The Medical Student - December 2013

theMEDICALSTUDENT

December2013

The voice of London's Medical Students/www.themedicalstudent.co.uk

STARSurg

A student-led first >> page 4

2020 Medicine

Are you being prepared? >> page 13

Cycling in the Capital

What needs to be done? >> page 11

2013 Film Roundup

We rank the best >> page 16

Foundation Programme Oversubscribed for Fourth Consecutive Year Krishna Dayalji It’s your final year at medical school. Electives, Foundation programme applications, SJT exams and finals are just a handful of items on your checklist, all in the hope that you will graduate with the ability to think and act like a doctor. But what happens when you cannot secure your first job?

For the fourth consecutive year, the foundation programme is oversubscribed.

The UK Foundation Programme Office (UKFPO) released a statement last October confirming there are more applicants than foundation programme posts available for those students commencing work in August 2014.

The UKFPO, jointly funded and governed by Health Education England (HEE) and three other UK Health Departments, facilitates the two-year programme, enabling newly qualified, eligible doctors

from both the EU and the UK to provisionally register with the General Medical Council (GMC).

The main problem lies in the fact that only on successful completion of the first year of the programme are eligible doctors able to apply for full GMC registration. This was first introduced through the Medical Act of 1950 with the prime aim of protecting patients.

Previously, all eligible applicants from UK medical schools have been able to secure a place on the Foundation Programme as the number of posts exceeded the number of applicants, and therefore they have had the opportunity to achieve full registration with the GMC and go on to practise as a qualified doctor. The converse has been true for the past three years.

When applicants exceed the number of vacancies available, the UKFPO place the top scoring applicants (for the number of posts...[cont’n on page 2]

London’s Doors Remain Open Peter Woodward-Court Readers of our November issue will recall that the University of Cambridge have made the decision to stop all students from transferring to London for their clinical studies from 2017.

In late November, The Medical Student received exclusive news that all the five London medical schools will continue to be receptive to transfer students despite Cambridge’s decision.

Since Cambridge currently accepts new students on a 3

year, and not a 6 year, course it remains unclear whether students will be permitted to leave the university after their preclinical medical sciences degree against Cambridge’s will. London remarked: “We confirm that London’s clinical transfer doors for Cambridge and Oxford clinical students will remain open beyond 2017, in the firm belief that students should continue to be permitted the opportunity to make considered decisions about experiences available for their clinical training.”

Shape of Training Review Krishna Dayalji October saw the Shape of Training Final Report be published. However, there seems to be some confusion surrounding how well the report has been received.

Based on Sir John Tooke’s 2008 report Aspiring to Excellence, The Shape of Training Report offers an approach in the hope that all doctors are trained to the highest standards and prepared to meet changing patient needs. The report was primarily written by key figures of the General Medical Council (GMC) and Medical Education England (MEE), with a number of stakeholders sponsoring the review. It is believed that this report will provide a framework to help

deliver changes with minimal disruption to the existing health service and that the approaches described will be fit for purpose for many years.

The three main aims of the report were to ensure we continue to train effective doctors who are fit to practise in the UK, provide high quality and safe care, and meet the needs of the patient and service now and in the future.

It was believed that the review was needed to ensure UK medical education and training was complementary to society’s everchanging needs.

Driven by a growing number of people with multiple co-morbidities, an ageing population, health inequalities and increasing patient expectations, there is a need for

more doctors who are capable of providing general care in broad specialties across a range of different settings.

As a result, the report argues that we need doctors who are trained in more specialised areas to meet local patient and workforce needs. Postgraduate training needs to adapt to prepare medical graduates to deliver safe and effective general care in broad specialties. Medicine has to be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers, and local workforce and patient needs should drive opportunities to train in new specialties or to credential in specific areas.

The report further adds that doctors...[cont’n on page 4]

theMEDICALSTUDENT / December 2013

News Editor: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

T

[Editor's Letter]

he end of the first term sneaks up on us once again and invariably we make promises to catch up with missed lectures, poorly understood physiology and the piles of unsorted lecture notes.

Inevitably, we’re not nearly as productive as we intend to be as we immerse ourselves in the festivities. There’s nothing worse than not enjoying time spent procrastinating, so why not settle down to a good film?

But, dear reader, I hear you cry “How do I separate the wheat from the chaff on the overly laden TV guide?” John, our diligent culture editor, has put together TMS’ review of the best, and worst, films of 2013 for your delectation (p.16).

We continue the festive

[Editorial Team] Editor-in-Chief/Peter Woodward-Court News Editors/Chris Smith & Krishna Dayalji Features Editor/James Wong Comment Editor/Robert Cleaver Culture Editor/John Park Doctor's Mess Editor/Zara Zeb Education Editor/Sarah Freeston Sports Editor/Mitul Patel Images Editor/Upi Sandhu Treasurer/Jen Mae Low Illustrators/ Edward Wong (p8-9), Alexis Nelson (p10)

[Advertising] If you would like to advertise with us, please contact: editor@themedicalstudent.co.uk

[Distribution] We need distribution officers. If you are available midweek and on campus, please contact: editor@themedicalstudent.co.uk

> [cont’n from Foundation Programme article] ...available) on the ‘primary list’. The remaining students are placed on the ‘reserve list’.

The number of places that arise subsequently depends on the number of applicants on the primary list who withdraw from the process. Last year saw 300 students be placed on the reserve list. Rumour has it that it could be even higher this year.

It was only after intense lob-

bying from the BMA that we saw the Department of Health increase their capacity to accept all UK medical school graduates on the Foundation Programme 2013. However, this temporary solution is not enough to solve this everevolving problem.

The Medical Students Committee (MSC) at the BMA have expressed concern over the alarming uncertainty surrounding the extent of oversubscription this year, as well

[NEWS]

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theme with our ‘best things to do’ in London over the holidays (p.19) and review ICSM’s production of ‘One Flew Over the Cuckoo’s Nest’ (p.20).

In News we take a look at the winner of the John Maddox prize, neuropsychopharmacologist Prof. David Nutt, for his work on influencing evidence-based classification of drugs (p.4). It being the season for eating a bit too much, perhaps we should be including beetroots in the trimmings this year as new research reveals their potential benefit in reducing high blood pressure (p.5).

In Education this month we take a fascinating glimpse at ‘2020 Medicine’ and whether we should be better prepared

as students for the forthcoming ‘technological revolution’ coming to medicine (p.13). Also in Education this month, we look at ‘Problem Based Learning’. A handful of schools in London have adopted PBL as a method of teaching, with others staunchly remaining lecture based.

PBL has been coming under fire recently and we take a look at its place in medical education (p.14).

As a cyclist myself, I was especially saddened by the recent rise in cyclist deaths on London’s roads. In Comment this month, we look into the problem and how to make roads safer (p.11). The threat of an increasingly privatised NHS never seems far away,

and we consider its potential dangers (p.12).

There’s no Christmasthemed crossword in Doctors’ Mess this month, I’m afraid.

However, you do stand to win another cracker of a book. We also have a fascinating feature on Dame Cicely Saunders - a Nightingale (KCL) nurse turned doctor who played a key role in starting the hospice movement, and took palliative care to the mainstream.

We round off the paper this month with sporting articles on the Novice Regatta (p.23) and the recurring BUCS controversy (p.24).

From myself and the rest of the TMS team we wish you a Merry Christmas and Happy New Year!

as the lack of knowledge available from the government on how the problem would be resolved.

Newly elected BMA Medical Students Committee (MSC) co-chairs, Mr. Andrew Wilson and Mr. Harrison have pledged to continue lobbying for fellow UK peers. Mr. Wilson said, ‘We will be keeping a particularly close eye on the Foundation Programme and fighting to secure places for all eligible students from UK medical schools, after successfully lobbying the government to create extra places this year.

‘All medical students should have the opportunity to fully qualify as doctors and we will be pushing for a long-term solution to the continued problem of foundation programme oversubscription.’

More importantly however, Mr Carter added, ‘We need the government to find a long-term solution to oversubscription of the Foundation Programme.

‘This causes great anxiety to final years at UK medical schools who have spent many years studying and often racked up huge debts to begin their first jobs as doctors.’

From another point of view, by establishing a long-term solution it can be ensured that the great financial investment made towards educating and training medical students to later work in the NHS is not wasted.

The Medical Schools Council has also raised concerns regarding the oversubscription issue, adding that ‘the time has

arrived to re-examine the purpose of the GMC provisional registration’. They argue that in a era where ‘medical education and training are now much better for being regarded as a continuum’, in terms of fitness to practise, ‘the value of provisional registration as originally conceived is therefore questionable in terms of protecting patients’. As a result, ‘the graduation/registration divide is a necessary but ultimately minor point on a long journey ‘.

Furthermore, Health Education England outlined in their recent mandate that ‘the existing system needs reform, so that there is a clear and sustainable path which enables all suitable graduates to secure full GMC registration’.

Potential solutions have been discussed by a number of stakeholders. One thought has been to change the GMC registration system such that all UK graduates are able to register with the GMC after completing the medical degree.

The alternative solution has been to include a F1-equivalent year into the undergraduate course.

However, before any potential solutions are seriously considered, more clear and concise information from the government is required.

Mr Carter from the BMA MSC said, ‘We call on the government to once again commit to providing foundation programme places for all eligible UK medical school applicants, as they did last year,’ said Mr Carter.

The MSC added that they will be providing students with any updates and development and ensuring all students who are unfortunately placed on the reserve list are offered adequate support.

The UKFPO has said that applicants who do not provide proof of their right to work in the UK by January 17 will be withdrawn from the national process. They will publish the exact numbers for oversubscription on 21st January 2014, and students will have to wait another two months before they discover if they are on the primary or reserve list in March 2014.

So as the first cohort of nervous final year students prepare to sit their life-determining SJT examination this December, fears surrounding the uncertainty of securing a job remain in the air.

[NEWS]

theMEDICALSTUDENT / December 2013

News Editor: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

Medgroup Chairs Dheeraj Khiatani & Mark Gregory The run up to Christmas is fast approaching, and the prospect of the GKT Christmas show is sending the festive feeling at UH into overdrive.

There have been some interesting developments from Cardiff medical school this month relating to the age old BUCS dispute. This has been ongoing for over 2 years now and has had drastic implications for the autonomy of medical school sports teams this year. Any new developments are sure to be welcomed by London medical students so be sure to read Mitul Patel’s excellent article on the subject in this edition. Needless to say we at UH are monitoring the situation carefully.

Late November traditionally sees a flurry of activity among freshers as they face their first of approximately 987 exams at Medical school. Best of luck to everyone taking these and remember; the first one is always the hardest.

Best of luck also to all the finalists taking the SJT exam next week. Remember to rub out those mistakes thoroughly, lest ye receive 0 marks and end up in Bognor Regis.

Enough with the exam chat, December is always positively overflowing with medic events. Put the work aside, throw on the new Christmas jumper and be merry; everything else can wait until January.

Mark and Dheeraj

RUMS President Swathi Rajagopal

ICSM President Steve Tran

The last month in RUMS has been a busy one, with many successful changes.

The opening of the Royal Free student hub was a roaring success and is a great place for students to hang out, work and socialise in with free tea and coffee to boot.

We welcomed our two newly elected education reps, Katherine and Owais who have already planned a Q&A session with the medical school staff (for 5th year students).

Moreover, RUMS students have become even closer as a community, close enough to strip off for the annual RUMS naked calendar in aid of ‘Sue Ryder’.

It doesn’t stop there - we’re bringing you plenty to look forward to before we part ways for the holidays, 999 the biggest pan-London event of the year (where RUMS will be out-doing the other universities on the dance floor), mums and dads part 3 to rekindle those family connections (with free pizza!) and of course, the annual, glamorous RUMS winter ball which will be held on the bank of the Thames at Opal bar - don’t miss out!

A big thank you to all the students who get involved and have made RUMS a success – without your enthusiasm and commitment, we wouldn’t be able to call ourselves the best medical school in London. That’s all for now!

GKT President Juliet Laycock Bloody hell, another month has gone by so quickly!

In the past couple of weeks Guy’s Campus has been buzzing. GKTers came in their hundreds for the MSA Bonfire Night; some to just fight with the piñata, others to find love beneath Southwark’s most romantic fireworks display.

And following the theme of love, RAG hosted their first ever speed dating event on 18th October – a great day for all the charities involved, not such a great day for the Guy’s Hospital GUM clinic...

Our biggest upcoming project is Wellness Week running 18th-22nd November; it is completely free and with activities ranging from self-defence classes to our smoothie social there’s something for everyone. It’s a great chance to kick back and give yourself a bit of TLC, check out the Facebook event for full details: https://www.facebook.com/ events/679012088789252.

On a side note: a huge thank you to ICSMSU for a brilliant MedSoc Conference. It was great to better understand how MedSocs across the country work and have a chance to get to know them (some a little too well!).

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Before I start next month’s update on ICSM, I would like to note for the record a certain Dheeraj, one of our esteemed Medgroup Chairs, was found enjoying himself at an Imperial bar last month during the annual MedSoc Committee conference. Sadly he was too chicken to challenge me to a pint off, but what else can you really expect from GKT? Opera Week dominates the first week of December with our own production of the Drowsy Chaperone.

We are also going to be running our first Mental Health awareness week spearheaded by our welfare officer and other student campaign volunteers.

Both ICSM RAG and ‘Right to Play’ are hosting their annual Christmas charity events such as the infamous ICSM Take Me Out night. According to the organisers, this year’s batch of contestants rival many Abercrombie models.

I recommend you to search ‘ICSM Flatline’ on youtube. #Flatline was ICSM’s final year dinner video and has had over 6600 hits in 6 days since it was uploaded.

