mediscope FRESHER’S SPECIAL
Sept 2008
Impact of Climate Change on Skin Cancer Peripheral Vascualar Examination Poster Interview with Gunthor von Hagens Medicine Abroad Sexual Health
Global Health
Manchester Medical School’s Student Magazine
mediscope
Issue 3 Sep 2008
mediscope
Submit all articles to subeditor.mediscope @manchester.ac.uk 2
mediscope
Manchester Medical School
CONTENTS 04 News Infoscope keeps you up to date with the latest medical news.
06 Feature Impact of Climate Change on Skin Cancer 06
08 Education Becoming a Psychiatrist 08 Research 09 Medical Careers 10 Sexual Health 12 Peripheral vascualr exam poster pull-out 14
16 Comment Prescription Drug Abuse 16 PBL for Dummies 18 Climate Change and Public Health 19
19 Society Find out about medical student activities past, present and future
23 Life Personality Types 22 Gunther von Hagens Interview 23 Medicine during WW2 24 Working Overseas 26 Medics Abroad 28 Past editor Interview 30 Agony Aunts 31
A word from the editors... We cannot believe how successful the new Mediscope has become. The past year has been a lot of fun for your editorial team but it is now time to hand over to a new set of editors. We must say a big thank you to everyone who contributed to this and the last two issues of Mediscope; without you there is no magazine. We hope you enjoy the Global Health themed Fresher’s Special. Please keep up the support for the new team and look out for the flashy new website that will be activated this year. With it, article submitting and editting should prove far easier and productive. Mediscope can only get bigger and better. Thanks again
The Editorial Team subeditor.mediscope@manchester.ac.uk
Team l a i r o t The Edi nderson James A lquhoun o Jessie C elley K Thomas abherwal S Rohini liams l i W Anna
mediscope Front cover and formatting by James Anderson 3
mediscope
Issue 3 Sep 2008
infoscope Welcome to Manchester Medical School Dr Caroline Boggis This is an exciting new stage in the careers of the first year students. Starting at University offers such a range of new and different opportunities. In addition, starting to study medicine also offers lots of opportunities and different and exciting experiences. To become a doctor does take time and encompasses acquiring a large quantity of knowledge in a variety of scientific
and allied disciplines, proficiency in clinical and communication skills and also learning to become a young healthcare professional. Being a medical student is a privileged position, which necessitates being in close contact with many patients. These patients will have expectations of student doctors; they will expect them to ask about their health, their personal and social circumstances and for intimate information. They will tell students about themselves and maybe even information they would not tell their close families. Patients will expect students to examine them physically. This close contact with others is not normal in regular society and students will have to learn to do this with confidence and in a manner to ensure the patients feel safe in their presence and by their actions. In undertaking such clinical activities they will need to
be done with the patients’ consent and their privacy will have to be safeguarded at all times. Although students starting to study medicine this year may feel inexperienced, patients often cannot tell the difference between students early in their studies from those approaching their final exams and may treat them as an “almost” doctor. In the clinical environments tutors and supervisors will be there to teach, facilitate, and enable clinical learning. In these interactions with patients, students will be developing this privileged patient/doctor relationship which will be the foundation for their whole career as a doctor. Dr. Caroline Boggis is the Head of the MB ChB Curriculum and is a Consultant Radiologisit.
Dr. Neel Halder Undergraduate Prize for Psychiatry Students are to pick one essay out of the following: Essay 1: Mental Illness. Does it exist or is it overmedicalisation of normal emotions? Essay 2: Stigma and prejudice towards mental illness. How can it be reduced?
1st prize £400 2nd prize £100 Certificates will be awarded to all who enter.
Guidelines:
Please read the guidelines and submit the essay to subeditor.mediscope@manchester.ac.uk by 19th December 2008. 4
Maximum word count of 2000 words. Please ensure that the text is typed and double spaced A summary should be included at the beginning of your essay that gives a brief overview of the main points. This should be a maximum of 100 words and will not be included in the overall word count.
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Manchester Medical School
info
Keeping the person in mind Thanksgiving ceremony 30th April Dr Lis Cordingley
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his year many medical students and staff attended a service of thanksgiving and remembrance for the people who had donated their bodies for use in the education of medical and other students at the University of Manchester. The service was very well attended by staff, students and families. I was particularly moved by the number of students who attended and by their thoughtful comments afterwards. Seeing the families and friends of the deceased reconnected students with the other components of their lives; a tangible reminder that the people who have donated their bodies had been part of society, of a family, and had different roles and relationships. Students have a wide variety of reactions to their first experiences of working with the bodies in the DR;fascination, fear, excitement, revulsion, intellectual curiosity – often a mixture. For many, attendance in the DR can feel like an important rite of passage into ‘proper’ medical training. However, it is very common for students to have initial difficulties in being able to concentrate because they feel overwhelmed by the enormity of what they are doing; worried about being disrespectful; struggling to put aside what, after all, are ‘normal’ responses to seeing a dead body; confronting death in a very direct way. Eventually, all students seem to adapt to the DR, and perhaps this process of adaptation is the beginning of doctors learning how to temporarily set aside “normal” responses while focusing on challenging tasks – performing surgery or invasive procedures, for example. In these situations, the ability to block out other information and focus only upon the biological aspects of the body is appropriate and functional. However, it is important to recognise the temporary nature of this activity, and for doctors to be able to reconnect with the whole person the rest of the time. Doctors (and students) need to retain their humanity when interacting directly with patients and their families, when discussing prognosis and treatment options, when planning with the rest of the health care teams and when remembering they too have lives outside of medicine. It is noticeable that the clinicians who are often most admired by medical students are those able to make strong therapeutic relationships with patients and
families whilst also having the flexibility of approach to be able to focus down onto technical aspects of their work. For these reasons, the service of thanksgiving provides an important acknowledgement that students have feelings about the body with which they are working. Knowing that at a later date they will have an opportunity to pay their respects to the deceased and think about the people in the context of the rest of their lives, will enable students to make the most of the very valuable educational opportunities they are being offered by the generosity of the deceased person.
Professor Crossman
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ach year, the University accepts about 40 human bodies into the Dissecting Room (DR), primarily for teaching anatomy to medical students. This is subject to a licence which we hold under the Human Tissue Act (2004). The bodies we receive are invariably those of people from Manchester and the surrounding area who have indicated, in writing, prior to their death, that they wish to donate their bodies for this purpose. We currently hold the records of about 6000 living individuals who have already bequeathed their bodies to us in this way. On 30 April this year we held, for the first time, a Service of Thanksgiving in remembrance of the 39 individuals who had donated their bodies in the previous academic year. The Service was held in the Holy Name Church, adjacent to the Stopford Building (Medical School) on Oxford Road. The Service was attended by approximately 400 people, including over 130 relatives and friends of the donors. There was an impressive attendance by the undergraduate students and this was much appreciated by the relatives of the donors. Approximately 200 students attended, some of them taking an active part in the Service. The anatomy teaching staff and senior officers of the University were also present. Officiating at the Service were senior clergy representing the spectrum of religious affiliations of the deceased. Recognising that the donors were local people, the Service was also attended by the Lord Mayor of Manchester, the Deputy Lieutenant of Greater Manchester and representatives of the Chief Executive of Manchester City Council. Other guests
included Dr Jeremy Metters, previously HM Inspector of Anatomy and Prof Susan Standring, Professor of Anatomy at King’s College, London and President of the Anatomical Society of Great Britain and Ireland. It is hoped that the Service will become an annual event.
Matthew Fell, Year 3, intercalating in Anatomy
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t often strikes me how lucky we are to have the dissecting room as a teaching resource. Having a room dedicated to anatomy with hands on access to real human tissue is an incredible thing and sets the Phase 1 Medical degree in Manchester apart from other lecture based courses. A service was held in April to commemorate and give thanks to the thirty nine bodies donated to the medical school in 2007/2008. Amidst fears of a poor turnout, I witnessed humbling scenes as hundreds of family members of the donated bodies, staff and students turned out to fill the Church of the Holy Name next to the Stopford building. There was literally standing space only, which is quite a feat in that huge space. Some medical students were involved in the service by ushering guests to their places and doing readings. A candle was lit for each of the thirty nine bodies donated accompanied by the haunting sound of the University of Manchester Chamber choir who were outstanding. The hymns were suitably uplifting and what the medics lacked in a sense of tune they certainly made up for in enthusiastic volume as “How Great Thou Art” rose to roof to finish the service. Afterwards, everyone collected for biscuits and drinks giving a chance for some interaction. I talked to an elderly woman who was overwhelmed with gratitude for the respect shown for her relation. She told me that the service had meant an awful lot to her. Having access to the dissecting room is an absolute privilege. Obviously this is a widely held view as demonstrated by the large numbers of medical students who attended, looking smart and prepared to show their appreciation. The service provided an opportunity for us to reflect on the incredible act of someone leaving their body for our education and it made me very proud to be a part of Manchester Medical School.
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Issue 3 Sep 2008
featurescope Impact of Climate Change on Skin Cancer Kathryn Howe
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urrently, the overwhelming popular belief is that tanned skin equates to health, athleticism, success and beauty; qualities that many aspire to. Historically, those who could afford to spend
time indoors, rather than working the fields, developed pale skin; a fair skin type was deemed a positive sign of affluence. Nowadays, tanned skin is considered to be a sign of wealth and prosperity, indicating the ability to partake in holidays to sunnier climates and suggesting a healthier outdoor lifestyle. Public compliance in safe sun behaviour is encouraged by imaginative slogans such as ‘slip slap slop’, ‘sun smart’ and the American Academy of Dermatology ‘ABCs’ (Away, Block, Cover-up, Shade). Furthermore, the effect of various celebrity endorsements for the beauty of pale skin may be profound in altering the current trends in the popularity of tanning, sun-worshipping behaviour and the fashion of sporting minimal clothing as soon as the sun shines. Such behaviour leads to an increase in the time exposed to ultraviolet radiation and, as the temperature increases, the population is expected to spend more time enjoying the sunshine. Indeed, it has been identified that the probability of sunburn approximately doubles when the temperature is 1927OC in comparison to the maximum temperature of a typically average British Summer; 18OC.1 With five or more episodes of sunburn, a person’s risk of skin cancer also doubles.2
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Manchester Medical School
feature
Climate change is an important topic. Kathryn Howe explores its relationship with skin cancer and discusses the possible implications.
Some experimental evidence carried out on human cells
“the probability of sunburn approximately doubles when the temperature is 19-27OC”
does support their claims whereby at temperatures above 23OC the effectiveness of DNA repair induced by UV damage was decreased and genetic instability was encouraged, resulting in a preponderance of tumorigenic cells. Van der Leun and de Gruijl conclude that if the relationship between temperature and UV carcinogenesis does manifest in humans, as in mice, then skin cancer may well develop into one of the
It is widely acknowledged that all 3 types of skin cancer are related to sun (UV) exposure. Less well substantiated, yet gaining support, are the emerging theories regarding the interaction between ozone depletion and global climate change. Studies carried out by Bain et al. investigated the effect of
significant consequences of climate change.
E
ven the most sceptical of analyses must recognise the important consequences of increasing temperatures on human behaviour and accept that even this alone,
may have an effect on the risk of skin cancer.
exposing groups of mice to UV radiation at three different
Further investment in public awareness campaigns is
air temperatures; 3-5OC, 23OC and 35-38OC. Their results
required, moreover, a change in current trends would
concluded that tumorigenesis was evidently more prevalent
appear fundamental in altering the public perception of
in warm environments.
fair skin, without which, attempts to influence the behaviour of the masses will be futile.
Van der Leun and de Gruijl attempted to use the results from this, and other studies, to generate a model, from
Regrettably, the significance of these actions may be
which the influence of temperature on human skin
underestimated until the detrimental impact of climate
carcinogenesis could be appreciated.
change on human skin is realised.
