THE BLACK BAG
BRISTOL MEDICAL SCHOOL Autumn Term 2019
Editor-in-Chief: MARIA HANCOCK Vice Editors: DAVID MORILLO MOLLY VAN DER HEIDEN Contributions: Professor Trevor Thompson, Dr Michael Dixon (College of Medicine), Dr Eugene Lloyd, Dr Ellen James, Victoria Roberts, Natasha McGowan, Katie Martin, Abbie Festa, Genevieve Clapp, Chloe Wong. @BlackBagBristol The Black Bag theblack_bag The Black Bag has been the medical school magazine since 1937. Published as many times a year as we can muster, we are the voice of both students and alumni. Initially designed by the Faculty of Medicine as a scholastic publication, the Black Bag was taken over by students in the 1970s and replaced with a slightly less-polished perspective on the raucous life of medical students. Today, our articles range from the informative to the satirical, providing a platform for both thought-provoking discussion and comical musings. We look to reflect on the wide variety of Galenicals sub-societies (sports, music, drama) as well as to evaluate (and lampoon) the current state of the Bristol Medical School and the world of medicine.
THE BLACK BAG The Black Bag are always looking for contributors. If you are interested in writing for us, please email: blackbag@galenicals.org.uk
EDITORIAL HELLO FROM GALENICALS THOMPSON TALKS: ELECTIVES ON TRIAL DOs AND DON’Ts OF YEAR 2 CLERKING FEATURE: COLLEGE OF MEDICINE INTERVIEW: AWESOME MEDICS GLOBAL CLIMATE STRIKE CLEAR AS MUD - CLEANING UP OUR CLINICAL TRIALS DR EUGENE LLOYD: A MEDICAL HISTORY OVERHEARD IN THE MEDICAL LIBRARY INTERVIEW: FROM YEAR 1 TO F1 DRAWING: CHLOE WONG RARE DISEASE BOX POEM: GOLDEN THREAD
EDITORIAL With the calendar year galloping, stumbling and wheezing to a halt, it is our honour to receive the weighty truncheon of editorship into our youthful hands. In a blitz of chaos, borderline incompetence and a love for dotting the Is and crossing the Ts, we bring you the final issue of the decade. If this is your first experience of the Black Bag magazine - welcome. We hear this is the magazine for Bristol medics, by Bristol medics. As you peruse its pages, it gives you a chance to unwind, laugh at our Herculean undertakings (and Herculean mishaps), and ponder upon some pressing issues. This edition seems to have brewed into an environmental and climate-change flavour, in response to the great wave of change taking hold of our times (and minds!). Hopefully, it may even motivate you to open a blank page amidst all that frantic Googling and unleash your inner creative beast. With the artistic developments of the MB21 programme, there's never been a better time to make friends with the written word. It might just offer you a little catharsis at a particularly spicy moment. We welcome submissions about anything to do with your life at medical school - be thought-provoking, satirical, controversial, hilarious, artistic, holistic, we'll take it all. Whether you're flicking through this at your leisure, or casting cheeky glances at your phone screen in E29 or A1.4, we hope you enjoy. If you're in first or second year, please get back to your genuinely useful lecture. That MB21 stuff is the crème-de-la-crème from all the suffering your predecessors endured.
Without further ado, I'll detach myself from this caffeine drip and head over to the printing press. We'll think twice about how much paper we're using. MARIA HANCOCK 2nd year, Editor-in-Chief DAVID MORILLO AND MOLLY VAN DER HEIDEN 2nd year, Vice-Editors
Hello from Galenicals! As if Medicine isn’t keeping us busy enough, the committee have been working in a blur of caffeine-induced tachycardia to bring you an action-packed first term. We have approved twelve new subsocieties already, ranging from outdoor swimming to plastic surgery. If you can extend that number further, and would like to set one up of your own, please get in touch! We have officially launched our Medical School Building Campaign. This campaign will be a long-term endeavour to implore the university to give us something that we feel we deserve. The newlyrecruited team will be preparing for the first rounds of student consultation. This will include a survey and a round of focus groups in order to direct the focus for the campaign. The main aim is to keep students involved at all points, and you will receive updates throughout the year with the progress. Sport has been going swimmingly, with a trip to Varsity and an ever-successful round of intramural matches in our sport clubs. On the social side, they have already organised three events, the most recent being the Christmas meal for all teams. Wellbeing hit the ground running with our campaign this year, starting with two events in October. One was entitled “GMC Mythbusting: The Facts” and “Tips to Surviving Life on the Wards”. These brought in a substantial audience, and following this we are releasing a document on the topic of myth-busting. This has been written by Nicola Taylor, to put fears at rest. Top tip: to find out why doctors have been suspended in the past, Google “doctors tribunal" for some interesting reads. The Medics’ Colleges have run some Christmas film nights to aid relaxation before the
holidays. Planning is still underway for our annual welfare month, so keep an eye out for updates. The Ents reps have been very busy this term, having relentlessly organising 7 events already. From fancy dress at Gravity to cocktails at the Florist, we have had a rather entertaining term (in many ways). Always keeping medical students engaged in organised fun and organised chaos) they are prepping a fabulous large scale annual ball in March. We have increased our charity fundraising for the year, with our recent charity raffle raising £235. As well as this, some of the proceeds from our three major events of the year are going to our chosen charities. These are St Peter's Hospice and Kinergy. St Peter's Hospice is where the late MB21 director, John Henderson, was cared for. It is Bristol's only adult hospice caring for local people with life-limiting illnesses. Kinergy provides free long term counselling and support for survivors of sexual assault and rape. They are an inclusive service and support anyone regardless of gender, race, or sexuality. That’s it for this term! We have been trying to raise some voices this year with lots of events and campaigns planned for next term. V. ROBERTS GALENICALS PRESIDENT 4th YEAR MB16
Electives on Trial Moral questions over long-haul travel in the climate emergency Electives are a thrilling part of UK medical education, combining opportunities for medical and cultural learning with a darn fine holiday - often in far-flung locations. Here is the outbound trajectory of a typical “two-centre� elective: four weeks in a rural hospital in the Philippines, and four in pristine paediatric teaching hospital in Auckland, New Zealand. A beach in Bali also figured.
