Article Responses: April 2003

Articles	Responses
REVIEWS Are patients your first concern Tsanee Smith (April 2003) [full text...]	Dan Edgcumbe (March 27th, 2003) Read this response

LETTERS We should help patients differentiate between us and doctors John Henderson (April 2003) [full text...]	Simon Harrison (March 30th, 2003) Read this response Aneel Bhangu (April 1st, 2003) Read this response Chris Gough (April 1st, 2003) Read this response Clare Hughes (April 2nd, 2003) Read this response Michael Caley (April 2nd, 2003) Read this response Graham Newport (April 9th, 2003) Read this response James Wood (April 11, 2003) Read this response Ranjith Kamity (April 20, 2003) Read this response

EDITORIALS Water, water everywhere Rhona MacDonald (April 2003) [full text...]	Martin Huntley (April 8th, 2003) Read this response

LETTERS Stethoscopes are not a badge of honour Penny Diffley (May 2003) [full text...]	Kate Alldred (April 20th, 2003) Read this response

REVIEWS
Are patients your first concern
Tsanee Smith (April 2002) [full text...]

Dan Edgcumbe (March 27th, 2003)
3rd year medical student, Christ's College, Cambridge dpe23@cam.ac.uk

Perhaps a more 'doctor/medical student-centred' interpretation of the GMC guideline is called for if we are to make patients our first concern.

If 'some doctors see all their patients, even when this means working late and risks making errors through tiredness', then it might be suggested that these doctors are not making the care of their patients their first concern.

To look after patients effectively, we need to look after ourselves. It is probably because doctors fail to look after themselves adequately that so many doctors become cynical and disillusioned.

Looking after yourself is not always an easy thing to do, particular given the multitude of calls on a doctor's time discussed in Smith's article; nevertheless, it is important to try.

'Primum non nocere' - an exhausted doctor who has failed to look after him/herself adequately is a potentially dangerous doctor, although sadly this may be merely a reflection of the system in which they work.

	LETTERS We should help patients differentiate between us and doctors John Henderson (April 2003) [full text...]
	Simon Harrison (March 30th, 2003) 2nd Year, Bristol sh1927@bristol.ac.uk
	John Henderson urges students to observe 'the unwritten rule stating that only doctors should wear a stethoscope around the neck.' I had innocently thought that where one put one's stethoscope said more about one's preferred TV soap, that whether one knew what to do with it. Thank you, then, to the BMA for its guidance: in its Annual Report (sent out with the April sBMJ), a student is pictured wearing both a white coat AND a stethoscope around her kneck (p.27). Or perhaps her colleague in the same photograph shows us the real way forward: she is has no white coat, and carries only a copy of the sBMJ, ready, presumably, to roll up and politely to place on her patients chest. And as for TV soaps, I expect, and am happy to be called 'Newbie', for the rest of my life.

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

Aneel Bhangu (April 1st, 2003)
4th year medical student, Birmingham Medical School aneelbhangu@yahoo.co.uk

Reading the BMJ and studentBMJ of late you may be forgiven for losing faith in medical students. I agree with Henderson1, we are students and any premise as other is wrong, but I worry there is an emerging trend of criticism which may result in the student becoming so restricted that most of their time will be spent waiting in corridors and giving directions to lost patients.

The very nature of the beast is that every situation in medicine is different, and today's medical student must be dynamic. I have been on a large firm where the consultant makes us introduce ourselves as 'Dr Bloggs,' (yes, you do substitute your own name here) and it is yet another lesson in how things are done differently and not a lesson in deceit.

Caldicott et al illustrated the variation in students obtaining consent2. Most of the (brisk) knee-jerk responses were of shock and talking of deceit, blaming both irresponsible students and doctors, and how the student must obtain consent for everything they do and see; in principle an obvious idea.

However, as other responses showed, the practice is that situations arise where this is not possible, but with responsibility no harm is done3,4. Talk of doctors telling students to lie is also reported5. We may all at some point say we felt Mrs Blogg's 70bpm regular radial pulse when we didn't (it was an obvious irregularly irregular pulse6) but, to speak up for the student in this tide criticism, this doesn't make us bad people. We may in fact learn not to do it again.

Experience, already reported to be stretched in today's packed hospitals7,8, will soon be out of the student's domain. Patients in teaching hospitals are starting to instantly reject 'medical students,' but using the term 'student doctor' can get a little leeway - I'm not being deceitful, just dynamic.

However, for those of you who insist on 'constructive' criticism, remember: a lesson in how not to do it is just important as the perfect example.

