The Medical Student - January 2014

theMEDICALSTUDENT

January 2014

The voice of London's Medical Students/www.themedicalstudent.co.uk

Unemployed Doctors?

The Hippocratic Oath

Private medical schools >> page 4

We look at its history >> page 18

Medical School Life

Legal Highs

Are we losing ourselves? >> page 11 We take a look >> page 7

NHS Entry Exam Proposed Krishna Dayalji What would you say if you were told that you would receive full General Medical Council (GMC) registration at the time of graduation from Medical School? Would your opinion change if you had to pass an additional exam to work within the NHS? This part of the proposal that has been put forward by Health Education England (HEE) this December.

In a recent report, HEE have proposed that the ‘point of registration should be brought forward to align with graduation, coupled with enhanced selection processes to the Foundation Programme to ensure the best applicant’s progress.’

Under these new plans, all medical students in the UK would be granted full registration to practise medicine upon graduation from university.

However, to secure a place on the Foundation Programme, students must successfully pass a new national entry exam, ensuring only suitable candidates work in the National Health Service (NHS).

The exam is seen as one way of improving the quality of foundation trainees entering employment within the NHS. HEE argue that the proposal will “shift the moral imperative from the promise to medical students into a promise to patients for the highest quality care from the best candidates entering UK training.”

However, those who fail to pass this additional exam would be registered doctors able to work either privately or abroad. Therefore, medical graduates would no longer

need to begin their medical careers within the NHS in order to gain full GMC registration to practice. They would not be left as they are now without a registered professional qualification.

In concordance with the recent Shape of Training review, the report aims to provide a permanent solution to the oversubscription of the Foundation Programme. Currently, only upon successful completion of the Foundation Programme can junior doctors achieve a full licence to practise in the UK. 2014 will be the fourth consecutive year that the programme has been oversubscribed, and the demand for places on the programme is likely to continue with medical students applying from UK and European medical schools as well as the development of private medical schools.

The mantra of the report is that HEE ‘must ensure that medical trainees who are competent and able to complete training programmes successfully are supported to secure full registration.’ This is in sync with the Shape of Training review, which advocates for early GMC registration for medical schools after graduation from medical school.

Previously, the National Health Service (NHS) has created extra places, increasing costs further. Last year, 160 more places were added to the programme, however the report highlights how this is an unsustainable solution, and the introduction of the entry exam is the preferred option for HEE. If the proposal is approved, fundamental changes will be required to the Medical Act, resulting in a major change

to recruitment and training of junior doctors within the NHS. The report states that a decision to proceed should be taken as swiftly as possible, ensuring that the changes to the Medical Act can be enacted as part of the Law Commission review of regulators in 2014. There will also be a three-month consultation on the final proposals, and it is believed that it could take five years to implement.

The intention is to make a transition away from the ‘moral obligation’ school of thought and towards improving the standard of medics joining the NHS. But will the proposal simply act to reduce spending and save costs, or will it act towards improving patient care?

The BMA Medical Schools Committee (MSC) have expressed concerns over this very point.

Co-chair, Harrison Carter, highlighted the fact that despite HEE claiming improvements in patient safety, the worry remains that ‘reducing basic medical education by a year will result in the opposite.’

He added, rather worryingly, that ‘The proposal could also mean that medical graduate unemployment is more likely, with more applicants to the foundation programme being possible from those outside the UK and Europe.

This would be an enormous waste of both public and student investment in medical education.’

Of further concern is the potential ending of the fouryear graduate-entry medicine programme, as losing the extra year could disqualify the courses from meeting the European minimum length of basic medical training (by in-

cluding the foundation year one).

MSC co-chair Andrew Wilson asserted: ‘A number of safeguards need to be in place if this proposal is to work for patients, for medical graduates and for medical education.’

A fear amongst medical student committees is the lack of evidence to suggest that an additional national exam would be of any benefit for graduating medical students, patients and the NHS as an entity, and there are queries as to whether this proposal is likely to solve the oversubscription of the foundation programme.

I suppose the real question is, will it work? TMS would love to hear your views regarding this proposal. Send forward your thoughts to news@medicalstudent.com and we’ll publish them next month!

theMEDICALSTUDENT / January 2014

News Editor: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

D

[Editor's Letter]

uring my first day at UCL I remember looking at my new ID card and noting the expiry date: 2016. It seemed so far away as to be difficult to imagine.

Things would be so different, I will have learnt an awful lot and will feel ready. As the clock ticked over to midnight and we entered 2014, I had my first unnerving feeling that the cushion of time was wearing thin. In two academic years I will be thrown out onto the wards, expected to make decisions about the care of real patients, with real diseases. This is, of course, what I signed up for but it is somewhat unsettling all the same. It made me realise that, actually, being able to simply tag along on the ward round, leave for

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an early lunch, have absolutely no responsibility for the care of any patients and enjoy an uninterrupted two week break for Christmas is something I may well miss when I do, all being well, finally become a doctor.

It’s tempting to see exams as being one of a seemingly endless series of hoops to jump through en route to the end goal of qualifying. The truth is, even when we become FY1s, according to the Francis report, we will only be the ‘eyes and ears’ and not have that much responsibility, so we relish moving on to the next stage. We wait, do more exams and become registrars.

After tiring of that we work to the bone to get our CCT and reach the ultimate aim of consultancy. It is all too easy to get

[NEWS] stuck in the race of becoming a consultant, only to see that an auspicious time in our life has passed us by. Perhaps we would do well to appreciate exactly where we are, and all the benefits that come with it, since we won’t have that opportunity again.

In light of this, how can we make the most of our time at medical school? And just how do some students manage to squeeze so much in alongside their studies? We take a look in Doctors’ Mess this month (p.18).

Not long ago, having a degree in medicine was seen has a key to a guaranteed job.

With the impending opening of a number of private medical schools, will we see that guar-

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antee go? Find out on page 4.

I think all medical students have day-dreamed about being the hero in a medical emergency, but how would we really act if the situation presented itself? And how likely would we be to perform the task well?

Daryl Cheng takes a look on page 8.

We have a number of excellent articles in Comment about the dangers of targets and binary goal setting (p.13), as well as a report from the recent GMC conference at Manchester (p.10) Sarah, our edication editor, has come up with a list of 19 medically-related resolutions for us to start the year with and, as usual, we finish the issue with our prize crossword.

2014 sees cuts to SGUL’s graduate entry course Chris Smith News Editor St George’s University of London (SGUL) medical school is reducing the graduate entry course from 120 places in 2012 to just 50 offered in 2014.

SGUL blames the impact of the recent tuition fee changes (i.e. the increase to £9000) and uncertainty over future government funding.

Since 2012, graduates now have to contribute £3,375 towards the first year of tuition fees.

There has also been concern over an EU ruling that could have invalidated all graduate entry medicine courses in the UK. The school intends to increase places on the undergraduate course to partially

compensate the loss of places.

A spokesperson, quoted in the sBMJ, said the five year course is a more accessible course than graduate entry course, since it “can be targeted at schools with low higher education participation rates and students from families or neighbourhoods with no history of university experience.”

Graduate entry medicine has been uncertain for a while, with many predicting a drop in applications post 2015 as the first group of graduates consider applying with £27,000 of debt.

SGUL’s spokesperson said: “We anticipate that graduates already carrying a significant burden of debt will be less inclined to enrol on a medical course and incur additional tuition costs.”

Kate McFarlane, Student Finance and Bursary Manager at QMUL, says the worst is yet to come for current graduates, predicting that “students on the £9K fees” will struggle to support themselves “when they are mid-way through their course”.

This is not the first graduate entry course to face cuts. In 2012, Barts and the Royal London Medical School made the decision to close the graduate entry dentistry course due to rising costs and concerns over future funding.

With places dropping nationally, this had led to increasing competition between school leavers and graduates for undergraduate offers.

The government has yet to provide reassurance to the funding concerns of medical schools and students. They have agreed to continue to support graduates starting in 2013 and 2014 through the NHS bursary and student finance system, however no agreement past 2014 has been secured by the BMA. There are currently 15 medical schools in the United Kingdom that offer graduate entry medicine and dentistry.

theMEDICALSTUDENT / January 2014

News Editor: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

Medgroup Chairs Dheeraj Khiatani & Mark Gregory The festivities are over and we’ve already returned most of our grandparents presents. We hope everyone is feeling refreshed and that the new years resoloutions are already out the window. For the majority of the UH finalists the big finals exams loom. Meaningful lists are being furiously drawn up in preparation and haematology has already been crossed off most of them. For all non finalists however it’s important to take this opportunity to reflect...on the fact that you’re not taking finals and as such can spend your time doing something interesting instead!

The UH medgroup has had it’s second meeting of the year and lots of exciting ideas from all 5 medschools were discussed. The position of UH within wider student representation bodies is high on the list and we are looking at how best we can represent our large cohort of medical students.

On the BUCS front we are still chasing up the outcome of the advisory group meeting, where Cardiff medical schools latest proposal was discused. Furthermore, the majority of UH sporting competitions are this term, so time to brush up on the fitness and get training.

All the best for the new term, and good luck to all the finalists.

GKT President Juliet Laycock Season’s Greetings! Whether you’ve spent the Christmas break overindulging at home, skiing in the Alps, or familiarising yourself with the library – I hope it’s been an enjoyable one.

GKT certainly saw 2013 out with a bang. The festive highlights included the MSA Xmas Show, the Christmas Party, and a very successful Jingle RAG. Congratulations to Fresher Katie Thompson for raising the most money that day with a brilliant £666.87 total.

As we enter 2014, it’s time to start thinking about resolutions,. This year the MSA are taking part in Dry January. For every GKT student that successfully abstains from alcohol for the 31 days of January £10 will be donanted to GKT RAG! Check out our page here: http://uk.virginmoneygiving.com/fundraiser-web/ fundraiser/showFundraiserProfilePage.action?userUr l=kclmsadryjan&isTeam=true Upcoming events: GKT vs Barts: RAG Refreshers @ Concrete: 10th Jan (Time for GKT to show those Eastenders how it’s done!)

MSA Musical Theatre Presents: RENT: 22nd-24th Jan GKT’s Got Talent and GKT RAG Week Happy New Year to you all!

RUMS President Swathi Rajagopal Happy New Year RUMS! Hope you’ve all had a lovely Christmas break, caught up on plenty of sleep, and been nourished with mince pies.

Firstly I would like to congratulate everyone on their successes of 2013, both academically and in extra-curricular activities. We would not be able to call ourselves the best medical school in London without your enthusiasm, commitment and energy so bring on more for 2014 and let’s make it an even better year!

How will RUMS top freshers’ fortnight, sports team successes, balls and the charity calendar of last term I hear you ask? Fear not, RUMS exec will be bringing you more spectacular and more outrageous events including taboo fortnight in February, sports ball, a new big charity event and of course, summer ball.

Before all that, the first date for your diary, and an annual tradition, is Bill Smiths, which will be taking place at the famous location of Regents Park on 15th January at 2pm. Hope to see you there.

Lastly, I would like to wish our final years a great time on their elective, or a welcome back for those who have just returned, with a quick reminder to submit yearbook entries at www.gradfinale.co.uk/ students/register - the deadline is looming!

SGUL President Mohammed Amer We’ve had a hectic month here at George’s, we had our famous show season, with 3 shows in 4 weeks! Diwali show gave us a talented combination of singing, acting and dancing that made for a truly fantastic show full of artistic backdrops, props and decorations to the theme of ‘The Wizard of Oz’. The rather confusingly named dance show ‘The Fashion Show’ presented a scrumptious Charlie and the chocolate factory theme that was located in the bar with the famous (or rather infamous) underwear dances! Following that we had the revue Christmas show, where students were teary with laughter following a range of hilarious jokes aimed around university matters. This was just a warm up to the UH revue, where we will be keen to snatch that trophy back from GKT! Our Christmas disco followed, where an ice vodka luge, bucking reindeer and Santa’s grotto went side by side with some Christmas tunes that got everyone in the festive mood! In the near future the Students’ union will be rallying students to get involved with various sub committees and be putting on a competition to design their ideal SU games-room! We also have our Traffic Light Disco to welcome back our students this Friday, before most people go into exam hibernation and bury their faces in books till early February. Good Luck to all students with exams!

