Autumn 2016

THE BLACK BAG

BRISTOL MEDICAL SCHOOL Autumn Term Ed., 2016 1

Editors-in-Chief: V.K. MANDAGERE & M. Y. QUINN Illustrator: S. N. MOHAMMED Sponsorship Director: P. MODI Crossword designer: A. CLARKE Contributions: B. GOMPELS, A. YONGA, T. J. ROBINSON, M. THOMAS, R. J. CLARKE

@BlackBagBristol The Black Bag theblack_bag The Black Bag has been the medical school magazine since 1937. Published thrice every year, we are the voice of both students and alumni.

Initially designed by the Faculty of Medicine as a scholastic publication, the Black Bag was taken over by students in the 1970s and replaced with a slightly less-polished perspective on the raucous life of medical students.

Today, our articles range from the informative to the satirical, providing a platform for both thought-provoking discussion and comical musings. We look to reflect on the wide variety of Galenicals sub-societies (sports, music, drama) as well as to evaluate (and lampoon) the current state of the Bristol Medical School and the world of medicine.

The Black Bag are always looking for contributors. If you are interested in writing for us, please email: blackbag@galenicals.org.uk 2

THE BLACK BAG EDITORIAL GALENICALS INTERVIEW with Dr. Fiona Godlee

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SATIRE Medic Tribes: The first year shmedic Cartoon: TURNTing point

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Grey’s Anatomy: a snapshot into the medical profession?

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COMMENTARY Climate Change: it is our duty to respond

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Quiz: Which epithelium are you?

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COMMENTARY THE NOTORIOUS R.O.B.

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NARRATIVE Homoeopathic Elective

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Crossword

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EDITORIAL surprising to you all, the first of our foreign correspondents is not a Bristolian. Rather, he is of a university equally notorious for its Oxbridge rejects. Robert Clarke of Durham University writes on the effects of globalisation on medicine.

With the political events of 2016 shocking many of us to our very core, you, our trusted readers, should find comfort in the musings of our first term’s edition of THE BLACK BAG. Upon taking our new positions as Editors, we have made a few changes. Although the THE BLACK BAG fashion is to serve exclusively riotous banter, we have introduced a COMMENTARY section with more serious topic discussion. A particular mention is required for Mia Thomas, who reports from the UN Climate Change delegation.

Medical students are often accused of being insular and closed-minded.

In what we hope will become a regular tradition, we have decided to introduce a foreign correspondent (a non-medic) to this edition. Perhaps

As I’m sure you well-read fellows will notice, a particular highlight of this issue is the exclusive interview with BMJ’s Editor-in-Chief, Dr. Fiona Godlee. With her wise words and guidance, we hope that some day, THE BLACK BAG will eclipse her journal in the not-too-distant future. As per the rest of the magazine, we hope you find our (and our contributors’) fresh take both mildly informative and deliciously whimsical.

The Black Bag is Bristol Medical School’s answer to the Private Eye, poking fun at our chosen profession, our teachers and our building-less medical school. We hope that once you’ve read it, your brain will be saturated with ideas for future articles. And with each passing issue, THE BLACK BAG will rise higher than the prices in the Source Café, spread faster than an outbreak of chlamydia at UWE and last even longer than a Clinical Epidemiology tutorial.

Yours, The Editors.

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GALENICALS President’s Speech To be read in the voice of (President Elect?!)

Donald J. Trump.

My fellow medical students… I am here today to talk to you about one very simple thing: Galenicals. I have to tell you folks I mean I don’t mean to brag but I am an unbelievable president! I am making Galenicals great again! I mean honestly just let me tell you about some of the major strives forward we are making this year. Just one example are the amazing drop in sessions that we are running this year where you can talk to me and my crack team of subordinates. No one else thought to run drop in sessions. Those drop in sessions are an amazing idea. I came up with that all by myself. Drop in sessions. Drop in sessions. Drop in sessions.

I have to tell you as well folks those private schools are laughing at us.

So many of their students get in here and it has to stop. They’re bringing champagne, they’re bringing quinoa, they’re charming. So I, Matthew A Brimfield, are calling for a total and complete shutdown of all posh people entering Bristol Medical School. I mean what about all those state educated people? We have to make sure that they have a fair chance of becoming miserable as well!

Finally, before I leave all you lovely people! Do you know what annoys President Matthew A Brimfield?

When all you folks who don’t drink out there are stopped from enjoying yourselves by a big (beautiful!) wall of social injustice. This is a classic example of how the old corrupt system stopped your voices from being heard. Well Matthew A. Brimfield is on your side and I pledge to organise more socials less focused on drinking and more about actually being social.

