1989 2

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1989

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Bereavement: Who needs counselling?

Fron ihe LiirarY

5 'W:cL, ! wouLDir?

600r( A ttOLrD^ r'ug7 yer.

Paper, Dear Bob, Bag-EYe And All Your

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BLACK BAG SUMMER 1989

EDITORIAL lf we arenl prepared to tackle diflicull issues during the relatively experimental and responsibility-free years ol our undergraduate training, then when? A@ we merely clones of our @ntemporaries or imitators of our predecessors?

Every day, as studenls, we come face to face with difficult social and ethical issues, often for the first time in our lives. Usually we judge critically the beliefs and actions of lhose in charge. But how much further do we go?

Bereavemenl is cerlainly a difficult area to comprchend fully. lt is, however, a central feature of community and hospital medicine. There are practical and emotional processes that have to bâ&#x201A;Ź worked through and the time we have to think on these things now may create the impetus for change later. ln this issue we open lhe debate on how doctors are trained to deal with and actually do cope with dead and dying patients and thek relalives. There are as

many approaches as there are personalities; and personalities shape the profession.

Whal is your opinion? What will be your experience?

Editor: Nigel Lester

Sub-editors: Susan McEvoy (Reviews)

lvladin Plummeridoe (Regulars) Andy Tutt (Features) Kieren Smart (Preclinical) Business lranager: Sharon Dreweti Photography: Shauna Longfield Art Work Andrew Demie Typesetling ancl Printing: lmpress All articles/enquides should be sent to THE EDITOR, BLACK BAG' DOLPHIN HOUSE. BRISTOL ROYAL INFIRMARY, BRISTOL 2.

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CONTENTS

..... - . . . . . . . . . . . . . .3 Editorial .-........... lnsight BeGavement l.Life alier Death, Alexander Stemberg . .. ... ...6 2.Communicalion And Caring, Lindsay Shaw . . .7 3.Death And The Doctor, Dr B. Baker ..........4 Folitics: White Paper End Of The NHS? Dr S. Macara . . . . . .9 - or The Siudenb: You Whnt You'd Setde For, You Get . . . . . . . . . . . . . . . . . . . .14 An Arable

Parable

. . . . . . . . . . . . . . . 15

A Day ln The Life: A BRI Patient Rachel Motfat . . . . . . . . . . . . . . . . . . .17 Feople Dr. Cole-s, Retiring Clinical Dean . . . . . . . . . . . . . . . . . . . . . . . . . 18 Book$ An Aid To Clinical Surgery Reviewed By Proiessor Farndon Regulars:

.

Competfion BagFAge

--.

.........

Borborf,gmi.... --. --.

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Auscultalions Do-lt-Yourseff Bag-Eye -.--.-..--,..

Letters . . . . . . . . . . . . . .

Dear Bob . . . . . . . . . . . . fuelry comer

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1 1

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1 1

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15

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20th Edition

BAILEY & LOVE'S

SHORT PRACTICE OF SURGERY Revised by A. J. HARDING RAINS, CBE, MS, FRCS

and CHARLESV. MANN, MCh, FRCS with 36 specialist contributors xii+ 1406 pp.

t3s.00 net.

H. K. LEWIS & CO. LTD 136 Gower Street, London WCl E

felO'l-387-4282

19

........22

Now available

1355 illustrations (236 coloured).

1 1

.......12,13

685 Telex22607

Insight: Bereavement

Life After Death Alexander Sternberg looks at one of the most pressing practical issues surrounding the death of a patient and questions if we are doing enough informing bereaved. lnforming relatives is difticult enough for a young inexperienced doctor but will you be pre-

pared

to ask for a gift of

organs

someones deaih? ln the UK there is a problem with organ donation that should not exist Currently the potential number o{ organ

donors per year outstrips lhe number of patients on waiting lists for tansplants. Yet the waiting lisls remain. How

could this be so?

Simplify the picture by just considering kidneydonations. The five year survival rate tor a kidney graft is up to 9O%.

The mainlenance cost of a transplant patient is cheaper than for lhe same palient on dialysisand lhe quality oI lite

for lhal palient js

dramatically

improved. ln shorl, kidney kansplants are a good thing. The estimaled ne€d tor kidneys in the UK is 5OOO per year.

There are 8000 kidneys potentially

avaihbb each year. But only about one fifth of potential donors beclme actual donors, so lhat there is a netwailino tist of 34OO patients.

Nrost donors die in an ITU inspite of artificial ventilalion. What is so intriguing is that some health regions have much higher rates for kidney donations per year than olherc. Clearly it is important to find out why the one region is so

markedly successful whilst the other remains suspiciously below average.

Even stranger still is thal some hospitals have obtained 90% agreement to organ donalion whilst others virfually never provide organs for transplantalion. These kinds of discrepancjes cannat just be put down to an ill-infomed,

poorly educaled public. lll-infomed, poorly educated doctors make their contribution loo. ln 1 987, the Hof{enberg Report was

published in an attempt to explain the shortfalls in organ donation and to provide recommendations to improve the situation- The primary concem oI the

report was that amongst doctors "knowledge of the criteria for brain stem death, of the anangements for transplantation and of the benefit of transplantalion is not unive6al". Le Poidevin, from the London Hospital, suggests that one of the main problems is that the uncedainty and lhe embarassment about the management oI g ef expressed by some doctors and

to give othe. patients the

nurses makes them reluctant to ask grieving relaiives about organ donalion. This findinq is confirmed bv lhe Hoffenberg Report which states that "skill and sensilivity in the approach to patients is variable"- So there are two prgblems. The first is lhal relatives are just not being asked. The second is that when they do ask, medical stiaff mav lack lhe techniques frcr obtainino ; posilive answer.

