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BLACK BAG SPRING 1989

EDITORIAL Fighling against all the odds lo keep the esteemed institution of Black Bag from succumbing to the Black Death and disappeadng into a Black Hole we think wo ghtly deserve our Black B€lts, {That's enough, Ed.) A magazin€ such as ours only keeps aioal by the coming togother ol lhree essenlial ingredients: 1. A sober €ditodal team. 2. Ad€quate fnancial backing. 3. People motivat€d to write in order to inform, entertain or simply inspir€ th€ t6st of us. All th€ adv€rtisers in in this issue have have b€en €xtremoly generous in in h€lping us adjust to a vastly inflat€d budget and make this publlcation possibl€, albeit rather later than usuel. Given that the first ingr€disnt is something of an impossibilily, that iust leaves us to thank all the cont butors to this lssu€ and make this plea to the rgadershipl if you care about your medical school and the p€rlinent issues on a domestic, national or €mational level, or ol you want a mors rowa.ding outlet than just another cas€ pres€ntation, NOW lS THE TIME TO GET INVOLVED. There is of course no shortage of topics to debate. We have decided to devote a large chunk of lhis issue to a topic of great in-house impodance: lhm grad€s. lt is a subject that it seems never fails to raise a responsg from all parties concerned but sludents reading this issue might be sulprised at the str€ngth of teeling among the teaching f raternity. Next issue is already on lhe drawing board, There is a lot more we would like to include, all we need is your input.

All article/onqlides should be sent to THE EDITOR, BLACK BAG, DOLPHIN HOUSE, BRISIOL ROYAL INFIRIIIARY, BRISTOL 2.

Editor: Nigel Lester Sub-editors: Susan lvlcEvoy (Fleviews) N,lartin Plummeridge (Regulars)

Andy Tutt (Features) Kieren Smart (Preclinical) Business lranager: Sharon Drewitt Photography: Shorna Lonqf ield Art Work: Simon Grange, Andrew Demie Typesetting and Printing: lmpress (Post of nursing editor, newly created but slill vacant. All interested enquiries to

editor please.)

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TheWorldbeaters

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CONTENTS

Now available 20th Edition

BAILEY & LOVE'S

SHORT PRACTICE OF SURGERY Revised by A. J. HARDING RAINS, CBE, MS, FRCS

and CHARLESV. MANN, MCh, FRCS with 36 specialist contributors 1355 illustrations (236 coloured)

xii+1406 pp.

t35.00 net.

H. K. LEWIS & CO. LTD 1

felO1-3AT -4282

36 Gower Street, London WC1 E 685

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INSIGHT: FIRM GRADES

Wheels of Fortune! THE SURGICAL student who was awarded a 'B' by a consultant whose lirm he was not on' The psychiatric student awarded a C+ by a consultant he did not work with. D's to the shy' A's to ihe extrovert? ls firm grading really as haphazard as we all think? Peter Jenks tinds that the present method leaveJa lot to be desired and wonders why, when a working alternative exists, most departments are not taking a more thoughtful approach to their students grades'

While irm grades undoubtedly re-

firm grade. Such a system is successfully used

ward the outstanding studeni, very few firms differentiate the abilities of the rest, block grading everyone else- Such a system seems unfair when the block gradevaries from firm to lkm and on the same firm at differenl times of the year. No separaling out those who have and have not put in the same eflort on a firm not only leaves people disgruntled but is also damaging to motivalion: "A C+ is all you can expect. It seems equally ditficult to fail a irm, which may be a good or bad thing depending on how you look at it. A D'

by the

may not be qreeled with unbounded enthusiasm by all students bul would provide some idea of what should be

covered and also give much needed practice in the formal presentation of

to be

Some firms do make an effort lo objectively assess their students. However, it is the discrepancy in the

last year.

ways in which this is done which gives rise to lhe need lor a standard scheme. Such a scheme has actually already

awarded to people not on a particular firm, with one such anonymous person managing to pick up a B

Such criticisms would nol be so imporlant if firm grades were the innocuous things it is tempting to think they are. Aparl trom the fact that most people would like some objective

assessment of their progress lhroughgrades assume greater significance in Bristol

oul lhe clinical course, firm

house job inlerviews and do count in varying degrees towards finals.

Obsteirics &

grading system, also greatly assists the sludents with leamang the work covered during the course. Whilst accepting that current clinical and teaching commftmenis may make such a system appear unatlraclive, such assessment should not take too much time and could easily iit into a teaching session in the frnalweek ofthe firm. The prospect ol continual exams

running off with the deparlmental secre-

attending. lt is not unheard of for grades

a fair

would seem roughly equivalenl lo assaulting you consullant and an 'E'to tary! ln fact, anyone disappoinled wilh their grades could well do betler not

Department

Gynaecology and, as well as producing

been proposed by Galenicals

with

assessmenl @vering three areas: (1) Medical knowledge, as evaluated by a short informal exam. (2) The ability lo examine and presenl a patient assessed at the end of the

frm. (3) General appearance, atlendance and atlatude to the frm, assessed in the usual manner of the existinq

patients. ll is these aspecls which would be the main benelits of a re_ vamped system- ltwould be nice to see such a system adopled by all teaching firms

And In The Blue Conler . .

Having opened up the firm grades debate we iust couldn't leave it there. A copy of this article was sent to all departments involved in undetgraduate teaching, inviting them to comment on the points raised. Many points were repealed by different departments, and the following excerpts indicate the views of some of those involved in the assessment of students,

Dr. Coles, retdng clinical dean, recalls the aims of ihe curenl system,

of the doubt principle applies,

of the assessors, Whilst confessing to

used by rnost deparlments, on its initia-

"exam circus of spot questions and viva questioning", Dr. Black mmments that-

being 'flattered by your comments", she adds the warning: ". . . don't make O & G out to be the ideal, because I

tion over 20 years ago: ''The idea was that the assessmenls should be made by the group teaching the student. This includes ward sister, house officer, regisfar and consultant, They were nol to be 'mini exams'." He concludes that: taken alongside oiher assessments . . . lhe firm grade is a reasonable measuremenl in a clinical situation."

