PB&J | Issue 2

CoverDescription

“The pen is mightier than the sword” – Edward Bulwer-Lytton

Butwhyisthat?Incomparisontothemeaslypen,the sword seems much more awe-inspiring. But a sword is only capableofcarvingwoundsoftheflesh,whileapen’snoblenib carvestheveryfuture.Itetcheseternalwordsthatremainfor generationstocome,storinginitsstrokeshistories,ideologies, andotherteachings.Mostimportantly,thepencandowhat theswordcannot:changetheveryheartsofthepeoplewho comeacrossit.Sowhileaswordisatoolthatcantakeonefar, amanwithapencangomuchfurther.

For those of you who recognize the boy from the coverpage,welldone!Thisissue’scoverartwasreproduced fromamuralonVasilLevskistreet,nearIvanRadoevtheater. Ifyouhaven’tseenitalready,werecommendyoucheckitout!

@bulgariablog KaylakaPark,Pleven

Rabeeh Ur Rahman

Letterfrom theEditor

-AbrahamLincoln

Although the famous Gettysburg address is farfrombeingrelatedtoPB&J,thislittleexcerptdoes apply to our lovely journal. After all, PB&J is a medicaljournalofPleven,createdbythestudenstof Pleven,forthecommunityofPleven.Sowhetheritbe a platoon of soldiers gathered to win the American Civil War or a squadron of medical students reviewingandeditingmedicalpapers,theideaisthe same: working together for the sake of others is somethingtobecommended.ThereforeIwouldlike totakeamomenttothankthebrilliantwritersand photographers that made this edition of PB&J possible. I am sure the readers of this issue will appreciatethetalentsshowcasedinthisissue.

Butofcourse,itisnotjustthoseinvolvedin thecreationofPB&JthatIwanttoapplaud.Hereisa shout of appreciation to all of the students and doctors that are putting their time and effort into studyingmedicinetobeofservicetopatientsaround

forget about yourself! Taking care of oneself takes priorityoverallelse.

An important matter addressed in our journal this edition is that of mental health. As medicalstudents,readingaboutmentalhealthissues while simultaneously experiencing them is an irony lostuponnoone.Butbuckup,wearysoldier!Itis easytogetlostinabattlefieldofbenzeneringswhile navigating the lands of organic chemistry. Or get exhausted while plowing through the trenches of internal medicine sub-specialties. But be kind to yourself, and take cover from gloom and burnout. ThecommitmentyoumadetocometoPlevenand study medicine is something to be proud of. Each colloquium you got through deserves a medal of achievement, and each passing grade a distinction. Everystepthatyoutakeforwardisafeatwithinitself, andshouldbeappreciatedassuch.

Sowhenyou’restartingtofeelthecreepof despair coming close, take a break from gathering intelondiseasesandgoAWOLforafewdays!Take sometimeoutforyourselftocatchuponsleep,TV, andsomelightreadingwiththisissueofPB&J!

-AbrahamLincoln

“…Ofthepeople,bythepeople,forthepeople.”

Rabeeh Ur Rahman

“…Of the people, by the people, for the people.”

Jasna Naghavi

MaikathaBulgaria,Pleven

MunazzaKhan

RacialDiscrimination inMedicine

Keywords:inequality;discrimination;healthcare

Itisnoveiledmatterthatthemedicalfieldis embroiledwithracialdiscrimination;despiteDoctors taking an oath to treat all patients equally, this unfortunatelydoesnotalwaysoccur.1Discrimination has shapeshifted over the years, from individual remarks,toembeddingitselfwithinthesystem.Itcan be seen in every aspect of healthcare, but more specifically, discrimination can be seen in the misconductofmedicalprofessionalswhoareethnic minorities.Tobringaboutanypositivereforms,there mustbeastructuralchangewithintheinstitution,

butduetothecomplexityanddepthofthisissue,it maybeeasierinprinciple,thaninpractice.

Medicalgraduatesentertheworkforcewith the belief that their medical knowledge, bedside manners, and professionalism will allow them to prevail as doctors, but are rudely met by the reality thatthejudgementoftheirskillmaynotbebasedon their actions, but rather on the colour of their skin andthemannerbywhichtheyspeak.Regardlessof theiraccoladesandachievements,somephysiciansof colour are reduced to false prejudices and assumptions leading to their skills being deemed subpar.AstudybytheBritishMedicalAssociation; “Racism in Medicine”, stated that “Respondents from Black backgrounds were most likely to have experienced racism (91%), followed by those from Asianbackgrounds(85%),otherbackgrounds(85%), Mixed backgrounds (82%), White non-British backgrounds (67%), and White British backgrounds (43%).”2Itfurtherdetailshowtheseethnicminorities werebulliedmoreoftenbypatientsas wellastheir

Mitchelle D'Silva

“Medical graduates… are rudely met by the reality that the judgement of their skill may not be based on theiractions,butratheron thecolouroftheirskin.

peers, had their clinical skills doubted and were ignored and excluded socially by their colleagues.Eventhoughthesemedicalprofessionals gave away their youthful years to pursue this venerated career; they were met with mistreatment and neglect. Many believe that the path of a physician is the most respected, but unfortunately, regardless of their accreditations, doctors of colour areseentobeinferiortotheirwhitecounterparts.