"ln Bristot, if the donol is suitable, the relatives are alwalE asked" A number oI solulions have been proposed. One is a legally required

requesl a system pioneered in the USA whereby there is a legal requirement for doctors to ask for a gift of organs. There

is no doubt that this has led lo an increase in lhe number of organ donations. ln lhe UK however, legalty

required requesl is a conhoversial subiect particulany amongst a profus,sion which relishes its own autonomy- The idea was dropped by the Hoffenbero Report in favour of a syslem oI reterrt and audit Every lime brain stem dealh

is diagnos€d, organ donation should

be considered and lhe lransplanl team intormed. ff this is to occur, it has been

suggested, lhough not specifica y by the Hoffenberg Reporl that ITU staff should be lrained in bereavement couns€lling in order 1o facilitate lhe process of discussion wiih bereav€d relatives- Thus one scenario might be

that when brain slem death is diaonosed, ihe doctor in ITU informs tie relalives and contacts the transplanla-

tion

co-ordinalor- Transplant co

ordinatoG are often fomer ITU nurses who are particularly skilled in dealino with bereaved relalives They, in con: junction with lhe ITU nursing staff, discuss the possibility oI organ donation in terms that the relalives can unders-

tand.

lf the answer is ,\€s", lhe

hansplant co-ordinator liaa€s with ihe surgical team to set lhe wheels in

motion. There

is no rcason for

lhe

possibility

of lite ;fter

relatives of suitable donors to go unas-

ked. ln fact, it is unethical not to ask bereaved relatives since this may deprive them of choi@, meaning and comfort, lnslead of making this a legally required reterral, the Hoftenbero

Report recommends thal hospital; should be audited to record all instances of brain stem death. lhe number of requests made, the numberand nature of organ donations and the reason for lhe shortfall. The results lo be collated by the Department of Heatth. Auditinq

began in January of this year but there. are no results yet lt is unclear, however,

how many hospitals have defined a prolocol lor calling in a transplant coordinator in those cases requiring refural. ln Bristol, ff the donor is suitable, the relalives are always asked. There is also a lransplant co-ordinator who is skilled at discussing organ donation with relatives. ln other areas the procedure for calling in the transplant coordinalor seens ill-defined. This means that the problem of asking for a gift of

organs may still be left to a dodtor unskillecl in lhe subtleties of counselling lhe bereaved and in the throes of his own emotional response to the

patients death.

Whilst public education and opinion is extremely important in increasing lhe number of organ donations. education of the medical team shoutd not be forgotten. Such teaching should begin as eady as possible in a doctors career. llshould include the practical legal and

elhical problems of death and dying with particular refe(ence to the value of asking for and receiving a gift of organs. Only then may we expect the transplant programme to realise its tull potenlial.

Communication And Caring Lindsay Shaw writes about one approach to helping doctors deal with the dying. lt is a sub,ect all too easily dismissed as untangibleand therelore unteachable. But is nothing really b€tter than something when one day we will all be in the hot seat?

Few situations call on lhe necessily for "human" skills such as etlective communicalion and caring as much as lhat which faces a doctor whose

patient is dying. Many doctors, experienced or otheMise, find this an exlremely traumatic situation. The experience may bring feelings of in' adequacy, guill and rolo conflictwhich in turn may cause more anguish for the patient and their family.

Hugh l\4cMichael, who occupies the newly established post of Senior Lecturer in Pallialive car€ in Brlslol, sees the care of the dying as a necessary extenglon of patient care as a whole. ln the past very llttle of the medlcal curriculum has been involv€d inwhal is

probably best described

as

the

emotional side of medicine. Perhaps a part of lhe explanation for this is th€ fact that there is no tormal academic model for caring. The lntangible nature of the subject does nol €asily lend ilself to tho formal teaching or gystematic examination charact€riEtlc ot the mgdical model. lt is also possible that inherent in the medical institulion is a notlon lhat there is conflict between caing and curing, Doclors are expected to func_ tion objectively and are led to believe that they don't have tlme to respond lo

their patients on an emotional level.

This mayputa hugoshain on individual doclors and may mean that expedenco loads them not to cope with death and

dying but simply to avoid the caring role and the anguish they assume it will bring.

Hugh McMichael runs seminars on 'Death and Dying'forthird year medical students and sees himself not as a teacher but as a facilitator of lho learn" ing process. The seminars were to some extent allowod to run lheir nalural

course using experiential oxercis€s aimed at allowing studenls to examine lheir own feers associated wilh death.

They were also aim€d at forstering

some posilive attitudes about dealh

"Doctors ar€ expectEd to lunctlon oblectlvely ... they don't have time to respond on an emotional level" and dying, which may in tum rgmove some of lhe sens€ of lnadequacy which

faced students

al lhe time of

the

s€minar.

The exerclses were fairly broad-

based and many students lelt that they had leernl some us€ful lessons about communioalion in general, suoh as the power ol eye oontact, listening and, porhaps above all, of silonoe. The idoas that "lhat sort of thing can't be taught " or "only some people can do it" still

abolnd and perhaps this is partly kue.

