EDITORIALS ANZJSurg.com
Surgeons of the future: where will they come from? The engagement of medical students in a future career in surgery is clearly important to the community. It is a concern that many medical schools seem to be decreasing the exposure of students to both surgical science and surgeons. Decreasing exposure to anatomy,1,2 in particular, is a concern with some universities offering anatomy courses of substance as summer electives or as rather expensive postgraduate diploma courses. Clinical surgical attachments seem to be becoming less with ‘problem-based learning’, leaving some medical students to fend for themselves, without adequate mentoring. This is despite the strong belief that a generic approach will increase student learning.3 It is well recognised that medical school surgical mentoring can lead to a career choice in surgery.4,5 When we reflect on the strong trend towards postgraduate medical degrees with a truncation of the medical course into 4 rather than 6 years, it is clear that something will miss out. In the eyes of many surgeons, it is structured surgical teaching. How then can students be attracted to a surgical career if they haven’t seen it? How many reject the prospect of a career in surgery before their clinical career even begins? Perhaps a reflection of this is the development of student surgical societies. Students with surgical interest are banding together and approaching the Royal Australasian College of Surgeons and surgical societies directly to provide them with surgical support. Some feel this is a positive thing for a surgical career, but equally it might reflect a frustration of lack of surgical substance in their university curriculum. This call for assistance must be recognised and headed. It is a clear call for the surgical community to be advocates for surgical content in medical school curriculum. In June 2012, the first Australasian Students Surgical Conference (ASSC) was held at the University of NSW, with over 600 registrants from Australia and New Zealand. There clearly is an interest. The literature suggests, however, that this interest is waning.5 In this issue, Dolan-Evans et al. explores the interest in surgery as a career amongst students in their postgraduate 4-year medical
programme.6 In this study, it was found that only 22% of final-year students had an interest in surgery as a career. The importance of surgical mentorship is evident, as 31% of those with a desire to do surgery have an identifiable surgical mentor compared with those with no surgical aspiration, of whom only 12% can identify a mentor. Of those interested in surgery, 53% had joined their student surgical society (Surgica). This article highlights lifestyle and autonomy as a significant impediment to a career choice in surgery for medical students. Is this perception real or apparent? Are medical students being discouraged from a career choice before it even begins due to a lack of exposure? Student surgical societies are a good thing but they can only be sustained by the support and engagement of the surgical community.
References 1. Parker LM. Anatomical dissection: why are we cutting it out? ANZ J. Surg. 2002; 72: 910–2. 2. Mitchell R, Berry L. Undergraduate perception of the teaching and learning anatomy. ANZ J. Surg. 2009; 79: 118–21. 3. Hamdorf JM, Hall JC. The development of undergraduate curriculum in surgery: ll. ANZ J. Surg. 2001; 71: 108–13. 4. Mark DM. New Zealand medical school teaching and surgical training. N. Z. Med. J. 2008; 121: 11. 5. Ek EW, Ek ET, Mackay SD. Undergraduates experience of surgical teaching and its influence on career choice. ANZ J. Surg. 2005; 75: 713–8. 6. Dolan-Evans E, Rogers GD. Barriers for students pursuing a surgical career and where the Surgical Interest Association can intervene. ANZ J. Surg. 2014; 84: 406–11.
