We'd like to react to the article "Feeling faint?" in which medical student Jessica Whitworth describes her personal experiences with recurrent vasovagal faints while in operating theatre.(1)

The author is absolutely right is stating that breaking the vicious cycle of anxiety leading to syncope, augmenting again anxiety, is the key to the solution of this problem. Therefore in addition to the psychological counseling as described by Whitworth we'd like to draw your attention to simple physical manouvres that recently have been introduced in the management of vasovagal fainting. Lower body tensing (2); leg crossing combined with muscle tensing (3); and total body tensing (4), started at the first symptoms of a vasovagal reaction (light headedness, sweating, paleness, nausea) have all shown remarkably effective in preventing fainting. Rationale of these manouvres is that the initial blood pressure decrease during a vasovagal reaction can be counter acted by increasing venous return to the heart and thereby increasing cardiac output.(3) Similar muscle tensing techniques were added to psychological deconditioning programs in the 1980 by Őst and co-workers, for the treatment of severe blood-needle-phobia.(5)

Such manoeuvres are simple to apply. Especially leg crossing combined with muscle tensing can be used in operating theatre with hardly anyone noticing it. They can be very helpful to regain self confidence in stressful situations. As all trainee-interns know, even without fainting operating theatre can be charging one's confidence.

1. Whitworth J (2002). Feeling Faint. Stud BMJ 10: 250.
2. Krediet CT, van Dijk N, Linzer M, van Lieshout JJ, Wieling W (2002). Management of Vasovagal Syncope. Controlling or Aborting Faints by Leg Crossing and Muscle Tensing Circulation 106: 1684-9.
3. Sabin N (2001), The use of applied tension and cognitive therapy to manage syncope (common faint) in an older adult. Aging Ment Health 5: 92-4
4. Brignole M, Croci F, Menozzi C, Solano A, Donateo P, Oddone D, Puggioni E, Lolli G. (2002) Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope.J Am Coll Cardiol 40: 2053-9.
5. Ost LG, Fellenius J, Sterner U (1991). Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia. Behav Res Ther 29: 561-574.

I am writing this letter from a hospital room, my training hospital's room, sitting next to my grandma and waiting for her to get better after a traumatic debulking surgery of ovarian tumor w/periton metastasis.

I was just a medical student here before, never had to know about the bureaucracies of our health care system this closely. I belonged to the group that bought toast or coffee from the canteen, while there were others who bought toilet papers, paper towels and so forth. Now I feel like changing sides. I now know that walking along those corridors passing through patients will never be the same.

The surgery was not curative so it was just saving the day and I know that I will loose her, a part of my inner circle.

And now all I can do is sit and watch; hold her hand, comfort her as much as I can and just try to be there for her.

Reading the article "Trainee Doctor or Daughter?" by Wendy Brown meant so much to me, on the first post-op night where everything is blurred. I felt like I was not alone being stuck inbetween.

I believe sometimes you just have to be "the daughter" and should stop feeling responsible for every little detail that goes wrong.

Because sometimes you just want to cry like a daughter although impossible, as you are to be the strongest one in the family, as you "are" a health professional.

It is long overdue for a change in the German curriculum. Several German doctors work in the British system and it is easy to see that they are brought up with a very technical curriculum that relies heavily on investigations rather than clinical skill.

Even the doctors themselves complain about their curriculum. Hopefully these changes should go some way to rectifying the situation.

It was quite amusing to read your article. Patients in South Africa would be breaking the record every hour. Patients at Baragwanath Hospital in Soweto have been known to lie in hospital trolley's in casualty for up to 8 days waitng to be seen!!!!!!

I would suggest that all medical students and doctors who feel that the dignity of our patients (viz a viz informed consent for vaginal/rectal examinations) can be ruthlessly brushed aside with the rather arrogant assertion that " we need to learn" be prepared to put up or shut up; what is good for the goose is good for the gander, and unless they themselves welcome the idea of being used as a teaching tool, without their consent or permission, as though they were objects and not sentient beings, whilst in a position of vunerability i.e. under anaesthesia or in a clinic, I would suggest that they alter their thoughts on the subject.

I believe the importance of acquiring experience at internal examinations is exaggerated; unlike listening to heart sounds or auscultating the lungs the variety of presentations of the various physiological/p[athological states that a medical student and PRHO needs to be familiar with as regards the vagina/rectum are limited, and thus it stands to reason that one or two internal examinations under expert supervision should be enough to instruct, with experience coming as a natural product of time spent on the wards.

Patients come to doctors in order to be diagnosed and treated. They do not attend Clinic/Casualty/Theatre to be prodded and poked by the largest number of students as possible, all of whom are using the excuse that " they must learn". If medical students are permitted to examine them/take a history, it is a privilege and NOT a right, and students everywhere, including those at teaching hospitals must understand this, but more importantly accept this.

The more patients one examines the more one learns from, and thus the better doctor one becomes, seeing as disease always manifests itself differently. However the excuse that this will help future patients and that thus one is somehow justified in examining a patient against their will using the wisdom of " greatest good for the greatest number" is not acceptable. None of us would like our own relatives to be treated in such a manner, so why should we insist that other people's relatives be treated thus? Another example of medical arrogance perhaps?

It is high time the big food makers are confronted with the facts concerning the health benefits their consumers derive from their products. They should be made to know that their marketing strategy- that of targeting their advertisement at children and young adults leaves much to be desired.

I believe it would not be too much if governments begin to control junk food advertising, more or less the way they are doing with tobacco advertising (but maybe not as strictly). It is wrong for everyone to fold their arms and adopt a "sit and look" posture. Epidemiologists have continued to maintain that we are witnessing a rise in the number of diabetics and patients with heart disease and a lot of people strongly feel that junk food consumption certainly does not help alleviate these conditions!

Whilst I totally agree with John Henderson's sentiments that Students should be more easily distinguished from doctors, I cannot agree with his suggestion for tackling the problem.

The idea that the wearing of white coats should be more rigorously enforced is problematic for two reasons. Firstly, white coats are not exclusively worn by medical students and until recently were more associated with doctors. In fact about half of patients actually prefer their doctor to wear a white coat(1). As such for many, especially the older patient, the white coat remains the emblem of the doctor(1). So the wearing of white coats may actually add to the confusion rather than help it; who amongst us has not been confused with a doctor BECAUSE we were wearing a white coat?

The second issue is one of patient safety. The white coat has been shown to be a potential source for spread of infection(2) especially those worn by students(3). The implication of this is illustrated by the fact that most ICUs insist that white coats are not worn.

Given these two factors I feel that it is arguable that students should be encouraged NOT to wear white coats!

But where does this leave us with the problem of patients mistaking students for doctors? Ultimately it is the responsibility of the individual student to make SURE that the patient knows you are a student and not a doctor - white coat or no white coat!

1. Menahem S, Shvartzman P. Is our appearance important to patients? Fam Pract 1998; 15: 391-397
2. Wong D, Nye K, Hollis P. Microbial flora on doctors' white coats. BMJ 1991; 303: 1602-1604.
3. Loh W. Ng VV. Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect. 2000; 45(1):65-8.