[NEWS]

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ICSM President Steve Tran Welcome back and I hope you’re enjoying 2014 so far!

After such a eventful first term, I trust you’ve all been able to charge your batteries over the Christmas holidays and started the first steps towards fulfilling your New Year Resolutions…

At ICSM, the partying continues this month, kick starting with our annual ‘New Year Resolution’ event organised by the ICSM Summer Ball Committee. This year we will be celebrating the start of 2014 in style at Jewel Bar. In addition to this, this event also coincides with the end of our freshers’ first formative exam at medschool and our third years’ Law and Ethics exam.

However the biggest event that we are all looking forward to in January is our RAG Week, commencing on the 27th January. All the favourite events are back including RAG Games and Invasion as well as the biggest event of the ICSM calendar: Circle Line. A whole day devoted to charity and other merry activities. This year we are fundraising for Dacorum Mencap and I wish Erika and her RAG committee the best of luck with all the organising for such a worthwhile charity.

Until next time, enjoy January! Except you GKT (The immaturity of ICSM has been noted - Ed.)

BLSA President Ali Jawad A great big welcome back to everyone, and a Happy New Year! 2013 was a great year down at BL, and everything planned that’s on the horizon seems to indicate a great 2014. Hopefully we can continue the successes in sports, societies, volunteering, RAG and so much more. The New Year sees a change with the Students’ Association Building.

Amongst a few things, a new multi-faith space has been established where students can practice their faith in a convenient and inviting space.

We will also see the always-anticipated RAG week in February, with the annual Fashion show, and BLAS’s Elegance also taking place this term...very exciting stuff! The Surgical Society are also hosting their 3rd national conference this term and I’m sure they’ll follow the pattern set by our other outstanding societies and their conference so far this year.

Lastly, good luck to the finalists who’ll be hearing back about their SJTs soon, and of course preparing for the almighty task that is finals towards the end of the term. I’m sure they’ll be fine…

theMEDICALSTUDENT / January 2014

News Editors: Chris Smith and Krishna Dayaji news@themedicalstudent.co.uk

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Will private medical schools create the first generation of unemployed doctors?

Chris Smith News Editor The first cohort of students to study for a medical degree at the independent University of Buckingham will start in January 2015, with each student paying fees totalling £157,500.

The MB ChB will last four-anda-half years as part of a partnership with Milton Keynes NHS Foundation Trust. University of Buckingham’s tuition fees are significantly lower than the estimate of £269,000 to train an undergraduate medical student produced by the British Medical Association (BMA), so the quality of training will be closely watched by the General Medical Council (GMC).

State-funded medical schools cannot accept more than 7.5% of their total intake from non-EU applicants, a figure set by the Department of Health and the Higher Education Funding Council for England. However, the University of Buckingham has no cap on overseas students and the first intake is anticipated to be composed of around 75% international students.

A Buckingham University spokesperson said its course was not part of the number controls imposed by the government. This could mean extra medical graduates competing for

foundation programme places, raising the prospect of medical unemployment.

The University of Central Lancashire (UCLan) has submitted an intention to open a private medical school for September 2014, to the GMC, with tuition fees of £32,500 a year. It will be the full five year course in partnership with East Lancashire Hospitals NHS Trust. The course is aimed at predominantly overseas students who “have a lack of opportunities in their own country” says UCLan’s Professor StJohn Crean, Dean, School of Medicine and Dentistry.

In 2012, the GMC expressed concerns that the influx of privately educated medical students would impact on training places, and the subsequent ability of trainees to register.

Training posts for doctors were cut by 2 per cent last year, yet in England the demand for places is expected to continue to rise with more applicants from Europe and the development of private medical schools.

There were almost 300 more applicants than foundation programme places this year, the third consecutive year of oversubscription. The government had to create 132 extra places in England to ensure no doctor was without a foundation job. The government

Follow A Second us: Krishna Dayalji News Editor As the first cohort of final year medical students were preparing to sit the Situational Judgement Test (SJT), it was announced in November 2013 that those students attaining an exceptionally low SJT score would be given the chance to attend a face-to-face meeting in which the low score would be reviewed.

This change came about after intense lobbying from the British Medical Association (BMA) to introduce a system of reprieve after 12 UK medical students were withdrawn from the national application process after obtaining a low SJT score last year.

In previous years, those with an exceptionally low SJT score were

has made no agreement to honour this arrangement for 2014.

The BMA has also identified the fees for private tuition as a threat to the efforts to widen participation to medicine. BMA medical students committee cochair Alice Rutter condemned Buckingham University saying it did ‘nothing for workforce planning or for widening access to the profession’.

Andrew Wilson, the BMA

medical students committee cochair, added: “We fear it could pose a direct threat to future jobs of medical school graduates. Not only this, but £35 000 a year fees will be affordable only to those from higher socioeconomic backgrounds, which is detrimental to the ongoing work to widen access to medicine.”

It is already well publicised that 7% of all pupils attend a private school yet they make up 28%

of those studying medicine and dentistry. Private medical schools have attracted the attention of The National Union of Students.

They insist the course would “rank among the most expensive on Earth”, closing it to all but the wealthiest students.

The GMC will undertake multi-year quality assurance reviews of Buckingham University. They declined to comment on the status of the application by UCLan.

Lifeline for Medical Students

withdrawn from the national process and not provided with any opportunities to review these scores.

In concordance with Health Education England, the BMA argued that more research was required into the validity of the multiplechoice test, especially since it was being implemented for the first time last year.

The SJT score is a key determinant in the Foundation Programme application process, in which it is used to assess the performance of applicants against the attributes required to work as an F1 doctor. It was believed that those achieving a low score do not meet the requirements of the national Foundation Programme person specification.

Now, those with low SJT scores of at least 2.5 standard deviations from the mean will have their application reviewed.

The UK Foundation Programme Office (UKFPO) will inform those attaining a low score on 10 March 2014 that their application has been removed from the national application process. However, these students twill have he opportunity to attend a face-to-face meeting with two panel members to review the low score. Details of the venue, timings and the interview itself will be sent to the individuals concerned on that day. Students will need to confirm their attendance by 17 March 2014. The interviews will take place across the UK on 31 March 2014. For those students who are either living abroad or on electives, UKFPO will be providing the opportunity for video/Skype interviews on the same date. Only those students with extenuating circumstances will be able to attend face-to-face interviews on 10 April

2014.

Following the interview, there will be a period of mediation where the individual’s review application will be discussed, the outcomes agreed and then forwarded to the UKFPO national director who will make the final decision – to re-instate or withdraw the individual’s application.

The decision made by the panel will be final and students will not be able to appeal the decision. If the decision made is not in favour of the student, the application will be withdrawn from the national process. However, students are free to re-apply to the Foundation Programme the following year and retake the SJT. Elated with the decision, BMA Medical Students Committee (MSC) joint deputy chair, Samantha Dolan, added: ‘The SJT alone

should not determine whether students pose a risk to patient safety when they have achieved the required competencies during several years at medical school. These students deserve another chance to prove themselves capable of working as doctors.’

DATES DIARY:

FOR

YOUR

10 March 2014: SJT result released 17 March 2014: Deadline for attendance confirmation 31 March 2014: Face-to-face interviews

theMEDICALSTUDENT / January 2014

News Editors: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

[NEWS]

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A New Direction for MI

Research In Brief UNIVERSITY COLLEGE LONDON Researcher at UCL have discovered a gene causing neuromuscular disorders in children. In combination with the University of Leeds, they have identified a novel mechanisms responsible for childhood onset of neuromuscular diseases with associated brain involvement. Published in Nature Genetics, the group identified mutations in the gene MICU1. They used exome sequencing on 15 children with similar clinical symptoms, finding two different mutations of the MICU1 gene. The protein product of the MICU1 gene is found in mitochondria, with impairment having severe effects on the nervous and muscular system of the patient.

IMPERIAL COLLEGE LONDON Imperial College London has been awarded funding to establish four centres of excellence in health protection by The National Institute for Health Research. The units, partnered with Public Health England, will provide centres of excellence in multi-disciplinary health protection research.

KING’S COLLEGE LONDON Scientists at KCL have identified two distinct types of fibroblasts in the skin of mice: those found in the upper layer for the formation of hair follicles and those in the lower layer, for repairing skin damage and producing collagen. It was previously believed that all fibroblasts are the same. The research could pave the way for treatments aimed at repairing injured skin and reducing the impact of ageing on skin function.

BARTS AND THE LONDON SCHOOL OF MEDICINE AND DENTISTRY Queen Mary University of London have found a way to influence specialisation of stem cells. Researchers have found that growing adult stem cells on microgrooved surfaces disrupts interactions that determine the length of their cilia. This change in length ultimately leads to a change in behaviour and subsequently influences the differentiation of the cell.

ST GEORGE’S, UNIVERSITY OF LONDON New research has shown that the non-hallucinogenic components of cannabis could act as effective anti-cancer agents. The team has carried out laboratory investigations using a number of cannabinoids, either alone or in combination with each other, to measure their anti-cancer actions in relation to leukaemia. This latest research is part of a growing portfolio of studies into the medicinal properties of cannabis by the research team at St George’s.

Suburno Ghosh Guest Writer Myocardial infarctions (MIs) occur when a coronary artery becomes partially occluded by a blood clot, leading to the area of myocardium being supplied by the occluded artery becoming infarcted. MIs are divided into 2 types according to severity. A ST segment elevation myocardial infarction (STEMI) is the most severe type of MI as cell death occurs in most of the myocardium area that is being supplied by the affected artery.

Currently, the gold standard treatment strategy for STEMI is primary percutaneous coronary intervention (PPCI). This treatment option centres on mechanically restoring blood flow and salvaging functional myocardium.

Consequently PPCI reduces infarct size, preserves left ventricular ejection fraction (LVEF) and prevents the onset of heart failure. Unfortunately the immediate restoration of blood flow is not without its problems as the rapid return of blood flow causes a localised acute inflammatory response that damages the endothelium and the myocardium. This reperfusion related damage (termed

‘reperfusion injury’) is thought to account for approximately half of the final infarct size.

Although the introduction of PPCI, in conjunction with other therapies, has significantly reduced mortality at 30 days, considerable mortality and morbidity rates still exist. Infarct size is a key determinant in the prognosis of acute myocardial infarction therefore there is a clear need to identify additional therapies that specifically target ischaemia-reperfusion (I/R) injury with the aim of infarct size reduction and improvement in outcomes. In preclinical models, a number of treatment strategies have been shown to be effective in reducing I/R injury, however the translation of these agents has been disappointing with no current treatment available to reduce I/R injury.

Exciting and novel research being conducted by the William Harvey Research Institute (in collaboration with the London Chest Hospital) is currently assessing the safety and efficacy of infusing sodium nitrite during PPCI. Much preclinical evidence has demonstrated the cardioprotective effects of nitrite after AMI. Indeed the first demonstration of nitrite’s cardioprotective effects were in

2004 when administration of nitrite either prior to or at reperfusion decreased infarct size, as well as improving other parameters, following I/R insult (Webb A, et al. Proc Natl Acad Sci USA 2004).

Since then much laboratory based data has been published confirming the beneficial effects of nitrite in myocardial I/R injury models.

It is thought that these effects are mediated through nitrite’s ability to be converted to the important signalling molecule nitric oxide (NO).

This area of research has now reached an exciting point of potential translation into the clinic.

Using a randomised, single-centre, placebo-controlled study design, investigators are trying to determine whether intracoronary nitrite injection reduces infarct size in patients that have presented with STEMI undergoing PPCI (Jones, DA, et al. BMJ Open 2013). Sodium nitrite or placebo is injected through an over the wire balloon distal to the coronary artery occlusion, prior to reperfusion during the PPCI procedure. This is the first clinical study of its kind and it is hopeful that results from this trial will identify a potential new simple solution to the problem of I/R injury.

theMEDICALSTUDENT/January 2014

News Editors: Chris Smith and Krishna Dayalji news@themedicalstudent.co.uk

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Trade Unions Strike Again for Pay Rise Krishna Dayalji News Editor This winter saw University and College Union (UCU), Unison, Unite and EIS go forth with another day of strike action. University employees from across the UK, ranging from lecturers to researchers and library staff to administrators, lined up together hand-in-hand at the picket line to fight for a modest and affordable pay rise.

