1987 1

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rcE>

BLACK BAG Joumal ofthe Medical Faculty of Bdstol Udve$ity

SPRING

T987

Editor

Phil Stokes Busiaess Managers Abi Beryer Andlew Padkio IllustratioDs RichardJennings Typesetting YorkHouseTypographic Printed by GPS Priuters Lettas and eontibutio$ are uehome and shotM be sent u The Edito, Black Bag, Dolphin House, B^tol RcJal Infimtry, Bristul2. Aryona i. ercsud in helping uirt the ptoduttion ol the nseaziw shouA abo contzct the ditln.

Contents

Editorial

Who treeds a space blalket atrYwaY? by illike Polkey Doctor Coles - The matr behind the myth

This issu€ of Black Bas shows a marked swirs to sndent writitrg. Perhaps this is because you thought th€ last issue, larg€ly wriften by outsiders, was such

by S. Donim

that you ktr€w you could do better, or perhaps because they awakercd your erest. Eittrer way its a healrhy sigtr, though partly due to maDy promises of artides

i

........'..

The loatrs issue

by Jonathan Fielden Four rrheels good, two legs bad

by Bernhad Stacey

Overdosed.trd underteated? by a B.istol Samaritan A group home

by Phil Stokes A surgeotr's guide to cboosi[t a carcer

by Manwatcher

Drug prescribiag ia the third rporld

by Paddy McMaster The Modca Brittotr Hall

by Susan Langley A room of my own

tmm'outsid€' coming to nought. It's reassuring Io trote thst studetrts ar€ mor€ reliabl€ than (say) profesrors in this wry.

10

Anyway, in this issue you will 6nd discussed the possibility of loans mther than grants for medical

ll

students as a test cese, the ebuse of freebies by doctors and dnrg compenies, and a criticel ourside view of the teatment of overdoses. In a ligiter vein there ere a

l3

number of offerirgs from under ridiculously transpsrcnt pseudolyms, and the offer of €10 for a decent

t4 t7

l8

m

rhyme about someone on the stafl There will be one more edition this academic year, before someone unlock this door atld lets me go, so if there's something you've be€n sittiDg on all year and walted to send in, now is rhe dme- More chairs wo'nd be rLice-

I$(/HO NEEDS

A SPACE

BLANKET ANY'$TAY?

As students, the amount of largesse we receive from drug companies only runs to the occasional free lunch, but after qualification the possibilities for benefits increase enormously. Mia e polkey looks at what is handed out, and how a system of controls might work to reduce the cost ofdrugs.

A friend of mine recently rtent to a

slap up drug company lnnch, As well as free sampl€s, he elso returned with four l3 amp fuses, a "musicassette for acne patients", and a space blanket. I fail to see the benefit to patients, and therefore in the longer term

to doctors, of meetings of this sort, I intend to discuss here the interplay between drug companies and doctols, the industry itself, and finally to ask how we might impaove the situation.

M.Erial suppon to doctori by drug comp€ni€s rarges from a cup of coffee at hospital rneetirgs through pens and books to symposia in exotic locations. In otber parls of the world the industry is more generous. One American physician was rccendy offer€d $100 to go to dinner and heqr about a new IV globulin preparation.

If he managed lo bring along a coleagu€ he would receive a further $1001. On one Philippin€ island a doctor was offered two motor cars if he would set up a pharmacy, which would have had a monopoly, selling the products of iusr one 6rm'?. In this countrv ethical codes restrict the actions of the industry, although ttre recent censure ofBayer UK by

tle

Associadon

of

Bdtish Phermaceutical Industries is e reminder that thes€ are sometimes broken3. The ,,hpertension screening uiel" set up by Bayer, which had no valid scientmc protocol, and whose result$ were not even collated, was run only with the aim of incr€asing the prescription of Adalat. Doctors were offe.ed ar ECC machine if they would presclibe the druE to fifty

patients,

Doctors aim to improve the herlth and well-behg of (heir p|tients, while a drug company aims to make a profit for its shsreholders. Clearly these aims sorneumes overlap, bur equally rhey may be in opposirion; for example 6nal devetopmenr of a vaccine againsr malaria has been delayed indefnirely because of comm€rcial unviabilitya. Many would argue rhat drug reps are an important source of information. Yet such a vielv is incredibly naive. Orw€ll once obseryed tllat just because something is printed in fie Daily Telegraph does not mean that ir is not true. Likewise a rep may be correcr if he asserrs that his product rcpres€trts a genuine advance, or he may not. The doctor cannot know without a rhorough and expen recourse to the

ftl

suRE '(ouR Pno{ATRtC

PATIENTS CAN DO !.IITI{OIJT TOU FOR FIY€ T,IINUI€S, TNHITE TEL!

'(0U AL! agour ci.rq ANTIDEPR€SSANTS

I

NEuJ

literature. But how many docto$ spend al1 aftemootr in the library after meetiry reps? A doctor gmuinely interested in updating his knowledge will attesd meetings with his colleagues in academic medicine, vrho are paid to keep abreast of current developme s. It

is bizarre $at

supposedly intelligent professionals should consider ftemselves immure from the effects of marketing. If they were, the industry would not waste its money. The more cynical wil regad the bbndishmerts of the indusEf as "perk"- But geouirc perk offered in the real world, such as the company car, are quit€ different. They represent a vray of raisilg the ir:come ot r-he conpanies employees. without having ro

it dfough taxation. Anyway position here is fundamentally dillereot since

pay the govem-oeent for

tie

doctors do not, ofcourse, work for the pharBacelltical

indusrry.

The drug busi ess, like any oth€r, op€mt€s for profit, although its product could be argued to be more worthwhile ftan most. Nevenheless the industy will take as

it catr. The most notorious exsmple itr this country was publicised in fte 1973 report by the Monopolies Commission on transfer pricing by Roche for lhe supply of Valium to the NHS. Roche had sold the raw materials to their British subsidiary at f922 p€r kilo, who had then sold to the NHS at a maryinal profit (and paying only marginal ta{). Curiously the cost of the mw materials to the parent compary was only f20 p€r kilo, represeDting gross profireerings. This scandal ended with Roche actually making a cash paymetrt to the UK by way of compensatioo.