They proposed that a 4OC rise in temperature, as predicted
Kathryn Howe is a 4th year medical student
for this century, would result in an additional 100,000 patients per year with skin cancer worldwide. This amplification would indicate an estimated further 6000 cases of skin cancer in the UK per year by 2050: their treatment will require an investment of at least £7 million into the NHS and will cause a huge burden on healthcare provision.
“skin cancer may well develop into one of the significant consequences of climate change” 7
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Issue 3 Sep 2008
educationscope Neel Halder Becoming a psychiatrist Qualities of a good psychiatrist Patience Good communication skills Warm and empathic nature Good listener Good at picking up nonverbal cues (Body language, facial expression) Works well in teams Ability to appreciate the biological, psychological and social aspects to illness Genuine interest in how others think and feel
Tips for students who want to become psychiatrists Intercalate/ obtain BSc in psychiatry/ psychology Consider elective in mental health unit Be proactive and seek out enthusiastic teachers in psychiatry Enter student competitions related to mental health Discuss what the career involves from senior psychiatrists Find out more information from www.rcpsych.ac.uk
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t is worth thinking about what speciality you want to do after qualification at an early stage. If psychiatry interests you, here are tips that may help in future. Tap into the research facilities and do an intercalated BSc in psychology/ psychiatry whilst at medical school. It would not only increase personal knowledge, but look impressive on the CV when it comes to applying for posts. An elective spent in a mental health unit would be beneficial too. In the last few years psychiatry has become a highly competitive speciality, and your application form needs to stand out from the others. I regretted not doing that at medical school, but later completed a postgraduate Masters in psychiatry after qualifying.
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Psychiatry training module I remember not getting much in the way of psychiatric training. And yet it is so important no matter what speciality you go into. Many students end up becoming GP’s, and research has shown mental health problems make up about 1 in 3 consultations. Underlying psychological issues also play a part in many physical illnesses and presentations to other hospital specialities. In one study, questionnaires were sent to graduates from all UK medical schools, and found that only 4 % of doctors chose psychiatry as a long term career shortly after qualifying (Goldacre et al, 2005). It concluded that recruitment may help if medical students had greater exposure to psychiatry. From that respect I am pleased that training seems to be improving. I was in the last year to experience the “traditional” teaching methods of being spoon-fed via daily lectures. We piloted the PBL method, and I found it quite difficult to adapt, like many St Andrew’s students who have to switch from one to the other. However, for all the time spent in lectures, I can remember very little of what I learnt then. As a PBL tutor now, I can appreciate the advantages: things stay in the memory banks for a lot longer it helps you consider the whole person and the wider impact of the illness it teaches skills in group-working and effective communication; vital components for any doctor, let alone psychiatrists. Make the most of the communication skills training using simulated patients. It’s the most useful practice for OSCEs and life as a doctor. I’m always impressed by the standards of communication (verbal and non-verbal) when examining at OSCEs.
The initiative lies with the student. It is easy to slip through being quiet or not doing much work, but you’ll pay for this after you qualify. In my clinical years , I used to get frustrated by doctors making me feel like I was a burden; teaching sessions would be low in priority and often get cancelled. I vowed never to be like that. There are enthusiastic teachers, but they have to be sought out; they will not come to you. We have clinics, home visits and inpatients to juggle, but will gladly make time to teach as long as students can be flexible.
First year after qualifying This is when many doctors make their minds up about future career speciality. In my surgical rotation I would amuse the surgeons by my indepth history taking leading to knowledge of family dynamics, and patient fears and feelings toward surgery. “It’s a lump, we cut it out. You should be a psychiatrist”, I was told. I spent 4 months in primary care, working alongside GPs. This provided my best training experience, and would recommend it to anyone, whether or not you want to be a psychiatrist. Many students veer into specialities where they received the best and most enthusiastic teaching as students. For me, it was Paediatrics. From here I became fascinated with looking after patients with Anorexia. This is mainly a psychiatric problem, and from there I was hooked. How does the mind work? How does it push people into committing extreme acts?
Why I chose psychiatry I like the way that psychiatry didn’t feel like a tick box speciality. To me when someone has a heart attack, there is a very prescriptive course of action that I feel takes away a lot of the thinking by doctors. With psychiatry, I think there is more autonomy and freedom for doctors to decide what would be best. Don’t be put off by other peoples’ prejudices and mis-conceptions in what used to be known as a “Cinderella speciality”. Psychiatry will continue to grow as a specialism. 1 in 4 people will suffer a mental health problem in their lives. Mental illness is set to become the 2nd biggest global burden of disease by 2020 (2nd to cardiac disease). The Government have recognised this and is putting more money into mental health. I have never looked back in choosing psychiatry as my career path. Dr Neel Halder is a ST4 Psychiatrist
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Manchester Medical School
education
James Young Has anyone thought about research?
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have spent the last two summers working in The Centre for Stem Cell Biology at The University of Sheffield. This entailed being involved in creating neural stem cells from different embryonic stem cell lines. The future of this research could end up helping patients with diseases such as Parkinson’s. My colleagues are very passionate about research and made me think, for the first time, about the importance of the involvement of medics in research. I am a third year medical student at Manchester University finding my hands full keeping up and covering all the basics. My view on my future career path is of a conveyor belt from student to consultant, with some anxieties about stepping off. There is little time to sit back and consider different options: I wonder how many medics through their training consider being involved in research as an option? The world of research has revealed itself to be very different, sometimes refreshing and often frustrating. You find yourself in a different mindset. In medicine you are expected to be confident and have the answers. In research it is OK to question, ponder and not be sure. This is not to say there is no job satisfaction. I see people glowing as they submit their latest paper which they are proud of, but also happy it is finally finished. I do agree with a statement once made to me in the lab that ‘scientists have to be masochists’. I have twice seen weeks of work thrown in the bin all because of one mistake. All you can do is start all over again. Peter Andrews is a Professor at The University of Sheffield and director of The Centre for Stem Cell Biology. Professor Andrews explains that developments in medicine must depend on research into basic biology. We need people who can straddle both areas as medicine would be impoverished if the split between the researcher and the practitioner became too wide. Clinical academics fulfil this role by having significant clinical activity but at the same time being at the forefront of research into basic biology. These people, he says, ‘are able to appreciate what is going on at the basic biological level, to translate this and decide what makes sense in a clinical setting’. Furthermore, he feels, ‘it is equally important for information to go in the opposite direction.’ He worked for a number of years in the USA and is aware that in that country there are many clinical academics. He contrasts this with his experience of the UK where he believes
the career structure for medicine makes it hard to be a clinical academic. Professor Freddie Charles Hamdy, is a clinical academic at the University of Sheffield. His first exposure to research was out of necessity because as a registrar he needed a higher degree to advance in his career. Having completed his thesis for his higher degree, he returned to a clinical environment as a senior registrar, and says, ‘I missed research as I did not feel intellectually stimulated enough in a clinical environment’. To be able to get a mixture of both he applied for a clinical academic post to become a senior lecturer. Currently his job is split down the middle with half of his time spent completely on research. The research carried out comprises of three parts, basic science, translational and clinical research projects. He explains ‘ninety nine percent of your research will never be translated into anything but if you are lucky, the one percent could end up being helpful. However you need to do the ninety nine percent to get the one percent’. It can be very rewarding, he explains, ‘you close the loop being able to follow research from the lab to the bedside’. When asked if he thought being involved in research made him a better doctor he answered ‘I think it gives me a better appreciation of the literature, of the big research questions and how to answer them systematically to provide the much needed evidence to change clinical practice, and a better global view of big issues in medicine.’ The link between smoking, cancer and heart disease, using beta blocker drugs to treat high blood pressure, treatments for stomach and duodenal ulcers and cardiac catheterisation are all examples of developments in medicine made by clinical academics. In 2004 the BMA released a final paper on the cohort study of 1995 Medical Graduates saying ‘recruitment of doctors to academic posts is at an all time low’. Alongside this the Council of Heads of Medical Schools in 2004 published data saying numbers of clinical researchers in the UK’s medical schools have dropped 17% since 2000. Clinical academics are an ageing population. Between 2004 and 2007 the clinical academic population aged over 46 has increased by 16%3. This is worrying as clinical academics are critical for the UK to remain at the cutting edge of clinical research. Young doctors do not often perceive an academic career to be attractive. In recent years the government has taken steps to address this deficit. The Savill
Clinician Scientist scheme and the ‘Walport’ initiative have created new ways for people to enter clinical academia4-5. The NHS R&D strategy, Best Research for Best Health, was launched in 2006 with the aim to refresh health research within the NHS. This created the National Institute of Health Research with 11 Biomedical Research Centres around the UK and many funding streams to support and aid NHS based biomedical and public health initiatives6. This pace of change has never been seen before. There is a little evidence to say these new plans could already be bearing fruit. The government’s initiatives have created a career structure whereby after your F2 year you can go straight into an academic path. You become appointed as a clinical fellow with two thirds of your time spent on clinical work and one third on research. Within two years you prepare a project for a PhD and then take three years out to complete it. Once completed you are guaranteed a place to come back as a lecturer. This is the first time an academic career structure has been implemented making a career in academia more accessible. My experience of research has been positive. Had I not, by chance, found myself in a research environment I may not have thought about these issues. It has left me with an interest that could encourage me to become involved in research as my career develops. Professor Hamdy wishes he had the opportunity to have taken three years of full-time research out to do a PhD, which he says he would have enjoyed had he not been under pressure to obtain a recognised training position at that time. This indicates previous constraints to short change research in order to concentrate on a medical career, which appears to have been rectified through the new academic career path. It would be a shame if research remains a tick box on your CV to gain consultant status. James Young is a 4th Year Medical Student
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education
mediscope
Alex Langhorn
Issue 3 Sep 2008
So, you’re not sure
T
oday’s job market is changing. Graduates of all disciplines are increasingly adopting a crazy paving approach to their career development, moving from one job to another to develop their skills. Whilst it is true that not many doctors leave the NHS, (according to the BMA as few as 3% of doctors graduating in 2005 left medicine), there are many alternative options open to medical graduates. Whether you are considering working as a doctor outside of the NHS, using your medical knowledge in another sector or moving into something entirely different, there may be more options than you think.
The NHS and beyond If you are looking to apply your medical skills in a setting that takes you beyond the work of the NHS you might want to consider some of the following career areas: Medical officers in the Armed Forces Both the Royal Navy and Royal Air Force accept applications for Medical Officers straight from medical school. The Royal Army require you to have completed professional training (usually F1/F2, sometimes specialist training) before you can apply. Employment prospects are currently good but be prepared to work in war zones around the world and to undertake some basic military training. See the Army, Royal Air Force and Royal Navy careers websites for more information or make an appointment at your local Army Careers Office (Peters Street, Manchester). Sports medicine If you are keen to apply your medical skills to patients that are generally fit and well you could consider gym/sports team roles. Work patterns tend to include evening and weekend work and the poten-
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Alex Langhorn gives an overview of the job market for medical graduates beyond being a doctor
tial to travel. The British Association of Sports and Exercise Medicine offer postgraduate qualifications, most commonly studied alongside specialty/GP training, for those interested in a career in this area. See the BASEM website for more information. Travel medicine If your career wish list includes international travel, you might consider travel medicine. Prior clinical experience in tropical and infectious diseases or general practice is generally sought in this area as you will be dealing with immunisation programs and managing and treating infectious diseases associated with overseas travel. Pharmaceutical medicine Options in the industry range from working for large multinational firms such as Pfizer to smaller specialised biotech facilities such as those based on Manchester Science Park. Roles particularly relevant to those with medical training include clinical research posts, drug safety officers and medical advisers. Whether you want to work at the bench or prefer the challenge of communicating with scientists every day there are a diverse range of roles in the industry. The Association of British Pharmaceutical Industries has a fantastic
careers website listing in excess of twenty different roles! Often graduates entering these areas will have some previous research experience. Medical writing If you have a passion for communicating scientific concepts to others, be that academically, journalistically or in an educational capacity, you may consider medical writing. There’s potential for freelance work here as well. Start building a portfolio of written work as soon as you can to demonstrate your style. For more information the following organisations are helpful; the Medical Journalists Association, the European Medical Writers Association, and the Association of British Science Writers. Medico legal work There are opportunities to work in medical protection, defence, risk management and forensic medicine however most medico legal roles require a number of years of previous clinical experience. If you are looking for a complete move into the legal field, then you could consider training to become a solicitor or a barrister. As with any career change, this would require a good deal of forward planning. Postgraduate legal education is expensive (most courses cost in excess of
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Manchester Medical School
£6000) and competition for initial training positions is fierce with approximately twice as many students qualifying as there are training places. It is possible to specialise in medical law at the end if you want to use your knowledge of the healthcare system, but with two years of postgraduate legal study followed by two years working as a trainee ahead of you this is a lengthy and expensive option.
