Pharmacy for the Curious

professor for advice on how to become a great pharmacist. I have been
asked this question by students who are applying for admission into our
program (who are considering whether or not they want to become a
pharmacist) and by students currently enrolled in our pharmacy school. In
my early years as a professor I advised them to study hard, learn the
curriculum and get good grades. Now I realize that my counsel to these
students may have been misguided, or at least overly simplified. The secret
to becoming a great pharmacist is actually more complex.

It is certainly impossible to be a great pharmacist if you don’t study hard
and learn the curriculum; however, I have not observed any correlation
between those pharmacists who get the best grades and those who become
great pharmacists. That is not to say the students with the best grades will
not become great pharmacists; I have just not observed a direct correlation.
I have realized that studying hard and getting good grades makes it possible
for a student to practice pharmacy competently, but to become a great
pharmacist is something totally different.

The first trait that I have observed to be correlated with all great
pharmacists is that they care. They care about the pharmacy profession that
they are a part of and they care about trying to make it a better profession.
But more importantly they care about their patients. Pharmacy is a health
care profession and if your primary reason for pursuing this profession is
not to make the lives of individual patients better and to improve the health
of your community, you will not be a great pharmacist and you may very
well be in the wrong profession. The problem is that I do not believe that
we, as pharmacy professors, can teach students how to care and I do not
believe you can learn to care. You either care or you don’t. But the greatest
pharmacists I have ever met care deeply about the patients that they look
after.

Three Additional Traits That Are Correlated With Great
Pharmacists

The good news is that there are three additional traits that I have observed
to be correlated with great pharmacists, all of which I believe can be
learned. The first is confidence. Pharmacists are increasingly being asked
to take on significantly expanded responsibilities within health systems
around the world.

In Canada, pharmacists are independently prescribing, administering
injectable drugs, working on interprofessional teams, and counseling on
smoking cessation (just to name a few). It requires a certain minimum
degree of confidence for pharmacists to comfortably (and competently)
accept this high level of responsibility. Great pharmacists must be confident
with their skills and their role within the health care team. Shy, introverted
individuals who lack confidence may struggle as a pharmacist; however, I
believe this trait can be taught to individuals who do not posses it.

The final two traits that I have observed to be correlated with great
pharmacists are: (1) individuals who are logical and practical thinkers; and,
(2) individuals who have the ability to think and make decisions under
pressure. Pharmacists generally practice in settings that are extremely busy
and demanding. Often pharmacists are simultaneously filling
prescriptions, educating patients about their medications, assisting patients
to manage minor self-limiting ailments and talking to insurance providers
regarding drug coverage issues, all while the phone is constantly ringing
with physicians asking questions about the safe and effective medication
management of their patients.

Can the Traits To Be A Great Pharmacist Be Taught?

Great pharmacists thrive in this sort of environment and are able to be
confident, logical, practical thinkers who work well under pressure. But
fear not, if you do not currently possess these traits, I believe that they can
be taught in pharmacy school; however, you must be open to the fact that
you will need to learn these traits to become a great pharmacist.

The tough part is that, although most of the traits of great pharmacists can
be learned (except for the ability to care), they are actually very difficult to
teach in a pharmacy school. Prospective students should inquire how the
various pharmacy programs address teaching these traits within their
curriculums before selecting a school to attend. One thing to look for is a
program that provides early and frequent exposure to authentic patient
care interactions. The more patients you care for and take responsibility for
as a student, the more confident, practical and logical you will become.
However, there are many approaches that schools can take to teach these
traits and it is important for prospective students to consider this, in
addition to the academic strengths of each pharmacy program, prior to
enrolling.

The profession of pharmacy can be a rewarding career that provides great
personal fulfillment and satisfaction, while having a positive impact on the
lives of many people who are in need of a caring and competent health care
provider. Selecting pharmacy as a career is a big decision and considering
the traits that make a great pharmacist may assist current and prospective
pharmacy students in making this decision.

Chapter 11: Pharmacy/Pharmaceutical
Health Outcomes and Policy Research - Ruta
Sawant, MS and Professor Sujit S. Sansgiry,
PhD

Ruta Sawant, MS
Graduate Teaching Assistant

University of Houston

Miss Ruta Sawant is a student at the University of Houston currently
pursuing her PhD in Pharmacy Health Outcomes and Policy Research. She
holds a Master of Science degree in Pharmacy Administration from the
University of Houston and a Bachelor of Science in Pharmacy from the
University of Mumbai, India. Ruta has performed a number of research
projects in pharmaceutical health outcomes with an area of concentration
in patient reported outcomes, patient safety, and risk behaviors. She has
been working with Dr. Sansgiry as her advisor and completed her
Master’s thesis which was aimed at assessing risk perception of
medication side effects with different formats of risk communication. Ruta
has just begun with her PhD program in Pharmaceutical Health Outcomes
and Policy, and wishes to continue working in the areas of behavioral
research and pharmacoeconomics.

Sujit S. Sansgiry, PhD
Associate Professor

Department of Pharmaceutical Health Outcomes and Policy
University of Houston

With over 20 years of experience, he uses sophisticated statistical models
to understand consumer purchase behavior and health disparity issues.
His research has had a major impact on the US pharmaceutical industry,
especially the over-the-counter (OTC) drug market. The US FDA has used
his research to develop guidelines for packaging and labeling of OTC
products. Dr. Sansgiry’s research work was referenced in the FDA
published guidelines titled “Over-the-Counter Human Drugs: Labeling
Requirements”. He was also invited twice to present his work to the FDA
and the NDAC. His focus has been to evaluate disparities associated with
pharmaceutical use and its impact on society. He has over 100
publications and over 200 abstracts presented during the past 20 years
his efforts have led to the development of the Pharmaceutical Health
Outcomes and Policy department as well the PhD program in this area.
He served as the director for graduate studies at the University of
Houston for over 10 years and has graduated over 50 graduate students
with MS or PhD.

The Impact Of The Pharmacy Profession On Public Health

Pharmacy is mainly viewed as a career path eventually leading to
recognition as a professional registered pharmacist. The scope however is
not limited to serving at a community clinic, or a hospital or getting
characterized with the stereotypical image of a pharmacist who works
behind the counter in a retail practice setting. Pharmacy as profession
entails responsibility towards all aspects of the healthcare system. As a
pharmacist, there are several research areas which you can explore, right
from basic laboratory research, clinical pharmacy to population-based
studies. One such field of research that we will be focusing on in this article
is Pharmacy or Pharmaceutical Health Outcomes and Policy (PHOP)
Research. There are a number of institutes that offer this program under
different names and each program may have a slightly different
concentration. The objective of this article is however to give a brief
introduction and a few insights into what PHOP research is all about.

As the names suggest PHOP research can be described as a field of
investigation or experimentation in the health system organization and
involves the study of the impact of the pharmacy profession on public
health. It encompasses study of design and execution of programs and
policies to influence the practice of various healthcare providers and
evaluation of these programs for their effect on patient outcomes. In simple
terms the main idea behind PHOP research is to improve outcomes of
patients by improving the quality of healthcare which is provided to them.
It is an extremely broad area of research which is composed of number
branches. To name a few, these include pharmacopidemilogy,
pharmacoeconomics, pharmaceutical marketing, and consumer health
behavior. We will briefly go over these topics and look at educational and
work opportunities in this field.

Why PHOP Research? Who Benefits From PHOP
Research?

To begin with, let us first understand why we need to perform PHOP
research studies. The healthcare system involves a number of players such
as physicians, nurses, pharmacists, insurers, economists, statisticians and
many others who work collaboratively for the care of patients. However, in
every working organization or system, there needs to be evaluation of the
end results of the processes, to keep a track of effectiveness of the
programs, strategies or services, to ensure economic and prudential
allocation of resources and to provide evidence for better decision making.

PHOP research can thus be called as a diagnostic and analytical tool which
takes care of these issues. PHOP researchers use information generated
from various facets of healthcare to perform systematic and scientific
inquiry. New knowledge about drug therapy safety and effectiveness,
patient and provider health behaviors and preferences, health system
organization and delivery is generated and is used to enhance safe and
effective delivery of pharmaceutical and pharmaceutical care. The PHOP
research evaluates policies made and recommends new policies to help
consumers and providers to collaboratively evolve in the healthcare
environment.

