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October 2012

RCGP Chair Clare Gerada on Health Service reform and general practice

also in this issue: The futility of public health crusades The perils of the European Working Time Directive Steve Peters’ new book reviewed


M 2012 Northwing editor Rob Walsh

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Editorial

edicine is currently undergoing major changes. Whether it is the changes to the structure of the NHS brought about in the health and social care bill, our pensions and wages as witnessed by the recent BMA strike, or those to our working lives and training brought about by the European Working Time Directive, everything seems to be in flux. Northwing’s long history as the medical school’s in-house magazine means we’re well placed to engage with these controversies. In this issue, we have an interview with RCGP head Clare Gerada, one of the key players in the health reform debate, whilst NGH core medical trainee Frankie Anderson gives us her take on the impact of the EWTD. Dr Mike Fitzpatrick, Sheffield native and a forthright commentator on everything from the MMR row to public health, critiques the trend for “brief interventions” to promote lifestyle change. We also have Tabitha Izmirova on her experiences as a researcher, the Medics’ football and rugby teams go head-to-head as to who is better, and the latest book and events reviews. We’re keen to expand our coverage of everything from medical and educational issues, to culture, food and reviews; if you’d like to get involved, get in touch! I’d like to thank all of the contributors, and in particular Emilie Green for her invaluable help as deputy editor and David Holland (info@ davidholland.me.uk) for graphic design. Rob Walsh Mda10rw@shef.ac.uk

Contents Page 4-5 The European Working Time Directive... is it working? Frankie Anderson Page 6-7 A futile intervention into our drinking habits. Mike Fitzpatrick Page 8-9 Clare Gerada - General Practice: the greatest pleasure, the greatest flexibility... the greatest impact Rob Walsh Page 10-11 The Nature of Research: A Survivor’s Story Tabitha Izmirova Page 12-15 Book and event reviews Emilie Green, Lucy Faulkner, Alice Manley, Sabreen Ali, Neil Lawrence, Jacob Reynolds, Amy Jeffries, Alice Rutter Page 16-17 Sport. Iain Ruddick, Giles Dixon and Viren Kadodwala Page 18-19 Next Stop is Vietnam Emilie Green Page 19 Treatment of medical emergencies. Page 19 Medsoc Events 2012 3


knows the patient. In addition, the shorter the hours of each on call means the more actual on calls are done overall, so that one 24 hour on call is now split into three 8 hour on calls, thus reducing the time spent on the wards covering more junior staff and patients. The second concern is that the EWTD is detrimental to training. A recent study has indicated that in 1995 a surgical trainee could be expected to work over 30,000 hours between SHO level and Consultancy, yet now he or she can be expected to work only 6,000 hours (3). With such a drastic reduction in time at the table, it’s difficult to see how the same standard of skill is going to be achieved in just over a quarter of the time. This lack of training opportunity in favour of service provision has led to a general dissatisfaction among junior doctors with their training, with over 50% saying in a recent survey, that if they had their

Frankie Anderson, a CT1 at Sheffield’s Northern General Hospital, questions the notion that a shorter working week for junior doctors is necessarily a good thing.

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he implementation of the European Working Time Directive (EWTD) in 2009 fundamentally changed how hospitals and doctors worked and trained. It covered three key points. First, it stipulated that time spent on-call in hospital or health centre counted as working time whether or not any actual work was being done. Second, it stated how much time juniors should have off as ‘rest periods’ following on call commitments. Thirdly, it restricted working hours to 48 hours a week (1). There was a general agreement among both patients and doctors that the previous system wasn’t safe. Long hours and working under intense pressure with limited supervision led to junior doctors making mistakes, and highly skilled expensively trained people quitting for other jobs. However, the introduction and implementation of the EWTD has in itself caused problems, with several colleges, including the Royal College of Physicians, Royal College of Surgeons and the Royal College of Obstetrics and Gynaecology, criticising its implementation. The head of the Royal College of Physicians calling it ‘a complete disaster’ and trainees themselves are clambering to opt out (2). So in a move that initially seemed so popular; why the criticism? The major concern regarding the EWTD, is that patient safety may not in fact be improved by its implementation, though clearly this should be its key objective. Paradoxically, the fewer the hours that junior doctors work the greater the need for multiple shifts and multiple handovers, continuity care may be lost and important information may not be conveyed. Even when extensive handover protocols are put in, such as Hospital @ Night, it does not replace the continuity that occurs when a healthcare professional 4

lack of training opportunity in favour of ser“viceThis provision has led to a general dissatisfaction among junior doctors with their training, with over 50% saying in a recent survey, that if they had their time again they would not have trained to be a doctor.

The European Working Time Directive... is it working?

