Contents

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Letter from the Editor

Essays

Gender pay gap: is it a thing? Yep by Leah Ginnivan 

A Melting Iceberg Sinks More than the Titanic by Josh Druery 

Book reviews

The World Without Us- Mirielle Juchau by Aneka Larsen

The Man Who Mistook His Wife For A Hat – Oliver Sacks by Aneka Larsen 

Humour

Misunderstood Medical Words – a compendium by Callum Gin

Med School Comics by Tharuka Bodaragama

Art

HEART FAILURE  by Leah Ginnivan 

Interviews

Innominate interviews Dr Zeshan Qureshi by Imogen Thompson 

 

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Prescription: Books

Aneka Larsen has some medicinal book recommendations for those idle holiday minds… 

Two common ailments among medical students are:

  1. The desire to run away and hide, just for a little bit, please
  2. Constantly asking yourself why you are putting yourself through this

To cure you of these truly debilitating conditions, I offer you two very important prescriptions.

PRESCRIPTION ONE: A BOOK TO HELP YOU ESCAPE MEDICINE

The World Without UsMireille Juchau

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This is a book that feels like Australia. The Australia of my childhood, tucked away in a neat little bundle of memories, sacrosanct and intangible. What a treat to dive back in, to explore the muddy riverbanks, bush land and tight-knit community of a rural town that is infused with its own unique history and culture. The Big Smoke is a whirlwind of excitement, but it sure feels nice to momentarily escape, nestle into the cosy, green tableau of the Ghost Mountains and dream for a while.

The Müller family are a made-up family in a made-up town somewhere in a northern rainforest. Their family is complex. A distant mother heals herself with painting and secret sojourns to the woods. A gentle, eccentric father tends to bees and his two young girls, Tess and Meg. The girls try to make sense of their world, their mother, and the ever-changing emotional landmine that is growing up.

Juchau offers up a plethora of and touching and nostalgic insights into life and adolescence in rural Australia. They are a community of strange yet jarringly familiar characters; A doomsday fanatic, a wily family friend, busybodies, cult members, farmers, merchants and criminals. As well, the imagery is familiar and comforting; sections of the book are demarcated with odes to flowers, the rain, and the bees. There are narratives I remember from my own past; Silly competitions with my sister, a refusal to speak, running away from home, riding silently in the passenger seat through the dirt roads of my hometown. The knowledge that members of your community do not like your family for reasons you are too young to understand. The special attention proffered by a favourite teacher who encourages your curiosity and offers you books to devour. The feeling of being home.

If you come from somewhere else; somewhere quieter, somewhere that flickers behind your eyes as you fall asleep, a place far from flashing, beeping, bustling Sydney, then I hope you read this book. It was a pleasure to fall into, a pleasure to be carried away by, and a truly dream-like dance through the warming nostalgia of an Australian childhood.

 

PRESCRIPTION TWO: A BOOK TO REMIND YOU OF WHY YOU’RE DOING MEDICINE

The Man Who Mistook His Wife For A HatOliver Sacks

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As someone who today listened to six lectures in the library, came home to read a chapter on the GIT exam, and then fall asleep across the table from my dinner, I have a deep understanding of what it feels like to question one’s life choices. Luckily for me, there are those in the world who act as beacons of inspiration, guiding the way from out behind my bowl of soup, into the wider world of real medicine making a real difference to real patients. The first of such beacons was, for me, Oliver Sacks. A brilliant neurologist and author, whose books emanate a profoundly sincere respect for his patients, and a humbling acknowledgment that the people we care for can be our most important teachers.

The Man Who Mistook His Wife For A Hat is a series of case studies that detail the intriguing and bizarre neurological phenomena Sacks encounters throughout his career. Such cases include a man suffering from agnosia who is compensated with a gift for music, a woman who can no longer feel her own body, an elderly man seemingly stuck in his past, a man who cannot believe that his leg is his own, and a ninety year old woman who has started to feel “frisky”. Sacks regales these stories with deep consideration not just for the neurological pathology, but for the character and substance of the patient before him. Each case study illuminates a special individual and reminds us of the privilege studying medicine affords us – the ability to play a significant role in the lives of significant individuals.

Anatomy atlases, ankis and academia abound can make anyone feel apathetic from time to time. Admonish these unwelcome feelings by reminding yourself of the people you will meet, the stories you will hear, and the difference you can make. There is no better way to do that than with the tried and true, evidence-based method of immersing yourself in an Oliver Sacks novel. This is one of his best. NNT = 1.

