the public purse. [6] In effect, governments have been held ransom by firms privatizing the profits accruing to publicly-financed knowledge. The barriers of access and cost also extend to developing nations. Without access to reliable medical literature, efforts to develop sustainable health care systems in these regions are severely undermined.

Researchers are equally culpable for their current plight. Typically, works of intellectual property warrant financial remuneration. However, writing for impact instead of payment has become both intrinsic and unique to academic journals, a paradigm from centuries before when journals were unable to pay authors for their work. [3] Impact, a proxy measure developed by commercial publishers, reflects an academic journal’s visibility for a given year. It is derived from the ratio between the average number of citations per article received during the two preceding years and the total number of articles it published during the same period. [7] The higher the impact factor of a journal, the greater its clout and influence. The importance placed on impact factor has become ingrained in the collective psyche of academia. Academics are competitively assessed on their publication record in scientific journals to secure grants and advance their careers. Inevitably, researchers have become servile to an archaic system, which serves only the interests of commercial publishers.

Open access (OA) represents a new business model in the academic journal industry, underpinned by the growth and reach of the internet. It provides unfettered online access to all research material, as well as the right to copy and redistribute it without restrictions. [1] Open access (OA) uses two channels of distribution: the “gold” or the “green” paths. [1] The “gold” path publishes articles in freely available OA journals that maintain peer review to preserve their academic reputations. The Public Library of Science (PLoS) and BioMed Central (BMC) are leading examples of OA publishers. The “green” path requires authors to self-archive their work on an online repository, available free of charge to the public. [1] Table 1 highlights some of the differences between traditional and OA journals.

Open access (OA) offers many advantages compared to traditional journal publishing. Evidence shows that OA has substantially increased the amount of scholarly work available to all, regardless of economic status or institutional affiliation, increasing the probability of research being read and, accordingly, of being cited. [8] Open access (OA) can integrate new technological approaches such as text mining, collaborative filtering, and semantic indexing, and has the potential to encourage new research methodologies. [8] A significant bone of contention with traditional journals has been the need for authors to relinquish copyright of their material. Open access (OA) allows authors to retain copyright, and provides readers and other authors with the rights to re-use, re-publish, and, in some cases, create derivatives of their work. [8] Furthermore, OA bridges both the digital and physical divide between the developing and developed worlds, mitigating some of the limitations faced by scientists in low-income countries to publish their work. Institutional repositories and OA publication fee waivers have been instrumental in promoting their research profile onto the international stage, by shedding the burden of cost. [9]

Despite offering free access to readers, OA has been plagued by its share of criticism. Traditional publishing firms, one of its fiercest opponents, contend that OA journals shift the cost of production from consumer to author, with fees ranging from $1,000-5,000 per article. [3] Whilst levelling this critique, commercial firms overlook the fact that they also foist publication fees onto authors which may even exceed the costs of OA journals. [1,3] Publication costs are now a common element in grant fund applications, and authors incur minimal to no charge. Inevitably, ethical concerns also arise from the OA model. The author-pay model may compromise the peerreview process as journals become financially dependent on researchers to publish articles. However, these concerns have been assuaged in recent years, due to the widespread number of high-quality OA journals that employ robust peer-review on par with their subscription counterparts. [1] The “green” route also poses problems for authors who may not possess the technical capabilities or resources to self-archive articles.
Open access (OA) represents the fastest growing business model for academic journals, and is likely to remain sustainable in the long-term. Many OA journals are now highly trusted, referenced, indexed, and well received. Its support has been bolstered by the evolving mandates of research funding agencies, including Australia’s National Health and Medical Research Council (NHMRC), the United Kingdom’s Wellcome Trust, and the NIH, placing research funded by their grants into the public domain within a year of initial publication. [7,10] Major data aggregators are also facilitating this trend, including PubMed and OVID, releasing OA databases and platforms dedicated to OA material. [11] Estimates project that 60 percent of all journal content will be published in OA journals by 2019. [11] Moreover, OA journals are rapidly approaching the same scientific impact and quality as subscription journals, particularly in the field of biomedicine, as suggested by one study. [7] Many have opined that OA could redefine measures of impact, using additional metrics such as number of downloads, bookmarks, tweets, and Facebook likes.Proponents of OA have turned their attention to how corporations like drug and chemical companies can support its efforts, which benefit from free access while contributing only a small subset of scientific articles and fees overall.

The advent of the internet has created a realm of possibilities for some and a minefield of challenges for others. Journals have navigated such obstacles for centuries, embracing new opportunities and adapting to change. Although the internet has effectively transformed publishers into “de facto” gatekeepers of their lucrative commodity, it has also been the impetus behind the OA revolution, proving to be a more cost-effective and equitable alternative to traditional publishing. But while OA continues to develop into the mainstay of journal publishing, perhaps its most immediate impact will be to diversify competition and precipitate a cultural change within the industry that sees science re-emerge at the forefront of its interests.

Conflict of interest
None declared.

Correspondence
S Chatterjee: s.chatterjee@amsj.org

References

[1] Albert KM. Open access: Implications for scholarly publishing and medical libraries. J Med Libr Assoc. 2006 Jul;94(3):253-62.

[2] Jha A. Academic spring: How an angry maths blog sparked a scientific revolution. The Guardian. 2012 Apr 9.

[3] Owens S. Is the academic publishing industry on the verge of disruption. U.S. News and World Report. 2012 Jul 23.

[4] Taylor MP. Opinion: Academic publishing is broken. The Scientist. 2012 Mar 19.

[5] Australian higher education statistics [Internet]. Council of Australian University Librarians; 2009 [updated 2012 Nov 29; cited 2013 Mar 5]. Available from: http://www.caul.edu.au/caul-programs/caul-statistics/auststats.