The bad old days before the EWTD?

time again they would not have trained to be a doctor. Finally, the EWTD has effectively lead to the breakdown of the old firm structure, where doctors previously worked within a team consisting of a consultant, registrar, senior house officer and junior house officer. This team, who worked on a ward together and undertook on calls together, is being replaced with rapidly changing on call teams, meaning that junior doctors often report feeling isolated and struggling to get feedback on their clinical practice. However, the introduction of the EWTD is an example of a wider change that has occurred within the medical profession, the NHS and wider employment practices. The concept of medical training as an apprenticeship and ultimately a profession is changing towards the idea that it is just a job and service commitment. The EWTD is a product of both the demand for a work/life balance and the increasing feminisation of medicine, but is also part of a substantial shift in how both the NHS and medical profession work today. The way in which hospitals work has changed. The huge patient load with greater demand and greater treatment options mean that it is not feasible to have the same cosy set up as before. In a way, the argument over the advantages and disadvantages of the EWTD is inconsequential as the shift has already happened, but the question now is how do we ensure the next generation of doctors are fit for practice? References (1)European Working Time Directive, FAQ, NHS Employers http://www. nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/EWTD/Pages/EWTD.aspx (2)H.Philip, Z.Fleet, K.Bowman, ‘The European Working Time Directive-interim report from the Royal College of Surgeons of England Working Party’ (3)Royal College Of Surgeons ‘Surgery and the European Working Time Directive –Background Briefing’ http://www.rcseng.ac.uk/policy/documents/ RCS%20EWTD%20briefing.pdf

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Dr Michael Fitzpatrick argues that while levels of alcohol consumption might well be problematic, the idea that a doctor’s ‘brief intervention’ might be the solution is simply deluded.

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ne of my responsibilities as a GP in our practice is that I keep the book of the dead - an audit of every patient death at the practice. This involves getting together to discuss whether we can learn anything from a particular death, whether it was well managed, badly managed and so on. And one of the interesting things over the past year is that we’ve had only three deaths of people under 50 and they’ve all been related to alcohol. This, I think, reflects the general perception that there is a significant problem with alcohol. I doubt there’s few people who have not experienced the destructive effects of alcohol in their own lives, whether its someone in their family or in their own circle of friends. It’s a well-recognised social problem that is probably on the increase. What I want to concentrate on is the efficacy of medical intervention in this phenomenon - what is known as a brief intervention. Now, a brief intervention has been studied by NICE and other bodies as the most effective form of intervention in dealing with the problem of alcohol. As time has gone by the intervention has got shorter and has become more effective. We used to talk to patients for about 10 or 15 minutes – it’s now down to just five minutes. The efficacy of the brief intervention has been discussed for quite a few of years, not to mention lauded in various medical publications, but in the past six months it has really made its way into general practice. Now we have countless templates which we use to guide consultations with all sorts of patients with all sorts of problems. Every single template, whether it is for a diabetes sufferer or a high blood pressure patient, raises the issue of alcohol consumption, which means that doctors will ask people about their alcohol consumption. So while you may go to your doctor with an ingrowing toenail or a boil on your finger, your doctor will have to ask you about your alcohol consumption so that he or she can complete the template. When your doctor says ‘I’m not interested in your finger or your toe, tell me about how much you drink’, it’s a strange scenario. But it’s coming to a surgery near you if it hasn’t already. The basis for this notion is the idea that this five-minute discussion between GP and patient is the answer to the greatest public health panic of our time. And what does this discussion involve? It involves sitting down and the doctor saying ‘Look, how much do you really drink?’ The doctor will then get the chart out showing how to calculate the units of alcohol in a pint, in a glass of wine and so on, before turning to the chart which very helpfully indicates the destructive effects of alcohol on every single organ of the body. The terms in which this is posed are quite interesting. It indicates the extent to which the world of public health has become so contemptuous towards the public that it is exempted from the requirements of political correctness. People will remember recently that the UK minister of health Anne Milton wanted to be able to call obese people ‘fat’ – anyone who is overweight can be abused in these terms. And likewise for heavy drinkers: if you drink too much you are told that you can have children who are ‘retarded’ and ‘deformed’. So, the children of people who drink too much do not have ‘learning difficulties’,

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Has binge behaviour become normalised in the uk?

Dr Michael Fitzpatrick: East London GP and critic of public health ‘crusades’.

a practice that claims the authority of medical science “for anIt’sintervention which is actually of an entirely moralistic, crusading character. We have got the Band of Hope and the Salvation Army without the brass band now marching through the surgery

A futile intervention into our drinking habits.

they are ‘retards’. I am surprised public health officials don’t talk about spastics and mongols given that Down’s syndrome was for many years entirely attributed to alcohol until it was discovered to be a chromosomal disorder. So you have this discussion, and the patient might say, ‘I didn’t know I was drinking so many units, I didn’t realise it could have such a wide range of effects on every organ of my body.’ To which the doctor can respond: ‘Well let me suggest to you ways in which you might be able to reduce your consumption.’ And there is indeed a whole list of options available to GPs, such as going to the gym after work instead of for a drink. These are the sorts of suggestions that feature as part of the brief intervention. I’ve been sent on a course on motivational interviewing so I supposedly know about how to motivate the patient – or at least I’ve been trained in it. The idea is that this intervention has been studied exhaustively by bodies who evaluate the efficacy of the intervention with the utmost statistical rigour. But think about it for a minute. We’ve got a major social problem, it’s destroying people’s lives on a vast scale. And one five-minute chat with doc later, and it’s all sorted. It couldn’t possibly be true. It’s wishful thinking on a cosmic scale. If you look at all these studies they’ll cite references allowing you to look at how they have arrived at their conclusions. First of all they involve a small sample of

