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Breaking new ground in adolescent medicine: Dr Rachel Skinner

07 March 2011

Dr Rachel Skinner

Position: Adolescent Physician; Associate Professor, Sydney University , Paediatrics and Child Health, Children's Hospital Westmead.

Question: Are there still barriers to women achieving senior level positions in medicine and have you experienced them? It's sometimes difficult to identify specific instances where one may have been discriminated against on the basis of gender. Other reasons are often given for why you may have been overlooked for a more senior position. However, in medicine, as elsewhere, the data tell us that women are not progressing to the most senior levels at the same rate as men. While at least 50 per cent of medical graduates are female, only 28 per cent of medical specialists registered with the Royal Australasian College of Physicians (Fellows) are female. The disparity at the most senior academic levels in medicine is even more stark: 23 per cent of medical academics who hold the title of Professor or Associate Professor in the Faculty of Medicine at Sydney University are women.

Rachel Skinner is a professional and personal pioneer - not in that ad-hoc, let's-get-in-the-car-and-drive sort of way, but in the meticulous way a lover of research and problem solving would approach the challenge of a journey into the unknown. Rachel's answer to the question (above) on 'barriers to women' provides an insight into how she rates the importance of research. (Rather than just offer an off-the-cuff response, Rachel took the time to round up the stats in her professional worlds of medicine and medical academia indicating the size of the disparity between men and women at the top in both.)

The discrepancy between percentages of females graduating and those reaching senior levels leaves Rachel feeling there's something going on. Ascertaining what the contributing factors are producing this bias - while not her project - would make interesting research.

Just as her chosen research and teaching specialty in Adolescent Sexual and Reproductive Health has made for fascinating study. (Rachel is also an Adolescent Physician, consulting in adolescent gynaecology but trained to see all manner of problems affecting young people.)

Breaking new ground

\"Adolescent Medicine is new in Australia . The Royal Australasian College of Physicians is only just developing an educational framework and training guidelines to formally recognize Adolescent Physicians. In the US it's been recognized for a few decades now.

\"When I began, I'd trained in Paediatrics and then joined what was the very new Centre for Adolescent Health in Melbourne , affiliated with the Royal Children's Hospital, under its Founding Director Professor Glenn Bowes,\" explains Rachel.

In those early days training to become an Adolescent Physician meant attending either the Centre in Melbourne (there's also one in Sydney at the Children's Hospital Westmead), or travelling overseas.

Rachel did both. But her experience at the Mt Sinai Adolescent Health Centre part of the Mt Sinai School of Medicine in New York could not have been more different.

\"One of the major problems for the clinic was teenage pregnancy and sexually transmitted infections including HIV. Patients were predominantly from very low socio-economic and deprived backgrounds and were largely Hispanic, Black Americans. There were very few whites.

\"Here I was fresh from Melbourne , having focussed on eating disorders - something we see in more wealthy, white, Anglo backgrounds - working with a very different profile of health issues affecting young people.\"

Complex care

The training she received in both countries coupled with Rachel's admiration for her father, a Physiologist whose own research uncovered \"important information about certain hormones that play a role in hypertension\", have both played a part in setting her other-than-average career path.

Rachel is quick to admit she was attracted to Paediatrics in the beginning for the patient rewards: \"A young person or baby can come in very, very unwell and within no time of treating them they recover. A great deal of adult medical care is really just helping round the edges, especially as people get older.

\"The move into adolescent health was for its challenges and opportunities. It's where the psychological and the developmental aspects of health impact upon the physical. Many doctors don't like that at all. They like pure organic or physical medicine where there is a physical problem with which you deal.

\"What appeals to me is the interplay of the psychological, mental health or social issues with the physical. It is so much more complex. Certainly, in terms of formulating my research career, that has been integral to what I do,\" says Rachel.

The research part of Rachel's career, she is also quick to admit, has had nothing to do with quick fixes, short-term rewards or commensurate remuneration but has given her long-term job satisfaction, control and autonomy, and led, eventually, to a more stable and healthy bank balance.

According to Rachel, it's a small group of specialists who take the academic research track.

Catch 22

\"Studying medicine, caring for patients - it is exciting and time consuming. A patient presents, you work out the problem provide the correct treatment and see them cured... that's very exciting, very rewarding and gratifying.

