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CAREERS

Illustration: Ella Beese

Change or Die?

The cult of innovation is nothing new. “Change or die”, declared Roman poet Claudian, writing more than 1500 years ago. Yet, this truism still feels startlingly modern, almost made for today's healthcare professionals.

The last twenty years have seen a visible shift in the selection of medical students, in the way that they are taught and in the recruitment of doctors at foundation level. A greater flexibility in the entrance criteria have seen students from a broader social background entering the profession, and graduate courses have tempted those from different professional milieu to reconsider a career that they may have eschewed at eighteen. Once at medical school, the focus and method of education is changing too, with a move from the traditional division of pre-clinical and clinical training to a more integrated course with patient contact throughout. Peer-assisted learning is increasingly in vogue, with students teaching students, and this method of delivery has proved useful not just at medical school, but for the training of other health care professionals too. We look at how a scheme managed, as well as assisted, by a group of students is revolutionising the way that training is delivered to Manchester medics.

Also in medical and allied health education, the Government is looking to revamp the NHS Bursary scheme, a vital source of funding to many students on healthcare courses. The consultation is underway, so read on to find out more about the proposed changes and how to make your voice heard. There's no doubt that the decisions made today will influence the doctors, nurses and allied health professionals of the future. And with the application process for the UK Foundation Programme under review again, it looks like the educational merry-goround may be spinning once more.

Of course, today's junior doctors and doctors-to-be are used to hitting moving targets as they progress through their careers. In a new strand of personal profiles, we ask a fledgling F1 doctor how to survive the transition from student to professional.

Earlier this year, Barack Obama, the first Black President of the United States, both embodied and extolled virtues of change: “Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek.”

We look at his attempts to shake up the American healthcare system - we look at the debate raging, and hear how one student's experience of the US system of caregiving in a psychiatric unit in the heart of the Bronx has altered her perception of the mental health sector.

Whilst US healthcare is changing, the UK is looking to its larger cousin when it comes to workforce planning. Could the introduction of Physician Assistants, a job already established in America, alleviate the pressure on already overstretched NHS resources? Or will this latest addition to the multi-disciplinary team deprive those training for more traditional roles of valuable hand-on opportunities?

With the MTV generation now all grown-up and attention spans shorter than ever, health campaigners and charities are having to find increasingly innovative ways of securing their share of our collective capacity for concentration. One CEO has taken inspiration from social networking sites, and harnessed the power of the flashmob, to raise awareness of the devastating consequences of drinking whilst pregnant.

We are on the cusp of an election year, and as those on the campaign trail vie for our affections, there is no doubt that health will be high on the political agenda, with the electorate looking to see how the parties at Westminster propose to improve the delivery of caregiving.

Next issue we'll take a look at the main parties' policies on healthcare, and how these might affect healthcare professionals of the future.

As ever we welcome your views on these topics, and your opinions will help us shape these pages. Contact us on careers@thelsjm.com Sonia Damle Section Editor Careers

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INTERVIEW

Publishing a Textbook: De-mystifying the Process Sunita Deshmukh and Newton Wong Year 5 medicine, University of Nottingham Medical School sunitadeshmukh@f2s.com, newronw31@yahooo.ca doi:10.4201/lsjm.car.004

‘The Renal System Explained: An Illustrated Core Text’ ISBN 9781904761846

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Writing books is a full time occupation for some, so when a couple of medical students set their minds to writing a brand new text book, the path to publication was far from easy. Sunita Deshmukh and Newton Wong share their experiences of medical publishing.

What prompted you to write a book for medical students?

NW: We were actually in the medical school library studying together when the idea of writing a book was mentioned in passing purely as a joke, but we both wanted a bit more clinical relevance and an easier-to-learn format from our textbooks, so we started to develop the suggestion and things blossomed from there.

SD: I was immediately drawn to the idea because I love writing and drawing. Co-authoring and illustrating a textbook offered an ideal creative opportunity. I enjoy teaching and team-working, so was keen to work with colleagues in developing an educational resource.

What did the process of securing a publishing deal involve?

NW: Obtaining a contract with a publisher was new to us and challenging. Firstly, we had to draft a list of potential publishing companies. Next, we visited their websites to familiarise ourselves with the whole publishing process and what is expected in terms of a proposal. The proposal had to be concise and reflect our commitment to writing a renal textbook. Once the proposal was submitted, we waited for responses and answered questions from publishers. We had a few telephone conversations and face-to-face meetings with representatives of publishing companies. The whole process had its ups and downs, but perseverance was key to us finding an appropriate publishing contract.

From your experience, what are some of the pros and cons of undertaking a substantial project like this during your full-time studies?

NW: Having a side project of writing a book in the midst of fulltime university studies was a good opportunity to fine tune our time management and organisational skills! Authoring a book of this nature and at our stage of medical training forced us to do additional research into certain aspects of the renal system which may have been beyond core medical curriculum. In retrospect, whilst researching and writing, we were actually revising and learning about the renal system.

Finding the time to work on the book was a constant challenge as we had our school and personal commitments. This was probably the most difficult part of the whole experience. Having a healthy balance was what got us through!

SD: That is the diplomatic answer to this question… truth be told, I will never forget December 2008 and the self-motivation we needed - it really was a case of sink or swim. The end of the year brought with it numerous deadlines and really demanding time-pressures. With ongoing fourth year coursework and competency assessments, clinical exams imminent, Student Union representative work, personal commitments, plus the impending contractual deadline for the final manuscript, this all amounted to work-intensive days and nights, hectic weekends and a Christmas holiday that passed by in a blurry mess of insomnia and worry. The health and balance to which Newton refers were only maintained with family support. The night before leaving for the airport, instead of packing my usual holiday suitcase with a fun book for the journey and painting my nails, I found myself packing six USB memory sticks, reference textbooks and my laptop, which accompanied me 12000 miles to India and back. Much of my work on the final draft was completed under a fan in a flat in Mumbai.

It’s lovely to reflect positively on this project for the characterbuilding experience that it was. Gratitude and a sense of accomplishment are certainly the overwhelming feelings that remain when you hold a printed copy of your book, flick through chapters you’ve written, and glance over your own diagrams (blissfully ignorant to self-criticism for at least a couple of days).