The second one-day national strike took place on 3rd December2013 following refusal from employers to improve the 1% pay rise offer. The issue herein lies in the fact that this offer represents a 13% pay cut in real terms over the last four years, since October 2008.

It is believed that more than 4,000 workers are currently paid below the Living Wage (£7.65/hour or £8.80/hour in London).

On the other hand, the employers say the offer is ‘sustainable, fair and final.’

The first nation-wide strike took place on 31st October 2013 with the aim of obtaining a significant improvement on the employer’s 1% pay offer. The decision to go ahead with the second strike came after the employers refused to increase their pay offer at a dispute meeting held on 20th November 2013.

The walkout resulted in cancellation of classes and seminars, and the closure of many key teaching facilities and libraries.

Whilst supporting the trade unions in their fight for fair pay, the National Union of Students (NUS) highlighted their concerns about the unnecessary and serious impacts of the industrial action on students, in terms of assessments and the ability to graduate.

They point out that it is “entirely possible to undertake industrial action in a manner which limits negative impacts on students, and which actually encourages active support from students”.

UCU general secretary, Sally Hunt, added: “The strength of support for this action by staff has meant it has not been business as usual at many of our colleges and universities. Staff have reached rock bottom with massive pay cuts over a long period yet they see their institutions ploughing money into new buildings and giving those at the top six-figure salaries.” The industrial action was seen a last resort She added: ‘What we are asking for is a modest and affordable pay rise to reward those who are the backbone of our post-16 education system and who have made it the success story it is today.’

On the other side of the debate, university employers and the government alike believe the pay cuts are a reflection of the overall cuts and financial constraints facing the education institutions. Government spending on higher education and further education institutions has decreased by 25%. In their eyes, the in-

dustrial action increases the burdens of non-teaching staff and non-union members to reduce the disruption to the education and training of students, whilst also undermining the reputation of colleges.

Despite these comments, Unison’s higher education service group executive plan to highlight the pay inequality

within the sector throughout January alongside seeking to co-ordinate any further action with other trade unions in February 2014.

In accordance with NUS, despite what the future holds,” a speedy resolution” to the current dispute is needed such that “a fair and sustainable settlement”

Write for Us! The Medical Student is always looking for keen writers to get involved with the paper, if you have an idea for an article, big or small, don’t hesitate to contact us: editor@themedicalstudent.co.uk

[FEATURES]

theMEDICALSTUDENT/January 2014

Features Editor: James Wong features@themedicalstudent.co.uk

Legal Highs Narmadha Kali Vanan The term ‘legal highs’ has been making its rounds in the newspaper headlines as of late, with two such substances (black mamba and methoxetamine) being classified as Class B substances under the Misuse of Drugs Act 1971 and with the unpleasant statistic of the increasing number of deaths due to legal highs.

What are legal highs? They are substances which mimic the effects of better known drugs such as cocaine, ecstasy and cannabis but are structurally different enough from controlled substance to not be classified as controlled substances under the Misuse of Drugs Act 1971. This means that these substances can be marketed to the general public without risk of legal complications. Although

they are not allowed to be sold for hu- man consumption, they are usually advertised as bath salts or plant fertilisers. Some of these substances are known by their brand names such as Ivory Wave while others are known by their chemical names.

The popularity of legal highs can be attributed to the fact that they are readily available online, with a simple Google search giving me many websites from which to choose from. One of these web-

sites even had ongoing offers, gift vouchers and loyalty points up for grabs. With websites like these around, legal highs are just a few clicks away, with an online transaction to pay for it and free delivery of the goods to your doorstep.

The main problem with the legal highs lies within the fact that it is a highly unregulated industry. Impurities could be added to bulk up the product, hence cutting down on the actual drug content itself, allowing the dealer to make a larger profit. Analysis of certain

samples of these substances has also shown that they contain controlled substances.

All in all, this means that the use of legal highs could lead to unexpected and undesirable side effects since you can never tell what it is in the product.

The lack of research in terms of the side effects of legal highs, especially in the long term, constitutes another danger of the usage of legal highs. The varying strengths of legal highs may also results in different effects of the drug itself. The main effects of all psychoactive substances can be divided roughly into three categories, being stimulants, sedatives and psychedelics.

Stimulants can make a person feel euphoric and induces feelings of anxiety, panic and confusion. A person often feels quite low after stopping the usage of a stimulant.

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Sedatives can cause drowsiness and reduced concentration and its use can lead to unconsciousness, coma and death especially when combined with other sedatives or alcohol. Psychedelics induce hallucinations and create strong dissociative effects, making the user feel like their mind and body are separated. This leads to impaired judgement which may cause an individual to act recklessly and put themselves in danger.

There is a vast spectrum of the characteristics of users of legal highs, which applies to controlled substances as well, with one time users who may have tried it once at a party or long term users who have developed an addiction.

Help is available no matter what category an individual may fall in.

For example; FRANK, a national drug education service jointly run by the Department of Health and the Home Office provides a 24/7 confidential helpline for people seeking advice and treatment about legal highs and drugs in general.

almostadoctor app- Almost Worth it?

Devon Buchanan Guest Writer The almostadoctor app is a general references for medicine, launched on the Apple App Store in December 2013, it contains the same information as a website by the same name which has existed since 2009. It covers lots of systems, specialities and clinical skills, much like the Oxford Handbook of Clinical Medicine or Kumar & Clark. Unlike these books, the almostadoctor app and website are the product of only around twenty young doctors and medical students, and everything is being made available for free. (The website is free, but the app currently costs £1.49.) I wanted to see how useful the app could be, by considering how well I could navigate with the app and how useful its contents were.

The apps main competition is its own website -- it has to convince you to pay £1.49 for something you can get for free. It tries to do this by being faster and

easier to navigate than viewing the site in a phone web browser.

It succeeds at having fast navigation. On my modestly powered iPhone 3GS the app starts up in 1-3 seconds and loads articles in around a quarter of a second.

You’re not likely to be put off this app by loading spinners. Search results appear after each character you type, so you usually only need to type the first four or five characters of a topic to navigate to it. This makes the app feel even faster to navigate around.

However the search

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only looks at page titles, so you’ll find queries like “STEMI” and “MI” will produce no useful results, then you’ll have to guess what title the authors put the information under (hint: it’s under “myocardial infarction”). Version 2.0.0 of the app is also prone to crashing while searching. For example, the app can crash if you tap a search suggestion while an auto-correct balloon is on screen.

These are bugs that will hopefully be fixed in future updates.

The app is also easy to navigate. It uses un-

derstandable icons and standard navigation behaviour, so it’s never confusing how to do something. The app’s “home page” is a weird knock-off of the iOS home screen, but this excessive decoration is limited to only that screen.

The app also bizarrely hides the status bar that normally displays the time, something no other apps like this do, so I found myself quitting and re-launching the app just to check the time.

Though it’s important for the almostadoctor app to be fast and easy to use, the text it contains is what students care most about, and will spend the most time looking at. The apps contents can be summarised as “revision notes written by medical students”. It contains the minimal information needed on a subject and I think is therefore more suited to checking you haven’t missed something or revising than acting as a primary source of learning. Contrast this with a reference text like Kumar & Clark. These have information that isn’t immediately important to patient care but which I think is important in my learning. The

extra information allows me to understand topics and therefore remember things better than if I only attempted to memorise a list. This meant that instead of learning from the almostadoctor app alone, I used it help me pick out which parts of longer reference texts were important, and which were not right now. This is the sort of thing I could also learn from practicing clinicians, for example by asking them “what are the most important differentials for nephrotic syndrome” then focussing on just those. But the almostadoctor app offers an additional place to receive such suggestions, one that might be easier to get hold of on some occasions, such as preparing for a grand round late at night.

Overall, the almostadoctor app is well made and very useable except for a few inconvenient design decisions and some situations where searching will crash the app. It allows you to read other medical students’ notes, which I found helped me identify what is important to learn from longer reference texts.

theMEDICALSTUDENT/January 2014

Features Editor: James Wong features@themedicalstudent.co.uk

[FEATURES] /8

A perverse fantasy Daryl Cheng Guest Writer It’s another typical journey on the tube at rush hour in the evening. After a long day, you’re just happy to listen to your music whilst your thoughts flit across your consciousness, with you barely paying them any attention.

The carriage is somewhat crowded, but you manage to perch at the end.

The car jolts and comes to an abrupt stop. Some incomprehensible announcement comes over the PA system, with the driver offering a half-hearted apology for the momentary delay. Your eyes drift to catch glimpses of your fellow commuters, gormless, tired, and possibly hungry. In fact, prob- ably hungry. Your stomach growls. Next to you an elderly man is snacking. You eye up his food, and notice he seems slightly alarmed.

He gestures to his partner, wide eyed and pointing to his throat. After pulling out your earphones, to try and calm the gentleman down, delivering the back blows, and when that fails, the Heimlich manoeuvre. Meanwhile, hysterical people around you shout at the wall in an effort to communicate with the driver through the panels.

The blue patient (because at this moment, that’s who he is) collapses in a heap on the floor. The basic life support algorithm is seared into your brain, but inexplicably you pull your biro out of your pocket. You snap it in half, identify the cricothyroid membrane and in one inspired, confident motion, deliver it into the airway.

The carriage fills with rapturous applause. Strangers approach you to shake your hand, and pregnant women vow to name their unborn

child after you. And, scene.

You step off smartly at your stop, passing the gentleman, still eating his peanuts.

It sounds like a cold opening for some bloody medical drama, and that’s probably because that is all it ever should be. We all know it’s a terrible idea, for a veritable smor-

gasbord of reasons. The fantasy serves only to pander to the ego of this sleep deprived and slightly delusional medical student. An emergency cricothyroidotomy is a non-trivial and nerve wracking procedure at the best of times, one that most consultant anaesthetists hope never to do and many may never do.

But suppose some unhinged lunatic forced you, at say, gunpoint, to perform this proce-

dure. What are the chances you’d succeed?

A study by Neill and Anderson (2013) tested this scenario using junior doctors and medical students, none of whom had previously done a cricothyroidotomy before.

Having not been previously trained, they were presented with a clinical scenario similar to the one above. They were then given a No 26 scalpel, a Papermate Flexigrip Ultra ballpoint pen, and wished the best of luck as they were told to place a cricothyroidotomy into an undissected and embalmed cadaver (“as quickly as you feel you can”, the card read).

And how did they do? A total of nine participants performed 14 procedures on 14 different cadavers, and eight of them were classed as ‘successful’, a success rate of 57%.

Only counting their first goes, five out of nine were successful, a comparable 56%.

However, many of the participants caused traumatic injuries in their attempts. The cadaver model itself is not without problems: as anyone who has ever dissected one before will tell you, it doesn’t feel or look much like a body.

The flesh is hard, the skin rubbery, and the blood—well, there isn’t any.

It’s handy to have a ballpark figure, but in no way changes how we should handle emergency situations. In any case, the next time the tube gets stuck at a red signal, you’ll have something to think about.

References 1. Neill, Andrew and Anderson, Philip. “Observational cadaveric study of emergency bystander cricothyroidotomy with a ballpoint pen by untrained junior doctors and medical students.” Emergency Medicine Journal 30.4 (2013): 308-311.

[FEATURES]

theMEDICALSTUDENT/January 2014

Features Editor: James Wong features@themedicalstudent.co.uk

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Gin & tonic anyone?

James Wong Features Editor It was a Saturday, about tea-time in the quaint village of Athelstaneford, East Lothian. Mrs Alexandria Agutter sat in her cottage, enjoying the delights of the latesummer evening with a glass of gin and tonic. She listlessly sipped from the rather generous pick-me up, no doubt chewing over the happenings of the day.

Blast! The taste was much too bitter to her liking. She stood up.

And promptly crumpled to the floor in a dizzied heap. It had not been five minutes when a fiery pain gripped her parched throat and in her frenzied turn she watched the bleary room become draped in a gossamery silk.

How Dame Agatha would approve. But this is no crime novel, on that fateful day, 24th August 1994, poor Mrs Agutter immortalised herself in the history books of forensic medicine; she was the victim of a revered toxin and a vintage one it was too. She had unwittingly imbibed a G&T laced with a classic poison of antiquity.

