Summer 2018

THE BLACK BAG

BRISTOL MEDICAL SCHOOL Summer Term Ed., 2018

Editor-in-Chief: J. KONDRATOWICZ Assistant Editor: V. K. MANDAGERE Treasurer: C. HARMER Illustrators: M. ACHANTA Crossword designer: A. CLARKE Contributions: Prof. T. THOMPSON, B. GOMPELS, O. COLLERTON, O. ANGKANAWATANA, M. SUHAIL, E. LEE, Prof. A. LEVY @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 The Black Bag are always looking for contributors. If you are interested in writing for us, please email: blackbag@galenicals.org.uk

EDITORIAL

4

AGAINST EMPATHY

8

DOCTOR WHO UNDER FIRE AS GMC REVALIDATION DEEMS UNFIT FOR PRACTICE 13

THE MB21 DICTIONARY

15

‘NEWS FROM THE SUMMER’

16

THREE GRADUATES SHARE THEIR TOP TIPS ON SURVIVING MED SCHOOL 19 AN INTERVIEW WITH PROFESSOR LEVY

22

CROSSWORD

29

EDITORIAL Ah, September, a month that fills one with all the hopefulness (and/or dread) of a new academic year. Armed with new stationary, freshly trimmed hair and a brand-new copy of Clinically Oriented Anatomy tucked under one arm, a crop of freshers will begin their foray into the world of medicine. What better way to introduce them than by some serious (and not so serious) advice from those of us who continue to muddle our way through medical school and beyond.

In this first issue of the 2018/19 academic year Professor Trevor Thompson is back with a new instalment of Thompson Talks exploring the dangers of empathy (p. 8), whilst Professor Levy spills the beans on the lessons learnt from a lifetime of medical encounters (p. 22). If you want to start off your term on the right foot, be sure to turn to page 19 to see what wise words On, Mo and Ellie have on successfully navigating 8 hour lecture days in LT 1.4, Yeovil wardrounds, OSCE’s and electives, to come out the other side as shiny new doctors.

And of course, as always, our writers are here to offer some light-hearted relief from information overload. Speaking of which, you might feel compelled to put aside those summer novels, but before you sink too deep into a quagmire of biochemistry notes, I’ll attempt to convince you that perhaps fiction can still offer us some relevant advice. In this case, a timely reminder of avoiding the real danger of Medical Student Syndrome…

“I remember going to the British Museum one day to read up the treatment for some slight ailment of which I had a touch – hay fever, I fancy it was. I got down the book, and read all I came to read; and then, in an unthinking moment, I idly turned the leaves, and began to indolently study diseases, generally. I forget which was the first distemper I plunged into – some fearful, devastating scourge, I know – and, before I had glanced half down the list of “premonitory symptoms,” it was borne in upon me that I had fairly got it. I sat for awhile, frozen with horror; and then, in the listlessness of despair, I again turned over the pages. I came to typhoid fever – read the symptoms – discovered that I had typhoid fever, must have had it for months without knowing it – wondered what else I had got; turned up St. Vitus’s Dance – found, as I expected, that I had that too, – began to get interested in my case, and determined to sift it to the bottom, and so started alphabetically – read up ague, and learnt that I was sickening for it, and that the acute stage would commence in about another fortnight.

Bright’s disease, I was relieved to find, I had only in a modified form, and, so far as that was concerned, I might live for years. Cholera I had, with severe complications; and diphtheria I seemed to have been born with. I plodded conscientiously through the twenty-six letters, and the only malady I could conclude I had not got was housemaid’s knee. I felt rather hurt about this at first; it seemed somehow to be a sort of slight. Why hadn’t I got housemaid’s knee? Why this invidious reservation? After a while, however, less grasping feelings prevailed. I reflected that I had every other known malady in the pharmacology, and I grew less selfish, and determined to do without housemaid’s knee. Gout, in its most malignant stage, it would appear, had seized me without my being aware of it; and zymosis I had evidently been suffering with from boyhood. There were no more diseases after zymosis, so I concluded there was nothing else the matter with me.

I sat and pondered. I thought what an interesting case I must be from a medical point of view, what an acquisition I should be to a class! Students would have no need to “walk the hospitals,” if they had me. I was a hospital in myself. All they need do would be to walk round me, and, after that, take their diploma.

