Vol. 4. No. 3
International Journal of Epidtmtotogy O Oxford University Prats 1976
PrinMd in Great Britain
Letters to the Editor is to be delivered to a whole community) but they are not personalized and may therefore look too cold and diffuse, losing power of attraction.
Can We Make Epidemiology More Attractive to Medical Students? From Dr. Rodolfo Saracci:
3. Clinical medicine shows quick returns Even when treating long-lasting diseases clinical medicine appears to offer an opportunity to check the results of most therapeutic acts within a short time. However fallacious this assessment may be it makes clinical medicine (and indeed surgery) something very tangible. Compare this with the slow, medium to long-term and almost anonymous returns of most interventions at the community level.
CLINICAL MEDICINE MORE ATTRACTIVE THAN EPIDEMIOLOGY
4. Epidemiology''s practical role is often ineffectively delineated While clinical medicine is taught as a Unitarian discipline centred on the clinical method, epidemiology is currently taught in a variety of ways, many of which fail to delineate its profile as the method for tackling health problems at the community level (particularly local) in everyday practice. What matters here is not so much the formal content of an epidemiology course as the teaching approach. One approach, which usually benefits from excellent teachers, is frankly oriented to research, i.e. it presents epidemiology as a tool for aetiological and evaluative research. In this case one should obviously assess the relative attraction of epidemiology to medical students (e.g. from the number and type choosing it as a career) by comparison with clinical as well as other research branches rather than with clinical medicine as a whole. On this restricted ground epidemiology is not likely to score much below average. A second approach is oriented to practice but it makes epidemiology disappear under a heap of heterogeneous and loosely related techniques, ranging from how to vaccinate children to how to provide adequate sewerage to how to sterilize milk. This is, for example, the approach still dominant in most medical schools throughout continental Europe. Students can hardly be attracted by a subject they cannot even recognize. A third approach, also oriented to practice,
The reply to the first question may be sought in at least four directions (leaving aside considerations like careers and salaries within different health and social systems): 1. Clinical medicine is a Unitarian discipline to which epidemiology is peripheral Clinical medicine is basically Unitarian. However distant the individual contents of the different disciplines, all of them are but variations on the single theme of the clinical method, that is the process of going through the problems of diagnosis, prognosis and therapeutic decision when faced with an individual case. During their clinical years students are almost entirely absorbed, time and mind, by this intellectual and practical exercise and by its emotional implications. It is not terribly surprising they tend to skip over a discipline like epidemiology, which is presented for a much shorter time and which does not appear to fall in line with the other clinical disciplines. 2. Clinical medicine involves direct responsibility for the individual patient Clinical medicine teaching prepares students to take full responsibility for individual ill persons. This is a neat and emotionally appealing aim. The responsibilities for which epidemiology gives a training may be even bigger (e.g. to contribute to the decision on whether, when and how a given service 239
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
SIR—A discussion at a recent meeting on epidemiology and general practice (1) brought back some familiar themes raised in an editorial in this journal (2). In both instances two related questions emerged which remained largely open to answer: Why does clinical medicine exert more attraction than epidemiology on medical students? Can we hope to attract more students to epidemiology and to enhance their interest and knowledge in the field of epidemiology ?
