As a fellow Newcastle medic with a very similar background to Mr Kirkman I was interested in what he had to say with regard to his financial situation and top up fees. I may then be a little bias and offer no review on the many rapid responses Kirkman's article has generated.

I don't find it difficult to come across students like myself and Kirkman, from such backgrounds, but of course his year may be different. However I do know what he means as a work class background does not normally give rise to a medical career. I also have my fees paid for me and receive a student loan, to supplement this further I have a long standing part-time job, but unlike Kirkman I don't find it too hard to survive (still here after 4yrs). Although I live at home so don't incur this huge expense, which I am quite sure if I did I would have tremendous debts by now, or be out of Med School due to the increased burden.

With regard to the top up fees, I am sure it will not apply to students from a background such as ours; some provision must have or will be made for such students. If anything, as pointed out by Mr Roberts (RR), it may make the decision to apply for UNI (also medicine) harder for middle class students i.e. they are just outside what boundaries exist for financial help. Also even students with "well off" parents may not want or receive help, financially, from their parents and may well be footing the bill.

Kirkman's point of more medics' working abroad to recoup debts is a good point, one which I had not thought of! However, I am sure most medics, including myself, did not join medicine for the money (there are easier ways!) and to change your clinical ethic after 5yrs at Med School, I feel, is unlikely.

On a final note I wound like to commend Mr Kirkman and his article, which has raised an interesting debate. I also agree fully with his own rapid response to his own article, but may be Mr Kirkman should limit his socialising, well just a little!

It was really heartening to find out the article on handling the torture vicims by the medical personnels.In our country as well we have workshops conducted to make the junior doctors aware about the cases of torture.The programs are run by the Centre For Victims of Trauma and Torture(CVICT).I should feel lucky to have attended a session of the workshop when i was just a second year student.The session was run really well and i got to know so much of information regarding torture.The way the session cunductor elaborated about torture was impressive but we feel that in our medical field he implementation is what is missing courtesy to the intervention of the government in the treatment of the casualties of the civil war of our country.

Medical personnels were strictly prohibited in any acts regarding the treatent or even the alleviation of the condition of the help seekers mostly inflicted from torture of some kind.This has been the weaklink in our medical system.

A full fledged doctor can hence be undeservedly unable to handle the cases of torture given that he has to work under some obligatory conditions. Workshops intended for medical students like us can help us sensitise to the issues of torture early in our build-up as a medical professional.As we don't have any curriculum related to torture ,an early exposure to such workshop can help us enormously and we can act subsidiary to the profesionals.Medical students can have a different chapter of their own under such umbrella and can play a pivotal role in the identification of the torture cases and their reporting to the concerned authority for the solution or alleviation to say.

According to the opinions of many muslim scholars, muslims are forbidden to alter any aspect of their physical appearance for the sake of vanity; they are howver permitted to do so in situations where gross deformity exists e.g. cleft palate, where severe injury results e.g. burns and where psychological distress will result if an otherwise normal body part is not altered surgically.

Thus plastic surgery is allowed under all situations, whereas cosmetic surgery is only permitted under the last mentioned condition.

I have entered medical school at the age of 33, having earned a post graduate degree and work experience.

In the study of medicine, age does matter. Although I have acquired lifes experinces and become wiser, the rigours of a medical training places enormous stress on me. It would have been good to enter medical school at a younger age. The training is also long: 6 years of undergraduate training, 2 years of internship, 5 years of specialist training. This adds up to 13 years before one can actively contribute to the profession.

Whilst I do agree that entering medical directly after school is not the ideal, so is entering medical school at a late age is far from the ideal. A balance needs to be struck. I therefore agree that the age of 35 years as the upper limit of acceptance be used.

Medical schools should encourage applicants with a basic degree, or suitable work experience to apply. It should however not prevent the 15 year old, directly out of school from applying as well.

A balance is attained with the older graduate. It is true that an older person has less human years to offer to the profession, but they have a more holistic view of the profession, and the patient, hopefully making them better clinicians. What they lack in quantity is compensated by quality. Age does matter!

It is often argued that it is ridiculous to take pride in your nationality, because it is something you have no control over.

Well for the first time in my life, I'm very proud to be Irish. The current administration is not one that receives many plaudits from myself, but this legislation demands congratulation and support. As a medical student who works in a bar part time, smoking in the workplace and the harmful effects of passive smoking are issues that concern me especially. This legislation is the most progressive in Europe, and for Micheál Martin to stand firm against the huge pressures exerted by powerful lobby groups is especially commended.

I am looking forward to March 29th. I'm looking forward to working in a smoke free environment and hopefully as I progress in medicine, to seeing the many beneficial effects this will have on our smoking practices and public health. I hope this ban can be enforced and policed effectively and I hope similar legislation becomes the EU norm in years to come.

Editor - Upasana Tayal suggests medical students must begin to accept responsibility in their relationship with the pharmaceutical industry1. An interesting point to highlight but what exactly does she recommend?

