Obliques Out. These were the only words I remembered from a lecture on cranial nerves given by a neurologist during my second year at medical school. And I went through the entire third year with this huge piece of knowledge to save my neck during consultant ward rounds.

But during my fourth year rotation in ophthalmology, my colleagues and I were faced with a similar controversial situation regarding the movement of extraocular muscles. Except that our controversy involved the consultant ophthalmologist. Lets just say that we weren't exactly 'eye to eye' on the subject. After a little inquiry into the matter, I discovered that the cause of the confusion in my mind and others was the fact that we were making the question too simple. The matter needed a little dissection. So actually we have two issues here. one is the movement of the extraocular muscles and the other is the way we test their movement.

When we say that obliques abduct and the recti adduct, we are making an assumption that the muscle under question is acting alone with all others dissected away. But in reality we all know that eye movements are brought about by interplay of these muscles. Unfortunately for the clinician dealing with non-cadaver humans the situation is a little more complex. But he or she tries to come as close to the ideal situation as possible and test the eye movements in a position where the single muscle predominates.

The origin of the recti are medial and posterior to their insertions. So to straighten them out the patient is asked to look laterally, thus fixating the eye with the lateral rectus and placing the superior and inferior recti in an optimal position for moving the globe up or down. The origins of the obliques are also medial but anterior to their insertions. And so to straighten them out the patient is asked to look medially and then move the eye up and down because in this position the obliques are placed in an optimal position to be tested. In short the obliques if acting independently move the globe out wards or abduct. But to test their action the patient has to adduct the eye. The reverse is true for the superior and inferior recti. This would be much easier to explain and understand with diagrams in front of you but I hope this was enlightening. You would want to have a look at the topic from Clinical Anatomy for Medical Students, fourth edition, by Richard S. Snell, M.D., PhD.

Always remember - Obliques move Out.

My experience as both a senior clinical student and a college supervisor in preclinical anatomy puts me in a good position to comment on the findings of Ahmed and Ali concerning eye muscles that change their action about half way through the medical degree.

Preclinical anatomy is taught in terms of movement of the eye from its position of rest, i.e. with the pupil facing forwards. The independent actions of the eye muscles are described, for example that superior oblique on its own would move the eye to look down and out in a curved path, i.e. it would be depressed and abducted. However, it is not necessarily made clear that a person depressing and abducting their eye will actually use several different muscles simultaneously. Hence in terms of clinical examination, this information is not very useful as all movements from the position of rest involve several muscles and several cranial nerves.

Clinical examination is taught in terms of demonstrating the independent actions of the six eye muscles, to test cranial nerves III, IV and VI. To isolate all six, it is necessary to get the patient to move their eye in an H shape, where abduction isolates the rectus muscles and adduction isolates the obliques. From a position of full adduction (using medial rectus), depressing the eye uses only superior oblique. Clinical students are sometimes incorrectly taught to test eye movements in a + shape, where depression of the eye in the midline combines both superior oblique and inferior rectus. The oblique muscles do not adduct the eye from any position and I am surprised if textbooks genuinely state that they do.

The moral of this story is that luckily anatomy, like other fundamental forces of nature, does indeed remain consistent over a five or six year period of training. However, there are two issues working to confuse dedicated medical students. Firstly, preclinical students are often taught information in a different context to what they will encounter later in their training. Secondly, word-of-mouth teaching techniques on the wards promote the Chinese whispers effect, where knowledge often passes from medic to medic without facts being checked along the way. Over time inconsistencies can develop.

Ahmed's greatest lesson from his experience is that, whilst teaching is designed to highlight and correct the deficiencies in the knowledge of the pupil, it works much more effectively for the teacher than for the student!

I am writing in response to a letter written by Fiona Hayes regarding 'students taking responsibility for their finances' in July's student BMJ. I am one of the graduates on the 4 year fast-track scheme at Leicester-Warwick Medical School. I am also one of the students who is fortunate enough to be in receipt of an NHS bursary.

I felt Miss Hayes letter was very self-defeating and wish to clarify some of the points that she raises. I do not pretend to fully understand the sacrifices and hardships that Miss Hayes must have suffered as a single parent doing medicine, but neither can she pass judgement on the situation at Leicester-Warwick. This debate should not become a poverty contest and resentment about past experiences at the hands of government or funding agencies should not be handed down to future medical students. This country is desperately short of doctors in a variety of specialities and we as a body of medical students, whether graduate or undergraduate, should become more proactive in pushing for change regarding student funding. Medicine is hard enough without adding enormous financial pressures.