When I was planning my elective (Bangalore, 1990) the only issue around flights was how to pay for them. But unfairly, unfortunately and undeniably, a new factor has crept into decision-making around long-haul travel - the annoying spectre of climate change. The medical student community, bound by ethical codes to “do no harm”, finds itself on the horns of a dilemma. Debates are always better if we have some skin in the game. If we respect international scientific consensus, we’ll believe that climate change is real and a really bad thing for human health. We’ll be against the rapid expansion in coal-fired electricity generation in China, India and Africa. We’ll be concerned about the Amazon rainforest going up in smoke. But we may not, on balance, want to cramp our education and recreation by choosing not to fly. Our recent Year One debate defined the dilemma in sharp terms. We heard an F2 doctor describe the awesome experiences she had clocked up in forest communities, state-of-the-art hospitals and on the tourist trail. Seasoned international development medic, Dr Matt Ellis, iterated the multiple benefits of visiting low- and middle-income countries for our sense of the world and of ourselves. Long-haul flights, for Matt, are a necessary compromise, because “we can’t put aeroplanes back in the box”. Kieran Tate, a fourth-year engineering student, refreshed proceedings with some data. News to me was the contrail effect, a.k.a. “Aviation Induced Cloudiness” (AIC). When aeronautical fuels combust, carbon dioxide and other climate-forcing gases are released. But aviation’s biggest contribution to global warming is actually water vapour, which condenses to form high-altitude clouds. These trap heat with twice the efficiency of conventional greenhouse gases. Kieran was able to quantify the climate impact of last year’s elective programme using destination data from the medical
school. In 2018, 177 Bristol students went overseas on elective to 38 countries. The average student’s emissions were 3800Kg of eCO2 (the “e” bit accounts for AIC). That is around annual per capita eCO2 emissions of middle-income countries such as Mexico, Romania and Lebanon. You could barter that consumption by not driving (average UK mileage) for 1.3 years or not eating meat (average UK consumption) for 3.7 years. So we have climate change, and the 3.5% of this attributable to aviation. But whether this can respectably be called an emergency is a matter of definition. I see a child with a petechial rash and a fever but who is playing normally. The rash is likely not due to septicaemia but, if it were, she might die and I might be out of a job. So, I reach for the benzyl-penicillin. Similarly, we are not sure that global temperatures are rising out of control but, if they are, the consequences for humanity are dire. Hence, so the argument goes, strenuous and immediate action is indicated. This is the precautionary principle – defining urgency not on what something is but on what it might become. It fell to me to set out these future (and current) impacts of climate change on global health, something I am mildly qualified to do as co-author of Sustainable Healthcare by BMJ Books. I’ll spare you the details, but the headlines include drought, flood, storm, water insecurity, food insecurity and mass migration of a scale we can’t even imagine. A veritable apocalypse. So how’s your moral arithmetic? How do we balance the selfevident benefits of far-flung travel with the equally evident harms of aviation? On debate day we benefitted from some moral coaching from Dr Jonathan Ives from Bristol’s Centre for Ethics in Medicine. He got us considering the difference between needs and wants (do we need or just desire an elective in Nepal?) and the idea of moral sainthood (do we need to be saints or is it OK to be just
“good enough”?). I was tickled by this cartoon raised in response to the “planes will still fly even if I am not in them” argument. The motion “This house believes that in this age of climate emergency it is a moral wrong for medical students to fly long-haul on elective” was defeated with 31% in favour and 69% against. From the floor came the understandable question “why should we be denied a long-haul elective when you (meaning all previous generations of medics) had that opportunity?”. I guess some people voted with what they would most likely in fact do (fly away on elective). Are there mitigations, things we could do to reduce the overall carbon impact of the Bristol elective programme? Electives in the UK have the major educational advantage of preparing us for life in the system in which most of us are destined to work. Other slightly less far flung places can be reached by short-haul (one of my mentees did hers with the Norwegian Air Ambulance Service) or even train (possible to the likes of Morocco). Another option, controversial to some, is to offset the carbon costs of a flight by paying someone to sequester carbon on your behalf. The medical elective is under threat from other sources – the GMC is concerned about the length of the medical training and is questioning the relevance of electives to the creation of NHS footsoldiers. Personally, I think the idea of a period of truly “elective” study is brilliant. It is a tough degree, we need a few perks. But I do think climate change thing is going to catch up with us, maybe not in your time, but soon. And when it does, we’ll be required, likely via legislation, to travel within a carbon quota. As a medical school, could we get ahead pour encourager les autres? We could agree an average carbon allocation and those with their hearts set on the Cook Islands could trade with those settling on hearts at the Hammersmith. Meantime, hardcore sustainistas can sign up for
www.2020doctorsdontfly.com – seeking 2020 medical practitioners and students to pledge not to fly at all in 2020. PROFESSOR TREVOR THOMPSON Head of Teaching, Primary Care
The Do’s and Don’ts of Year 2 Placements Dear Future Year 2s, So you’ve survived numerous BED Mondays, powered through three-hour anatomy sessions, and just about understood half of Jan Frayne’s adrenaline-fuelled lectures - i.e. your first year as a Bristol Medic is complete. Now it’s time to hit the ground running again for Year 2, with a double whammy of Student Choice placement and Effective Consulting Clerkship (ECC). No lectures for six weeks sounds like the ideal start to Year 2, right? Well, you might want to think again when you’re told that you’re getting a 7:30am bus to Weston every day, or that you’re living in Taunton for three weeks (and yes, to anyone that is lucky enough to get placed in the BRI, we do hate you). To make your transition from first year to second year that little bit easier, we’ve been kind enough to compile an essential list of the Do’s and Don’ts of Student Choice and ECC (this is as close as you’ll get to us making up for Medic Mums and Dads night).
