more_vertChristine Montross wrote her first memoir, Body of Work: Meditations on Mortality from the Human Anatomy Lab, when she was still a medical student. In it she described the process of dissecting a cadaver with a poet’s attention to detail and metaphor. When her female cadaver inexplicably lacked an umbilicus, for example, she and her lab partners named her Eve. Anatomy lab became for her, as for many medical students, an initiation into the complicated emotional work of being a doctor. She learned to contain her emotions without becoming indifferent.
Preference: Physiology and Anatomy
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[Review] Transfusion reactions: prevention, diagnosis, and treatment
Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.
[Perspectives] Revealing the secrets of the dead
Human skeletons have played a fundamental role in medical training for centuries, with individual bones and articulated skeletons routinely used to convey the form and function of the musculoskeletal system to knowledge-hungry students. The process of siding a lone radius, or identifying the scalene tubercle on the first rib will be familiar to everyone who has been through, or teaches in, anatomy laboratories in medical schools. However, many of us are guilty of seeing these bones in impersonal isolation, shorn of the rich personal, cultural, and medical history associated with the individual from whom they came.
[Comment] Improving outcomes of dialysis patients by population health management—the Global Chief Medical Officer Initiative
Renal replacement therapy (RRT) by dialysis is a life-sustaining treatment that globally enables almost 3 million patients with end-stage renal disease to survive while maintaining daily activities of living.1 Despite technical progress in dialysis machines and dialyser performance, better understanding of uraemic pathophysiology, improvement in dialysis tolerance, and better management of anaemia and other comorbidities, patients have a high burden of chronic illness with substantial morbidity and mortality.
[World Report] 2016 Nobel prize in medicine goes to Japanese scientist
This year’s Nobel Prize in Physiology or Medicine has been awarded to one scientist from Japan for his work uncovering the processes of cell autophagy. Dara Mohammadi reports.
New method for harvesting stem cells could improve donor-patient treatment
Scientists in Australia have developed a novel, less invasive stem cell-harvesting method that reduces side effects for donors.
Current harvesting methods are lengthy and require numerous injections of the growth factor granulocyte colony-stimulating factor (G-CSF) to boost stem cell numbers.1
As described in Nature Communications,2 the discovery reduces the time required to obtain sufficient stem cell numbers without the growth factor.
Developed by the Commonwealth Scientific and Industrial Research Organisation (CSIRO), working with the Australian Regenerative Medicine Institute (ARMI) from Monash University, the method uses a newly discovered small molecule (BOP; (N-(benzenesulfonyl)-l-prolyl-l-O-(1-pyrrolidinylcarbonyl)tyrosine)) with an existing small molecule (AMD3100) to mobilise stem cells from bone marrow to the blood stream.
Susie Nilsson, from CSIRO, and her team demonstrated that stem cells could be seen in the blood stream an hour after a single dose of the combined molecules was administered.
“The new method eliminates the need for the growth factor G-CSF, reducing a procedure that once took days down to around an hour,” Nilsson said.
“Until now, AMD3100 has only been effective in increasing stem cell numbers when combined with the growth factor,” she said.
Not only does the combination eliminate the need for the growth factor, but transplanted harvested cells replenish the entire bone marrow system.
The scientists found no known side effects from combining the two small molecules.
According to ARMI Director, Professor Peter Currie, harvesting stem cells will become more effective and efficient using this method and will considerably reduce donor stress.
Successful pre-clinical studies in mice and humanised mouse models have so far demonstrated the efficacy of the treatment.2
A phase 1 clinical trial will assess the combination of the BOP molecule and G-CSF, before the eventual combination of the BOP and AMD3100 molecules.
[Perspectives] Mortal remains, immortal work
Padua was a Mecca for art and anatomy students in the 16th century. In the 1530s Andreas Vesalius performed revolutionary dissections at its university, which shifted the focus of anatomy away from written authority to the body. The young Belgian professor encouraged students to “see for themselves” (the original meaning of autopsy), using their eyes, rather than their mind’s eye conditioned by Galenic theory. “Seeing is believing” was his cardinal lesson, “believe what you see, don’t see what you believe”.
Teaching doctors how to live
From the day I sat my first interview for medicine, there was a decision to be made about what place medicine would take in my life. The interviewer asked how I felt about personal sacrifice in medicine, given that the degree was difficult and time consuming, and that it would take away time I could have spent with friends, parents and siblings.
There seem to me to be two types of answers that an applicant could give. The first, that they’re committed to sacrificing whatever is necessary in order to be a doctor. The second, that they’re committed to doing whatever is necessary to strike a successful balance between medicine and the other parts of their life.
As is the case with so many who’ve entered the medical profession before me, I’m driven by a commitment to providing the best possible patient care.
I knew from the outset that commitment would mean long hours, a long training pathway and moving a long way from home, and those remain sacrifices well worth making in order to become a better doctor.
Unfortunately, I’ve seen this same commitment to medicine drive medical students and doctors alike into the ground. The 2013 beyondblue study of doctors and medical students, now well known to many of us, highlighted the impact of stressful and demanding work on a dedicated profession. One in 10 doctors reported having had suicidal thoughts in the 12 months prior to the study; for medical students, that number was one in five.