It’s been a pleasure typing this out for you and I hope you can now better appreciate my genius!

PRESIDENT MATTHEW A. BRIMFIELD: MAKING GALENICALS GREAT AGAIN

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Music Galenicals Music has had a great start this year. Both the choir and orchestra have got a large amount of members and we are currently working towards our Christmas Concert on the 10th of December (stay tuned for details). The orchestra are playing a varied repertoire ranging from Bizet to John Williams and the choir are ranging even wider. We are always wanting new members and there is still time to come and join before Christmas!

P.S. rumour has it that a certain lecturer famed for bright shirts has just joined…

Theatre We’re incorporating the major medic drama shows under one umbrella. We also want to get medics interested in producing, directing, costume designing, writing and being stage techs – no prior experience necessary.

The main shows: • Medics Drama (usually between January and March) • Pre-Clinical Revue (PCR) (usually in March) • Clinical Revue (CR) (usually in March) • Cancer Tales (performed to 1st year medics as part of Whole Person Care) • Vagina Monologues (in conjunction with Bristol Obs & Gynae Soc in Feburary) To sign up, just drop an email to galenicalstheatre@gmail.com and we’ll get back to you!

Sports Rugby: Wins: UBHRFC vs. Penninsula: 27-0; UBHRFC vs. Bernadette’s 82-5 UBHRFC vs. Old Colstonians: 62-10 Draw: UBHRFC vs. Bristol Saracens 26-26 Lost: UBHRFC vs. Thornbury 17-24 Tennis: NAMS, Leicester: 4th overall (out of 7) (Girls came 2nd, Boys came 6th) 3rd December: VARSITY AGAINST CARDIFF AT COOMBE DINGLE

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INTERVIEW WITH DR. FIONA GODLEE: EDITOR-IN-CHIEF OF THE B.M.J. At Elizabeth Blackwell annual lecture 2016: “Too much medicine, why we need to push back the tide of medical excess”

As the average medical student uses a Monday night to stumble drunkenly from bar to club, we, the more vexatious lot, use our time to sit in yet another lecture about medicine. Now, before you shut this magazine, throw it across L.T. 1.4 in disgust, and question why you ever chose medicine in the first place, we must remind you that the subject at hand is “TOO MUCH MEDICINE”.

This phrase “too much medicine” should resonate amongst all you readers- from the lazy fresher to the weary 5th year, petrified of his finals and the dreaded SJT. Here, in the aptly named Great Hall, spoke Dr. Fiona Godlee, editor-inchief The BMJ, a journal once described as “only secondary to The Black Bag”. Her lecture presented the threats to human health provided by over diagnosis and medicalisation.

“…a pill for every ill, and an ill for every pill” At the risk of quoting the Clinical Epidemiology handbook, it is fair to say that the classification of diseases has been adapted, reformed and reorganised throughout history.

Increased disease parameters have lead to more patients subjected to unnecessary interventions, where often, evidence shows no net benefit. This medicalisation is partly caused by “disease-mongering”: the process of making-up diseases and spreading lies about its danger to human health. Dr. Godlee outlined the role of the pharmaceutical industry where intentional misuse of statistics, endless spin campaigning and false advertising have caused public health scares.

By far the most memorable part of her lecture was the controversy over a BMJ article published on genital cosmetic surgery. Dr Godlee cited the following e-mail conversation received in response to the paper:

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What is your problem with women, Ms. Godlee? This article’s hysterical claims that a lack of testing and rigor in these procedures could result in permanent genital damage is nothing short of misogynistic propaganda.

Tell you what, the women of the world can keep their hands off your genitals if you can keep your hands off theirs.

When I’m faced with the choice, I’ll pick the vagina attached to a woman who won’t bow to the British Medical Journal’s opinion.

Best wishes, Laurence Shandy, feminist.

Dear Laurence Shandy, Thank you for this. I have no strong opinions on the matter, except that I hope to get through life without surgery to my genitals, and think it appropriate for a medical journal to point out the potential dangers of surgery and the alternatives, at a time when reliable evidence is currently lacking.

All best wishes, Dr Fiona Godlee, Editor in chief, BMJ Dear Dr Godlee, I feel I owe you an apology. I’m sorry your genitals were dragged into this debate.

Best wishes, Laurence Shandy, gentleman.

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After her talk, we endeavoured to creepily follow her until she appeared free. We pounced. But rather unexpectedly, she welcomed us both with a hug- almost as if she wasn’t repulsed the overenthusiastic medical students posing her irksome questions. *** VKM: Firstly, why did you decide to switch from practicing clinical medicine to medical journalism?