\"Research is a long path. You do a lot of work and it can be many years before you get a result. Convincing students of the efficacy and need for research while getting across to them that the result - when it does come - is worth all the little wins they get everyday caring for patients doing clinical work is not easy. The lack of immediacy is a disincentive in itself.

\"It's a long time before you earn a reasonable amount of money and you never do earn as much as being a full time clinician. I was 36 before I had my first 'real' job,\" explains Rachel with the tinge of a backward glance.

It seems to beg the question: Why do something where the rewards seem so distant?

\"Well, firstly I'm stubborn and if I choose to do something I stick at it. But I've always been interested in public health and you really can't do effective public health unless you know how to do research.

\"The appeal of public health - as opposed to clinical medicine - lies in the fact that you can impact the health and wellbeing of a much larger amount of people and potentially have much greater impact. This is what I try and teach my students with varying degrees of success: the important role research plays in medical and clinical care and how discoveries in research can change the way we practice medicine.\"

Inspiring outcomes

Having worked closely with Professor Fiona Stanley in Western Australia (health and disease in children) and Professor Suzanne Garland in Melbourne (HPV research), Rachel has first hand experience of the benefits rigorous research can bring to public health. Her own work in Adolescent Sexual and Reproductive Health, begun when she received her first research post with the University of Western Australia a little more than 8 years ago, has also garnered her praise.

\"I want my research to lead to informing appropriate educational outcomes for young people in schools and for clinicians. That is the challenge, converting research findings into the real world. It is not just about publishing and presenting the work. It needs to become real and inform services for young people and that takes a lot more work, a lot more lobbying.\"

Overcoming the ethical challenges of undertaking research about sexual risk taking in young people, particularly vulnerable young people, has been a high point for Rachel. For example, she and her team were successful in recruiting large numbers of adolescents who were independently accessing reproductive care through clinics in Perth without the need for parental consent, thus recognizing their autonomy and right to confidentiality in research

\"The data we were able to collect is unique and very broad. I think it will have a big impact on our understanding about why young people start their sexual lives and, in particular, why they are starting them earlier and earlier than previous generations. In this country we are lucky. Our systems, including education, provide good information for adolescents on their various health needs but there are areas that need further work and the research findings evidence this.\"

Teenage pregnancy turnaround

In fact, one of the more surprising findings was in teenage pregnancy, and it's one Rachel believes we need a new approach to.

\"I began the research from a very traditional and conservative public health view that teenage pregnancy was a bad thing. Teenagers should not be having babies: there are poor outcomes. The babies don't do well. They're born with lower birth weight, tend to have more problems in the newborn period and they don't do very well educationally, developmentally and behaviourally as they grow up.

\"Documenting the teen mothers we followed from pregnancy to two years post delivery, going into their homes and collecting data regularly we could see why they don't do as well. The general adversity under which they live makes the poor outcomes unsurprising.

\"However, we also found that having a baby for some of the young people we worked with was very important in terms of their identity, in terms of their development and what they wanted in their life. Not everyone fits the same mould and, for some, having a baby and becoming a mother was seminal, changing their life for the better... but they are vulnerable and they need more support.

\"Rather than just focusing on preventing teenage pregnancy what has come out of the work is the need to support that group of young people who are on the path to having children at a young age. We need to ensure they are well supported so that they can continue education, if that is something they want to do, and we also need to ensure that their children have a good chance and good outcomes in life.

\"I am committed to developing ways in which to reduce inequality in health, especially in the case of young people.\"

Things I've learned, so far

Virtual penury in New York taught me a great deal about the value of money, saving and managing it wisely.

Property can be a great investment and if you're going to try other styles of investment do your research, get an expert's opinion and if someone recommends you invest in something and your instinct is to check it, then go and get a second opinion and listen to it.

A combination of factors taught me about the importance of work life balance. It's about learning to say no, because not only do you suffer but those around you and with whom you work also suffer if you have no filter, no ability to decide which are the things you should not be doing and which are the opportunities you should be taking.

Passions

France , well actually it's a passion about working in and experiencing different cultures. I did live in France for three years, taught myself the language and worked as a doctor in a community hospital in a regional area of France where no one spoke English.

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