Reply to letter by Natasha in July's Rapid Responces.

Natasha is of course right pointing out that 'facts are important', but unfortunately her letter is neither factually correct nor even related to the main point of my previous letter. If she re-reads my letter it will become obvious that my letter is not biased and does not 'take sides'. The letter is trying to emphasise the importance of safety when students are planning their electives, and emphasise that medical student status will not give any sort of special immunity.

She claims that I implied by having 'Asian names' the two students had 'sinister alterior motives', something that is simply not true. My only reference to the students ethnicity was in relation to them being in more danger, as two weeks previously two similarly aged British men of similar ethnicity had set off a suicide bomb. At the time of the bombing Israeli security officials said that they were going to increase security in regard to foreign nationals, and I was simply repeating this message.

I did say that 'tourism was unlikely to be there only motive', and I think after the statement by Birmingham University Palestinian society this is obvious. This statement though is in no way implying that they were involved in terrorism, it implies that there was a political motive for their visit. I think it is likely that the pair were visiting the area to see the poverty and repression for themselves, an admirable, if foolhardy task.

Natasha goes on to say that I 'decided on the guilty motives of the medics that they were searching for trouble` which is a blatant untruth. I was very careful to not comment on whether the students were guilty or not, and I did not comment on whether the Israeli (or Jordanian) border police were correct to arrest them or not. Although I think it is obvious to everyone that as they were released and not charged they must have been innocent.

She also says that 'medics should use their electives to truly go to places where the people are in need of their help'. This I find as one of the most disturbing things she has written, as not only is it untrue but also very dangerous. Elective students are students, not doctors; they are not qualified and are never in any position to overstep their knowledge or responsibilities. One of the most important duties of any doctor/student (GMC guidelines) is to 'recognise the limits of your professional competence`1 Student abroad have little knowledge of local diseases, procedures and medications, not to mention the language barrier. I suggest that Natasha searches through the student BMJ archives and reads the October 1997 issue that goes into this in some depth.

Lastly she states that most students go 'on a glorified vacation to the States', a comment that will no doubt be hurtful for hundreds of students. I like many other went to the USA for my elective, and like many others I worked 9-5, Mon-Fri, for 8 solid weeks. Like others I was attached to American medical students and was expected to 'pull my weight' in clerking patients as well as sitting an exam at the end of the block. I worked harder on my elective than at any other time prior to final year, and Natasha's comments are generalist, thoughtless and like many of her other points completely untrue.

1. 'Duties of a doctor', General Medical Council

I would like to commment on David Casey's letter to the Student BMJ Volume 11 of August 2003, titled "Drug abuse among medical students may pose real problem".I take issue with Mr Casey's statements and logic as stated in his letter.¹ Whilst I agree that stress is a problem in both medical students and doctors, I feel that the debate over drug and alcohol abuse has become increasingly hysterical in the current socio-political climate, and that the argument for routine testing of doctors has yet to be supported with any evidence.

The logical chain of evidence necessary to support routine drug testing in doctors is: That drug abuse is widespread in the medical profession, that drug abuse lessens competence below acceptable levels and causes a risk to patients, and that drug testing with appropriate follow-up would reduce or eliminate this risk. I have not found any evidence to prove each of the links in this chain. Until in particular the relationship between recreational drug use and incompetence is established, I would argue there is no rationale to drug test doctors.

Furthermore, Mr Casey's statement that "medical students are exposed to the same illicit experiences as other students", whilst ostensibly true, does not support his argument. Research conducted in the year 2000 demonstrated that illegal drug abuse rates are falling in the 11-15 year old age segment², who will in September 2003 begin to join medical schools.

Finally, I would support his statement that it could take "one event to shatter the public trust in young doctors. . . " One such event would be the media frenzy caused by a series of positive drug tests in perfectly competent young doctors, generated without any evidence to show that these doctors were posing a risk to anyone but themselves.

1. Casey D; Drug abuse among medical students may pose real problem; studentBMJ 2003;11;300
2. Department of Health; Smoking, drinking and drug among young people in England in 2000; http://www.doh.gov.uk/public/sddsurvey.htm.

I don't see what's the point Max Godfrey has objection about...he claims that Ayesha Nunhuck politicise her article, which is not true, as she used what happened in Palestine as an example, among other examples throughout the article.

On parallel, Max stated an opinion about Israeli government as "the only democratically elected government in the Middle East" as a fact without proper refrence.Inserting such political view as a settled fact is what called "politicisation"!