With new drugs being discovered continuously, new technological
advancements in treatments, new policies, and with procedural
progressions, it becomes a difficult choice for Consumers of the healthcare
system to decide upon what is best (optimum) for them. It is the study of
such questions and development of evidence based information that PHOP
research caters to such concerns. The eventual beneficiaries are therefore
all the preliminary and end users of the healthcare system.

Results and findings from PHOP research are published as articles in
scientific journals, presented at scientific meetings, included as
recommendations or guidelines for practice and it is through these

resources that the information reaches the healthcare providers and
sometimes to consumers A provider such as a physician thus may use this
information in selecting the correct (sometimes optimum) treatment
option for their patients depending on the knowledge gained from PHOP
research studies. Results of PHOP studies are presented at various
conferences and meeting. Following is the list of organizations that conduct
conferences and meeting all year round.

Table 1: List of organizations conducting annual conferences and meeting

relevant to PHOP research, in general

Organization Website

American Public Health http://www.apha.org/
http://www.pharmacist.com/
Association (APHA)

American Pharmacists

Association (APhA)

Academy of Managed Care http://www.amcp.org/
Pharmacy (AMCP)

Academy Health http://www.academyhealth.org/

Drug Information Association http://www.diahome.org/
(DIA)

International Society of http://www.ispor.org/

Pharmacoeconomics and

Outcomes Research (ISPOR)

International Society for http://www.pharmacoepi.org/

Pharmacoepidemiology (ISPE) http://www.epiresearch.org/
Society for Epidemiologic
Research (SER)

Society for Medical Decision http://smdm.org/
Making (SMDM) https://kelseyresearch.com/
Health Services and Outcomes

Research Conference

What Can A Pharmacist Do?

You must wonder now where exactly does a pharmacist fit in this picture? A
pharmacist is an important player in every step of the PHOP research
process. The process begins with identifying a problem area. It requires
thorough review of literature, tracing out atypical observations or findings
from published research or reports of drug evaluations, and reasoning and
scrutiny of the findings. Bachelor of Pharmacy or Doctor of Pharmacy
graduates and pharmacists possess the clinical knowledge about drugs and
usage trends that can effectively probe out ideas and suggestions to address
such issues at hand. With the combined knowledge of outcomes research
and pharmacy, they can sketch out an appropriate design for the study,
identify resources required and provide training to assistant researchers.

For example, if an intervention involves counseling of patients, pharmacist
are the most pertinent healthcare providers who can provide guidance and
training to carry out the intervention. Assistance can be obtained from
other professionals such as biostatisticians, epidemiologists, economists,
physicians or other health care practitioners depending on the objective of
the study. Pharmacy expertise is required right from the beginning such as
problem recognition to the final stage of interpretation of results, exhibiting
findings to other researchers, evaluating the effectiveness of the study,
making suggestions and recommendations based on study results and
generating evidence to promote evidence-based practice among healthcare
providers. Thus pharmacy education and knowledge is required in almost
every step of a PHOP research study.

In the sections below, let us look at some of the branches of PHOP research
in brief. Please keep in mind that these are not the only branches or
research areas in PHOP research. The idea is to just give an overview and
introduce you to the field in general.

Pharmacoepidemiology

Pharmacoepidemiology is the science of study of use and effect of drugs in
large numbers of people. It combines two research areas, clinical
pharmacology and epidemiology. Clinical pharmacology deals with the
study of effects of drugs in humans whereas epidemiology concerns with
the study of the distribution and determinants of diseases in populations.

Since pharmacoepidemiology studies are performed in populations after
the drug is in use, it allows the study of beneficial and adverse effects of
drugs in populations which are not included in pre-marketing studies. It
helps us study the effects of drugs modified by other drugs and illnesses,
discovery of uncommon or delayed effects not observed in pre-marketing
studies, patterns of utilization, effects of overdoses, and economic
implications. This field is useful both in understanding effect of drugs
during post marketing period as well as understanding public health
implications of policy decisions. It provides reassurances about drug safety
and are thus required as a general fulfillment of ethical and legal
obligations.[1]

Pharmacoepidemiology is included as a core course in the syllabi of PHOP
research in most of programs. Basic things that you would learn in this
course are the various study designs available for pharmacoepidemiologic
research, factors that should be taken into account when performing a
pharmacoepidemiology study, types of data sources available and
knowledge regarding which database is useful for which design. Depending
on your interest, you may take advanced courses or even a separate degree
in pharmacoepidemiology.

Pharmacoeconomics Or Heath Economics And Outcomes
Research (HEOR)

Health economics is a broad term which implies the use of economic
techniques in public health system. It helps realization of economic
methods used for analyzing and improving delivery of healthcare, economic
issues related to efficiency and effectiveness, prioritization of health

services, and evaluation of new healthcare technologies. It deals with
appropriate allocation of healthcare services. Health economics studies
examine factors that affect our health which are not actually concerned
directly with the treatment such as expenses incurred to achieve
accessibility to healthcare services.

Pharmacoeconomics is a branch which deals with the economics of
pharmaceuticals and pharmacy services. It can be defined as “the scientific
discipline that assesses the overall value of pharmaceutical health care
products, services and programs.”[2] Resources are limited, demand is high
and therefore there is a need for judicious allocation of resources to gain
maximum benefits to patients, providers, payers and the healthcare system
in general.

In pharmacoecomonics you will learn different methods of cost analysis
such as budget impact models, cost-of-illness, cost-effectiveness, cost-
benefit, cost-minimization and cost-utility analysis. These methods are
used for comparisons between medications, equipments, diagnostic tools,
or delivery services. It is mostly a weigh-off between the costs and
consequences. The outcome of comparison depends on the method used.

For example: In cost-effectiveness analysis of two drugs A and B, you would
compare cost/effectiveness ratio of drug A with cost/effectiveness ratio of
drug B; the outcome considered in terms of effectiveness can be based on
the study definition, such as reduction in cholesterol, or improvement in
blood pressure, reduction in health care resources or other outcomes. In a
cost-benefit analysis, one would use the ratios of cost/benefit for
comparison and both the cost and outcomes which will be measured in the
same monetary unit.

In current times, the number of healthcare options are large, be it with
respect to treatments, medications, devices, insurance, and policies. At the
same time there may be an increased involvement of patients in decision-
making. With so many choices available and so many factors to consider,

even healthcare providers like physicians need a basis for making the
appropriate selection. Health economic studies can help in making the
selection process easier by narrowing down the options to the best possible
scenario and explaining the role each factor plays.

With respect to where such programs are taught, not all colleges offering
PHOP programs with a concentration in health economics but with the
growing demand, colleges are now incorporating these topics more and
more in their required coursework. Health economics and outcomes
research is a fast growing field with ample opportunities for internships
and jobs. A good place for networking in the field of pharmacoeconmics is
ISPOR annual or regional meetings. ISPOR is a non-profit public
organization for education and scientific purposes. It provides a platform
for interchange of scientific knowledge in pharmacoeconomic/health
economics and patient health outcomes. It holds annual meetings and
conferences where students and healthcare professionals from all over the
world participate and present their research. For more information on
ISPOR you can visit the website ‘http://www.ispor.org/Default.asp’.

Consumer Health Behavioral Research

As the name suggests, consumer health behavioral research deals with
issues of social and psychological behavior of consumers towards
healthcare use and its effect on health outcomes. It takes into consideration
the relationships among consumers and healthcare providers i.e. patients
and physicians, patients and pharmacists or pharmacists and physicians.
This research area is too broad to define using a few terms and includes a
wide variety of studies performed. Socio-psychological models are used to
study factors of consumer behavior which affect their behavior towards
healthcare services.

Examples of studies performed are, intention to quit smoking, effect of
label warnings on risk perception, effect of patient counseling on intention
to adhere, or descriptive studies such as studying type of interactions

between patients and physicians, perceptions of medication side effects
amongst elderly and so on. The scope of behavioral research is very broad.
Most of behavioral research studies are survey based. Information is
obtained by using self-administered questionnaires, interviews or by
observations.

As a student you will learn about how to design such studies, understanding
and application of theoretical models, designing and validation of surveys
or questionnaires, analyses and interpretations of results, and design and
administration of interventions. Depending on results obtained from these
studies, recommendations can be made or interventions can be designed
and implemented to address the concerns. Understanding factors that
affect health behaviors can help us bring about changes in behaviors such
as tobacco use, smoking, sedentary lifestyle unhealthy diet, medication
non-adherence, and medication abuse which are some of the high
contributing causes of death and diseases in the United States and the
world.

