I agree to the article above (titled - Medical training did not teach me what I really needed to know) and believe that the medical education that i have received to-date will be ill-defined to make me cope with life as a PRHO (assuming I pass my exams in May).

Too often you hear about consultants who are not interested in teaching medical students and leave them to their own devices (even though their contract state that they have a teaching obligation. The reasons may be manyfold - 1. they are too busy with their own work load to offer their valuable time, which is fair enough. 2. They may be more concerned with academia or private practise. 3. They may not care at all to teach!

I feel as if doctors in todays society are geared towards being excellent clinicians or academics - with little time spent of medical education and this is something that may be expanded.

In my opinion, the way students are taught today is well inadequate for preparing us for the rigors of life as medics. I therefore reckon that specific consultant posts should be produced with medical education being the main job criteria. I am sure their are plenty of doctors out there who would love to spend more time teaching on the wards or in surgery and hence jobs geared towards teaching would be ideal to make sure as students we came into contact with individuals who taught us what we needed to know. This would be much better than learning in the ad-hoc manner we do today.

Do you suggest a book then? Maybe something along the lines of: What you really need to know but no one told you in medical school?

Sir,

In addition to the useful information given, it is a modern era and I personally found that using a handheld device for logging the pertinent data of patients especially blood results to be helpful. This is particularly helpful for surgical trainees who can also log patient progress into and out of operating theatre(1).It takes a while to get accustomed to but once you get the hang of it, your data entry and managent will be more efficient.

The preparation for the consultant rounds must be thorough despite the degree of enthusiasm shown by the consultant. At the end of the day, a well prepared resident will always learn more and will be able to make a more meaningful contribution to the overall management of the patient.

In addition one must arrive to the ward way in advance of the time of the scheduled rounds in order to ensure that all the material is ready before the onslaught.

1. Fischer S, Lapinsky SE, Weshler J, Howard F, Rotstein LE, Cohen Z, Stewart TE. Surgical procedure logging with use of a hand-held computer.Can J Surg. 2002 Oct;45(5):345-50.

Respectfully,

Sashi Kommu

With sex education widely discussed over the last years, there are still not enough satisfying results.

The problems are worse in developing countries, some of which have no sex education in schools, no public health campaignes to raise awareness. In some countries in Africa for instance, there is still the belief that HIV is the result of witchcraft! In Eastern Europe, the incidence of sexually transmitted HIV in increasing.

Changing traditions, beliefs, attitudes that have been there forever is a daunting task. That is why I think every culture, every country needs a personalised apporach. You can't educate people in Tanzania who think AIDS is witchcraft in the same manner you educate the British people, who have been exposed to a lot of public health campaigns so far.

A previous reply has been talking about normal and abnormal sexual behaviours. How can you draw the line between normal and abnormal? Oral or anal sex may be normal for some and abnormal for others. How can you tell young people what to like and what to dislike? Ask 10 young people what they understand by "risky sex" and you will get different answers. The best thing is to inform people of the risks and implications of certain sexual behaviours, not just tell them "Say No to it". Imposing it agresively is not a solution, as youngsters tend to be a bit rebel and stubborn, and might want to do exactly what they are not supposed to (or told not to). This is a risky thing considering that youth is the period when you mostly define your sexuality and sexual behaviours. That is why giving them the information and then the feeling that the decision is theirs, giving the the liberty of the decision and the responsability that comes with it, might be a better approach. And this can be done at all levels, from parents' or teachers' attitude(whoi sometimes tnd to have the "I am the older and the smarter one here, i know better" attitude), to the attitude trasmitted by public health campaigns and the media.

It is everyone's right to choose the sexual behaviour they like, even if we consider normal or abnormal, as long as it doens't hurt others. The role of the public health and governmental bodies is not to impose a sexual "normal" behaviour, but to promote the ideas of responsability, of protecting yourself and protecting others.

in the end, the only correct definition for "normal sex" may be "responsible sex" or better "safe sex".

Cry me a river.

This ghost writer should be kept as far away from the OR as possible. Although he (or she) sounds like he may be an adequate medical counterpart, he has no place in surgery. The author wishes surgeons to be caring and empathetic. I disagree. If the author took Medical Psychology in his medical school, he may have heard of something called "isolation of affect". I would like my surgeon to be cold, calculating, and technically competent as he is resecting cancer from my colon and has my blood and guts all over his hands. I do not want the surgeon to start thinking about how much my wife loves me, or how many children i will be left without a father if he messes incises half a centimeter too far to the left.

The surgeon cares about one thing: cutting. The patient's life depends on one thing: the surgeon's ability to cut.