Anyway, as this is not the scope of studentBMJ, we should not go in such discussions about political regimes in region.

Perhaps a debate about medical link to politics could be run in future, especially the journal is international!

In south asia male is considered as dominant.To show their dominance in the community many of them smoke.Elderly ladies too smoke cigars in some areas of asia.

Many labourers ,both men and women chew tobacco and keep it in the cheek so that the nicotine is absorbed sublingually which gives the same effect as smoking.They add betel nut betel leaves and lime along with tobacco which will give the kick as well as the red colour to the tongue.It is well proven beyond doubt that tobacco and this combination causes cancer in oropharynx and GIT.For the same reason Thrombo angiitis obliterans is common in india.

I am not sure what is meant by "once you're in Bali you can travel overland to East Timor". There are about 5 islands inbetween Bali and East Timor. Whatsmore overland travellers would have to cross the West Timor/East Timor border, which is actually quite unsafe, and certainly not recommended. You may wish to warn your readers about this.

"Overland" in the travel industry means "not by air", which includes boats. Perhaps it would be better to say "surface" in this case.

We strongly recommend that you look online for further more detailed information and that you check with your government's foreign office before travelling for the most up to date information on the safety of the area.

I agree that in this day of ill-founded litigious practice against doctors that it is probably wise, for the doctor's sake, to always have a chaperone present during a genitourinary examination. But I say this grudgingly.

I would like to share my different perception of this practice, which I am sure is not just my own:

1. I have recently gone to two doctors where such an examination took place, and I was not presented with the option of a chaperone,--one was provided each time without discussion--clearly implying that the doctors assume the worst about their patients' intents (not ill-deservedly).
2. I do not automatically feel more comfortable with a female nurse in the room during an examination any more than I would automatically feel more comfortable with a female nurse in the room while my husband and I have sex. While these are clearly different situations, they are both highly personal, and the old saying, "Two's company, three's a crowd" certainly reflects my own comfort level. Clearly, for me (and, I am sure, others), the presence of a nurse is actually MORE upsettling than being alone with a doctor I trust. If I feel comfortable enough to go through with the exam in the first place (something which I dread), I certainly don't want to feel like I am in an arena with a spectator. This is, apparently, not a popular view, but I find it unsettling that the article takes the position that if "most" women prefer chaperones then that is the way things SHOULD be.
3. Having a nurse, or other chaperone, present also poses the problem of that third party's potential for misunderstanding. For instance, current interpretation of what is considered sexual harrassment includes many jokes or personal remarks to which I, myself, might not take offense if made by the doctor, but which the chaperone might. This puts the doctor under pressure to become even more circumspect than he otherwise might had our conversation been of the private nature so well-established in the traditional doctor-patient relationship.

For all these reasons, from the point of view of myself as a patient, I am not happy with the need of chaperones for doctors. But, in the interest of doctors' need to defend against illegitimate legal action, I am (grudgingly) happy to oblige.

Akbar Lalani's epic marathon across the Moroccan desert is truly inspiring¹. His total commitment and passion in both the training and the event should be a remainder to us all that there is more to life than medicine.

Frequently, our hobbies and pursuits are put on the backburner, usually in response to impending exams. More often than not these hobbies which once enthused us begin to take a more reticent tone, and cannot usually be reinstated with the same vigour as previously. A number of factors may play a role. Students may feel guilty about pursuing such interests in the face of an ever-increasing workload. In addition the sporadic devotion to an interest may not allow it to continually progress as it should, leaving nothing more than a half baked project.

However, even in the face of seemingly insurmountable pressure, these passions should be kept alive. If ever we are in doubt, then we should look towards students such as Akbar Lalani, or David Burckett-St. Laurent, (who has recently reached the North Pole², who are making great sacrifices in their medical education, so they can achieve their dreams. Considering the magnitude of their achievements, the sacrifice is undoubtedly worthwhile.

1. Hebert, K., Profile: Desert Marathon Madness. StudentBMJ 2003; 11 287 (July)
2. http://news.bbc.co.uk/1/hi/england/devon/2966827.stm

Well I never! McManus and colleagues¹ report that success at A levels - which requires basic ability, rote learning, intensive revision and good exam technique - predicts success at (time to passing) membership exams - which requires...er...basic ability, rote learning, intensive revision and good exam technique.

