M E N T O R

M E N T O R
Issue 4
November 30 th 2016
10 Questions with:
The coroner
Practical medicine:
The poorly understood perils of
disease screening
Extreme physiology series:
Extreme cold
Reaching the end:
Should families get a say in
end of life care?
-
From day one to the end of year
five, your family will think of
you as their own, most personal
doctor

Start discovering the world of medicine.
Page 7
10 Questions with the coroner
Page 11
Making the same mistake twice
Page 15
Keep me alive // Let me live
Page 18
How to calculate QALYs
Think about what you have learnt and question it all.
Page 21
Family matters
Page 26
Is there a doctor in the house?
Page 30
No shame in fat shaming
Study to get the knowledge you need.
Page 35
The screening paradox
Page 40
Ask a physiologist: Baby, it’s cold outside
Page 47
Unprepared for autopsy
Page 48
Why we shouldn’t have got rid of the LCP
Get involved with Medic Mentor and help others, too.
Page 53
We’re going through changes
Page 63
Demystifying MMIs
Page 66
Puzzles
Page 70
Bad parenting
Page 72
Dope article, bro
MEDIC MENTOR magazine
Motivating medical minds
Issue 4; November 2016
2 3

References
Making the same mistake twice: 1. International centre for evidence in disability (London school of hygiene and tropical medicine) “The Zika babies what do we know and what should be done?” 2. BBC News Health: Zika outbreak:
What you need to know 31 August 2016 3. Spain registers first Zika microcephaly birth in Europe 25 July 2016 4. Zika vaccines show early promise 4 August 2016 5. Zika outbreak: ‘Small number’ of cases found in Scotland 4 Augut
2016 6. The Guardian: Scientists edge closer to creating effective Zika virus vaccine 4 August 2016 7. The Guardian: World Health Organization declares Zika virus public health emergency 1 February 2016 8. The Guardian: Zika
virus spreading explosively, says World Health Organization 28 January 2016 9. ScienceMag WHO director calls emergency zika meeting 28 January 2016 10. News medical life sciences: Researchers estimate total number of people
who may become infected by Zika virus 26 July 2016 11. WHO: Factors that contributed to undetected spread of the Ebola virus and impeded rapid containment January 2015 12. NBC News: Experts Urge Quicker Action on Zika
27 Jan 2016 13. The Telegraph: Science News: Zika outbreak is now a global emergency, says World Health Organization 2 Feb 2016 14. UK Reuters: U.S. researchers call for WHO to take rapid action on Zika 27 January 2016
15. PBS News HEALTH: Why is Zika virus spreading so quickly? 28 January 2016
Keep me alive // Let me live: 1. The Other Side, Kate Granger 2. The Price of Life, Adam Wishart https://vimeo.com/4796083 [Accessed 19th November 2016]
How do you work out a QALY: Material is entirely original, but inspired by an online e-learning module, Valuing Health, produced by the University of Sheffield on futurelearn.com [Accessed 19th November 2016 with permission
from the University of Sheffield]
Idiosinkratic [artwork]: Artwork by Jamie Crawford. More artwork can be viewed at facebook.com/idiosinkratic or idiosinkratic.wordpress.com
No shame in fat shaming: 1. http://www.bbc.co.uk/news/uk-england-york-north-yorkshire-37265752 [Accessed 19th November 2016] 2. https://www.b-eat.co.uk/about-beat/media-centre/information-and-statistics-about-eating-disorders
[Accessed 19th November 2016]
Write for us
All of the articles, photographs and illustrations included in this magazine were submitted by medical students or
sixth formers. Your past experience should not dissuade you from contributing; I can assure you, first drafts rarely
resemble the final, printed piece. We are here to help you develop your writing ability, all that is required is enthusiasm
and dedication. The two are usually linked.
We have produced a writing guide to aid authors, as well as a list of article suggestions for those struggling for ideas.
Both are available from the Medic Mentor website group, Magazine Contributors. Sign up now and give them a read
before you start work, http://medicmentor.co.uk/groups/magazine-contributors-28021278/
If you want to see your work in the next issue of Medic Mentor, please get in touch.
No shame in fat shaming [artwork]: 1. Meghan Trainor, All About That Bass 2. Image taken from Kumar and Clark’s Clinical Medicine Eighth Edition
mag@medicmentor.org
The articles printed do not necessarily reflect the views of Medic Mentor, its staff, or even the authors themselves.
From the editor’s desk
In September 2017, Medic Mentor will launch the Mastering Medical School Conference, and students will attend
from a range of ages and stages of life. For those who are yet to even get an offer for medicine, but are attending
a workshop on how to make the most of their time at university, it will doubtless end up redundant. They will, of
course, hear excellent ideas from inspiring speakers, but the kind of student who thinks that far ahead needs little
more than a gentle nudge in the right direction - the first domino.
By the end of the first half of the year, I will have sat my final medical school exams and there will be nothing to
prevent me from graduating and claiming the title, Dr The Editor. It may seem like that is a very long way away
for many of you, in the same way that it may seem like an awful lot of hard work to write two thousand words for a
magazine. Allow me to convince you otherwise.
I commenced university in 2011, and that plant in the background picture to the left was half its current size. I
had never considered writing an article, let alone running a magazine; in fact, I thought that magazines were a big
waste of money and largely ethically disastrous. A few magazines have maintained that impression. I was a scientist
through and through, and my first university essay assignment (on the history of medicine) was an awful disaster. If
it was submitted to me as an article now, I can imagine I would have my work cut out in editing it.
My family were not particularly surprised when I came to them with my concerns regarding the career choice I had
seemingly made too young. They were hugely supportive of me taking an extra year to complete university, even
though that meant living in London and the financial support this necessarily entailed. I think they were behind me
because they could see that I was doing something I genuinely enjoyed and was putting all of my energy into. They
will, however, be hugely relieved when all of this is over, I’m sure. That extra year was the beginning of my realisation
that it is not enough to just get on with what you are told to do, and allowed me to see the parts of medicine
that I could genuinely love.
I would suggest that what you do in 2017 is of vital importance. Medical school’s impact on your life is prescribed
only insofar as you are required to pass exams once a year, the rest is open to interpretation. With your free time you
need to find things you’re interested in and pursue them with vigour (and then write an article explaining why we
should all be interested too). It is never too early to start, and your family, whatever form they may take, will support
you in your choices along the way.
The screening paradox: 1. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072602/ 2. http://gut.bmj.com/content/early/2011/11/22/gutjnl-2011-300843.full#ref-7 3. http://gut.bmj.com/content/56/5/677.abstract?ijkey=07da10c991ab026abc43f67e658d9d627f91a3e0&keytype2=tf_ipsecsha
4. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival#heading-Three 5. http://
www.cancerresearchuk.org/about-cancer/type/prostate-cancer/about/screening-for-prostate-cancer 6. http://jnci.oxfordjournals.org/content/107/1/dju366.short 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002498/
8. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/563505/nhs_breast_screening_helping_you_decide.pdf 9. http://www.breastcancer.org/research-news/false-positives-may-be-linked-to-higherrisk
[All accessed 19th November 2016]
Unprepared for autopsy: 1. Bamber, A. R. & Quince, T. A., 2015. The value of postmortem experience in undergradutae medical education: current perspectives. Advances in Medical Education and Practice, Issue 6, pp. 159-170.
2. Bamber, A. R. et al., 2013. Medical Student Attitudes to the Autopsy and Its Utility in Medical Education: A Brief Qualitative Study at One UK Medical School. Anatomical Sciences Education, Issue 0, pp. 00-00. 3. Goodwin,
D., Machin, L. & Taylor, A., 2016. The social life of the dead: The role of post-mortem examinations in medical student socialisation. Social Science & Medicine, Volume 161, pp. 100-10
Family.
Dear reader: The retracted article is taken from the Lancet; Wakefield 1998 (full reference as per the image).
Bad parenting: 1. http://www.telegraph.co.uk/news/health/children/10880127/Parents-arrested-over-15-stone-child.html 2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30054-X/abstract 3. Health
and Social Care Information Centre. Health Survey for England, trend tables: 2014. HSCIC, Leeds, 2015. www.hscic.gov.uk/pubs/hse2014trend 4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and
adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814 5. Steinbeck K. The importance of physical activity in the prevention of overweight and obesity in childhood: a
review and an opinion. Obes Rev. 2001;2:117-130. 6. Sjoberg RL. Obesity, shame, and depression in school-aged children: A population-based study. Pediatrics 2005;116(3):389-392 7. Griffiths LJ, Dezateux C, Hill A. Is obesity
associated with emotional and behavioural problems in children? Findings from the Millenium Cohort Study. Int J Pediatr Obes. 2011;6:e423-432. 8. Bouchard C. Childhood obesity: are genetic differences involved? Amer. J. Clin.
Nutr. 2009;89:1494S–1501S. 9. Hoed, Marcel, et al. “Genetic susceptibility to obesity and related traits in childhood and adolescence influence of loci identified by genome-wide association studies.” Diabetes 59.11 (2010): 2980-2988.
10. Johannsen DL, Johannsen NM, Specker BL. Influence of parents’ eating behaviors and child feeding practices on children’s weight status. Obesity 2006;14;431–439 11. Department of Health. Healthy Lives, Healthy People: Our
strategy for public health in England. DH, London, 2010. www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_127424.pdf 12. World Cancer Research Fund and American Institute for Cancer
Research . Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. American Institute for Cancer Research; Washington, DC, USA: 2007 13. Carlson SA, Densmore D, Fulton JE, Yore MM, Kohl
HW. Differences in physical activity prevalence and trends from 3 U.S. surveillance systems: NHIS, NHANES, and BRFSS. J Phys Act Health 2009;6:S18--27
Dope article, bro: 1. http://www.telegraph.co.uk/sport/football/players/lionel-messi/10487181/Lionel-Messis-improbable-progression-from-struggling-youngster-to-world-super-star.html [Accessed 19th November 2016] 2.
http://www.dailymail.co.uk/sport/worldcup2010/article-1282961/Gordon-Banks-Peter-Shilton-Jeepers-keepers--I-split-Englands-legends.html
In this edition we are going to explore some issues related to families. They play a huge role in both early life, as
they raise you into the adult you are now, and end of life, when the table is turned and you need to care for your
old and decrepit parents.
I hope you enjoy it. If you have any comments, I would be delighted to receive them, and they may even be printed
as Medic Mentor magazine’s first ever letter.
Michael Houssemayne du Boulay
Editor
Down: 1. Embolus 2. Carcinoma 3. Sputum 4. Alveoli 5. Tachypnoea 6. Inhaler 7. Oxygen 8. Salbutamol Across: 4. Asthma 9. Tuberculosis 10. Bronchi 11.
Cilia 12. C.O.P.D 13. Pulmonary Anagrams: 1. High blood pressure 2. Respiratory rate 3. Gastrointestinal 4. Morphine 5. Asthma 6. Oestrogen 7. Myocardial
Puzzle answers
infarction 8. Nervous system 9. Osteoarthritis 10. Diabetes mellitus
Many thanks to Jennifer. N. R. Smith,
who produced the cover artwork.
www.jnrsmith.co.uk
4 5

10 Questions with: the coroner
Michael Houssemayne du Boulay
DDiscover
After several requests from readers
and medical students, I decided it
was time to set aside a little time to
find out what a career in medical law
entails. I got in touch with Richard
Baker, who was, until recently, an
assistant coroner in South Yorkshire.
1. What is a normal day like, if a ‘normal’
day exists for you?
I am a barrister, practising medico-legal
work, who sat as an assistant
coroner between 2011 and 2016. An
assistant coroner holds a part-time
role in the coroner’s court and usually
undertakes sittings in between
working full-time as a barrister or
solicitor. As an advocate, I was naturally
drawn to the side of the work
that involves examining witnesses
and testing evidence. I soon discovered
that this is only a small part of
the role, though, as a coroner has
conduct of an investigation from the
point where they are notified of a
death, through to the conclusion of
an inquest. They are responsible for
organising the investigation, determining
which witnesses will need to
be called, which experts are needed
to resolve the issues in the case and,
ultimately, calling those witnesses to
give evidence and reaching a conclusion
on the case. No two days are the
same.
2. What are the official and legal duties of
the coroner?
The coroner is responsible for investigating
all unnatural
deaths that occur within their jurisdiction.
This can be as simple as
determining that a person died from
natural causes, or could involve the
investigation of major disasters. The
coroner is not, save in very limited
circumstances, expected to conclude
that a person’s death was somebody
else’s fault. Attributing blame for a
death is the role of the civil or criminal
courts. In most cases, the coroner’s
role is limited to examining:
who the deceased person is, when
they died, where they died, and how
they died.
3. How many coroners are there in Britain?
Or how large an area do you serve?
I’m not sure I would like to hazard a
guess at the total number of coroners
there are in England and Wales. The
country is split into 108 geographical
areas, covered by 98 senior coroners,
who each has a number of assistants.
South Yorkshire, for example, is split
into Western and Eastern Districts,
each responsible for 3,000 – 4,000
deaths per annum.
4. Do you need to have a medical or legal
background to become a coroner?
Many coroners practised as doctors
before becoming coroners, otherwise
all coroners are barristers or solicitors,
who have been qualified for at
least seven-years.
5. What was your route into this career?
After my A-Levels, I read law at
university before undertaking the
bar vocational course. Afterwards,
I obtained pupillage at a chambers
in London, where I practised as a
barrister for 10-years before applying
to be an assistant coroner. People
qualify as solicitors or barristers
through different routes, though. It
is far from essential that someone
reads law at university, for example.
Vacancies for assistant coroners are
now advertised by local authorities
and posts are allocated after a competitive
interview process.
[Murder mysteries] are frequently too neat and I
think that they might tend to encourage people
to believe that life necessarily involves twists and
turns or surprise endings. Most cases are routine
and rely more on hard work than inspiration.
6. Are you a fan of murder mysteries? Silent
witness comes to mind…
Not since I started working as a
lawyer. Very often they are too far
removed from reality to engage me.
They are frequently too neat and
I think that they might tend to encourage
people to believe that life
necessarily involves twists and turns
or surprise endings. Most cases are
routine and rely more on hard work
than inspiration.
7

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Making the same mistake twice
Sandra Mireku
7. I suppose you find yourself faced with some pretty
gruesome cases at times. Do you find the job of the
pathologist [who performs the autopsy] unpalatable
or is that another area you would be interested in?
It does not help to be squeamish. I lack the
medical training to do the work of a pathologist
but being comfortable with traumatic
photographs and accounts is an essential
part of my job. It is perhaps more important
to remember that the images represent
a human being who may have had family
and loved ones. Their experiences, grief
and loss are often more difficult to come
to terms with than the images in a book of
photographs.
8. I understand there are medieval laws that require
treasure troves [long lost treasure with no identifiable
heir] discovered to be declared to the coroner: has this
ever happened to you?
I’m sorry to say, it never has. Treasure trove
is a speciality in itself but absolutely fascinating.
It requires skills that are common
to all areas of coronial practice, the ability
to marshal evidence, analyse that evidence
and reach a conclusion.
9. Where does one go in their career once they are
the coroner?
The role of senior coroner is an end in itself
and having responsibility for a coroner’s
area is a full-time job. For assistant coroners,
the role either leads to a full-time post
or is an adjunct to their main career.
10. What advice would you give to a student who
thinks they might be interested in medical law?
Ask why the role appeals to you. A good
medical lawyer will have an analytical mind
but also human empathy. A person who can
deal sympathetically and justly with the bereaved
is better qualified than someone who
is fascinated by death and trauma.
93
million. This is the
estimated number
of people that will
be infected with Zika
virus in Latin America and the Caribbean.
Not only due to a lack of
vector control but the fact that no
vaccine has been found yet.
When I first heard a news report on
the Zika virus I naively thought: it is
just another mild, small scale virus,
exaggerated by the news, but will
quickly blow over in a few weeks.
However, I have come to understand
that there is certainly more to the
no symptoms. This unawareness
could lead to Zika spreading quicker
and, in fact, more than one million
have been infected so far.
After further research into this virus,
it is clear to me that the epidemic has
become even more complex. New
findings are constantly evolving with
the virus and there is still a wealth
of knowledge that researchers are
yet to discover concerning the havoc
that the Aedes aegypti mosquito
is wreaking. Also, according to researchers
Gostin and Lucey, even
with accelerated research, it will take
more likely to struggle financially,
exacerbating the situation. In many
pockets of the world, there is already
limited access to health services, particularly
in the poor and underdeveloped
north-east of Brazil where
the outbreak is more concentrated.
There is also worry about the future
of these children because of the low
quality of life that they are likely to
experience, especially where social
stigma, isolation and discrimination
is rife.
There is also another question to
ponder: does Zika have the potential
Just as ebola spread rapidly in urban areas and densely populated slums containing
poor infrastructure, limited healthcare resources, and hospitable
environments for the mosquitoes, the Zika virus is also following suit.
A good medical lawyer will have an analytical
mind but also human empathy. A person who can
deal sympathetically and justly with the bereaved
is better qualified than someone who is fascinated
by death and trauma.
story after the World Health Organisation
(WHO) declared the Zika
virus a ‘public health emergency of
international concern’ in February
2016. This was due to the widespread
nature of the outbreak and
its ability to cause serious complications
for the babies born of infected
pregnant women, namely congenital
Zika syndrome (the microcephaly
we have heard so much about).
80% of the people infected by Zika
do not develop significant symptoms.
You may perceive that this is at least
some good news as it is a relatively
mild virus, however it makes the situation
“more serious than we can
imagine”. People have been infected
but don’t know because they show
3-10 years to find a vaccine or treatment
due to the complexity of this
virus.
Therefore, the question that hangs
in the air is: what happens during
this time? Will Zika spread to further
countries in Europe since it
has already made an appearance in
Scotland and Spain? Will the Aedis
aegypti mosquito die out or will it
linger; persistent and intolerable?
How many more innocent babies
will die or become disabled for life as
a result of microcephaly?
There are many psychosocial impacts
aside from the health implications
to babies. As a result of treatment
needed, poorer families are
to kill as many people as the Ebola
virus did? As I have already mentioned,
Zika infection is largely mild,
with most people developing no
symptoms of note. Despite this, we
should be aware that it is escalating
and should not rule out its potential
to be as large scale as Ebola was. As
the world saw, it sadly killed over
10,000 people.
Zika is not contagious in exactly the
same way as Ebola was but there
is evidence to compare the mechanisms
of the spread of the Ebola
and Zika viruses which points to
some similarities. Firstly, with these
two viruses, it is difficult to know if a
person has it as the symptoms could
be mistaken for other ailments. Sec-
10 11