people. Secondly anyone with harmful levels of drinking will be excluded and only those with hazardous levels of drinking will be included. Thirdly the sample patients are only followed up for a short period of time – six months at the maximum. Fourthly, the goal posts are subtly moved so that the desired outcome is not abstinence nor even a reduction of drinking to safe limits: it is simply a reduction or a reduced number of binge episodes. And having done all that those conducting the test can confidently assert: ‘the practice of brief intervention clearly works very, very well’. It’s simply deluded. So, although there is a problem that has medical consequences, here it becomes a medical problem for which there is a medical solution. In historical terms, there are economic, cultural factors which affect levels of alcohol consumption. But there is no medical solution to this problem. Furthermore, the idea of there being a medical solution is not itself without its own problems not least because it is very bad medicine. It’s a practice that claims the authority of medical science for an intervention which is actually of an entirely moralistic, crusading character. We have got the Band of Hope and the Salvation Army without the brass band now marching through the surgery. The other problem is that this is going to be visited upon the entire population. It is not targeted at the damaging and serious drinkers, it’s going to be targeted at everybody. It is ironic that a doctor’s authority is invoked to play this role at the very time when the notion of the authoritative, paternalistic doctor is supposed to be a thing of the past: the sort of doctor who tells people how to live their lives that is now being reconstructed. And it is very bad for patients, too. It is intruding upon their own medical consultation with an entirely different agenda, a manipulative, intrusive, authoritarian one which not only does not solve the specific problem, it opens up a whole new set of problems. Dr Michael Fitzpatrick is the author of MMR and Autism: What Parents Need to Know and Defeating Autism: A Damaging Delusion .

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Rob Walsh talks to Clare Gerada, the outspoken Chair of the Council of the RCGP, about the pleasures and pains of contemporary general practice.

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he recent passage of the Government’s Health and Social Care act has been one of the most forceful rows in the recent history of the health service, and Clare Gerada was one of the most outspoken of those involved in the dispute. Alongside representatives from the BMA and some of the other Royal Colleges, she was one of those excluded from David Cameron’s February summit that attempted to drum up support to rescue the bill. Gerada is the Chair of the Council of the Royal College of General Practitioners, and one of the most high profile and outspoken of today’s medical leaders. Northwing magazine

I don’t think we needed another reorganisation of the health “service. We certainly didn’t need a major reorganisation at the

same time as facing severe financial constraints, and at the same time as having to make £20 billion efficiency savings

caught up with her after she’d spoken at the Battle of Ideas festival in London (www.battleofideas.org.uk). So why was she so militant in her opposition to the bill? “The key problem with the bill is that I don’t think we needed another reorganisation of the health service. We certainly didn’t need a major reorganisation at the same time as facing severe financial constraints, and at the same time as having to make £20 billion efficiency savings. The NHS a year ago was performing as well as it has done in its history, evidenced by documents from the Commonwealth Fund, the WHO and the government’s own research”. 8

The job that’s given me the most satisfaction, the greatest pleasure, the greatest flexibility, and the ability to make the greatest impact has been being a GP.

General Practice: the greatest pleasure, the greatest flexibility... the greatest impact

As for the potential consequences of the bill, she suggests it is “leading to disillusionment, demoralisation, for a situation that I’m not sure will deal with the issues that we have to deal with; how to address the aging population and increasing health costs”. Is the NHS itself at risk? “I think that’s a difficult question. I’ve no doubt that the NHS will continue to provide free care at the point of use irrespective of your ability to pay, as it always has, but I think that the service it provides may be under threat.” More broadly, she suggests that also under threat “is the trust between the GP and their patients. I worry that GPs are being put in the position of decommissioning and rationing care. Whilst I think GPs need to be responsible for the budgets that they spend, I think to single us out, amongst all the professional groups, is as time moves on going to damage GPs”. But if such negative consequences are so readily apparent from the bill, why does the government persist in bringing its reforms forward? “I think the government’s initial thought to bring it in was to put patients at the centre of the health service which is a good thing, and to address increasing health costs. Whilst involving clinicians is important,

I think to have to do that through structural reorganisation is not the way forward. The Government believes that improving commissioning will address the big issues facing us – such as health inflation, aging population and increasing expectations”. But is there a more political motivation for the direction and pace of these reforms? She doesn’t demur, agreeing with the suggestion that the bill marks “the end of a 20 year journey towards the marketisation or commercialisation of the health service”. So if there is such a clear and present danger to the health system, why is she so outspoken whilst others in positions of influence in the medical profession have often been somewhat reticent about criticising the government publicly? “I’ve learnt a lot in my year as a leader, about why people don’t speak out in public, but do in private. I’ve learnt a lot about the fears of leaders, and I think there are legitimate reasons why other health leaders haven’t spoken out. I may not agree with those, but I can understand them.” Finally, as the leader of Britain’s GPs, what does she have to say to medical students, some of whom are often keener on the alleged glamour of hospital medicine or surgery in comparison to general practice? “I have been a physician, an A&E doctor, a psychiatrist and a GP. The job that’s given me the most satisfaction, the greatest pleasure, the greatest flexibility, and the ability to make the greatest impact has been being a GP. As a GP I can reinvent myself every 2 – 5 years, I can work harder when I need to, to earn more money at the pinch-points in life, and every 10 minutes I have patients reinforcing the pleasure of why I went in to medicine. I think general practice is the speciality to be in, the hardest and the most challenging, one to do. I’d strongly urge any medical student to go into general practice.” 9


ability to bully others, and bribe using biscuits”. Whilst it is important to note that ethical rules strongly state that a participant should be able to withdraw at any time and should not feel forced into doing the study, there may be times where your less amiable side dreams of ignoring this fact, in a desperate attempt to increase participant numbers.