[6] Soos P. The great publishing swindle: The high price of academic knowledge. The Conversation. 2012 May 3.

[7] Björk BC, Solomon D. Open access versus subscription journals: A comparison of scientific impact. BMC Med. 2012;10(73).

[8] Wilbanks J. Another reason for opening access to research. BMJ. 2006;333(1306).

[9] Chan L, Aruachalam A, Kirsop B. Open access: A giant leap towards bridging health inequities. Bull. World Health Organ. 2009;87:631-635.

[10] Dissemination of research findings [Internet]. National Health and Medical Research Council; 2012 Feb 12 [updates 2013 Jan 25; cited 2013 Mar 4]. Available from: http://www.nhmrc.gov.au/grants/policy/disseminationresearch-findings

[11] Rohrich RJ, Sullivan D. Trends in medical publishing: Where the publishing industry is going. Plast Reconstr Surg. 2012;131(1):179-81.

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The Australian Medical Student Journal: a nationwide endeavour

Welcome to Volume 4, Issue 1 of the Australian Medical Student Journal.

This issue of the AMSJ continues to develop our core aims of supporting medical student research by providing a dedicated journal for publication of outstanding medical student work and a focus on issues relevant to Australia in general and Australian medical students in particular. Key milestones for the Australian Medical Student Journal over the past months have included the online publication of the Australian Students’ Surgical Conference, the expansion of our editorial team to include seven new members, each talented upcoming physician-scientists, and a broader expansion of our medical student staff. Senior AMSJ staff are now located in every state across Australian and there are representatives at each medical school.

This issue the AMSJ received an unprecedented number of outstanding submissions from medical students across the country. Some key highlights for this issue include a timely review by Boulat and Hatwal of the case for male HPV vaccination. This review, published as the Australian government announces its world first initiative of immunising young men against HPV, was identified by our editorial team and reviewers as a excellent review of an important contemporary public health issue and has been awarded the best article prize for Volume 4, Issue 1. Other notable submissions include a rigorous comparative review of anaesthetic methods for paediatric elective inguinal herniotomy, a synopsis of treatment options for preventing cardiac sequelae in Kawasaki disease, a reflective essay on the humanising influence of fiction in psychiatry, and a case report of spontaneous intracranial hypotension. Editorials by Saion Chatterjee and Janindu Goonawardena discuss structural changes occurring in academic publishing and the current challenges faced by the medical workforce across Australia. We are also privileged to host articles from prominent Australians: Professor Larkins, Chair of European Molecular Biology Laboratory-Australia (EMBL-Australia) and the Victorian Comprehensive Cancer Centre (VCCC), Professor Bolitho, President of the Royal Australia College of Physicians (RACP) and Professor Hollands, President of the Royal Australia College of Surgeons (RACS), to provide a top-down perspective on issues important to medical students.

Health and medical research in Australia faces key challenges including sustainability and international competitiveness. The recent McKeon Review of Health and Medical Research in Australia provides a framework for how Australian researchers can help to maximise the health of all Australians and contribute on a global scale. A major facet of this review is the emphasis on collaboration. In a country with a population less than one fiftieth of our neighbours, China and India, and public research expenditure less than one thirtieth of the United States, collaboration is an integral component to achieving global impact. In his guest article, Professor Larkins, Chair of EMBL-Australia and the VCCC, offers his advice and experience as the Chair of two leading collaborative research initiatives in Australia. With the upcoming federal budget and election, we also spotlight the issue of sustainability in the healthcare system. Professor Bolitho of the RACP provides a considered perspective on the measures required to accommodate increasing numbers of medical graduates. Professor Hollands of the RACS and Associate Editor Janindu Goonawardena provide complementary perspectives on contemporary surgical training in Australia and discuss potential measures to address rural medical workforce shortages.

This issue of AMSJ represents the accumulation of many hours of voluntary work from AMSJ staff and reviewers. We have been privileged to lead a team of highly motivated, intelligent and hardworking medical students from across the country, without whom publication of this journal would not be possible. We would additionally like to thank our external peer reviewers, many who completed their first review this issue and many more who regularly contribute their time and expertise to the AMSJ. The initiative of publicly thanking reviewers will be continued this year, and their names published in the latter half of the year. Finally, we would like to thank all authors who contributed to the AMSJ and all our readers, who provide content and meaning to this publication. We hope you enjoy this issue and that it serves as motivation for medical students and nascent authors of future publications.

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Modelling human development and disease: The role of animals, stem cells, and future perspectives

Introduction

The ‘scientific method’ begins with a hypothesis, which is the critical keystone in forming a well-designed study. As important as it is to ask the correct questions to form the hypothesis, it is equally important to be aware of the available tools to derive the answers.

Experimental models provide a crucial platform on which to interrogate cells, tissues, and even whole animals. They broadly serve two important purposes: investigation of biological mechanisms to understand diseases and the opportunity to perform preclinical trials of new therapies.

Here, an overview of experimental models based on animals commonly used in research is provided. Limitations which may impact clinical translation of findings from animal experiments are discussed, along with strategies to overcome this. Additionally, stem cells present a novel human-derived model, with great potential from both scientific and clinical viewpoints. These perspectives should draw attention to the incredible value of model systems in biomedical research, and provide an exciting view of future directions.

Animal models – a palette of choices

Animal models provide a ‘whole organism’ context in studying biological mechanisms, and are crucial in testing and optimising delivery of new therapies before the commencement of human studies. They may be commonly referred to under the classification of invertebrates (flies, worms) and vertebrates (fish, rodents, swine, primates); or small animal (fish, rodents) and large animal (swine, primates, sheep).

