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Propaganda Techniques Used by the AVN

The issue of childhood vaccination has lately been forefront in the media. As the great majority of parents have little to no scientific background, they can be vulnerable to scare-mongering when it comes to information regarding health risks to their children. The Australian Vaccination Network (AVN) purports to provide healthcare information to parents seeking evidence-based information regarding the vaccination safety. However, the AVN has a decidedly anti-vaccination stance. The AVN implies that if parents decide to vaccinate their children, they are increasing the risk of their child developing autism or another serious disease. Many are drawn in by this dangerous propaganda. How does the AVN seduce parents to do what is most dangerous for their children? And how can we combat their methods?

The AVN uses a number of propaganda techniques in their provision of information. The most noticeable technique is the ‘Appeal to Fear’. A link under ‘Autism’ on the AVN website states “Anyone who thinks that the vaccine-autism link began and ended with Dr Andrew Wakefield needs to do more research.”[1] Without stating outright that vaccination is involved in the pathogenesis of autism, the AVN raises this fear in the minds of parents. And what parent would willingly place their healthy child at risk of autism?

The AVN also uses the ‘Repetition’ and ‘Loaded Language’ to dissuade parents from vaccinating their children. The website repeatedly states that ‘vaccination is not compulsory’ and that parents will not lose their government benefits by refusing to vaccinate their children.[2,3] By repeatedly stating that parents don’t have to vaccinate, the AVN are implying that parents would undoubtedly prefer not to vaccinate, if only given the choice. This implies in turn that vaccination is an ill-advised choice for the health of their children.

Using the ‘Red Herring’ technique, the AVN presents data that, although accurate, does not relate to the issue under discussion, while claiming that it does. Under ‘General Vaccination Information’, the AVN lists studies reporting an increase in the prevalence of autoimmune and neurological disorders in Australia.[4] Although these studies are evidence based, they do not discuss or hypothesise any link with vaccinations. However, to parents without training in the analysis of scientific literature, it may seem to be a large body of trustworthy knowledge raising doubt about the safety of vaccination. I suspect that parents may see a wall of ‘evidence’ and trust that it is given in good faith. They may then be too embarrassed to admit their ignorance in front of their GP by questioning the ‘evidence’ that the AVN provides.

Combating propaganda is difficult and can be frustrating. The response of the international health community has been to thoroughly investigate legitimate health claims and to make clear evidence-based information readily available to the public. This has worked in countries where there exists a high degree of confidence in the health system, such as Finland, but not in countries with a more sceptical population, such as New Zealand.[5,6] The Australian Government Department of Health and Ageing provides an excellent resource in a booklet entitled ‘Myths and Realities: Responding to Arguments Against Vaccination’ for health care providers.[7] Patients seeking evidence-based information in an accessible format can be directed to http://www.immunisation.health.nsw.gov.au.

Combating scientific propaganda will continue to be a daily challenge. Being aware of the techniques used and having the means of negating them will enable us to provide evidence-based information effectively to patients, enabling them to truly make an informed choice regarding the health of their children.

  1. Australian Vaccination Network Inc. Autism [Online]. Available: http://avn.org.au/latest-news/autism/. [Accessed 16 July 2013].
  2. Australian Vaccination Network Inc. V for Vendetta << No Compulsory Vaccination [Online]. Available: http://avn.org.au/2012/04/v-is-for-vendetta-no-compulsory-vaccination/. [Accessed 16 July 2013].
  3. Australian Vaccination Network Inc. Know Your Rights! [Online]. Available: http://avn.org.au/making-an-informed-choice/know-your-rights/. [Accessed 16 July 2013].
  4. Australian Vaccination Network Inc. Is the general health of our children worsening rather than improving? Autoimmune and neurological disorders have been increasing significantly from the 1990’s (sic) to now. Why is this? [Online]. Available: http://avn.org.au/vaccination-information/general-vaccination-information/. [Accessed 16 July 2013].
  5. Balinska, M. Vaccination in tomorrow’s society. The Lancet Infectious Diseases. 2003;3(7):443-7.
  6. Mulholland, K., Korczak, V. & Tangcharoensathien, V. Confidence in vaccines in developing countries: social, cultural, economic and political influences. Journal of Epidemiology & Community Health. 2010;64(7):563-4.
  7. Australian Government Department of Health and Ageing. Immunisation Myths and Realities: responding to arguments against immunisation 5th edition [Online]. [Accessed 16 July 2013].
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A missed opportunity for a good death