Nonetheless this short experience has shown that bY facing hypothetical situalions that lear and ignorance

would olheMise lead us to avoid we can begin to leam how to be effective and competent in lhe situalions we most tear. Clearly third year medical

students feel that caring for the dying is

an importanl issue. Almost all the studenls otfered a fuvo day seminar attended and early resulls suggested that many felt they gained something positive trom the experience It we want some Practical kind ol counselling or communicatlon training in lhefuturethenthis has to be included

icrmally in the medical curriculum. financial considerations are algo

impodant. The post of S€nior Lecturer in Palllative Car€ is charitv funded and the money will expire in 5 years time Howgver pefiaps more important is a

re-evalualion of the Gquirements of medical training. The force to bring

about this chang€ must ultimalely

come from the sludents themselves for

It is them and hopefully thelr patients who will benefil.

Insight: Death And The Doctor T.E.Adderly on Bereavement.

Few who had thegood fortune to work for Mr T.E.Adderly can forget the experience. He bes. trode the worlds of surgery and the arts like a colossus; Mnemosyne at one hand, a Caduceus in the other. His clinical acumen was legendary, his erudition unparallell. lt is of his views on bereavement that I propose to speak; but first something ot the man.

He was a great showman and loved

to statle by

perhaps examining an abdomen with a naked toot or palpating a pulse with the tip of his nose. lndeed in his later years he took to conducting ward rounds locked in a large metal cabinet on wheels from which he

would shout his often obscure diagnoses. "l am a disembodied brain", he would bellow from wilhin, "you are my

eyes and hands, my ears

whiske6".

and

He loved also to wilness lhe runnino

of the ward in camera'. Often wnei called to see a patient in the middle of the night one mjght find him crouched

under the bed, carefully noting all. I recallonce being deep in thought next

toa particularly conlusing case when a WRVS lady, who had been hovering, slrode up and said "Good pasture's plain asthe nose on your Syndrome

-

face." Adderly, of course, in disguise.

Few things were, indeed, quite as plain as the nose on'lE.'s face. He frequently joked aboul his vast appen-

dage. "l have a nose for wine," he would say, "ln fact I have a nose for opening bottles of beer should I so wish". He had a su;table quotation for every occasion, many of which I have been unable to kace to thek originals, but forever apt nonetheless. On being told, for instanCe, that a particular patient came trom Peckham, he would say: "Ahl Peckham! Lovety Arcadia ol lhe fair" or "Droitwichl Elysian Grove ol

puresl loveliness! Hopkins, I believe."

We, being junior stalf, would of course

gasp and applaud his stupendous knowledge. lcould recounl endless anecdotes of Nrr Adderlys invigoraling outlook on life, but I must address myself lo lhe topic in hand. For it is my belief that few finer role models exist. On this. as on any topic, he had read thoroughly and his theory was based on Elizabeth Kuebler-Boss's treatise. She divides

sledgehammer would

a

walnul.

'Denial', I think, was his favourite. (,,Of course he's dead, Mrs X.,lookathim he's stiff as a board"). 'Anger', I believe, lroubled him, but he always took trouble to remind the bereaved thal he hacl been a boxing Btue at Cambridqe.

-

'Bargaining'

he

dismissed c;n-

temptuously. ("God is no usurer, madam, he ente6 no pacts.") As lor 'depression' well, he would point - beglum out, who could in his stimulaf the process into five stages. Adderly ing company? At the first hint of'accepdiffered only in thetime-scale involved. tance', he would be on hjs feet with his "They said I couldnl whip out a pan- hand on the door-knob. He took it as a creas in under 11 minutes," he said, tribute that no'one ever seemed to need io reiurn for further counsellino T.E. is, unfortunalely, no longer wih "The chief weapon us, but I believe we can all learn frcm he used in his war on him still. lwouldn't recommend that you grief was reason" copy his style verbalim bul sortout something suitable of your own. How amazing it is thal he should have "and I did. Same with grief". His ambi- developed such an effortless technition was to conlract the whole counsellque without any of the tuition in ing procedure into the same span as bereavement counselling that we, as doing lhe 'Times' crossword, at which spoonled graduates have taken for he was highly adept. lndeed he would granled. As T.E. oflen said: "The ontv perform often the two simultaneously. I thing that stands between the patieni once overheard this comic gem: "Your and the mortuary is lhe relalive". husband has died and gone to heaven,

MrsSampson.Ah, Heavenl Purcst Elysian Arcadia of loveliness! How do you

spell Ptarmigan Nlrs Sampson?"

The chief weapon he used in his war

on grief was reason. He would take

each stage in turn and demolish itlike a

a

How salulary.

Bob Baker

Politics: White Paper or The End of the NHS?

-

Concerned discussion abouttheWhite paperabounds in the press, campaign leatletsand in the corridors of NHS Hospitals. Dr Sandy Macara, a man deeply involved in many ol the higher level discussions, gives us an inside view of the most important medico-political issue of recent times.

The aims of lhe government's White Paper on the "refom" of the NHS {note

the pejorative word) are admirable:

-

the needs ol patients must be paramount the NHsshould continueto be available to all, regardless of income patient choice should be extended those who provide the services should be resPonsible for day to day decisions about operational matters health authorities should

of lhe elderly). Proposals for increasing patient choice include restrictions privately (notably in lhe case

upon the freedom of the general practitioner to refer palients to the hospitals and the consultants which in his opi' nion would provide lhe most appropriate clinical care. Theyalso includethe elimination of every represenlative of the community from health authorities, converting them into administrative

rubber stamps ilr the application of central govemmental diktats. Without

the patient's voice, where is

the

patienfs choice?