sible to organise a foundation rotation. Public Health
Useful resources
education
if you want to be a doctor? Association of British Science Writers http://www.absw.org.uk/
Medical Journalists’ Association If you are interested in public University of Manchester www.mja-uk.org/ health policy and strategy, Careers Service consider looking in to the Fac- Information, advice and guidance LawCareers.net ulty of Public Health training to support your career plans. www.lawcareers.net programme. Once you have www.manchester.ac.uk/careers Medicines Sans Frontieres completed your foundation Prospects www.msf.org training you will be eligible to Options with your Medical Medical posts in overseas aid organisations apply for training to become a degree. Voluntary Service Overseas Posts in this type of work (particularly in registered specialist in public www.prospects.ac.uk www.vso.org.uk developing countries) tend to require sub- health. Support4Doctors Expedition Medicine stantial prior clinical experience, after all, Articles on career management www.expeditionmedicine.co.uk you could be working in a far flung part of Competing in the and alternative career areas. the globe, managing a team on limited wider graduate labour www.support4doctors.com General Medical Council resources and responding to a wide range market http://www.gmc-uk.org/ of medical emergencies. There are a Royal Army Medical Corps For those of you considering number of medical aid organisations placwww.army.mod.uk NHS Graduates Scheme http://www.come2life.nhs.uk/gr ing doctors in such posts, these include; leaving medicine altogether, aduate Medecins Sans Frontieres, Merlin, the Red you will be encouraged to Royal Air Force www.raf.mod.uk/careers learn that as a medical graduCross, and Voluntary Services Overseas British Association of Medical ate you are eligible to apply (VSO). Royal Navy Managers alongside graduates of other www.careers.royalnavy.mod.uk www.bamm.co.uk Expedition medicine disciplines for many of the jobs If your desire to travel and experience the advertised by graduate recruit- United Kingdom Association of Health Service Journal Doctors in Sport http://www.hsj.co.uk/ great outdoors surpasses your desire for a ers. large (or any) salary you might consider Bear in mind that these re- www.ukadis.org NHS Careers expedition medicine. Safari, marine and cruiters don’t often see appli- British Association of Sport and www.nhscareers.nhs.uk polar expeditions for scientific or even cations from medical Exercise Medicine charity incentives all require accompany- graduates. They will need you www.basem.co.uk The Academy of Medical Sciences ing medics. It goes without saying that to describe how the skills you www.academicmedicine.ac.uk this is another area where experience in have gained during your time Liverpool School of Tropical emergency medicine and infectious diseas- as a medical student can be Medicine www.liv.ac.uk/lstm Modernising Medical Careers – es is sought after. transferred to the job you are Academic Medicine applying for. As a medical de- London School of Hygiene and www.mmc.nhs.ac.uk/academic Management gree is not classified, it will Tropical Medicine As a new graduate you can apply directly also be necessary to demon- www.lshtm.ac.uk Medical Research Council www.mrc.ac.uk to the NHS Graduate Management Train- strate your academic abilities ing Scheme alongside graduates of other by providing your transcript of Association of British Pharmaceutical Industry Academic & Research Posts disciplines. The GMC also have a Gradu- merits, distinctions and passes. www.abpi-careers.org.uk Online ate Management Scheme as do some of www.jobs.ac.uk From business, finance and European Medical Writers the providers of private healthcare. management to the public sec- Association Faculty for Public Health It is most common for those involved in tor and creative industries, the www.emwa.org Medicine clinical management to have worked as a options are vast. Check out the www.fphm.org.uk/ doctor for some time before moving into list of graduate vacancies admanagement. The British Association of vertised on the Careers Service Medical Managers has some useful re- website and sign up for email updates to long time and is best begun with a thorsources online. get a flavour for the opportunities availaough exploration of what it is you want ble to you. Academic Medicine out of your future career. Gaining a better understanding of yourself, and a clearer If you are thinking of embarking on a Next steps? career in research or would like to combine If you are reading this then you have picture of what it is you are aiming for, clinical practice with research, it is now already taken the first step towards getting will help you to begin setting achievable possible to undertake a dedicated training the career you want. Whatever your rea- goals. Talk to people around you, your pathway in Academic Medicine starting at sons for considering an alternative career tutors and your peers. For impartial and foundation level. If you are not sure at this path the sooner you start doing something confidential advice and support, visit the stage whether you wish to commit to a about it the more likely you are to reach a Careers Service. career in academic medicine it is also pos- fulfilling decision. This process can take a Alex Langhorn is a Careers Consultant
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mediscope education
Issue 3 Sep 2008
Sexual The fifth year elective is an important time for medical students. Sarah Gillingham, explores how she got the most out of hers.
Juliette Oxford and Lizzie Shiner “So what can I do to help?” said the doctor pleasantly, settling into his swivel chair. Chloe didn’t want to be there. She sat down on the edge of the seat facing the doctor clutching her bag to her chest and waited whilst he clicked on his computer. The room was so stuffy and the smell of disinfectant pinched her nose. It all started a few days ago; this burning pain when she went for a pee, and a kind of dull ache in the base of her belly. Chloe chose to ignore it. There was no one she was comfortable talking to yet about things like that; private things. Not even Josh. He was busy all the time anyway, working late nights in a bar in town. So whenever they did have time together he wanted to have fun, not talk about things like that. They had met in a club; she liked his dark curly hair, he liked her white skin and naivety, pretty as an English rose, vulnerable in this new town. That morning Chloe untangled herself from Josh’s heavy arms and went to wash her face in the sink. The burning when she peed was getting worse, and sleeping with Josh last night had been more painful than ever. Looking in the mirror she thought about what Josh had said a few weeks ago. They had been in a café celebrating their second anniversary with a coke and cake. Two months, the longest ever, Chloe had thought. Josh leaned across the table and brushed away her fringe. “We’re gonna have a special night tonight,” he said, “just you wait.” Chloe smiled shyly and looked around to see if anyone had overheard. “And I don’t think we need to use a condom anymore, you’re on the pill now,” he added casually. Chloe nodded, that’s what couples did when they trusted each other, wasn’t it? After all it is our anniversary. But looking in the bathroom mirror, Chloe had the feeling that all these problems had started then. Talking to the doctor was going to be even more embarrassing. “Is everything alright?” She was suddenly transported back into the doctor’s surgery. Looking up from her lap, Chloe realised the doctor had been waiting for her to speak. Parting her lips she didn’t know where to start. “I….I’ve….I’m not feeling well.” The doctor waited for her to go on. “I’ve got this pain when…” she hesitated, “….I go to the toilet.”
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Chloe came out of the doctor’s room feeling slightly relieved. She had finally told somebody. He had been very nice and understanding, and had given her a pot to collect urine in. The doctor had also asked her about Josh; had they been together for a while? Did they use protection? Then he had suggested she make an appointment at the local sexual health clinic. ‘Just to make sure you’re 100 per cent OK.’ But lying flat on her back with the nurse fussing around with cotton buds and pots, Chloe felt mortified. She couldn’t believe Josh would put her through this. It was all his fault that she was having swabs poked up inside her and questions like ‘is it ok if we check you for HIV as well?’ She called up the clinic later on in the week to get her results and the nurse asked her to come in to talk to the doctor. Ushered into a small room Chloe met a new doctor who was holding a sheet of paper in her hand. “We’ve had your results back and they have shown that you have Chlamydia. All the other tests came back negative.” Chloe didn’t know what to say. She didn’t really know what Chlamydia was. Seeing her worried expression the doctor continued. “It’s quite a common infection that is passed on during sex or oral sex, or even sharing sex-toys.” Chloe was too shocked to blush. “It’s a good thing that you’ve been tested because many people don’t have symptoms and don’t get treated until it’s too late.” “Too late!” exclaimed Chloe. “Too late for what? What’s going to happen to me?” “Sometimes people can have Chlamydia for years and not know. It’s not picked up in smear testing, and they can pass it on to their partners. If it’s not treated it can cause permanent damage in your pelvic organs and even make you infertile. But you are one of the lucky ones. We have detected the infection and now we can treat you.” Chloe had never realised that a sexually transmitted disease could be so damaging. How did she get into this situation? She wasn’t like the other girls, sleeping with anything that moved. She had just slept with Josh, and he was nice. The thought that he could have had this disease all along and infected her made her feel sick and ashamed. Did he know? Did he do it on purpose? “We’d like to give you some antibiotics to kill the Chlamydia bugs, but it’s important that you wear protection during sex because the antibiotic might reduce the effectiveness of the contraceptive pill.”
mediscope
Manchester Medical School
Don’t worry, Chloe thought. I’m never going to sleep with anyone again! “And I know it may be hard, but it’s important that you tell your partner so that they can get tested and treated too if necessary.” Chloe stayed quiet. Josh didn’t deserve to be told. “Your partner might not have known.” The doctor held her troubled gaze before turning away to fill out a prescription. As Chloe got up to leave clutching her bit of green paper the doctor said, “Remember, the pill doesn’t protect against sexually transmitted diseases like Chlamydia and you should get tested regularly. Here are some leaflets with more information, and we’re always here if you need help.” Chloe felt like she had suddenly aged; become wiser and more troubled. She took the leaflets and left quickly.
Taking a Sexual History Taking a sexual history is not something many students feel comfortable doing; however, to take a comprehensive history it is important we are able to ask personal questions in a way that makes you and the patient feel at ease. To make this a little less daunting we have come up with a few helpful hints: Before you start, ensure there is complete privacy, most patients wouldn’t feel happy discussing their number of sexual partners or genital warts with the whole ward listening! Emphasize confidentiality before asking any questions. The way you approach the patient will influence what they tell you, do not assume anything – the seemingly straight woman you are talking to may be gay or bisexual, or the happily married husband may have been having an affair, these issues should be discussed sensitively in order to gain the patient’s trust. Using words such as partner instead of boyfriend/girlfriend will show the patient that you are non-judgemental. As always begin with open questions and let the patient divulge the information they feel comfortable with before asking specific questions. The choice of language you use should be guided by the patient, try and use the same words the patient does, often these are colloquialisms. The patient may present with the guise of another symptom; “I’ve got this terrible cough….oh, and by the way I think I might have caught something off my boyfriend…” It is important not to ignore this
education
Health
but ask appropriate questions to clarify what is actually wrong in a tactful way as the patient obviously feels embarrassed. Signpost before asking certain questions, for example; “I’m going to ask you a few personal questions about your sexual risk factors, is that ok?” Through out the consultation observe the patient’s body language; this will also help to guide you as to what the patient feels comfortable discussing. Think about how you would feel if you were in the place of the patient, sex is an embarrassing subject to talk about to strangers, respect the patient and give them the time and patience they need.
Questions to be asked in sexual history Find out the reason the patient has presented, is there a particular symptom such as an unusual discharge or dysuria? The patient may present because they are concerned after having unprotected sex, or they may have a problem such as loss of sex drive. Ask open questions to find out this problem then use closed questions to find out details such as how long the symptoms have been there. Ask about sexual partners; you will need to inquire about the number of sexual partners in the past year, the gender of the partners and their sexual risk factors. Ask direct questions about sexual practice (remember to signpost) such as the type of sex the patient is having – vaginal, anal or oral. Did the patient use any form of contraception? If they did what type of contraception did they use and was it used effectively? Remember to ask if the patient may be pregnant. Has the patient had a sexually transmitted disease before? Ask about their immunization history, specifically Hepatitis B and C. Find out if the patient has been tested for HIV in the past. Remember that other parts of the full medical history may be relevant, for example certain chronic illnesses and some drugs can cause sexual dysfunction. Advise the patient on safe sexual practice and explain to them any further tests or management that may be needed. Finally, thank the patient and ask them if there are any other issues they would like to discuss.