In February of last year, Dr Ken Murray published a story in the Wall Street Journal story entitled, “Why Doctors Die Differently”. In this, he describes how doctors know the limits of medicine and know when it is time to stop treatment in order to have a good death. As a paramedic who continues to work during breaks in medical school, this concept of a good death is something that I have found to be interesting. I have come across very few “good deaths”, some terrible deaths, and many dreadful deaths, that could have potentially been good deaths.

Early one morning we responded to a home for a 72 year old female who was unconscious with a history of cancer. With just that information, I had a sinking feeling about how things were going to go. We entered the house and found Mrs Peterson lying supine on the floor in cardiac arrest. As we prepared our equipment and began resuscitation, we spoke with the husband about the history and the patient’s wishes. She had likely been down for 10 minutes with no CPR and had a history of breast cancer with metastasis “everywhere”. She had no written do not resuscitate order or advance health directive and Mr Peterson maintained that she would want a resuscitation attempt.

We began the resuscitation attempt, delivering high quality compressions and careful ventilations. The patient sprawled out on the floor in front of us appeared to be a skeleton of her previous self, cancer having ravaged her body. As I tilted her head back to deliver the ventilations and felt my hands against her bald head, I couldn’t help but silently hope that our efforts would be unsuccessful so that her ordeal would finally be over.

The defibrillator was quickly attached and to my dismay it showed ventricular fibrillation. We knew what the final outcome was going to be and this only meant a longer road to that same destination. The shock and a few more minutes of CPR she led to a return of spontaneous circulation. We transported her to hospital and Mrs Peterson died in the ICU the next day without ever having regained consciousness.

If Mrs Peterson had been asked about this situation when she was still in relatively good health, having time to consider the realities of resuscitation attempts, it is extremely unlikely she would have wanted this. This bothers me, not because a patient ultimately died but rather because we managed to get a pulse back. We achieved a return of spontaneous circulation, but we certainly did not save this patient.

This is just one case of something that happens routinely across Australia. Doctors die differently because they know better. If our patients are not as informed as us in their end of life decisions then this represents our failure to communicate with our patients. It is our failures that often lead to people like Mrs Peterson missing an opportunity for what could have been a good death.

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The wrong way to talk to students about Aboriginal and Torres Strait Islander health

All medical students in Australia are likely well aware of the health issues faced by the Aboriginal and Torres Strait Islander peoples that must be urgently addressed. There are no easy solutions and this is an area where students in all health professions should be aware of the issue so that they can engage in the dialogue as potential solutions are discussed.

I was recently reminded of how important it is to approach this issue carefully, especially when discussing it with health professional students. At a national paramedic student conference, I was impressed to see that the program included speakers representing a group seeking to improve Aboriginal and Torres Strait Islander health. Given the importance of this issue and my interest in this area, I was eager to hear what would be said about what these students will be able to do to contribute to improving Aboriginal and Torres Strait Islander Health.

As the talk got underway, I became disappointed at the message from the speakers. What was being said also disheartened many of the paramedic students who I spoke with after the conference. Sadly, this is not the first time that I have heard a speaker convey a message like this to a largely non-Aboriginal or Torres Strait Islander audience. It seems to be taboo to raise an issue like this as I am about to do, but it is important to do so in the interest of possibly preventing hundreds more students becoming disheartened and disinterested.

So what was said that caused me so much concern? It wasn’t one single statement, but rather a recurring theme of the implication that only Aboriginal and Torres Strait Islanders can provide effective care for Aboriginal and Torres Strait Islander people. I do not disagree with the suggestion that culturally appropriate care is most easily provided by someone from within the cultural group. However, the idea that non-Aboriginal or Torres Strait Islander people are by their very nature incapable of providing this appropriate care is incorrect. All too often though this is the message that seems to be conveyed during these talks. This serves only to push students away from an interest in Aboriginal and Torres Strait Islander health by implying that non-Aboriginal or Torres Strait Islander people will never be able to meet the medical needs of these groups.