Discrimination can impact doctors to varying degrees, with some feeling as though they must work twice as hard to be respected, whilst others feel that their work is not met with appreciation; regardless of how much they do. As reported by the BMA, many physicians of colour have recounted feeling the need to work harder to provetheirworth.2Thisunduepressurecantakea mentalandphysicaltollonanindividual.

To overcome these racial issues, medical professionalsmustfirstcomeforwardandsharetheir experiences, but this has caused more harm than good. The British Medical Association stated: “Reportingexperiencesofracismultimatelyleadsto

backlash. Of those who had reported experiences of racism, nearly 6 in 10 total respondents(58%)saidthatdoingsohadanegative impact on them. Such examples included: being viewedasatroublemaker,beingmadetofeellikethe reportwasanoverreaction…andbeingmadetofeel like the incident was their fault.”2 This further emphasises the fact that physicians are not able to confidently voice their negative encounters. They must not only endure racially charged confrontationswithpatients,butarealsometwith dismissal and negative repercussions from their managementaswellastheirpeers.

As physicians have found, reporting these incidents have led to no avail; they have therefore resorted to tackling the issue on a wider scale via research and publications. Though they may have been able to shine the spotlight on the issue of discriminationofdoctors,itwasbyfarnowherenear enough to make the required changes, and has negatively impacted those involved. The paper, “Racial Discrimination in Medicine” by Aneez Esmail and Sam Everington, was an in-depth retrospectivestudyon1500medicalgraduates

Prabesh Angbuhang

CityhallofPleven

whichdescribedtheunequalopportunitiesgivento Britishmedicalgraduateswhoselastnameswerethose of ethnic minorities. It brought to light the inequalitieswithinthesystem,wheredoctorsofthe samecalibrewerenotgiventhesamepositionsastheir ethnicallyBritishcounterparts.3Whenthispaperwas released, the authors were charged with fraud and professional misconduct by the GMC. Though the charges were never chased, this clearly shows how determined the GMC was to conceal their systemic inequalities; rather than take on this newly found information and implement appropriate reforms.4 Theracialprejudicewithinthemedicalsystemruns deepthroughitsfoundation,anditseemsasthough therehasbeenlittletonoprogressmadeinthelast29 yearssincethepublicationofthispaper.

acommunity.Asamedicalstudent,Iamhopeful forthefuture,whereIamtreatedasanequalto myCaucasiancounterparts.

With the advancement of technology, societyhasbecomemorediverse.Moreandmore doctors are of ethnic minorities, and thus the medicalfieldmustprogressinawaythatembraces diversity. There needs to be a drastic transformation in the leadership of medical institutions, as currently the vast majority of individualsinpositionsofpowerarewhitemen. Workshops for anti-racism should be implemented in core medical training, as well as for management of medical institutions.5 The gravityofcomplaintsmadebyphysiciansshould be acknowledged and appropriately acted upon. Changecannotbemadebyanindividual,butby

References

1. HarvardHealthPublishing.Racismanddiscriminationin healthcare:Providersandpatients.2017[cited2017January 16].

Availablefrom:

https://www.health.harvard.edu/blog/racism-discrimination -health-care-providers-patients-2017011611015

2. BritishMedicalAssociation.RacisminMedicine.2022[cited 2022June15].

Availablefrom:

https://www.bma.org.uk/media/5746/bma-racism-in-medic ine-survey-report-15-june-2022.pdf

3. BritishMedicalJournal.Racialdiscriminationagainstdoctors fromethnicminorities.1993[cited1993March13].

Availablefrom:

https://www.bmj.com/content/306/6879/691

4. EsmailA,EveringtonS.Theperilsofresearchingracial discrimination.2020[cited2020February13].

Availablefrom:

https://blogs.bmj.com/bmj/2020/02/13/aneez-esmail-and-sa m-everington-the-perils-of-researching-racial-discrimination/

5. Carryl,LM.WaystoEradicateSystemicRacisminHealth CareandMedicalEducation:ALettertoMedicalEducators andHealthCareInstitutions.2021.[cited2021June].

Availablefrom:

https://journals.lww.com/academicmedicine/Fulltext/2021/ 06000/Ways_to_Eradicate_Systemic_Racism_in_Health_C are.4.aspx

E-mail:ruju.thillai@icloud.com

“As a medical student, I amhopefulforthefuture, where I am treated as an equal to my Caucasian counterparts.”

@bulgariablog

HowCouldSnow-Shovelling beLife-Threatening?

Keywords:snowshovelling;cardiovascular;myocardialinfarction,winter;publichealth

Introduction

You cannot avoid snow shovelling during winter in temperate climates, but you have to be careful if you have a diseased heart. There are potentialfactorsthatincreasetheriskfordeveloping acute coronary syndrome during snow shovelling. These factors include cold temperatures, heavy snowstorms and low atmospheric pressure.1 The association between snow-shovelling activity and acute myocardial infarction have been observed worldwide.

Acutemyocardialinfarction

Acutemyocardialinfarction(AMI)involves interruption of myocardial blood flow. The interruption is caused by atherosclerotic plaque the formationofwhichisacceleratedbyelevatedserum lipidlevels.Theruptureofplaquecausescatastrophic thrombusformationdecreasingthebloodflowtothe coronary artery. The myocardial oxygen demand increaseswithincreasedheartworkload.Thecardiac demands are increased by reduced myocardial efficiencyofarmexercise,uprightposture,isometric

Jasna Naghavi

exertion,expiratorystrainandinhalationofand/or exposure to cold air.2 For the heart to maintain optimalfunction,theoxygendemandhastobemet.