Phil Truskett, MBBS, FRACS Department of Surgery, Prince of Wales Clinical School, Sydney, New South Wales, Australia doi: 10.1111/ans.12569
Publishing trauma-related topics in ANZ Journal of Surgery We live in an era of increasing pressure from academic institutions, granting bodies, training programmes and peers to write and publish scientific papers in peer-reviewed journals. It is not a skill that everyone is born with and not a skill that everyone desires to acquire, but still most of us have to do it to some extent. Trauma-related topics are frequently selected by junior surgical trainees and by supervisors to get something published and meet requirements to progress with surgical and/or academic training. The © 2014 Royal Australasian College of Surgeons
most frequent examples are case reports with fascinating mechanism and rare injuries with photographic documentation. The other lowhanging fruit is the trauma registry. Many non-trauma surgeons think that there is an imaginary ‘trauma database’ that exists in their hospital, which can answer all questions and somebody can pull out thousands of injuries of any description for the last decades. As an editor, editorial board member and reviewer of several trauma, surgical, orthopaedic and critical care journals, I would like to share ANZ J Surg 84 (2014) 399–400
400
some of my experience with the readers how these relatively lowevidence studies can still be portrayed in an attractive way towards the editors. Case reports: It is very hard if not impossible to publish case reports in high-ranked scientific journals. Many declare in their instruction to authors that they simply do not consider case reports. Although the level of evidence is lowest for case reports, some top general medical journals still consider them. A case which can be considered as the beginning of a new diagnostic and treatment modality or a case which potentially can change the previous dogmatic approach in treatment has a better chance. These case reports are attractive to editors because they take up a small space in the journal but are likely to be cited as ‘first’ by many researchers who later investigate the new approach through descriptive epidemiological and interventional studies. Any rare injury published as number one, two or three in the literature is unlikely to be published; also, the rarity itself (‘first in literature’) as an injury mechanism is unlikely to be educational or relevant to the readers and is unlikely to be cited. Some journals will consider case reports if the review of the literature is included and some clear future research directions are identified from the review. Registry-based studies: It is essential to know what can be expected from the registry and what is not. In my opinion, a trauma registry primarily is not a research tool. It is good to monitor how the resources are used and to see what the trends are in certain mechanism and injuries. Registries in comparison to databases are not purpose-built for a particular research question and do not include practically relevant outcomes.1 Registries are best used for power calculation for future interventional studies or hypothesisgeneration for prospective cohorts or controlled trials. Registrybased studies can be important building blocks for progressive quality research if they are used appropriately. Trauma registry studies can be more attractive if they are population-based, able to describe long-term trends, and meaningful outcomes are included beyond survival and length of hospital stay. It is important to be able to show with the trauma registry-based paper that it will lead to further higher level research, which potentially eventually improves care. Without being overly critical, trauma registry-based retrospective studies lacking population-based epidemiology are unlikely to have an impact on future research, and with already known or practically irrelevant findings are unlikely to be accepted in quality surgical journals. We know that most paediatric head injuries are mild; we know that it is treated mostly non-operatively, that the mechanisms are primarily due to sports and road traffic injuries
Editorials
and that it has a male dominance.2 Beyond the fact that we know these findings ahead, none of them have any impact on how we are managing our patients into the future. Gender is singled out as a variable to compare because it is one of the few variables available in the limited minimum dataset registry. However, we do not treat men and women differently. We also tend to pay attention to injury mechanisms to eliminate the injury itself rather than prevent only boys or girls from doing something. Can we say based on the paediatric head injury study in the current issue of ANZ Journal of Surgery that paediatric head injuries have a good outcome generally? This conclusion is probably a little overenthusiastic with most injuries in the mild category and the only clinically relevant outcome measured is mortality. Without measuring functional outcomes, potential cognitive, sleep and social problems arising from mild head injury, it actually can be misleading to conclude that most of them do fine. My recommendation is to carefully design these registry-based retrospective studies and ask a relevant and answerable research question. Aim for a population-based description and try to monitor trends in incidence, management and outcomes. Trauma is a fascinating area for research; during the relatively short span of my research career I have been able to see major changes in care as a result of focused systematic research. There are intriguing areas to explore in traumatology beyond case reports and trauma registries. The response of the human body to injury is fascinating and still not completely understood. Many of our standard treatment modalities are dogmatic rather than evidence-based; more patients survive with catastrophic injuries that historically were not investigated due to their early mortality. We see a fundamentally different (older and sicker) population today than when most of our treatment guidelines were developed. There is no reason to dedicate trauma research to study designs from the bottom of the evidence-based medicine pyramid.
References 1. Balogh ZJ, Martin AB. Prospective cohorts and risk adjusted outcomes for trauma. Injury 2010; 41: S24–6. 2. Amaranath JE, Ramanan M, Reagh J et al. Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia. ANZ J. Surg. 2014; 84: 424–8.