The message when speaking to groups predominantly composed of non-Aboriginal or Torres Strait Islander health students should focus on how all Australian health professionals will someday be able to contribute to improving Aboriginal and Torres Strait Islander health. This is the type of positive message that can help to nurture an interest in Aboriginal and Torres Strait Islander health regardless of the student’s background.

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Patient autonomy in real life

From very early on in our medical training, we are taught the importance of patient autonomy. We all know that this is one of the basic principles of medical ethics and that we must always respect it. In preparation for entering the clinical years, we are taught of how to respond when put in a situation that might cause us as students to compromise a patient’s autonomy. Unfortunately, these discussions often fail to recognise the social aspects of situations that students end up in and do not provide adequate advice on how to realistically respond.

During the preclinical years, most of us have probably been presented with a hypothetical case where we are asked to examine an unconscious patient strictly for our own practice who has not consented to being examined by a student. After much discussion, some “solution” will be presented that is meant to allow the student to maintain the patient’s autonomy without jeopardizing the medical student’s relationship with their supervisor. One favourite answer at my medical school to this hypothetical scenario is to play the role of the naive medical student. They suggest that we ask the doctor who suggested we examine the patient how that informed consent thing we learned about in medical school comes into play in a situation like this. In the hypothetical discussions, this prompts the staff member to reconsider their suggestion, apologise for putting you in that situation, and commend you for your patient advocacy. Real life isn’t this easy.

I recently found myself as one of a small group of junior medical students in an intensive care unit. When we checked in with the consultant as instructed, we were immediately each assigned a patient to examine and then present to the consultant. These patients were all unconscious, intubated, and none had provided specific consent for medical students to be touching their unconscious bodies. Despite my attempts to tactfully play the naive medical student as we had been taught, we were told simply that this is what all of the other medical students have done and we need to learn. This isn’t like what had happened in those hypothetical discussions in the preceding years.

The options are clear when in a situation like this. You can choose to violate the patient’s autonomy, no one would ever question you on it, and you will learn from examining the patient. Alternatively, you can stand up for the patient, potentially burning a bridge with the consultant, and making waves at the medical school.

I took the easier way out. I regret that that is what I did, but the reality is that the situation does not leave much room for choice for a student who is trying not to stand out. The social pressures for medical students to follow the instructions of their seniors are quite strong. The ethical discussion around cases like these during the preclinical years should shift from only talking about what is ethically right to actually addressing the critical social component of these situations.

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Health on Australia’s Streets

Rudolf Virchow was an esteemed pathologist known best to medical students for his eponymous triad of factors predisposing patients to thrombus formation. What I didn’t realise until recently was that he was also an impassioned advocate for social and political reform and the advancement of public health, famously asserting that ‘physicians are the natural attorneys of the poor’. I discovered this aspect of Virchow’s outlook during my Social Justice Project. [1] Through involvement with various homelessness services in my area, this project challenged me to consider the specific health needs and service utilisation patterns of the homeless population in Australia, and to examine ways that service provision can better target homeless persons in order to improve their health outcomes.

In Australia on any given night, 1 in 200 people are homeless. 25% of these people are Aboriginal and Torres Strait Islanders, 30% are born overseas, and 27% are aged 18 years or less. [2] The Australian Bureau of Statistics describes a person as homeless if their place of dwelling is inadequate, has no tenure or a short tenure, or does not allow them to have control of and access to a space for social relations. [3] This includes people who stay in boarding houses, those who ‘sleep rough’, and those in supported accommodation for the homeless.

