Northwing 2011

northwing 2011

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editorial This year at Northwing, our aim was to put together an issue that housed articles of quality, that showcased the talent and creativity of Sheffield medical students and to prove that the art of good writing is not dead. Even more importantly, that the desire to produce good writing is still palpable; even in today’s times of 140 character conversations and abbreviated text messages.

Our features are examples of exactly this standard of writing. Topics as varied as face transplantation, to GP Commissioning and the Cuban healthcare system; all are covered within these pages. A familiar face to many of us - Patsy Stark grants us an interview on pg. 6. Check out the winners of the yearly elective photo competition on pg. 20, and the FPAS diaries feature on pg. 25, a must-read for this year’s applicants. Our educational spread demystifies fluid management - one not to miss if you’re as confused about fluids as most of us are.

I’d like to thank all the brilliant contributors to this issue; they’re the reason why we’re still here.

Thanks also to our sponsors at the MDU and Oxford University Press, as well as the editorial team who’ve helped put together this issue. It’s been a great experience, and hopefully we’ve inspired the would-be writers amongst you to give it a try.

Sabreen Ali Editor 2011

The Editorial Team

Emily Thomas Deputy Editor

Rob Walsh Associate Editor

Molebedi Segwagwe Associate Editor

contents 5 a few thoughts about cake 6 patsy speaks 7 the peer teaching society 8 new society intro’s 9 the white paper 2010 12 face the facts 13 professional values in action 14 big pharma 15 life vs career 16 europe; hands off our medicines!

17 the paradoxical Cuba 20 gallery 22 fluid management 24 international health 25 fpas diaries 29 medical journalism 32 book reviews 34 creative writing

opinion

a few thoughts about cake...

rachna malani

My friends always said a medical degree from the University of Sheffield is more like a communications degree. Now, I know I can attest to my fair share of communication skills sessions, but I do believe that somewhere in those 5 years, I did learn some real medicine.

Now that I am in the “real world”, having graduated, I’ve had some time to think about the luxury we have as medical students. Not the lie-ins or the night-outs or the relative freedom from responsibility, but the luxury to see how physicians interact with their patients. Every doctor has their own style of working with and talking to their patients. Some doctors are great with their patients, and they will always come back to them, whereas some seem to have not evolved from our Neanderthal ancestors as of yet.

what is it that makes them the best?

Is it that they lend their ears to their patient’s woes, or that they really do all they can for them? Are they truly the doctors each of us should aspire to be?

Perhaps some of the communication skills we get taught, in combination with some of the doctors themselves, together have an “un-disease” effect on their patients. This probably sounds strange, but think about it. By having your patient genuinely like you and bring you lovely cakes in tins, they won’t be as angry with you if you make a mistake. It’s almost as if you’re defrauding this person with everyone smile you flash them, with every pat on the hand, with every ‘cheerio old chap!’ How is that any better than our friend the Neanderthal? At least they are staying true to who they are.

But wait, I’m getting off topic. What I So much of medicine is now moving really want to talk about is, those away from the doctor’s making doctors, who are the ‘best’ at decisions to the patient’s leading their communicating with their patients, own care. I’m not saying that this is

Image by flickr: rox sm

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good or bad, but I think in all of this, we are trying to hide the disease. I know a patient with diabetes is not just a diabetic patient. He’s Joe, the obese construction worker who has 3 grandkids, fishes on the weekend and enjoys the chippy every Friday. The disease isn’t their label. However, this attempt at de-labeling could cause us to forget about it, and that would be more of a danger to our patient.

As important it is to have our patients like us, and I am in no way condoning a bad bed side manner (just look at the Swiss study) but just like a parent should never be their kid’s best friend, we shouldn’t be our patients’.

It is important to remind Joe the diabetic to lose weight each time we see him, to remind him to take his meds and make lifestyle choices, not just hold his hand through it. We don’t need to berate them about it, but we don’t need to coddle them either. If you’re a good doctor, they will come back, just without the tin of cake.

interview

Patsy Speaks...

an interview with vishnu vijayakumar

to know many Sheffield students was truly the best part of my job, whether that was through the committee structures, as an ILA facilitator or during the research SSCs. I was also a mentor for 28 students in the 2003 cohort- the new curriculum. Their graduation day was especially joyous as I reflected on the culmination of 6 years of work.

“being a good medical educator means you should like, respect and represent the students you work for and with.”

What is ASME and what does your new role there entail?

I am now Director of Strategic Development for the Association for the Study of Medical Education (ASME). ASME is an international organisation that promotes evidence based, high quality medical education. There is a medical student/junior doctor section called JASME which is thriving at the moment and providing all kinds of opportunities for those who may want medical education to be part of their career portfolio. My job will be to drive the organisation forward to meet the new demands in undergraduate, postgraduate and continuing professional development while ensuring there is a wide international membership.

Where did you go!?

I returned to Leeds, from where I came. I am Professor of Clinical Education and Director of Clinical Skills for Leeds, responsible for delivering a £2.85m project to develop a multi professional, multiagency clinical training facility which will open in April 2011.

I do a lot less travelling than when I was in Sheffield but I have been to Colombia and Libya to work, and I managed a week’s sailing on my friend’s yacht in Croatia, a lazy week in Marrakesh and a couple of weekends away with friends.

What does your current work with the Belgian Red Cross involve, and what are your plans for the future?

I am part of an EU team (managed by the Belgian Red Cross) working on HIV/Aids in Libya. I am one-third of the curriculum group which is writing the postgraduate/post registration curricula for doctors, nurses and scientists working in the field. I also deliver the “Educational Leadership Course” there which aims to leave behind a trained cohort of clinicians to carry on the work when the funding finishes in 2012.

Why did you decided to move on from Sheffield Medical School?

My reasons were mostly personal. As many people know, my husband died in 2008 so I re-evaluated my life. I decided that after being the lead on the implementation of the 2003 curriculum (which I am very proud of but was then completed) it would be a good time to make the break.

How did you get into Medical Education and eventually come to work at Sheffield Medical School?

I am not a conventional medical educator but like many working in the field it was a matter of serendipity. I had been a nurse for 25 years when I did a Cert Ed, just for fun. Stimulated by that, I did a degree in Social Policy, got a 1st and looked for a new challenge. I developed the clinical skills centre at the Leeds Medical School, then only the 2nd one in the UK and the 3rd in the world. I had some ideas about the impact of what was happening professionally and politically on undergraduate medical education so I did a PhD. It was a lot of hard work to do the PhD part time while still heading up clinical skills but I loved the process. Once I got the PhD I came to Sheffield in January 2002 as a Senior Lecturer and then got the Chair at the end of 2007.

What is your fondest memory of Sheffield Medical School?

In my view, being a good medical educator means you should like, respect and represent the students you work for and with. Getting

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societies

the peer teaching society

alice rutter reports on a successful year Since it was established in 2007 the Peer Teaching Society has gone from strength to strength. Developing each year to become bigger and better, the Peer Teaching Society now has initiatives that provide teaching experience and sessions to all year groups.

education roles to seminar teaching. It gives the teachers a chance to hone in a range of useful skills such as power point production, teaching session preparation, public speaking and communication skills, which as we all know are vital parts of the medical school curriculum!

This year, there has been the introduction of some new, larger scale projects as we expand our horizons, such as Street Medicine - all day courses which arm first year nursing and medical students with the skills they need to walk the walk and talk the talk when out and about, and respond to emergency situations. The teaching opportunities span a wide range, from lectures to small group seminar sessions – and have had unprecedented interest and attendance.

Teacher training, with sessions such as how to give feedback and first-aid teaching have improved the quality of teaching, and new training sessions look to raise the quality of seminar sessions.

Teaching sessions are tailored around the needs of the year group, so as to best match the content to the students and the medical school curriculum. This has meant a big shake up in the teaching schedules this year and in response to feedback, changes have been made with the ambitious intention of making the Peer Teaching Society more accessible and smoother running than ever before.

Teaching sessions - which have run so far for phase 2 and 3a and will soon be run for Phase 1a,1b and 4, have been universally fully booked, with numbers reaching higher than ever before. It is a testament to the quality of the teaching and its organisation that the program has been such a success.

The best thing about Peer Teaching is that it relies upon the goodwill and effort of medical students to act Teachers have enjoyed the opportunity to take on a as both teachers and willing students, and whilst it is number of roles, from lecturer to clinical skills teacher mutually beneficial, it is a real testament to the spirit of and from mentor on the wards in the clinical the medical profession.

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societies

acute care & trauma society marcin klingbajl introduces ‘acts’ ACTS is the a new medical society at the University of Sheffield medical school, and welcomes all medical students who have an interest in trauma, pre-hospital and acute care medicine. We feel these areas are traditionally under-taught in medical school, and so we plan to run lectures, seminars, clinical skills and simulation sessions that will promote and encourage development in key practical skills. We aim to foster an interprofessional approach and plan to develop links with other

societies in the medical school, The Territorial Army, Fire and Ambulance services, student nurses and paramedics, to name just a few.

Our aim is to increase medical student access to principles of trauma, emergency medicine and pre-hospital care. If you would like to be part of ACTS please contact Marcin mdc08mk@sheffield.ac.uk, we look forward to hearing from you!

paediatrics society amy dehn lunn talks kids...

Paeds Soc is a recently formed society that is open to everyone interested in paediatrics. We plan to hold lectures on key issues in paediatrics and to provide careers information and talks.

We also want to fundraise for the Children’s Hospital and Bluebell Wood Children’s Hospice, and encourage students to become

involved with voluntary projects.

If you’re interested in getting involved in any of our projects or coming along to any events, do drop us an email at sheffield.paediatrics@gmail.com and we will add you to our mailing list. We look forward to meeting you!

chloe shaw brings us the...

gp society

A big hello from the GP Society! are wondering what on earth the White Paper is all about, join us We are a newly formed society every Monday at 6pm at The aiming to educate and discuss Interval Café in the Union for the goings on in GP-land. infor mal discussions about anything and everything related We recently had our first major to General Practice. You can also event - a presentation and find us on facebook, and look out discussion of the “White Paper” for notices on Minerva about in conjunction with the BMA. forthcoming events.

