Kinesh Patel makes a vigorous and swingeing attack on the position taken by student leaders against tuition fees in England and Wales.(1) Is this the same Kinesh Patel who was just such a student leader until barely a year ago? As a fellow national representative on the BMA Medical Students Committee in 2001-2002 either Kinesh or I am obviously suffering from a severe case of retrograde amnesia, since my recollection is that the committee campaigned hard against moves to increase tuition fees partly to help the fight to widen access to medicine. Yet he now berates those, 'who campaign on these issues', mocking, 'the voices of student organisations [...that] learning should be free for all'.

Notwithstanding the above, Kinesh arguments lack the force of basic logic. Twenty years ago it may well have been the case that having a degree was a passport to a life of riches. But with 33% of UK young people now entering higher education, and with government plans to increase this to 50%, simply being a graduate no longer offers access to, 'a lifetime opportunity to earn high wages in a satisfying and interesting job', as he claims.

Furthermore, his suggestion that the way to overcome the deeply ingrained aversion of working class kids to thousands of pounds worth of debt is simply to sit them down and explain, 'the ease with which a £30 000 or even £40 000 debt can be managed' lacks credibility.

But the fundamental error Kinesh makes is to view the benefit of education from a purely individualistic, self-centred perspective. Living in an educated society confers benefits to us all in many complex ways, not merely through personal advancement and private wealth generation. Aren't these societal goods worth us paying for collectively?

Kinesh seems to be moving against the tide of public opinion. In the UK, Scotland has got rid of up-front fees, the Liberal Democrats [political party] are against them, and the Conservative Party now advocates scrapping tuition fees for undergraduate courses. Even the Labour government is starting to recognise the unwelcome effect of high levels of debt in deterring those from lower socio-economic groups from applying to university. Perhaps in time Kinesh will cast his sails around once again and argue for a different course.

References

1. Patel K. Tuition fees in England and Wales: a big whinge? studentBMJ 2003; 11: 391 (October)

Kinesh Patel is quite right, the debate about tuition fees is often a big winge. Money is desperately needed by the universities of this country and it doesn't grow on trees. Free education is an utterly ridiculous and unworkable concept. Money is needed, that's the bottom line, the debate should be the fairest way to get it.

Noone wants debt, but it's a sad fact of life. Education is an investment in a similar manner to a house(financially speaking). Knowing that the system should be set up so those with money help to pay for those with less.

Finally it's also worth remembering that something like 50% of students don't pay fees, i.e those from the 'lower socioeconomic groups' (i apologise if i sound patronising). So it's not really such an unfair system is it?

In response to Bruno Rushforth's rapid response to my Personal View, I am happy to report that I am not suffering from any form of amnesia.

I distinctly recollect being a member of the BMA Medical Students Committee in 2001-2002, and I also recollect the committee campaigning hard against moves to increase tuition fees. As an elected member of the committee, it was my brief to represent what I believed to be the majority view of students at Imperial. It is a shame that Bruno cannot appreciate the fundamental difference between personally (hence Personal View) and professionally held opinions. In all forms of public life this distinction is quite clear - just look at any political party.

It is also unfortunate that Bruno has deigned to dismiss my arguments as lacking "basic logic". He argues that a life of riches followed for graduates twenty years ago. It is interesting to note that the same difference in earning power still exists today. A 2002 report from the Higher Education Careers Services Unit charity showed that "young graduates aged 21-30 have average earnings of £22,302 pa compared to £15,948 for non graduates in the same age bracket, a difference of £6,354 per annum ". This difference grew consistently larger as graduates grew older. And in the case of a career in medicine, I would still hold that a degree offers guaranteed employment, high wages and an interesting job.

Of course education is not purely individualistic and self-centred, and there is a net benefit of having an educated society. Dustmen should help pay for doctors (they might need us one day!). But it is also necessary to recognise the substantial personal benefit of a medical degree, as outlined in my original article.

Even with increased fees of £3000 per annum, this still represents a subsidy of around 85% from the taxpayer. Just think if that frilly top were discounted by a similar amount, even Bruno might be tempted...

Yes, tuition fees are terrible.

I'm a BMA Medical Students' Committee Rep.

