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M E N T O R<br />
Issue 4<br />
November 30 th 2016<br />
10 Questions with:<br />
The coroner<br />
Practical medicine:<br />
The poorly understood perils of<br />
disease screening<br />
Extreme physiology series:<br />
Extreme cold<br />
Reaching the end:<br />
Should families get a say in<br />
end of life care?<br />
-<br />
From day one to the end of year<br />
five, your family will think of<br />
you as their own, most personal<br />
doctor
Start discovering the world of medicine.<br />
Page 7<br />
10 Questions with the coroner<br />
Page 11<br />
Making the same mistake twice<br />
Page 15<br />
Keep me alive // Let me live<br />
Page 18<br />
How to calculate QALYs<br />
Think about what you have learnt and question it all.<br />
Page 21<br />
Family matters<br />
Page 26<br />
Is there a doctor in the house?<br />
Page 30<br />
No shame in fat shaming<br />
Study to get the knowledge you need.<br />
Page 35<br />
The screening paradox<br />
Page 40<br />
Ask a physiologist: Baby, it’s cold outside<br />
Page 47<br />
Unprepared for autopsy<br />
Page 48<br />
Why we shouldn’t have got rid of the LCP<br />
Get involved with Medic Mentor and help others, too.<br />
Page 53<br />
We’re going through changes<br />
Page 63<br />
Demystifying MMIs<br />
Page 66<br />
Puzzles<br />
Page 70<br />
Bad parenting<br />
Page 72<br />
Dope article, bro<br />
MEDIC MENTOR magazine<br />
Motivating medical minds<br />
Issue 4; November 2016<br />
2 3
References<br />
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:<br />
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<br />
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<br />
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<br />
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<br />
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<br />
15. PBS News HEALTH: Why is Zika virus spreading so quickly? 28 January 2016<br />
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]<br />
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<br />
from the University of Sheffield]<br />
Idiosinkratic [artwork]: Artwork by Jamie Crawford. More artwork can be viewed at facebook.com/idiosinkratic or idiosinkratic.wordpress.com<br />
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<br />
[Accessed 19th November 2016]<br />
Write for us<br />
All of the articles, photographs and illustrations included in this magazine were submitted by medical students or<br />
sixth formers. Your past experience should not dissuade you from contributing; I can assure you, first drafts rarely<br />
resemble the final, printed piece. We are here to help you develop your writing ability, all that is required is enthusiasm<br />
and dedication. The two are usually linked.<br />
We have produced a writing guide to aid authors, as well as a list of article suggestions for those struggling for ideas.<br />
Both are available from the Medic Mentor website group, Magazine Contributors. Sign up now and give them a read<br />
before you start work, http://medicmentor.co.uk/groups/magazine-contributors-28021278/<br />
If you want to see your work in the next issue of Medic Mentor, please get in touch.<br />
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<br />
mag@medicmentor.org<br />
The articles printed do not necessarily reflect the views of Medic Mentor, its staff, or even the authors themselves.<br />
From the editor’s desk<br />
In September 2017, Medic Mentor will launch the Mastering Medical School Conference, and students will attend<br />
from a range of ages and stages of life. For those who are yet to even get an offer for medicine, but are attending<br />
a workshop on how to make the most of their time at university, it will doubtless end up redundant. They will, of<br />
course, hear excellent ideas from inspiring speakers, but the kind of student who thinks that far ahead needs little<br />
more than a gentle nudge in the right direction - the first domino.<br />
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<br />
prevent me from graduating and claiming the title, Dr The Editor. It may seem like that is a very long way away<br />
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<br />
magazine. Allow me to convince you otherwise.<br />
I commenced university in 2011, and that plant in the background picture to the left was half its current size. I<br />
had never considered writing an article, let alone running a magazine; in fact, I thought that magazines were a big<br />
waste of money and largely ethically disastrous. A few magazines have maintained that impression. I was a scientist<br />
through and through, and my first university essay assignment (on the history of medicine) was an awful disaster. If<br />