Everyone had a great time, and the free pizza went down very Hope to see you soon! well. If you missed this event and

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THE WHITE PAPER 2010

features

“In July 2010, the Coalition government published a White Paper called “Equity and Excellence: Liberating the NHS”. The paper set out a series of marketfriendly reforms that devolve financial decision-making in the English NHS in the hopes of reducing bureaucracy and increasing patient choice. A key part of these reforms is the abolition of Primary Care Trusts (PCTs), which are currently responsible for distributing money and are often criticised for being overly bureaucratic. The White Paper proposes exchanging PCTs for GP consortia, where GPs would be the main fund holders. Crucially, consortia would be run by “any willing provider”, meaning private companies will participate in English healthcare provision on a scale never seen before.” molebedi segwagwe All of this is to happen in the context of the ‘Great Recession’, an economic downturn that has brought Britain’s budgetary deficit and national debt under public scrutiny.

Whilst a series of cuts have been announced in other departments, the Coalition has promised to increase health spending in real terms. But others make the point that one way for governments to improve their balance sheet in times of need is through privatisation of services to raise income or bundle off spending to the private sector. Therefore allowing private GP consortia may be less about empowering patients and clinicians and more about cutting costs. If so, is privatisation really the best way to cut spending in the NHS?

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What Do We Actually Owe? There are 2 measures referred to when considering how much Britain actually owes.

The first is the deficit – the difference between government expenditure and government income annually. The second is the national debt, which is the total sum of liabilities that the country has accrued over time.

Each year, the budget deficit, currently at £159 Billion (Bn), is added onto the national debt, now standing at £1 Trillion. At £110 Bn per annum, the NHS is the largest source of government spending, and thus a huge contributor to the deficit. It is also the largest employer in the country (1.3 million people), but can be quite wasteful.

features Administration costs alone range from £10-15 Bn a year. With facts like these, it is understandable why the Coalition would look to the NHS for savings. The White Paper aims to find these savings through restructuring the service.

The ‘internal market’ of the NHS particularly grew under the last Labour government despite opposition from health workers. The structure of the NHS has also been changed - In the 1990s there were 100 English Health Authorities each serving 500,000 people. These were replaced by 302 The New NHS PCTs serving 170,000, and then amalgamated to 152 PCTs serving In the current system, PCTs hold 80% 350,000. Under the Coalition reforms, of the NHS budget and make it is estimated that between 300-600 purchasing decisions for their localities GP consortia will emerge. (also called ‘commissioning’). The White Paper proposes abolishing The NHS is thus an institution under them and transitioning to complete “perpetual reorganisation”. The danger GP-based commissioning through of this is the fact that re-organisation consortia by 2013. It is hoped this will distracts front line providers from their cut administration costs by 45%. duties as they try and acclimatise to In the new system GPs will be able to form consortia in any region or form they see fit, and patients will be able to register with any practice they choose.

This will be a dramatic shift from PCTs, which are responsible for well-defined geographic areas. The resulting competition for patients is supposed to make the NHS more patientresponsive. Additionally all NHS hospitals will have to become autonomous Foundation Trusts (FTs) and will be free to treat an uncapped amount of private patients. The FTs regulator “Monitor” will be given more teeth in the new legislation to regulate prices and prevent anti-competitive behaviour. The net result of all this will be is an expansion of market principles in the NHS, and a system whereby patients behave much more like consumers of healthcare with providers competing for their business.

A Chequered Past...

Since the 1980s, different governments have tried to curb growth in health expenditure through various market-style practices.

Strategies such as limited GP practice based commissioning have been tried before, as well as outsourcing acute hospital services to private companies.

the new bureaucratic form. Structural change also takes a long time to demonstrate any savings, and can actually increase costs in the short term. It is estimated that the Coalition’s proposals could cost £2-3 Bn to actually implement.

“The NHS is an institution under “perpetual reorganisation” ... reorganisation distracts front line providers from their duties as they try and acclimatise to the new bureaucratic form” Structural change also distracts from e f f o r t s t o i m p r o v e t h e N H S ’s productivity, which has fallen by 1% for the past few years despite interventions by the previous government. Furthermore, the White Paper breaks an election promise to stop more NHS reorganisations and were not presented to the public in any election manifesto, thus it is 10

unclear if there is a public appetite for these reforms.

Does The Market Actually Work?

The underlying assumption of the White Paper is that markets are more efficient than central planning when it comes to healthcare. This has not been borne in previous NHS attempts, where it was demonstrated that acute care expenditure was up to 11% more expensive when outsourced to private companies versus public institutions.

One of the key reasons for this lurks in the profit motive of private companies.

It in the interests of such companies to drive up costs, particularly transaction costs (the sideline costs of purchasing goods and services) in order to increase their profit margin. While this is a successful business strategy, it diverts money away from actual healthcare expenditure. Fragmenting 151 PCTs into (up to) 600 private consortia will likely exacerbate this as each consortium will still have to purchase the same goods and services but with less buying power as they will serve smaller populations.

Thus the economies of scale which exist in PCTs will be lost, making things more expensive.

Another effect of fragmentation is that consortia will be less financially stable.

The larger populations found in current PCTs allow for a greater spread of financial risk between patients, meaning that for every sick patient using up resources there will be many healthier ones not using resources, leaving more money for the PCT to spend on the sicker ones. In smaller populations, this ‘risk pool’ is much smaller, meaning that if costs rise there are fewer resources to work with and a consortia can quickly find itself in financial trouble. The White Paper recognises this but states that if a consortium finds itself in the red it will not be “bailed out”. This bodes the question what will happen to services in areas where consortia go broke?

features In order to avoid this financial risk, it may be necessary for consortia to group themselves into sizes similar to current PCTs (calling into question the point of reform) or to avoid areas where the disease burden is particularly high. The latter is called “cream-skimming” in insurance circles.

Cream-skimming could thus lead to a more inequitable distribution of services where healthier wealthier populations have more consortia competing over them, and poorer areas have less choice. This could further health inequalities between the poor and the rich. In addition, competition between consortia may lead to unnecessary duplication of services and waste as seen in other marketized systems.

deciding which drugs are cost effective and would allow for more evidence-based prescribing, and an end to the so called ‘post code lottery’. Unfortunately Health Secretary Andrew Lansley has acted to actually decrease some of NICE’s limited powers. Further, there has historically been more expenditure in tertiary centres than primary care in the NHS. Tertiary centres tend to be costlier due to inpatient care, thus trying to find procedures that can be done on an outpatient basis or by cheaper staff (nurse practitioners for example) may be a way to cut costs.

Whilst many of the suggestions in this brief list may be politically difficult to implement, it remains important to question the assumption that more structural reform and privatisation are better options.

What Are The Alternatives?

“Healthcare as a product is much more complicated and expensive than other commodities, and thus the question should be asked, what are we trying to achieve?”

The Kings Fund suggests that the NHS should focus on “a relentless drive to improve productivity”. Given that 70% of the budget is spent on staffing, productivity gains are certainly possible there. For example, retrenchment on PCT administration staff independent of any structural reform would too have reduced bureaucracy. Also, whilst pay rises for staff will be frozen from April 2011, perhaps there is some utility in enacting actual pay cuts especially for those in higher income bands.

Conclusion Image: Google

Perhaps there has been a failure to manage public expectations of what we can achieve within our system.

While the NHS should always aim to be improving clinical outcomes, patients should be made to understand that such large degrees of choice that are available to them when buying other services are simply not financially possible in a publicly funded health service without exorbitant costs. This is because healthcare as a product is much more complicated and expensive than other commodities, and thus the question should be asked, what are we trying to achieve? An equitable service which remains free at the point of need but with some limits on individual choice, or a consumer experience that will benefit those who the market wants to serve but may entrench inequality?

Though this would be difficult politically, the Coalition has shown itself capable of passing unpopular pieces of legislation such as increasing higher education tuition fees.

Others have also argued that NHS institutions are underused, and that productivity gains can be made by using operating theatres and pathology labs 24 hours a day. This would need healthcare professionals to commit to working in this way but would reduce capital expenditure over time, for example, as it has in manufacturing.

Another area of savings can be found in pharmaceuticals expenditure, which has risen by £7.1 Bn since 1991. One way of controlling this is to give NICE more teeth in

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features

face the facts. arpita chattopadhyay talks facial transplantation...

In the past, face transplants were considered fiction, appearing in Hollywood thrillers such as Face/Off, yet in recent years, it has become a very real possibility. In 2005, Isabella Dinoire, a French woman whose face had been mauled by her pet dog, became the first recipient of a partial face transplant. Since then, facial transplants have been performed a number of times worldwide, and 2010 saw the first full facial transplant being conducted in Spain.

individual who resembles their deceased loved one, and the friends and family of the recipient will be faced with a stranger.

Face transplants therefore differ from plastic surgery, as the recipient is not simply having a change to their own appearance, but will be assuming somebody else’s appearance, as well as their identity.

Yet this argument has little logical grounding. Technically, once transplanted, the face will mould to the recipient’s own bone structure, and so the face will not resemble the donor, nor that of the recipient, but a new face. Secondly, identity is not only skin deep; memories, social relationships and personality all constitute an individual’s identity.

It is therefore possible for an individual to remain themselves even if they do not look it.

Though the transplantation of the face is of huge medical, surgical and psychological relevance, and improves the prospects of those with gross facial disfigurement, aspects of the procedure still strike us as unsettling. As Mr. Peter Butler, a consultant plastic surgeon from London, put it, the question is no longer “‘Can we do it?’ but ‘Should we do it?’. In this article, I will discuss face transplants and briefly outline some of the ethical issues that have arisen as a result of this new surgery.

The rationale for performing a face transplant is to improve the recipient’s quality of life. Recipients are often suffering from the psychological distress of severe disfigurement, are socially isolated, are unable to communicate, or have difficulties in eating and drinking. A facial transplant is intended to improve all of these factors by rebuilding the face, and therefore normalising function. The recipient would hopefully then be able to use their new face to communicate words and emotions to others, as well as regain some function and aesthetic appearance.