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Issue 3 Sep 2008
commentscope Selina Ahmed these drugs in an attempt to mimic relieving pain (analgesia), heroin’s (diamorphine) effects. euphoria, he history books inform us cough suppression, that drugs have always lurked The most dangerous of these that a user pupillary constriction, in the shadows, legally and illegally. In the 19th century can tamper with is fentanyl, which is denausea, Sigmund Freud was a frequent signed as a transdermal patch (Duragesic® constipation, user of cocaine as was apparently Stephen patch). Fentanyl is an opioid analgesic and the most harmful: respiratory times more powerful than King in the 1980s. Judy Garland was that is 50-100 depression 4 reportedly addicted to amphetamines and morphine and is prescribed for acute pain of course Kurt Cobain allegedly died of a in the UK. The patch is stuck onto the skin Respiratory depression occurs because heroin overdose. Remember when Chan- and lasts for 72 hours, delivering 25- the respiratory centre in the medulla obdler from Friends lost a lot of weight? At 100mcg/h,4 depending upon the dosage of longata decreases in sensitivity to the artethe time he was heavily dependent on the patch. It is because of its great poten- rial partial pressure of carbon dioxide prescription drugs, including Diazepam. cy that transdermal administration actual- (Pco2). Consequently the concentration of More recently, you can not open a news- ly alleviates pain because only a small the Pco2 increases but remains undetected. paper without reading about Amy Wine- amount needs to enter the bloodstream Under normal circumstances, the respirahouse and her struggle with drug through the skin for fentanyl to take ef- tory centre would detect the rise in Pco2 fect. addiction. And the story goes on. and induce rapid breathing to remove the At the turn of the 2nd Millennium a Drug abusers have been known to excess CO2 from the body. However, in strange new phenomenon began to take squeeze out the gel based drug from the the case of respiratory depression, incentre stage as the abuse of prescription patch and place under the tongue for creased ventilation does not occur and the drugs erupted onto the scene. How can transmucosal absorption, or they simply person may go into a coma caused by prescription drugs be abused? Well the eat it. Other more practised users have respiratory acidosis, or stop breathing and answer is surprisingly simple: the active adopted sophisticated techniques by add- die. form of the drug is released by various ing certain solvents to the fentanyl gel, in home-made purification methods and the order to separate the mixture of active How to treat an opioid overdose drug is either injected, eaten or smoked to fentanyl from the jelly-like hydroxyethyl attain the infamous ‘high’ we hear so cellulose in which it is bound. After that If the drug misuser reaches hospital their much about. Even simpler, users may take the fentanyl is either injected or smoked. opioid overdose can be reversed by adminmore than the stated amount, literally This can kill. istering Naloxone, which is a pure antagooverdosing themselves. This misuse is Tolerance to opioids occurs rapidly, com- nist and blocks µ-receptors. It can reverse much more prevalent in the USA and ap- pelling the user to increase the quantity of respiratory depression and Naloxone’s efpears to be sweeping the states like a dead- drug to experience the Possession Dealing ly virus. The problem is not as serious in same “hit” as before. the UK, but as tomorrow’s doctors, I feel This can create a sense Class A Up to 7 years in prison, Up to life in prison, an we will also be contending with the creep- of grandeur in a habit- Ecstasy, LSD, diamoran unlimited fine or unlimited fine or both. both. ing problem of prescription drug abuse in ual user but their de- phine (heroin), morluded impression of phine, fentanyl, opium, the future. immortality can lead cocaine, crack, magic them to consume ex- mushrooms, methaMisused Drugs and Their Dangers cessive amounts of done, any class B subdrugs, more than their stances when prepared Prescription drugs go through vigorous body can handle, caus- for injection tests before they become licensed, in order ing death. Up to 5 years in prison, Up to 14 years in prison, Class B to ascertain the optimum dosage and theran unlimited fine or Amphetamines, methyl- an unlimited fine or apeutic window. Toxicity is the most im- Opioid Poisoning both. both. phenidate (Ritalin), coportant factor because obviously the deine, barbiturates safety of the public is of the greatest imI have mentioned the Up to 2 years in prison, Up to 14 years in prison, portance. Therefore when abusers delibClass C cause of death to be Cannabis, benzodian unlimited fine or an unlimited fine or erately tamper with drugs that have been overdose, but what ac- azepine tranquilisers, both. both. formulated and designed to be used in the tually occurs in the GHB, ketamine, anabolic specified manner, they are placing their body on a physiological steroids, less potent anlife in jeopardy and literally risk death, not level to bring about algesics to mention jail. death via opioid poisoning? The answer is Box 1: Penalties for possession and dealing The Law Opioids respiratory depression. Misusing prescription drugs is illegal and so is possession of a prescription Opioids act primarily drug for which you have no valid prescription for. The table below outlines Opioids are the prescription drugs that on µ-receptors, and the penalties of possessing and dealing drugs that have been illegitimately abusers have honed in on, such as codeine, along with other recep- obtained. The Misuse of Drugs Act 1971 has classified controlled drugs into hydrocodone, morphine and fentanyl. tors, opioids are re- class A, B and C. The drugs are categorised according to the “harmfulness attributable to a drug when it is misused”. Class A drugs are considered the They manipulate the formulations of sponsible for:
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most harmful, followed by class B drugs and then class C.
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The Abuse of Prescription Drugs fects last for 2-4 hours hence may have to when taken properly and within the legal confines of medical practice. be given more than once. Benzodiazepines alone can also produce a hedonic effect if taken in exAmphetamine-type Stimulants cess and finally some users consume Another drug that is misused is methyl- the drug to counteract the jittery efphenidate, better known as Ritalin, and is fects of other illegal substances. For a central nervous stimulant that is phar- example, one user from a drugs fomacologically similar to amphetamines.7 rum commented: It is available in immediate-release, ex- “I take three 0.5mg generic alpratended-release and sustained-release for- zolam tablets to combat the high dose mulations. Methylphenidate is actually panic I usually get with cannabis.” used to treat attention deficit hyperactivity disorder (ADHD) or sufferers of narcolepsy (a sleeping disorder) whilst Drug Seeking Behaviour patients are carefully monitored by their GP. However, students are once again the As future doctors and prescribers, we culprits of exploiting this drug, but they should be able to recognise drug-seeking are of a different type to the cavalier recre- behaviour. ational user. These students are ones that You are most likely to encounter patients desire high grades and down fistfuls of that seek benzodiazepines and opioids. Ritalin in order to stay awake and remain There are 4 groups that have been identialert for longer when studying or cram- fied who cover the majority of drug-seekming for exams. Ritalin is addictive if tak- ing patients. en in high doses and when abruptly They are: discontinued, severe withdrawal symptoms can ensue, such as depression and 1 Patients known to the doctor who are dependent on benzodiazepines who erratic mood swings. Other side effects want to maintain a continuous supply. include insomnia, dry mouth, headaches, 2 Patients known to the doctor who nervousness, vomiting and if used imhave become dependent on opioids properly can cause heart problems. following treatment for chronic pain and want to maintain a continuous Benzodiazepines supply, even though they are no longer in pain. The use of benzodiazepines are primarily 3 Patients unknown to the doctor seekfor the “short-term relief of severe anxieing benzodiazepines. They are usualty” (2-4 weeks). Long term use is not ly younger than those in 1 & 2 and are recommended because tolerance and denot dependent. pendence can quickly transpire. Benzodiazepines have an anxiolytic (sedative) and 4 Patients unknown to the doctor seeking opioids. They are usually younger hypnotic effect and induce sleep when takthan those in 1 & 2 and are generally en at night and correspondingly sedate dependent on opioids. during the day. Misuse of benzodiazepines is predominantly undertaken by swallowing 10-50 times more of the drug than recommended, some users opt to crush the tablets and administer intranasally whilst others administer intravenously. The primary purpose of misusers consuming benzodiazepines is to prolong the high attained from opioids, amphetamines, cocaine and alcohol, exploiting the synergism of such a noxious combination. This carries the greatest risk of death through central nervous system depression. Another danger of benzodiazepines is their dependence potential. Severe withdrawal symptoms can develop following the discontinuation of this drug, even
dependence and as doctors have a duty of care, we need to have the patient’s best interests at heart. You could either refuse to write them a prescription or refer them to a drug treatment centre but do not deny them your assistance.
Tamper Proof Pharmaceutical companies desperately need to impose greater barriers on drugs by making them more tamper proof. Tablets should be difficult to crush to prevent intranasal and intravenous routes of administration. An antagonist could be added to the drug, that is released when the drug is administered incorrectly (intranasal and intravenous), preventing the desired effect if used defiantly. Pharmaceutical companies can prevent purification of drugs by adding gels and solvents. Therefore if attempts to separate the active form of the drug via heating or mixing with chemicals are made, then the drug would be trapped in a jelly-like matrix, rendering it useless. Even simpler, the addition of an unpleasant flavour or dye may suffice and deter most drug abusers.
Conclusion
Additional signs to watch out for are when patients: request a certain drug, know a lot about the drug and refuse your alternative suggestions of treatment, describe symptoms that appear contradictory and on the exterior they do not appear to be suffering from pain, are new to you and keep changing doctors and move areas often.
In 2004, death caused by drug poisoning climbed to 2,595 in England and Wales of which 55% were related to drug misuse. Drug poisoning is increasingly being established as the cause of death but is this because more people are taking drugs or is it because toxicologists are better equipped in detecting substances in the body? Technological advancements in the drug testing arena are likely to have contributed to the statistical rise in drug morbidity but If a patient appears to be suffering from there is no denying that drug abuse espewithdrawal symptoms or enters your sur- cially that of prescription drugs is on the gery intoxicated or high, then it is likely increase. they will attempt to convince you to prescribe them some more drugs. Such paSelina Ahmed is a 4th year medical tients are likely to be suffering from student
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education
education
mediscope
Issue 3 Sep 2008
How to do a...