Henderson J. We should help patients differentiate between us and doctors. StudentBMJ 2003; 11:124
Coldicott Y. The ethics of intimate examinations-teaching tomorrow's doctors. BMJ 2003;326:97-101
Bhangu AA. Intimate exams-Students need experience. Student BMJ 2003; 11:73
Frayn FH. Ethical mountains out of everyday molehills. Student BMJ 2003; 11:73
Rushford B. Where is integrity in medicine? StudentBMJ 2003; 11:124
Bhangu AA. Author during 3rd year teaching (lesson learned). Birmingham, February 2003
Bhangu AA. Increasing number of medical students. Student BMJ 2002; 10:295
Prowse S. Critical Shortage of quality clinical teaching must be addressed. Student BMJ 2002; 10:295

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

Chris Gough (April 1st, 2003)
4th year medical student, University of Nottingham mzytcag1@nottingham.ac.uk

I write to disagree with a recent letter from one of my colleagues.1 I am one of many students who do not wear a white coat as I find it uncomfortable and cumbersome. Yet I do not feel that this causes patients to confuse me with qualified doctors. White coats are worn sporadically by doctors of varying seniority in varying situations and so how are patients to know exactly what it signifies nowadays?

I think it more likely that confusion is due to two things. The first is the propensity of both staff and students to introduce us as a "student doctor". Patients hear the word "doctor" and but fail to hear or understand the word "student". This should be avoided by introducing yourself as a "medical student".

The second is the expectation of the general public. It is well known that patients have a tendency to group males as doctors and females as nurses. It is accepted that this will happen and so is not an issue. In a similar manner, patients will automatically assume that medical students are doctors. I have had patients address me as "doctor" despite having introduced myself to them as a "medical student" not five minutes beforehand.

I would also like to disagree that putting my stethoscopes around my neck means that I want everyone to see me, and accept me, as a doctor instead of as a student. It is merely because that without my white coat I do not have the pocket space in which to put my stethoscopes. It is also easier with stethoscopes around your neck - you do not have the problem of trying to disentangle them from your whatever detritus may be in your pocket with them and subsequently avoid the associated look of ineptitude.

In the end such issues are not important. The main reason for students to be differentiated from doctors on the ward is to enable staff to find qualified people when necessary. As far as patients are concerned, what matters most is a first name and a friendly face with whom they can interact in comfort and with reassurance, whatever that face may be wearing and wherever they may have their stethoscopes.

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

Clare Hughes (April 2rd, 2003)
fourth year medical student, Guy's, King's and St Thomas's School of Medicine clare.a.hughes@kcl.ac.uk

As something of an unconventional medical student it's not infrequently that I come across things within the establishment that I don't feel comfortable with. White coats are certainly no exception.

From the first moment that I was expected to wear a white coat I resented having to do so. Most of my colleagues seemed to love the fact that they could waltz around the wards, stethoscope at the ready, preying on patients to practise their new-found doctoring skills on. However, I felt that parading around in a white coat only enhanced the arrogance that is inevitably linked with the transition into the world of clinical medicine.

Not only does the white coat create a barrier between patient and student, implying that medics are a cut above the rest, it also provides a perfect shield for the student to hide behind. Instead of working hard to build up rapport with the patient by gaining trust and respect through professional ability and attitude, the student can relax safe in the knowledge that professionalism is implied through the donning of a white coat.

I agree with John Henderson that we are not doctors and should not let patients believe that we are(1). However, I think there are better ways of doing that than wearing a white coat: introduce yourself to patients properly. On several occasions doctors have introduced me to patients as a "young doctor" - I always reintroduce myself as a medical student, checking that it's still ok to take a history or do an examination.

As far as I'm concerned there are only two things that the white coat is good for - appeasing old school consultants and carrying medical gadgets. Evidence shows a highly significant association between the weight of the white coat and the seniority of the medic with perimembership candidates wearing the heaviest coats(2).

Henderson J (2003) We should help patients differentiate between us and doctors. studentBMJ 11:124 (April).
Gordon P, Keohane S, Herd R (1995) White coat effects. BMJ 311:1704 (23 Decenmber).

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

Michael Caley (April 2rd, 2003)
Final year medical student, University of Sheffield mikecaley@doctors.org.uk

In response to the suggestion that medical students should be further differentiated from doctors by our attire1, I feel that instead of trying to distinguish between us we should, in fact, be blurring the distinction and trying to integrate medical students into the team of doctors that they are attached to. Students are being trained to be PRHOs and in the final year are more than capable of carrying out locums for the house officers to a degree of comparable competence. We should all be striving to make this transition as smooth as possible.