Australia’s political response to the significant healthcare needs of the homeless population has been slow. Australia’s Health 2012 noted the lack of comprehensive national data collection for this population group; the few sources that do exist emphasise the tendency towards the complex health needs of this population. [4] I was surprised to find that the previous publication, Australia’s Health 2010, had no data on the homeless population in Australia, despite the significant health concerns of this population group. [5]

Being at university in Darlinghurst, Sydney, homelessness is something I see most mornings, yet it is only recently that I have begun to understand the grave disconnect between this population group and our health services. A study conducted through St. Vincent’s Hospital, Sydney on homelessness in the area found that homeless patients at St. Vincent’s utilised four times the number of acute ward beds compared to the state average. [6] Furthermore, the homeless population experience a high prevalence of substance use disorders, and a disproportionate rate of mental illness exists among people who are either marginally housed or homeless. [4] In light of this, the study showed that there was high usage of mental health and drug and alcohol services by homeless people, and follow-up with these services continued post-discharge. [6]

The homeless population also experience a high burden of physical health comorbidites, and disease is more likely to be detected at a more advanced stage than in the general population. Homelessness is associated with a ‘risk of chronic disease of increased severity and complexity than the general population, as well as infectious diseases associated with poor living conditions.’ [4] Importantly, relatively low rates of linkage with GPs and ambulatory care services exist in this population group. [6]

So what can be done to increase health service access and utilisation in this population group? Australia-wide many organisations are already creating viable and sustainable solutions. One commendable example is ‘StreetHealth’, a mobile after-hours primary healthcare service currently implemented in Victoria. [7] Another model of integrated healthcare management that has generated interest is the provision of health services offered in conjunction with supported housing programs. These innovative healthcare models demonstrate the way in which committed and passionate healthcare professionals can create a just society by advocating for, and facilitating, access to healthcare for members of underserved populations.

I hope that Australia’s medical practitioner and student organisations can work together to increase awareness of the complex healthcare needs of Australia’s homeless population at a political level, and support the adoption of strategies similar to ‘StreetHealth’ nationwide.

1. The Social Justice Project is a part of the University of Notre Dame Australia, Sydney School of Medicine’s course. It consists of one week of voluntary assistance to an elected organisation. The aim is to identify an area of need in the community, and to address that need. It fosters a commitment to advocate for members of underserved populations and facilitate access to health services for these population groups.

2. Homelessness Australia. Homelessness statistics [cited 2013 April 30] Available at: http://www.homelessnessaustralia.org.au/index.php/about-homelessness/homeless-statistics

3. Australian Bureau of Statistics. Information Paper – A Statistical Definition of Homelessness, 2012 [cited 2013 April 30] available at: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4922.0Main%20Features22012?opendocument&tabname=Summary&prodno=4922.0&issue=2012&num=&view=

4. Australian Institute of Health and Welfare. Australia’s Health 2012 [cited 2013 April 30] available at: http://www.aihw.gov.au/publication-detail/?id=10737422172

5. Australian Institute of Health and Welfare. Australia’s Health 2010 [cited 2013 April 30] available at: http://www.aihw.gov.au/publication-detail/?id=6442468376

6. Chin, C.N., Sullivan, K. and Wilson, S.F. A ‘snap-shot’ of the health of homeless people in inner Sydney: St. Vincent’s Hospital. Australian Health Review, 2011 (35): 52-56.

7. Hookey, S.J. StreetHealth: Improving Access to Primary Care. Australian Family Physician, 2012 (41): 67-69.

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Picture Perfect?

Before reading this, take a moment to go and browse through your Facebook. Don’t be looking for what happened last Friday or what your ex is up to now, but instead, visit the profile of friends who have gone overseas for placements or volunteering and look at their photos. Once you’ve done that, come back and allow me to tell you about the day I met Emmanuel.

A few months after the 2010 Haitian earthquake, I found myself volunteering in Léogâne, a city of around 100,000 people. The city was near the epicenter of the earthquake and as many as 30,000 were killed here in the disaster. Due to the earthquake, not only were homes and businesses of many people destroyed but the health facilities in the city were decimated as well. Because of this destruction of local health facilities, residents were forced to seek care at foreign-run temporary replacements such as the field hospital where I volunteered. This is how I met Emmanuel.