Then I wondered how long I had to live. I tried to examine myself. I felt my pulse. I could not at first feel any pulse at all. Then, all of a sudden, it seemed to start off. I pulled out my watch and timed it. I made it a hundred and forty-seven to the minute. I tried to feel my heart. I could not feel my heart. It had stopped beating. I have since been induced to come to the opinion that it must have been there all the time, and must have been beating, but I cannot account for it. I patted myself all over my front, from what I call my waist up to my head, and I went a bit round each side, and a little way up the back. But I could not feel or hear anything. I tried to look at my tongue. I stuck it out as far as ever it would go, and I shut one eye, and tried to examine it with the other. I could only see the tip, and the only thing that I could gain from that was to feel more certain than before that I had scarlet fever.

I had walked into that reading-room a happy, healthy man. I crawled out a decrepit wreck.”

‘Three Men in a Boat’ — Jerome K. Jerome J. KONDRATOWICZ Editor-in-chief 4th year MB ChB

AGAINST EMPATHY A rare literary event occurred in Clifton this year: a bookshop opened. I walked in, was greeted by a very congenial bookseller, and walked out with eight books.

One of my spontaneous purchases was a work of popular psychology called Against Empathy by Paul Bloom. Clever. I bet most people buying this book consider themselves empaths. An empath would therefore see it part of their empathic duty to try and view the world through this set of contrarian lenses.

Though I have always felt aligned to the concept of empathy; I have, if I am really honest, never quite understood what it is and how it relates to cousins like sympathy and compassion.

Bloom kicks off by outlining the popularity of his quarry. You get, for instance, over 3000 returns on searching Amazon books for the term “empathy”. Higher ranking examples include “The Empathy Gap, Why Empathy is Essential”, “The Empathy Instinct: How to Create a More Civil Society” and “The Roots of

Empathy, Changing the World Child by Child”. Websites include one listing everything Barack Obama ever had to say on the subject including an oftenquoted statement that “The biggest deficit we have in the world….is an empathy deficit”.

Blooms takes the view that all this empathy isn’t just ‘not good’ but is an overall harm to the progress of society. To understand this view you need to understand his definition – empathy is the “act of coming to experience the world as you think someone else does”. Empathy by this definition is literally feeling another’s pain. We are reminded of the science of “mirror neurones” – cells that fire when we feel or do, but also when we watch someone else feel or do the same thing. A neural substrate for empathy in this Bloomsian sense.

And why bad? Because when we act on the basis of vicarious sensation we act narrowly, we act with bias and we act without reason (hence the book’s subtitle “the case for rational compassion”). He has examples. After the fatal shootings at Sandy Hook, Connecticut, in 2012, this affluent town was overwhelmed with children’s gifts often donated by poor people. He argues people felt the pain of the community and acted irrationally in response (the toys were no help). We feel, he says, much more the pain of those with whom we can identify and thus ignore the pain of those with whom we can’t. Empathy is innumerate and lacking in any long-term view.

Also empathy is bad for the empath – it can lead to burnout and make us less useful in responding to need. This is a major issue in the caring professions.

Whilst many decry the documented (but disputed) erosion of empathy scores as medical students progress through the curriculum, I’ve wondered if this might be a maturing, rather than a hardening of the heart, as students learn to stop responding emotionally to the pageant of human suffering.

But while the book’s argument is enjoyably debunking, it is also flawed. Bloom excludes from his critique what is elsewhere defined as cognitive empathy. This is not so much feeling the pain of the other but understanding it. Whilst we can feel moved by the plight of the patient, much better that we try and understand that plight with the hope of being able to respond usefully to it. There are two big barriers to students understanding patients. First, students come mainly from high income backgrounds and most patients (especially in hospitals) come from low income backgrounds.

Second, most patients are sick and most students are well – and sick is another country. And there are two trusted ways of crossing the frontier – really listening to what patients have to say and engaging with the arts (film, theatre, literature, visual arts etc) where alien perspectives are defined and refined, above the

cognitive noise of the hospital. This is something we are slightly good at in Bristol even if the Arts signal is weak and intermittent.