240
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
TWO SUGGESTIONS TO MAKE EPIDEMIOLOGY MORE ATTRACTIVE THROUGH TEACHING
My previous remarks tend to support the hypothesis (not new) that clinical medicine is more attractive than epidemiology to medical students because they can clearly see it as the method (i.e. a lively intellectual construction) by which they can learn to solve, through prompt action, those practical (i.e. of immediate relevance) problems they will be involved in. On this hypothesis a couple of tentative remedies can be suggested to improve the appeal of epidemiology through teaching: 1. Use of'community cases' as the main teaching tool •" Medical schools will be for a number of years and in most countries based on clinical teaching, whether it be more in hospitals or more in general practice. Against this background a reasonable possibility to make epidemiology more attractive to medical Students is to show it as branching from the common stem of clinical medicine in adopting essentially the same method (diagnosis and prognosis' followed by intervention) to a different level of observation (community instead of individual). Here, however, a common confusion between the method and its component elements should be avoided. The clinical method is not the various techniques (often loosely called 'methods') of physical, instrumental and laboratory diagnosis. It is the ability to set these elements in motion, to frame them in a logical sequence which leads to therapeutic decision. This is also the real raison a"itre of
the clinical teacher, which shows again and again the method in action. Similarly the epidemiological method is not the individual techniques, like retrospective investigations, statistical techniques etc. Rather it consists in identifying a 'community case' (be it the countering of an infectious epidemic, the provision of a dialysis service or the removal of an occupational hazard), in assessing its qualitative and quantitative aspects by suitable epidemiological techniques (diagnosis), in forecasting its likely outcome under different hypotheses of intervention (prognosis) and finally in selecting and implementing a course of action. Some of the examples in the IEA Guide to teaching methods (3) clearly illustrate the point. 2. Publication and circulation of'community' cases reports and discussions Clinical and clinico-pathological reports are most instructive not only for students but also for experienced clinicians, including those working mainly in research and teaching. In parallel, the publication in epidemiological journals (or the circulation in other written forms) of well-edited, concise reports and discussions of typical 'community cases' as they happen and are actually diagnosed and treated would add to the knowledge of the professional epidemiologist and stimulate his acumen when called to solve everyday problems. Mounting pressures from interested parties,. real urgency of many health problems, and the crudeness and incompleteness of available-factual data are three exceedingly common traits when dealing with a community health problem. These situations are nevertheless usually tackled in practice one way or another, and. it may be presumptuous tp let them to go ignored as irrelevant. To the epidemiologist engaged in teaching, these cases would provide a source of examples and models. These two suggestions try and exploit as far as possible the affinity in method between clinical medicine and epidemiology to the benefit of the latter when dealing with a medical student audience. Following this line epidemiology would be taught with constant focus on problems (cases) arising at the local community level and with emphasis not only on epidemiological diagnosis but on the chosen interventions and results as well (some link to the clinical teaching at the general practice level could be useful). This would, hopefully, make the immediate relevance of epidemiology more readily perceptible to medical students and enhance their interest in the topic. Finally, it is worth remembering that the
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
essentially consists in amplifying the epidemiological, preventive and social aspects of diseases as they are introduced through clinical medicine teaching. This offers a much better prospect of interest and attraction. However, when it is used not as a useful starting point but as the only viewpoint, it entails a risk of self-defeat by reinforcing in the students a 'disease dominated' and exclusively clinical attitude to health problems. Finally there is the spectrum of approaches oriented to practice and centred on the unique functions of epidemiology as a tool to assess health problems and needs in a community, to plan and evaluate health interventions and to provide indications of risks for preventive action. Within this spectrum the success in making the students interested may be no less variable than the actual approach chosen by the individual teacher.