I also (used to) pay fees. These fees really do make no difference the cost of training me, for a year is around the figure of £20,000. That doesn't include Additional Cost of Teaching (ACT) money, called SIFT in England, which is paid to the NHS for teaching and totals roughly £80 million/year. And into this I would be paying my rather measly £1000, which the NHS meets for me. So what effect does this have?

I also look at evidence. Another hot topic is widening access. The Joseph Rowntree Foundation published research in Nov 2000 showing that perceived level of debt deters students from applying to university - particularly ones from disadvantaged backgrounds. Ironically, the Higher Education White Paper makes the universities ability to generate income dependent on their ability to avoid the direct consequences of that action.

I'm also lucky to be in Scotland, which offers students from Scotland, studying in Scotland a 'good deal' - based on the very well received Cubie report. Some of the Cubie recommendations have been incorporated into the Higher Education White Paper.

But things are set to get worse. The advent of top-up fees in England may push English applicants into Scotland, forcing them either out of medical school, or to apply for places in England. Even this is a simplification because we do not yet know what effect these will have on the quality of medical education. Whilst we have all heard about the crisis in medical academic recruitment, I have doubts about the efficacy of these measures - after all, tuition fees were meant to revitalise higher education and I have yet to be convinced that they have!

References

• Patel K. Tuition fees in England and Wales: a big whinge? studentBMJ 2003; 11: 391 (October)
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i would like to assure ms slater that the criticism in my column was never intended to be aimed at those who persue reasonable compensation for actual acts of negligence. my column was intended to discuss the cost and real harm generated by spurious and speculative lawsuits both within medicine and in society at large. i accept that this distinction may not have been entirely clear from the wording that appeared in the published version of my column and i would like to apologise for any misunderstanding this may have caused. Ms Slaters point about the distinction between blame and responsibility was one which was central to my thinking when i wrote the column. i am also sorry that Ms Slater felt the need to include the last paragraph in her letter thus adding an unneccessary personal dimension to her otherwise quite valid criticism.

yours

ben lawton

In his article Domhnall MacAuley interestingly chooses to present (1) a paper which is systematic review and contains a meta-analysis (2). However, the author does not distinguish correctly between the well-defined terms "meta-analysis" and "systematic review".

A systematic review is defined as "a review of clearly formulated question that attempts to minimise bias using systematic and explicit methods to identify, select, critically appraise and summaries relevant research" (3). It is absolutely essential to formulate a focus question, draft a search strategy and conduct the systematic review accordingly, and then apply inclusion/exclusion criteria (3). Change the search strategy after having begun the search will be a systematic bias. Antman and colleagues could show that a systematic is superior to an narrative review (4). It may be possible that a systematic review protocol returns 0 studies matching the criteria. This is, however, a valid result and should nevertheless be communicated if only the topic is relevant.

A meta-analysis, on the other hand, is a "quantitative synthesis of the results of primary studies" (5) or "quantitative (statistical) pooling of estimates from indivial studies" (6) which is comparable due to similar methodology of data collection. A meta-analysis can but does not necessarily have to be the summary of a systematic review. It may also be possible to do a meta-analysis of data deriving from a non-systematical review. The minimum of included studies is 2. The preferred graph to present the data is the forest plot.

Many groups, such as the Cochrane Collaboration (7) - which chose the forest plot as their logo (8) - chose to only include Randomized Controlled Trials (RCTs) in their systematic reviews/meta-analyses. The purpose of the meta-analyses of RCTs is often the prove of effectiveness of drugs. However, it is a myth that meta-analysis can only include RCTs (6).

The QUOROM statement (9) does, whatsoever, only give recommendations for authors and journals publishing meta-analyses of RCTs based on systematic reviews.

For further details on common misconceptions of systematic reviews and meta-analyses, we suggest reading Petticrew 2001 and Montori 2003.