Interruption of blood flow by rupture of atherosclerotic plaque causes ischemia due to oxygen-supply-demandimbalance.

Whoismostatrisk?

Oneofthemajorriskfactorsformyocardial infarctionisdiabetesasitpredisposestoaccelerated atherosclerotic plaque formation and thrombosis and also contributes to post infarction complications. The other risk factors include cigarette smoking, high cholesterol, high blood pressure, family history of premature heart disease and sedentary lifestyle. Physical effort during snow shovelling in itself aggravates angina pectoris symptoms. The risk is higher in patients who have had reduced daily physical activity.3To reduce the risk of AMI, physical activity should be regularly performed and maintained. Physical activity also improvesglycemiccontrol.

Patients older than 50-years old with a diagnosed heart disease are in danger during snow work. There are patients that may not even have a heartdiseasediagnosed,butduringsnowworkthey

havethesamesymptomsofmyocardialinfarction as those who have been diagnosed with a heart disease. To reduce the incidence of the acute myocardialinfarction,everyoneover50-yearsold should be reminded of the risks of myocardial infarction.

Whenaretheymostatrisk?

The effect of cold weather on the body is widely known. Cold weather stresses the heart by causingvasoconstrictionandmakingtheheartwork harder to pump. Would the information of daily weather allow us to predict the incidence of myocardialinfarctions?UsingSweden'sheartattack registry (SWEDEHEART) during the period of January1998andDecember2013,researchersfound a link between myocardial infarctions and colder temperatures,thecolderthetemperaturethehigher incidence of myocardial infarctions. Reports have alsobeenpublishedaboutcardiaceventsinsnow.4,5,6 In1979,therewasasnowstorminChicagowith50 cm of snow. 60 men survived acute myocardial infarctioninthecourseofacoupleofweeksafterthe snowstorm.4Theinformationonweathercouldhelp to predict the incidence of acute myocardial infarctionandhelptoreducethediseaseburden.

Prabesh Angbuhang

Exertion stresses the heart through several pathophysiologicalmechanisms.Theonsetofacute myocardial symptoms in patients during winter is usually related to vigorous activity of snow shovelling.AstudybyOuluUniversityHospitalhas shownthatupto30percentofcardiacarrestsoccur during strenuous exercise. The exertion caused by snow work is the most common cause of cardiac arrests in Finland every year, says Oulu University Hospital professor of cardiology Heikki Huikuri. Winter-time activities such as skiing, cycling, and snow shovelling are triggers of sudden cardiac death.7 Studies show that males with a family memberofprematurecoronaryarterydiseaseareat higher risk of acute coronary syndrome than the generalpopulationduringsnow-shoveling.8Exercise has opposing effects, it can prevent or cause AMI dependingontheconditionofheart.Toreducethe incidenceofAMI,itisprudenttoroutinelyscreen all patients over 50-years old to exclude high-risk patientsfromheavyactivities.

The most dangerous thing is to do snow shovelling in the early morning, when a variety of pathophysiologic mechanismsforacutemyocardial infarctionaremorelikelytohappen.Morningrisein blood pressure, heart rate, catecholamines and cortisolareregulatedbycircadianeffectors.Platelet aggregability, coronary vascular tone, plasma viscosityandfibrinolyticactivityareassociatedwith awakening.9  Therefore to reduce the risk of myocardial infarction in the morning, the heavy morningactivitiesshouldbeavoided.

Conclusion

Snow shovelling increases the risk of a coronary attack. For this reason, a word of cautionisinorder,especiallyforoldermenwho smoke, do not exercise regularly, or have adult-onset diabetes. Last but not least, snow removalservicesinmanywelfarestatesshouldbe moreactiveduringwinterafterheavysnowfalls

toprotectpeoplefromtheriskassociatedwiththis formofphysicalexercise.

References

1. JanardhananR,HenryZ,HurDJ,LinCM,LopezD,Reagan PM, Rudnick SR, Koshko TJ, Keeley EC. The snow-shoveler's ST elevation myocardial infarction. Am J Cardiol. 2010 Aug 15;106(4):596-600. doi: 10.1016/j.amjcard.2010.03.075. PMID: 20691323; PMCID: PMC2958046.

2. FranklinBA,ParkerS,MitchellM,RubenfireM.Hazardsof SnowShoveling.PhysSportsmed.1980Dec;8(12):40-48.doi: 10.1080/00913847.1980.11948665.PMID:29251214.

3. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med. 1993 Dec 2;329(23):1677-83. doi: 10.1056/NEJM199312023292301.PMID:8232456.

4. GlassRI,WiesenthalAM,ZackMM,PrestonM.Riskfactors for myocardial infarction associated with the Chicago snowstorm of jan 13- 15, 1979. JAMA. 1981 Jan 9;245(2):164-5.PMID:7452833.

5. Franklin BA, George P, Henry R, Gordon S, Timmis GC, O'Neill WW. Acute myocardial infarction after manual or automated snow removal. Am J Cardiol. 2001 Jun 1;87(11):1282-3. doi: 10.1016/s0002-9149(01)01520-x. PMID:11377355.

6. Heppell R, Hawley SK, Channer KS. Snow shoveller's infarction. BMJ. 1991 Feb 23;302(6774):469-70. doi: 10.1136/bmj.302.6774.469-c. PMID: 2004181; PMCID: PMC1669339.

