Mediscope Issue 9 by Andrew Cheng

Issue 9 May 2011

mediscope In this Issue

Front Cover

• Mediscope Debates: Physician Assisted Suicide • Feminisation of Medicine • Online Conduct • Introduction to Audits

Dispute & Controversy

Manchester Medical School’s Student Magazine

CONTENTS

W Issue 9 web www.mediscope.org.uk editor editor@mediscope.org.uk articles articles@mediscope.org.uk advertising funding@mediscope.org.uk design and layout Alex Gawthrope Chris Jacobs Mediscope is a magazine for medical students and other healthcare professionals. It is designed and edited entirely by medical students at Manchester University. All articles and statements printed are the responsibility of the authors and advertisers, not Mediscope. All content is © Mediscope 2011. All rights reserved. No content contained may be reproduced or copied without the prior permission of the editor. Feedback We would love to hear what you think of this edition and any suggestions for improvement. Please email the editor!

elcome to Issue 9 of Mediscope. The theme for this issue, ‘Dispute and Controversy’, was chosen because medicine is a profession intricately associated with areas of ethical controversy. A basic knowledge of the issues is vital as a medical student as they are frequently encountered in examinations, interviews and on the ward. The debate over physician assisted suicide (p8) has received particular attention recently and raises questions about the exact role doctors should play in society. Mental health is also an area frequently embroiled in controversy; some of the issues are addressed in two articles on the impact of the recession (p7) and stigma (p10) on mental health. We hope these articles together with a diverse range of other student written pieces offer a stimulating and thought-provoking read.

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Medical School News OSCE changes Catching up with the programme reps

Professionalism: Online Conduct Why being careful online is important features

The Feminisation of Medicine Are increasing numbers of female doctors good for the NHS?

Impact of Recession on Mental Health The hidden effects of the economic downturn

Debate: Physician Assisted Suicide Should Physician Assisted Suicide be legal in the UK?

Stigma and Mental Health Winner of the Neel Halder psychiatry essay prize

Mediscope Editorial Team

EDITORIAL TEAM Wai-Yee Cheung

Year: Intercalating: Ethics and Law

education Poster: How to describe skin lesions

Alex Gawthrope

12 14

Alastair Gibb

Top Revision Tips For phase 1 students

Year: 3, Hope

Year: Intercalating: MRes

careers

Chris Jacobs

Year: Intercalating: MRes

Want to write for us? Writing an article for Mediscope is a great way to voice an opinion, share experiences and impart knowledge. Getting published is also fantastic for your professional and personal development. We are always looking for talented writers from any year, course or university. The theme for our next freshers edition (Issue 10) will be ‘Weird and Wonderful’, focusing on areas of medicine that are out of the ordinary. In addition to themed articles we would especially welcome stories of personal experiences, reviews and career pieces. If you have an idea or would like some suggestions, please get in contact. Writers guide: www.mediscope.org.uk Submit to: articles@mediscope.org.uk Deadline: 31st July 2011

The importance of Bone Marrow All about bone marrow and the work of the Anthony Nolan Trust

Audits! An introduction to the audit process and how to get involved as a student

SOCIETYSCOPE Fastbleep Foundation & the Health Olympics

REVIEWSCOPE Key surgical skills and the royal college views and opinion

Pharmaceutical Ethics The responsibilities of big pharma

Testamonial: Medical Summer School The annual doctors academy international summer school is in Manchester again this year

Mediscope are looking for a new team! We need enthusiastic individuals to join the team for 2011-2012. We are looking for talented students to help recruit, write and edit articles. Desktop publishing skills are a bonus! Please email with your name, year and base hospital, plus any examples of your work. Tell us in <200 words why you want to be part of Mediscope and what you will bring to the team! Email: editor@mediscope.org.uk Deadline: 24/6/11

news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international, news, events, snippets, local, natonal, international,

infoscope

News

News, Views, Events

CHANGES TO OSCE EXAM CRITERIA DUE TO BE INTRODUCED Controversial move to bring in changes ahead of next year’s final exams announced

Catching

he medical school’s assessment lead Dr Benbow recently announced on Medlea the introduction of a new OSCE marking system to be implemented in 20112012 to bring the school up to date with GMC requirements. The change involves implementation of a limit to the number of individual OSCE stations a student can fail in an examination. Currently, students pass if their average mark over the whole examination is greater than 4. Under the new criteria a student who fails four or more stations with a 1, 2 or 3 mark or a student who fails three or more with a 1 or 2 mark will fail the examination. Dr Benbow states “inevitably some students will fail under the new system who would

have passed under the old one.” Reasons for this change are given to be GMC required, and to keep up with other medical schools. However, this informal announcement (with a formal one to follow in the Phase Handbooks and further information to come) has provoked controversy, with 139 comments made from students so far. Concerns include the introduction of this system before final examinations, rather than piloting an introduction to it in earlier years, the inevitable subjective element of OSCE examiners and a lack of individualised feedback following OSCEs.

FRESH WARNINGS ABOUT CONFIDENTIALITY

NEW ARTS INITIATIVE AT MRI

n reference to confidentiality breaches, concerns have been raised about the use of USB sticks to store patient data. Trusts have in previous years purchased encrypted USB sticks in an effort to combat this. However, further warning has come from Trust staff about students using websites such as Prezi, an online tool for making Powerpoint presentations, and students are advised to make sure these presentations are not accessible online and do not contain even the initials of patient names – other initials should be used. See Professor Boggis’ blog post on 01/05/11 for

For further details or to take part in the debate, see the Medlea blog. Wai-Yee Cheung

he 2nd Art Exhibition in Education South in Central Manchester Foundation Trust (CMFT) is opened on Monday 28th February 2011. Joint efforts of two artists: Moira Walton and Kate Jablonska culminated in a series of illustrations of the Central Manchester University Hospitals. It aims to engage the hospital community in creative activities and provide a sense of civic pride among staff members and visitors. It’s the opportunity for staff members to join and exhibit own photographs or drawings of the hospital site. The artworks will be soon available as postcards, posters and calendars, and will be sold to support CMFT Charity. Everyone can join and exhibit own photographs or drawings of Central Manchester University Hospitals site. Simply email your images to kate.jablonska@cmft.nhs.uk or post them to Kate Jablonska in Education North in CMFT. The artworks will be soon available as postcards, posters and calendars, and will be sold to support CMFT Charity. The exhibition will be open until June 2011.

up with the

Programme Reps

ost medical students will probably know about year reps but many are probably not aware of the existence of programme reps. This may be because programme reps are a new addition to the medical school here in Manchester. One might ask what exactly a programme rep does? To be entirely honest, when we started officially last September we were not entirely sure ourselves. We were very excited, however, at the prospect of creating our own role. Now that we’re more than halfway through our term as Programme Reps, we thought we’d reflect on where we’ve been and where we’re going. We spent the first few months finding out how the medical school works and exploring how this new role could fit in with the current structures already in place. We were invited to be part of many different committees and were able to contribute a student perspective in all of them. There are many different committees in the medical school, all covering a different aspect of the programme. These all have to report to Programme Committee, which is where all the important decisions are made. We have been involved in meetings like the Medical School Reception Scheme Meeting, where we came up with and subsequently organised the Wall Competition, which received a very good response. The building work in Stopford has already started and, before the end of this semester you should be able to admire the new reception, complete with inspirational student-chosen quotes on the walls! In February we were involved in appointing Dr Leena Patel as Student Experience Lead (you can contact her at Lp@manchester.ac.uk). With her help we hope to set up a highly functional rep system, integrating programme, year and hospital reps, in the setting of a revamped Staff-Student Liaison Committee alongside new regular meetings between year reps and their relevant Phase Lead. We are also getting involved in the training for next year’s reps, so less time is spent getting used to the role and more being effective reps. In addition to this, with the help of Dr Patel and Dr Halder, we hope to start a student led Excellent Teacher award, to recognise and reward the best teachers and also encourage others by highlighting the example of excellent teachers. We aim for this to continue in the future, and we have included it in both programme and year rep job descriptions. This brings us on to the fact that elections for some of next year’s reps will be happening soon: we hope to find enthusiastic students to take over our job! Finally, if you would like to contact us for any reason, our email is medicprogrammereps@manchester.ac.uk. You can also check out our facebook page (Manchester Medic Reps), which we update regularly. Emma Vaccari Emmanuel Oladipo Nathan Huneke Programme reps 2010/11

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How worried should YOU be about your conduct online and elsewhere? venting their anger in the doctors’ mess was unlikely to come back to them – but vent your anger online now and it becomes almost immortalised in cached websites and servers. So how does “social professionalism” fit into this new context for medical students?