This debate is not just about 'students taking responsibility for their finances', but also about governments and funding agencies providing reasonable means for people to study. To fulfil many of its election pledges, the government needs more doctors and medical students may be in a strong position to push for improvements in funding.

As for the situation at Leicester-Warwick. At the time that we all applied to the course (2000), we were led to believe that everyone who was a UK national would be eligible for a reasonable NHS bursary after the first year. Many of us had places at other established medical schools in the UK and chose to risk the uncertainty of a new course and medical school because of the prospect of an NHS bursary. With hindsight, this was a 'carrot on a stick' and despite the best efforts of many responsible students, no information was available on the NHS bursaries until we had done nearly a year of the course. Miss Hayes was perhaps fortunate in going to an established medical school and being fully aware of what she was letting herself in for. Being the first year of a new medical school is not an easy thing to do and many of us have had to make large sacrifices to do it.

I sympathise a great deal with Holly Thomas. It must be a terrible feeling to read around subjects as bizarre as Public Health and get no reward for it. I agree that it does not support self-directed learning. However, she should not be despondent. Those students who have read around their subjects will be able to impress a great deal more on their ward rounds at the start of their 3rd year clinical attachments. Those consultants who bother to listen will think you are fantastic, and will mark you well in your end of term assessments. At last, some recognition! Or not. The consultant grades count for nothing in the year grades. The message is that self-directed learning is a useful skill in acquiring the knowledge to be a good doctor, which is far more important than getting high grades in pre-clinical public health examinations. It is when you are on the wards that you will get your reward, in the form of a smile from a patient or an impressed look from your registrar, or most importantly that wonderful feeling that you actually know something. And don't worry about those people who haven't read around their public health course - you'll get it all taught to you again next year.

Boughey and Norman seem to have completely missed my point as they exclaimed their "disturbance" on my views of the Government's budget resources for the health service. Never once in my earlier piece, did I describe nurses as "little more than glorified healthcare assistants", and by drawing this conclusion they have displayed the type of knee-jerk reaction that the media rejoices in sensationalising as, whether they like it or not, nurses do attract more public sympathy and indeed act as political "weapons" more than doctors.

I in turn wonder about their views on other members of the hospital team. The phrase "glorified healthcare assistants" is derogatory to both these roles. Nurses are undeniably more trained and play a more central role in patient management but, let us now belittle the role of auxiliaries. Many I have encountered are studying for extra qualifications and possess a great deal of practical knowledge and experience; in my employment as an auxiliary I have been aided immensely by both nurses and auxiliaries all of whom, particularly on learning of my medical student status, have most graciously offered as much help and advice as possible for both my immediate and future duties. In doing so I have been able to improve both my practical and patient-communication skills, and am certain I will be a better doctor for having done so.

What I was intending to highlight was the disparity that exists between medicine and all the so-called "professions allied to medicine", not just nursing but also physios, chiropodists etc. All of these careers require a high amount of training and self-sacrifice, and a range of varying roles and responsibilities. But for efficient patient care we need a fully motivated and integrated system, where these professions can work together, not a "doctors vs. everyone else" attitude that clearly still exists, as demonstrated by the underlying tone of Norman's words. Nurses are an essential commodity but so are doctors. I am just calling for this to be recognised and for equality to be complete, not just at the convenient discretion of those in authority.

We are writing in response to a letter by P. Krishnan (April issue) that we have just been made aware of. This letter relates to a laboratory project by Ms Krishnan, carried out under our supervision as part of her studies towards an intercalated BSc degree. In her letter, Ms Krishnan alleges that a paper published by one of us last year was "essentially a copy of my experiment with similar results" and that "I had not been acknowledged for the three months that I had spent in the lab.". Ms Krishnan concludes by alleging that she did the "donkey work" and that we were not "professional enough" to acknowledge her work. These allegations have no basis in the truth. None of the results presented in the relevant paper (Br. J. Pharmacol. 131, 659-662) were from Ms Krishnan's work: the paper reports only data from measurements of intracellular pH, but no such measurements were carried out by Ms Krishnan as part of her project. Furthermore, the published data were obtained well before Ms Krishnan started her project; indeed they formed the rationale behind her project, as Ms Krishnan acknowledged in her project report. The only place in the paper where Ms Krishnan's work is mentioned is in the Discussion, where her contribution is appropriately acknowledged. Here, it states "Indeed there is preliminary evidence that . [the drug] inhibits the positive effects of phenylephrine on (1) cell shortening under normal conditions, and (2) the recovery of cell shortening following intracellular acidosis (P. Krishnan and J.C. Kentish, King's College London, personal communication)." This is the accepted format for citation of unpublished data.