Emmanuel was a 28 year old labourer who was brought in by friends while experiencing an asthma exacerbation. He had a long history of asthma, which was often made worse by the dust that he worked amongst. He initially appeared to be experiencing his typical asthma attack that usually resolved with salbutamol. The small oxygen concentrator used to provide him with nebulized salbutamol seemed to be providing some relief. However, after a few minutes of improvement, his condition suddenly deteriorated. Emmanuel began to display the unnerving appearance of someone who has reached the point of complete exhaustion from breathing. The only monitoring equipment available was an old pulse oximeter, but even this told an alarming story. The oxygen saturation dropped from a high of around 95% to 89% and his heart rate plummeted from 110 to 45 beats per minute. Emmanuel was close to death. Adrenaline was administered and repeated in hopes stopping this deterioration. After a few very tense minutes, Emmanuel’s condition improved and it became evident that there would be a happy ending to this story.

But this story is not really about what happened to Emmanuel during the worst of his exacerbation but rather is about what happened immediately after. At this point when things were calming down, one of the foreign volunteer nurses, who had been contributing to his care, took a picture of Emmanuel. He did agree to this but he certainly wasn’t in a position to truly give informed consent for this. In your Facebook friends’ photo albums you will likely find pictures of their Emmanuels.

The desire to capture a lasting image of someone whose care you have helped with overseas is understandable. For some reason, it even seems to be socially acceptable. None of us would ever take a picture of a patient on the wards. How is it that we don’t frown upon pictures of patients taken overseas?

Enjoy your overseas volunteering or placements. Take lots of pictures when touring around the country. When at the hospital though, patients deserve the same respect as they get here in Australia.

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Smartphones in the clinical environment: a help or hindrance?

It’s not an uncommon scenario: The medical team arrives at the patient’s bedside for the daily round. A phone rings and the registrar excuses herself from the bedside to answer it. Meanwhile, the intern checks the dosage of the medication being prescribed online. One of the medical students is looking up one of the patient’s diagnosis whilst the other replies to a personal text. During the time spent with the patient, most of the team has used their smartphone.

The use of smartphones by medical staff and students in the clinical environment has increased dramatically in recent years. Purported advantages include ease of access to information, use as clinical learning tools and improved communication with other medical staff. [1-3]

Smartphone use amongst medical students is already high, with a recent Australian study showing that the majority of medical students own a smartphone and 72% of these use their phones to access medical apps. [4]  Given this, medical schools in Australia are investigating the role that formalised introduction of mobile phone technology into curricula could play in medical education. [4,5] In the United States, some medical schools already require that students have access to a smartphone or other handheld device during their clinical years. [6,7]

The implications of increased smartphone use in the clinical environment may not be entirely positive. Medical students and staff report potential disadvantages of smartphone use to include spending less time with patients, [8] challenges navigating personal/professional boundaries [2] and potential for distraction from clinical tasks. [2,8] The risk of distraction from clinical tasks is not insubstantial. In a recent study performed in the United States, 57% of junior medical staff self-reported using smartphones during rounds, with 37% admitting to using them to access personal texts or emails. [9] As a consequence of smartphone use, 19% further reported that they had missed important patient information during rounds. [9]

The use of smartphones in clinical settings, whether for personal or professional purposes, may also have implications for doctor-patient communication. One report has suggested that junior medical staff frequently interrupt clinical encounters to answer phone calls and that this behaviour was sometimes perceived as unprofessional by other staff. [10] The impact of the digital device on non-verbal aspects of communication [11] and patients understanding of the doctors’ reasons to use a smartphone [12] are other potential ways that this communication could be negatively affected. There is, however, little research that directly examines patients’ perceptions of smartphone use by clinicians.

Smartphones are undoubtedly useful clinical tools and uptake by clinicians and medical students reflects this. As smartphones become a permanent fixture on the ward round, we need to think about how our use of smartphones affects communication and care of patients.

1.         Kajewski CM. The iPhone: Is it an indispensable tool for medical students? Australian Medical Student Journal 2010;1(1):61-2.

2.         Wallace S, Clark M, White J. ‘It’s on my iPhone’: attitudes to the use of mobile computing devices in medical education, a mixed-methods study. BMJ open 2012;2(4).

3.         Wu RC, Morra D, Quan S, Lai S, Zanjani S, Abrams H, et al. The use of smartphones for clinical communication on internal medicine wards. Journal of Hospital Medicine 2010;5(9):553-9.