it was submitted to me as an article now, I can imagine I would have my work cut out in editing it.<br />
My family were not particularly surprised when I came to them with my concerns regarding the career choice I had<br />
seemingly made too young. They were hugely supportive of me taking an extra year to complete university, even<br />
though that meant living in London and the financial support this necessarily entailed. I think they were behind me<br />
because they could see that I was doing something I genuinely enjoyed and was putting all of my energy into. They<br />
will, however, be hugely relieved when all of this is over, I’m sure. That extra year was the beginning of my realisation<br />
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<br />
that I could genuinely love.<br />
I would suggest that what you do in 2017 is of vital importance. Medical school’s impact on your life is prescribed<br />
only insofar as you are required to pass exams once a year, the rest is open to interpretation. With your free time you<br />
need to find things you’re interested in and pursue them with vigour (and then write an article explaining why we<br />
should all be interested too). It is never too early to start, and your family, whatever form they may take, will support<br />
you in your choices along the way.<br />
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<br />
4. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival#heading-Three 5. http://<br />
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/<br />
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<br />
[All accessed 19th November 2016]<br />
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.<br />
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,<br />
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<br />
Family.<br />
Dear reader: The retracted article is taken from the Lancet; Wakefield 1998 (full reference as per the image).<br />
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<br />
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<br />
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<br />
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<br />
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.<br />
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.<br />
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<br />
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<br />
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<br />
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<br />
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.<br />
http://www.dailymail.co.uk/sport/worldcup2010/article-1282961/Gordon-Banks-Peter-Shilton-Jeepers-keepers--I-split-Englands-legends.html<br />
In this edition we are going to explore some issues related to families. They play a huge role in both early life, as<br />
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<br />
old and decrepit parents.<br />
I hope you enjoy it. If you have any comments, I would be delighted to receive them, and they may even be printed<br />
as Medic Mentor magazine’s first ever letter.<br />
Michael Houssemayne du Boulay<br />
Editor<br />
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.<br />
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<br />
Puzzle answers<br />
infarction 8. Nervous system 9. Osteoarthritis 10. Diabetes mellitus<br />
Many thanks to Jennifer. N. R. Smith,<br />
who produced the cover artwork.<br />
www.jnrsmith.co.uk<br />
4 5
10 Questions with: the coroner<br />
Michael Houssemayne du Boulay<br />
DDiscover<br />
After several requests from readers<br />
and medical students, I decided it<br />
was time to set aside a little time to<br />
find out what a career in medical law<br />
entails. I got in touch with Richard<br />
Baker, who was, until recently, an<br />
assistant coroner in South Yorkshire.<br />
1. What is a normal day like, if a ‘normal’<br />
day exists for you?<br />
I am a barrister, practising medico-legal<br />
work, who sat as an assistant<br />
coroner between 2011 and 2016. An<br />
assistant coroner holds a part-time<br />
role in the coroner’s court and usually<br />
undertakes sittings in between<br />
working full-time as a barrister or<br />
solicitor. As an advocate, I was naturally<br />
drawn to the side of the work<br />
that involves examining witnesses<br />
and testing evidence. I soon discovered<br />
that this is only a small part of<br />
the role, though, as a coroner has<br />
conduct of an investigation from the<br />
point where they are notified of a<br />
death, through to the conclusion of<br />
an inquest. They are responsible for<br />
organising the investigation, determining<br />