Professor Caroline Boggis, Programme Director for Curriculum Development and Student Support, has warned students of the dangers of the internet on her regular Medlea blog. When asked if students ought to change their names on Facebook and Twitter accounts, she replied, “I would personally advise them not to use them at all”, but urged students who do to consider the risks before posting any controversial content online. The Faculty of Medical and Human Sciences has issued University guidance on social networking, aimed particularly at those entering a public profession.4 It advises students to ensure privacy settings are restrictive and to watch inappropriate language, stating that one should not post content that “might have repercussions for you later, or might not be in good taste e.g. it relates to sexual activity or inappropriate behaviour, or it expresses inappropriate views.”4 This includes posts by friends on your account. It may also be worth noting that although access settings can be restricted on Facebook, Twitter is accessible to anyone. In either case, changing your account name is unlikely to help you avoid being associated with content you are uncomfortable with others knowing about – the message from the medical school is to simply avoid putting yourself in the position to be worried in the first place. Professor Timothy David, Fitness to Practise Lead of the Faculty of Medical and Human Sciences, warned that online conduct also “includes inappropriate communications in emails, which I would see as just as great an issue… anything that’s written can be accessed, and you may not be as careful expressing yourself assuming it’s a one-to-one conversation… the minute you press a button, it’s gone.”

he public’s fascination with medicine is well documented by the popularity of hospital dramas and “medical” documentaries detailing people coping with rare disease. Following the emergence of reality TV that began with Channel 4’s Big Brother, a warped parody of Nineteen Eighty-Four’s omniscient force watching your every move,1 this fascination has grown into the emergence of the drama-documentary. Many have probably watched at least an episode of ‘Junior Doctors: Your Life In Their Hands’. Although there are some aspects that appear scripted or dramatised, the BBC3 programme prides itself on showing a level of reality that has rarely been witnessed by the general public, except when they have the assumed misfortune to go to hospital in the first week of August. These developments, alongside social networking sites such as Twitter and Facebook and the ease of sharing videos via YouTube, give an impression of a public interest stretching to a Big Brother force watching over those in the medical profession. When asked about privacy over the internet, Eric Schmidt (previous CEO of Google) famously said “If you have something that you don’t want anyone to know, maybe you shouldn’t be doing it [on the internet] in the first place.”2 Rumours have surfaced in the medical school about ‘internet trails’, where having a pseudo-name on Facebook is considered wise to avoid anything incriminating assigned to your name when looking for a job. Media stories have surfaced of employees losing jobs after posting on the internet - for example, infamous bank intern Kevin Colvin, who skipped work over ‘family illness’ and got caught in a date-stamped photograph on Facebook in a fairy costume at a party.3 Is Big Brother watching your every move?

Professor Boggis referred Mediscope to the case of ‘Dr Scot Junior’ as a word of warning of “how damaging some …Probably not, but there is some truth behind the paranoia. actions on the internet can be.” The case involves a surgical trainee who posted a personal opinion Binge drinking is often associated based on his displeasure about the MMC/ I would personally with students. It’s unlikely that our MTAS system on Doctors.net.uk.5 The post, predecessors were angelic and always advise students not to use removed a few hours later, is said to have sensible, but had they vomited in a public Facebook at all vividly criticised a very senior colleague fountain after a night out there was no Prof Caroline Boggis (Professor Dame Black, a “powerful and platform to broadcast it upon. Similarly,

“

”

When asked about posting critical comments online in general, Professor David explained, “there are other mechanisms available for students to raise problems with other students or staff that will be properly investigated and dealt with by the University of Manchester. One problem with raising these criticisms via social networking sites or by email is that the person in question cannot respond to them.” Another BMJ article has warned that although the occasional disagreement amongst juniors and seniors is inevitable, when it comes to airing it online, “Doctors should be wary, because defamation laws apply online, and anonymity is illusory.”8 There is undeniably both increased scrutiny and a higher standard expected from medical students and doctors, due in part to the movement from medical paternalism to propatient autonomy. Patients are more interested about their conditions and the doctors that treat them, and information on both is more readily available than ever before. The issue we face is much wider than online conduct – it is the existence of potentially controversial material in the public domain. The internet is but one mechanism by which dissemination or disclosure of such material may occur. However, social networking sites supply a means by which future NHS employers can access this information relatively easily. The GMC has subsequently issued guidance specifically for medical students.9 It may be comforting to note that areas of concern listed refer to serious misdemeanours – these include criminal offences, drunk driving, violence or behaviour that affects professional or clinical work. It does not include specific examples of what students do in their social lives, unless these were to affect The photo that cost intern Kevin one’s working life, Colvin his job. breach confidentiality or amount to

harassment or discrimination. Similarly, although both Professor David and Professor Boggis mentioned there had been cases where students faced remedial action due in part to online conduct, these had been more extreme cases involving illegal activity or explicit photographs. Professor David said, “it’s a myth that ‘Fitness to Practise’ has to do with minor misbehaviour, which is dealt with the medical school itself.”10 However, it is perhaps not the extreme examples that are the most relevant to the majority of students, but the fact that seemingly benign actions can have repercussions. Although advice not to post videos of drunken antics, explicit insults about tutors, or compromising photographs online may seem trivial and somewhat obvious, nevertheless it does occur and may result in problems for students later on. Part of what ensures trust in a profession is regulatory standards – thus a little more discretion inside and outside of the hospital or university comes with the territory. In conclusion, the use of common sense to avoid breaching professional standards is key – simply be aware of the risks, and think before you post. Wai-Yee Cheung Mediscope Editorial Team With thanks to Professor Boggis and Professor David (April 2011) for their insights. References available online

Professionalism in another context

2011

Last year when a group of medical students posed nude for a charity calendar, a blog post by Professor Boggis described this behaviour as risky. The calendar committee itself responded stating that the calendar ought not to be compared with drunken antics on Facebook, it had been tastefully done, a great deal of money was raised as a result, they had successfully sought prior legal and GMC advice, and the existence of modern attitudes to doctors relating to their patients in society ought to encourage similar projects. The calendar itself is copyright so cannot be reproduced online or otherwise. The medical school itself did not take any action. When asked now what concerns existed as a result, Professor Boggis outlined the following points: patient perceptions of professionals without their clothes, the public interest in training students to be doctors and the increased scrutiny as a result, and the fact that it had occurred on hospital grounds, “irrespective of whether it was done for charity.” Professor David added that any apprehensions related to the calendar would be “for the reputation of the profession.” Do you have any views you’d like to share? Write to us at: editor@mediscope.org.uk.

Mediscope May 2011

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controversial figure”6). He was subsequently suspended from work after the comment was picked up by two senior figures in the North of Scotland Deanery, Aberdeen. Both senior figures were investigated by the GMC for fitness to practise following allegations of bullying by the wider medical community, many of whom believed the trainee to have been severely mistreated. No further action was taken b y the GMC, but the incident has certainly provoked some controversy on both sides (see Needham’s BMJ article and the rapid responses).7

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Is more female medics good or bad for the future of the health service?

Male and Female intake into Medical Schools (1960 vs 2007)6

Charlotte Li

t only occurred to me recently after many raised eyebrows about the male to female ratio in PBL groups and comments from consultants that there was a hidden outcry in the medical profession over the number of female graduates. After looking into this further it is apparent that there has been fierce debate over whether the increasing number of female medical graduates is a positive step for the future of medicine. In 2004 the President of the Royal College of Physicians, Professor Carol Black, commented, “we are feminising medicine. It has been a profession dominated by white males. What are we going to have to do to ensure it retains its influence? Years ago, teaching was a male dominated profession - and look what happened to teaching. I don’t think they feel they are a powerful profession any more. Look at nursing, too.”1 She also voiced concerns that women were less likely to opt for high status work intensive specialties, as they were “incompatible with having a family.”2

Are there too many female medical graduates? “Yes” Brian McKinstry

McKinstry concentrates on the burden women produce in the workplace, arguing that until society relinquishes the view of women as the main child carers, “we need to take a balanced approach to recruitment in the interests of both equity and future delivery of services”. •

• • •

Being a potential role model for many women, it is ironic that she publicises this. Her credentials as both a professor and the second female President of the Royal College of Physicians in over 500 years of its existence puts her high in the list of strong female medics who haven’t diluted medicine’s influence in society, nor shunned a committee position for a family-oriented career. However, she has made a pertinent point: many females in medical school are now weighing up specialty choices with future family commitments even before they have graduated and have decided on a training pathway. Should female undergraduates really be considering a less rigorous medical or surgical career in favour of family life when so many are still ignorant of the nuances in a doctor’s lifestyle choices? A discussion in the BMJ (2008)3, 4 highlighted the concerns many doctors had for the “feminisation” of the NHS. The points raised from this are summarised below:

Are there too many female medical graduates?

HEAD HEAD TO

“No”