Peripheral Vascul
1. Introduce yourself “Hello my name is <include surname>, I’m a third year student doctor.”
2. Obtain consent “I’ve been asked to have a look at some of the blood vessels in your tummy and legs and see how well they’re working, is this okay?”
osce poster two
Arte
10. Aus
Listen over f
3. Wash hands, check name and DOB
Arterial disease 9. Palpation of Legs
4. General inspection look to see if patient at ease Any drugs around the bed – hypertension, diabetes, cigarettes, high cholesterol Cyanosis Signs of heart failure – SOB, oedema
5. Hands look at both sides Cold hands Discolouration – tobacco stains, purple discolouration from atheroembolism, pits and healed scars (Raynaud’s) Palmar / tendon xanthomata
6. Face Corneal arcus – creamy yellow discolouration at boundary of iris Xanthelasma – yellowish plaques around eyelids
7. Abdomen Pulsation – aortoiliac aneurysm Scars – previous operations
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Pulses – whether present, if so how strong, compare with oth usually reduced or absent in arterial disease a Femoral – over inguinal ligament b Radial-femoral delay – coarctation of aorta c Popliteal – with knee flexed and foot resting on bed, hands around knee, place both sets of fingers in pop space using moderate pressure d Posterior tibial – behind medial malleolus e Dorsalis pedis – over dorsum of foot, 1st metatarsal sp Temperature – use back of hand, start at feet and work up leg paring like to like, normal or cool in arterial disease Capillary return – if reduced do Buerger’s test (Elevate legs to grees, hold for 2-3 mins (pallor develops rapidly) Sit up and ha over bed for 2-3 mins (reactive hyperaemia) Positive test = ar disease)
Arterial disease 8. Inspection of Legs Obvious signs of (pre) gangrene – blackness, missing toes, nail infection Ulceration – usually painful (unless diabetic neuropathy) a Size, shape, b Site – pressure areas c Edge – regular, indolent, “punched out” d Bed – no granulation e Slough – green or black f Surrounding skin – no changes Skin changes – staining due to previous ulceration, loss of hair extremities, pallor – normal or pale
Scars
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Manchester Medical School
11. Inspection LEGS Ulceration – pain present in 1/3 patients, relived on elevation a Size, shape, b Site – gaiter areas c Edge – irregular with neo-epithelium d Bed – pink and granulating e Slough – green f Surrounding skin – chronic venous insufficiency causes haemosiderin deposition, leads to lipdermatosclerosis usually present, from blue/black to purple to red, medial aspect Skin changes – staining due to previous ulceration, pallor – visibly cyanosed, varicose eczema Swelling – associated with varicose veins, deep venous reflux and DVT Varicose veins – best seen with patient standing, comment on superficial phlebitis a Anteriomedial – tortuous, dilated branches of the long saphenous vein from below femoral to medial sign of lower leg b Posteriorly – varicosities of the short saphenous veins from the popliteal fossa to the posterior calf and lateral malleolus Scars – groin, medial aspect of thigh
erial disease
scultation of Legs
femoral artery and abdominal aorta for bruits
Venous disease
her leg,
12. Palpation LEGS
wrap pliteal
pace gs, com-
o 45 deang legs rterial
education
lar Exam
Venous disease
Arterial
Venous
muscles, usually calf whole leg, “bursting” but may involve thigh in nature and buttocks unilateral, if femoro-
unilateral
popliteal
Pulses – whether present, if so how strong, compare with other leg, usually present in venous disease, may not be able to feel due to oedema Temperature – normal or increased in venous disease Trendelenburg test (Patient to sit on edge of examination couch. Elevate limb as far as comfortable, empty superficial veins by “milking” the leg. Leg still elevated, press over saphenofemoral junction. Ask patient to stand with pressure maintained. If competent, will not fill until pressure removed.)
bilateral if aortoiliac disease onset is gradual after gradual, from mowalking ment walking com“claudication” dismences tance relieved on cessation elevate leg to relieve of walking after 1-2 discomfort mins Clinical Features of Pain of Arterial and
Good lu ck In your exams
Venous Claudication
By Anna Williams Compiled by James Anderson 17
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mediscope
Issue 3 Sep 2008
PBL for Dummies Lousie Garcia-Rodriguez
P
roblem-based learning is a bit like marmite; you either love it or you hate it. Here at Manchester, you will be in your element if you fall into the first box, but you’re a bit stuffed if you’re in the latter. The problem is you don’t really know until you’ve tried it. We all know the pros and cons in theory…well, if you did any preparation for your interview! Yet it’s hard to imagine as a fresher what to expect, as you embark on a course where you’re learning without the traditional system of 9-5 lectures. When I started the course, part of me wondered if I had done the right thing: I rejected a place at Kings College, London where there is a lecture-based course in favour of Manchester’s PBL.. Even with the introductory course I remained sceptical, not really understanding how I was to get through so much information in just one week. PBL forces you to confront poor time management and organisation skills and it takes a while to learn how to get the most out of the course. I won’t lie - it’s a hard slog to begin with, but as you get used to it, it can be incredibly rewarding. The structure of PBL groups makes the whole thing very sociable and bouncing around ideas and theories keeps
“PBL forces you to confront poor time management and organisation skills”
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Louise Garcia-Rodriguez is a 2nd year medic
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you interested and engaged in the topic. It’s not long before everyone learns to work together to achieve the learning objectives and although there are fewer lectures, it means you are more focused for the ones there are. After all, who wants to sit in a lecture theatre all day? That’s a really wonderful thing about PBL- if you want an afternoon off or a few extra hours in bed just make up the time at another point. Yet you cannot ignore the advantages of a traditional system. The idea of ‘spoon feeding’ can be very appealing, especially when the going gets tough and you have an exam coming up. Having something explained by an expert in their field instead of searching for and gathering information yourself is less effort and it is certainly reassuring ‘knowing what it is you need to know’. This is, after all, one thing we all struggle with on a PBL course – what depth should I go into? Should I read around the subject more? The silver lining here is that it does prepare us for clinical practice; do you know many hypertensive patients that could tell us what depth to go into for studying contraction of smooth muscle? Being made to use your brain just that little bit more, picking out what’s relevant and what’s just ‘nice to know’ means you really get out what you put in. Naturally I am biased, I did choose Manchester after all, but I really do believe that PBL trains us better in team work, lateral thinking and patient based care, ultimately making us better doctors.
MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
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Manchester Medical School
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Climate Change & Public Health James Conole here are few contemporary issues as ubiquitous as that of climate change. Yet, even with all this coverage of its current and potential implications, we are in a rather peculiar situation in so far as real action, it seems extremely slow if not completely absent. Seemingly, we are in a state of denial towards a problem that, if left unchecked, could lead to a catastrophe on par with nuclear war.
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The only solution to a global problem like this is governmental action and government action that starts today. This could start by supporting the BMJ in its call for the implementation of a worldwide policy of carbon contraction and convergance or by joining pressure groups for change such as I count or Medact. For further reading on policies for change in the UK I would recommend reading the report “Zero Carbon Britain”, produced by CAT. Any action, we must remember, is better than no action.
What is the correlation between this and medicine however, you may be asking? The answer is that climate change can not be separated from its public health implications. People are already suffering from its effects and the future impact has been predicted to include changing food production worldwide and associated malnutrition; an increase in tropical diseases and waterborne illnesses and a generally increased worldwide burden of illness We in the UK will also be unable to escape the effects and it will be our generation of medical students that will have to treat those affected.
This summer I personally tried to do something by attending the Camp for Climate Action by Heathrow Airport which was set up to highlight the hypocrisy of a government that encourages us to change our light bulbs to more energy efficient ones whilst continuing to expand airports (the biggest growing contributor to Carbon emissions in the UK). Many environmental activists as well as climate scientists and concerned people gathered to discuss strategies for change all demonstrating many differing ideas at how to avert this disaster. From my experience there, I have realized the ideas for change are abundant and that all we need is action.
This leads to the question: what can we do? Firstly, and most importantly, we must realize that there is still scope for change as, unlike many other public health issues, we have the possibility to hugely mitigate the effects of this potential disaster. However, this action must occur now; and this is why action on climate change carries with it such a sense of urgency. As terrible as all this sounds there is hope as we have the potential to actually at best stop, and, at worst, reduce this problem. In fact, I think we have a duty to do something about this problem as by ignoring it we are in fact accepting it.
PHOTO: www.flickr.com by CXK
What can we as medical students then do to tackle the causes of climate change? It is easy to believe that individual actions such as cutting back on driving and/or buying local are solutions but one must not be fooled into thinking that, laudable as these practices are; they will ever address a problem as huge as this.
“we are in a state of denial towards a problem that, if left unchecked, could lead to a catastrophe on par with nuclear war”
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limate change is but one example of our ruinous relationship with the natural environment but it is the most important element of it as it has the potential to fundamentally alter the viability of life on this planet. As future doctors we will be in a unique position to influence policy making in our respective areas and it is my view that this is why we should treat Climate change as the most pressing issue that there is. The clock is ticking but, even still, we should not underestimate the power that we have to effect the future direction of our planet. The quality of life of future generations and their health is very much in our hands. James Conole is a Manchester medical student
“What can we do?” 19
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Issue 3 Sep 2008
societyscope Leeds NAMS 2008 Hannah Sevenoaks The weather looked set to be glorious, yet several members of the club are scrambling around the bargain sports shops of Manchester in search of woolly hats. We realise that commissioning a Granny on eBay to make our 26 “Where’s Wally bobble hats” (yes, there was a posting) would have been a better move, but based on pom-pom time requirements alone that would probably have meant an order date sometime around 2002, depending on the arthritis. But that's not the spirit is it, so we made do, and a few UHU joined fingers later we were “wallified” and set sail for Leeds Hockey NAMS 2008. The van men of the M62 looked quite confused. Considering we hosted NAMS last year, which was by the way…the best one yet, we were ready to lay into our chums in Leeds if anything were to go pear shaped. But jokes aside, we were looking forward to being on the receiving end of months’ worth of hard work on their part. Aside from the medics football team, who won their NAMS this year (CONGRATS!), you may all be pondering the format of this joyous weekend / highlight of the year. Well, actually maybe not, its pretty much the cliché you’re imagining right now: sports-teams drinking too much, making crude jokes on loudspeakers and occasionally playing some hockey. Some would hate it I’m sure, but with amazing team-mates and friends, I think it’s pretty hard to beat. After settling in on the Friday night we were entertained by the dulcet tones of the Amateur Transplants…London Underground….?!? A couple of Drs from London who sing really fast about medicy stuff and tube strikes. Good fun. By this point in the evening it was time to step back and just take it all in, or in fact just play real life 3D Where’s Wally. 26 Wallys scattered amongst Smurfs, Grannies and Mr Muscles. On Saturday the sun shone, the hockey got going and the gossip of the evening was flowing. As serious competitors we had obviously been planning tactics for the If you are interested in playing hockey with Manchester Medics Hockey Club, visit the website www.medicshockey.weebly.com
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Find out about medic societies and charities both new and old on these pages
past year. A few air raids, team strops and gaffa-tape incidents later, and the competition were trembling at their knees. Saturday night’s fancy dress theme was more of a worry. “Tight is right”… obviously a product of many hours of procrastination on the part of a male medical student somewhere in Leeds! Boys and Lycra…what are you like! Needless to say the majority of us girls were concerned, but “Primarni” to the rescue. A few neon shopping baskets later and we are ready to roll. The sights that we saw on that night will never leave us: a “mankini” is not a nice thing Ok, so I’ve probably lowered the tone of the magazine sufficiently by now so I’ll wrap up with some hockey. Sunday was the second half of the tournament.. There was plenty of hockey to get on with, with both teams making headway in their respective rounds. The first team eventually battled into the quarter finals- only to be knocked out on penalty flicks to Peninsula. The Manchester Monkey had something to say about that though!
Interested in getting involved? Come along to meetings, or get more information by emailing medicalstudentcharity@yahoo.co.uk or visiting the facebook group
competitive and fun morning was had by all involved. Well done to the deserved winners consisting of Graham Finlayson, Thomas Woodward, Ben Darwent, John Berwell, John Campbell and Fraser Graham who comfortable won in the final and played lovely football throughout. This year we were supporting Manchester Kids, which has recently been renamed “Cash for Kids”. Itis a local charity supported by the radio station, Key 103, that raises money for underprivileged children in the Greater Manchester area. This year we hope to have raised in excess of £1800 which is a fantastic achievement, so thank you to all involved. We hope you have found our events to be worthwhile and fun. For next year we are planning on adding many more exciting events (such as ‘The medics game show) to our current events calendar. In the meantime, I shall pass over my position of chair to Andrew Cheng (4th yr, MRI) and wish him the very best of luck for the forthcoming year. However, if anyone (in any year) wishes to get involved with the charity then you are more than welcome to come along to one of our weekly Constantinos Papoursos meetings – just get in touch!
Manchester’s Medical Student Charity
This year has been a very productive year for the Medical Student Charity. We have officially expanded from an MRI based group to include students from all the hospital bases. Many people who were keen and had fresh ideas helped to make this year the best so far for the charity. Most of the 3rd and 4th year students will recognise the name of the charity and will have supported us by attending one of our highly successful OSCE revision sessions, which shall continue to prosper next year. However we have also hosted nonacademic events, such as the welcoming curry at the beginning of the 3rd year and a cocktail party with live performances from medic bands. At Halloween we organised a “Trick or Treat” bucket collection trek in Fallowfield. The other most recent major event, which was a huge success, was our annual 5-a-side football tournament attracting many ambitious football teams throughout the clinical years, including a team of dentists. Despite monsoon-like weather conditions at the start, a quick turnaround in weather conditions quickly lifted spirits and a
Fresher’s questions Sarah-Lindsay Jones & Helen Johnson 1. With so many people in a year group is it really difficult to get to know people? SLJ:Yes, there are a lot of people in a year group at Manchester, however that doesn't stop people from getting to know each other. There are plenty of people to socialise and make friends with. You are unlikely to get to know everyone really well, and it will definitely take time, but as the year progresses and you meet new people you will start to recognise more and more people in your year and the lecture theatre will become full of familiar faces rather than strangers! One thing I will say is during Freshers’ week and the following introductory weeks make as much effort as you can to chat and introduce yourself to people as there is plenty of time spent in queues! The more effort you make to get to know people the quicker you will make friends at Manchester.