A clue from the 21st century: do you recall the first Hunger Games film adaption? Those inviting purple-black berries or as Suzanne Collins coined them ‘Nightlock’; a portmanteau of hemlock and Deadly Nightshade. True to the laters’ real life appearance those onscreen fictional fruits played a recurring cameo role.

Deadly Nightshade is a perennial shrub of the family Solanaceae and a relative of the humble potato (a member of the Solanus genus). It is a resident of our native woodland and may be found as far afield as Europe, Africa and Western Asia. The 18th century taxonomist, Carl Linnaeus gave the plant an intriguing name in his great Species Plantarum. The genus Atropa is aptly named after one of the three Greek Fates, Atropos. She is portrayed shearing the thread of a mortal’s life so determining the time and manner of its inevitable end. The Italian species name belladona (beautiful woman) refers to the striking mydriatic effect of the plant on the eye. The name pays homage to Pietro Andre Mattioli, a 16th century physician from Sienna, who was allegedly the first to describe the plant’s use among

the Venetian glitterati - ladies of fashion favoured the seductive, doe-eyed look. Belladona is poisonous in its entirety. It was from the plant’s roots in 1831, the German apothecary Heinrich F. G. Mein isolated a white, odourless, crystalline powder: it was (surprise, surprise) atropine.

Atropine is a chiral molecule.

From its natural plant source it exists as a single stereoisomer Latropine, which also happens to display a chiral potency 50-100 times that of its D-enantiomer.

As with many other anaesthetic agents it is administered as a racemic mixture. How strange that atropine now sits among the anaesthetist’s armamentarium, its action as a competitive antimuscarinic to counter vagal stimulation belies its dark history. It was a favourite of Roman housewives seeking retribution against their less than faithful husbands and a staple of the witch’s potion cupboard. Little wonder how belladona became known as the Devil’s plant. Curiouser still it’s also the antidote for other poisons, most notably the organophosphates or nerve gases.

On account of its non-selective antagonism, atropine produces a constellation of effects: the inhibition of salivary, lacrimal and sweat glands occurs at low doses; dry mouth and skin are early markers. Pyrexia is a central effect exacerbated by the inability to sweat. Flushing of the face due to skin vessel vasodilatation. Low parasympathetic tone causes a moderate sinus tachycardia. Vision is blurred as the eye becomes dilated, unresponsive to light and accommodation is impaired.

Mental disorientation, agitation and ataxia give the impression of drunkedness or a delirium tremens like syndrome. Visual hallucinations, often of butterflies or silk blowing in the wind, are a late feature.

It was then that Mr Agutter, seemingly untroubled by the sight of his wife’s problematic situation, proceeded to leave a message with the local practitioner. How fortunate they were to have the vigilant locum check the answering machine and come round to the Agutter’s lodge accompanied by an ambulance crew. The attending paramedic had the presence of mind to pour the remainder of Mrs Agutter’s

beverage into a nearby jam jar, while Mr Agutter handed over what he suspected to be the offending ingredient: the bottle of Indian tonic water. As it soon transpired there were seven other casualties in the surrounding countryside of East Lothian – all involving an encounter with tonic water.

In fact by some ironic twist of fate, two of the victims were the wife and son of Dr Geoffry Sharwood-Smith, a consultant aneasthetist. Obviously very familiar with the typical toxidrome of anticholinergic agents, he was quick to suspect atropine poisoning. Although for a man of his position with daily access to a sweetshop of drugs, it was not something to draw attention to.

Through no small amount of cunning had the poisoner(s) devised the plan. It was elegant; atropine is very bitter. So much so that it can be detected at concentrations of 100 parts per million (0.001%). Those foolish enough to try the berries of belladonna during walks in the woods are often saved by the berry’s sour taste. They are soon spat out.

But the quinine in the tonic water was a worthy disguise.

The lethal dose for an adult is approximately 90-130mg, however atropine sensitivity is highly variable. In its salt form, atropine sulfate, it is many times more soluble: >100g can be dissolved in 100ml of water. So 1ml may contain roughly tenfold the lethal dose.

There ensued a nationwide scare; 50 000 bottles of Safeway branded Indian tonic water

were sacrificed. Only six bottles had been contaminated. They had all been purchased, tops unsealed, from the local Safeway in Hunter’s Tryst. Superficially this looked like the handiwork of a psychopath with a certain distaste for the supermarket brand, and amidst the media furore, it did have some verisimilitude: one of the local papers received a letter from 25 year old, Wayne Smith admitting himself as the sole perpetrator.

The forensic scientist, Dr Howard Oakley analysed the contents of the bottles. They all contained a non-lethal dose, 1174mg/litre of atropine except for the Agutter’s, it contained 103mg/litre. The jam jar holding Mrs Agutter’s drink bore even more sinister results, the atropine concentration was 292mg/L. It would appear Mrs Agutter had in some way outstayed her welcome. But she lived. A miscalculation on the part of the person who had added an extra seasoning of atropine to her drink. According to the numbers she would have had to swallow a can’s worth (330ml) to reach the lethal dose.

Thankfully she had taken no more than 50mg.

The spotlight suddenly fell on Dr Paul Agutter. He was a lecturer of biochemistry at the nearby University of Napier, which housed a research syndicate specialising in toxicology . CCTV footage had revealed his presence at the Safeway in Hunter’s Tryst and there was eye witness evidence of him having placed bottles onto the shelves. Atropine was also de-

tected by the forensic investigators on a cassette case in his car.

Within a matter of two weeks he would be arrested for the attempted murder of his wife. Despite the calculated scheme to delay emergency services and to pass the blame onto a non-existent mass poisoner, he had not accomplished the perfect murder. Was there a motive? Allegedly his best laid plans were for the sake of a mistress, a mature student from Napier. He served seven years of a twelve year sentence. Astonishingly, upon his release from Glenochil prison in 2002, he contacted his then former wife proclaiming his innocence and desire to rejoin her in their Scottish home. A proposition she was not very keen on.

Dr Agutter was employed by Manchester University as a lecturer of philosophy and medical ethics. He is currently an associate editor of the online journal Theoretical Biology and Medical Modelling.

We will never know the true modus operandi as Dr Agutter never confessed to the crime.

Perhaps all this story can afford is weak recompense for the brave followers of the Dry January Campaign. Oddly these sort of incidents never appear in their motivational testimonials.

Acknowledgements 1. Emsley J. Molecules of Murder. 2008, Cambridge, RSC Publishing, p.46-67.

2. Lee MR. Solanaceae IV: Atropa belladona, deadly nightshade. *J R Coll Physicians Edinb*. March 2007; 37: 77-84.

[COMMENT] /10 A Few Points to Consider for 2014 theMEDICALSTUDENT / January 2014

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Rob Cleaver Comment Editor Another year has passed and we are all a little older, a little more world-weary and perhaps, for a lucky few, a little wiser too.

There are those amongst us who sit on occasions like these and drive biro through paper in search of a new manifesto to live their life by. Agonising by agonising bullet point they resolve to improve themselves before the fireworks have even exploded above them.

I for one am relishing the new year, although whether I am to set myself any resolutions I am not too sure yet. I’m more likely to give myself targets in line with the academic rather than Gregorian calendar - go to more lectures, write up my notes, try

not to spend my time laughing at Buzzfeed lists until no tears are left to be shed. I’m not one to give up the vices so delightfully indulged throughout the festive season.

Last year I wrote under pseudonym in the Doctors’ Mess section about my resolutions to go out and see more of the world. I went to more public readings and more open mic nights. I saw more live music in the capital than I had done the previous two years combined. I succeeded in being that little bit more outgoing in my spare time. I still haven’t been to Hampstead Heath but I got as far as Highgate Cemetery for a nod of my cap to Karl Marx, to George Eliot and to Jeremy Beadle. Perhaps 2014 will be the year I linger on the heath but I won’t set anything in stone oth-

er than the epitaph on my own grave whenever I should happen to arrive there.

The comment section this month has a theme of resolution running throughout, that there are changes we may choose to make to our practices and our protocols that can serve to enrich our ability. We must try not to be too one dimensional in our devotion to our textbooks and nor should we dwell too much on treatment of a condition when we can treat an individual on a personal level as well.

We must also consider our professionalism both in the real world and the vortex of social media so that whoever we targeted and were ashamed of kissing at midnight on the occasion of December 31st 2013 will not affect our fitness to practice.

Professionalism - Whose Job is It? Rhys Davies Staff Writer On a grim December day in Manchester, the GMC held a conference for doctors and medical students entitled Professionalism: Who’s Job is it Anyway? The conference came at an apt time, at the end of a challenging year for the medical profession. The Francis report recommended changes to avoid another scandalous breakdown in care like at Mid Staffordshire hospital; Don Berwick highlighted ways to improve patient safety and innovation; and the Keogh report looked into mortality rates across the UK. All this against the background of the nascent Health and Social Care Act which promises to change the landscape of medicine in the coming years.

The conference was chaired

by BBC health correspondent Fergus Walsh. After sharing his own experiences of the changing face of healthcare in the UK, he handed over to Niall Dickson, Chief Executive of the GMC. As well as the already mentioned events of 2013, he

made note that complaints to the GMC against doctors has increased. However, improved methods of stratifying complaints, coupled with the newly introduced revalidation scheme for doctors, the GMC was doing to identify and help doctors who might be struggling. His vision, he shared, was that the GMC could be carrot, as well as stick, for doctors. There was clearly much to discuss.

The morning was spent in three workshops; examining the reality and the challenges post-Francis and Berwick, and professionalism of the future.

The latter workshop attracted a great deal of medical students, including this reporter. Students from Queen’s University Belfast and Bart’s and the London debated the motion that whistleblowing would ruin one’s medical career. The regulatory and legal pathways and protections for whistleblowers were contrasted against the real life examples of people who have found themselves unemployable after speaking out about poor care. This was followed by a somewhat muddled debate on doctors and social

media between Southampton and Manchester Universities.

Over the lunch break, an extra seminar on social media was tabled. The event was hosted by Dr Anne-Marie Cunningham, a Cardiff GP with a special interest in social media. After helping to clarify the GMC’s social media guidelines, she went on to elaborate on the manifold benefits of social media for doctors and medical students.

These included engaging with other colleagues, to reflect, share and be challenged. She also mentioned several Twitter-based case-based discussion groups such as #GasClass #ECGClass and #Twitfrg.

After lunch, the conference reassembled for a plenary session discussing the subjects of transparency, leadership and the patient voice. The panel comprised of Dr Judith Hulf, GMC Responsible Officer and Senior Clinical Adviser; Ros Moore, Chief Nursing Office for Scotland; Dr Naila Kamal, AoMRC SAS Doctor Committee Chair; Charles Ellis, patient representative; and Professor Ben Bridgewater, University of Manchester. The panel were

in agreement that candour and openness are vital to changing the culture of medicine postFrancis, with Professor Bridgewater noting that it was a shame that transparency had to be forced upon the profession.

On the topic of leadership, there was the suggestion that previously, skills in management were expected to be picked up by osmosis en route to consultantship. This lax attitude is no longer acceptable and we must do more to instil aspects of leadership at every level from medical student upwards.

The final event of the day was a keynote speech on professionalism, delivered the Secretary of State for Health, Jeremy Hunt.

He began with several personal anecdotes of the care he and his family had received by the NHS and he praised the doctors and nurses for their care and devotion to duty. He acknowledged his lack of medical background and his attempts to remedy this by routinely volunteering at the “coal-face” of medicine. It was difficult to marry this genuine and earnest speaker with the Health Secretary who saw the Health and Social Care Act pass

through parliament and who appealed a High Court ruling that it was outside his power to close Lewisham hospital. Hunt described feeling truly humbled by the professionals he has met, and the real hunger in the profession to address the problems of Mid Staffs and change.

Echoing one of the conclusions of the conference, he said, “We must never have a culture where we are sweeping poor care under the carpet,” adding that, “The NHS is a moral being, or it is nothing.”

This seemed an apposite period to mark the end of the conference on professionalism.

The real challenge of the day is ensuring the outcomes of such discussions filter all the way down. In 2014, professionalism cannot just be visible in Royal Colleges and consultants’ offices – It has to be seen in medical student rotations and in the FY1 shifts at 4am. This conference made clear that professionalism cannot be sterile and anodyne – it must be passionate and innovative. 2014 will be a challenging year for the medical profession, but it is a challenge we can surely meet.