241
LETTERS TO THE EDITOR
substantive issue is people's health not more doctors or scientists in one area or another of medicine, be it clinical medicine or epidemiology. Therefore attracting more students and more interest in epidemiology is legitimate only as far as there is evidence that epidemiology is a better bargain than other disciplines in terms of health improvement. Clinical Epidemiology and Biostatistics Section, CNR Laboratory for Clinical Physiology, University of Pisa, Via Savi 8, Pisa, Italy 2 June 1975
the p value being 0 05 which is significant. These results suggest that the psychological trait of neuroticism may predispose to peptic ulcer. As far as the contribution of extraversion to the predisposition to peptic ulcer is concerned, the results fail to show an appreciable difference between the peptic ulcer and the control group, the relevant p value being 0 -65 which is not significant. Department of Preventive and Social Medicine, R.N.T. Medical College, Udaipur-313001, India 24 June 1975
Personality Assessment of Peptic Ulcer Patients From Dr. S. K. Chaturvedi: SIR—In order to find out whether personality and psychological factors played any role in the aetiology of peptic ulcer, 50 patients, randomly selected, were assessed by the Eysenck Personality Inventory; 50 patients suffering from other diseases served as controls. The data obtained regarding the psychological determinants have been outlined in the following table: Comparison of mean scores of neuroticism and extroversion of peptic ulcer patients and controls Personality variables Neuroticism Peptic ulcer patients Controls Extroversion Peptic ulcer patients Controls
50 50
22-5 17 9
115 9-3
2-58
Disaster Epidemiology From Dr. B. Velimirovic: SIR—I have just read the editorial in the March issue {Int. J. Epid. 1975 4: 5) raising the question of health and epidemiology of natural disasters. I do agree with its ideas and general tone but the field is not as 'untouched' as the text suggests. See, for example, The Pattern of Morbidity -after Typhoons in a Tropical Country (1) or East Bengal Cyclone of November 1970 (2) or Report on Peru (3). The epidemiologists, therefore, have 'touched' the field. The editorial is, however, right in saying that systems study and research are needed, and that institutions rather than individuals are lacking interest in the field of disaster epidemiology. For several years attempts to stimulate national health authorities and the international health organizations in a typical typhoon-prone region to undertake research and systematic evaluation of the effects on health of such catastrophes have failed. In South-east Asia and the Pacific, typhoons alone cost about US$500 million annually of material damage, not including human suffering and deaths. In 1970, nine typhoons, four tropical depressions and eight tropical storms took a toll of 2,517 lives and destroyed property worth more than 920 million Philippine Pesos in the Philippines alone.
0-05 level REFERENCES
50 50
29-9 29-2
6-85 5-75
0-65
Not significant
It is clear that the peptic ulcer patients had a significantly higher neuroticism score than the control group, the relevant / value being 2 -58 and
(1) Velimirovic, B. and Subramanian, M.: Int. J. Biometeor 16: 343, 1972. (2) Sommer, A. and Mosley, W. H.: Lancet 1: 1029, 1972. (3) Renie, D.: Lancet 2: 704, 1970.
Ministry of Health, 1010 Vienna {Austria), Stubenring I
20 July 1975
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
REFERENCES
(1) Conference on Epidemiology and General Practice: Unpublished minutes (J. Ipsen, ed.). Aarfaus: Socialmedirinsk Institut, 1975. (2) Editorial: Int. J. Epid. 2: 3, 1973. (3) IEA: Epidemiology, a Guide to Teaching Methods (Lowe, C. R. and Kostrzewslci, J., cds). Edinburgh and London: Churchill Livingstone, 1973.
242
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
The need to expand From Dr. E. F. Krohn:
Department of Social Medicine, University of Odense, Denmark
August 1975
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
SIR—Allow me, please, to refer to the message from our Chairman which appeared in the March issue of this year. I cannot but feel slightly surprised by the great emphasis he has put on the desirability of, indeed need for, a rapid further expansion of the membership of the Association. The statement that we need to double our membership in the next three years is, I believe, in need of justification. The Chairman goes even further, however, in introducing the theme 'Every Member Get a Member At Least Once a Year'. The thought of the exponential expansion the realization of this theme would lead to even within a few years is quite disturbing. I realize that with an increase in membership the income of the Association would increase, but so would its expenses at the critical point beyond which it will no longer be possible to manage the Association by the part-time and voluntary services of its officers, or to run its meetings with one single working language. My worry is of course not primarily caused by administrative or financial considerations but by
my belief that a rapid further expansion might change those characteristics of the Association which has over the years made it so highly appreciated and useful. As an international association without political obligations the IEA has been free to pursue a high professional level of research and application within its limited scope of defined interest. A rapid expansion of our membership would of course have its costs, in terms either of a lowering of the professional level or of a widening of the field of the Association's concern. Some of us could not help wondering, at our most recent scientific meeting, whether the latter has not already taken place, in that some of the papers presented were on subjects only peripherally related to the discipline of epidemiology. There may, in my opinion, be a danger that in forcefully trying to 'spread the gospel' by increasing the membership we may come to confuse the concept of epidemiology and thus do harm to the gospel itself.