...

Dr. Barry, clinical dean elect, in a thorough analysis, raises the following points:

''Most of the perceived problem is caused by 1) the very small minority of consultant ims who appear to be somewhal casual in assessing the students' grades, 2) unrealislic expectations by the student body on what the grading system can achieve.

''...

the subjective qualities (diligence, attitude, ability etc.) are important to patients selectjng their doctors

and also to consultanls selecting lheir junior staff. Am end of frm examinatjon

would be disastrous and negale the whole concepi of an on-going assessment.

''C+ is a good grade with which a student should be well pleased. The average is C.. . Weak students should be identified early in the fm and helped

to improve.

According to Dr. Black, Senior Leclurer in Anaesthesia: ''There are very few who do not feel hard done by at some time or olher. . .

our aims in the assessment are to identify those few ... who are sufficiently under par lo conslitute a danger to the public. ln anaesthetic teaching:- "Each interaction beiween teacher and student tends to be limiled to no more lhan 2 or 3 hours. For the most part 'the benefit

On the subject oI an end of flm

"Doing this

-,.

would require us to

dream up a fresh batch of 20 to 25 questions once every 2 months. lf there were too many repeat questions, we

are confident these would soon

spotted, so thal we would soon again have a situaiion which was ineffeclive or unfair lo both." The shortcomings of an end of frm

exam were lhe subject of Pofessor Famdon s comments for the department of surgery: "lwould have thought

that repeated contac{s by multiple members of stafi over a pedod of weeks would give a belter measure of lhe adequacy of medical knowledge held by a student. . , . There is no good reason ,{teaching and audit ol student leamjng dudng an atiadrmem is effeclive that a sfudent should not leave a firm with a comprehensive selection of knowledge of surgical matters and ability to examine lhe surgical paiient." Some might say lhat is mlher a big if. Child Heallh and Neonatology draws on an Amalgamied mark' of dinical

assessment, dissertalion, viva voce,

South Westem altacfiment and a sepa-

rale neonatal assessment comprising M.C.Q., slide quiz and written dissertation- Dr, Alan Emond, Lecturer in Child Heallh; says: We make great efforts to be intemally consistent and to try to maintain lhe same standard ihroughout the year, although. . . you will appreciate how difficull this is as ihe level of compeience of sfudents varies considerably ftom the beginning of the year to the end." Gillian Tumer, Consullant Senior Lecfurer in Obsletrrcs and Gynaemlogy feels: 'lhat a mulli-person approach is important because of study leave, holidays. sickness and such like on behalf

assure you we are not, but perhaps we are getting there little by little." Sorting out the B s and C's takes lime and on a two week clurse this is no easy mafter. Richard Maw, departmenl

Otolaryngology, writes: "Whal we

really need is a full-time academic inpul for the E.N-T. Department for at present we have no full-time University staff aM allthe teaching is done either by Senior Registrars or consultants. " Mr. Gordon Bannister of the Department of Orlhopaedic Surgery feels suffi-

ciently slrongly about this subiect lhat he has writien a paper (Ref. l/edical Education 1987, 21, 59-62). The paper

concluded that the various forms of

assessment considered Consultant "lf used as lhe sole cfteria of assessmenl in

Assessment was least reliable;

short murses it may fail both to reward better students and differentiale those too weak to practice effectively." ln ophthalrnology there is of course a

quiz to aid the assessor. Prot. Easty insists

thal

lhey appear arbitrary then

this is of course not intended, and is probably not in fact true'. We have heard of at least one c+ for nol even attending the course!

Perhaps the final word from the assessors should go to Dr. Emond:"My personal feeling is that students get unnecessarily disressed about the firm grades, and seem to forget that the

final lvlB is a pass/fail exam. I cannol comment on the siqnificance qiven to

firm grades in house-job

interviews,

except to say that I think the arrangements aie made ridiculously early in a

student's career.' Thereby hanqs another debate.

Continuous Harrassment. David Jewell of the General Practicâ‚Ź Unit offers the most radical solution of all, an ending to grading but a beginning of rcal assessment,

The problem of firm grades are aF ways with us. Like wailing times lor

'ilins' in genepractice, perennial ral il is a talking point that defies any definitive solLrtion. I have antenatal palients, and

been discussinq it not must during mv years of being a leclurer in Southampton, but even as far back as my own time as a clinical student. Here, you may say, is another buml out case patonisingly parading his sense of deja vu in order to resist change. Well, not exactly. lf the problem has been around so long without solution, one is entilled

to ask whether there is an underlying reason for it,

The unde ying cause ofthe problem,

I should like to suggest, is confusion about the purpose of firm grades. Are they a form of conlinuous assessment (known by one professor of general practice as @ntinuous harrassment)?

Are they

beauty contest

help

decide who gets the plum house jobs

as Miss (or [/aster) Bristol

Medical

School 1 989? Are they a swots' charler, rewarding attendance and general toadying over inlellectucal excellence? Or the precise op@site, rewarding lhe brilliant absentee over the @nscientiously attending artisan? Are they indeed, as many will have wondered in momenls oI quiet conlemplalion, a syslem of social conlrol, designed to ensute unquestioning attendance? Or are lhey, and here I am showing my own preference, syslem of formative assessmenl, providing not a melhod of grading but detailed feedback on stu-

dents' strengths and weaknesses

differenl areas of learning?