[COMMENT] /11 We Mustn’t Stop Being Medical Students When Textbooks Close theMEDICALSTUDENT / January 2014

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Luisa Peress Staff Writer

Illustrated by Alexis Nelson

We are repeatedly told by faculty members, relatives and people we know that as medical students, we are different.

This shouldn’t only mean that once graduated we will probably earn a higher than average salary and wear the esteemed badge on our clothes that says “Dr.”, followed by our surnames.

In my opinion during our university years we should strive to find balance between being driven by academic success and being driven by our personal values. To put it in the words that Doctor Zubin Damania used in his TEDMED Talk in 2012: “If we just kept our head down, followed the rules we progressed to the next step; but each time we did that we lost a bit of our autonomy, we lost a bit of our ability to take risk, we lost a bit of who we were.”

[I am left with the impression that students are prevented from engaging in altruistic activities by academic pressure] We receive a lot of guidance from our institutions as to what we are expected to do in order to successfully complete our medical degrees, but what we do in our free time is entirely up to us. I myself think that as autonomous adults, we should have the freedom to decide what, if any, altruistic activities we engage in. However, I also am of the opinion that we

academic direction. A possible solution to this situation is for staff to support the view of medicine as a broader concept rather than being purely academic. An example is a lecturer pointing out that with good time management, it is possible to be both academically successful and an active member of our communities at the same time. Universities offer a wide range of opportunities to do so and if students notice that this view is shared by staff, it can be a powerful tool for us to reflect on the meaning of medicine and become more active outside of university hours.

[We lost ourselves between routines and tick boxes to proceed to the next stage of our careers]

are too driven by academic pressure.

Having completed my first year as a medical student and acting as a Course Representative in that first year, I am left with the impression that students are prevented from engaging in altruistic activities by academic pressure. At the beginning of the course, faculty members advise students to engage in a couple of extra-curric-

ular activities and to learn how to manage their time well. However, they are often vocal about striving to be academically successful, while remaining silent about extracurricular activities such as volunteering or raising money for charity. The implicit conclusion many of us make is that these activities are counterproductive, because they only take up time that could be used to score higher in exams. For

this reason, students are less prone to do anything that is not accompanied by a certificate that can be added to our CVs, forgetting that life does not offer us documentation for every time we perform a good deed.

I reiterate, I am in favour of students having the possibility to decide how to use our free time. On the other hand, I still believe that academic staff involuntarily steer us in an

This is a plea for you to think back about medical interviews, when most of us spoke about helping others as being part of medicine. Yet, once accepted into medical school, we became too busy following strategies on how to be successful academically, forgetting that medicine is not only about how we perform in an exam. We lost ourselves between routines and tick boxes to proceed to the next stage of our careers. We kept becoming more perfect but less human. It is true, pursuing a career in medicine definitely means making sacrifices, but it is also true that medicine doesn’t require us to sacrifice our passions, humanity and who we are. I believe that we can be academically successful whilst pursuing things that we enjoy and taking an active role in our communities.

Are you still at a loss for a new year’s resolution? Send your ideas and articles to comment.medicalstudent@gmail.com

[COMMENT] /12 Knowledge is Only Half the Battle theMEDICALSTUDENT / January 2014

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Oscar To Staff Writer As doctors, it is our solemn duty to treat our patients to the best of our abilities. However, there are limits to what we can do. Our art is not perfect and we must always be on the lookout to improve. Nonetheless, we also find ourselves confounded by our least likely enemy: the patient that we are treating.

Patients come in many types, from the fully submitting, the educated, and to the horribly misguided. Most doctors will at some point see a patient who would rather take homeopathic sugar pills than trust the tried and tested techniques that an experienced doctor can provide. We respect the choices of our patient, regardless of their delusions, so long as they can understand the consequences of their decision. However, it was not always this way. Respecting patient choice is only a recent development in the long history of medical practice and amongst the elder statesmen of our profession is yet to truly bed in.

[The combination of these factors means that knowledge is no longer a product of a heroic scientist; it is an expensive and specialised industry] There was a time when science was a small and rapidly expanding field; bringing a new age as the impossible became reality. However, as the pace of change intensified, problems became evident. Firstly, the expansion of knowledge meant that an understanding of everything became impossible. Each field has become increasingly specialised, to the point where understanding requires deep study of each separate field. As a result, knowledge now clusters in separate, specialist islands. Understanding things as a whole is no longer possible; we rely on experts to interpret their knowledge for us. Gone are the days where a key discovery led to rapid application.

Knowledge requires stepwise assessment in order to gauge whether it is useful to pursue a greater end. Our reliance on

Illustrated by Alexis Nelson

evidence naturally needs this.

The combination of these factors means that knowledge is no longer a product of a heroic scientist; it is an expensive and specialised industry. The realm of pharmaceuticals is one such industry, which now produces knowledge for profit. This leads to a key issue, if money buys knowledge, how do we discover that which is unprofitable? And is profit truthful?

Clinical trials are expensive and negative results are often unpublished as they appear to show nothing. Yet this has led to a positive selection bias most notably seen in SSRIs, where their lack of efficacy has been shielded by publication bias towards good outcomes. Not to mention that many drugs have outcomes that cannot be foreseen after many years exposure.

[the majority of people at large will find news and information that suits their current viewpoint rather than challenging it] And yet almost paradoxically, we place a great deal of reliance on consultants. The complexities of disease warrants someone experienced enough to know how to react in specific situations. But at these stages, consultants stop relying on evidence; their experience acts as a stamp to allow them to attempt what works best in virgin territory.

The explosive proliferation of knowledge culminated in the internet; a practically limitless fountain of knowledge at our fingertips. This has led to two key outcomes for society.

People have now, more than ever, been able to spread their thoughts and ideas. However, this has not arisen alongside an inquisitive and sceptical viewpoint. Instead, the majority of people at large will find news and information that suits their current viewpoint rather than challenging it. Meeting others with these viewpoints in remote reaches of cyberspace serves to reinforce it, strengthening radical viewpoints. The second issue is that posting on the internet also seems to register as a source of authority. Of course, these people have no

point of reference with which even to dispute their views.

Even more troubling, most people will happily accept these views as justified in some shape or form. Of course, there are already other areas of life such as politics and religion which take these as norms, to the point where it is rude to even dispute them. The information age appears to have ushered in the postmodern, where no facts have basis, as everyone is, to some extent, wrong.

Our trust in doctors stems from an era of magic bullets.

However, this image is increas-

ingly challenged by the rise of chronic disease where current measures offer only symptomatic rather than successful and curative relief.

[A patient is flung about from team to team like a product on a factory line, often with little understanding] Where our field can offer few answers, many others have exploited and, most worryingly, indoctrinated. Alternative medicine is a massive industry based off nothing more than

faith and yet we can learn a lot from why it has succeeded.

A patient is flung about from team to team like a product on a factory line, often with little understanding. It is no surprise that a patient who personally feels failed by medicine moves to its alternative form, with welcoming answers.

We need to ensure that patients get what they need; not by simply curing them, but by showing that we care for them as individuals. Medicine is about treating people not just their diseases.

[COMMENT] Confused in the Crosshairs theMEDICALSTUDENT / January 2014

Comment Editor: Rob Cleaver comment@themedicalstudent.co.uk

Rob Cleaver Comment Editor There’s an ongoing discussion in medicine, in particular, about the efficacy of a target orientated service. Does being seen within four hours in A&E give someone a better experience or does it just mean that when they are eventually seen that the process is rushed and they feel just as anxious as they did when they turned up? Should it really matter how quick the bed turnover on a ward is?

In my opinion a person should be in hospital as long as they need - if they’re medically well but they aren’t safe in their own home then they should not be sent home before everything is checked and everything is double checked. We shouldn’t feel obliged to dump the frail and fragile in the street any more than a policeman has to

quickly make a frail and fragile conviction. The process takes the amount of time that it takes to do a good job. If it takes five minutes then brilliant, if it takes three weeks then that is also a good turn around should the circumstances have required it.

[“Are you in pain?” is never enough. Humans are far more complex than the index of a textbook could ever suggest] The problem is that I feel like the whole of society is preoccupied with targets. Everything is competition, nobody feels satiated any more. We fight amongst ourselves, passiveaggresively, for the best profile pictures on facebook, and we fight amongst each over the amount of qualifications that we get when we should just be encouraging everyone to do as well as they can - as well as they

Dear Doctor..

D

ear doctor, I got yet another stethoscope for Christmas this year. I’m not entirely sure where Grandma keeps finding the £65 or so that has afforded me the complete rainbow-spectrum selection over a period of ten years. How can I tell people that I’m not going to be a cardiologist? Or how can I possible put all of my instruments to good use?

Dr. Dai Astolic-Murma

F

ear not, There are things that experience can teach you. Time has the uncanny ability to allow experimentation and innovation if you let it. There are corners of the cardiology world that would leave a stethoscope here and there, dotted across wards in

drawers and in cupboards, in lab coats and in lockers but I suggest another use. They need not be peppered across a hospital site. Stethoscopes may be designed to reveal signs of illness through careful listening. They too can be used to reveal different kinks that hitherto they have not uncovered. You, your scrubs, your steth and a loved one - the seldom seen night off.

Just make sure not to get your work model confused with your home device. It could be messy.

The Love Doctor

D

ear doctor, One of my resolutions last year was to be more fun. As I went through the year, a gallon of wine here and there, I became more popular with the sports clubs

need to - to be happy.

University has a particularly poisonous culture of competitiveness, where there are those that try to limit the progress of others and I can’t comprehend such a disdain for your fellow man. For a generation so socially aware, so socially able, we do not believe in society as much as we should. Society isn’t just numbers and statistics and thumbs up versus thumbs down, it’s respect and it’s togetherness and it’s joy in variety and diversity. When I hear of students changing wikipedia articles to mislead other students, however true they are (and these rumours always have the basis in truth), I begin to feel let down by a culture so heavily dependent on results and rapid turn arounds, rather than the journey to get there and individual nuances of individual situations.

On firms I’m often left feel-

Have you got a problem? Let us solve it! and have acquired the nickname Mr. Fun. My only worry is that ever since summer my tan has failed to disappear and I have in fact found myself looking more tanned than usual and I can’t lose the belly I’ve developed after all of those late night kebabs.

As a second year medic I feel that I should be able to work out what exactly is wrong with me but I can’t. Have you any ideas?

Mr. Fun

J

aundice That is what is wrong with you. I am very sorry that your enjoyment has come at the price of your body.

You’ll no longer be Mr. Fun, unless of course your new found friends are planning on becoming hepatologists, in which case it would be a perfect opportunity to offer yourself to them as an aca-

ing that patients are placed on and then plucked from a clinical conveyor belt.. They’re seen by a doctor, they’re seen by a nurse, another doctor changes the medication, they’re told they’re leaving, the pharmacist sees them and they’re gone. The ticklist of life has been signed for and they’re free again. At no point are their feelings attended to or dwelt upon. “Are you in pain?” is never enough.

Humans are far more complex than the index pages of a textbook could ever suggest.

[I wish that society was less binary-derived yes-no] Yet, when I leave the hospital grounds, I’m back on a conveyor belt - we all are. The bus. The tube. The nightclub bar queue.

Everything becomes a means to an end, where everything is done to achieve some benefit

demic aid. Either way I think you may need to do a Dryathalon, perhaps until the very end of your life which, if you keep attending sports night with the joy and excitement that you are currently, may actually be sooner than you think. If, by the time of publishing of this response, you are dead after a rather over the top new year then I apologise.

Dr. Nofun

D

ear doctor, I hope this letter finds you well.

I have recently decided that I don’t want to be a medic like my parents decided for me. They’ve spent years and years carving a career out for me. Father used all of his connections to get me good work experience at his best friend’s lab and mother did awfully well persuading the university to accept me despite my three Ds at A Level. I think that going to university has helped me to work out however that I am my own person and need not live my life by their rules.

/13

for ourselves without too much self-destruction. On my way home I may overhear two kids hyperventilating about a facebook status with eighty three likes and I’ll pretend that it’s a ridiculous reaction. Honestly, we’d all notice it, we’d all see the number and be impressed, stalk the person for a moment and then move on.