Stage 4: “Thank you so much for taking part...”

Stage 5:

Congratulations, your manipulation/persuasion techniques have worked and now you have to test the participants that you have recruited. At this stage, no matter how interesting you thought your study was, it will be described as boring/ too long/difficult/too easy, with a scattering of odd individuals who found it fascinating. These wonderful souls will just about keep your enthusiasm glowing long enough for you to reach the end of this stage.

Tabitha Izmirova exposes the dark arts of the research project

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t was around a year ago when I first considered that I might be interested in research. I was perched opposite three would-be supervisors, nervously navigating my interview, when the key question of “so why do you think you would be good at research” inevitably reared its head. Before I could help it I had blurted out “because I find the subject interesting”, and attempted to back this up by rewording my enthusiasm in different ways. Oddly, blind passion for the subject must have been what they were looking for, as I found myself with a BMedSci offer without having to offer many other credentials. A year later, it seems that such keenness is indeed an integral component of succeeding at research. My research looked at the role of sensory electrical stimulation to the forearm as a rehabilitation tool. Whilst this project may not match the specifics of other types of research, the process of research itself has several key features:

Stage 1: “There’s a reason I’m doing this study, honest...”

The first stage of research is reading, or (as your supervisors may cunningly rename it) defending the project. This involves reading all of the relevant papers on topics similar to your research, and spotting a gap in the market which can be filled by your project. These papers will most likely then be hastily saved somewhere under a filename that you will later forget, and not within the helpful referencing software that you were advised to use (see the write-up stage later, where this becomes a cause for panic).

Stage 2:

“This is new research, honest...”

Stage 3:

“Please someone do my study...”

For me, the planning stage involved designing an experimental paradigm in which to test different patterns of stimulation. This process might involve a level of frustration, as you quickly realise that what you thought was going to be a ground breaking experiment based on innovative techniques, is in fact going to be a repetition of a very similar experiment that someone did last year. Some departments may want to do a form of research that will be most likely to result in a publication, rather than allowing you to spread your proverbial investigative wings. At this stage your enthusiasm may begin to wane, but hold that off for a moment, as you will need it to deal with the next stage... The next stage is recruiting participants, at which point you may quickly realise that one of the skills you could have cited in your interview should have been “an

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Now that you have some data, it’s time to make sense of your research. Did you find anything? This would mean that you have that magic P value of less than 0.05 and your results are significant. In research terms, any findings other than this magic number result in comparative invisibility. Of course this is not quite the end of the story. Are your results approaching significance? Can you do various complicated statistical tests, or perhaps remove outliers? There has to be some way to make the numbers behave, and this is the very reason that books like “How to Lie with Statistics” exist.

matter how interesting you thought your study was, “it No will be described as boring/too long/difficult/too easy, with a scattering of odd individuals who found it fascinating. These wonderful souls will just about keep your enthusiasm glowing long enough for you to reach the end...

The Nature of Research: A Survivor’s Story

“These results are significant, honest...”

Stage 6: Perpetual writer’s block

Stage 7: Reflecting on the nature of research

Finally, the whole process needs to be transferred to paper in a vaguely scientific format and without any references from Wikipedia. You will need to find all of those papers you read in stage 1 and re-read them, this time making the notes as you should have done in stage 1. You will need to justify everything you have done, and explain away any mistakes in a ‘limitations of the study’ section that claims that you are exceptional, and that it was the world around you that has conspired against the perfection of your research. The nature of research is perhaps best described as inspiring, frustrating, and then inspiring again in an ever-constant cycle. Initially, the idea of discovering something new and potentially useful fills the individual with the same level of enthusiasm that I exhibited back in my interview. As the work begins, the frustrations of research begin to show: a lack of time/people, unrealistic goals, and practical constraints. Yet these cannot quite squash the ideals of a first-time researcher; the experience of discovering something that you have contributed to, and the next potential stages of research, are enough to inspire that initial passion once again. In short, if you have an interest in something and want to try something different, research may be the path for you. Facing the aforementioned difficulties enables growth of character (enough confidence to face consultants without paralysing fear), and in any case, allows you to be a student for one more year. So the next time you see the BMedSci prospectus floating around Minerva, you might want to take a little look and see if there is anything in there to inspire the budding researcher within you!

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Reviews Medical Management and Therapeutics By Parveen Kumar and Michael Clark Saunders Elsevier 2011 ISBN 9780702027659

On the surface, this handbook appears to be a miniature version of Kumar and Clark’s Clinical Medicine; however its unwavering focus on patient management is its unique selling point. Therefore, it is perhaps best suited to senior medical students and junior doctors, who already have a broad foundation of knowledge and are starting to focus on applying theory to the clinical context. Throughout the text, there are highlighted boxes outlining the precise therapeutic management of certain common or lifethreatening conditions in a step-by-step manner. These succinct directions render this handbook an ideal pocket-filler for junior doctors who find themselves on-call during a night-shift. Despite the focus on management, each colour-coded section delineating a particular medical specialty opens with comprehensive background discussions of individual pathologies, including information on pathophysiology, clinical features, diagnosis and management. The handbook is therefore equally as useful to those seeking a pocket-sized general guide to medicine, and is ideal for quick reference while on placement, or for cementing knowledge during revision. Information is well-structured according to different areas of medicine, and the colour-coded chapters enable easy use. In addition to the medico-surgical sections, there is a chapter discussing issues such as breaking bad news, “do not attempt resuscitation” orders, clinical trials and statistical analysis, which gives the handbook a holistic feel in terms of the information it provides. Emilie Green