Do’s: Do remember to bring your stethoscope for ECC. Nobody wants you sticking their stethoscope in your ears because you’ve forgotten yours. Do be prepared to be grilled by consultants on diseases and drugs you know nothing about – they can’t differentiate between second and fifth years and understandably they don’t have the time to care. If you’re in Bath do offer to take the Dean’s dog for a walk – so cute. Do bring some kitchen equipment with you if you’re in Taunton, otherwise be prepared to share one pan between ten people. Do socialise with and talk to everyone in your ECC group – this is your chance to make friends outside of your first year Stoke Bishop bubble *gasp*. Do make it very clear to patients that you are a SECOND year, otherwise you’ll be getting lot of questions that you know none of the answers to. Do be aware that the F1s are the best people to go to if you have a question about a patient. Unlike most of the other doctors, they won’t bite your head off for not knowing all of the possible causes of abdominal pain. Don’ts: Don’t think that you can leave your house at 7:40am and still make that 7:45am bus to Bath, it’s not gonna happen. On that note, don’t expect the bus driver to wait for you if you’re late.
Don’t choose to be stuck in a lab for three weeks for Student Choice when you could choose to be in the Alps. That’s just common sense. Don’t leave your student choice report to the night before – no one likes writing essays, but trust me you’ll save yourself A LOT of stress. When presenting a history after looking at a patient’s notes, don’t tell the doctor that the patient is allergic to NKDA (it’s an easy mistake to make, okay?). Don’t go onto the wards and try and find the patient with the most complicated condition. Just find someone who’s bored and wants to chat. Don’t laugh at someone because you’re in Southmead and they’re in Yeovil. Karma will come back to bite you in the butt and you’ll be dumped there for six months next year. Don’t steal a fourth year’s patient on the cardio ward; that’s how you make enemies my friend. N. McGOWAN 2nd YEAR
We are living longer than ever before. But adding years to your life does not always correlate with adding life to those years. The recent explosion in chronic illness and its toll on the NHS budget is testimony to this. We live in an era of matching symptoms to recognised conditions, and illnesses to drugs. In an acute, emergency setting, this is essential. But what happens when you enter the world of chronic illness and see a patient who doesn't fit a neatly circumscribed box? Is symptomatic relief really enough, and is there a chance that their affliction could have been prevented? A Word from Dr Michael Dixon Dr Michael Dixon is the Chair of the College of Medicine, and is also GP to Prince Charles. He has kindly offered the following words to the Black Bag magazine: “I find that today's medical students and young doctors have strong ideals and more open minds than their predecessors. They are keen to learn about anything that might help their patients and many have an active interest in integrated medicine with its focus on things such as lifestyle, social prescribing and including evidence-based complementary therapies. Their future careers will need to extend beyond the consultation to playing a key role in improving the health and resilience of their local communities. In short, you are our
hope for the future and it is so uplifting to witness the enthusiasm and passion of today's medical students - no more so than those that have joined the College of Medicine and our crusade to take medicine beyond the confines of medical drugs and procedures. With many having attended our College Foundation Courses, I will be looking to Bristol medical students to lead the way towards a more inclusive interpretation of medicine that values the psychosocial every bit as much as the biomedical and which is relevant to the huge challenges facing medicine today.”
CoM Foundation Course at Penny Brohn The first sparks of something more than medicine were revealed to me while being shown a formation of starlings. As I watched these birds swirl in wondrous calamity, I was brought to realise that understanding an individual starling cannot possibly explain the complexity of the patterns they form together. The link to medicine slowly emerged - only understanding the function of cells and tissues cannot provide full insight into the complexity that constructs a human being. As a result, the conditions that afflict human beings cannot be localised to cells and tissues alone. There
is so much more - biological, psychological, and social factors contribute to the biopsychosocial model of health and wellbeing, paving the way to Integrative Medicine. Through a student bursary very kindly provided by the College of Medicine, I was able to attend a Foundation Course in the summer of 2019, held at Penny Brohn (PBUK) in Bristol. PBUK offers an integrative approach to those living with cancer and their supporters, and represents an expanding frontier in the management of long-term conditions. This two-day event helped me glean an insight into the nature of Integrative Medicine and demonstrated how a few flickers of interest are now becoming concretely embedded into the healthcare system. Integrative Medicine (IM) is an evidence-based, whole-person approach to medical practice. It is usually applied to long-term illness, and can be incorporated into a wide variety of specialities (oncology, gynaecology, General Practice, among many others). As suggested by its title, it integrates conventional medicine with complementary therapies, providing an "and" rather than "or" approach. The treatment plan may also include individual lifestyle changes, such as nutrition, exercise, stress management and sleep. Whilst lifestyle is sometimes addressed in the current model of healthcare, all too often we may feel insufficiently equipped to help patients make manageable and lasting changes. The logic is that a society that promotes health would prevent the need for people to spend decades in their later life suffering the consequences of preventable disease. It is important to stress that lifestyle and complementary therapies are not an alternative to standard Western healthcare. Instead, used together appropriately, they aim to improve the patient's confidence in managing their own condition, and their adherence to
conventional treatment. In a nutshell, IM focuses on restoring the forgotten art of healing the root cause of a condition, rather than fixing the symptoms. To those familiar with the pressures of our current healthcare system, these notions may sound like an idealistic yet inconceivable prospect. For others, they may echo some of the reasons for pursuing Medicine, or may spark a desire to join the movement to reform our current attitudes to chronic illness. This is where the College of Medicine plays such a fundamental role. In fact, thanks to its work, NHS England’s Long Term Plan has committed to construct the infrastructure for social prescribing in primary care: “there will be 1,000 new social prescribing link workers in place by 2020/21, so that at least 900,000 people will be referred to social prescribing by 2023/24”.