Dr Godlee: I didn’t mean to do it really! The BMJ have a one-year post, which we still have, that brings someone out of clinical practice for a year. I did that, I was a journal medical registrar. I wanted to do general medicine and to be fair I was struggling; there weren’t really jobs in general medicine at the time, you

had to specialise. I think I was of some doubt over which specialist area to go into. I think if there was a general medicine career I would have stayed in medicine. The year at the BMJ was so interesting and they asked me to stay on. I asked the hospital to keep my old job open, which they did. It was a kind of gradual thing. It is so interesting, the joy of medicine for me is the breadth. I’m much more of a wideview person than wanting to specialise down into something very niche. It was a combination of factors but I still feel like I’m very much ‘in medicine’. I don’t know if I’m being naïve, but I do still very much feel that medicine is a vocation, I don’t know if you feel like that?

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MYQ: I definitely agree with that, I found it so hard at the medical school interviews to actually define why I wanted to do medicine! I think if you’re doing it for the right reasons then it’s much more of an instinct and you just know that this is what you feel connected to.

Dr. Godlee: I hope that feeling continues! There have been times when I’ve moved into different roles and I’ve felt like I’ve left my vocation, it was a mistake and you find your way back. I took a job in a publishing role for a while; it was a good job to do but I knew I had stepped too far away from medicine so I think it’s very important to hang on to that feeling.

MYQ: What’s your favourite and least favourite aspect of your current job?

Dr Godlee: There are so many things that I could say were my favourite! I work with such amazing people and meet with brilliant teams. It gives me a real sense of mission and wanting to make the world a better place, I know it may sound naïve but I just have such a passion for the people I work with and the people I meet.

However, I don’t love managing people! I have a team, and I best manage people when they’re great which most of them are. I find the most difficult thing when someone is being slightly less great and we have to have a difficult conversation.

I tell myself that that’s when you really earn your money, when you have to have that difficult conversation. I mean as a doctor I used to have to tell people that they were going to die, so you learn from that.

VKM: What advice would you give to current students that want to go into medical journalism or do something similar to you?

Dr. Godlee: I think what’s interesting in medicine is how many can write exceptionally well, we’re very lucky in that respect. I would say if you want to write, start writing and keep writing, even if it’s only for yourself. With all the blogs there are nowadays it’s easier than ever. I feel rather unequal to advise you because I didn’t take a traditional route, I didn’t write a lot while I was in medical school.

MYQ: Is there any way you would change medical education early on?

Here at Bristol it feels very science orientated in the first years, whereas I know students from other

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Universities that tell me their course is much more patient-orientated from the beginning.

Dr Godlee: I would say one of the joys of medicine is that it can find homes for people with a very wide range of interests, from people who love the pure science aspect, right along to the social science side and a focus on communication. One should never apologise for being more interested in one end than the other, as we need such a broad range of clinicians… Medical education is hard to get right for everyone. I’d like to feel that it never dehumanised patients in the way that it traditionally has done. Students come in so young and full of enthusiasm, I know there is a real risk of students graduating as junior doctors and feeling rather different to when they began. I think case based learning is a good way to keep students enthusiastic because it gives you an idea of how the science applies to the individual patient. I would say that it has to be done very well though to be effective.

through to medical school you must be quite good at absorbing information, and I think that helped me a lot. I found so many aspects of the degree so fascinating. I loved learning the skills of presenting, taking a history, those skills that can be so useful in all walks of life. I would say journalism is actually quite similar – you’re asked to take in information and then re-present it in an organised form. To me that contact with the patient, hearing their story, getting the information that you need and then presenting that to your colleague, that’s such an important thing to learn and you’ll never regret getting that right.

VKM: What exactly was your experience of medical school? Did you enjoy it?

Dr Godlee: I was a medical student in London. I remember I didn’t go to many lectures, it’s so good that they record all of yours now. I didn’t do any dissection either, I hated the dissection room. I think if you get

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MYQ: Why did you originally decide you wanted to apply for medicine?

Dr Godlee: I think from the age of seven I had decided I wanted to be a doctor. My siblings are all doctors too. I think it just seemed like a good thing for us all to do, I have really never regretted it. Some people ask me if I would recommend it to other people and I really would. I have eleven nephews and nieces and two children. Of all eleven nieces and nephews, none of them went to university to do medicine, and now four of them have gone on to do graduate medicine. It’s very interesting, it does seem to come through in families.

Dr Godlee: It was very nice to meet you both, good luck with it all! And don’t lose your spark!

