CHAPTER 25 The profession of medicine
Medicine is an old profession. The purpose of the medical profession is to diagnose and treat the wide variety of human diseases and illnesses. The study of medicine has been documented since the times of Hippocrates in Ancient Greece. It is claimed that Hippocrates was the first to see medicine as science, separating it from the study of philosophy and proving that illness was not retribution for sin (University of Virginia 2007). Medicine has always been a profession that required a period of study — initially it was as an apprentice to another doctor, later it was time spent studying at university.
The oldest medical school in Australia is at Melbourne University, established in 1862; however, many medical schools are extremely new. For example, Deakin started in 2008. Medicine was traditionally a 6-year degree in almost all Australian universities and this usually consisted of 3 years of preclinical work and 3 years of clinical work. The pre-clinical years consisted of learning anatomy, physiology, biochemistry and pathology much like an undergraduate science degree. In the clinical years, the students were based in the teaching hospitals and learnt at the bedside, following more senior doctors around the wards, into theatre and clinics, learning clinical and procedural skills on patients, learning about their illnesses, admitting them to the hospital, looking after them when they were inpatients — learning by learning on patients.
The traditional way of learning medicine has changed in the last few years with almost all the established medical schools undergoing some sort of curriculum reform. While most undergraduate degrees in Australia are still 6 years, divided into pre-clinical and clinical years, there have been changes with more clinical skills and patient contact being introduced into the pre-clinical years. Also, many medical schools have adopted problem-based learning (PBL) as the basis of their curriculum. In a PBL curriculum, students still attend lectures and practicals but a large part of their studies is taught through the PBL process. The process of PBL is to use a patient problem, such as pneumonia, to start to learn about the inflammatory response, the anatomy, histology and physiology of the lungs, microbiology of infection and pharmacology of antibiotics. In groups of about eight and facilitated by a tutor, students discuss the case and the knowledge underpinning the condition. A lot of the learning is self-directed, with the students investigating the learning issues that arise from the case on their own and then presenting and discussing this with the group. The rationale is that the PBL process encourages students to be self-directed learners and this, in turn, should assist them in becoming lifelong learners, although this has not been proven (Finucane, Johnson, Prideaux 1998).
Since 1996, a number of postgraduate medical courses have been introduced into Australia based on the ‘American’ model of a 4-year postgraduate degree. These 4 years are also divided into pre-clinical and clinical years.
One of the major difficulties for medical schools is their ability to provide students with access to patients for students to learn on. This is a problem across the sector for every health profession, from paramedics to medicine, nursing and allied health. With more medical schools and more students in medical schools in Australia, there are fewer patients per student. Additionally, patients are now more likely to refuse to be examined by a student or a have a procedure performed by them, and hospital clinicians are busier and have less time to spend teaching. Access to good quality teaching in the clinical years is a dilemma all medical schools are now facing.
Pause for reflection
How would you feel if, as a patient, you were asked to participate in medical student teaching? If you were sick and in pain and a student wished to examine you, would you agree or refuse? If the student asked to perform an intimate examination (e.g. rectal examination) on you, would you agree? If an inexperienced student asked to perform a procedure on you, like taking blood, would you agree?
All medical schools are accredited by the Australian Medical Council (AMC), which is an independent national body established to determine if the standard of medical education at each medical school in Australia and New Zealand reaches the required level.
In the past, when all medicine schools were undergraduate, entry into medicine was based on Year 12 scores except in exceptional circumstances. This led to concern that medical schools were selecting only those with academic ability and not interpersonal skills. There is no doubt that medical students do require a high level of academic ability to cope with the amount and complexity of knowledge that must be acquired, however, most complaints about doctors are made about their lack of ability to communicate (Pincock 2004) not their lack of knowledge. Medical defence organisations (professional insurance organisations for doctors) run workshops to reduce a doctor’s risk of being sued and the major focus of these workshops is improving communication skills, not knowledge. Some medical schools introduced an interview as part of the entrance criteria to get a rough approximation of students’ interpersonal skills, communication skills or reasoning skills. The validity of the interview and other selection methods has recently been called to question as if it is not clear whether these selection methods are actually choosing medical students who will graduate with better communication skills or not (McManus & Powis 2007).
Most medical schools in Australia use the Undergraduate Medical Admission Test (UMAT) for undergraduate medical courses or the Graduate Australian Medical Schools Admission Test (GAMSAT) for graduate medical courses as an entrance exam. There are other health-related professions which also use the UMAT. Selection into a medical course is also based upon Year 12 or university marks or grade point average (GPA) and in some cases an interview. Additionally, some medical schools use a written portfolio submission. The weighting universities give to these entry requirements is different across the country. Both the UMAT and GAMSAT are overseen by the Australian Council for Educational Research (ACER). There are preparatory workshops advertised widely, that candidates can pay to attend, which ‘claim’ to increase their chances of scoring well in the tests and performing well in the interviews.
