Article Responses: May 2003

Articles	Responses
LETTERS White coats and Stethoscopes Michael Caley (May 2003) [full text...]	Simon Jones (April 27th, 2003) Read this response

LIFE The Torres Strait: an ancient yet modern Australia Vibhore Prasad (July 2002) [full text...]	Katie Henderson-Brooks (May 4th, 2003) Read this response

LETTERS Students lack interest in careers in psychiatry Katherine Boodell (May 2003) [full text...]	Tom Oates (May 8th, 2003) Read this response Thomas Round (May 20th, 2003) Read this response

EDUCATION Evidence based case report Sore throat: diagnostic and therapeutic dilemmas Anna Graham, Tom Fahey (September 1999) [full text...]	Ronny Gunnarsson (May 9th, 2003) Read this response

EDITORIALS Is it time to end taking oaths? Andrew Moscrop (May 2003) [full text...]	Alex Keith (May 16th, 2003) Read this response

NEWS Scottish medical students accept acts of academic misconduct Stephen Goldie (May 2003) [full text...]	Alex Keith (May 16th, 2003) Read this response

LETTERS Medical students should be taught suturing Paul K Wright (May 2003) [full text...]	Sameer Trikha (May 20th, 2003) Read this response Richard Wilkin (May 20th, 2003) Read this response

LETTERS Clinical attachments need reform Bhavesh Kumar (April 2003) [full text...]	Shivani Misra (May 21th, 2003) Read this response

LETTERS
White coats and Stethoscopes
Michael Caley (May 2003) [full text...]

Simon Jones (April 27th, 2003)
Physiotherapist, Bedford simonjones63@hotmail.com

My problems in this area go far back and with my hope of reading medicine later this year looks as if they may well be here for some time yet!

I fully agree that to the rest of the medical fraternity, white coats and stethoscopes are part of the great medical 'Rite of Passage' into the profession but I am not hugely convinced that this is so anymore. Having been in the Services for 16yrs and made by virtue of the job to wear a uniform every day, I now have a real problem wearing one at work. Much have I annoyed the authority with this but my reasons are simple.

I greatly agree with some of the other respondees that this creates a barrier between us and our patients who in truth just want to know who you are and what you propose to to to them. I feel that if you are wearing a name badge clearly stating this and are smartly dressed then what the hell is the problem. Okay putting all the infection issues aside for the sake of this article, some areas require us to be properly attired but they are obvious such as ITU/Theatre etc. In Physiotherapy at this time we are experiencing big changes with the advent of the Extended Scope Practitioners who generally work one on one in clinic with the Orthopods. Most of these wear no white coat or Physio uniform and are frequently asked if they are Consultants! My point to this I feel is that if we make our initial approach to treat a pateint then arent we all taught to clearly identify who we are and to primarily put the patient at ease. It should then be down to the individual if you feel happier with pockets full of flash gadgets and the complete works of the Oxford Handbook series!! (For Physio's its usually the smartest Litmann on the Market to prove that we know how to use one too!!) or you want to discard the barriers and just get on with trying to be a good safe and competent practitioner from Med Student to Consultant.

Sorry its a bit long winded and hope I still get a Med School place!!!

LIFE
Torres Strait: an ancient yet modern Australia
Vibhore Prasad (July 2002) [full text...]

Katie Henderson-Brooks (May 04, 2003)
year 8, Sydney Girls High widget93@hotmail.com

Thankyou for this moving and informative article. Although I am only a high school student, I can feel a lot of the passion hidden behind this article. The Torres Strait Islanders are an ancient people, and their traditions and culture is still very much alive, as the author pointed out. But I weep for the lost culture, who have let a Western world take over their beautiful way of life. Motor boats instead of canoes, frozen food instead of freshly caught fish... I hope that some Torres Strait Islanders are standing up for what they believe in.

Once again, thank you so much for putting this touching article on the web where people have access to it.

LETTERS
Students lack interest in careers in psychiatry
Katherine Boodell (May 2003) [full text...]

Tom Oates (May 08, 2003)
2nd Year Clinical Student, Royal Free & University College Medical School, London oates_tom@hotmail.com

I write in response to Boodell's letter regarding a lack of interest in psychiatry amongst medical students. It is my experience that such a lack of interest is not restricted to psychiatry but in fact generalises across care of the elderly and general practice. I wonder if this is because these careers are those which contain the largest element of social work as opposed to straight application of clinical skills and knowledge taught in didactic teaching sessions.

Whilst the medical courses of today are structured to stress the holistic approach to patients I feel that the unequivocal nature of much of the practice of the medical and surgical specialties will always mean that these attract more students than psychiatry, care of the elderly and general practice, which focus more on problem solving in a broader, more socially orientated sense. Whether this discrepancy is something that can be examined and redressed by medical educators, or is related to the deeply held preferences of those that are selected as medical students is unclear. However, the figures quoted in Boodell's brief study point tantalisingly towards the former.