We would like to wholeheartedly thank Dr. Fiona Godlee and the Elizabeth Blackwell Institute.

If you’re interested in listening to the lecture, visit: http://www.bristol.ac.uk/blackwell/n ews/2016/third-annual-elizabethblackwell-public-lecture.html

MYQ: If there’s anyone I’d want helping me write a personal statement, it’d be the editor of the BMJ! Thank you so much for talking to us tonight.

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SATIRE MEDIC TRIBES: THE FIRST YEAR SHMEDIC

You'll hear them before you see them: enunciation flawless, tan fading from constructing wells in Cambodia and reminiscing about how the Home Counties ‘just aren't as green as they used to be’.

Gleaming in the corner of your eye you’ll spot it - glaring at you across the room. "Oh this" they’ll say brandishing more value than your account balance following a heavy Freshers’ week, "it's nothing". Don't be fooled so easily- signet rings aren't created from nothing. Five generations of eating crumpets and playing international croquet; [insert double barrel name here] 's connections have created a family heritage so rich and thick it might as well be double cream.

Just as you regain your sight from the blinding, you’ll be lambasted by a story of how they did actually not realise that a gap year could be so rewarding yet, (as they found the depths of Africa remarkable peaceful with full strength Wi-Fi signal) simultaneously meaningful.

If you didn't get this hint that they had a gap year- do not panic there'll be plenty more.

Often clustered in packs the first year shmedic tribe is the the beating soul of L.T. 1.4. They'll flutter from conversation to conversation with a swish of blonde hair or in the rarer male form: a well greased top knot.

Yet do not be misled-a carefree attitude to eBiolabs and a sub-par attendance to post-sports night lectures doesn't signal they are slacking. You'll approach your January exams only to find them recalling not only that the off piste in St Anton was terrible, but more worryingly that they can recite every branch of the brachial plexus whilst standing on their head in Churchill eating quinoa.

Annoying friendly and chirpy following any night out the first yar (sic) shmedic are devilishly cunning at squeezing in two terms worth of socialising and one of absolutely bashing out a final year average, to ensure that resits won't rule out the biannual visit to daddy’s tropical paradise. Everything has to be just "tickety boo" of course...

A TRUE CYNIC 3rd YEAR M.B., Ch. B.

Next time on modern medical tribes: THE KEEN CLINICAL MEDIC

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GREY’S ANATOMY: A SNAPSHOT INTO THE MEDICAL PROFESSION? This show is huge. Its fame stretches far and wide, leaving those who are touched by it forever changed. In fact, I would go so far as to say that there probably isn’t anyone who hasn’t heard of it. This show has been in my life for seven years.

Seven wonderful, painful, emotional and exciting years and upon arriving at medical school, I realised that it was more than just television. Below is evidence – strong evidence – that Grey’s Anatomy might actually be a useful revision tool.

Case 1: Methicillin-Resistant Staphylococcus aureus

Where to find it in medical school: 1st year, MCBoM, Element 8.

Where to find it on Grey’s Anatomy: Season 9, Episode 21. A surgeon has to come to grips with the fact that they might have spread an infection to every patient they’ve touched within the past few weeks. While it’s interesting seeing how she tries to deal with that, the more intriguing part is how the hospital – administration, doctors and patients alike – reacts to this.

Case 2: Malignant Hyperthermia Where to find it in medical school: 1st year, MCBoM, Element 3 and 4.

Where to find it on Grey’s Anatomy: Season 8 episode 10. Michael, a patient, comes in with a liver injury from his car accident. The initial shock and drama subsides, it all seems pretty straightforward, but things begin to deteriorate quite quickly. Michael was having a malignant hyperthermia attack triggered by the drug used in his anaesthesia: Suxamethonium. This can lead to circulatory collapse and death (SPOILER ALERT). It’s rare, but anything is possible on Grey’s.

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Case 3: Cystic Fibrosis Where to find it in medical school: 2nd year, Respiratory. There’s a whole symposium dedicated to it.

Three. Hours. Long.

Where to find it on Grey’s Anatomy Season 2 episode 4; Season 7 episode 16. A recurrent case, normally quite rare for the show but the two patients suffering from CF illustrate different aspects of the disease. In the first episode, a close friend of the surgeon comes into hospital due to seizures and painpossibly a result of a pancreatitis flare-up.

In the second episode, the patient is receiving new lungs; but it focuses more on the fact that the patient’s girlfriend also has Cystic Fibrosis.

CF patients are not dangerous to anyone but other CF patients. The doctors try to make the patient aware of the fact that once he has the new lungs, his girlfriend could spread infections to him and cause the transplant to become worthless.