The transplant, however, is a significant surgery, and may generate more harm than benefit. The whole procedure for arranging a face transplant is a lengthy process, and there is a significant amount of time between the initial insult and the surgery. During this time, the individual may eventually learn to accept their disfigurement and adjust their lifestyle to their disability. To then go and inflict another significant change upon the individual would be unnecessary; yet another alteration in appearance can be confusing and will destroy the progress that the patient has made in terms of self-esteem and psychological adjustment. Not only are there psychological risks with face transplants, but physical risks too. The transplant may be aesthetically successful, but functionally inadequate, there are risks of infection and malignancy, and risks associated with the toxic drug regime.

Worst-case scenario? : The tissue graft is rejected, and it diesleaving the recipient with a large wound on their face, which is likely more distressing than a disfigurement.

Face transplants involve the removal and transfer of a combination of bone, muscle, cartilage, skin, fat, arteries, veins and nerves from a donor’s face to a recipient. Like other forms of transplantation, the donor and the recipient must have their tissue carefully matched and the recipient must take lifelong anti-rejection drugs to minimise the chances of rejection. The tissue must also be carefully matched according to colour, tone, age and gender, in order to achieve the most accurate match of the recipient’s natural face. In addition, the recipient must be given sufficient psychological support, as this is life-altering surgery.

Both plastic surgery and transplantation of other organs are performed on a daily basis, and the results are greatly appreciated and celebrated. Yet, there is something about face transplants that strikes us as innately wrong- what I like to call the “yuk factor”.

Additionally, by putting an emphasis on treating all disfigurement is to imply that individuals with disfigurements have an inadequate quality of life, and this is not necessarily true. By creating pressure for everyone to look “normal”, discrimination could be generated against those who chose to remain with their disfigurement.

The issue may arise from the fact that it is a face that is being transplanted. The face is the most personal, identifiable and visible aspect of a human being. We associate a person’s face with their personal, racial and social identity, as well as a reflection of their persona- a window to their soul. Faces are associated with who we are and where we come from. It strikes us as disturbing to know that once we die, somebody else may be walking around with our faces- walking around as “me”.

To ensure that the recipient fully understands the procedure, informed consent must be gained. The recipient must understand that they will never regain their previous facial structure, nor will they look exactly like the donor. They must also be aware of other psychological aspects of facial transplantation, possible rejection and the need for lifelong immunosuppression. As long as the recipient fulfils the criteria for capacity as outlined by the legal case Re C, they are legally able to consent to any procedure.

Not only is this a serious issue for the donor, but the recipient would also feel as though they are wearing the mask of a deceased stranger, which is distressing in itself. Friends and family of both the recipient and the donor are also affected.

The donor’s acquaintances may risk running into an

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features Questions, however, have been raised over the validity of this consent. The recipient may be so desperate for change that in his/her psychologically vulnerable state, agrees to the radical surgery without objectively and autonomously evaluating the risks and benefits, and without considering realistically, the prospect of failure.

eating or drinking. Should the surgery be limited to only individuals with severe disfigurement, or could other individuals with other forms of facial disfigurement be entitled to it? Knowing where to draw the line could become an issue in the future: people who believe themselves to be unattractive could opt for a face transplant, as could people with ulterior motives. Though these are ‘slippery slope arguments’, they should still be considered as potential longterm consequences of the procedure.

Informed consent must also be given by the donor, or their family, before their death. Procuring organs for facial transplants is somewhat different to that of other organs, as the donor’s face must be disfigured in the process, and this has a number of negative implications. We have a duty to respect the bodily integrity of the deceased. Harvesting the donor’s face could cause complications with after-life rituals, particularly ceremonies such as open-casket funerals. The transplants that have been performed so far have been for severe facial disfigurements that interfere with the patient’s life, by limiting communication or stopping the patient from

In conclusion, medical advances have allowed the technology and the knowledge for facial transplants to occur. Though the surgery is still experimental, with further refinement and improved drug therapy, face transplants could become a routine procedure. Ethically, however, there are a number of issues, including that of personal identity and informed consent of both the recipient and the donor, which may hinder the progress of this procedure.

Image by flickr: dmoola

news in brief

Medical students: Professional Values in Action sabreen ali

The General Medical Council (GMC) has created the interactive Medical students: Professional Values in Action, a website to help students face real-life dilemmas, and apply GMC guidance to them. Students will be able to test their knowledge via quizzes and case studies, as well as ‘spotting the mistake’ in medical cartoon strips. The site will act as an aid to improve understanding of professionalism and good practice before commencing work as foundation doctors, where they will face such problems on a day-to-day basis. It acts as useful supplementation alongside the medical school curriculum, and the activities reinforce good practice in line with the GMC guidance; Medical students: professional values and fitness to practise.

“This is a great way for medical students to understand the professional standards expected from all doctors. Parts of GMC guidance have been transformed into real-life scenarios and though the site is not designed to replace the guidance, it is there to increase students’ understanding, stimulate further interest and in turn, better equip the doctors of tomorrow,” said Professor Trudie Roberts, GMC Council member and Chair of the Basic Medical Education Fitness to Practise working group.

Example scenarios include students having to decide how best to respond to the receptionist of a busy GP surgery who has asked if they can perform a cervical smear on a patient, or choosing whether or not to declare a previous caution for shoplifting when applying for registration. The site aims to make understanding and implementing GMC guidance more entertaining, interactive and engaging. Visit the website, and see for yourself: www.gmc-uk.org/studentvalues

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features

big pharma practice on interactions has been tightened in recent years to head off criticism. In the US, the so-called “Sunshine Act” has brought in rigorous l i m i t s o n p hy s i c i a n payments.

The pharmaceutical industry got a rare piece of good press in popular culture earlier this year. Love and Other Drugs, a rom-com about a Viagra salesman starring Jake Gyllenhaal and Anne Hathaway tells the tale of a pharma rep who falls in love - for those interested in such things. But for an industry more used to depictions as a Machiavellian and malignant force, such as in the 2005 film The Constant Gardner, such light-hearted fare is probably very welcome.

But it’s not just the general public who are distrustful of “Big Pharma’s” m o t i ve s. Wi t h i n t h e m e d i c a l profession, there are increasingly vocal lobbyists who are critical of the role that the industry plays in medical practice. Groups such as “No Free Lunch”, “Healthy Scepticism” and Medsin’s “Pharmaware” campaign seek to raise awareness of what they see as unethical practices, and professional bodies are attempting to tighten up the rules for how pharma and physicians interact.

However, many other physicians are insistent that a close working relationship between industry and academia is essential. Indeed, a very l a r g e p ro p o r t i o n o f postgraduate medical education is funded by industry, and the majority of new therapeutics in recent decades have been developed by pharma companies. It’s not just industry apologists who hold these opinions; Steve Nissen, the cardiologist who was instrumental in having Vioxx removed from the market after it was shown to increase cardiovascular mortality, has been quoted as saying he has a “duty to work with industry” for the benefit of patients.

It might be worth breaking down the kinds of relationships between doctors a n d i n d u s t r y t h at ex i s t ; d r u g companies want to raise awareness and increase prescriptions of their drugs by directly contacting doctors in two main ways – getting them to see drug reps, or to speak at or attend industry-sponsored symposia and conferences. The latter was historically most open to abuse, with tales of allexpenses-paid 2-week “conferences” in the Caribbean-days which, perhaps unfortunately for us, have since passed.

Additionally, there is a great deal of collaboration in research or via c on s ultin g ar ran gements, both between individuals and institutions.

The literature in this area is often characterised by opinion more than evidence, but the evidence that does exist suggests that such marketing does have some impact on prescribing.

Psychological experiments into the “neurobiology of reciprocity” show that gift receiving creates a sense of indebtedness and can alter behaviour, but this relationship isn’t as simple as the straight-up bribery that it is often presented as.

One case in point is the BMA students committee, who early last year released guidelines on how medical students should interact with drug companies, suggesting that they do not accept gifts, or meet with reps without a senior colleague present. Other organisations such as the Royal College of Physicians have released reports into the area, highlighting a “failure of trust” between industry and the NHS, Some evidence shows that many whilst the Association of the British doctors hold industry-sponsored Pharmaceutical Industry’s own code of education and detailing in low regard,

14

rob walsh

but are still influenced by it.

Others considered that gifts would influence other doctors’ prescribing, but not their own.

Most interestingly, institutional policies can have a large impact on such interactions; a trial at two US medical schools showed t hat s tuden t at t it u de s to industry could be moulded by their respective schools’ policies (Grande et al, 2009, Arch Int Med). Perhaps more i m p o r t a n t l y, i n d u s t r y advertising isn’t the only factor affecting prescribing; as one commentator notes "pharmaceutical advertising is not half the enemy of rational prescribing as the phrase ‘in my

experience’ is" (Ryan et al, 2010, Australasian Psychiatry).

A critical awareness of these influences, a greater degree of openness and mindfulness of evidence-based practice should mean that doctors needn’t be credulous automata; an advert for pharmaceuticals ideally ought not to be any more malign than an advert for cornflakes. A demand for a clampdown on interactions avoids the hard work of educating medical students and junior doctors to be sufficiently critical and professional to be able to both work with industry, and avoid being suckered.

“Drug companies are by no means saints, but neither are they the uniquely evil institutions they are often painted as” But if these conflicts of interests are manageable, why is there so much hostility to pharmaceuticals? Much of it comes from the dual nature of what a company has to do; make both medicines and money.

People find it offensive that companies should try to profit from ill health; but people need food more than they need medicine – and criticism of Waitrose for making money out of people’s need to eat is somewhat muted. Likewise, there is often less hostility to private medical practice, or the plethora of private companies currently pitching for a piece of the NHS via private finance initiatives (PFI’s) and the like, than to drug companies. Many of the problems with what pharma companies do are more down to the perverse incentives of the market than any ill intent. Take for instance their preference for developing “me too” drugs in classes that have already been discovered rather than innovative drugs; a new statin will be prescribed millions of times, whilst a new antibiotic will be kept in a cupboard to prevent

resistance from developing. A sensible approach here would be to more effectively target NHS money towards more useful medications rather than penalising producers.