LETTERS
Students lack interest in careers in psychiatry
Katherine Boodell (May 2003) [full text...]

Thomas Round (May 20, 2003)
Medicine fifth year, Imperial College thomas.round@imperial.ac.uk

Having just completed my fourth year psychiatry attachment I read with interest the letter1 regarding student interest in this speciality. From my experience I had a great number of negative attitudes, along with my colleagues, about psychiatry. However most of these were shown to be false, and I have found my interest in this speciality has actually increased.

Recruitment in psychiatry has been a topic of interest2. The letter states "interest in entering the speciality itself is low"1, however does not fully address the reasons for this, placing emphasis on medical education and psychiatric attachments modulating attitudes.

Whilst I know that psychiatric attachments can make a difference, as shown from my own experience, it is not the whole picture. Personality, social background, experience of mental illness, tolerance of ambiguity are all important2. Malhi GS et al (2002) found that with regards to attitudes, one of "the least attractive aspects of psychiatry" was "a perceived absence of a scientific foundation"3.

I believe the ambiguity in psychiatry and the perceived lack of a scientific foundation are of importance regarding careers in the speciality. The requirements for medical school, with the emphasis on biological sciences of the positivist paradigm, rather than interpretative sociological science, may be an important reason for the lack of interest in psychiatry.

Also of importance is that the preferences of students are unstable, a "poor predictor of career choice"2, with many choosing psychiatry as a career after graduation2 4.

I would argue therefore that the reason why a "small percentage of doctors intend to enter this speciality"1 is more to do with the actual students who go to medical school rather than the attachments they partake in.

Boodle K. Students lack interest in careers in psychiatry. StudentBMJ 2003;11:166. (May)
Brockington I, Mumford D. Recruitment into psychiatry. British Journal of Psychiatry 2002;180:307-312
Malhi GS et al. Shrinking away from psychiatry? A survey of Australian medical students' interest in psychiatry. Ausralian and New Zealand Journal of Psychiatry 2002 Jun;36(3):416-23
Mowbray, R. M., Davies, B. & Biddle, N. Psychiatry as a career choice. Australian and New Zealand Journal of Psychiatry 1990;Mar;24(1):57-64

EDUCATION
Evidence based case report Sore throat: diagnostic and therapeutic dilemmas
Anna Graham, Tom Fahey (September 1999) [full text...]

Ronny Gunnarsson (May 9th, 2003)
MD PhD, Dept of Primary health Care, Gothenburg, Sweden ronny.gunnarsson@infovoice.se

Carriers of potentially pathogenic bacteria (such as Streptococcus pyogenes) simultaneously ill from a viral infection, complicate the diagnostic procedure in respiratory tract infections (such as the sore throat). The present statistical methods available for the evaluation of common diagnostic tests either ignore the phenomenon of carriers or provide test characteristics that are difficult to apply in clinical decision making.

The etiologic predictive value (EPV) is a new statistical method developed for determining the probability of symptoms being caused by a bacteriological finding, while taking carriers into consideration. This enables us to estimate the impact that carriers will have.

A webbpage describing EPV, (including an on-line EPV-calculator) and providing a link to a thesis presenting evaluation of throat cultures in patients having a sore throat is found at: http://www.infovoice.se/fou/epv/

EDITORIALS
Is it time to end taking oaths?
Andrew Moscrop (May 2003) [full text...]

Alex Keith (May 16th, 2003)
BMSc after 4th year, University of Dundee siegfried47@hotmail.com

What is an oath except a public declaration of an awareness of ethical principles and an expression of a moral viewpoint? Whehter or not to act in accordance with that oath is entirely up to the conscience of the individual. The point is it is directive. To be made aware of ethical principles is not to say "i will adhere to them". An oath, by the very nature of it's public declaration, does not just invite the "swearer" to be aware of the principles enshrined within it. It encourages him to think before he takes the oath about what it will mean for his practice following the declaration.

In this era of "grey areas" and "ethical dilemmas" this may be an unfashionable idea. My assertion is that the idea is unfashionable not because it is wrong, but because it doesn't allow for uncertainty and equivocation. An oath, based upon a concrete ethical code, allows for only one correct answer to any situation. Why is this deemed unworkable?

I do not accept that their is a danger in doctors having strongly held moral or religious convictions because I do not believe that a competent physician would act purely upon the strength of his own moral viewpoint. To say "i would not have acted as this patient has done; what i would do ni this situation is different from what they want" is not to say "their actions are inexplicable and they do not deserve my help". Doctors need tohave a moral viewpoint that simultaneously directs their action and that can accommodate the temporary moral, or amoral, world that each of their patients represents.

NEWS
Scottish medical students accept acts of academic misconduct
Stephen Goldie (May 2003) [full text...]

Alex Keith (May 16th, 2003)
BMSc after 4th year, University of Dundee siegfried47@hotmail.com

It will, I hope, be seen as a rather entertaining juxtaposition - an article declaring that students should stop taking oaths side by side with an article suggesting students accept academic dishonesty.