However I think it is worth noting the degree of responsibility and associated stress when you take on a publication of this magnitude.

It was an invaluable experience – the lessons learned will stay with me forever and hold us in good stead for similar ventures in the future.

What is the single most important learning point from this experience?

NW: I actually learned two very important things with this book project: if you have a dream, pursue it, there’s always a way, and I discovered I have a passion for medical education. I hope to take what I’ve learned from this experience into the future.

SD: A medical author we met described writers who prepare manuscripts which remain unpublished because they never feel their work is ready for submission. He advised us that there comes a point when you have to ‘let go’. I learned a lot about myself, and that I owe every happiness and success in my life to my family.

What are your hopes or aspirations for the future?

NW: My future academic aspirations are simple - graduate from medical school, be fortunate enough to find a branch of medicine which I will enjoy and be good at, and perhaps get involved in medical education. I’d also like to have a decent car and a golden retriever.

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NEWS

SD: I'm working towards passing finals and qualifying. I've accepted an Academic Foundation Programme post which offers a first step to applying for a clinical lectureship in the future. This career pathway will hopefully enable me to contribute to evidence-based medicine in the long-term, whilst developing my clinical skills and working with colleagues on research and education publications.

Ultimately I aspire to finding a happy balance between an exciting career and fulfilling family life.

Do you have any suggestions for fellow readers who may be interested in a similar project?

NW: Always have a plan and sense of direction - this will either make or break you! Be confident and persevere. Seek out individuals who are willing to help you along the way, they are good assets.

SD: I agree. It took us real persistence, determination and a lot of hard graft to establish and to successfully complete this project.

Minor setbacks in either of these aspects of writing a book may be disheartening, but you can overcome mistakes and failures, learn from them and use the experience to your advantage. Actively seek and take on board advice and feedback from academic contributors and other students. Our faculty advisors were enthusiastic and helpful.

Publishers are an excellent source of information and guidance.

Take the time to negotiate a suitable contract – as an author you are choosing your publisher as much as they are choosing you. We had a brilliant working relationship with our publisher, characterised by open and consistent communication with friendly and approachable team members, including the production manager and business development manager.

Sincerity, dedication and reliability are essential qualities in good co-authors. Trust, compromise and the ability to recognise and complement each other’s talents and limitations also help. No matter how difficult the challenges we faced, it never felt as though our friendship was being tested. I think that signifies both professionalism and the strength of the partnership.

Any regrets?

SD: It’s encouraging that inspection copies of the book have received positive responses from the universities in the UK and internationally. In the grand scheme of things it’s just one book contributing to a massive medical education market, but I feel very lucky. So I try not to have regrets. I like to believe (and hope for my own peace of mind) that things happen for a reason. We tend to attribute ‘the way things turn out’ to the outcome of our most agonising decisions and painstaking efforts. But actually sheer luck and chance probably play a much bigger role in determining this than we like to think. On that philosophical note, I hope the tradition of students teaching students continues and wish any budding authors the very best of luck.

NW: There is always a nagging feeling of self-doubt but as Sunita mentions, you have to conclude a project eventually. I hope ‘The Renal System Explained’ becomes a helpful tool and inspirational resource for fellow students and authors-to-be.

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U.S. Ends HIV-Immigration Ban On 30 October 2009, President Obama announced the end of the ban on HIV-positive people entering the US. The ban, which had been in place for 22 years, prevented both HIV-positive people from immigrating to the US and HIV-positive tourists from visiting the country.

Speaking on the policy change, Mr. Obama said: “If we want to be a global leader in combating HIV/AIDS, we need to act like it.” He added: “Now, we talk about reducing the stigma of this disease, yet we’ve treated a visitor living with it as a threat.”

UN Secretary-General Ban Ki-moon welcomed the change, stating: “I urge all other countries with such restrictions to take steps to remove them at the earliest.” Some 11 other countries still impose bans, including Saudi Arabia and Libya.

Under the US ban, all potential immigrants had to undergo testing for HIV. Whilst waivers were available for those in a heterosexual marriage, they were not available for gay men. In addition, although waivers were available for tourists, many felt the process was too arduous as to be worth it. Gay-rights campaigners say the ban has separated families and discouraged HIV testing and treatment in the US. Now, for the first time since 1990, the US – which has a strong record in the attempts to control the AIDS epidemic in Africa – will be able to hold a conference on HIV/AIDS on home soil. Up until now, conferences have not been held in the country so that HIVpositive activists and researchers are able to attend.

The new ruling was will take effect from January 2010.

Sources: 1.

The New York Times – http://travel.nytimes. com/2009/10/31/us/politics/31travel.html?s cp=2&sq=October+31+2009&st=nyt 2. The Guardian – 3. http://www.guardian.co.uk/commentisfree/2009/ nov/03/america-hiv-aids-needles 4. The Philippine Star – 5. http://www.philstar.com/Article.aspx?articleId =519465&publicationSubCategoryId=200

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Publish or Perish Emily Pull

Year 6 Medicine, University College London e.pull@ucl.ac.uk doi:10.4201/lsjm.car.005 It seems to be unavoidable now, that pressure to be able to type your name into the Pubmed search and find some publications. It counts on Foundation Application Form, looks great on your CV and is bound to make you sound so much more intelligent in front of your consultants - that’s right, medical students need to publish, publish, publish. For the former PhD students and graduates embarking on medicine, this may be a less worrying pressure, but for us run of the mill medical students who have quite enough to keep us occupied with just the medical degree, how can one go about getting into a lab and our names on a paper? And is it as vital as we’re led to believe?

Professor Jane Dacre, Vice Dean Director of Medical Education at UCL is clear about the merits of academic publishing as a medical student: “medical school offers an education, not just training for a job, so we encourage a more in depth approach to the subject, and academic publications are a way of demonstrating students have engaged in that”.

However, a publication is no mean feat and it can be difficult to get practical advice on where best to start.

The first place that you may encounter as prime publishing ground is an intercalated BSc or BA. For many students this is the first experience of getting into a lab and with time devoted to research, this is a great opportunity to mingle with researchers, see what they’re doing and what’s more, offer to help out. It may not even be your project that ends up getting published but if you’re in the lab and willing to contribute, you could well find yourself as one of the authors of a published work.