ondly, delayed detection means that it
takes months to identify the viruses as
the causative agents for the diseases that
they each cause. Thirdly, the locations
heavily affected were caught unprepared
for both viruses. For Zika, it had never
touched South America and the Caribbean
before; and with Ebola, most West
African countries had never experienced
an Ebola outbreak, and there had never
been one of such magnitude. This means
that the countries were ‘immunologically
naïve’ as each of the populations had no
immunity to the diseases and were susceptible.
Just as Ebola spread rapidly in
urban areas and densely populated slums
containing poor infrastructure, limited
healthcare resources, and hospitable environments
for the mosquitoes, the Zika
virus is also following suit.
Additionally, international travel has
played a role in rapid transmission. The
importation of Ebola into Lagos, Nigeria
on 20th July and Dallas, Texas on 30th
September marked the first times that the
virus entered a new country via air travellers.
Zika, which first arrived in Brazil
last year, has found its way into around
40 other countries in the Americas – and
now including Florida in the USA. Countries
such as India, Indonesia and Nigeria
are also predicted to be at high risk with
up to 5,000 passengers a month arriving
from Zika endemic areas.
You can see why it is important that the
extent of human disaster witnessed with
Ebola is not repeated in history with the
Zika virus. Certainly, lessons should be
learned from what happened with Ebola
and applied to Zika to prevent its rapid
spread. The WHO have been widely criticised
for their delayed response to slow
the rapid transmission of the Ebola virus,
and they have admitted that they were, in
fact, too slow to act.
Although vaccine trials are underway,
it is indispensable that the international
community is mobilised to act faster to
prevent the rapid spread of Zika after its
delayed detection and response. Moreover,
some experts have even said it is past
time to act, just like it was with Ebola.
This follows claims that the WHO is not
acting as swiftly as it could since the Zika
infection is not seen as clinically serious
for the majority of infected individuals, it
is microcephaly that is more concerning.
Therefore, they are being urged to take
quicker action to stop what could become
a devastating epidemic. It is simply not
safe enough to continue at the pace that
we are going now, as the virus is advancing
dangerously.
Artwork by Emma Rengasamy
12
13

Editor’s Prize for
Keep me alive // Let me live
writing 2016
Congratulations to Elizabeth Georgina Ryan Harper who has won this year’s
Editor’s Prize for a written contribution. Her work, “Been there, done that, got
nothing but the t-shirt” can be seen on page 19 of the May edition.
Elizabeth will receive £100 in book vouchers.
Highly commended goes to Rebecca Wray, whose work, “The screening paradox”
can be seen in this issue on page 31.
________________
All submissions in a calendar year are eligibile to win the Editor’s Prize. The award
goes to the piece of work deemed to be of the highest quality; taking into account
the originality and polish of the final piece, as well as the steps undertaken to achieve
it. The winning piece is chosen by the editorial team.
Simple daily decisions, such
as whether to have an apple
or a chocolate bar, to take
the stairs or the lift, or even
whether to re-read your favourite
book or binge-watch yet another
TV show all have an important impact
on a person’s life. The ‘correct’
choice for each of these scenarios
can lead to a healthier lifestyle and
increased longevity; values we ordinarily
rate highly. What you choose
to do with your time ultimately boils
down to how you want the rest of
your life to play out, although it does
not normally seem that our decisions
will have such far reaching consequences.
Sometimes, when you do
not have a whole lot of life left, the
decision you have to make is whether
to try and increase the number of
days you have left, or to make the
most of the ones that remain. Often,
both can be benefitted or detrimented
from the same decision; smoking
will lead you to an early grave, and
it will do so from a hospital bed attached
to an oxygen canister.
Ela Karbaron
out every last drop of life at any cost.
In my opinion, to prolong life in this
way, without regard for the way you
spend each day, is to live without
satisfaction. There is nothing about
spending your last days in a hospital
bed attached to countless tubes that
says ‘living’ to me. This may seem
unjust; after all, I’m not living each
day to the fullest. Many people my
age and younger, even adults in the
work force, are unsure of what they
somewhere you have always wanted
to go, to volunteer with the elderly
to give you a sense of responsibility
and fulfilment, or even to make that
extra effort with your friends and
family. One thing all of these examples
have in common is that they encourage
and secure enjoyment and
happiness. These may not be your
goals, but you must have a purpose,
whatever it is, in order to meet the
definition of living: ‘the pursuit of a
lifestyle of a specified type’. It is not
There are those treatments that give you extra
days, and others that give you better days. There
are some that do both and others that, sadly, end
up doing neither. When it comes to make the
choice, if you cannot have both, which do you
decide to take?
To be alive is simply to continue
breathing. It is what you do whilst
you are alive and breathing that
matters. To prolong life, with
no purpose other than to keep the
heart ticking over, would be to completely
disregard the quality of life
a patient desires. They are existing
without any fulfilment or satisfaction.
To prolong living, however,
is to increase the time in which
you can achieve the things you want
to achieve and live the life you wish
to lead. Most of the time, there is no
decision to be made between the two
but, eventually, for many patients,
push comes to shove and we have to
decide; go out in flames or squeeze
are aiming for in life. We are living in
the rigid routine that school or work
forces upon us. We are unable to live
each day exactly as we wish, but that
doesn’t mean to say that teenagers
are not living. Each of us must draw
our own line, but it is rarely a case
of choosing the single best thing in
all walks of life. It is usually other
choices that determine whether we
are truly experiencing enjoyment
and doing things we love, and it is
up to us to make choices that have
a positive impact on our lives, with
whatever spare time we have to
make them. This could be to travel
enough to spend your days without
aim; we talk about a person’s raison
d’être for good reason.
The terminally ill are faced with
the very real decision of what to do
with their remaining days. For the
purpose of this article, I have divided
their options in two: prolonging
living, or prolonging life. There are
those treatments that give you extra
days, and others that give you better
days. There are some that do both
and others that, sadly, end up doing
neither. When it comes to make
the choice, if you cannot have both,
14
15

which do you decide to take?
Cancer patients have been exposed to this
dilemma more than the regular person,
and their treatment is shaped around it.
Chemotherapy is the use of cytotoxic drugs
to target cancer cells. They kill cells very effectively,
but are not so good at distinguishing
cancer from normal tissue and this can
lead to some serious side effects: fatigue, for
example. Tiredness can take over your life
and last for months after the treatment has
finished. Your quality of life is on the line
when you cannot continue to do the activities
that define you as you. When that is the
situation you are faced with, when you are
too tired to seek any enjoyment from life,
which option have you really chosen? Other
rapidly dividing cells such as your hair can
be badly affected, leading to a change in appearance.
This can be horrifying for women
or younger patients as they stand out from
their peers, or feel stripped of who they are.
Maintaining self-esteem is vital, right to the
end of life, in order to go on living the life
you want to lead.
When reading ‘The Other Side’ by Kate
Granger, what struck me as harshly unfair
was the lack of choice the patient (who was
also a physician) had. She had been unintentionally
tasked with making the decision
of prolonging her life or prolonging
her living. After initially deciding to try to
squeeze out all of the extra days she could,
her final decision was to go with the latter,
something I consider a brave choice. It is
not a choice isolated to the patient at hand,
it affects other sick people too. By opting for
palliative care, you usually free up an extra
hospital bed as most of your treatment can
be done at home, leading to better care for
others. Additionally, attempting curative
treatments and further investigations tends
to be significantly more expensive than palliative
care. Those funds can be redirected
to someone with a more positive prognosis,
or that slot in the CT scanner can be used
in an emergency. This is not a case of martyrdom,
nor is it supposed to encourage patients
to give up the fight so that someone
else can have a shot – it is about accepting
when the battle is lost, and moving on.
These reasons are partly why I believe
to prolong living should be a priority. Of
course, how can I, or anyone, put myself
in the position of a cancer patient? It may
seem unfair to spout these beliefs, however I
hope these ideas may help put an important
decision in perspective for others that need
to decide.
In fact, people who do not have a terminal
diagnosis are making these kinds of decisions
for us on a daily basis. QALYs (quality
adjusted life years) are used to determine
the economic benefit of a medical interven-
Think NICE are getting it wrong?
Have a go at
working out QALYs
These may not be your goals, but you must have a purpose,
whatever it is, in order to meet the definition of living: ‘the pursuit
of a lifestyle of a specified type’. It is not enough to spend
your days without aim; we talk about a person’s raison d’être for
good reason.
tion. They allow healthcare funding bodies
such as NICE (National Institute for Health
and Care Excellence) to weigh the benefits
and drawbacks of permitting certain procedures,
or prescribing certain drugs. A price
tag is attached to each year of life saved by
a treatment, and this is amended depending
on the quality of that year (for instance, a
year spent in constant pain is not equal to
a year spent in perfect health). A problem
associated with the use of QALYs is that
they are ultimately assessing the economic
benefit of certain interventions, which fails
to take into account every personal factor
and whether intervention would be in the
interest of prolonging living or prolonging
life. What do I mean by this? Well, if a patient
only ever has one year left to live, and
a treatment would give them near perfect
health for that time, the intervention is still
only going to be worth one QALY. Technically,
a treatment which provides someone
with 20 years left to live, but at only at half
perfect health, is worth ten times the first
treatment. In effect, we are saying the second
patient is worth ten times more.
Fortunately, NICE does not have to directly
choose between two treatments in this way.
They have come up with figures that are
used to determine the viability of intervention,
with any treatment costing less than
£20,000 per QALY as ‘cost-effective’ and
£20-30,000 approved so long as certain criteria
are met.
The problem is still a real one, though, and
it is illustrated perfectly in a documentary
by Adam Wishart. It uses the case of patients
with multiple myeloma to explain
why QALYs disadvantage the terminally ill.
The drug in question was Revlimid, which
would be extremely beneficial in prolonging
living. It saw enormous symptomatic improvement
in a number of patients at trial,
but only increased their lifespan by months
or maybe a handful of years.
There is a lot more to this debate than can
be fit into one article. It is possible people
would never reach a consensus, given all of
the facts and all of the time in the world.
Perhaps no one can truly understand the
magnitude of this decision until they are going
through it themselves. The GMC makes
it clear that it is a doctor’s duty to show
respect for any life, so surely fulfilling this
respect requires allowing patients to continue
or start any treatment that will enhance
their ability to live. In saying this, there are
measures put in place to ensure that every
patient can still live in comfort and with
support. Palliative care provides a truly dignified
end to the dying, whether they are old
or young, active, or bed bound and allows
families to spend quality time together for
months or years before the end. If I were
asked to say what it means to prolong living
in one sentence, my response would be to
live life with intention and meaning, and to
make the most of every situation.
16 17

How do you work out a QALY?
It’s your turn to decide! The last thing that’s important to remember
is that you are supposed to choose assuming you will die at the end of
each scenario, not return to full health.
Health state 1:
Working out someone’s expected QALYs is simply a mathematical equation:
(Length of Life) x (Quality of Life) = Quality Adjusted Life Years
Full health gets a score of 1, and being dead gets a score of 0.
I am in no pain day to day.
I have moderate difficulty washing and dressing myself.
I have severe difficulty walking about.
I have moderate difficulty in my usual day to day activities.
I have no anxiety or depression.
So, if our patient was expected to live for 5 years, with a quality of life of 0.7, that is a total of
3.5 QALYs.
Obviously, it can be hard to predict how long someone is going to live for, but we can use a good
estimate. It is really hard to determine the quality of someone’s life, though.
Would you prefer:
10 years in health
state 1
Health state 2:
5 years in full
health
Or are they the
same?
Quality of life is determined by comparing
different health states and how much we value
them. In practice, this is done by giving
many people many paired scenarios and asking
them to choose one option in each pair.
For instance, would you choose to live for
10 years in a wheelchair or for 1 year in full
health?
That is a crude example, but it illustrates the
point. Have a go at the scenarios across the
page to see what you value most. In reality,
the health states people are asked to choose
between have multiple different factors to
consider.
Once enough data has been collected, the responses are used to apply a numerical value to each
health state (somewhere between 0 and 1). This allows them to be used for QALY calculations.
When you compare your answers to others, you will probably find that you don’t agree on
everything. That’s why these questions are asked to many people from all walks of life to try
and get a better understanding of what qualities people value in general. Of course, it can never
be perfect or accurate for every patient we will ever treat.
I am in severe pain day to day.
I have no difficulty washing and dressing myself.
I have no difficulty walking about.
I have mild difficulty in my usual day to day activities.
I have moderate anxiety or depression.
Would you prefer:
10 years in health
state 2
Health state 3:
I am in no pain day to day.
I have no difficulty washing and dressing myself.
I have no difficulty walking about.
I have severe difficulty in my usual day to day activities.
I am severely anxious or depressed.
Would you prefer:
10 years in health
state 3
5 years in full
health
5 years in full
health
Once you have made up your mind on each scenario:
Or are they the
same?
Or are they the
same?
If you chose the health state, increase the number of years in full health until the options are
equal in your eyes. If you chose full health, decrease the number of years of full health until you
would change your mind.
18 19

Family matters
Kirsten Vizor
TThink
sisters are obsessed
with his
bowel habits. I
“His
mean obsessed.
Every time I go in there I’m trapped
for ten minutes talking them through
it all. They just don’t get how unwell
he is, that he isn’t going to be making
it to his daughter’s wedding no matter
how much they want him to and
no matter how hard we try.”
Quiet smiles of understanding ripple
across the group.
Ward round, palliative care. This
happens a lot. There isn’t really a
sense of resentment from the staff,
but it does highlight an important
issue: many families feel they have
a right to be involved in their loved
ones’ end of life care. Do they?
Should they? In the face of stretched
resources, educated doctors, experienced
nurses, and limited time, do
they really get to be involved to any
real degree? Of course they do. In
the face of many reasons why they
should be kept well clear from any
decision making, kept a little more
than arm’s length from the drug
card, and politely requested to pipe
down when claiming they know best,
of course they should be involved.
Before I go on, I first want to address
the idea of ‘family’. When we ask
how involved families should be in a
patient’s end of life care, we should
be answering it with the patient in
mind. Traditionally, when we all
lived closer to one another in smaller
tribal communities, big life events
(weddings, births and, yes, deaths)
meant having your relatives around.
They saw you grow up, cared for
you, educated you, and loved you
for most of your life, but as UK demographics
shift so must our definition
of family. We scatter across the
world to chase our dreams, but we
still need those close bonds with people
who love us, and whom we can
love. Here, the term ‘family’ will refer
to anyone with whom the patient
has a real sense of love, trust, and
mutual support.
Let us briefly acknowledge the family’s
point of view; a nod to the
blindingly obvious. To face losing a
loved one seems an impossible, and
impossibly cruel, challenge. Dealing
with the enormous grief requires an
endless amount of patience, time,
and support. That support needs to
start before the end of their loved
one’s life. To be shut out by the
doctors only puts pressure on the
situation – pressure for the patient
to be the sole communicator about
their illness, pressure for the family
to learn about the disease process
and prognosis alone, and pressure
for everyone to keep their emotions
in check all the time for each other,
with no professional outlet. Distress
reverberates through a family pretty
quickly. If we can be a source of information
and a source of counselling,
we help families do what they
need to do: be there for each other.
There are many obvious reasons
why keeping people who know and
love our patients nearby might be a
positive part of their care package.
When someone is unwell, particularly
when reaching the end of their life,
there are many difficult conversations
to have and decisions to make.
Which treatment? Any treatment at
all? Where do you want to be when
you die? You’re tired, you’re poorly,
you’re probably on the spectrum of
feeling slightly uneasy to absolutely
petrified, and chances are you aren’t
going to remember every little salient
point the doctor or nurse makes
about your condition and care. Having
someone nearby to listen and
take notes, and who has the time to
go through all the facts again with
you later is hugely valuable. Having
someone else there, ironically, makes
it more likely that any decision you
make is your own.
We scatter across the
world to chase our
dreams, but we still
need those close bonds
with people who love
us.
Family involvement helps us manage
our patients and that is important.
We’re pack animals; for the most
part, we live and work in dynamic
circles and interact with other beings
as part of our basic instincts. We
rely on each other, look out for each
other, look after each other. Why on
earth should that stop right at the
moment that one of our pack needs
us?
For many reasons, actually. I am
not so idealistic as to think family
protection isn’t vulnerable to forcing
massive mistakes on a situation.
Families can pressure their people
to go through invasive and painful
treatments, against medical advice,
because they’re afraid of the in-
21