Dianna Melrose 6rst brought t-be ouLmgeous actions of rh€ drug companies in the third world to oul aftetrrion2. Four years later on the situatiotr is "cha4ed but nor improved"6. "Etrc€phabol", a viramh 86 d€riyarive alleged to improve "the uptake and utilization of glucose in the btain" is promoted in India for "strokes, orgadc brain s''odrome ot rhe elderly. post coocussion much as

industry atrd the profession totally, bur it is possible to forc€ itrdusEy to support th€ profession in a less panisan way. The Swedes enioy a rigidly tegulated syst@, at l€ast:s far

hospital doctors are concemede. reps are oot allowed ro speak to In Swedish hospitals must address the whole departindividual doctors, but alowed to speak morc than ment, atrd sre not usually year. th€ meeting the scientific standard rwice a Before checked by the head of department. of rhe material is presentauon is of gifts and if th€ are allowed, No fr€e

poor quality

as

tie

rep is not allowed back. Drug compaaies may not pay for doctors m€rcly to attend meerings. Tho6e sp€aling trIay oDly bave their expenses paid if local commine€s are conv bced that it is appropriateIn Briraitr th€rc is oo prospect of central control and ir is rherefore up ro hdividual doctors to de.ide their own practice. Because of th€ unethica.l aspects of rhe industry and its mark€ting practices, I propose a reduction of exposure to promotional activities- As a simple 6I5t step I would suggest that doctors do not meet reps olr a one to oDe basis. A typical medical traioing for a drug rep lasts about sevm we€ks. The process of such a rep trying to convince docbrs, with probably litde erperieDce of th€ scientific method, of t}le advanrages of Fadasricapam is so parhelic as to be lawhable, hile a mass of space blanke6 metely degndes the profession. r- Mubs, D.M. 0986) N. Ens. J- M.d.t/5(9) 5m Mdrw, D. (1982) Biaer PiIs, olfu l. Amn 0986) BMJ 292 64 4, M.ct@ie (1984) N- Scidtist 2484 4 5, Mompolis cmni$iM ReFn O97l) H.M.S-O. 2-

6-

7.

Gt€hsleh, T. 0986) L@et

(8493) I31a-1t20

v€isl]u, M.H-

(1985) I. Rnem r2(J) 615 G-R. (1986) J. Rheun lj(r) 224

8, K@s, e. SEith, R. O98s) BMJ 290 ,148450

syndrome, and pedtratal dislr€ss"- Dr Greenhalgh informs us that ma*€tiDg patlems bave cbtrged widr the emphasis now on s€Iitrg products that are used itr

rhe developed world, but for differetrt itrdicatiotrs.

Competition

Thus Chloranrphenicol cotrstitutes an astotrishing llolo of antimicrobiat prescriptions. Chlorampheniml is, of course, only used in rhis coutry t'l srtrenn because of ils rare fatal side effects.

Drug companies c:tr show disregad for doctors participating in clinical reseaich for them, atrd those who do should thereforc be cauuous as rc how their reputations will be used. P6zer recendy withdrew a$ adv€rtisemeot in which s€veDteen Fomifttrt Catradirn rheumatologlsts app€ared to endo$e the compa.oy's contentiofl tlat Felderc was superior to other nonsaeroidal-anti-infammatories in the ueatment of rheumatoid ardrritisT'3. ft is not my intention here ro criticise co aborarive clinical work in specialised fields. It nay only be hoped rhar risks are nor b€ing taken for fte sake of drugs that are chemicaly similar to, arxd no morc emcacious dlan, exisring ooes. However, given Lhal it bas beetr esrimated that Fomotion accounts for 20% of the total cost of a drug, anyding whicb reduces lbeir cost is, in the present economic climate, to be welcomed. It

Wrile a te ing rhyme about a member of staff and win yours€fclo. A couple ofexamples app€ar below ro set your mind iorking-

would be faolish of course to s€ver contact between the

issue.

I suppos€ it is jusr possible that Mr I-€aper miglt sel€d his fenale hous€men or1 the g/ou[ds that they are bright.

But persomlly I think he iust consults his little winkie.

Tbe wods ofMr Cooper came dnging rbrough my stupor as he told me wirh the F€cisiotr ol a Vernier

"Your €xam isn't complete from the hesd to th€ feet unril you've checked they havml got

a

herda"

Sptrd your entries (which should be printable!) to The Ediror, Black Bag, Dophin House, BRI. As well as flo for the best otre, we hope to print a selectiotr in th€ nexr

f)J IT

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'

DR COLES: THE MAN BEHIND THE MYTH Myths and legends fom an imponant pan of atry culture. Which of us has not been thrilled by impossible

ofKing Arhur, Bigfoot or theAbomiDable Strowmar? For the bistoriaq however, such legends present a more challengiDg task - that of discoveriry the grain of Euth, if any, q'hich lies behhd the romantic folktale. Here, we will egmine iust one such local legend; that of $e mysterious DOCTOR COLES. We all know the leg€nd; drc benevoletrt if somewhat nebulous fgure of the wise old doctor, whose ever vigilanr eye keep6 conshnt watch over his beloved flock of students and patients, exening, Iike th€ HoIy Ghost, a]l invisible but benign induence over us all.

A childish fable? The opiurr ofthe medicsl students?

Or mighr we fild, as in so rnatry legetrds, a nugaet of fact behind rhe clords of obfuscation? Many have sought for it, and various schools of thought contend for the most likely interprctation of the m''rh.

The historical approach is orc of the most popular.

For example it is often claimed that far back in the very distahr past, ahere was an actual living penon called Coles who realy did work as some kind of doflor in Bristol - a tradlEoa rememb€red to this day in the charmilgly quaint local custom of keeping the name 'D.R. Coles'on the N.H.S- pay-roll.

Others sug.gest that the real Dr. Coles was indeed a clinical dea! at the tum of the ce ury, and died heroically at his post in 1908, from a surfeit of tea and tales

biscuits- To $rppofi ttris are garbled repons from students who claim to have penetrat€d as far as his musty skehton in &lwardian costume, with its fe€t on the table, ard Lbe remai$ of a digestive stil cleoched between irs fleshless iaws.

Matry p€ople, howeyer, claim that the figure of Dr. Coles is completely fictiiious, and that no such p€rson ever existed- Some cydcs blame the fable otr th€ B.R.I. office, ard sefn

a

stil propp€d in

a chair

pbysicians, whom they accuse of fosteriry the myth of Dr. Coles as a Puck-like spriE who trips mefiily dllough lie wards afier dffk, admidstering spurious and uwholesome Dedicatioos ro his unlucky victims.