Oxford Handbook of Medical Sciences

By Robert Wilkins, Simon Cross, Ian Megson, and David Meredith Oxford University Press 2011 ISBN 0199588449 There may still be time before the summer exams, but as the new academic year begins, students may be thinking about which books they will use for revision. The Oxford Handbook of Medical Sciences may appear much smaller and less daunting than the huge textbooks on the Phase 1 reading list, but don’t be deceived by its size. This book is packed full of surprisingly detailed knowledge, making it a great accompaniment to lecture notes. It is structured according to the different systems of the body, and breaks down the information into concise and manageable bullet points. The clear and organised layout makes information easy to find, so this book is particularly useful as a reference or when trying to remember a particular fact. All topics are well explained, making it ideal for getting to grips with confusing concepts. On the other hand, there are no photos and only a few diagrams. In conclusion, although not completely sufficient as a replacement for all other textbooks, this handy guide would definitely be of use as a supplement throughout medical science studies. Lucy Faulkner

Oxford Handbook of Practical Drug Therapy

By Duncan Richards, Jeffrey Aronson, John Reynolds, and Jamie Coleman Oxford University Press 2011 ISBN 0199562857 Pharmacology can be rather a dry subject, however there is no escaping that it is something that needs to be learned. Medical students are constantly quizzed on their drug knowledge while on placement. A Practical Guide to Drug Therapy is a very well-structured book. It does however require some basic knowledge of pharmacology as its main aims are to guide the safe use of drugs, in preparation for foundation years and onwards.

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Reviews

A huge variety of drug classes are covered and each has a brief description of how the drug works. Also included for each drug is in depth prescribing information, including indications, contraindications, interactions and notes on monitoring. The book is well organised and concise, like the others in the Oxford Handbook range. Although drug therapy and dosages are best learned by through experience., this book would certainly make a good reference guide for students in clinical years, and would help increase knowledge regarding drug therapy. Prior to buying this book, or similar, it would be worth flicking through a few books to find the text to suit you. Alice Manley

Medical Finals on Exam Consult: 3-Month Access Pack

By John Rees, Chris Chan, Daniel Horton-Szar, Chris Kosky and Anne Collett. Elsevier, 2010 ISBN 978-0-7020-4530-1 When I’m practising revision questions for exams, my standard response is usually one of two things. Either I feel that I don’t know enough and the standard is too high, or I whizz through them thinking that they are deceptively simple. Neither is good for when exam day rolls around. Elsevier’s latest offering, Exam Consult, didn’t have me cornered into either one of these categories. The questions provided within the extensive bank, currently numbering more than 2000, are an accurate representation of what actually comes up in finals. Set at an appropriately challenging level, the questions built my confidence and taught me things that I didn’t previously know or sometimes had overlooked. Answer feedback is sourced from several well-recognised textbooks, including the Crash Course series and Kumar and Clark, so you’re well informed about where you went wrong. Tests taken are saved for review later and you can compare results with averages from other students’ performances, providing a useful measure of your relative standard. At only £35 for 3 months’ worth of access, this bank of questions is well worth the price, as it accurately represents the topics, tone and angle of commonly asked questions. An excellent choice for revision at any stage, but a must-have for finals! Sabreen Ali

The Chimp Paradox: The Mind Management Programme to Help You Achieve Success, Confidence and Happiness By Steve Peters Ebury Press 2012 ISBN 009193558X

Sheffield students may remember Steve Peters from a couple of inspiring lectures he delivers at the beginning of the course. Older students will have experienced even more of the benefits of his lecturing, as he was once more closely associated with the Medical School. Further, plenty of fully-fledged doctors in the Psychiatry department will tell you that he was one of the reasons they decided upon the specialty. It was therefore with great anticipation that I awaited the delivery of The Chimp Paradox at the start of 2012. This book did not inspire me as much as his lectures have in the past. A few chapters in, and it became quite apparent that this would not make it onto the recommended reading list for the Medical course. However, this was never likely to be the case, and was definitely not the reason that Dr Peters decided to put pen to paper. His pragmatism shines through in the book as he tries to define the natural struggle that we have in modern society between controlling our emotions (the ‘inner chimp’ of our limbic system in the world of Dr Peters) and our thoughtful, reasonable, personable side (our ‘human’ side dominated by our prefrontal cortex). Although the book is packed full of examples of fairly minor dilemmas that may cause an unreasonable, emotive reaction (and thus the need to control our ‘inner chimp’), you are reminded of his impressive career by means of various ‘asides’ that offer great insight into the potential causes of serious psychological distress. These sections, however, are not the main focus of the book, and certainly left me wanting more. His reasoning is faultless, but his overall insistence upon classifying various parts of the human personality and social structure into cartoon characters and scenarios often leaves you wondering whether you bought this book at an American self-help seminar. Steve Peters changed my life, but not through writing this book. Neil Lawrence