In the sections above, we saw some research areas of PHOP research. In the
sections below, we will see some of the career opportunities in PHOP
research.

Where Will I Be Working As A PHOP Research Scientist?

As mentioned earlier, health economics and outcomes research is a fast
growing sector with plenty of job opportunities available. Job descriptions
vary depending upon the type of organizations and positions. The
establishments that you can work in as health economics and outcomes
research scientists are pharmaceutical industry, consultancy firms,
managed care, government organizations, and academia. Duties vary
according to the requirements of the organization.

A pharmaceutical company needs to define the value of its products, in
terms of effectiveness as well as costs. Research on pharmacoeconomics

provides valuable insights as to the placement of their products in the
market as well as understanding which products to develop. Depending on
the position the job of an outcomes research scientist would involve
conducting primary research to evaluate market perceptions of new and
existing products, developing, leading and execution of strategies to
demonstrate product values in the market, defining strategy to generate
required evidence and outputs, communicating with vendors for
outsourcing of analysis, economic modeling, team report development and
others.

A consultancy firm works for its clients to generate evidence in terms of
providing scientific and consulting expertise that helps value proposition of
their products and communication of evidence to the right audience. These
clients may be pharmaceuticals, bio-medicals, medical devices or others.
Responsibilities would entail performing extensive literature reviews,
retrieval and analysis of data, developing health related communications
including dossiers, abstracts, manuscripts, posters, implementing
retrospective analyses, developing health economic models, summarizing
and interpretation of data, and others.

Similarly even managed care organizations need outcomes analysis and
economic evaluations as they contract out to various providers of care. They
have access to patient data bases or claims databases and serve as a good
resource for pharmacoeconomics and outcomes evaluations. Thus, you can
choose which setting you would want to work based on your research
interests.

Apart from industry, there are ample career opportunities for pharmacy
graduates in the field of academia. The American Association of Colleges of
Pharmacy (AACP) publishes annual reports and profile which describe
aspects of academic pharmacy such as vital statistics of academic
pharmacy, profiles of pharmacy students: application pool, enrollments,
degrees conferred and pharmacy faculty profile. This information can be
obtained on AACP webpage (www.aacp.org). An article published in the

American Journal of Pharmaceutical Education called ‘A career in
Academic Pharmacy: Opportunities, Challenges and Rewards’ discusses
about three presentations given at a symposium presented at the American
Society of Health System Pharmacists (ASHP) on ‘Top ten reasons to
consider a career in academia’. A very interesting read for those considering
an academic career in pharmacy [3].

As with respect to financial prospects, the salaries of PHOP research
scientists in 2013 on an average in the US started from about
$60,000($45,000 - $80,000) annually for a Masters graduate and about
$100,000 ($70,000-120,000) for a PhD graduate.
Funding resources

As a researcher, one requires suitable resources to study the objectives of a
well-designed research. These resources include datasets, researchers,
assistants, computers, analytical software, and space Depending on the
scale of a research project one may require funding which has to be sought
to execute the project efficiently. Funding for scientific research can be
obtained from various organizations in the form of research grants. Grant
application process entails detailed development of a research plan,
defining the significance of the project, specific aims, investigators and
their roles, innovations, strategy or methodology to be used, environment,
resources and institutional support and several other specific review
considerations to be fulfilled before submission. Some examples of the
sources for large scale funding opportunities for researchers in PHOP are
National Institutes of Health (NIH) grants, Patient-Centered Outcomes
Research Institute (PCORI) grants, Agency for Healthcare Research and
Quality (AHRQ) grants, and the pharmaceutical industry. Several other
organizations make funds available for scientific research and grant
applications can be made depending on the nature of research.

Outcomes Research Across The Globe

As mentioned earlier, the purpose of pharmaceutical outcomes research is

to define and successfully communicate full value of pharmaceutical
products, services and programs. Requirements for PHOP may be for
decision-making process for regulatory (market access) approval,
reimbursement and economic evaluations of pharmaceuticals and medical
devices and diagnostics and vary according to country/region.

In United States, health economic research in not mandated by FDA and
there are no standards to be met for market access, reimbursement or
pricing. However in United Kingdom, National Service Frameworks (NFS)
sets evidence-based national standards for a number of therapeutic areas
which requires outcomes research studies. These standards eventually
impact prescribing practice, budgets and overall expenditure of UK
National Health Service (NHS).

In Canada, approval process of a drug undergoes a Common Drug Review
(CDR) which then provide participating drug plans with formulary listing
recommendations based on consistent, scientifically rigorous, evidence-
based review [4].

Australian Government system makes decision about pharmaceuticals
under Pharmaceutical Benefit Scheme (PBS). The government applies
subsidies to medicine costs according to the recommendations made by the
Pharmaceutical Benefits Advisor Committee (PBAC) which are based on
the effectiveness, cost-effectiveness and clinical place of a product
compared with other products already listed on PBS, or with standard
medical care [5]. Similarly different countries and regions have different
healthcare operating systems with different utility of PHOP research.

The College of Pharmacy at University of Houston (UH) offers PhD degree
in PHOP Research. The mission of the graduate program is to advance
research and development in the field of pharmaceutical health outcomes
and policy to enhance the safe and effective delivery of pharmaceuticals and
pharmaceutical care. The program requires the completion of minimum of
70 credit hours. The program offers graduate assistantships to all their

students with a stipend of about approximately $25,000 per year. A
separate Graduate Tuition Fellowship (GTF) is also awarded which is
approximately $2100 annually that is provided to pay the tuition. Graduate
students are entitled to receive other scholarship awards based on eligibility
criteria and academic standings. For more information about the program
at UH, please visit its website [6].

References
1. Storm BL, Kimmel S. Text book of pharmacoepidemiology: England:
John Willey and Sons, Ltd, 2007.

2. Berger ML, Bingefors K, Hedblom EC, et al. Health Care Cost, Quality,
and Outcomes. ISPOR Book of Terms. International Society for
Pharmacoeconomics and Outcomes Research 2003

3. Draugalis JR, DiPiro JT, Zeolla MM, et al. A career in academic
pharmacy: opportunities, challenges, and rewards. Am J Pharm Educ
2006;70(1)

4. ISPOR Global Healthcare Systems Road Map. International Society of
Pharmacoeconomics and Outcomes Research.
http://www.ispor.org/htaroadmaps/Default.asp. Accessed on June 10,
2014.

5. Pharmaceutical Benefits System, Department of Health, Government of
Australia. http://www.pbs.gov.au/pbs/home. Accessed on June 10, 2014.

6. Pharmaceutical Health Outcomes and Policy - Ph.D. Degree Program.
University of Houston, College of Pharmacy.
http://www.uh.edu/pharmacy/prospective-students/graduate-
programs/phop/index.php. Accessed on July 3, 2014.

Chapter 12: Physiology in the Twenty-First
Century – T. Richard Nichols, PhD

T. Richard Nichols
School of Applied Physiology
Georgia Institute of Technology

T. Richard Nichols received his PhD in Physiology from Harvard
University. After postdoctoral work at the University of Alberta and a
first faculty position in the Department of Kinesiology at the University of
Washington, Dr. Nichols joined the faculty of the Department of
Physiology at Emory University in 1983 and achieved the ranks of
Professor and Interim Chair. In 2007, Dr. Nichols moved to Georgia
Institute of Technology to take the position of Chair of the School of
Applied Physiology, a School devoted to the study of movement, the
physiological systems that support voluntary movement, balance and
posture, and prosthetics and orthotics. Dr. Nichols’ research interests are
focused on the interaction between the musculoskeletal and central
nervous systems in motor coordination. In particular, the work includes
investigations of sensory pathways from muscles that transmit
information about muscular force and length to neural networks in the
spinal cord and brainstem. This sensory feedback is thought to regulate
the mechanical properties of limbs, to contribute to responses of the body
to postural disturbances, and to be modulated according to the specific

motor task. This work has contributed to a computational model of the
spinal motor system, and to translational research on spinal cord injury,
peripheral nerve injury and functional electrical stimulation.

What is Physiology?

This essay concerns the importance of the discipline of physiology in
contemporary biomedical research and in the health professions. First,
let’s define “physiology” and provide a little history of this important
discipline. The term “physiology” was first used by Jean Fernel, a French
physician who lived in the 16th century. He coined the term to represent the
study of the body’s function. In order to comprehend the inner workings of
the human or animal body in health and in disease, we rely on an
understanding of the structure of the body and its components, and on the
functions of the body’s systems and subsystems.