The College offers the following words: “New patterns of chronic illness are emerging in our culture, affecting millions. We don’t think that any one intervention or re-organisation is the answer, but instead want to bring together a patchwork of much broader ideas – from food and exercise, to new science, patient empowerment and integrated health. We want to bring people together to create a more compassionate, progressive, value-based, sustainable healthcare system.” Food on Prescription CoM's Foundation Course at Penny Brohn in July was followed by the Integrative Health Convention in London in early October. With boundless energy, CoM seized the reins for yet another conference, Food on Prescription, in late October. Our second-year student attendee, Aidan Warren, offers the following words of reflection: “The conference was a curvebreaking experience, and I'm glad that I attended. I've always known that there was a link between food and health, but not to the extent that was revealed at the conference. We even heard from the Bristol medical students who founded Nutritank. The most inspiring talk in my opinion was by Dr. David Unwin, who showed how potent diet can be in reversing Type 2 diabetes, and keeping it in remission. There was also a talk delivered by the children taking part in the Edible Explorer's pilot scheme in Lancashire. This is a scheme where schools can implement healthy eating and nutrition into their curriculum. The adults of the future are learning about how
to eat well (especially under a tight budget), where they are given the skills to take their diets into their own hands and teach their parents that healthy eating can be quick and cheap. It is a fervidlyheld myth that eating well is purely for the wealthy. There was a haunting message at the very end of the talk, delivered by Professor Dean Ornish. "If doctors themselves don't know how to live well, how are they expected to help their patients live well?" This touches on one of the most radical principles of Integrative Medicine - the responsibility of the healthcare provider to be a whole person too . The words "Physician, heal thyself!" are often used. My ultimate realisation that there is no one way to live healthily. One person's idea of a healthy diet, such as strict veganism, could cause harm to another, such as Vitamin B12 deficiency or anaemia. And also, the emerging models of healthy eating are slowly moving towards a less culturally heterogeneous tradition. There are so many options for eating well, that it gives us hope to spread the message about nutrition to the wider public. These are the people who really need to know what this conference is about, hence it is even more important for us to apply what we have learned into practice. If you would like to be involved with the College of Medicine's future events, student membership is free and can be found on their website, www.collegeofmedicine.org.uk. M. HANCOCK AND A. WARREN 2nd YEAR
Awesome Medics: Katie Martin and Bristol Homeless Period Project Awesome Medics is series that will look at the extraordinary work that medical students are doing outside of their degree. If you would like to nominate anyone then please email us at blackbag@galenicals.org.uk. For this issue, we spoke to Katie Martin, a Y2 medical student, who is currently running Bristol Homeless Period Project (BHP). What is BHP? “BHP is Bristol Homeless Period, a student-led, voluntary organisation that raises money to buy and distribute sanitary products and other hygiene products to both women and men who are experiencing homelessness in the City of Bristol. We cater to the needs of the shelters and charities we work with, so if a particular shelter is in need so flip flops, or umbrellas, we try and make sure that is what we supply them with, so it goes beyond just tampons and pads” How did you get involved with BHP? I became involved when I first moved to Bristol, having seen a friend posting about it on Facebook, and then earlier this year I became president. I became involved in BHP as I have strong opinions about women health and the lack of access to basic healthcare for those who are experiencing homelessness face. Sanitary products are expensive enough as it is for someone who earns a salary, let alone for someone without permeant accommodation/without somewhere to change/wash/clean.
How does this influence your view of women's menstruation and contraceptive health? It certainly influences my views and opinions about local councils and governments and their funding for such matters, and that both free sanitary products and free contraction should be available to all women (although Bristol is pretty good compared to many places, the councillor Helen Godwin was the first in the UK to vow to have all schools with free products). It has opened my eye to the poor sexual education that is given in schools, and the prejudice that stills exists around periods and sexual health. How can we get involved? Join the team! Or come to some of our fundraising events. Like us on Facebook. Send us an email! What was your biggest challenge? Understanding that only 10% of those that are homeless live actually on the streets. Many are in temporary accommodation or some surfing around the city, and it is trying to help these people that can be the most challenging, as they are not as visible, and are less likely to accessing help from shelters and charities. Also, as period poverty has become more in the public eye, which is a brilliant thing, more members of the public now donate sanitary products, which is amazing, but did mean that we had to shift our focus on to other products as well as sanitary products. Because of our name, shelters often initially don’t think that we could help them, whereas in reality we will cater for whatever they would like. What’s your greatest achievement? I think I would struggle with feeling overly gratified with the work that we do, as it is just the smallest scratch on the surface for helping these women, who live incredibly challenging lives. I think
whenever a charity or shelter comes to us with a specific request which we are able to fulfil, that’s always pretty cool. For more information visit BHP’s Facebook page or email bristolhomelessperiod@gmail.com K. MARTIN AND M. VAN DER HEIDEN