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Reviews

Reviews

Future Excellence: International Medical Summer School

Sheffield Salon: Does Doctor know best? Minimum alcohol pricing, fat taxes, plain packaging and personal autonomy On Wednesday 16th May, the Exhibition Space at Jessop West hosted a forthright and challenging public discussion on the role of the state and the medical establishment in regulating lives. The first speaker, Dr Kate Reed, Senior Lecturer in Medical Sociology at the University of Sheffield, kicked off the discussion by contextualising the debate in both the glamorisation of drinking in the media and a moral panic that attempts to exaggerate the problems of alcohol and fat consumption. Given this, she argued that it was important to move beyond the scare stories and have a more nuanced discussion about the particular social causes and consequences of both unhealthy lifestyles, and the basis of the new consensus of health intervention. In addition, she argued that the rise in problematic drinking was a reality and the detrimental effects of this were played out on our streets every Friday and Saturday night. Dr Reed argued persuasively that governments have a job and a responsibility to mitigate the effects of excessive consumption of alcohol, but concluded that the most recent measure proposed, a 45p minimum price per unit of alcohol, would have little or no effect. Following on from Dr Reed, Dr Mike Fitzpatrick, an East London GP (and a contributor to this issue of Northwing), grounded the discussion in his personal experiences of both the effects that excessive alcohol consumption had had on his patients, and the increasingly intrusive state funded initiatives that encouraged him to monitor his patients lifestyles, particularly their intake of food, cigarettes and alcohol. Dr Fitzpatrick highlighted the unintended consequences that prohibition-style legislation could have, from increases in smuggling to counterfeit products. However, he went to particular lengths to show that the broader sociological implications of such interventions in personal lifestyles were far more damaging; telling people what they should and shouldn’t drink or eat has the effect of infantilising people, making them less likely to ever be able to take ownership and control of their lives and thus living healthy, productive lives. The contributions from the floor were wide-ranging and thought-provoking. Several members of the audience wanted to highlight that any attempts to change the current social norms around alcohol were doomed to failure because of the stake that the market has in such things is too great. Other contributors gave this line of critique short shrift, arguing that individual agency was central in tackling alcohol abuse. There was also concern for the inevitable effects, both socially and on health, of the current culture of high alcohol consumption and a far reaching discussion of what drove the overconsumption of alcohol and what should ultimately be the response to it; whether focusing on individual behaviour or on the social inequality that promotes ill health. Other contributions from the floor focused on the particular social climate that exists around health. A student at the university noted how removed the ‘New Temperance’ movement is from its historical predecessors, which had a broad popular appeal, whereas the new initiatives to temper drinking and smoking had a tendency to bypass public debate and conduct the debate either at the level of evidence or try to exert pressure on government as a health lobby group. Several contributors attempted to analyse the new ideology of health, arguing that the focus we put on health and the body seems to be both a replacement for, and stemming from a lack of, any transcendent vision of either the self and of society. The discussion concluded, as always, with more questions left unanswered than answered, but this merely provided for a fertile discussion in the pub over a non-minimum priced drink!

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Jacob Reynolds

This week long summer school at the University of Manchester aims to give undergraduate students a better understanding of the training program for Foundation doctors in the UK, and what one can expect from the different specialties. It offered a great opportunity to mix with a diverse range of medics, and to gain insight into the varying approaches to medicine across the globe. Attendees were separated into broad streams of Medicine or Surgery, then further subdivided into various specialties, allowing for small group sessions to be tailored to the students’ interests. There was a fair dose of lecturing throughout the week, which despite having a fairly dry format, was spiced up by some incredibly engaging, dedicated and passionate speakers. There were two full Skills and Activities days that were the highlight of the week, plus a vast array of social events in the evenings, from bowling to laser quest, and a tour of the most studentfriendly clubs in Manchester.The week was a great success and very enjoyable that I would highly recommend to students at any stage of their training. Neil Lawrence

Joint Operation ‘Joint Operation’ was a multi-disciplinary event in which mixed teams of studen Medics, Nurses, Dentists, Speech Therapists, Orthoptists, Social Workers and Occupational Therapists from Sheffield University and Hallam worked together to solve hypothetical medical scenarios. This enabled students to discover the extent to which their profession would come into contact with others in the workplace, and how this would shape their role in a clinical setting. The case studies each presented a different hypothetical situation involving a patient’s current situation and medical history, ensuring involvement across several professions. For example a road traffic accident victim who has serious head injuries potentially requires the involvement of a variety of professionals. This was professional, well executed event which tackled a important matter in a fun and engaging way. The event will run again next year, aimed at phase 1Bs - please visit www.sheffield.ac.uk/lets/salt Amy Jeffries

Peer Teaching 2012 Over the last year, the Peer Teaching society has facilitated a variety of free of charge programs for phases 1a, 1a, 2, and 3a, as well as a weekend event for phase 4. These events have consisted of clinical mentoring, lectures, small group sessions and examination skills. Now in its fourth year, the Peer Teaching Society is larger and stronger than ever, with its success evident in the popularity of the programs, often filling within hours of their announcement. Amongst our greatest successes are the clinical peer education programs, which match all students in 1a and phase 2 on clinical placement with more senior mentors, acting as friendly faces on the same site. Peer teachers volunteer to help with developing history taking and examination skills. Communication skills and the ability to take a focused history improve dramatically from the start of the clinical years, and it is important that this expertise is shared with students starting out on the wards. Above all, it is a relief to know that you are not expected to be perfect straight away! This year we hope to add a new feather to our cap, and hold the first national Peer Teaching Conference in May. Our aim is to foster similar societies at other UK universities, so that more students can gain crucial teaching experience, and so that people have the opportunity to learn from each other. Though this is far from a one-way process – peerled teaching is a growing movement across UK medical schools, which vary enormously. In order to best serve students, we hope to gain new ideas and fresh initiatives that will maintain the evolution of our Peer Teaching Society. Peer Teaching relies on the good will of students, and the quality and quantity of volunteers and the work that people produce is outstanding. Teaching is also a great way to improve communication skills and to consolidate learning – meaning that taking on the most challenging topics can be the most rewarding – and offers the opportunity to practice teaching skills in preparation for the foundation program. The society is something that we are proud of and if there is any way we can make it better, please let us know, or get involved! Alice Rutter