Zsolt J. Balogh, MD, PhD, FRACS Trauma Service, Division of Surgery, John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia doi: 10.1111/ans.12572
© 2014 Royal Australasian College of Surgeons
Surgeons of the future: where will they come from? The engagement of medical students in a future career in surgery is clearly important to the community. It is a concern that many medical schools seem to be decreasing the exposure of students to both surgical science and surgeons. Decreasing exposure to anatomy,1,2 in particular, is a concern with some universities offering anatomy courses of substance as summer electives or as rather expensive postgraduate diploma courses. Clinical surgical attachments seem to be becoming less with ‘problem-based learning’, leaving some medical students to fend for themselves, without adequate mentoring. This is despite the strong belief that a generic approach will increase student learning.3 It is well recognised that medical school surgical mentoring can lead to a career choice in surgery.4,5 When we reflect on the strong trend towards postgraduate medical degrees with a truncation of the medical course into 4 rather than 6 years, it is clear that something will miss out. In the eyes of many surgeons, it is structured surgical teaching. How then can students be attracted to a surgical career if they haven’t seen it? How many reject the prospect of a career in surgery before their clinical career even begins? Perhaps a reflection of this is the development of student surgical societies. Students with surgical interest are banding together and approaching the Royal Australasian College of Surgeons and surgical societies directly to provide them with surgical support. Some feel this is a positive thing for a surgical career, but equally it might reflect a frustration of lack of surgical substance in their university curriculum. This call for assistance must be recognised and headed. It is a clear call for the surgical community to be advocates for surgical content in medical school curriculum. In June 2012, the first Australasian Students Surgical Conference (ASSC) was held at the University of NSW, with over 600 registrants from Australia and New Zealand. There clearly is an interest. The literature suggests, however, that this interest is waning.5 In this issue, Dolan-Evans et al. explores the interest in surgery as a career amongst students in their postgraduate 4-year medical
programme.6 In this study, it was found that only 22% of final-year students had an interest in surgery as a career. The importance of surgical mentorship is evident, as 31% of those with a desire to do surgery have an identifiable surgical mentor compared with those with no surgical aspiration, of whom only 12% can identify a mentor. Of those interested in surgery, 53% had joined their student surgical society (Surgica). This article highlights lifestyle and autonomy as a significant impediment to a career choice in surgery for medical students. Is this perception real or apparent? Are medical students being discouraged from a career choice before it even begins due to a lack of exposure? Student surgical societies are a good thing but they can only be sustained by the support and engagement of the surgical community.
References 1. Parker LM. Anatomical dissection: why are we cutting it out? ANZ J. Surg. 2002; 72: 910–2. 2. Mitchell R, Berry L. Undergraduate perception of the teaching and learning anatomy. ANZ J. Surg. 2009; 79: 118–21. 3. Hamdorf JM, Hall JC. The development of undergraduate curriculum in surgery: ll. ANZ J. Surg. 2001; 71: 108–13. 4. Mark DM. New Zealand medical school teaching and surgical training. N. Z. Med. J. 2008; 121: 11. 5. Ek EW, Ek ET, Mackay SD. Undergraduates experience of surgical teaching and its influence on career choice. ANZ J. Surg. 2005; 75: 713–8. 6. Dolan-Evans E, Rogers GD. Barriers for students pursuing a surgical career and where the Surgical Interest Association can intervene. ANZ J. Surg. 2014; 84: 406–11.