7. ToukolaT,HookanaE,JunttilaJ,KaikkonenK,TikkanenJ, PerkiömäkiJ,KortelainenML,HuikuriHV.Suddencardiac deathduringphysicalexercise:Characteristicsofvictimsand autopsyfindings.AnnMed.2015May;47(3):263-8.doi: 10.3109/07853890.2015.1025824.Epub2015Apr10. PMID:25861828.

8. NicholsRB,McIntyreWF,ChanS,Scogstad-StubbsD, HopmanWM,BaranchukA.Snow-shovelingandtheriskof acutecoronarysyndromes.ClinResCardiol.2012 Jan;101(1):11-5.doi:10.1007/s00392-011-0356-6.Epub2011 Sep9.PMID:21904937.

9. MullerJE.Morningincreaseofonsetofmyocardial infarction.Implicationsconcerningtriggeringevents. Cardiology.1989;76(2):96-104.doi:10.1159/000174480. PMID:2568181.

E-mail:mozajen1@hotmail.com

ChildMentalHealth andAnxiety

Keywords:childhood;anxiety;psychiatry

Introduction

Childhood is a part of every person’s life. Somehaveiteasy,somehaveittough.Mostofthis childhoodtraumacanbeseeninyoungadults.While boystendtoexternalisetheirproblems,girlstendto internalise them. Surveys show that 1/5 children under the age 15 are affected but only 19.5% have receivedtreatment.1

Causesofmentaldisturbances

Thebrainofachild(especiallythecerebral cortex)doesnotcompletelydevelopuntiltheir20’s. Soifachildissubjectedtoharshbehaviour(shouting, hitting and bullying) or traumatising events even fromtheirpeersorfamilymembers,itwillaffectthe childmoredeeplythantheyrealiseandcouldaffect them permanently. These behavioural traits can be seenwhentheygrowintoadults.2

AarshaAjithDeepa

Rabeeh Ur Rahman

awareofitsimportance.In1920atJohnsHopkins University,anexperimentwasconductedtoevaluate theeffectsofclassicalconditioningonfearformation inbabies.Heusestheunconditionalreflexofbabies toloudsoundstocreateaphobiaofharmlesstoysor objects.Thescientistscreamedwheneverthetoywas nearthebabyanditcreatedaresponseoffearinthe baby towards the toy. The reaction of most of the parentstowardasituationcreatesastimuluswithin thechild.Theyoftenunderestimatetheemotionsof achild.Exhibitingtantrums,cryinganddisobedience ismisunderstoodandunderminedcomparedtotheir problems (2022 conversation from VY to me, unreferenced,see“Acknowledgements”).

Mainreasonsforbehaviouralproblemsinchildren are:

● Hereditary predisposition, physical defects, intelligence level, unhealthy parent-child relationshipandabnormalparentattitudeslike overprotectiveness,negligenceandunnecessary comparison.

● Illnessbothmentalandphysicalofaparent,a tragedy in the home like death, divorce, desertion,disharmony,etc.

● Ignoranceonthepartoftheparentaboutthe needsofthechild(love,discipline,protection, security,independenceetc).

● Separation of one or both parents due to occupation, illegitimacy, social and cultural factors, physical environment, attitude of grandparents,institutionalisationcanalsoplaya role.2

Child mental health is one of the most importanttopicstodiscussasmostparentsarenot

Anxietydisordersinchildren

Fear is part of the group of negative emotions, and it causes us to want to avoid the stimulus which causes it, while. Both fear and anxietycausestress,depressioncanalsobeacauseof anxiety. Anxiety is a continuous worry about encountering something that we fear. Anxiety disordersareoftenseeninchildren.Whenaperson isanxious,it affectstheirabilitytothink.Whilethe fear that you face just before a sports event or an examishelpfulasitcanimproveyourperformance. Thisstimulustriggers astressresponseintheperson andreleaseofcortisolandadrenaline(fightorflight response).

Therearethreeexpressionsofanxiety:

● Panicdisorder-suddenoutbreaks

● Social anxiety disorder - fear and avoid situations

“Childhood is a part ofeveryperson’slife. Some have it easy, somehaveittough.”

● Generalised anxiety disorder - defined as excessive anxiety that is difficult to control and is accompanied by various somatic complaints3

Themainsetofsymptomsare:

1. restlessnessorfeelingonedge

2. easilyfatigued

3. difficultyconcentratingormindgoingblank

4. irritability

5. muscletension

6. sleep disturbance (difficulty falling asleep or stayingasleep)4

Only one symptom is required for a child to confirmanxiety.4Mentalhealthimpactsphysical health.

Homesickness is often seen in children who live away from their home. The main difference between adults and children showing signsisthatforadults3/6symptomshavetobe exhibitedforittobeconsideredaclinicaldisorder whereas1/6symptomsexhibitedbychildrenare

consideredaclinicaldisorderwhereas1/6symptoms exhibitedbychildrenareseenasaclearindicationof a disorder. Also it is found that children consider their fear to be reasonable and often express them thantoavoidsituations.Thishoweveraffectsalmost everyone independent of age and brings about distress, depression and anxiety.5 (This is not a substitutionforclinicalinterventionandprofessional help.Parentsshouldconsultaprofessionalforhelpin casethechildexhibitssuchsymptoms.)