many female Are there toograduates? medical

h among genHowever, researc many dren are older. shown that n oners has their childre eral practiti their 50s, when continue to women in ly independent, e of other carare relative becaus gentime, often work part 7 8 In addition, more female age the ds. female ing deman to retire before g life Too many oners plan ne, just as workin practiti medici their eral are bad for shortening have found that male ones 60 than men, try, one study ants (41%) too many and of .7 In psychia rs of men consult further numbe female past. The twice as many nish work on or before school should been in the g medical d to fi . The nearly than men women enterinthe numbers in societyequal as male planne y.9 Fewer women e ect birthda 8 the increas grounds of roughly refl their 55th of hours, and influenced is simply on also strong ecoto work out case for this are have partly of out . I will choose But there doctors may abdication opportunity. planning reasons of my in women l the recent workforce tive ntrate of hours work by genera nomic and the perspec UK. largely from doctors conce ed practitioners in the argue this prac- Women lties regard y, general research own specialt most in a few specia and tend not Although some r male illustrates ly younge which friend 10 tice, the as family lties suggests that impact of careers, some specia tion of part time strongly the medicine. y ng feminisa to take up or of also seeking Is the increasi celebration they are actuall feminisation doctors are ? a cause for past 30 years evidence that medical of services health care Over the attending there is little lifestyle. future delivery a threat to tion of women in many countries for this the propor opting risen Ausshown steadily studies have Canada, and had schools has several large ces are very small feminisathe UK, US, l schools Although including Time bomb effect of the UK medica these differen ance.13 Men and the per12 2002-3, all to feel the full UK and elsewhere. male, with 3 differences, tralia. In We are yet care in the some. practical importt, complementary students than mostly workof primary ing 65% in and of little more female differen 45 years men, ty, whereas r of tion e that bring of women exceed age numbe may of the some evidenc women centage increasing e. There is comtheir Above time, are still the majori r than 45 reflects the full younge l courses and skills to medicin in more patient centred for This partly . For ing g for medica g part l practitioners engage science applyin in workin genera women consult women women most success mainly 14 However, retire, doctors examination female and one UK study munication. increasing years are lack of female full time doctors s from s,14 and in 30% the relative 11 As older mainly turning and with patient they were change are our longer many years ations time. tables consult presment behavi ty. This ned, but the shortfall in l increasing of out of hours was bemoa be in a minori many unless employthere will be a major recent to refer to hospita doctors will 15 Moreover, y care in patterns, more likely s. soon male past primar on. in service l female provisi the case also affect sure on hospita even full time male is already primary care raphic change may In an h shows that their UK. This demog UK researc development. parts of the patients than nication and h, fewer medisee l researc in interna consultants 16 and commu education, and Empathy concerns implications study of women that compared are efficiency colleagues. Workforce American ? The main n hers found ant, but so docmatter childre this 12 import researc women with the s of skills are Why does risk. y disof the cine, men with children, women P < 0.001). to live with the work pattern been unfairl v 29.3; the ability development centre on with tions (18.3 women have around the trate in between I fully suppublica also years ces ne. concen and fewer For s tors differen medici had bring to against in Women doctoras family friendly no significant without chilcriminated and the strengths they 5 d profession. However, seen for doctorscare we found absence ties regarde 4 and psychiatry ) y port their role ne. However, in the terms a few special the sexes were care in study in primar about 60% of ties such le, primary modern medicichange in our society uting (for examp some special means dren. In our to to take up nd aspects were contrib care, we need in of a profou l distribution and tend not that women men in development child for of g, 4 This unequa ment tions of , teachin of responsibility approach to recruit delivas surgery. feel the implica such the activity e such as training ed 7 not clear specialties ity leave, general practic take a balanc both equity and future work. It is that some g and matern e use of committee or lack ts of the interes part time workin ity of care and resourc research, and this is through choice is s. review. BMcK ery of service the literature as lack of continu to what extent nt. ately. for his help with to work Scottish Governme the future feminis I thank Iain Colthart Scientist Office of the disproportiona s are more likely 6 of opportunity. Chief s that argued that Despite funded by the Female doctor male colleagues. Some have on the ground None declared. still their e is justified g interests: in underthan society se medicin men time Competin of part than tion discour 336 of feminist perform better men to reduce examinations. 2008 | VOLUME many years BMJ | 5 APRIL rather than n and womente and postgraduate after childre expects women gradua tments to look the chilwork until work commi to full time not to return

ty Health fellow, Communi , of Edinburgh y senior research Brian McKinstr Practice Section, University Sciences: General 9DX Edinburgh EH8 d.ac.uk brian.mckinstry@e graduates

Women choose “family friendly” specialties, therefore there are less women surgeons. Moreover they tend to work part time, take maternity leave, and refuse out-of-hours work meaning some specialties suffer as a result. Societal traditions still prevail. Women are expected to be the main carers of children and bear the brunt of childcare in the family. Women contribute less to professional development - for example, teaching, training and participating in research. Women take longer to see patients, and thus see fewer of them. They are also more 30% more likely to refer to hospital from out-of-hours consultations, which increases the workload on

Jane Dacre Dacre concedes that there are more women than men in medicine, but concentrates on promoting change in the workplace instead of blaming socio-demographic factors for perceived shortfalls in the provision of care. She suggests that the system ought to embrace flexibility, change the way work is structured, including child care on site, and offer more attractive part-time positions.

748

secondary care.

This issue is not specific to medicine as many other professions in the upper echelons of society are also experiencing similar issues. The article “the future is female”5 is far more flattering, describing women as having well rounded, desirable skills and being better at “team-work, leadership skills, communication and emotional intelligence”. Perhaps this will engender a change in both society and the workplace traditions. In alignment with McKinstry and Dacre, it is not just a problem with numbers, it is a deeply ingrained issue led by gender stereotypes

• •

Women are more empathic and embody the view that doctors should be altruistic, compassionate professionals. Their holistic approach to patient care produces better outcomes. Women are under-represented despite having better exam grades. There are fewer females in clinical academia and in acute, oncall and technical specialties. This is because they are perceived to be less attractive. Perhaps we need to look at “equality of opportunities”? Despite taking time off for children women, then become more well-rounded in life outside medicine. There are barriers to women becoming leaders - for example a lack of role models, a lack of flexibility in a job, low tolerance of career breaks and part-time working.

and it only serves to highlight the deficits endemic in the current workplace structure. Charlotte Li Year: 4, Hope Hospital References

1. Laurance J., 2004. The medical timebomb – ‘too many women doctors’. The Independent, 2 Aug 2. 2004. Your view – Are there too many female doctors? The Telegraph, 2 Aug. 3. McKinstry B., 2008. Are there too many female medical graduates? Yes. BMJ; 336 : 748 4. Dacre J., 2008. Are there too many female medical graduates? No. BMJ; 336 : 749 5. Sawer P, Henry J., 2008. The Future is Female, Job figures show. The Telegraph, 11 Oct 6. Elston MA: Women and Medicine, The Future. (Report for the RCP, htp://www.rcpsg.ac.uk)

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The Worldwide Effects of Recession on Mental Health

he economic downturn of the last few years has had massive implications for the wellbeing of those living in today’s dark and gloomy socioeconomic climate. For the vast majority of people, the hard-faced reality of recession means balancing debt-repayments, increasing costs, potential pay cuts and redundancies alongside getting by day-to-day and supporting their loved ones. Undoubtedly, these “stresses” are bound to make people vulnerable and prone to mental health problems, whether it is something as common as anxiety or something as serious as suicide. The last few years have seen the unemployment figure sore, leaving many people facing unsustainable debts and bankruptcy. Groups of people particularly at risk are those of a low socio-economic status, the vulnerable, the elderly and the disabled. But it is not just these that are being affected. What about all those students pouring out of universities with no graduate job prospects, unable to utilise the skills learnt from their courses? It is important to be aware that the recession has evidently had a huge impact on diverse groups of people. Last year, the MIND charity conducted a survey investigating the impact of recession on mental health in the UK where it found an increase in the number of people suffering from mental health conditions. 50% of those interviewed reported low morale in the workplace and 30% had started working extra hours to sustain a minimal standard of living. Furthermore, half of those interviewed suffered from insomnia whereas 25% complained of having depression. A staggering 91% of people with personal debt reported deterioration in their mental health1-2, highlighting the severity of the problem. For the vast majority of people, work provides more than just a source of income; it gives them a structure to their day, it gives them a role in society as well as providing them with regular social interaction. The effect of losing a job has many effects; financial strains upon individuals and families can lead to a falling standard of living and unsustainable personal debt. Social

consequences can include family break down, increased drinking, gambling, recreational drug use and mental health problems. This all results in a vicious circle where one component complements another. Recession is commonly a time when change and uncertainty is introduced into one’s life. The way in which “change” can affect one’s mental health can vary from person to person and depends upon lots of different factors; perception and social support are just some examples of the variables involved. The overall effect on mental health depends upon how well the individual copes, deals with and adapts to this change. Timing and the ability to seek help if needed is also a crucial factor that ultimately determines the potential severity of the mental health problem. Research has shown that the overall best coping strategy is social support – whether this means talking to people or professional services. People under stress may have impaired insight into their well-being and thus may turn to alternative coping strategies. Alcohol is a wellknown coping mechanism for people who are stressed. A report suggests that 1 in 10 individuals have been drinking more because of the recession3. Furthermore, an increase in the use of addiction services indicates that people are becoming more prone to utilising recreational drugs to create a sense of false well-being. Suicide rates in the recession as a result of redundancies have also been on the increase. A spokeswoman for the Samaritans says that people who are unemployed are 2-3

30%

working extra hours due to the recession.

7% 50%

on anti-depressents

complaining of low morale in the workplace Results of a survey for MIND charity1

times more likely than those employed to take their own lives4. An important question to ask is why could this be? Should we, as part of the health service become better at identifying those at high risk earlier on? As we have seen, the effects of the recession on mental health is a complex topic and the way in which it impacts upon individuals is enormously variable and influenced by many factors – often beyond one’s control. A number of services are available for people to seek help and support – but as we have already seen mental health is still something that is stigmatised in today’s society and so those needing help may not always go and seek it. This way of thinking needs to be changed and people need to be made aware that mental health problems are more common than perceived. It is also ironic that since the current economic crisis hit, there has been a rise in the number of mental health problems being suffered, yet paradoxically, there have been budget cuts within the NHS, resulting in loss of professionals being able to provide psychological therapies. The end result is likely to mean increased costs due to the delayed treatment and severity of the problems that have resulted. We are now coming out of the recession and the key focus should now be to provide adequate help and support for those individuals who have been affected, and enable them to deal with their problems and move forward with their lives. Ideally, increased funding and availability of “ad hoc” services like talking therapies should be improved and made widely accessible to the public. Rita Prajapati Intercalating: MRes References 1. UK survey looks at impact of recession on mental health In the Media. Available from: http://www.digitaljournal.com/article/292180. [Accessed 11th March 2011] 2. Men suffering “recession blues”. BBC News. Available from: http:// news.bbc.co.uk/1/hi/health/8040699.stm [Accessed 11th March 2011] 3. One in 10 have been drinking more because of recession. The Telegraph. Available from: http://www.telegraph.co.uk/health/ healthnews/5489769/One-in-10-have-been-drinking-more-because-ofrecession.html. [Accessed 11th March 2011] 4. Samaritans launches new strategy to reduce suicide in Wales. Samaritans. Available from:http://www.samaritans.org/media_centre/ latest_press_releases/wales_strategy_launch.aspx. [Accessed 11th March 2011]

Mediscope May 2011

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Mediscope debates...