Whilst organisms have their own niche area of research, the most frequently used is the humble mouse. Its prominence is attested by the fact that it was only the second mammalian species after humans to have its genome sequenced, demonstrating that both species share 99% of their genes. [1] Reasons for the popularity of mice as a choice include that mice share many anatomical and physiological similarities with humans. Other advantages include that they are small, hardy, cheap to maintain and easy to breed with a short lifespan (approximately three years), [2] allowing experiments to gather results more quickly. Common human diseases such as diabetes, heart disease, and cancer affect mice, [3] hence complex pathophysiological mechanisms such as angiogenesis and metastasis can be readily demonstrated. [2] Above all, the extraordinary ease with which mice are manipulated has resulted in the widespread availability of inbred, mutant, knockout, transgenic or chimeric mice for almost every purpose conceivable. [3] By blocking or stimulating the overexpression of specific genes, their role in developmental biology and disease can be identified and even demonstrated in specific organs. [4]

Humanised mice are another step closer in representation of what happens in the human body, thereby increasing the clinical value of knowledge gained from experiments. Humanised mice contain either human genes or tissue allowing the investigation of human mechanisms whilst maintaining an in vivo context within the animal. Such approaches are also available in other organisms such as rats, but are often adapted from initial advances in mice, and hardly mirror the ease and diversity with which humanised mice are produced.

Aside from the mouse, invertebrates such as the Drosophila vinegar fly [5] and Caenorhabditis elegans worm [6] are also widely used in research of genetics or developmental biology studies. They are particularly easy to maintain and breed and therefore large stocks can be kept. Furthermore, there are fewer ethical dilemmas and invertebrates have a genome simple enough to be investigated in its entirety without being cost-prohibitive or requiring an exhaustive set of experiments. Their anatomies are also distinct and simple, allowing developmental changes to be readily visualised.

Another alternative is the Zebrafish, which shares many of the advantages offered by Drosophila and C. elegans. Additionally, it offers greater scope for investigating more complex diseases like spinal cord injury and cancer, and possesses advanced anatomical structures as a vertebrate. [7] Given the inherent capacity of the Zebrafish for cardiac regeneration, it is also of interest in regenerative medicine as we seek to harness this mechanism for human therapy. [8]

Large animals tend to be prohibitively expensive, time-consuming to manage and difficult to manipulate for use in basic science research. Instead, they have earned their place in preclinical trials. Their relatively large size and physiological similarity to humans provides the opportunity to perform surgical procedures and other interventions on a scale similar to that used clinically. Disease models created in sheep or swine are representative of the complex biological interactions that are present in highly evolved mammals; hence may be suitable for vaccine discovery. [9] Furthermore, transgenic manipulation is now possible in non-human primates, presenting an opportunity to develop humanised models. [10] Despite this, there are obvious limitations confining their use to specialised settings. Large animals need more space, are difficult to transport, require expert veterinary care, and their advanced psychosocial awareness raises ethical concerns. [9]

The clinical context of animal experimentation

A major issue directly relevant to clinicians is the predictive value of animal models. Put simply, how much of research using animals is actually clinically relevant? Although most medical therapies in use today were initially developed using animal models, it is also recognised that many animal experiments fail to reproduce their findings when translated into clinical trials. [11] The reasons for this are numerous, and require careful analysis.

The most obvious is that despite some similarities, animals are still animals and humans are humans. Genetic similarities between species as seemingly disparate as humans and mice may lead to assumptions of conserved function between humans and other animal species that are not necessarily correct. Whilst comparing genomes can indicate similarities between two species such studies are unable to capture differences in expression or function of a gene across species that may occur at a molecular level. [12]

The effectiveness and clinical relevance of experimental animal trials is further complicated by epigenetics. Epigenetics is the modification of genetic expression due to environmental or other cues without actual change in DNA sequence. [13] These changes are now considered just as central to the pathogenesis of cancer and other conditions as genetic mutations.

It is also important to consider the multi-factorial nature of human diseases. Temporal patterns such as asymptomatic or latent phases of disease can further complicate matters. Patients have co-morbidities, risk factors, and family history, all of which contribute to disease in a way that we may still not completely understand. With such complexity, animal models do not encapsulate the overall pathophysiology of human disease. Animals may be too young, too healthy, or too streamlined in sex or genetics. [14] To obtain animals with specific traits, they are often inbred such that two animals in the same experiment will have identical genetic make-up – like twins, hardly representative of the diversity present in nature. Understandably, it can be an extraordinary challenge to incorporate all these dimensions into one study. This is especially so when the very principles of scientific method dictate that variables except for the one under experimentation should be minimised as much as possible.

A second area of concern is the sub-optimal rigour and research design of animal experiments. Scientists who conduct animal experiments and clinicians who conduct clinical trials often have different goals and perspectives. Due to ethical and cost concerns, the sample size of animal experiments is often kept to a minimum, and studies are prolonged no more than necessary, often with arbitrarily determined end-points. [14] Randomisation, concealed allocation, and blinded outcome of assessment are poorly enforced, leading to concerns of experimental bias. [11] Additionally, scientific experiments are rarely repeated due to an emphasis on originality, whereas clinical trials are often repeated (sometimes as multi-centre trials) in order to assess reproducibility of results. Furthermore, clinical trials are more likely to be published regardless of the nature of results; in contrast, scientific experiments with negative findings or low statistical significance often fail to be reported. These gaps highlight the fact that preclinical trials should be expected to adhere to the same standards and principles of clinical trials in order to improve the translatability of results between the two settings.