Misunderstood Medical Words- a compendium

 Callum Gin explains what those words you’ve been fumbling really mean. Yield = high.

‘I got all the words, I have the best words’ – Donald J. Trump

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Genu: collective noun for a group of genie

Uncus: an uncle with a multi-personality disorder

Target cells: terrorist groups that are currently under investigation

Supinator: A cyborg chef bent on killing Sarah Connor

Catalase: the enzyme used for digesting felines

Corona Radiata: the incidence in which a sunlight passes through a glass of Mexican beer creating a halo

Hippocampus: A popular, adventurous holiday destination for hippopotami

Optic radiation: the feeling you get when someone is staring at you

Retrograde ejaculation: sperm that have penchants for jackets from the 70s

Moluscum contagium – when the sweet deal you receive at the fishmarket isn’t so sweet after all

Gallbladder – The bladder of gulls

I cells – the cells that make up you

Pancreas – the classic case of the bent skillet

Barium Meal – the last meal of Alexander Litivinenko

Cardinal ligament – The Roman catholic priest that has a passion for holding bones

Hypersecretory – the most important secret you will ever be told

Innominate interviews Dr Zeshan Qureshi

unofficialguidetomedicine-sixbooksDr Zeshan Qureshi is a paediatrician based at King’s College in London, with a special interest in Medical Education. Dr Qureshi founded the successful Unofficial Guide to Medicine textbook series, which is regularly among Amazon’s best selling medical textbooks. Imogen Thompson was fortunate to be able to sit down with Dr Qureshi when he visited Sydney as part of a trip to learn more about how medicine is taught outside of the UK. They discussed med school, a life in paeds, the art of getting published and resuscitating zombies, here is the transcript of their chat: 

I: What first sparked your interest in medical education?

Z: It’s one of those things, that just seem to just happen. I guess the most powerful stimulus was that when I teach, students are always very receptive and grateful. I remember starting a s a junior doctor, and I felt like – oh I’ve been given overwhelming amounts of work to do. A lot of it was quite mundane, a lot of it was following orders and I didn’t really have ownership or control over any of it. But when I taught, it was something that I could prepare, I could do what I thought is best for students, and it was a very worthwhile experience – literally every time that it happened. And then after that experience, I thought how can I expand teaching further, how can I have more of an impact and create something more positive. And so I went from teaching at the bedside to helping implement teaching programs to helping implement teacher training programs so we reached even more people. And then to writing medical books, which meant that although even more work had to go into preparation, all it took was one click on amazon for people to buy them.

I: So you’re visiting Australia to learn about how medical school is taught here. What have you found to be the biggest differences between the way that medicine is taught in the UK compared to Australia so far?

Z: The biggest difference that’s been most immediately noticeable is the relationship between the students and the faculty. I feel that although there’s hierarchy, it isn’t anywhere near as embedded. I see students asking way more questions in lectures, I see them refer to their professors by their first names, I see teachers in the same bars as students and it’s a very positive relationship, which ultimately can only be a good thing. Another thing that is very obvious compared to the UK, is that there is a much greater culture of advocacy amongst students, a much great culture of organisation and engagement. I’ve seen medical student societies which have 70 plus members with their own legal advisors that are intimately involved in developing curriculum. Not just on the basis of the opinions of a few individuals, but actually gathering organised data from the student body and looking at the long term improvement for the medical school.

The biggest difference that’s been most immediately noticeable is the relationship between the students and the faculty. I feel that although there’s hierarchy, it isn’t anywhere near as embedded.

I: That actually links really well with my next question, our medical school is currently in the process of developing a new curriculum. What aspects of medical education do you see as being the most important for the training of good doctors?

Z: I think it’s difficult to say. The most important thing actually is not what is in the curriculum, but the process by which the curriculum is arrived at. Two groups of people that I think are very important – one is the patients themselves and what they perceive is important, even in paediatrics where we increasingly consult children who are teenagers or even younger about what they want in hospitals and what they want from their doctors. And they say very simple things, like having unisex bays, having a play area, having Wi-Fi access in the hospitals. And you know even just informally speaking to my friends that have had medical experiences as patients, they speak of wanting communication to be better, wanting to be listened to when they have ideas of what needs to be changed. And so yeah, I think patients are a very important group to be listened to. And then the other group is the students. Academics, professors, consultants, they have the learned experience of treating and managing disease. But the student body know their own methods of learning, and their own knowledge gaps. And I think curricula should be as sensitive and responsive to that as possible. Particularly considering it’s the students that pay for their education. So what sort of things does that mean? I really value the use of comedy or drama in medical education. One thing that I saw in a conference in Edinburgh a few months ago, was an alternative way of teaching resuscitation, instead of using standardised scenarios, for example “Stephen gets hit by a car driving 90mph”, fantasy scenarios are used. The scenario was Stephan gets bitten by a zombie and has his blood drained – and it was all run in a SimLab. Everyone had lots of makeup on, and it was made fun and interesting but with all the same principles behind it. And then when the group studied outcomes comparing the zombie apocalypse stimulated scenarios with the standardised ones – students had greater retention of knowledge and more fun when it was associated with the comedy. It’s non-traditional but it’s something that works and is effective.