Traditionally, the discipline of anatomy has informed us about the
structure of the components of the body, namely, cells, tissues, organs, and
their physical relationships. In a complementary way, the discipline of
physiology has provided information about the functions and dynamic
interrelationships of these components, and, most importantly, how these
components work together to mediate all the activities of the body, both
internal and external.

As an example of the contributions of physiological research to the
understanding of bodily functions and the integration of physiological
systems that these functions demand, consider the manner in which several
physiological systems regulate the internal state of the body. Having
knowledge of the structure of the heart and the cardiovascular system,
physiologists have studied how the heart pumps blood and interacts with
the remainder of the cardiovascular system to determine perfusion of the
tissues, blood pressure, and other related properties and variables.
Furthermore, by studying the interactions of the cardiovascular, renal and
respiratory systems, physiologists have investigated how these systems

work together to regulate, very precisely, the chemical composition of the
blood and the fluid bathing the cells and tissues.

During exercise, the internal chemical balance is potentially dramatically
altered by the required increase in metabolic demand from the muscles, but
neural and hormonal mechanisms are in place to maintain blood pH,
electrolyte balance, and other critical variables. Physiologists are interested
not only in how this internal regulation comes about, but also in the
mechanical output of muscles and the mechanical transactions that lead to
movement, posture and balance. With this understanding as to how the
systems of the body work together to regulate the internal state and at the
same time produce external work, health care workers have been able to
understand much about the cascade of pathological changes accompanying
cardiac disease and the benefits of exercise.

The anatomy and physiology of cells, tissues and organ systems were the
major approaches to medical research until the early twentieth century,
when new experimental tools allowed the deeper investigation of molecular
processes within cells. As the century progressed, the more traditional
approaches of physiology gave way to molecular and cell biology and
genetics. Great strides were made in the understanding and treatment of
disease processes, based on new insights into the cell biology of cancer,
deficiency of the immune system, and other conditions. This general
approach can be termed “reductionist” in that whole diseases were
attributed to individual genetic mutations, environmental influences on
single molecular pathways and the like.

However, with the explosion of information about molecular processes
within cells and the knowledge that cellular function depended upon
complex molecular systems, it became clear that an understanding of
normal and abnormal cellular function required systematizing this
information. It was shown that the behavioral and physiological
characteristics of an individual resulted from complex interactions of many
genes, proteins and environmental influences.

From this need to systematize the known molecular and cellular biology,
the new discipline of systems biology was born. Systems biology depends
upon the analysis of large amounts of data concerning intracellular
processes and the use of mathematical models to understand cellular
function. Although the stated goal of researchers in this discipline has been
to understand and model biological processes at all levels of organization,
even to organ systems and behavior, most of the emphasis has been at the
cellular and molecular levels.

At the moment, physiology remains the discipline that links cellular activity
to the function of the organ systems. Physiological research has shown that
behavior and organ system function do not result simply from a summation
of the actions of individual cells, but instead result from two-way
communication between cells, tissues and organs. In other words, cellular
events affect organ function, but organ function also affects cellular events!

A particularly accessible and entertaining introduction to systems biology
and physiology can be found in a recent book by the physiologist Denis
Noble1. Professor Noble is noted for his fundamental work on the electrical
and ionic mechanisms that control the activity of cardiac cells leading to the
coordinated functioning of the heart. He led a team of researchers in
developing a large-scale computer model that simulates cardiac function.
This model includes both cellular dynamics and function of the intact,
working heart.

1 Noble, Denis (2006) The Music of Life. New York: Oxford University Press.

With these developments in systems biology and physiology, interest in the
consequences of manipulating the genome and intracellular events on
animal behavior and organ function re-emerged. This new emphasis on
integration of systems of the body across levels of organization (cells to
organ systems) re-invigorated the discipline of physiology. Many
universities are recruiting new faculty into physiology departments and
programs, and the societies such as the American Physiological Society and
the International Union of Physiological Societies are alive, well and
thriving.

What is the state of Physiology today?

Additional factors have led to a re-emergence of the discipline of
physiology. For example, it had become clear that cellular function is
dependent on the environment of the cell and signals derived from cells and
tissues elsewhere in the body. Cells grown in a dish often did not display
the same behavior as similar cells in situ. For example, it had been shown
that muscle and bone tissues exchange chemical factors that influence
repair, growth and maintenance of both tissues. Furthermore, as suggested
above, many of the key signals influencing growth, development and
function exist at the level of organs and organ systems, such as blood pH,
hormones, stresses and strains in the musculoskeletal system, and
circulating factors in the cerebrospinal fluid.

Another factor in the ascendency of physiology has been the increase in
interdisciplinary approaches in groups of scientists with different
backgrounds, such as engineering, biochemistry and genomics. The fields
of locomotion biomechanics and the neurophysiology of the motor system
were for a long time quite separate with little intercommunication.

In the last few decades, biomechanists have studied neuroscience and
neuroscientists have learned about biomechanics, together forming a
physiological research area known as motor control. In order to

understand how the central nervous system controls movement, it is
essential to incorporate not only muscle physiology but also deep
knowledge about the physics of movement and of the musculoskeletal
system.

Furthermore, the entire area of neuroscience is a highly integrative field of
research that includes physiologists, anatomists, biochemists, geneticists,
physicists and engineers. These neuroscientists all have one feature in
common: they wish to know more about what the brain does and how it
works. That is, they all mostly share a physiological perspective.

A third factor contributing to the ascendency of physiology has been the
development of new computerized tools that allow the acquisition of large
amounts of data and the use of mathematical models to simulate complex
physiological systems. Physiology is and always has been an inherently
quantitative discipline that provides the essential concepts and data for
medical applications through biomedical engineering and other newly
emerging translational approaches.

A Nobel Prize was awarded to Sir Andrew Huxley and Sir Alan Hodgkin in
1963 (along with John C. Eccles) for their discovery and mathematical
simulation of the ionic mechanisms underlying the conduction of electrical
activity along nerves. More recently, investigators have used computation
methods with computers to understand the complex functioning of the
brain. Understanding how the brain works requires not only an
understanding of the mechanisms of nerve conduction and also synaptic
transmission, the mechanism by which nerve cells intercommunicate, but
also knowledge of the structure and function of complex networks of cells
that mediate the brain’s activities.

The Study of Physiology as Preparation for Careers in
Biomedical Science

An excellent background for the health related professions or biomedical

research would be a combination of physiology, the physical sciences and
mathematics. In addition, newer interest in building robotic systems
inspired by biological design has benefited immensely from a physiological
perspective. Since physiological research requires quantitative approaches,
and is closely related to research in biomedical engineering, it is no
accident that physiology is represented in technical universities such as
Georgia Institute of Technology.

For example, the Schools of Applied Physiology and Biomedical
Engineering at Georgia Tech feature basic and translational research that is
multi-scale (investigating phenomena at the level of cells, tissues and organ
systems). Physiologists in these departments interact with engineering
faculty to develop better treatments for disease and to advance the
development of engineered systems that are inspired by biological design.
Most physiology departments are found in medical schools. However, since
physiology is a quantitative discipline and closely allied to biomedical
engineering, it is particularly advantageous to have a physiology
department in a technical university where advanced technical resources
are available.

Basic research interests of the faculty of the School of Applied Physiology
are focused primarily on the physiology of movement, and range from the
cellular physiology and stem cell biology of muscle, to the role of sensory
feedback from muscles in the regulation of motor coordination, to the
biomechanics of locomotion, to the influence of the autonomic nervous
system on motor function, to the effects of exercise on fluid balance and
cognition, and finally to the control of skilled movements and tool use by
the cerebral cortex.

This spectrum of research illustrates the highly integrative aspect of the
study of human and animal movement, from molecules to behavior.
Professors in the School use approaches of modern biochemistry,
electrophysiology, genomics, motion analysis, muscle mechanics, robotics,
electroencephalography, transcranial magnetic stimulation, exercise

physiology and computational modeling to understand how we move.

The School of Applied Physiology offers undergraduate and predoctoral
training in physiology, and Masters level training in Prosthetics and
Orthotics (MSPO) for careers in clinical practice. For doctoral training,
students are normally supported in the first year by graduate teaching
assistantships, and then by the research grants of the advisor.