Welcome to our new series of Mediscope Debates, where differing arguements in controversial and often confusing ethical areas of medicine are examined.

PHYSICIAN ASSISTED SUICIDE AND THE LAW

By Alexandrea Mullock, PhD Student, Manchester Law School

n the event that a doctor ‘helps’ a patient to die, there are two possible areas of the criminal law which might engage; the common law offence of murder, or the statutory offence of assisting or encouraging suicide. The doctor who actively and intentionally kills a patient, for example by administering a lethal injection, will be potentially liable for murder, irrespective of whether the patient requested euthanasia. Consent is not a defence to murder and, although the motives of the doctor might have a bearing on sentencing with respect to the life term or tariff which a judge will recommend following conviction, the fact that the doctor was only motivated by mercy will not negate liability for murder. The only possible exception might arise when a doctor provides palliative pain relief and/or sedation which, as a side-effect to the therapeutic benefits of relieving pain and distress, also hastens death. This is known as the doctrine of double effect, and was first outlined in the case of Dr Bodkin Adams in 1957, when the court stated that a doctor ‘...is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten human life.’1 Adams was acquitted and, serial killers such as Harold Shipman aside, no doctor has ever been convicted of murder for intentionally killing a patient for merciful reasons, although in 1992

Dr Cox was convicted of attempted murder after injecting his patient with potassium chloride following her request for euthanasia.2 Encouraging or assisting suicide under the Suicide Act 1961, as amended by the Coroners and Justices Act 2009, remains a criminal offence despite the fact that suicide itself is no longer a criminal offence. Following the decision of the House of Lords in the case of Purdy3, the Director of Public Prosecutions promulgated the ‘Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide.’4 This Policy sets out determining factors for potential culpability, which will assist prosecutors in the task of deciding whether it is in the public interest to pursue a prosecution in any given case. The Policy indicates that compassionately motivated and reluctant assistance in the suicide of a competent adult is unlikely to be prosecuted. However, it should be noted that doctors, health care professionals and health workers are, according to the Policy, more likely to be prosecuted than lay people for this offence.5 References

1: H Palmer, “Dr Adams’ Trial for Murder” (1957) Crim LR 365, at 375. 2: R v Cox (1992) 12 BMLR 38. Dr Cox was convicted of attempted murder following the death of his patient, Lilian Boyes, who died from an overdose of potassium chloride, a drug with no pain relieving properties. The defendant escaped a murder conviction only because a causal link between his actions and the victim’s death could not be sufficiently established. Dr Cox was sentenced to serve 12 months in prison although this was suspended for one year. The GMC found that Cox had acted in good faith and he returned to medical practice. 3: R (on the application of Purdy) v Director of Public Prosecutions [2009] WLR 403; [2010] 1 A.C. 345 (HL). 4; Available at http://www.cps.gov.uk/publications/assisted_suicide_ policy.html 5: For more details see A Mullock, ‘Overlooking the Criminally Compassionate: What are the Implications of Prosecutorial Policy on Encouraging or Assisting Suicide?’ Medical Law Review 2010, 18(4).

Q: Should physician assisted suicide be legal in the UK?

KEY DEFINITIONS Physician assisted suicide - also termed passive voluntary euthanasia: a competent patient requests a doctors help to die. The final act is done by the patient. (illegal) Passive non-voluntary euthanasia - premature termination of life from an incompetent patient, usually via withdrawal or withholding of life support (legal) Active voluntary euthanasia - relative or doctor accomplished suicide, where on a competent patient’s request the doctor or relative actively causes their death (illegal) Involuntary euthanasia - “mercy-killing” without consent (illegal)

Photo Credit: Associazione Luca Coscioni

Example: Dignitas, Swizerland

Founded in 1998 by Ludwig Minelli (pictured), Dignitas is the Swiss clinic that aids euthanasia and physician assisted suicide under Swiss law. The clinic has been made famous in the UK by cases such as Daniel James, who travelled there to die following a rugby accident that left him paralysed. Their mission statement is “to live with dignity – to die with dignity”, having aided 1,062 people in bringing about their deaths.1 The clinic also states they have helped thousands who have travelled there to continue living with their conditions rather than choose an earlier death. The clinic has been known to be controversial and is often the subject of media debate, particularly as it has been reported that over a fifth of those who have died did not have a terminal illness.2 References

1. Dignitas, ‘How DIGNITAS works: On what philosophical principles are the activities of this organisation based?’ 1st edition June 2010. www.dignitas.ch. Quote on page 2. 2. Brown, D, ‘Dignitas founder plans assisted suicide of healthy woman’, The Times 03/04/09. www.timesonline.co.uk/tol/news/ world/europe/article6021947.ece

By Samuel Cocksedge University of Liverpool

he crux of the ethical argument surrounding physician assisted suicide is that we must remember exactly what is being argued. It is not about the practical aspects of administering the means of death or which government body is intended to be in charge. Instead the argument is regarding the moral integrity we give to choice and life – whether these two elements of the debate can co-exist and if we can ever, as a society, consciously deny those in suffering their final free-willed choice when requested. Physician Assisted Suicide is not the same as euthanasia, whereby the physician would ultimately administer the lethal medication themselves – here there is no direct action and the event is subject to a voluntary request. In this argument it is the voluntary conscious choice of the patient that must be considered at all times, other forms of euthanasia are beyond the scope of this article. Autonomy and the respect for others’ decisions remains the most compelling view point in favour of PAS. How can we respect a patient’s life and the choices they make in it regarding their own health and treatment, and then not allow them to make their own decisions regarding their death?

We hold people’s decisions in such high regard in common medical practice; can we truly draw the line at any point? A 2009 study for the State of Oregon Public Health Division (where PAS is legal) showed that 90% of patients utilising their service were concerned about the loss of autonomy regarding their end of life. Some would regard death, when it comes to those in suffering as a ‘blessed relief’ – it seems as though death may only be acceptable when it comes of its own accord. But if there were a choice to have a ‘better death’ would we be obliged to give it to those who wanted it? Where someone chooses death and firmly believes that their life no longer holds value for them, then surely death can be seen as a benefit to this individual – if no third party directly suffers it seems as though their death cannot ultimately be morally wrong. If death is encouraged or brought upon the patient early due to their own unrestricted choice then it appears that those asked to induce it and perform the task are not morally wrong, when death is the patient’s chosen best option. Overall we must view the idea of continued suffering against that of conscious autonomous choice, and thus attempt to act in the patient’s best interests, respecting their own subjective moral code.

INS

A AG

By Amy Dickson Intercalating: Ethics & Law

hysician-assisted suicide is also a term used to describe the act of euthanasia where a physician aids the dying process. Derived from the Greek word Euthanos, meaning “good death”, euthanasia is the act of bringing about, by medical means, a terminally ill person’s death. Euthanasia is often also referred to as mercy killing. However, how merciful is it really? There is no doubt that bringing about the death of another person is not seriously wrong as it is classified as a criminal offence. Physician-assisted suicide undoubtedly compromises the roles of doctors and nurses involved in any ‘mercy killing’ procedures. Physician-assisted suicide undoubtedly compromises the roles of doctors and nurses involved in any ‘mercy killing’ procedures. Doctors are trained to save lives, not to end them. The Hippocratic Oath states “to please no one will I prescribe a deadly drug nor give advice which may cause his death.” I cannot imagine that if voluntary euthanasia was legalised in England, that doctors would be happy to perform such a task. Bringing about the death of another person is murder, whether or not the person wanted to die. Furthermore, who is to say

that a doctor could be ending the life of someone who could actually have been cured? In medicine, it is never set in stone that a person will either live or die, miraculous things can happen, who’s to say euthanizing a patient hasn’t actually brought about an unnecessary death. One of the main contentions when considering the euthanasia debate is the slippery slope viewpoint. Legalising physicianassisted suicide will most likely lead to the permitting of both non-voluntary and involuntary euthanasia, resulting in the abuse of a medical procedure and the murders of many victims who either do not wish to die, or were not ill initially. If a system for physician-assisted suicide were implemented, it would be easy to abuse, and the lives of many people could be at risk. The Human Rights Act 1998 grants a person a right to life, it does not allow the intentional death of another, even if this death is wanted by the ill individual. A “mercy killing” is the violation of a person’s right to life, and a death, whether requested or not, is not permissible at the moment and should never be treated as such.

Mediscope May 2011

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FOR

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From the

“C” word to the “M” word

Winner of the Neel Halder Psychiatry Essay Prize 2010

How negative attitudes are shaped and overcome

Introduction Millions of people around the world suffer from chronic illnesses and whether it is hypertension, cancer or schizophrenia the person must endure it every day. Whatever their illness, most try to find a way to deal with their preoccupations and the fact that they may never recover completely. What counterfeits their fight against the disease is their misplacement in society. It is not just about feeling at ease with yourself, it is also all about how you feel about your place in society. Everybody functions optimally in an environment where they are comfortable and feel at ease with their surroundings.