Caring about performance is the only thing I want my surgeon to be empathetic about.

I was very interested to read the article by Mr/Miss anonymous. I am also a PRHO who has done my medical job and now am currently doing surgery. I myself have always favoured a career in surgery, but medicine is still a posibility.

During my very busy DGH medical job, felt that i was basically a secretary for my firm, who did not make many if not any clinical discisions. However this experience has not put me off of medicine. If you were instantly put off of a surgical career by an initial introduction talk, then you did not seriously want to be a surgeon if this is all you need to detract you! I also feel that such strong anti-surgery views in an influential journal read by many medical students could potentially be very destructive.

You should know from your medical school attachments that not all surgeons are patronising and arrogant. I do agree that their is the odd character but they are now a dying breed. The majority of surgeons these days work very closely with the medical tams and other members of the mulitdisciplinary teams to make the best choices in clinical care for the patient. I find that surgeons now view surgery as the last resort because they now put the patient first. I feel very sorry for you that you have not had the pleasure of working for such a consultant.

I also regularly hear the familiar story said by most of my seniors "that in my day day i worked a 1 in 2", however one must realise now that in their day they could do to patients whatever they wanted and it was accepted. In the post-Shipman era that we now work in, this sort of practice and attitude is unacceptable, and clinical governance and audit is now common place to stop this.

You also say that you have too much free time and so spend your time in the mess being bored! I myself have found that i havelots of free time now, but i have used my initiative and go to theatre whenever possible. I also attend other consultants list, so am seeing a large range of procedures. I have found surgeons extremely welcoming and willing to teach me, so i now get to operate unaided as my skills and competence grows. I have also spent much time learning cystoscopy and other methods of imaging, which has contributed to my very enjoyable educational experience, this is what a PRHO year is all about!

I have am currently involved in a number of research project within the medical school so am using my free time constructively.

We have a number of medical students on my firm so i teach them whenever the would like a make sure they understand what is going on so they do not feel left out a ignored on morning business rounds.

Latly, you commented that your surgical team care leaves your patients psychologically mistreated. Perhaps with all of your free time, you could spend some more time at the bedside and rectify this.

I hope you do wventually find a career suited for you and do not mean to persecute you. I also hope that the original and this reply do not put off impending house officers from making important career choices that will effect their lives.

Many thanks

'Fees will only discourage those without a genuine desire to study medicine'

I read Matthew Kirkman's letter in the February edition of student BMJ with great interest. I strongly believe that what medicine needs is people who are passionate about studying it, treating their patients, and contributing to its future, completely irrespective of their background. Medicine also requires people who can work as a team alongside with people of all backgrounds, and who can integrate with and accept the values and beliefs of people from all walks of life. In his letter, Matthew Kirkman states "it has been hard to find other students from similar backgrounds to me", - it disturbs me that he actively finds this to be an important issue. Since beginning my medical course in October 2003, I have met people from vastly diverse backgrounds - some of my peers have parents who are unemployed, and others went to some of the most expensive private schools in the country - despite this, everyone seems to integrate well and has a good time together, and personal background does not appear to play a significant role in friendship formation.

Once you have graduated with a degree in medicine, you are guaranteed employment as a doctor and no matter what your original background is, your salary will be much the same as anyone else with the same qualifications. As a PRHO, you will have little time to go and spend your hard-earnt salary, and relatively speaking you will be well off. A medical degree practically secures a well-paid job for the rest of your life, which in turn means that you are also guaranteed a good income. As I see it, my desire to become a medical professional together with the knowledge of my potential earnings over a 35+ year career far outweigh the debt (and its implications) that I could build up during my 6 year degree, even if I did have to pay top-up fees, and I therefore find it very difficult to believe that anyone - whatever their background - who has a genuine desire to study medicine could justify not applying to do so because of financial reasons. However, if top-up fees were to be introduced, I believe that an efficient means- and merit-based bursary system would need to be set up in order to provide some financial assistance to highly gifted students with genuine cases of hardship.

Given the potential amounts of money that can be earnt from even a small amount of practice in private medicine, it appears that Matthew Kirkman is rather exaggerating the effect that the introduction of top-up fees will have on the NHS; moreover, it may reduce the number of people who study medicine as a degree not really knowing if it is what they want to do (and thus never become practitioners - a huge waste of both government and NHS teaching resources), and therefore may actually improve the national health care in the long run.