Global Climate Strike For a long time, I truly believed I was ‘doing my bit’. I’d been happily duped into thinking that by using a bamboo toothbrush, metal water bottle and a Mooncup, I was somehow saving the planet. It took a rather unconventional global health lecturer during my first week of placement to completely change my perspective. Midway through the lecture, and out of seemingly nowhere, he declared that climate change is the single greatest threat to human health worldwide. From then onwards, his slides became a dizzying blur of photographed climate catastrophes; typhoons, flooding, hurricanes, extreme temperatures, alongside their consequences on human life; famine, hunger, war, illness, poverty, displacement and death. As we watched these horrors unfurl, we learned that the vast majority of this is experienced disproportionately in the Global South. His lecture ended. Everyone left nonchalantly for lunch, another lecture crossed off the schedule. I sat in my seat, stunned, and began to cry. How could four years of medical education have failed to not once
mention the inextricable link between the climate crisis and human health? How had I not opened my eyes and realised sooner? From that point on, I couldn’t really think about anything else. Every spare minute was spent either sending emails, or reading the Lancet’s series on climate change. I learned of a Global Climate Strike taking place in Bristol on September 20th. There was no question of my desire to join and show my support as a medical student. I promptly pinged off yet another email to my Academy Dean, explaining why I would be absent. Soon after, I joined forces with Healthy Planet (a society which focuses on climate health). Together, we drafted a letter to send to the programme directors, asking for their support with the Global Climate Strike. With such minimal time, we were only able to allow 14 hours for students to sign the letter – during which we got 215 signatures from medical students! The demonstration and march itself was humbling and inspiring; elderly grandparents flocked the streets hand-in-hand with their grandchildren, demanding climate justice for all. We connected with other climate-conscious healthcare professionals and students from all over the South West. Since, I have attended the NHS Climate Change Summit, joined a national group of climate-conscious healthcare professionals lobbying for change within the NHS, and have started setting up a local branch in Bristol called Health Declares Emergency. I believe it is so important to demonstrate as medical professionals and highlight the global injustice and health crisis of the climate emergency. We are the doctors of the future, and have a duty to our patients to advocate for their safety - both as individuals, and as members of a
global community. We need as many of us as possible working together to ensure this. There are plenty of ways to be involved in Bristol – please do get in touch if you’re interested! A. FESTA 4th YEAR
Abbie leads Health Declares Emergency, a group for Bristol healthcare students who want to advocate for sustainable change within universities and hospitals. Their aim is to engage and co-ordinate healthcare students and professionals who want to tackle the climate crisis but are unsure as to where to turn to. For more information, join their group on Facebook.
Clear as Mud – Cleaning Up Our Clinical Trials When choosing the clinical interventions that are best for patients, doctors depend on clinical trials to guide their decision making. However, all too frequently, a large proportion of the evidence regarding the efficacy of an intervention is invisible to those that need it. This is because universities, hospital trusts and pharmaceutical companies declare that they have started a trial, but then most only post the results when they are positive. This makes it appear that the evidence points towards a drug working, when in reality it could easily be the opposite. For example, in 2008, an analysis of clinical trials for 12 antidepressants was conducted by the US Food & Drug Administration (FDA). It found that of the 74 trials conducted, only 52 were visible to doctors. Of the 52 that were visible, it seemed just 3 had indicated that the drugs didn’t work. But once the hidden results saw the light of day, there were a total of 36 studies showing that the medications were not effective. I don’t know about you, but I wouldn’t consider prescribing a treatment that had only been shown to work 52% of the time, particularly if that remedy could cause a harm.
Figure 1- Green = positive trials, Red = Negative trials Not only does irresponsible reporting affect patient safety, but it also wastes large amounts of funds. In fact, it has now been predicted that around £250 million that the NHS has invested in research, could be becoming wasted research. This is because if the results of completed studies are not published, it will look as if there is a lack of evidence in that area, and will may to people starting more unnecessary trials. The ultimate consequence is that this slows the rate of medical development. As if this wasn’t enough cause for concern, without accurate trial data, healthcare agencies could invest heavily in medications that are ineffective. This may still be a sore spot for the NHS, as it was involved in one of the largest examples of this between 2005 and 2014 in the form of Tamiflu. When it was initially released to the market in 1999, Tamiflu was seen as a breakthrough drug for those vulnerable to influenza. Then in 2005, amongst fears of an impending flu pandemic, many countries began stockpiling the drug, with the NHS spending a total of £650 million on Tamiflu and a similar medication called Relenza. In their desperation to try and protect as many people as possible, not enough individuals questioned why GSK and Roche (the manufacturers of the two drugs) wouldn’t release vital trial data. After a hard-fought battle, Cochrane was finally allowed access to the data in 2014 and subsequently carried out a revealing trial that showed that Tamiflu and Relenza did more harm than good. The merciless slaughter of ministers who authorised the purchases in the press made it seem that they were the ones to blame. However, all could have been avoided if the trial data had been present from the start.