In a previous life I worked for Glaxo Smithkline, as a medical sales representative. Tayal refers to an ostentatious world of gold plated pens, fancy dinners and lavish holidays; I never saw it. I refer her to the Association of the British Pharmaceutical Industry (ABPI) Code of Practice2. Here she will find specific guidance about industry gifts and meetings. It states:-

..gifts must be inexpensive and appropriate to the recipients work i.e. less than £6 (inc. VAT). Hospitality provided at any meeting should be secondary to the function of the meeting, that being medical education..,

This document will place any health care professional on solid ground when evaluating the legitimacy of a pharmaceutical company initiative.

Ultimately Tayals point can be articulated as follows. The pharmaceutical industry and the NHS must be considered as separate entities. The latter is accountable to and funded by the state. The former is accountable to the stock market and company share holders. Both should have patients at the centre of all decisions. Since the industry researches, develops and manufactures medicines for patients there has to be a relationship with the NHS. Conflicts of interest are inevitable.

Does she advocate Michael Wilkes, vice dean of medical education at University of California, stance? He aims to prohibit all pharma exposure to medical students. Personally I find this ostrich head in the sand mentality laughable. Medical students, and doctors, must be independently critical of information. When a pharmaceutical representative start waxing lyrical about the side effects profile of drug x, your response has to be ‘let me see the data’. Be critical, assess the methodological quality, but don’t be an ostrich!

The argument that someone other than the pharmaceutical companies must "foot the bill" betrays a fundamental misunderstanding of commerce. The price of drugs is not set by summing the costs of development, marketing, and administration and then adding, say, 5%. Pharmaceutical companies are not charities, they are businesses, and they will charge the highest amount the market will accept. Removing the marketing cost will not change this.

For the doctors themselves, every prescription is for an individual patient. Every prescription should be appropriate for that patient, with evidence-based backing where possible. If a prescription is not, whether the prescriber accepted pharmaceutical company gifts or not is irrelevant.

I read Nicola Cooper's "Acute care" series with great interest each month and find the current edition, Volume resuscitation, no different. However, I am a little lost with: "Five litres of crystalloid replace one litre of lost blood because only a quarter of the volume stays in the intravascular compartment."

Should it be Four litres of crystalloid? Or am I getting my maths wrong, yet again?

I just returned from Romania a week and a half ago. I worked with a Gypsy Church there. I visited their little hovels. I visited a family that was living in a building that was condemned. The stairs shook as I walked up a few flights to their apartment. The people were very friendly and won my heart. I felt that medical work was needed, but I was really impressed with the need for good dental care. I visited a Saturday night soccer game in a Gypsy ghetto area. Teenagers were playing. It struck me that this was about the most exciting thing happening in their lives. My heart goes out to the people of Romania who live in such poverty. And my heart really goes out to the Gypsies who live in unbelieveable poverty.

Upasana Tayal’s article ‘Free for all’ on the gift-giving mentality of so-called ‘Big Pharma’ made me smile. Not least because a few hours earlier, I had been at a surgical meeting followed by a drug company sponsored lunch. In fact, I draft wrote this letter with my obligatory free pen! On a more serious note though, I think it is more than a little naive to propose that such gestures are the route of all prescribing evil.

As I exchanged niceties with the afore-mentioned drug reps, I felt an overwhelming desire to stick my fingers down my throat. No, not because of the very impressive free lunch but because everything about them was artificial and smarmy, like when you walk into a car showroom or when a double-glazing salesman visits. Maybe I am just more cynical than the average medical student but I felt no such desire to reciprocate their ‘generosity’. On a grander scale, another household name pharmaceutical giant recently sponsored some research I carried out (you could make a lot of free pens with the money that cost), but still I feel no obligation.

I agree with Ms Tayal on one thing, that the relationship with Big Pharma is a necessary evil. I have always regarded the profit-driven pharmaceutical industry with contempt, but it is a symbiotic relationship. How many life-changing discoveries have been made through research sponsored by drug companies?

The simple fact is that it is human nature to select products based on recognition. To prevent Big Pharma wielding its influence you would have to ban all drug advertising. The fact that the very next day, a full-page drug advertisement dropped through my door in the form of the BMA News, made me smile even more.

Drugs should be selected based upon effectiveness, cost, potential side effects and ease of regime. I think this is something more of your colleagues are aware of Ms Tayal than you give credit for.

FEARFULLY AND WONDERFULLY MADE:

I write with the objective of offering my support to Robin Edwards, who in the December issue remarked 'Religion should be considered in medical practice'1. As a Christian medical student, I recently attended two meetings examining the Christian view point on topical issues enveloping genetic advances, which are currently a prime focus in the media. These meetings were conducted by the Chairman of the UK Gene Therapy Advisory Committee who is a Christian. I would like to share a few guidelines which were suggested to help other Christian readers make decisions, without compromising their faith, in relation to these demanding matters.

I was reminded that we should have compassion for persons captivated in these moral dilemmas, and Christian Doctors should not be afraid to be implicated in the predicaments sometimes broached by genetic therapy. Indeed it is important for us to play our role as Jesus himself was involved in healing 'all manner of sickness and all manner of disease'2. However a responsibility comes with this involvement such that it MUST include acknowledgement of moral boundaries. So how are we to respond?