References

1. MacAuley D: Paper plus: Systematic review of evidence supporting preparticipation physical examination for athletics. studentBMJ 2003;11:378-9 (October).
2. Carek PJ, Mainous III A: Preparticipation physical examination for athletics: a systematic review of current recommendations. BMJ USA 2002;2:661.
3. Needleman IG: A guide to systematic reviews. J Clin Periodontol 2002;29(Suppl.3):6-9.
4. Antman E et al.: A comparison of results of meta-analyses of rendomized control trials and recommandations of clinical experts: Treatments for myocardial infarction. JAMA 1992;268:240-8.
5. Glass G: Primary, secondary, and metaanalysis of research. Educ Res 1976;10:3-8.
6. Montori et al.: "Methodological Issues in Systematic Reviews and Meta-Analyses". Clin Orthop 2003;413:43-54.
7. http://www.cochrane.org/cochrane/cc-broch.htm#CC
8. http://www.cochrane.org/cochrane/cc-broch.htm#LOGO
9. Moher D et al.: Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet 1999;354(9193):1896-900.
10. Petticrew M: Systematic reviews from astronomy to zoology: myths and misconceptions. BMJ 2001;322:98-101.

I'd like to know what year the article on Tibet was written. It states that life expectancy in Tibet is about 45 years yet most published statistics claim a life expectancy of about 67 years. Is the article claiming that the other sources are wrong, or is it very old and out of date?

While we agree with Susmita about the sorry state of affairs of regulation about female feticide in India; her suggestion of stringent implementation of the laws, as a solution to the problem seems to have limited utility. This is because, this is a behavioral problem of Indian public and law is known to be a poor solution to human behavioral problems. This is something inherent in Indian psyche that having a girl child is bad. For this, the basic change required is the attitudinal change.

India, as we know is crippled by several social problems; the origin of many of which dates probably back to thousands of years. Child marriages, dowery seeking, and sex discrimination leading to female feticide are just a few to name. The worse is this is acceptable socially. We do not seem to be voicing our concern about that at all. But then why is rate of female feticide is so high in this country? One reason is heavy dowry, which girl's parents need to pay to the groom. Recently a girl named Nisha Sharma, 3rd year Engineering student sent her groom back; because she refused to pay exuberant dowry. This was given disproportionate hype and the girl became The National Heroin, the very next day. But then, how many students did it before her?

The fact that her efforts were acknowledged and courage appreciated suggests that we do want a change, but in a more dramatic fashion. That does not happen overnight, unfortunately. Has Indian government or non-governmental organizations ever done enough to campaign heavily against dowery? They have just formulated redundant laws and even when a girl is burnt to death for dowery, the perpetrators roam scot-free. There seems to no fear of law.

The solution lies in educating public, especially the newer generation in schools against dowery, extensive media campaign, action against the faulty doctors and punishing those who get the sex determination of their babies done as well.

It is not very encouraging to remark that the same sorry state of affairs as depicted by Susmita in India exists, with same force, in the neighbouring country of Pakistan. Being a medical student of fourth year, in a tertiary care hospital of repute, i have seen number of cases where parents are actually anxious to find out the sex of their coming child. No doubt that quacks come to the rescue of such anxious parties and female feticide occurs in these cases, though not very frequently.

Same behavioural and social conditions, which lead to such demands by the parents, apply to the families in Pakistan as pointed out in Susmita's article and the response by Namrta and Vikas. Parents don't want female offsprings because they are seen as an added burden on already poor family with meagre per capita income. A female child has to be wed with a huge amount of dowry. Also because of cultural restrictions female offsprings don't form an earning member of the family. Therefore parents tend to favour the male child.

I think the problem can't be fully resolved by implementing laws but needs to be addresed on a more basic level. That level is educating masses, so that we can change their attitude toward sexual descrimination. This is a giant endeavour which involves govt. support and media involvment but if put into practice can nip the evil of female discrimination in the bud.

Education, extensive media campaigns, arrest of Doctors who practice such atrocites is not the ultimate solution to such a problem. I agree that feticide is a result of some corrupt traditions that still decide how society should function.

the key, i know is God. i beleive he is the only one who can change the minds of traditional belivers and activists.

Educating the next generation is a fine idea on its won, however, education without results has not lead to anything. Aren't affluent families educated? yet don't they also commit murder?.

Extensice media campaigns to some extent will be effective but we must remember that a country such as indai who is very traditional, the media will not be able to penetrate past traditionl belifs.