Fear is a powerful emotion, and our calmer moments can quickly leave us.
evitable loss that will follow if they
do not. Of course they are coming
from a place of love and devotion
but, equipped with fierce emotional
instinct and not enough reasoning,
a family member is often the most
dangerous person in that hospital
bay.
Put bluntly, families can be a massive
problem. They don’t know how not
to be. When you are about to lose
someone you love, you go into fight
mode and shed a detached sense of
perspective. In a situation where you
have very little control, you anoint
yourself the protector. Your world
becomes fighting for their life and
with that comes an understandable
but undeniable selfishness: keep
them comfortable and keep them
alive. Now.
Are patients sensitive to this? Of
course. You’re in bed, you’re exhausted,
you know what is happening
and what is going to happen.
You’ve had the difficult talks with
the doctor and have come to accept
your fate. But you look up from the
bed to see the terrified eyes of your
family and feel that, by ‘letting go’
and saying no to Drug X (despite
its delightful side effects that keep
you up all night in a nauseous daze),
you’re hurting them. Somehow, patients
find themselves in this impossible
situation of feeling guilty, trying
in vain to extend their lives to avoid
disappointing the pack. The wolves
are circling, but they aren’t here to
hunt. No, this pack is here to keep
you alive until the agonising end.
Without wanting to seem completely
heartless, families get it wrong. They
are being selfish. They have forgotten
how to think and function within
their family unit and wider society
with a nuanced sense of intelligence
or responsibility. When we aren’t
in that state of panic I hope we realise
that life isn’t permanent, that
we aren’t owed a certain amount of
time in this world and recognise that
it could be cruel to try and make it
so; that we live in a society trying
to do its best for everyone in it with
restricted resources. In our calmer
moments we can have intelligent (if
sometimes slightly heated) conversations
about quality of life and letting
go when the time is right. But fear is
a powerful emotion, and our calmer
moments can quickly leave us.
It is neither realistic nor helpful to
hope for a world where families
completely shed their selfish instincts
and approach this logically.
Their job is to love and protect, and
most families do this well. So, this
is where doctors come in. Our job is
to learn everything we can from the
families - let them tell us about their
person, about who they were before
they became ill so that we never
once lose an ounce of compassion
or forget about their strong sense of
spirituality. Let the family come and
hold us accountable for absolutely
everything we do. We should also
encourage the families to visit and
be grateful for the time they spend
caring – changing socks, bringing
favourite snacks, reading the paper,
and providing comfort and company
in the final days. Everyone has a part
to play in this tragedy.
I’m asking a lot from everyone here,
because this requires bravery and a
great emotional effort. We have to be
willing to both trust and defy families,
to trust ourselves to know when
to listen to the family and when to
listen to the patient. How? Watch
the interactions between patients
and visitors, listen to the patients
talking, listen to the family talking;
figure out who is really providing
that love, trust, and mutual support.
It might not always be who we think
it is. Not everyone walking into that
bay will be going in with the best intentions.
We’re going to have to engage,
to sort out the voices of grief
and panic from the facts. Try to find
the patient there, somewhere within
the family. Are we adequately taught
these skills as medical students? I, for
one, am unconvinced, but that’s a
whole other article on its own. So, it
is up to us to learn how: you need to
talk to families, talk to patients, talk
to other doctors and it is never too
early to start.
Consider the alternative for a moment.
If we do not let families in, we
lose a huge amount of insight into
our patient. We cripple their support
system and, in the absence of any
real direction from the patient, difficult
decisions are left to the system.
What type of care we provide, and
for how long, and where we provide
it, and where the patient is going to
end up spending their final moments
are decisions that need to be made
and we risk handing these responsibilities
over to a service without the
nuance or resources needed to make
them correctly. We would do our
best to make people as comfortable
as we can, but clinical acumen is not
enough. Patients need their people
and, like it or not, that means we
need them too.
Artwork by Jamie Crawford
facebook.com/idiosinkratic
22

Available to download at
www.medicmentor.co.uk
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Is there a doctor in the house?
The rest of the conversation falls away as meaningless chatter. Behind every
pause or slipped sentence I am wondering if this is the face of the disease.
My grandma was diagnosed
with vascular
dementia and my
family do not know
what this means. Not only do they
not understand the definition of the
problem (I partially blame the team
responsible for her care for this) but
also what shape her future is going
to take. What this means for me is a
host of phone calls and difficult conversations.
This is not new to me; I
received them in that proto period
of uncertainty before her diagnosis
took shape. The reason that I am
the one contacted in such an event is
that I’m the go to guy for my family’s
medical problems.
None of my family have any sort of
medical background and, despite
this modern age of medicine overreaching
itself and appearing all
over the media, they do not understand
what is happening. Why is she
behaving in that way? What can we
do to help her? In just five years of
medical training, I’m not sure I have
the answers, but it doesn’t stop the
phone from ringing.
Many of you who are applying, or
who have already applied, to read
medicine will have done so with the
same trouble I had. Medical experience
is invaluable for interviews and
personal statements alike. Of course,
it is only when you think back that
you realise how little you actually
knew. It is not just that you are unaware
of the vastness of the ocean,
you’ve never even seen the sea. All
the same, that modicum of information
is gold dust. However, if you
don’t have a close relative or a friend
who is a doctor or nurse or GP receptionist,
you may find yourself
George Aitch
shut out. I ended up working as a
healthcare assistant for a year (which
I enjoyed very much) to furnish my
CV. It was a leg up but meant I had
to defer my application.
At the other end of things, I expect
to finally graduate this summer. For
my family this means I am basically
a doctor, unless I am telling them
something that they don’t want to
hear:
‘I don’t think you have appendicitis.’
‘What would you know, you’re not even a
doctor yet.’
In August I attended my first family
wedding, which was lovely. All of my
relatives under one roof and a real
chance to catch up. People asked my
sister where she was applying to university
and my brother what it was
like to live in Hungary. When it got
to my turn everyone wanted advice
on their latest joint replacements or
this funny rash which had come up
on their arm. Resisting the urge to
roll my eyes, I dispense advice and
discuss problems. By the way did
you see that article I wrote about
volunteering in Guyana? No? Never
mind, back to your mother in law’s
cataract surgery then.
When it comes to GP visits, my family
fall into two different camps. First,
you have my dad. You have all met
this type; he ‘saves up’ his visits under
the misapprehension that he is doing
the doctor a favour. If you have him
sat in your waiting room, you can bet
that he has a rolled up piece of paper
in his pocket with all of the problems
he has suffered from in the last year.
It is impossible to get him to see a
doctor when anything happens. My
mum is the opposite. Whenever she
gets a blood test or result back, I am
the first to know. Luckily for all of us,
neither of my parents have anything
seriously wrong with them and are in
great health. Part of me is proud that
they put their trust in me (in a really
minor way), but it would also be nice
if both of them had more sensible
approaches to their health.
This won’t stop when I qualify, it will
probably get worse. I already have
an extensive background in telemedicine
via Skype and FaceTime. Has
anyone else had to diagnose a rash
via Whatsapp? If you’re really worried
then why not see a doctor? I say endlessly,
but it feels bad just telling them
to Google it. In fact, I’m sure I saw
something about that in the news a
few months ago…
We’ve long been aware that something
has been wrong with my
grandma; getting to her age tends
to have a few consequences on your
health. However, during a hospital
admission for a fall my parents and
aunt and uncle became concerned
about a change in her behaviour. As
is usual, they called me asking what
might be wrong. Cue an hour long
chat about delirium. Though when
it came to discharge these problems
did not go away. Being at the other
end of the country I asked them to
push for a psychiatry review, some-
And so I explain to my
kind and loving grandparents
the underlying
process behind vascular
dementia.
thing that none of them were keen
on.
Then suddenly, following a review
by the hospital staff, it all came out:
grandma’s gradual decline which
grandad had done everything to
mask. This recent fall was the tip
of the iceberg and he was running
out of his ability to cope. Being the
stoical type that he is, he never mentioned
what was going on and so we
never realised how difficult things
were becoming for both of them.
Now, one month later, grandma has
a diagnosis of vascular dementia
and I am on the phone with them
trying to put a brave face on it yet
give an accurate explanation at the
same time, all the while trying to
keep my emotion out of it. Needless
to say it is difficult.
What can you say? Dementia is as
a good as a terminal diagnosis (the
average life expectancy from diagnosis
is four years). This is the elephant
in the room. They know it
and I know it. Grandma has had to
watch her brother and sister suffer
with the same thing for a number
of years now. She dreads ending up
like them and we both know that it’s
inevitable. This is the curse of medical
knowledge; analysing with terror
every symptom and biopsy result,
scan and blood test. Not only can I
provide a realistic perspective on unfolding
events, but every worst case
scenario also flashes before my eyes.
It’s an extension of hypochondria.
And so I explain to my kind and
loving grandparents the underlying
process behind vascular dementia;
how it is distinct from Alzheimer’s,
how her recent short term memory
loss and anxiety have been caused
by a series of strokes affecting small
blood vessels in her brain. I compare
it to grandad’s TIA which he
had a few years ago. She is quick to
cut across me and point out that her
condition isn’t going to get better. I
can’t think of anything to say.
Already they have begun to plan
for the latter stages of the disease;
today they visited a day care centre
for people with dementia. Grandma
restates her fear of ending up like
those with advanced disease. I try
to reassure her but it’s an acknowledged
truth between us that one day
she will find herself in that position.
The thought of slowly losing your
memories and sense of self is terrifying,
even more so when faced with
the certainty that it will happen to
you. I cannot begin to understand
the place that she must find herself
in. I hope that I may never have to.
The rest of the conversation falls
away as meaningless chatter. Behind
every pause or slipped sentence I
am wondering if this is the face of
the disease. She forgets that I’m not
a doctor yet and in the back of my
mind I turn over how innocent this
lapse in memory might be. I am an
adult and a realist; I know that nobody
is around forever, but I was
hoping for a less cruel exit. The end
of the phone call is austere. Being
cheery seems inappropriate, as does
the usual ‘it was lovely to hear from
you’. Neither of us says it. I mention
that I’ll call back in a week or two
when they know more and we say
goodbye.
I can’t help what is set in stone. What
I can do is make the remaining time
more bearable: call more often and
check how she’s doing, that sort of
thing. It’s very do-able. The news has
destroyed me inside, I knew it would
from the first moment of my mum’s
voicemail message. The worst part is
repeating that same phone conversation
twice later to the rest of my
family.
Herein lies another challenge to
those entering a medical career,
one of many: the puzzling knot of
separating the personal from the
professional. Adopting the cool clinical
manner whilst still empathising
with the person in front of you is a
paradoxical skill which takes experience
to master. Breaking bad news,
discussing serious complications,
possibilities and anything with gravity
or even putting up an emotional
barrier for therapeutic reasons all
require it. The first experience we
might have of this could be in the
dissection room. The body in front
of you is a delicate learning tool but
first and foremost it used to be a person,
one whose generosity should
command respect.
With this in mind, I continue to be a
medical dictionary for my family. As
I write, my mum asks which meningitis
vaccines my sister should have
before going away to university.
When I go home for Christmas I am
sure that it will rear its head. On top
of that, mum will continue to keep
me up to date on my grandma’s advancing
dementia and I will try to
interpret everything that is happening.
Remind yourself that you were
once ignorant of the ocean and then
think how much wisdom you can
impart from just your short voyage
out of port. As a final year student I
have already accrued more medical
knowledge than most will gain in a
lifetime and I should feel incredibly
privileged. My parents have had to
support me, I suppose it is only fair
that they get something out of it.
26 27

No, I’m not a doctor yet
how are you?
oh really? that’s a shame
it was lovely to hear from you
no, that’s not until next week,
grandma
it was lovely to hear from you
it’s going to rain this weekend
it was lovely to hear from you
neither of us says it
I was hoping for a less cruel exit

No shame in fat shaming
Recently, a story emerged
out of the usual NHS media
flurry that will seem
particularly pertinent to
an ever-increasingly large proportion
of society. The Vale of York
CCG (care commissioning group,
the people who decide what treatments
the people of York are entitled
to) proposed a restriction on those
with a BMI over 30 receiving nonlife
threatening procedures. The proposal,
which would also have applied
to smokers, could have seen those
falling into these categories being
subjected to delays of up to a year in
receiving their surgery. Workarounds
to these rules were, however, present
(motivation, almost). Those with a
BMI of 30+ would have to lose 10%
of their body weight, and smokers
would be required to cease smoking
for eight weeks.
Shortly after this proposal was announced,
it was met with widespread
criticism from many organisations,
including NHS England and the
Royal College of Surgeons, who
damned the proposal as dangerous
and radical, eventually resulting in
the initiative’s rollout being halted.
Despite this, the topic was a springboard
for polarising debates amongst
many, especially those directly involved
in the healthcare field. Just
what motivated the York CCG to
reveal plans for such seemingly radical
interventions? Is their stance balancing
on the precipice of a greater
societal issue?
India Corrin
If one looks at the situation from a
purely medical perspective, there is
logic behind the proposals. It is well
documented in a plethora of medical
literature that obesity is crippling
people, both at an individual and a
population level. Obesity is just the
first step in catalysing a whole host
of debilitating medical conditions:
hypertension, stroke, diabetes, osteoarthritis.
The list reads like a practitioner’s
worst nightmare.
Once an obese patient has reached a
level of illness for which surgical intervention
is required, whatever the
surgery is for, risks increase dramatically.
Simply anaesthetising an overweight
patient poses significant challenges,
as ventilation once sedated
and supine on a table is significantly
more difficult to achieve (think of
all that weight pressing down on the
chest). This is, of course, in addition
to the greater duration required in
surgery to delve down past the adipose
tissue, the decreased visibility
once the organ or tissue layer has
been reached, and the increased
volume of blood loss throughout a
procedure. If ‘primum non nocere’
is one of the creeds lying at the heart
of medicine, then it would seem that
requiring patients to lose weight before
undergoing surgical procedures
is acting only to preserve this central
notion.
You cannot hope to write an article
on any aspect of the NHS without at
least considering financial implications.
There is constant and consistent
negative press regarding the dire
state of the NHS deficit, and a move
such as the one proposed by the York
CCG is surely designed with an element
of financial motivation. By
reducing non-essential surgical rates
in the excluded groups, it not only
cuts the hospital costs associated
with carrying out these procedures,
but would hopefully prospectively
save money by means of prevention.
Providing motivation for these
high-risk groups to stop engaging
in health-compromising behaviours
would hopefully break the initial
link in the chain of events ultimately
leading to costly medical intervention,
or at least delay the need for
surgery.
So, why the backlash? Central to the
issues clinicians have in simply dictating
what weight patients should be
is the warped modern manifestation
of free choice. Free choice is fundamental
to an increasingly progressive
stance on human rights and equality;
how could such a concept possibly
have sinister connotations? With
time, the phrase has been somewhat
manipulated to fit the seemingly
self-serving choices that individuals
make, especially with regards to
negative health behaviours. It has
become impossible to direct people
on the lifestyle they should be living
without being branded dictatorial,
a ‘nanny state’. Telling people what
weight they should be, or that they
should cease smoking, apparently infringes
on this basic human right to
choose to treat one’s body however
they wish. But are these decisions to
exercise free will in such a manner
really the way we should be using
the responsibility of free choice?
When the actions made by individuals
start to have a negative impact
on society at a greater level, is free
choice as beneficial as it is made out
to be? It may be a person’s right to
indulge in a third slice of cake, but
it is not their right to then incur a
cost on the taxpayer to fund the knee
replacement they eventually require.
Such championing of an individual’s
rights, whilst neglecting to consider
the wider impact one’s actions are
having, is starting to set a dangerous
precedent.
Should the blame be placed on individuals?
It does not take an expert
to see the staggering presence
that unhealthy foods and lifestyles
have in our society. With unhealthy
options costing less than half or a
third of a healthy equivalent, people
are almost constrained to making
poor nutritional choices; hands and
feet bound as they coast through
obesogenic life and straight off the
cliff that is diabetic middle-age. It
automatically creates an exclusive
environment where the ‘haves’ are
blessed with antioxidants and superfoods,
and the ‘have-nots’ are
condemned to a life of additives
and saturated fat. The government
has a responsibility to adopt a role
in preventing obesity-related illness,
and if prevention is the main aim of
York’s controversial proposals then
the CCG is simply fulfilling that
role. This should extend to widening
access to healthy food and providing
education to encourage health-conscious
behaviours. Sadly, this has yet
to come to fruition in any meaningful
way.
Violation of individuals’ perceived
freedom of choice is not the only
criticism of the proposals. Culturally,
the presence of social media in
society has made steady growth, to
a point where it is almost a defining
feature of rising generations. Social
media today is now an incredibly
powerful tool for communicating
one’s opinions on a widespread
scale, breeding various sub-cultures
and trends through which individuals
can share such opinions. Rising
up through the ranks are the ‘selflove’
and ‘body positivity’ movements
which belong to one particularly
prominent sub-culture.
These movements have honourable
aims: to encourage self-acceptance
and appreciation for oneself in the
face of society’s stringent rules of
what constitutes beauty or worth.
This is undoubtedly a step in the
right direction, and such attitudes
need to be broadcast; the prevalence
of eating disorders is rising at a rate
of almost 7% per year in the UK.
Younger and younger generations
are being plagued with vicious mental
and physical health issues surrounding
the need to have the ‘perfect’
figure or face, the attainment
of cachectic physiques or unrealistic
physical parameters.
Whilst being happy in one’s own skin
is laudable and not something towards
which we should be sceptical,
there is a distinction to be made in
the promotion of self-love and a lack
of desire to promote health. There
is a fine line between accepting one’s
appearance and demonstrating apathy
to implement change, and it
is in this balance that social media
has contributed to muddying the
waters. In place of the traditional
skeletal models, there has arisen
a new generation of social media
models inspiring people; models
labelling themselves as ‘plus sized’
are championing curves and ‘more
realistic’ physiques. These new, internet-made
celebrities have been
instrumental in spreading awareness
and acceptance of the self-love
movement, with a cult following on
social media acting to encourage
this message further.
Unfortunately, in promoting body
positivity, the movement has unwittingly
started to spread the message
that it becomes acceptable to be
grossly overweight, as long as you
are content in, and acceptant of, this
state. Even if someone is happy with
their size and appearance, if they
are overweight to a point where it
starts to impose a risk to their health,
should we be promoting the mindset
that they do not need to change
their figure? A difficult environment
is being created in which the ability
of health professionals to advise
patients on lifestyle choices is being
diminished by a feeling that such
changes need not be applied.
Where does progress lie in this maelstrom?
Chasing improvement at one
extreme of the spectrum just pushes
society too far in the other direction.
Using a dictatorial approach in directing
our patients towards better
health runs the risk of alienating
them and decreasing co-operation
and adherence to medical advice. As
prospective and current clinicians,
our concerns must lie primarily with
the safety and wellbeing of our patients
– it would be tantamount to
neglect if we were to simply ignore
these duties.
It cannot be denied that obesity levels
are on the increase and breeding
hosts of co-morbidities with resultant
increasing medical needs. Longitudinally,
the growth of this epidemic
must be stemmed and those
already falling into the obese category
must be helped to find a way
out of such a health-compromising
state. The solution may not lie in denying
certain groups access to surgery
or healthcare, but it is imperative
that we as a medical profession
persevere and keep trying to find
ways to turn the tide.
30 31