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Manchester Medical School fun if you go out and don't drink, in fact you will be able to remind everyone of the stupid things they did when they were drunk (although that's not always a good thing!)
HJ: I think it’s harder to get involved in medics events if you don't drink but if you really make an effort to still go out and socialise no one is really that bothered if you’re not drinking. Also this year, there are meant to be more medics events that don't involve drinking, like bowling 2. Describe your Freshers' week in 5 words. etc.
SLJ: A blur, hectic, fun, overwhelming 5. What would be your advice about the and enjoyable. introductory weeks i.e. should I be working really hard? HJ: Fun. Hectic. New. Exciting. Tiring. 3. What's the best piece of advice that was SLJ: During the introductory weeks the best thing to do is socialise, get to know given to you? your flat mates, as well as meeting other SLJ: Make sure you are organised, as this medics, as making friends will mean setallows you to achieve everything you want tling into uni is easier. Familiarise yourto, it enables you to go out, socialise, com- self with the university surroundings (get plete work and any additional activities to know the Stopford building), but don't such as playing for sports teams, joining worry about working hard, the first few an orchestra or performing in plays etc. weeks of the course give you time to settle in and provide you with useful informaHJ: Talk to other people if you’re stressed tion about the course at Manchester. I about work or anything, most of the time would strongly recommend joining a your friends in the year are worried about sporting club (medics or uni) or a society, the same things and it helps to talk about whatever suits you as becoming involved it. in something you enjoy will give you a 4. What happens if you don’t drink? release from the course and benefit you SLJ: Noone is pressured to drink, it is throughout the year. completely your decision whether you HJ: No, just enjoy your first few weeks at drink or not and everyone respects that. uni and don't worry about work, or what Just remember you can still have plenty of booksto buy etc.
Christmas Hampers Emma Illingworth The idea behind the Christmas hampers project is to help make Christmas for elderly people living alone a more enjoyable time, and for them to know that someone is thinking of them. Delivering the hampers for the past two years has certainly brought a smile to many people’s faces, not only because of the hampers themselves but the prospect of a visit and a chat from new faces. These small, but very significant contributions would not have been possible without the generous donations from second year medics. We received such numbers of food items that we were able to make up approximately thirty hampers this year (compared to ten last year), and send a box of donations to our
local homeless shelter, for which the voluntary staff were extremely grateful. For the past two years we have liaised with the charity, Independent Age. Independent Age provides elderly people with household items that make their everyday lives easier, for example a specially adapted kettle to assist someone who suffers from severe arthritis. As well as supporting Independent Age in delivering the hampers, the number of additional items received this year meant we were also able to deliver some hampers to local nursing and residential homes. A huge thank you to all the second year medics that contributed, we hope you saw the cards of appreciation on the medics’ notice board from some of the Independent Age beneficiaries to whom we delivered the hampers. We could not have done anything without you!
society society
HJ:It’s hard as it is such a big year group but I think slowly you get to know more and more people and start recognising them in lectures and places around uni so that's good! I think it really helps changing PBL groups for semester 2 as you get to meet a new group of people and you can meet their friends as well. If you go on medics nights out you get to meet more people from the year and your friends introduce you to their friends so you end up getting to know a lot more people!
MSRC - More than just party planners Friyana Dastur Mackenzie The MSRC (Medical School Representative Council) has always seemed to me like a somewhat vague organisation. When this year’s election came round and I was trying to rally up first years to support my campaign I was faced with a wall of blank expressions; I lost count of the number of times I was asked to explain “what the heck is the MSRC?”. As newly elected president of the MSRC I am striving to make every Manchester medic aware of how useful the MSRC is to them. The MSRC are in the process of producing an online forum, which would give you a direct link to other students and us, but for now contact us at msrc@manchester.ac.uk
Nobody can question the party planning abilities of the MSRC; medics’ parties and pub crawls are infamously wild and crazy affairs. These bashes are vital for the bonding of medical students and creating our sense of community. However the more than just party planners MSRC for booze-hound medics. As the name suggests the original purpose of the committee was to have a group of students who would listen to students’ problems and concerns and then voice these concerns to the relevant faculty members trying to tackle and solve any problems. With increasing numbers of medical students at Manchester it is easy for students to feel their voice is insignificant in the structure and operation of the medical school, and as if they are merely insignificant cogs in a doctor producing machine. The staff at Manchester do genuinely appreciate this school is for training us and without our feedback they can’t achieve the best course possible. My vice and I attend numerous medical school board meetings with the Deans of hospitals and the medical school, so we can make a difference. We want to be your link to the faculty.
The hampers project has grown over the last two years and we’d love for it to continue this Christmas, and in particular for people who would like to be more involved in other years to help out in co-ordinating, collecting and delivering items. We’re looking for enthusiastic and dedicated people (with excellent skills in wrapping boxes!) to help us. You would need just a few spare hours in November, to rally round and let people know what we are doing, and then again in December to collect the items and make and deliver the hampers. If you are interested please let us know your name, year and email address: emma.illingworth@student.manchester.ac.uk
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mediscope
Issue 3 Sep 2008
lifescope Dr Neel Halder ST4 Psychiatrist
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ersonality is the individual’s pattern of perceiving, relating to, and thinking about the environment and oneself. It manifests in their speech and behaviour. It develops in childhood and adolescence and by the time one gets into Medical School, the personality acquired tends to remain relatively stable thereafter, in spite of mood changes. It can of course be adaptable to environmental factors. Like many conditions in medicine, personality is thought to be shaped from a combination of genetic inheritance and environment. Children tend to learn from observation and imitation of peers and parents, in a process that psychologists call “modelling”.
Personality Types mally aggressive or seriously irresponsible conduct on the part of the person concerned
Unsuccessful attempts to reduce the frequency of behaviour Preoccupation with the behaviour Persisting in the behaviour despite clear evidence of harful consequences A need to engage more and more in the behaviour to achieve the same “reward” (eg satisfaction, or temporary reduction in anxiety).
Another term often used is that of “addictive personality”. This is not an actual diagnosis as such, but often taken to mean people who have a tendency toward engaging in certain acts that ultimately become destructive. These include gambling, drinking, drugs, sex. Features that Don’t worry too much if you can identify may point towards a problem include: with certain elements from the above list. It is common to have personality traits but affecting your day-to-day activities, not to the extent of meeting the full criteincluding work, studies and relation- ria for a disorder (book an appointment ships. with me if you do!). A strong sense of desire or compulsion to engage in the act Dr. Neel Halder is an ST4 Psychiatrist in Impaired capacity to control the behav- the North West. iour
Cluster
Disorder type
Main features
A
Paranoid
Argumentative, suspicious, sensitive to critism, bears grudges
A
Schizoid
Emotionally cold, detached, isolated finds few activities pleasurable, lives in “fantasy” world, not many friends
Where I, as a psychiatrist, become involved in this subject is in the diagnosis and management of personality disorders. This is where someone has an enduring pattern of maladaptive behaviour in significant areas of functioning of their adult life. It is abnormal within their cultural or religious group and not the result of any other illness. It can be traced back to childhood. It is not something one should diagnose on one meeting, and requires a lot of information gathering from a variety of sources.
A
Schizotypal
Odd beliefs, eccentric, isolated
B
Antisocial
Irresponsible, callous, low frustration tolerance, incapable of maintaining relationships, incapable of feeling guilt, prone to blame others
B
Borderline
Impulsive, irresponsible, instability of mood, behaviour and relationships, feelings of emptiness.
B
Histrionic
Dramatic, shallow, attention-seeking , manipulative
There are many different classification systems. One of the most widely recognised is the DSM-IV (Diagnostic and Statistical Manual for Mental Disorders- Part IV) given below. The different personality disorders can be further organised into 3 groups or clusters A, B, C, sometimes referred to (somewhat unhelpfully, I feel) as “Mad”, “Bad” and “Sad” respectively.
B
Narcissistic
Self-centred, grandiose (eg. True example of woman who’s life was severely affected due to not being able to walk past a window without stopping to look at herself; later found with 150 polaroid pictures of herself in her handbag!)
C
ObsessiveCompulsive Dependant
Perfectionist, inflexible, cautious, indecisive, pedantic, preoccupied with rules and lists Submissive, helpless, weak-willed, compliant, fear of abandonment, allows others to make important decisions Timid, self-conscious, socially uncomfortable, hypersensitive, fear of criticism, disapproval or rejection
Personality Disorders
The often quoted “Psychopathic” personality disorder, is actually a legal classification defined as: persistent disorder or disability of mind which results in abnor-
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C C
Avoidant
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Manchester Medical School
life
Gunthor von Hagens What inspired you do what you do? I think it’s wonderful to change and develop the uninformed knowledge of the general public on anatomy and pathology. What’s the most fascinating thing about your work? The fact that there are many different aspects to my job: anatomy, art and learning languages. What’s your background? I spent 10 years in school in East Germany before becoming a postman and then an assistant male nurse. At the age of 20, I went to medical school and then trained in anaesthetics and general practice. I partake in professional ballroom dancing and play the violin. Would you ever sell a body to a medical school? Yes, about 20% of my activity is for this purpose. How long does it take you to do an average model? 1500 hours. Where do you get the babies from? They are all from museums where they have died from natural causes. They are normally preserved in formalin and then converted to plastination. What would be your ultimate challenge? Presently it’s plastinating an elephant, which I estimate will take about 30,000 hours. Where do you see yourself in 15 years time? Happy about having plastinated an elephant…then writing scientific papers and returning to be a scientist. How did you develop your technique? It is constantly developing but originally I found a way to impregnate specimens with polymers. Why do you wear a hat?
Gunther von Hagens Anatomist
Because the tradition of anatomists during the Renaissance period was to wear hats in order to show their independence. I always wear it, including during my sleep. The only time I take it off is to shower. What are your plans for your body? I would definitely donate it to medical research.
An interview with...
Mediscope meets Dr Gunther von Hagens, the anatomist behind the famous Body Worlds
Professor von Hagens is famous for his technique, plastination. Plastination is a way of preserving body parts. Plastics replace water and fat leading to specimens with their microscopic properties retained, which do not smell and can be touched.