Finally, I wish all final years sitting their SJT in December the very best of luck. And for those at GKT, don’t forget to buy the app for your exams this year!

BLSA President Ali Jawad Once more, it’s that time of year when the weather starts to turn, revision and exams seem to dominate the calendar, and we here at BL look forward to the holidays!

The past month has continued to be an exciting time. Along with a plethora of undefeated sports teams this seasons, the BL Tennis Club acquired the UH Mixed Doubles Cup, for the first time in its history, but definitely not the last!

The Medical Student-Staff Conference had an impressive turnout and highlighted the issues we’re facing here at BL. Two of the major issues emphasised were research opportunities and student support. So from now till the next conference, BLSA and the staff at the school will be working towards improvements in those and several of the other areas highlighted.

The next few weeks before the winter break will include freshers experiencing the highs and lows of their first exams, Christmas dinners, the Freshers Play, and everything else that makes this a great time to be at Barts and The London!

theMEDICALSTUDENT / November 2013

News Editors: Chris Smith and Krishna Dayaji news@themedicalstudent.co.uk

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David Nutt Winner of 2013 John Maddox Prize Sam Wong Guest Writer Professor David Nutt is the winner of the 2013 John Maddox Prize for Standing up for Science.

The international prize is awarded for courage in promoting science and evidence on a matter of public interest, despite facing difficulty and hostility in doing so.

The judges awarded the prize to Professor Nutt in recognition of the impact his actions have had in influencing evidence-based classification of drugs, in the UK and elsewhere in the world, and his continued courage and commitment to rational debate, despite opposition and public criticism.

Professor Nutt is the Edmond J. Safra Professor of Neuropsychopharmacology at Imperial College London. He was named chairman of the UK Government’s Advisory Council on the Misuse of Drugs (ACMD) in May 2008. His role was to make scientific recommendations to government ministers on classification of illegal drugs based on the harm they can cause.

In 2009 Professor Nutt was dismissed from his role at the ACMD by Home Secretary Alan Johnson after speaking out about the Government’s policies on drugs being at odds with the evidence. Concerns among the scientific commu-

nity following Professor Nutt’s dismissal led to the creation of the Principles for the Treatment of Independent Scientific Advice, which are now part of the Ministerial Code.

The Prize is a joint initiative of the science journal Nature, the Kohn Foundation, and the charity Sense About Science.

The late Sir John Maddox, FRS, was editor of Nature for 22 years and a founding trustee of Sense About Science.

This year is the second time the prize has been awarded.

In 2012, the winners were psychiatrist Professor Simon Wessely of King’s College London and science journalist Fang Shi-min.

Professor Nutt said: “Science is arguably the defining characteristic of humanity. It therefore is imperative that scientists play their full role in all aspects of human life. Being awarded this prize gives me the confidence to continue to do what’s right, and hopefully will inspire others to follow suit.”

The judging panel consisted of Tracey Brown, Director of Sense About Science; Philip Campbell, editor of Nature; Lord Rees of Ludlow OM FRS of the University of Cambridge and Professor Colin Blakemore of the Universities of London and Oxford.

Professor Colin Blakemore said: “The 2013 Prize recognises Professor Nutt’s exceptional strength of character and his personal commitment to the

open presentation of scientific evidence. In circumstances that would have humiliated and silenced most people, David Nutt continued to affirm the importance of evidence in understanding the harms of drugs and in developing drug policy.

He took personal risk to his reputation in the name of sound science and in defending the right of researchers to present scientific opinion publicly. Policy makers are, of course, not compelled to follow scientific

> [cont’n from Shape of Training article] ...in academic training pathways need a training structure that is flexible enough to allow them to move in and out of clinical training while meeting the competencies and standards of that training.

It also recommended that full registration should move to the point of graduation from medical school, provided there are measures in place to demonstrate graduates are fit to practise at the end of medical school. Patients’ interests must be considered first and foremost as part of this change.

Finally, it was mentioned that implementation of the recommendations must be carefully planned on a UK-wide basis and phased in. This transition period will allow the stability of the

overall system to be maintained while reforms are being made.

Subsequently, a UK-wide Delivery Group should be formed immediately to oversee the implementation of the recommendations.

However, different organisations involved UK medical education and training have expressed differing opinions with regards to some of these recommendations.

In support of the reports key messages is Health Education England (HEE). They added that they ‘there needs to be sufficient flexibility to meet ever-changing needs and for there to be a greater focus on the development of generalist capabilities, with scope for greater specialisation as required to meet the needs of the service and patients’. The organization also believes that the report’s findings complement HEE’s work

on the broader healthcare education agenda.’

On the converse, the Medical Schools Council (MSC) and the British Medical Association (BMA) have expressed some concern over certain recommendations.

Firstly, the MSC has argued that the review should include a separate section on the academic workforce, and that there should be a general research base for all postgraduate training programmes, as well as a specific need to protect and enhance the academic training pathway and the flexibility to accommodate the onerous requirements of clinical academic training alongside clinical training, and to support those who require periods of less than full time training.

On the other hand, the BMA’s main concern is a major overhaul of medical training without

advice, but they are accountable to the public and to their own advisers if they choose not to do so. We need people like David Nutt to assert the independence of scientific advice and to inform the public when government policy departs from that advice.”

Tracey Brown said: “John Maddox was a strong and brave communicator and in his years as a trustee of Sense About Science he urged us to be stronger and braver too. The a commitment to consult on the changes.

Despite supporting the concept of broader-based training including generic capabilities and greater flexibility for trainees, the BMA Junior Doctors Committee cochair Kitty Mohan has expressed concern over the rapid pace of implementation.

The association worries that the review could lead to the creation of a sub-consultant grade by moving highly specialised skills outside the scope of postgraduate medical training.

Dr. Mohan added: ‘We are very concerned by the recommendation to move the achievement of highly specialised skills outside the scope of postgraduate training, and fear it will lead to a de facto sub-consultant grade.’

The BMA is also concerned

nominations for the John Maddox Prize were humbling. They showed that his values are carried forward in the courage and responsibility that people are taking to communicate sound science and evidence in diverse situations around the world.

I am pleased that the prize is being awarded to David Nutt, who has put that responsibility at the centre of everything he does, from international policy meetings to debates in pubs and community clubs.” by the review’s suggestion that full GMC registration should be moved to the end of medical school, placing the duty on medical schools to demonstrate that graduates are ‘capable of working safely in a clinical role’.

Having expressed surprise at this recommendation, Mr Wilson, BMA Medical Students Committee co-chair added: ‘We are also concerned about the effect this change could have on workforce planning, with additional scope for applicants from many more EU member states to an already oversubscribed foundation programme.’

With uncertainty surrounding Foundation Programme posts again this year, we now also learnt that there will be an uncertainty surrounding the training we then undertake.

theMEDICALSTUDENT / November 2013

News Editors: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

The First Student-led Surgical Research Collaborative Chetan Katri Staff Writer This autumn has seen the formation of the Student Audit and Research in Surgery (STARSurgUK) group. The first studentled research collaborative, have been engaging medical students across London (and the country) to work together as part of one, united, clinical audit.

Research collaboratives formed in the West-Midlands.

Here, trainees realised the potential to lead and deliver largescale projects successfully in a limited time-scale before they rotated to different hospitals.

Similarly, students have aspired to undertake meaningful studies, but due to relative inexperience and frequent rotations, it is often difficult to undertake a meaningful study outside a formalized research degree.

Collaborative research comes with many advantages. The multicentre approach allows for collection of a large volume of data whilst reducing the burden on the individual student during their training. The success of such measures is exemplified by studies such as a ROSSINI trial.

Published in the British Medical Journal, the ROSSINI trial was the first RCT to be delivered by a trainee collaborative, causing a shift in the way future research within the United Kingdom

and beyond can be conducted.

Unlike most surgical trials, it consistently recruited ahead of schedule. This fantastic model facilitates PUBMED authorship.

The STARSurgUK group, led by four students across the country, with senior input from surgical registrars and an academic FY1, has presented students with the opportunity to partake in a unique project, answering an important clinical question.

In this first project, the safety profile of non-steroidal antiinflammatory drugs is being investigated after bowel resection.

A project that would take years to complete in a single site, it is asking for a mere two weeks of data collection from students, with the combined effort resulting in large numbers.

Across London, all five medical schools have engaged enthu-

siastically with the project, with 56 students collecting data for the project across 28 hospital sites. Across the country, the excitement for this project has lead to over 400 students coming together across every medical school in the country to collect data from 107 hospitals in the U.K. The project has allowed the paradigm of research to change, rather than students seeking projects to assist in, it has given students the opportunity to seek support for a project, which they are proposing.

The support for the project has been spread through many tiers, clinicians across the country, Deans of Medicine and more recently the Medical Schools Council have sent personal letters expressing their thanks.

To ensure understanding of the protocol and facilitate a dis-

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Research In Brief

IMPERIAL COLLEGE LONDON Researchers at Imperial College London have uncovered that men who are unemployed for more than two years shows signs of faster DNA-ageing, in particular increased shortening of telomeres, which in turn are linked to higher risks of various agerelated diseases and earlier death.

the months prior to conception as well as during pregnancy could potentially decrease the chance of complications such as pre-eclampsia or premature birth, according to a new study led by scientists at King’s College London. Researchers suggest that maintaining a healthy weight and blood pressure prior to conception, could boost women’s chances of an uncomplicated pregnancy.

UNIVERSITY COLLEGE LONDON Researchers from UCL Cancer Trial Centre and Cancer Research UK have developed a drug called Cedranib, which has been shown to delay tumour progression and improve the overall survival in women with ovarian cancer that has returned. Used in conjunction with the platinum-based chemotherepay, the therapy has been shown to extend life by another three months.

KING’S COLLEGE LONDON Leading a healthy lifestyle in

BARTS AND THE LONDON New research from Queen Mary University of London shows released prisoners with schizophrenia are three times more likely to be violent than other prisoners, but only if they receive no treatment or follow-up support from mental health services.

It was found that maintaining psychiatric treatment both during imprisonment and after release can substantially reduce the risk of violent reoffending. Better screening and treatment of prisoners is therefore essential to prevent violence.

cussion directly with the steering committee, an afternoon meeting was organised for all investigators at the Royal College of Surgeons. The meeting was well attended, with over 70 delegates attending from across the country. An open Q&A session allowed for any student to directly assess any concerns with the steering committee.

The model is being expanding in the coming year to include European medical schools. Registration for the project is open at bit.ly/ STARTnetwork.

‘Over 70 delegates attended the RCS for explanation of the STARSurgUK protocol and a Q&A session with the steering committee’

Can Beetroots be the cure to Hypertension?

Suburno Ghosh Guest Writer In England about ¼ of people have high blood pressure and if left untreated can cause cardiovascular and renal disease as well as increasing ones risk of a heart attack or stroke. In many circumstances the causes are unclear however lifestyle choices such as smoking, lack of exercise and not eating enough fruit and vegetables are just some of the many possible contributing factors. This in part is the focus of some of the research going on in the William Harvey Research

Institute where a mix of researchers and clinical doctors are working together to investigate the potential beneficial effects of eating a diet that is rich in fruits and vegetables.

Fruit and vegetables contain many nutrients, however recent research has led to the proposal that it is their inorganic nitrate content that underlies their beneficial effects.

Inorganic nitrate is particularly abundant in green leafy vegetables such as beetroot (Beta vulgaris). Studies have indicated that the protective effects of inorganic nitrate lie in its ability to ultimately be converted to the pleiotropic

signalling molecule nitric oxide (NO). This conversion is a 2 step process where initially nitrate is converted to nitrite by facultative bacteria that live in the crypts at the back of the tongue. Once swallowed nitrite can be converted to NO in the acidic environment of the stomach or can re-enter the circulation where conversion to NO is catalysed by numerous enzymes. In the systemic circulation NO facilitates a number of functions such as inhibiting platelet aggregation and mediating vasodilation. Indeed many cardiovascular related diseases such as atherosclerosis and hyperten-

sion are characterised by a reduction in bioavailable NO therefore replacement of this critical vascular regulator is of vital importance.

Previous work in our group has demonstrated that dietary nitrate supplementation in the form of beetroot juice caused dose dependent reductions in blood pressure in healthy volunteers. In those dose response studies, at a dose that caused a decrease of 1.7/4.6mmHg a drop of 11.2/9.6mmHg was observed with a slightly lower dose in stage 1 hypertensives.

What was particularly encouraging was the observation that blood pressure remained re-

duced even at 24 hours post nitrate intake and more significantly when the circulating levels of nitrite as well as nitrate had almost returned to baseline.

Although the work is still at an early stage the future prospects of where this research might lead is particularly exciting. Given that approximately half of treated hypertensive patients fail to reach their target blood pressure it is imperative that alternative means are found to aid treatment. A dietary strategy could provide a simpler, cost-effective and more favourable option for the public.

[FEATURES]

theMEDICALSTUDENT/December2013

Features Editor: James Wong features@themedicalstudent.co.uk

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A belated hello James Wong Features Editor Punctuality evidently isn’t my strong suit. Festive preparations for the forthcoming holiday however, seem to arrive earlier every year. But before I can make my excuses, I must first thank my predecessor, Alex Isted, who has so boldly entrusted the reins of this section to my less steady hands.

As the new standard bearer for features, I will do my best to keep the banner flying high.

A well done to you too, the end of the first term has or will soon come to its end. For the newcomers among us, it will be their first Christmas as fledgling medical students.

Cherish this special time. It is with etiolated nostalgia your more senior colleagues, accustomed to the usual salvo of

dinner table questions, recollect their holiday celebration.

“So what specialty will you go into?”, “Could you just take a look at this rash?” - the novelty is fleeting. However over the years, during the brief reprieve while passing the sprouts from one distant relative to the next, thoughts about the direction of your career path become all too earnest.