which witnesses will need to<br />
be called, which experts are needed<br />
to resolve the issues in the case and,<br />
ultimately, calling those witnesses to<br />
give evidence and reaching a conclusion<br />
on the case. No two days are the<br />
same.<br />
2. What are the official and legal duties of<br />
the coroner?<br />
The coroner is responsible for investigating<br />
all unnatural<br />
deaths that occur within their jurisdiction.<br />
This can be as simple as<br />
determining that a person died from<br />
natural causes, or could involve the<br />
investigation of major disasters. The<br />
coroner is not, save in very limited<br />
circumstances, expected to conclude<br />
that a person’s death was somebody<br />
else’s fault. Attributing blame for a<br />
death is the role of the civil or criminal<br />
courts. In most cases, the coroner’s<br />
role is limited to examining:<br />
who the deceased person is, when<br />
they died, where they died, and how<br />
they died.<br />
3. How many coroners are there in Britain?<br />
Or how large an area do you serve?<br />
I’m not sure I would like to hazard a<br />
guess at the total number of coroners<br />
there are in England and Wales. The<br />
country is split into 108 geographical<br />
areas, covered by 98 senior coroners,<br />
who each has a number of assistants.<br />
South Yorkshire, for example, is split<br />
into Western and Eastern Districts,<br />
each responsible for 3,000 – 4,000<br />
deaths per annum.<br />
4. Do you need to have a medical or legal<br />
background to become a coroner?<br />
Many coroners practised as doctors<br />
before becoming coroners, otherwise<br />
all coroners are barristers or solicitors,<br />
who have been qualified for at<br />
least seven-years.<br />
5. What was your route into this career?<br />
After my A-Levels, I read law at<br />
university before undertaking the<br />
bar vocational course. Afterwards,<br />
I obtained pupillage at a chambers<br />
in London, where I practised as a<br />
barrister for 10-years before applying<br />
to be an assistant coroner. People<br />
qualify as solicitors or barristers<br />
through different routes, though. It<br />
is far from essential that someone<br />
reads law at university, for example.<br />
Vacancies for assistant coroners are<br />
now advertised by local authorities<br />
and posts are allocated after a competitive<br />
interview process.<br />
[Murder mysteries] are frequently too neat and I<br />
think that they might tend to encourage people<br />
to believe that life necessarily involves twists and<br />
turns or surprise endings. Most cases are routine<br />
and rely more on hard work than inspiration.<br />
6. Are you a fan of murder mysteries? Silent<br />
witness comes to mind…<br />
Not since I started working as a<br />
lawyer. Very often they are too far<br />
removed from reality to engage me.<br />
They are frequently too neat and<br />
I think that they might tend to encourage<br />
people to believe that life<br />
necessarily involves twists and turns<br />
or surprise endings. Most cases are<br />
routine and rely more on hard work<br />
than inspiration.<br />
7
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Making the same mistake twice<br />
Sandra Mireku<br />
7. I suppose you find yourself faced with some pretty<br />
gruesome cases at times. Do you find the job of the<br />
pathologist [who performs the autopsy] unpalatable<br />
or is that another area you would be interested in?<br />
It does not help to be squeamish. I lack the<br />
medical training to do the work of a pathologist<br />
but being comfortable with traumatic<br />
photographs and accounts is an essential<br />
part of my job. It is perhaps more important<br />
to remember that the images represent<br />
a human being who may have had family<br />
and loved ones. Their experiences, grief<br />
and loss are often more difficult to come<br />
to terms with than the images in a book of<br />
photographs.<br />
8. I understand there are medieval laws that require<br />
treasure troves [long lost treasure with no identifiable<br />
heir] discovered to be declared to the coroner: has this<br />
ever happened to you?<br />
I’m sorry to say, it never has. Treasure trove<br />
is a speciality in itself but absolutely fascinating.<br />
It requires skills that are common<br />
to all areas of coronial practice, the ability<br />
to marshal evidence, analyse that evidence<br />
and reach a conclusion.<br />
9. Where does one go in their career once they are<br />
the coroner?<br />
The role of senior coroner is an end in itself<br />
and having responsibility for a coroner’s<br />
area is a full-time job. For assistant coroners,<br />
the role either leads to a full-time post<br />