Mr Henderson claims that patients may be confused by what position we hold in the health care team but I feel that identifying medical students as part of the medical team is a significant step in itself. Many of my colleagues, especially females, after introducing themselves in the correct manner to patients have later been asked if they are physios, social workers or, more commonly, nurses. Student nurses and physiotherapists, although students, are identified by patients as their qualified colleagues and there seems to be no qualms about this.

I believe that the closer integration of medical students into the medical team, almost as a sub-PRHO grade, would encourage students to be more involved in the day-to-day business of patient care and boost the degree of learning they achieve by a substantial amount. It would help students to feel valued within the health care environment and be beneficial to them, the rest of the team they work with, and ultimately and most importantly, the patients. We have all seen in so many situations that inclusion and unity are better than division and distinction, why should our case be any different?

	LETTERS We should help patients differentiate between us and doctors John Henderson (April 2003) [full text...]
	Graham Newport (April 9th, 2003) Deputy ODP Manager, Stafford District General Hospital. ga.newport@btopenworld.com
	I think when working in an environment that cares for the patient who is after all at this stage completely vulnerable in the operating theatre, it is important that confidentiality, professionalism, attitudes and the morals of individuals who work in the operating theatre are kept in check and that theatre personnel do not become complacent and focused to much on the repetative nature of their skills. It is also important to remember that the patient is a human being and more often that not extremely anxious! The article also forgets to mention the ODP!!!!

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

James Wood (April 11th, 2003)
4th Year Medical Student, University of Birmingham. jameswood@doctors.net.uk

Whilst I agree with John Henderson's sentiments that Students should be distinguished from doctors, I cannot agree with his suggestion for tackling the problem(1).

The idea that the wearing of white coats should be more rigorously adhered to causes more problems than it solves for two reasons. Firstly, white coats are not exclusively worn by medical students and until recently were more associated with doctors. In fact about half of patients actually prefer their doctor to wear a white coat(2). As such for many, especially the older patient, the white coat remains the emblem of the doctor(2). So the wearing of white coats may actually add to the confusion rather than relieve it. Who amongst us has not been confused with a doctor BECAUSE we were wearing a white coat?

The second issue is one of patient safety. The white coat has been shown to be a potential source for spread of infection(3) especially those worn by students(4). The implication of this is illustrated by the fact that most ICUs ban white coats from being worn. With increased spread of MRSA and the problems of hospital acquired infections there is considerable time, effort and money being spent on combating these pathogens. It is nothing less than counter-productive to then insist a proportion of the staff roam around the hospital in pathogen sodden white coats.

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

But where does this leave us with the problem of patients mistaking students for doctors? It seems to me that there is no definitive piece of kit that doctors wear and students don't - or vice versa. The identity badge is helpful but ultimately it is the responsibility of the individual to make SURE that the patient knows they are a student and not a doctor - white coat or no white coat!

Henderson J. We should help patients differentiate between us and doctors. StudentBMJ 2003; 11:124
Menahem S, Shvartzman P. Is our appearance important to patients? Fam Pract 1998; 15: 391-397
Wong D, Nye K, Hollis P. Microbial flora on doctors' white coats. BMJ 1991; 303: 1602-1604.
Loh W. Ng VV. Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect. 2000; 45(1):65-8.

LETTERS
We should help patients differentiate between us and doctors
John Henderson (April 2003) [full text...]

Ranjith Kamity (April 20th, 2003)
3rd year medical student, JSS Medical College, Mysore, INDIA jith2much@yahoo.com

I totally agree with Mr.Henderson, that it is an un-said duty of the medical student to make it clear to the patient, the difference between us and doctors.

There are several ways in which this can be done.

First of all, White aprons...this just gives us a recognition as a medical personnel, but does not clearly distinguish the status.Also there is the risk of transmission of pathogens. Thus, clear name plates are sure to help the patient.

Next, there is the talk about wearing the stethescope over the neck. this may be a normal distinguishing feature among the medical people, but not vey much for a few patients. Also, there are a few students who wear the stethescope over the neck.

Thus the best solution lies in the students themselves explaining to the patients about their own position in the health care system.

The main reason for making this differentiation clear is that the expectations of the patient from a doctor, are entirely different from that from a medical student. The patient is the only source of clinical knowledge to the student and hence, his interests should be respected.

If a patient is ignorant about all this, it is the bound duty of the medical student to make it ckear to the patient and obtain his consent.

The medical student today is the doctor tomorrow. The shift should be smooth. There is no big need to create a physical difference among them. The difference is all behavioural. It is in the talk , not the appearance.