At this tender age, before our professional careers have even taken flight, the coordinates of our planned trajectory must be keyed in. As I was once told about the foundation programme, it’s not the first job you’re applying for, but the one after that. Preparations, in all their forms, can never be in place soon enough.

For many the first stepping stone towards discovering your calling or attaining that

elusive publication is their choice of intercalated Bachelor of Science (iBSc) degree. The new rolling column of iBSc reviews, which started in last month’s issue, is to give prospective students a flavour. As I recall, deciding my iBSc was a lengthy process, I hope this new series will be of aid.

Obviously it’s not all about nourishing your CV here on features. Unique to this section is the huge breadth of subject matter - anything of interest to your fellow medical student comes under our umbrella. If over the course of this term and Christmas break an idea pops-up: an aspect of student life untouched by the pages of the Student BMJ, an area of medicine you want to wax lyrical about - why not take up your drying pen and share your insight.

The BNF - which source is best?

Devon Buchanan Guest Writer Doctors and medical students definitely need the British National Formulary (BNF).

As the cover of the print edition puts it, it’s “the authority on the selection and use of medicine”. But the BNF isn’t only available as this book -it’s available online and since 2012 it has been available for download as a smartphone app.

So, which of these sources of the BNF is the best?

What is “best” depends on what you want from the BNF. I think the BNF is usually used as a rapid reference, and consequently it should 1) be available when you need it and 2) take you to relevant information as quickly as possible.

So even though I, as a third year medical student, typically look at different parts of the BNF from F1

doctors, both of us probably care most about having it and navigating it quickly.

I looked at three sources of the BNF: the printed book, the MedicinesComplete website and the NICE BNF smartphone app. These are not the only sources of the BNF, but they’re accessible to medical students for free. Other sources include the BNF.org website (which is for use by the public only and prohibits healthcare professionals), the NICE evidence website, an eBook in the Apple iBookstore (which costs £39.99) and smartphone apps made by MedHand (which costs £28.99).

Printed editions of the BNF can be found in doctors’ offices and consulting rooms across the country.

Finding one isn’t always straightforward

however. They can be absent, misplaced, hidden under back issues of The Medical Student or carried elsewhere by staff in defiance of the warning scrawled across most of their covers: “property of <location>, do no remove”. Even though you can go to a page of information on a drug via the index in under a minute, it can take you rather longer to locate the book.

The MedicinesComplete website is better than the printed BNF with respect to accessibility and speed. Computers with web browsers are easy to find in most hospitals, and there’s often one not in use.

The website has a well thought out search facility, with search term suggestions, correction of common

misspellings (e.g. “imatenib”) and results pages that displays sections titles that help you distinguish between different entries (e.g. codeine has separate entries for its antimotility and analgesic action).

The NICE BNF smartphone app is available for iOS and Android devices - I looked at version 3.1. The app has some advantages over the website.

It works without an Internet connection and it’s on a device that can always be at hand. But the app is much slower to use. I timed my use of both the app and the website, and it took me an average of 22s and 8s respectively to get to a drug’s entry by searching. The app is slower because it

spends around 5s loading on my iPhone 3GS and its takes 5-10s to return results. That is a long time to search the BNF, a relatively small document, and I suspect the application is not not using common techniques to speed up searching.

The app feels even slower as a result of the monthly updates which take around 15 minutes to download, during which you can’t use the app or do anything else with your phone without interrupting the download.

Overall, I feel the MedicinesComplete website is the best way to get the BNF. The speed and helpfulness of its search makes it more useful than the mobile, but slow smartphone app.

[FEATURES] /8

theMEDICALSTUDENT/December2013

Features Editor: James Wong features@themedicalstudent.co.uk

iBSc Review: Global Public Health and Primary Care Sarah Khan Guest Writer I studied global public health and primary care for my intercalated degree at Barts. I have always been drawn towards the sociological aspects of public health as well as issues surrounding medical ethics, and have wanted to learn more about how healthcare is delivered and experienced in other countries, especially those that are less economically developed.

We had a thoroughly inspirational introduction to the topic of global health during fourth year through a series of lectures and discussions about key issues as far-ranging as the global epidemic of HIV, the restructuring of our National Health Service and its consequences for patients, and learning about Non-Governmental Organisations (NGOs) such as ‘Medecins Sans Frontières’. Excited by these topics and keen to learn more, when I heard the subject was being offered as an intercalated degree I applied for it immediately.

We were taught by a range of academics at the Centre for Primary Care and Public Health, and we were fortunate to be able to work with some truly inspirational public health researchers, who were all committed to the core issues of reducing health inequalities and the provision of universal healthcare.

There were a number of modules offered on the course, some of which were mandatory and took place in the first term, such as health inequalities and social determinants of health, epidemiology and statistics, health illness and society, health systems, economics and policy. In the autumn term we chose from primary healthcare, theory and practice; globalisation and health care reform; migration, culture and health; contemporary medical ethics; and public health, law and governance.

I initially welcomed the change in pace on the intercalated degree compared to the medical course- with only a few hours of lectures or seminars a day, it was beginning to look easy! However as we got further into the course the amount of time available to us outside of the timetable rapidly diminished. We were encouraged to read very widely and were guided throughout with interesting articles suggested for reading prior to seminars, and we soon became en-

grossed in our work.

Students intercalating are taught alongside international health students who can attend fulltime over the course of a year or part-time over two years.

It was strange at first being taught in the same classes as MSc students, whose vast experience often made us humble BSc-ers feel out of our depth (students on the course ranged from unassuming intercalaters to GPs with years of experience, and some were completing their MSc as part of their work placements), but we quickly realised we all had

something to offer!

I loved the mix of students on the degree, who were from a range of disciplines, countries and backgrounds, all of whom offered a wealth of experience to the group and also provided a fascinating glimpse into healthcare systems around the world. It was so interesting to be able to learn from students who had experienced these directly and who were looking

for ways in which they could make a real difference, which was very inspiring.

We developed our public health research skills during the course as well as learning about critical appraisal of research, and with essays and assignments due in regularly, we were able to refine our writing skills also, which was definitely needed (having had very few written assignments in medical school).

Seminars often directly followed lectures for each of our modules which helped us enormously as they provided a forum in which we could discuss as a group any interesting areas or could bring forward any questions we had. The format was similar to the “problem-based learning (PBL)” format in medical school, but with greater guidance from our tutors.

The research projects on offer were very interesting and

var- ied tremendously (one research project option was about the Bill & Melinda Gates Foundation, for example), however students can self-organise if they are keen and can demonstrate that they have planned their projects well in advance.

For my BSc project I conducted a literature review on COPD and patients’ perspectives of their symptom management, which linked well with an audit I had conducted during my respiratory placement in my third year into asthma. It is astonishing how little patients

are actually listened to by medical professionals, despite the great social and financial gains that can be made from paying attention to their concerns, and I enjoyed exploring this topic further.

There are many opportunities for developing your ideas, research and publication during the BSc year so the more effort you put into your work, the further you can grow- it really is up to you. BSc students have to demonstrate how they have planned their projects very early in the year, as being a very short year there is a lot of work to cover alongside the project, and the presentation of our project outline formed part of our assessment, with viva-style questions from tutors which, although initially nerve-wracking, was a valuable experience.

The course was very cutting-edge, and it was unsettling during lectures on health policy studying countries that are struggling to provide universal healthcare, whilst learning about the present state of the NHS in England, currently undergoing the biggest reorganisation since its inception, with potentially negative consequences for patient care.

I especially enjoyed ‘migration, culture and health’ as it had lots of relevance to patients living in the East End of London, where we are based, and I was able to learn more about health issues surrounding migration and how they affect patients from different backgrounds.

‘Health, illness and society’ focused on looking at healthcare from a sociological viewpoint, which was very refreshing as there was more focus on patient perspectives. I was also very interested in studying the work of NGOs and how we can improve healthcare in LEDCs. The course was very wellstructured and was a fascinating exploration of global public health issues with plenty of research opportunities. If you’re passionate about global health, I would wholeheartedly recommend that you seriously consider intercalating!

[FEATURES] /9 Grand Round: Dos and Don’ts theMEDICALSTUDENT/December2013

Features Editor: James Wong features@themedicalstudent.co.uk

James Wong Features Editor “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”

The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black & white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuition-centred flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch.

I gest, they serve a social as well as an educational function.

On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpreted as a vanishingly rare condition, which even your adjudicating consultant has never encountered in a lifetime of experience. It falls short of the primary

aim: to learn about the patients who you will be seeing as a junior doctor and as the adage goes - common things are common.

What will make your grand round interesting is not the patient you choose but how you choose to present that patient.

solid introductory line about the patient with all the salient points goes out saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so.

red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/ family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the

Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about.

Structure. This is the back bone of your presentation. Obviously a

It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset.

The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important

consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first.

Performance. Never read your slides in front of an audience.

Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present

uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store.

Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.

The same may be said of imaging.

Perusing the radiologists report and using it to guide the audience through (anonymised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments.

Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints.

Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renowned for. Oratory is a universal skill and is responsible for so much (undue) anxiety.

The more timid can take comfort; Grand Rounds aren’t quite the grand occasions they used to be.

Write for Us! The Medical Student is always looking for keen writers to get involved with the paper, if you have an idea for an article, big or small, don’t hesitate to contact us: editor@themedicalstudent.co.uk

[COMMENT] /10 I Can’t Bear the Christmas Adverts theMEDICALSTUDENT /December 2013

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Rob Cleaver Comment Editor This time of year is a time of cheer, of merriment, of love and joy and photocopying your nether regions at the office party. This is the commercial, winter wonderland that is Christmas in the twenty first century. Gone are the days of religious contemplation and quietly observed traditions and in come the giant candy canes, the German pilsner, the battle for the number one single, the console wars and the bludgeoning, bludgeoning, saga of advertising.

I went into a John Lewis store once before, it was around this time of year actually, to try to find something overpriced but lovingly wrapped as a present for a family member. I’d bought my dad a bottle of whiskey from the off-license but sometimes gifts require more deliberation than that of alcoholic strength.

It is this shop that seems to have become the go-to expert in the field of Christmas advertising. This year we have the extravaganza that is The Bear and the Hare, lovingly hashtagged, to bring to the fore their brand name, a liberal dribbling of a shrill cover of a Keane song by Keith Allen’s daughter and the improbable friendship between a lethal carnivorous tyrant and Lepus Europaeus.

[The turkeys. They don’t often see Christmas really do they?

They’re there but they’re not really enjoying it, a bit like Grandad asleep in his party hat in the corner.]

The saga opens with the words, “there once was an animal who had never seen Christmas”. Initially I was not struck by the potential allusion to hibernation but thought more arduously about the amount of mulled wine that someone would have to drink on the annual Christmas Eve bender to actually miss the 25th entirely, skipping the dry meat and the dry conversation for the wholly more scintillating serving of turkey sandwiches on Boxing Day in a room of silent hango-

vers in front of Chicken Run for the third time in a week.

It then also struck me that perhaps the bear is an allegorical grumpy father, waiting for his whiskey, being unappreciative of the 5am wake up call by his child, whom he may have bought a lump of coal as a badger seems to do for a fox cub at one point, before begrudgingly spilling himself downstairs into a corner of a sofa for the Generation Game conveyor belt of gift opening.

My next thought, after understanding the concept that the advert was going for, was that our ancestors had not been as successful as they had thought on their hunting trips in the country’s forests. There’s still a bear out there, fraternising with our badgers and our foxes! We haven’t quite exterminated them all with our longbows! Heavens above. Christ almighty. Attenborough has really missed a trick with that

one.

One notable problem with the advert however was pointed out to me by a friend - what does the bear do after he is rudely awoken from his slumber? He has no food. He has got a few months to kill and, quite possibly, a large collection of friends to kill in order to survive. Hare didn’t understand that Bear slept for so long to get control of his cravings.

Hare disrupted a highly complex treatment plan, as created

by Bear’s doctor, that may just result in undue bloodshed.

There is one other issue that has arisen. The Bear is not the only animal not to see Christmas. This isn’t me being a pedant over multiple species going into hibernation but one that I’ve mentioned already - the turkeys. They don’t often see Christmas really do they?

They’re there but they’re not really enjoying it, a bit like Grandad asleep in his party hat in

the corner. Bear isn’t going to be subjected to Bernard Matthews’ evil designs. He is going to be there at Hare’s big time to shine as the Easter Bunny, he’ll be there for the following Halloween even, but turkey, he’s going to be hard pushed to make any commitments for 2014.

[It means that in the haze of tinsel and wrapping paper, the togetherness is lost, the same togetherness that the adverts probably wanted to, at least to some extent, get across in the first place.]

Why do we pander so easily to emotional guilt tripping in this way? To, excuse the pun, cave in to an advert without the overt mention of a specific product to go above and beyond our means to ensure “the perfect Christmas”. We even moan that the weather isn’t bad enough.

It means that in the haze of tinsel and wrapping paper, the togetherness is lost, the same togetherness that the adverts probably wanted to, at least to some extent, get across with their £7 million investment.

What I would say is that no child is going to beg its parent to get them a gift exclusively from John Lewis - children do not want a twenty four piece, bone china tea service - but they will want a bear or a hare or any of the inevitable tie-in products. However, when that other Christmas advert comes on, you know the one, chugging along with its vocal riff and eighteen wheelers, all of those children get thirsty for a more traditional, commercialised celebration and as soon as Santa booms that trademark laugh there are countless chanting kids tugging on their parents’ arm, “holidays are coming, holidays are coming, holidays are coming...”