Arresting doctors would not serve any purpose. No matter what, there would always be doctors underground carrying on feticides.

With God, it is possoible to destroy evil traditional convections that destroy people and families

i think it is a benefit for these innocent people to realise the side effects of having sexual contacts/relationships with others.

With the refugees migrating to Ghana for a better life is sponsered by the UN and by doing small business to help raise up money. With the help of Mareeni, all thanks goes to him because of the passion he has in him to prevent HIV/AIDS from spreading.

Congratulation for coming up with this article I believe this will go a long way to wake others up to join in their own small way to help in the combat of this deadly disease aids.the efforts of the UN in fighting the spread of HIV/AIDS in Africa is laudable.

Denial and stigma are just what HIV/AIDS needs to thrive in our communties.this article captures just the tip of the iceberg, but is a great article to get anyone thinking and wanting to help in the fight against HIV/AIDS.HIV must be giving a face,PLWHA's must come out and let people that AIDS is real and could happen to anyone.it is not just a moral issue. the late philiy lutaaya sings and say "today is me to morrow someone else it's me and you we've got stand and fight, we shed a light in the fight against AIDS,lets come on out let's stand together fight AIDS"

The answer to hiv/aids is in the bible. God knowing that the world would suffer from Aids and Hiv told us to ABSTAIN from sex, but we as people didn't pay attention to it.

Condoms do not protect one from aids. According to research it is only 99.8% safe. it seems people do not take into consideration the 0.02% risk of catching an infectious diease.

We seem to surround ourselves with education about safe sex. It is preached in schools, to children of 10 years and above. What business do they have in sex?. It seems that we feel the only soultion to sex is education. Rather it has caused us so much grief, with teenage pregancies on the high, hiv/aids increasind daily etc.

We should instead be praying and asking for guidance of how to reverse this problem.

It is sad, that we leave God out of it and instead rely on our own knowledge. This unfortunately is what is destroying Children and families.

I was horrified to read the article about the use of the drug Ritalin by US students and even worse the approvel of its use by Professor Farah. Surely this is not acceptable! I do not understand Professor Farahs logic of allowing the students to take the stimulant during the whole of the study year but not when taking examinations, why not during examinations when the students have not performed with their natural effort and ability throughout the whole year.

Students should be discouraged from taking the easy way out by just popping a pill and should be incouraged by peers or tutors to address any problems they have properly. A few less late nights out and less hangovers may just improve their ability to concentrate and remain focused.

What are the long term implications of this? Has she considered that? Are these students expected to keep taking Ritalin during their working life to remain focused and work to the best of their ability.

Why is coffee not prescribed? obviously because its effects are a not as dangerous as those considered by Ritalin.

Not only is Professor Farah not taking in to the account the welfare of the students but by not cracking down on the use of the drug she is encouraging the growth of the black market of the drug too.

I am very disappointed that a figure of authority that has the ability to take action and do something instead chooses to give her approval because she was guilty of having a coffee!

After numerous American articles about overprescription and abuse of Ritalin by kids across the country, this novel article caught my attention. Is this not some sort of flashback? In the thirties amphetamines were discovered. They were stimulants of the nervous system, about 10-20 times more active than cocaine, much cheaper and capable of improving physical endurance and considerably improving cognitive functions. Formidable amounts were given to soldiers during WW2. However the postwar period shifted the use to civilians. They were freely available without prescription throughout the world and in 1950s the US was producing 1000 tons yearly! Housewives and students were the number one consumers, the former to overcome boredom the latter to be able to revise better, overcome exam related stress and undoubtedly to enhance their performance during those exams. It was pure and simply legal drug abuse but due to the nature of the drugs the side effects very soon caught up and amphetamines were outlawed. Now we have Ritalin known pharmacologically as methylphenidate. Research has created a less powerful stimulant from the "high" point of view, with less side effects than amphetamines but still preserving a lot of the neuroenhancing effects. Does that make it more acceptable?