Although deficiencies in research conduct is a concern, the fundamental issue that remains is that even the best-designed preclinical study cannot overcome the inherent differences that exist between animal models and ‘real’ human patients. However, it is reassuring to know that we are becoming better at manipulating animal models and enhancing their compatibility with their human counter-parts. As such, this drive towards increasingly sophisticated animal models will provide more detailed and clinically relevant answers. Additionally, with the recognition that a single animal model is inadequate on its own, experiments may be repeated in multiple models. Each model will provide a different perspective and lead to the formation of a more comprehensive and balanced conclusion. A suggested structure is to start initial proof-of-principle experiments in small, relatively inexpensive and easily manipulated animals, and then scale up to larger animal models.

‘Human’ experimental models – the revolution of stem cells

Given the intrinsic differences between animals and humans, it is crucial to develop experimental systems that simulate human biology as much as possible. Stem cells are ‘master cells’ with the potential to differentiate into more mature cells, and are involved in the development and maintenance of organs through all stages of life from an embryo (embryonic stem cells) to adult (tissue-specific stem cells). [15] With the discovery of human embryonic stem cells [16] and other tissue-specific stem cells [17] it is now possible to appreciate the developmental biology of human tissues and organs in the laboratory. Stem cells may be studied under various controlled conditions in a culture dish, or even implanted into an animal to recapitulate in vivo conditions. Furthermore, stem cell transplantation has been used in animal models of disease to replace lost or damaged tissue. These methods are now commencing high-profile clinical trials with both embryonic stem cells [18] and tissue-specific stem cells. [19] Although stem cells hold great potential, translating this into the clinical environment has been hindered by several obstacles. Chiefly, tissue- specific stem cells are rare and difficult to isolate, while embryonic stem cells can only be created by destroying an embryo. In order to generate personalised embryonic stem cells for cell therapy or disease modelling, they need to be created via ‘therapeutic cloning.’ The considerable ethical quandary associated with this resulted in a field mired in controversy and political debate. This led to research coming almost to a standstill. Fortunately, stem cell research was rejuvenated in 2007 with the revolutionary discovery of induced pluripotent stem (iPS) cells – a discovery notable enough to be awarded the 2012 Nobel Prize in Physiology/Medicine.

Induced pluripotent stem (iPS) cells are created by reprograming mature cells (such as skin fibroblasts) back into a pluripotent ‘stem cell’ state, which can then re-differentiate into cells of any of the three germ layers irrespective of what its original lineage was. [20] Cells from patients with various diseases can be re-programmed into iPS cells, examined and compared to cells from healthy individuals to understand disease mechanisms and identify therapeutic opportunities. Rather than using models created in animals, this approach represents a ‘complete’ model where all genes contributing to a specific disease are present. Crucially, this enables the previously inconceivable notion of deriving patient-specific ‘disease in a dish’ models, which could be used to test therapeutic response. [21] It also provides unprecedented insight into conditions such as those affecting the heart [22] or brain, [23] which have been difficult to study due to limitations accessing tissue specimens and conducting experiments in live patients.

However, if a model system rests purely on stem cells alone this would relegate the approach to in vitro analysis without the whole organism outlook that animal experiments afford us. Accordingly, by combining this with rapidly evolving cell transplantation techniques it is possible to derive stem-cell based animal models. Although this field is flourishing at an exponential rate it is still in its infancy. It remains to be seen how the actual translation of iPS technology will fit into the pharmacological industry, and whether personalised drug screening assays will become adopted clinically.

Conclusion

Experimental models provide us with insight into human biology in ways that are more detailed and innovative than ever before, with a dazzling array of choices now available. Although the limitations of animal models can be sobering, they remain highly relevant in biomedical research. Their contribution to clinical knowledge can be strengthened by refining models to mimic human biology as closely as possible, and by modifying research methods to include protocols similar to that used in clinical trials. Additionally, the emergence of stem cells has shifted current paradigms by introducing patient-specific models of human development and disease. However, it should not be seen as rendering animal models obsolete, but rather a complementary methodology that should improve the predictive power of preclinical experiments as a whole.

Understanding and awareness of these advances is imperative in becoming an effective researcher. By applying these models and maximising their potential, medical students, clinicians and scientists alike will enter a new frontier of scientific discovery.

Conflict of interest

None declared.

Correspondence

k.yap@amsj.org

 

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Articles Editorials

Medical students in the clinical environment

Introduction

It is common amongst medical students to feel apprehension and uncertainty in the clinical environment. It can be a daunting setting, where medical students can sometimes feel as if they are firmly rooted to the bottom of the pecking order. However, there are many ways medical students can contribute to their respective healthcare teams. Whilst students are not able to formally diagnose patients or prescribe medications, they remain an integral part of the healthcare landscape and culture. The step from being ‘just’ a medical student to being a confident, capable medical professional is a big step to take, but an important one in our development from the textbook to the bedside. By being proactive and committed, students can be of great help and achieve improved outcomes in a clinical setting. Through this editorial we hope to illustrate several methods one can employ to ease this transition.

Concerns of medical students

When faced with the clinical environment, most medical students will have some form of reservation regarding various aspects of clinical practice. Some of the concerns listed in the literature revolve around being accepted as part of the team, [1] fatigue, [2, 3] potential mental abuse, [4, 5] poor personal performance and lifestyle issues. [6, 7] These points of concern can mostly be split up into three parts: concern regarding senior clinicians, concern regarding the clinical environment, and concern regarding patient interaction. [1] Practicing clinicians hold the key to effective medical education and their acceptance of medical students is often crucial for a memorable learning experience. [1] Given the hierarchical nature of most medical organisations, senior clinicians being the direct ‘superiors’, are given the responsibility of assessing students. Concerns regarding the clinical environment refer to the demands on students during clinical years, such as on calls, long hours, early starts and the pressure to gain practical knowledge. Anecdotally, it’s common to hear of medical students becoming consumed by their study of medicine and rarely having the time to pursue other interests in life.