Here is the root of the problem-

imagine that anyone reading ihe above

will have answered yes' to several of the above questions. However il would

unreasonable lo expect a single assessmenl system, even one prepared with a greal deal of lhouqht

be quile

towards its faimess and obiectiviv, lo fill more than one or two of the above

is reduced to a single letter lhen it is diffcult to understand what it means, and it is not surprising if the system be@mes a more or less arbitrary labelling of students according to the prevailing prefunctjons. When the endpoint

iudices of the teacher who happens lo

be organising the exercise that term. Peter Jenk s article illustrates my poinl neatly: if I understand him correctly,

what he asks for is feedback on his own

progress, while he reports the Galenicals opting for a summative assessment of ability in which siudents are maiked against each other a tradilionally British exam in which the leamers are sorted into one or olher calegory of gâ‚Źzing animal. Before descibang my own solulion, there is one other important apsect of the system. Weshould all, teachersand students alike, be wonied about the

'tyranny

of examinations. Much has been witten about examinalions determining curiculum (rather than the other way round), and lhe wony in medicine is relatively short courses, followed by assessmenls which enmurage a superficial attilude to leaming in which facts are absobed for the exam, only 1o be quickly forgotien afteruards. Students are entitled to. and should be asking for, rather more from their teachers. Whatever melhod is used, the aim should be to provide studenls with detailed feedback on their performanceThe categodes would not be the same in all firms, but could be, for instance,

attendance, appearan@ (although if I were slill a sludent I should regard it as an insult to be a graded on thal), knowledge, clinical skills (and at best this section would be further subdivided into interviewing, examination skills, managemenl, etc.), relalionshinps with staff, proqress duing lhe and

im,

keenness. Whelher the assessmenl is based partly on a formal exam or only on teachers' opinions through the firm, sludents should have the opportunity to

discuss it with teachers face to face. Then, if it was slill thought to be helptul a grade could be assigned, but at least

students would understand how the letter had been anived at, and perhaps

the full assessment schedule could be made available with lhe studenls' permission if it were needed for any of the

sittirE down with lheir sfudents to discuss progress, while giving the appearance of some superior scientific insbument being applied. As teachers we need to get away from the superficial attitude engendered by our present system io one encouraging a deeper approach. Whatever melhods are used, lhe pdmary puPose should be to help

the students in their leaming, wilh any other purpose cominq a long way tlehind.

subsidiary purposes. I should like to see an end to grades. They tdvialise the learning, divert the teachers trom the more difficult task, both technically and emolionally, ot

THE TANGE CTINICAL MI\NUAI SERIES lnternal

Neonatology

Medicine Dlagno€ls and

Easlc

lherapy

J. H. Steln Univers,ty of Health Scien.e Cent:et To berevised

lelas

w€ryother year, this poc[et-

{7.d'el.'en.€ ofi€'i.6n.+ d.rr'led

coveraCeotsigns,symptons,laboratory tesrs,diaSnostic proceduresand nedicar therapy foralr major,

(onnon dis*ses.

FocussinConwhatthe

uernedstoknowin

theclinical*tting, itincludcsallstcpsol

l9aa

542 pages a3a5-4041-/r

Manags ent,'On-

Call' Probleln3, Dlseases, DruAs

Spt.l

T. L. Gomella John Hop ns Universtty

M. D. Cunnlneham Univesity of Rentucky Thisnscompactmanual pr@idesessentia intordationlo nanage thenormaland sick ntubornchi d.Themanualisdvided ntotive

*ct

on5, Bas c

roceduies SOecia

Pro(edures, Disea5esand Cond tions Neonalal Pharmacology, p usa uiique

*crion

'On-CaI Probems Theeasyno-

s dcsigned to nake c in .a euidelines.eadilya(cessib eforthose perforninC. 5p..il. pro(edure diagnosin€ a prob em manacincadiseaseor admin sterincand mon tor ngdrugtherapy lgaa 4oapages aJg5-667G7 Spi.al

u$ format

Psychiatry Dlagnocls and Therapy J.A. Flaherty, R.A. Channon, J. M. Davis all of the Univesity ol lllino6

Clinical Pharmacology

ne pdk.L5ized manual provides ready.c(esrtothedia€nosisand manacemenrol all inponant, conmon

Tnis

psrhi.tric.ndbehviourdisrdeEwith debils ot patied history, signs and symptoms There is a strong locus on

turl

th.

diffee.tialdiagno*s,dia€nonic

asssment(in.rudinethc DSM-I r l-R c.iteta) and the crfidltherapyfor each

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Pligare.oRralfutmofpj4boleg't

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Universw of califonia rnis rcturen.€ provldesinrornation ondrugs foruse in generar med.ineand isorganised by maiordru€Croups,as!heyapplyto clini.al indicarions and organ system dileases Ea.h drugdes.ripuoi cov€15 Enin€n!palll oprrvsio opv,flrerap€ut r €tionaleand mechanism. pharmacokineti.s, jndi.ations. containdicatons, warn ncs, adver* r€actionsand ntera.tions lgaa 44apages Spiral

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ol two) and 'Feel Ljke A New Gran" with the charming Dr. Murphy-

Just imagine the lhrill of passing through a total body scan and seeing your organs light up on a screen for all the family to enjoy. And in relum all we ask is a little of yourtime and a lot of your money. Yes, give us the dosh and we'll feel better even if you don't.

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THE BRI: BRISTOL FEELS BETTER FOR IT lssued by Saatchi & Saatchi on behalf ofBRl lnc PLC in a!3 million campaign to get people io think more positively about running down the NHS. 10

Bag-Age: A Glance Through

The Black Bag Archives.

Part ot an article from our predecessor, "The StethoscoP", published monthly at the turn ot the century. In 1900 (the eadiest edition so lar unearthed), the new Radium lnstitute had iust been opened, the University had iecerltly been granted its charter and Bristol's senior surgeon had the lollowing to say at a local B.M A. meeting about

the increasing need for biochemical and physiological knowledge: A mere 40 vears ago, 'Black Bag 'lt is appalling to think of lhe number were once more available at a cost of

monlh of lectures the studenl of lhe fulure will €4 16.s 6d, and Neo Epinine (isopropyl have to attend. One may think that by noradrenaline sulphate) was being old Nalon;l Heafth Seruicei ,.The profession has resigned itsell the time he reaches that part of the haibd (by the drug companies at least) to something trom which there ap@ar6 curiculum when h€ has attended as the new trealment of choice for lunacy demonstrations (sic) he will be asthma. to be no eacape." Pre-war qualitv ophlhalmoscopes well qualifed lo become an inmale.

was comlno to_terms with the 3

Borborygmi. "Some people do not eat meal . . . we calllhese people vegetarians. Some do not €at any animal producls al all. We call them vegans. " A,E.R,

"Faecal inconlinence

vedtable

pool of sufiering." K,WH.