I'm all about that bass
'Bout that bass... bass... bass... bass
Yeah, it's pretty clear, I ain't no size two
But I can shake it, shake it, like I'm supposed to do
'Cause I got that boom boom that all the boys chase
And all the right junk in all the right places
I see the magazine workin' that Photoshop
We know that shit ain't real, come on now, make it stop
If you got beauty, beauty, just raise 'em up
'Cause every inch of you is perfect from the bottom to the top
Yeah, my mama she told me "don't worry about your size"
(Shoo wop wop, sha-ooh wop wop)
She says, "Boys like a little more booty to hold at night"
(That booty, uh, that booty booty)
You know I won't be no stick figure silicone Barbie doll
(Shoo wop wop, sha-ooh wop wop)
So if that's what you're into, then go 'head and move along
Because you know I'm all about that bass
'Bout that bass, no treble
I'm all about that bass
'Bout that bass, no treble
I'm all about that bass
'Bout that bass, no treble
I'm all about that bass
'Bout that bass... Hey!
I'm bringing booty back
Go 'head and tell them skinny bitches that
No, I'm just playing, I know you think you're fat
But I'm here to tell you...
Every inch of you is perfect from the bottom to the top
Yeah my mama she told me, "don't worry about your size"
(Shoo wop wop, sha-ooh wop wop)
She says, "Boys like a little more booty to hold at night"
(That booty booty, uh, that booty booty)
You know I won't be no stick figure, silicone Barbie doll
So if that's what you're into, then go 'head and move along
Because you know I'm all about that bass
'Bout that bass, no treble
I'm all about that bass
'Bout that bass, no treble
I'm all about that bass
'Bout that bass, no treble
I'm all about that bass

The screening paradox
Rebecca Wray
SStudy
There is pressure on doctors
to deliver screening
regardless of negative
or controversial expert
opinion. When faced with medical
decisions, the public sway towards
the desire ‘to do something’ or adopt
the opinion ‘anything is better than
nothing’. However, this well-received
view, this yearning and enthusiasm
for screening, is not appropriate;
screening is not a miracle cure, in
fact screening is neither a cure nor
a standalone method of diagnosis.
For every survival time improved by
screening there is a hidden figure:
the number of lives disintegrated by
over-treatment.
We fear disease. The idea that illness
may be lurking inside is scary. Many
of us believe screening can put our
minds at rest or at the very least raise
our awareness so we can take action.
However, we may be unaware or
ignore the fact that the subsequent
treatment can be terrifying, even
more so than the disease itself. Charities
have a tendency to promote and
glorify screening programs, but in
reality the outcomes are not all they
are made out to be.
A perfect screening test does not
exist. No test can detect all patients
with a disease and simultaneously
rule out everyone without it. Instead,
there is a trade off between sensitivity
and specificity. Overly sensitive
tests can lead to over-diagnosis
and over-treatment. As well as the
unnecessary expense on the NHS,
over-treatment places strain on the
patient’s body, the effect of which
spirals into anxiety and stress in the
patient’s life. The ensuing tests could
even do damage that is completely
avoidable. Conversely, overly specific
tests often come at the expense
of sensitivity. You are sure to have
the disease if your doctor tells you
so with a perfectly specific test, but
you end up erroneously discounting
many patients with the disease causing
false reassurance. Some doctors
worry patients don’t completely understand
the consequences a positive
test result will have on their lives.
Truly, there is no such thing as an
overly-specific or overly-sensitive
test, just so long as one does not come
at the expense of the other. It is an
important point and one that might
need clarifying: if you take everyone
who smokes and tell them they
could have lung cancer, on account
of that being the greatest risk factor,
you end up catching nearly everyone
with lung cancer because it is rare
to get lung cancer in a non-smoker.
However, many of your smokers will
not have, nor will they ever get, lung
cancer and you have unnecessarily
worried them.
The opposite is also true of very
highly specific tests. You decide to
do a test to try and predict who will
get a cough. You screen your population
for everyone who has just started
smoking and take those people as
your positive result. You plough on
and tell all of the new smokers that
they might get a cough, on account
of that being one of the commonest
causes. In the meantime, you reassure
the rest of the population that
they will not suffer and no one goes
away unnecessarily worried. When it
comes to follow up testing, all of the
smokers have a cough as expected.
None of them are pleased about it,
but they were all warned in advance
and so they are largely content. However,
given the many other causes of
cough, you are inundated with angry
patients who do not smoke and were
falsely reassured; they have all been
coughing with bronchitis for weeks.
Multiple screening programs for
asymptomatic patients are offered on
the NHS with the aim of increasing
lead time (the length of time between
diagnosis of a disease and when it
would ordinarily start showing clinical
signs) to improve outcomes. Studies
into some screening tests uncover
clear positive outcomes, while others
are more controversial. In this article
I am going to discuss three screening
programs that span the spectrum of
screening success: the PSA test for
prostate cancer (no longer routinely
performed in the UK), mammography
for breast cancer (a program
discouraged by many doctors), and
the FOB test for colorectal cancer (a
program with largely positive outcomes).
The PSA (prostate specific antigen)
blood test and the DRE (digital rectal
exam) are used as screens for prostate
cancer. Levels of prostate specific
antigen in the blood are highly
variable, noticeably increasing after
physical exertion or intercourse.
High levels of PSA are associated
with a number of very treatable
and very common diseases such as
BPH (benign prostatic hyperplasia)
and prostatitis, so much so that up
to two out of three men with elevated
PSA levels do not have prostate
cancer. So what does a positive PSA
test mean? In just an ordinary, symptomless
member of society, who is
purely being screened because there
is a screening programme, the test is
35

so sensitive that the result is not hugely significant.
But, after a positive PSA result, the
seed of fear embedded in the patient’s mind
has sprouted and spread. It seems counterintuitive,
even reckless, to shun further testing.
The next stage of screening is invasive, time
consuming and uncomfortable. In short,
it is not an experience patients want to go
through needlessly. The subsequent tests
aiming to determine the cause of elevated
PSA carry a risk of infection, bleeding and
difficulty urinating. The standard next step
is to perform a prostate biopsy. Initially, a
transrectal biopsy is performed under the
guidance of an ultrasound probe. In this
approach both the needle and ultrasound
probe are inserted through the rectum. The
more extensive and invasive approach, the
transperineal template biopsy, is used to
gain additional information beyond that obtained
in the transrectal biopsy if required.
The issue with prostate biopsies is the difficulty
identifying aggressive cancers from
slow growing cancers that may never cause
problems in the patient’s lifetime. Treatment
of prostate cancer is aggressive and
invasive with possible side effects including
impotence and incontinence causing a significant
reduction in the patient’s quality
of life. Many men with cancerous prostate
cells will never require treatment. If they
hadn’t opted for screening the only role
prostate cancer would have played in their
life would be the fear that it may some day
happen. Over-treatment and its effects on
quality of life caused by screening are some
of the main factors that question the effectiveness
of the PSA test and subsequently
have prevented its routine performance in
the UK.
Every three years women aged 50 to 70 receive
an invitation for breast cancer screening.
The initial test is a mammogram aiming
to detect early stage cancers that the limited
clinical examination is ineffective at identifying.
Mammograms pose minimal risk to
patients and, although they are uncomfortable,
they are considered to be harmless. A
study from 1994 to 2009 showed that out
of the 1,297,906 women who had a combined
total of 2,207,942 mammograms
there were 182,340 false positives, which is
roughly 14% of women screened.
The next step for women with a positive
breast cancer result can be more mammography,
ultrasound screening or a breast biopsy.
Like with the tests for prostate cancer,
the biopsy is invasive, slightly painful and
carries a risk of infection. The data from
previous scans is used to target the biopsy to
a suspicious area where cells or fluid is sampled
from. These tests are invasive, but the
fear of disease is an embedded part of our
nature. We feel compelled to go on, choosing
to ignore the fact that another positive
test will lead to the next stage of screening.
In no time at all we have agreed to procedures
that will stall our lives and occupy our
every thought, but the alternative seems unthinkable;
how can I just ignore a finding
that might be cancer?
Similarly to prostate biopsies, it is difficult
to identify fast growing cancers from slow
growing cancers in a breast biopsy. Studies
show that many of the slow growing cancers
picked up by screening would never af-
fect women in their lifetime if left untreated.
About 1 in 5 women diagnosed with breast
cancer through screening will have ductal
carcinoma in situ (DCIS). This is cancer of
the milk ducts. In some women this will never
cause an issue, but if the cancer spreads
from the milk duct it becomes invasive. Unfortunately,
there is no way to tell if ductal
carcinoma in situ will spread. For every one
life saved by screening, roughly three women
are diagnosed with a cancer that would
never have become life threatening.
The treatments of breast cancer are very
aggressive and involve a combination of
chemotherapy, hormonal therapy, radiotherapy
and possibly mastectomy. All of
these therapies can have severe side effects
and greatly reduce the patient’s quality of
life. The main issue associated with breast
cancer screening, like prostate cancer
screening, is over-treatment and the negative
effects it will have on the patient’s quality
of life post-diagnosis. For these reasons,
many doctors in the UK and around the
world do not think breast cancer screening
is effective and there are questions over
whether it should continue to be performed
routinely.
In contrast to the PSA test and breast cancer
screening, the colorectal cancer screening
programme is more specific. Colorectal
cancer screening has been introduced
in the UK for patients between 50 and 74
years old in Scotland and 60 to 74 in England.
Tests are sent via post every two years
and results are usually received within two
weeks of submission. The FOB (faecal occult
blood test) involves the collection and
analysis of a faecal sample, a positive result
occurs in around 2 out of every 100 tests.
A study into a BCSP (bowel cancer screening
program) in England showed that out
of 1.08 million returning tests, 2.5% of
men and 1.5% of women had abnormal
tests. Out of the patients that went on to
have further testing, high risk adenomas
were found in 43% of men and 11.6% had
cancer. In women, high risk adenomas were
found in 29% and cancers in 7.8%. 71%
of the cancers were ‘found early’. Patients
with a positive FOB test are offered colonoscopy
or flexible sigmoidoscopy (camera
tests up the back passage), the first being the
more invasive procedure exploring more of
the colon. These tests aim to look for cancer
or polyps in the colon. If these endoscopic
procedures reveal the patient does have polyps
they are usually removed at the same
time, minimising the number of visits to
hospital. Economic analysis deems screening
for colorectal cancer to be cost effective.
It is important for doctors to ensure that patients
are aware of the risks and potential
outcomes as well as the positives associated
with screening for cancers. A positive result
in any of the tests discussed entails massive
change, anxiety and disruption to a patient’s
life. Furthermore, treatments for the
cancers are aggressive and can often bring
patients’ lives to a stand still; a false positive
result is not only a massive unnecessary expense
on the NHS but, more importantly,
brings needless physical and psychological
suffering to the patient and their family.
36 37

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Ask a
physiologist
Artwork by Jennifer. N. R. Smith
www.jnrsmith.co.uk

Baby, it’s cold outside
Editor’s Prize for
Alistair Roddick
One of the greatest
achievements of the human
race has been our
ability to colonise vast
swathes of land across a full house of
continents, irrespective of climate,
from the Tuareg people of the Sahara
Desert to the Inuit of the arctic
circle. From the Steppe plain to the
thickest rainforest, humans have settled
most everywhere at some point
in history. This is in part due to our
ingenuity. Not to blow our collective
trumpet, but we invented clothes,
mastered fire and continue to build
ever more complex and efficacious
shelters. This has allowed us to survive
in climates that otherwise would
not permit a dwelling. However, being
clever can only get us so far. To
survive in the most unforgiving of
climates, the human body has been
crafted and fine tuned by millions of
years of evolution into the tall (usually),
imposing (sometimes) survival
machine that we see today.
Even the human body has its limits,
though. In the previous issue we discussed
the physiology and danger of
extreme heat. This issue, we will go
to the polar opposite: the physiology
of extreme cold.
The human body has evolved to
function as efficiently as possible,
and this can only be achieved within
a very narrow temperature range
(around 36.5-37.5 o C). As a result,
just as with an increase in temperature,
the body has a variety of mechanisms
to respond to a decrease in
environmental temperature, ranging
from the highly effective to the completely
useless to the highly effective.
I like extreme adventurers, so let’s
use an explorer on a cold day in
Antarctica as an example. Our adventurer
wakes from sleep and leaves
their tent to begin the day. Almost
instantaneously, a drop in blood
temperature is detected by cells in
the hypothalamus. Interestingly, cells
cannot determine body temperature
beyond a fairly narrow range and,
whilst we have both heat-sensitive
cells and cold-sensitive cells, no cells
can detect both. These cells trigger
activation of the autonomic nervous
system, this time driving a set of unconscious
responses that act to either
generate or conserve heat. At the
same time, the hypothalamus signals
to the cortex of the brain, activating
behavioural pathways that are executed
via conscious sensation and
complex neuromuscular programs
with environmental components.
Or, explained more practically, you
will feel cold and put on a jumper.
So, about those unconscious responses;
let’s start with the useless.
The sympathetic nervous system
(that is, the fight-or-flight part of the
autonomic nervous system) signals to
tiny muscles distributed throughout
the skin called arrector pili. Each of
these little muscles attaches to the
base of a body hair in a hair follicle
and when activated they heave
all the hairs into an upright position,
producing characteristic goosebumps.
In our furrier ancestors, this
would serve to trap a warm layer of
air against their skin, keeping them
warm in chilly weather. In humans,
whose fur is somewhat less impressive,
this response does, well, basically
nothing.
Probably the best physiological method
for preserving heat that is useful
to humans is the process of vasoconstriction
– constriction of blood
vessels around the body. In particular,
the body loses loads of heat due
to blood flow through the skin. We
saw this in our desert explorer last
time. To combat this heat loss on a
chilly morning in Antarctica, sympathetic
nervous system signals will
be sent via nerves to major arteries
and smaller arterioles supplying the
skin, causing them to constrict. This
reduces the blood flowing to the skin
and therefore minimises the amount
of heat lost into the surrounding air.
These same signals are sent to the
veins at the surface of our explorer’s
arms and legs (like the veins that
you may be able to see in your own
arms after exercising), causing them
to constrict. As a result, cold blood
coming back from the fingers and
toes towards the heart is diverted
along deep veins that run alongside
the major arteries. Because heat always
moves from hot to cold, hot
blood reaching the hands and feet
would normally conduct its warmth
out into the cold atmosphere. Instead,
the hot blood transfers its heat
into these deep veins carrying cold
blood back from the limbs, which
become warm, while the arterial
blood becomes colder as it heads
off towards the fingers and toes.
This system means that the blood in
the extremities stays cold while the
blood in the body core (where all the
important stuff is) stays warm. This
process is known as counter-current
exchange, and is one of the most
important mechanisms of holding
on to that precious heat in freezing
climates.
Everything we have mentioned so
far is a means of preserving heat, but
artwork 2016
Congratulations to Jamie Crawford who has won this year’s Editor’s Prize for an
artwork contribution. His work can be seen on page 21 of this issue.
Jamie will receive £100 in book vouchers.
Highly commended goes to Jennifer Smith, whose work can also be seen throughout
this issue. In particular, the artwork attached to “Unprepared for autopsy” on
page 40.
________________
All submissions in a calendar year are eligibile to win the Editor’s Prize. The award
goes to the piece of work deemed to be of the highest quality; taking into account
the originality and polish of the final piece, as well as the steps undertaken to achieve
it. The winning piece is chosen by the editorial team.
42 43