Until late 2017, Bristol University was one of the culprits when it came to publishing trial results. A joint investigation carried out by The Bristol Cable and Till Bruckner - leader of TranspariMED, an organization dedicated to increasing clinical trial transparency – revealed that the university had 3 completed trials that hadn’t posted results and 11 trials that appeared complete, but were still marked as ongoing.I asked Till how the University responded to being called out on such a major issue; thankfully his response was positive: "The University of Bristol had a central Research Governance team that was already working on improving clinical trial reporting. Publicly calling the university out on its weak performance probably helped that team to get the resources it needed. Since then, Bristol has become a hub of excellence in trial reporting, something we can all be proud of. Experience shows that public pressure works extremely well in improving trial reporting."So surely this means we can all sleep easy? As I continued my conversation with Till, it seems this may not be the case. Unfortunately, missing data is still a huge problem within the University Hospitals Bristol (UHB) and North Bristol Hospital NHS trusts. Currently, just 29.4% of UHB’s and 50% of North Bristol Trust’s due trials have posted their results, which could be skewing the evidence used by doctors in daily practice. Regrettably, these trusts are not alone; with around 500 clinical trials being run by NHS trusts still going unreported, we have a long road ahead if we are to solve this problem. To make matters worse, these are just the clinical trials reported on the European trial registry. There are other lesser-known registers, which may be home to more trials, that have unreported data. I asked Till if we would ever be able to resolve this issue or whether it would be a continuous fight, he responded “Following advocacy by Universities Allied for Essential Medicines and other groups, the UK government is planning to set up a national clinical trial monitoring system. This would make the UK the first country worldwide to systematically monitor whether all trials are registered
and report their results. Once that system is in place, I'm optimistic the problem will largely be solved in the UK, though not internationally.” If you would like to be involved in improving trial transparency within our trusts, there are many organisations you can join. As Till mentioned, Universities Allied for Essential Medicines (UAEM) is one of the organizations trying to improve access to medicines on a global scale, by increasing clinical trial transparency and lobbying pharmaceutical companies to lower their prices. In November, UAEM Bristol is running an Access to Medicines evening, in partnership with Students for Global Health. Throughout the evening, we will be sending out Freedom of Information requests to many hospital trusts, with the intention of getting them to publish the results of their completed trials. Alternatively, you could look into helping Till at TranspariMED or the charity JustTreatment. If you have any further questions please email me at pu18699@bristol.ac.ukor have a look at the following websites: https://uaem.org/ https://www.transparimed.org/about https://justtreatment.org/ G. CLAPP 2ndYEAR MB21
Dr Eugene Lloyd: A Medical History Tell us a little about your early life/childhood? I grew up in the 70s and 80s in a Welsh town called Blackwood. I was lucky as there was lots of countryside to explore with my friends. At what point in your life did you decide you wanted to study medicine? I remember a conversation with my grandfather when I was about 6 years old, where he said: “You’re going to be a doctor”. One of my older cousins studied Medicine, so I decided that it was my goal when I was about 14 years old. I went to a comprehensive school and a sixth form college. I remember several inspirational teachers and enjoyed doing science experiments. I worked with a group of friends that had a good balance study/life balance and achieved our career goals. I must admit that I have quite a low threshold for boredom. A summer job colour coding scaffolding was tedious, so I wanted a career where I constantly learned new things. Did you enjoy medical school? My time at medical school was one of the best times of my life. The course was fascinating and challenging. Being away from home in a vibrant city, meeting people from all parts of the UK and abroad was very exciting. In year 4 I delivered 12 babies which I will never forget. One of those deliveries was in the back of a taxi when the midwife realised there wasn’t enough time to get the expectant mother in to the delivery room.
What would you have done if you didn’t do medicine? My back-up plan was to do a chemistry degree. I’m also a little jealous of the broadcaster Kevin Fong OBE an anaesthetist and an expert in the fields of Extreme Physiology and Space Medicine. What is your favourite lecture to deliver and why? Over the last twenty years I’ve taught physiology and pathophysiology to medical, dental and BSc students. Each of those cohorts is quite different. I don’t have a favourite lecture per see but I most enjoy lectures that involve audience participation to illustrate key principles - such as using a Mexican Wave to illustrate action potentials or the “breath-holding £10 bet” to help illustrate the shape of the oxyhaemoglobin dissociation curve. What do you do in your free time? In my free time I like cycling; I’m built for comfort not speed(!) so it tends to be off-road cycling between Bristol and Bath, Portishead or on the Strawberry line to Cheddar. I enjoy visiting National Trust properties especially the gardens. My family and friends are very important to me. What was your favourite/least favourite class at school? My favourite class at school was either physics or chemistry. Every lesson there was always an experiment, so there was always something practical going on. Especially with physics, I loved to see the laws ‘in-action’ therefore I enjoyed it and found it easy to remember.
My least favourite class was probably history; I found it impossible to remember lots of dates. Now I think history more and more fascinating and nuanced. One of the things I like reading about these days is the history of medicine. What would be your advice for dealing with failure? Asking for a friend… I think that failure is a part of the reality of living. We all fail many times during our life in different ways. Failure can feel overwhelming at first, but the skill is to pick yourself up, dust yourself off and move on (with the help of friends, family, counsellors, mentors etc.). I don’t like the word failure in the context of examinations. I would rather people look at them as: ‘I just haven’t passed yet. I need to do a bit more work but next time I’ll get through OK’. What’s the most common mistake that medical students make? Believing the rumours that do the rounds amongst the medical student body especially around exam time. They have the potential to cause stress and distress. One of my favourite non-exam related rumour was that a certain biochemistry teacher had been suspended by the GMC for possessing cocaine. Though fact can sometimes be a little stranger than fiction… What is your greatest achievement? My greatest achievement is playing a small role in the education of almost 5000 students of medicine. Graduation day marks their rite of passage, and hopefully many of them will go on to teach medical students because I think that continuity is really important. Each
generation of doctors must teach the next if we are to pass on our professional knowledge and values. Why did you get involved in medical education? In my final year, I had to give a presentation on a clinical pharmacology project that I had written. I enjoyed preparing and delivering the presentation, with a little help using Greek mythology to provide some flare. What do you do when you’re not teaching? On a Wednesday, I spend the day working in emergency medicine at Southmead Hospital. I work with one person I graduated with, and three consultants I taught. I was interesting seeing people I had taught achieve their consultant posts. I think the emergency department is an excellent setting for learning many aspects of medicine. When I was a medical student, we spent one evening in our first year at the emergency department in the BRI. One evening, it was the turn of myself and my friend Daniella. We started at 8pm. At 10pm the red phone rang to alert alarm to a trauma patient coming - someone had fallen out of a window and hit his head. We thought “Oh, this is real major stuffwe’re very lucky to be here”. Unfortunately, when the patient arrived it turned out to be Daniella’s boyfriend, who had been experimenting with THC and had fallen out of his hall window. Luckily the damage to his head was minor, and he went on to have a very fulfilling career.