1. McManus IC, Smithers E, Partridge E, Keeling A, Fleming PR. A levels and intelligence as predictors of medical careers in UK doctors: 20 year prospective study BMJ 2003; 327: 139-142 (19 July)

Caution is given to encouraging lower entry grades for students from low performing state schools in the August edition of the Student BMJ when one article claims that A level results are a reliable measure of success in medical careers¹. It suggests that students with lower A level grades at entry to medical school have less successful careers than these with higher A level grades. However, the applicability of the study to today's applicants is uncertain. How many of these doctors, who were students between 1975 and 1982, actually attended a 'low performing state school'?

In the same issue, a study finds that medical students have 'too little social and cultural awareness' and suggests that 'medical universities need to produce doctors who are sensitive to and competent at working with the diversity of their communities'². Surely this can only happen if medical students, i.e. our future doctors, are representative of the communities they serve?

Whilst I do not advocate changing university entrance requirements depending on which school a pupil went to (I believe this creates more problems and inequality between students), I do believe that medical schools need a broader mix of students. Trying to discourage any measures by quoting studies of doubtful applicability to today's situation is not helpful to those trying to encourage this.

1. Tayal U. A level results are reliable measure of success in medical careers, report says. studentbmj 2003;11:270 (August)
2. Haivas I. Medical students have too little social and cultural awareness. studentbmj 2003;11:269 (August)

I think, A level student, share two important factors:

1. Personality factors (which we can improve... they are patient ,hardworking ,challenging.
2. Natural intellectual ability.

At the same time, there are many non A- level student who are successful in their medical career, Because they are hard worker, patient, and challenging.

So we can see that, the success in medical career is determined by personality factors rather than the A level (which combines the personality factors and intellectual ability).

I think.that, the medical teaching system must concentrate on this factor to improve the career future of their graduates.

Up until a few years ago and for many years previously the psychology/psychotherapy department at UCH London ran a scheme supposedly 'to teach students listening skills.'Perhaps it still exists.It taught them a great deal else. It was also described as a student psychotherapy scheme and since as student Psychiatry Balint groups. People who participated in the scheme were treated in an extremely dishonest and deceitful manner. After a discussion behind the scenes without the knowledge of the persons who were being considered for training material, information disclosed as confidential between a GP and the person was passed on without consent.The person has no way of verifying what had been passed on between a liason psychiatrist who was promoting the development of psychotherapy and the persons' GPs who had an interest in psychotherapy.But no qualifiations.S/he was told that an 'arrangement would be made for them to talk to someone'.The 'someone turned out to be student' - disclosed only at the point of receiving a letter out of the blue from a student.

Again without consent files containing sensitive information were passed around groups of students so that'they could choose someone they wished to work with'. The students were then told to send out a letter describing that'I am a final fourth year student with a vacancy for therapy on .......' During the meeting this deceipt was confounded by the student who had been told 'try not to tell deliberate lies but to be evasive' if people sensed they were not therapists. One declared that 'what (you) tell me is between the two of us and will never go outside this room'. In fact they had no qualifications or experience in anything.They belonged to a group which discussed every detail of the meetings with each other and a supervisor. If anybody expressed dissatisfaction they were barred from seeing a supervisor - it being treated as a transference problem. One trainee was advising a married woman to separate from her husband. Another was persuading a woman not to have a baby. They were too young and naive to be in the role and there was no way people could express their unease except by leaving. Few did as it was made clear there was nothing else on offer.People were used simply as training and research fodder.Students who are practicing now were taught right from the outset that it was acceptable to deceive, to claim qualifications they did not hold, all actions in contravention of the GMC guidelines and other laws.Moral and ethical behaviour simply went out of the window. I raise this now as I have met a recently qualified GP from UCH who stated that he gives some of the people who consult him 'therapy' He simply took part in this highly unethical scheme which was allowed to continue with the active participation of GPs and members of the psychotherapy department. It is more than likely that enough people would agree to participate in these schemes if treated honestly and not simply have their vulnerability and lack of information exploited. A therapeutic realtionship cannot be based on lies and and arrogance. Several of those involved in this scheme have been involved in successful breach of confidence cases since. But the students were too much part of the culture to speak out about the way they were being trained to treat those who placed a certain level of trust in them.