In conclusion, pharma companies clearly have an interest in influencing the prescribing behaviour of doctors, but they are not uniquely manipulative, and physicians aren’t uniquely gullible – indeed, many in the industry complain about the ineffectiveness of detailing. Increased openness and awareness ought to redress the balance in favour of doctors.

Drug companies are by no means saints, but neither are they the uniquely evil institutions they are often painted as. Their failures are often those of the market system, seen in other industries as well, rather than something specific to pharmaceuticals.

For the time being, the pharma industry is an indispensable part of the division of labour in healthcare – whether the medical profession likes it or not, they will have to find a way of living with it.

Image: Wikimedia Commons

features

life vs career. alice rutter examines the pros and cons of general practice As a medical student, GP is a dirty word. And, you get some very strange sideways glances and stunned silences if you express any sort of interest in public health. But, as much as I dislike it when a consultant says at the start of a lecture: ‘you’ll need to know this when you’re a GP…’ of the 218,000 doctors currently registered with the GMC, 43,000 are General Practitioners. The fact is, they’re coming from somewhere, and play a crucial role in our healthcare system.

So why does settling down feel so much like selling out?

home and reflect on the positive things I did that day. Days blur into each other; a successful cannulation no longer seems such an achievement. I come home completely exhausted and out of touch with the world. But we’re young; we can live through the fatigue, the hours and losing touch with old friends. Time for kids, time to get away, time for loved ones - all that doesn’t seem that important just yet.

We’re ambitious and want to leave our mark. To do medicine in the first place there has to be a natural competitive edge that makes you push that bit harder to get through exams and interviews, and be at the top of your game. Within hospital medicine, there is a clear career path - something to strive for, to aspire to, and to achieve. No one defers to the higher judgment of the GP, consultant opinions count, and GP’s are mocked regularly for incompetency.

Wrongly so, I agree, but it is a common observation within hospital.

Everybody knows the 9 to 5 hours of GP practice, the free weekends and the lack of night shifts along with the excellent pay make it a pretty attractive proposition. The problem is, it doesn’t seem to fit with the idealism and ambition of many medical students. Let’s face it; nobody is going to change the world from behind a GP desk in Grimsby. It’s falling back into the 9 to 5 slog that we were all so desperate to avoid, never mind that we are instead choosing the 7 ‘til 7 slog. The long and the short of it is, the life of a GP is where you can have a family, see the kids, get away at weekends and still have real friends with whom you don’t only communicate via the internet or the oncea-month phone call.

Becoming a GP feels like taking yourself out of the race – and while it may be the route to a better life, happiness and a less stressful career overall, there is still a sense of ‘they’re the ones who couldn’t take real medicine’ within the medical profession.

Where next then? You’re a GP, then a GP making more money, then a better, more senior GP. Perhaps move on to a GP Specialist, with better expertise, more potential to progress and take on a more important role, such as cardiology or respiratory GPs - who have a similar level of specialist training to a medical consultant and are able to diagnose, refer for investigations and manage patients. This is an important aspect for the future, allowing pressure to be taken off the hospital environment and consultant clinics and allowing a similar level of expertise to exist both in and out of hospital. It would take the focus off the ‘generalist attitude’ and move onto a positive view of community lead care. The existing system allows GPs to take on a special interest in a certain area, but not to generate the same level of expertise or respect in the field that can be cultivated in a hospital career.

“No one defers to the higher judgment of the GP, consultant opinions count, and GP’s are mocked regularly for incompetency.”

I would argue that as we get older, we should become more sensible and say: enough of the chronic backache and the early mornings, and most of all, the hospital beaurocracy. By all means take the comfortable life over the competitive life, and I will applaud your good sense in doing so. Being a GP is a great option, and lets you have a ‘real life’. Only don’t expect me to take myself out of the game just yet…

As a third year student I can see the pattern developing, and it is easily recognizable in junior doctors. Leaving the house at 7 each morning and returning at 5, I come home and want to sleep, watch TV, eat whatever is in the fridge. I don’t come

Image: Wikimedia Commons

15

features

europe; hands off our medicines! kate markham Millions of people in developing countries rely on affordable generic medicines to stay alive.

More than 80% of the medicines used by Médecins Sans Frontières (MSF) to treat AIDS across the developing world are produced in India. However, the European Commission is planning to close the tap, and thereby stem the flow of affordable medicines by pushing for aggressive policies that will severely restrict treatment and increase costs.

This means that instead of multiple generic manufacturers pushing down the cost of AIDS treatment by more than 99% to $70 per patient per year, the cost can be as much as $10,000 per patient per year. If Europe succeeds, millions of people across the developing world could be denied access to affordable medicines.

drugs identical in quality to the original product, but at heavily reduced prices. As a result, these generic drugs manufactured in India are among the most affordable in the world. This has allowed MSF to give AIDS treatment to more than 160,000 patients from generic producers in India.

However, since 2005 the World Health Organisation’s TRIPS agreement has obligated India to begin patenting medicines, meaning that newer patented medicines are blocking the production of generic affordable versions. Furthermore the EU is now pressuring India to further restrict production and sales of medicines by introducing ‘data exclusivity’. This would delay production of affordable generic medicines for up to a decade; even for those without a patent.

“What the Europeans are doing is effectively snatching the medicines out of our hands. Because generic medicines are more affordable, we have been able to put more and more patients on AIDS medication. This has meant a lot of hope for our patients who can work again, who can bring up their children again. But if Europe has its way and shuts off this source, we risk killing the success of what has been achieved here in the last five years.”

What can be done?

Accessing affordable medicines from India is a lifeline for all developing countries. However due to the European Commission playing a leading role in preventing this, the situation is now seriously under attack.

On Friday 10th December 2010, members of stopAIDS societies from the UK, France and Germany attended a protest at the EU-India summit in Brussels. It was intended to raise awareness that provisions concerning data exclusivity and patent law extensions should not be included in the Free Trade Agreement.

The EU has already responded positively to the campaign so it is important that we keep up the pressure to ensure pharmaceutical property rights are not placed above the human right to life.

Dr. Marius Müller MSF’s Medical Co-ordinator in Kenya How does a drug patent work?

Get involved

When a drug company holds a patent on a medicine, it prevents other companies from producing or selling the drug for the duration of the patent’s term. This allows the company to charge high prices in countries where it holds patents because there are no competitors in the market; therefore meaning drugs remain unaffordable.

Until recently, India did not grant patents on medicines, so local companies could produce

Join the campaign and support the millions of people that rely on generic drugs around the world: https://action.msf.org/en_GB/action/ index/ If you would like to be involved in the stopAIDS society, visit the facebook group “Sheffield Stop AIDS Society” for information on meetings and events.

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features

the paradoxical Cuba raisa ahmed

Image by flickr: Alcino

“Cuba’s history is fascinating. A former Spanish colony, Cuba became the first communist state in the Western world, after leader Fidel Castro led a revolution and overthrew the US-backed dictator Fulgencio Batista. Castro’s core supporters included the famous Argentinean physician, Ernesto Che Guevara. Batista had enjoyed a wealthy lifestyle from the money generated by tourism and influx of American corporations, while the poor became even more impoverished.

His Mafia ally Meyer Lansky had also turned Cuba into an international drug trafficking port.

Castro’s government dissolved the corrupt capitalist system, and created more social provisions for the poor under a state controlled system.

As punishment for their defiance, the US enforced an economic embargo, one of the very few in the world to include food and medical supplies. This has had devastating effects on the people of Cuba. Despite the UN calling it illegal and repeated votes by the UN general assembly in favour of lifting the embargo, the US has refused. Astonishingly, in spite of overwhelming economic sanctions, Cuba has managed to create and sustain a world-class health system; and is widely respected for providing universally free, easily accessible and high quality of health care to its people.”

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features The foundation of the Cuban healthcare system is built on primary care, provided in consultorios and deal with 80% of the health problems.

Consultorios are the doctors’ and nurses’ consultation offices located in the neighbourhoods they serve.

Defined communities have a family physician and they typically live above or near the small consultorios; for example in 3 storey consultorios; the ground floor is the consultation office, the first floor houses the doctor and second floor is the home of the nurse. In the mornings, the family physician sees patients in the consultorios and makes home visits in the afternoon. The doctors and nurses are well integrated into the community they serve.

Cuba has the highest family physician-to-population ratio in the world (1:600). Patients requiring more specialised care are referred to polyclinics (secondary care).

Polyclinics are similar to outpatient departments of a hospital and consist of interdisciplinary teams. They focus on providing basic emergency services, specialist clinics and rehabilitation services. Many family physicians join their patients for a half a day per week for their visits to polyclinics. This provides continuity of care, builds collegial relationships between family physicians and specialists, and is educational for all three parties.

Family physicians are the forefront of the core features of the Cuban health system: disease prevention and health promotion. They meet each patient in their catchment area at least twice a year: maintaining detailed records, using a checklist formula, ongoing risk evaluation accompanied by personal patient prevention and education programs.

Public health officials visit regularly to review each consultorios’ health statistics. As needs are identified, action plans are developed.

Polyclinics also play an important role in prevention for example routine immunisations are performed here.

The immunisation program has been hugely successful. Over 95% of Cuban children are immunised against 13 vaccine-preventable

diseases. Polio, measles, mumps, rubella, diphtheria and tetanus have disappeared. Cuba has developed a s t ro n g v a c c i n e m a n u f a c t u r i n g program using its own domestic capacities, ensuring security of supply.

Vast improvements in non medical and social determinants, along with integration of these with the health service have greatly contributed to the outstanding health outcomes.

C a s t r o ’s g o v e r n m e n t h a s revolutionised the entire social system, concentrating their efforts on: sanitation, subsidised quality housing, widespread job creation programs that have resulted in lower unemployment rates, social security and retirement benefits, day care and nutrition.