 

But the student body know their own methods of learning, and their own knowledge gaps. And I think curricula should be as sensitive and responsive to that as possible.

 

I: Given that you have a successful book series, undertake research and are a practising clinician, how do you go about maintaining a good life balance considering all of these different demands?

Z: In everything I do, I work in teams and I make sure that I recruit people and work with people that share the same values and the same vision as me. And I found that increasingly as my work grows, more people are aware of it and more people want to do similar things. I think one of the greatest things that I have achieved is creating pathways for people to be successful that wouldn’t have otherwise existed. So for example the last book that I published: “The Unofficial Guide to Medial Research, Audit and Teaching”. I worked with a really bright young student from Oxford University, who I rapidly promoted to chief editor for the book, despite her only being a final year medical student. After months of hard work, it was published before she graduated and she won a “BMA Medical Book of the Year” award. And that all happened because of pathways that wouldn’t have existed without the work of the “Unofficial Guide to Medicine” textbook series. So I find that very valuable – helping other people be the best they can be, giving them opportunities and helping to achieve outcomes that I really believe in at the same time.

I: I think it’s a sign of a good leader as well

Z: And then the second thing is, I put a lot more thought into my personal wellbeing than I used to. I really value and invest in my friends and I know that they’re people I can always talk to when things go wrong. I do simple things, like making sure that I eat three meals a day, I sleep, I exercise, I reflect on things even when they don’t go particularly badly, just so I know that I am being the best version of myself that I can be.

I: Onto your research – what role do you see research as playing in a medical career?

Z: One of the big problems with research to me is that lots of people feel obliged to get involved in research despite it not being important for them in their career.

And there are whole sways of research done that is technically not very good, that crowds the literature and makes it hard to discern what is good and what is bad. And this all stems from a desperate desire to get published.

Because you need to get published to get ahead. In terms of what the true value of what research is in a curriculum, I think the most important thing that people need to know is how to apply research into their clinical practice. How much of the curriculum this requires I don’t think is very much. Particularly as we move away from a very strongly basic science based curriculum, to one that is more integrated and clinical.

I: What has been the most rewarding aspect of your life as a paediatrician?

Z: I remember my first shift as a registrar, I was working in the new born baby unit. I was covering the labour ward and a 33-week mum developed pre-eclampsia and she was being monitored. She then developed eclampsia, she started fitting, and her blood pressure went up to over 200 mmHg. I remember going to theatre because they’d called a category one caesarean section. And then whilst in theatre, I was there with my team of nurses and junior doctor, and then all of the sudden, this lady’s heart stopped pumping – she arrested. Then everything changed, chest compressions were started, mum was given adrenalin (she eventually got 8 rounds of adrenalin) and the baby was carved out of her stomach in about 20 seconds with no anaesthetic. And I was handed a blue, floppy baby, with no signs of life, I thought that they were dead, that they were stillborn. But then with my team we stimulated the baby, we applied basic resuscitation measures to them, and by about 8 minutes the baby had started breathing for itself. We took them across to intensive care, within a week both the mum and the baby had gone home. Mum’s biggest complaint about the baby was that it had the sniffles! And this is the greatest personal thing I get in paediatrics – where you know that there are simple things you can do, that make a really big difference. That baby would have been stillborn in most parts of the world. But what we were able to do as a team, was save that baby’s life so that for all intents and purposes they are going to have a normal life.

I: On the flip-side of that, what do you think has been the greatest challenge of your career so far?

Z: The hardest thing for me has been when things aren’t going well, when I see that things might be able to get done in a better manner. And I raise concerns or ask questions and it doesn’t go anywhere. And that process has always been extremely frustrating. And sometimes me raising the concerns has made things worse, because it’s forced people to become more defensive and maybe even try and silence me because I’m questioning authority. What I’ve learnt as I’ve gotten older and more experienced with healthcare services is that everyone has the same shared vision of wanting to provide extra patient care but you just have to work out the appropriate pathways to voice concerns and to make a change.