[COMMENT] /11 Capital Caught in a Vicious Cycle theMEDICALSTUDENT /December 2013

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Alex Howells Guest Writer Six cyclists have been killed in road accidents in London over the past fortnight, the most recent of which occurred down the road from where I live, on a junction I’ve travelled through many times. My heart goes out to the families of those who have been killed.

I’m a Londoner and I’m a cyclist. For anyone of either population these statistics are scary but for me they are doubly so.

The number of people telling me to be careful when I head out on my bike in recent weeks shows how concerned other people, the non-cyclists, are about this situation. However, it annoys me how so many people have jumped on the “blame Boris” bandwagon. I agree that thorough, large-scale improvements to London’s cycling infrastructure need to be made but I’ve seen so many irresponsible cyclists recently and I feel that this point has been overlooked.

Cyclists have a responsibility to obey the law whilst on the road. The number of times recently that I’ve seen cyclists go through red lights, cycle at night with no lights/reflectors, pull into a road without looking is frankly ridiculous. Some cyclists get cocky. They think they’re invincible as if they’re the size of an HGV. They’re not.

They’re vulnerable. It is these few irresponsible cyclists that give the rest of us a bad name.

The only thing that stands between me and my funeral is a

Illustrated by Alexis Nelson

helmet, a small metal frame and some wheels. Roads are dangerous places, and people need to realise how vulnerable they are while cycling amongst fast moving cars, buses and HGVs. You can’t afford to take risks.

People just need to act sensibly and cautiously.

[The only thing that stands between me and my funeral is a helmet, a small metal frame and some wheels. Roads are dangerous places.]

This being said, drivers play a huge part in making roads dangerous places. Some drivers find cyclists naturally infuriating and act irresponsibly around them because it gives them a kick. Some aren’t aware that London is teeming with bikes and find it difficult to cope with having to constantly overtake cyclists. If you don’t like cyclists, don’t come to this city.

Simple. Then there are the HGV drivers who like to turn left.

Sometimes a cyclist manages to get into their blind spot just as they turn and we all know how that unfortunate tale is going to end. A solution to this may be to limit the number of HGVs, fit them with additional cameras and sensors which allow for better all-round vision or simply provide higher levels of education for the drivers about the presence of cyclists on London’s roads.

Due to the dangers posed by traffic in this city, better infrastructure needs to be put in place too, in order to keep cyclists safe. Segregated ‘Dutch-

style’ cycle lanes, routes that avoid main roads, cycle paths on bridges and tunnels that avoid major intersections are just some of the ideas that could help but even with the finest cycling infrastructure in the world, deaths can and will still occur. There needs to be a balance between proper cycling

infrastructure, cyclists acting sensibly and not taking silly risks and drivers being more cautious while travelling about London.

I’m not one to speak up publicly about my views but the recent rise in cyclists’ deaths is quite harrowing and too close to home. This is not going to

put me off, as with all risks considered, cycling in this city is amazing. It is free and healthy and most importantly quick. I just hope that it is not getting more dangerous. To all you other cyclists in London, keep safe, keep sensible and keep your fingers crossed for a safer, more cycle friendly future.

Thinking of your New Year’s Resolution already? How about taking up writing for us? Send your ideas and articles to comment.medicalstudent@gmail.com

[COMMENT] /12

theMEDICALSTUDENT /December 2013

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

History States that Privatisation Fails Oscar To Guest Writer After the Second World War, the UK was in ruins. We’d lost our empire, our people lost in blood and iron, and our money owed to the USA. Wisely, we ousted the jingoistic Churchill from office and Attlee fought tooth and nail against the BMA, bringing healthcare to all Britons regardless of their background. Our wartime spirit had brought us together and we could look toward a brighter future. Thatcher strived to bring our old laissez-faire Victorian values back, slowly culminating in the successive re-privatisation of all of our public services. It would take many successive governments but politicians have slowly sold everything that the state once owned back into the private sector. The latest victim being our post office and soon the NHS, our crown jewel, could be heading under the hammer.

The current government views our health service as a lumbering behemoth on life support from the taxpayer. By their good will, to ensure that we Britons get the best care possible, they have applied their beloved ideology to the NHS by opening it up for Darwinian selection in a free market. In their generosity, the coalition has jumpstarted the process by cutting 10% of the NHS budget year on year to help speed up efficiency reforms. Unfortunately, it appears that cutting 10% of services has become the outcome rather than increased efficiency. There is also doubt for the functioning of corrective market mechanisms by letting trusts die and allowing more efficient, “fitter” trusts to survive; banking style bailouts at taxpayer expense are the far more likely outcome.

Moreover, improving efficiency usually requires infrastructure investment. Any person who has ever been on a ward round will know how it is near impossible to get a set of patient notes from another hospital, even if it is within the same trust. Fragmenting services with separate private

providers is likely to make the problem worse. Attempts to improve technology ultimately failed at huge taxpayer expense currently amounting to approximately £10billion with the amount still rising due to poor government attempts to contract overhauls to private firms on their terms. The Private Finance Initiative is an additional example of private firms abusing the public system for personal gain. Poor government negotiations appear to form a great ecological niche for firms to settle in and suck money, like a cannula in reverse, straight from patients’ hands. Opening the whole system to the free market with little protection will form a mighty new environment for businesses to prey on.

Dear Doctor..

D

ear doctor, With Christmas on the horizon, I have been unfortunately involved in a secret Santa group. I hated these things at school and I still hate them now but I’m still trying to pretend to myself that I like my flatmates.

The problem I have is this: the person I have to buy a present for is a strange boy who never seems to leave his room, never washes and never speaks.

[Healthcare should be I don’t even know his name. about treating individu- I therefore have no idea what als, not milking them like to buy him. What would you proverbial cash cows.] get the invisible man? Is there anything that’ll save me from Previous efficiency initia- looking thoughtless come the tives via a target culture have big reveal? proved just how much ‘better’ the NHS can do if forced to play by another’s rules. Similar processes at BP have acted as a shining example: by hitting shareholder targets and becoming a profitable business, BP cut all their safety spending and came close to destroying the delicate eco-system in the Gulf of Mexico. Setting targets to generate money will probably have a similar impact on the NHS, driving up profit margins at the expense of healthcare. One simply needs to look at how, a decade ago, Italy made the same reforms for an insight into how effective these measures were. Healthcare costs as a whole went up for no discernible change in quality. The Government’s evidence-based approach for NHS reforms is going to work wonders for shareholders but not for patients.

Healthcare should be about treating individuals, not milking them like proverbial cash cows. Privatisation will convert our NHS into a more efficient money making machine but is that what we really want? I guess if you own shares in the NHS, the answer is yes.

Y

Unlucky Lady

ou are going to die.

Of shock. For there is indeed something that such a human mistake will love you for eternally if you were to buy it for him. It’ll take a long time to retrieve but what you lose in time and energy you’ll profit in monetary terms - it is free of charge. First you must hike across the Great Plains of Golders Green and then onwards through the Mines of Morden and there atop a golden tree you will find the divine conjuration that you are looking for - a personality. He’ll finally leave his man cave, turn off his PlayStation and have a conversation. He’ll never have had one before so take things slow, talk about the weather or something. The only problem you will encounter along the way is a trivial one. Just how the hell do you wrap a personality?

Dr. Indiana Jones

D

ear doctor, I am incredibly poor at the moment having spent my last £400 on the hiring of a banter bus for The Lads tour to Oxford last weekend. When I went to the cash point last night in order to buy a round of shots for The Lads, I realised that I’d finally reached the pit of despair, my overdraft ran out.

I scrambled some money together from Wonga and managed to get the shots in so I’m still well liked by the Lads, that’s not my problem but how am I going to pay rent this month as well as pay Wonga back? I don’t want to be homeless, The Lads won’t rate me for that!

L

Lads on Tour

ad, you’re doomed.

I fear that you’ll soon be disembarking the banter bus any moment now, choosing instead the more restricted lifestyle choice of the poverty pony.

Of course that seems impractical too because you’d have to buy the pony. With money.

Money that you do not have.

You are now the Walking Waster forever more.

How will you survive this month, you ask? You could sell your body but I imagine The Lads won’t rate you for that. They prefer ladies to do that because they have skewed and antiquated gender roles. That isn’t their fault but your monetary woe is yours. You’re doomed to be indebted to Wonga for life, borrowing more and more money at 5,000,000% APR until you’re hunted down by the three old biddies that seem to run the show, brutally kneecapped by the bald one and then forced at gun point by the old women to sell your

Got a problem?

body just like you rejected all those months ago.

D

Dr. Amigo Loans

ear doctor, I hope that this email finds you well. I am a fresher at Imperial and I was wondering if you’d be able to see my grandmother at short notice because I believe her diabetes may be getting worse. I’m sorry if this isn’t the right email, I obtained it from a friend who recommended you as someone to turn to when times get tough.

She’s had her condition for ten years or so now and I don’t think it can be maintained by her diet alone any more, she’s getting terrible fluctuations in her blood sugar and I am worried that she’s going to get very sick very soon. I don’t know anything about medicine yet so can’t recommend anything. Would you please see her for me?

Nicola Bevan-Smith

H

ello Nicola, This isn’t the right person to email. In the world of correct emails this is in the same ball park as sending a hilarious email, probably with an expletive as the subject, to your friends about someone you saw on firms that you accidentally sent to your personal tutor and your supervising consultant. It happens.

I suggest talking to NHS Direct to address your grandmother’s diabetes and your own naivety. In any case, this seems like a problem that a lowly GP can deal with. Don’t disgrace me with your own ineptitude. Gah. Mr. Big Shot Consultant-Surgeon

[EDUCATION]

theMEDICALSTUDENT /December 2013

Education Editor: Sarah Freeston education@themedicalstudent.co.uk

/13

Regenerative medicine generation: ready for 2020 medicine?

Sarah Freeston Education Editor As medical advances occur daily and medical school curricula rarely change from year to year, are students missing out on teaching about state-of-theart techniques and tomorrow’s potential treatments? Are we sufficiently well informed about where 3D printing is heading and its potential in revolutionising the way we treat transplant patients? Is stem cell technology a practice confined to the lab or will it be more of a clinical reality by the time we qualify? Radiology will likely play a more significant role in diagnosis, all surgery may be carried out robotically and stem cell technologies could allow paralysed patients to walk again. So how much do we need to know? To whet our appetites during a dreary DNA replication lecture and to remember why we’re actually at medical school (to save lives, obviously), argu-

ably quite a lot or at least enough to allow us to look forward to and embrace the future rather then fear it. We are told about developments and changes in practise in terms of medication and research, but nothing in too much detail. In the early years, you hear a lot of “by the time you qualify this may well be wrong” or “don’t learn the details because there will likely be a new method in the near future” or, even more frustratingly, “this technique hasn’t been used for years but you still need to learn how it works.”

Professor Stuart Carney, Dean of Medical Education at King’s College London School tells The Medical Student that “Students will see cutting edge developments as well as established practice. Translational research is one of King’s Health Partners major strengths, and both within the core MBBS programme, and within the very wide range of SSC modules for which the School was complimented by the GMC in a recent review, stu-

dents have access to innovative practice.” In clinical years UCL also offers plenty of radiology teaching and provides opportunities to watch interventional radiology. On surgical attachments there are opportunities to watch keyhole surgery and UCL Surgical Society run events where students can practice those techniques. Students in all years can also observe surgeries in their speciality of choice. Anatomy is now taught as anatomy and imaging and early years modules are being reorganised to focus on “sexy new stuff” such as personalised medicine and genomics.

The urology team are also keen to show students robotic surgery – nothing in much detail though.

Although this may be more registrar level teaching, I can’t help but feel this should filter down more to undergraduates, to enliven, excite and inspire the next generation of clinicians if nothing else.

Or, on the other hand, do we have enough information to get our heads around with

Image source: http://scienceroll.com

Image source: www.majawi.net

medicine’s trusted and dependable basics rather than worrying about what may or may not be? A final year UCL student certainly thinks so: “While some areas of medicine are changing, the fundamentals such as history taking and examination must not be forgotten as they have been tried and tested over many years and are cheaper and less invasive and can sometimes give us as much information, if not more, than technology can.”

Medicine is changing and the curriculum needs to reflect this.

However, there is no denying the challenges associated with this: challenges that Deborah Gill, the undergraduate lead of UCL Medical School must know only too well. “Who knows what will be the gold standard of the future?” asks Gill in correspondence with The Medical Student. “I liken this to the development of technology: how many people bought Betamax video recorders instead of VHS? Who knew Blu-ray would crash and burn? Who knew we would all be using smartphones and not a myriad of other things?

We can only guess. I think we have a healthy mix at UCL – we expose to superspecialist, state-ofthe-art science in cancer, cardiology and other disciplines but we reinforce the social determinants of health, the importance of mental health, the needs of an ageing population and that the patient-doctor relationship is the key to making things better.”

UCL’s vision for the revamped curriculum (rolled out in 2012) was to nurture 21st century doctors able to thrive in modern healthcare environments and provide a course that reflects the needs of tomorrow’s patients.

This involves e-learning, e-portfolio and mobile technologies, focusing attention on how patients experience illness, providing early patient contact and encour-

aging ‘patient centred, evidence based, cost effective, and safe practice built on a firm foundation of the sciences as they are applied to medicine.’ In essence: learning for a life of learning. Gill describes the 2012 changes to the curriculum: “[There were] lots and lots of drivers for change including: new recommendations in Tomorrow’s Doctors 2009; the very rapidly changing and somewhat unpredictable changes to the health services provider landscape in London which made ‘the old way’ no longer possible; changes in technology-enhanced learning that made new delivery methods possible; the ever developing body of clinical education research; and, most importantly, a change in the way patients access and move through health systems.”