There is also a special funding mechanism for students wishing to pursue
doctoral research that is related to prosthetics and orthotics. This program
is funded by the National Institutes of Health (NIH) and provides three
years of support, including a stipend and tuition. This NIH funded
program is open to U.S. citizens, but the regular PhD and MSPO programs
are open to all. The curriculum for the doctoral programs is quite flexible.
The course of study provides fundamental training in systems physiology
and biostatistics, and also for elective coursework in fields that are related
to the interests of the student, such as neuroscience or robotics.

Chapter 13: Why Study Global Health? –
Professor Richard Skolnik

Richard Skolnik

Yale School of Public Health

Yale University

Richard Skolnik is a Lecturer at the Yale School of Public Health and the
Yale School of Management. Richard teaches introductory and advanced
Global Health courses in Yale College and introductory Global Health
courses in the School of Public Health and the School of Management.
Richard has more than 40 years of experience in development and Global
Health work. He spent 25 years at the World Bank, retiring as the
Director for Health and Education for the South Asia Region. At the World
Bank, Richard worked on education in West Africa. He also worked on
health in the Middle East and North Africa, Latin America and the
Caribbean, West Africa, and South Asia. At the World Bank, Richard’s
health work focused on health systems financing and development,
improving equity, maternal and child health, nutrition, and the control of
communicable diseases. After leaving the World Bank, Richard was the
Vice President for International Programs at PRB and the Director of the
Center for Global Health at The George Washington University, where he
taught undergraduate global health courses for 9 years. Richard also
served as the Executive Director of the Harvard PEPFAR program for
AIDS treatment in Botswana, Nigeria, and Tanzania. In addition,
Richard served on the Technical Review Panel of the Global Fund and a
number of WHO Advisory and Working Groups. He was also deeply
involved in the establishment of STOP TB. Most recently, Richard has
focused his efforts outside of teaching on reviews of the financing of HIV
in India, Cambodia, and Nigeria, working with the Results for

Development Institute. Richard received a BA from Yale University and
an MPA from the Woodrow Wilson School of Princeton University.
Richard is the author of the widely used Global Health textbook, Global
Health 101.

Reason to Study Global Health

Over the last fifty years, the world has made significant progress in
improving human health. From 1950 to 2012, for example, the death rate of
children under 5 years fell from 148 deaths per 1000 children to fewer than
48 deaths per 1000 children.i From 1950 to 2010, life expectancy for the
world grew from 48 years to 68 years.ii,iii Smallpox has been eradicated,
polio has been eliminated in all but a few countries, and great progress has
been made in reducing the burden of vaccine-preventable diseases in
children and the burden of parasitic infections, such as Guinea worm. One
reason to study global health is to gain a better understanding of the
progress made so far in addressing global health problems.

Another reason to study global health, however, is to better understand the
most important global health challenges that remain and what must be
done to address them rapidly, effectively, and efficiently. Despite the
important progress in improving human health:

 289,000 women are estimated to have died of maternal causes in
2013iv

 6.6 million children under five years of age died in 2012v
 1.3 million people died of TB in 2012vi.
 1.6 million people died of HIV in 2012vii
 627,000 people died of malaria in 2012viii

In addition, the world is shrinking and the health of people everywhere
must be of concern to all of us. This is particularly important because many
diseases are not limited by national boundaries. Tuberculosis, HIV, and

polio, for example, can spread from one country to the next. Prior to 1960,
dengue fever used to be concentrated largely in Southeast Asia and the
coast of South America. However, cases are now seen in five continents.
The “avian flu” first appeared in East Asia but it, too, is spreading to other
regions. Recently, the Chikungunya virus has also been spreading globally.

There are also exceptional disparities in the health of some groups
compared to the health of others. Life expectancy in Japan and France, for
example, is about 83 years but it is only 45 years in Sierra Leone.ix In
addition, there are a number of life saving technologies that have been used
in high-income countries for many years that are not yet used as widely in
low-income countries, such as the hepatitis B vaccine. These points raise
important ethical and humanitarian questions about the extent to which
people should be concerned about disparities in access to health services
and in health status, wherever they occur.

The important link between health and development is another reason to
pay particular attention to global health. Poor health of mothers is linked to
poor health of babies and the failure of children to reach their full mental
and physical potential. In addition, ill health of children can delay their
entry into school and can further affect their attendance at school, their
performance in school, and, therefore, their future economic prospects.
Countries with major health problems, such as high rates of malaria or
HIV, have difficulty attracting the investments needed to develop their
economies. Moreover, having large numbers of undernourished, unhealthy,
and ill-educated people in any country is destabilizing and a health,
economic, and security threat to all countries.

The nature of many global health concerns and the need for different actors
to work together to address them are more reasons why we should be
concerned with global health. Although locally relevant solutions are
needed to address most health problems, some health issues can only be
solved using a global approach, such as the recent Ebola outbreak. In
addition, some problems, such as ensuring access to drugs to treat HIV,

may require more financial resources than any individual country can
provide. Still other global health issues require technical cooperation across
countries because few countries have the technical capacity to deal with
them. Global cooperation might be needed, for example, to establish
standards for drug safety, to set protocols for the treatment of certain
health problems, such as malaria, or to develop an AIDS vaccine that could
serve the needs of low-income countries.

The concepts and concerns of global health are also becoming increasingly
prominent worldwide. The spread of HIV, the SARS scare, the fear of the
avian flu, and a new outbreak of Ebola virus in West Africa have all brought
attention to global health. The advocacy efforts, for example, of Doctors
Without Borders and the rock star Bono, the establishment of the
Millennium Development Goals, and the philanthropy of the Bill & Melinda
Gates Foundation have also dramatically raised attention to global health.
The topic has become so important that there is a push in many universities
throughout the world to ensure that all students have a basic understanding
of key global health issues.

Critical Global Health Challenges

As you consider studying or making a career in global health, you will want
to keep in mind what are likely to be the key global health challenges in the
coming decades. It will also be important to examine what these challenges
will mean for work in the global health field. I believe that there are six
global health challenges on which we will have to focus our attention in the
short and medium term, as noted below.

First, the poorest countries and the poorest people in low- and middle-
income countries will continue to face for many years the problems of
communicable diseases; maternal, neonatal, and child health problems;
and critical nutritional deficits. It is progress that “only” about 6-7 million
children under five years of age are dying each year now, a substantial
decrease from before. However, surely no one believes that over 18,000

under-five child deaths a day is acceptable.

Second, all countries will have to address more effectively the growing
problems of noncommunicable diseases. These are the predominant causes
of death in all regions of the world, except sub-Saharan Africa but even in
this region the burden of noncommunicable diseases is rising. This burden
will be driven significantly in many countries by the aging of the
population. If countries, including poor ones, act now, they may be able to
put in place policies and programs that can lead to healthier aging for a
larger share of their populations. A world with a large share of older people,
who spend many years living with disability before they die, is not a
tantalizing one.

Addressing inequity and inequality, both within and across countries, will
also need to be central to global health work over the next few decades.
Equity and social justice are central to all public health and global health
efforts. It is not acceptable that the poorest women in the poorest countries
should have maternal mortality ratios that are more than 50 times those
among the richest women within the same countries or among most women
in better off countries. Of course, we will need to address disparities based
not only on income but also on ethnicity, location, occupation, sexual
orientation, and gender.

Making health systems work more effectively and efficiently will also be a
central concern. The Ebola outbreak has further highlighted the exceptional
weaknesses of the health systems in some of the poorest countries. These
systems face critical issues with financing, staffing, the coverage and quality
of services, logistics management, and the demand for and utilization of
services - among other things. It will take many years to improve the health
systems in countries with weak governance and low skill levels and a
carefully phased approach to improving these systems will have to be taken.

Whether it is SARS, Bird Flu, Mad Cow Disease, Ebola, or new forms of
resistant bacteria, there have been and will continue to be emerging and re-

emerging infectious diseases and anti-microbial resistance. The world
needs to have a system to identify these threats and an ability to respond to
them effectively, efficiently, and in a timely and well-led and coordinated
manner. We are very far from where we need to be in this area, as the Ebola
outbreak has tragically highlighted.

Emerging and re-emerging infectious diseases and anti-microbial
resistance, however, are just one of many areas in which we need to be able
to work cooperatively across countries to better address what are referred
to as “global public goods.” As you know, market forces will not produce the
diagnostics, drugs, and vaccines that are needed to address the health
problems of poor people in poor countries. We need to build on the
progress in some areas and the lack of progress in others to develop much
more rapidly the affordable diagnostics, vaccines, and drugs that are
needed.