EDITORIALS
Water, water everywhere
Rhona MacDonald (April 2003) [full text...]

Michael Caley (April 8th, 2003)
fourth year medical student, Leeds University ugm8mph@leeds.ac.uk

Macdonald's article provides a disheartening account of the barriers that prevent access to safe water for a majority of the world's population(1). However in light of the current war in Iraq, it is important to draw further attention to the devastating effect of human conflict on this situation.

We have recently grown accustomed to images of intense military power reigning down on Iraq. Witnessing this conflict evolve in the media will have undoubtedly spurred many to consider the inadvertent loss of civilian lives through misguided military strikes. However it is important to acknowledge that the greatest impact of war on civilians is represented by a dynamic relationship that unfolds, and continues to unfold long after the plumes of smoke have settled. This is extremely pertinent in the case of access to safe water.

Just over a decade ago, Iraq's sanitary infrastructure provided 95% of the urban and 75% of the rural population with clean, safe water. However, the 1991 Gulf War crippled electricity-generating stations and rendered the majority of treatment plants as inactive or active at inadequate standards. Consequently, raw or partially treated sewage is now pumped daily into fresh water sources, with water quality studies showing contamination sometimes greater than 40%(2). Postwar U.S. sanctions have also contributed significantly to the degradation of Iraq's water supply by preventing acquisition of water purification chemicals(3)

It is estimated that approximately 100 000 Iraqi people died from the health effects of the Gulf War, and under 5 mortality increased from 56 deaths per 1000 live births in 1985-89 to 131 deaths per 1000 in 1995-99(2). The majority of these deaths are attributable to an inadequate access to safe water(2,3).

UN officials also estimate that the war on Iraq will result in 2 million internally displaced people, and between 600,000 to 1.45 million refugees(4). This will undoubtedly disrupt the community organisation and existent aid networks that facilitate access to water.

A final worry concerns the capacity of the new administration in Iraq to formulate policies on water and sanitation. Clearly this is dependent on a smooth transition between governments, which from experience in Afghanistan may indeed be problematic(5).

The effects of war on access to safe water are devastating both in the short and long-term. Perhaps next time you have a drink of water, consider how the benefits of liberation through force should be balanced carefully by the damaging effects of destroying vital infrastructure.

MacDonald, R. Water, water everywhere. StudentBMJ 2003;11:88-89. (April.)
Frankish, H. Health of the Iraqi people hangs in the balance. Lancet 2003;361: 623-625. (February.)
Nagy, T.J. The Secret Behind the Sanctions: How the U.S. Intentionally Destroyed Iraq's Water Supply, 2001. www.progressive.org/0801issue/nagy0901.php (accessed 5 Apr 2003)
Kapp, C. United Nations reveals aid plans for war in Iraq. Lancet 2003;361:622. (February.)
Horton, R. Iraq: harm reduction through health. Lancet 2002;360:1031. (October.)

LETTERS
Stethoscopes are not a badge of honour
Penny Diffley (April 2003) [full text...]

Kate Alldred (April 20th, 2003)
Final Year Student, University of Liverpool md0u8132@liv.ac.uk

Perhaps all contributors to this argument have missed an important point about the wearing of stethoscopes. From my first day on the wards almost 4 years ago, I was very much aware that students should not hang their stethoscopes around their necks. This is not because it prevents patients from identifying us as students. There is a simple, time honoured reason. Wearing your stethoscope around your neck, shows a lack of respect for those more senior members of our profession. It sends a message that the wearer is cocky and arrogant, and above their station, and is thus not conducive to working harmony between students and their seniors. Students show less and less respect for their seniors these days, and simple symbols like putting your stethoscope on the wrong part of your person only demonstrates this.

Another problem springs to the fore when everybody on a firm looks the same. Patients and their families make more complaints about 'doctors' hanging around doing nothing in the nurses' bay, only to be told that it is in fact a medical students, or students awaiting a teaching session, when students are indistinguishable from those who are qualified. Other members of the healthcare team also find difficulty distinguishing between students and doctors, which can become dangerous when students are asked to sign forms and scripts, or administer IV injections. Not all students are aware of their limitations.

Being readily identifiable as a student, can often be much more beneficial to the learning process. In my experience, patients will tell you more than they will ever tell a house officer if you look like a student - you are found to be less threatening.

There are plenty of pockets in a white coat to store the necessary tools of the trade, and even those specialties where a white coat is not worn, you still have two hands. Call me traditional, but I am looking forward to wearing my stethoscope round my neck in August, having hidden it away in my pocket for the last five years. It will make me feel like I'm a proper doctor.