4.         Koehler N, Yao K, Vujovic O, McMenamin C. Medical Students’ Use of and Attitudes Towards Medical Applications. Journal of Mobile Technology in Medicine 2012;1(4):16-21.

5.         Luanrattana R, Win KT, Fulcher J, Iverson D. Adoption of mobile technology in a problem-based learning approach to medical education. International Journal of Mobile Learning and Organisation 2010;4(3):294-316.

6.         Stanford School of Medicine: eStudent [cited 2013 April 30]; Available from: http://med.stanford.edu/estudent/.

7.         Georgetown University School of Medicine: Handheld computing requirement [cited 2013 April 30]; Available from: http://som.georgetown.edu/studentservices/informatics/about/HandheldComputing/.

8.         Robinson T, Cronin T, Ibrahim H, Jinks M, Molitor T, Newman J, et al. Smartphone Use and Acceptability Among Clinical Medical Students: A Questionnaire-Based Study. Journal of Medical Systems 2013;37(3):1-7.

9.         Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. Smartphone use during inpatient attending rounds: Prevalence, patterns and potential for distraction. Journal of Hospital Medicine 2012;7(8):595-9.

10.       Wu R, Rossos P, Quan S, Reeves S, Lo V, Wong B, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. Journal of medical Internet research 2011;13(3):e59.

11.       Alsos OA, Das A, Svanaes D. Mobile health IT: the effect of user interface and form factor on doctor-patient communication. International journal of medical informatics 2012;81(1):12-28.

12.       Miller KH, Ziegler C, Greenberg R, Patel PD, Carter MB. Why Physicians Should Share PDA/Smartphone Findings With Their Patients: A Brief Report. Journal of Health Communication 2012;17(sup1):54-61.

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Politics in the Medical Curriculum

“What? Margaret Thatcher is dead!” exclaimed the first medical student.

“Um…Who is Margerie Tha-that-sure?” replied the second with a blank expression. I could not help myself overhearing this conversation and my jaw nearly hit the ground.

As medical students, we are constantly being reminded of the expectation that we, as future practitioners, will eventually step into leadership roles within our communities. This often puts doctors in positions to shape government policies. Indeed, it is almost impossible to separate modern medicine from politics. Therefore, adding a political element to our curriculum would provide medical students with an ideal opportunity to prepare for these responsibilities.

Political studies would not only keep us informed regarding current policies, it would enlighten us to the process through which new policies are formed and existing policies are altered, replaced or removed. Individuals involved in this process must often maintain a broad knowledge of multiple disciplines including, but not limited to, cultural studies, religion, sociology, business studies, science, and technology. Therefore, it is important for medical schools to emphasise the importance of non-medical knowledge amongst medical students. This will equip our future clinicians with the insight to effectively fill leadership roles within society, and also provide holistic care to the wide array of patients that live in Australia.

Without such political knowledge, it is difficult to understand how scientific breakthroughs come to be applied to patients. The United Kingdom (UK) needle exchange programme, which provides clean needles for drug users, was introduced by Margaret Thatcher’s government in response to the then emerging knowledge of patterns of HIV transmission. This contrasts with the Australian needle exchange programme, which was born from civil disobedience but also inarguably effective. Despite remaining contentious within our society, this programme paved the way for the current stance of harm minimisation in Australian drug policy. A broad knowledge of social issues and an understanding of the actions of both doctors and politicians are required to appreciate how these politically controversial decisions were made.

Despite this, the lack of political knowledge among many medical students is startlingly obvious as illustrated by the “Thatcher conversation” above. I am currently in the fourth year of my studies, and apart from a few lectures which I have encountered in public health regarding health policies, the curriculum is lacking in political studies. The importance of a broad non-medical knowledge and understanding of policy-making has not been impressed upon students. While dedicated and ambitious students may find time to fill these holes themselves, it may be beneficial for medical curricula to touch on these important issues.

There are several ways in which political studies can be integrated into our curriculum. One way is to introduce a series of lectures complemented with tutorial discussions; another way is to implement a policy to mandate the selection of at least one general education subject related to politics in medicine. Such approaches would help students to appreciate the importance of political knowledge in the medical field. After all, how can medical students become the leaders of tomorrow if we don’t have the knowledge to do so?