"Flow meters are incredibly

simpte

lhings to use . . . even nurses can use

them." K.W-H.

(Noxt issue 'Eloborygmi' returns under its new title 'Heatohballs'. li you have any words ol wisdom you've picked up on the rounds, lot them down and pop

"We can take read."

the haemoglobin as K,W.H.

them ih the Black Bag pigeon hole, Dolphin House.)

Auscultations . .

Firstly Perlect Pizza have asked that we thank all the pre-clinical revue membeas lor raising lhem so much money this year. What a shame you don't have the budget ot the clinicals you could all have had gadic bread too! Captain Sensible of the Good Ship The third years yawn continue most of lhe fourth year are not ashaGalgnical conlinues to plunder on the to - sigh - give great cause lor med to show their true colours pink high seas of the London school. And concorn,TTzz-zz-z'. Our advice is that for the boys. you all slow down before you burn oul. Finally, wele not jusl here to start what a treasure her lalest catch is! prove beyond doubt The parenting scheme has linally run rumours we squash them too. So we The Wendies that the only way to win is to put your aground with dozens ol parents/ must state quile categodcally thal conbest players on the opposing team. But chiHren complaining they iust can't trary to what you may have heard, keep playing lads, it's the only way recognise each other with clothes on. Beverley lrarshall is not running the The Valenlines Partv showed that BRl. you'll ever gel a B from Bartolo. 11

INTERNATIONAL: India and New York. You could not choose two more difterent places, geographically and culturally at different ends of the earth. The question is: where would you rather have your baby? Nigel Lester looks back on a recent birth passage to lndia while Andy Tutt reports on life in a Manhattan maternity unit.

Born in the USA. Litigation, the big'L'word. lhave heard stories ot a surgeon being sue_d_Ior creiting a less than chic scar on a woman weighing in at over 3O0 pounds. what if I werd to deliver a baby that wasn't cute enough to fultill the American dream? Would I spend the rest of my days washing up in Macdonalds paying off a two million dollar law suit? Lenox Hill Hospital is on the 'Upper East Side' of Manhattan, home lo lhe cily s rich and lamous. lt has a relalively large obs and gynae department, handling about 4,000 deliveries a year. For the majority, antenatal care is aranged with lheir private obstetrician and takes place in his office. The mothers only attend lhe hospital at the time ol delivery, where the obstectrician will deliver the baby personallv. A great dealof doctor shopping goes on eady in pregnancy. Expeclant mums wanl to find Doctor Right'. lt would appear thal some obsletricians woo

prospeclive clients with promises of ''pain free labour with minimal distulbances lo your social life". Nlore than 90% of mothers wanted epidural. Al limes one could have been foEiven tor confusing lhe delivery suite with lhe catwalk of a Paris fashion show. N,lalernity wear by Chanel and Gucci, make-up by Lancome and han by Vidal Sassoon. A marked contrast to Molhercare, Boots No. 7 and the unisex salon on Colham Hill. One woman ar ved on lhe delivery suite asking if she could be induced there and then. The'tump'had

apparently become "simply too unsightly . The Caesarian section rale in the hospitalwas 28%. This may seem very high bul is only slightly above the American average. One ol the older obstetricians explained that he had always previously delivered his breech

babies vaginally unless lhere was a posfive indicaion for Sec{ion. Now it is slandard practice to perform Caesarian section breech presentalion. Consequently, Iew of the younger obstetricians know how to deliver a breech ard those thal do dare not. ll seems that

any degree of fetal mobidity can be blamed on vaginal delivery. Obstretdcs attracts the highest insur

ance premiums

of any specially,

$100,000 per annum per head in New York. Despite this, the insurance companies only cover lhe practitioner for $1,000,000, wilh a lunher million being provided by the hospilal. Some law suils in obslretrics can end in awards in excess ot live million dollars, leaving the

doclor to lind millions trom his own pocket. Enough to put You oul ol practice tor life. ll i6 easier, apparently, to delend lhe complicaiions ot caesadan seclion in @urt, lhan il is to delend

laulty vaginal delivery. Thus ihe

caesarian rate conlrnues to soat,

For those not tortunalo enough to aflord the six or seven thousand dollars for pdvale care, care can be provided by the hospilal's iunior residenl staff,

they run an anle-naial clinic in lhe hospital and will subsequently delaver lhe molhers. This seruice will only cosl you $2000 all inclusive, or may be paid by Medicare, the U.S. equivalenl of the D.H.S.S. ll is in these clinics that the real lile problems of New York come to light.

There is an increasing drug problem, with a signifrcant proportion of mothers taking heroin, cocaine or 'crack'. This isn't a comrnon prcblem al Lenox Hill, although on two separale occasions women were found smoking heroin, and snorting cocaine on the delivery suile. The prcblem is much grealer in the city hospitals ot Queens, Harlem and the Bronx. lt was rouline praiice 10 perform a urine drug screen on all mothers at the clinic, and similady to soeen lor Hepatitis B. The frequency of viral infection here is so great thal doctors are very reluclant to transfuse patients. 5% of the Lenox Hill blood supply is eslimated to be infected with non-A non-B hepatitis. D€spite the 'no frills' atmosphero of ihe clinics, with motheE sitting in lines wearing nothing but paper gowns, lhe standard ot care was very good. The

logic pehaps, being lhat lhe

less mon€y you have, the l€ss lik€ly you are to sue. Any dreams I had about lrealing lhe gynaecological problems ol lhe dch and

famous, were sadly unlounded. I was kept at lair distance from them . . . al least whils lhey were conscious. ll was

rumoured

al one point that

Bridgitle

Nielson, one lime wife ol Sly Stallone, and somelime girllriend of one of lhe New Yo* Jets, was coming lo Lenox

Hill lor

gynaecological operation. Sadly lhat all fell through, along with my gynaecoloqical career in Beverley Hills.