“What is they key to Cuba’s remarkable achievements despite limited resources? The answer appears to centre on Cuba’s adherence to 3 underlying principles: equity, integration of public health services and the imaginative harnessing of human resources in a collaborative manner” The economic embargo has often created food shortages. However, Cuba’s ration card system ensures that everyone obtains a guaranteed amount of affordable food regardless of wealth or location. Education is also free and almost 100% of the population are literate. The current social infrastructure promotes social cohesion and abolishes inequalities.

Population-based organisations, which consist of people with different backgrounds, are able to interact with government bodies and ministries 18

without a social barrier. This has allowed the sharing and discussion of information on public health issues.

Expenditure on healthcare includes drugs prescribed for outpatient treatment, hearing aids, dental and orthopaedic equipment, wheelchairs, crutches and glasses. Dental and optical services are free.

Medical education system Medical education in Cuba is also free. The course is 6 years long, with the first 5 years being a combination of learning basic clinical sciences and clinical practice. The 6th year is an internship. After obtaining their MD, graduates must complete a 2 year residency program in family medicine.

Following this, they may apply to a residency program in a secondary speciality should they wish to.

Currently, there are 30,000 foreign students studying medicine in Cuba.

10,000 of these are enrolled into the Latin American Study Program. This school offers international scholarships (free medical education) to students from poor and underserved communities, including students from the US. In return, they are expected to make a commitment that after graduating they will serve in their own or another underserved community.

The Cuban healthcare system and medical curriculum focuses heavily on integrative medicine: a combination of alternative, complementary and conventional medicines. These practices are known as natural and traditional medicine in Cuba. In medical school, students learn the science of Complementary Alternative Medicine (CAM) on CAM rotations and it is also integrated into physiology, anatomy and clinical courses. This may be partly due to the lack of allopathic medicines available due to the economic e m b a r g o . T h e re i s n o d o u b t , however, that integrative medicine has proved successful; allowing people living in rural areas greater access to medical services and physicians are able to deal with health problems effectively even in the face of shortages of medical supplies.

features Exporting the Cuban health system

Critics and propaganda

Mainly ignored by the Western media, Cuba’s medical assistance in foreign aid is immense: she is one of the world’s most generous countries in providing medical teams and medical supplies to third world countries and in disaster relief situations. Developed countries tend to donate money; while undoubtedly useful, there is always a risk that it will fall into the wrong hands. The first Cuban medical team was sent to Chile in 1960 after a devastating earthquake hit the country, despite there being no formal relations between the two governments. Over the next few decades, such disaster relief missions were dispatched to other countries.

In fact, Cuba was one of the first countries ready to send a medical team of 1500 doctors and medical supplies to the US after Hurricane Katrina rampaged through New Orleans in 2005. Hurricane Katrina was one of 5 of the deadliest hurricanes in US history, and its costliest natural disaster; nearly 2000 people lost their lives. The US government did not respond to or even acknowledge Cuba’s offer.

By no means is the Cuban healthcare system perfect. Since about 50% of the most important drugs on the world market are controlled by US manufacturers or their subsidiaries, the US embargo has severely limited access to essential medical supplies.

This has opened up a black market for trading drugs. The salaries of the health professionals are also very low, resulting in many physicians defecting to seek greater fortune elsewhere. Some have criticised that the physician-to-population ratio is too high.

Castro has been accused by the West as being a brutal dictator and some see Cuba’s international medical missions as a way of disguising Cuba’s supposedly human rights flaws. Moore comically asks us about how we know that Cuba is the “world’s most evil nation ever created”, home of its leader “Lucifer.”

More recently, I came across an article in the Independent (Dec 26 2010): “Cuban medics in Haiti put the world to shame.” The 2010 Haiti earthquake left 250,000 people dead and 1.5 million homeless. Haiti is one of the most impoverished countries in the world.

Cuban healthcare workers have been in Haiti since 1998 so when the earthquake struck, the medical team of 350 jumped into action.

Hundreds more healthcare workers arrived soon after. Many other countries including the US and UK provided medical assistance, but most countries were gone after 2 months, leaving Cuba and MSF as the principal healthcare providers. Since October, Cuban medical personnel have treated 30,000+ cholera cases across 40 centres in Haiti.

Since 1998, Cuba has trained 550 Haitan doctors through the Latin American Study Program and is currently training another 400 doctors for free.

In Ju ly 2006, 26,664 Cuban health professionals were serving abroad in 68 countries. In each country, Cuba aims to strengthen the public health infrastructures often providing the desperately needed medical staff in remote areas. It is impossible to cover Cuba’s vast involvement in the development of viable healthcare systems in the third world in a mere paragraph but sadly, these contributions go largely unrecognized.

The simple answer is: that’s what we have been told for over 45 years. Yes, I agree that genuine problems exist in their health system but it is no myth that much has been tried to discredit it unfairly. The West’s, particularly the US, hatred of communism has given birth to continuous propaganda about Cuba, including its health service. It is sad that the US wastes so much energy trying to discredit such a phenomenal system, when there is so much it could learn from. And it begs the question of how much more advancement could Cuba achieve if she was not so heavily strained under the current illegal economic sanctions?

Conclusion Unfortunately, even a piece of this length cannot fully describe the intricacies of the Cuban health system. Although economic conditions have deteriorated, Cuba manages to maintain its world class health system by always prioritising healthcare. Cuba has shown that developing a viable health system is possible even when resources and funding are low. She has achieved this with the only other means available to her: human resources. The Cuban health service was developed after officials visited several countries including the UK and studied their health systems. I believe that Cuba has not only implemented the ideas of the UK’s NHS but also refined it. I think we can learn a lot from their core principles of preventative medicine and perhaps produce a more cost effective system of our own.

19

Sicko Funnily enough, I first came t o l e a r n a b o u t C u b a ’s exceptional healthcare system in Michael Moore’s documentary film, Sicko (2007). Moore compared the for-profit US healthcare service to the non-profit systems of Cuba, UK, France and Canada.

He highlighted the plight of millions of Americans, who despite having medical insurance cannot afford treatment, as well as horrific practices by health insurance companies that actively try to keep people from obtaining insurance in the first place. In fact, the doctor with the highest percentage of denials was awarded with a bonus.

Moore eventually rounded up several American patients with chronic health conditions, including 3 9/11 fire-fighters, who could not afford healthcare. Amusingly, Moore attempted to take them to Guantanamo Bay on a boat: the only place on US soil with universal free healthcare.

They ended up landing in Cuba. Moore took them to a hospital, where they received healthcare to the same standard as their fellow Cuban citizens: for free.

Image: Wikimedia Commons

gallery

elective photo competition

1st Anil Joshi East Timor

3rd

2nd

Philippa Grant Philippines

Mark Graham Shetland Isles

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gallery

RU Laura Gillis India

RU Amy Kang Uganda

Highly Commended Helen Casey Ghana

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“Northwing brings you the insightful photography of this year’s elective photo competition winners, as chosen by MEDSOC.”

education

fluid management rachna malani

Appropriate fluid management is a source of agony for many medical students and junior doctors. The physiology and anatomy associated with this topic is complex and the risks of inappropriate management are high.

There is always the fear of fluid overloading a patient, or of giving them the wrong type of fluid and causing an electrolyte disturbance. This review of fluid management is not comprehensive but provides the reader with an outline of the basics and some key points.

The average 70 kg man is roughly 60-70% water, which equates to roughly 42L. This water is then further distributed between the intracellular fluid compartment (ICF) and the extracellular fluid compartment (ECF). The ICF is roughly 2/3 of the water and ECF 1/3. The ECF is then further divided into the intravascular space, interstitial (surrounding cells) space, and the often neglected transcellular space (includes ocular fluid, pleural fluid, etc). !

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So what determines these fluid compartments? Osmotic forces determine the ECF and the ICF, and Starling forces determine the intravascular vs interstitial compartments. A simple way of understanding the osmotic forces is as the total number of solute particles in a solvent. The osmolarity is determined by looking at the uncharged and charged ions. A simple equation is: 2(Na+K) +urea + glucose. The number you get with this equation should be equal for the ICF and ECF. If there are differences, it will cause fluid shifts

between the two compartments. Unfortunately, this subject is out of the scope of this article and will hopefully be addressed in a different one.

Starling forces consider oncotic pressures and hydrostatic pressures. Arterioles tend to have a higher hydrostatic than oncotic pressure, which is why fluid leaves arterioles. Venules are the reverse. Their oncotic pressure is higher than their hydrostatic, which is why they tend to reabsorb fluid. Now that basic physiology is done, what is our normal daily fluid input and output?

22

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So on average, we need roughly 3 L of water a day. Another Then, administer a fluid challenge. This is when you give a way of thinking about it is: 40 mL/kg/day. Of that, we need patient 250 mL of colloid over 5-10 min. Once you’ve done !+7)+')#6-$#(-)8-)'--/)$+1(2%3)L)D)+*)8#"-$)#)/#34)5'+"2-$)8#3)+*)"2&'K&'()#;+1")&")&.@)MG)=DNK(N/#34)A*) 100 mmol/L of sodium and 60 mmol/L of potassium. this, re-assess the patient, going over your checklist again.

Has there been an improvement? If not, you can give the "2#"7)8-)'--/)BGG)==+%ND)+*).+/&1=)#'/)OG)==+%ND)+*)0+"#..&1=4)) When do we need to give fluids to patients? We give fluids to patient another fluid challenge and see if this elicits a change patients who are in need of resuscitation (i.e. have suffered in their status.