There’s an ethical debate (shout-out to HBoM Ethics & Law) on whether the patient should still get a transplant if he understands the risks. Despite it being rather romantic, one of the doctors refers to it as ‘suicidal’.

The above cases should offer serious backing up to my initial hypothesis: Grey’s Anatomy is a revision tool.

Indeed, these are only a few out of 275 episodes. What else does Grey’s tell us about life as a doctor?

My extensive research has also led me to the realisation that the show offers a rather accurate snapshot of things going on in the medical community worldwide. In Grey’s, doctors are constantly falling for their patients. According to Medscape, the percentage of doctors who disagreed with relationships between doctors and patients has fallen from 83% to 68%. Art imitating life or vice versa?

Not to mention the regular use of IV fluids to cure hangovers which happens on Grey’s, more often than not. But, how does this fair in the medical profession? Apparently it fairs pretty well if we take the word of CBS news. Their article states that doctors mainly use it for an energy boost to either work long hours or cram for a big test not to cure hangovers but close enough.

There’s actually a whole club, ‘The Hangover Club’, dedicated to making this available to the public.

So there; all you need to be convinced to start watching this remarkable show. Honestly, you’ll only be the better for it.

A. YONGA, 2ND YEAR M.B., C

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COMMENTARY 4th year medical student Mia Thomas writes Climate Change: it is our duty to respond.

Mia has represented UK medical students at the United Nation’s COP22 Climate Change conference.

Full Disclaimer: I am no vegan ecowarrior and rarely do I hug any trees. However, when I started looking into climate change and how it will impact health I quickly realised just how important this is.

Did you know the effects of climate chare are already affecting the health of our patients? Over half of respondents to a survey in Bristol reported that their health is affected by air pollution.

We have crossed 400ppm carbon in the atmosphere and even with countries projected actions to cut green-house gas (GHG) emissions we are not going to meet our target to stay 2⁰C below pre-industrial limits. These stats can seem to relate little to the world we are living in – everything is running smoothly isn’t it? We have been hearing about global warming since childhood, but nothing has actually changed right?

Well actually, wrong.

Hurricane Matthew, whilst barely causing a ripple in our media left behind a death-toll of over 1000 people, mostly from Haiti – a

country that was trying to recover from the 2010 earthquake that killed over 220,000 people. The rise in these extreme weather events has been irrefutably linked to GHG emissions.

The protests in Syria that preceded this brutal war were partly due to climate change, with a 6 year drought forcing people to migrate into cities, causing overcrowding and anger. The UN predicts that by 2050, 10% of the world’s population is at risk of forced displacement due to climate change.

How does climate change affect health?

The health impacts of climate change are huge. It will affect our access to absolute basics of human survival – water, food, clean air – and increase exposure to infectious diseases. Thinking about the impacts on health forces us to acknowledge how vital it is that we act quickly to protect our environment.

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What is COP? The political world has slowly woken up to the dangers of climate change and has realised that a global effort to curb GHG emissions is needed. The international political response to climate change began with the 1992 adoption of the UNFCCC (United Nations Framework Conventions on Climate Change) which sets out a legal framework for stabilizing atmospheric concentrations of greenhouse gases (GHGs). The UNFCCC, currently made up of 197 signatory parties, meets annually at the COP – Conference of Parties – to assess progress in dealing with climate change. This November (7-

18th) is the 22nd COP (COP22) meeting which occurs in Marrakesh, Morocco.

COP22 follows from the hugely successful COP21 in Paris at the end of last year, which for the first time saw the world successfully coming together to agree to a climate deal committing all countries to cut emissions and honour the aim to keep global temperatures below a 2degree rise above pre-industrial levels. The Paris agreement will come into effect when 55 countries that account for at least 55% of global emissions have ratified it. So far, 87 have signed – including crucially the US and China (the world’s 2 major polluters), and a promise from Theresa May. So far, 23

the countries that have ratified account for 39% of the worlds emissions – leaving 16% remaining to bring the agreement into force.

We must therefore maintain pressure on our government to ratify the treaty and keep momentum from the historic Paris agreement.

COP22: a reflection The first week has been interesting, with a lot of talks gathering speed now towards the end of the week.

For me as a first timer I have found the process frustratingly slow – a lot of the initial talks were taken up with discussing how the discussions should be undertaken rather than getting on with the actual discussions themselves. I’m sure you get used to this if you have been in this world for a long time, but the need for immediate action seems to be discussed more than felt.

The links between health and climate change are obvious and important to us as a delegation of medical students, and yet it is a real challenge to hold other COP22s attention on this topic because everyone here – youth and negotiators – have their own

agendas and special areas of interest.