Patient-student interaction is another common source of anxiety, as medical students are often afraid to cause harm to real-life patients. Medical students are often encouraged to perform invasive practical skills (such as venipuncture, intravenous cannulation, catheterisations, suturing, invasive clinical exams, nasogastric tube insertion, airway management, arterial blood gases) and to take sensitive histories. We have the ability to physically or psychologically hurt our patients, and Rees et al. [8] have recently reported the performance of intimate examinations without valid consent by Australian medical students. This has to be balanced against our need to learn as students so that we avoid making errors when we eventually enter clinical practice. These are all pertinent points that have to be addressed to ensure that the average medical student can feel comfortable and contribute to the team in an ethical manner.

Attitudes towards medical students

Despite the concerns of medical students regarding the attitudes of clinicians, allied health professionals and patients towards them, most actually take a positive view on having students in the clinical environment. Most studies have shown that the majority of patients are receptive to medical students and had no issues with disclosing personal information or being examined. [9-11] In particular, patients who were older and had prior admissions tended to be more accepting of student participation in their care. [9, 12] These findings were consistent across a number of specialties, even those dealing with genitourinary issues. [13] On a cautionary note, students should bear in mind that a sizable minority of patients prefer to avoid medical student participation, and under these circumstances it is important to respect patient autonomy and refrain from being involved with their care. [14] Graber et al. [14] have also reported that patients are quite apprehensive regarding having medical students perform procedures on them, particularly more invasive procedures such as central line placement or lumbar puncture. Interestingly, a sizable minority (21%) preferred to never have medical students perform venipuncture, [14] a procedure often considered minor by medical professionals. It is a timely reminder that patient perspectives often differ from ours and that we need to respect their opinions and choices.

Ways we can contribute

As aspiring medical professionals our primary objective is to actively seek ways to learn from experienced colleagues and real-life patients about the various conditions that they face. Being a proactive learner is a crucial aspect of being a student and this in itself can be advantageous to the clinical team by sharing new knowledge, promoting academic discussion or as a source of motivation for senior clinicians. However as medical students we can actively contribute to the healthcare team in a variety of practical ways. These methods include formulating a differential diagnosis, assisting in data collection, preventing medical errors and ensuring the emotional well-being of patients. These are simple yet effective ways of fulfilling one’s role as a medical student with potentially meaningful outcomes for patients.

Preventing medical errors

As medical students, we can play an important role in preventing patient harm and picking up medical errors. Medical errors can be caused by a wide variety of reasons, ranging from miscommunication to a loss of documentation to the lack of time on the part of physicians. [15-18] These are all situations where medical students can be as capable as medical professionals in noticing these errors. Seiden et al. [19] reports four cases where medical students prevented medical errors and ensured patient safety, ranging from ensuring sterile technique in surgery to correcting a medication error to respecting a do not resuscitate order. These are all cases within the circle of competence of most medical students. Anecdotally, there are many more cases of situations where a medical student has contributed to reducing medical errors. Another study has shown that up to 76% of second-year medical students at the University of Missouri-Columbia observed a medical error. [17] However, only 56% reported the error to the resident-in-charge. Various factors contribute to this relatively low percentage: inexperience, lack of confidence, hesitancy to voice opinions, being at the bottom of the medical hierarchy and fear of conflict. [17] Whilst medical students should not be relied upon as primary gatekeepers for patient safety, we should be more forthcoming with voicing our opinions and concerns. By being involved and attuned to the fact that medical errors are common, we can make a significant difference to a patient’s well-being. In recognition of the need to educate medical students about the significance of medical errors, there have been efforts to integrate this formally into the medical student curriculum. [20, 21]

Assistance with collecting data

Physicians in clinical environments are notoriously limited with time. Average duration of consultations may range from eight to nineteen minutes, [22-24] which is often insufficient to take a comprehensive history. There are also a range of administrative duties that reduce patient interaction time, such as ordering investigations, filling out drug charts, arranging referrals or finding a hospital bed. [25,26] Mache et al. [25,26] have reported that pediatricians and surgeons spent up to 27% and 21% of their time on administrative duties and documentation. Medical students tend to have less administrative duties and are thus able to spend more time on individual patients. Medical students can be just as competent at taking medical histories or examining patients, [27,28] and they can uncover crucial pieces of information that had gone unnoticed, such as the presence of a ‘Do Not Resuscitate’ order in a seriously ill patient. [19] Students are also often encouraged to try their hand at practical skills such as venipuncture, history taking or clinical examination, all of which saves physician time and contribute to the diagnostic process as well.