Working in Global Health

As you think about a possible career in global health, it is important to keep
several points in mind:

 There are a wide variety of ways to work in global health
 There are many different areas of global health on which one can

work
 Many organizations, of many different types, work on global

health
 There are a large number of professions that can serve global

health needs

These points may seem trite. However, many people believe that only those
people trained in the health professions can work in global health. Of
course, you can work in global health as a physician, nurse, or public health
graduate; however, you do not need to be trained as a health professional to
work in this field. Rather, there is also an enormous need for people in

global health who understand communications, ecology, economics,
engineering, finance, health systems management, law, logistics
management, and water and sanitation - among other things.

In addition, there is a wide range of functional areas in global health in
which one can work. These include, for example:

 maternal health
 child health
 adolescent health
 nutrition
 communicable diseases
 noncommunicable diseases
 environmental health
 humanitarian health

Moreover, while working in any these areas, one could work on a range of
global health efforts. Separate from clinical work, these efforts are generally
grouped as activities that are oriented towards advocacy, research, policy,
or programs. Different types of organizations engage in different kinds of
global health efforts. Some do only advocacy. Some cover only research.
Others, however, engage in a range of activities.

There is also a wide array of global health organizations with which one can
work. Among the most important types of such organizations are:

 Local and international non-governmental organizations, such as
BRAC in Bangladesh and Save the Children worldwide

 Governmental development assistance agencies, such as AUSAID
and USAID

 UN agencies, such as WHO, UNICEF, UNFPA, and UNAIDS
 Multilateral development banks, such as the World Bank and

Asian Development Bank

 Foundations, such as The Bill &Melinda Gates Foundation or
Rockefeller Foundation

 Global partnerships, such as the Global Fund to Fight AIDS, TB,
and Malaria, and the GAVI Alliance (formerly the Global Alliance
for Vaccines and Immunization)

 Government or private research establishments, such as the US
National Institutes of Health or the Welcome Trust

 Government public health institutions, such as the US Centers
for Disease Control and Prevention

 Public-private partnerships, such as the Malaria Vaccine
Initiative

 Private consulting firms, such as JSI, PSI, FHI, and McKinsey
 Private pharmaceutical companies
 University research and practice programs

Wherever you might want to work in global health, you must take account
of the knowledge, skills, and experience you will need to carry out this work
effectively in the future. You must also consider how you can acquire this
knowledge, skills, and experience as you go through each stage of your
educational and professional development.

A great help in developing your thoughts about the training and
experiences you need will be to identify people you think you “want to be
like” and to examine their careers. Seizing opportunities to work with such
people, if possible, can also be of enormous benefit to your personal and
professional development.

For the most part, no matter what you work on and no matter what type of
organization you work with, you will need to have a good “feel” for:

 A range of cultures and languages
 The way in which low- and middle-income countries “work”
 The manner in which key health issues play out in different

settings

You will also need to bring to this work a broad and multidisciplinary view,
that will allow you to look at global health problems from a number of
perspectives, including scientific, epidemiological, cultural, political,
organizational, managerial, financial, and economic. In addition, you will
need to understand not only the direct causes of burdens of disease, but
also the broader determinants of health in different settings. As much as
anything else, the recent Ebola outbreak in West Africa and the ways in
which the affected countries and the global community have addressed it
highlight the fact that knowing the science and epidemiology of this kind of
problem is necessary – but not at all sufficient - to dealing with key global
health problems in a timely, effective, and efficient manner.

In this light, if you continue to aspire to a career in global health, there are a
number of steps you can take, as noted below:

o Start your intellectual and professional development in the field
with an introductory global health course

o Get exposed early to an understanding of demography and
epidemiology, since you need to “think like an epidemiologist
and a demographer” to be effective in the global health field

o Take courses, such as in medical anthropology, that will help you
gain a better understanding of the social determinants of health

o Take courses that will expose you to the economics and the
“health-development” link, since much of your work may have to
be framed in these contexts

In addition, as early as you can, seek opportunities to live and work in low-
or middle-income countries in an area related to health, if at all possible.
This could be done, for example, through research projects or work on

projects and programs during your long school breaks. It could also be done
through appropriate study abroad.
Finally, let your long run interests drive the type of training you seek, rather
than deciding in advance whether you should study, for example, public
health or public policy. You can do this by asking yourself from time to time
… in 15 years, what will I want people to say is my impact on global health?
Then ask yourself about the platform from which you will seek to have that
impact. Only after answering these two questions will you be able to
sensibly determine the knowledge, skills, and experience needed to get
where you want to be and the programs of study that are most appropriate
to meeting your professional goals.

Chapter 14: Nursing for the Curious: Why
Men Should Consider a Career in Nursing? –
David Hrabe, PhD

David Paul Hrabe, PhD
Associate Professor of Clinical Nursing

The Ohio State University

Dr. David Hrabe has almost four decades’ experience as a nurse,
consultant, and educator. At The Ohio State University College of Nursing,
Dr. Hrabe serves as associate professor of clinical nursing and executive
director, Academic Innovations and Partnerships where he teaches
courses on leadership in advanced nursing care and scientific thought in
nursing and conducts numerous workshops on personal development and
self-care for health professionals. Throughout his career as a psychiatric
nurse, Dr. Hrabe has a long-standing interest in how to improve the work
lives of nurses, receiving grants and awards, publishing papers, and
lecturing on these national healthcare issues. He is a member of Sigma
Theta Tau, Beta Upsilon Chapter and is Vice President, Arizona Nurses
Association Board of Directors. Dr. Hrabe received his PhD in nursing
from University of Arizona, his MS from Arizona State University and his
BSN from Fort Hays State University.

As a man, it is not likely that you grew up wanting to be a nurse, but, here
you are, reading this chapter. I am glad that you are taking the time to
consider your career options since there are a many things to consider in
making this decision. Nursing offers men (and women) an amazing array
of specialties and roles around the world. In this chapter, we will explore a
bit about the history of men in nursing, current employment trends and
factors to consider in deciding to become a nurse. We also touch on how to
go about learning more about nurses, nursing and nursing school. Let’s get
started!

Men in Nursing: A Historical Perspective and Current
Trends

It may be surprising news to learn that men have served in a nursing role
for centuries. Some of the earliest accounts come from India in the 2nd
century where men cared for the sick in an institutional setting (Kenny,
2008). According to Kenny, male religious orders were established in the
Middle East during the 3rd century to care for the sick and wounded. The

trend spread to Europe during the 4th century where men continued to
serve as untrained nurses until the mid-19th century when Florence
Nightingale “…firmly established it (nursing) as a woman’s occupation”
(Evans, 2004, p. 322). Nightingale’s influence and the strict gender-role
norms of the late 19th and early 20th centuries virtually assured that the
large majority of the world’s nurses would be women.

Most recently, nursing has been seen as a viable career option for men.
Regan (2012) conducted an online search of available data to determine the
percentage of men in nursing by country between 2005 and 2010. She
found that China had the lowest percentage of men in the nursing
workforce (1%) compared to Saudi Arabia’s high of 32%. Most western
countries hover between a 5-10% male nursing workforce, while Spain
(18%), Israel (21%), Italy (21%) and Kenya (22%) exceed the norm. Conduct
a search of the Internet using terms such as “male nurse” or “men in
nursing” focused on your country of interest. You will likely find that more
doors are opening for men in nursing as demand for their services
continues to increase across the globe.

Why Men Choose Nursing: Why it Might or Might Not be
Right for You

In a 2004 survey about why men choose nursing, Meadus and Twomey
cited career opportunities, job security and salary as the top three reasons
men chose nursing. Another survey conducted in 2004 (Hart, 2005) found
that “a desire to help people” (p. 47) was the number one reason men
entered nursing. Hart found that the men in her survey confirmed that
career options and stability were important to them. Other factors include
feeling “called” to be a nurse, being encouraged by a family member and
personally knowing nurses who recommend it (Harding, 2009).

A World Health Organization bulletin (2010) emphasized that there is a
worldwide shortage of nurses and that the shortage is expected to continue
for the foreseeable future. As the world’s population ages, so do nurses.

With increasing healthcare needs of an older population, the large number
of nurses and nursing faculty who are about to retire in the next decade and
the inadequate production of new nurses, demand for nurses throughout
the world is expected to be very strong.