One thing is sure, a good supervisor is of great benefit and Dr Robert Dudas writing on the Royal College of Psychiatrists website gives some good advice, suggesting that bigger is not necessarily better. He advocates choosing someone who is not necessarily high profile, but who can spend time actually supervising you.

One of the important things to remember with all research is that it is not a quick process,it can take months or more from finishing the lab work to the final publication. Writing up your BSc dissertation Top tips from Trish Groves (Deputy Editor, British Medical Journal): • Simple questions, answered with simple methods, can make great studies if they add usefully to what’s known and/or raise further important questions • Before you start the study decide who will do which aspects of the work and who will be an author on any papers • Always seek patients’ signed consent for publication if your paper could allow them to be identified • Always cite all your sources - plagiarism is a tempting shortcut, but never worthwhile or right

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may be done in a haze of parties and late nights but a manuscript fit for publication can take many attempts with feedback from peer reviewers and the journal editors.

Dr Dudas states that, for the most part, producing publishable data is not the tricky part. The difficulty often lies elsewhere, for example in devising the initial research and study design.

Trish Groves, Deputy Editor at the British Medical Journal has some good advice for first time researchers: “Think of a good research question first and ask a librarian to help you search previous studies so you can narrow it to something original enough. Plan, conduct, and write up your study around the question - don’t collect some data and then try to analyse them hoping that a research question will emerge”.

Most journals will be looking for an original research question that, importantly, their readers will be interested in. Picking the most appropriate journal for your work can greatly increase the chance of publication. “Choose a journal because it will reach the right audience and publishes similar work, not because it’s big and famous” says Groves.

Dr Dudas presents a realistic view of the world of publishing for a student, suggesting that talent is not the only ingredient needed to achieve publication. Rather, he emphasises luck as a key player in the process, coupled with a dogged determination not to give up.

So don’t be downhearted if getting into a lab and published is more difficult than you expect. Talk to students in later years to find out how they got published, and try to work out which research teams are working on projects likely to get published.

The most important skill it seems when it comes to publishing is to have a thick skin. The most eminent scientists and researchers will have had papers rejected by journals and rejection doesn’t necessarily mean a paper is bad. It could be something as simple as the fact that a journal never publishes a particular type of study or that the work is good but the important messages are not clear enough for the readers of the journal. The key thing to remember is don’t give up - according to Dr Dudas most journals only publish a fraction of the manuscripts they receive.. So when that rejection letter comes through the door, see if you can improve your work and resubmit to someone else.

Although the perceived pressure to get published can be daunting, Professor Dacre is clear about why it can be useful: “we should not stress students unnecessarily, however, as the practise of medicine requires high standards and academic rigour, it is helpful to start practising that approach before you qualify”.

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Obama’s Healthcare Reform: Hope or Hyperbole?

Katherine Adlington BA(Oxon) Year 4 Medicine, King’s College London katherine.adlington@kcl.ac.uk President Obama arrived in the White House on the back of a promise to bring hope to the American people. Now, nine months after his inauguration, he has chosen to deliver this promise through ambitious healthcare reform that has kept politicians and the public embroiled in heated debate over the past few months.

Unlike the National Health Service in the United Kingdom, there is no universal public healthcare coverage in the United States.

Instead, the majority of healthcare facilities in America are owned and operated by the private sector. In most states, individuals are responsible for arranging their own health insurance, and this individual policy is then used to fund medical treatment as required. Insurance coverage is usually offered by employers. Those not so fortunate have to sign up independently for private insurance schemes.

The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted by the federal government in 1986, required that hospital emergency departments provide a medical screening exam and stabilise all patients on presentation to hospital regardless of their ability to pay. However, there was no concurrent increase in funding for hospitals to cover the cost of this emergency care, and hospitals largely still bill their emergency patients directly after discharge under a fee-for-service model. If a patient needs healthcare from any other part of the system, they need to have adequate insurance to cover their costs. If they are found to have no insurance, or their insurance won't cover their costs, and treatment has already started, they will personally have to foot the bill themselves - and if they can't, the treatment may be stopped or the hospital may pursue legal proceedings.

The American government does not completely abandon their public when it comes to healthcare. As well as the essential medical care offered by Emergency Departments, there are two healthcare schemes that provide health coverage for specific social groups:

Medicare - this scheme is a social insurance programme providing coverage to people who are aged 65 and over. It is partially funded by federal payroll taxes.

Medicaid - scheme caters for low-income parents, children, pregnant women, and people with certain disabilities. This is a means-tested program that is jointly funded by the state and federal government.

Children and military veterans are also covered by other public schemes. Yet, even with coverage for the young, infant mortality

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is comparable to sub-saharan African in some southern and mid-western communities1 . Shocking facts such as these, go some way to explaining why Obama has made healthcare reform such a priority.

So, what are the problems with the system in the US? Despite the fact that more money per person is spent on healthcare in the US than in any other nation in the world, it still lags behind other wealthy nations in measures such as infant morality and life expectancy2. In 2000, the World Health Organisation (WHO) ranked the US health care system as the highest in cost, 1st in responsiveness, 37th in overall performance, and 72nd by overall level of health (191 member nations were included in the study)3. However, this overpriced system fails spectacularly if the per capita spending is correlated to health outcomes.

Premiums for employer-provided healthcare schemes have risen four times faster than wages over the same period, doubling in just nine years4. This, coupled with the dramatic rise in individual healthcare costs means that a burgeoning number of individuals and employers are unable to afford health insurance. In 2008, the US census bureau estimated that 46.3 million Americans do not have insurance - this from a population of 300 million.

Millions more are deemed 'underinsured’ – with inadequate coverage for their specific needs5 . The consequences of this can be catastrophic financially, phsycially and emotionally. Medical debt is the commonest cause of personal bankruptcy in the US, accounting for at least half of all cases6. Many people do not seek healthcare for serious conditions and consequently suffer because they simply cannot afford the interventions.