Less plausible are rhe th€ories of rhose who look to the Bible for 3tr explaBtion, seeing the Cliaical Dean as a quasireligious motif fm some deeper, more spiritual idea. They suggest for ifftatrce, thar Miss Bryden is in fact a Hish Priestess, iealously guardiq he that on the Day of Judgement wiil rerum again to

this world, to breck the seven seals on the Book of Grades, atrd read out the tram€s ofthos€ who are saved, atrd thos€ who arc consiged to everlasting tormen! alrd pedition.

Finally, we come lo the most controversial area of the debate - the sGcalled "sightings". As in the case of th€ I-och Ness motrsler, the Coles legend is fuelled by iftermift€trt atrd coDfus€d rcpons from people who b€lieve they have actually caught a glimpse of him.

A few studetrts who daim to have gained entrance !o

the inner sarctum of his ofice muner strangely of a murky shap€ ha]f p€rceived in the gloom' which (*tey say) seemed almost to lod while they were explaining their elective plans. Othe$, who have clearly had an altog€ther mor€ harowitrg experience, are so shaftered by what th€y have s€etr that they babble insanely of a harnless ad aseeable old m!tr, som€what brusque perhaps, bur (according rc rhem) wholy hunan. G.ecenr s'uggestiotrs rbrt this is in fact a hologam have yet m be

investigated),

Virrually a[ the e4€rts have dismissed such sightings as deluded trolts€nse. So why is the mJ'th of Dr. Coles so pffsisteDt? The atrtimpotogists will tell us 6ar irrarional rrust in such a fgure is an inevitable huEan weakftss. Their opponetrE might reply thar we live in an age of reason, and should tllrow off the

of superstition ard consig:i our naive and primiLive faith in Dr- C,oles to the dustbin of harory. \0hatever lbe trulh of lbe mrlter, one thing is certaljl: the vilal evidence needed to solve the problem may sooD be lost to us forever- For yeals Miss Bryden has jealously guarded the terible s€cret which lurks behind thar door marked 'Clinical De3n'. Now, however, she has evidently decided lhat more drastic measures are ne.essary. Studmts vrill have aoticed the gmdual bncking up of corddors ard passages which once led ro the Dean's o(ice. Where once we could freely etrter shackles

Dolphin House, v,/e now face a barricade of cement. At the undoubted insdgation of ldiss Brydm, a concrete curtain is inexorably desceoding aromd her office, and that of the Clinical Dern. EveD the entrarces which are left are controlled by combination locks whos€ secrets are known only to tie initiated few. Already it requires the irtrepid dadng ofan Ind;ana Jones iust !o get as far as Miss Bryden. If we don'a establish the exislerce or otherwise of Dr. Coles very soon, i! will be too late - he

will be utterly cut off ftom the entomH together tor aI ererniry.

-

and Miss Bryden ourside world

S. Donim (Ms)

Somefhing wrong?

A surgeon and his son were travelling alotrg th€ M4 ro Bristol, when a blow-out rnade them swerve off rhe rcad, hirting cars as they crent, atrd enrling up in the middle of a tangled heap of metal. Th€ farher was killed ourright, but the son, though badly itriured, \r'as rescued and driven in an ambula.Dce to hospital. Need-

irg

urgent surgery, he wmt straiSht to theaffe- A sugeon scrubbed up, but on entering th€ room was seen to halt, turtr pale alrd say - "l can't do this operation, ttrat's my son!"

If

sonzth;ns str;hes Jou as be;ns ,ot'g hqe, and Jou exblanarim, ftn ash anl uonan in me"4nnz.

naed an

$"tt{Atitr;,a

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THE LOANS ISSUE "lX/e haoe concludBd that thate is an urgent ,Eed fot at inoease, in real ams, in satdent awards . . ."

"We recomma that stude a@atds be indeased abooe thc generul lcoel of prices unt the leoel of awards opproximates to the costs whih studenc indt-"

l

Thes€ ab6tracis from the important series offtcommendations made in the 6fst rcport ofthe Educarion, Science

and Ans Com ttee (ESAC)r, recendy published, s€rved to add furher con$ov€$y to the topic.l debate over how to furd studeDts. The rccommerldations, all essentially in favour of imploving the prese$ syslem rather tian charging ir , were ajl $e more impona.Dt in that thev reEesent the fiIst major depaftu€ of a CoF senative domi[aled mmminee away from advocating a change to a loals system. To be relisric thes€ will not in thems€lves become gpvemment policy, altbough tley will be stroog iDdicatioos to the 'Waldell Ioquiry' into student financial supporr of an increasing groundswell of opinion on the backbeDches. The publication of the !(alden report is eagerly awaited as the 6rst statement of policy on this subiect from rhis govemment since 1979; we have a[ floutrd€I€d in a void of non-policy for roo long. However, despire th€ rcminal impaniality of this wide rarging review, Mr Waldetr has made his bias tovrards loalrs as well knowtr as b;s stubbormess ao acc€pt altemative points ofview.

It is in drc light of the likely pmpocal ofa loans system by the Sp€cial Review rbat this aficle is written, to outline some of the maiD issues involved- A poitrt of palticular imporrarce to medical stud€nts itr all this is rhat Kennetl Baler (Secretary of State for Education) has already suggested medical students as a possible tdal group, alory wirl ""g'ners atrd other 'graratrt€€d irtue

income' stud€trts. The gleqt exp€trs€ of the medical cou$€ (about !40,0m tuition atrd f12,000 maiDr€nance) makes the possibl€ savitrgs amthff atdactiotr for this pilot scheme.

The Prcsert System

As we are all too axffe, rhe present level of gant doesn't meet the expenses lhat eveD t[e 'averagd studetrt incurs. ID facr the DES is oD recod as sBtitrg tiat the sludetrt glant is not €veD designed to me€t €xpetrdi-

ture2, and no accurate calculatiotrs of studetrt ou.lay are rn fact made. The ressoD the presetrt sysrem has lasted so long is its trumerous merits; the availability of the glant has cotrEibuted to the expansiotr of higher education and, in th€ past, encouraged access fiom a wider rangE of social goupsi il has helped ninimise visible disparities betweetr studenrs; it assu€s atr award for all qualified studetrts once they ar€ accepted oD a couls€, and it aIows, until recedy, a wide choice otwbere ro srudy without fffffial restrictions.