Everybody has "access to a @m_ prehensive range of high qualiiy ser-

ensure that the health needs of

the population for which they are responsible are mel, that there are effective services for the prevention and control of disease and lhe promotion of health. and that their PoPula'

tion has ac@ss to a com' prehensive range of high quality, value for money services,

"The proposals are clearly designed to reduce the level ol public expenditure devoted to health care"

addilional resources although our NHS

receives a much lower share of lhe national wealth than any comparable system. worse than that, the proposals are clearly designed io reduce lhe level of public expenditure devoted to health care whilst massively increasing the costs of management and accountancy, which will inevitably be at the expense of services to patients, olher than those who can afford lo insure

the importance of lhe currenl link-s bet-

ween the health service and medical schools whose future is now in question. Whatwillhappen to junior doctors' career planning when self-goveming hospitals are free to employ whomever they like, or not, as the case may be?

The govemments proposals will

destroy the NHS as we know it by substituling the ethos of cash for our ethos of care.

There has been no consultation with

any reputable representative of the medical or any other health care profession about these proposals at any stage. lMin isters insist lhat they will discuss only implementation of proposals,

nol the pdnciples or the proposals

themselves. Negoliations on general practilioner' contracts a@ an entirely separate matter, which were clearly imposed as a smokescreen,

vices", albeit with delaysdue to lack of

funds. How can health aulhorities A resounding statement of commitment, you might think, and one which the proposals in the White Paper and lhe eight working papers could not be bâ&#x201A;Źtter designed to nullify.

For a starl, not a word about

And we have other concems. What will happen to medical education and research, which receive scarcely a mention in all these documents, other than the clistressing inabilfty to grasp

ensure that the health needs of the pop-

ulation are met when it is fragmented self-governing hospitals and

by

budget holding GP's? How free will "those who provlde the sewices" be in their responsibility for day to day decisions? Already District N,lanagerc, on shorl tem qontracls and performance bonuses, are being blackmailed to persuade their hospilal conultants to express an interest in opting out of an inlegrated sâ&#x201A;Źruice so that lhe Secretary of State can claim voluntary support for his proposals. How can the

govemment expect us

to lrust their

intentions when such blatant hypocrisy

is implicit in their major proposals?

Competition lF YOU remember, we asked you to supply us with a suit' able caption for a very levealing shot ol our esteemed leader.

There were numerous wrong

,/' HeL? ! \ /IT3we MLN ', d;i.tT"^ii{;:(rr^tspr-qN;";IcK

answers and some lhat were so crealive we could not possibly print them.

(Gedditt?! Ed.) Here is just a s€leclion of lhe wrong ones:

6n lneuro t< -- L'6 Ltj<E You To fieer D(.SlDweLL FrY

zw

HOVSe OFFEe

And the winning entry comes from a siqnatman with British Rail Western diviiion, who havmg come across a copy of this maaa_

eAtloNN,'-

a DoN? (Not^'

t{AT To sAY...

Mr Albed Dorkin,

zine left behind on the paddinoion express by one of our more lasmopolitan readers, sent us lhis entrv mistakenly lhinkino it was a ohoto of their esteemed leader, Mr. Jimmv Naoo

(Could they be in somewav relatedi

IT3 t4(.

7HE

^IANA4EMENT KNftPP -- 6% ts ?.r. Bur1}t€. BvFFer C.ARS rvgt oN T{e rA8Le.

-

Ed.):

And here is the next competition photo, we thought it better not to reveal

lhe subjects name in view of the fact thai some readers may find lhis picture rather dislurbing (and some of us wanl to pass obs & gynae, Ed.)

10

Borborygmi

Bag-Age: 50 years ago Despite

the loss ol staff

"l don't want to go into the ons and outs of reprod uction." K.C.

and

colleagues, and an influx of Preclinicals from the lMiddlesex, "Black Bag" managed to keep going, if irregularly, throughout world war ll, albeit in "utility'' form.

Overhead in outpalients:"Bul whal Hitler doesn't know is that lhe whole

"Envkonment reters lo all external influenceson man. They may afiect his well-being." R.P. "Risks thal some other person pays to put right are regarded as worse lhan risks individuals have to pay themselves to remedy." R.P.

ol

Staple Hill's against him."

lvlore regular material was interspersed with wartime advice such as "Blood Transfusion for Battle Casuallies" which concluded: "This war may well decide lhe real value ot blood transfusion and show also lhe advanlages and uses of

Auscultations

plasma, serum, concenlrated serum and olher substances designed to increase the amount of tluid in circulation." lf lhrown by all lhis into a state of "mild neNous disorder" then fore5 5s a week there was a place for You at Dorset House Residential Clinic, Cllf' ton Down. Four Guineaswould pay for similar lreatment, plus a private golf course and fresh oroduce from lhe farm eEtate at Northwoods, Winter-

Professor S.V.Chatteriee

sailed

home in tho recent elections which had

a record tumout, Still, at least we can feel proud that more people tumed up for oureleclions than did for lhe Euroelections. The other posb were ho y contesled with almosl as many third years standing as came to the clinical dlnner (and they wers allstanding then too, unllke thâ&#x201A;Ź lourth years and some member of thâ&#x201A;Ź staff we had befier not mention). And whilstweargon the sub-

boume,

ject of the Clinical Olnner whoever said that onlyAustrallans and Surgeons tell really dirty jokes was obviously right, Thank goodngss the guest speaker of that evening is lrom Newcastle else someone might have had to resussitale

Dr

Parry.