'He hath showed thee, O man, what is good; and what does the Lord require of thee, but to do justly and to love mercy and to walk humbly with thy God.'3

Is it justly that embryos can be used and then destroyed in embryonic stem cell research? I don’t have the intellect to comprehend the intricate workings of these advances, nor the medical experience to cross-examine scientists’ findings, but I know that as I embark a future medical career I would like my Christian faith to be firmly implanted in my genes and would encourage the many other Christian readers to stabilise their own opinions, without forgetting that we are 'fearfully and wonderfully made'4 and what a sense of awe that brings'

I feel the need to leap to the defence of medical schools in light of Chibuzo Odigwe's article about the lack of attention paid to smoking in the curriculum. At least, I wish to defend my own medical school, the University of East Anglia.

Now in my 2nd year at UEA, smoking has already been discussed at length in both the cardiology and respiratory modules. We are encouraged to see smoking as BOTH a medical and social problem, to be tackled in both primary and secondary care. Yes indeed, we've even had lectures on the pharmacology of NRT, bupropion and its clinical effectiveness.

It will be interesting to see if such teaching is reflected in clinical practice upon our graduation!

Yes, it must be 4 litres crystalloid are needed to replace 1 litre blood. Sorry for the confusion - in my defence I was not able to proof-read this issue and it sure is hard to squeeze in essential facts in so many words. These subjects are so much better taught in small groups! For more info, please look at the further reading at the end of each article.

The rationale behind access schemes encouraging applications to study medicine, especially from 'disadvantaged' students, is the argument that "the social mix of doctors should be representative of the society they serve" [1]. This has gained momentum with the delcaration by the BMA that "medicine already over represents students from professional or managerial backgrounds" [1].

Why shouldn't the same reasoning apply to gender? If the downward trend in male medical students persists, will we need to address it with access programmes aimed at men? Or should we just accept that some people, be they of a particular gender or social group, are more inclined than others to become doctors?

[1] from a Memorandum submitted by the BMA to the Education and Skills Parliamentary Select Committee, March 2003
http://www.parliament.the-stationery-office.co.uk/pa/cm200203/cmselect/cmeduski/425/3031907.htm

I am glad that more females are entering the medical profession. If the medical profession is to be in touch with patients, then it must reflect the population that it serves (not only by gender but by socioeconomic status, race etc). It could also be argued that women make better doctors because they are, for example, more empathic. (I know I generalise, but, when speaking in general terms, generalisations may be appropriate)

An interesting issue which may be worth investigating is whether medical schools admission criteria currently discriminate against boys. Communication skills are an important factor determining interview success. While women are generally regarded as having improved communication and social skills, these differences are more acute at school age because girls develop these skills earlier than boys.

Is it possible,therefore, that by assessing the characteristics of prospective applicants for medical school at such a young age, the current admissions process is, to echo a phrase, "institutionally sexist"? We boys might need a little more time to mature and develop our communication skills compared to girls. If this is true, then this should be accounted for in the admissions process.

While the current high female intake serves to redress the gender balance, a propagation of this trend may, as Miss Herbert suggests, have serious implications for the capacity of the NHS.

The article was wonderful and very motivating to people like me who have a good interest in Neuropsychiatry, having recognized it to be the most tremondously potential field of research in coming years. especially your statement that neuropsychiatry is not synthesized out of psychiatry as a special interest field but by itself it is the mother of two identical siblings - Neurology and Psychiatry.

I hope young aspirers like me will be able to build a rewarding career in Neuropsychiatry under able guidance from inspiring enthusiasts like the author.I feel the Royal College should expand its subspeciality branches to include NeuroPsychiatry - one doubtlessly promising field in mental health.

The course that I am undertaking will qualify me as a sports therapist in a matter of months. Long term, my goal is to work in professional rugby clubs. In order to bring myself closer to this goal and stand me in better stead when it comes to applying for jobs in professional clubs, I have worked voluntarily over the past two seasons within local amateur rugby clubs and with the Rugby Academy at my campus.

On average, I work Tuesday evenings at club training, Wednesday daytimes at college matches, Thursday evenings at club training and Saturday daytimes at club matches - not including evening cup matches, extra training sessions and tournaments. In addition to this, due to financial constraints of the local club that I work for and college policy, I claim no expenses for petrol etc. I do this work entirely to help my career in the long run and to improve my CV.

I am becoming increasingly aware, however, that all this work and time spent doing voluntary work experience counts for absolutely nothing. Despite all the effort and dedication I put in to gain experience, I am still refused so much as work experience (let alone jobs) time after time by professional clubs. When it comes to applying for jobs, I am repeatedly told that experience of working within professional sport is imperative; although I fail to see how this is possible when even work experience within the field seems to be entirely unachievable.

Admittedly, there are always going to be some people who want to work in professional sports clubs for the so-called glamour of the industry, so I can appreciate employers being reluctant to grant work experience left, right and centre. But please don't dismiss those of us who genuinely want to do this work without so much as a second thought.

If nothing else, my CV shows a hell of a lot of dedication and hard work for no money whatsoever - it's about time that employers such as professional clubs wake up and realise that there are dedicated, hardworking people out there desperate for a chance to prove themselves.