International Journal of Epidtmtotogy O Oxford University Prats 1976
PrinMd in Great Britain
Letters to the Editor is to be delivered to a whole community) but they are not personalized and may therefore look too cold and diffuse, losing power of attraction.
Can We Make Epidemiology More Attractive to Medical Students? From Dr. Rodolfo Saracci:
3. Clinical medicine shows quick returns Even when treating long-lasting diseases clinical medicine appears to offer an opportunity to check the results of most therapeutic acts within a short time. However fallacious this assessment may be it makes clinical medicine (and indeed surgery) something very tangible. Compare this with the slow, medium to long-term and almost anonymous returns of most interventions at the community level.
CLINICAL MEDICINE MORE ATTRACTIVE THAN EPIDEMIOLOGY
4. Epidemiology''s practical role is often ineffectively delineated While clinical medicine is taught as a Unitarian discipline centred on the clinical method, epidemiology is currently taught in a variety of ways, many of which fail to delineate its profile as the method for tackling health problems at the community level (particularly local) in everyday practice. What matters here is not so much the formal content of an epidemiology course as the teaching approach. One approach, which usually benefits from excellent teachers, is frankly oriented to research, i.e. it presents epidemiology as a tool for aetiological and evaluative research. In this case one should obviously assess the relative attraction of epidemiology to medical students (e.g. from the number and type choosing it as a career) by comparison with clinical as well as other research branches rather than with clinical medicine as a whole. On this restricted ground epidemiology is not likely to score much below average. A second approach is oriented to practice but it makes epidemiology disappear under a heap of heterogeneous and loosely related techniques, ranging from how to vaccinate children to how to provide adequate sewerage to how to sterilize milk. This is, for example, the approach still dominant in most medical schools throughout continental Europe. Students can hardly be attracted by a subject they cannot even recognize. A third approach, also oriented to practice,
The reply to the first question may be sought in at least four directions (leaving aside considerations like careers and salaries within different health and social systems): 1. Clinical medicine is a Unitarian discipline to which epidemiology is peripheral Clinical medicine is basically Unitarian. However distant the individual contents of the different disciplines, all of them are but variations on the single theme of the clinical method, that is the process of going through the problems of diagnosis, prognosis and therapeutic decision when faced with an individual case. During their clinical years students are almost entirely absorbed, time and mind, by this intellectual and practical exercise and by its emotional implications. It is not terribly surprising they tend to skip over a discipline like epidemiology, which is presented for a much shorter time and which does not appear to fall in line with the other clinical disciplines. 2. Clinical medicine involves direct responsibility for the individual patient Clinical medicine teaching prepares students to take full responsibility for individual ill persons. This is a neat and emotionally appealing aim. The responsibilities for which epidemiology gives a training may be even bigger (e.g. to contribute to the decision on whether, when and how a given service 239
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
SIR—A discussion at a recent meeting on epidemiology and general practice (1) brought back some familiar themes raised in an editorial in this journal (2). In both instances two related questions emerged which remained largely open to answer: Why does clinical medicine exert more attraction than epidemiology on medical students? Can we hope to attract more students to epidemiology and to enhance their interest and knowledge in the field of epidemiology ?