No student I spoke to felt particularly let down by the lack of opportunities to engage with state-of-the-art techniques and methods – perhaps the current tried and tested gold standards are enough to deal with! So my message to first and second years would be this: plough on through the biochemistry, anatomy and epidemiology. They are part of a broader and well thought through plan for our learning and all subjects have a place in what needs to be a complex web of information. “We need to educate doctors who are able to thrive in new settings, some of which have not even been designed yet, in undefined roles and who are able to investigate and treat diseases in ways we don’t yet know about and use technology that is yet to be invented. A tall order I am sure you will agree!” shares Gill. Fear not freshers, the sexy new technologies will come later and we need to know our pericardium from our peritoneal cavity so we’re ready when they do.

theMEDICALSTUDENT / December 2013

Education Editor: Sarah Freeston education@themedicalstudent.co.uk

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What’s the issue with problem-based learning?

Sarah Freeston Education Editor

The world of medical education is vast and you don’t need to trawl through Google for long before finding a multitude of studies aiming to reveal the secrets behind the ‘most successful’ medical teaching.

Firstly, let’s consider the GMC guidance on medical curricula.

Although seemingly broad and flexible advice (‘It is for each medical school to design its own curriculum to suit its own circumstances, consistent with Tomorrow’s Doctors) students ‘must have different teaching and learning opportunities that should balance teaching in large groups with small groups. They must have practical classes and opportunities for self-directed learning.’

But what do medical students want? Value for money? Efficient and easy acquisition of knowledge? Ability to cram in facts?

More long-term learning skills?

There has been a trend towards problem-based learning (PBL) for teaching medicine and there are many big supporters. PBL involves students working together in a small group to research, understand and explain the pathogenesis, diagnosis, management, treatment and prevention of certain disorders. This is meant to mimic life as a qualified doctor: independently keeping up to date with continuing professional development and being able to think on your feet when seeing patients. The development of an independent attitude to learning is the hope with PBL – making decisions on what and how to research a topic should translate into a logical, pragmatic and independently minded practising

clinician. Indeed, a systematic review found that PBL students were more concerned with understanding than memorising, more readily used journals as sources of information and demonstrated better interpersonal skills with patients. Although not achieving grades as high as their conventional counterparts in basic science exams, they scored more highly in clinical exams (Nandi et al., 2000). In numerous studies students have been found to favour a PBL approach to learning the intricacies of medicine. However, others are put off by missing out on lectures presented by experts and instead receiving guidance by a sometimes less qualified mentor. Small group sessions run by experts would probably be the teaching style of choice by many. Indeed, some see lectures as ‘school-like’ and small group work as fully embracing the move to university, a way of learning only ‘mature’ learners are capable of. At the end of the day, as long as students are fully equipped to tackle clinical scenarios with a strong foundation in the basic sciences, does the way this knowledge is put forward and integrated really matter?

Barts use PBL scenarios that are designed to foster a collaborative learning community.

A programme of lectures and other group work also facilitate learning. Imperial utilise lectures, clinical demonstrations, tutorials, computer workshops, laboratory practical and clinical skills classes, and some problembased learning. “I think Imperial should have more PBL than it does now because it encourages independent learning and knowledge sticks better when you’ve had to research it yourself instead of being spoon fed,” expressed a final year Imperial stu-

dent. “But having said that you need to do loads of independent study when you get to clinical years anyway so maybe it’s nice to have information on a plate for the first couple of years!”

The course at King’s is integrated, so from term 2 in first year through to the end of second year students are presented with a case and everything surrounding it, for example patients who have a myocardial infarction, asthma, diabetes or scotoma. You learn about the mechanisms of the condition, the causes and the treatment and it’s good at joining all the physiology, biology, chemistry, psychology, sociology, epidemiology and statistics together. “I like this approach as you deal with a lot of common conditions,” explained a third year King’s medical student.

“However, I’m hoping in the following years it may become more obvious that comorbidities exist and how you’d treat them, as patients won’t always have the same presentations or disease progression, and therefore real life treatment will be different.”

Although there is more complexity to learn, this early grounding in clinical scenarios may be the envy of some first year UCL students struggling through amino acids lectures, feeling detached from the clinic and real patients.

“King’s College London School of Medicine is about to embark on a curriculum review to anticipate changes to the continuum of medical education recommended by the Shape of Training Review,” explains Professor Stuart Carney, Dean of Medical Education who is “well placed to align the undergraduate curriculum with the changing needs of the NHS and patients.”

“We use a range of teaching styles with emphasis on students consolidating their learning in Phase 5 as they prepare to be safe and effective patient-centred foundation doctors.” King’s “students also benefit from the Inter-professional Education programme, which offers learning with other King’s health professions students, to prepare them for working in a healthcare team,” explains Carney. St George’s students witness the importance of interdisciplinary teamwork from day one as the first semester of teaching is called the Inter-professional Foundation Programme, where lectures and tutorials are held with students from all degrees. “This was useful to meet people who you could

possibly be working with in the future,” explained a current student. St George’s seems to agree with UCL’s matra to ‘mix small and large group work, workbased learning and the use of the virtual learning environment’ and takes it one step further. The rest of the course is quite hands on, as after learning about each organ system students are taught the relevant clinical examination, for example cranial nerves exam after the neuroscience module.

The communication skills teaching seems very similar to vertical modules at UCL – sessions on how to conduct interviews, different types of history to take, understanding empathy, confidentiality and note-taking. “At St George’s we did role plays with each other and with actors – I loved doing this! Role plays were definitely a good way to practice. You get good feedback and it was helpful practise for on the wards,” expresses one student.

In an attempt to offer students the ‘best possible student experience’, UCL have also integrated basic and clinical sciences and teach in systems, not subjects, in line with the other medical schools. Their aim is to teach ‘the right things, at the right time, in the right way, in the right place.’

I’m not sure all students would be satisfied with their timetabling, 9am starts or treks to the Whittington, but it is certainly a worthy aim. “We are no longer a traditional course – but do not exclusively use PBL either,” explains Dr. Deborah Gill, undergraduate lead at UCL Medical School. “We are an integrated course. This is complex but we are dealing with complex learning and systems. I have no problem with PBL but it works best when the programme is new and requires extensive faculty development.” The new curriculum rolled out in 2012 includes fewer lectures that are spread out more across the years, small group work for exploratory issues, technology-assisted learning (computer packages, Case of the Month on the virtual learning environment, @QUCLMS on Twitter and the authentic NES NHS e-portfolio and skills, procedures and simulations sessions for some complex skills and practical procedures).

UCL believes their course “provides skills to capture achievement and plan ongoing learning based on emerging needs; teaches core skills but extends these to information handling and

governance; teaches information searching and assessing information; as well as teamwork, leadership and communication.” These may not always be popular aims with students (and some older faculty) who would prefer to just be taught the information necessary to pass exams. But medical schools need to see the bigger picture – the career rather than the certificate.

It seems all London medical schools are employing these integrated teaching methods with varying levels of self directed learning; they certainly seem to be getting the balance right between traditional teaching methods and practical sessions, as highlighted by the GMC. It makes sense that such a rounded curriculum is likely to foster a well rounded clinician capable of showing empathy, employing teamwork and demonstrating clinical expertise in a range of scenarios.

So what style of teaching do students prefer? Of course it depends on how you like to learn – I’m personally not adverse to lectures but also admit that putting in that little bit more effort during group work can actually be enjoyable and rewarding too!

With UCL ranking highest of the London medical schools in the Guardian 2014 league table with 94% student satisfaction, maybe PBL isn’t as popular as some studies would have you believe.

Although there are many factors at play in how satisfied we feel as students, for me at least the course would play a large part.

The further down the road you get towards clinical competency, the more the onus is on you to direct your own learning. Differences in teaching and learning become more evident within a university (in different hospitals/firms) than between universities. Students expect teaching to vary depending on where they are placed, “but selfstudy will kick in” reckons one optimistic third year! All in all, a feeling expressed by many is that medicine is stressful no matter where you go. It seems that strong pastoral support, clarity surrounding exams and transparency and praise from senior staff may be better regarded by students than precisely how the course is structured because let’s face it, we all qualify with the same degree and the most valuable learning experiences are likely to be individual and unplanned.

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theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

Catching Fire Jack Steadman Guest Writer Catching Fire is a sequel. It’s a sequel to a very good film, at that. All of which means it must be subjected to the Law of Sequels (with Unnecessary Capitalisation and everything) – that is to say, does it measure up to the original? Or is it, as is so often the case with sequels to really, really good films (see: Robocop 2, Robocop 3, Yes I’m Really Upset About Robocop Okay, etc.), an abject failure that takes everything that was so good about its predecessor, throws it in a blender, and then presents the resulting, completely unrecognisable goo as a film?

In short: No. Catching Fire is not Robocop 2, which is a really backhanded way of saying this is a genuinely brilliant sequel that deserves just as much, if not more praise as the original. It does fall into that traditional sequel trap of going ‘grittier’ than the first, but considering the first was gritty enough that’s not really an issue here. What is far more noticeable is the shift in the visuals: where the original featured the contrast between the greys of District 12 and the greens of the Arena, Catching Fire has

beautiful wintery landscapes to add to the sense of overwhelming gloom, followed up by the beach/dense forest of the Arena this time around. It’s rather gorgeous for such a bleak and miserable film, all-in-all, and credit goes to the cinematographers for nailing the aesthetic.

It’s not just the cinematographers who bring their A-game either (no, that wasn’t a pun) – the actors are on top form as well. Jennifer Lawrence (obviously) is amazing, earning her money in the first few minutes (and then continuing to earn it for the remaining two-and-a-

lot hours), while Hutcherson delivers admiriably as Peeta.

Woody Harrelson provides the required quip quotient as Haymitch (with said quips being pretty much the film’s only laughs), while Elizabeth Banks has a stand-out moment as the heart-broken Effy at the Reaping that becomes one of the film’s most poignant images.

Sam Claflin is engaging as newbie Finnick Odair (he certainly looks the part, and when he’s given a more interesting role than the sappy priest of On Stranger Tides proves he can actually act), although Phillip

Seymour Hoffman’s performance is a tricky one – it’s hard to tell if he’s just dialing it in, or being deliberately enigmatic (obviously, taking in how awesome everything else is, I’d lean towards the latter, but still).

On a slightly less effusive note the sledgehammer-subtle political commentary that goes on is slightly lacking in bite – President Snow is menacing enough, but a little dull when he threatens Katniss for the first time – although the satire in other areas (not least the TV show sections) is still fantastic, with the transition between the

Capitol and the Districts as jarring as ever.

Equally jarring is the brutality on display – the scene in District 11 (featuring the execution of a pensioner) is shocking in how near it skirts to the boundary of its 12A certificate – if anything, skirting close than the original (which was classified as a 15 at first until being cut down). It’s a move I’m grateful for, hammering home the fact that this is as much an adult movie as anything else.

‘Anything else’ here means ‘a really damn long film’ as well – weighing it at near two and a half hours, it’s a lengthy beast, so it’s fortunate that it manages to keep a fairly brisk pace through events, although as in the original it encounters the problem of masterfully building pre-Games tension, only to hit its peak early and consequently spend a good ten or so minutes giving the impression of simply delaying the good bits. And they really are the good bits – the (disappointingly short) Arena sequence is a stand-out, featuring excellentlyshot action scenes, before culminating in the cliff-hanger that leads into Mockingjay. Which, on the basis of this showing of that rare thing – a sequel that outshines its predecessor in almost every way - will be absolutely fantastic. 9/10

Foreign Bodies, Common Ground Kiranjeet Gill Staff Writer Like many of the exhibitions at the Wellcome Collection, London’s ‘free destination for the incurably curious’, the title of its latest offering doesn’t give much away about what might actually be inside.

‘Foreign Bodies, Common Ground’ is an intimate showcase of the work of six artists from across the world who were commissioned to spend time working in medical research centres in Malawi, South Africa, Thailand, Kenya, Vietnam and the UK, and produce art based on their experiences. The works take many forms – sculpture, photography, painting, film, music and performance art, reflecting

both the cutting-edge research the artists observed, and its perception by local communities.

Starting in Malawi, artist Elson Kambalu spent time at a major HIV/AIDS, TB and malaria research centre, but chose to focus his work on people in local villages. Research interest in blood is a huge concern for many, given the widely-held belief that it is collected to be sold for witchcraft, an idea that is addressed via collaborative mud paintings created by the villagers. Another exhibit deals with the commonly held belief that sleeping with a virgin will cure AIDS, a poignant reminder that folklore and myths surrounding treatments and cures persist, despite the ground-breaking research taking place so close by.

In South Africa, Zwelethu

Mthethwa posed the question ‘what is good health’ to a group of students from a population more usually noted for its high prevalence of HIV. The students were armed with cameras and asked to document their perceptions of good health, with the result being an uplifting set of photos showing a village full of life and hope. Meanwhile in Kenya, two photographers aimed to break down the barriers between researchers and local people through a series of humorous portraits in a stylised laboratory, with local people invited to don lab coats modified with traditional Kenyan fabrics.

‘Foreign Bodies, Common Ground’ is an incredibly thought-provoking exhibition, linking together two subject areas that are often considered to be

opposite ends of a spectrum, and perhaps unfortunately thought of as little more than frivolous pursuits by those of us who spend more time with our heads in textbooks rather than behind a camera. It is fascinating to see things from the perspective of individuals who think very differently to us scientists, and how the artists have made something so creative from experiencing what, to most of us, is a very disciplined and rigid pursuit.

However, the exhibition also raises some interesting and possibly troubling questions. I was particularly struck by how multi-million pound research centres can co-exist in such close proximity with local populations often more inclined to take traditional approaches towards medical treatment. By all means,

there is a need to be culturally sensitive, but what duty, if any, do researchers have towards educating the public? And despite the benign intentions, could this all perhaps be just colonialism in a different era?