Getting other youth groups to include health in their policy papers or speeches is an uphill struggle as although they see the links, the space that youth have to share our views to state members is limited.

I will be very interested to see how the second week’s negotiations play out and how many commitments can be made to implement the Paris Agreement. The box below covers the proposals that impact specifically on health – although as

Proposals and their impact on health Health at COP22 is brought into discussion via the Nairobi Work Program (NWP) Sessions. The NWP is a mechanism that facilitates the development and dissemination of information and knowledge that informs and supports adaptation policies and practises (reference). The NWP invited parties and organisations to submit information on their recent work in health and climate change this year and found that information covered three main areas: changes in disease distributions, new and emerging health issues – e.g. tropical diseases – and the impacts on social and economic structures and issues of malnutrition, waterborne diseases, and disaster impacts. 15 parties and 11 relevant organisations submitted these contributions, which was disappointingly low given the importance of health management with regards to climate change.

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mentioned we would argue that we would that health permeates throughout all discussions around climate change.

The Future - What can we do?

As medical students in the UK, we have many opportunities to spread knowledge and campaign for our future. By using health to highlight the threat of climate change we can cut through the political and economic slow-dance our governments are using to defend their unsustainable exploitation of our planet. No-one is immune from the effects of climate change and now is a critical period for immediate action to safeguard the future of all people. Here are some societies in Bristol to get involved with: Healthy planet: Healthy Planet is a network of students across the UK that advocate and educate on the importance of climate change and its impacts on health. Healthy planet is an affiliate of Medsin which is another great student society: https://www.facebook.com/healthypl anetbristol/ Fossil Free Campaigns: Bristol University currently invests £5.6

Health also looks on with an interested eye to progress made by the Warsaw international Mechanism on Loss and Damage (the push for developed countries to take responsibility to the current effects of climate change on developing countries) which does not directly mention health but nonetheless covers it in “noneconomic” effects of loss and damage due to climate change.

million in dirty energy. Join Fossil Free Bristol University to campaign for this to change! https://www.facebook.com/FossilFree-University-of-Bristol736811169768956/?fref=ts Other ways to get involved: Write a letter to your MP calling for divestment and urging them to support the ratification of the Paris Agreement. Have a look at the IFMSA training manual on health and climate change – it gives a really comprehensive guide to the implications on health and the science behind climate change.

M. THOMAS, 4th year M.B., Ch. B.

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WHICH EPITHELIUM ARE YOU? It’s 9am on a Monday morning. Where are you?

1) a. b. c. d. e.

Probably in the lecture.

Front row, with my Dictaphone (just in case Mediasite is down), my laptop (just for good measure) and ten highlighters Just pulling into St. Michaels in my Uber. Bit late though, Tarquin and Sebastian’s party was LIT. Running 10 minutes late, it takes a while to choose between tie dyes?

Tactical chunder in the toilets It’s your first day of placement. What are you wearing?

2) a. b. c. d. e.

Skinny suit trousers and cream sheer shirts The same outfit you wore to your interview.

Over my Ralph Lauren Oxford shirt? A classic adidas windbreaker.

A crop top and the hair braid you got from your summer holidays, topped off with your festival wristbands Still hungover- whatever clean clothes you found in the dark

3) Full day of lectures/placement. What are you eating in your lunch break? a. b. c. d. e.

Packed lunch I made last night/Sainsbury’s basic meal deal Whatever I can find in the vending machine when I’m in the library. Or source café if it’s a special occasion Money’s a bit tight at the moment. Have to probably get Deliveroo or Waitrose sushi.

Anything organic, vegan and ethically-sourced. Did you even know I volunteered in Nepal?

Chip shop. Need to nurse this hangover

4) Which SSC title is yours? a. b. c. d. e.

The effects of obesity Discuss the role of the FMR1 gene in the Sherman paradox The therapeutic effects of croquet The therapeutic effects of medical marijuana The therapeutic effects of binge drinking 26

Mainly a’s: Simple squamous- you’re just so basic.

What more is there to say?

Mainly b’s: Cuboidal- you’re a total square, so nerdy. You probably write up notes immediately after a lecture.

I bet you even enjoyed Clinical Epidemiology.

Mainly c’s: Pseudostratified Squamous- this one is for those who pretend like they’re skint: only when they’re not going shooting with Mummy and Daddy on the weekends.

Mainly d’s: Ciliated columnar- you’re so wavey, literally. You probably wear harem pants and go on about your Gap Yah where you swam with an elephant.