Were there any teachers/lecturers who you admired/looked up to and why? I was taught by Professor Judy Harris, who retired last summer. I had the pleasure of being taught by her, and then going on to work with her. Her gift was to make her lectures extremely clear, logical and sequential. I have always thought that clarity of communication is one of the key attributes of a good lecturer. If you were hosting a dinner party and could invite three people who would you invite? Hmm, that’s a very good question. I think I would invite: Nelson Mandela, Stephen Fry and Maggie Smith. What is your pet-peeve? I would say that my pet-peeve is when people are not precise. For an example, when someone says ‘the blood pressure has gone up’ I’m much more interested in what the change has been. I think that accuracy and precision are really important in medicine. If you could change one thing about Medicine, what would you change? I can’t remember who said it, but there is a quote that goes: ‘Even if there is nothing that we as doctors can do to treat a disease, we must always be kind’. This stems from my relatives who have been ill over the years, and the treatment they have received from medical and nursing staff. I think that kindness is what patients always remember, and you can’t have too much of it.
What advice would you give to someone just starting medicine? Be curious. I think medicine is a fascinating subject. Being a medical student opens up a world of possibilities with relatively little responsibility. What advice would you give to someone graduating medicine? My advice to graduating doctors is to be kind and support one another. What is your favourite series/film? I would have to go for two favourite series. One of them is ‘Yes Prime Minister’ which I re-watched last year; the acting and scripts were fantastic and predicted our current political climate. The second is “The Night Manager” which I think was an excellent series, and I would like to see Hugh Laurie as a future bond villain. There are too many films to choose from, but my favourites include the original Star Wars trilogy and Dead Poet’s Society.
Dr E. LLOYD & D. MORILLO
Overheard in the Medical Library “Infection control standards just weren’t designed for signet rings” “These Case Based Learning sessions are really helping me get to grips with the core science of medicine” “I just don’t see the point in voluntary HCA shifts on the weekend when I could be skiing in Tignes” “Andrew Blythe’s nasal tones are surprisingly seductive when played at 1.5x speed on RePlay” “No, it wasn’t reduced, but it was only £4.99 and they are Waitrose organic figs after all” “Could easily just sack this all off and become a city w*nker in Clapham”
Top Tips: Anaesthetist Small Talk Where did you cycle on the weekend? Just can’t deal with ward rounds… they’re so long aren’t they So in my third year I intercalated in physiology… Which aerobic exercise did you partake in this morning?
I’ve been saving up for a fully carbon fibre bike, but the student loan just won't stretch Bikes bikes baby I love bikes Bikey McBikeface If you had to pick between your bike and your spouse, what would you do with the extra space after they’d left you? Do you love your bike more than you love saying “sharp scratch”? If you had to pick between your bike and never saying ‘work life balance’ again, which one would it be? Orthos are such primates aren’t they? B. GOMPLES 5TH YEAR
From Year 1 to F1: An Interview with Ellen James Ellen James graduated from Bristol in 2019, and is currently on her first F1 rotation in Swindon. A paragon of all things wholesome, Ellen’s interview was conducted whilst equipped with an astonishingly good cup of tea. If you'll excuse the medics' cliché, tell me more about life in the great beyond. I'm enjoying it a lot more than I thought I would. You'd have thought it would be an overload of hospital "madmin" and the thought of actually being responsible. But so far, I'm struck by the learning curve for my personal and professional resilience. Again, you seldom hear it said, but resilience isn't just something you're born with, it's something you can cultivate. F1 is that stage where you're actively encouraged to think about what resilience really is, and develop it. From Y1 to F1 - what’s changed in you? Over the years, I think we pick up a much deeper understanding of people and how they tend to work. You see them on the worst days of their lives, and instead of feeling overwhelmed or personally targeted, we start using that to determine what advice and support they need. Personally, I've learnt to develop a fine-tuned confidence, but not arrogance. Without a level of assertiveness, you just can't do the job. But it's vital to still have humility to admit when you're unsure.
What have been the most difficult parts, and were you expecting them? Â The hardest things I've found are at the human level - especially difficult conversations. You find yourself leading such personal and intimate discussions with someone you've known for less than 24 hours, and what you say will possibly impact their condition for the rest of their life. But it's a chance to really listen, offer a cuppa, and a privilege to be there with them at such a pivotal part of their life. Â We've all heard horror stories about the Titanic-scale workload and selling your soul to the hospital - how have you coped with the changes? These things might seem simple or intuitive, but you see how important they are when you start to practically live them out. I find that personal and professional challenges are dealt with differently, which leads to building a work persona. It sounds callous, but it means I can be at my best self to serve patients, and the mask makes it easier to take criticism. Try your best not to take a roasting personally - consultants are probably having a bad day themselves, and it's a really useful skill to learn how to be gentle with others on a bad day. An effective team makes a huge difference, and yes, all those times you used the word "teamwork" at your med school interviews really come into play. It's when you start to realise that CBL is actually useful - others know things you don't, and that can be used for the better! There is a pool of "communal knowledge" and everyone fills in the gaps for each other. Ultimately, the way you'll get there will vary for everyone, but it's about knowing that you must pick yourself up and know that tomorrow will be better. Â
Doctor or med student - which do you prefer? I'll throw a curveball and say I actually prefer being a doctor. Everyone knows that med student stereotype of waddling around on the wards looking for something to do, and getting in the way when you finally find something to do. But as a doctor, I feel actively able to contribute, and it feels immensely rewarding to truly be useful. That doesn't come without its teething issues, however - there are certain things that you feel like you should know how to do, but you learn so quickly that after the initial period of headless-chicken running it all settles down. There is only so much room in your brain at any one time! What words of wisdom would you offer? Number one: cups of tea really are the universal love language of the NHS - so simple, yet the joy is always there. Nurses are your anchor, your stronghold and your shield, so look after them. Ask how they are, do as they say, or explain why you won't do as they say. Patient care is so much better when there's a well-functioning team. In terms of doctoring, do take the time to explain what's going on to patients and establishing what their concerns are. We're so used to MRIs and CT scans, that we may forget how terrified patients might be of them. Let's not forget the social repercussions of being in hospital either - people can feel so lonely and forgotten. Building a warm and open initial rapport will save problems later on, and it's much easier to address people's needs when they feel they can trust you and open up. Also, be mindful of your own responses amidst this all - it's so easy to snap on a bad day when tensions are rife, so be aware of when it happens and find your own way of managing that response.