'Say Aaaargh' Talk about patient's righls. Call it Karma, call it Nirvana, call it bedside manner doctors sure know how to handle their customers.

security quard aren'tenough, the lndian

patient who incurs the wrath of the doctor will at best be shouted at but

And this nay sound like a bad dream, fun ft's true. Sevenl week ago, a doctor at the Employees State lnsur-

risks being shut away and possibly

having his prescriptlon torn upThose 'lucky' enough to be selected tor teaching purposes will be retained in a side room. A parade ol students will

prod and question him, and then he'llsit

for an hour or more through a teaching

in a

ri:"hs.:

language he doesn't

understand (fortunately for him) until he is curtly dismissed willDut a word. Thank you very much ldr. Krishnan, I'm sure you realise how helpful you have been for the studenls. Or what about the lady who suffered a fractional curetage without anaesthe tic under the disinterested gaze of not one but seven students. Her tears of pain and embatassment were dismissed by the doctor with a disapproving qrunt.

ln fact some of lhe lady doctors of a certain 'OG' department were a most formidable group. Their severe manner rivalled that of lndian Airline stewardesses (the same caste Pefiaps?) On one of my tlights, a stony faced stewardess setlled a dispute over cabin storage (a continual problem given the lndian understanding of hand baggage to mean everything you can carry in two

lndian

Whal a shock lo retum lo lhe pussyfooting niceilies of a Western hospital. How I miss lhe opportunity to have a good yell and release the stress of lhe day with a spot of patient bashing.

Take an average clinic lor example. queueing for hours in a crowded conidor and being beaten into line by a

session

.,fM outstretched arms) by telling the pas' sengers to "shui up and sit down Sir". He didn'i enjoy his med either. Such can be lhe ierocity of an lndian ob6telrician. Ard nowhere is the crud lo be knd' approach more in evden@ than in a labour room a veritable battelfield oI yelling doc{oF and tearful patients, Unless of course, like my frst delivery, you sulfer in silence un{l the

head is about

ance dispensaty at Ajmei Gate, Delhi, had to cau in the cops lo get rid of an unwanted patient. The kttels cime? Going to the dispensary to collect some rnedicines he was entifed to under the ESI scheme. What happened was truly shocking: the doctor who had to sign the prescription slip, threw it back on the

poor man s face afu gBhed him away, after which the polbe wete ca ed in to lathidBrge hin. The pafient, wlb was saved only by sywathetic onk)okers at the dispensary sti doesn t ktow what

hit him. luhat arc

the soraled

'noble prctessional in the counry con-

hg to? 'The lllustrated Weekly of lndia

crown, let out a

bloodcurdling scream, and give birth in under five seconds. ln lhis case mother and baby were sent packing withoul so

mudr as

form from the doctors.

Obviously an experienced cuslomer

Do-It-Yourself: 1. IJAKE YOUR OWN SNELLEN CHART collect the letters exclusively from the nexl 23 issues of Black Bag.

(Ha, ha. Ed.)

NEXT ISSUE: Make your own Pocket

I\rRl

for this you will need sticky back plastic and two empty washing-up liquid bottles. 13

The ^{rrrrY offers medical students riruch more than

justf6,354 ayeaft

If you are a student, rnale or female, at a British medical school, you could be eligible for a Cadetship with the Royal Army Medical Corps. You'll need to have passed your second MB or equivalent. And you'll be required to attend an Army selection boald. But you'll get !6,354 to continue your medical studies in the frrst year. This increases each year thereafter When you become Fully Registered, to prepare you for your frrst appointment as a Regimental Medical Offrcer, we will send you on an introductory course which lasts about four months. This course includes training

Sand

hurst, training in administration and field medical organisation at the RAMC Training Centre and in the various asPects of Military Medicine at the Royal Army Medical College at Millbarrk. Then, it's six years in the Army, starting with the rank of Captain. By converting to a Regular Commission you cai, or course' stay longer, until you're 60 ifyou wishAs a doctor in the Army your Practice will be much the same as a good civilian one: fully equipped and professionally sta.ffed. You could be working in a group practice or on your own; though you'll be entirely respon sible for your own patients, be they soldiers or their families, rather like a busy G.P. But don't think that, because you're in t-he Army, your charces for study wiil be in any way limited. While still in clinical training a number Th.

Am.d

Fu^

of selected cadets may, with the approval of their Dean, undertake elective attachments at Military Medica.l Units in Germany, Cyprus, Hong Kong. Nepal or USA And you'll have the same opportunities as in civiliarl life for your post-gr:aduate training in General Practice, Community ald Occupational Medicine or one of the Ilospital Specialities. But a doctor's life in the Army doesn't stop there. As an offrcer, you'll be able to

ta.ke advartage

of a wide range

sporting facilitiesYou'll a-lmost certainly travel abroad, and your social life will be busy too. Many of those you meet and work with will become lifelong friends. Finally, should you decide to leave the Army on completion of your Short Service engagement we will give you a very useful tax-free gratuity. How much depends on the length of your initial Cadetship and the amount spent by the Army on your medical training. Regular and Special Regular Commissions are pensionable. For further details Please contact Major General (Retd.) R. N. Evans CB FFARCS' Dept. 0788, Royal Army Medical College, Millbank, London SWI 4RJ. Tel: 01-970 4466,Ext 8120He'll send you our blochure, 'Doctor in the Army,' and arrange an interview.

#nt-yfficer

dd Equtl OlrttutuE Ea(n fm, uaiz A. t

afdt nu' Rtbtiw A'1

1976

So You Want To Be

A Neurosurgeon? Peter Garrard on how not to 9o about raising funds for research.

A preclinical Dean once arranged for a neurosurgeon. A lew weeks earlier, having just tinished read-

me to meet

ing Michael S. Gazzaniga's Bisected Brain", lhad wdtten to the author to tell him how excited I had The

been bythe book and by its implications

for the tuture ol mental phibsophy, which was my principal preoccupation.