Nevertheless, the exhibition is timely and relevant given that so much research today is carried out collaboratively, with large multi-centre trials spanning not just one but many countries, and this is certainly reflected in the exhibition.

Just like many researchers, the artists were transplanted into unfamiliar surroundings, the ‘foreign bodies’, united by their common goal.

Foreign Bodies, Common Ground is at The Wellcome Collection until 9th February 2014

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theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

The very best John Park Culture Editor

2013 is coming to an end, and what a year it has been for the film industry. There have been ups and downs as with any year, and with awards ceremonies proudly lined up to celebrate the great critical cinematic successes of 2013, The Medical Student, too, would like to participate in this endlessly fun game of going through the best of the bunch, reliving the powerful, immensely entertaining moments.

So here is the list of our favourite films of 2013, all 26 of them. Some you might have loved, others you might have hated, and perhaps some you haven’t had the chance to catch. Whatever your opinions, please accept our humble views not as something solidly concrete, but as a general guidance as to what some of the main highlights of this year were.

(Side note: we only counted films that were on general release strictly in 2013 in the U.K. ONLY. Films with release dates in early 2014 such as 12 Years a Slave, Inside Llewyn Davis or Labour Day, have not been taken into consideration)

26. Wreck-it Ralph Walt Disney’s charming, funny animated film offers plenty of surprises not only in terms of endearing qualities but also with its smart, original concept and even better developments of the many characters. Something for both the adults and kids alike.

20. The Impossible It’s difficult to stomach, as the disaster feels all too real even when it’s only happening on the screen, with the gut-wrenching performances from the entire cast bringing out a real sense of terror and anguish whilst still instilling that all-poweful sense of hope.

25. I Give it a Year A brilliantly assembled cast gives it their all, no matter how small their roles are (Olivia Coleman is a real scene-stealer), and a surprisingly bold set of ideas that does something different with the overly familiar rom-com genre deserves to be applauded.

19. Les Misérables Sure there are some bum notes (yes Russell Crowe, those are pretty much all on you) but the nearly three-hour long musical spectacle packs in a good strong punch, and even the pitching issues behind the live singing seem to add more to the stirring, powerful finish.

24. Don Jon Honest and a wholly confident view of sexuality and pornography, often a very taboo subject matter, here is something that can be as informative as it is entertaining. Joseph Gordon-Levitt has talent behind the cameras, and Scarlett Johansson is superb.

18. All is Lost Robert Redford is alone and lost at sea, and that is essentially it for the film’s plot. But what follows is an unimaginable set of unfortunate events that will have this 77-year-old man give everything he’s got, and go up against Mother Nature with his survival spirit.

23. Flight It offers nothing particularly revelatory in terms of substance abuse and its dangerous slippery slope, but Denzel Washington’s outstanding portrayal of an alcoholic pilot is gripping. Plus the film’s opening is one hell of a thrill ride of utmost technical marvel.

17. The Way Way Back Two of the three writers of The Descendants try their hands at directing and are immensely successful.

A bright, sunny coming-of-age story with memorable characters, a script full of hilarious gags and a huge heart to top it all off, this is indie dramedy done right.

22. Star Trek: Into Darkness Kirk (likable hero Chris Pine) and Spock (Zachary Quinto, perfect as ever) are once again reunited for a solid, action-packed science-fiction adventure that further boosts the credibility of this franchise. Benedict Cumberbatch also makes a quality villain.

16. Pacific Rim Without doubt this summer’s dumbest, but funnest blockbuster, Guillermo del Toro gives his audience exactly what they want: large, bombastic action set pieces in which fancy robots and huge ugly monsters punch each other to death. There isn’t a film quite like it.

21. What Maisie Knew Something all adults with kids should watch, here is an uncomfortable but important viewing of a family meltdown seen through the eyes of an innocent girl. The supporting cast is beyond excellent, but the real star is the young Maisie (Onata Aprile) herself.

15. Blue is the Warmest Colour The endless controversy aside, this year’s Palme d’Or winner is an expertly-made, intimate, extensive look at a couple’s life. The performances of the two actresses are to die for, which is why this emotional rollercoaster ride is one you cannot afford to miss.

theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

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films of 2013 14. Quartet It may be too cheesy, sugary-sweet and neatly presented but the sheer feel-good factor on display here through classical music and seasoned actors on top of their game is one that is hard not to warm to.

Plus we have the one and only Lady Grantham dropping the f-bomb.

8. Lincoln Steven Spielberg makes American history comprehensible and interesting even to outsiders who may not know a single thing about it. Daniel Day-Lewis in his Oscarwinning turn is superb as usual, and opposite him Sally Field is too

13. The Selfish Giant The best performance from a young actor this year is hands down given by Conner Chapman who is extraordinary in Clio Bernard’s debut film, telling the heartbreaking and touching story of a young boy having to grow up far too quickly for his own good.

7. Saving Mr Banks Turns out bringing Mary Poppins to the screen was no easy job for Walt Disney: and so we are given a glimpse of how things went down between Walt and author P. L. Travers. Witty, surprisingly poignant, with two amazing actors: Tom Hanks and Emma Thompson.

12. Pieta Last year’s Golden Lion winner at the Venice Film Festival, South Korean oddball director Ki-duk Kim’s latest offering is difficult to recommend to a wide audience, but for those who can handle bold content, here is a challenging but beautifully rewarding experience.

6. Nebraska Director Alexander Payne is a consistent high-achiever as he has a knack for mixing very naturalistic human drama with outstanding humour that arises from simple everyday happenings. Bruce Dern is a triumph, and June Squibb is quite the hilarious scene-stealer.

11. Zero Dark Thirty The manhunt for Osama Bin Laden took ten years, and Kathryn Bigelow has achieved the impossible - condensing so much material into a gripping slow-burning thriller of intelligence and espionnage with the stakes growing higher and higher every minute.

5. Django Unchained As you’d expect from Quentin Tarantino, there is a lot of blood, but an equal amount of style as well as an outstanding script. Jamie Foxx is a leading man worthy of Tarantino’s film with Christoph Waltz pitching in yet another fascinating role. And DiCaprio? Biggest Oscar snub.

10. Blue Jasmine Writer/director Woody Allen may have his quality ups and downs but with his 2013 feature he is definitely on a career-peak form, as his Oscar-worthy lead Cate Blanchett goes from riches to rags when her husband is arrested. A 21st Century Streetcar Named Desire.

4. Gravity If there is one film you need to fork out a big lump of money to watch in 3D IMAX (preferably BFI IMAX), it’s Alfonso Cuaron’s space thriller that is guaranteed to have you pumped full of adrenaline from the very start to its grand, loud, dramatic finish.

9. Stoker Chan-wook Park’s English-language film debut is one filled with hauntingly beautiful images, creepy ambiance, and a trio of performances so perfect that they fit right in to tell this dark, twisted, mysterious story. Matthew Goode’s best performance to date for sure.

3. Before Midnight The Before series turns into a trilogy as we follow the third, but hopefully not last, romantic journey of Celine (Julie Delpy) and Jesse (Ethan Hawke). They are a stable couple who have children now, although even that can create friction and problems of its own.

2. Cloud Atlas The most expensive independent movie ever made certainly shows where all that budget went, in creating over 400 years of six different interwoven stories all of them grand and epic in nature with a tremendous acting ensemble. If you haven’t seen it, go check it out now.

1. Philomena Dame Judi Dench goes on a search to find her long-lost son she was forced to give up 50 years ago by evil Irish nuns. Her journey, along with Steve Coogan, takes us all to unexpected places, and is all the more better for it. As funny as it is immensely moving, this is our #1.

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theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

And the absolute worst films of 2013 10. Kick-Ass 2 Even worse than its unfunny, uncool predecessor, Kick-Ass (Aaron Johnson) once again tries to be the hip new thing thinking he’s better than everyone else. As villains go, M*therf*cker is neither smart nor funny, and Chloë Grace Moretz seems like a thing of yesterday.

8. R.I.P.D. The Ryan Reynolds + Jeff Bridges pairing should have been given better material to work with. Instead they’re stuck here fighting monsters designed by some of the worst CGI ever used this year.

This bombed at the box-office, and it’s not surprising to see why.

6. A Haunted House Marlon Wayans, one of the Wayans brothers who participated in the Scary Movie franchise, tries his own thing spoofing modern horror films. The resulting final product could not be more bland and laughfree, as Wayans shows his desperation by humping a teddy bear.

4. After Earth Jaden Smith proves he doesn’t have the acting chops to carry an entire movie all by his brat self, Will Smith has never been this dull with zero charisma, and this truly is M. Night Shyamalan’s absolute worst film to date which is really saying something.

2. Scary Movie 5 Let’s spoof Paranormal Activity, Mama, Black Swan, Rise of the Planet of the Apes, Sinister, Inception, Evil Dead, The Cabin in the Woods, Insidious, The Help etc. why...? Oh dear God why...? And Charlie Sheen actually signed up for a cameo role? Unbelievable.

9. Percy Jackson: Sea of Monsters As if one Percy Jackson (a charmless, weedy Logan Lerman) film wasn’t enough, the studios found the need to bring him back for a painful second time to insult their audience with their immature, badly-acted sequel that is anything but fun and adventurous.

7. Safe Haven Critics love to bash Nicholas Sparks and he doesn’t help himself as he continues to arm his critics with his trashy romantic novels that are even worse as they turn up on screen. Julianne and Josh are a good-looking couple, but there’s not much more here.

5. Movie 43 Remember this horrendous badtaste ensemble comedy where lots of famous people signed up for some mysterious reason that’s still not clear even to this day? The film is 90 minutes too long in its misguided attempt at trying to figure out what being funny entails.

3. The Host Stephenie Meyer’s young adult fiction novel is once again adapted for the screens with this hopeless, laughable futuristic teen angst drama in which our young heroine finds herself battling with her mind over which boy to kiss.

That’s really it for the film’s plot.

1. The Big Wedding It’s a sad thing the worst film of 2013 has big, famous names such as Robert De Niro, Diane Keaton, Susan Sarandon and Robin Williams in the cast. It’s one big mess of a rom-com, one that doesn’t even begin to cover either aspect of what it promises.

The Emperor of All Maladies: A Biography of Cancer Zara Zeb Doctors’ Mess Editor Published in 2010, this interwoven history is an elegant map of the medical professions relationship with cancer. Jumping between continents, time periods, and key figures, the history of cancer is brought to life in a novella-esque way with Mukherjee masterly combining the element of storytelling with clinical facts. This style of writing enhances the comprehensible nature of the book and its enlightening ability to capture our understanding of cancer in the present day. Over 400 pages, with references and an index, this is most definitely not a work of fiction, but rather an epic story of one of the greatest killers of human kind. Created with the lay person in mind, this book is easily accessible for patients, scientists, students, and lovers of literature, deepening the readers’ understanding of the complex world of cancer.

Although cancer as a disease has been around for a very long time, with its identification 4600 years ago by an Egyptian physician Imhotep, much of the book focusses on the last seven decades where most of the progress in our understanding of sub-groups of cancer and the techniques of diagnosis and treatment of cancer has developed. Lab work is combined with

surgical work in this masterpiece that gives detailed biographies of something we still consider our greatest enemy today. Referencing individuals who have made a contribution to the battle, for good or bad, be they great or small, Mukherjee has created a great encyclopaedia-like resource.

Mukherjee holds a deep respect for history, wanting to remem-

ber those who gave their lives for our understanding of the disease, wanting to create a biography of cancer, but overall to answer a patient’s question to allow patients’ to know what exactly they were battling. It has bought cancer’s brutal and vulgar face to life, without losing the message of hope, of compassion, and of progress being made.

This book includes everything for lovers of science and lovers of books: from personal stories of patients and health care professionals holding rigid views difficult to break down, to the mechanism of drugs, the importance of statistics, and the influence of politics on the development of the battle against cancer. The book looks both retrospectively and prospectively; it looks at where we are today, how we got here and where we are headed.

Siddharta Mukherjee is a practising haematologist and oncologist at Columbia University Medical Centre in New York City and an assistant professor of medicine in the Oncology department at Columbia university. The Emperor of All Maladies won the 2011 Pulitzer prize for General Non-Fiction, as well as an award from The Guardian and was named one of the 100 most influential books written in English since 1923 by TIME. An educational yet emotive read.

theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

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Bored at Christmas?

Zara Zeb Doctors’ Mess Editor Let’s face it, Christmas isn’t for everyone. Aside from the increased food consumption because chocolate is suddenly very cheap, Christmas for me is a tad… boring. Not forgetting that a large number of medical students won’t be going home for Christmas, we can sometimes find ourselves with little to do. Below are a range of ideas to keep you, and me, busy this December for less than £10.