I have the great privilege this year of hearing the views of medical students all around the country. I’ve frequently heard that even during a medical degree, there are rotations where students find balancing hospital hours with time to study, exercise, eat a reasonable diet and get a serviceable amount of sleep a challenge. That balance will only get more difficult as they progress through medical training. As students develop their habits around work and wellbeing, they look to interns, registrars and consultants to set an example of what being a good doctor looks like.
Doctors have a great deal of influence in teaching those junior to them, and those lessons aren’t limited to anatomy and physical examination.
When doctors promote doctors’ wellbeing as important, that shapes the way wellbeing is seen in that team all the way down to the student. Similarly, doctors who make sure their teams are aware of initiatives such as the Doctors’ Health Advisory Service, shape the ability of their juniors to seek help when it’s needed.
Sitting in that first medical interview, I said I’d do whatever it takes to become a good doctor. Today, I know that no small part of ‘whatever it takes’ is prioritising personal wellbeing. I have some outstanding doctors to thank for that understanding; watching the example they set shapes the way I live and work.
The statistics tell us just how high the stakes are in making doctors’ wellbeing a priority.
You too will set an example that influences the lives and livelihood of those around you; give thought to the lessons you want to teach.
Email: elise.buisson@amsa.org.au
Twitter: @elisebuisson
Driving fatigue
Doctors are very well acquainted with what it’s like to work long hours under pressure.
The experience begins in the undergraduate years with what seems like a Herculean effort to keep passing all of those exams.
By my second year as a medical student, I didn’t even sneeze when the anatomy lecturer said that we could be examined on anything at all from the 820 pages of Gardner, Gray and O’Rahilly’s textbook – that is, except for anything about teeth.
Looking for some respite, I quickly flicked through the pages to find that Chapter 61’s description of teeth was only eight pages long, leaving another 812 pages to memorize.
On my first day as a resident in a hospital with 300 beds I was rostered to do the 4pm to midnight shift in Casualty, with the last two hours in the hospital on my own.
That was until a phone call just before midnight to tell me that the night RMO had called in sick and that I’d need to work on my own until 8am.
Fast forward to life as a hospital registrar with the once-a-week 8am to 5pm (the next day) shift.
Or worse still, the monthly 8am Friday until 5pm Monday mix of on-duty and on-call.
The words “proximate” and “remote” don’t quite convey how gruelling the work was.
Of course, there was no possibility of complaining about the hours worked. The threat of not having a position in the following year would silence any complainers.
You are most vulnerable to fatigue when you don’t get enough sleep, you work at night, are awake for long periods of time, or some combination of the above.
But my experiences pale in comparison to the hours involved in some forms of surgery.
One well-known neurosurgeon recently found his gown dripping with saline and blood after a 14-hour operation.
He commented, “Oh my God, it looks like I wet myself”, only to then find himself the subject of an AHPRA investigation when his off-the-cuff comment was taken literally.
Thankfully, heavy vehicle drivers can attend to calls of nature in a more timely fashion, compliments of the Heavy Vehicle National Law (2012).
After 5¼ hours of work they can take a 15 minute break or, if they choose to keep working, they must have a 30 minute break after 7½ hours or at least a one hour break after 10 hours.
They also must have a full seven hours of rest every 24 hours, and can’t work for longer than a total of 12 hours in that period.
There are heavy penalties for not taking the stipulated rest breaks, and all of this is recorded in a National Driver Work Diary for verification.
That is, of course, everywhere in Australia except for Western Australia and the Northern Territory, where they presumably don’t drive long distances.
Oh, by the way, any hours spent waiting to be loaded and not resting in a bed are all counted as work hours.
The fatigue-regulated heavy vehicles that this legislation applies to includes any truck with a gross vehicle mass (GVM) over 12 tonnes and buses over 4.5 tonnes with a seating capacity of more than 12 adults (including the driver).
There are very good reasons for preventing fatigue on the road, as truck drivers are more than 12 times as likely to be killed on the job compared with the average worker.
This easily makes road freight transport Australia’s most dangerous job. It carries a 50 per cent greater risk than farming, which is our next most dangerous occupation.
The community expects that pilots and truck drivers are taking enough breaks to ensure they are performing well and are not fatigued.
Undoubtedly, fatigue management practices have improved in medical workplaces, but as I recall it, this change has always lagged behind other industries, which is just not good enough.
[Correspondence] Tu Youyou’s Nobel Prize and the academic evaluation system in China
Tu Youyou, an 84-year-old, female scientist from China, won the 2015 Nobel Prize in Physiology or Medicine for the discovery of artemisinin, which is used in the treatment of malaria. She was the first Chinese biologist in China to win this international, high-level award. However, she is regarded as a “three nos” professor (a professor with no doctorate, no background of studying abroad, and no membership in any Chinese national academies) and has never won a domestic prize, which means that, to some extent, she is not acknowledged by the mainstream Chinese academic society.