But these, and other, benefb of the system have all been undermircd by ahe consistent reduction io the value of the gmnt since its ifimduction b 1962, and the precipitate fall sitrce 1979. In this iater period tle DES now admits to a decrease of 13% in rcal terms,

though the NUS estimates

a

20% cuta. These esrimates

are bas€d on th€ r€tail pdc€ index, and are thus pmbably

utrdercstimates as the maitr articles of srudent exp€nditEre (board books) bave mcreased in excess of

ad

infation.

The inad€quacy of Lbe slan r is sbowr bv lhe increasing depe[dence of smdenrs on welfare benefits5, where the DHSS estimates that half the srudent population in 1985 claimed housidg beiefir6. These benefits can be claim€d b€caus€ snrdent incomes fal below rne quafi&ing 'hardship' levels. The NUS estimates tha. half the studetrts itr the country have recours€ to the banks for additioml 6nance; BMA surv€ys in Bristol revealed that 70% ofr€spotrdents had overdrafts.

For medical studetrts the situation is further embinercd by the clinical grant, vrhere b€yond a 30 lveek year our allowance is se! at t5 per week less ftan the basic gatrt :nd we are not deemed to ne€d books or

clothing duriry these exEa week. In addition, the rcmoyat of the C90 equipment grant (1986) asd the alteration of [avel grants (1985) - described by even the DES as 'rollgh justice' - add a corsiderable extra burden. Medical students ar€ also hit by the dramatic iffreases in parcntal contibution, atr ircrease of

300o/o

siDce 1979 while govemment €xpenditure over the same pericd only increased by 4l%7. The gov€rnmert is iacrersingly passing the buck to paretrts, who arc less and less wiling to accept it. 43% of parents fail to pay al Lbeir cootriburioo, a p€rcetrrage which increases with mlrse tength3, again to our detriment.

Tte Loaff Syst€m The nuny problems of th€ present syst€m have be€n effectively by-pass€d by the govemm€nt in th€ir id€ological rush tovrards a system of loatrs. while its advocst€s call loans a p3lrace3, opporcnts are worded at ttre additional problems tbat such a syst€m q'ould €ntail.

Loans were advocat€d itr 1958 by the committ€e set up to make ttcommm&tions for the hitial student fiDafte system. They were rciect€d then itr favour of gratrts, as thev have been by various successive governments.

The pres€4 government has had two abortive attempts to futroduce dem, and is now in the tbmws of its third a.nd most calculared move. The case rlat advocates of a loa.ns systern will have to prove is tbat the inroduction of loans q,ill be of beoeft to education, govemment, tle corntry, and the studefts.

The basic ploviso tbat has b€€n put forward constatrdy by the loatrs lobby is Lhfl the pr€s€trr system is inequi I able be.ause the maiority arc forkitrg out for a sma[,

elitGt minority, who will b€neft geatly in terms of income atrd status as a Esult. However, the extra €ducaLion r€ceiyed by Lhe studeot is of ben€6t ro sociery as

a

whole, enabling them ro join the highly skiled

sec-

tion of the workforce which we currendy lack so much.

Indeed rhe green paper on higher €ducatioD (1985)e estimated ttre rare of relurn on univ€rsity degees at 5 to 8%. The present income tax sysEm is also designed ro recoup more from rhe high earners' rhus relurning more to the €ountry from ihose who have beneftted as

which Loans Systeh?

Sir Keith Joseph found thar back bench opposidon to the idea ofabolishing the state payment offees in falour of a loans system was too strong. So it se€ms that fte govemment would condnue to cover tuition fees. The proportion of loans to gxants for maintenance is also likely to be a difficult subiect. An all loan system would subiect students and parents to a large immediate debt' and miglt therefore be politicatly undesirable. So it s€ems

tlar a mixed

rEants and loans system would be

Similar oroblems hav€ been s€€n in Canada and Denmark. r$d other EuroDean countriesro. The wary approach of low income fanilies to lostrs was contrasr€d to hiaher incode families usiDg loans as a cheap investment.

c-nclusions close scrutiny the claims made for a loatrs system fail to show my sig!ficant adva[tage over the present

on

system. The solutiotr to curcnt problems must lie in l.lle overhaul of rhe currmr system to ensure its €mciency in me€ting stud€ot needs, keeping administration cosrs dowtr, end alowing access to higher education. The direct and indirecr benefts to society of good numbe$ of graduates should be calculated end used to refute the claims tbat th€ costs of$ants arc too high. We can iustifably say that we cannot alford not to meet this cost.

As medrcal students, we n€€d parity in the level

of

rcquired.

ouf grant, and proper reimburs€ment of our equip' ment and tnvel expmditure. D€spite the short term

The Costs

attractions of a loan trow, sootr to be peid off by a se€hingly large salary, opening the door ro loans will soon lead to the dismantling of our ef&cient end univensly admiftd grants s''stefl. The weight of evidenc€ ftom all concemed bodies prompted the ESAC to conclud€ the view of fie commirce an its recenr reportr av'/ard system, analagous to that idtroduced in 1962, vrill contilu€ to be ess€ntial in the years ah€ad national requir€ments ere to be met".

lr

is sugge$ed that the cost of inlroducing a loans for mainrenaDce would be C500mrr. Even if

sysrem

exaggerated this is of th€ same order as that of parental

contribution (f300n)t'z. The loDg term costs arc equally difficult to predict in ttre absence of concrete proposals. Real returns on loalls would not start for abour ren y€ars afrer the initiation of the scheme, allowing for graduation, finding a job, and clearing the inter€st

charges accumulated. If the governm€nt decided to administer and finance loans itself it is doubdul, from obse|ations abroad, that there would be a significa saving on admirustration. In countries wher€ som€ or all the adminisEatior is done by the barks this is onlv done under sufferance and government pr€ssurerl. In lhis country the baDks are adama:rtly r€sisting such

Th€ cosls of financing loans are dimcuh to predict because of the variability in means of repayment. If inrerBt mtes arc subsidised then the coct must be bom' by the govemment. In Denmark where mtes are not subsidised, the higl cosl of loatrs encourages stud€nts ro take time off to work and thus pay off some of their toan b€fore graduation, lengdrening their course. Repayments have to be d€layed until eamings have teach€d a threshold level, and loans can be defaulted if eam' ings never r€ach this. The govemment has to statrd as gllaranlor for such defaults, and these can be consider_ able, nearly ll% in rhe American scheme, while 14% of Swedish students defaultu. These costs make Swedm's srstem of 93.5% loan and 6.50lo cxart, believed to be one of the most efficient, mote costly per stud€trt than the British systemr3. It is telliag to note that orc ofrhe staunchest opponents of loaas in this country is the Treasury itselt becaus€ it fears ihe extra costs.