By return I received a flatle ng

and

unexpected invilation to spend a year working in his laboratory in Now York. I hurriedly wrote a letter ol unqualified

acceptance and wailed lor his re' sponse, dreading that it would all tum oul to be a mislake - an eror in lhe automatic addressing subroutine of his

word-processing softlvare, or just a dry marlini on an empty stomach. To mY roliel il was neither ot these, bul to my dismay I was reminded that research costs mon€y: I was lo g€t back in touch as soon as I had 'identified a source ot

tunds". Just where lo begin looking for such a source I had nol the taintest idea, so

inslinclively lumed to the preclinical

Dean who, even if his repulation as a benefactor fell somewhere short of a Gulbenkian or a Guggenheim, was a proven sourc€ of practical wisdom. He

recommended lhat I should lake mY problem to a friend of his, a nourc-

surqeon who was experiencod in making-granl applicalions tn lhe neurosci' ences, and whose sterling qualilies he

summaised in four words on which I would like to be able to ofler him the copywright for his lombstone: Splendid chap. Balliol man.

Thanking heaven lor preclinical Deans, I set out to catch mY neurosurgeon. He turned out to be no easy quarry. ll he had a phone number he was very much too splendid to tell it lo British Telecom, and if +!e was golfing,

he was much too Balliol to carry a cordless phone. At long last I reached him, and discovered that he would be only too delghled , dear boy, to meet me and ofler whatever advice he could. so one october afternoon I set off for Frenchay Hospital, having only the vaguest ol notjons as to its whereabouts, and only fifteen minutes to reach it. Fifteen minutes laler I was slillon the

M32, too busy invenling excuses for my

laleness to notice that the fuel gauge needle of my car was covering lhe zero.

I\ry heart sank as the engine began to weaken, then spluttered and failed. by great good luck I had reached to top of a long downward incline, and I managed to coast all the way to the end of an oxil lane, where I rcluctantly applied lhe brakes, and stopped ignominously on the edge of the roundabout. Without thinking, I got out of the car and ran to the nearest corner to look for atelephone box. There was none. lran to the next comer and caught sight of the roadside signpost of a large busF nossmen's hotel. I ran lowards il as fast as I could. Was there a phone? Yes. Could I use il? By all means, Ivly neurosurgeon @uold not have been more understanding. Of course

its uneven grass verge, there being no pavemenl. Suddenly a familiar car flashed past riageway and ran along

me, and ltumed around to see itwailang

by the roadside some fitty yards back. I sprinted towards it and as I came close lhe nearside door clicked ajar. I opened il and was about to offer some politiely fatuous apology, when I tound that I was at uncomfortably close quarters

with

a face no

long€r benign and

sympathetic, but dark wilh anger. From

reproachful index finger hung lho

missing k€ys. I grabbed them and ll€d. On entering his otfice a little later I was abruptly shown a chair. lt was one of those easy chairs with truncated legs that are not particulady comfortable but very good tor otlering to an intedocutor

whom you may intend to humiliate. From lhis interior vanlag€ poinl I could

thissortotlhing happened to us all, and just see his head and shoulders behind I was not to worry aboul being lale. He the dosk. lf I had thoughl for one would drive out with some appropiate moment thal the siluation was so bad conlain€r, take me lo a p€trol station, lhat it could not possibly gel worse, I and then back to my car. He did not was a crass optimist. keep me waiting for long, and when he "So" he began, intefiupiing a weak arived, in a jacket and car that were jest I was in lhe process of making, both sports, he made easy and Polite ''you want lo be a neurosurgeon do conversation. I felt a great sense of ' This was a qu o unexpecled misdelivorance as we sped from lhe filling plastic of canhister full but as mY grave was with a understanding, stalion petrol, back to where my oar lay akeady dug, and I did not really want to stranded. As I left, he b efly told me start construoting my cotfin, I otfered how to oel fiom whore I was to the only the mildesl exprsssion of disseht. "l\4arvellous job, you know, being a hospital,-then wilh a valediclory smile neutosurgeon' he continued.'Really and a tight U-tum, disappeared. The importance, and indeed the pur-

pose ot my visit, had almost escaped me dunng the course oi this episode,

and as I emptied the pelrol into my tank

I began once again 10 tehearse some ot the questions I would ask when I al

long lasl made il to my appointmont. The petrol in, and the cap replaced, I reached in the pocket of my trousers lor my keys. They were nol there. ln vain I scanned the ground nearby, and then the ignition, but the awful lruth was already clear lo me: I had leli them on

the passenger seat of mY

maruellous. Do you like fiddling around inside cars?" I nodded. "Well I don't see why You shouldn l be a neurosurgeon then. Really, as long as you've got a bit of basic horse-sense about cars, neurosurgery jusl follows on

naturally."

"l'm sorry" lsaid al lasl. "lthink You

must have misunderslood. l don l really

lo be a neurosurgeon. I just wanted a bit of advice about getting a want

granl for some research in neurosci-

neuro-

surgeon's car,

"Research? IvlaNellous business. I used to do a lot of lhat when I was a

spurred on lhis time more by desperation than determinalion. Following my instructions I tumed onto a dual car-

student.

Off I set again, again at a run, bul

had

paper

Published

cont. on Page 17 15

MEDICS AGAINST STT]DENT SLOANES

The Govemment proposes lo increase lhe number ol atudenl sloanes in medical schools' HOW DOES IT AFFECT YOU? 1. No Labradors. 2. lncreasing dependence on lvlummy and Daddy. 3. Only t1,000 a week allowance. 4. No working class dff raff. WHY DO WE WANT IT STOPPED? 1. Probable closure of all London Medical Schools because lhere is nowhere to palk a Range Rover' 2. Still no wo&ing class dff rafl. 3. Maggie ite. You may think it doesn't atfect you now but it does when you're in hosprtal as a patient later in iunior doctor will be treating You?

life

what kind of

Competition: Can you supply a suitable caption for this revealing shot of our esteemed leader? Winnang contribuiion will appear in lhe ne)d issue.

cont. tom page 15 actually. Lovely little experiment. I could give you the reference . . ."