or is an adjunct to their main career.<br />
10. What advice would you give to a student who<br />
thinks they might be interested in medical law?<br />
Ask why the role appeals to you. A good<br />
medical lawyer will have an analytical mind<br />
but also human empathy. A person who can<br />
deal sympathetically and justly with the bereaved<br />
is better qualified than someone who<br />
is fascinated by death and trauma.<br />
93<br />
million. This is the<br />
estimated number<br />
of people that will<br />
be infected with Zika<br />
virus in Latin America and the Caribbean.<br />
Not only due to a lack of<br />
vector control but the fact that no<br />
vaccine has been found yet.<br />
When I first heard a news report on<br />
the Zika virus I naively thought: it is<br />
just another mild, small scale virus,<br />
exaggerated by the news, but will<br />
quickly blow over in a few weeks.<br />
However, I have come to understand<br />
that there is certainly more to the<br />
no symptoms. This unawareness<br />
could lead to Zika spreading quicker<br />
and, in fact, more than one million<br />
have been infected so far.<br />
After further research into this virus,<br />
it is clear to me that the epidemic has<br />
become even more complex. New<br />
findings are constantly evolving with<br />
the virus and there is still a wealth<br />
of knowledge that researchers are<br />
yet to discover concerning the havoc<br />
that the Aedes aegypti mosquito<br />
is wreaking. Also, according to researchers<br />
Gostin and Lucey, even<br />
with accelerated research, it will take<br />
more likely to struggle financially,<br />
exacerbating the situation. In many<br />
pockets of the world, there is already<br />
limited access to health services, particularly<br />
in the poor and underdeveloped<br />
north-east of Brazil where<br />
the outbreak is more concentrated.<br />
There is also worry about the future<br />
of these children because of the low<br />
quality of life that they are likely to<br />
experience, especially where social<br />
stigma, isolation and discrimination<br />
is rife.<br />
There is also another question to<br />
ponder: does Zika have the potential<br />
Just as ebola spread rapidly in urban areas and densely populated slums containing<br />
poor infrastructure, limited healthcare resources, and hospitable<br />
environments for the mosquitoes, the Zika virus is also following suit.<br />
A good medical lawyer will have an analytical<br />
mind but also human empathy. A person who can<br />
deal sympathetically and justly with the bereaved<br />
is better qualified than someone who is fascinated<br />
by death and trauma.<br />
story after the World Health Organisation<br />
(WHO) declared the Zika<br />
virus a ‘public health emergency of<br />
international concern’ in February<br />
2016. This was due to the widespread<br />
nature of the outbreak and<br />
its ability to cause serious complications<br />
for the babies born of infected<br />
pregnant women, namely congenital<br />
Zika syndrome (the microcephaly<br />
we have heard so much about).<br />
80% of the people infected by Zika<br />
do not develop significant symptoms.<br />
You may perceive that this is at least<br />
some good news as it is a relatively<br />
mild virus, however it makes the situation<br />
“more serious than we can<br />
imagine”. People have been infected<br />
but don’t know because they show<br />
3-10 years to find a vaccine or treatment<br />
due to the complexity of this<br />
virus.<br />
Therefore, the question that hangs<br />
in the air is: what happens during<br />
this time? Will Zika spread to further<br />
countries in Europe since it<br />
has already made an appearance in<br />
Scotland and Spain? Will the Aedis<br />
aegypti mosquito die out or will it<br />
linger; persistent and intolerable?<br />
How many more innocent babies<br />
will die or become disabled for life as<br />
a result of microcephaly?<br />
There are many psychosocial impacts<br />
aside from the health implications<br />
to babies. As a result of treatment<br />
needed, poorer families are<br />
to kill as many people as the Ebola<br />
virus did? As I have already mentioned,<br />
Zika infection is largely mild,<br />
with most people developing no<br />
symptoms of note. Despite this, we<br />
should be aware that it is escalating<br />
and should not rule out its potential<br />
to be as large scale as Ebola was. As<br />
the world saw, it sadly killed over<br />
10,000 people.<br />
Zika is not contagious in exactly the<br />
same way as Ebola was but there<br />
is evidence to compare the mechanisms<br />
of the spread of the Ebola<br />
and Zika viruses which points to<br />