Counter-current flow
is also how fish breathe,
except gills exchange
oxygen instead of heat.
the body has another way to keep
warm. Ditch the vest and do some
press-ups. Most metabolic activity in
the body will generate a little bit of
heat. In particular, muscle contraction,
which involves a whole host of
metabolic processes, is a particularly
‘hot’ activity. This is where shivering
comes in: the ‘shivering centre’ (a
little bit of brain located at the back
of hypothalamus) causes coordinated
muscle contraction; firing up all
of those cold, dormant muscle fibres
throughout the body. Since muscle
activity increases blood flow to the
active muscles, more blood is delivered
to the warmest muscles, where
it collects the heat and transports it
back to the body core. Shivering is a
great way to warm up, and can increase
the body’s heat production by
up to five times. Now we’re cooking
with gas.
Until recently it was believed that
shivering was the only way that
adults could generate their own
heat. However, there is another way
that we can produce heat. Brown fat
(or brown adipose tissue) is a type
of fat that is widely distributed in
new-born babies and hibernating
mammals. The cells in brown fat go
through the same process of energy
production as every other cell in the
body, but with one important difference:
at the very end of the energy
production line, instead of producing
ATP, brown fat cells release their
stored energy as heat. This is, in
normal circumstances, a massively
inefficient use of all that glucose and
fat that the cells use to produce energy.
However, in very small babies
(who have yet to fully develop their
shivering centre), this inefficiency
can be crucial, providing a means
to fight off the elements. Although
brown fat tends to decrease with
age, it has recently been shown to be
important in adults for maintaining
heat in extreme cold weather (my favourite
kind of cold weather). Also
great for hibernating through long
winters, if that’s your cup of tea.
As with everything in the human
body, our capacity to keep warm,
although impressive, can be overwhelmed
in extreme scenarios.
Maybe our Antarctic explorer gets
lost, and can’t get back to the tent
in time for the bitter cold of night.
Before long, their body temperature
will drop beneath the 35 o C mark –
the cut-off point for hypothermia.
This is where things begin to go
wrong. In the early stages of hypothermia
(roughly 32-35 o C) the cold
heart begins to weaken, pumping
out less blood with every beat. In order
to keep blood circulating around
the body, the heart must speed up
to compensate. This means blood
is pumped through the lungs more
rapidly, so breathing has to speed
up as well in order to maintain adequate
oxygenation. In the extremities,
blood vessels shut down to
maintain heat within the core, cutting
off circulation to the fingers and
toes (and in really bad hypothermia,
the nose too). This is the first step on
the path to frostbite, which causes
severe damage and can require amputation
of the affected digits.
As the explorer starts to get colder,
things begin to get progressively
worse. The heart rate, initially increased,
begins to drop. Breathing,
too, slows down as metabolic processes
throughout the body become
sluggish. More worryingly still,
mental function slows as the brain
becomes affected by the cold, causing
confusion and tiredness. The
cold also plays havoc with the hypothalamus
(as with hyperthermia),
making regulation of body temperature
even more difficult. Often the
hypothalamus can send incorrect
messages to the conscious parts of
the brain, creating a sensation of
warmth. This causes a phenomenon
known as ‘paradoxical undressing’,
where severely hypothermic individuals
start stripping off their clothes,
becoming even colder in the process.
Once body temperature drops below
around 28, nearly ten degrees
below normal body temperature,
the outlook begins to look bleak.
Breathing becomes so slow that carbon
dioxide begins to build up in the
blood. This causes the blood to become
more acidic, which promotes
dysfunction of multiple organs. In
particular, acidic blood makes the
heart very unstable, and prone to
trigger fatal heart rhythms. At this
temperature, the heart is very unstable
anyway due to failure of the
vital enzymes that keep it beating;
together, the cold and the acid will
bring the heart to a gentle halt.
Is this the end for our brave (and fortunately,
hypothetical) explorer, lost
and alone in the dark of the Antarctic
night, with dwindling brain function
and a cold, motionless heart?
Well, not quite. Dangerous though
hypothermia is, there is still hope for
this explorer.
Every cell in the body must balance the
amount of energy it produces (in the form
of ATP, made using glucose and oxygen)
with the amount of energy it needs to carry
out its functions. During exercise, for example,
muscle cells work harder to contract
and therefore must produce more energy
to fuel this process. The brain, however, is
active all the time, and must always have a
constant supply of energy to fuel the many
neural impulses criss-crossing through the
white and grey matter 24 hours a day. If
the brain loses blood supply (say, in a stroke,
or in a cardiac arrest) then the brain cells
cannot generate enough energy to remain
active, and they will begin to die.
However, in a cold brain, all the enzymes in
each cell move at a snail’s pace, slowly doing
all the work needed to send the neural
messages around the brain. These messages
may be moving so slowly that the brain is
not functional (i.e. the owner is in a coma).
At this pace, however, the brain cells are
not working very hard, and do not need a
lot of oxygen or glucose supplied to them.
In our plucky explorer, even though their
heart is not beating and not supplying the
brain with blood, their sluggish, cold brain
can survive on what little oxygen is left in
the stationary blood for a long time.
This means that severe hypothermia can actually
protect the brain, and can save lives.
Take the inspiring story of Swedish doctor
Dr Anna Bågenholm, who became trapped
in an icy stream during a skiing outing in
the frosty mountains of Norway. After 40
minutes, the freezing cold overwhelmed her
heart and her circulation stopped. 40 minutes
later, she was pulled from the stream
and airlifted to the nearest hospital an hour
flight away. Here, over three hours after
falling into the water, Dr Bågenholm’s heart
was restarted and she was revived. She suffered
no permanent damage from her incident.
Since this incident, and many similar others,
we have begun to realise the power of
hypothermia. Research has begun to show
that cooling dying patients in ambulances
can increase their chance of survival, while
so-called ‘therapeutic hypothermia’ is used
in operations such as open heart surgery
in children, allowing surgeons to stop the
heart completely and repair it, all the while
protecting the child’s brain from damage.
So, hypothermia: is it bad?
The answer is a resounding maybe. It depends
on when you are cold, and why. But,
despite its benefits, in most cases hypothermia
is a highly dangerous situation, with serious
risks and consequences. So, don’t turn
down those gloves or ditch the scarf just
yet. Instead, dress appropriately, wrap up
warm and, unlike our hypothetical explorer
(who luckily was rescued by their team
and returned to full health), when exploring
the cold and dangerous wilderness, bring a
map.
44 45

Unprepared for autopsy
Lok In Lam
After badgering my fellow
medical students about
what their post-mortem
visit was like, I had a rough
idea of how the visit to the mortuary
would go. I was to remember
my name badge, remember to wear
socks, remember to get signed off.
There was to be blood, new smells,
new sights, and all kinds of sensory
overstimulation. Having gone to a
medical school that performed fullbody
dissection, I (wrongly) thought
I would be prepared for what I was
going to see.
The first thing that hit me when I
walked into the autopsy room was
how peaceful the bodies looked, as
though they were sleeping. In the
world of medical school, we learn
about the wonders of modern medicine
and technology every day, often
forgetting to reflect on its limitations.
The autopsy can be a way of promoting
positive attitudes towards
death and bereavement and can help
us come to terms with the harsh reality
that all patients must eventually
die; an essential for medical students.
The series of events leading up to
the person’s death and why the autopsy
needed to be carried out was
explained to us as we watched the
procedure. This allowed a greater
appreciation and understanding of
the legal framework applied when
working with patients after they have
died. As medical professionals, contact
with the dead and medico-legal
aspects are inevitable, and as such
it was beneficial to learn about the
laws and regulations.
As the bodies were opened and organs
removed, again I was amazed
at how different the procedure
seemed to dissection. The embalming
process reserved for cadavers
produces a completely new specimen.
The post-mortem procedure
has been set up to allow the viewing
of three-dimensional anatomy in its
original space and appreciation of
the relationships between structures
in a more ‘realistic’ form.
The examination of the organs was
fascinating; the careful slicing and
scrutinising of each organ in order
to determine the cause of death was
something completely different from
any other medical specialty. Pathology
can be a specialty that medical
students have little to no contact
with, and the post-mortem was a
good opportunity to learn about the
role of a pathologist. This can allow
further exploration of future career
options, as well as fostering an appreciation
for other healthcare professionals
such as anatomical pathology
technologists.
After the autopsy, the body was
washed and made presentable. This
was a sharp reminder that this person
was somebody’s partner, relative,
friend. It made me consider the
wider clinical context of this patient,
and the life they must have lived
before I met them in the mortuary.
This consideration of other people
is important in order to prevent
clinicians from becoming distanced
from their patients, and from losing
the empathy which is so important
in providing good care. Of course, it
is well and good saying that autopsy
benefits career choices and anatomical
knowledge, but the downside
is that we are, for a brief while,
exposed to a body not a person. It
seems as though that patient’s personhood
is put on hold from the moment
the pathologist makes the initial
incision until the body is closed
and dressed. For that short period of
time, a doctor who otherwise only
deals with patients, not organs, who
deals with diseased people, not the
disease itself, is allowed to think of
their patient as just a body.
These patients are all somebody,
not just some body, and giving doctors-in-training
a glimpse of the
other side of the curtain could have
disastrous effects. To allow medical
students the opportunity to think
they are treating the lungs, that
the disease stops with whatever is
cut open and diagnosed at autopsy,
when really they are treating the
breathless patient at the end of the
corridor, may lead to a workforce devoid
of human awareness.
Despite my initial fears about the
visit, overall the benefits of attending
a post-mortem were numerous
and unique. I gained knowledge and
attitudes that I would be unlikely to
achieve in other settings. However, it
must be mentioned that post-mortem
visits can be very emotionally
distressing. As such, students undertaking
the sessions should be adequately
supported, and their time
there should be well structured in
order to fully reap the benefits of a
visit.
Artwork by Jennifer. N. R. Smith
www.jnrsmith.co.uk
47

with the end of the Liverpool Care
Pathway, we can look forward to an era
of compassionate palliative care
Daily Mail 2015
The LCP is dead.
Long live the LCP.
The Liverpool Care Pathway (LCP) was
introduced in the late 1990’s at the
Royal Liverpool University Hospital,
along with the Marie Curie Palliative
Care Institute, with the goal of ensuring
dignified and peaceful deaths.

Why we shouldn’t have got rid of the
Liverpool Care Pathway
Katie Faulkner
You matter because you are you, and you matter until the last moment
of your life. We will do all we can, not only to help you die peacefully,
but also to live until you die - Dame Cicily Saunders
The Liverpool Care Pathway
(LCP) was introduced
in the late 1990’s
at the Royal Liverpool
University Hospital, along with the
Marie Curie Palliative Care Institute,
with the goal of ensuring dignified
and peaceful deaths. Produced
according to best practice and evidence
based research, the intention
was to recreate the care received
by patients in a hospice setting and
apply it to hospital wards as well. It
was not long before the pathway was
attacked for being used to catalyse
deaths, clear beds and save money. A
series of articles were written on experiences
of patients’ families watching
their loved ones dying “an awful
death” on the pathway, with news
headlines depicting the pathway as
“the road to death”, “a one-way ticket”
and, most commonly, “the death
pathway”.
Whilst unethical in itself to display
such a sensitive topic so tastelessly,
the impact of the media meant the
minority of cases where the pathway
was not well carried out over-shadowed
the massive benefits the pathway
had to offer. Enough so that in
2013 the Department of Health and
NHS commissioning board instigated
an independent review of the
LCP establishing a table of 44 recommendations
and, finally, the withdrawal
of the pathway altogether.
For this reason, I will establish two
major principles of medical practice
to explain why it was not only
unnecessary, but unwise to have rid
ourselves of the LCP, whilst also
drawing out what we should learn
from the mistake we have made and
demonstrating why the LCP was an
effective tool in managing dying patients.
The first principle is this: we should
never replace an effective and
well-established practice because
some doctors don’t know how to
use it. The LCP provided beneficial
treatment for patients who were dying,
with numerous stories of good
practice. It is partly because of the
LCP that the care of the dying patient
in Britain was ranked by the
Economist Intelligence Unit as best
in the world in 2010, with quality of
care and public awareness of palliative
medicine recognised as our
main strengths. Likewise, in the independent
review of the LCP, Baroness
Neuberger herself stated,
“there is no doubt that, in the right hands,
the Liverpool Care Pathway supports people
to experience high quality and compassionate
care in the last hours and days of their
life”
The main recommendation given in
her review was simply the use of the
word “pathway” in the name, which
she believed might suggest that patients
are on an unstoppable road
that they cannot step off. These indications,
and many more, demonstrate
that the pathway itself was not
the problem but the application of
the pathway by doctors untrained in
how to use it. It is thought that there
was a great discrepancy in its use;
implemented properly under hospice
circumstances where the staff
are trained to offer the pathway in
its intended holistic nature, versus
the hospital environment where the
pathway was too often regarded as a
tick-box exercise, by staff who were
as impermanent as the patients.
Therefore, should we not have kept
the pathway (in which the problem
did not lie) and improved training
and staff-turnover on wards working
with those managed under the
guidelines of the LCP?
Just as we would not stop giving insulin
as a treatment for diabetics or
anticoagulants for those at risk of
stroke simply because some doctors
do not know how to use them, discarding
the LCP for dying patients
simply because some doctors misused
it denies us of a great tool for
providing very good quality care.
Secondly, it is never acceptable for
the pressure of the public and the
media to dictate how the NHS operates.
In a typical Hippocratic Oath
style, we agree to “provide a good
standard of care, uninfluenced by
political or religious pressure”. We
had been using the pathway for years
and the LCP itself had not really
changed. So, where did this sudden
pressure come from that terrified us
into removing the pathway? Maybe
society’s expectations of practitioners
had increased causing a limited
acceptance of the fact that illness
cannot always be cured which led to
more friction than before between
health professionals and relatives of
dying patients. Maybe increasing
financial and time pressures put on
the NHS meant doctors were less
able to fulfil their roles as previously.
Or maybe the media just love to find
any fault in doctors which they can
use to stir up an emotional response
amongst the public and sell papers.
Whatever the cause may have been
for the pressure put on us to change
our approach towards care for dying
patients, we should never have been bullied
by the medically unqualified to change current
practice. If there is an obvious fault
in the current procedure which needs to
be addressed, it is logical and good to address
it. Yet, withdrawing such a vast set of
guidelines as the LCP without any evidence
to suggest harm caused directly by them is
sadly testifying to the fact that we are unable
to stand strong as a body for what we
have determined is good for public health.
Further to this, by changing current practice
we have actually appeared to agree
with the outrageous claims made in the
newspapers and have confirmed people’s
doubts in our ability to care for their dying
relatives and have given them a reason to
suggest that doctors lack genuine concern
for these vulnerable patients. Instead, we
ought to have spent our time reassuring the
public of the benefits of the LCP and why
it was practised, highlighting positive experiences
such as that of a family spoken of in
the Neuberger Report stating:
“They spoke to us as a family in a sensitive way...
She died with my mother holding her hand, surrounded
by the people she loved in the place where
she wanted to be... I believe we could only do this,
because the LCP provided staff with the guidance
to prepare us for her death and also gave them the
confidence to provide the right care at the right time”.
This brings me on to my final point: the
LCP represented best practice in managing
terminally ill patients in their final moments
and so should not have been removed. Supported
by literature review which showed
that using the LCP promoted better care
for dying patients, it brought the ‘gold
standard’ care found in hospices into a conventional
healthcare setting. Evidence supports
the fact that symptoms could be adequately
managed using the LCP guidelines,
that the LCP provided staff with assistance
in communicating with patients and their
relatives about the patient’s condition and
their eventual death and the pathway recognised
that views of patients and relatives
should be listened to and documented appropriately.
In all ways, the LCP brought
excellence to the care of patients. That is
not to say that the pathway was perfect, but
its problems should have been addressed
individually and corrected; what a waste to
throw it all out and return to the drawing
board.
Dame Cicely Saunders, the founder of the
hospice movement, said,
“You matter because you are you, and you matter
until the last moment of your life. We will do all we
can, not only to help you die peacefully, but also to
live until you die.”
Certain doctors and nurses weren’t doing
all they could do, but the Liverpool Care
Pathway should not be made a scapegoat
for them.
We should never replace an effective and well-established practice
because some doctors don’t know how to use it.
50 51