Many Americans feel let down or neglected by the system, raising questions about their basic human rights to healthcare. President Obama wanted to leave the fine detail of the reforms for Congress to decide. After this broad-brush approach led to criticism, Obama's address to Congress at the beginning of September was an important one. Offering more detail, the President highlighted the three main aims of his reforms: to provide increased security and stability to health-insured Americans,to achieve universal health insurance coverage and to slow the growth of healthcare costs. Tougher regulation of the insurance industry is proposed, prohibiting the currently common practices of refusing insurance to those with pre-existing conditions and discontinuing insurance if people get ill. The reforms will also look at alternatives for employees who are not provided with health insurance at work. Emphasising the importance of rights as well as responsibilities, the address also stressed the need for individuals to take personal responsibility if the system was to succeed. This is reinforced with the threat of financial penalties for those who fail to arrange healthcare insurance.

Obama stated that his reforms will cut the number of uninsured Americans by 30 million, while costing no more than $900 billion and not raising the federal deficit by “one dime”7. On 16th September this year, Max Baucus, the head of the Senate's powerful Finance Committee, unveiled a bill, carved out through intense bipartisan negotiations, that seemed

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PERSPECTIVE to offer hope of fulfilling both Obama's aims and meeting his financial specifications. To increase insurance coverage, the bill suggests the creation of internet-based insurance marketplaces that would simplify and standardise insurance offerings, whilst making refundable tax credits available to low-income families to help them buy health insurance. Mr. Baucus' plan also proposes expanding Medicaid to cover a greater percentage of the poorest American citizens. This plan also seems like the most economically viable option, with some agencies suggesting it might even result in a reduction in the federal deficit.

Opponents said the bill is too good to be true, and claimed that savings would only be made through dramatic cuts to doctors’ pay and a significant, unacceptable reduction in the funding of Medicare. Many medical industries are already gearing up to contest or escape the substantial levies that Baucus hopes could partly fund this bill.

As NHS in the UK shows, it is possible that a public healthcare system might offer basic healthcare coverage for all citizens.

However, such a system can also curtail doctors’ wages and funding for medical research. Of course, once access to healthcare becomes a fundamental right, the distribution of inevitably limited resources and becomes the focus for controversy.

The President has staked his political reputation on this - his first bold domestic manoeuvre. Recognising the need for support from medical professionals in order to popularise and push forward the reforms, President Obama invited 150 doctors from across America to a high profile summit at the White House early this month.

The US reform bill is currently awaiting approval from various committees. Inevitably, different versions of the bill will continue to be proposed before agreement is reached between all parties.

There is clearly a long way to go before the debating is over, and many people have yet to decide whether Obama's reforms offer hope or hyperbole.

References 1.

2.

3.

4.

5.

6.

7.

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MacDorman, M.F., Mathews, T.J.. Recent Trends in Infant Mortality in the United States. National Center for Health Statistics, Centers for Disease Control. October 2008. http://www.cdc. gov/nchs/data/databriefs/db09.pdf. Retrieved 6-10-2009.

UN. World Population Prospects: The 2006 Revision (Table A.17.

Life expectancy at birth (years) 2005-2010.) United Nations.

2007. http://www.un.org/esa/population/publications/ wpp2006/WPP2006_Highlights_rev.pdf . Retrieved 6-10-2009 WHO. World Health Statistics 2009. World Health Organization. May 2009. http://www.who.int/whosis/ whostat/2009/en/index.html. Retrieved 7-10-2009.

BBC. Q&A: US Healthcare Reform. British Broadcasting Corporation. September 2009. http://news.bbc.co.uk/1/ hi/world/americas/8160058.stm. Accessed 7-10-2009 US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau. Issued August 2008.

Himmelstein, D, E., et al. Medical Bankruptcy in the United States, 2007: Results of a National Study.

American Journal of Medicine. 2009.122;8: 741-746.

The Economist. Half a loaf, or half-baked?: The latest American health-care reform plan is unveiled in the United States. The Economist. 2009, September 17th. http://www.economist.com/ world/unitedstates/displaystory.cfm?story_id=14460017 Accessed 7-10-2009

Psychiatry in the Bronx Katherine Adlington

Psychiatry has always struck me as one of the more interesting areas of medicine. An exciting and unique discipline that often had unclear pathophysiology. However, a brief six week canter through psychiatry in the first year of clinical medicine seemed limited in its scope and only gave the opportunity of a brief dip into the ocean of mental health services available. So with graduation looming a short two years away, it seemed a good idea to explore this interest in psychiatry further over the long summer break.

Four weeks working at the Schizophrenic Research Unit in the Bronx Psychiatric Hospital (BPH), New York was a far cry from the glitz and glamour usually associated with the Big Apple. The BPH is a state run facility and is well recognised as the birthplace of the Positive And Negative Symptom Scale (PANSS). This is a rating scale that was originally developed by Stanley Kay, Lewis Opler and Abraham Fiszbein in 1987 and is now an internationally recognised method of identifying classic symptoms of schizophrenia1.

As a general volunteer on a female-only ward for 24 patients with chronic, refractory schizophrenia, my responsibilities were both clinical and research based. From collecting data for studies; trying to establish a link between risk of schizophrenia and immigration status, vitamin D levels or ethnic grouping; to interviewing patients, the work was interesting and varied. It was a steep learning curve given the extreme psychopathology on the ward and not without risk. I found myself in threatening situations on more than one occasion: On day one a patient told me in no uncertain terms that she intended to assault me. Learning to deal with aggressive and confronting behaviour, whilst terrifying, was a challenge that ultimately gave me confidence on the ward It also gave me more insight into the frustrations that many of these women felt at having their liberty so severely restricted. One patient on my ward had been institutionalised for nearly 50 years.

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Illustration: Jonathan Hyer

As with mental health services in the UK, psychiatric hospitals in America regularly come into contact with the legal system, in order to facilitate formal admissions and medication-over-objection orders. The Bronx Psychiatric Hospital is a large facility with a makeshift courtroom on the premises, which a Supreme Court judge attends weekly to hear any pending cases and I was fortunate to be able to observe the hearing of one of the patients that I had been following.

There is a much more powerful patient lobby in the in America compared to theUK, as well as a powerful legal service. This is perhaps as a consequence of the many high profile cases of abuse of institutionalised psychiatric patients in the 1960s, such as the infamous class action suit brought against the Bridgewater State Hospital for the Criminally Insane, which showed that the institution was acting in clear breach of its patients’ civil rights2 .