The degree given to Australian medical graduates is a MBBS which comes from the Latin for Bachelor of Medicine and Bachelor of Surgery. Flinders University awards graduates a BMBS, while the University of Newcastle/University of New England awards graduates a Bachelor of Medicine. In England, the degrees are often MBBCh (using the French word for surgery — chirurgie). In the US, this degree is an MD, but in Australia, an MD is awarded to someone who is granted a Doctorate in Medicine — a special PhD in medicine.
In Australia, after completing the medical degree, graduates are given the honorary title of doctor. This is a title which is also given to dentists and veterinary surgeons and earned by those who complete a PhD (in Australia, this is a 3–4 year full-time thesis). Surgeons were always called Mr — reflecting their barber origins and the fact that until recently there were very few female surgeons (Pringle 1998).
After graduating from the 4–6 year medical degree, the graduate is given provisional registration by their state or territory medical board. In Australia, this is followed by the compulsory intern year, where graduates are paid for the work they do under the supervision of other doctors. Once the intern year is satisfactorily completed, doctors are given full registration and must make a decision about which postgraduate training program they will enter. When an intern enters a training program, they are called a ‘registrar’. While medical student education is under the control of the universities, the postgraduate training is controlled by the professional medical colleges; for example, the Royal Australasian College of Surgeons. There have been recent calls for the universities to have a major role in the teaching of postgraduate trainees, rather than it remain solely with the separate colleges (Lawson, Gregory, van der Weyden 2005). These colleges control the selection of trainees, the number of training posts, the educational program for the trainee, the assessment, and decide who is allowed to qualify as a specialist in their college. The colleges are self-regulated and have been able to exert much power over their specialty but, in the last 10 years, they have been subjected to scrutiny from the Australian Competition and Consumer Commission (ACCC), the Australian Medical Council and other government bodies (Lawson et al 2005).
Table 25.1 is a list of medical colleges’ specialties and subspecialties, taken from the college websites. The list of specialist medical colleges can be found on the AMC website (see online resources at the end of this chapter). Please note that when someone refers to the specialty of medicine, they are referring to ‘internal medicine’ which is what a physician practises. Some doctors decide not to enter a specialty training program immediately and are in the general basic program. The amount of time to train to be a specialist varies from 4 years for general practice up to 7 years for physicians. The amount of time needed to be a specialist varies between countries.
|Medicine||General physician||Cardiology, clinical genetics, clinical pharmacology, endocrinology, gastroenterology and hepatology, geriatric medicine, haematology, immunology and allergy, infectious diseases, intensive care medicine, neonatal/perinatal medicine, nephrology, neurology, nuclear medicine, oncology, rheumatology, sleep medicine and thoracic medicine. Also, occupational medicine, rehabilitation medicine, public health and palliative medicine|
|Surgery||General surgeon||Cardiothoracic surgery, otolaryngology, head and neck surgery, neurosurgery, orthopaedic surgery, paediatric surgery, plastic and reconstructive surgery, urology, vascular surgery|
|General practice||General practitioner||Rural and remote general practitioners|
|Psychiatry||General psychiatry||Child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, psychoanalysis and psychotherapy|
|Obstetrics and gynaecology||Obstetrician and gynaecologist||Gynaecological oncology, maternal fetal medicine, obstetrical and gynaecological ultrasound, reproductive endocrinology and infertility and urogynaecology|
|Paediatrics||Paediatrician||Community child health, paediatric emergency medicine, paediatrics and child and adolescent psychiatry, paediatric rehabilitation medicine|
|Anaesthesia||Anaesthetist||Pain medicine and intensive care|
|Pathology||Pathologist||Anatomical pathology, chemical pathology, genetics, haematology, immunology and microbiology|
|Radiology||Radiologist||Nuclear medicine and radiation oncology|
|Rural and remote medicine||Aboriginal health, rural medicine|
|Emergency medicine||Emergency physician|
|Medical administration||Medical administrator|
These case studies represent some of the specialities in medicine and some personal comments by doctors on their work. This information was sourced from real case histories but names and identifying details have been changed.
It’s a lot of hard work but I like the collegiality of the other registrars. I thought I would get more of an intellectual buzz out of solving the diagnostic challenge of patients’ problems. Sometimes I do but mostly it’s just a lot of hard work.