After having read this article in the August 2003 issue of the Student BMJ, I was rather disappointed at the attitudes of medical students towards the importance of cultural awareness.

I was surprised that "tomorrows doctors" had very little regard for respecting the impact that their patients' cultures, values or beliefs would have on their healthcare decisions and lifestyles.

I am fortunate to say that at my university ( GKT Medical School,Kings College London)we are taught an Ethics and Law module mainly in the pre-clinical years of study though the emphasis of it is also taught within the clincal years. There is a slight heir of snobbery from some students about this area of study within Medicine, most of this group of students feeling that it is time wasting, snapping out phrases like, "This isn't real medicine." However, it has to be said that in being culturally aware we are infact learning the practise of "real medicine".

Although not a clinical student yet, I feel that I have benefitted from learning about cultural diversity just from observing medical consultations withtin a surgery and also from work experience within a surgical ward. It has made me more aware of my own healthcare decisions with respect to both my own and others' culture and values.

I strongly agree with Dr. Beagan's point of view and hope that notice will be taken by medical students of her formula for producing better, socially equipped doctors.

Yours sincerely,

Christine Sathananthan

After having read this article in the August 2003 issue The education article by Suneeta Kochhar and William Marshall on biochemistry in this month's studentBMJ is first rate. Covering all the essentials for undergraduates, it presents the information in a clear, concise and accessible manner.

Just a minor point - I'm sure other readers will have noticed the error in the paper edition, where the values for sodium and potassium have been swapped.

I was surprised, to say the least, by the article entitled "UK medical students arrested in Israel" published in BMJ Student of July 2003. This article, which offered a tribune to two medical students from Leeds, certainly lacks some depth of analysis.

Those two young british citizens, after an elective in South Africa, decided to tour the middle-east. They went to Lebanon, Syria and Jordan, and tried to enter Israel from there. May I recall that Lebanon and Syria do not recognise officially the existence of Israel, and that, as such, it is impossible to cross the Israeli border with a Lebanese or Syrian visa stamp? It is no more possible to go to Lebanon or Syria with a visa for Israel.

After a bombing involving two British citizens during the night of the 29th of April 2003, in Tel Aviv, it is hardly surprising that those two young men have been interrogated. Anybody who has been to the US since 9/11 will not be very surprised by the behaviour of the Israeli border police. Moreover, they were trying to cross illegally (I presume from the diplomatic facts recalled above) the border of a sovereign state. The dirty dark cells they experienced are probably no darker or dirtier than the British immigration ones.

That said, and leaving aside the much used argument that Israel has the only democratically elected government of the area, it is useful to stress the fact that its institutions are certainly the most closely scrutinised by NGOs. As a consequence, fears of torture expressed by one of the students' sister would certainly have been more justified had they been held in any other of the countries they visited.

The account of their experience is certainly very interesting, but should have deserved a more in-depth investigation.

Yours faithfully,

I read Scott's letter (1) with some bemusement and wondered why he feels the need to defend drug abuse within the medical profession so passionately, especially as it is not tolerated in any other profession where public safety is of concern (2). True human error alone has led to many medical mistakes in the past, surely the risk does not need potentiating by illicit drug use.

An article published in the public arena (2) showed that medical students were in favour of random drug testing 'as a method of securing patients' goodwill as the medical profession struggles to stay self-regulated.' Health authorities were keen that random testing was introduced, despite protests from the BMA and the Royal College of Nursing on grounds of 'invading privacy'. Where public safety is paramount, should such 'privacy' really take priority?

To counter his first argument, evidence does show that drug and alcohol use is widespread amongst medical students and the profession. If Scott refers to his pharmacology teaching, he would know the effects of many of the common recreational drugs on a person's physical and psychological health. Surely these facts alone should be cause for concern, and emphasise the fact that a medical student should know better.

In the same issue as his response, Tayal states that thirty per cent of 16-24 year olds in England and Wales admitted to using drugs in the last year and that almost half had used drugs at some stage (3). This age group covers current and future medical students and therefore does not support his argument.

Finally, he implies that it is acceptable to use illicit drugs, as there is no 'evidence to show that these doctors were posing a risk to anyone but themselves'. As I understand it, illicit drugs and alcohol lead to impaired judgement and negative behavioural changes; this is supported by a recent press release by the Royal College of Psychiatrists (4). There is the risk. I have nothing to hide...