We’re going through changes
By now you’re all avid readers, so you know what I have been up to this year, but what about the rest of the
Medic Mentor family? Well, some pretty big changes have taken place in the latter months of 2016 that we
wanted to share with you.
Perhaps the most exciting of all is the arrival of a swathe of fresh faces; the new scholars. It’s out with the
old and in with the new as we come to terms with handing over the projects that have become our babies
to our Medic Mentor Scholarship successors.
You may have already felt the presence of the company’s wisest new recruits; the Medi Council. The pun
is bound to split opinion but their expertise is indisputable. These junior doctors hold a previously unheard
of level of insight and, in the absence of dark forces to be fought, will be keeping the scholars on their toes.
Weak minds need not apply.
Drs Dhakshana Sivayoganathan and Iain Kennedy have a new arrival of their own on the way. At minus
three months old and already drafted in as Medic Mentor’s youngest member, have we finally found a job
that Dhakshana cannot take in her stride? No. Dr Sivayoganathan is moving from CEO to Director of
Communications to allow for greater flexibility, but she remains just a phone call away if you need help.
Conference attendees will still get time with our best known mentor, but she now comes equipped with
bump or baby boy. Iain is currently trying on Dhakshana’s very large CEO boots; I think he rather likes
them but there’s a lot to learn and Medic Mentor’s 2017 diary is filling up fast.
That would leave Dr Kennedy’s role as Director of Education open but it is being filled by Dr Rebecca
Yates, last year’s Widening Access Scholar. Dr Yates is currently working as an FY1 in Wales and will add
taking care of the incoming scholars to her long list of responsibilities.
The more attentive amongst you may have realised that this makes the November edition my last as Publishing
Scholar and therefore my last as editor. Do not fear, I’m moving on up but I’m not moving away. At
the beginning of December I hand over the magazine’s production to its new editor (the new publishing
scholar) and I become the Director of Publishing. You should still see my articles and know that I’m somewhere
behind the scenes, making sure we get a great magazine to you every quarter. My fan-mail should
now be directed to publishing@medicmentor.org.
GGet involved
We’ve profiled the new lot below, be on the lookout for their faces at upcoming events.
53

The Medi Council
Dr Rebecca Yates
Director of education and leader of the medi
council
I don’t want to sound mushy but being part of Medic Mentor
is really awesome. Being able to use your own experience
of applying to medical school to help others in their applications
is incredibly rewarding. Medic Mentor provides the opportunity
to design and create resources distributed to prospective and current
medical students; the company really goes above and beyond.
“No” isn’t a word that is used very often and I love that.
I’ve been involved with Medic Mentor for just over a year, initially
as a scholar working with school societies and then as a Fellow.
Now in my role as Director of Education I will be working alongside
the Medi Council to support our team of talented scholars
and mentors.
I’m hoping that we will complete some incredible projects that will
benefit many current and prospective medical students. I’m also
excited for our first ever national mentors conference, Mastering
Medical School, designed to give our mentors all the info they
need to make the most out of their time at university.
I decided I wanted to become a doctor around the age of 14 however, despite my best efforts, I didn’t
get any interviews when I first applied. Not wanting to accept defeat, I decided to study for an
undergraduate degree and apply to medical school as a graduate. I read molecular medicine
at the University of Sussex and had a fantastic time, but I was still determined to go into medicine.
I applied to four graduate entry medicine programmes, was lucky enough to be offered places on three,
and decided to study at Keele University. I graduated in July 2016 and I’m now working as an FY1.
Dr Claire Gillon
Lister Hospital - aspiring surgeon
My first degree was in anatomical sciences at the University of Manchester which also involved
studying Japanese. After this I opted to do an undergraduate medicine course in Manchester so that
I could do the European Studies Programme - this enabled me to complete a 16 week elective in Berlin
in 2016 before graduating. I found doing a degree beforehand to be incredibly useful; I had developed
graduate skills whilst gaining a broader knowledge base in the biological sciences.
I have practised tai chi for over ten years and am a qualified instructor; at university I set
up and ran a society for tai chi. I particularly love travelling, and went to Japan in the summer and even
more recently to New York. I can frequently be found reading and watching movies, although asking
which are my favourites is an impossible question.
I first got involved in mentoring when I started 6th form, mentoring younger pupils who, for whatever
reason, were struggling at school. From there I developed my teaching skills whenever the opportunity
arose - usually on an informal basis. During my medical degree I was involved in the Scalpel society
which aims to further the knowledge and experience of those interested in surgery. My role primarily
was organising and running weekly lectures but I also helped teach at various day courses and supported
the running of the annual conference.
Make the most of the wide array of opportunities available to you: get involved in societies, especially
non-medical ones and build up a variety of non-medical interests and activities. In doing so you will
improve your transferable skills and at times they can help you to stay grounded. Remember, there
isn’t just one way to do medicine.
Dr Husay Janebdar
Ipswich Hospital - Core surgical trainee
My journey of getting into medical school was one of the classic straightforward ones (boring I
know!). I had straight As and A*s at school and college, gained work experience at a variety of different
places, a few other extra curricular activities and achievements … and then just took my passion
for medicine to the interview! It worked.
Being part of the Medi Council I look forward to mentoring the Medic Mentor Scholars, I am particularly
excited about organising the Mastering Medical School conference this year and generally
being part of an enterprise and group of like-minded intellectuals who feel passionate about teaching,
mentoring and widening access to medicine.
I love the concepts and values of Medic Mentor. I love that with us, anybody from any background
with a slight passion or interest in medicine can have all the support, information and access
to opportunities they need to nurture and blossom.
My advice to current medical students? Enjoy the journey, and make the most of every Christmas and
New Year you have off as it won’t always be the case once you start working.
Dr Sarah Bassiony
William Harvey Hospital - aspiring surgeon
Throughout medical school I have had multiple mentees and had the opportunity to help them develop
and see them blossom to the doctors they have now become. As an FY1 I was the teaching lead for
final year medical students and arranged a year-long teaching programme which combined a mixture
of lecture-based and bedside teaching.
Simulation is being increasingly used to train doctors and I love it. I have always thought it was a
brilliant way to learn. Since FY1 I have been part of the faculty team in organising simulation session
for medical emergencies using SimMan and helping them reflect on their performance. I realised that
a lot of the students were worried about their first on calls, so this year I launched “HotlineBleep” (if
54 55

you don’t get the reference, we can’t be friends). This virtual on-call programme allows students to
develop their confidence in dealing with common calls they are likely to receive, and helps them to
recognise when and how to escalate to their seniors
When I was at school I remember being torn between wanting to study clinical psychology and medicine.
I am not going to lie and say that getting into medical school was an easy ride. I came from a
school where not all of my teachers believed I would get into medical school, let alone graduate. My
performance in the interview meant that the University were willing to overlook me
slightly missing out on my grades, which I am really grateful for. So, I would say getting experience
in and out of medicine is key in helping me develop as a person. To me, medicine is more about
being a well-rounded, caring individual, and less about being a book worm.
The 2017 scholars
James Everson - Leadership Scholar
University College London - sixth year
I’m hoping to start my career in August 2017 with the Academic Foundation Programme in clinical
leadership, moving on to train in emergency medicine and, later, to sub-specialise in the rapidly
developing field of pre-hospital emergency medicine. I love teaching too, so I am very keen to keep
this up throughout my career! I have taught other medical students in various capacities at UCL, and
through my experience with the Army Reserve I have spent a lot of time mentoring juniors, which I
find really rewarding and is a fantastic way to help people develop. I have also been a presenter with
Medic Mentor for the past year, which necessarily entails a great deal of teaching.
Only since joining Medic Mentor have I realised how lucky I was with my journey to medical school.
I applied straight from school, and after interviews at St Andrews and UCL, I got an offer from UCL.
It turns out that you only need one opportunity to make it in! Looking back, I think taking a gap
year would have been a fantastic idea, and I really encourage everyone to consider it.
In the coming year I would like to try and focus some attention on our medical students and start looking
at getting formal mentoring and teaching for the vast number of medical students in our ranks.
George Huntington - Publishing Scholar
University of Sheffield - fifth year
I had to work hard to get into medical school. I’m not the most studious student. Unsuccessful on my
first application, I was told that it wasn’t worth applying a second time. After getting my A levels I
concentrated extensively on getting medical experience to line my application. A friend of the couple
who I used to babysit for introduced me to an ICU consultant at a barbeque. I ended up spending
a month shadowing him. After that I worked as a healthcare assistant on a trauma and orthopaedic
ward. In this time, I resubmitted for medicine. When it didn’t seem as though I was going to
be successful, the ward began training me as a nurse via the diploma that was available at
that time. Out of the blue, I received a Sheffield interview and here I am.
In medicine I would like to work towards the marriage of the two specialities which interest me most:
mental health and acute medicine. Ideally, working as a mental health specialist. My wider ideal career
would also involve teaching and academic medicine. Outside of healthcare, I write short fiction
to relax. It has always been a dream of mine to see this published as a collection.
I have written for this magazine since its inception. I like the accessibility of the articles and also
the writing process itself; I have seen essays written by physiologists, interviews with medical course
directors interspersed with articles by contemporaneous medical students and future applicants to
the course. What a wide perspective on things! The previous editorial team have worked so hard to
produce the Medic Mentor magazine. The very least that I could do in my role would be to carry
the fire and continue to put out such a quality publication.
Oluwafunto Ogunleye - Work Experience Scholar
University of Sheffield - second year
When I was about 17, I really was not sure what I wanted to do as a career but I loved my biology
practicals at school. I was passionate about anatomy so I went to Bristol and studied anatomical
science. During my final year I was able to carry out an independent research project in the field of
56 57

orthopaedic surgery - shoulders, specifically - in which I became very invested. I loved every minute
of operating on fresh cadaveric shoulders. I also found my supervisor, an orthopaedic surgeon, to be
inspiring and I think it was a combination of those factors that made me begin to seriously consider a
career in surgery or medicine. From there I organised work experience, got a job as a hospital healthcare
assistant, gained some real life insight into medicine and made an informed, calculated decision.
Two years after I graduated, I started my medical degree at Sheffield.
Medic Mentor is unique. Gaining admission into medical school is no easy feat and it is certainly not a
level playing field. I like that Medic Mentor brings the
real, uncoated truth and information to keen school
students directly from motivated medical students and
doctors. Additionally, the medical students benefit
from the increasing list of opportunities such as scholarship
roles with challenging projects that make driven
medical students stand out.
It is easy to get bored and end up going through the
motions as you go about your work experiences. Try to
pay attention at every experience or scenario you encounter.
Don’t be afraid to ask ‘why’ to the people
you’re observing or working with and try to reflect on
what you’ve witnessed at the end of each day while
thinking of how it could be important.
Lauren Quinn - Medical Schools Compendium Scholar (Research)
University of Birmingham - fourth year
Research and academia is real passion of mine and so I devote much of my time to getting involved
in projects, hosting events and endeavouring to engage students in research. I was awarded a Nuffield
Science bursary between year 12 and 13 during which I undertook a research project looking at risk
factors and preventative measures for diabetes. This was my first exposure to academic (research)
medicine and I loved it and knew I wanted to further this interest during my time at medical school
- and I have done!
My first involvement with Medic Mentor was at a medical careers day when I had the opportunity
to present a poster and deliver a lecture on my organisation, the Birmingham Academic Medicine
Society. It was a very inspiring day to see young people who were so engaged with medicine. I later
invited the medic mentors to attend our national student conference in January 2016 and they were
delighted to attend. They made a huge impact and were very well received by medical and prospective
students alike.
The passion and vocation for medicine has to stem from yourself. Medicine is a long haul, it’s a marathon
not a sprint and you have to be the driver! Also, you must not compare yourself to those
around you, not now or in your future career; you must endeavour to be the best you can be
and continually strive to improve yourself, rather than feeling inferior to those around you. This way
you’ll be much happier!
Caitlin Gibb - Medical Schools Compendium Scholar (Education)
Queen Mary University - third year
Having enjoyed sciences all the way through school, I wanted to keep my options broad and decided
to study biology at university. During my degree, I did work experience and internships in career
paths such as finance, event management, and teaching. I enjoyed all of them but I couldn’t imagine
myself doing them for the rest of my life. In my third year we got to choose a module and I choose
mine on ageing - it was one of the few human modules and I thoroughly enjoyed learning about age
related disease. I think I shocked myself and the people around me when I told them I wanted to
study medicine! But having found out that there were graduate medicine courses, completed some
work experience in a hospital, and spent some time researching it, I felt I had found what I wanted to
do as my career - it had just taken me a bit of time!
Medic Mentor is unique in that it offers an opportunity to link up doctors, medical students and
pre-medical students in one place. Forming this sort of network is invaluable as we can all learn so
much from each other! It’s great that it enables everyone to access advice and guidance that can be
hard to get if you don’t have certain contacts. This allows students to be better prepared with the help
from people who actually have been through it. The brilliant thing about Medic Mentor is that it is
the people who really make it what it is!
I work for the widening participation team at Queen Mary University and regularly work on events
for students who want to get into medicine and dentistry. These have included one day events where
they get to have a go at practical skills and have talks on a specific area of medicine. I have worked
on summer schools for years 11 and 12. I have immensely enjoyed these and it has been great to see
the students progress and watch their confidence increase over the week. I was a mentor for a small
group of students on the summer school who had to complete a presentation. It was great to coach
and support them through the planning and presenting of their work.
Angela Yan - Research Scholar
University College London - fifth year
I started medical school straight after finishing my A Levels. I went to a grammar school where medicine
was a popular option to study for university but there was a lack of information and support.
This, coupled with the fact that my parents were non-medical and had no experience of higher education
in the UK, meant I made some ill-informed choices when applying for medical school.
I like how Medic Mentor aims to help everyone make an informed choice about whether medicine
is right for them. It caters for the entire spectrum and does not exclude any group. I’m
looking forward to creating a work experience workbook in the coming year that will enable students
to get the most out of their work experience and hopefully help them decide whether medicine is truly
for them.
I am also interested in creative writing and classical music (I have achieved Grade 8 in both the cello
and the piano) and in my first three years at university I was an officer cadet in the University of London
Officers’ Training Corps. Take good care of your physical and mental health; medical
students need to be able to look after themselves before they can take care of others.
Raymond Diallo - Widening Access Scholar
University of Nottingham - fourth year
I have been involved in medical education and mentoring since my first summer holiday in medical
school. This took place in the form of MedSoc teaching, anatomy revision lectures and teaching
58