Treatmentoptions

Thefirstlinetreatmentsuggestedis:

CognitiveBehaviouralTherapy(CBT)

CBTisaboutidentifyingfaultypatternsof thinking, emotional response, or behaviour and substitutingthemwithdesirablepatternsofthinking. Mainly through keeping daily records, confronting yourfears,relaxationandstressreductiontechniques. Helping the patient understand what patterns were wrongandredirecttheirthoughtsinapositiveway. (2022conversationfromVYtome,unreferenced,see “Acknowledgements”).

Parents should not perform CBT on their own, if the child is exposed to a higher amount of thantheycanovercome,itwilltraumatisehimorher. Forexample,lockingupaclaustrophobicpersonina smallroom,willnothelpthemovercomethefear,it will make it worse. Exposure should be temporary andcontrolled.

Rabeeh Ur Rahman

MindfulnessBasedParentingProgramme(MPP)

MPP consistently decreases the child's behavioural problems. Parents and children attend sessions to help them listen to the child with full attention, to be emotionally aware and to have a non-judgemental acceptance towards the child and self.2

ChildGuidanceClinic(CGC)

CGC is a method for management rather than treatment. It is headed by a psychiatrist, psychiatric social worker, clinical psychologist, paediatrician.2

CGC is a centre for scientific study and treatmentofpsychologicalmaladjustmentinchildren and adolescents. The details of the problem are collected from parents and children are kept in the play area for therapy sessions. Normally 50-60 sessions would be conducted in 3 months. Regular meetings with parents are also conducted.2 Pharmacotherapycanbeusedinsevereanxiety.

Conclusion

Children learn from our behaviour, rather than our words. Healthy cognitive development in a child depends on having a safe home and their needs met. Along with being aware of the difficulties and anxiety faced by a child, parents and caretakers can make use of the different services and treatments provided by care centres. Most importantly, children should be taken care of so they can envision a beautifullifeaheadofthem.

Acknowledgements

Deepa, Aarsha Ajith. Conversation with: Vesselina Yankova (Department of Psychology, University of VelikoTarnovo,VelikoTarnovo,Bulgaria).2022Nov 15.

References

1. GandhiE,OGradey-LeeM,JonesA,HudsonJL.Receiptof evidence-basedcareforchildrenandadolescentswithanxietyin Australia.Australian&NewZealandJournalofPsychiatry 2022;56(11):1463-1476.doi:10.1177/00048674211068780

ShahLP,ShahH.AHandbookofPsychiatry.Bombay:Kothari

AndrewsG,BellC,BoyceP,etal.RoyalAustralianandNew ZealandCollegeofPsychiatristsclinicalpracticeguidelinesforthe treatmentofpanicdisorder,socialanxietydisorderandgeneralised Australian&NewZealandJournalofPsychiatry 10.1177/0004867418799453

AmericanPsychiatricAssociationD,AmericanPsychiatric Association.Diagnosticandstatisticalmanualofmentaldisorders: DSM-5.Washington,DC:Americanpsychiatricassociation;2013

BeidelDC,TurnerS.Childanxietydisorders:Aguidetoresearch

E-mail:aarshajith@gmail.com

Rabeeh Ur Rahman

PlevenCenter,ChristmasMarket

Runningthe MarathonofLife

#mentalhealth#well-being#awareness

MaariyahHussain

Fromabrisk5-minutewalk,toa10-minute jog, to a lifelong race - the memoir of life. Living vicariously through other people feels pleasant, as theirwoesarenotyourstokeep.Everyonehasaches, painsandfearsoftheirown;howwedealwiththem iswhatmakesussimilar,orpolesapart.Araceweall run is the race of life, some faster than others and sometooslowtocatchup.Weallrun,whetheritisto keepup,tooutrun,towin,orjusttoavoidlosing.We aretoldthattheonlywaywecanmakeaplacefor

ourselves in society is with the trail of dust we leavebehind.Competitionishealthy,itkeepsus driven, yet only first place matters; no one acknowledgesthehardworksecondplaceputsin. In life, is there really such thing as healthy competition? Outrunning your peers to declare theprivilegeofreachingtheendfirst.Wheredoes itend?Isitworthitwhentherewardisafeelingof mental, emotional and physical exhaustion; why areyouburnt-out?

Prabesh Angbuhang

As children, we hold onto words and notionswithoutfullyunderstandingthemeaning behind them, and once we are grown up, those words no longer require a meaning, and instead become our reality. Comprehending how little people’s mental health means to them, in the exchangeforsuccess,trulypaintsapictureofhow little we have progressed in the promotion of mental wellbeing within society. Either we are willing to forego our health for the promise of futurehappiness,orperhapswearejustunaware

ones. Spiritual wellbeing is feeling at peace with yourself and those around you; it is a feeling of purpose. Psychological wellbeing is slightly more complicated, as it consists of several facets. These include personal growth, positive relationships, self-acceptance,andautonomy.

Wellbeing does not necessarily mean that youdon’texperiencesituationsthatareoutofyour handsortoodifficultforyoutodealwith.Everyone encounters moments that stagger them, where they are unable to focus and feel too weak to stand tall. Alternatively,wellbeingiseachindividual’sabilityto copewithandenduretoughtimes.

of our own exhaustion. Students are seldom provided with the help they require to ensure mental wellness. Mental distress is a common occurrenceamongstudents,andwhenneglected, its effects can be damaging. Whether it be burnout,depression,amooddisorder,anxiety,or even stress, everyone should have access to support.

"Health is a state of complete physical, mental and social wellbeing and not merely the absenceofdiseaseorinfirmity."[1].Wellbeingisa conceptthattakesintoaccountmultiplefactors, including social, physical, mental, spiritual and emotionalhealth[2].