The frcurth year interviewo passed off

without

a

hlnt of ill-feeling, back-

stabbing, rule-breaking,

Do-It-Yourself: Are you one of lhose

hysteria,

broken friendships or confusion. ln fact it was a thoroughly enjoyable time for

one ahd all. N4ay we take this opportunjty to say what a joy it has been to

strange,

discover the unknown recesses of Manulife house and we wish them all success in lheir massive task that lies

deluded people who doosn't relish lhe prospect of standing in thealre slaring at a surgeon's back for 6 hours a day?

ahead: that of trying to sort and tell us which jobs we already know we have

Then why nol make this handy little instrumenl so that you can see whal's

got Let's hope Kenneth Clarke never finds out about their exislence.

going on (however, we can't guaranlee

you will be any more enlighlened or entetained by what you see!)

So another academic year is waning.

Captain Sensible weighs anchor and sails for pods anew. The sports club have demolished their last reslaurant The final year have trotted off as quietly

as they came, in fact were they ever herc? And to the pre-clinicals who are

to have summer holiday we say a fond "p**s Ofi!" lucky enough

NETT 6SUE: Snellen Chart

Letter

E for Your 11

a

@

Bag-Eye.

D. 51r

":#:;

Eo:t yo,tc A,cer t o4t 8c,r aaed tlcrr^,13 .

12

Hcac' toeace ? ( Af.r.r"t i."rrog gocd too)

a\ftd ?

Students 1: YOU WANT, YOU'D SETTLE FOR, YOU GET You want to say, "l've spent three hours

taking blood this moming, and I'd tike to do something else now."

You'd settle for saying, "But he was

eaf

inq his breakfast, and I didn't want to disturb him."

You end up saying, "OK, and blood cultures too?"

You want to say, faintest idea."

"l really haven'l the

You'd settle for saying, "l'm afraid I haven't reached that chapter in the book yet Sir." You end up saying, "Well, as I understand it . .."

You want to s,ay, "The only lhing I can

You want to say, "He's skiing in the Swiss Alps with your youngest

hear is the man in the bed next door being sick" You'd settle for saying, "l've qot a cold,

and

I

daughter, Sir."

You'd setUe for saying, "He's overslepl again."

You end up saying "llhink he,s gotftu; he wasn't feeling too well yesterday."

can't hear too well at the

moment."

You end up saying, "Oh )es, mid diaslolic."

LETTERS: The last word on

_ You want mysrcan.

lo be a

You'd sehle for a

7a

consullant

hour weeklv slol on

GWR talking about

.,waierworks

problems" You end up as a colorectal surgeon.

You want to say, ..No I can't seâ&#x201A;Ź anv_ thing except your back. Mr X_ You d settte tor saying, ..ll I could iust get a little closer " You end up saying, ..Oh ves. that p'nk thing."

firm grades Dear Editor I

was honified to read in your last edi-

tion how haphazard, in the students view the firm gradings are assessed.

On my firm a completely fak policy operates. Continual assessment takes

the form of Special-Hourly-lnterrogation-Tests or SHIT for short. The

more SH lT a student can take the better

his fkm grade.

Before a student is failed the frrm there is a Complete Reassessment of Apptitude and Potenlial or CRAP. Thus a studenl thal can'l take the SHIT or handle the CRAP will tail the firm.

Before an A grade is awarded there Assessmenl Surgical Specialities of Uver lnteslines and Kidneys, or ASS-LIK. Thus a student both take the SHIT and be able to ASS-LIK lo get an A grade.

I like to pride myself on theamouniof SHIT lgive my sludenls and how they, in turn, handle the CRAP and cannol wait to ASS-LIK. lt is only unfortunate you do not see more SHII on other firms.

You want to say, '.Whal do you mean 'oDvrousty melaDlastic'?"

Youd sehle for saying,

,.1

can.t ouite

seem to gel this thing in focus.,, You end up saying, ..Oh, yes, thev,re ctearty abnormal, aren't they?"

-

is an

of

You want to say, yours will do."

need a job, and

You'd settle for saying,

enjoy doing you job.,'

,,1

think I would

"lactua ytind looking at stool charts fascinaling.., You end up sâ&#x201A;Źying,

Yours,

DCCB

',1

14

Students 2: AN ARABLE PARABLE One fine summeds day Mr Jones went to the maftet to buy some live stock. Mr Jones wenl to the markel with

all the other farm hands al about this time evety year, to buy some animals to work on the farm. However this market

was a little skange in several ways.

Firstly, the animals had to put them_ selves forward to be chosen. but each animal could only ask to be bought by six farm hands. Secondly, a farmhand couldn't take the an imals away from the

market wilh him once he'd boughl them. lnstead he had to wait for over a year and a half until the animals had been httened up. This was slrange for the animals too because some ofthem did n'l yet know whether they wanted to work in lhe fields, in the farmyard or in the hay barns. Lastly, and perhaps slrangest of all, both the animals and the farmhands had lo ask the market

animals used to think the farm hands were bad but at least they were the devils they knew. Now il was clear why theGrifiithson brolhers had been putin charge so that they could carry oul the evil plans of Mrs Carte Blanche.