I was in my first year at Dundee University when a fourth year student presented us with a questionnaire for her fourth year project - a year long research SSM. I can assure your readers that myself and my classmates never thought that the results of the study might be published and would come back, some day and haunt the participants by suggesting, to a national audience, that we are dishonest. I draw only a little comfort from the fact that out of the students who participated my year was the most "honest".

The defence of the students at the time of first publication was pretty lame and the robust response of faculty secretary, Walter Williamson, this time might be related to the slant the current re-print has taken: the students became more dishonest whilst passing through medical school; cheating is learned (by modelling?), not congenital!

Whatever, the thing that most grates with the students who participated, is that the study makes no comparison with other medical students. There is an implication that Dundee students are dishonest, but maybe students elsewhere aren't. It would also have been appreciated if the faculty of medicine, who are always delighted to see their students work published, had shown a little more foresight in this instance or at least apologised to the affected student body for allowing an (over?) eager classmate to besmirch our name!

LETTERS
Medical students should be taught suturing
Sameer Trikha (May 2003) [full text...]

Sameer Trikha (May 20th, 2003)
5th year Medical Student, Southampton University Medical School st298@soton.ac.uk

In response to Paul Wright's article (May 2003), I can only whole-heartedly agree with the author's point of view regarding Suturing techniques being taught at an undergraduate level. As a final year student at Southampton University Medical School, I have been in the fortunate position of experiencing Suturing 'workshops' in both the third year and final year, whilst on general surgery placements. These workshops took the form of 2 hour sessions, initially based in 'clinical skills areas' - departments created purely for undergraduates and Junior Doctors to hone their clinical skills. These workshops were principally conducted by a clinical skills co-ordinator and a consultant surgeon, and supported by two or three registrars. Students were shown basic techniques and then allowed to practice on models with artifical wounds. The sessions were a fantastic success, serving both to instill confidence in the students, whilst providing some basic skills applicable for future clinical situations. I would encourage all students to take up these workshops at their respective institutions.

Paul K Wright (2003) Medical Students should be taught Suturing, Volume 11, Student BMJ, May 2003 submit: Send response

LETTERS
Medical students should be taught suturing
Sameer Trikha (May 2003) [full text...]

Richard Wilkin (May 20, 2003)
4th Year Medical Student, University of Liverpool richardwilkin@doctors.net.uk

I write in response to Wright's letter(May) regarding the teaching of suturing to medical students. I am in agreement that stundents should be taught to suture. Here at Liverpool we are taught the basic technique and have the chance to practice our skill on plastic arms as early as the second year. I believe that this is a valuable part of the undergraduate course, however the reasoning behind delaying the teaching may be that there is a risk of overload of information too early in a persons medical teaching.

The one proviso involved in the early teaching of suturing would be that it needs to be backed up with a regular opportunity to practice the skill. If there is no refreshment of techniques then they will inevitably fall in standard.

LETTERS
Clinical attachments need reform
Bhavesh Kumar (April 2003) [full text...]

Shivani Misra (May 21th, 2003)
Medical Student, 4th year, Bart's and the London shivanimisra@netscape.net

Kumar, in his recent letter, suggests that clinical attachments need to be reformed1. While I agree with this notion, my main concerns lie in the perceived responsibility attachments have in directing career choice.

Experience of particular specialties, is very much team dependent. A good firm where Consultants are proactive and encouraging, Registrars happy to teach, and SHO's /PRHO's friendly and approachable, undoubtedly results in an excellent clinical attachment and consequently experience of the particular specialty.

Specialties, which have initially been found to be of little interest, may result in changed opinion, based on the fact there was a good team, who were pleased to be shadowed and keen to involve medical students. Unfortunately the converse is also true; subjects, which have inspired early on in training, may cease to do so subsequent to poor attachment experience.

A recent study examining career intentions pre and post-psychiatry attachments concluded that 'Change in attitudes and career intentions was dependent on the actions of the clinical teachers and that the undergraduate teachers may also have an important influence on the numbers of doctors who choose this specialty as a career. 2

If this conclusion can be extrapolated to other specialties then it is perhaps misguided to exclude or include career choices on the basis of attachment experience.

Consequently medical students should base career intentions on where their interest lies, without relying too heavily on experience of firms. Career days and specialist advisers should be taking advantage of, if an informed decision regarding which field to pursue is to be made. Medical schools also need to integrate career advice into their undergraduate programmes in order to promote career choices in keeping with national needs and in tune with students' initial intentions. 3

Kumar, B.Clinical attachments need reform. StudentBMJ. 2003; 11 :124
McPartland, M. Noble, LM. Livingston, G. McManus, C. The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career. Medical Education.2003;37,5: 447
Katona, CLE. Maidemnt,R. Livingston, G. Katona, M. Whitaker,E. Medical career choices - lessons for undergraduate training. BMJ. Rapid response (31st Jan, 2003)