Yours sincerely,

Zoë Little

First year Medical Student Imperial College, University of London

I was interested to read Matthew Kirkman's letter in which he argues that the introduction of university 'top-up fees' will discourage students from working class families from applying to study medicine. Whilst I support the fight for free university education funded by general taxation, I have to disagree with Kirkman's main argument. The government's proposals will involve no payments upfront, with students only paying off fees once they are earning more than £15,000 per year. After graduation, medical students will all be on the same pay scales, and therefore those from working class families will have the same ability to pay off any debt as those from richer families. As such, there is no reason why students from working class backgrounds should be discouraged from studying medicine, especially as a degree in medicine effectively guarantees a job after graduation. However, even if a student could not find a suitable job, or decided to take a year out after qualification, no fees are repaid unless wages are being earned, with payments proportional to annual salary.

Also, Kirkman's statement that he can "only imagine how hard it will be for those in a few years' time who are from similar working class backgrounds" does not make sense. As the new proposals mean no increased payments until after graduation, university will not be an increased financial struggle for anyone.

I thought Mr Kirkman's article showed an interesting perspective on the possible outcome of introducing top up fees in medical school. I have to disagree however, with his main point that 'working class' students will be the hardest hit by the new fee system. Given that students do not have to pay off their debt until they leave university and the new bursaries available to students from less well off backgrounds (the government says the poorest full-time undergraduates will qualify for a grant of £1,500 a year from 2006), students may even be encouraged. I think that the middle class student whose parents fall just above the government grant cut-off limit will be the hardest hit. The only thing stopping working class students from studying medicine is the negative knee-jerk reaction that top-up fees have received.

Dear Editor,

As a sixth form student and potential medic I am due to process a UCAS application next year .Thus, I have taken full interst in the university fees debate. Reading both Kirkman and Hugh's perspective on the issue ,it struck me that there is a growing confusion in the public as to how to view higher education.

The government informs us that graduates earn a significant more than non-graduates .Meanwhile , a large sum of tax money is spent on encouraging youngsters from diverse backgrounds to study medicine in the 'access to higher education scheme'.It strikes me that the government's initiative has lost focus.I was fortunate enough to attend a government funded summer school called 'an introduction to medicine' at a prestigious medical school and discovered after a week my enthusiasm for medicine had not been altered. My fellow summer school students were also left undecided despite having a lot of fun. Following the GCSE results it also became apparent it had been a waste of government resources on all similar courses nationwide, as many pupils failed dismally to gain required grades for medicine.

Having witnessed many family members and friends study medicine , I have become increasingly aware that to succeed in medicine, one has to have self-motivation and desire to learn the subject. Despite the introduction of higher fees , many friends and I have not been wavered in our decision to study medicine.In the USA , fees have long been a successful part of the higher education structure.

I find the financial saving schemes available sufficient and realise the personal and social benfits of the course far outweigh the personal costs.At the end of the day, my earning power will be greatly increased to repay and it is obvious in our modern day world nothing comes for free!

Yours sincerely

Amaka Ogeah

Reading Zoë Little's response to my article, she seems slightly naive in her perception of how the real world works. Her opening paragraph states how she believes that medicine "requires people who can work as a team alongside with people of all backgrounds, and who can integrate with and accept the values and beliefs of people from all walks of life." While I do not disagree with this view in the slightest, I do not see the relevance at all of this to my article and it sounds like something quoted from her medical interview! Not once did I suggest that students from middle class backgrounds are poorer team workers etc so this statement is rather irrelevant. I find it quite disturbing that she believes that people from working class backgrounds do not possess the ability to team work effectively, which is what she is suggesting.

As Zoëë wrongly commented, I do not actively look for people from a similar background to myself, but when you do actually socialise with other students background is something that tends to come up in conversation usually flowing from the introductory "where are you from?" type questions. I genuinely do not mind that there are not many working class students in my year, but I do think it would bring more diversity and culture to a course dominated by middle class people. I have a lot of friends here who are from "rich" backgrounds who read my article with great pleasure and agreement; and as Zoë correctly states social class does not play a role in friendship formation. I do feel, however, that you are more likely to get on with someone who is from a similar background to yourself simply because you have more in common.

Finally, I think that the title to her response "fees will only discourage students those without a genuine desire to study medicine" is outrageous. There are financial boundaries some people have that mean that they can genuinely be put off medicine. I really don’t think Zoë seems to be aware of this fact. After the degree of course there would be no problem in paying off the debts accumulated at University. But if, like me, your parents can not afford to give you any financial support and you have to pay everything yourself, then top up fees really do become an issue. As I said in my article, the government bursaries that are to become available are not likely to cover tuition fees, accommodation and living costs. Students like me who enjoy going out and socialising frequently find it hard to be able to afford it as much as I wish I could. When top up fees are introduced, I truly believe that living as a student from a less well off family will be made that much harder.