Although nurses are in demand, you should carefully consider if it is right
for you. One of the biggest barriers that men report as a concern about
nursing is sexual and gender stereotypes (Clow, Ricciardelli, & Bartfay,
2014; Hart, 2005; Harding 2009; Meadus & Twomey, 2004; MacWilliams,
Schmidt & Bleich, 2013; Rajacich, Kane, Williston & Cameron, 2013).
Because the actual word “nurse” is associated with a woman’s physiological
functioning and because of long-standing, socially-constructed gender
roles, it may be seen by some as an inappropriate profession or as a low-
status career for men to enter. Another potential barrier is a lack of male
role models in nursing. Since male nurses are still relatively rare, the
opportunity to see how a man enacts the nursing role is hard to find. This
made lead to feelings of isolation and uncertainty for the man practicing
nursing.

Salary, advancement opportunities and job stability may be barriers for
some men, depending upon their location. Many countries will have
employment information posted online from a variety of organizations.
Usually, a government agency lists requirements to be a nurse and some
information about the country’s nurses. Search terms that might be useful
include “nursing registry”, “board of nursing”, “registered nurses”, “nursing
licensure” to learn as much as you can about nursing in your area. Look for
organizations that employ nurses and review their advertisements for
nurses—this can give you a good idea of what the job market is like and a
sense of salaries.

While men in nursing have traditionally sought careers in specialty areas
considered to be more “masculine” (psychiatry, administration, emergency
department, military; Evans, 2004), opportunities are expanding to other
specialties and worksites. Conduct an online search in your country to

determine what types of nursing specialties exist in your area.

As one example, Johnson & Johnson’s “Campaign for Nursing’s Future”
lists 104 nursing specialties in the United States
(http://www.discovernursing.com/explore-specialties#no-filters). This is
just a glimpse into the diverse areas where nurses specialize. Multiple
specialty combinations, roles (staff nurse, advanced practice nurse, nurse
manager/administrator, nurse educator, etc.) and practice areas (i.e.
hospitals, ambulatory care, long term care, clinics, community, etc.)
provide a wide array of areas for men to practice nursing.

Questions to Ask Yourself

Still interested? Here are some questions to consider in making your
decision:
Do I have an interest in and aptitude for both natural and social sciences?
Nurses must be able to understand how the human body and mind work
during health and illness. In providing care, nurses apply their scientific
knowledge to clinical situations under complex and ever-changing
conditions every day.

Do I like working with technology? Today’s healthcare environments are a
jungle of technology ranging from diagnostic and monitoring devices to
life-supporting machines to electronic health records. Nurses are the
“connectors” between technology and people by understanding the
technology, analyzing the information it provides and intervening
appropriately when needed.

Do I enjoy working with people? If you do not enjoy being around people,
nursing is not for you! Nurses interact almost constantly with patients and
their families. Even when you are not at work, people will ask you about
their health-related questions (“Since you are a nurse, could you take a look
at…”).

Do I enjoy working in teams? Nursing requires a great deal of teamwork.
You will be working with other nurses as well as physicians, social workers,
administrators and many others. Healthcare is a complex business where it
is important to communicate well to promote the best outcomes for
patients.

If you answered “yes” to these questions, nursing might be right for you. To
explore further, consider taking the United Kingdom’s National Health
Service “personality quiz” (a free, online assessment) that asks 24 questions
about your personality and work-style preferences. Feedback, based on
your answers, is generated. You can find the online survey here:
http://nursing.nhscareers.nhs.uk/careers/personality_quiz.

Informational Interviewing

The next step to your exploration is talking with someone who is a nurse.
Informational interviewing is a structured way to approach professionals
who are working in the field that interests you. Here are the steps to a
successful interview:

Be prepared! By reading this chapter and other chapters in this book, you
will have a good understanding of what nursing is about. Searching the
Internet for local schools of nursing, regulatory boards and healthcare
institutions will help you learn more about the nursing scene in your area.

Identify whom you want to interview. The easiest person to approach may
be someone in your family or a friend who is a nurse. Also, consider setting
up an appointment with a nurse from a local healthcare facility. If possible,
identify a man who is a nurse so you can ask him more about what nursing
is like for him.

Next, prepare for the interview and initiate contact. You should develop a
15-30 second overview of yourself and explain why you are contacting this
person. The following telephone script was adapted from University of

California-Berkeley’s career center website

(https://career.berkeley.edu/Info/InfoInterview.stm). It should be useful

for this stage of your exploration:

Hello. My name is Steve Smith and I'm a local high school student who is
interested in nursing. Is this a good time for you to talk briefly? I found
your name on your organization’s website. I have become very interested in
nursing and would like to find out as much as I can about the field. Would it
be possible to schedule 20 to 30 minutes with you at your convenience to
ask you a few questions and get your advice on how best to prepare to enter
the field?

You can easily adapt this script to email format.

Prepare your questions. While there are a number of questions you may
want to ask, keep in mind that the person you are interviewing is probably
very busy. Here are a few questions to get started:

 How did you begin your career in nursing?
 Where did you go to school to become a nurse? Do you have any

advanced degrees in nursing?
 What is your specialty? In what other areas of nursing have you

practiced?
 What are your main responsibilities as a nurse?
 What is a typical day (or week) like for you?
 What do you like most about your work?
 What do you like least?

For more question ideas, conduct an online search for “informational
interview questions.”

Conduct the interview. Arrive a few minutes early appropriately dressed.
Be clear that you are exploring nursing as a career option and that you are

not seeking a job. Be yourself and really try to connect with the person you
are interviewing. Remember that most nurses are “people-oriented people”
and will probably be delighted that you are taking the time to learn more
about their work.

Follow up! Send a note of appreciation within 1-2 days after the interview.
If the interview was very formal, send a formal letter. If somewhat
informal, a handwritten note or email will suffice. If you really connected
with the person, stay in touch with them and let them know how your
exploration is going. Keep in mind that this connection may be an
important one later in your career.

Job Shadowing, Internships, Volunteer or Entry-Level
Opportunities

If your interview has gone really well and you are still interested in nursing,
you may want to ask if it would be possible to follow the nurse for a shift (or
part of a shift). This is called “job shadowing” and can provide keen insight
into the work-a-day world of nurses. Most healthcare organizations,
however, have strict guidelines to protect patients’ privacy, health and
safety so it is extremely important to know about these policies and follow
them. You should never just “show up” at someone’s worksite (even if they
have agreed to it) unless you have been officially approved by the
organization.

Some organizations may have internship programs. An internship is an
unpaid, formal arrangement that may last for a few days or weeks,
depending upon the agreement. These are rare in nursing due to staffing
and patient safety/privacy issues. As an alternative, many healthcare
organizations have volunteer programs. Finally, if you are old enough to be
employed, seeking an entry-level position (e.g., “nursing assistant” or
“patient care assistant”) in a nursing setting may give you the best picture
of what to expect.

Professional Associations and Internet Resources of
Interest to Men in Nursing

A number of organizations may be helpful to you as you enter the
profession. Conducting an online word search for “men in nursing
organizations” or “male nursing organizations” should yield a variety of
resources. Here are few to consider:

American Assembly for Men in Nursing (AAMN): http://aamn.org/
Johnson & Johnson, Men in Nursing:
https://www.discovernursing.com/men-in-nursing
Minority Nurse: http://www.minoritynurse.com/ (This online resource
frequently carries articles about men in nursing).

Many professional organizations may have sub-groups of men who discuss
education or research-related issues regarding men’s health. A number of
articles have been written about men in nursing (a few of these have been
cited in this chapter) which may help to complete your exploration.

Because preparing for nursing school, successfully completing your
educational program and taking your licensing exam is a huge emotional
and financial investment, it is very important that you have a good
understanding of what is involved. These ideas for exploration are only
guidelines for your consideration. The main point is this: know as much as
possible about nursing before you “jump in”. Your exploration could save
lots of time, money and later disappointment.

I’m Still Interested in Nursing. Now What?

Exploring the right school for you is the next step. Here are some things to
consider:

What degrees does the school offer? In the United States, some
schools provide only entry-level education for roles such as a nursing
assistant (a few months) Licensed Practical Nurse (about 1 year) or

Registered Nurse (about 2 years). Other schools offer a Bachelor of Science
in Nursing (BSN) degree and may also offer masters and doctoral
programs. Your country’s governmental nursing agency likely regulates
nursing schools in your area and may have a list of approved nursing
programs. You should target a school that will help you achieve the highest
level of entry into practice possible. Most employers in the United States
prefer to hire bachelor’s prepared nurses. As level of education rises, career
possibilities expand exponentially.