Social wellbeing involves the feeling of belonging, and contributing to society or to a community. Emotional wellbeing allows you to express how you feel, and it enables you to overcomenegativefeelingswithmoreaffirmative

Shazana Aziz

“A race we all run is the race of life, some faster than others and some too slow to catch up.

Maariyah Hussain

RevivalSquare,Plevencentre

OutsidetheMedicalUniversityPleven

Physicalwellbeing

Physical wellbeing is the ability of an individual to recognise and understand the need for healthy foods, physical activity, and sleep alongside good management of chronic health conditions, and preventing future illnesses with good habits [3]. When exploring the topic of physicalwellness,itisimportanttoacknowledge the impact that our small, everyday lifestyle choices have on our long-term wellbeing. It is easiertofeedachildabalanceddiet,butasadults livingindependently,wearemorelikelytomake poorchoices.Foroptimumphysicalwellness,even asinglegoodhabitgoesalongway.

● Areyoudrinkingenoughwater?

● Areyougettingaminimumof6-8hoursof sleep?

● Are you eating a balanced diet, what is the nutritionalvalueofthefoodyouconsume?

● What is your sexual health status, are you practicingsafesex?

● Are your coping mechanisms for stress effective?

● Is there a consistent hygiene routine incorporatedintoyourdailylife?

● Howmuchphysicalactivityareyoudoing?

● Do you limit the amount of time spent on socialmedia?

● Are you able to control your alcohol and nicotineintake?

Emotionalwellbeing

Another aspect of wellbeing is emotional wellness. It is an individual’s ability to successfully dealwiththestressesoflife,andadaptingtohandle changeandemotionaldistress[4].Itconsistsofhow wellweareabletoexpressouremotionsandpreserve

Shazana Aziz

a positive mindset in order to maintain stability. Checkinwithyourself:

● Howwellareyouabletoexhibitemotionsand conveyyourfeelings?

● Areyouabletosay“no”,withouttheguilt-trip?

● Howeasyisitforyoutoaskforhelp?

● Are you able to relax and feel good about yourself?

● Doyouhaveaself-careroutine?

Acknowledgingthatwearenotallmoulded inthesamewayallowsustobeconsideratetowards othersandourselves.Wearenotalwaysincontrolof ouremotions,butwecantryourbesttofeelgood throughpositivereinforcement,self-compassion,and byensuringwehaveagoodself-careroutine.Itmay comeacrossasreductionist,butinthelongrunsmall actsofself-carecanmakeaworldofdifference.

Mentalwellbeing

Mentalwellnessisapositivestateofmental healthandnotmerelytheabsenceofmentalillness. Mentalwellnessintegratesemotional,social,financial and physical factors [5]. The term mentally well suggeststhatthemindisworkingintheindividuals’ best interests. It implies the ability to act, feel and thinkinwaysthatcreateapositiveimpactonyour physical, emotional and social wellbeing. The significanceofmentalwellbeingcannotbeexpressed enough.Whenyoufeelgoodaboutyourselfandyou share that positivity, you perpetuate a sense of self-assuredness and happiness. This allows you to feel in control of your emotions, behaviour and thoughts;overcomingchallengesandbuildingstrong, healthyrelationshipsbecomeseasier.

Sometipstoincreasepsychologicalwellnessare:

● Havingtheabilitytofindpeacewithoneself

● Acknowledging mistakes and overcoming disappointmentwithapositiveattitude

● Being able to place your own needs before others’.Treatyourselfeverynowandagain

● Keepingajournaltoexpressfeelingsthatyou don’twishtoshare

● Trytomaintainahealthylifestyle(nutrition, exercise etc.)

Having good mental health is not about continuallybeinghappyandfreefromdifficultiesin life;itisaboutlivingandcopingwelldespite

Nitya Rosilint

“It is never too late to implement change, even in small increments, a littlecangoalongway.”

problems.Ourhealth,justlikeourlives,willconsist of good days and bad days. Pacing yourself, and providing yourself with the opportunity to relax fromtimetotimewillgoalongwayinpreventing exhaustion. Medical school can be particularly stressful,andasstudents,wefindourselvesattimes navigatingthroughchallengingsituations.However, itisimportanttorememberthatbothyourmindand body need to be healthy in order to deal with challengestodayandinthefuture.Itisnevertoolate to implement change, even in small increments, a littlecangoalongway.Itissoeasyforustogetlost in everyday life that we often forget about the one thingthatmattersmost–us.

● Therearealsoonlinecommunitieswhereyou canseeksupportfrompeoplewhomayhave similarexperiencestoyou.

Emotionalwellbeing

A few mental health resources that are free for studentstoaccessinclude[6]:

● Woebot Health app (mental health ally, aimedatstudentsandevencollegegraduates)

● Wysa Mental Health support app (designed tohelpyoucopewithpandemicanxietyand lockdowns)

● Other free apps include: MindShift, PTSD Coach, Shine (an app targeted towards mentalhealthhelpforpeopleofcolour)

● If you enjoy more creative outlets, you can also write blogs to help you navigate your thoughtsandfeelings.