I was surprised that the book, which has a lot (of mainly negative things) to say about moral implications of empathy, doesn’t reference the idea of “moral imagination”. This term from moral philosophy signifies the lofty ethical work of extending oneself “beyond the barriers of private experience and momentary events”. In other words, moral perceptions don’t only derive from principles but from the human ability to imagine situations we hope to never actually encounter in our private lives. No amount of psychology will convince me that it isn’t a good thing to try and imagine the diverse, perverse and poignant predicaments to which we humans are prone.

Did a patient ever make you cry? I recall some moments as a junior doctor: watching a bewildered man in his thirties cradle his wife at the moment of her death in a side ward in Ealing Hospital. Though the occasions are few, tears at such times feel absolutely OK - evidence that we are indeed human. To be honest I wish I could cry a bit more. But a tear is different to a prolonged weeping fit, and should only enhance our willingness and our ability to be helpful. So, I am a fan of a certain amount of emotional empathy and a relatively larger amount of (trained) cognitive empathy.

This brings me to compassion. Compassion, by my definitional system, is more than empathy. Where empathy (both emotional and cognitive) triggers helpful action we have compassion. It can of course trigger other types of action. For instance, if I feel your pain I might want to run like hell and if I really understand what makes a man tick I might use that knowledge to manipulate him. It is said (think Hannibal Lecter in Silence of the Lambs) that psychopaths have an abundance of cognitive empathy but no emotional empathy – they get you then

they gut you. But where empathy makes us act thoughtfully we have compassion – my fav definition of which is “intelligent kindness”.

I am glad I picked up this book. It has helped me better define some very important terms, reminded me of the futility of many emotionally driven responses, and introduced me to some interesting psychological experiments.

For instance, subjects primed to be empathic were more likely than controls to bump a child up a waiting list of similarly deserving children, proving for Bloom the moral vacuity of empathy-based action. But the narrowness of Bloom’s definitional scope, excluding the imaginative and cognitive aspects of empathy, mean his conclusions lack credibility and I sallied forth with most of my original preconceptions intact. It is however a good exercise to lead one’s sacred cows to the slaughter.

PROF. TREVOR THOMPSON, Reader in Healthcare Education, Head of Teaching for Primary Care, Bristol Medical School

DOCTOR WHO UNDER FIRE AS GMC REVALIDATION DEEMS UNFIT FOR PRACTICE A consultant doctor from Gallifrey, N. Wales has been under fire this week as the General Medical Council have deemed him unfit for practice.

Dr. Who, who for the past year has been working independently, has been criticised for his unorthodox methods of examining patients. Shying away from the regular stethoscope and sphygmomanometer, Who has been inventing his own medical equipment which he brands as a ‘sonic screwdriver’, though scientists have concluded it does nothing but emit a high-pitched buzzing noise.

THE BLACK BAG Galenicals publication Bristol Medical School, University of Bristol

His patients had a lot to say about the doctor. 70% of his patients noted that he was often late to consultations, with one patient stating that “the man just has no grasp of time!”. The very same patient described his bedside manner as ‘rather alienating’ and often paternalistic. Who appears to have been on the run from the GMC as he has changed his practice address over thirteen times in the last 200 years. Perhaps most surprisingly, he has been accused of highend plastic surgery to change his appearance in order avoid the hearing.

Dr Who’s patients have been extremely concerned by the quality of care they recieve, with some questioning his very qualifications. After searching historic GMC records, it was noted that the doctor had been struck off thrice and his original medical degree certified by Bristol Medical School. We caught up with Bristol’s medical faculty, who had this to say: “Who had a great e-Portfolio. Sure, he didn’t really attend anything, but he’s reflected on his absence really deeply. A deeply empathic bloke, and that’s all you really need to become a Bristol doctor.”

Thomas Beddoes, M. D., Bristol Pneumatic Institute.

THE MB21 DICTIONARY ‘Case Based Learning’ 1 A method of learning which completely ignores the fact that you are in a University environment.

2 Students can ignore the wealth of expertise at a Medical School in order to Google some random medical words instead.

‘Early clinical integration’ 1.

A term used to justify filling wards with entitled students from the home counties who possess less combined medical knowledge than a medieval apothecary treating a case of syphilis with leeches.

‘Giving something back to the NHS’ 1 A way of morally justifying enticing genuinely bright A level students into being trapped in a medical career.

2 Demoralizing (and or) reducing any chance of a normal student experience by integrating HCA sessions in first year, followed by creating the most bureaucratic and illogical junior doctor experience for just above living wage. (But at least you’re morally sound till Richard Branson inevitably assumes control).