Access to Education I-eaving aside the social and cultural attitudes to education and debt, there is scaDt evidence to suggest that loans per s€ improve access to educatiotr In America, the participation from low income families is decreqsing. In Sweden low incomepaniciparion in higher educadecreased as the loan elemmt was increasedr3.

lm

"h

if

Jonatlun Fieuen 1 Fi6i rcpon ft@ ih€ Edudtion,

So@ce

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4. ESAC Repon. Crmntr of DireloB o( Polttechnics 5. lfbite PaFr 1985, "Refom of scial Seurily"

6, ESAC Repori, "Studerts dd Bmefts" 7. ESAC ReFn, Memotudd by NUS 8, NUS Incon€ ed E:penditure Sw€y 1983 9. Greo PaFr on Hichd Edu@tio!, HMSO 1985 10. Lloyds Bek Fron@ic BulLtin 1986 ll. BMA Aswiate Mmbes paps on l@s 12. Tih€s editorial lu1l87 13. NUS rcpon or "stud{r L@s, !h. Csts dd Crmequoc6" 14. SDP

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I'm sorry I didn't clerk my

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Thev They They They

w€Ie talkitrg to tle doctor vrere talking to the truls€ were talking to themself

felt too ill I felt too ill They werc haviry atr M They were haviry atr MSU They were having an MI (that's eroug[ excuses. Ed.) Daf in Sr).ll

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Feel you know everything about the body? Or as much as you can take? Then let Bemhard Sncry take you on a rapid tour of a very different aaatomy.

Its alright for them docto$ of course, only one macbine . and two models, bua io ask me to lecture on well I ask you, there's hundreds oftypes, all dilferent l;ke. Bur I lldo mc hesr' Sid Spamer. at vouFervice.

And seeing how you lot don\ understand normal words like up. down. front and back. I'lleven throw in your

cars

in $is is not unknown, and causes the car to shudder (an unintention tremor) and finally stop. On the hard Th€ most posterior-rnferior part is

a

small black tube

protuding from beneath the car's equivalent of DNA (irs unique, inexplicable, number plate). Ttris tube has

posh talk, all for the usual consideradon, catch ml' drift, guv . . ? (yes, aldghl, but get on wi(h it. Ed ) Wcll, to start with, most cars are unlike us in lhat they go on all fours, although they have been knowtr to assumc the more erect position, albeir briefly - e g.

Bmnd's Hatcb. Like us though they can go backwards and forwards, and one rather better (han the other.

This enables the observant studenl !o perform the esscntial lask ofdisdnguishing anterior from posterior' The former is usually cheractedsed by two white lum! nous discs, whereas the letter has dumerous red ones

thrce functions: I . To expel waste gases without any of the social constraints imposed upon its biped cousins.

2. To emit a series of loud explosions whenever il feels unwell. Motor anthropologi$ts suggest that this is analagous to our doctor's certificate.

3. To enable the best man at a wedding to stuff a potato in it, thus wreaking havoc with the innards,

it standing up'.

The v€nllsl sloping sspect of the car houses the engine (from the Latin eng- to go) and the Greek iru - sometimes). This is more or less constant except in certain dumpling-shaped German cars wherc it has herniated to the rear early in life. This presents no

a

and a sign $aying 'Windsurfers do

problems cxcept perhaps to the witless petrol attendant caught napping on Candid Camera. The engine itself consists of between four and twelve cvlinders and pistons, This is where the action is The car's flexors end extensors, Here we encountd another drfference have petrol Which makes them smart€r than us, or have you ever heard of four-star being screened for AIDS? Anylvay, between us and them. 17, havc blood,

tle,

this petrol (from the Greek for overpriced) is csrried from the storage tank posteriorly along the deep dorsal fuel line - an unpaired midline stlucture. Thrombus

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not to mention the honeymoon, in a prank childish it sdll puzzles the anthropologists.

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During a car's life this tube can atherosclerose, with rcsult nor dissimilar to that achieved by the best man, excepr thet it happens after the honeymoon.

An interesting aspect of motor anatomy is the similarily between all four points of contact with the ground. Being all exactly the same, they make

'identify precisely' questions

in

spo!-tests totally

impossible. The one consolation for the disillusioned student is that a transplant on to the wrong axle (hip) doesn't matter a damn. However lysis of these wheels does matter; air channels in the membnne open and air flows down a pressure gradient. Quickly. This has an inlibitory influence on the movement of the cer, which will either grind to a lop-sided halt, or overtun spectacularly if a camera is pointing at it. lnside. ro the right of the midline sits the brain, or driver. This is where the maior decisions are taken, unless he is drunk. when the orlly utterances emerging from under his beer sodden moustache will be phrases such as 'Vow, this motorway has six lanes!' Such drivers can usually be found the following morning in a ditch, with thei cars shortened antero-postenorly.

Finaly in this whirlwind tour of ihe four-wheeler we come to the three insignficant looking pedals near the

fi

ddver's feet (provided they are sitting in lhe right place). The most medial of these is there solely to contuse learnen (cf Folamen of Wimslow). It alone is responsible for uDdignfi ed kangaroo impersonations, fathers writing children out of their wils etc.