I wish that society and that social life was less computerised, less binary-derived yes-no and more ‘well perhaps’ and ‘either/or’. I wish I didn’t feel like a cog, rustily clinging to the mechanism hoping to ping free from the hydraulic force pointing me towards a bullseye of isolation - if all we care about is targets, if all we care about is some downstream reward, how are we ever to know whose views we share, whose views we could come to care about and whose targets are as equally lax as our own.

I’ve already freed all the horses and told the gardeners that they deserve more money than they are given but how on earth do I tell my parents that I don’t want to be an emmiment dermatologist at my parents’ private clinic but want to be a bin woman like the aunt that I’m never allowed to see?

The Rt. Hon. India Cambridge-Mountbatten

D

ear madam, As I fear that by offending you I may be hunted down by a Lord Lucan related lynch mob, I think you should move house a few times, head for Hull or somewhere equally undesirable and cut off your parents. Don’t let them ruin your life. If you want to throw bags into a giant crushing device then you should do it. Actually, now I think about it, that sounds a lot more fun than general practice. I may join you.

Dr. I Hatehull

[EDUCATION] /14 Pocket Kumar & Clark: A Review theMEDICALSTUDENT / January 2014

Education Editor: Sarah Freeston education@themedicalstudent.co.uk

Rob Cleaver Comments Editor We often lament in medicine that knowledge gleamed from a textbook often isn’t so easily recalled on the wards and in clinical practice. The large textbooks, behemoths of breadth and wisdom, can teach us almost all that we need to pass our pre-clinical exams but they aren’t as portable as we would hope. Medical Management and Therapeutics, a relative newcomer to the Kumar and Clark series, aims to fill that gap and to provide both the overwhelmed student and the overworked houseman with a pocket-sized assistant for dayto-day use.

At first glance, an inspection from the end of the bed, the book is an equally transportable but better looking cousin to the Cheese & Onion. The book is more slickly bound and has withstood a good few batterings in my rucksack that the rival title would have struggled to endure. The print is larger and there are a greater number of diagrams, graphs and flowcharts to break up the wall of text that the rival is often criticised for. To that end, the hunched, squinting student in the common room may soon be a thing of the past. The book seems more comparable in my opinion however to the Oxford Handbook of Clinical Diagnosis in terms of a management driven narrative albeit fuller fleshed.

This book is ordered by system, symptoms and the most commonly reported conditions within that field of medicine.

Chapters include those on the major systems (cardio, resp, gastro, neuro et al) as well as supplementary passages on emergency medicine, critical care and nutrition. It lays out, in a coherent and logical format, a management and treatment regimen for each condition in turn. When compared to the rival title it is more comprehensive in its coverage and its explanation, something we’ve come to expect from the full, unabridged delight of the Kumar and Clark. The accessibility that the book champions is a major selling point but it did, at times, feel a little too dense and too wordy for the ward.

The book undoubtedly helps to apply the theory to the clinical setting in a way that its larger siblings cannot do. I’ve found it to be a useful guide and a welcome refresher when you’re left grasping for understanding of presentation, management and treatment of a condition you’ve only seen at home in a textbook. It is most able when it is dipped into, from time to time, for reassurance rather than as a steadfast study-mate but that is what it needs to be.

Whether encroaching onto Oxford Handbook territory will be fruitful and whether it has the strength of content and popularity to usurp that well entrenched establishment is yet to be seen but a student’s bookshelf can only be enriched by the inclusion of this title.

2014 - The Year to....

Sarah Freeston Education Editor

there is some value in reflecting about whether you’re making the most of your student days, what a certain situation taught you about yourself and 1. Have a sober January. Join your values or how you could the Dryathlon fun, give your have managed that patient liver some TLC and raise mon- better. ey for Cancer Research.

5. Get more sleep and nap 2. Keep more up to date with at every opportunity. The changes in the NHS. Working warm bodies surrounding life will hit us all too soon and you in a lecture theatre and although politics in general the dimmed lights are all you may elude some of us, no-one need: resistance is futile. Just wants to be the “politics is ir- make sure you have a snooze wingman on hand to hide the relevant to me” person. dribble (and take photos).

3. Work on your ‘key skills.’

They may sound fluffy and 6. Money matters – there is pointless but you don’t want enough stress without needto be the one to struggle filling ing to worry about financial in a spreadsheet, stumble over insecurity. Remember every a presentation or fumble try- little helps: those £1.20 coffees really add up. Budget for the ing to find the ‘on’ button. months ahead and stick to it, 4. Reflect more. Tomorrow’s set achievable goals and know Doctors specifies that doctors your financial aid options and need to continually reflect on utilise them. their practice and translate that into action wherever nec- 7. Banish self doubt. essary. This all begins quite confusingly and with much 8. Not make 30-year-old men hesitation in first year when cry when taking their blood. you’re asked how you felt about ‘that’ patient visit when 9. Get your head round those all you can remember is how statistics so you can actuhungover you were. However, ally interpret published data with persistence and practice, for yourself. Just because it’s

published doesn’t mean it’s gospel.

qualified consultant. Adapt and survive!

10. Become the junior doctor’s new best friend - purely for an invite to the mess parties (and practice the less glamorous ward jobs so you know what to make students do once qualified).

14. Help the nurses on clinical placement – you’ll learn a lot about communication, may get made the odd cup of tea and you’ll admire the sheer amount of work they do. There is plenty of evidence that conversation with patients is hugely therapeutic and underestimated.

11. Ask questions while you can. You’ll look engaged, will build closer relationships with senior doctors (by giving them something to laugh about) and learn so much more. A stupid question now may avoid a costly error later on.

12. Start living the lifestyle you advise your patients to live. But don’t fear - the 3am illicit yet therapeutic BigMac is totally GMC approved.

13. Get to know your consultant to get the most out of your placement. Do not underestimate the importance of punctuality and organisation to get on the right side of the ‘old school’ consultant; expect spontaneity and regular outbursts from the quirky and eccentric archetype; and regularly demonstrate your grasp of the up-to-date medical literature for the recently

15. Let go of the Grey’s Anatomy dream – no-one has ever found a Dr McSteamy so Shonda Rhimes has a lot of explaining to do.

16. Learn how to take blood

pressure the old school way.

17. Have opinions – what do you think about taxing sweetened drinks? Should there be a charge for visiting A&E? What measures need to be in place for the ageing population?

No-one wants to be caught out over dinner after proclaiming to be an all-knowing ‘student doctor.’

18. Never refer to yourself as a student doctor.

19. Make the most of every experience. It’s easy to stand back but this is the time to broaden your horizons! At least dream big until February...

[CULTURE] /15

theMEDICALSTUDENT /January 2014

Culture Editor: John Park/culture.medicalstudent@gmail.com

Stephen Ward the Musical Sara Tho-Calvi Culture Writer 1963. The scandal that shook society. The Profumo Affair has its place in history as one of the biggest political scandals of the twentieth century. For those of you who are not familiar with it, I shall give a brief account of the events which threatened to blacken the name of the Conservative government at the time. In 1961, John Profumo, the Secretary of State for War, had a brief affair with the showgirl Christine Keeler, who was also allegedly having a sexual relationship with the Soviet naval attaché, Yevgeny “Eugene” Ivanov. During the height of the Cold War, such a liaison could have posed a serious threat to national security, and indeed it was thought that Keeler might have been passing on highly sensitive information about the British nuclear missiles to Ivanov. Following the exposure of the affair, Profumo lied about his relationship with Keeler to Parliament, and was subsequently forced to resign upon his admission of the truth.

The musical, however, does not centre on the main protagonists of the scandal itself, Profumo and Keeler, but on the society osteopath and portraitist, Dr Stephen Ward, who introduced Profumo to Keeler at a party at Cliveden, Lord Astor’s country house.

The prospect of a musical adaptation of such a notorious scandal received mixed opinions from its critics; however, no one was better suited to this task than musical theatre maestro Andrew Lloyd-Webber, known for turning somewhat unlikely stories into musicals, from a rock version of the biblical story of Jesus to a musical about cats.

Ever since the disappointment of “Love Never Dies”, the sequel to arguably his most successful musical, “The Phantom of the Opera”, the world of musical theatre has been waiting with baited breath to see whether his new production would live up to his pre- “Love Never Dies” triumphs.

Having read a little about Stephen Ward, his unconventional lifestyle and his love of

socialising both with the upper echelons of society and working class girls, I formed a negative opinion of him and was later surprised to find myself warming to him as the show progressed. He had in fact been made a scapegoat and the target of political revenge when Profumo’s affair with Keeler was exposed, and I was saddened to discover that Ward committed suicide the night before the verdict of his trial as he realised that he would be found guilty of a crime which is now believed he did not commit.

Alexander Hanson, one of the most talented British musical theatre actors, portrays Ward as a highly intriguing and mysterious character. Hanson brings a sense of sophistication to the role, engaging the audience with his charming yet questionable manner with the showgirls and a heartfelt final monologue which depicts the tragic outcome of ‘getting up the nose of the establishment’.

The recurring theme of manipulation throughout the show is used to clever effect, and makes the audience question whether Ward was manipulating women for his own gain, or whether the government manipulated these very women for their own political gain.

Keeler (Charlotte Spencer) is a boisterous yet naive and silly 18 year old, hardly likely to be capable of extracting and passing on sensitive information.

The clarity of her voice is beautifully balanced against Hanson’s robust tone, and the two charac-

ters share a powerful on-stage connection from the moment they meet in a London nightclub. This scene is set upon a sultry and seductive backdrop of showgirls dancing to suave music, an authentic example of a 1960s American speakeasy.

One of the most poignant moments in the show is when Valerie Profumo forgives her husband following his admission that he had lied in Parliament. Her ballad is probably one of the most notable songs in the show, and it deeply conveys the sincerity of her emotions.

The music by Andrew LloydWebber, with lyrics by Don Black of “Sunset Boulevard”, “Aspects of Love” and James Bond fame, is pleasant but forgettable. It certainly does not have the panache and flair of his songs from his previous musical successes; its simplicity, however, works well in a musical of such a serious nature. The scenery is simple yet highly effective; a series of intertwined curtains are pulled across the stage and allow for flawless and seamless transitions between scenes and for archive footage of the real Profumo, Keeler and Ward to be projected onto them.

This musical is a far cry from the mainstream musicals we have come to love; however, its intensity and high-drama add a new dimension to this sophisticated adult musical. The entire show is captivating and makes the audience eager for more as the story behind the greatest political scandal of the twentieth century unfolds.

[CULTURE] /16

theMEDICALSTUDENT /January 2014

Culture Editor: John Park/culture.medicalstudent@gmail.com

The Fault in Our Stars Ashra Omr Culture Writer

A truly unique and poignant story that plays with your every emotion, John Green has written a book that encompasses both comedy and tragedy wrapped up in 313 pages of pure brilliance.

The story focuses on Hazel, a sixteen year old diagnosed with Stage 4 thyroid cancer with metastasis forming in her lungs.

Forced to go a support group for children with cancer, there she meets Augustus “Gus” Waters – the new kid. An amputee who has battled osteosarcoma and now battles to win Hazel’s heart.

As the weeks stretch on, their meetings are frequent and their relationship deepens.However Hazelis desperate to keep a firm distance between them, to avoid becoming a “grenade” in another person’s life. Yet all her efforts fail as Augustus does everything he can to prove that love is worth taking risks for. As romance novels go, this is not your typical boy-meets-girl plot.

They both know there will not be a ‘happily ever after’ but that does nothing to limit the love

and affection that gradually and firmly blossoms between them.

They embark on a journey together that will make you cry, laugh and smile at the simplicity of it all.

The core of the novel centres on Hazel’s search for Peter Van Houten, the enigmatic author of her favourite book, ‘An Imperial Affliction’. The search takes them to Amsterdam,where answers are sought and secrets are revealed.

‘The Fault in Our Stars’ is a truly heart-warming book that keeps you entertained and gripped right to the end. The characters are not just labelled by their diagnoses; instead they are your average teenagers with embarrassing haircuts and overprotective parents. And their cancer? Well, Hazel sums it up nicely as a “side effect of dying.”

Through these amazing and inspirational characters, you are taught that love really has no bounds and to live your life without regrets.