The student excellence conference: 1 An event that is neither attended by normal students or excellent.

2 An annual reminder that although you were Head Boy and fairly intelligent at school, you are never going to be as academic as the majority of the cohort. Instead, you may as well out-drink them before you inevitably heckle them, jealous of their achievements.

Central Study Days 1 An appalling dull nine hours of talks of which could feasibly cure insomnia cure feasibly insomnia and the central messages of which could be delivered in one third of the time.

‘NEWS FROM THE SUMMER’ Matt Hancock’s NHS pledges rejected by Turnitin for being “nearly identical" to those submitted by the previous 43 Health Secretaries Initial excitement at the prospect of a new health secretary has given way to disappointment as his pledges are bounced by the program Turnitin.

According to the program there was a 96% similarity, most of which appears to be either the words “more money" or a string of random expletives. In fairness, it is still true to say this accurately reflects the position of the NHS. When questioned Theresa May revealed the thought process behind the appointment : “The issue is people think of the NHS as a healthcare system when really it’s more like 3 healthcare systems, a large cities worth of infrastructure and a slightly larger cities worth of people on a tightrope.

The idea of shaking the rope is sickening. Instead it requires a steady hand on the tiller. The sort of waxy automaton who looks simultaneously like they never sweat but at the same time, always appears slightly lubricated.”

In place of these pledges it is proposed that public submissions will be collected and voted upon. So far they have included “Just make less people sick" and “telling all those foreigners to sod off”. So it seems all hope is not lost.

Brexity McBrexit face sinks on maiden voyage A replica 1859 British Navel Vessel entitled Brexity McBrexit face has sunk in the English channel following collisions with several other vessels in the international shipping lanes. The captain claimed “This disaster is something we just could not foresee.”. However experts countered with the view that, while a charming reminder of Britain’s splendid antiquity, without modern GPS capabilities and radio allowing the ship to communicate, it was doomed from the moment it set sail.

Shortly after departure, the ship was struck head on by a trade vessel from Germany, before being ultimately sunk by a blow from behind by a luxury American yacht.

The ships creator was unavailable to comment but apparently never expected it to gain this level of public traction. As it is it will remain a blot on our nation's history, like a tortured allegory in an otherwise sterling publication.

During summer heat Met office advise against having any fun whatsoever During a period of intense heat the Met office has advised against taking part in any activities that could be seen as enjoyable, and instead suggest limiting oneself to griping, grouching and muttering “big yellow bastard" at standardised intervals.

The heatwave has already caused chaos, with citizens in the South East crippled by rapidly spoiling humus, and Scotland gripped by fear as certain trees began sprouting strange, brightly-coloured orbs the locals claimed never to have seen before. The heats affects appeared particularly pronounced on middle aged males who suffered an inexplicable compulsion to remove their shirts during normal daily activities and not go a single sentence without mentioning “an ice cold lager".

One person not convinced by the heat was American President Donald Trump, a man who appears to be permanently on the verge of melting.

Like a soft cheese on a summer picnic. His climate change scepticism is well documented however when questioned about the heatwave during his recent state visit he instead went on an extended diatribe about the current weather in Russia surprising precisely no one.

O. COLLERTON, 2nd year MB ChB

THREE GRADUATES SHARE THEIR TOP TIPS ON SURVIVING MED SCHOOL MO What is your biggest piece of advice for medical students?

“After 2nd year, you might find yourselves split from your close friends not just due to intercalation but also due to placement rotations. You MUST keep meeting up with them. Seems obvious but organising it is harder than it seems.

But it's what probably kept me sane for 3 years. Placement can get quite isolating at times, especially in 4th year due to the demands of some of the modules' portfolios. So you may not even see people that are on your placement that much.”

Medical school highlight?

“I went to Jordan on elective and also spent time in RUH Bath. Take this opportunity to travel but also make the most of it. This is essentially an eSSC period where you can do anything you wanted to do anywhere in the world.”

What’s next?

“I’m heading to the Salisbury District Hospital for Foundation programme.

I haven't decided on a specialty, but I do have various plans for F3, F4 (maybe even F5) years such as CTF, locum work or work abroad.

Good luck with the rest of med school!”