In my experience, this seemed to lead to a highly charged hearing between the patient's treatment team and the patient's legal representatives. Often, the former held the view that it was in the patient's best medical interests to remain in the hospital, whilst the latter were trying to secure the patient's liberty as early as possible.

At these hearings, patients have the right to self-representation in court. Given that they could be floridly psychotic at the time, this throws up an interesting ethical dilema and whether this affords them the best opportunity for fair legal representation, is a matter for debate.

The provision of American healthcare in general and the role of health insurance was the topic of lively discussion at the hospital, and this reflected the national mood, following the first sparks of the debate over President Obama's proposed healthcare reforms.

Many of my colleagues were baffled by how free healthcare could be provided for all at the point of entry in the UK.

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BPH is a state psychiatric facility funded largely by Medicaid - a state and federal-funded health program that provides healthcare cover for low income adults, pregnant women, children and people with certain disabilities. The patients at BPH were representative of the general population of the Bronx, and almost entirely of low socioeconomic status. Many were first or second generation immigrants; many had minimal work history. Often their families were unable - or unwilling - to be financially supportive, and thus they relied on Medicaid for health coverage.

BPH currently receives significantly more funding from New York state than the national cross-state average, but this did not seem evident in the standard of facilities and levels of staffing. While Obama’s proposed health care reforms will mean increased funding for this state hospital, it could also result in a greater pressure on services as more of the currently uninsured patients begin to be covered by the widening healthcare safety net. This is particularly relevant for mental health services given that low socio-economic status and immigration status have been suggested as risk factors for schizophrenia3.

Overall, this work experience was incredibly informative and really helped focus some of my previously vague career ideas. I would definitely be more likely to consider psychiatry as a career option now that I have had an in depth clinical and cultural experience.

References 1.

2.

3.

4.

1. Kay, S.R., Fiszbein, A., Opler, L.A.. The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia.

Schizophrenia Bulletin. 1987. 13;2: 261-276 2. Gilligan J., The Last Mental Hospital, Psychiatric Quarterly, Vol. 72, No. 1, 2001 (Springer Netherlands) http://www.springerlink.com/content/ wm33461q2805mm07/fulltext.pdf 2. Cooper, B., Immigration and schizophrenia: the social causation hypothesis revisited. British Journal of Psychiatry (2005) 186: 361-363

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Donna Tooth

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Year 4 Medicine, King’s College London donna.tooth@kcl.ac.uk Donna is an active the British Medical Association Donna Tooth is an activeTooth member of themember British ofMedical Association (BMA), (BMA), sitting on the board of a number of student committees. sitting on the board of a number of student committees. She ensures the views She ensures the views of her GKT colleagues are heard at a national of her GKT colleagues are heard at a national level, a represents the views of level, a represents the views of fellow students to the UK Foundation fellow students to the UK Foundation Programme Office Medical Student Programme Office Medical Student Board. andfinds time to be a Board. andfindsmum-of-one. time to be aWe mum-of-one.

We she asked what shefor feltthethecoming asked her what felt her the priorities priorities for the year coming year were at a national level. were at a national level.

The year ahead is a time of change with the government looking to review the funding of medical education, and talk of the Foundation Programme Application process evolving too. The BMA student committee is working hard to represent student views, and it’s going to be a busy year! Here’s a flavour of what’s on the agenda over the next 12 months, and how you can get involved.

1. Shaping new funding proposals for NHS students If you are one of the many healthcare students relying on the NHS Bursary to support yourself through your undergraduate years, you should know that this funding may be about to change. This year, the government published a document setting out proposals to change the NHS Bursary Scheme1.

The BMA is asking for student views on the options presented in this paper, and we will be running focus groups at each medical school this winter, to find out how you feel about the current funding scheme, and what you think about the new proposals put forward by the Department of Health.

Contact your BMA student rep to find out when and where your local meeting will be taking place, and come along and have your say. Your views will then form part of our response to the government consultation, and help to shape the future of the bursary scheme.

2. UK Foundation Programme Office (UKFPO) Much debate has surrounded this, the current system being used to allocate medical graduates to their first ‘foundation’ jobs. Earlier this year the BMA conducted focus groups in medical schools as part of a consultation on the future of the foundation programme application system. Through the input of medical students the MSC were able to feed into the consultations process and effect change.

process, as well as information provided by the applicant’s medical school. In addition, a ‘Situational Judgement Test’, similar to the one faced by prospective trainees for the GP scheme is going to be piloted as part of the new Foundation Programme application process.

We anticipate that the earliest a system like this would be implemented is for the application round of 2012-13, but small scale pilots are likely to happen from as early as next year. A larger pilot is planned for applicants in the 2011-12 cohort.

On an individual level, I’ve also been helping current GKT finalists to make their applications, and now that the forms are in, I’ll continue to offer advice throughout the process.2 If you need some additional help with this process, contact your local school representative or visit the UKFPO website.

3. Medical Students’ Conference This year’s conference will be at the University of York on the 9th and 10th April. Here BMA members will set the agenda for the 2010-2011, looking to build on the work currently being done by the Medical Students’ Committee. You can get more information on this from the BMA website, which will be updated throughout the year.3 We need your ideas for issues that need debating at the conference, and your local representative will be in touch before Christmas.

Through the work of the BMA, and on behalf of those I represent, I hope that I can usefully contribute to ongoing debate around medical education - issues of funding, access, and hours and fair selection will always be on the agenda, and hearing the views of as many medical students as possible is really important to ensuring we are an inclusive body, who can put forward a truly-representative point of view to this country’s health-makers, movers and shakers.

It’s more important than ever that you get involved with this work, so have a look at the website, come along to one of our events or get in touch with your local BMA representative to find out what’s going on.

References & Useful Links 1.

At a recent board meeting, tentative plans were laid out for the future of our Foundation Programme application system. Following a rigorous cost-benefit analysis, two options came out on top.

Although at this early stage we don’t yet know the details of which proposals will be taken forward, we expect educational performance to remain a key determining factor in the selection

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{

The View from a Bridge

2.

3.

4.