However perhaps the most worrying

-

thing lo the farm an imals was the way in

which the farm hands chose which animals they were going to buy.

Flumours had been going around ihal some larmhands liked fillies with well shaped fetlocks, while others plumped for athletic geldings. The farmhands only means oI assessing the animals

hands wolld be more discerning when choosing animals lo work on the farm?

So, allin all,the market was a bit of a shambles thal day. The farm hands

were

a

little disgruntled, the tam

animals were most distressed and the

market keepers were absolutely livid.

But surely lhere was nothing lo worry about

-

weren't there more jobs than

animals? Wellthe rumour wenl thai one ofthe chielfarm hands had told allthe animals thal if you wanted to woft on the farm in the future then a job in Tr{rro was about as useful as a pitch fork ior

was when some of the animals had mucking out a pig sty. worked for lhem on the farms for a few months, However the farm grades were no laughing matter. They were so arbil_ rarylhal many ofthe animals wondered whelher the farm hands decided after a keg or two of scrumpy. Surely the farm

keepers if, afler they had decided they

wanted each other, they could have

each other. This market ritual had evolved from an attempt to give the maximum amount of happiness to the maximum number of animals and fum hands, but had turned into something quite different. The market keepers lived in a hut near to the largest farm and they were really quile nice people

whodid their best to herd the animals in the right direction. The trouble was that

they didn't really like farms, farmhands or farm animals and certainly

didn't relish the thankless task of pleasing as many of them as possible.

I\rarket time was very stressful for all thefarmyard animals; some of the chickens had gone right off their egglaying and some of the peacocks were strutconvince ting around, trying evelyone that they werenl neNous.

Some of the animals went to see some

to

o{ the farmhands and were told that they would only be bought if they agreed to the dealrightthere and then.

This was untair in two ways. Firsily some of lhe animals would have Pre_ ferred to be bought bY other farmhands, who would give them more oats

and less beatings, but had to accept their first offerfor fear ot being left out to

pasture. Secondly, because lots of animals were being bought eady on, some of the farmers who were late lor the market could not buy animals for love or money or plomises of fewer hours in the fields. As if this was not

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16

N

A day in the life of

...

Rachel Mofiat, out-patient turned in-patient, classic case or interesting signs. During her admissiontothe BRl, shetried to shake ofl the depersonalising labels and after her expefience gives us her . . .

...

GUT REACTION TO WARD 15

be

mined to fight it. Within a couple of hours of ariving I'd broken the rule of no more lhan two visilors al one time and was merrily chatting away with a group of students (allof which I'm sure will wish to remain anonymousl)

similar.

I had made the decision to have an operation after a couple of years sufiering from Crohn's dis€as€. My consultanl convinced me he wasn't a knife

lnitially I was surprised at how little I camg into contact with both the nurses and doctors. Nurses appoar€d to make beds and lake temperalures. lt wasn't until after my operallon did I really

My desk at work looks over the BRI what a sight! Even from the outside, let alone the inside, it doesn't resemble my idea (very naive) of a hospital. As a child I watched Angels and General

-

Hospital, lexpocted the BRI

to

happy surgeon and lhat I really did

need part of my gut removed. This itself was a big enough shock,Itound itvery hard ic understand why'it'had cometo

lhis

-

was there nothing else?

"ON THE day I rang up to contlrm my bed was free only to be told lt wasn,t,, After agreeing lo have surgery I was booked inlo ward 15. I didn't thlnk that I

was worried bul as the day approached tor me to be admitted (mY

birthday incidently) I began thinking .. . Yet again my naivety showed through when I told a friend that I was terrified of being put to sleep bya mask over my face. I had no idea! I realised howwound up lwaswhen onthe day I rang up to confirm my bed was free only to be told il wasn'1. I felt avvful and very let down afler having built myself up. Eventually I was told a bed was free and I set olf for ward 151 My experiences in hospilal I should imagine were much the same as any patient. I had been wamed aboul depersonalisation and became deter-

appreciate the extent

of

"l thanked everyone and everything I saw,, As I recovered in re@rd time and was allowed home. I can't say my stay in ward 15 was enjoyable the com-

-

panywassllghtlyolderthan I'm used lo and the enlertainment, well, what can I say: the highlight of my 6tay was when

I

There is also nothing more intimidating than belng sunound€d byt€n m€di-

was invited (or as il was ordered) to attend a lulo al with a lirm of third years. Unfortunalely I had vEry little ic otfer.

cal strdents, a houseman, SHO and a consultant, especlally when I discov€r

lstlll

'nursing'

n€cessaryl

that I was such e clesslc case of en ileoca€cal rosection I was exhibited to 5th years as well as th€ 3rd y€arsl My deep concern to remaln undepersonalised continued lhroughout my stay at the BRl. My first words afler waklng up from the anaesthelic werg 'Did I behave myselr.r' and 'Was it all worth it?'! I was so impressed with lTtJ that I am lold I thanked everyone and practically everything I saw as I was being wheeled back to ward 15.lmust

point out that by this tihe the immediale post operative euphoria had worn ofi and I was doped up to the eyeballs.

I

was determined

to

be

remem bered not only as anolher sem

i-

conscious body!

The next few days were spent coming to terms with a very sore tummyl I didn't leellike doing much for a couple of days. I was dying to eal something after a while but I cedainly.wasn't looking forward to hospital food there is no denying the fact it was disgusting!