Mainly e’s: Secretory (w/goblet cells)- can’t handle their alcohol. Often chunders. Total lightweight.

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THE NOTORIOUS R.O.B. Robert Clarke of Durham University on Has Globalisation left medicine behind?

The USA and China have recently ratified the Paris Agreement, a legally binding document requiring nations to limit emissions of greenhouse gasses. Although states sign up individually, the worldwide implications of climate change are what have made it a success. Global warming doesn't care about lines on a map. Modern global governance and the spread of neoliberalism has started to render borders more and more arbitrary. The world has become smaller, compressing distances between locations and peoples. Spaces of interaction are shortened and warped as technological advancements have created a new interconnected globe.

This is globalisation and it has led in a huge shift of power, from the nation-state to the institutions that transcend them. Despite this, globalisation’s largest effects have been societal, and this is where the structure and influence of medical practice comes into question.

One of the major sites of globalisation is the human body.

How we perceive our bodies, our own embodiment, is being shaped by globalising processes. Traditional Western medicine has viewed the body as something material, susceptible to physical, external forces and often dichotomised as healthy or unhealthy. Both treatment and preventative discourse are

engaged with physically, for example taking medication or increased sanitation.

There have been staggering developments in diagnosis, pharmaceuticals, and therapies, but these have all been in a narrow spectrum; a spectrum in which the body is the site of medicine, and the mind and greater society are put to one side. A more fluid appreciation of these spaces as somewhere in which medicine has a role would move the field forward into a globalised world. A real world example is skin bleaching, an issue almost solely due to globalisation and the spread of western beauty standards. In Nigeria, statistics show around 77% of women try to lighten their skin. Despite this, global estimates for body dysmorphia range from 1-3% and treatment tends to be Cognitive Behavioural Therapy.

Medicine is taking a social issue, enacted through our bodies and diagnosing a mental condition onto the person. In the long run, this isn't productive for improving global health and wellbeing, as it reinforces what it is trying to combat.

As the mass movement of commodities, knowledge, labour and peoples across the globe has created globalisation, the body itself has been commodified in the process. Even something as basic as someone’s occupation is part of the process of imprinting society upon the body.

Physical labour which, in early Western society, was done by slaves, the working classes or immigrants worked to assign people into classes 28

and racial groups that stratify society.

In contrast, work thought to be more cognitively engaging was reserved for elites. This split of labour defines bodies through structures of value, imprinting societal notions of worth.

Similarly, bodies are gendered and racialized as Western discourse spreads universally. Globalisation hasn't changed these elements of Western culture, but reinforced them as the economical practises of the west have been taken up globally.

With this, elements of all cultures have been appropriated and blurred into a monolithic global society.

Individuality and difference are oppressed through mass marketing and the proletarianization of identity.

In America, this process is insidiously played out in the perceptions of traditional African hair. White celebrities and models will wear dreadlocks or braids and be praised for their pushing of boundaries. However, there are hundreds of court cases of African Americans alleging discrimination at the workplace for having the same styles.

Medicine, whether through global bodies such as the WHO or on local scales, needs to find its moral positions on these issues. Does it stand for personal liberty on issues such as skin bleaching or try to fight Western beauty standards in what could be the new frontier of preventative healthcare?

Alternatively, does medicine have a duty to provide cosmetic services whilst also opposing the sort of

society that they arise in? If so, is there any role for preventative healthcare, beyond the individual, that fights medical issues associated with embodiment. If healthcare is moving from a biological to anthropocentric stance, does duty of care extend to counter-culture movements? I believe that all this puts state healthcare into question.

The provision of healthcare as a national right has always been dependent upon a rigid definition of what is and isn't a medical issue. For example, gender dysphoria is a mental condition that is often treated through physical surgery. How can there be a diagnosis, beyond self certification, without engaging in the social processes that exacerbate the condition? These questions are complicated for a publicly funded body. The lines between what is and isn't a health issue are blurred and usually down to failures of rigid medical labels.

All these ideas are embedded in complicated ideas of medical practice and morality, with few answers provided at the state level.

From here, there are two paths. At the moment, we are headed down the path that labels medicine a service and the body a commodity.

R. J. CLARKE, 3rd Year B.Sc. Geography Hatfield College, Durham University

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NARRATIVES Tim Robinson, a previous editor of THE BLACK BAG, writes about his Homoeopathic elective

I believe it was October when I chanced upon my ideal elective on the internet- helping the poorest women and children in India by providing access to free healthcare in the Himalayas. I could foretell a great stormy cloud of Facebook likes.

I arrived and was greeted by the kindest and friendliest doctor I had ever met who immediately gave me the first day off to sleep away the jet lag....and the second day...unsure of the reason. But anyway, things were going very well.