Matthew Kirkman,

First Year Newcastle University Medical Student

What I would like to add to the above discussion is that increase infees not only just affects the local working classes but for foreign students like that from Asiatic countries a rise in just a few hundred pounds mean a rise in many thousands in their local currency like that in our country. So before taking such a step the Govt should take maximum care of looking at well being of foreign students who come with alot of difficulty from faraway countries just to take education.

A growing group of students at the University of Illinois at Champaign, Urbana have joined the Link Community Development, which is a group who raises money that will go towards HIV/AIDS prevention, treatment, and education in elementary schools in Northern Cape, South Africa. Right now we are dividing into committees, trying to reach different groups of students and companies on campus to donate money for the cause, and even walk in our finale event on April 25th. The finale is called the Walk for Africa. Individuals and organizations who pledge money will walk from First to University, exhibiting banners and Walk for Africa t-shirts, then end at the quad where a motivational speaker, music, and food will be waiting.

The goals of our compaign sound very similar and actual coincide with the ideas stated in the "Women are being let down in effort to stem HIV/AIDS".

Maybe there's a way students at U of I can work with the ABC group or the Global Coalition on women and AIDS to further the cause.

I would like to express my support for Vittal Katikireddi's article entitled "CRACK for birth control". I have also investigated the CRACK scheme and find it wholly repugnant.

I have written a paper, published in the March 2004 issue of The Journal of Obstetrics and Gynaecology, condemning the CRACK initiative. It relates the US scheme to tactics used during India's 1975 National Emergency as depicted in the Rohinton Mystery Novel "A Fine Balance".

My paper calls for those clinicians involved to be investigated by both medical governing bodies as well as legal prosecution services. The paper argues for an immediate stop to the CRACK incentive by using legal and ethical frameworks.

I thought that those who read Vittal Katikireddi article may find my publication of further interest.

Thanks

M Morgan

FEARFULLY AND WONDERFULLY MADE

EDITOR

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...

1. studentBMJ 2003;11:476
2. Matthew 4:23
3. Micah 6:8
4. Psalm 139:14

In this article the author states that the country placements are oversubscribed. Could it not simply be the case that the selection procedure will pick candidates who have already proven themselves better than other students in previous exams? This would obviously lead to the observed trend in exam success regardless, or perhaps even in spite, of the teaching environment.

It is not really a random control group if the students are competitively selected.

Mr Katikireddi is correct, oversubscription could be down to selection bias by the authors of the study. But if Mr. Katikireddi had actually read the study, by Flinders University, in question he would have noted that it is a cohort study and the authors do state under their method that, and I quote: "As there were usually more applicants than places, we selected students on the basis of an autobiographical statement and interview, with an emphasis on their intention for future practice in a rural or remote setting. Academic results for year 2 were not available at the time of selection."

I would not cast aspersions on their selection process as it is plainly stated in their study and the authors have even accounted for selection bias by stating that year 2 results were not available at the time of selection.

In fact the matter of selection bias forms the major part of the authors' discussion in the paper.

Perhaps Mr Katikireddi should assess the study first and then comment on the news article. He may find his questions are already answered.

Please note that I have not written this news item or a rapid response to it. Previous comments that have been attributed to me have been done so erroneously.

The original news item is written by Saffy Rushworth and a response seems to have been posted by Hamish from Oxford.

I hope this clarifies authorship.

Thank you.

There seems to have been a mistake. My sincere apologies go to Mr Katikireddi for naming him as the author of the first rapid response although on March 10 when I wrote my reply his details were there as the original author of the rapid response. There are witnesses to this also.

Please could the webmaster please let me know why Mr Katikireddi's details were originally there as I would not want to cause undue distress and would have, of course, directed my first reponse to Hamish instead of Mr Katikireddi.

The error occurred during the coding process of the responses.

I apologised for this mistake and hope this does not cause any further misundertanding

Another first class article by Nicola Cooper explaining the principles underlying acute medical care, together with interactive case scenarios to work through.

All the articles in her series have been an excellent educational resource.

But are there a couple of (very minor) mistakes in the text?

1. The anion gap given in the answer to case two is given as 26 mmol/l, but according to the equation given in the text and the numbers in the case scenario is it not 30 mmol/l?
2. The answer to case three states that, 'The PaCO2 was appropriately low in compensation', yet the value given for the PaCO2 in the case is 6kPa, which is normal.

Thanks for your comments. Terribly sorry about the mistakes / typos you have spotted! You are quite right.