Phil Truskett, MBBS, FRACS Department of Surgery, Prince of Wales Clinical School, Sydney, New South Wales, Australia doi: 10.1111/ans.12569
Publishing trauma-related topics in ANZ Journal of Surgery We live in an era of increasing pressure from academic institutions, granting bodies, training programmes and peers to write and publish scientific papers in peer-reviewed journals. It is not a skill that everyone is born with and not a skill that everyone desires to acquire, but still most of us have to do it to some extent. Trauma-related topics are frequently selected by junior surgical trainees and by supervisors to get something published and meet requirements to progress with surgical and/or academic training. The © 2014 Royal Australasian College of Surgeons
most frequent examples are case reports with fascinating mechanism and rare injuries with photographic documentation. The other lowhanging fruit is the trauma registry. Many non-trauma surgeons think that there is an imaginary ‘trauma database’ that exists in their hospital, which can answer all questions and somebody can pull out thousands of injuries of any description for the last decades. As an editor, editorial board member and reviewer of several trauma, surgical, orthopaedic and critical care journals, I would like to share ANZ J Surg 84 (2014) 399–400
400
some of my experience with the readers how these relatively lowevidence studies can still be portrayed in an attractive way towards the editors. Case reports: It is very hard if not impossible to publish case reports in high-ranked scientific journals. Many declare in their instruction to authors that they simply do not consider case reports. Although the level of evidence is lowest for case reports, some top general medical journals still consider them. A case which can be considered as the beginning of a new diagnostic and treatment modality or a case which potentially can change the previous dogmatic approach in treatment has a better chance. These case reports are attractive to editors because they take up a small space in the journal but are likely to be cited as ‘first’ by many researchers who later investigate the new approach through descriptive epidemiological and interventional studies. Any rare injury published as number one, two or three in the literature is unlikely to be published; also, the rarity itself (‘first in literature’) as an injury mechanism is unlikely to be educational or relevant to the readers and is unlikely to be cited. Some journals will consider case reports if the review of the literature is included and some clear future research directions are identified from the review. Registry-based studies: It is essential to know what can be expected from the registry and what is not. In my opinion, a trauma registry primarily is not a research tool. It is good to monitor how the resources are used and to see what the trends are in certain mechanism and injuries. Registries in comparison to databases are not purpose-built for a particular research question and do not include practically relevant outcomes.1 Registries are best used for power calculation for future interventional studies or hypothesisgeneration for prospective cohorts or controlled trials. Registrybased studies can be important building blocks for progressive quality research if they are used appropriately. Trauma registry studies can be more attractive if they are population-based, able to describe long-term trends, and meaningful outcomes are included beyond survival and length of hospital stay. It is important to be able to show with the trauma registry-based paper that it will lead to further higher level research, which potentially eventually improves care. Without being overly critical, trauma registry-based retrospective studies lacking population-based epidemiology are unlikely to have an impact on future research, and with already known or practically irrelevant findings are unlikely to be accepted in quality surgical journals. We know that most paediatric head injuries are mild; we know that it is treated mostly non-operatively, that the mechanisms are primarily due to sports and road traffic injuries
Editorials
and that it has a male dominance.2 Beyond the fact that we know these findings ahead, none of them have any impact on how we are managing our patients into the future. Gender is singled out as a variable to compare because it is one of the few variables available in the limited minimum dataset registry. However, we do not treat men and women differently. We also tend to pay attention to injury mechanisms to eliminate the injury itself rather than prevent only boys or girls from doing something. Can we say based on the paediatric head injury study in the current issue of ANZ Journal of Surgery that paediatric head injuries have a good outcome generally? This conclusion is probably a little overenthusiastic with most injuries in the mild category and the only clinically relevant outcome measured is mortality. Without measuring functional outcomes, potential cognitive, sleep and social problems arising from mild head injury, it actually can be misleading to conclude that most of them do fine. My recommendation is to carefully design these registry-based retrospective studies and ask a relevant and answerable research question. Aim for a population-based description and try to monitor trends in incidence, management and outcomes. Trauma is a fascinating area for research; during the relatively short span of my research career I have been able to see major changes in care as a result of focused systematic research. There are intriguing areas to explore in traumatology beyond case reports and trauma registries. The response of the human body to injury is fascinating and still not completely understood. Many of our standard treatment modalities are dogmatic rather than evidence-based; more patients survive with catastrophic injuries that historically were not investigated due to their early mortality. We see a fundamentally different (older and sicker) population today than when most of our treatment guidelines were developed. There is no reason to dedicate trauma research to study designs from the bottom of the evidence-based medicine pyramid.
References 1. Balogh ZJ, Martin AB. Prospective cohorts and risk adjusted outcomes for trauma. Injury 2010; 41: S24–6. 2. Amaranath JE, Ramanan M, Reagh J et al. Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia. ANZ J. Surg. 2014; 84: 424–8.
Zsolt J. Balogh, MD, PhD, FRACS Trauma Service, Division of Surgery, John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia doi: 10.1111/ans.12572
© 2014 Royal Australasian College of Surgeons