Emotional well-being of patients

Due to the unique nature of the hospital environment, patients often have a range of negative emotions, ranging from anxiety to apprehension and depression. [29-31] A patient’s journey in the hospital can be an unnerving and disorientating experience, where he/ she is referred from unit to unit with several different caregivers at each stage of the process. This issue is further compounded by the fact that clinicians simply do not always have sufficient patient contact time to soothe their fears and emotional turmoil; studies have shown that direct patient contact time represented a small proportion of work time, as little as 4% in some cases. [25,26,32,33] Most patients feel comfortable and enjoy their interactions with medical students and some even feel that they benefit from having medical students in the healthcare team. [9,10,12,14,34] By being empathetic and understanding of our patient’s conditions, we can often alleviate the isolating and disorientating nature of the hospital environment. [12,35]

International health

Most medical students, particularly earlier in the course are motivated by idealistic notions of making a difference to the welfare of our patients. [36,37] This often extends to the less fortunate in developing countries and students often have a strong interest in global health and overseas electives (38, 39). This can be a win-win situation for both parties. Healthcare systems in developing countries stand to benefit from the additional help and expertise provided by students and students gain educational benefits (recognising tropical conditions, public health, alternative medicine), enhanced skills (clinical examination, performing investigations), cultural exposure and fostering certain values (idealism, community service). [38] However, it is important to identify our limits as medical students and learn how to turn down requests that are beyond our scope of knowledge, training and experience. This is an ethical dilemma that many students face whilst on electives in resource-poor areas, and it is often a fine line to tread between providing help to those in desperate need and inappropriate abuse of one’s position. We have the potential to do more harm than good when exceeding our capabilities, and given the lack of clear guidelines it comes down to the student to be aware of these ethical dilemmas and draw the line between right and wrong in these situations. [40,41]

Student-run clinics and health promotion activities

In other countries, such as the United States, student-run medical clinics play a crucial role in the provision of affordable healthcare. [42- 45] These clinics number over 120 across the country and have up to 36 000 visits nation-wide. [43] In these clinics, students from a variety of disciplines (such as medicine, nursing, physiotherapy, dentistry, alternative medicine, social work, law and pharmacy) collaborate to manage patients coming from disadvantaged backgrounds. [46] Whilst this concept is still an emerging one in Australia (the first student run clinic was initiated by Doutta Galla Community Health and the University of Melbourne this year, culminating in the REACH clinic – Realising Education, Access and Collaborative Health), [47] there has been a strong tradition of medical students being heavily involved with health promotion projects in their respective local communities. [48] It is not uncommon to hear of students being actively involved in community health promotion clinics, blood donation drives or blood pressure screening, [49] all of which have practical implications on public health. Through modifying our own health behaviours and active participation in local communities, students can have a tangible impact and influence others to lead a healthier lifestyle.

Note of caution

Whilst medical students should actively participate and be an integral part of a medical team, care must be taken to not overstep the professional boundaries of our role. It is always important to remember that our primary aim is to learn how to care for patients, not to be the principle team member responsible for patient care. There have been several ethical issues surrounding the behavior of medical students in clinical settings in recent times. A prominent example of this is the lack of valid consent whilst observing or performing intimate examinations. This report by Rees et al. [8] generated widespread controversy and public outrage. [50] The study showed that most medical students complied with the instructions of more senior clinicians and performed sensitive examinations without explicit consent, sometimes whilst patients were under anaesthesia. There were a variety of reasons leading up to the action, ranging from the lack of similar opportunities to the presumed pressure from supervising doctors. This is not a new issue; a previous study by Coldicott et al. [51] had also highlighted this as a problem. As emerging medical professionals we must avoid getting carried away by the excitement of clinical practice and ignore the vulnerability of our patients.

Conclusion

The clinical environment offers medical students limitless potential to develop their clinical acumen. As medical students we have the opportunity to participate fully in all stages of patient care, from helping formulate a diagnosis to proposing a management plan. Holistic care for our patients goes beyond the physical aspect of disease and medical students can play an important role in ensuring that the psychosocial wellbeing of patients is not ignored. Our impact is not just restricted to a hospital setting; we are only limited by our imagination and determination. By harnessing the idealism unique to medical students we are able to come up with truly inspirational projects that influence local or overseas communities. Through experiencing a full range of clinical scenarios in different environments we can develop a generation of doctors that are not only clinically astute, but also well- rounded individuals with the ability to connect to patients from all backgrounds. As medical students we have the potential to contribute in a practical manner with tangible outcomes, and we should aspire to that as we make the fifth cup of coffee for the busy registrar on call.

Acknowledgements

Michael Thompson for his feedback and assistance in editing draft manuscripts.

Conflict of interest

None declared.

Correspondence

f.chao@amsj.org

 

Categories
Articles Editorials

The clinician-scientist: Uniquely poised to integrate science and medicine

Introduction

Growing in the world of academic medicine is a new generation of doctors known as “clinician-scientists”. Trained in both science and medicine, with post-graduate research qualifications in addition to their medical degree, they serve as an essential bridge between the laboratory and clinic.

The development of sophisticated experimental approaches has created opportunities to investigate clinical questions from a basic science perspective, often at a cellular and molecular level previously impossible. With new and detailed understanding of disease mechanisms, we are rapidly accelerating the discovery of new preventative measures, diagnostic tools, and importantly, novel therapeutic approaches. In these emerging avenues there is not just a need for collaboration between scientists and clinicians, but a need for individuals who are fluent in both science and medicine – hence, the advent of clinician-scientists. The terms “translational research” or “translational medicine” are often associated with clinician-scientists, alluding to the notion that these people facilitate the two-way process of translating scientific findings into clinical applications (bench-to-bedside), and provide clinical data and specimens back to the laboratory to investigate underlying disease processes (bedside-to-bench).

From a student’s perspective however, these concepts can be confusing and finding their way through the breadth and categories of research conducted in academic institutions and hospitals may prove daunting. A discussion of the clinician-scientist niche and some of the challenges and opportunities faced may prove helpful.