P2-')/+)8-)'--/)"+)(&6-)*%1&/.)"+)0#"&-'".>)P-)(&6-)*%1&/.)"+)0#"&-'".)82+)#$-)&')'--/)+*)$-.1.,&"#"&+') haemorrhage), to patients for maintenance (i.e. patients who areQ&4-4)2#6-).1**-$-/)2#-=+$$2#(-R7)"+)0#"&-'".)*+$)=#&'"-'#',-)Q&4-4)0#"&-'".)82+)#$-)'&%);3)=+1"2)+$)82+) nil by mouth or who are post-op) and we to those with Once you’ve decided to give your patient fluid, the major electrolyte disorders. question is: what type? Crystalloid or colloid? Crystalloids are #$-)0+."S+0R)#'/)8-)"+)"2+.-)8&"2)-%-,"$+%3"-)/&.+$/-$.4)) fluids that form a true solution and are able to cross a semiIt can be tempting to just fill in a fluid chart in a repetitive permeable membrane. Some of them do stay in the fashion, covering adequate fluids for a patient, but this is intravascular space for sometime before distributing I+8)/+)8-)K'+8)82-')0#"&-'".)'--/)*%1&/.>)!+=-"&=-.7)&"),#');-)"-=0"&'()"+)T1.")*&%%)&')#)*%1&/),2#$")&') irresponsible practice. Fluids are just like any other drug you themselves to other compartments, whereas others such as #)$-0-"&"&6-)*#.2&+'7),+6-$&'()#/-U1#"-)*%1&/.)*+$)#)0#"&-'"7);1")"2&.)&.)&$$-.0+'.&;%-)0$#,"&,-4)F%1&/.)#$-) write on a prescription chart and as such need to be given in 5% dextrose (which should never be given in an emergency anT1.")%&K-)#'3)+"2-$)/$1()3+1)8$&"-)+')#)0$-.,$&0"&+'),2#$")#'/)#.).1,2)'--/)"+);-)(&6-')&')#')#00$+0$&#"-) appropriate fashion. First, review the patient’s notes and situation) distribute across all compartments evenly. Colloids their obs chart. Look to see if there have been any changes have a high molecular weight and do not pass through a *#.2&+'4)F&$."7)$-6&-8)"2-)0#"&-'"V.)'+"-.)#'/)"2-&$)+;.),2#$"4)D++K)"+).--)&*)"2-$-)2#6-);--')#'3),2#'(-.) (have they undergone an operation, has their blood pressure semi-permeable membrane, and as such will stay in the changed, etc). Next, look at their fluid balance chart and see if intravascular space for a period of time. If you are giving a Q2#6-)"2-3)1'/-$(+'-)#')+0-$#"&+'7)2#.)"2-&$);%++/)0$-..1$-),2#'(-/7)-",R4)<-H"7)%++K)#")"2-&$)*%1&/) they are producing adequate urine (a good rule of thumb is patient maintenance fluids, a normal regime is 1 salty and 2 0.5;#%#',-),2#$")#'/).--)&*)"2-3)#$-)0$+/1,&'()#/-U1#"-)1$&'-)Q#)(++/)$1%-)+*)"21=;)&.)G4C)=DNK(N2+1$)+$) mL/kg/hour or roughly > 30 mL/hr). After this, review the sweet. This means, IL saline followed by 2 bags of Dextrose. patient by observing them and assess their haemodynamic To this, you can add 20 mmol/L of potassium. $+1(2%3)W)LG)=DN2$R4)5*"-$)"2&.7)$-6&-8)"2-)0#"&-'");3)+;.-$6&'()"2-=)#'/)#..-..)"2-&$)2#-=+/3'#=&,) status. A mini checklist for this could be: ."#"1.4)5)=&'&),2-,K%&.")*+$)"2&.),+1%/);-@)) Also, it is important to add any losses that patient may have • Temperature suffered to their maintenance fluids. Losses include fever (add 20% extra fluid/day), operative fluid losses, diarrhoea, :-=0-$#"1$-) Time • Capillary Refill nasogastric aspirate and ileostomy. Furthermore, if a patient is post-op, a rule of thumb is to avoid adding the potassium into X#0&%%#$3)Y-*&%%):&=-) • Skin Turgor the fluids. This is because surgery often causes cellular injury !"#$%&'()*$*+,#-&'&./0*(&1"'//#$2#3&!"*+&*+&4"#$&560&2*7#&'&8',*#$,&9:;&)<&6.&16//6*(&67#-&:=>;&)*$3&?$1#& !K&'):1$(+$) and thus potassium ion leakage ( as it is a largely intracellular • Pulse 560@7#&(6$#&,"*+%&-#='++#++&,"#&8',*#$,%&26*$2&67#-&560-&1"#1A/*+,&'2'*$3&B'+&,"#-#&C##$&'$& ion) which can alter its’ levels in serum.

Z1%.-) *)8-67#)#$,D&E.&$6,%&560&1'$&2*7#&,"#&8',*#$,&'$6,"#-&./0*(&1"'//#$2#&'$(&+##&*.&,"*+&#/*1*,+&'&1"'$2#&*$& • Blood Pressure If you are administering resus fluids these can include blood, [%++/)Z$-..1$-) ,"#*-&+,',0+3&& colloid or crystalloid. There is always a debate between which JVP • to give, but current evidence shows that there is no real ?9Z) difference between the two. Colloid does stay in the • Eyes?$1#&560@7#&(#1*(#(&,6&2*7#&560-&8',*#$,&./0*(%&,"#&)'F6-&G0#+,*6$&*+H&4"',&,58#D&I-5+,'//6*(&6-&16//6*(D& \3-.) intravascular space longer, but crystalloid is as effective in a I-5+,'//6*(+&'-#&./0*(+&,"',&.6-)&'&,-0#&+6/0,*6$&'$(&'-#&'C/#&,6&1-6++&'&+#)*=8#-)#'C/#&)#)C-'$#3& • Mucous membranes resus situation. Determining how much fluid to give will J6)#&6.&,"#)&(6&+,'5&*$&,"#&*$,-'7'+10/'-&+8'1#&.6-&+6)#,*)#&C#.6-#&(*+,-*C0,*$2&,"#)+#/7#+&,6&6,"#-& ]1,+1.)=-=;$#'-.) depend on the patient’s status and situation (i.e. what caused Rate • Respiratory 16)8'-,)#$,+%&4"#-#'+&6,"#-+&+01"&'+&:K&(#L,-6+#&M4"*1"&+"60/(&$#7#-&C#&2*7#$&*$&'$&#)#-2#$15& the fluid loss).

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23

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careers

"How should we practise medicine in a world where half of the world’s population lives on less than US$2 a day, one billion people go to bed hungry every night, a quarter of the world's population never gets a glass of cold water, and a woman dies in childbirth every minute?" emma firth speaks about her experiences during her intercalated BSc This is the opening sentence on the Leeds University website advertising the intercalated BSc degree in International Health. A desire to find answers to such fundamentally significant questions was a uniting factor between myself and my fellow medical students who chose to study this course last year. Whilst UCL, Birmingham and Bristol also offer intercalated degrees in International Health, here is a taste of my experience at Leeds.

men or women, and a poster on policy attempts to reduce sexselective abortions in India were two of my favourite chosen assignments.

The course structure can be looked up easily on the internet; modules include health policy and planning, communicable and non-communicable diseases and maternal health. Of particular mention are Projects A and B. The former is undertaken early in the year, and comprises a literature review on any chosen topic related to global health. This then forms the basis of the design and completion of independent research, which is project B.

Around half of the year group were students already studying medicine at Leeds University, whilst the rest were made up of medics from Sheffield, London, Dundee, Newcastle, Manchester and various other cities. I was one of the babies of the group having only done 2 years of medicine; many on the course had intercalated after 3rd year, and a few after 4th.

One of the nice things about the degree was the opportunity to meet great people in different stages of their medical degree (good for advice) and from across the UK (good for visiting after the year is up!).

International Health students at Leeds are encouraged to take the opportunity to travel abroad in order to carry out their research project. Whilst some students chose to remain in the UK, popular destinations included India, Tanzania, Bangladesh, Mongolia, and South America.

Through the start of the course I became interested in the cultural barriers of introducing new technology into less-developed countries, and focussed my literature review on the clinical benefits, feasibility and cultural acceptability of routine foetal ultrasound in rural Tanzania. In May and June, I then carried out my project B in antenatal clinics in Bomang’ombe, Northern Tanzania: this comprised of interviews with pregnant women, and questionnaires about the local women’s beliefs and experiences of the new obstetric ultrasound service. My study showed that many women had disturbing misconceptions that ultrasound could harm themselves or their baby, and/or over-estimated the diagnostic capacity of ultrasound – findings I hope to publish in the near future.

Whilst non-Leeds students technically had more ‘need’ to make friends than the more settled Leeds students, the whole group was very sociable and we gelled quickly. Through the powers of facebook, I managed to get into a brilliant house with 5 other people doing international health from different universities.

Those who were familiar with Leeds were happy to help us newcomers explore the city and surrounding areas.

Department socials and mixed seminars with the Masters courses also allowed our year to mix with teachers and Masters students, many of whom were health professionals of different nationalities. The variety of cultures and experiences of students and teachers, plus relatively small class sizes and the subjectivity of many of the course topics made for lively and often heated debates in class. This was a refreshing contrast to the deafening silence of 200 startled students in medical lectures when a question is asked of them.

During the research period, I lived for 5 weeks in a doctors’ compound at the Kilimanjaro Christian Medical Centre just outside of the town of Moshi; being part of a community of international students there was a great experience, and a real pleasure to be part of in itself. After completing the research, I took on the opportunity, and the challenge, of a sponsored 7 day climb of Mount Kilimanjaro and went on a safari in the Serengeti.

To end the trip, everyone who had done research in East Africa met up in Zanzibar for the full moon party. A memorable end to an unforgettable year.

The nature of the course also allowed me new freedom to create study topics that I was particularly interested in, and, as assessment was through group and individual essays, posters and presentations, freedom from exams! An essay on whether female-genital cutting in sub-Saharan Africa is perpetuated by

24

careers

the fpas diaries emily thomas gives us the inside scoop 4th October The day of reckoning has arrived.

FPAS registration….

Joking aside, this convoluted form filling exercise will actually change my lifewho knows if for better or worse? The programmes are available to view on the website…..Should I look? Nah, best not get my hopes up. Might end up anywhere yet Aberdeen, Carlisle, Isle of Mann...yeah, definitely NOT going to look.

I submit my details on the website with some anxiety. Days earlier a BMA bulletin appeared on Minerva confirming media speculation that this year there would be more applicants than jobs. But, we mustn’t panic- the BMA also wanted to reassure us that they are coming up with a contingency plan. All will be fine...