240
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
TWO SUGGESTIONS TO MAKE EPIDEMIOLOGY MORE ATTRACTIVE THROUGH TEACHING
My previous remarks tend to support the hypothesis (not new) that clinical medicine is more attractive than epidemiology to medical students because they can clearly see it as the method (i.e. a lively intellectual construction) by which they can learn to solve, through prompt action, those practical (i.e. of immediate relevance) problems they will be involved in. On this hypothesis a couple of tentative remedies can be suggested to improve the appeal of epidemiology through teaching: 1. Use of'community cases' as the main teaching tool •" Medical schools will be for a number of years and in most countries based on clinical teaching, whether it be more in hospitals or more in general practice. Against this background a reasonable possibility to make epidemiology more attractive to medical Students is to show it as branching from the common stem of clinical medicine in adopting essentially the same method (diagnosis and prognosis' followed by intervention) to a different level of observation (community instead of individual). Here, however, a common confusion between the method and its component elements should be avoided. The clinical method is not the various techniques (often loosely called 'methods') of physical, instrumental and laboratory diagnosis. It is the ability to set these elements in motion, to frame them in a logical sequence which leads to therapeutic decision. This is also the real raison a"itre of
the clinical teacher, which shows again and again the method in action. Similarly the epidemiological method is not the individual techniques, like retrospective investigations, statistical techniques etc. Rather it consists in identifying a 'community case' (be it the countering of an infectious epidemic, the provision of a dialysis service or the removal of an occupational hazard), in assessing its qualitative and quantitative aspects by suitable epidemiological techniques (diagnosis), in forecasting its likely outcome under different hypotheses of intervention (prognosis) and finally in selecting and implementing a course of action. Some of the examples in the IEA Guide to teaching methods (3) clearly illustrate the point. 2. Publication and circulation of'community' cases reports and discussions Clinical and clinico-pathological reports are most instructive not only for students but also for experienced clinicians, including those working mainly in research and teaching. In parallel, the publication in epidemiological journals (or the circulation in other written forms) of well-edited, concise reports and discussions of typical 'community cases' as they happen and are actually diagnosed and treated would add to the knowledge of the professional epidemiologist and stimulate his acumen when called to solve everyday problems. Mounting pressures from interested parties,. real urgency of many health problems, and the crudeness and incompleteness of available-factual data are three exceedingly common traits when dealing with a community health problem. These situations are nevertheless usually tackled in practice one way or another, and. it may be presumptuous tp let them to go ignored as irrelevant. To the epidemiologist engaged in teaching, these cases would provide a source of examples and models. These two suggestions try and exploit as far as possible the affinity in method between clinical medicine and epidemiology to the benefit of the latter when dealing with a medical student audience. Following this line epidemiology would be taught with constant focus on problems (cases) arising at the local community level and with emphasis not only on epidemiological diagnosis but on the chosen interventions and results as well (some link to the clinical teaching at the general practice level could be useful). This would, hopefully, make the immediate relevance of epidemiology more readily perceptible to medical students and enhance their interest in the topic. Finally, it is worth remembering that the
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
essentially consists in amplifying the epidemiological, preventive and social aspects of diseases as they are introduced through clinical medicine teaching. This offers a much better prospect of interest and attraction. However, when it is used not as a useful starting point but as the only viewpoint, it entails a risk of self-defeat by reinforcing in the students a 'disease dominated' and exclusively clinical attitude to health problems. Finally there is the spectrum of approaches oriented to practice and centred on the unique functions of epidemiology as a tool to assess health problems and needs in a community, to plan and evaluate health interventions and to provide indications of risks for preventive action. Within this spectrum the success in making the students interested may be no less variable than the actual approach chosen by the individual teacher.
241
LETTERS TO THE EDITOR
substantive issue is people's health not more doctors or scientists in one area or another of medicine, be it clinical medicine or epidemiology. Therefore attracting more students and more interest in epidemiology is legitimate only as far as there is evidence that epidemiology is a better bargain than other disciplines in terms of health improvement. Clinical Epidemiology and Biostatistics Section, CNR Laboratory for Clinical Physiology, University of Pisa, Via Savi 8, Pisa, Italy 2 June 1975