Mental illness Congratulations to the winners and runners up of the Neel Halder psychiatry essay competition: 1st (joint): Christiana Hadjidemetriou Michael Johnson 3rd (joint): Phil Neill Ayodeji Jaiyesimi 5th (joint): Sarah Williams Lucy Cornthwaite

The ‘C’ Word Cancer, one of the most dreadfully unspoken words, affects millions of people every year worldwide. The general public associates it with doom and death; health professionals regard it as more of a common, fairly treatable condition. In recent times, people have been sensitized to the word cancer through campaigns to increase cancer awareness. As a result, people donate vast amounts of money to cancer charities (GBP 500 million yearly) the most popular being Cancer Research UK1 and feel empathy for a person as soon as they find out that they have a history of cancer. Stigma surrounding the disease itself makes people react differently, they feel uneasy and try to pretend that they understand the effects the disease has on patients and try to provide encouragement even if patients themselves feel fine. This leads to a vicious cycle of social isolation, being labeled and being looked at differently. As soon as a cancer diagnosis is announced to the patient and the relatives, family members sometimes withdraw from the patient as death looms. Where is the patient going to receive support if they can’t from the people nearest to them? Younger generations of this modern era have benefitted and still are, from the ongoing work to diminish the stigma and negative emotions associated with cancer. A greater understanding of the pathologic processes involved in tumor formation and migration as well as advances in

investigational methods, means that cancer is picked up earlier and often more successfully. Psycho-oncology issues are being tackled, especially with educating doctors and health professionals how to break bad news in a way that will make those receiving them more hopeful2. Educating the patient as well as the relatives is paramount in sustaining positive attitudes towards the disease. The ‘M’ Word Compared to a wide range of other disease, attitudes towards cancer patients are more positive, with empathy being the ubiquitous sentiment. At the other end of the spectrum lies an umbrella term identified as mental illness. As many as 1 in 4 people living in Europe experience mental health problems at some point in their life3. Whilst most people go with no hesitation to their doctor if they suspect that they might physically have something sinister (cancer), far fewer seek a professional opinion regarding mental health. Numerous scientists researched the attitudes of the public towards mental illness. One of the biggest studies in the UK4 relevant to attitudes towards mental illness, set out to investigate whether the attitudes of people (n=6000) changed between the years 1994- 1997, 2000 & 2003 in England and Scotland. Interestingly, what was suggested was that public attitudes towards mental illness not only remained predominantly negative, but answers to some questions were answered in a more negative manner in 2003 that they were answered in 1994. A large majority of people reported that: “People with mental illness do not deserve our sympathy”. They also disagreed with the statement presented to them that “We need to adopt a far more tolerant attitude toward people with mental illness in our society”. Similarly shocking results were published in other countries (in 1994-1996) such as the USA and Hong Kong. Studies in Germany and Greece around the same time actually showed improved attitudes toward mentally ill individuals4. Mentally ill people are victims of an

absentminded society who has exercised stigmatized behavior against them for hundreds of years. Subconsciously, they have internalized5 all the negative attitudes from the people around them and they are embarrassed and shameful of what is happening to them. Even if they are willing to find help, they are apprehensive about what the psychiatrist will think of them. What if they are tagged as neurotic and dysfunctional by their own doctor? They have to convince the world that they are not dangerous and dysfunctional or developmentally disabled people6. Why stigma develops A number of suggestions as to the origin of stigma have been offered. Devaluing individuals has a psychological advantage of boosting one’s self esteem5. It is the product of living within a society where inequalities between people flourish. The symptoms of mental illness can be threatening to people around the person affected. Anxiety and tension tend to remind the observer that they might not be in control of their own mind forever. A sense of stability that every individual needs to function normally is endangered. Only a few million pounds are donated to mental health charities each year for research and support, mostly for neurodegenerative disorders (e.g. Alzheimer’s) as opposed to the earlier onset disorders (e.g. Schizophrenia), which could help many more people1. In addition, through evolution we are programmed to instinctively avoid and be socially distant to those who have different values, expectations and norms as they are perceived as a threat to one’s picture of the world. The Media and conflict within medicine The role of the media in perpetuating and even expanding this negative perception regarding mental illness has been recognized for years. The negative portrayal of mentally ill people as violent and unpredictable is the major collaborator in propagating the stigmatization of mental illness. The theory of cognitive economy suggests that negative characteristics identified in one person of one group in society, tends to generalize for all the members of that particular group. This is how stereotypes are formed. It is not only the general public that depict negative attitudes toward mental illness, but also people who should be helping in the fight of stigma against mental health. The last thing that mental health professionals need hindering their commitment and hard work is colleagues from other specialties expressing their own negative views about mental health and how it should be dealt with.

“Mentally ill people are victims

of an absentminded society who has exercised stigmatized behavior against them for hundreds of years.” What can be done now and in the future? Education is vital both at the time of diagnosis of a condition and long term. In Germany7 a mental health education program aimed at high school students, encouraged the personal encounter between students and people who were mentally ill. It found that students’ attitudes towards mentally ill people were more positive than negative. Nongovernmental organizations need more support for the work they are conducting across the country in increasing awareness and decreasing the stigma associated by supporting sufferers and their families. MIND is one such example in the UK, set up to increase schizophrenia awareness. Changing how media portray mental illness is not easy as the economic needs and values of journalists and others in the field have to be taken into account. Stories concerning mental illness seem to have that surreal, intriguing quality that helps to sell. A short mental health course could be suggested to be included in the curriculum of training young reporters on how they could cover mental illness in the news without sending any negative and discriminatory signals to the public (contagion). This has been implemented for suicide and it has proven successful8. Recently in Japan2&9, schizophrenia was renamed to ‘Integration disorder’, and what they found was that the misconceived notion that connected schizophrenia with criminality was largely decreased. Yes it is difficult to change preformed attitudes of hundreds of years, but if we all help to diminish this burden on society we could make the lives of millions of people more tolerable. Christiana Hadjidemetriou This article is a shortened edited version of the winning essay. References

1. ‘A decade for psychiatric disorders’, Nature, 2010; 463(7277):9. 2. Levin T.T., ‘Newer conceptualizations of schizophrenia demand a name change’. Schizophrenia research,2009; 115: 374. 3. Baumann A.E. ‘Stigmatisation, social distance an exclusion because of mental illness: The individual with mental illness as a ‘stranger’’. International review of psychiatry,2007;19(2):131-135. 4. Mehta N., Kassam A., Leese M., Butler G., Thomicroft G. ‘Public attitudes towards people with mental illness in England and Scotland 1994-2003’. The British Journal of Psychiatry, 2009; 194: 278-284. 5. Hinshaw S., Stier A.,‘Stigma as related to mental disorders’. Annu. Rev. Clin. Psychol., 2008; 4:367-493. 6. Klin A., Lemish D., ‘Mental disorders stigma in the media: Review on studies on production, content and influences’. Journal of health communication, 2008; 13(5):434-449. 7. Angermeyer MC, Richter-Werling M. ‘A mental health education program: the school project “Crazy? So What!” initiated by “Irrsinnig Menschlich (Madly Human) e.V. Leipzig”’ MMW Fortschr Med. 2003 Mar 10;145(12):38, 40-1.

Commentary

Dr Neel Halder Introduction

I’ve always been passionate in helping medical students learn about writing scientifically for future publications, and also about expanding the knowledge base of psychiatry among undergraduates. The essay prize covers both aspects and allows students to receive feedback on their written work.

Why the topic was chosen

Stigma against mental illness is a huge problem within society and indeed within medical students. I have come across many with misconceptions about what mental illness is and what psychiatry entails. 1 in 4 of us will go on to have a mental illness at some point in our lives, and I’m convinced medical students are at a higher risk. I thought this would be a great subject matter for that reason. The title came from a poster by Ruby Wax who regularly talks about stigma and openly talks about her overcoming depression. Indeed at the time of writing this she’s just appeared on the news to comment on Catherine Zeta Jones who bravely admitted her bipolar illness.

Final thoughts

If you’re writing an article about anything for publication, the first rule is to make sure you are genuinely interested in the subject matter as this comes across to the readers. All winners for the annual essay prize gets to receive individual tuition and help on getting things published as well as doing major research with me (on top of the £150 cash!). We are currently leading the UK arm of the world’s largest research on recruitment of medical students into Psychiatry (ISOSCCIP study). We intend to present it at the World Psychiatry Association conference in Buenos Aires this year; so look out for future essay competitions that I run and the next one could be you. Dr Halder is happy to be contacted by students wishing to learn more about psychiatry. His email address is neel.halder@manchester.ac.uk

How to Describe Skin Lesions Whether itâ&#x20AC;&#x2122;s macules, papules, cysts, telangiectasia, weâ&#x20AC;&#x2122;ve got it covered. Here are our tips on how to examine and describe skin lesions... By Seunghyun Melissa Lee (3rd Year Medic, St Andrews) & Brian Diaz Tay (4th Year Medic. Manchester)

History Taking

Think about history taking as FC Delta: F- Family history of skin disease and atrophy C-Change. Has it changed? D-Duration. Onset? Previous episodes? E-Exacerbating and relieveing factors L-Location. Where did it start and spread T-Response to treatment A-Associated symptoms. - - -

Itch Tenderness Bleeding or discharge Systemic symptoms

Examination: As always, you start by checking ABCDE of your patients...

Looking (ABCDE!) i)General ii)Focussed A-Asymmetry B-Border (irregular, ragged, or blurred edges) C-Color (a mixture of colors of marks that change color) D-Diameter & Distribution E-Evolution(any change including shape, size, or color) Touching Curious Consultants Touch Skin Thoroughly Curious- consistency Consultants- coldness/warmth Touch-Tenderness Skin-site within the skin Hair Eyes Thoroughly- thickness

Mucous membrane

Inspect and Palpate...

Regiona Lymph Nodes

Pick a lesion, any lesion...* Macule Any colour change of the skin

Papule Hard raised lesion smaller than 1cm in diameter

Patch Macule larger than 1cm

Primary Lesions

Pustule Raised circumscribed lesions.

rimary lesions are caused by the disease process itself.