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mediscope
Issue 3 Sep 2008
Studying Medicine Dr Lawrence Goldie MD, DPM, FRCPsych, MAE, FLLA
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always wanted to do medicine and psychology. However in 1941 there was not the slightest chance of me ever doing medicine as one had to be quite well off to afford to do a medical degree and so instead I opted for a Psychology BSc (Hons) before I went into the RAF and became a pilot. Before I left, however, I received a letter from the Dean promising me consideration for a place in medicine after the War. I suspect that with their memories of the Great War, they didn’t expect many of us to return! I managed to do the BSc Honours course for 18 months paying for the fees by doing night watching which became common after the War started and was paid quite well. After the War ended I came back to Manchester, there was a new Dean of Medicine and the promise of a place was honoured. I think it is important to mention that the university, and particularly the medical school were transformed by the landslide general election, which Labour won with Clement Atlee as the Prime Minister after the War. Before I went into the services I spent a lot of time in the medical school, there was a charismatic Professor of Anatomy, Freddie Wood-Jones whose lectures were fantastic and the lecture theatre was full with people sitting on the floor, even people who weren’t doing medicine. All the people doing medicine were fairly well to do
and middle class – they could retake their exams several times without being thrown out. The students union was a lively place with some charismatic characters, ‘the Red Dean’ Johnson Pople, Rosen, Professor P.M. S Blackett, Professor of Physics and a Nobel Prize winner, were all frequent debaters in the men’s union before 1941. After the War the whole scene changed and the medical school intake was virtually all on scholarships, which was instituted by the Labour government and consisted of a majority of people who had got medical scholarships on the basis of their results in the Higher School Certificate and ex-servicemen. Romantic and exciting debates ceased, the Professor of Anatomy was dour and strict and anybody who failed more than twice was thrown off the course. The mixture of ex-servicemen and diligent students from working and lower middle class backgrounds, made it a hardworking place without the humour and relaxed atmosphere of before. At first I felt self-conscious being a student again, although I was only three to four years older than the average age of the other students. I felt a grizzled veteran and I also had doubts about my capacity to settle down and study. There were members of the teaching staff, lecturers and consultants, who I had known before I joined the RAF and for one reason or another they had not been in the services and were now my teachers –I felt that I had to do well to save face when I was examined by them. I was doing medicine on an ex-serviceman’s grant, which paid the fees and gave us an allowance which helped for expenses but was quite inadequate for living independently and so I had to live at home. The majority of students in my year were in a similar situation – living at home as they couldn’t afford to live in halls. For the
“All the people doing medicine were fairly well to do and middle class”
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“I operated on patients without general anaesthesia but using hypnosis” ex-servicemen it was very important that they passed the exams as failing any examination twice would mean that the grant would stop. There were financial difficulties for me and so I did odd jobs: lecturing at night school, using what I had learned in psychology and being a driving instructor. Many ex-servicemen were married or got married during the medical course including myself. Fortunately our joint incomes made it less necessary to earn some extra money. One of the difficulties I had as an exserviceman was that in our final year I was given various appointments which were really for qualified doctors – we were considered to be more mature than the other students by some of the consultants who themselves were ex-service. I was working as a house surgeon, or a thoracic surgeon, and I had the task of telling patients when their cancer was inoperable or telling their wives what had happened. Frequently the custom was to tell the wives but not the patients that their cancer had been found to be inoperable. I also worked as a House Surgeon in Warrington for a Mr. Young who was a protégé of the famous surgeon at that time who worked at Ancoats Hospital and did all his surgery using local anaesthesia very successfully. So did Mr. Young, it worked beautifully. I assisted at major operations without general anaesthesia, we used barbiturates and then local anaesthesia and the patients generally went to sleep during the operation, even a gastrectomy. When Mr. Young said “I have finished”, the patients usually woke up and I was convinced that they really weren’t sedated but hypnotized because they so trusted Mr. Young.
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Manchester Medical School
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during World War 2 Perhaps it was this experience, although I have never thought of it before, that led me subsequently when I was a house surgeon properly qualified to do a series in casualty where I operated on patients without general anaesthesia but using hypnosis which led to a paper on that topic published in 1961. It remained a source of wonderment to me that patients seem to be completely oblivious to the operation and they never experienced any pain even though the suggestion was simply that they think of other things rather than the operation and there was no special ritual or other suggestion. So my experience as a medical student is not going to be considered as typical because of the circumstances of the War, the sea change that occurred with the labour landslide immediately after the war ended and being ex-service medical students that is, receiving an allowance and having fees paid by the government. Obviously most of our teachers in surgery and medicine
would be the products of the university education and medical education prior to the Second World War so they were better educated we thought, and we thought quite appropriately with posh accents. I cannot recall any of our professors having a Manchester accent. he immediate post Second World War years were unique, for it would be the first time ever that students were married, and some had children whilst on the medical course. But the mix of ex-servicemen, students who were much younger and the wives of students made for a very much more exciting and interesting social life compared to the boisterousness of the pre War men’s union and medical school which appeared
“my experience as a medical student is not going to be considered as typical”
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to be largely a continuation of public school life with a sense of liberation from the domination of masters. They often seemed princely and arrogant and certainly unworried about the expense of being at a university. Throughout I considered medicine an exciting adventure and it was source of wonderment to me that I was there at all. Realising of course that I never would have been able to do medicine had it not been for the War with the provision of ex-service grants.
Medics at Heaton Moor Golf Club
Heaton Moor Golf Club has made arrangements with the Medics Golf Society for Medical Student membership to run from September to August each year at a very advantageous rate. There are some restrictions on playing times but these are not too bad! If you would rather play as a Full Member – enter competitions etc – membership is available and between the ages of 18 and 29 subs are on a sliding scale so this would not prove too expensive.
The gently undulating parkland course is set in a mature and protected conservation area and has two separate 9 holes starting from the Clubhouse. If time is short, the layout lends itself to playing just a few holes, if preferred, since there are several starting points. A small practice area adjoins the main drive and there are practice putting greens by the Clubhouse and at the 1st tee. The Clubhouse is open every day and the kitchen opens at 12 noon serving lunches, snacks and drinks; the bar also opens at 12 noon. There is a snooker table and two TVs with Sky channels. If you want to find out more visit the website at www.heatonmoorgolfclub.co.uk call in the Club at Mauldeth Road, Heaton Mersey, Stockport, SK4 3NX Or phone
0161 432 2134 We look forward to meeting you!
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mediscope
Alex Langhorn
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Issue 3 Sep 2008
Working Overseas
here is no right or wrong time to take time out of your UK training so long as you consider your career plans carefully and take into account the following points: It is very difficult to get a clinical job anywhere if you are not yet registered in your own country. Overseas work is therefore unlikely prior to completion of foundation years. Think about how much use you will be with your current level of training. You can take time out of specialty training in uncoupled specialties, between core and specialty programmes but do consider the pros and cons of the timing. This will vary between specialty and geographical area. You can’t defer a UK training place to travel.
Working in Australia Why Australia? The Australian health care system is considered to be one of the best in the world. A good balance exists between the public healthcare (Medicare) and private healthcare systems. Opportunities exist to practice a wide range of medicine from posts in advanced teaching hospitals in the cities to Third World medicine in the Aboriginal communities. With a current shortage of doctors, particularly in rural areas, Australia offers a diversity of settings to suit most lifestyle choices. The Medical Training System in Australia The medical training system in Australia is not dissimilar to what we are used to in the UK. Australian doctors study for a primary medical degree before undertaking a 12 month internship in an approved accredited training post. Specialist medical training involves prevocational training in broad clinical experience during both the
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The information found here has been gathered from a number of different sources which are listed in the useful links section. It is your responsibility to check material facts with the appropriate authorities prior to committing to any decision regarding career choices. internship and second postgraduate years. of the organising for you. Make sure the This is followed by vocational training of agency you are using is recognised by the 3 – 7 years in a chosen specialty. Australian Association of Medical Recruitment Agencies (AAMRA). International Graduates Practising www.rcsa.com/au/aamra Medicine Very few overseas doctors have completed It is also possible to apply directly to a their specialty training in the UK when hospital, especially if you are looking at a they consider a period of work in Austral- smaller hospital in more rural areas. If the ia. It is therefore common for an overseas hospital considers you to be eligible for the doctor to first work under a temporary post they will sponsor you for immigravisa with conditional medical registration tion purposes. before completing the requirements for A useful jobs page can be found at full registration or specialist recognition. www.doctorvacancy.com.au. Full details of the registration procedures The North Western Postgraduate Medifor overseas medical graduates can be cal Deanery also has contacts in Australia found on the website of the Australian which you may find useful. See their website www.nwpgmd.nhs.uk. Medical Council at www.amc.org.au. Funding Finding a job Not all vacancies may be filled by overseas Good website for research and travel doctors; it is most common for those avail- grants www.rdinfo.org.uk able to be in areas of need or shortage. Directory of Grant Making Trusts These may well be posts that Australian (available for reference at the Careers Service) doctors do not want to take. A good starting point can be the medical Educational Grants Directory (available recruitment agencies as they often do all for reference at the Careers Service)
Useful links www.amc.org.au – Australian Medical Council. www.bma.org.uk/ap.nsf/Content/Workingabroadguide - A really useful guide to overseas work. www.doctorconnect.gov.au – A government initiative developed by the Department for Health and Aging for doctors trained outside Australia. www.immi.gov.au – Australian Government Department of Immigration and Citizenship. www.rdinfo.org.uk – A good website for research and travel grants.
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Manchester Medical School
Working in New Zealand Why New Zealand? There are many similarities between the UK and New Zealand healthcare systems. There exists a wide choice of healthcare services funded both privately and through government subsidies. There are currently shortages of doctors in some areas of practice however there is also oversupply in others so check your area of interest. The Medical Training System in New Zealand Basic medical training involves the completion of a medical degree followed by two years working as a house surgeon. Doctors must do six months of medicine and six months of surgery in order to get registration. Following this they must work as a senior house officer for one to two years before beginning to work as a registrar. Registrar training programmes include specialist examinations which must be passed before applications can be made to senior registrar posts. Specialist training lasts for five to six years leading to eligibility to apply for consultant posts.
“A good starting point can be the medical recruitment agencies”
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Working Overseas Useful links www.bma.org.uk/ap.nsf/Content/Workingabroadguide - A really useful guide to overseas work. www.immigration.govt.nz – Immigration New Zealand. www.kiwicareers.govt.nz – Information on labour market trends and working conditions. www.mcnz.org.nz – Medical Council of New Zealand. www.nzma.org.nz/journal/vacancies.htm - New Zealand Medical Journal.
International Graduates Practising Medicine The Medical Council of New Zealand (MCNZ) registers doctors to practice medicine in New Zealand. Unlike the UK and Australia, there are no registration categories. Doctors are instead registered within a ‘scope of practice’ which determines the level of professional service they are allowed to perform. This is dependent on qualifications and experience. International medical graduates are usually registered within a provisional general scope of practice. These are supervised roles for up to two years. To be eligible to apply you must hold a recognised medical degree and have one year general medical experience and full registration with the GMC. There is a really easy to use self assessment tool on the MCNZ website which allows you to check your eligibility for registration within a scope of practice. You can also make an application for registration online. All new registrants work under supervision for at least their first 12 months during which time their performance is assessed by a senior consultant.
“You can make an application for registration online” Registration with the MCNZ within a scope of practice is only granted when you have a confirmed job offer under supervision in an approved hospital. Details can be found on the MCNZ website at www.mcnz.org.nz Finding a job Most District Health Boards advertise their positions on their website so it is possible to apply directly to them. Posts are often advertised in UK medical journals such as the BMJ or the careers section of the New Zealand Medical Journal available at: www.nzma.org.nz/journal/vacancies.h tm
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mediscope
We met up with medical students from around the world. How do their experiences compare to ours? We asked them the following questions: 1 How many years are you at Medical School? 2 Is it an undergraduate course? 3 Give an example of your typical week. 4 Do you spend all of your time in hospitals? 5 Who teaches you i.e. doctors, scientists etc? 6 Do you have lots of lectures or is it mainly private study i.e. own personal work? 7 Do you have to pay for your university education? If so, how much? Australia 1 6 freaking years! 2 Yes, it was when I enrolled, now it follows the Melbourne model, which is a post-grad degree 3 Since I’m doing paeds…lectures on Monday from 8am till 4 pm, Tuesday - tutorials, Wednesday - clinics, Thursday – tutorials, Friday PBL…and wards all day all week. 4 No 5 Doctors 6 Combination of both 7 Aussies pay about 6.6k AUSD a year, internationals about 56k AUSD a year.