And so it was, on Wednesday morning I made my way into the clinic. Bright-eyed and desperately eager to practice all the skills in my CAPS log book that I had been signed off for but still didn't have a clue how to do, I took a small stool in the corner and patient #1 entered the room. I listened attentively as she described her symptoms of splitting headaches over the temporal region...

I already had my differentials and was waiting for the doctor to start asking some questions to narrow the options down a little. But no, the questions didn't come. The doctor let her speak for about 10 minutes without saying a word... once she had

finished the doctor removed her spectacles, and looked long and hard into the patients eyes and said "that must be terrible for you." The patient nodded silently.

"Aha!" I thought, she is bound to now do a simple SOCRATES followed by some detailed questions about aura... but no, I was still wrong. The doctor smiled and said "what sort of person are you?" The patient babbled on for another 10minutes about herself and what foods she liked...rice...dhal.... mango...chapattis....an unsurprisingly small repertoire for a woman from one of the most rural areas of northern India.

The doctor turned to me and said, "What do you think?" I was a bit taken aback and replied, "I'm not really sure, I would like to ask a few more questions first". She smiled at me as if to say "oh you medical 30

students, you really do have a lot to learn". She then said, "I think I will treat this with Pulsatilla." I immediately assumed this was the brand name of some sort of Triptan, and asked her what it was.

The response was not quite what I was prepared for... "Oh, it's a homeopathic remedy, I have had a lot of success with it".

Sirens went off in my head, I was worried I might be about to have a migraine too. What was this utter bull shite? There was no mention of this on "The Elective Network" when I signed up for it. Was this some sort of joke? Did this woman really believe that some bit of plant juice diluted one drop to 1x102,000 (this isn't an exaggeration; this is an accurate representation of homeopathy) was going to cure this poor woman’s' life-

disabling migraines? I controlled my emotions, smiled, and said "Oh...really....how does it work?"

This was a mistake; I had clearly thrown a spanner in the works. It was like I had been rude. How dare I question the mechanism of action of a homeopathic remedy? The answer that it "strengthened the brain" seemed to be enough for the doctor and the patient, so I decided not to ask any more questions for the time being.

The patient cheerfully collected her prescription and left. An awkward silence fell upon the room....my eyes were scanning the bookshelves staring at the homeopathic textbooks looming out amongst other, more familiar things such as the cheese and onion (why the f*** hadn't she used that?)

"So....ermmm, do you use much homeopathy then?" I tentatively asked.

"Oh yes, for some things the results are excellent. But I don't use it for everything" "How do you decide when to use it?"

"Well it depends on the sort of person. People fall into different categories, you are either an animal, a plant or a mineral... and depending on your traits I match this to substances found in each of these 3 kingdoms...."

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My eyes started to widen further... I was full of questions-what happens if you feed a bit of animal homeopathy to someone who is a mineral? Do they die? What bits of animals do you use? Are you deluded?

*** This was however, not some sort of practical joke, as I found out over the next month. I was faced with the use of homeopathy day in day out. Not only that, but I myself became the resident protégé as I learnt the art of "Laser Acupuncture" and "Cupping".

I was however, able to spot some definite patterns in these treatments and their success. The use of homeopathic remedies alongside allopathic treatments was common. I saw someone with high blood pressure treated with an ACE inhibitor....and also some plant extract. When their follow up came 2 weeks later, it was naturally the plant extract that was praised for the decrease in BP.

"miracles" and I would call the "placebo effect". There was definitely a certain type of person and problem that would respond well to homeopathy. A young person with athlete’s foot for example, would not be a good candidate. Neither would a lady with a fractured neck of femur.

However, someone with low mood due to the death of their pet rabbit or high levels of stress due to difficult neighbours would be perfect, but only if they believed in homeopathy at the start. In these groups I saw miracles in recovery from problems that had been going on for months and sometimes years.

So, my opinion has changed rather a lot. If a patient was to tell me that they would like to try homeopathy for their anxiety as they believed strongly in alternative therapies, I would not poo-poo the idea at all. No harm can possibly come from itthey're only consuming water after all, and if they believe in it, and want it to work, it may well make a big change for them. As for people with illnesses like broken bones or infected wounds and health problems with physical signs, I remain to be convinced.

T. J. ROBINSON, FY1 DOCTOR, CARDIFF EDITOR OF THE BLACK BAG (2015-2016)

I witnessed what some would call 32

CROSSWORD

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THE BLACK BAG Galenicals publication Medical School, Faculty of Health Sciences University of Bristol

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