the p value being 0 05 which is significant. These results suggest that the psychological trait of neuroticism may predispose to peptic ulcer. As far as the contribution of extraversion to the predisposition to peptic ulcer is concerned, the results fail to show an appreciable difference between the peptic ulcer and the control group, the relevant p value being 0 -65 which is not significant. Department of Preventive and Social Medicine, R.N.T. Medical College, Udaipur-313001, India 24 June 1975
Personality Assessment of Peptic Ulcer Patients From Dr. S. K. Chaturvedi: SIR—In order to find out whether personality and psychological factors played any role in the aetiology of peptic ulcer, 50 patients, randomly selected, were assessed by the Eysenck Personality Inventory; 50 patients suffering from other diseases served as controls. The data obtained regarding the psychological determinants have been outlined in the following table: Comparison of mean scores of neuroticism and extroversion of peptic ulcer patients and controls Personality variables Neuroticism Peptic ulcer patients Controls Extroversion Peptic ulcer patients Controls
50 50
22-5 17 9
115 9-3
2-58
Disaster Epidemiology From Dr. B. Velimirovic: SIR—I have just read the editorial in the March issue {Int. J. Epid. 1975 4: 5) raising the question of health and epidemiology of natural disasters. I do agree with its ideas and general tone but the field is not as 'untouched' as the text suggests. See, for example, The Pattern of Morbidity -after Typhoons in a Tropical Country (1) or East Bengal Cyclone of November 1970 (2) or Report on Peru (3). The epidemiologists, therefore, have 'touched' the field. The editorial is, however, right in saying that systems study and research are needed, and that institutions rather than individuals are lacking interest in the field of disaster epidemiology. For several years attempts to stimulate national health authorities and the international health organizations in a typical typhoon-prone region to undertake research and systematic evaluation of the effects on health of such catastrophes have failed. In South-east Asia and the Pacific, typhoons alone cost about US$500 million annually of material damage, not including human suffering and deaths. In 1970, nine typhoons, four tropical depressions and eight tropical storms took a toll of 2,517 lives and destroyed property worth more than 920 million Philippine Pesos in the Philippines alone.
0-05 level REFERENCES
50 50
29-9 29-2
6-85 5-75
0-65
Not significant
It is clear that the peptic ulcer patients had a significantly higher neuroticism score than the control group, the relevant / value being 2 -58 and
(1) Velimirovic, B. and Subramanian, M.: Int. J. Biometeor 16: 343, 1972. (2) Sommer, A. and Mosley, W. H.: Lancet 1: 1029, 1972. (3) Renie, D.: Lancet 2: 704, 1970.
Ministry of Health, 1010 Vienna {Austria), Stubenring I
20 July 1975
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
REFERENCES
(1) Conference on Epidemiology and General Practice: Unpublished minutes (J. Ipsen, ed.). Aarfaus: Socialmedirinsk Institut, 1975. (2) Editorial: Int. J. Epid. 2: 3, 1973. (3) IEA: Epidemiology, a Guide to Teaching Methods (Lowe, C. R. and Kostrzewslci, J., cds). Edinburgh and London: Churchill Livingstone, 1973.
242
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
The need to expand From Dr. E. F. Krohn:
Department of Social Medicine, University of Odense, Denmark
August 1975
Downloaded from http://ije.oxfordjournals.org/ at Michigan State University on June 16, 2015
SIR—Allow me, please, to refer to the message from our Chairman which appeared in the March issue of this year. I cannot but feel slightly surprised by the great emphasis he has put on the desirability of, indeed need for, a rapid further expansion of the membership of the Association. The statement that we need to double our membership in the next three years is, I believe, in need of justification. The Chairman goes even further, however, in introducing the theme 'Every Member Get a Member At Least Once a Year'. The thought of the exponential expansion the realization of this theme would lead to even within a few years is quite disturbing. I realize that with an increase in membership the income of the Association would increase, but so would its expenses at the critical point beyond which it will no longer be possible to manage the Association by the part-time and voluntary services of its officers, or to run its meetings with one single working language. My worry is of course not primarily caused by administrative or financial considerations but by
my belief that a rapid further expansion might change those characteristics of the Association which has over the years made it so highly appreciated and useful. As an international association without political obligations the IEA has been free to pursue a high professional level of research and application within its limited scope of defined interest. A rapid expansion of our membership would of course have its costs, in terms either of a lowering of the professional level or of a widening of the field of the Association's concern. Some of us could not help wondering, at our most recent scientific meeting, whether the latter has not already taken place, in that some of the papers presented were on subjects only peripherally related to the discipline of epidemiology. There may, in my opinion, be a danger that in forcefully trying to 'spread the gospel' by increasing the membership we may come to confuse the concept of epidemiology and thus do harm to the gospel itself.