The median p€dal slows everything dowtr (cf punc"

Alternoon Snacks

56 PARK ROW, BRISTOL

turcs and Fdday afternoons), and is used when approachiDg a red light. If, however, a green light is showing, the lateral pedal is depressed, allowing the car ro pass al man-ner of fiings. pedestrians. push-bikes, but rot, alas, exams. A fe\ cars have only th€ median ard lateral pedals, and are those that most rcsemble their driverc, Iinguistically at least, beins bipeds.

t0

OVERDOSED AND UNDERTREATED? Does the patient with self inflicted damage get a fair deal in hospital? A member of the Bristol Samaritans tlinks not, and writes here of some of the problems tley have encountered, both in casualry and on the wards. cal oD the Sanaritans include some who have laken overdoses, and some who evetr motinue to swallow pills while talking to us. In these cases' they will oft€tr €ventually agree to go to hospital, but possibly only if we can either take them or accompany thern. For this rcason Sa.malitals tend to s€e how patients who have overdosed are ueated itr hospital, and in this article I want to describe some of drc problems I have seen aris€, atrd ask how they might be avoided. Being medically unqualified obviously makes me unable to comment oD the medical treatment dispensed, but it is the other side of the coin, namely how such patienls are cercd for, that I want to concentlaie on, The casuahy department is lhe frst port of call for the patients we bring to hospital, and wbere the first treatbent is administered. This seems frequendy to include a wesh out of the stomach by weter induc€d vomidng. This is a highly unplessrnt procedure to undergo, and if not explained end performed with as much consideration as possible, could have a dramatically edverse effect on them. Remembering that someone who has been prepsred to take theL own life is alrerdy likely to be $uffering from feelings of isolation and reiection, any further peinfu.l experience, if insensitively administered, can be s€en to be potentially disasterous. I have heard stallcommenting how such a paiaful shock would make fteir patient less likely to try suicide in future, but I would maintain tha! it cotld h.rease the likelihood while making it less likely that the patient will come to hospital afterwards.

Casualty wards cen be intimidating for the most well-balanc€d individuals, and if you coupl€ this wilh a general wariress of the m€dical professioo (oft en maniPeople who

they have been admitted, when they still ring us and ask us to visit them, Here the same story app€ars from time lo time as well, all lhe medical tr€atment in the

world, but a wall of silence and non-communicarion s€parating them from the rest of the ward . This seems less likely to occur if their mood has changed, they regxet their arrempred suicide, and are anxious ro

appear as lhe convendonally smiling and grateful patient. But someone whose life drives fiem to try and

kill themselves is likely to remain deprcssed and dificuh to deel with. They don\ smile, and they don\ feel gratcful. Despite their awkwardness they surely have a greater need ofconsideration and explanation from the staff, ifthey are toavoid funher depression, alienadon and attempts on their own life.

Fortunately, this is far from the way that many overdose patients are treated, and I've been privileged to se€ somc very compassionate and unde$tanding care administer€d, but I have se€n iust the opposite as well.

Such poor care can be changed very simply, without investment itr manpower or machinery, but iust by a mor€ sympathetic understanding of the problems of someone who tri€s to kill themself, on the part of you, the carers.

fested amoog call€rs to the Samaritans by atr utrwillingness to go to hospital unaccomparxied) and aD acuie

emotional disturbance, the[ an overdos€ patient dcserves a lot of effor! to make them as comfortabl€ and informed about lheir position as possible.

I have always expeccd, from my non-medical point ofview, that someone suffici€ntly disturbed to artempt suicide would merir a psychiatric investigation, and yet this seems not to happ€n a[ the tim€. I've known of

refeml psychiairist parienfs behaif beforc the duty on the is caled, as if a purely m€dicql assessment aDd treatment of an overdose was suffci€nt. Aldrough I've b€€r pl€ased to see such sympath€tic treaErcnt and ieferral mary times, when th€ opposite happ€ns I am left fe€ling thar the staffs motivation is realy ju$ to remove the pauent from the premises as quickly as possible' withour realy coDsidering what may bapp€tr later.

The orher environment itr which Samaritatrs can view th€ €are of overdoses is on a medical ward, after Samaritans having to rcpeatedly reques! such a

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A GROUP HOME Vhat is it like livirg with a group of meotally handicapped p€ople? AIrd bow compatible is it wir! a llll day's work in hospial? The answels sr€ tbat it is larsely

very etrioyable, ard fits pedecdy $eI with the life of a (moderately) conscientious srudetrt. The SCA gtoup home itr Mortpelier

wil

shordy enter its f:fth ye3r, still

maintaining a household of studeds and hardiczpp€d people living on an equd basis. The ploblems for thos€ labelled 'handicapped' stem not so mucb from aDy iDability as fron the fact llar they hsve been insrirutiotul.ised all tbeir lives, always living witi someone iD

authority over them, never amongst ordimry p€ople.

This is a pmbl€m that the house rlies to tackle, and the commmts of thos€ workitrg i! Mental Hadd.icap in Avon who have se€n the effect over four yeals on the oliginal occupanis describe the improvements in their confidence atrd extroversion es rcmarkable. Whether the noD-students will ever be eble to move out on their

applies to other people's nouolN ofus, and both sets ot miscoaceptions can be best altered by experience.

Each summer the $udents in ihe hous€ move out, so that this sunm€r a turther six students will be needed for the folo*ing year. If you might be inreresred, and the prospect of large communal meals, visils to pubs, and plenty oftine spent iust beiry therc doesn't appall you too much, then do get in touch with us, eirher via Clare Mockridge in tbe SCAoficeat the Union, or jus( rhg us on 421837 and invite yourself over to se€. You cenaidy don't treed to commit yours€lf to livhg rhere initially. The house was first s€t up by m€dical srudents, and althougi these days it has a mix of students from differmt disciplines, it would be sad to se€ no medics ahere next year. So be bold and come and see; you've noahjng ao lose but your inhibitions.

Phil

Stokes

own into the community is still uncerrain, but the positive sides of a period speDt living in rhe group home, as a half-way stege to the coEmutity as can be se€n as ends in themselves.

a

*hole,

However, the benefits of living in such a hous€ cut

bofi wa,s,

and the hundreds of studenis to ha\,E passed

through over the years, either living !he.e or,ust se€irlg the place as regllar visitors, have all gained a more reqlislic view of mental handicap. Ard iusr es $tudents may hsve mi$taken notions of lEndicrps, the s€me

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A SURGEON'S GUIDE TO CHOOSING A CAREER

has, alas, never been possible for everyone ilr medicine to achi€ve theii ambiliotr of pracucing surg€ry' bur today's greater competition means that more than ever will you have to consider second rate specialities

It

for a carecr, should you fail to make it in your fust choice, the only branch of medicine tlut actuallv cures anyone, gen€ral surgBry. This is obviously a souce of great disappointmmt to soEe people, but mor€ and more I see students coping with it, to the exEnt that some peopl€ even come to medical school without the slighrest wi5h lo be surgeons. For such eccentrics. as well as thc remainder of you, I have compiled a short guide to the l€sser caree$ open to disappointed wouldbe surS€ons, which wilt give you a doqm to earth assessm€nt of what you are letting yous€lf in for.