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Being a doctor. Being a patient.

I recently heard that one of my friends – a medical resident, had developed pneumonia and had to be admitted to hospital for a week of intravenous antibiotics. She had been working long hours on a stressful rotation and as a result had not been sleeping or eating particularly well. She began to notice a pain in her chest, shortness of breath and hot and cold flushes, but chose to ignore the symptoms. It was only when she had a near collapse that she sought help.

Her story did not surprise me. I myself waited almost ten days before booking an appointment to see a GP for extreme lethargy, progressively worsening moist cough and shortness of breath. When I finally had the appointment, I realized how uncomfortable I felt being the person sitting in the patient’s chair. I did not like waiting 40 minutes in the waiting room for my appointment. I particularly disliked the examination process and having someone else auscultate my chest. The whole experience felt strange and somehow ‘not-quite-right’. I was not used to being in this position. On talking to other medical staff – it was the same. Doctors do not like being patients.

The British Journal of General Practice in 2008 performed a systematic review investigating doctors’ access to health care and the barriers they faced. One of the key barriers to accessing healthcare was: ‘embarrassment’. Davidson and Schattner found that 71% of doctors described themselves as embarrassed when seeing another doctor. While ‘embarrassment’ is a broad term, the studies reviewed described this as:

  • general discomfort with the patient role
  • concern that the treating doctors might think they were over-reacting to a trivial illness
  • concern (embarrassment) that they should not impose upon another doctor’s time, especially if the illness was a trivial one
  • discomfort in exposing self to peers personally and emotionally
  • feeling like a failure as should be able to cope
  • mental health issues

Other barriers listed included lack of time to see a doctor, costs involved, trying to find the ‘right’ doctor to see, confidentiality, fear of loss of control, self-treatment, and inside knowledge into the limitations of the health system. While much needs to be done to overcome many of these barriers, it is reassuring to know that there is now greater awareness about these issues. Health promotion is being taught at the university level to medical students with the emphasis on looking after one’s own physical and mental health and not falling into the thinking patterns listed above – i.e. feeling ‘embarrased’ to seek help. At the hospital level, systems are being established for providing support to stressed and ill doctors. On a national level, programs such as the Beyond Blue Doctor’s mental health program and the General Practice Registrars Australia helpline are now available. It may also be worthwhile establishing a GP database listing GP’s that are willing to care for doctors as patients. With greater awareness of these issues and better support services in place, hopefully doctors can become more comfortable assuming the patient role and taking care of their own health.

 

References:
Kay M, Clavarino A, Doust J. Doctors as patients: a systematic review of doctors’ health access and the barriers they experience. Br J Gen Pract. 2008 July 1; 58(552): 501–508.

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Student Versus Sleep

In a world where sleep deprivation is the new normal, there are medical students.

Most of us spend a third of our lives in this state of suspended consciousness and yet we still understand very little about what sleep really is. This ambiguity has led many to conclude that sleep may be wasted time. Society values output, efficiency and, by implication, sleeplessness. But what are we really sacrificing before the mighty altar of productivity?

Sleep has been linked to better mental health, cognitive function, and general wellbeing, and its absence has been correlated with a number of pathologies, including depression and hypertension. [1] It follows then that by cutting sleep in our quest for more time, we could end up sicker, sadder and stupider.

There is considerable evidence emerging in the form of both animal and human studies for the role of sleep in consolidating memory and learning, particularly procedural learning. [2,3,4,5,6] It is thought that learning tags neural pathways, which can then be reactivated and consolidated during the following period of sleep. [7]

But what about those times when we simply can’t make a full night of sleep?