-

17

I

was treated really well by everyone.

can't com€ to terms with the

thoughl, however, that if I have another operation in years to come I might well

have to b€ clerked in

by

.

..

soms-

People: Dr. Coles, The Retiring Clinical Dean Some students are under the impression that Dr. Coles is a ligure created bythis publication forthe sole purpose of poking fun at theteaching establishment. To some he is the man whose iob it is to provide them with good reasons as lo why not to give up medicine. (l can onlythink of one drug lunches, Ed.) To others he is there to change your elective from group C ("1 don't want to go away right before finals") to group A ("1want to go now"). lt maybe he is simply the man to whom you once said "l've always wanted to study medicine because I really like people", and then waited for an offer ot AAB. A briefchat with our outgoing Dean and you realise he is in tact all these people . . - and more!

-

Dr. Coles qualified from Bristol in 1951. After an exciting period as a MRC research fellow in Belfast, St. Mary's and Oxford (working alongside

Talkingwith Dr. Coles instillsin you a very old-fashioned, and some would say unfashionable, feeling: pride in your medical school. lf we can hang on to just a little of lhe pride this man has forthis schoolthen we might alsolake

such notable figures as Pickedng at Oxford) he returned lo Bristol for whal was to be the rest of his professional career. He was appointed consultant

to medical education both here and

physician in 1961 by what he calls "an enormous slroke of luck" but it cannot

elsewhere. His farewell speech to the Universityin October promisesto bean

have been unrelated to his obvious ded;cation to medicine and his im-

entertaining memorial to a lifes work, .

We wish him the very best in his retkement.

away with us some of his committmenl

portant research in the fields of hyper-

tension and vascular disease.

He became clinical dean in 1977. a decision he has never regretted and a positon that has enabled him to help and influence generalions of Bristol

students. Whether through personal difficulties, university politics or simply at admission, those who have had con_

tact with Dr. Coles agree that his enthusiasm and down-to-earth approach have made him an easy person for sludents to getalong with. He is well aware, for example, that most have wanted to come here because it is such a pleasant city (so it really does nol hurt to be honest at interviews) althouoh he confesses to having experienced a moments hesilation when admitting a sludentwho had chosen Bristolon the

basis of its' lce skating rink.

Over the years, whilst he has seen

the academie standards rising

he

lhinks the medical sludents commi! ment to humanity still remains: "big heads will always come to grief

faiF

Tell meDoclor.

Iltttts eqn

I

.

be

SIIM? out

',lc!,se4, t pn4, eql. nolnal ynzal). ol ,rte !"

bt&

'\1i

ing that they become professors!"

("Don't quote thatl") He has fought to relain the 1st N4B and is proud ol the mixlure of backgrounds that Bristol

students can bring

to the

medical

school.

As for relirement. the first rule according to Dr Coles is notlocling on to the past and not interferc. Nol such a

simple thing when you have been so central to all that is going on in the clinical course for such a long time.

DoN'r woRR.Y MosTl4EN puT ON WEIGHT AR,OUND YOI,'R AGE.

UNIVERSITY OF BRISTOL DEPARTMENT OF MEDICINE BRISTOL ROYAL.INFIRMARY ARIST.)I

A:\qZ-29 \@9-

BS2 IIHW

Telephonc: ({l?72) 2l(xxl0

?*9s' popped up to Town lo collect my It occurred to me the other day over the mid-moming snack thal I haven't seen you since I gong the olher week. On the whole, it was a thoroughly iolly occasion, allhough the party nibbles were rather on the scanly aide, I bumped into that perception chappie from the University; the one who bears more thao a passing resemblance lo Pat_ dck Moore, bul without such good clothes sense. Apparenlly he was up to receive an honour similar to mine, and candidly I think he'd been going rather heavily at the Bristol Cream. There wag a rather slrained silence when, before leaving lo deliver a lecture to the Royal Society, he lurched up lo the lady ol the house and offered to show her something her eyes wouldn't believe, Fortunately, his car ardved before she had a chance to send him to lhe lower Sorry you couldn't make the lrip sp to tho R.C.P., which seems lo havo be€n great fun. They manag€d to smuggle plenty of brown ale aboard the coaches, and had quite a time. I still don't know how lhey succaed€d in €xplaining away to the police ths sight of a usually resen€d and gminenl physlclan displaying his rear end from the back s€al in a lrattic jam on the M4.

Only deft work on the spot with thg sigmoidoscope by K,WH. convlnced the officer thal he was preseni at a genuine medical emdrqency. One man, at leasl musl have b€€n rolieved lo flnd standing room only when they eventually arriv€d al Regsnl's park,in tr6 end, as you xnow, the post ot Prssidgnt went lo a member of the falrer sex for lhe first lime. I wonder lhe Fellows had lhe courage, having s€€n whal a similar belng is trying to do to the N.H.S. lmagine my surpri6e the other day when, lnstead of all trying to avold calching my 9)€ and sllnklng out as quickly as possibb, o;e of lhe sludents actually half-ralsed an incompetgnt hand following one of my leclu,es. Always willing, if mod€stly, to share my scanty medical knowledgq I signalled her to carry on. She rath€r floor€d me for a second or lwo by agklng a ques' tion whiCh began: "ls il true that . . . " before proc€€dlng lo make it glaringly obvious that she knew damned well it was. Maintaining an aiiof aulhortly, lsilenc€d lhe impeluous youth with the ever useful Kimmetstiel-Wlsotl kidney. On€ up to

the Prof.