Defining the clinician-scientist

Most clinicians at an academic hospital are engaged in research to some extent, but this tends to be mainly clinically-oriented, with patient care, treatment outcomes, and population health being broad areas commonly involved. Their day-to-day job is mostly defined by their clinical duties, often with some teaching responsibilities involved. Clinician-scientists, by contrast, dedicate a significant proportion of their time to research, typically spending ≥50% protected time in order to be remain academically competitive. [1] Whilst still loosely defined, in a purist sense this is a clinician who is involved in research at an organ, tissue, cellular, or molecular level, as opposed to focussing solely on whole patients as a clinical subject. Such research may not always have clinical findings that are directly relevant to everyday medical practice but the difference from a pure basic scientist is that the science has been approached with clinical relevance in mind. Interestingly, on the other hand, science itself has become inter-disciplinary and is recognising the importance of clinical relevance and translation with new ventures such as the Stanford University PhD in Stem Cell Biology where graduate science students interested in involvement with translational research in regenerative medicine undertake rotations shadowing clinicians in order to develop a clinical perspective to their research. [2] These developments indicate that not only are the frontiers between science and medicine becoming blurred, but that translational research is the exciting intersection where clinician-scientists, as well as scientists well-attuned to clinical practice, are uniquely poised to thrive.

The clinician-scientist niche

Clinician-scientists possess a distinctive set of skills, being trained as a clinician to apply scientific knowledge to patient care, and trained as a scientist with an enquiring mind designed to test hypotheses. Understanding the clinical relevance of observations in science and the ability to translate this back into clinical practice is truly the domain of the clinician-scientist, and uniquely so.

The pursuit of additional post-graduate research qualification such as a Masters or PhD has traditionally been the main pathway to becoming a clinician-scientist in Australia, unlike in the United States where combined MD-PhD programs have been well established in the past. However, the recent development of similar combined MBBS-PhD and MD-PhD programs in Australia is likely be instrumental in building a body of clinician-scientists that have been moulded specifically for this task. [3] Skills developed in scientific training essential for success in research include literature appraisal, manuscript and grant writing, and mastery of laboratory techniques, all of which are life-long skills honed over time, and which are rarely acquired in medical school.

It goes without saying that clinician-scientists are expected to be experts in both medicine and science. Anything subpar of clinical competence would pose a threat to patient safety and cannot be compromised. On the other hand without a solid commitment in research with the appropriate output in terms of publications, conference attendance, and grant proposals, a career in research will not take off since a track record is something that needs to be built on constantly. Given that clinical training itself takes a good number of years before being able to practice as an independent clinician it is little wonder that many are unwilling to tackle both clinical and scientific careers at once. Again, this lends further credence to the MD-PhD path where scientific training would have already been completed by the end of the program, although this itself has its drawbacks, since the science gained can become neglected in the last clinical years and will need to be polished again upon completion. [4]

But where lie challenges also lie opportunities: for the determined few, funding statistics indicate that the rigorous training is entirely worthwhile. Clinician-scientists have been found to consistently perform better in national funding programs such as the National Institutes of Health Research Project Grants (United States) than their pure clinician (MD only) and basic science (PhD only) counterparts. [5] Although the pool of clinician-scientists in Australia is significantly smaller than that of the United States and data on funding trends are less widely discussed in literature, it is generally acknowledged that clinician-scientists also do well in obtaining NHMRC funding. This may be due partly to the fact that clinician-scientists are afforded more flexibility in labelling their projects as “basic science” or “clinical”, and therefore have access to funds for both basic science and clinical projects, whereas pure clinicians and scientists are generally limited to their own funding areas.

When describing the clinician-scientist niche, an aspect of research “translation” that is often neglected is the importance of the delivery of research-based medicine into actual practice. The classic bench-to-bedside process refers to the invention of a new drug, device, or diagnostic tool where the hope is that it will undergo clinical evaluation in a controlled setting with a specific patient cohort. But bringing a discovery into the market is simply the beginning, and to bring this to the general public a much more concerted effort is required involving collaboration between public health experts, policy makers, and clinicians amongst others. So drawn-out and complex is the process that it is well acknowledged that this area of “translational” research often fails, with many potentially important discoveries unable to make changes to everyday medical practice.

[6] However, clinician-scientists are well suited to play an active role in negotiating the many hurdles in this endeavour by facilitating communication between the various experts involved, whilst providing a first-hand inventor as well as treating clinician’s perspective that is not only unique but critical in ensuring that an invention is appropriately implemented and evaluated. In the Australian context, the National Health and Medical Research Council (NHMRC) has recognised this gap in research translation and the Centres for Research Excellence and Translating Research Into Practice (TRIP) Fellowships are specific measures aimed to address this issue. [7]

Wearing two hats: double the challenges?

A commonly quoted recommended research:non-research ratio for workload is 75:25, with the majority of time devoted to research in order to succeed as a clinician-scientist. [8] In reality this is more likely to be exactly opposite the case, where a 75:25 ratio in favour of clinical work becomes the norm instead. [9] This may be particularly so in the early years after graduation when specialist training is being undertaken, despite the fact that this is also the time when a solid research foundation needs to be built in order to establish a clinician-scientist’s academic presence. As pressing as clinical demands may be, it is widely recognised that a research career cannot flourish without negotiating some protected time from clinical duties with the hospital department.

The biggest challenge for clinician-scientists is therefore time management. In addition to patient care, clinical training, and teaching responsibilities, clinician-scientists are expected to undertake labwork, keep abreast of advances in both scientific and medical literature, and engage in professional development and conferences on both fronts. They must maintain manuscript preparation and grant proposals, complete administrative duties, and often lead research teams. To realistically keep up with these demands of juggling a dual career, the ability to delegate and seek cooperation from scientist and clinician colleagues is critical. The lack of a supportive environment and a suitable mentor who can share their experiences and show the way can present an impossible struggle to the time-constrained clinician-scientist.