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Societies

Sheffield Medics Rugby Club

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espite the popularity of football in Sheffield, Sheffield Medics Football Club started slowly but has now become a great club that is progressively growing. There are currently well over 80 members involved in various levels of the beautiful game. With four 6-a-side teams, we have taken over most of the many intra-mural leagues. The teams play once a week and include Phase 1as and Phase 1bs of differing abilities, therefore the games are usually close and everyone enjoys them. Medics Green currently lead the way but the Reds and Daffodils will continue to make it an exciting season. Each year, the 6-a-side has continued to be a massive success in both introducing people to football for the first time as well as integrating new talent that can move up to the first and second teams. A new addition this year has been the entry of teams to a late night 5-a-side intra-mural league, allowing those in phase 2 and above, who are often limited by placement, to get involved. The Club helped to create the league in the hope of emulating the 6-a-side league’s success in giving people of all levels an extra opportunity to enjoy football, and so far it seems to have worked. Those who impress at this intra-mural level are quickly snapped up by the second team manager Tom Hendry, who recently took over from Steve Wyatt. The team, which was once only considered to bea Fresher’s team, has grown and improved considerably. Whether or not this is down to Hendry’s ability as manager, it remains to be seen. Due

Unlike the Rugby socials we cannot promise male “nudity, but other than that, anything goes

to pitch repairs, the 11-a-side intra-mural leagues only got underway shortly before the winter break; but despite this, in two games the second team amassed a credible four points. The first point was won by playing against a strong ‘Law’/University first team side, and was followed by a great win over a Boltonesque side, who were no match for our free-flowing passing game that even Barcelona would have been proud of. The final team, ‘The Firsts’, imaginatively known across South Yorkshire as Sheffield Medics, currently play in the Premier Division of The South Yorkshire Amateur Football League. Many critics wrote the team off after the resignation of player/manager Tim Sandals. However, despite a number of games where points have been needlessly dropped, new manager Joel Lawson has so far guided the team to a respectable fifth place, which in the New Year could easily turn to third if the team perform well. It is not all hard work though, especially with Martin Vaughan and Frankie White in charge of Socials. Unlike the Rugby socials we cannot promise male nudity, but other than that, anything goes (even drinks laden with sardines as Chris ‘Iron Stomach’ Mayo found out). Each year both the first and second teams travel the British Isles and Ireland to compete in NAMS, an 11-a-side tournament exclusively for Medical School football teams. Sheffield Medics last lifted the trophy in 1993 but in recent years have come close to equalling this triumph. In the previous four years, only once has Sheffield not been represented in the final four. This year’s NAMS takes us passport in hand across the border to encounter the notoriously angry Scottish Medical School Football teams in Dundee. It is unclear if Chris Platt will come out of hiding to make the journey up North as he is still under investigation following a sordid incident at last year’s event in Nottingham. Iain Ruddick and Giles Dixon

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heffield Medic’s Rugby Club has been in existence for over 40 years and in that time has developed into the force it is today. Be it the level of rugby we play, the socials or tour, we don’t do things by halves.

There are three teams at the club representing a range of standards. Our extremely competitive first team has been unbeaten at home for over a year and is (at the time of writing) in the hunt for back to back promotions. The spirited second team play both in a local Yorkshire league and fulfils the fixtures against other medical schools, recently playing at Cardiff Arms Park in the plate final of the medical schools competition. Finally, our third team has rapidly progressed from a team with sporadic fixtures to one that plays well week in week out against an array of oppositions, both student teams and big (but extremely slow) Yorkshiremen. In addition to playing XVs, the club can also boast of our sevens prowess of recent years, winning the plate final of the medic’s sevens competition. There is training every Tuesday and an extra session on Fridays for those playing on Saturday.

In keeping with the club’s tradition there are no initiation “antics, but the captains and social secretaries are punished at the Freshers’ social

Sheffield Medics Football Club

Every Saturday night is social night, so the fun does not have to stop after we leave the pitch, as many of the ‘social’ members of Medic’s Rugby will testify. Every Saturday night a copious amount of lager shandies are responsibly consumed before we go to the infamous Pop Tarts and dance the night away to cheesy 90s pop music. However for many the night does not end after Pop Tarts as the local curry house, Balti King, will still be open to provide you with a delicious curry at four in the morning. It can be quite a surreal experience having a meal in a restaurant at such a time, but not one to be missed. In keeping with the club’s tradition there are no initiation antics, but the captains and social secretaries are punished at the Freshers’ social. Each year there is an Old Boys’ Dinner, where the Medic’s Rugby Club past members join the current members for a black tie dinner. This is the highlight of the year for many members and is not to be missed. Be warned though, it is not guaranteed that your dinner jacket will survive the night stain-free. Every two years the club goes on tour, and each member of the club will tell you that this is definitely not an occasion to be missed. The last tour was a ‘Magical Mystery Tour’ with the location not revealed until we boarded the bus to get there, which turned out to be Bruges. The previous tour was to Prague, and it’s anyone’s guess where the next location will be.. There is plenty of fancy dress, very little sleep and a little bit of rugby too. Tour is everything you imagine it to be and more! This is Medic’s Rugby, so get involved in our friendly, welcoming club! Viren Kadodwala