ON What’s your biggest piece of advice on what to do/not to do in med school?

“Do: Get involved, find a community - in or outside of medicine. My favourite memories of uni will always be with the people I met through CLIC & FUZE.”

“Don’t: let the thought that “medicine takes up too much time” hold you back from doing other things outside of it - it stopped me from dancing more in first year and I still regret wasting that time.”

Best medical school memory?

“Going to Uganda for Year 4 eSSC is probably most memorable for me - I never would have gone there on my own, so I’m glad I took the opportunity.”

Where did you go on elective?

“Thailand (Bangkok) for a month, and Japan (Tokyo) for a month. My top tip is to plan ahead and ideally choose places where you can understand the language - you’ll get much more out of the elective on the medical aspect. I chose places I’d like to live in rather than have a holiday in, as there is plenty of time for you to have a proper holiday after. Also, choose places where food is good - Japan and Thailand were winners.”

What’s next?

“I’m going to start work in Poole Hospital!

I want to hopefully specialise in Dermatology - and keep dancing along the way.”

ELLIE Tell us a little about you…

“I’m Ellie and have just graduated from Sheffield Medical School, between third and fourth year I intercalated and did a Masters in Public Health – also at Sheffield. I love baking, cooking, running, and exploring new places.”

Do you have any advice for surviving med school?

“Enjoy the nights out and socializing, join every club and society you can! Say yes whenever anyone tells you to go home early. Enjoy your placements – some of them you may never do again. Study hard but take plenty of breaks, look after yourself and look out for others.”

What was your elective highlight?

“I went to Louisville, Kentucky, USA for 6 weeks in cardiothoracic surgery, particular highlights were assisting with heart and lung transplants!”

What's next?

“I’m starting my FY1 in Sheffield in Urology, followed by infectious diseases and care of the elderly; then FY2 in Doncaster in Psychiatry, A&E and intensive care.”

What do you want to do in the future?

“I’d love to be able to combine anaesthetics or emergency medicine with my public health masters!”

AN INTERVIEW WITH PROFESSOR LEVY How are you enjoying retirement?

Very much, thank you. I've been practicing not getting up at 5 in the morning.

What are you filling your time with?

Aside from gardening, decorating, designing and building furniture and travelling in the UK and abroad - stu that I've always done I'm a very uncommitted 'Visiting professor and health-tech entrepreneur' in the Bristol Robotics Lab at UWE. When the weather closes in this autumn, I'll spend more time learning SolidWorksŽ to get ideas out of my head and into a form that can be read by 3D printers. I continue to run a company (Bristol Medical Pro Ltd) designing and making manikins (such as the googly eyes) and selling them in the UK and around the world, as well as marketing 'Speaking Clinically', albeit in a rather lackluster fashion.

No more medicine in any form though. I've had my time and have always been disillusioned by medics who reappear six weeks after 'retirement' like smug idiots-savants, carrying on selfishly and arrogantly fiddling around in medicine way beyond their sell by date.

The baton is yours now.

Would you have done medicine given the chance again?

I'm not sure whether self-determination entirely governs life trajectory once the genetic lottery numbers have been drawn. When you look at twin studies (identical twins separated at birth and brought up in completely dierent circumstances) it seems that psychopathology, dress sense, tendency to addiction, sense of humour, social attitudes, musical taste and even political inclination are significantly heritable.

Having spent much of my life considering it and wondering at it, I honestly believe that antisemitism is at least partly genetically encoded.

I just cannot think of another explanation for something so ubiquitous yet irrational. To answer the question, I think I would have entered medicine again because my intellectual bent and neuroticism are darkly suited to it. I haven't been bored at any time, but I would be diverging wildly from the truth if I led you to assume that my career in medicine has been unalloyed enjoyment and wonder.

If you weren’t a doctor what would you have liked to have done?

I wanted to be a silversmith, but without real design flair and in a society that has yet to show any sign of taking craftsmanship back to its heart despite once again embracing vinyl, film photography and corner shops, such a career would have been doomed.

Do you have a most memorable case/patient?

I was still a student at the time and sitting in on an antenatal clinic. The doctor was a petite, late-middle-aged Indian woman and the patients were working people from a deprived area and generally came and went with scarcely a word exchanged.