{

“No, there aren’t enough jobs for all of you but, quite frankly if you can’t see off the competition you don’t deserve a job!”

}

6th October Medical School to the rescue.

Eddie Hampton and Professor Bax hold a crisis FPAS talk with the phase 3Bs. Gathered en masse, the undercurrent of panic sweeps through the room - the rumour of the applications to jobs ratio increasing in number minute by minute. Is there even any point in applying? Will we get jobs?

Fortunately Eddie Hampton is there with carefully chosen reassurances: “No, there aren’t enough jobs for all of you but, quite frankly if you can’t see off the competition you don’t deserve a job!” Well, that’s alright then.

He then expands. FPAS - simple. Just answer the questions, in English, in sentences, (with no spelling mistakes) and you will be fine. We gather that simplicity and relevant answers are going to be key in this. No need to answer a question about prioritisation in the workplace with an answer that manages to include your solo climb up Everest/saving the world on elective. I feel a bit better.

11th October FPAS questions are online!

Question 1: list your additional publications, national prizes, etc.

educational

Uh oh - 0/10 for that one...NEXT!

25

qualifications,

peer

reviewed

careers

6) “Essential attributes of a foundation doctor are the ability to deal effectively with pressure and the ability to prioritise tasks. Describe two different personal achievements to demonstrate that you possess both of these qualities, relating each achievement to a single attribute. For each attribute, give one specific example of how your achievement can contribute towards improving your performance as a foundation doctor. 200 words to answer.”

Aaaaaaarrrrrghh.

I really want to ask everyone else what they’re writing about… but no-one will reveal ANYTHING. Competition has arrived… and it’s dog-eat-dog.

So I’ll come back to that one later I think, I’ve got two weeks to answer these; it’s going to be fine. Just do what Eddie says...simple language, answer every part of the question. Easy. Clearly, answering these questions is a brilliant way of separating the good candidates from the bad ones.

And then there’s the ranking of all the foundation schools! I know I want Yorkshire top - but there are a lot of places I don’t want to be. What should I put second, or at the bottom? The competition ratios from last year are on the foundation school website - think I’ll have a look at those - it might give me some inspiration, some tactics.

20th October (2 days until deadline) Bax and Hampton throw emergency FPAS session.

Everyone knows there’ll be no new information but goes along: just. in. case. Out of pure desperation. The usual suspects ask the usual questions (about sentence structure and pedantic interpretation of wording). Hampton tells us one thing. Bax another. But which is better? There’s only one way to find out……

It’s a nightmare. I still haven’t got a good answer. I haven’t got enough words to write a good answer; I haven’t got a good enough scenario. Am I even answering the questions? Have I answered all four parts?

Oh my days.

I go on facebook...everyone’s status is FPAS related! There’s no escape! Well, must join in the craze “FPAS stress has hit. It is killing me please help.” Someone “likes” this. Smug medics’ statuses proclaim they’ve already submitted their forms.

11.30 pm, 21st October (the nice countdown clock on the FPAS website tells me there’s 12 ½ hours to go) I have redrafted, redrafted and redrafted. Time to copy and paste answers into online form. Note to self: Do NOT copy and paste into wrong box.

26

careers

12.30 am - Press submit. Just press submit. Now or never...

12.32 am - It’s done. There’s no looking back (literally – I never want to see that form ever again in my life.)

12 noon, 22nd October Deadline. I wonder if everyone got their form in? Apparently last year the website crashed at the last minute and people didn’t know if their forms had made it!

Horrendous!

12 am, 8th December Foundation School Results day.

Foundation school allocations are out! However - all the medics in the country are trying to log on, so of course the website has crashed! C’mon...The tension is unbearable! Then, the screen loads...

Yorkshire and the Humber Foundation School.

Happy days! Now, must get on facebook to see where everyone else is!

Mid December It’s the

last phase 3b lecture. Eddie Hampton congratulates us all.

“Well done. You’ve all got a foundation school. You might not all be where you wanted, but everyone from Sheffield medical school got a job.”

It turns out others weren’t so fortunate; in most medical schools some people where without jobs - 10% of HYMS(Hull York Medical School) were unsuccessful! “So don’t forget that when you fill out your National Student Survey,” Hampton adds.

Just the interview to go now...and the job ranking. Time to rank 590+ jobs in Yorkshire - which is easier than it sounds. I rank my top ten. And then get confused with the order. I decide that the best thing to do is to at least rank bottom all the jobs I definitely do not want. So long Grimsby!

Unfortunately we have been told that, because there were too many applicants for jobs, we can still fail these interviews and be without a job. So, no pressure then!

The sole purpose of the interviews is to see if we can communicate properly...we’ll see.

27

careers

{

“the interviews are your chance to shine and make up a good overall score”

}

26th January 2011 Interview Day. My interview is the last of the day, and they’re running late. So we’re sat waiting.

Some people are calm, some people are nervous, some people have travelled up from London because despite scoring 40/40 for quartile ranking and having papers published, they’ve scraped a score of just over 50/100 on FPAS. Ouch. Then again, the interviews are your chance to shine and make up a good overall score. My advice to people in the year below would be to remember this.

Station 1 - communication skills “Consent this woman for a cannula!” Wow, easy...these interviews aren’t too bad!

Station 2 - clinical scenario “The nurse on the ward rings you. There is a confused man she is worried about. What do you do? “ Assess the patient ABDCDE??

But the questions don’t stop!! What next? What then? I’m starting to panic! And I’m losing my ability to form coherent sentences and use medical vocabulary. It transpires that the patient is on warfarin and has a large bruise on his temple where he fell and banged his head the day before. Possible diagnosis? “Bleeding in his head...BLEEDING IN HIS HEAD” I shout out in panic. So glad to get out out of that room.

Station 3- professionalism “A patient on your ward, that you know has a DNAR order, has a cardiac arrest and someone calls the crash team. You’re the F1 doctor; what do you do?”

Long pause.

I tell the crash team that the patient has a DNAR order?

The interviewer gives me a long look. “They’re ignoring you” she says.

Oh okay, so I let someone else know - like the sister in charge. “They’re ignoring you too” Silence. This can’t be real. But, then I remember...what did I read in the foundation programme curriculum?? “Ask for help, speak to your clinical supervisor!” Can I possibly salvage this interview……

The ten minutes end. I’m going to be in Grimsby aren’t I? location, good fish and chips I hear...

28

Oh well, nice seaside

careers

medical journalism; my six weeks at The Lancet sabreen ali

“The medical professional is required to keep abreast of new research, supplement clinical medical practice, improve patient care and increase personal knowledge. Opinions and viewpoints of other doctors across the world also contribute to personal and professional development, and help doctors gain varied perspectives of medical practice. Evidence-based medicine defines current clinical practice in the developed world, and there is a need to carry on this trend in developing countries. Medical journals lie at the centre of this operation, publishing news, views, and research for health professionals worldwide. The Lancet, a weekly peer-reviewed publication, is one of the oldest medical journals in the world. Established in 1823 by Thomas Wakley, it has continued its tradition of producing quality articles and research for its general medical readership. Its focus on global health also makes it relevant on an international level. I chose to combine two of my passions–medicine and writing–by undertaking a placement at The Lancet. I wanted to understand how a medical journal worked, and to get involved with the editing and writing processes.”

Image: Wikimedia Commons

29

[We deplore the] "state of society which allows various sets of mercenary, goose-brained monopolists and charlatans to usurp the highest privileges...This is the canker-worm which eats into the heart of the medical body"Thomas Wakley

careers Get your pens out...

Comment Writing

Book Review

The Lancet Student & TWIMS

In my 4th week I was given the opportunity to write a short Comment. The experience was amazing - I really enjoyed writing it and then working through the editing process. I went through several journal articles and news stories before coming up with a feasible and interesting idea, which I then wrote about. The piece needed a lot of work and editing before it was complete, but I learnt a lot about writing a balanced article that also reads well. The final comment was entitled ‘Fast food feud at Golden Gate’; and was published in the November 20th issue of The Lancet. It was a real privilege to be able to write a piece for this journal, and I certainly hope it isn’t my last time!

I was able to review a book for the “Perspectives” section of the journal, and selected “My Innocent Absence; Tales from a Nomadic Life” by anaesthetist Miriam Frank. This was no hardship, as my nose is usually buried in a book most days anyway.

Also, e xploring the humanities alongside medicine is something I have always found to be important, and reviewing this book reminded me of that. It also encouraged me to try and review more books in the future, medical or not. The review was published in the Dec 4th issue of The Lancet.

Although they are unsigned pieces, writing ‘This Week in Medicine” (TWIM) pieces were a useful way to get into the rhythm of writing a short news story (they are no longer than 50 words) trickier than it sounds.

The Lancet Student (TLS) is the studentrun website based at The Lancet, and provides a similar global-health platform for students of health-related disciplines worldwide. Although I was not a student editor for TLS, I was able to get involved extensively by writing blogs every week, placement reports, and engaging in discussions for themes of the week.

A fly on the wall Comment Meetings

The main meeting of the week. All senior editors are present at this meeting, and manuscripts that have gone through peer review are discussed. Before the meeting, manuscripts are available to be read by editors, who then write their comments on a form at the front of the manuscript. These are then read out during the course of the meeting.

The Comment section at the beginning of the journal is a section for commentary and opinion, usually about research papers featured in the same issue, but also discusses other topics of interest. On Thursday mornings, the previous week’s section is briefly discussed – pointing out what worked, what didn’t, and any errors/changes for the future. The following week’s Comments, illustrations, and ‘Online First’ Comments are also discussed.

The first half of the meeting is for the Articles section, studies and trials that have been written up. The second half is for seminars/reviews that have usually been commissioned by editors. If most editors agree that a manuscript is to be accepted (determined via the comments on the form), these manuscripts are sent for subediting. Discussions of manuscripts that aren’t immediately accepted then take place, with each commissioning editor presenting the paper and reading out comments from the form. A decision is then made as to whether to keep the manuscript ‘alive’ or to reject it. If most editors reject a manuscript via form comments, it is not discussed. Case reports are also peer reviewed and are discussed at this meeting.