1. Astronomy Photographer of the Year (FREE!) Hosted at the Royal Observatory in Greenwich, this free intimate exhibition presents winning images of the Astronomy Photographer of the year 2013. With photos taken within our solar system as well as far in deep space, expect to be taken out of this world, with photos capturing the transit of Venus, shooting comets, and other mind-boggling space stuff. The exhibition is on until 23 February 2014 and is FREE! It’s also set in a fantastically beautiful location so wrap up warm and walk around Greenwich Park, take photos of the breath-taking views from atop the steep, steep hill, and wander the shopping streets taking in the old with the new. More information about opening times for the exhibition can be found on the Royal Museums Greenwich website: http://www.rmg. co.uk/whats-on/exhibitions/astronomy-photographer-of-the-year/ 2. Wildlife Photographer of the Year 2013 (students £5.40 excluding 60p recommended donation) I’ve attended this exhibition for the last two consecutive years, and this year won’t be an exception! Hosted at the Natural History Museum in South Kensington, this exhibition has 100 images capturing nature in breath taking shots. Categories include “Animals in their Environment”, “Urban Wildlife”, and the “Gerald Durrell Award for Endangered Species”. Expect to be captivated by the human-like qualities of some of the animals and their behaviours captured by photographers of all ages and all levels. Why not make a day of it and spend some time in the rest of the museum or window shop down High Street Kensington? More information about the exhibition can be found on the Natural History Museum website: http://www.nhm.ac.uk/visit-us/whats-on/temporaryexhibitions/wpy/exhibition/index.jsp 3. Ice-skating @ NHM (£8.50 with student ID including skate hire and a free drink) With ice rinks popping up all over the city, eager friends dashing to get their skates on, and London being London, I wanted to know where the best (cheapest) place to skate actually is. With some relaxed research, I was quite surprised to find that Natural History Museum offered skating for £8.50 for students with a valid student card all day Monday or Tuesday, including a free drink and skate hire. Any draw backs to this offer? When you read further, you need to arrive 40 minutes earlier to collect skates and it seems that they are quite strict about timing with each session lasting 50 minutes and you will be taken off the ice when your time is up. Also, bags are not allowed on the ice, and cloakroom charges are £2 per item. Alternatively, my personal favourite, is the rink at Broadgate which is only £10 for students on any day and time, with each session lasting the full hour and has non-refundable £1 lockers for personal belongings. So in a way, I have given you a choice of two venues, both of which can be found online for more details.

4. The Circus @ Winter Wonderland (students £8.50 with an NUS card) Which Londonder has not heard of Winter Wonderland? Hosted every year in Hyde Park, it attracts millions of visitors and is incredibly busy every night. However, who knew that Winter Wonderland wasn’t just overpriced fair rides, food and skating? There are other attractions available including a circus (starring no animals that I am aware of). Two versions are offered: the family friendly Zippos Christmas Circus with thrills and circus skills including jugglers, clowns and aerialists; or the daredevil show Zippos Cirque Berserk with knife throwing, fire, ultimate High Wire, and the sensational Wheel of Death. Both are priced the same, and both are something different to be doing at this time of year. More information can be found online at: http:// www.hydeparkwinterwonderland.com/attractions

So we’re coming up to our final recommended event. What will it be? A pantomime show? Another commodity where a venue puts prices up for something it does year round but now it’s Christmas the venue is installing a Santa’s grotto and putting fairy lights up to justify the increase in price?

Another touristy thing? All great ideas my dear readers, but none of those tend to be less than £10. So I’ve gone with a non-traditional Christmas market.

5. The Book People The Book People pop in places with lots of books from non-fiction to fiction, with a mixture of bestselling authors and little known authors. The sorts of books found will vary from event to event, all are brand new, and the prices are far cheaper than in store. You can treat yourself to something to read in between watching Christmas telly and eating Christmas goodies. Events are held all over London on specific dates throughout the year, with 3 dates in December: 4th – 201 Bishopsgate, 12th – Broadgate Welcome Centre, 12th + 13th – Exchange House. Don’t worry if you miss them as they have an online website!: www.thebookpeople.co.uk Enjoy your December folks!

[CULTURE] /20

theMEDICALSTUDENT /December 2013

Culture Editor: John Park/culture.medicalstudent@gmail.com

One Flew Over the Cuckoo’s Nest ICSM Drama Production Narmadha Kali Vanan and Rupert Boyce-Bown Features Sub-Editor & Staff Writer “Wire, brier, limber lock, Three geese in a flock, One flew east and one flew west, And one flew over the cuckoo’s nest.”

The play One Flew over the Cuckoo’s Nest by Dale Wassermann was never going to be an easy one for an amateur society to put on. However, we were very impressed by the quality of the sets, directing, lighting, and not to mention acting!

First impressions were good with the front of house being friendly and efficient. The programme was humorous and credit goes to the art director, Pe-

ter Zhang for his striking use of a Rorschach logo on the front page.

With humorous passages from the actors and the back stage crew, the programme kept us occupied until

curtain up.

What a start! We were gripped from the very beginning, with Edward James MacDonald playing a very ominous Chief Bromden, and wonderful lighting by Sheena Cheung and Alex Compton.

The rambunctious personality of Rhys Davies playing R.P. McMurphy, the protagonist contrasted well with the frigid disposition of Nurse Ratched, played by Anna Hurley. The sense of tension between the two was palpable during the power struggles in the play.

The powerful characterisation of the other actors led us to empathise with them, with the likeable Elvin Chang as Dale Harding and skilful Qamar Mustafa as Billy Bibbit. The actors with fewer lines were able to hold their own too, with Maria Goryaeva stealing the show as Martini. This is a definite indication of a talented cast along with inspired direction by Thomas Elliot.

The highlights of the play include the impressive mental breakdown by Chang during the ‘chicken pecking sessions’ run by Nurse Ratched. Rijul Buhra deserves a mention too, as a hilarious elderly patient who elicited laughs at every turn. The death of Billy Bibbit was well done, and the fact that the operating room was the only place on the stage with any colour highlighted the significance of it very well.

Our only real qualm was with the death by smothering of McMurphy. Had we not have already read the book, we might have been left adrift as to the motivation behind it. This could have been explained slightly better in this adaptation than it was.

The backstage teams contributed a great deal in terms of costumes, lighting and props. The costumes, although simple, were appropriate and the white scrubs when combined with emotive,

well timed lighting and sound effects and a predominantly black stage lent a strong contrast of colours, and an eerie sense of foreboding where needed. It was nice to hear the backstage crews being warmly congratulated at curtain call time. The props were thought through and added to the realism of the scenario.

Overall, the performance was well adapted to the stage, with humorous moments interwoven within the threads of a thoughtprovoking and emotional play.

We take our hats off to everyone involved in providing us with a thoroughly enjoyable evening and we look forward to seeing more productions from you in the future! The Medical Student rating: 5/5

and knuckle biting tension for the events happening in the foreground. Whilst some scenes – the opening especially, linger for long period, it is compensated by an overall short film of only 91 minutes.

Gravity comes across as a much more personal film than a franchise. Unlike other films, it does not have super heroes; it does not rely on sci-fi gadgets, but rather is just the free-reign imagination of Alfonso Cuarón.

Interestingly, those long scenes I mentioned above do create a starling picture, with minutes of

uncut footage as we see astronauts gliding to make repairs to the Hubble.

The film doesn’t come in pure perfection, scientists have rather unsportingly pointed out the technical inaccuracies within the film. It also takes a considerable stretch of imagination that the inexperienced, nervous Bullock is able to operate the complex controls in a Chinese and Russian spaceship. Although, perhaps, this is simply because of Bullock’s most recent performances, all to films that weren’t all that serious.

Alfonso Cuaron’s ‘Gravity’ Chetan Khatri Staff Writer Alfonso Cuarón’s incredibly fascinating, optically stunning film focuses on two astronauts lost in space, with the title referring to the sole missing feature in the film: gravity. A film full of awe-inspiring sequences, director of photography, Emmanuel Lubezki has created great vistas of light painting celestial bodies with perfection. With earth used as a contrast background to black emptiness of space, its blue aura

provides such crisp vision that not even the darkening 3D glasses can ruin.

The movie focuses on Dr Ryan Stone (Sandra Bullock), in space after a gruesome 6 month training programme to install a new scanning device on the Hubble telescope accompanied by Matt Kowalski (George Clooney), a space veteran on his last space-walk.

Whilst Dr Stone nervously installs her device, we see the calm Matt Kowalski floating around, listening to country music as he enjoys his last moments in space. Playful, yet serious in his communica-

tion to ground control, he jokingly jibes ‘I have a bad feeling about this’ and soon enough ground control at Houston (voiced by Ed Harris, in homage to the spacedisaster Apollo 13), announced a terrifying situation about to unfold.

As debris from a near by satellite destruction hurls towards them, it very quickly destroys their shuttle and the Hubble. Sent spinning out into space, the movie really does open with a bang.

Director (and co-writer) Cuarón manages to create a film full of awe for his space views

The Doctors’ Mess

A new hope for Down’s Syndrome Detection Utsav K. Radia Guest Writer A new antenatal blood test, developed by Professor Kypros Nicolaides and his team of researchers at King’s College London in collaboration with University College London Hospital, with the potential to diagnose Down’s Syndrome in developing foetuses is being considered for trial in the NHS. Down’s Syndrome, also called Trisomy 21, is a genetic condition affecting around 750 (1 per 1000) newborns in the UK each year and is one of the most common genetic causes of learning disabilities.

Trisomy 21 is caused by the presence of all or part of an extra copy of chromosome 21 in a person’s DNA. Down’s patients suffer from many physiological disabilities such as hypotonia (reduced muscle tone), sandal toe, congenital heart defects, brachydactyly (short fingers), a flat facial

profile and skeletal deformities. Down’s patients struggle with day-to-day activities like walking, sitting, standing, reading etc. There is no current cure for Down’s Syndrome but support is given to help patients lead a healthier, active and independent lifestyle.

Current antenatal screening involves a combined test done in the first trimester between the 11th and 13th weeks of pregnancy and includes ultrasound screening (used to measure thickness of tissue at the back of the foetus’s neck) and a hormonal test of the mother’s blood (to detect high levels of human chorionic gonadotrophin and oestriol).

The results of these tests along with the mother’s age are used to predict the risk to the foetus – this method picks up about 90% of cases. For high-risk pregnancies, further methods of testing include: chorionic villus sampling, which involves taking cell samples from the placenta; and, am-

niocentesis, where a sample of amniotic fluid is taken. These are subsequently analysed for presence of the extra chromosome 21 copy. However, both methods are invasive and carry a 1% chance of miscarriage and a false positive chance of 3-4%.

The new antenatal blood test uses ‘foetal cell free’ (cf) DNA that is present in the mother’s blood to scan for the presence of the extra chromosome 21. The study, published in the journal ‘Ultrasound in Obstetrics and Gynaecology’, shows that in the 1005 pregnancies trialled at 10 weeks, there was a much lower false positive rate of 0.1% and a 99% rate of Down’s Syndrome detection.

Currently, this test is only being offered privately and to any pregnant women who volunteer to participate in the ongoing trials. Professor Nicolaides added that this new technique “if offered across the UK, would have the po-

tential to increase the diagnosis rate from 1,000 cases to almost all of the 1,200 which occur every year”. Professor Lyn Chitty of Great Ormond Street Hospital confirms that this could “very significantly reduce the number of invasive tests” as only 0.5% of cases that had the blood test required any form of invasive testing. Early detection of the condition in foetuses can help parents to plan ahead and also

gives them time to learn more about the condition and how they can help their child. Nevertheless, widespread access of this method of early detection through the NHS still remains to be in question.

Ultrasound in Obstetrics and Gynaecology DOI: 10.1002/uog.12504

History Corner - Dame Cicely Saunders To fully appreciate the transforming revolution Cicely Saunders brought to patient care, we need to know what the medical profession was like during her time. The medical mentality pervading the treatment of cancer patients heavily emphasised a cure; often by bombarding patients with toxic drugs and radiation or by deforming patients’ bodies in radical surgeries (with ultra-radical surgeries removing the breast, collarbone, ribs and muscles to eradicate breast cancer due to the lack of understanding surrounding the development of breast cancer and no staging system) regardless of the sideeffects of such treatment: both mentally and physically. Surgeons and chemotherapists had to re-learn how to care for a patient because caring was akin to admitting defeat and therefore failure. Palliative comes from the Latin word ‘palliare’, which means “to cloak”, and many

health care professionals saw pain relief as cloaking symptoms rather than attacking the disease.

Saunders trained initially as a nurse, amongst many roles, at the Nightingale Training School of St Thomas’ Hospital (existing as part of King’s College London today). In the late 1940s she attended to a Jewish refugee dying of cancer in London who left her his life savings of £500 (valued around £13000 today) with the wish to be a “window in your home”. Saunders went back to St Thomas’ Hospital Medical School to retrain as a physician, qualifying in 1957. In 1958 she began working at St Joseph’s Hospice in East London researching pain control. Walking the oncology wards of London hospitals in the East End during the 1950s, Saunders witnessed terminally ill patients denied dignity, denied pain relief, and often denied basic care.

The dying in the worst conditions were confined to rooms without windows as they were viewed as hopeless cases and were said to bring morale down for other patients and for those physicians hell-bent on a cure. Saunders reacted by creating palliative medicine where she persuaded other specialities to do what oncologists wouldn’t do – to provide care for terminally ill patients so they could die painlessly and gracefully. In 1967 she created the first purpose built hospice in London naming it St Christopher’s - the patron saint of travellers. The hospice combined teaching and research, providing holistic care to meet physical, social, psychological and spiritual needs of patients and their families and friends.

It would take a full decade for her movement to spread to the USA with the first hospice being created in 1974, but by introducing palliative medi-

cine as a speciality, clinical trials soon took place to find out about pain and pain relief.

These trials destroyed many myths and revealed unexpected principles of pain. One such example was the revelation that opiates used on cancer patients did not cause addiction, deterioration and suicide; but ceased the punishing cycle of angst, pain and misery. Antinausea drugs were created to improve the side-effects of chemotherapy and therefore improve quality of life for many patients. Not only were drugs created that go on today to benefit millions of people, but oncologists started seeing patients with compassion.