Supporting our future NHS workforce: a consultation on the NHS Bursary Scheme http://www.dh.gov.uk/en/ Consultations/Liveconsultations/DH_105110 UKFPO: http://www.foundationprogramme.nhs.uk/pages/home Careers Advice podcasts: http://www.foundationprogramme. nhs.uk/news/story/careers-advice-podcast-now-live BMA Medical Students Conference http://www.bma.org.uk/whats_ on/branch_practice_conferences/mscconference2010.jsp?page=1 MSC Local Representatives: http://www.bma.org.uk/representation/ local_representation/medical_student_reps/index.jsp

lsjm 30 november 2009 volume 01

PERSPECTIVE

Breaking into the world of NGO medicine Laura James

Year 4 Medicine, King’s College London laura.2.james@kcl.ac.uk

Volunteer to work in a developing country and you can find yourself working with some of the most underprivileged societies in the world. You’ll have the opportunity to gain experience outside the realms of high-tech, well-equipped western medicine and to learn about major issues in global health. It also offers the chance to travel whilst studying, opening your eyes to different lifestyles and cultures.

But just how easy is it for a medical student to go about organising such an experience?

Many well-known humanitarian organisations, such as Medecins Sans Frontieres (MSF), Voluntary Service Overseas (VSO) and Merlin are reluctant to take medical students abroad with them.

Nell Gray, who recruits doctors for MSF, explained why: “It’s an autonomy issue,” she said. “In order to provide stability for our projects, we aim to train people who are local to the area so that they are better skilled when MSF leave. At most, one in ten of our overseas staff are international. We also want our volunteers to be able to work for at least nine months in the area and to have at least one year of training post Foundation Year 2.”

VSO take much the same attitude, stressing the focus on building capacity within the country they are helping, rather than parachuting in aid and assistance. They only take on skilled doctors who can pass on their expertise to local professionals.

“We do not have the capacity to train people to go overseas,” said Petra Michalas, who works for Merlin, an organisation which sends medical teams into disaster zones. “So the type of people we need must already have experience.”

Which presents something of a catch 22 situation. With the NGOs crying “no go”, can you be taken seriously enough to be considered for working overseas, without any actual experience overseas?

Making the most of your elective part of your undergraduate training can be a good way to get started, as can having an interest in sub-specialisms which may be helpful to developing countries.

“Those who have knowledge and interest in infectious and tropical diseases and HIV are useful areas of expertise for any future involvement.” says Nell Gray at MSF.

lsjm 30 november 2009 volume 01

Louise Hill who works for VSO said: “We obviously would encourage medical students to volunteer abroad, although not with VSO. Organisations such as Medsin have a Global Health Education Project which, among other things, is looking at how to make sure medical student electives are ethical and sustainable.”

Medsin, is a UK based student network, which promotes health and educates members about disparities in standards and access to healthcare, both locally and globally. Global health issues are taught via special study modules, intercalated BScs, e-learning and Medsin projects and campaigns and these are all good ways of getting a taste of what working in the developing world may entail.

Like Medsin, Friends of MSF is a student based organisation that aims to promote interest in global health issues. Its president, Tom Conway, a student at King’s College London, says the group aim to promote interest in global health issues and the work that MSF does.

“The society attracts a lot of people who want to work with MSF in the future and we do have strong links with the organisation. We give opportunities to help out at MSF conferences and provide lectures from professional volunteers.”

Holidays can turn into valuable opportunities to gain experience - it might be worth introducing yourself to the local hospital, if only to visit for the day.

Alternatively, many companies exist to set up overseas placements, though these opportunities come at a cost. However, paying to be placed may make ethical sense as well as being an investment in a future career abroad. The fees you pay may go towards setting up local projects and health infrastructure, as well as offering students a safe way to get real experience of working within a different healthcare setting.

Despite the NGOs’ reluctance to directly facilitate the student experience, many opportunities exist for those with an interest in working in developing countries. Forward planning, persistence and a little initiative are essential to planning a safe, interesting and worthwhile placement.

Sorce: Wellcome Images

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REPORT Sangoh Lee a 5th year medical student at Imperial College, London, paid over £1,500 to spend a month volunteering in Namibia over the Summer break between his 3rd and 4th year.

What made you decide to volunteer abroad?

“I wanted to go to Africa and America for my elective and couldn’t decide on which. So I decided to use my Summer between third and fourth year as an opportunity to experience volunteering in Africa. After some searching I found a website for people wanting to go on gap years called 'Frontier'. Through them I found an organisation, which offered medical volunteering internships in Namibia and Malaysia. £1600 included transport within the country, food, accommodation and support. This was reasonable compared to other schemes I had found.”

What did you do?

“In Namibia’s capital, Windhoek I worked in a general hospital. I was given quite a lot of responsibility and had my own room to clerk and examine patients. I ordered and took blood, interpreted X-rays and carried out procedures like suturing.”

“I then went to a town called Epukiro. The clinic was small and gave free health care to Bushmen, the poorest people in the community who are often discriminated against. Here it was quite frustrating as often there was not a lot that could be done.

I bandaged a lot of burns, as sadly a lot of the children got burnt from fires that were made to keep them warm as it is winter in Namibia when it’s our summer.”

“I gained a lot of practical experience, I learnt how to take focused histories, work in a team, live in a different environment and see how other health care systems operated. It was generally a safe place and Namibia is a beautiful country. I would love to go back to do more.”

09/09/09 Pregnant Pause: Flash Mob

Useful Links: Medsin: www.medsin.org/ projects/globalhealth Friends of MSF: www.msf.org. uk/friends Na’an Ku Se: www.frontier. ac.uk/gap_year_projects/ Namibia/Namibia_Medical_Internship

Useful links National Organisation on Foetal Alcohol Syndrome UK: www. nofas-uk.org Foetal Alcohol Syndrome Aware UK: www.fasaware.co.uk

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Susan Fleisher , Founder, National Organisation on Foetal Alcohol Syndrome UK

A Pregnant pause. .

Imran Ahmed Year 4 medicine, King’s College London imran.u.ahmed@kcl.ac.uk It’s 9:09am in London on the 9th day of the 9th month of 2009.

The concourse at Victoria Rail Station, is as busy as ever, when suddenly - stop! Without warning, hundreds of people are frozen in time, suspended mid-action. They remain stuck for a full minute, a flashmob, united momentarily, and then, as suddenly as it began, it is over and the participants just walk away. Though flashmobs are not a new phenomenon, this was one with a difference. Keen-eyed onlookers were left scratching their heads and asking - why did they all have balloons up their jumpers?