Green strongly outlines the importance of defining people by who they are, and not by the stage of their tumour. This is a must-read book carefully crafted with warmth, sorrow and humour that will leave you wanting more.

What to watch this January

American Hustle (Released 1st January) David O. Russell’s smart, hysterical new film is finally given the wide general U.K. release on New Year’s Day, and what a way to kick off 2014. The actors dazzle in their immaculately designed 1970s backdrop. One of 2013’s best for sure.

Mandela: Long Walk to Freedom (Released 3rd January) Nelson Mandela passed away last year, but his legacy lives on.

And in the latest biopic, one of many to follow for sure, Idris Elba takes centre stage in his commanding performance as the iconic, legendary South African President.

12 Years a Slave (Released 10th January) A strong contender at the awards ceremonies to come, English director Steve McQueen’s brutal, unflinching slavery drama doesn’t hold back, and is all the better for it. Featuring this year’s most touching performances, get ready for a good cry.

The Railway Man (Released 10th January) This immensely powerful true story tells the horrific tale of Eric Lomax, who endured endless torture at the hands of Japanese soldiers. Years later, the still traumatised Lomax is given the chance to face one of his captors.

Starring the spot-on Colin Firth.

The Wolf of Wall Street (Released 17th January) Leonardo DiCaprio is once again on tip-top Oscar-deserving form in Martin Scorsese’s three-hourlong film of excess in portraying Jordan Belfort, a stockbroker whose wealth, prostitution and drug use are all frankly shown in Scorsese’s up-front dramedy.

The Wolf of Wall Street (Released 24th January) The Coen brothers’ tragi-comedy has Oscar Isaac, who sings as incredibly as he acts, struggling through the tough, cold, unwelcoming environment of New York City’s 1960s folk music scene. Plus the film’s soundtrack is up there with the very best.

August: Osage County (Released 24th January) Yes, that’s Julia Roberts trying to strangle Meryl Streep. The Weston family gathers for a family tragedy where plenty of snarky dark comedy ensues. Be sure to check out this cinematic adaptation of Tracy Letts’ Pulitzer Prize winning play of the same name.

Out of the Furnace (Released 29th January) It doesn’t get any more grizzly and dream-shattering than Scott Cooper’s new film where we find two brothers (Christian Bale, Casey Affleck, both excellent) in an economically challenged part of America get mixed up in criminal activities.

Lone Survivor (Released 31st January) Peter Berg’s violent but ultimatley sensitive and respectful war drama is a non-stop action ride in which four out-numbered American soldiers are forced to square off against a Taliban army. Every bang, every thud add immensely intense effect.

[CULTURE] /17

theMEDICALSTUDENT /January 2014

Culture Editor: John Park/culture.medicalstudent@gmail.com

The best performances of 2013 Best Actor

Best Actress

Best Supporting Actor

Best Supporting Actress

Best Couple Chemistry

11.

Michael Fassbender

11.

Greta Gerwig

11.

Steve Coogan

11.

Pauline Collins

The Counsellor

Frances Ha

Philomena

Quartet

10.

Forest Whitaker

10.

Helen Mirren

10.

Michael Shannon

10.

Julianne Moore

5.

Scarlett Johansson Joseph Gordon-Levitt

The Butler

Hitchcock

Man of Steel

What Maisie Knew

Don Jon

9.

Christian Bale

9.

Naomi Watts

9.

David Oyelowo

9.

Nicole Kidman

American Hustle

The Impossible

The Butler

Stoker

8.

Denzel Washington

8.

Rooney Mara

8.

Jake Gyllenhaal

8.

Vanessa Redgrave

4.

Julia Louis-Dreyfus James Gandolfini

Flight

Side Effects

Prisoners

Song for Marion

Enough Said

7.

Hugh Jackman

7.

Melissa McCarthy

7.

Bradley Cooper

7.

Melissa Leo

Prisoners

The Heat

American Hustle

Prisoners

6.

Tom Hanks

6.

Sandra Bullock

6.

Colin Farrell

6.

Oprah Winfrey

3.

Chris Hemsworth Daniel Brühl

Captain Phillips

Gravity

Saving Mr Banks

The Butler

Rush

5.

Christoph Waltz

5.

Amy Adams

5.

Matthew Goode

5.

June Squibb

Django Unchained

American Hustle

Stoker

Nebraska

4.

Michael Douglas

4.

Jessica Chastain

4.

Barkhad Abdi

4.

Kristin Scott Thomas

2.

Adèle Exarchopoulos Léa Seydoux

Behind the Candelabra

Zero Dark Thirty

Captain Phillips

Only God Forgives

Blue is the Warmest Colour

3.

Bruce Dern

3.

Judi Dench

3.

Sam Rockwell

3.

Anne Hathaway

Nebraska

Philomena

The Way, Way Back

Les Misérables

2.

Robert Redford

2.

Cate Blanchett

2.

James Franco

2.

Sally Field

All is Lost

Blue Jasmine

Spring Breakers

Lincoln

1.

Daniel Day-Lewis

1.

Emma Thompson

1.

Leonardo DiCaprio

1.

Jennifer Lawrence

1.

Julie Delpy Ethan Hawke

Lincoln

Saving Mr Banks

Django Unchained

American Hustle

Before Midnight

The Doctors’ Mess

The Exceptional Medical Students The great among human kind, past, present and future, had, have and will always have twenty-four hours in their day, no less and no more than anyone else. Some manage to fill it with fun, while others fill it with chores. Yet looking at my peers, I am proud to be included amongst the few who know how to work hard and play hard. Taking a snapshot from some of the remarkable medical students amongst us, they will hopefully inspire us to use our twenty four hours wisely.

Those with dependents studying medicine continue to put me in awe. Imagine having to do a full day in clinics and lectures, only to also have to make sure the house is clean, meals are cooked, and whoever your dependent is has their needs met. Aeishah from King’s College London in addition to being a final year medical student is also a wife and mother of two very young children. She says, “I have learnt that when you

have less time you manage it so much more effectively! The key to being a good wife, mother and medical student is organisation. I work hard while at uni so that I can enjoy myself when at home with my family.”

Medicine has opened my eyes to a world where people do extraordinary things simply by doing lots of ordinary things all at the same time. Our very own Editor-in-Chief Peter puts this revelation quite succinctly, “When I was in first year I came in with the naive view that medical school was synony-

mous with work and that students would fail if they spent any of their time doing extracurricular activities. Of course, this was completely unfounded and I soon realised that some of my colleagues were doing some amazing extra things outside of medicine.” Peter, like many medical students, is on the committee for a number of societies, as well as representing his year at UCL. But why do so much in the first place? Alison from King’s College London is incredibly active, at one point being on seven committees all at one time. “I got involved in all I did because I found it fun. Of course, it... gives you loads to talk about when you’re asked about your leadership, extra-curricular and team working experiences, and what makes you stand out from the crowd. The fact that I’m a medic probably has something to do with it as well. We’re all competitive people, and getting involved in society work is one

way of stretching ourselves.”

Alison, despite being in clinics this year, is still involved with a number of societies, saying “there’s still enough time to keep the things you really feel passionate about going.”

I started off saying what I hoped was a profound sentiment that we all have twenty four hours in our day, yet many of us still grapple for the excuse that we don’t have time.

Alison’s advice to those who struggle to find time would be to “find something you enjoy, because then it becomes a social activity... If you consider how much time you spend sitting around or surfing the internet, it’s not hard to find an extra hour or two a week, with which you can get involved in all these amazing things happening.”

As Peter points out, “medical school is probably going to be the time in our career when we have the most free time”.

Wise words from Alison sum up quite nicely why busy med-

ics do what they do, “It would be such a pity to get to the end of five or six years at uni and find that, although I got a first, I never did any sport or went out clubbing, or got involved in societies, and had literally spent my whole time at medical school studying. There are so many opportunities at medical school, everyone can get involved.” So the next time you are tempted to say the words, “I don’t have time”, just remember you can make time.

treatment was rather passive; believing the body would rebalance the four humours contained within and heal itself.

The four humours were blood, phlegm, black bile and yellow bile. When a disease struck, the humours were unbalanced and the physician could try to correct the balance. For example, citrus was thought to counteract excess phlegm which made the patient lethargic. Similarly, Hippocratic medicine prescribed rest, cleanliness and calmness for certain ailments, and in a poorly understood way, these treatments worked for broken bones and simple illnesses.

Hippocratic medicine encouraged professionalism with Hippocrates recommending that physicians always be well-kept, honest, calm, understanding and serious. The work “On the Physician” held specifications on how a patient examination would take place

including the lighting, the instruments, the positioning of the patient and the techniques of treatment. Everything down to the length of a finger nail was set out in these guidelines.

Although medicine has evolved since Hippocrates’ time, we still look back to remember where we came from and help shape where we are going.

History Corner - Hippocratic Oath Going back to the origins of western medicine, we travel back to c. 460 – c. 370 BC. Hippocrates of Cos, an ancient Greek physician, helped separate the discipline of medicine from religion. According to Wikipedia, Hippocrates is accredited with being the first person to believe that diseases were caused naturally, through our environment, diet and living habits; not inflicted on humans by spells, spirits or gods. The Greek authorities, not pleased with Hippocrates thinking, imprisoned him for twenty years, during which time he wrote books bringing together the medical knowledge that was known at the time and some of which is still known to be true today.

We can attribute terminology and categories to Hippocrates.

He classed illnesses as acute, chronic, endemic or epidemic as well as used terms such as exacerbate, relapse, crisis, and

peak. He also described pulmonary medical conditions and their surgical treatments still relevant today. He also encouraged diet and exercise modifications to treat diseases such as diabetes.

But most famously, Hippocrates is remembered by the world of Medicine for the Hippocratic Oath. The Oath was created to distinguish real physicians from con men wanting to fleece patient. Although the Oath is rarely used in its original form today, it helps shape our current guide lines and laws that define good medical practice. Hippocrates’ greatest work, the Corpus Hippocraticum in which the Oath is found, is thought to be compiled by several writers, including his students, so very little is known for certain about what Hippocrates’ personally thought. The Corpus provides a wealth of information on medical observations and is

claimed to be the most detailed to date in the Western world.

The work also speculates about causes of symptoms, implicitly forming a step by step guide of diagnosis and treatment. One of the strengths of Hippocratic medicine lay in prognosis as Hippocrates’ encouraged physicians to keep detailed case histories in order to create a data bank of the progression of different illnesses.

Hippocrates train of thought led him to generalise symptoms to allow physicians to apply treatments on a trial and error basis. This skipped the diagnosis stage and didn’t take into account the role symptoms played in the disease or distinguished the cause of the evolving symptoms. The treatment was then only guessed at unless the exact mixture of symptoms had been treated successfully by another physician who had documented it.

Hippocrates’ approach to

theMEDICALSTUDENT /January 2014

Prize Crossword Causes of Rashes and Lesions

Doctors’ Mess Editor: Zara Zeb/ mess.medicalstudent@gmail.com

Diagnostic Corner 1. A 32 year old male comes in for an asthma review. He was diagnosed 6 years ago having had childhood asthma. He is currently using a salbutamol inhaler 100mcg pm combined with beclometasone dipropionate inhaler 200mcg bd. The patient complains of feeling short of breath a lot of the time, regardless of inhaler use. On examination his chest is clear and he has good inhaler technique. What is the most appropriate next step in management? a. Increase salbutomal to 200mcg pm b. Increase beclometasonen dipropionate to 400mcg bd c. Switch steroid to fluticasone propionate d. Add an inhaled long acting B2 agonist 2. What are the possible causes of the poorly controlled asthma? a. Allergens - such as dust mite faeces b. Pets c. Smoking d. Damp housing e. All the above 3. What is the typical sign of life-threatening asthma? a. Silent chest b. Difficulty breathing climbing stairs c. Exhaustion d. Using their salbutamol inhaler more than 4 times a day 4. A 70 year old male with a 60 pack-year history of cigarette smoking presents to A&E complaining of shortness of breath, an involuntary 20kg weight loss over the last 5 months and blood in his sputum when he coughs (hemoptysis). On examination you find right handed ptosis, anhidrosis and miosis. What is the most likely diagnosis?