So you don’t immediately shout out the first thing that comes into your head when it appears that things aren’t going as they should be.

But you take time to reflect on it, to collect information to objectively quantify the problem. And then go through the pathways that are there already to raise it appropriately so that a proper long term solution can be implemented.

I: You’ve spoken about the importance of mental health and self-care, something that is particularly important to medical students. Do you have any advice regarding this?

Z: I think that the first thing to note is that if you have a problem don’t blame yourself, don’t think it’s a weakness on your part.

In the UK the suicide rates of doctors are double that of the normal population. Depression is rife, anxiety is rife, post-traumatic stress disorder is rife. It’s a problem with the system, rather than you as an individual.

Be honest with yourself as soon as the problem arises, as early as possible. Work out what you can do to genuinely improve things, the day-to-day challenge is preventing mental health problems and the solution is very individual. Simple things like making sure that you eat well, spending time with your friends, and you sleep well are often easier said than done but important to be aware of – in the same way that you are aware of deadlines for essays. Put personal wellbeing in the same league as academic commitments. I’d say also be honest with yourself, really try and think about how things are, the challenges you have on a day to basis and reflect on them. Keeping a diary is a wonderful that you can do. Remember the experiences you have at medical school: they are nothing like what normal human beings do, you could easily have a shift where one or two babies die – and most people never see a baby die in their whole life. And the trauma that comes with that is important to recognise.

I: Just on that note, this is a particularly pertinent issue in the UK at the moment with the changes that have been made to NHS junior doctor contracts. In an ideal world what provisions what you like to see put in place to protect the mental health of junior doctors and create a safe working environment for both staff and patients?

Z: I think that the difficulty in the UK has been that the government are felt to be completely out of touch with junior doctors and the problems on the frontline

One of my colleagues, Professor Clare Gerada, she said that if the NHS was a coal mine, it would have been shut down years ago because of how awful the conditions are, and that’s just the implementation of the NHS.

I think that the job itself needs to give people time to spend with their family and with their loved ones, it needs to give them time to rest between shifts and within shifts so that doctors can be healthy themselves. And then if things do go wrong, the culture has to be one of I want you to speak out, I will support you if you speak out. And there will be something meaningful we can do about it if a problem has been identified. Rather than now, when people feel ashamed to talk about mental health problems, because its seen as a weakness, a weakness that you as a doctor who has learnt about depression should know how to overcome, and should be clever enough to overcome. Mental health doesn’t work that way, and back in London, we have anonymous specialist services for doctors with mental health problems to help deal with this unnecessary dilemma.

I: Do you have any last pieces of advice or words of wisdom for our medical students?

Z: One thing that medical students forget is how special they are. I remember when I started at Southampton, a guy called Professor Norman Carr stood up and said that you are the brightest of the bright, the majority of you are going to sail through medical school, you are going to enter into them top tiers of society and will have a long term fulfilling career, that you will be very proud of. I think that being drowned in assessments, being told what to learn and what to do, can often drain that spirit out of you. But just remember you’ve got another 60 years to contribute to medicine and you can start that contribution as a medical student, right now. With the medical books that I do, I have over 500 students across the world working on various titles, but it doesn’t have to be medical textbooks that is your passion. You can get involved in global health, local community action, you can get involved in education. You have the intelligence to do it. Keep the drive alive that got you to apply to medical school in the first place and do what you want, so that you can be the type of doctor that you want be. You don’t have to wait until you graduate to do this, you can start doing this now.

I: Excellent advice, thank you so much for your time.

More information about the Unofficial Guide to Medicine textbook series can be found at http://unofficialguidetomedicine.com.

Problems with women in medicine begin at medical school

By Victoria Cook and Josephine de Costa

 

In 2015 I started my first year of medical school and for the first time in my (very privileged) life I was confronted with a setting where being a woman was quite openly considered a factor in my future career. Perhaps I was naïve, but I wasn’t expecting that.

Women have made up the majority of medical students since 2001. Yet, despite what people hoped or expected, gender norms in medicine have not evolved at a similar rate.

I was surprised, amused and then frustrated as well-intentioned friends and strangers reminded me to consider family-friendly specialties like dermatology, or general practice. They cited their predictable hours and flexibility making them ‘good careers for women’. Didn’t I want to specialise in paediatrics?