The patient was in her early teens and she followed her father and mother silently into the consulting room. All three of them, it took a fraction of a second to realize, were intellectually even more challenged that the rest of the patients that we’d seen. The daughter was very plain, had lank hair and wore glasses for long sightedness that made her eyes appear to fill the lenses. The GP rather unnecessarily tried to carry out a bimanual examination even though it was obvious from abdominal examination alone that the girl was at least 24 weeks pregnant. She clearly found the GPs attention incomprehensibly terrifying but didn’t utter a word. The doctor turned to the parents who were sitting huddled together on the other side of the room and explained that there was nothing she could do - the pregnancy was already far advanced. I have to confess that at this point my opinion of the sad trio was, I’m ashamed to say, more callous than caring, but I vividly remember the father saying to the GP, 'Look, we know that she’s not the brightest girl in the world, but she’s our daughter and we love her and we want to do our best for her.’

And at that moment and in the brief silence that followed, I was almost overwhelmed with compassion and the three, who in my eyes I’m embarrassed to admit, even now, 40 years later, had barely been human when they’d first entered the GP surgery moments before, were transformed into real people with real lives and real hopes and fears, real love for each other and real worth.

I think it may have made me a better doctor, but it took much too long for that to happen.

How did you organise your time to do all your projects (patient interviews, medical models, inventions etc.) -Do you sleep?!

Everything that seems to be important at the time just snugs in somehow. But working at weekends, leaving for work at 5.15am only to return at almost 7pm for so many years, has meant that I partly missed out on my children growing up. They're all fine and I'm still married to my first wife, but who knows how dierent things might have been.

What does your ideal day look like?

Well, it involves some passion, some fabulous food and drink, new excitement and intrigue, opportunities to add to a creation or concept if I'm lucky, and making someone laugh unexpectedly You were interviewed by the Black Bag in 2007- in what ways, if any, have your views about medicine/the NHS changed since then?

I am more convinced than ever that the NHS is a miraculous and wonderful embodiment of social justice. Given that so many crazy things are happening in politics and the wider world, it remains a world-beating conjuring trick - a magic carpet that makes it much easier for us to just do the right thing for our patients. We need to cherish it and not take it for granted. If you're studying medicine for your own personal enrichment, you're in the wrong job.

If you were Health Secretary what would you do?

I would defend the NHS and NICE at every turn. I would not let a moment pass without reminding people how astonishing these institutions are. Being ill is a terrifying ordeal, but the things you don't have to worry about are that you're been denied treatment because you

can't afford it, or that you won't make it home because you've had to sell your house to pay for treatment.

In your opinion what are the keys to healthy living? What can we be sure of, if anything, in nutrition and is it true that you are antiexercise?

The key to healthy living is being surrounded by a supportive family and wonderful friends throughout life and into old age. The beneficial mechanism is truly puzzling, but remarkably, there is very good evidence collected in studies some of which are still reporting with complete consistency after nine decades. Quite fascinating.

On a more prosaic level, not smoking tobacco (or anything else), avoiding street drugs or the services of sex workers or those who tend towards promiscuity helps too, as does confining alcohol to moderate consumption. I would certainly avail myself of bowel cancer screening initiatives and have every immunisation going. I'm not quite so sure about breast and other screening programmes.

In countries where food accounts for a greater proportion of income (such as South East Asia) obesity is much less common and it would be better for us all if calories and sugar cost more. If you tax salt (as they used to in Italy) its addition to bread and prepared food is more modest and there is less taste for it. As for organic and whole food, vitamin and mineral supplements, antioxidants and detoxifiers, vegetarianism, fasting days, low-carb and high protein diets, they confer absolutely no health benefits whatsoever, but are spectacularly successful marketing strategies.

I would contend that if you've no tendency to indigestion, a little aspirin a day beyond the age of 40 or perhaps 50, reduces risks of heart disease and bowel cancer. The benefits might be offset by an increase in stroke risk, but personally, I think it's worth it. My GP refused to give me a statin that I’ve requested twice from him on the basis that I'm a man and aged 60, but if a statin de jour turned out to be side-effect free, I'd take one if offered.

Anti-exercise?