From its origins in viral communications to a major marketing tool for the movie moguls, the humble flash mob has come a long way.

It started as a social experiment at the beginning of this decade, with just a hundred people gathering for a giant pillow fight. The flash mob has now become a powerful customer-gaining tool for industry giants. The latest manifestation sees a strange lifeimitating-art, with street dancers bursting into action to promote the new film Fame. Elsewhere, charities are using the craze to their advantage, courting audiences not for box office returns, but to highlighting important causes.

The Pregnant Pause, an event organised by the charity the National Organisation on Foetal Alcohol Syndrome UK (NOFAS-UK), was a flash mob which saw people putting not pillows but balloons up their jumpers and stopping for a minute in rush hour, in the hope that pregnant drinkers would take the time to stop and think for a minute too.

It is thought that as many as 1% of children born in the UK have Foetal Alcohol Spectrum Disorder (FASD) as a direct result of women drinking alcohol during their pregnancy. NOFAS-UK was set up by Susan Fleisher, after she discovered that her daughter had this devastating syndrome.

“I adopted my daughter Addie when she was three years old. At the time I wasn’t aware she had the condition and I wasn’t aware that her birth mother’s drinking would have such a severe impact on the rest of her life. The full extent of FAS became clear only when she was growing up. She had problems at school, trouble with learning, trouble with making friends. She was diagnosed with the condition at Great Ormond Street Hospital and that’s when I first heard about it. I looked for any support for individuals suffering with FAS but there was hardly anything. That’s when I decided to give up everything else and start the charity.”

Now Executive Director, Fleisher has dedicated her life to helping those with Foetal Alcohol Syndrome and their families.

“We have a helpline service Monday to Friday to give advice and support. We have support group meetings for parents and carers as well as playgroups for children affected by FASD. Also we hold regular conferences where we discuss FASD and provide training

lsjm 30 november 2009 volume 01

.................

sessions to educate the public about the condition... We also hold events such as our annual family picnic, and of course events like The Pregnant Pause.”

“There are loads of major effects of alcohol consumption during pregnancy,” said Fleisher. “Physical effects include kidney damage, heart defects, limb damage, eye problems, hearing problems and damage to important parts of the brain.

“They suffer attention deficits, memory deficits, hyperactivity, and poor impulse control. Also they have poor judgement, and have difficulty with abstract concepts so they can’t do simple maths. Most significantly they have difficulty learning from the consequences of their actions.

“The big travesty with all of this is all of these effects are 100% preventable if a woman just stops drinking during pregnancy,” she continues with some force. “Women only need to stop drinking alcohol for nine months to have healthier children and to avoid these devastating effects. People froze at nine past nine on 9th September 2009 to highlight this.”

“Don’t drink during pregnancy. The safest amount of alcohol is no amount of alcohol at all.”

Those with Foetal Alcohol Spectrum Disorder are also more likely to be the victims of crime, as highlighted by the case of Mathew Verity, the first child in Britain to be diagnosed with the condition.

“Mathew had never been in a proper relationship and he hardly had any friends.” explained Fleisher. “He met a younger man over the internet. Recognizing Mathew’s vulnerabilities the man pressurized Mathew for £5,000. Mathew’s naivety meant that he kept the relationship confidential. Then when the money didn’t show up, the young man waited outside Mathew’s flat, tied him up and assaulted him. Cases like this are very common with FAS sufferers.”

What is Foetal Alcohol Spectrum Disorder?

A set of mental, physical and neurobiological birth defects that occur directly as a result of alcohol consumption during pregnancy.

How common is it?

UK prevalence is 1 in 100 births

What are the specific damage areas to the brain?

Alcohol deprives the brain of oxygen and thus permanently damages brain cells which can’t regenerate. This causes a reduced brain size, and regional loss, particularly of the frontal lobe. The loss of the frontal lobe means FAS sufferers have difficulties with critical thinking, reasoning and judgement.

PERSPECTIVE

Medical Notes - The Newby Name: Dr. X Age: Mid 20s Gender: Female Occupation: Foundation Year 1 Doctor

Management Plan: Advise and reassure: Get a little notebook to jot down the millions of codes & numbers because the bit of paper stuck to the wall is guaranteed to disappear/implode/self-destruct just at the moment you need it.

Presenting Complaint: Fatigue, stress and nausea caused by excessive hospital politics

ALWAYS carry a drink. Kidney stones are not much fun.

History of Presenting Complaint: Symptoms began 1/12 ago

When the fax machine AND computer AND telephone AND your bleep all break at once - STOP! Resist the urge to fling all said technology out of the window - and breathe.....

Previous Medical History: Nothing of note. Previously fit and well Drug & Alcohol History: Gin and Tonic - self administered as required. Chocolate - unable to quantify weekly units. Non-smoker (no, really!)

Allergies : No Known Drug Allergies. Health and Safety lectures proving to be an irritant factor.

Family History: Patient’s mother has ensured all cousins, second cousins and 7th cousins twice removed are aware that her daughter is (finally) a doctor.

Social History: lsjm 30 november 2009 volume 01 Pt has experienced a marked decline in hardcore partying since qualifying.

Mistakes are bound to happen and there will no doubt be many times when your colleagues will royally p**s you off. So make sure you socialise with them – it’s much easier to forgive a friend a total stranger. And they’ll be much happier forgiving you when it all goes wrong!

Never be afraid to stand up for yourself. Previously frightening colleagues will become much nicer and respect you more.

Become a professional pest. Pester seniors for advice, even if they become annoyed - you are a junior and they are meant to help! You (and they) will thank me when you aren’t hauled up in front of the 193 GMC.

REPORT

The Physician Assistant

Illustration: Jonathan Hyer

Gurpreet Kharay Year 5 Medicine, King’s College London gurpreet.kharay@kcl.ac.uk

“Physician assistant” - the words conjure up the image of a hapless junior doctor struggling to keep up with his consultant on a busy ward round, juggling a mountain of files, trying to write notes as he valiantly tries to keep pace. In fact a physician assistant (PA) is not just an overworked doctor’s dream but a reality that has been in existence for nearly 50 years. Appearing in America in the 1960s1, the first physician assistants were paramedics, trained to fulfill this adapted role. These semi-autonomous practitioners are now an established part of the healthcare fabric across the pond. The role of a physician assistant involves far more than being a medic's minion. Rather, their job description seems to run in parallel with their doctor colleagues - history-taking and examination, ordering investigations, conducting referrals are all within their remit - as well as teaching medical students. They even have the power to prescribe.1

The idea, which has its roots in 17th century Europe, was originally adopted by the United States in a bid to mitigate the shortage of primary care doctors1, with some success.