By the early 1980s, hospices existed worldwide, but Britain alone had close to 200 hospice centres. Saunders was incredibly active, being awarded many awards and titles between the 1970s-2005. She is an inspiration to all students. Maybe we

won’t create a revolution like Saunders did, but she dedicated her time, her skills, and her passions to creating a better place, which I hope many medical students go on to do, regardless of what discipline, what speciality, what field they choose to enter, medical or not.

theMEDICALSTUDENT /December 2013

Prize Crossword Causes of Abdominal Pain

Doctors’ Mess Editor: Zara Zeb/ mess.medicalstudent@gmail.com

Diagnostic Corner 1. An 18 year old female has an intra-uterine device implanted (IUD). How long will it take before it can be relied on as a method of contraception? a. Instantly b. 72 hours c. 7 days d. First day of her next period 2. A 20 year old female commences the combined oral contraceptive pill. How long will it take before the pill can be relied on as a method of contraception? a. Instantly b. 72 hours c. 7 days d. First day of her next period 3. A 34 year old pregnant female at 26 weeks pregnant has a blood pressure of 146/94mmHg. Her pregnancy to date has had no complications and her previous blood pressure reading at the start of pregnancy was 110/80mmHg. Urine dipstick has normal readings. What is the likely cause of the rise in her blood pressure? a. mild pre-eclampsia b. gestational hypertension c. normal physiological change in blood pressure d. pre-existing hypertension e. white coat syndrome

ACROSS shock (8, 7)

4 Aching loin pain, haematuria, frequent UTIs and palpable renal masses (10, 6, 7) 5 Central abdominal pain radiating to left iliac fossa with fever, vomiting and local tenderness and guarding (14) 7 Condition more prevalent in those over 60 years old; presents with severe central abdominal pain radiating to the groin and signs of shock (8, 9, 8) 8 Suprapubic pain during micturition, with haematuria and increased frequency (7, 5, 9)

11 The most likely disorder when the patient has a history of acute suprapubic pain, abnormal bleeding, dysmenorrhoea, dyspareunia, nausea, fatigue (13) 12 Iliac fossa pain with tender mass and swinging pyrexia (9, 7)

4. What can women at high risk of developing pre-eclampsia do to reduce their risk? a. Northing b. Take aspirin 75 mg throughout the pregnancy c. Take aspirin 50 mg throughout the pregnancy d. Take aspirin 75mg from 12 weeks until the birth of the baby e. Exercise and reduce salt intake 5. What is the normal pattern for blood pressure in a normal pregnancy?

DOWN 2 Right iliac fossa pain, amenorrhea, abnormal vaginal bleed, nausea and signs of hypovolaemic shock (7, 9) 3 Disorder related to Streptococcal upper respiratory tract infections and clinical features similar to 6 down, with a preponderance in young children (10, 8)

a. No change throughout pregnancy b. A slight rise in the first trimester, but back to normal by delivery c. No change in the first two trimesters then a small rise in the third trimester d. A fall in blood pressure from the beginning of the pregnancy to the 24th week, before increasing to pre-pregnancy levels by term Questions adopted from http://www.medicaleducator.co.uk/

Answers: 1a. 2 c. 3 b, 4d. 5d.

1 Likely cause of acutely ill patient in which presentation is of generalised abdominal pain which worsens on movement with tender and rigid abdomen, and signs of shock (11)

6 Colicky central abdominal pain that moves to the right iliac fossa with nausea, anorexia, low-grade fever and flushed cheeks (12)

9 Involuntary abdominal muscular contractions during gentle palpation (8) 10 Rare medical cause of abdominal pain with emergency features of vomiting, weakness and signs of Congratulations to Christopher Holland from King’s College London for winning our Prize Crossword: Complications of Myocardial Infarction in our November issue!

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For your chance to win a copy of the Interpreting Chest X-Rays provided by Scion Publishing Ltd, simply send a photo of your completed crossword to doctorsmess@themedicalstudent.co.uk

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Then send me anything and everything!

Doctors’ Mess would love your elective photos, your articles, or to answer any questions you may have.

Why not enter our fantastic monthly competition with statiscally higher chances of winning our fabulous prizes than getting into Medicine?

[SPORT]

theMEDICALSTUDENT /December 2013 Sports Editor: Mitul Patel

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RUMS & George’s Victorious at Novice Regatta Mitul Patel Sports Editor

The overcast morning of November 24th saw the annual UH Novice Regatta take place on the 800m stretch of water on the Thames between Kew Rail and Chiswick Bridge.

Fifteen novice crews amongst the London medical schools entered hoping to take the start of year bragging rights, won in 2012 by ICSM in the boys division and Vets in the girls.

The heats in the boys divi-

sion saw a fairly predictable set of results unfold as RUMS1, ICSM1 and George’s 1 all come through; George’s having the closest race of the morning overcoming a spirited ICSM second crew by a canvas. Barts 1 also made the semi-finals by beating ICSM3 - the only third eight to have entered this year’s regatta.

The girls’ heats saw Vets 1 make a successful start to the defence of their crown, staging a remarkable comeback against ICSM1 after the latter crew caught two crabs whilst in the lead. Georges 1sts and Barts 1sts overcame

George’s first boat [right] beat RUMS first boat [left] in a close finish in the girls division

Barts put Best Foot Forward Elizabeth Blackburn Guest Writer Founded in 2010, Barts and the London running club is now a well established club with a healthy core teamof runners.

October 16th saw the club start what is now proving to be a strong campaign in the London Colleges League’s (LCL) in cross country, currently at the half way point following three races.

The LCL league opened with a meet on 16th October in Parliament Hill, Hampstead Heath.

The women’s division was raced over 2.5 miles and was a promising start for Rosie Hel-

ler who picked up 75 points for Barts; more than half the total achieved by Barts that day! Unavailable for the second race in Richmond Park on 30th October, Heller returned to rack up another 72 points in meet three at Wimbledon Common on 13th November. After 3 races Barts ladies are only 24 points off of tenth place Reading University, and are looking to make inroads in meet four.

Barts men on the other hand sit ninth in the overall standings after three races, sandwiched in between university teams after a strong start to the season, particularly for Rob Walker and Jordan Ali. Walker finished 28th

GKT and Vets 2s respectively to make the last four, alongside RUMS1 who had been given a buy.

The semi-finals of the boys division saw a convincing victory for ICSM; executing an impressive start sequence and taking their stroke rate down before the finish line to defeat George’s. The second semi-final saw RUMS beat Barts with similar ease, setting up a final with ICSM for the third year in a row.

RUMS also handed a defeat to Barts in the girls’ semi-final to set up a meet with Georges, who defeated holders Vets with a confident display.

Meanwhile, the crews who lost in the heats were entered into the repercharge. The boys draw saw Vets beat GKT by five lengths to take home the consolation prize.

In the girls draw, there was a closer result as Vets 2nds made up for the heartache of the knockout of their 1st crew by defeating ICSM by two lengths despite strong vocal support on the banks for the latter in the run up to the finish.

The final of the girls division brought victory to George’s; who beat RUMS by a length to

at the 5 mile meet at Parliament square, followed by 17th in Richmond Park and consistently enough, 16th at Wimbledon Common. He currently sits 9th overall in the points standing for men which is a fantastic achievement and everyone here at Barts is hoping he can continue his impressive form.

The third meet was combined with the UL cross-country championships and the UH cup. Beginning on the flat of Wimbledon common, the race involved 5km for the women and 10km for the men through the steep ups and downs of the beautiful, muddy and very leafy Wimbledon common. After a cracking run, Jordan Ali finished the race 10th overall; and in 3rd position out of all UL entrants behind James Pigot of UCL and Joe Morwood of Georges. This followed an 8th place finish at Richmond Park as he looks to

RUMS 1st boat collect their medals after victory in the boys division the delight of the support on the banks. The defeat ultimately denied RUMS of a clean sweep at the regatta, as they comfortably despatched ICSM in the boys final. The boys from North London looked composed and well in time as they came through the finish line two lengths in front of their counterparts from the west.

Alongside the UH competition, the invitational regatta saw Imperial College Boat Club win

the men’s final against UCL, whilst Imperial College girls also overcame Queen Mary’s giving the West London outfit a coveted double.

The regatta closed with celebrations from the winning crews and further boat races took part on the pub crawl back to Hammersmith later that day.

For 2013, RUMS remain the crew to beat in the boys division, whilst George’s have the bragging rights in the girls.

join Walker in the top 10 having missed the first LCL race.

The overall result of the UH cup was also a victory for Barts.

Although the legendary cup donated by Sir Roger Bannister in 2012 returned to East London by default, the club are delighted after having to hand it over to UCL last year, and are aiming to successfully defend it in 2014.

Both Barts men and ladies have made strong starts to the new season, against stern competition from non-medical universities for valuable points.

We are hoping to make further progression in the final three LCL races, and look forward to taking form into the upcoming cross country events and marathons later this year.

Barts and the London Running Club Picture Courtesy of Elizabeth Blackburn

[SPORT] /24

theMEDICALSTUDENT /December 2013 Sports Editor: Mitul Patel

Caution Advised as BUCS Rumours Gather Pace Mitul Patel Sports Editor The saga of the infamous BUCS merger, which has been at the forefront of medical sportsmen and women’s minds for the last two years, has taken yet another twist in recent months. BUCS had successfully completed the administrative merging of medical school sports teams for the 2013-14 academic year, despite ongoing disagreement with the institutions that were primarily affected (Cardiff University and UH Medical Schools) as well as the student protest in March earlier this year.

However, on 8th November 2013, a leak on social media site twitter read “@CardiffMedsRFC and all other medics sports teams are back in @BUCSsport”, sparking gesticulation that the merger was close to its end.

Further to the tweet, Cardiff University Sports President Edore Evuarherhe told

The Medical Student, “As of the 2014/15 season BUCS will amend their regulations to include the ‘separation’ of teams.

Separation means that Cardiff University will enter as a single membership but under that umbrella can designate teams as “Cardiff University Medics” or by any such designation if it wishes to”.

The original options proposed by BUCS last year allowed anomalous schools two options; either to remain divided by nomenclature, but restricting a student’s participation to either medical school or university sport only, or a complete merger whereby all teams played under the name of the parent institution. The affected institutions had responded by counter-offering different options tailored to each of them, all of which were rejected by the BUCS advisory group.

The remaining issues surrounding the latest proposal is that BUCS points won by

medical school teams would be allocated to the parent institution, and at the highest leagues only, regulations regarding promotion and relegation would come into play if more than one medic team were to be in the same league as a non-medic team, or vice versa, with additional restrictions applying to the Premiership.

Evuarherhe suggests that the recent development may represent abandonment to BUCS’ apparent commitment to bureaucracy and a return to their pledge for “enhancing the student experience through sport”, as long as the entry under single membership does not limit a student’s choice as to which team(s) they can play for.

It would however be surprising for BUCS, having attempted to iron out these anomalies for years, to go back on their decision merely two months into the new campaign. In the light of news emerging from

Cardiff, it is imperative to note that, as yet, BUCS completely deny that this is the case.

UH Medgroup chairs Dheeraj Khiatani and Mark Gregory have also both urged caution.

Gregory reiterated that BUCS have in no way confirmed the rumours emerging from Cardiff, “Certainly the word from BUCS is that this is not true.

Having said that there is some promise in what we are hearing and I would be delighted to see any positive movement on this after seeing such a bitter blow to our sports teams last year”.

Furthermore, any policy agreed in principle by BUCS would have to be approved by the advisory group, whose next meeting is on 28th November.

Gregory is more hopeful of the advisory group agreeing to the notion this time round, “Having one notion applicable to all the institutions, instead of the case last year whereby different notions were put forward by different institutions,

is probably more favourable”.

Lastly, approval by the advisory committee would require ratifications by the sporting bodies in place at the parent institutions in question.

It is possible that Cardiff University may have been more amenable to the reversal because there were allegedly legal proceedings in place following the merger due to the long history of their Medics rugby club. Whether this process will prove more difficult among the London institutions is purely speculation.

Developments on the BUCS merger will inevitably unravel in the coming weeks as this saga refuses to go to bed.

For now, the news emerging from Cardiff should be a source of encouragement to all involved, but taken with a pinch of salt; until there is official word from the BUCS advisory group and the parent institutions in question, the anomalies will remain ironed out.

UH Sports Night Sets Infernos on Fire Elisabeth Kostov Annabelle Mondon-Ballantyne Guest Writers On the 13th of November, Disco Infernos in Clapham played host to the second annual UH Sports Night in aid of Right to Play. Sports teams across UH Medical Schools came together to enjoy the evening, meet some new faces and raise money for the charity.

The frivolities all began with dates between two willing sports teams, with the meals taking place in BYOB venues across the capital. Thanks go to Elisabeth Kostov for managing to successfully harass restaurant owners to accommodate the numbers that attended the night; over 800 people came through those doors at Clapham Infernos.

The dance floor was awash with new couples interspersed by demons that were evidently enjoying the set-list provided

by George Apperly.

Overall, it was a huge success. The end of night rush for taxis home left a rare moment to reflect on how UH came together once again, put aside sporting differences and the preconceived stereotypes in the name of charity. The event raised over £8000 for Right to Play, which was almost twice the amount raised in 2012s debut edition.

Imperial Right to Play raised a total of £6,725.57 last year, allowing us to reach 224 children. This year’s takings will go towards teaching peace keeping and leadership skills to children in developing countries though sport.

Right to Play at Imperial

would like to thank all the teams for coming down and the individuals who came to the club for making the event such a success. As this year’s event had more attendees and raised more money than lasts, we are looking forward to seeing you all again next year and making 2014s UH sports night even better!

Write for Sport!

The Sport section is looking for more staff writers to contribute to the paper. If you are a regular player, captain, or just have an avid interest in sport, email us at sport.medicalstudent@gmail.com

Imperial Right to Play; From Left to right - Kalon Hewage, Elisabeth Kostov, Annabelle Mondon-Ballantyne, Sandeep Dubb Picture Courtesy of Elisabeth Kostov