"Well thal's very kind of you, but

really only wanted to know how best to

go about applying for a research grant fora year. I have an ofler ot afellowship in the States, and I want lo fund it. I'm interested in lhe higher funclions of lhe cortex, such as aesthelic judgomenl and emolion. I have some rudimgntary ideas lhat a lot more can be explained if we lree outsolves from the mentalistic

vocabulary."

I felt quite pleased with

lhis speech, and half believed that ihe interview had laken a tavourable lurn. Bul it hadn't. "You don't want to start getting bog-

ged down in all that, you know. I did myself ai one time. And thal business about monlal philosophy arising trom linguistic imprecisions . . ."

''Semantic" I cofiected.

"Linguistic, somantic, it's all the same. Besides, it was all sorted out in the fiflies wasn't it?" "Noi as far as I know, no." "Whal you reallywanl lo start getting involved jn is inventing. You can do research in your spare lime. Do it in your head. I was sitling in the baih the

other night and my hand quite blindly reached tor where the soap was. That made meihinklhere must be some sort of short-term proprioceptive memory. Marvellous thing the nervous syslem. ' I left Frenchay reflectjng on the lessons I had learned thal evening: never leave home without checking your tuel level; never try to interest anybody else in your reseatch; and never underestimale a neurosurgeon.

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People: The New Professor Of Surgery. Sue McEvoy and Nigel Lester had early morning colfue with the new professor

of surgery.

He's finally achieved a lifelong ambi tionl lt look a while to realise the mistake he had made in pufting Bistol 2nd on his UCCA form but that is all forgotlen now. Born in Shetfreld, Prof. Famdon has trained and wo&ed for most of his career to date in Newcastle, Atter a brief spell at Duke Llniversily in North Carolina he was lured back to Newcastle in 1981 with the offer of a lectureship. This was maybe the irst clear indication of his commitment to

me.li.,al education and students in

general (if his warm reception, excellent coftee and uncontrollable enthusiasm

during his participation in this yeals revue weren't enough!) So Brisiol appealed to him but the chance of a chak obviously sealed it. ll seems to have been a haPPY transition for him and his family, three children N,lark, Emily and James. Bristol, he @ints out is a lot like Newcastle:

(lhls could be controversial Ed.) A srnqle major cenlre tn a lalge area wilh a strong regional identity (impossible

accent and appalling wealher we might add) Prelerable, for the Prol. to the

ol the Big Smoke. The call ol the West C,otlnw might also have something to do with one of his amorphous mass

marn interests outside medcine the countvsde. Wth his long lime love of aoncuiure, nowadays mainly conlined to his back garden plot, we may see the establishment of a University department in Yeovil. ln surgery the Prof's research interest is in endocdne diseases and surgery of the breast, thyroid, adrcnals and pandeas. Again, there were hints of this in he ls the frrst surgeon we hrs have sooken ic who will openly admit to havinq been liom between medicine and surgery. I like to think ol surgeons as physicians with the added advan_

pasl

iaoe of beinq able to use their hands H;m, thal\,ii not do much io allay the olcl fear thal professors cannol opelale.

The Prof. is obviously enjoying his 'honeymoon Pedod ("PeoPle ha/e been vetu friendlv l but the questrcn

that vou are probably all asking ls will lhere be any changes? During lhe course ol dlscussing curriculum lea_ tured hiqhlv or' the list ol topics With Newcastle s 20 vear history of iniegration, possessing'perhaps the most radr_ cal approach lo course organ6aton ol anv school in the country' thâ‚Ź ls probabiv the area to watch and lhis is

lo speak out so lhe studenl verdict? ln his own words "l don't think lcould survive orobably the time

without student conlact" This is surely a man wilh which vou can do business. wP all wtsh him the very best of luck.

UNIVERSITY OF BRISTOL DEPARTMENT OF MEDICINE BRISTOL ROYAL INFIRMARY BRISTOt_ BS2 sHW

Telcphonc: ({1272) 2i{)000

?-9*, poinled Poooed over the road to see you the other day. but wasnl allowed in wilhout an appointment. when I humbly ttiit is piotessor ot Medic';e, it might be p6ssible to bend the rul€s a litlle. I was senl away with a 1ea in my ear' avoid interception by anO a AightanO tonier snapping at the cucci befers. I'm consequenlly sending lhis letter chez toiio in th€ lo every hosp1al dispersed boing daiedonian Securities lnc., sinie I'm not too keen on the conlents in the butch€ry department has settled in comfortably. I hope ho's happy to be here, even if he -rnt"rpurt nas naa to'eiinangb tlis 8 bedroom€d manor house in G€ordieland for an unrenovated garage in Clifton Perhaps.you miont aroo hm a fr-iendlv warninq about the local boys he pipped for lhe post. Rumour has it that they ve tak€n a sudden iri*.neU'.ufirrSiery, whi;h woutd appear somewhat outsde their usual line of wo*. Actually. I was Ether hoping iniE ""i iriii irii Ciniiiog" itrip'woutd get the iob, as between ourselves I wanied lo quiz him about this di€t thing ol theirs *tricn G oiovino ;inoutailv innetdctive, a! you've no doubt observed, Frankly, I'm getting a bit sick of the whole thing, asking to ieacti his students on me, and K.W.H. popping out lrom behind ddp stands.wilh *itti A.E.E. students '"ft"i "oistanity if,iilo6i of firgne"" on tiis lace-worn onty by those still capabl€ of fitting into their graduation suits Even thehop€l€ssly foil lheir I atlempt to condition medical every obscure a's icause of work in obesity malnaging fo it now, Modem M€dicine about xno*r*d 6r ine irrelevant withi lncidentally' no joi as yel from the publlsher you how vindictive these arty know tne illustralor riristak6 io upset ""-.nw th" on p. 112. I knew il was a 'llrtrjtion "rrinrji"g tvoes can be, - "1'rnii uor. bv the wav. for vour conqratulations following my recent honour lrom on high. ll's nice to get some |.""*nitioi' eueri if tf'" oi'o"rs ;nsist€ntiy pul my name undir "Services to the Calering lndustry" Do sllp over some with that case'oi Tatti;ger I managed to gel out of th€ Glaxo rep for essential research inlo iiniJiiiJ*i cin ""i"oi;i; gaslric emptying the eflects of alcohol on Yours at the helm.