BSc project supervisors devote a considerable amount of time and energy to ensure that their students' projects are interesting and successful and, like us, often allow the students to use state-of-the-art research equipment. The main aim is to give the students experience of research work and of critical analysis. It is unrealistic to expect that, within the limited time available, BSc students without prior laboratory experience can commonly obtain sufficient novel data from their projects for publication in peer-reviewed literature. Nevertheless, we strongly support the notion that a student who has contributed, in however small a way, to work that is submitted for publication should be duly acknowledged.

As scientists, we have a duty to ensure that we are sure of the relevant facts before we submit any article for publication. We would expect this principle to be adopted also by contributors to the Student BMJ.

I think many people are missing the point about Professor Von Hagens Body Worlds exhibition. He has not discovered new arteries or bones that we didn't already know about. What Von Hagen has done is to find a new method of communication of anatomical knowledge. Speaking as a medical student who has done an intercalated BSc in Anatomy, his work is groundbreaking in that a large amount of detail has been preserved and an observer can view the cadaver from all angles and truly appreciate the relationships between structures. It's great for medical education even though though it's exhibition, with tickets, profits, and for a limited time only - the technique could catch on, and of course they gave consent.

However, I think it would naive to think that so many members of the public are going simply because they are fascinated by the human body and want to be educated (although many are). Personally I think the histeria surrounding the exhibition has enticed many people to go in the first place, controversy is popular, people may perceive it as a freak show especially in light of the angles taken by certain sections of the press.

The exhibition is a huge success, it has pulled in the crouds and educated many. The main benefit to be gained from this exhibition is a way forward for medical education (albeit costly) where dissection, plastic models and specimen pots would still be used in conjunction with plastinated bodies which would aid memory and understanding of a difficult subject. However, I have a feeling that this will never occur as it is far too expensive with some medical schools not even using dissection any more. I don't think medical students who go there will become better doctors. However, if the only people to benefit from this are members of the public then the effects will be short-lived, the exhibition will eventually close, people will forget all about it and all that resulted was a piece of history and the deepening of Von Hagen's pockets.

Tim, I would not consider your work a failure at all! You have accomplished much in your relationships and in raising all of our consciousnesses. However, I would encourage you not to give up! I have worked to put together projects for medical students and young doctors throughout my career, and they are frequently difficult and often derailed.

As second year medical students a portion of our class organized a community development project in the Philippines. As a fourth year student, I worked with my colleagues to create a project called Public Health and Diplomacy. This brought together medical students/doctors from Harvard School of Public Health, Russia, Lithuania and Kenya to work on a participatory rural appraisal project on nutrition in Kenya. The plan was to then have reciprocal projects in Russia and the USA. We fought like anything to raise the money, keep the group together, keep everyone safe, etc. It nearly collapsed many times. After a successful project in Africa, however, it was difficult to continue. As students we did not have the wherewithall to keep it going. I was disappointed, but have continued to remain friends with the other participants and our lives were changed by working together.

Organizations like the IFMSA can help bring students together, and other organizations and international medical societies provide contacts and relationships on which to build projects/rotations/experiences. "Building Bridges through Health" organized by the Economic Cooperation Federation and Palestine Council of Health organizes Israeli-Palestinian cooperation in health, medicine and social welfare. Perhaps they can help you continue your work.

You and your colleagues should be commended on your effort. Our common oath to cure illness, prevent disease and alleviate suffering can help us bridge the differences that otherwise would tear us apart. Now, more than ever, we need to work together to bring peace, understanding and development to the world.

In her article Layla McCay was exasperated with inability to comprehend just one languge and that too in a foreign country. Well just think about the country where you have to try to get several different languages.

Well that is something the situation is like in India. As a medical student besides the clinical skills you also have to pick up the ability to comprehend several dialects and that too of differnt languages. Many a times after talking with the paitent for something like half an hour you have to be content with the job of guessing as to what he/she is saying and if you are lucky you will find the attendant to have a basic knowledge of the language you are comfortable with.

If you belong to say, North India then the guess work in that region is slightly easier because most of the languages in this part would have some common relations. But what really is interesting!!? is your colleague from north-east or south trying to do the job....and many a times looking helplessly at you for help. The only thing which is helpful is that atleast you are in your own country unlike Ms. McCay

Strange how people living in war zones never seem to complain, whereas those living outside them seem to want sympathy for just being normal and reacting to real life sitautions as 99% of people on this planet do.

Personally I think anyone suffering from any of these new " syndromes" should be given a free ticket, accomodation supplied to any of the following of their choice: Iraq, Afghanistan, Chechnya, Kashmir where one would hope they will get a reality check and thus cease asking for sympathy that is not deserved.