Medic Mentor
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Summer School 2017 & 2018
5-Day Super Intensive Residential Course
Sat 18th - Sun 19th March
Locations:
*London *Lancaster
*Birmingham
What
you
get:
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Making it into Medicine (UCAS Lecture)
MASTERCLASS (wider reading & interview prep)
2 days of Personal Statement Tutoring
UKCAT and BMAT Crash Course
MMI and Panel Mock Interviews
8 Medical Application Textbooks
Insight into Medicine (Saturday)
Making it into Medicine (Sunday)
Dates:
Location:
24 th – 28 th Jul 2017
31 st Jul – 4 th Aug '17
7 th – 11 th Aug 2017
23 rd – 27 th Jul 2018
30 th Jul – 3 rd Aug '18
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07738914395
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clinical skills for medical students. I also mentored A-level students in Lincoln and assisted in running
mock interviews and tutorials that prepared students for medical school application. Furthermore, I
have featured in OSCE-style clinical skill videos as a mock patient as well as a medical student.
Demystifying MMIs
I took a very unusual route into medical school. After finishing high school, I started studying economics
at the university of my hometown in Hungary. However, I soon realised that it wasn’t a genuine
interest of mine and I moved to Paris where I have some family. I got a part-time job and I spent
my free time trying to figure out my next step in life which is when I came across medicine. I got some
work experience in France and in Hungary, and I started building my CV towards medicine. I was
working hard but I hadn’t left myself enough time to put together a strong UCAS application and I
started to lose faith by the time the application deadline had come. I ended up applying to only two
medicine courses and three pharmacology ones as this was (and still is) another interest of time. I got
into pharmacology at King’s College London but I was forced to quit after a year and a half due to
financial hardship. I spent the next year working full-time, volunteering, gaining work experience in
the UK, in Hungary, and in Gabon, taking private lessons, resitting high school exams, the IELTS
and the UKCAT. My hard work was eventually rewarded by three interviews followed
by three unconditional offers.
Do not make the mistake of leaving CV-building extra-curricular activities to the end of medical
school. Stick your head out and get involved early. There are countless opportunities to network and
collaborate with professors, doctors as well as other medical students. Take advantage of the fact that
you are in such an inspirational environment and focus on your personal and professional growth.
Oluwafunmilayo Nofisat Abari - Student Anthology Scholar
University of Leeds - second year
At present, I am quite interested in women’s health and holistic healing methods. As a Muslim, there
is a lot of emphasis in my religion on natural health and wellbeing practices, and I would really like
to explore this further; marrying my understanding of medicine and biological sciences with traditional
practices. I appreciate that my current interest in obstetrics and gynaecology may well change
throughout my time at medical school, though, with so many other specialities to venture in to.
Prior to working with Medic Mentor, I set up a social enterprise called TIMS - The Institute of Mad
Science. Through this organisation I set up projects to teach children aged 7-14 STEM subjects (science,
technology, engineering and mathematics) beyond the scope of the curriculum. I also provided
mentorship to college and secondary school students aspiring to study medicine. I applied for medicine
after college and was unsuccessful. I went on to study chemistry with biochemistry and
after graduating applied to study medicine. I worked for a year as the Curriculum Associate at The
Challenge, a charity committed to bringing different people together to develop their confidence and
skills and understanding in connecting with others, through designing and delivering programmes.
Medic Mentor is a safe haven. It is a family that is so welcoming and completely committed to supporting
everyone that is involved: current medical students, aspiring, doctors, volunteers and families!
I am so grateful to be a part of something so rich and so special.
I’m Angela,”
I smile, holding
out my hand
“Hi,
to the nervous-looking
year 13 student who has
just sat down in front of me. She
takes it.
“Hi,” she stutters. “I’m Clara.”
“It’s very nice to meet you, Clara,” I
replied. “This is the communication
skills station, i.e. the roleplay scenario.”
I watch her face drop like her five
predecessors had done. “You are
the captain of your medical school’s
hockey team. I am your best friend.
Please tell me that I did not make it
onto the final team this year.”
She stares at me in response, frozen.
I decide to help her start.
“Hi Clara,” I relax back into my
seat, acting like we had just met up.
“How are you?”
“Hey Angela,” she mumbles back
awkwardly. “I’m OK. How are
you?”
“I’m still recovering from the hockey
try-outs last Wednesday,” I laugh.
“They were exhausting, weren’t
they?”
“Yeah,” she fidgets with her hands.
“Um, look Angela, I know we are
friends and all but I’m going to have
to tell you that you didn’t make it
onto the team.”
I pretend to act shocked. “What?” I
gasp, starting to look upset. “What
do you mean I haven’t made it onto
Angela Yan
the team? I’ve been on the team
for two years, you know how much
hockey means to me!”
The student cringes in response to
my outburst and for the next five
minutes I’m unable to get anything
else out of her apart from being
repeatedly told I hadn’t made the
hockey team.
This is a common performance by
a prospective medical school student
at this station which I have seen
more often than not during my past
year of volunteering for mock medical
school interviews. At first my initial
response had been one of sympathy;
these students remind me of
my 17-year-old self. Five years ago
when I had found myself in the same
position, I can recall the sinking feeling
in my stomach as I panicked over
what to say. I had no idea how to
break bad news to someone, or how
to talk about a sensitive topic like
weight-loss to an obese patient. All
the pre-reading I had done on my
personal statement, current medical
news and ethics had not been able to
help me in this situation.
It is only five years later that I really
understand what the interviewer
had been looking for in this scenario.
I had to show that I was empathetic,
that I could treat the actor
with respect and sensitivity. Sure, at
17 years old I was able to rattle on
about how communication skills are
an essential trait every good doctor
must have, integral for creating good
patient-doctor relationships and
therefore good patient care. I had
no doubt that Clara knew how important
communication skills were,
but how could I get her to be able
to use her knowledge and put it into
practice? It had earned me my first
rejection and it was only then that
I began to understand what the interviewers
were looking for. I didn’t
want Clara to make the same costly
sacrifice I had to.
“It’s OK,” I smile gently at Clara.
“Remember this is only a mock interview;
any experience, good or bad
will help you in the real thing. Now,
let’s change the scenario. Imagine
that you have just been told you got
rejected from your favourite medical
school. How would you feel?”
“Upset,” she replies, her face paling
at the mere thought. “I’d be really
upset.”
“Exactly,” I nod. “How would you
like to be treated if you found yourself
in that position? “I’d want someone
to comfort me,” she replies. “I’d
want someone to tell me it’s OK.”
“Anything else?” I press her. “From
the medical school perhaps?”
“Feedback,” she starts to realise what
I’m getting at. “I’d want to know
how I can improve.”
“Of course you would,” I reply.
“Now let’s apply it to this situation.
It’s never a good idea to just give
some bad news straightaway is it?”
She shakes her head. “You want to
broach the subject gently. Start by
talking about what she’s good at or
why she’s a good friend. She’s going
to be feeling very low after you break
the news to her so it’s important you
remind her of her other skills and
good qualities. When you tell her she
didn’t make the team, it’s important
62
63

you give her a reason. It’s important that
she knows where her weaknesses are so she
can improve for next time. You can make
up any reason but you have to give her a
reason.”
“Any reason?” she repeats. I nod, this is a
common misassumption students make;
there is no set script for the station and the
actor will follow the student’s story unless
it’s inappropriate.
“Finally,” I reply, “in real life, if I was your
best friend, you’d want to help me make it
onto the team again, because you’d want to
support your friend. For example, if the reason
I hadn’t made the team was because of
my lack of fitness, you could have offered to
go to the gym with me, or do extra practice
sessions with me. In this station, the interviewer
wants to see that you are a caring
person who is aware of the feelings of her
friend and wants to help her. These are all
desirable qualities a good doctor should
possess.”
The list of possibilities that can come up in
the communication skills station is almost
infinite. Sometimes they can be very obviously
medically-related; for example, talking
about a sensitive topic like obesity, but
sometimes not, like comforting a distraught
stranger. It can be very difficult to think of
what to say and do in these situations, especially
when you will be given very little time
to prepare for these stations. My one piece
of advice would be to put yourself in the
actor’s shoes, and start thinking about how
you would like to be spoken to and how you
would like to be treated. That way, you will
be able decide what would be appropriate
to say and not to say in this situation, and
formulate your response accordingly. Don’t
forget that this is an unscripted role play as
well and you are allowed to put your own
twist on the setting. Good luck to all our
readers with upcoming MMIs!
Our February edition will be themed ‘Hate your body’ and will
feature a number of articles on mental health, exercise, the media
healthy living and more.
As well as this, we are looking for articles on the following topics
specifically:
-Your journey into medical school.
-Your perspective as a parent.
Thinking about writing?
-The things you have done with Medic Mentor and what you thought of the company
and its events.
-Current affairs: many seemingly non-medical things affect the medical world.
-Is there someone you could interview that you think our readers would like to hear
from?
-Letters discussing the previous edition’s content.
We want more of you to get involved with the magazine, no matter who
you are or where you’re coming from. Our writers are mostly medical
students but that is only because those of you who are still at school don’t
get in touch! Three of this edition’s articles were written by pre-university
students.
mag@medicmentor.org
64
65

Respiratory crossword
Everything in this crossword is to do with lungs, their physiology, and the diseases
that affect them - It’s quite tough!
maangras
Anagrams
granamas
Sangrama
Namagras
1.
2.
3.
4.
5.
6.
8.
7.
9. 10.
DOWN
1. The name for something that moves in the blood, normally
a blood clot from the veins in the leg to your lungs (7).
ACROSS
4. A common respiratory disease of childhood. It gives you a
wheeze (6).
1. High blood pressure
2. A vital sign that you can count from the end of the bed
6. Hormone released by the ovaries
7. Medical term for heart attack
2. The name for a cancer of lining (epithelial) cells. In the
lungs, there are two broad types: ‘small cell’ and ‘non-small
cell’ (9).
3. Phlegm (6).
4. The smallest unit of gas exchange in the lungs (7).
9. A bacterial infection. There is a rise in multi-drug resistance,
especially in Eastern Europe. It causes you to cough
up blood, and used to kill a lot of people. It is more common
in people who live in crowded houses and who have weak
immune systems (12).
10. The largest tubes in the lungs (7).
3. The tract that digests food
4. A very strong painkiller
5. Respiratory condition
8. Your brain, spinal cord, and nerves make up your…
9. Wear and tear of the joints, more prevalent in older
populations
10. An endocrine disorder characterised by high glucose
5. The medical term for fast-breathing (10).
6. The device used to deliver medication for 4ACROSS.
When using 7DOWN it is made of blue plastic (7).
7. The gas that we breathe in which diffuses into red blood
cells and is carried around the body. It is used by cells to
perform respiration and produce ATP (6).
8. The mainstay of treatment for 4ACROSS. It dilates the
airways over a short period of time. (10).
11. The small hairs lining the respiratory tubes that move
mucous. Burned when you smoke cigarettes (5).
12. The commonly used acronym for a crippling, chronic
disease in people who smoke all of their life. In the developing
world, cooking on indoor fires and inhaling the smoke is a
common cause (4).
13. The medical term for things to do with the lungs (9).
Answers to all of the
Puzzles
can be found on page 4
66
67

Dear reader,
Early report
EARLY REPORT
If you have something to say, arrive early, stand
up, and speak clearly.
-
There are articles printed in here that, despite my best efforts, may contain mistakes. It is
also realistic that some of you will disagree with some of the opinions. In fact, I would encourage
you to do so.
If you spot a mistake, or you want to discuss an issue further, or you plainly want to call out
an author on the tripe they have written that, somehow, I have allowed to be printed, I want
you to write in and tell me.
The worst that can happen is that your e-mail remains in my inbox; I give it one look and
decide it isn’t worth printing. That shouldn’t be a concern.
The concern should be that you’re sitting on knowledge that we all need to hear, because if
an article gets printed, that means I think it’s correct, and our readers will think it’s correct.
What does a mistake like that mean? Probably nothing, but it might cost someone their
interview when they reel off a ‘fact’ that is ten years out of date. More likely, an opinion
will go unchallenged when really there ought to be people begging me to
print a counter piece.
The best that can happen is you enlighten our readers, get a letter printed in a national
magazine and improve your writing skills, articulation and logical reasoning - all in time
for your interview or for writing your personal statement. These are transferable skills that
graduates need in abundance; start working on them now.
So, I have picked two articles waiting to be argued with and printed them below. Have
a think about how you might respond. Across the page lies an example of what happens
when we are mislead; thankfully someone spoke up.
Faithfully yours,
The Editor
Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and
pervasive developmental disorder in children
A J Wakefield, S H Murch, A Anthony, J Linnell, D M Casson, M Malik, M Berelowitz, A P Dhillon, M A Thomson,
P Harvey, A Valentine, S E Davies, J A Walker-Smith
Summary
Background We investigated a consecutive series of
children with chronic enterocolitis and regressive
developmental disorder.
Methods 12 children (mean age 6 years [range 3–10], 11
boys) were referred to a paediatric gastroenterology unit
with a history of normal development followed by loss of
acquired skills, including language, together with diarrhoea
and abdominal pain. Children underwent
gastroenterological, neurological, and developmental
assessment and review of developmental records.
Ileocolonoscopy and biopsy sampling, magnetic-resonance
imaging (MRI), electroencephalography (EEG), and lumbar
puncture were done under sedation. Barium follow-through
radiography was done where possible. Biochemical,
haematological, and immunological profiles were
examined.
Findings Onset of behavioural symptoms was associated,
by the parents, with measles, mumps, and rubella
vaccination in eight of the 12 children, with measles
infection in one child, and otitis media in another. All 12
children had intestinal abnormalities, ranging from
lymphoid nodular hyperplasia to aphthoid ulceration.
Histology showed patchy chronic inflammation in the colon
in 11 children and reactive ileal lymphoid hyperplasia in
seven, but no granulomas. Behavioural disorders included
autism (nine), disintegrative psychosis (one), and possible
postviral or vaccinal encephalitis (two). There were no
focal neurological abnormalities and MRI and EEG tests
were normal. Abnormal laboratory results were significantly
raised urinary methylmalonic acid compared with agematched
controls (p=0·003), low haemoglobin in four
children, and a low serum IgA in four children.
Interpretation We identified associated gastrointestinal
disease and developmental regression in a group of
previously normal children, which was generally associated
in time with possible environmental triggers.
Lancet 1998; 351: 637–41
See Commentary page
Inflammatory Bowel Disease Study Group, University Departments
of Medicine and Histopathology (A J Wakefield FRCS, A Anthony MB,
J Linnell PhD, A P Dhillon MRCPath, S E Davies MRCPath) and the
University Departments of Paediatric Gastroenterology
(S H Murch MB, D M Casson MRCP, M Malik MRCP,
M A Thomson FRCP, J A Walker-Smith FRCP,), Child and Adolescent
Psychiatry (M Berelowitz FRCPsych), Neurology (P Harvey FRCP), and
Radiology (A Valentine FRCR), Royal Free Hospital and School of
Medicine, London NW3 2QG, UK
Correspondence to: Dr A J Wakefield
Introduction
We saw several children who, after a period of apparent
normality, lost acquired skills, including communication.
They all had gastrointestinal symptoms, including
abdominal pain, diarrhoea, and bloating and, in some
cases, food intolerance. We describe the clinical findings,
and gastrointestinal features of these children.
Patients and methods
12 children, consecutively referred to the department of
paediatric gastroenterology with a history of a pervasive
developmental disorder with loss of acquired skills and intestinal
symptoms (diarrhoea, abdominal pain, bloating and food
intolerance), were investigated. All children were admitted to the
ward for 1 week, accompanied by their parents.
Clinical investigations
We took histories, including details of immunisations and
exposure to infectious diseases, and assessed the children. In 11
cases the history was obtained by the senior clinician (JW-S).
Neurological and psychiatric assessments were done by
consultant staff (PH, MB) with HMS-4 criteria. 1 Developmental
histories included a review of prospective developmental records
from parents, health visitors, and general practitioners. Four
children did not undergo psychiatric assessment in hospital; all
had been assessed professionally elsewhere, so these assessments
were used as the basis for their behavioural diagnosis.
After bowel preparation, ileocolonoscopy was performed by
SHM or MAT under sedation with midazolam and pethidine.
Paired frozen and formalin-fixed mucosal biopsy samples were
taken from the terminal ileum; ascending, transverse,
descending, and sigmoid colons, and from the rectum. The
procedure was recorded by video or still images, and were
compared with images of the previous seven consecutive
paediatric colonoscopies (four normal colonoscopies and three
on children with ulcerative colitis), in which the physician
reported normal appearances in the terminal ileum. Barium
follow-through radiography was possible in some cases.
Also under sedation, cerebral magnetic-resonance imaging
(MRI), electroencephalography (EEG) including visual, brain
stem auditory, and sensory evoked potentials (where compliance
made these possible), and lumbar puncture were done.
RETRACTED
Laboratory investigations
Thyroid function, serum long-chain fatty acids, and
cerebrospinal-fluid lactate were measured to exclude known
causes of childhood neurodegenerative disease. Urinary
methylmalonic acid was measured in random urine samples from
eight of the 12 children and 14 age-matched and sex-matched
normal controls, by a modification of a technique described
previously. 2 Chromatograms were scanned digitally on
computer, to analyse the methylmalonic-acid zones from cases
and controls. Urinary methylmalonic-acid concentrations in
patients and controls were compared by a two-sample t test.
Urinary creatinine was estimated by routine spectrophotometric
assay.
Children were screened for antiendomyseal antibodies and
boys were screened for fragile-X if this had not been done
THE LANCET • Vol 351 • February 28, 1998 637
68
69