Now, with general practices hiring US-trained PAs to work for them, a training scheme is being piloted in the UK.Home-grown courses lead to qualification as a PA and are offered at several institutions including Birmingham University, and St. George’s Hospital Medical School2.

Krista DeWys is a physician assistant at the Saint Francis Memorial Hospital in San Francisco, USA. She feels that the role offers a better work-life balance than a career as a doctor: “I wanted to be in the medical field as a professional and considered being a doctor but I also wanted to raise a family someday.”

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DeWys is one of a growing number of physician assistants working as part of the multi-disciplinary team in hospitals today. “I work in the Emergency Room and can diagnose and treat under the supervision of my attending doctor, and according to my comfort level and experience. We can order investigations, diagnose, treat and prescribe but we are more limited than doctors. Legally, we can not work unless under a supervising physician.”

Although pleased with the more flexible nature of her role, she says the job is not without its drawbacks, mainly in the attitudes from colleagues who know little about the position, but may have preconceived notions about the usefulness of a PA. “There sometimes is a lack of support from attending physicians,” she says, “and the pay is also much lower than that of a doctor, even though we sometimes we do just as much as a doctor or more.”

After graduating from University, DeWys trained as a physician assistant, and then sub-specialised in Emergency medicine.

Nonetheless she acknowledged that the limitations of her role can sometimes be frustrating. “It can be frustrating when you feel your lack of experience may limit your ability to treat. I think more training and stricter requirements for pre-PA school would help address this. But I also think that educating doctors about our role would help our skills to be better used within the team.”

References 1.

2.

www.paworld.net/whatpadoes.htm www.wlv.ac.uk/default.aspx?page=14123

lsjm 30 november 2009 volume 01

PROFILE

Profile: PA Amy Green and Neil Howie both chose the physician assistant route into a hospital career, and are student representatives from the UK Association of Physician Assistants.

What made you decide to be a PA? AG: I was drawn to the profession for several reasons. It is a two year postgraduate course and, even though it is incredibly intense training, it is perfect for graduates looking for a profession based on the medical model that is not medicine itself. The physician assistant role is still largely unknown in the UK which can come with disadvanatges as formal registration is still being developed, but there is the opportunity to qualify in two years if you pass the university exams and the national exam. There is a regular revalidation exam which aims to keep the standard high for all physician assistants over their careers. Whilst this is not medicine and we are not doctors, there is a great deal of demand for physician assistants in all healthcare environments as we are trained to deal with all medical conditions and perform many medical procedures.

What are the application requirements?

NH: There are four universities in the UK which offer the physician assistant diploma. The University of Birmingham, University of Wolverhampton, St. George's University of London and University of Hertfordshire.

For Wolverhampton, applicants need either at least a lower second class degree in a biological science, nursing, an allied health profession, or chemistry; or a diploma in nursing or paramedic science plus two years or more profesional experience.

AG: At Birmingham, it's a minimum upper second class degree in a life science or allied health profession, as well as chemistry A-level at C grade or more, plus at least B grades in Maths and English GCSE. And for St. George's, University of London, applicants need a second class honours degree in life sciences or a health-related subject, and it must have been achieved within the last five years.

What are the main ways a PA's job differs from the more established medical professions, such as nurses or doctors?

AG: A physician assistant is part of the medical team and is trained to perform duties under the supervision of a doctor. There should be no confusion between the roles of a physician assistant and a doctor as we do not have the depth of knowledge or the same qualifications. We are physician 'extenders' rather than replacements.

There are many different qualifications nurses can take to develop their skills and their careers, such prescription rights, and so nurses have the opportunity to work at very high levels with supervision.

lsjm 30 november 2009 volume 01

All these professions are striving to achieve the best possible care for patients and there may be crossover in certain duties but it is down the individual and the supervising doctor as to the specific role of the physician assistant in that firm and the duties they can perform competently. A physician assistant is trained to act as a generalist and this means being able to do a wide variety of procedures and manage many medical conditions but no medical professional should ever act beyond their competence.

How much responsibility do PAs have for patients?

AG: Physician assistants are trained to take histories, order tests, plan treatments and prescribe medications. However, a PA must act under the supervision of a doctor and therefore the full responsibility lies with that doctor.

Is there scope to progress in the career of a PA? NH: PAs do not progress along a career path like, for example, a doctor might. However involvement in PA education is one route open. In America, PAs have gone on to hold positions such as directors of clinical research institutes in the same way a doctor would. PAs can specialise to a certain extent, but must retain generalist status by resiting the national exam.

What are the positives of being a PA? NH: It's great being able to be hands on with patients and knowing this won't change throughout your career as a PA, as is not having to worry about advancing along the medical career path with all the new requirments, title changes and worry about getting a training post. The role doesn't tie you down to one area of the country. It's exciting to be part of something so new.

And what are the negatives?

NH: The uncertainty over registration and the limitations this brings in terms of prescriptive powers and ordering x-rays is sometimes frustrating, as is the lack of public and professional understanding about the role. Many doctors and medical students have some strong views about PAs but when pressed will admit to not actually knowing what PAs do, how they are trained or the history of the role. It is a knee-jerk reaction that is based on fear that the Government is trying to replace doctors on the cheap.

How do you think this misconception can be changed?

NH: As people increasingly come into contact with physician assistants when they come to hospital, or see them portrayed on shows such as Casualty and Holby City, they'll get to see what we really do. Doctors should be taught about the part that PAs can play in the healthcare team while at medical school. Or perhaps their professional bodies such as the GMC or the Royal Colleges can educate them about the PAs' remit. Ultimately, it will be through working with talented PAs that our medical colleagues will see that PAs are neither a threat, nor a danger. Rather they can do a good job and help with the smooth running of the healthcare team.

Amy Green

Neil Howie

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