References

[1]Anonymous.Healthandwellbeing[Internet].WorldHealth Organization(WHO).Availablefrom:

https://www.who.int/data/gho/data/major-themes/health-and-well-bei ng#:~:text=The%20WHO%20constitution%20states%3A%20%22Health ,of%20mental%20disorders%20or%20disabilities

[2]Anonymous.AboutWellbeing[Internet].5WaysToWellbeing.2018. Availablefrom:https://www.5waystowellbeing.org.au/about-wellbeing/

[3]Anonymous.PhysicalWellness:WellnessatNorthwestern[Internet]. StudentAffairs.Availablefrom:

https://www.northwestern.edu/wellness/8-dimensions/physical-wellnes s.html

[4]Anonymous.Emotionalwellness[Internet].Health&Wellness. UniversityofNewHampshire.2022.Availablefrom: https://www.unh.edu/health/emotional-wellness

[5]Anonymous.Understandingmentalhealth[Internet].Singapore associationformentalhealth.2018.Availablefrom: https://www.samhealth.org.sg/understanding-mental-health/what-is-me ntal-wellness/

[6]Anonymous.Onlinementalhealthtools.Mind.org.2018.Available at:

https://www.mind.org.uk/information-support/tips-for-everyday-living /online-mental-health/online-mental-health-tools/#OnlineCommunities

Shazana Aziz

LifeinPlevenTheFinalHurdle

Pleven,thecityIwouldneverhavethought tocallhomeforthenextsixyears.Onceupona time, on a cold February morning in 2017, a young girl aged eighteen decided to pursue her dreams of becomingadoctor.SheflewintoSofiaandhopped onto a bus headed to the Northwest of Bulgaria, embarking on her path to becoming a Medic. The crispicyairof Plevenrushedthroughherhair;her nose froze over; her fingers searched for warmth in her pockets.Hereyesweredrawntotheheapedpiles ofsnowsituatedrightoutsideofHotel Rostov.

thecoldestofwintersandthehottestof summersin Pleven. The journey to becoming a twenty-four-year-old independent, determined and enthusiasticMedicalInternhasdefinitelynotbeenan easyone. Nevertheless,thetranquillityandserenity that surrounds the town has made this journey a pleasantone.

“The journey to becoming a twenty-four-year-old independent, determined and enthusiastic Medical Intern has definitely not beenaneasyone.”

#memorable #proud#reminisce AnjaliAjithkumar

Fastforwardsixyears,thatgirlnowembrace

Ruby Sri Fountains,Plevencitycentre

consists of waking up bright and early at 7:30am and reaching Base 1 Hospital for rotations promptly at 8am. Currently, I am partaking in a Cardiology rotation, whereby I attend morning meetings and join the ward rounds with the Department Heads. Aftertheclinicaldayisover,Ienjoyagoodcheeky stroll through the Centre of Pleven, visiting my all-timefavouritecoffeeshopintown-CoffeePoint! Thesmell oftheroastedcoffeebeansandthecosy atmosphere is just perfectly splendid after an exhaustingdayatthehospital.

AsmyjourneyinPlevencomestoanend,

The centre of Pleven holds many memories;frommyeverydaygroceryshopatBilla, tothe tripstoRaffyinthescorchingheatandthe wonderful night lit fountains. There’s a certain warmth one feels while walking through the Centre with your best friends; just talking and giggling away – the besties who have been my pillars of strength throughout these years. Each andeverywalkthroughtheCentrehasadifferent story to paint: some days you might run into adorablecatswholovebeingthecentreof

Iwouldliketogivecredittoafewiconicplaces herethatI’vemadesuchfondmemoriesin;ones whichwillalwaysbecherished.

Ruby Sri

IvanRadoevDramaticTheater,Plevencitycentre

attention; other days you may see live bands performing on stage. If you’re really lucky, you mayevenseetraditionalBulgarian dancing!Allin all, the Centre is the place to be, regardless of whether you’re feeling under the weather or explodingwithhappiness;itholdsthepotentialto be healing and has all the means to uplift your spirits!

It’snowtimetoendthisbeautifulchapter. IneverthoughtthatPlevenofallplaceswould bea partofmyjourney,butIhavenoregrets.I’vemade lifelong friends and created memories that I will cherish and look back upon fondly. Thinking of thissmall townin Bulgariawillalwaysbring out thebiggestsmile.GoodbyePleven.

“It’s now time to end this beautifulchapter.”

Nitya Rosilint

Park,neartheHristoSmirnenskiHighSchool

TheBulgarian SummerAdventure

SlovakMedicalUniversity

Bratislava,Slovakia

ThefirstquestionIaskedmyselfwhenI was assigned Bulgaria was “should I do it?” BulgariaisacountryIhaveneverbeento,nordoI speakthenativetongue,butthingshappenfora reason,anditwasthechanceofalifetime.Iguess youneverknowwhatiswaitingforyouuntilyou try.Thereisasayinginlife,“Youdonotwantto liveinthe‘whatifs’andthe‘mighthavebeens’in life, you might as well figure out the truth for yourselfbysimplygivingitatry.”

My life has been nothing if not ambitious;Iwasreadytolearnandexperiencethe culturetoseehowitvariedfromSlovakiainallits

aspects.Shortly afterlandinginSofiaonthe2ndof July, my contact representative was fortunately waiting for me as I exited the terminal. We then journeyedtoPlevenwhereIwastreatedtoaproper tourofthecitybymycontactrepresentative,hadthe opportunity to meet her family, and partake in a fashionable Bulgarian supper. One of the more pleasant surprises was the newly renovated apartmentscompletedwithprivatelavatories.Itwas trulyacultureshocktomeasIhadneverseensucha combination together before with a shower and lavatoryinone.