1. Scott, A. Using drugs is not linked to incompetence. Student BMJ. 2003;11:343.
2. Paton Walsh, N. Random drug tests for doctors; NHS in crackdown on substance abuse at work. The Guardian: March 11th 2001.
3. Tayal, U. One third of young people try drugs. Student BMJ. 2003;11:312.
4. The Royal College of Psychiatrists. Cannabis use... Linked to depression, conduct problems, excessive drinking and use of other drugs. Press release: 1st March 2002.

In response to Scott's(1) dissection of my letter published in August, i would like to point out that he appears to have completely overlooked the original point. The general public would not tolerate the discovery of drug abuse amongst junior doctors, a simple street-poll would highlight this. In this increasingly transparent career, doctors must be more aware of their scrutiny under the public eye. Scott seems less worried about the senior medical students currently abusing; there is a huge socio-cultural gap between 15-19 year olds, where abusing can definitely take hold; I see no relevance of using 11-15 year old statistics, as stated in his response. There is no defending the actions of an abusing medical student and to attempt to hide from a 'media frenzy' is sheer folly; once the tabloids get a hold, there is no going back.

I am personally fundamentally opposed to doctors wearing ties. It may look smart, and it may give the patient a greater sense of confidence in the ability and professionalism of the doctor, but at the end of the day,the tie is a genuine health risk. During consultations, it will inevitably come into contact with the patient at some point, and in the case of infections transmitted through airbourne particles, such as tuberculosis or even the common cold,such contact may not be neccessary. Before you know it, you are faced with a situation whereby all of the infection control measures put in place for the safety of the patients are null and void. In a recent study of doctor's ties, it was found that a large percentage were harbouring the dreaded MRSA bacteria, which can wreak havoc with the recovery time of a surgical patient, and even cause death. The fact is that ties are very rarely washed unless they appear dirty, and microoganisms will never usually alter the! appearance of a garment to the naked eye. This makes them much more of a risk than ordinary garments, which will be washed on a regular basis. The same applies to the white coats that are the subject of this article, and are now, thankfully, being outmoded.

So, maybe you should be asking yourself what is more important: having a doctor who wears a colourful strip of material down the front of his shirt, or a doctor who is less likely to transmit infections that cost the NHS millions of pounds a year that could be spent treating patients, and cost thousands of families their loved ones, lost so unnecessarily.

Yours,

Peter Bolton

This well written 'self-help' article, which provides alarming epidemiological data regarding mental illness among the medical student population. It uses supporting evidence to claim that there are three times more emotionally disturbed medical students compared to unemployed young people. The authors provide a range of largely 'common-sense' strategies to help prevent the onset of and to reduce the likelihood of a recurrence of depressive episodes. They also offer a handful of useful contact details of charitable organisations, which may offer help to those in need emotional support. The article also is commendable for drawing upon contemporary theories on medical students' disease or hypochondria as being a reason for medical students' concerns being easily dismissed by health professionals. However, research which has been conducted by Singh et al (in press) at Guy's Hospital has shown that medical students actually experience lower levels of health anxiety and worry compared to control students.

Statements such as, ' If someone tells you are unwell, then you are probably are' may foster and encourage a culture of 'worried-well' behaviour amongst a cohort of already susceptible medical students. The authors also suggest that self-administration of measures such as the Hamilton's depression rating scale may be useful in assessing one's degree of emotional disturbance. However, it may be more beneficial to use a shorter screening questionnaire such as the Hospital Anxiety and Depression Scale rather than a long 'overly thorough' measure such as the Hamilton's depression rating scale which is used in the likes of large scale NIMH studies. The article offers sound advise 'if things get really bad' and include taking time out from studies (few months or a year). It is unlikely that those medical students on the brink of experiencing severe depressive episodes will be likely to take heed of this advise as it is this group of students who exhibit neurotic and type A personality traits and feel that more and more should be attained in as little time as possible and as a result go into meltdown.

Overall this is a balanced and well written piece which offers useful advice to medical students who feel that the academic and social demands may be taking their toll on their mental wellbeing.

As a) a smoker, and b) someone who incorporates the Darwin Awards into her lecture notes I was entirely in sympathy with the sentiments expressed by Mr Lawton in his article. That is right up until I reached the statement about 'Stinging your local hospital for a few hundred thousand pounds'. I'm the neighbour of a child who suffered catastrophic brain damage as a result of medical error during his delivery. I would invite Mr Lawton to suggest how else his parents, whose joint income is considerably less than what he can expect to achieve should he qualify, might fund the costs of what will be a lifetime of care other than through 'stinging' their local hospital.

I sincerely hope that Mr Lawton's words do not return at some future point to bite him on the behind. If they do however, then I hope he will have come to some measure of understanding of the profound difference between blame and responsibility.