Telangiectasia Visible dilated veins

Nodule Hard raised lesion larger than 1cm in diameter

Atrophy Absence of the superficial layer of skin

Vesicle Raised lesions <1cm in diameter containing fluid Bullae Similar to vesicle but >1cm in diameter Carbuncle Skin infection involving many hair follicles

Furuncle Infection of hair follicles

Secondary Lesion

al Fissure Cleavage of skin into the layer below

Plaque Similar to nodules but with flat tops

Cyst Closed filled pockets of skin

econdary lesions may have evolved from primary lesions or caused by external forces such as trauma, infection, and healing processes.

*All images and description in this page are adopted from Primary Care Dermatology Module Nomenclature of Skin Lesions, 2011. Gary Williams and Murray Katcher, Department of Pediatrics. [online] Available at: <http://www.pediatrics.wisc.edu/education/ derm/master.html#m> [Accessed 18 May 2011].

education scope

By Alastair Gibb - Mediscope Editorial Team

It’s what’s inside that counts!

f you were to ask the average person in the street, ‘Why are our bones important?’ it is probable that most would say something about how they keep us upright and assist in movement, or perhaps protect vital organs, such as the brain and those within our ribcage. Far fewer are likely to mention the significance of the soft, spongy tissue that resides within many of our bones: the marrow. Until around the third trimester of pregnancy, the liver and spleen constitute the primary sites for blood cell production in the foetus. After this point, continuing through childhood and into adult life, the bone marrow takes over this responsibility. The diagram opposite illustrates how the haemopoietic progenitor cells give rise to red blood cells, granulocytes, platelets and both T and B cells – all of which are crucial to physiological functions in the body. If processes within the marrow malfunction (for example, due to pathology or treatment) and cause blood cell production to be affected, it could be life-threatening. There are a multitude of conditions that cause a disturbance in the manufacture of blood cells. For example, acute lymphoblastic and chronic lymphocytic leukaemia (ALL and CLL) are characterised by excessive proliferation of lymphocytic cells, as are the lymphomas. In contrast, the acute and chronic myeloid leukaemias (AML and CML) as well as myeloma are as a result of problems with the myeloid lineage. However, aplastic anaemia can lead to the marrow ceasing to produce new cells entirely. In certain circumstances, the only effective or curative treatment for these diseases is transplantation of bone marrow stem cells. BSBMT 2008 stats: marrow transplantation • ALL • CLL • AML • CML • Myeloma • Hodgkin’s • Non-Hodgkin’s • Anaemias

157 + 4 50 + 4 391 + 9 46 + 1 43 + 824 51 + 162 116 + 431 67 + 0 TOTAL

921 (ALLOGRAFTS) + 1435 (AUTOGRAFTS)

Most common conditions for which allograft and autograft marrow transplants were performed. Includes bone marrow, peripheral stem cell and cord blood harvesting.

The haemopoietic progenitor/stem cell, which accounts for approximately 1 in 5000 bone marrow cells, goes on to differentiate into both myeloid and lymphoid lineages – eventually differentiating into the recognisable red and white blood cell populations and platelets.

As we age, the active areas of red marrow are gradually replaced by fatty yellow marrow. The regions to the left in red depict where the active marrow remain – throughout parts of the axial skeleton and proximal ends of the long bones

Nearly 3000 people undergo marrow transplants annually. Progenitor cells from bone marrow can be harvested in a number of ways: • • •

Collection from the peripheral blood Taken from the marrow directly Harvested from cord blood just after birth

The patient’s own cells can sometimes be collected and saved for re-implantation as a ‘rescue’ treatment. Unfortunately this isn’t always suitable and so allogeneic transplants are used too, which rely on finding closely matched donors. In order to meet this need, it is vital that that the public is made aware of the importance of bone marrow donation and encouraged to join one of the national registers. Read on to learn about the Anthony Nolan Trust, which focuses on doing just that...

Marrow Manchester

hirley Nolan, the mother who set up the Anthony Nolan trust in 1974 in the name of her son. He had a rare blood disorder, Wiskott-Aldrich syndrome, for which a bone marrow transplant was, and still is, the only hope for a cure.

Currently, the general public’s awareness of the bone marrow register does not seem to be great. Most students I have spoken too have either never heard of it or are filled with misconceptions, such as that it is for after you have died or that it is very painful. Taking the time to explain everything fully, for example the methToday the Anthony Nolan Trust is the charity that pro- od of taking stem cells from the blood is very helpful vides the most names for the bone marrow register but much more needs to be done to raise awareness. in the UK. It also conducts pioneering research into blood cancers and improving transplantation. Despite We always make sure that everyone who joins is fully having over 400,000 people on the register, only half aware of the implications of joining the register and of the people who need a transplant can find a match. that they understand the methods of donation and Anthony Nolan aims to expand the register to increase possible side effects. It is more important to recruit the likelihood of finding a close enough match. those who understand fully and are willing to donate if possible, if they were ever a match, than to have to let Potential donors must be between 18 and 40 (49 for patients down if people we have recruited later change the NHS registry), in good health and above 8 stone. their mind. For instance, I had to discuss at length with It costs over £100 to recruit, test tissue type and one girl whether she would be able to go through the maintain every new donor. Younger people, such as practicalities of the donation procedure as she had a students, are particularly targeted because they are, fear of needles. However, in the end, she was detergenerally, more healthy and can stay on the register mined that she would manage as her brother had had for longer. The role of ethnic minority donors is even leukaemia and she wanted to help other families. I more vital as certain groups are under-represented, think this is fantastic, and I find it so rewarding with for example, only 4% of the donors are registered as every person we sign to the register to know that they Asian. Worryingly, only 40% of ethnic minorities are could be a potential match and thus save a life. able to find a match.

Lorna Clemens - Year 2 Student

Manchester Medical school has teamed up with the Anthony Nolan trust and formed our own branch called ‘Marrow Manchester’ which aims to recruit more students to the register, to fulfil more patients needs. My volunteering work has mainly involved talking to students before or at the time of a clinic to help them decide if they want to join. At the clinics, we ask everyone to fill in a quick form and give a small saliva sample. I am always surprised and pleased how keen some people are to donate, after all, joining the register should be considered a big commitment and requires great altruism. Sometimes people have already heard of the register and been meaning to join, especially those who have had friends or family members with leukaemia and therefore know first hand the importance of stem cell donation. Others, already give blood and are perhaps on the organ register and are looking for new ways to help.

To find out more, visit: www.anthonynolan.org

Myths about Stem Cell Donation

• ‘Donating is very painful’ • Today 80% of donations are via Peripheral Blood Stem Cell Collection. Similar to giving blood, takes about 4 hours and uses a machine to filter off the stem cells. 20% of donations require Bone Marrow Harvest under general anaesthesia, associated with 1-10 days of lower back ache. The patient’s doctor will recommend one of these methods but the final decision is up to the donor. • ‘You cannot join the register if you are homosexual’ • Whilst homosexual and bisexual men cannot donate blood, people of any sexuality can join the bone marrow register. • ‘You donate bone marrow after you have died’ • All donations are from live donors.

Mediscope May 2011

Top Revision Tips

for Phase 1 Medical Studen ts

Top tips for

It’s that time of year again with examinations looming when phase 1 even the most laidback medic panics at the thought of revision. There are no right or wrong revision techniques; find what works best for you. Here are my top revision tips to point you in the right direction to ace those exams.

1. Don’t stress It is important to realise that you are not alone. Exams stress everyone, as we all want to do well! But make sure you look after yourself: have a balanced diet; get plenty of sleep and exercise.

5. Group Study Whether done in a library room or at home, group study and revision sessions allow you to test each other’s knowledge in a friendly environement. They can be especially beneficial in preparing for the OSCEs.

2. Speak up The Medical School invests money and time in us as they want us to succeed. Whether you are struggling with understanding a concept, or adjusting to the style of PBL, do not suffer in silence.

8. Use interactive websites Try to vary you revision technique. Here are a few useful interactive websites:

3. Take regular breaks Your short-term memory has a limited capacity being able to store 7± 2 pieces of information at any one time. Taking frequent breaks allows information to consolidate into your long-term memory. Revising continuously for hours and then taking a long break afterwards significantly increases the number of mistakes made, reducing the effectiveness of your revision. With the limited time you have you want to optimise the effectiveness of each revision session. 4. Be able to explain the cues within each PBL cases This will test your recollection and deepen your understanding of what you have revised. Remember that the semester exams are based on topics explored within the cases. So always go back to the PBL cases.

http://anatomy.med.umich.edu/courseinfo/video_index.html -anatomy http://www.anatomy.wisc.edu/courses/gross/ -anatomy http://www.vectors.cx/med/apps/abg.cgi -ABG interpretation quiz http://www.vectors.cx/med/apps/cranial.cgi -cranial nerve quiz 6. Be prepared on the day Although this sounds trivial, you might be surprised how often people come to the exam unprepared. The night before, re-check the time, place and duration of the exam, as well as whether a pen or pencil is required. 7. E4med- REVISE IT Let’s face it, many of us find E4med boring, but it is guaranteed to be examined. Revising it could be the difference between passing and failing.

Alicia Skervin (Year 2-3 Intercalating)

career scope

AUDIT! Maiedha Raza: Year 3, Manchester Royal Infirmary Oddities

‘Do an audit, it will look great on your CV.’ I bet this is something most of you have either had a superior or peer advising you on. Audits are a hot topic for medical students especially those starting out in their clinical years and looking for something impressive to add onto an imminent foundation programme application, or place in an ever expanding portfolio. Truth is, audits do look impressive but many students conducting them do not actually understand what an audit entails. If asked, ‘Have you completed the cycle?’ the usual response encompasses very little knowledge of a full audit cycle. It is not only an audit that makes you look unique and highly employable on paper, but more presenting the findings, implementing a change with them and completing the cycle! For those of you audit novices out there, a completed audit includes setting a standard to measure, collecting data, analysing, and then implementing a change. To close the cycle this change has to be measured, which then makes way for subsequent data collections.