oui

area

-l triir.v

iii-ii

Au. The Clinical Dean Elect

that his lirst priofty will be to attempt to who Dean tum the B.R.l. from lhe "bastion of Clinical newiv aoooinlod t*"6 ouei fro. Dr. coles wilh etlect gloomy despair" (he quoles ther prooa lrom Auqusl 1989. Dr' BaIry lkst came vious issue ol this magaztne) retain to 1960 suitable in nleasant envrronment, to Bristol as an undergraduale and aDart lrom short spells away in- ihe interesl and eagemess to learn that cluding a briet stay in America, he has he claims students lose within six Iound Bristol a 'very ditficull place to months of emba*ing on lhe clinical leave". AsClinicalDean, Dr. Barry says course. Any move in lhis directon will

conoratulations lo Dr. R E. Barry' the

surely be welcomed works in the B.R.l., students. doctors and nurses alike.

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A large part of learninq medicine is leaming a new vocabulary, and I can still recall the leeling of horror I had at looking al Gray's analomy and seeing all those unknown words. Every speciality has its own set of words that help

Proving Paternity. lmagine my surprise when the

smartly dressed young man trom Cellmark Diagnostics slood up and said he could prove the identity of my realfather using DNAfingerprinting! Unfonun-

al€ly, I'm noi sure the milkman still

blood (or hair roots, sem€n, elc) and various clever processes (including mend the appropriale furlher investigaelectrophorosis, "Southen Blofling", tion when necessary. Bocauso it uses binding with radioactive probe and X- the words made familiar by other discirays) produce an X-ray strip with a plines and has few special words of its

delivers (ooh errl) in our area anymore. DNA fingA touch more seriously erprinting, we wer€ lold, is now being used as (almost) ifiefutable evidence in

sorios of bands unique to that individual the DNAfingeFrint. Halfofthe bands will have been inherited trom the father and half trom the mother: Palernity is proved by matching those bands which

resolving civil paternity disputes, provid-

ing evidence in immigralion disputes

and in the identilication of ciminal

suspecls; a rapist was convicted using

this evidence for the tirsl time in a Bristol Courl lasl year. "So what is this technique?" I hear

you asking. Woll, DNA is oxtracted from

,ol

correspond with the mother's

prolile wiih that of the falhert and a criminalcan be identified by matching a samplefrom lhe scene ofthecrime with a blood sample taken later. Simplel Lot's hope the technique may also act as a delerrent lo fuiure pot€ntial rapists

and other criminals.

Leukaemia ln Childhood charity writes about lhe inaugural meeting and the background to thig home{rown

organisalion. On Friday 17th February the Bristol medics branch of CLIC was officially inaugurated. Bob Woodward, chaiman of the CLIC Trust, inlroduced the guesi

speaker, Prof. Baum, and then gave a short history ol lhe trust and ils work. He gave a very modest account of his own considerable personal devotion to the trust, which has achieved so much in ils shorl history for the care of children with malignant diseases. lt has

grown from the efforts of a few individuals sharing in personal tragedy lo an organisation spanning the Soulh West Reqional Health Aulhority and now pushing back the boundariesiof

monstratod in this book written by 2 Australian radiologisls. Atter an introduction to the technology of imaging it covels the resphalory, cardiovascular, skeletal, neruous, endoc ne and reproductive systems, together wilh the alimentary and urinary tracts. h ends with a chapler on 'intervontional radiology'

lioned.

The book is clea y written in short

cancer lreatmont, reseatch and most importantly complete support tor the

child and lamily involved.

own it bridges the pre-clinical and clinical gulf, and provides an easy route to learning 6nd revision of many ditferenl specialilies. This wide spread ol int€rest is de-

which intorosts many sludents and doctors. ln practice in mosl modern deparlments this is nol a specialarea standing on its own, bul an approach thal involves nearly all the systems men-

Charity Begins At Home David Mor.is, chairman of lhe new student bhnch ol lhe Cancer and

lo create an elitism amongst lhose lhat can understand them. Radiology is no exception, but has the advanlage of being the general praclitioner of the hospilal specialilies, since radioloqists have to know about the work ol each speciality lo discuss il with the consultanl, to be able lo inteprel the films taken on his patienls, and io recom-

This

approach ol taking health care to the indavidual and calefing to lhe individual needs is one which is sadly alltoo otten lacking in the NHS. A charity like CLIC

paragraphs and notes. lt does nol go into lhe subioct in great depth, but will inlroduce the reader lo the vocabulary

necessary to leel lamiliar with each subioct area. Each section starls by disucssing lhe appropiate invesligation to use, and then lhe appearances ol lhe

calers for the child s besl interests free lrom the constraints of a departmenlal

@mmon lesions found. ln addition ii has lhat essenlial component for any

budqet.

good book on

The evening continued wilh the presentalion of cheques. Nolably a donation ot !1300 was made from the 1988 Galenicals Clinical Rewe. The presentation was made on behalf ol everyone involved in the Revue by the director and producer, Nigel Lester and Bruce

future.

lols of good

can contidently recommend this book to any studenl who wishes to get an overview of not only radiology, but mosl clinical disciplines. Easy rcading at a reasonable price wilh lost of pic' tures. Not badl

Neal.

Thanks very much to all who came and for your support now and in lhe

radiology

illustrations.

W.D. Jeans

Poetry Corner. FareYrell Dr, Colc6,

(A poem on the r€tirgneit of ltr. Oolea a8 Clinical

Farew€ll Dr. Coles So you are leaving us. FarEwsll Dr. Coles, Farcw€ll.

Or should wa say adieu? Thanks.

W€ will miss you whoewr you are.

E.J.Thribb (94)

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