I listened as female friends considering a career in a specialty such as surgery were consistently reminded to consider how they would fit in family, and that ‘it would be hard for them.’ People, with the best intentions at heart, warned them of a ‘boy’s club’ culture.

Yet nobody questioned why, in 2015, medicine still had a place for ‘boy’s clubs’?

If you ask a female medical student she will tell you that at some point or other she has been mistaken for a nurse or referred to by a patient as a ‘lady doctor.’ As trivial as this may seem, these messages are pertinent reminders that gender is still very relevant and very visible in medicine.

And all this, in the context of a year full of revelations about sexual harassment of female surgical trainees by male surgeons, aggravated by a lack of consequences for perpetrators and the silence of bystanders and leaders.

This cultural environment where the challenges for women are viewed with resignation as simply ‘the way things are’ is a symptom of a powerful cultural concept at work in medical school- its called the ‘hidden curriculum’.

The hidden curriculum refers to the undercurrents of information, not formally part of the medical curriculum, that filter through from peers, patients and lecturers to budding doctors. It is particularly powerful in medicine. Students, keen to fit into the medical profession they idolise, rapidly adopt many of these tacit lessons. And thus outdated views propagate unchallenged.

The hidden curriculum perpetuates stereotypical representations of the qualities required for success in particular specialties. For example, the surgical stereotype is deeply ‘masculine, competitive, confident’. These embedded perceptions of specialties, combined with the scarcity of female role models, preclude female students from envisaging a ‘successful self’- the ability to imagine a successful career in surgery.

Although these messages won’t deter the most certain, committed female students from pursuing a career in a male-dominated specialty, like surgery, it is the students who are less set upon a particular specialty who are subtly influenced.

Studies consistently show that the most significant factor influencing a medical students career choice is gender. Intelligent, ambitious female students reconsider their career options, favoring the paths where their gender does not represent a significant obstacle. These include specialties with more accessible maternity leave or job share options, more flexible training programs and a higher proportion of women in leadership.

Such findings go some way to explaining the deeply gendered pattern of medical specialisation in Australia today.

Women represent 44% of GPs and 36% of specialists yet only 13% of general surgeons, 3% of orthopaedic surgeons, 8% or urologists and 16% of cardiologists. In comparison, 52% of geriatricians, 44% of GPs, and 72% of palliative care specialists are women. Women are concentrated in lower paid, less prestigious specialties.

Historically, female absence from some specialties was considered a reflection of differing professional and personal priorities including a lack of interest in ‘technical skills’, a preference for ‘patient contact’, and a desire for a career with more family friendly hours. Others argued that the disparity would simply correct itself with time.

Given the enduring nature of the problem, and the predominance of women in paediatrics, or obstetrics and gynaecology; two specialties that are both procedural and unpredictable, these hypotheses have been discarded for a more nuanced view of a structural barriers deterring women from selecting or succeeding in male-dominated specialties. This approach returns the onus for increasing gender diversity from individual women to the professional and educational institutions they belong to.

Medical schools have a role to play in countering the ‘hidden curricula’ to foster a more gender-neutral pattern of specialisation in their graduating students.

This includes ensuring exposure to female role models as lecturers or clinical tutors, as well as monitoring and addressing instances of gender discrimination in clinical rotations. It means training teaching staff to avoid subtle and overt patterns of gender discrimination and unconscious bias. It also includes an open and public commitment from leaders to improving gender equality in medicine, in order to counter the message that such disparity is inevitable or intractable.

It must be noted that confronting gender bias at medical school requires a simultaneous commitment by the medical profession to address the very real barriers faced by female doctors after medical school. Chiefly, measures to improve gender equality in medicine are futile without a simultaneous commitment to increasing flexibility of training programs and access to parental leave.

No strategy to increase the participation and progression of women in male-dominated specialties will be successful as long as female trainees are required to choose between delaying or foregoing children in order to pursue an ambitious specialty.

In 2016 there aren’t a lot of female firsts left in medicine, women achieve incredible success in all aspects of medicine- and so they should. But in applauding these ‘exceptional’ women it is easy to neglect a conversation about the way in which the majority of women experience a career in medicine.

Differential patterns of specialisation, pay, publication, promotion and leadership clearly indicate that gender inequality persists in medicine. We must have a frank conversation about women in medicine. This conversation can focus on barriers, or it can focus on solutions. And it begins at medical school.

Disclosure: Victoria Cook and Josephine de Costa are founding members of the group Level Medicine, a group that aims to start a positive discussion about gender in medicine. 

The views and opinions expressed in this article are those of the author and do not necessarily represent those of SUMS.