Hand Pictures

Having recently completed a month long audit looking at good medical record keeping, I highly recommend you take part in one or do one yourselves. Not only is it a rewarding experience, helping increase your knowledge base, it is also invaluable with regards to the clinical aspect (depending on what you are auditing of course). Although it may seem like an advantageous experience, I would advise always taking on audits with caution. You may find you are being approached by seniors who have formulated a title and want you to do the data collection, or you may find yourself agreeing with a title that involves a lot of painstaking medical note reviewing, which is not the easiest thing to do, considering most of them have legibility issues! Conducting my audit; reviewing the quality of written medical notes at Fairfield General Hospital was by far one of the most interesting experiences I have been fortunate enough to stumble upon at medical school. Looking through patient notes is beneficial as it can act as a learning tool. Reviewing management plans cements the understanding of the chronological order from diagnosis to treatment, and can help in interpreting different disease processes.

Brain Freeze Article

Not only is clinical information useful but communication between different disciplines of medicine is also an interesting read, in patients who are being cared for by multiple departments, not necessarily from the same hospital. Aside from acting as a learning tool, depending on the title you choose for your audit, it can help you get to grips with key tasks a junior doctor has to master in the foundation years. In my case I was able to understand the fundamentals of making written clinical entries. Learning simple skills such as this prematurely can then help ease the workload when practicing as a foundation year doctor, allowing you to concentrate on the more interesting but complicated skills! My experience of audits was excellent and I found it relevant to nearly all aspects of medicine. The only drawback being the time it takes and the sheer patience needed to trawl through patient notes when at times they can be filed in chaos. Otherwise, for a medical student it is definitely something worth considering.

The audit cycle, as described by Bolton NHS: <http://www.bolton.nhs.uk/yourcareer/ClinicalQuality/auditandgovernance/registration-and-feedback.asp >

Mediscope May 2011

SocietyScope Fastbleep Foundation:

Widening Participation in Medicine Traditionally, medicine has been a profession of the higher socio-economic groups; and today still only 10% of medical students in the UK come from the three lowest socio-economic backgrounds1. The Fastbleep Foundation is a scheme that aims to narrow this gap, advising and guiding pupils who are passionate about pursuing medicine as a career. The programme is run by Fastbleep; a team involving students from the University’s four faculties with an aim to build a network that would engage university students, faculty and NHS staff to provide educational resources to promote social mobility within healthcare education and training. With support from both the University teaching hospitals and partnerships with AimHigher, Connexions and the Social Mobility Foundation, the scheme aims to: 1. Encourage equal opportunities in medicine across the wider community, involving school pupils from all social backgrounds. 2. Provide advice and support to pupils studying in state schools who are passionate and determined in pursuing a career in medicine. 3. Run national events and build links across schools and universities. We have devised interactive discussion and practical workshops for the school pupils, as well as giving ample opportunity for the curious to ask further questions. We have focused and tailored our sessions across three different age groups, whether it be sparking an interest in the younger pupils or providing sustained support and instilling confidence to those going through the application process. The workshops are intended to motivate pupils through participation in activities such as learning CPR, basic suturing skills and using a stethoscope. Future mock interviews will be held to further enhance their skills and give them the confidence needed for the final stages of the application. This past month has seen a successful launch for Fastbleep Foundation, with workshops already delivered for over 200 pupils across seven different schools in Greater Manchester. The response and feedback has been overwhelmingly positive, and with many more sessions planned and even more medical students requesting to join, the future is bright for Fastbleep and the Fastbleep Foundation!

If you would like to be involved or would like more information, please contact the Fastbleep Foundation Chairs:

Bhamini Vadhwana, 4th year medical student Francesca Liuzzi, 4th year medical student James Giles, MBPhD student

bhamini.vadhwana@fastbleep.com francesca.liuzzi@fastbleep.com [1] Greenhalgh T, Seyan K, Boynton P. “Not a university type”: focus group study of social class, ethnic, and sex differences in school pupils’ perceptions about medical school. BMJ 2004; 328: 1541.

(Above) : Manchester Medical Students within Fastbleep Foundation delivering medical workshops for schools. Pictured Elspeth Hill.

Health Olympics Health Olympics is a brand new society at The University of Manchester. We are a Preston-based organisation run by dedicated and enthusiastic medical students who are keen to both raise awareness of health issues and help to reduce the risk of developing disease. We run various events at schools, colleges and in public places to promote healthy living. In doing so we highlight the impact lifestyle choice can have on the likelihood of people developing chronic illnesses, such as diabetes, as well as having cardiovascular events like heart attacks and strokes. This year, at Preston College, we held a very exciting event where students were offered ‘Health MOTs’ including memory and visual testing, peak flow measurements and blood pressure checks. The fabulous team of Health Olympiads were on hand to counsel students on issues raised from the testing as well as discuss other health topics such as smoking, drugs, alcohol and sexual health. Leading on from this the team of Health Olympiads made their way to The University of Bolton, where we offered health checks to a slightly older and diverse population of staff and students. The servicing began with registration and a brief history of smoking and diabetes, followed by BMI calculation. Blood pressure checks were performed before the ‘patients’ were whisked off to have their glucose and cholesterol levels checked by the keen doctors waiting with needles! After the cycle of health assessments were complete, the data was put into a computer programme that promptly calculated their risk of developing cardiovascular problems and diabetes in the next 10years. The trained counsellors were then able to make recommendations to the individuals regarding lifestyle choices and ways to reduce the risk of developing problems later in life. Overall the day was very enjoyable and saw approximately 90 people complete the cycle, ranging in age from 18 to 80! The events we have run so far have been fun-filled and have hopefully benefitted communities as well as medical students by helping them to develop their skills through volunteering and the training provided. We have been invited back to run an session at Preston College for the staff there and our next mission also includes a very ambitious event held on a weekend at a busy ASDA supermarket in Fullwood, Preston! Anam Ashraf Year 3, Royal Preston Hospital

Course Review

Future Surgeons: Key Skills, Royal College of Surgeons Edinburgh

ith opportunities for hands-on experience in surgery so difficult to come by, I was determined to make the most of my upcoming surgical block. What better place to start preparing than the Royal College of Surgeons in Edinburgh. I was unsure what the Future surgeons: Key skills course would entail and there was a nervous start with the expected segregation of participants from different medical schools. Everyone was soon put at their ease by the light hearted introduction from Mr Tandon, a charismatic, enthusiastic self proclaimed â&#x20AC;&#x2DC;politically incorrectâ&#x20AC;&#x2122; entertainer. He set the scene for what turned out to be a wonderful introduction to basic surgical skills. The teaching itself was thorough and appropriately paced. Skills taught included gowning and gloving, knot-tying, suturing,

diathermy and others: all invaluable for any opportunities of assisting. There was ample time for practice and there was nearly 1 surgeon for every 3 students. My attempt at cleaning up the chicken breastâ&#x20AC;&#x2122;s gunshot wound lead to the recommendation of psychiatry as a career, but the virtual laparoscopic machine really allowed people to get in touch with their competitive side. The College record of 10 sugar cubes was not under threat on this occasion, but there was certainly sweat, tears and pretend blood lost along the way. The pleasant lunch was served in the College library which gave some sense of the history of the building and allowed for conversation with the senior surgeons running the course. These teachers were fantastic: offering advice, anecdotes

and ideas about training and research in an altogether inspiring manner. Come the end of the day, we moved on to the Doctors pub in this beautiful capital city, armed with a series of skills that have indeed proven extremely useful throughout my surgical placements. I would strongly recommend this course for any medical student interested in surgery as it completely surpassed my expectations. Sam Neilson 4th Year, University of Manchester

Verdict:

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5/5

Occasionally, about once a week or so, you are on the receiving end of a brilliant teaching session. You think to yourself, if only every day was like that I would be a truly wonderful doctor! But then you think of all the hours you’ve spent staring at the curtains on J2 thinking what you might put in your sandwiches tomorrow (cheese and beetroot if you’re asking) and your blood begins to boil.

1) Shingles / Herpes Zoster 2) V1 - Opthalmic (Trigeminal Ganglion) 3) Hutchinson’s sign

Wasted Days - A note how not to teach medical students!

1) Diagnosis? 2) Nerve Segment? 3) Clinical Sign to predict Opthalmic Involvement?

Q. How does a medical student define shifting dullness? A. A medical ward round! A recent survey showed that 100% of medical students had thought about ending their lives on a ward round at least twice. Okay, I exaggerate. Maybe 95%. But trudging around at the back of a group of doctors, trying desperately to get a glimpse of the little numbers on the big computer screen, is at best mind numbing, and at worst completely useless. Solutions? Send the student off to take a history and examination to present to the team, get the student to write in the notes, or even a problem to solve, e.g. an ECG.

4) Cullen’s Sign 5). Retroperitoneal bleed, e.g. Acute Pancreatitis, aortic aneurismal rupture, ruptured ectopic pregnancy.

6) Diagnosis? 7) Treatment? 6) Bartholin cyst (Differential: Absess or tunour) 7) Usually resolves without treatment. Absess typically requires antibiootics or surgical draininge.

Clinics Another brilliant, but often abused, learning environment. Who will ever know why some consultants decide that putting a bored student in the corner of a clinic to ‘observe’ is the best way to do it. The stages are universally recognised. In stage 1 the mind begins to wander; perhaps reversible if a kind nurse offers a cup of coffee. But stages 2-4 are irreversible. Next the eyelids begin to draw close. It is now that you know the shot is fatal, but the human body is resilient and refuses to resign. In a desperate bid, you concentrate every muscle (never mind the patient at this stage) to keep your eyes open, but the eyes cross and you simply look mad or drunk. Next come the auditory hallucinations and with one last gulp of stagnant over-heated air the head lolls to the side; the engine has blown, the wings shot, and you swiftly plummet into the glorious state of sleep.