Leader Meetings This takes place post-Comment meeting, is attended by several senior editors, and students are also welcome. The Lancet has 3 editorials in every issue – 1 long and 2 short. They are written on a rota system by senior and assistant editors, and ideas are pitched by attendees at the meeting. Ideas usually stem from significant news stories that have happened during the week, or official reports that have been published pertaining to health.

The leaders usually have a clinical theme, a public health theme and a theme on health policy between them.

Attending these meetings and reading the manuscripts were a valuable process. I understood more about what makes a good paper, the importance of a good clinical research question, and how to conduct a critical appraisal. My knowledge of statistics was also vastly improved as a result, as this is central to being able to follow the information presented in these manuscripts.

Fo l l ow i n g o n f r o m l e a d e r i d e a s, ‘ T h i s We e k i n Medicine’ (TWIM) topics are selected. This section is a 1 page summary of important health news and events that have happened worldwide–12 stories in total, divided between developed and developing countries. I was able to pitch suggestions for both Leaders and TWIMS, and doing this gave me an appreciation for what was newsworthy and what would not be of interest. Exploring the different angles that a story could take for an editorial was a great brainstorming process.

Issue Meeting Every Friday the weekly issue is reviewed, along with one of the monthly journals (The Lancet Infectious Diseases, Oncology and Neurology). Quality control is vital for a prestigious journal - especially when it is a weekly.

Manuscript Meetings

30

careers How to...edit

Case Reports

The editing process is complex, and necessarily so. I can’t say enough about quality control.

Editors not only correct spelling and grammatical errors, they also rephrase sentences in the best possible way to improve readability and to make the point clear. It is also their responsibility to double-check all the facts presented in an article, as well as references. I reviewed weekly Editorials and pages from the Comment section, and tried to correct them; I got first-hand knowledge as to how editors actually work. While the title ‘editor’ might strike some as glamorous, it is actually extremely hard work and a lot of responsibility journals take a lot of flack for mistakes (even small ones), because they set a universal standard for healthcare across the world.

Case Reports are required to be accurate, interesting, and informative. Here’s the secret: the focus is less on rare and fancy conditions, but more to do with telling a good story. There should be good rhythm and flow to the case, with investigations revealing little clues along the way; rather like an Agatha Christie novel (but less long-winded).

I was able to read, review, and discuss my opinions of potential case reports with a Senior Editor, and learnt a lot of new clinical medicine and reinforced older concepts and conditions. It was difficult to know what to send for review and what not to; clearly, there’s a knack in picking out the best from the rest.

Image: Google

“Overall, I gained a wealth of knowledge and experience during my time at The Lancet, and working there was one of the most stimulating things I have ever done. The editors and the rest of the staff were always supportive, friendly, and never made me feel like an outsider – and I miss going in to work to see them every day. Although

the cycle of publication continued week after week, it was never once boring – each day presented itself with something new, exciting, and challenging. I realise now that being able to disseminate information well is as important as the information itself, otherwise, its quality and integrity will be in doubt. The high standards and consistency of research and writing gives The Lancet its reputation as a leading medical journal, and I’m grateful to have been a part of it, even if only for a short while.”

31

reviews

book reviews so you want to be a medical mum? elishba chacko

When my fellow medics learned that I was pregnant their responses ranged from happiness to horror. Juggling a medical career and motherhood has never been easy but it’s not impossible, as Emma Hill brings out very aptly. She understands the female psyche well and addresses many issues that medic mums have to consider when having a baby.

With countless professional exams and unsociable hours, no time seems quite right for a medic to start a family. However, with biological clocks ticking, would-be mothers must take the plunge at some point.

Emma skillfully weighs the pros and cons of taking time out to have a baby at various stages of training.

The book demystifies maternity leave, employment rights, and child care benefits. This is something even the smartest may have to puzzle over and set aside time to work through. I recall the frustration of endless forms requesting the same tedious information: all eating into the precious time I could have been spending with my daughter.

The book provides basic information that wouldn’t be out of place in any generic pregnancy manual, but quickly goes on to details and special concerns for medics. There are practical tips on breast-feeding when returning to work, advice on choosing the right childcare (something I struggled with, especially on a student budget), and whole chapters on general practice and academic medicine.

While I never thought of falling back on a guide to medic motherhood at the time, in retrospect it would have been an enlightening read. It complements rather than replaces discussion with other medic mums, although one of the book’s strong points is the range of experiences from a variety of medic mums. One of the contributors mentioned how much more useful the ward staff were in their duty of care in comparison to the doctor attending who seemed to shuffle a few sheets of paper at the foot of the bed before making a hasty retreat.

Only when you’re a patient on the ward do you notice the value of clean sheets, hot food, and a wash! The author’s style of writing is an added bonus making it interesting whilst educational, and softened the factual nature of this genre.

As a medical careers guide it ticks all the boxes. It is well researched, relevant, and practical. There is even a brief mention for medic dads but the book is primarily for their better halves. For good measure there is an exclusive chapter on further pregnancies if you are considering more children. As a medic mum you may find that it makes a lot of sense and will probably take away something from it. For me, the most useful message was to be a mum, not a doctor, to my baby and to enjoy the parenting process. If you’re thinking of becoming, going to be, or already are a medic mum, this might be just the book for you.

32

Dr Emma Hill Oxford University Press, 2008 Medical careers guide ISBN 9780199237586 Price £9—£10 (price range varied online)

“It complements rather than replaces discussion with other medic mums...For me, the most useful message was to be a mum, not a doctor, to my baby and to enjoy the parenting process.”

reviews

data interpretation for medical students emily thomas This book arrived through my letter box just in time to save me in my finals. And I wish I had discovered it earlier; it truly is a fantastic book.

The title is perhaps misleading - it doesn’t cover statistics or data that might be published from a clinical trial. Instead it covers all manner of laboratory and hospital bed-side tests in a logical and simple way with some background detail of the basic medicine behind them.

Finally - I understand and can interpret ECG’s!

The case summaries at the back are also very good for revision purposes. The only down side is perhaps the questions at the end of each chapter are a bit too obvious.

All the same, they are good for consolidating your knowledge.

I don’t think it’s comprehensive enough to be a stand alone text, but it certainly has just the right amount of detail you need to grasp the basics of each topic. I found it too late, I’d say it’s an excellent text to have on your shelf once you hit Phase 2 - you’ll never feel like you’ve been put on the spot when someone throws blood results at you on ward round and asks you what they mean once you’ve read this.

Paul Hamilton and Ian Bickle PasTest (2006) ISBN 9781904627661 Price £24.99

oxford handbook of acute medicine sabreen ali Acute Medicine is one of those specialties where having concise and thorough information quickly at hand is necessary in practice, so a handbook is probably at its most useful in this setting. The Oxford Handbook of Acute Medicine aims to satisfy this niche, and now in its 3rd edition, it does not disappoint. Continuing on the tradition of excellence that define the Oxford Handbooks, this little book is ideal for all stages of medical training.

I found it most relevant during my anaesthetics and emergency medicine modules, but it will definitely be making a reappearance during finals revision. The ‘2 page spread per topic’ remains a feature, and has a good visual and psychological impact on the reader both at the bedside and during revision.

This edition is up to date with regard to clinical guidelines, and is dotted with flowcharts, tables and algorithms.

Virtually all systems are covered in a good amount of detail without being overwhelming; I especially like the dedicated chapter to Shock; an important and unfamiliar topic until late-stage undergraduate training, which has been covered very well. The final chapter entitled Differential Diagnosis is a compilation of key symptoms and their differentials – very useful for ILA’s, or for when a patient presents and one needs some inspiration. This book is definitely one to add to your collection of core texts, or in my case, to my evergrowing collection of Oxford Handbooks!

Punit Ramrakha, Kevin Moore, Amir Sam Oxford University Press (2010) ISBN 9780199230921 Price £27.95

33

creative writing

just a stumble

anonymous

I couldn’t get off the floor. Nothing more.

Not hurt, not ill, not a fall - just a stumble.

No need to bother anyone.

The Rother Care button is there, around my neck. A medal for the elderly; insignia of the frail.

No need to press it, call someone out so late. I did not want to be found on the floor in that state.

The shame.

I just couldn’t get up. The ambulance came.

Whisked me away from my home.

Wired me up to a machine. Strapped up. Trapped.

Doctors and nurses crowd me, analyze me, record my every heart beat, breath.

Fussing incessant questions. And all the time their patronising sympathy.

I am a baby again helpless, dependent.

They take away my dignity and give me a cheese sandwich.

I couldn’t get off the floor. So I lay there and waited. Contemplated.

Watched the fire slowly dying, flames flickering out. The last glowing ember crumbles to ash.

I gave it a while, tried again. Tried again.

They think I’m senile. “Do I know what day it is?” “Can I count backwards from twenty?”

They tick boxes, leave.

I couldn’t get off the floor. A stumble, a fall - they take it as more.

Now what does my future have in store?

34

Want to write for Northwing? Or be part of the editorial team? Pitch your ideas to us, or enquire about becoming an editor next year at: northwing@medsoc.net

Contributors rachna malani vishnu vijayakumar alice rutter marcin klingbajl amy dehn lunn chloe shaw molebedi segwagwe arpita chattopadhyay sabreen ali rob walsh kate markham raisa ahmed emma firth emily thomas elishba chacko

or email the editor at: mdb07sma@shef.ac.uk

Northwing is the magazine of Sheffield University Medical School, produced with the support of the Sheffield University Medical Society. It is distributed free of charge to Medical students and Doctors (circulation 1200). For information about any advertising rates or to reserve a copy, please contact us at the address below.

The views expressed in this magazine do not necessarily reflect those of the Northwing team of the Sheffield University Medical Society. Likewise, companies advertising in this magazine are not endorsed by Northwing and we accept no liability.

We would like to thank those who have offered encouragement and help, especially the porters and Susan in the MedSoc Office.

Special thanks to University Print and the Medical Society for their continued support.

Northwing The Medical Society Office, Sheffield Medical School, Beech Hill Road Sheffield www.medsoc.net/northwing northwing@medsoc.net

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