Finally, the most important question of all: what's the secret to a proper brew? Â Ooh, now that's an art. Piping hot water, and hot water first (NOT the milk, unless you're pouring tea that's already been brewed from a teapot). Mash teabag with spoon. Leave for 2-3 minutes (but eventually you learn to measure that time with your heart). After a final hearty mash, add milk by the glugful until you've reached that perfect tan colour we know and love. A cheeky sugar is optional. Serve to anyone and everyone, and spread the joy. DR E. JAMES 2019 MBChB GRADUATE Question-bombarding by M. HANCOCK 2nd YEAR MB21
Waiting To Go
My creative piece is inspired by a patient in Gloucester, reflecting the theme of time and waiting. This theme was present throughout the hospital, but especially in the discharge ward, as the patients there were usually ready to leave. It also made me think about how scary hospitals can be for some people, and as students on the ward, we don’t think about it, looking at each ward as just another corridor with countless patients that have problems that need to be fixed, part of a routine. But for the individual, hospitals offer a completely different lifestyle, with different routines to follow and strangers to meet. This is represented by the box, where the patient feels trapped by doctors whose diagnoses go over her head. The cogs and the grand clock behind her reflect how conscious of time the patient was, counting down the seconds to go - to go back home, to see her family. Minutes talking to a doctor can plague their mind for hours, and this is shown by the business and frenzy of the machines. In essence, the aim of the piece is to show the patient’s perspective. As medical students and potential doctors it’s important to acknowledge to enable the best treatment and rapport with our patients. C. WONG. 2ND YEAR
Rare Disease Box: Gitelman Syndrome Gitelman syndrome is a kidney disorder that causes an imbalance of potassium, magnesium and calcium in the body. More common symptoms include fatigue, salt craving, thirst, frequent urination, muscle cramping, muscle weakness, dizziness, tingling or numbness, low blood pressure, and heart palpitations. Gitelman syndrome can be caused by mutations in the SLC12A3 or CLCNKB genes, which can be inherited in an autosomal recessive manner. Treatment may include supplementation of potassium and magnesium, and a high sodium and high potassium diet. It occurs in around 1 in 40,000 Caucasian individuals but is frequently undiagnosed or misdiagnosed. Therefore, it’s important to consider alternatives when adolescent patients presents with fatigue and bloods that are similar to eating disorders due to low nutrient levels. Remember not to stereotype but to ask more in depth questions rather than just making assumptions. Molecular genetic testing can confirm a diagnosis of Gitelman syndrome. The prognosis is very good in that most individuals live a normal life with medication. However, in some cases, patients can develop arrhythmias later on in life so this must be monitored. M. VAN DER HEIDEN
The Golden Thread For Penny Brohn UK
The gavel takes a final fall, the jury turns and flees. A poison, hushed and silent is injected into me. The sand timer turned over, spilling faster than deserved Yet Nature brings no justice with her iron, final word. We are mere servants to Nature's command, Her ruthless, destructive and whimsical hand. Yet the very same Nature that inflicts this ordeal Has the power to transform, to restore and to heal. We are caught up in cycles, inescapable tides Each spirit unique, yet inextricably tied. To glance in a circle of candlelit eyes Is an ancient reminder to the art of our tribes Who delighted, like us, in the light through the leaves And that blissful moment to pause and just breathe. But we power on, like cyborgs; barely human, we suppress For denial is protective from grief writhing in our chest. But there comes a time when the human soul can only bear so much weight. To be human, and not perfect, is our one unchanging fate. Because sometimes, there's nothing. Nothing to say Only the toll of unquenchable pain. To take root in the horror of the cards you've been dealt It seems wiser for feelings to never be felt. But there's a time and a place to uproot the false smile,
And acknowledge the despair and the grief for a while. Where, doctor, where, is your powerful skill? This parasite won't flinch at ointment or pill. It consumes me invisibly; an eye cannot see The destruction of my whole identity. The treatment eviscerates me to my core, A treatment that brings me more pain than before. To cut, burn, or poison; a generous choice I dissolve to a number, a body, no voice. I do not need your pity Or a lump of half-felt words. Just make me feel like I'm human, Give me hope that you have heard. Because I need more than medicine to heal mind, body and soul. Show me how my story unfolds into a greater whole. Cancer is not all that I am; it is just a part of me. For if I see it as a war, how can I make my peace? Thank you, cancer, for strengthening me For I dare to feel flickers of ecstasy At the tiniest joys which I wouldn't have known I take solace in darkness, bringing light of my own. We must shake hands with Death to know Life as a gift. To stand at the edge of that mighty abyss And to sit at Death's doorstep can bring you to learn A gratitude no other plight can unearth.
I met you once, but you took root in me. You brought me to utmost humility To cling on to whatever life we have left And weave tapestries with a Golden Thread. To make a constellation from a scattering of stars I'll delight in the truth that Medicine is most of all an art. Our souls at peace, immortalised, our stories I shall tell, Of how we came to be here and how we started living well. M. HANCOCK
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