New Zealand 1 Medicine in NZ takes 6 years, first year sort of general year after which you apply for the medical programme and you actually start medicine from 2nd year. 2 Undergrad 3 Typical week would be spent following the team your attached to, ward rounds, helping the reg/house officer with ward jobs or admitting patients if it's your teams on-call day. Also must attend tutorials and clinics. Plus, bedside teaching sessions with other students conducted by consultants
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Issue 3 Sep 2008
Medics
one bright spot is that you'll finally be 4 Most of our time is spent in hospital, earning a salary during these years. sometimes it involves community visits depending on what attachment your 3 My week typically involves morning doing lectures Monday through Friday with occasional afternoon sessions. I head 5 Mainly taught by doctors - also an home and study for the remainder of multidisciplinary team approach so the day. The highlights of the day, you can learn from the physiotherasadly, are during lunch and dinner pist, social worker or occupational where I reflect and question where my therapist social life has gone. Haha. (Yea it's 6 Both rather unglamorous...) I probably head 7 Locals earn about 12k NZD a year off to bed around 2:00 am and wake up (most of them are on student loans), at 6:00 am. They push us pretty hard, international students about 53k NZD but I'm sure you guys understand how a year it goes. 4 Again, starting in our third year, we France spend ALL of our time in hospitals, whereas our first two years were spent 1 We are at medical school for 6 years + mainly in a classroom with occasional 4or5 of training/specialising hospital work. 2 It's an undergraduate course 5 We are generally instructed by other 3 Typical week: Every morning 8:30 to physicians, but for certain lectures, i.e. 13:00 "en stage" in the afternoon lesPharmacology, Biochemistry, etc. we sons or personal work. Evenings you are taught by graduate professors can be on call just like weekends. (researchers). 4 We spend mornings and some 6 Our school is following a growing evenings/nights and some weekends. trend in U.S. medical schools where 5 We are taught by university doctors lectures are steadily being decreased in who spend 1/3 time for research 1/3 favour of what are called Directed Stufor teaching and 1/3 in the hospital. dent Assignments(DSA). DSA's are 6 It's mainly personal work off books. basically assignments where we're giv7 We pay university fees about 200 euen certain objectives to study, go look ros for the tuition for the year. So up, and learn on our own. In essence books are at our own expense. the idea is to get us into the habit of teaching ourselves. As you know, medicine is evolving by the day, and North America it's our responsibility to remain up to speed on all the research being con1 4 years on a post graduate course. ducted; so they hope to build the disci2 After high school (Grade 12), we apply pline we'll need after graduating. to an undergraduate school at any of 7 Yes, we must pay for our own educathe nationwide universities. On avertion. Education costs are an enormous age, around 4 years later, we come problem in the U.S. and if you've away with a Bachelor's Degree. For heard a thing or two about our current example, I came away with a BachU.S. presidential election battles, it's elor's in Biology, but there are many also a serious campaign issue along different disciplines represented with the economy, healthcare, and milamongst our class: Music, English, Enitary. Tuition cost ranges depending on gineering, etc. It doesn't matter as long the school you attend (private vs. pubas you complete certain core science lic). The average medical student owes courses. Then we again apply to a 4 more than $100,000 in student loans year medical program. The first two for a public medical school and over years are didactic classrooms courses. $135,000 in student loans for a private The latter two years are our clinicals in medical school. I'll let you convert that a healthcare setting (hospitals, local to pounds. I take out a loan from the clinics, etc.). At this point we are certigovernment for around $20,000/yr. fied physicians. After graduating we I've been lucky and received grants and apply to residency programs where we scholarships to help decrease my fucan specialize in the discipline of our ture financials pains, but I'll definitely choice. Depending on how specialized be suffering for the first few years. you end up becoming, this period could last anywhere from 2-8 years. But the
mediscope
Manchester Medical School
life
Abroad Working in the USA – From UK Medical Student to US Resident.
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espite many differences in medical education between the US and the UK, postgraduate medicine seems to have become very similar. In fact one could think that Modernising Medical Careers (MMC) have copied the US system. All students in America have to study an undergraduate degree first, which normally takes 4 years. They then have to apply to a Graduate Medical School, where they study medicine for 4 years, ultimately graduating with the prestigious MD (Doctor of Medicine). After this they pick their speciality and specialise, which normally takes between 3 and 5 years (residency period); specialities like family medicine take 3 years while surgery can take 5 years or longer. There is the option to sub specialise which takes a further 1-3 years (fellowship period). If you have decided that you want to work as a Doctor in the USA then you need to register with the Educational Commission for Foreign Medical Graduates (ECFMG), whose website can be found at www.ecfmg.org. When you register with the ECFMG they will give you an examination identification number, which you will need in order to sit the United States Medical Licensing Exam (USMLE).2 All international graduates have to sit the USMLE; in fact this is an exam sat by all US medical students too. It has three parts (Parts 1, 2 and 3). Part 1 assesses biomedical knowledge, part 2 assesses clinical knowledge and skills and part 3 understanding and ability to apply medical knowledge that’s considered important for unsupervised medical practice. Steps 1 and 2 can be taken before graduation, with the only requirement being that you have completed two years of medical school. However, there are a number of requirements that have to be met before step 3 can be taken; you must have a medical degree, passed steps 1 and 2 and met any other requirements of the state for which you would like to work e.g. fulfilled post graduate requirements. Therefore, my advice would be worry about step 3 later.2 In order to apply for residency programmes you will need ECFMG certification, however, note that as with the UK competition is fierce and certification does not mean that you will necessarily be ac-
cepted onto your desired training pathway.2 In order to get certification you need to have the following: the USMLE. graduation must be listed in the International Medical Education Directory (IMED) – to check visit (http://imed.ecfmg.org/) – don’t worry though Manchester is listed! Once certified you may decide that you do not want to commit yourself to a particular speciality at such an early stage. It is possible to do a 1 year transitional year where you get exposure to multiple different clinical disciplines. However, if you wish to just carry out research and not work directly with patients then you do not need ECFMG certification. It is recommended that international graduates wishing to work in the USA first complete observership rotations in clinical areas. This gives you an insight into the US system and will also enable US physicians to write you a reference, which can be invaluable when applying for residency. The application process is summarised below. For more detail visit: http://www.amaassn.org/ama/pub/categ ory/1554.html
Useful resources ECFMG Information booklet: Download at www.ecfmg.org BMA guide to working in the USA: http://www.bma.org.uk/ap.nsf/ Content/Workingabroadguide~ Workingintheusa Websites mentioned: i Visa Information: www.amaassn.org/ama/pub/category/15 53.html ii The residency application process : http://www.amaassn.org/ama/pub/category/15 54.html iii FREIDA website: http://www.amaassn.org/ama/pub/category/29 97.html
Volunteer for Visayans
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o plans for the summer? Want to travel abroad? How about volunteering in the Philippines? Last year we travelled to Tacloban in the island of Layte, Philippines, to volunteer in a rural health clinic for four weeks. The charity Volunteer for Visayans (VFV) is a non-profit organization set up by the local community and arranges volunteers around the world to participate in a range of placements including: Teaching English and Maths Assisting in Orphanages Helping out in Rural Health Clinics Volunteering with the Social Department Assisting at Street Children Centres VFV plays a major role in community development and projects we participated in included building homes for deprived families and organizing fundraising. Several volunteers are placed under the care of families in the local community so you can truly experience the Filipino life and culture. Filipinos love to sing and dance, so at any gathering (i.e. 3 people or more) the karaoke machine WILL come out...and you will be expected to sing solo! Our clinic experience was an eye-opener in terms of how basic the facilities were, but the medical staff encouraged us to get involved as much as possible. Many cases we saw were common diseases in third world countries including tuberculosis. Once we finished work at the clinic we would travel back to the VFV centre, which is located in the heart of the community, and teach English and Maths to the children after school. This provided an opportunity to get to know the children in the community and their families. Nothing but an open mind is required to volunteer here so if this sounds like something you want to do, feel free to ask us any question at visayans.uk@gmail.com or go directly to the VFV website www.visayans.org for more information! By Debbie Suen (4th Year) and Helen Rooney (1st Year)
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life
mediscope
Issue 3 Sep 2008
A former editor
An interview with...
1. What are you currently doing?
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GP Principal and trainer in Stalybridge 2. What was your role in Mediscope? Editor between 1991 and 1993 3. Do you currently do any medical journalism? Not really, I write a few articles for Update, the GP magazine every now and then. 4. What do you think about medical students and the current emphasis on extra-curricular activities? From the perspective of a GP I think it’s quite artificial. For trainee GP recruitment we have a formal interview, along with a mock consultation, written scenario and group discussion. There is not a great deal of emphasis on a CV. 5. How has your role as a GP changed between when you started and the present day? I started as a GP in 1999 and the role hasn’t really changed. The only major positive difference is IT and computerised records etc. 6. What do you think about polyclinics? I don’t really know. However, I do think that there does need to be a shake-up in inner city and remote area GP services. Unfortunately, politicians do not understand the essence of primary care i.e. the importance of establishing a relationship with patients. 7. Do you think GP salaries are justified? Everyone forgets about GP expenses as they’re self-employed. For example, photocopying bills come out of my salary etc. Furthermore, I could earn much more by being the chief executive of a company. Therefore, I think the balance is currently about right. 8. Would you still choose General Practice if you had your time again? Yes, definitely. 9. What qualities do you think a GP should have? The ability to practise patient-centred medicine i.e. a GP must be able to explain conditions to patients so that they can make an informed decision. 10. What are the highs and lows of General Practice? HIGHS – (i) It gets better the longer you’re there as you share people’s life journeys. (ii) Continuity. LOWS – Change driven from above when GPs have no perceived need. 11. What changes would you like to see introduced into General Practice? The government to stop being money driven: the Department of Health must start to value the same parts of General Practice that the general population value.
Mediscope meets a past editor of Mediscope and now GP Principal, Dr Joanne Bircher
mediscope
Manchester Medical School
life
Agony Aunts AGONY AUNT SECTION
Dearest Aunties, I’m no longer sure that medicine is for me, what’s your advice? Dear Uncertain, Medicine is an eclectic group of activities that range from no patient contact (lab based medicine), through to little patient contact (ICU, surgery – well little interaction anyway) and finally to very much hands on patient contact (general medicine; general practice). Medicine can also allow you to specialise in medicine applied to other areas such as law, psychology, IT or even government through getting involved with public health and legislation. Few other professions can give this degree of flexibility in careers. You need to decide what it is that you you would like about medicine and how the reality differs. Have you just had a bad experience in one placement or encounter maybe? Make a list of all the positive things you think you could like about studying and another list of the negatives. Be as honest as you can and don’t be worried about saying financial reward in the positive box, the reality is medicine is really quite well paid. The one thing that does unite all aspects of medical practice is the need to communicate in a team and work with colleagues, after that there are more differences than similarities. Speak to others about your doubts, you don’t say what year student you are, talk to those who may have been through similar doubts. Remember, this is not The Apprentice, you won’t be fired for questioning your motives, this is a healthy response to a big decision.
Candy
Dear Uncertain, If you want to spend the next 10 years moving cities every 6 months and never keeping a relationship, well not with a real person anyway, stick at it. If you want an approximately normal life then read on…! It doesn’t get any easier, go and train to be a hairdresser; at least that way you make people feel good. The only requirement is that you can ask “where you goin’n your holiday then…?” while burning someone’s scalp with a drier hot enough to nicely finish off a crème brûlée. No ungrateful patient is going to thank you for telling them off for mismanaging their diabetes or stitching up their scalp laceration after a Saturday night fight so wise up and get yourself a real job! You just can’t let rip at patients like the old days, but I digress… If you are female well, tough luck but give up trying to be an equal player in the big boy’s game, they won’t tell you the rules and they will steal your knickers after the shower while telling the others you don’t wear them! But don’t fret at least you can marry a rich boss, get good at filing and making coffee and don’t forget the M&S double choc chip cookies, that will really clinch the deal… If you’re male then why would you think about leaving, you must be mad! You’re about to enter one of the few remaining clubs that can be misogynous and get away with it, one that allows you to pretend to the wife you are working at that ‘conference’ in Dubai and when you come home she’ll have the G&T ready and let you off childcare duties for the rest of the month. On second thoughts if you are questioning your motives, then you are not one of them, old boy, lacking in moral fibre and all that. Time to become a teacher or social worker or something.
Cyneek 31
mediscope
Issue 3 Sep 2008
mediscope A big thanks to everyone who helped get Mediscope to its third issue. Good luck to the new editorial team! Advertise here
subeditor.mediscope@manchester.ac.uk 32