I am greatly touched by the AMA’s efforts to "protect" US medical graduates from the unnecessary inconvenience and expenses of a clinical skills test being proposed by NBME in apparent good faith to screen out bad doctors. And I extend full sympathy to the medical graduates who are raising a voice against it. I wish the international medical graduate community popularly referred to as FMGs or IMGS in US had a similar forum to register its voice on the same subject.

Apparently the fact that "the test will not achieve its aims and it is unproved in its ability to assess communication skills or to reduce medical errors" does not apply to CSA, a similar test already conducted for all international medical graduates since 1998 at two centers in the US. The $1200 cost of the test, the international airfare to take the test and the fact that an IMG has already passed MLE step 1 and step 2 in English in addition to demonstrating his skills in the language through TOEFL (Test of English as a foreign language) seem trivial to the inconvenience faced by the USMGs. And it’ll be totally inappropriate to bring up the issue that American consulates in countries like India choose to regard CSA as a reason "not adequate" enough for a doctor to be given a visa to take it.

I wish the esteemed association had carried over the American tradition of acting as a "World Police" and had given a little reflection to the issue of CSA for IMGs on a similar platform.Hail America!Take us in your stride, too.

When I read the paper of Timothy Rittman, has done me to think on the role of this type of experiences in our career, sadly these experiences are not well views or are not supported for some professors, because they consider that remove time to their courses.

Nevertheless, what I have been able to see bias of my university career, is the lack of teaching and experience in the work of management and administration of projects, divisions, or the active participation inside the management of the University. This it can be proper al interest of the majority of students in being focused alone in the clinical part. One of the explanations that I have found to this phenomenon is the quantity of competence that exists among the students that causes to be focused them alone in the clinical themes. Something that have been able to observe, that the alone fact to know other realities (the exchange with students of other you split) and as is the management of a system of health (or in general as is the management of a human group) does the difference among the future professionals. The goal of every student should be that its training and its learning go in benefit of its future patients, something that generally one is forgot for the urgency to learn all the symptoms and signs of the illnesses.

In my experience as student of medicine, I have had the luck to participate inside the organization as President of the Scientific Society of Medical Students of Medicine of the Peruvian University Cayetano Heredia and member of the executive committee of the Peruvian Scientific Society of Medical Students (SOCIPEM) besides being a local director of IFMSA (in the SCORP); all these experience (they were carried out in different times) require dedication andit is certain, but the group management experiences and elaboration of projects, something that should do the students to learn and to participate in their community, since the end of every physician are their patients and their community.

hi there. I want to report a very BAD experience with voluntary agency Ecotrackers. If you can offer advice on a more official complaint method if such a thing exixsts that would be great, but i have a feeling word of mouth is just as effective. Anyhow would welome your advice.

I went with 3 others volunteers, Dr Max Moreno [Director] and 2 of his daughters to Estero De Platano - a lovely lovely place between Punta Galera and Quingue on the coast. Here is what happened to us.... I would be very interested to hear what you think.

We have hac the most indescribable week in a tiny town on the coast. I absolutely loved it there, there was only one thing wrong with the week and that was Ecotrackers or more specifically the guide.

The initial problems were all to do with the large amount of money we handed over to him, on the understanding that the $50 reg, fee was for the company and the remaining $10 per person per day was for the community who was to give us food and board... but not only did we get the bus at 3 instead of 7.30am when we were all ready and waiting for him, but at last min he decided to take camping equipment and for us to camp on the beach (obviously this would mean that our $10 per day would be going into his pocket, except for food). This was very annoying. and we had to pay every single extra cent out of our pockets.... e.g for transport. He had $480 in total from us for the week.

His inappropriate behaviour with me began on the bus when he proceeded to ask me personal questions, and made plain his feelings on infidelity (that it was fine - analogy to dining out in a different restaurant once in a while).

Further when we arrived at our destination, his '5man tent' was a 2man tent, my companions had to use their own and we consructed one for me out of sticks and a mosquito net. I have NO objection to sleeping rough if I am expecting it, and i am paying accordingly, but we thought this not acceptable given we had paid a lot of money for the community and seen them get nothing (and all they did for us was give give give - everywhere we went they gave us more fruit, the fishermen brought us fresh fish for our dinner).

So all of us were feeling that the money we had given in good faith was not going to where he had led us to believe it would go. He had acknoweldged the $50 was for him and his business but not the rest.

We gave meetings for the community / the purpose of our visit was to begin a tourism /cultural initiative in the town.