ACROSS 2 Itchy, erythematous vesicular rash in response to allergens (6, 6)

12 Itchy, purple, flat papules on the wrist and appear when taking sulphonamides (6, 6)

4 Condition with principal features being purple ‘heliotrope’ rash around the eyes along with muscular weakness (15)

13 Symmetrical target lesions on the back of the hands, palms and forearms, which can occur post-herpes simplex infection (8, 10) DOWN

7 Flesh-coloured lesion with a characteristic pearly-rolled edge and found mainly on the side of the nose (5, 4, 9)

1 Transient pink merging rings on the trunk of individuals with rheumatic fever (8, 10)

8 Erythematous rash attributed to constant exposure to radiant heat (8, 2, 4)

3 Ulcers with blue/red necrotic edge located on the calf, abdomen, or face and can be a complication of inflammatory bowel disease (8, 11)

9 Symmetrical hypopigmented patches linked with autoimmune conditions (8) 10 Non-invasive malignant, red scaly lesion (6, 7) 11 Inherited disorder with charactertistic ‘cafe-au-lait’ lesions with auxillary freckling (17)

5 Salmon-pink, silvery scaling lesions on the scalp and extensor surfaces of the body, e.g. of the knees and elbows (6, 9) 6 Distribution of the chronic, erythematous papular rash on the cheeks, nose and chin mainly affecting middle-aged, fair skinned women (7)

a. Brain tumour b. Tumour in the eye c. Horner Syndrome secondary to a Pancoast tumour d. Pancoast tumour 5. A 78 year old female presents with a ten month history of generalised weakness.

On examination she has fasiculation and weakness in both arms with absent reflexes.

She has increased tone and exaggerated reflexes in the lower limbs. Sensations are normal and there are no cerebellar signs. What is the most likely diagnosis? a. Lead poisoning b. Motor neuron disease c. Vitamin B12 deficiency d. Multiple sclerosis 6. A 69 year old male with a diagnosis of hypertension presents with a 3 month history of worsening fatigue and shortness of breath. When questionned further, he reveals he sleeps on three pillows at night to help with breathing difficulties. What is the most likely diagnosis? a. Left ventricular hypertrophy b. Angina c. Chronic hypertension d. Pre-eclampsia

Questions adopted from http://www.medicaleducator.co.uk/ and The Unofficial Guide to Medicine Answers: 1 d. 2 e. 3 a, 4 c. 5 b. 6 a.

Congratulations to Amal Abdirahim Hashi from Bart’s Medical and Dental school for winning our Prize Crossword: Abdominal Pain in our December issue!

For your chance to win a copy of the Essential Examination provided by Scion Publishing Ltd, simply send a photo of your completed crossword to doctorsmess@themedicalstudent.co.uk

It’s my Birthday this Month So why not contact me?

Doctors’ Mess would love your elective photos, your articles, or to answer any questions you may have.

Please drop me a hello, ask me questions, or send all your contributions to doctorsmess@themedicalstudent.co.uk.

[SPORT] /20

theMEDICALSTUDENT / January 2014 Sports Editor: Mitul Patel

Two Horse Race Allom Cup finds New Home at Lee Valley Nat Ilenkovan Guest Writer This year, the University of London Athletics Championships were held at Lee Valley Athletics Stadium in the winter, as opposed to the customary spring meet.

The annual event gives London universities an opportunity to compete in a number of track and field events and ICSM had previously taken both the overall title and that of United Hospitals champions in April 2013. However, the earlier date of the 2013-14 competition meant that everyone was forced to put out another team just 6 months after last year’s event.

Despite fears that this change in date would have negative impact on participation, a number of universities attended with strong teams, but before long it was clear that the day was going to be a two horse race for the trophy between LSE and ICSM. Field events lead to a number of triumphs for ICSM, with Steph Ezekwe and club captain

Chris Chung taking gold in the shot-put, and a trio of bronze medals in the long, high and triple jump from Beth Nally.

The track also proved successful with Ewan Mackay and Nat Ilenkovan securing 2 more golds in the men’s and ladies 60m hurdles, as well as Megan Mackenzie and Emily Boyce who won bronze medals in the 3000 and 400m respectively.

Other notable athletes were Hallam Dixon of LSE who won both the men’s 60 and 200m in a spectacular fashion and Rob Walker from Bart’s, who was silver medallist in the men’s 3000m. ICSM final year and UL athletics veteran Chris Jones contributed 5 medals to the ICSM total.

The formidable LSE team, with 7 golds to show for, piped ICSM to the overall title. The west Londoners did however manage to come first of all competing London medical schools, and were again crowned winners of the UH championships, meaning the historic UH shield remains in the ICSM trophy cabinet for yet another year.

Mitul Patel Sports Editor

The second regatta of the 201213 Academic year came in the form of UL Boat Club’s Allom Cup on Saturday 7th December. UH competitors were joined in Chiswick by university crews from UCL, KCL, Royal Holloway and LSE, and it was UCL who were the early favourites in 2013s edition following strong showings at the Cambridge Head and Fours Head of the River Races. Indeed, the north London outfit won five of the eight categories at the regatta in 2012.

True to the formbook, UCL novice girls stormed to victory after thrashing KCL in their heats and beating their medic counterparts RUMS by over five lengths in the final.

However, it was RUMS who took home victory in the novice boys’ category; holding on to beat Holloway in the final by half a length after convincing victories against UCL2 and Royal Vets’ en route. Following their victory in the UH Novice Regatta in November, RUMS boys appear to be the crew the

rest of UH will have to beat.

The intermediate womens’ category also saw victory for RUMS as they beat LSE by three quarters of a length having despatched Georges in the semi-final. It was a day to forget for the south Londoners as seven of their crews were knocked out in the first races of the day. The intermediate men’s category was won by Royal Holloway.

UCL senior women replicated the feat of their novice counter-

parts by beating RUMS to take home the Redgrave Cup; the victory bought added enjoyment as it was RUMS who had won the trophy in 2012. Lastly, the Allom Cup, awarded to the winning men’s senior crew, was won by ICSM following a convincing victory in a threeboat final including UCL and cup holders Georges. It was also a special victory for ICSM as it was the first time their name would be engraved on the trophy.

UCL senior women (above) win the final to take home the Redgrave cup and ICSM senior men (below) celebrate winning the Allom Cup Photos Courtesy of UL Boat Club

BUCS’ Silent Night as Merger Reversal hangs in Balance Mitul Patel Sports Editor Last month The Medical Student reported on the status of the potential reversal of the medical school sports team merger with the hope that the BUCS advisory group meeting, last held on the 28th November would shed some light on the drawn out saga.

Sadly there was no Christmas cheer brought by BUCS as they failed to comment on the scenario. Both UH Medgroup and Cardiff University are also unaware of the situation at hand.

Discussions are certain to have taken place and the silence in the aftermath of the meeting would point to an un-

resolved situation. Surprisingly, the soft spot BUCS has for administration is not reflected by the fact that the last meeting minutes to be published were from May last year.

Therefore I would like readers to accept my apologies in that good news can not be brought to you in 2014. Although the next advisory group meeting is not scheduled until March, both Medgroup and themedicalstudent would expect an update prior to this.

Until that point, we would encourage students who are passionate about the issue to continue voicing their concerns, as it would appear that the decision to reverse, unlike the initial decision to merge, is not being met with adversity by all at BUCS.

GKT student council protest on Thursday 12th December, for sports teams to be called “GKT” not “King’s Medics” | Photo Courtesy of TP Macfarlane

[SPORT] /21

theMEDICALSTUDENT / January 2014 Sports Editor: Mitul Patel

UH Fail to Surprise Sydney on their 150th Birthday William Rea Guest Writer In a winter where England and Australia are dominating the cricketing headlines, it should not go unnoticed that Sydney University Football Club, the oldest rugby club in the world outside the UK, were celebrating their 150th anniversary by touring the UK and Ireland and facing the few clubs in the world older than themselves.

The origins of Sydney University FC date back to 1863, where games were played against visiting naval ships.

The club has had a long and successful history, producing 116 full internationals.

The sixth match of their seven match tour saw them line up against a combined UH team on the 7th of December. Whilst UH RFC is actually four years younger in age than Sydney, the fact that Guys Hospital RFC remains the oldest in the world (founded 1843), allowed for the fixture to be arranged.

A large squad of UH players, with players across four medical schools, met the Aussies with knowledge of what a hard game was ahead. Their

Club(s) Guy’s Hospital RFC Dublin University RFC Edinburgh Academicals; Liverpool RFC Blackheath RFC Richmond RFC; Sale RFC Sydney University FC

Founding Year 1843 1854 1857 1858 1861 1863

The Oldest Rugby Clubs in the World tour to date had featured three victories, most notably a 48-0 thrashing of Cardiff University Rugby club, alongside defeats to both Oxford and Cambridge.

The boys from New South Wales started strongly; quickly pushing deep into the UH half, where their large pack kept UH scrummaging on their own line.

This aggressive start set the tone for the first half, with UH playing their traditional barbarian rugby, but failing to fully penetrate the Sydney defence.

Brief moments of respite were earned firstly through the boot of ICSM fresher Jon Super, giving UH some much needed territory, and secondly from a

strong forward display led by George’s Arny Vyas and Bart’s Jeff Hopkinson. However, handling errors and conceded penalties continued to let Sydney back into UH territory, and the first half ended with Australians ahead by 3 tries.

A full squad change allowed UH to continue playing with their usual intensity in the second half, aided by RUMS’ Michael Nally playing the 16th man for a few minutes. The George’s half back combination of Nick Bisson and Chris Record allowed UH to start attacking in a more aggressive manner, culminating in a consolatory team try in the closing stages of the game.

Sadly it was too little too late, and Sydney took advantage of being 50 points ahead by bringing on their supersub- their 58year old manager, as a present for his hard work over many years at SUFC. This increased attacking threat didn’t deter UH, and the physical battle raged on until the final whistle.

Sydney emerged comfortable victors 59-7.

After the match, the Aussies ferocity on the pitch was exchanged for tour tales, bawdy songs and several beers. A plaque commemorating the

event was given to UH President Freddie Banks, who regaled both teams with stories of his own tour of Sydney 20 years ago.

With their last fixture cancelled, Sydney returned home with a 4-2 track record. Whilst the defeat may be tough on UH, they can be consoled by having scored a try against their formidable opponents, something which neither Cardiff nor Dublin University could force.

Their focus now divides into the UH Cup; with the final due to be played on 8th March 2013.

UH RFC and SUFC celebrate their history after the game Picture Courtesy of William Rea

ICSM Ladies Hockey finally break IC Hoodoo Charlotte Read Guest Writer After making history last season by achieving promotion, ICSM Ladies Hockey found themselves in unfamiliar yet exciting territory as they moved into the same league as rivals Imperial College.

Naturally, the initial transition proved to be a struggle but the cup competitions provided a valuable distraction as ICSM progressed into the third round of both the BUCS and LUSL cups. A nail-biting 2-2 draw between the sides earlier this season meant that

Imperial’s impressive unbeaten record against ICSM had remained intact but the league meeting on December 4th gave the medics another bite at the apple.

After a tense opening ten minutes, ICSM began to dominate possession and eased themselves into control. The ever-vocal Harriet Davidson’s commanding leadership of the medics’ defence enabled them to transition play with great effect, creating some beautiful chances. The killer pass was finally slotted through and gracefully turned in by Natalie Condie. ICSM had the momentum going into half

time 1-0 ahead, and visibly had the happier dugout.

As soon as the whistle blew for the second half it was clear IC weren’t going to let their record slip lying down.

They frustrated the medics with sustained possession and created a number of scorable chances. However, ICSM remained calm in defence and went 2-0 ahead against the run of play after a well worked short corner saw sweeper Rosie Belcher’s goal bound effort graze past the outstretched hockey stick of the IC goalie and deflect into the top left corner. ICSM celebrated as if they had fin-

ished top of the league already.

Despite the 2-0 deficit, IC were not going down without a fight. They were soon back in contention after another short corner and the scoreline read 2-1 to the medics with ten minutes to go. As the final whistle approached, the tension was palpable with both sides very hungry to win. IC put their medic counterparts under considerable pressure but the ICSM defence remained organised and refused to budge. In the end, history was made yet again by the ICSM side as the long awaited victory against IC was finally earned.

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