4) Clinical Sign? 5) Give 3 Causes?

Lectures It instils confidence in the student if the lecturer just seems to know what they’re talking about... Questions Never talk at a student for more than 3 minutes; attention spans rarely last longer than this, unless you are a very interesting person... ok, thanks for reading, I’ll leave it there. The GMC list of Ted Fletcher: Year 5,Hope Hospital. Registered Medical T Practitioners reveals ht ry t i d some peculiar entries... o p:// t fo ct w r or w y s/ w ou re .g r Dr Nurse (8 Entries) gi m se ste c- lf Dr Doolittle (1 entry) r/L uk. : Dr Pain (12 Entries) RM org P.a / Dr Doctor (8 Entries) sp Dr Pepper (23 Entries) Dr Slaughter (1 Entry) Dr Helps (5 Entries) Dr Butcher (34 Entries) Dr Sicklick (1 Entry) Dr Cash (14 Entries) Dr Cashman (11 Entries) Dr Killu (1 Entry) Dr Ow (2 Entries)

DR NURSE

(Right, below): The Manchester Medsoc outdid themselves with their spectacular “Cirque du Soleil” themed annual ball.

your scope

Pharmaceutical Ethics:

Voyaging Into Unknown Territories “The tumour is involving vascular structures. There is no role for surgery. Thank you for involving us in this patient’s care”.

he report of the elderly gentleman, dated some 18 months prior, read a sad ending to an unfortunate tale. Why had he returned to the General Surgery clinic now? I was on elective in one of the biggest hospitals in the country, which received its fair share of complicated cases. Almost 2 years ago this patient had been diagnosed with an inoperable pancreatic tumour and had subsequently developed liver metastases. He underwent various chemotherapy, radiotherapy and embolectomy procedures. However, 6 months ago he began taking a new drug, which was still undergoing clinical trials. The patient was ineligible for the trial as the embolectomy procedure was one of the exclusion criteria, but he obtained the drug through a personal connection with the drug company. His oncologist had made him an appointment at our clinic without giving him any further explanation. The surgeon and I examined the current CT scan and it was only after he opened the initial CT that I understood the look of amazement on his face. The tumour had shrunk dramatically in size and was now at the point where surgery could be considered.

A phase III study has just been published on the use of this drug in treating his particular tumour type and has shown excellent results compared with placebo; however the drug is not yet licensed or available to the public for this. I was intrigued by the ethics of the situation: was it appropriate for the patient to use his connections to obtain the drug? Should the pharmaceutical company have provided it? And lastly, was this exclusion criterion fair? Referring to ethical principles as our guide, the patient exercised his autonomy to obtain and use the drug. Yet there was an overall lack of justice: I saw another patient the same day with the same tumour and prognosis, but with no connections and thus no option to take the drug. The NHS is built on the concept of equity and resource allocation - with a limited number of resources we must look at the number of individuals that can benefit as well as the amount by which they benefit. The difficulty arises when, as in this case, autonomy and justice collide. From a pharmaceutical perspective it is a slippery slope from personal favours to other methods that could be used to obtain unlicensed drugs. Perhaps individuals will one day be able to pay pharmaceutical companies directly to use new drugs at their own discretion. When there are no other options, this might be tempting for those who can afford it. A similar idea which has already been implemented is the “top-up” payment system for patients in the NHS. Patients can choose to buy drugs, such as expensive anti-cancer treatments, without losing their access to NHS care1. Some have argued that this crosses the threshold of what the NHS stands for, resulting in as one doctor said, “second class citizens within the health service”2. On a larger scale there is the lack of responsibility to healthcare demonstrated by the drug company. Throughout his course of treatment this individual did not have the detailed expert follow-up that a patient in the

trial would have received. Furthermore, whilst his story is a positive one there was no prior evidence that he would benefit from the drug: it could have severely harmed him. Pharmaceutical companies earn our patients’ trust because they systematically test drugs through many phases, so that when we prescribe them we can say with confidence that this treatment will be safe and should work. There are tragic stories from the past, such as that of thalidomide and its birth defects, which show us the danger of using medications for unlicensed uses and without thorough research. Exclusion criteria for trials are also interesting: why are these particular criteria chosen? Perhaps the drug company felt that patients who needed embolisation were too far advanced to participate or that they would yield less promising study results. In either case the issue remains that this group of patients may still be unable to obtain the drug when it is licensed as it may not get approval for their particular case. In summary, pharmaceutical companies must remember that they have an ethical obligation to the patient: to deliver safe and effective medications. Just as doctors cannot bend the rules for family members or friends, so must these companies realise that it is dangerous and unethical to provide unlicensed medication in this manner. The trust patients have in them, and in us, depends on it.

Zahra Jaffer Year: 5, MRI 1 Coombes R. Rules on top-up payment risk creating two tier system in NHS, MPs warn. BMJ 2009;338:b1973 2 O’Dowd A. Top-up fees will lead to two tier NHS, doctors tell MPs. BMJ 2009; 338:b417

Mediscope May 2011

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ADVERTISMENT FEATURE

My experience at the International Medical By Gursevak Singh Summer School 2010

hen I first started medical school I had very little knowledge of what happens after we graduate. How do I get into the speciality I want? How do I decide what career I wish to have? I thought these questions would be answered as I progressed through medical school, but having spoken to many other medics at different stages of the course, it became clear that this was not the case. This was why the International Medical Summer School appealed so much to me. Organised by a large team of doctors and medical students, it aims to provide the students with the pros and cons of different specialities, teach them essential clinical skills and offer guidance on developing a balanced portfolio to help the students achieve their career aspirations. When I arrived on the first day, I was handed a timetable for the week and was immediately impressed. I was given the choice to choose whether my week would be medicine or surgery oriented and I was pleasantly surprised to see so many well-regarded consultants giving the talks. These consultants then proceeded to give a series of presentations based on â&#x20AC;&#x2DC;a day in the life of...â&#x20AC;&#x2122; their speciality. The sheer volume of the specialties covered was astounding and I found myself considering careers that I had never even thought about before! Over the next two days we were split into subspecialties that we had already chosen where we were given a number of lectures on current topics in that speciality. I was particularly surprised with how up-to-date the lectures were and how they gave me a real insight as to where the speciality was heading in the future. I was then given the opportunity to use a vast amount of equipment related to my speciality. I was able to use a laparoscopic simulator on model abdomen as well as a training programme used for foundation doctors. I felt privileged to be using such technically advanced

equipment which I had never dreamed of using during medical school. In addition, basic skills such as suturing, knot tying, basic life support and trauma life support were also taught. It was this part of the conference that I enjoyed the most. The final two days were definitely the most valuable and for me the reason why the summer school has so much appeal. These days were made up of lectures all about the different career pathways and the research to be undertaken to achieve this. Having had no previous knowledge of the need for research before qualifying as a doctor, I was intrigued to find out exactly what was needed. There was information on how to go about presenting at conferences, doing audits, how to get involved in research, and, importantly, how to get publications. I found this especially useful since, in medical school, a lot of emphasis is placed on publishing but there isnâ&#x20AC;&#x2122;t much information on how to go about it. As enlightening as the conference was, I was pleased to find that a number of social events were organised throughout the week for us to partake in. These events provided a relaxed atmosphere to get to know other students attending the conference as well as some of the lecturers. The consultants and registrars were really friendly with many providing their contact details for future research opportunities. Overall, I would say the International Medical Summer School is not one to miss as it is a unique event with a great appeal to medical students all over the world at any stage of their degree. I have gained a great level of focus towards my chosen speciality and the knowledge in order to get there. Gursevak Singh Year: 2, University of Manchester

FUTURE EXCELLENCE

INTERNATIONAL MEDICAL SUMMER SCHOOL 15 to 19 August 2011 th

University Place, University of Manchester

Features o Provide a clear insight, enhance under standing, and discuss the pros and cons of all competitive medical and surgical specialties o Endow with a taster of basic clinical and surgical skills in the specialty of your choice o Provide guidance on building a strong portfolio and develop your chosen career

Feedback “Very informative and opened me up to a whole array of new sub-specialities that I wasn’t sure of before which I can now explore over the rest of my medical school career. The lectures on what happens after we graduate were particularly useful. Thanks!” -Hammaad Khalil Year 1 University Of Liverpool

“Fantastic concept! There is a real need for such innovative programmes that will help the current medical students to understand and appreciate different careers, and help them choose what is best for them.” Mr Ravi Goyal Consultant Orthopaedic Surgeon Royal Blackburn Hospital

Fee: £145/-

o Provide opportunities to interact with Consultants and Registrars in an attempt to arrange clinical placements and undertake projects o Highlight areas that may be of future interest in the specialty

FUTURE EXCELLENCE

INTERNATIONAL ACADEMIC AND RESEARCH CONFERENCE 20th August 2011, University Place, University of Manchester

o Opportunity for medical students and junior doctors to present their work to an international audience o Talks from high profile keynote speakers o A number of prestigious named prizes awarded o Publication of selected abstracts in international journals o Forum for students and doctors to exchange interesting clinical observations and innovative ideas o Interact and network with like-minded colleagues from various countries o Instil attendees with the inspiration, awareness, comprehension and confidence to achieve remarkable and ground-breaking medical inventions and discoveries in the years to come

Fee : Students : £25 Doctors : £45

Closing date for submitting an abstract : 15th May 2011 For more information and to secure a place, please visit:

www.doctorsacademy.org

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