General Medicine For a long time thes€ chaps have

been proclaiming themselv€s the s€nior speciality.

Being a physician can tro doubl pmvide vou with an inreresting ard remun€rative tim€, seeing what happens to padeDts wheD you drug ttrem up to the eyebals with the latest poison dished out by unscrupu_ lous, m€an-mitd€d drug companies, who never take t/J out lo lunch. In the end, of cou$e, we'll have to sort your patient's Foblems out for you, but tlere's no

reason why you shouldn't enioy youlself in rhe mean_ time. Just look at Professor Read.

Orthopaedics You can still even call yourselfa surgeon if you should choose dris bunch, though you'll obviously be sittiDg b€low the sala at the Christmas beano. None-

if you're mechanically minded, and vou make kirchen cabinets in your spare tjme. then this extension of carpentry could wel b€ for you. Over tle years you may find that some of the sawdust accumulates theless,

FACINGFINALMB dePend on

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betlveen your eals, but you shouldn't 6nd that this affecb the quality of your work ir any wav.

G€neral hactice A pl€asant life this; GPs make excellent company at the golf club. always ar appreciarive

audience for our latest surglcal anecdotes lf you weren\ around when the brains were being hatrded out, thaCs noi your fault, and you'll probablv fnd that Iife as a GP suits you v€ry well. veaereolos/ No way.

Atraesthetics Another good refuge for you ifyou have dimculty holding a knile still aii€r an eveniog of 6ne clarets. At least you get to enter tlle lFllowed shdre of the theatre, where if you fnd our snee$ al your expense too cutting, you can always rake refuge in a draught of some bizarre mi-nd-betding gas.

Patholo$ If during your training you find yours€lf faitrting in the fteates, bembling at venflons' or throwilg a fit at the mere thought of talking to a parienr, $en thjs ;s Lhe career for you. The patjents are dead, the atmospherc deadenbg, and the conversa_

tion deadly. Should you still feel yourself a surgeon nanqu6 you can even make believe ar post_mortems, conjuring an admidng group of trurses, anaesth€tists and assistaDts from th€ bare walls. At least the oth€r corpses around you will do as a passable imitauon of students in theatle. commudty Mediche What is this?

Radiology A dangerous one this, with all those low flying X-rays and alpha partides buzzing aroud.

If you feel attmcted to dark rooms, narcolepsy, and expensive machir:es, then maybe it will do for you, but my advice is ro buy a generous amount of led underwear before you go. Hydra-headed children that glow in the dark are all very well in Gre€k mythologv' bul not so good in real life.

Psychiatry Surgeons have a reputation for being rude about psychiaarists, but I want to be completely objective about this. As it is numerically impossible for all m€dicsl students to b€come surgeoN, therc has to be some suitable dust-bin of a speciality in wlrch to throw all th€ perverts, communisls, women elc. who would only clutter up the place otheruise. Penonally, I would say that a lifeiime of psychiatry is suitable punishment for them, and at least stops them from getting near an operating theatre.

Administratior These iumped"up batrl clerks typify all that's wrong with the health service toalay. Complet€ly unqualified, they take decisions, appear on the tely, ard tell you tlat you can't park where you like. you can face a lifetime with such unspeakables, then you'[ be miles from an op€ratitrg theatre, but secure in th€ knowledg€ that you're fightiry in th€ front line ro west control of the heatth s€rvice back from the

If

bu€aucratic pinko€s.

MANWATCSER (FRCS)

l4

TheArmvoffers medical students much more than just 86p40 ayear.

Ifyou are a student,male or female,at a Briiish medical school, you could be eligible for a Cadetship with the Roya.l Army Medical Corps.

You'll need tohavepassed your second MB or equivalent. And you'll be required to attend arr A.rmy selection board But you'll get lti04O to continue your medical studies in the fust year. This increases each year thereafter.

When you become Fully Registered,to prepare you for your first appointment as a Regimental Medical Office4 we will send you on an introductory course which lasts about four months.

This course includes training at Sand hursl training in administration and field medical organisation at the RAMC Tiaining Centre and in the various aspects of

Military Medicine at the Roya.l Army Medical College at Millbark Then,it's six years in the Army, starting with the rank of Captain. By converthg to a Regular Commission you can, of course, stay longer, r:ntil youte 60 ifyou wish.

As a doctor in the Army your practice will be much the same as a good civilian one: fi:lly equipped and professionally sta.ffed. You could be working in a group practice or on your own; ihough you'll be entirely responsible for your own patients, be they soldiers or theirfamilies,rather like a busv G.P B'ut don t ttrink thal because you're in the Army your chances for study will be in any way limited.

Wlile still in clinical

t6

training,

a

number of selected cadets may, with the approval of their Dean, undertake elective attachments at Military Medical Units in Germany Clprus, Hong Kong, Nepal or USA. Andyor-fll have the same opporturrities as in civilial life for your post-graduate training in General Practice, Commr.rnity and Occupational Medicine or one of the Hospital Specialities.

But a doctor's life in the Army doesn't stop there. As an oftcer, you'll be able to take advantage of a very wide range of sporting facilities.

Youlll almost certainly travel abroad, and your social life will be busy too. Many of those you meet and work with will bemme lifelong friends.

Finally, should you decide to leave the Army on completion ofyour Short Service engagement we will give you a very useful tax-free gratuity How much depends on the length of your initial Cadetship and the amount spent by the Army on your medical training. Regular and Special Regular Commissions are pensionable.

For firther deiails please contact Major Genera.l (Retd.) R. N. Evans CB FEARCS,

Dept. O70t Royal Army Medical College, Mlbad<, London SWI 4\J. Tel: 0L834 9060, Ext 210.

He'll send you our brochure,'Doctor the Arm/ and arrange an interview.

in

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DRUG PRESCRIBING IN

THE THIRD \TORLD

"Orabolin" (ethylesninol - arubolic steroid) "Envtes nnrmal ganth", "Stinulates tPpetite" ' " Ptumous optinal weighf' . Oryaror. (Baryladesh) Lul. effectioe agairct all gram posititte and gam negathte bacteria pructical hqortntce" - Bayer (Indotesia).