In fact, sleep may not need to follow the traditional eight-hour block pattern to exert its benefit. A recent study showed that the natural deterioration in performance during repeated practice of a repetitive technical task was reversed by a thirty-minute daytime nap. [8] In the same study, subjects who napped for an additional thirty minutes actually experienced improved performance compared to their original ability, demonstrating the learning effect of sleep. The researchers went on to show that naps of sixty to ninety minutes can yield performance improvements equivalent to a normal night of sleep. [9]

The idea that a single afternoon nap can refresh the mind and enhance learning is particularly enticing to medical students and doctors, to whom the concept of an eight-hour sleep is often little more than a childhood memory. Such findings suggest that a biphasic sleep pattern (one sleep, one nap) may improve overall brain function, particularly if you need to maintain concentration and memory retention later into the evening. This siesta model is widely practiced in tropical climates to remedy the natural afternoon spike in sleepiness, and the phenomenon of power-napping has already entrenched itself in the vocabulary of the working public.

Of course, there are always those who insist on taking things further, which brings me to the vastly less scientifically validated portion of this article. Polyphasic sleep is a relatively new arrival on the scene, although its adherents cite the supposed sleeping habits of historical figures like Thomas Edison and Leonardo Da Vinci as early pioneers. It operates on the principle that much of our conventional eight hour sleeps are spent fluctuating through transitional states of semi-consciousness and low-grade rest and are thus wasted.

Building on the siesta model, by introducing more and more naps, the core sleep can be progressively whittled away, eventually culminating in the ultimate expression of polyphasic sleep, the aptly titled Uberman Cycle: a twenty-minute nap every four hours, indefinitely. That’s a total of two hours sleep per day!

While there are adherents posting on the internet who claim to have maintained rigid sleep diets like this for months and years at a time (i.e. Steve Pavlina), there is a notable absence of validated evidence for such minimalist sleeping patterns or their effects on wider health and cognition. Given the growing body of research asserting the importance of sleep for learning, performance and general wellbeing, I can’t in good conscience recommend such extreme sleep diets, no matter how appealing the idea of a twenty-two hour waking day might be.

What does all this come down to, aside from a thinly veiled excuse to live a Mediterranean siesta lifestyle? Firstly: sleep matters, and we medics are particularly prone to missing out on it. If you find yourself in a period of your life where adequate sleep is impossible (read “internship”), don’t underestimate the potential benefits of naps. Secondly: it could well be that sleeping is the easiest way to study that science has discovered so far. So next time you see me face down and snoring on my Talley & O’Connor’s, please don’t wake me or shake your head in disappointment–I‘m studying.

What are your sleeping patterns like?

References:

1. Skalski, M. (2010) Sleep Medicine. Overview of Medicine [Przeglad Lekarski], 67(9):721-5.

2. Ellenbogen, J.M., Hu, P.T., Payne, J.D., Titone, D. & Walker, M.P. (2007) Human relational memory requires time and sleep. Proceedings of the National Academy of Sciences, 104(18), 7723-7728.

3. Fischer, S., Hallschmid, M., Elsner, A.L., & Born, J. (2002) Sleep forms memory for finger skills. Proceedings of the National Academy of Sciences, 99(18) 11987-11991.

4. Rasch, B., Born, J. (2013) About Sleep’s Role in Memory. Physiological Review, 93(2), 681-766.

5. Wagner, U., Gais, S., Haider, H., Verleger, R., & Born, J. (2003) Sleep inspires insight. Nature, 427(6972), 352-355.

6. Walker, M.P., Brakefield, T., Morgan, A., Hobson, J.A., Stickgold, R. (2002) Practice with Sleep Makes Perfect: Sleep-Dependent Motor Skill Learning. Neuron. 35(1), 205-211.

7. Walker, M. P., & Stickgold, R. (2006). Sleep, memory, and plasticity. Annu. Rev. Psychol., 57, 139-166.

8. Mednick, S.C., Nakayama, K., Cantero, J.L., Atienza, M., Levin, A.A., Pathak, N., & Stickgold, R. (2002) The restorative effect of naps on perceptual deterioration. Nature Neuroscience, 5, 677-681.

9. Mednick, S., Nakayama, K., & Stickgold, R. (2003) Sleep-dependent learning: a nap is as good as a night. Nature Neuroscience, 6, 697-698.

10. Nishida, M. & Walker, M.P. (2007) Daytime Naps, Motor Memory Consolidation and Regionally Specific Sleep Spindles. PLoS ONE 2(4) 341.