Prof. Martha Farah has made a very fair point in that coffee is a intellectual lubricant which has got most of the world hooked, being widely used not only as an "eye opener" but also as a stimulant throughout the day. Why is this acceptable? Is it because coffee is less potent than Ritalin that it is an accepted stimulant or because it is deeply rooted in our culture and nobody thinks of it as a "bad drug"? Everyone sees the 10 o'clock coffee break as the extra push which will get us to lunchtime and allow us to continue work without feeling too drained. It is certainly very possible to go throughout the morning/day without a coffee, so why don't most people do it? Is it not because we all want to enhance ourselves and get through the day with the least hassle possible (in this case tiredness and lack of productivity) ? The fact that Prof. Farah doesn't see a difference between having a few cups of coffee at 2 am and popping a Ritalin is justified, because both substances are attention enhancers, so from this point of view there is no difference. There is a difference in potency, but the much sought after effect is the same, that is to keep us going this way we can finish that chapter and also remember it the next day! But in this case why shouldn't we take Ritalin before exams? I mean most of us have a coffee before sitting an examination so why not Ritalin? If we have been revising on Ritalin, then we should also take examinations on Ritalin, it's only fair. If Ritalin use is made "acceptable" it cannot be made acceptable only for certain uses, that would flirt too much with hypocrisy. I enhance myself when I revise, thus I can also enhance myself when I sit and exam, and if enhancement is acceptable, everybody is doing it thus there is no question of some people having and advantage over others (the non drug takers).

The problem here is not about enhancement; this is obsolete because anthropologically so deeply rooted in our nature that denying it would be denying our ourselves. The problem is about what level of enhancement we perceive as acceptable and that perception varies tremendously from person to person.

I do not support the idea that Ritalin as a widespread attention enhancer among students is acceptable, but I can see very clearly why Prof. Farah has made the statement. I guess my main reasons against Ritalin would be the side effects and dependency issues, which are more serious than those of caffeine. I don't think the drug is as safe as some say and it is probably too early to draw conclusions about it's effectiveness in long term use. Only long term follow up of users will give more accurate results. Let's not make the mistakes of the 50s with the amphetamines, barbiturates, pethidine and the famous meprobamate introduced in 1955 labelled as a "happy pill, granting moral tranquillity addiction". Years later experiments showed spectacular withdrawal symptoms although it wasn't withdrawn until 10 years later.

However I can easily imagine, that had caffeine been a much stronger stimulant while retaining its very minor side effects we wouldn't cringe at using it. Sure Ritalin needs a prescription, but that has not much to do with toxicity, one can easily buy enough alcohol to cause oneself pleasure, intoxication, serious damage, serious dependence or even death; while some other drugs much milder are very much illegal. Let's not a talk about tobacco, again another concentration enhancer as well, strongly addictive and toxic (mostly due to the administration methods) but freely available in any corner shop.

For me Ritalin is controversial due to the the relative ignorance associated with this chemical. It certainly has it's use in cases of ADHD, but due to misdiagnosis and moral laxity, it's use became more widespread, bad effects crept up and Ritalin made it in the news headlines. I'd rather leave it for those who really need it and go brew myself a nice cup of Java.

I just wanted to congragulate u all for this good news.

I hope that medical student would get more help through this union.

I wish that universities would be looked at with individuality that would give more chances to student than categorized in countries

I come fro sudan, and seek more concerning as a bless of this great union.

with respect

I recently had a chance to meet Emily personally and it was a great pleasure to spend even a short time with her.

She is not only a smart person but also very enjoyable with her funny comments.:>

Having spent several weeks myself in a lesser known Teaching Hospital in Philadelphia, USA, I read Mark Silvert’s elective report on his time at Harvard with interest. I can only reiterate his experience of unsociably long working hours, the requirement for punctuality, and the first-rate teaching available at American hospitals.

Taking on the same responsibilities as the American students, I started work at 7am in Medicine and 5am in Surgery. It felt almost inhumane to awaken patients at this unearthly hour just to check their vital signs and general well-being. How well can one be when awoken at an hour they are not accustomed to? My Attending or Consultant informed me that long hours were simply an accepted part of the work-driven society that is the East coast. The Hospitals on the West coast of America are a touch more socialised I am told. It wasn’t any wonder though that many of the medical students and doctors looked like zombies. I admired their ability to stay awake through often several hours of teaching per day.