Nicola

Vittal Katikireddi’s article(1) about the use of physician assistants (PAs) in the UK made informative reading. There are, however, numerous foreseeable problems associated with the use of PAs. The pilot PA training programme hopes to attract graduates with 2:1 degrees(2); considering such applicants are capable of and encouraged to secure graduate-entry places to read medicine at UK universities, it is difficult to justify how the PA pathway will be in their own best interest (considering the reduced social status, pay and career prospects compared to doctors). There is also a very "real" risk that as PAs such high-achieving and capable graduates will become perpetually trapped within a house officer style job (where a significant amount of time will be spent on mandate tasks), which will eventually lead to job dissatisfaction.

It is envisaged that PAs will not have powers to prescribe medications in the UK(3). How many doctors will be willing to sign prescriptions for patients they themselves have not assessed (considering the medico-legal ramifications which could arise). This is particularly true for accident and emergency physicians where misdiagnosing acute serious illnesses could have dire consequences. A significant portion of PAs will work within such settings. Will this lead to repetition with the PA first seeing the patient followed by the doctor - If so, will the physician’s workload be significantly reduced or will the PA become yet another burden on the doctor.

With regards to PAs working within primary care: who will decide whether a patient sees a PA or a doctor (will patients be pressurised into seeing PAs), and how easily will a patient be able to see a doctor if he remains unsatisfied after consulting a PA (will it be without delay or will another appointment be required).

A severe shortage of doctors exists within hospital medicine and general practice which needs to be addressed to maintain optimal patient care, but we must tread carefully and choose thoroughly researched strategies - not just "quick fix" solutions. The last thing we want is to create another group of disillusioned health care professionals.

Medical students must be aware of the issues surrounding PAs and other frontline healthcare staff because on becoming house officers they will be the ones working most closely with them.

1. Katikireddi V. UK universities to train physician assistants. StudentBMJ 2004; 12; 96 (March).
2. Katikireddi V, Rushworth S. Using physician assistants in the United Kingdom. BMJ Career Focus 2004;328:69 (14 February).
3. Julie Henry. Medical degrees lasting two years created to fill shortage of GPs. Sunday Telegraph 2004 February 1. Accessed March 3 2004.

Sir,

I agree with the article to the extent that male students suffer in their gynecological training and experience during graduation. I have completed PRHO training in Dept of Obstetrics and Gynaecology and I never got an opportunity to perform any examination procedure.

However the perspective changes completely in obstetrics where I had many chances to assist / observe delivery and other operative procedures.

This difference between obstetrics and gynaecologicalk training is in my belief related to motherhood being reverred in social mindset.

Sincerely

Dr V Mutha

I concur strongly with Deborah Cohen, that drug abuse is a commonly encountered, underemphasized issue reaching gigantic proportions of an epidemic.

Further it should looked upon as a clinical manifestation of an underlying disease rather than only being considered a measure of voluntary control and will of an individual and therefore is to be addressed in whole as we would pain in Myocardial infarction or cough in Acute bronchitis. The etiology of drug abuse is not only what meets the eye or only confined to text books but has deeper rooted psychiatric dwellings coupled with complex societal interactions of the unfortunate "individual" rather "patient".

A recent research on social anxiety disorder showed there is a strong predisposition in individuals with social anxiety disorders to resort to drug abuse, hence it recommended grass root screening with questionnaires and prompt treatment of social anxiety disorder, can nip many a case in the bud. Trying to change the society we reside in is undeniably a difficult and overbearing option to adopt into practice but a small contribution like screening questionnaires and patient education definitely wouldn’t be out of place.

The prevalence of parenterally transmitted diseases like HCV, which is notably high in injection drug users (IDU), can be modified by adopting new resolves described in the NIH consensus statement- "Dealing with HCV". It states, apart from counseling IDU on abstaining from the risky behavior and linking them to drug deaddiction programs and methadone treatments, there have also been recommendations for dealing with the non-abstainers by ensuring access to sterile syringes through Physician prescriptions and preaching hygienic practices of hand washing.

Eradicating drug abuse presently may be a far fetched idea but keeping the numbers in tab by inculcating the small abovementioned changes and sanitizing the practices will surely go a long way in helping to cope with the looming epidemic.

Reference

Available at cited 9 march 2004

I observed that drug using is getting realy common among children in secondary schools. For instance in Poland drugs are really good substitute due to alcohol for many pupils. I think tht in this area our knowedge is still poor.

I have noticed an error on your website concerning the origin of the word "robot". The word was invented by Karel Capek's older brother Josef. Karel Capek was the first one to use it though, that is in his play "RUR" (1921). In a 1917 short story "Opilec" by JOSEF Capek the word used for describing what we would now commonly call a robot was "automat".

More on the subject can be found at http://capek.misto.cz/english/robot.html