Bad parenting
Last year, history was made
when a couple were arrested
on suspicion of neglect
and narrowly escaped jail.
The reason? They allowed their
11-year-old boy to balloon to a
shocking 15 stone. The couple were
detained on the Children’s Act 1933
and held on bail. Do you believe
they should have gone to jail?
This is an extreme example, but
childhood obesity is a global epidemic
and an intervention is needed
as soon as possible. According
to the Lancet, there are now more
obese people in the world than underweight
and this should worry
everyone. In order to solve the problem
we need to find the cause. What
I’m wondering is: are parents at fault
here?
A recent government study found
that more than 30% of children
aged 2 to 15 were classed as either
overweight or obese, 10% of 2 to
5-year-olds are overweight and, since
1980, the proportion of overweight
children aged 6 to 11 has more than
doubled. These are shocking figures
that show a dramatic increase in
childhood obesity. The question is,
what has caused this increase and
how can we stop this epidemic progressing?
Obesity is a complex problem with
many drivers, including our behaviour,
environment, genetics and culture.
However, obesity is ultimately
caused by an energy imbalance:
taking in more energy through food
than we use through activity. When
we talk about tackling obesity, all we
are really talking about, in essence, is
tackling this energy imbalance, one
Rebecca Vere
fat person at a time.
Childhood obesity is such a worrying
epidemic as it is extremely likely
to progress to adult obesity. Lifestyle
patterns from our early years persist
over time, with childhood obesity
continuing into adulthood. Obesity
during childhood has been found
to be associated with significant
medical co-morbidities, and excess
weight in childhood independently
increases the risk of mortality related
to cardiovascular and metabolic
disease. It is important that we also
consider the psychosocial impact of
obesity as it has been linked to adverse
effects on social, psychological,
and academic development. Obese
children are more likely to experience
bullying, lower health-related
quality of life, and impaired mental
health. Therefore, it is clearly in the
best interests of parents to prevent
childhood obesity.
Although it may be tempting for parents
of an overweight child to blame
‘bad genes’ for problems managing
excess weight, in reality genes have
less to do with the problem than
we would like to think. Whilst they
do contribute to a child’s ‘natural
weight’, a large part of obesity susceptibility
remains down to their
lifestyle. Such a dramatic rise in
childhood obesity in such a short
space of time cannot be attributed
purely to genetic factors, as these do
not change in any substantial way
year on year, or even between generations.
There are many other factors,
such as diet and exercise, which
make a much greater contribution to
weight than genes. These are, arguably,
under the parent’s control.
Obviously parents influence their
child’s diet. Who feeds you before
you learn to feed yourself ? Your parents
do, and children eat what their
parents eat. If parents consume fast
food regularly, their children are
more likely to do the same, which
can result in obesity. Unhealthy eating
habits can result in serious health
complications for the children such
as diabetes and high cholesterol,
which will affect them throughout
adulthood.
So, of course it is the responsibility
of parents to monitor the nutritional
value of the foods their children
consume. Which means it is essential
that parents are knowledgeable
about nutrition and are able to identify
what is healthy and what isn’t.
Many parents simply don’t know
how to provide their children with
a healthy, balanced diet. All too often
parents are over-feeding their
beloved child because they feel it is
what they need to do to be a good
parent, ensuring their offspring grow
big and strong. Ironically, the reality
is that they are providing their children
with health problems that will
stay with them throughout their life.
In order to make healthier choices,
families need to be presented with
clear information about the food
they are buying. The UK has led the
way, working with industry to implement
a voluntary front of pack traffic
light labelling scheme, which now
covers two thirds of products sold in
the UK in response to recent government
guidelines.
Similarly, schools are making a
conscious effort to tackle the problem,
and parents need to do the
same. School dinners have already
been modified thanks to Jamie Oliver.
Unfortunately, I remember
the year that turkey twizzlers, fizzy
drinks and ice buns were confined
to the history books; a secondary
school lunch that the older years
would speak of fondly (although
now I appreciate their true damage).
Food isn’t the only problem. One in
five children aged 9-13 were found
to engage in no free-time physical
activity. This is a shocking figure and
obviously parents can make a difference
to this. Recent developments
in technology mean the easiest way
for a parent to keep their child occupied
is with an iPad rather than
a physical activity. Just go to any
family restaurant and you will see
children glued to a screen to keep
them occupied throughout the meal.
This also extends into the home, an
environment which is undoubtedly
an important setting in preventing
overweight and obesity. Television
viewing has been identified as an
independent risk factor for obesity
and, as a result, might in fact be
more dangerous than playing in the
woods or climbing a tree – activities
which do not seem to belong in the
digital age.
There’s also the matter of loading
children’s days with activities that
preclude kids from exercising more.
Given a choice — and the opportunity
— it is highly likely that children
would opt to spend more of
their time engaging in physical activity,
but they’re not being allowed
to choose freely. Rather, adults are
choosing for them. Parents, in the
most loving and mollycoddling way
imaginable, are over-scheduling
their children to ensure they provide
them with the ‘best possible’ childhood.
But what value is there in being
grade 5 clarinet if you’ve been
left with metabolic syndrome? Parents
are indeed partially responsible
for over-scheduling their kids, but
there’s also the matter of teachers
assigning copious amounts of homework.
Obviously, this will reduce the
amount of time they spend outside.
In a bid to tackle this, the Department
of Health are working to ensure
that from September 2017,
every primary school in England
has access to high quality sport and
physical activity programmes, both
local and national. As part of this,
national governing bodies will offer
high quality sport programmes to
every primary school.
However, it is ultimately the parent’s
choice if their children walk,
cycle or drive to school. Although
initiatives are set in place by schools
to encourage walking and cycling,
parents have the final say. Too often,
overly anxious mothers are driving
their children to school because they
believe it is unsafe to let them walk
or cycle themselves.
School is also tackling the problem
of lack of exercise since new PE
initiatives have already been put in
place. Following changes in recent
government guidelines it has been
recommended that all children and
young people should engage in
moderate to vigorous intensity physical
activity for at least 60 minutes
every day. Many schools already offer
an average of two hours of PE
or other physical activities per week.
However, we need to do more to encourage
children to be active every
day. At least 30 minutes daily should
be delivered in school through active
break times, PE, extra-curricular
clubs, or other sporting events.
The remaining 30 minutes need to
be provided by parents, outside of
school time.
So, schools are making a conscious
effort to make the lunches they provide
healthier and to engage children
in more frequent physical exercise.
Educating parents is the next step
required to tackle the issue. There
are several factors that will contribute
to childhood obesity, however
the two most important are diet and
exercise and these are usually under
the parent’s control. The solution is
to tackle all of the problems simultaneously,
but ultimately parents must
change their offspring’s eating habits
and they need to be educated in how
to look after their child’s health. We
need to improve awareness of this
horrendous epidemic and education
will follow. Otherwise we will be failing
our children with only ourselves
to blame.
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Dope article, bro
I
have felt the anger and bafflement
experienced by many fans
of sport upon discovering that
a successful athlete has cheated
their way to the top. The ‘top’, as
if they have actually ascended the
ranks of their profession. Rather,
they have just switched sports, the
same way boxers switch weight categories,
and are now competing only
with other like-minded dopers. Why
go to such lengths to win when the
victory is hollow? They must know,
deep down, that what they have
done is not just wrong, but a waste of
time. A gold Olympic medal is worth
much more in pride than it is in metal,
so you’re depreciating its worth
by defrauding the system.
This is a hard line to take and you
can’t walk down it for long before
you reach an unpalatable conclusion:
we need to ban coffee. It is often
an unwelcome voice that pipes
up to remind ‘true’ sports fans that
the line we have drawn to delineate
doping and competing is a completely
arbitrary one. We needn’t look
far back in sporting’s history to find
unacceptable practices that are all
but necessities today, but only those
completely blinded by tradition
would argue that sport is in worse
shape now than it was 50 years ago.
It seems, to me at least, that doping
is only a problem so long as we keep
saying it is.
Developments in training have made
a much greater contribution to improvements
in sporting outcomes
than anything that can be implemented
at the race, on the main stage, on
the night. I’m not talking about performance
enhancing drugs, either.
In Chariots of Fire, one of the main
Michael Houssemayne du Boulay
characters is lambasted for hiring a
coach. Indeed, historically, athletes
were discouraged from training at
all, relying instead on ‘natural’ ability.
Fast forward and we have personalised
nutrition programmes, where
nothing passes the lips of a top athlete
without it being logged. The
very idea of natural ability is such
a weak concept that it struggles to
stand up under its own weight. The
near interminable variables are too
many to even list, let alone control
in a desperate and futile attempt to
create a perfectly balanced competition
of raw talent. All we can hope
to do is provide equal access to performance
enhancement across the
board, but tell that to athletes from
underprivileged backgrounds (have
you ever enquired into the cost of
tennis coaching?).
To cheat is to garner an unfair advantage
over your competition. Unfair
implies that others do not have
access to it, but that cannot be the
only distinction drawn. Nutrition
has surely had the greatest impact
on physical prowess in history, but
even that is unequal amongst today’s
athletes. We would not turn
around and deny a sportsperson
their dietitian because the team from
Equatorial Guinea haven’t heard of
MyProtein yet, and rightly so. We
complain about our performance
in the Winter Olympics and blame
it on our lack of snow, but no one
is suggesting for a second that we
should be given a handicap because
the climate in Great Britain is not
conducive to developing a first rate
ski team. So, too, if you come from a
poor country you should be afforded
no privileges.
After all, the purists argue, hard work
is always available in abundance, no
matter where you originate. Certainly,
but how efficacious is hard work
when you have to devote most of
your day to going to your job and
feeding your family? What time is
left to train? Contrasted with the
sponsored athlete who is paid to go
to the gym our penniless underdog
can barely be consider a contender.
Doping this may not be, but it is certainly
more of an unfair advantage
than taking steroids which athletes
the world over have access to. What
do you think is more expensive: a
high altitude tent to sleep in every
night and a personal physician to direct
its use, or some make-me-hench
‘roids that you got from Gary down
the gym?
While we’re talking about drugs,
we ought to just touch on the medications
mentioned in this article.
Meldonium is an old Eastern European
treatment for ischaemic heart
disease. It is not licensed for use in
the UK and it was brought into the
spotlight following the scandal surrounding
Sharapova, one of the
highest grossing tennis players of all
time, who was banned for using it
by the World Anti-Doping Agency.
EPO stands for erythropoietin, the
hormone responsible for stimulating
red blood cell production. It is most
famous in sport for its widespread
abuse in cycling, in particular the
Tour de France where a number of
previous winners have been stripped
of their titles for its abuse (as well
as other substances). Most notable
of the disgraced Tour cohort is
Lance Armstrong who deceived the
competition organisers, fans and
sponsors for many years. Anabolic
steroid is the generic name given to
androgens that mimic the effects of
testosterone in the body, well known
for rapidly increasing muscle mass
and giving body-builders the Arnie
makeover.
What, then, does it mean to cheat?
The only answer I can reason is
that it means to do what your sport
says you can’t, and what your sport
says you can’t do is arbitrary and
open to change. Largely, the line
seems to be drawn on a feeling of
wrongness alone; we’re noticeably
uncomfortable with players taking
a perceived shortcut to success. To
take two football examples to illustrate,
Peter Shilton and Lionel Messi
were both too short as children to be
seriously considered for professional
careers. The would-be England
goalkeeper reportedly dangled from
the bannister in his home, with increasingly
heavy weights attached
to his feet (house bricks, apparently)
in order to stretch him out. Whereas
the world’s greatest player, diagnosed
with a growth hormone deficiency
in childhood, was prescribed
human growth hormone and he
has now reached average height in
adulthood. Suppose Peter Shilton
had decided to skip the undoubtedly
arduous process of drawing
his own legs, opting instead to have
his bones surgically fractured and
then positioned to promote growth,
or pressured his doctor to prescribe
him human growth hormone, like
Messi. It certainly doesn’t feel as if
we should allow the latter options to
go ahead, but they achieve the same
outcome, and put the player’s body
and mind through different, but still
difficult, ‘training’.
You’re all shaking your fists at the
thought, but what about the malnourished
child whose growth improves
in leaps and bounds when
they’re given a proper diet? Now,
what about the well-nourished child
who, when given a personalised
diet programme, reaches their full
potential instead of falling short
by an inch? Now, what about the
well-nourished child, with a personalised
diet programme, but without
the same testosterone producing capacity
of their peers? By no means a
disease, but they would undeniably
gain benefit from the use of anabolic
steroids. You might argue that it’s
just genetic variability – some people
are naturally predisposed to be taller,
stronger, faster – these aren’t diseases
to be corrected, so it’s wrong
to try and fix them with a medical
intervention. The only difference
between child two and child three,
dangers of their treatment aside, is
that we consider anabolic steroids
to be an unfair sporting advantage,
whereas dietary advice is well within
the boundaries of acceptability.
The dangers don’t really factor into
that ruling, either. In the grand
scheme of the perils of sport, blood
doping is relatively safe, especially
if it is above board and well controlled.
No one threatens to bring
an end to sport over the injuries,
sudden cardiac deaths and the psychological
trauma that goes into
training. (Youth rugby aside – although
look at the public outcry
when it was suggested!) Why has the
line been drawn, then? I believe it
boils down to the same feeling and
fear of the unnatural. Herbalism is
natural, meditation is natural, injecting
steroids into your eyeballs
with a big syringe isn’t natural. But
in the same way that you shout at
a patient for not taking aspirin because
they don’t like tablets, we’re
shouting at athletes for embracing
technological advances that move us
away from the roots of sport. People
swim in pools, not lakes, we have
carbon fibre everything and multiple
spares rather than one wooden
racquet, bikes weigh less than the
food a cyclist consumes in a day and
with each progression we step away
from naked Greco-Roman wrestlers
and towards e-sports, bionic super
humans and athletic competition
which requires a team and a holistic
strategy not just a go hard or go
home mentality.
Yet we have die-hard fans talk about
how doping is ruining sport. The
only thing ruining sport is a desperate
attempt to cling to the days
of yore in the face of unstoppable
change. Look no further than Sepp
Blatter’s repeated refusal to introduce
goal line technology for the
sake of nostalgia versus tennis and
cricket’s willing adoption of hawk
eye as the perfect example. When
will cycling realise that EPO is only
a problem because the organisers
say it is a problem? Crop dust EPO
over fields of cyclists and put testosterone
in their porridge and any unfair
advantage is gone.
We have all been getting outrageously
upset with the Russian state-sponsored
doping programme. The gall
of it! It is so obviously cheating and
so perfectly Putin. However, if we
look instead at a state-sponsored
training programme, pumping millions
of pounds into the development
of athletes, perfecting their
nutrition, designing the best bikes,
hunting down the perfect players
from all four corners of the globe,
no one bats an eyelid at its morality.
These were all new practices once,
and they all attracted disapproval. I
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would suggest that if we made sure athletes
were not put at harm, a goal much easier
to achieve by allowing widespread, above
board doping, all we are witnessing is the
next big development in sport.
Why are we so concerned about this
change? Some people cry that it takes away
the enjoyment of watching the competition,
but this is inconsistent with our love of the
performers and artists in every other walk
of life. I reach peak coffee about half an
hour after I neck a cup. It’s like carb loading
but for writing ability and as I type this I
feel warmed up and well stretched. It won’t
last, and when you spot a good paragraph
you can be assured there was an espresso
to thank. That’s performance enhancement
for you. Similarly, athletes gain a significant
benefit shortly after ingesting caffeine, so
much so that you would be a fool to not
take some tablets with you to a competition.
Of course, we cannot ban caffeine because
we would reduce our eligible pool of sportspeople
to a handful of post-menopausal
women with weak bladders who, in anticipation
of their call-up, have been avoiding
caffeine for years. But that is the conclusion
we have to reach if we keep up this Luddite
witch hunt for progressivists. The Olympic
Committee might as well revoke every
world record created after Starbucks was established
because all of them were created
unnaturally, on drugs. We should be fighting
the return to sport’s origins, not actively
seeking it. The only difference between
caffeine and Sharapova’s recent ban due to
meldonium is that we started banning drugs
after caffeine was discovered.
The same argument stretches to so many
walks of life. Would you deny The Beatles
LSD? Because I’m not a big fan of Sergeant
Pepper’s Lonely Hearts Club Band
but I hear they have a few followers out
there. The album wouldn’t be the same,
for sure, and their competitive status as the
greatest band of all time might have been
challenged. It frees my mind, man. Well,
EPO frees me from the crippling pain of
cycling up a 1 in 3 hill, friend. As the public
continuously clamours for the greatest
spectacle since the last time they turned on
the TV, the pressure on athletes and artist
to perfect their form builds. ‘Natural’ development
can only take us so far - if you keep
demanding entertainment then we need to
allow our entertainers to source new means
of improvement.
The competitive element is obviously fundamental
to the argument. Drugs tilt the
field quite significantly but that only matters
if you’re playing for spoils. This is not
so applicable to artists who are just trying
to achieve personal greatness, rather than
outdo each other as sportsmen and women
are. But let’s re-level the playing field: give
everyone on the Tour EPO and the problem
disappears. If you’re still uneasy with
its use, I suppose you must be unhappy with
them outdoing their historical counterparts.
Who else is being cheated? Though, as we
have seen, this is a not a problem of our
generation, nor a problem of illicit and
controlled drugs. Future generations will always
outdo their ancestors.
Purists of sport are frothing at the mouth
in rage, without stopping to consider what
they’re angry about. It’s just easiest, I suppose,
to shout about banning cheats loud
enough to drown out any progressive thinking,
but where do we end up? Like all angry
mobs, they will quieten down when no
longer stoked by reactionary voices and
slowly, but surely, sport will progress to its
natural end: giant, bionic humans on cocaine
battling each other to their simulated
death. I, for one, can’t wait.
___________
Originally published in North Wing Magazine,
available here:
http://northwingmagazine.com/
I look forward to reading your letters.
Fewer than 300 words, received no later than 14th
February 2017.
For submissions and enquiries:
mag@medicmentor.org
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