I do not always agree with Ben Lawton, however, on this occasion I think I really must defend him from the response by Suzanne Slater to his recent article.[1] Lawton raises a contentious issue which has been misinterpreted by Slater.[2] I agree with her that there is a "profound difference between blame and responsibility" but I would also hope that she will "come to some measure of understanding" of the vast difference between a medical error and medical negligence.

According to the recent report "Making Amends" by the Chief Medical Officer (CMO), Professor Liam Donaldson,[3] if a true medical error has occurred in any clinical situation then there should be no issue of blame. In fact Doctors should be encouraged to report these mistakes so that lessons can be learned and practices changed; "the primary aim must be to reduce the number of medical errors that occur".

Following the 1950s 'Bolam' test case, a Doctor "is not guilty of negligence if he has acted in accordance with the practice accepted as proper by a responsible body of medical opinion".[3] However, if proven to be negligent then the Doctor responsible should be reprimanded in respect to the grievousness of their actions, by the General Medical Council or the police as is appropriate.

The CMO report suggests that "the individual who has suffered harm as a result of the health care they have received must get an apology, a clear explanation of what went wrong, treatment and care, and where appropriate, financial compensation".

I don't believe that huge sums of money showed be given as compensation for an iatrogenic injury unless it can be shown to be negligent. If a child is born with a disability, as a result of a medical error or otherwise, then our society should have systems of support, both financially and practically, for the child's parents, making there no need for a cash lump sump. This would seem far more sensible and remove any notion of parents "stinging their local hospital". At present in the UK these financial support systems to provide continual care and rehabilitation etc, are woefully inadequate. Money paid out in compensation claims is diverted away from these systems and stretch already tight budgets.

1. Lawton B. Not my fault. Student BMJ. September 2003; 11: 374.
2. Slater S. Rapid response. 10th September 2003.
3. Making Amends. CMO Report. Department of Health. www.doh.gov.uk/makingamends

I react badly to any solution based on problems. In my view successful diagnosis is firmly based on a thorough knowledge of what is normal. Given that our knowledge is constantly evolving through research, "normal" is not a fixed factor. However, to start from the problem is to go from the particular to the general. I find it is better to take the wide view, and then narrow the focus. My problem might be your solution, since humans are infinitely variable.

Diagnosis is so allied to the process of audit, that one needs to be a fact-finder rather than a fault-finder in the initial phase. One of the many flaws in the "Nursing process" documentation which has hopefully been interred decently by now, was its emphasis on potential problems. In practice I have found that witch-hunting possibilities, blinds one to practical realities.

PBL skates over clinical observation, by creating potential scenarios. One of the great losses in current nurse training is the ward-time for students, and the invaluable clinical observations that can only be learned at the bed-side or clinic, dealing with actual people. No excellence in theory can compensate for this.

In summary: Problem based learning is a factor in learning, but the part should never dominate the whole.

Georgina Protheroe-Beynon makes two good points: there is no such thing as "normal" and student nurses miss out on lots of clinical experience as their curriculum becomes more classroom based.[1] Unfortunately these good points are shrouded by unintelligible gobbledygook from someone who obviously knows little of Problem Based Learning (PBL).

1. Protheroe-Beynon G. Rapid response. Student BMJ. 11th September 2003

As you have probably heard in August, the French health system is suffering from many problems which induced the death of over 10,000 elderly people due to excessive heat this summer.

One of these problems is the non-homogenous distribution of medical doctors and specialists in the country. Thus there are more dermatologists in Côte d'Azur than in whole England.

For several years, the goverments try to solve this problem by a modification of the medical studies. The project is going to be applied starting this year. The "concours" to become an intern is suppressed and replaced by an "Examen National Classant" (ENC). The difference is that people who want to become a GP also have to have this exam. Indeed, the number of different specialists and GPs are fixed by law in each area. It means the the best students at the ENC could choose the city they intend to be intern, the worst one will have to take the remaining places... Imagine that you wanted to be a GP and stay in Paris during your internship, and due to your rank you have to become a specialist in forensic medicine and train in an desertic area with your autopsies?

I wonder if in our plate where is written our name and title we will be allowed to add "first at ENC year 2004" or "4004th at ENC year 2005"...

About connections, that is true, they don't intervene up to basic training. But if you want to get good and well paid position in public hospitals after that, you need connections... it is another way the system is not so fair as it seems..

Reading Gordon Burke's letter in the last issue of the Student BMJ reminded me of what a former consultant quipped when reviewing the hobbies and interests section of my CV. He thought it curiously sadistic that potential employers were keen for you to list all the things that you enjoyed doing that you were clearly going to have to give up on taking up your new post.