"Birctaf' (ampicillin) "Thz anibiotie

DIAcNosIs: Inapplopdatemark€titrg TREATMENT:

MLAM (Medical Lobby for Approp.iate

DosE:

Marketing) Take l0 minutes every month.

The incidence of this dost sedous conditiotr is still very high aDd immediate ection should be taken by all medical personBel. It is more preveledt, morc severe and more innuential in Third World countries because of limited access !o scientifc informrtion. The mein predisposing factor is the codmerciel intercst of the multinetional drug company involved. Its mecroscopic eppearance takes the form of glossy literature, sman suits and free satrrples, while in microscopic print are the cautions and side-effects. The pethway ofspread is extremely rapid, with iet travel, from the primary site, often found in V/esrem Europe - i.ociudiDg some in England, to seconderies in Thftd World countri€s.

The mdignency of the problem should Dot be utder6tim4!ed es tie net result is often fatal due to iDapprcpdate lreetment. Accolding to a study iD Chile death fies dnong idallts fed Dilk substitut€6 instead of b$as! milk were tbrce tiEes hig!e!. The Boat coeEoo cause of deeth worldwide in cbildren ulder tbrce is dehydradon fmm diarrhoql dis€ase. The altidiarrboed drug 'Lomotil' is coDtra-ildicated in childrcn urder four iD Britaio, wbile ill Brazil and India it has b€en recommended for neonates. But a$ a lesult oflobbying Searle has revis€d its product labeUiog rh$ughout th€

several Westem natrons of the precautions necessary,

ir Indotresiar Malaysia and Thailand the drugs were promoted with no mention of precautions and sere even recomBeoded for long-tem teatment and yet

qdte irappropliatf

uses such gs

This lobbyiag includes a centralis€d letter crmpaig! from the M€dical Lobby for Appropriate Marketing (MLAM) in a similar fashion to that run for Dany years

by Armesty Intemational. Every mondr MLAM disuibutes a l€tter to a drug comprny containing quotes from their advenising, a recent literanfe suntrMry, aod questions for the company to answer. Members sign tbe letters and post them on to th€ compatry

"tension headache".

FiDally bowever Cibe Geigy announced a worldwide withdrawal of oxylhetrbutazone and strict contmindicarions to the use of phenylbutazoDe.

MLAM'S President Professor Garry

KneeboDe

stress€s ther MLAM'S eims erc benign, well-meening

It is a non-proft organisation entirely by members' subscriptions. It you arc

end well-iftentioned.

6.oe.oced

inter€sted in helping to lobby thc phadaceutical industry in this way, thetr writc for fu(her details to

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Padd! McMatat

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LIORI.D

DtSEASES?

Another example of such lobbyiry in the case of s drug company's double sta ards was the DArketing of phenylbutazone and oxypbeDbutaznoe. AloD€ or in combination with prednisolone they nrere promoted for itrdications itrduding "spnins, infectiotrs". MLAM wrot€ to cibr hich itrcidence of htal aplastic aaeemia C€igy about tie existence of safer alternatives. Britafu had alrd to baD systenic oxlphmbutazoDe and stricdy decid€d limit the us€ of phenylbutazone. Ciba G€igy iDformed bruis€s" atrd

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THE MONICA BRITTON HALL Having made the long trek out to Frenchay, have you ever then sat around for half a day between teaching sessions, without thinking of visiting the museum of rnedical history there? Here Susaz Iazglqy, Assistant Curator, describes the museum and its current exhibition, on the history of pharmacy. cists equipment for the storage and hanufacture of Before rhe middle ages, comrption h the world of healing, and the misuse of drugs, were conmonplace. The word "pharmacopolos", or druggist, was associared with poisoners and unscrupulous traders who travelled the country often providing poisons on demand for monetary gain. The current exhibition at the Monice Britton Museum charts lhe development of pharmacy from these bcginnings to the present day. Becruse pharmacy was initially uncontrolled, physicians were r€luctant to trust toitsproducts, preferring to dispcnse th€ own medicines. one of these, Claudius Galen, prcparcd his own lozenges and pills, rhe quality of his preparations earning him the descripuon of'1he father of pharmacy" and the admiration of generations of pharmacists. Dudng the medieval p€riod, grrilds were sel up rc lrv ro regllale pharmacv, a-lrd the repulation of aporhecaries gradually improved. The function of tle two prcfessions of the apothecary aDd the physician also became more clearly defned, and in 1617 fte aporhecaries separated from the Grocers Crmpany to form their own society. The Phartrncy Acr of 1868 inrroduced schedules of poisons, a since then the profession has become increasingly scientific, under ahe regulation of the Pharroaceurical Society.

The exhibition includes pill tiles and old phama-

drugs, togedFr with displats on the history of phamacy and its relation to lhe growth of medicine.

One of the most interesting permanent exhibits on display features the famous Bristol Irish Giant, O'Brien. Before the condition of acromegaly was d€scribed, acromegelic giants were the subject of much curiosity and edmiretion. One of the best known wss atl lrishman, Patrick Coner, who was born in Kinsale around 1760 and brought to Bristol by a sp€culative showman when he was 19. He changed his name to O'Brien afrel the legendary Irish king Brien Boru, and cras atr imhediate success. H€ died in 1806 and his will showed that the former p€nniless bricklay€r froh Coumy Cork died here wiih a fortune, owDing several propenies in Kingsdown atrd elsewhere.

The Monica Briaon Ha[ is a purpose built museum for Lhe displrv of medical history. and owes irs e'Ristence to a rctired Bristol industrialist who doDat€d the morley for its consruc[on itr memory of his wife, who had be€n very acrlve in the city's civic affairs. when tle currcnt phamacy exhibition ends, it will be followed by a display of "Bristol's Contribuuon to the Developmetrt of Anaesthesia".

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past lhe pig€on-holes where no letter ever arrives "Is tbat it, dear?" she asks, lookilg 3t your ftugal selectio! whrch is a vain attempt at comptomise betwee! the calls of youl rumbling innards, tle last l€cture otr atherosa, aIId your under-nourished wallet. However, behind the ptacid exterid lurks a volatile alter-ego

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leav€s €mpty-halded, mumbling an apology, and Sylvia rcturns to the position i.n which we found her, gazing with mpt contempletion at Avor's daily routine otr the other side of the window.

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