It depends how you define exercise. I'm certainly in favour of walking places and using stairs rather than lifts and escalators, and I've cycled to work for years, but my conjecture is that that's commuting, not 'exercising'. As for just cycling or running or engaging in competitive sports - particularly contact sports or any activity involving slippery surfaces, rock faces, horses or water (ie. floundering around in other people's dilute, chlorinated sewage), the evidence is very weak. It's just wear and tear, knee and hip injury waiting to happen, stress fractures, repeated heal strike and UV skin damage with no benefit as far as weight loss and only fleeting positive eects on general metabolism and glucose disposal. Almost all physical exercise teachers in Scandinavia have to retire early through joint injury, and professional athletes are usually spent by their 30s. Those who want to acquire knee injury and arthritis as latter day shrapnel wounds, are most welcome to it, but personally, ritual exercise as a daily torment brings to mind this curative Haiku (the 5, 7 and 5 syllable Japanese poetic form):Jewish triathlon Gin rummy, then contract bridge, Followed by a nap What do you think has been the biggest advance in medicine in the last 10 years?

Antibodies that turn o T-cell subsets to halt autoimmune destruction in its tracks rather than the blunderbuss of steroids, the introduction of DOACS, advances in treatments for cancer, hepatitis C and HIV. Gosh, it's all miraculous. You have no idea. As a student I had over 100 hours of lectures on biochemistry alone, yet only two lectures on drugs and therapeutics. Those two lectures covered everything, because there was almost nothing. When I qualified, the BNF had only just been introduced.

What change in medical knowledge has surprised you most in the last 10 years?

I remain in awe of the advances in cardiovascular medicine. Just a few years ago, survival from cardiac arrest was virtually unheard of even in patients who arrested under our noses in hospital. In the last year I

have interviewed several patients who had suffered out of hospital arrests. A quite remarkable volte-face.

What would you have in your medical bag in a desert island/ Armageddon situation?

A powerful opiate, chloramphenicol (great antibiotic, very broad spectrum and heat stable so won't go off without a fridge), aspirin (a true wonder drug), antiseptics, bug deterrent like DEET, a very high factor sun screen, a bottle of Lagavulin whisky (a.k.a Pater's nostrum), Wellington boots to stop my feet been shredded by coral, stabbed by cone shells or stone fish, and a satellite phone.

What 3 books would you take on a desert island and why?

I will assume that I'm up to speed with how to survive on a desert island and won't need any self-help or survival manuals. So:1. A Suitable Boy by Vickram Seth. Just the most wonderful, fascinating, transporting, engaging, stupendous, gorgeous work full of hope, mischief and complex family issues.

2. Love in the Time of Cholera by Gabriel Garcia Márquez. Fabulous magical realism. Ravishing.

3. Captain Corelli's Mandolin by Louis de Bernières or perhaps The Magus, by John Fowles What 3 textbooks would you recommend for clinical medical students?

I wouldn't presume: actually, I'm not sure that I'd recommend textbooks any more. That said, in the spirit of your question, the books that I had within arm's reach throughout my career were 'Lecture Notes in Clinical Medicine' by Rubenstein and Wayne, Neurological Differential Diagnosis by John Patten and Davidson's Principle and Practice of Medicine. Years ago, the latter was rather wonderful, but like so many things, it has become a little bloated with age.

Biggest piece(s) of advice to medical students/young doctors?

I wrote this as a coda for the students' year book in 2008, and my view hasn't changed:The patients you’re going to be looking after have been real babies, news of whose conception was overwhelmingly wonderful and who

were cherished and adored in infancy, real children who ran around the place like mad things, real teenagers and young adults who fought their way into their place in society in the way that you’re doing just now, real lovers, spouses and parents, real combatants in war and breadwinners in peace, real friends and grandparents.

When you get to see them they’re likely to be at their most frightened, most lonely and most helpless. Find out what they’ve been and who loves them still, and do your best for them if you can.

Will the giblets continue?

Well I hope so, but it's your turn to write them.

What question would you have liked to have been asked that I have not?

There were too many to choose, so may I ask you a question instead, bearing in mind that putting patients first is something that we all promise to do?

Without self-interest or resorting to misandry, do you think it's possible to be a good GP part time?

If you’re interested in reading Professor Levy’s 2007/8 interview you can find it in the Black Bag archives here: https://issuu.com/ galenicals/docs/2007 J. KONDRATOWICZ Editor-in-chief 4th Year MB ChB

CROSSWORD (Solution on page 30)


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