It is one of the responsibilities of the specially appointed Chief Resident or Senior Registrar to monitor the attendance and punctuality of junior staff and students. My Intern or Houseman was taken aside one morning after arriving at 0705 and warned that his timekeeping would be closely monitored. The implication seemed to be that any further such episodes would result in referral to somebody more senior! Similar rules apply to medical students. They must be experiencing a significant crisis or be seriously ill for them to even contemplate taking any unscheduled time off duty.

There is no doubt that anyone choosing to undertake an elective in America will come out of the experience a wiser person. But one must be prepared to put in the hours to reap the benefits. Anybody more interested in a relaxing holiday should probably apply elsewhere.

I have just returned from my elective, whish was an extremely valuable experience. For the first part of my elective, I, like Mark Silvert (Overwhelmed, overworked, overtired, and over there, Student BMJ,October 2003) worked in the USA. For 5 weeks I worked in Memorial Sloan-Kettering Cancer Centre (MSKCC) on the East-side of Manhattan,New York, combining a research project with clinical work. Like M. Silvert, I had been warned about my time in the USA, "I hope you know what you're letting yourself in for? All work no play!", one of my univeristy tutors had replied, when I told him about my planned elective. I headed across the ocean with excitement but a little apprehension!

My 5 weeks were fantastic! As a non-intercalating medical student, my time in the US provided my with a perfect opportunity to gain some 'real' research experience in one of the foremost cancer institutions in the world. I was also able to combine clinical work along with my research project, thus, in my view, encompassing the best of both worlds.

I'll be honest with you - yes it was extremely busy, with lots of early mornings (5:30am!!) and long-working hours, but the exceptional teaching available, the opportunity to experience a different healthcare system in practice first-hand, and observing the 'desire to learn' of interns&fellows who were working 85hour weeks was inspiring!

I would without doubt recommend an elective in the USA. Sure it's hard work but the experience is invaluable, and you can always work somewhere less 'hectic' for the latter part of your elective if you so wish.

And the early mornings weren't too harsh. They actually seemed quite gentle in a haze of coffee&bagel-induced euphoria. After all, New York is the city that never sleeps!

There has been a significant deterioration in doctor patient relationship in India; especially in last decade or so (1). This is because of a number of factors: doctors have become business oriented, there is huge patient load in state run hospitals, patients have become more assertive and aware; specially in Indian metros and doctors in general are perceived to be less compassionate and understanding (1).

Findings of World Medical Association (WMA) Research (2) clearly state that doctors are not entirely correct in considering what they believe to be true. This is exemplified by view that up to only 2\3 patients agree with their sentiments.

Doctors in India are now confronted, combated, threatened and in many instances beaten and killed by aggrieved patients (1). Some experts believe that this is the result of falling standards of care among doctors and inability of professional medical bodies and association to intervene sufficiently in cases of malpractice (1,3).

While finding of WMA provide some respite by the positive outlook shown by the patients; the fact is medical profession in general is under siege now a days; especially in India (1).

What do we need to do as doctors and students then? We need to consider that patients of 21st century are more aware, want information and explanation and demand more active role in decision making of their treatments. We have to be more compassionate, humane, understanding and pay more attention to our patients than we actually do presently. Communication skills and ways of dealing with patients should be taught to medical students.

,b>References

1. Pandya SK. Doctor-patient relationship: the importance of the patient's perceptions. J Postgrad Med. 2001 Jan-Mar;47(1):3-7.
2. Andrews. Doctor-patient relationship second only to family. http://www.studentbmj.com/current_issue/news/356.html
3. Doctor bashing and why the Indian medical profession must evolve.
4. Gandhi JS. J Postgrad Med. 2002 Apr-Jun;48(2):155

With such a shift to specialties in which less working/duty hours are required, over the next few year may result in less no. of available surgeons, obstetricions...etc. a possible yet costly, solution may be to increase the number of staff in these specialties so decrease the number of working hours required by each staff member. or better yet, meet the situation half way and assign those fully dedicated to their proffessions with certain hours and those wanting less working hours less hours, and adjusting salaries as such..