On the clinical front, to manage their workload clinician-scientists may tightly focus their interests to subspecialised areas to maintain an adequate caseload and expertise without stretching oneself too thin. This depends however on working in an environment where the volume and diversity of patients permits such subspecialisation, with appropriate facilitation by supervisors such as Department Heads. Unfortunately these conditions tend to be found only in major tertiary hospitals, relegating clinician-scientists to these settings.

Additionally, a research career is often less financially rewarding than clinical work particularly when private practice may need to be sacrificed in order to undertake lab work. This can pose a significant barrier particularly because the number of years required to gain appropriate training results in clinician-scientists being likely to be older than their scientist and clinician counterparts and may therefore have family commitments, and have often also accumulated student debts that need to be repaid. [10] Some solutions to this may be the Practitioner and Career Development Fellowships offered by the NHMRC aimed at clinicians involved in research, [11] as well as hospital and philanthropic organisation funding specifically for buying time out from clinical practice for research.

 

Opportunities for the clinician-scientist

 

 

 

For any researcher, securing funding is a lifeline in continuing their work and burnishing a track record, and it is here where clinician-scientists can be creative in sourcing their benefactors. Philanthropic organisations often affiliated with a disease or clinical cause, specialist training colleges like the Royal Australasian College of Surgeons, hospital based foundations, pharmaceutical companies, and fundraising from patient advocates are all important and significant funding avenues that clinician-scientsts may find more accessible than pure scientists. [12] These grants often allow pilot projects to be undertaken in order to generate sufficient amount of preliminary data to become competitive for major research funding such as from the NHMRC. Additionally, a number of these organisations offer clinician-scientist fellowships similar to the NHMRC.

Apart from funding success, it has also been found that many clinician-scientists opt to apply for and are successful in obtaining university academic positions. [12,13] Such engagement in academia provides synergy for research efforts by opening up institutional resources often more diverse than hospital settings, prospects for networking with likeminded professionals and mentors.

Additionally, the scope translational research itself is widening. An increasing number of academic hospitals are dedicating departments to translational research, with clinician-scientists often taking the lead. The need to prioritise translational research has been further underlined by the Chief-Scientist of Australia’s recent speech calling for increase in research funding for this area. [14] Whilst these are positive developments, further input from clinician-scientists themselves is required to shape policy changes and design steps to increase their numbers.

 

Moving forward

 

 

 

An apt saying may be, “Clinicians know all of the problems, but none of the solutions; scientists know all of the solutions, but none of the problems”. [15] This is where clinicianscientists represent a unique breed suited to fulfil this vacant niche, and are absolutely necessary in forging the next success stories of medicine. Despite the complexities of a dual career, the rewards and satisfaction in pursuing this path are evident and meaningful, and can lead to tangible health outcomes in patients. Although it is important to maintain a realistic notion that being a clinician-scientist is by no means an easy feat, it is equally important to take hope that the best of both worlds can be experienced. These perspectives are increasingly acknowledged in the form of progresses being made in the right direction to encourage clinician-scientists. In light of this, perhaps it is well worth noting that there may never be a better time than now to venture into, and indeed take charge in riding this next wave of medical evolution.

References

[1] Archer SL. The making of a physician-scientist–the process has a pattern: lessons from the lives of Nobel laureates in medicine and physiology. Eur Heart J. 2007 Feb;28(4):510-2

[2] Stanford University School of Medicine, Institute for Stem Cell Biology and Regenerative Medicine. PhD Program: Curriculum Overview. [updated February 17th 2009; cited March 8th 2012]; Available from: http://stemcell.stanford.edu/education/phd/curriculum.html

[3] Power BD, White AJ, Sefton AJ. Research within a medical degree: the combined MB BS-PhD program at the University of Sydney. Med J Aust. 2003 Dec 1-15;179(11-12):614-6

[4] Marban E, Braunwald E. Training the clinician investigator. Circ Res. 2008 Oct 10;103(8):771-2

[5] Dickler HB, Fang D, Heinig SJ, Johnson E, Korn D. New physician-investigators receiving National Institutes of Health research project grants: a historical perspective on the “endangered species”. JAMA. 2007 Jun 13;297(22):2496-501

[6] Woolf SH. The meaning of translational research and why it matters. JAMA. 2008 Jan 9;299(2):211-3

[7] McCallum J, Forster R. From the NHMRC: Research translation network targets the evidence-practice lag. Med J Aust. 2011;195(5):252

[8] Tai IT. Developing a clinician-scientist career. Clin Invest Med. 2008;31(5):E300-1

[9] Bosse D, Milger K, Morty RE. Clinician-scientist trainee: a German perspective. Clin Invest Med. 2011;34(6):E324

[10] Lander B, Hanley GE, Atkinson-Grosjean J. Clinician-scientists in Canada: barriers to career entry and progress. PLoS One. 2010;5(10)

[11] National Health and Medical Research Council. Fellowship Awards. [Internet] [updated December 21st 2011; cited March 1st 2012]; Available from: http://www.nhmrc.gov.au/grants/apply-funding/fellowship-awards

[12] Hayward CP, Danoff D, Kennedy M, Lee AC, Brzezina S, Bond U. Clinician investigator training in Canada: a review. Clin Invest Med. 2011;34(4):E192

[13] Toouli J. Training surgeon scientists. ANZ J Surg. 2003 Aug;73(8):630-2

[14] Australian Government – Chief Scientist of Australia 2012. Can Australia afford to fund translational research? [updated April 3rd 2012]; Available from: http://www.chiefscientist.gov.au/2012/04/can-australia-afford-to-fund-translational-research/

[15] Hait WN. Translating research into clinical practice: deliberations from the American Association for Cancer Research. Clin Cancer Res. 2005 Jun 15;11(12):4275-7