But we waited every day to get round to doing some work, and we didnt really do any - the 'work' was taking pics of the beautiful scenery for the next group to bring back to the town with them to begin construction of a tourism strategy.

But in one meeting it transpired that there was some physical work we could get on with. When we did so, we worked, he spent the entire mornign talking with [at] another pair of tourists. We couldn't believe he just sat there while we got stuck into cement mixing!

Here comes the nail in the coffin for our relationship with Ecotrakers. The one night we had stars I slept outside. He did too and kept on and on talking when I was trying to sleep (LOVES the sound of his own voice and being the 'doctor' bringing prosperity to the poor). When I woke up at 5am I was being felt up and prodded and stroked in various places, including between the legs.

It took me a few mins to work out what was going on then I was clearly horrified, told him not to touch me, he said 'don't you touch a cute dog when you want to know it better?' and I said that I am not a dog!!! so then he changed analogy to niña... I couldn-t believe how he continued justifying himself, talking all about how it was a shame we had to follow a morality in place of our feelings and desires in our society.

I told my compainions aboput it but we didn't really know what to do as it's the 'doctor' who would be coming back with the agency to continue the project we were settign up, not us. I was upset, none of us were happy being in his company, but felt saying something was very difficult because of the presence of his daughters. We didnt want him to rip them and more volunteers off either [or touch them up].

It blew up on the last day. But Max Moreno is such an egotist he decided to tell his eldest daughter everything...... so they then left amidst loads of drama (he was still trying to justify himself) but it was satisfying to see him disgraced. We discretely told a few people, especially those who appeared to be of some social standing in the village, warned them to be careful if / when he returns with more volunteers. Despite losing a day and our week's project being cancelled, we received no money back, and further he asked us to pay some remaining debts. There was just no excuse for his behaviour.

We moved off the beach to stay with one of the families, and paid them the next morning. We had a wonderful evening. Apart from the guide it was a wonderful wonderful place / The people were incredible. Moreno's daughter had pleaded with me not to tell and ruin his rep there, but I had already done so. I am not going to ignore what happened. My companions are willing to corroberate my report.

In Sum, I can strongly recommenrd you do not give this organisation your money, and warn all Gringa girls that Max Moreno at ECOTRACKERS thinks the Gringas [above all from UK and Germany [i am English]] are 'stupid' and cannot be trusted to stay in a hostal in these villages because they can't resist the local boys, who will make tham pregnant and get Ecotrackers into trouble [seriously this was his argument].

He said in front of me that people came with Ecotrackers to have a wonderful cultural experience, but NOT a sexual one! After he had "lain awake all night thinking about whether or not to touch me", and after much sober deliberation decided that yes, he would do so.

This man has 2 apartments and a business in Quito, took enough money from us to buy the materials for a refuge or just to restart the water supply, and to buy them a huge quantity of the biodegradable soap he preached about so as to lessen the contamination of the river from clothes washing. But all he did was talk and pocketed all our money. AND the fact that his 2 daughters were with us on this excursion did not prevent his disgusting machista commentaries on women, or his touching me inappropriately, without a hint of an apology.

Very interested to hear what you think, as Ecotrackers apperad nothing but a one-man con agency to us.

The article above studied medical schools admissions before the millenium, in 1999, for possible bias in their selection of students involving race and sex.

Since 2001 the age restrictions on mature student entry have changed too, allowwing students of all ages to apply for succesful entry to medicine.However I beleive there will be a number of teething problems with this age lift which will need to be addressed to avoid similar issues in the future.

For instance, traditionally medical applicants have been asked to provide a solid array of GCSE andA level results to enter medical school. A problem with doing this involves grade inflation, which is not significant over a few years, which traditional applicants in the past offered. An issue arises when a student from 10 or more years ago is asked to provide such GCSE grades - with some universities asking for 5 or 6 GCSE equivalent grades. This prospect would be impossible for someone of thirty five years of age or more to offer, from an era when virtually no one in the classroom offered such grades. An answer might be for that mature student to return to the classroom and resit GCSEs to the required grade, followed by A levels too - but is asking a thirty five year old to take 3 or 4 years out to sit all these exams really the answer here? They will be a lot older by then and their career progress possibly severely hampered more than the regular applicant.

It would be more logical for universities standardising GCSE and A level requirements to the year that the mature applicant gained those grades, augmented by evidence of recent study. These changes will probably come over the next few years, but if universities are avoid a claim of ageism against them, then perhaps they need to consider this issue today.