Is the school accredited? Although a school may be approved by your
country’s regulatory agency, accreditation is an additional credential that
you should consider. Accreditation is another educational quality check for
a nursing program, although not all countries may have this type of
mechanism.

Where do students receive their clinical experiences? How many
clinical do you receive as part of your program? Does the school have a
robust clinical simulation program? It is good to ask about because if the
school has limited placements, it could restrict the kinds of clinical
experiences open to you. You also want to know about how many hours
you will be in clinical so you can compare to other schools in your area.
Clinical simulations offer life-like experiences that prepare students well for
what they will encounter in the clinical setting.

Does the school restrict clinical experiences for male students?
Depending upon your culture and norms, some men may be restricted from
caring for women or children. It is important to know if this is the case in
your country as it may affect your decision to attend school there.

Can you get an appointment with a faculty member who is a
nurse? Many schools have advisors or clerical people who are not nurses
but who are the first point of contact for potential students. You can learn a
lot from them about the school, but you may not get a good sense of what
the school is like unless you talk to a faculty member.

Does the school have any male instructors? You can likely find this
information on the school’s website. If so, see if you can get an
appointment with this faculty member and ask them about what it is like
for men at the school.

How are you treated at the school? If you feel welcomed and you
establish a good rapport with the person you encounter, it may be a good fit
for you. If you are treated with suspicion or get the feeling that you are not
welcomed there, it would be a good sign to move on.

Can you talk to any students? Ask if it will be possible for you to talk to
students (especially male students) who are currently attending the school.
If this request is denied it could be another indicator that this school is not
an appropriate place for you.

What are the costs for school? Are scholarships available? Nursing
school is expensive and you need to find out not only about tuition, but any
additional program fees, technology fees, and clinical fees in addition to the
cost for uniforms, books and housing. Many schools have calculated total
costs; if not, be very careful about what you commit to.

Preparing for School

So, you have completed your exploration of nursing as a profession, have
decided nursing is for you and you have identified a school (or more than
one). You should know that admission to most nursing schools is very
competitive. Here are some tips for successful admission and completion
of school:

Understand your school’s admission requirements. Schools have
certain criteria that they use to evaluate candidates. One of the most
commonly used indicators is grade point average (GPA). You really have to
have an excellent academic record. Entrance exams and/or essays with

interviews are also common.

If you have had any legal troubles, be open and honest about
them. Because some legal issues may ultimately prevent you from being
licensed/registered, be sure to inform your school about this at the very
beginning. Honesty really is the best policy—always!

Prepare yourself and those close to you for what is to come.
Nursing school is very rigorous and time-consuming. You will be attending
class, studying or in clinical most of your waking time (sometimes even in
your sleep!). Your social time during school will be limited, so manage your
time well and build in time to be with your loved ones.

Eat well, exercise and get good sleep. All of three of these health
behaviors are important for your peak performance. Not only is taking care
of yourself important for your own health, it is also important because your
patients will look to you as a role model.

Go For It!

Hopefully, this chapter has given you some insight as to why men should
consider a career in nursing and how to go about finding out more about
this wonderful profession. From personal experience, nursing has provided
a fulfilling career I could never have imagined. I wish the same for you.

References

Clow, K., A., Ricciardelli, R., & Bartfay, W., J. (2014). Attitudes and
stereotypes of male and female nurses: The influence of social roles and
ambivalent sexism. Canadian Journal of Behavioural Science, 46(3), 446-
455. doi:10.1037/a0034248

Evans, J. (2004). Men nurses: A historical and feminist
perspective. Journal of Advanced Nursing, 47(3), 321-328.

doi:10.1111/j.1365-2648.2004.03096.x

Harding, T. (2009). Swimming against the malestream: Men choosing
nursing as a career. Nursing Praxis in New Zealand, 25(3), 4-16.
Hart, K. A. (2005). What do men in nursing really think? survey
respondents speak out. Nursing, 35(11), 46-48.

Kenny, P. E. (2008). Men in nursing -- a history of caring and contribution
to the profession (part 1). Pennsylvania Nurse, 63(2), 3-5.

MacWilliams, B., Robert, Schmidt, B., & Bleich, M., R. (2013). Men in
nursing. American Journal of Nursing, 113(1), 38-44.
doi:10.1097/01.NAJ.0000425751.42041.78

Meadus, R. J., & Twomey, J. C. (2007). Men in nursing: Making the right
choice. Canadian Nurse, 103(2), 13-16.

Regan, H. (2012). Male nurses worldwide. RealMansWork. Retrieved from
http://realmanswork.wordpress.com/2012/05/05/male-nurses-
worldwide/

Rajacich, D., Kane, D., Williston, C., & Cameron, S. (2013). If they do call
you a nurse, it is always a 'male nurse': Experiences of men in the nursing
profession. Nursing Forum, 48(1), 71-80. doi:10.1111/nuf.12008

World Health Organization. (2010). Wanted: 2.4 million nurses, and that’s
just in India. Bulletin of the World Health Organization. Retrieved from
http://www.who.int/bulletin/volumes/88/5/10-020510/en/#.

Chapter 15: A Recipe for Inspiring Learning
of Pathology: Just Add 7 M’s and Mix – A.M.
Currie and Professor J.E. Dahlstrom, PhD

Alex Currie
Associate Clinical Lecturer
Australian National University Medical School

Alexandra Currie [BHB, MBCHB, FRCPA] is an Anatomical Pathologist
from New Zealand, with a passion for the discipline of pathology
including learning about, teaching about, and understanding disease. She
is an Associate Clinical Lecturer at the Australian National University
Medical School and Academic Fellow in the Department of Anatomical
Pathology at ACT Pathology, Canberra Hospital, Australia. Alex is
currently completing her Postgraduate Certificate in Tertiary education
(University of Canberra).

Dr Jane Dahlstrom, PhD
Professor of Anatomical Pathology
Australian National University Medical School

Jane Dahlstrom [MBBS (Hons), FPAC, PhD, FRCPA, FFOP, FFSc, Grad
Cert Ed St (higher educ), SFHEA] is Sub Dean, Canberra Hospital Campus
and Professor of Anatomical Pathology at the Australian National
University Medical School, and Senior Staff Specialist in Anatomical
Pathology at ACT Pathology, Canberra Hospital, Australia. Her job
involves an interesting mix of undergraduate and postgraduate teaching
and examination in pathology, surgical and autopsy pathology and
research. Her principal research interests revolve around breast and
perinatal pathology. Jane has won a number of awards for her teaching
programs including the Carrick Award for Australian University
Teaching Excellence in 2007.

“Awaken people’s curiosity. It is enough to open minds, do not overload
them. Put there just a spark.” - Anatole France

Introduction

In order to create and maintain a successful and inspiring learning
environment a number of key areas need to be considered. At the
Australian National University Medical School (ANUMS) we have adopted

an approach that has produced an award-winning Australian program in
pathology that is enjoyed by both students and staff. 2 This approach
involves recognising the seven key components of learning; the seven M's:
the mentee (the learner), the map, the messenger, the method, the menu,
the measurement and meditation. This chapter summarises our approach.

The Mentee: Student-Centered Approach to Learning

Each student arrives with a unique personality, intelligence-type, learning-
style and learning- needs. We aim to understand learning from this student
perspective in order to encourage deep learning. 3

Research shows that students tend to have either ‘deep’, ‘superficial’ or
‘strategic’ approaches to learning, each of which are linked to distinct
motivations, methods and outcomes. 4, 5 The deep approach to learning is
the preferred one, for at its heart, it is motivated by a strong personal desire
to understand the subject, and its vocational relevance. 3,4, 5 In pathology
this is best achieved via relating theoretical ideas to everyday knowledge
with clearly-stated expectations for student learning.

For example, understanding why an infected wound will have particular
symptoms and signs based on the pathophysiology of what occurs in the
acute inflammatory response. This can then be related to why particular
management approaches such as wound-cleaning and antibiotics are
followed.
The surface learning approach is motivated by fear of failure and a desire to
complete course or task requirements. 3, 4 There is a heavy reliance on
rote-learning techniques, and limited efforts are made to understand or
meaningfully integrate facts within the larger curriculum framework.4,5
Such students may possess abundant factual knowledge without insight
into its contextual relevance. 4

The strategic approach is motivated by competitiveness and the pursuit of
academic success. 4 It is characterised by patchy, variable and inconsistent