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with juvenile rheumatoid arthritis. He had a hugely swollen and deformed knee that was not responding to NSAIDs. He had had many relapses in the past year and had a very poor prognosis. Throughout our time in the country it was obvious that the majority of the population earn a living through manual labour. I found it hard to deal with the fact that this child’s deformities were likely to prevent him from earning a living in future. Despite feeling incredibly anxious at the start of the placement, I was extremely grateful that we were welcomed into the hospital to observe and gain knowledge from many fantastic medical professionals with such a different outlook on medicine, and I’d recommend the experience to any open-minded medical student.

Medsoc Events 2012

Next Stop is Vietnam

Emilie Green recounts her elective experience of the Vietnamese healthcare system

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ur first placement found us at the Giadinh hospital in Ho Chi Minh City in the South of Vietnam. We were initially attached to the emergency department, which consisted of a long corridor with 2 large rooms (one being ICU and the other a reception room) with many other smaller offices and sleeping areas for the doctors. The heat was overwhelming – even in ICU, which was said to be the coolest room in the hospital. The majority of patients presenting in A&E had problems associated with alcohol-related liver disease and respiratory disease. It was interesting for us to see how conditions that are often seen in the UK were managed in Vietnam. We also saw unusual conditions such as a hiatus hernia that had ascended to sit behind the right lung, and a woman who had been struck by lightning. One patient in particular summarised the approach of and pressures on some Vietnamese healthcare professionals when dealing with their patients. A 47 year old woman was admitted with left side paralysis, confusion and headaches. It was suspected she had a brain haemorrhage, but a tumour was later identified on her CT scan. She was brought into A&E by her daughter who was extremely distraught; the doctors became agitated and asked her to leave the room. Although obviously I was not aware of everything that was being said, from my perspective she was not hindering the work of the doctors. She obeyed without any retaliation and in an apologetic manner. The doctors later mentioned that they frequently became annoyed with family members interfering with their work. Later, during out time at Bach Mai hospital in Hanoi, we gained experience of obstetrics and gynaecology in Vietnam. The single delivery suite resembled an industrial kitchen, with huge stainless steel tables and cupboards throughout. During vaginal births, women weren’t allowed to express their pain. When they reached out for a hand to hold, they were dismissed and even reprimanded by the nurses, midwives and doctors. The operating theatre where Caesarian sections were performed had a large glass door, through which the line of women waiting could watch the previous woman’s operation. There was no communication with these women, and no reassurance or explanation of the procedure they were about to undergo. This factor in particular was a huge culture shock, and I found it remarkable that the patients did not ask any questions and simply accepted that the doctors knew best. A young woman who looked about 20 weeks pregnant ran into the department crying and claiming that her waters had broken. Immediately on lying down on the delivery table, a tiny blue baby was delivered and left on the side. The staff did not pay any attention to the baby, later explaining that although it was breathing and showing signs of life, they did not have the technology on the neonatal ward to care for it. One paediatric patient who we saw at Bach Mai that stuck with me was a 2 year old boy

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Electives Fair - Thursday 13th September 2012 MedSoc International Students Induction Event - Friday 14th September 2012 Freshers Week - Monday 17th to Sunday 23rd September 2012 MedSoc Freshers Fair - Wednesday 19th September 2012 Freshers Fever - Thursday 20th September 2012 MedSoc Buddy Scheme Introduction - Friday 21st September 2012 Medic’s Fancy Dress Social - Thursday 11th October 2012 MedSoc Charity Weekend - Thursday 25th to Sunday 28th October2012 Think Pink! - Thursday 25th October 2012 Mock OSCE - Tuesday 6th & Wednesday 7th November 2012 Annual Ball - Saturday 24th November 2012 Merry Medsoc - December, TBC

Medical Emergencies: A is for Anaphylaxis

Definition: IgE mediated type 1 hypersensitivity reaction to an allergen which is both rapid in onset and potentially life threatening. Prevalence: Mortality rates are approximately 0.5 per 100,000 population in the UK. Clinical presentation: Itching, sweating, erythema, urticaria, dysponea, wheeze, laryngeal obstruction, stridor, hypotension and death. Common precipitants: Penicillin/Betalactams/Other medication/Peanuts/Bee stings/Shellfish/Latex/Condoms Acute management: Call for help/ITU. Secure the airway and access.Give 15 L through a trauma non-rebreathe mask. Lay the patient flat and elevate their legs Remove the precipitant, i.e. stop the IV penicillin. Give 0.5 ml 1 in 1000 IM Adrenaline, 10 mg IV Pirtion, 200 mg IV hydrocortisone. Repeat the adrenaline every five minute as necessary Give fluid to increase the blood pressure, insert catheter for fluid balance monitoring. Admit to MAU or HDU for further monitoring Not to be confused with: Anaphylactoid: a reaction that does not involve antibodies but is due to a direct release of inflammatory mediators from mast cells. It is typically seen after N-acetylcysteine is administered in paracetamol overdose.

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