The next day I was continually surprised whileshoppingandtouringthecity,contrarytomy expectationthateveryonewouldspeakatleastsome

#mybulgariansummer#exchange#experience

TerezaUrbanová

“You do not want to liveinthe‘whatifs’andthe ‘might have beens’ in life, youmightaswellfigureout the truth for yourself by simplygivingitatry.”

English,itdawnedonmethatthiswasnotso,andit providedachanceformetousemyRussianwhich hadbeendormantsinceprimaryschool.Whilethis challengewasawelcomeone,itwasmucheasierfor my fellow students and me to communicate in English while working around the hospital that we wereassignedto.

culturalperspective,involvedthehangingofphotos with complete obituaries from the front gates and finding them pinned to trees. In Slovakia it is customarytohangthemonanoticeboardinthecity hall,church,orcemeteries.Toseethemhangingin theseplaceslongafterthefuneralsisnotcommonat all in Slovakia, but still, it is a nice token of remembranceuniquetoBulgaria.

Anotherchallengethathadnotdawnedon me was that not every country in the world is preparedorequippedtoproperlyhandlethevariety of allergies that afflict me. This challenge became mostapparentwhen,duringmystayinPleven,Ihad troubleacquiringfoodthatwasdairyfreebutinthe endIwassuccessful.Oneofthehighlightsfood-wise was the constant and consistent availability of seafood in almost every restaurant, the octopus by thewayissecondtononeintheworld.

Oneofthebiggestshockstome,froma

The main purpose of my Bulgarian adventure is of course my internship with the International Federation of Medical Students Association(IFMSA).EversinceIwasasmallchildit has been my purpose in life to become a doctor. WhenIFMSAemailedmewiththeopportunityto work in the medical ward of the Cardiology department at the hospital in Pleven, to say I was elated is an understatement. The most important organinthebody,inmyopinion,istheheart,anda chancetogainexperiencefirsthandwithcardiology wassomethingIstronglydesired.

In comparison to Slovakia, medical studentshavedifferentpositionsthantheonesin Pleven or the rest of Bulgaria. Medical students here in Bulgaria are respected, treated as equals among colleagues, and valued for their desire to studymedicine.Beingawomanstudyingmedicine in Slovakia can be challenging at times and even discouragingtosaytheleastbutinBulgariaIwas treated as an equal. Every patient and doctor I encounteredwasexceptionallypolite,encouraging, and eager to impart information that they had acquiredthroughalifetimeoflearningorstruggle.

When medical students in Slovakia do their PRAXIS in a hospital, it is customary for the students to walk a few steps behind their assigned doctor and to enter the room after the doctorbutnotbefore.Thiswasinsharpcontrast toBulgariawhere,again,everyonewastreatedasa colleague and equal. Doctors would open doors forstudentswithoutanyideaorregardastotheir professional status. The hospital in Pleven went above and beyond to accommodate me and my allergies with latex free gloves and a desire to instruct, knowing that they were once students themselves.

Recreationally during my adventure in Bulgaria,Ihadthechancetoseethebeautyand natural history that makes Bulgaria unique. My friendsandIhadtheopportunitytoexperience the spirit of old towns such as Veliko Tӑrnovo and Nesebar, feel the shards of history past to include Belogradchik fortress and Nos Kaliakra. WewentsunbathingonthebeachinBurgasand Varna, hiked in Vitosha mountains and Seven Rila Lakes, went running at Kailaka park, and explored the astonishing capital Sofia while tasting the delicious cuisine of this Balkan country.

“Doctors would open doorsforstudentswithout any idea or regard as to theirprofessionalstatus.”

I would also like to use this blog as a chancetosaythankyoutoallthefriendsIhave made, the people that made me feel welcomed, and the journey you took us on as exchange students.Everyonethatassistedusmadesurewe saw Pleven and all the beautiful surrounding countrysideinallitsglory.Fromthemainsquare

While I gained practical skills and experience with regards to the Bulgarian healthcare system, I made not only Bulgarian friends but friends from across the world all chasingthesamedreamasI,tobecomeadoctor. We spent a lot of time together explaining our customs,traditions,cuisine,andhadfuntryingto pronounce words in the native languages of our fellowstudents.

withitsastonishingwatercascadesandfountains to its historic city hall then to the famous Panoramafollowedbythebestplacestorelaxand swim.Bulgariahascreatedasocialprogramthatis unrivaledformedicalstudents,andIshallcarry this experience forward in my life. Thank you againforthisonce-in-a-lifetimememory.

@tessie_u

“I made not only Bulgarian friends but friends from across the world all chasing the

Acknowledgements

ProjectManagers: ElaheNaghaviandMunazzaKhan

Editor-in-Chief: MunazzaKhan

AssociateEditors: AleehaAzharandMadihaNissar

Reviewers: RalitsaShentova

GudithAlionye

VysakhRatheesh

SocialMediaManager: LaibaShah

CoverPageIllustrator: MunazzaKhan

Photographers: VysakhRatheesh

NityaRosilint

JoséCosta

AnanyaMehta

MohamedAbdullahi

MitchelleD’Silva

RubySri

MaariyahHussain ShazanaAziz

@bulgariablog

RabeehUrRahman

PrabeshAngbuhang JasnaNaghavi

Formatting: ElaheNaghavi

Vysakh Ratheesh

Vysakh Ratheesh