Your's in the fray,

Ar.

19 -

Churchitl Livingstone $!

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Davidson's Principles and Practice ol Medicine

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iii

Professor Falndon reviews a new students lext.

Books.

SCOTT: AN AID TO CLINICAL SURGERY HAF Dudley, BP Waxman Fourth Edition

Churchill Livingstone 1989 Pp. 315 Price

This book puqrorts to provide "all that the student needs to know in iac-

muscles and lhe thyroid gland, when

tlal terms to

this review will know that the surgical examination in lhe University ot Bristol

tion (Figure 2O.1). Figwe 2O.2, lot example, demonstrates the applied

get through the standard surgical examinations". The readers of

is not a "standard surgical examination"!!

The book excludes orthopaedics and ENT surgery since it assumes lhat the student will buy lexts covedng

these surgical specialties The book does include some neuroslrgery, !rology, and vascular, cardiothoracic and plastic surgery These surgical specialtes are not always brought logether in a single chapter or seclion giving details of lhe disease conditions normally seen on such speciahywards.

The work of the plastic su€eon, lor example, usually encompasses bums,

reconstructive sutgety, hand surgery and some head and neck surgery The reader has to refur to the appropriate

chapters dotted around the textbook for lhese details.

The section on thoracic surgery is limited (8 pages)- The details in lhis small s€clion are probably inadequate flr the undergraduate curiculum.

Duplication is kept to a minimum but it would have made sense to include the four pages of infective com-

plicatons ol surgery in chapter 6, in

chapler 14, which deals with all infeclilrs

acute

The figures are mainly line diagrams with lhe o€casi'lal )0ay or CT scan.

The slandard

quale

od

tfle illustatons is

in most

diagram oI the

ade

parts. The st/iis€d dispo€itir of tfle st'ap

Cg-95

tatomegaly'- Prostalic hype.trophy has

al by a

thyroid surgeon, is enough to take the breath away!There looked

-

been in conveniional use for many

years and adequately describes prostatic enlargement in the elderly male, without the need to coin an ugly and unnecessary new term. ln the chapter on breast disease

is no excuse for such a shoddy illustra-

anatomy of the parathyroid glands and the recurrent laryngeal nerve in a very acceptable fashion.

For a fourth edition one would have hoped that errors of slyle and useage would have been eliminated. Fine nee-

there is one herelical statement

-

"Though cytology cannot be used as a

final means of making a diagnoslic decision

..

.

". I am sure Mr Webb and

would nol like studenls

dle aspiration lor cytology is abb-

lo

I

present

themselves in lhe final Bristol surgical revialed to FNAC. Subsequent use of exam believing lhis statement. The ihe abbreviation is as FCNA. N4ultiple authors also suggest that if an elderly endocrine syndromes are better patienl relapses following treatment referred to as "multiple endocrine with a first line lherpy Famoxifen) then neoplasia" ratherthan "multiple endoc- surgery has to follow. h is well underdne adenomas". Not all patienis i slood and described that considerable demonstrate adenomas and some I remission can be gained from second have hyperplasia as a precursor of an and even lhird line endocrine therapy. adenoma. I thought this debate had There may be no requirement lor surbeen settled several years ago and gery in lhis age group at all. No detail is current useage describes "multiple given on breast reconstruction.

The book is relatively shorl and endocrine neoplasia".

I was interested lo read the chapter 'easily read- lt does conlain many lists on biliarydisease and see the use of a but the editors excuse these by sugnew word. I always believed that an gesting that you might match your own Xray, taken with a cannula in the cystic analytical diagnosis against these duct demonskating the common bile strings of words.

This book is not the lop of my list as ducl, the common hepatic ducl and the intra-and extra-hepatic ducls, was an an undergraduate text You will recall operative cholangiogram. We are told that lhe final examinalion in surgery in lhat this should be called a "chole- the lJniversity of Bristol is not a stangram". The multiple use of this word dard surgical exami suggests lhat the authors would like sfudents to use lhis term rather than

i

cholangiogram.

Bristol

sludents

should not attempt to use or introduce this term in polile surgical circles!

"ProsAnother neologism

is

21

Back by popular demand

Poetry Corner: UNLIKELY APPUCANT d'dnt seern much to Wrote out nry C.V.

-

me,

With no prolec'ts and no pdz98 and no PhO; Feel ralher humblsd as small as a mous€ When I hand the torm ln at Manulib House.

-

Now evsry lunchtimq I hat s to slt through people going in about lhek inierview; It s€ems to me or is it a delusion?

That this subjecl blots out oth€rs to iobl exclusion.

-

-

lf anlone has lo eiay away tor a day, The rest of lh€ group all expect foul play; they would interest Freud, A bunch of neurolics The lourth yea6 are all beconing paranoid,

-

The day ol the inteliet', dawns bright and sunny, But there lsnt a soul wt|o finds it tunny That a ftiendly clBt caGes $rch a jam.

What will it be like tot the August exam?

So here I am u6iting lor my offers of employnent, Something that is not a source of much enioyment; say by Wednesday H they donl come soon I might be reduced to appMng io Frenchay.

-

Lefs hear it ior lhe people at Medical Sta{fing, Each new enquiry must s€t tlem all laughing; But they wool be so high and mighty, When !w slart lo treat lhem in 199O. Bernard Stacey

22

-

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