some similarities. Firstly, with these<br />
two viruses, it is difficult to know if a<br />
person has it as the symptoms could<br />
be mistaken for other ailments. Sec-<br />
10 11
ondly, delayed detection means that it<br />
takes months to identify the viruses as<br />
the causative agents for the diseases that<br />
they each cause. Thirdly, the locations<br />
heavily affected were caught unprepared<br />
for both viruses. For Zika, it had never<br />
touched South America and the Caribbean<br />
before; and with Ebola, most West<br />
African countries had never experienced<br />
an Ebola outbreak, and there had never<br />
been one of such magnitude. This means<br />
that the countries were ‘immunologically<br />
naïve’ as each of the populations had no<br />
immunity to the diseases and were susceptible.<br />
Just as Ebola spread rapidly in<br />
urban areas and densely populated slums<br />
containing poor infrastructure, limited<br />
healthcare resources, and hospitable environments<br />
for the mosquitoes, the Zika<br />
virus is also following suit.<br />
Additionally, international travel has<br />
played a role in rapid transmission. The<br />
importation of Ebola into Lagos, Nigeria<br />
on 20th July and Dallas, Texas on 30th<br />
September marked the first times that the<br />
virus entered a new country via air travellers.<br />
Zika, which first arrived in Brazil<br />
last year, has found its way into around<br />
40 other countries in the Americas – and<br />
now including Florida in the USA. Countries<br />
such as India, Indonesia and Nigeria<br />
are also predicted to be at high risk with<br />
up to 5,000 passengers a month arriving<br />
from Zika endemic areas.<br />
You can see why it is important that the<br />
extent of human disaster witnessed with<br />
Ebola is not repeated in history with the<br />
Zika virus. Certainly, lessons should be<br />
learned from what happened with Ebola<br />
and applied to Zika to prevent its rapid<br />
spread. The WHO have been widely criticised<br />
for their delayed response to slow<br />
the rapid transmission of the Ebola virus,<br />
and they have admitted that they were, in<br />
fact, too slow to act.<br />
Although vaccine trials are underway,<br />
it is indispensable that the international<br />
community is mobilised to act faster to<br />
prevent the rapid spread of Zika after its<br />
delayed detection and response. Moreover,<br />
some experts have even said it is past<br />
time to act, just like it was with Ebola.<br />
This follows claims that the WHO is not<br />
acting as swiftly as it could since the Zika<br />
infection is not seen as clinically serious<br />
for the majority of infected individuals, it<br />
is microcephaly that is more concerning.<br />
Therefore, they are being urged to take<br />
quicker action to stop what could become<br />
a devastating epidemic. It is simply not<br />
safe enough to continue at the pace that<br />
we are going now, as the virus is advancing<br />
dangerously.<br />
Artwork by Emma Rengasamy<br />
12<br />
13
Editor’s Prize for<br />
Keep me alive // Let me live<br />
writing 2016<br />
Congratulations to Elizabeth Georgina Ryan Harper who has won this year’s<br />
Editor’s Prize for a written contribution. Her work, “Been there, done that, got<br />
nothing but the t-shirt” can be seen on page 19 of the May edition.<br />
Elizabeth will receive £100 in book vouchers.<br />
Highly commended goes to Rebecca Wray, whose work, “The screening paradox”<br />
can be seen in this issue on page 31.<br />
________________<br />
All submissions in a calendar year are eligibile to win the Editor’s Prize. The award<br />
goes to the piece of work deemed to be of the highest quality; taking into account<br />
the originality and polish of the final piece, as well as the steps undertaken to achieve<br />
it. The winning piece is chosen by the editorial team.<br />
Simple daily decisions, such<br />
as whether to have an apple<br />
or a chocolate bar, to take<br />
the stairs or the lift, or even<br />
whether to re-read your favourite<br />
book or binge-watch yet another<br />
TV show all have an important impact<br />
on a person’s life. The ‘correct’<br />
choice for each of these scenarios<br />
can lead to a healthier lifestyle and<br />
increased longevity; values we ordinarily<br />
rate highly. What you choose<br />
to do with your time ultimately boils<br />
down to how you want the rest of<br />
your life to play out, although it does<br />
not normally seem that our decisions<br />
will have such far reaching consequences.<br />
Sometimes, when you do<br />
not have a whole lot of life left, the<br />
decision you have to make is whether<br />
to try and increase the number of<br />
days you have left, or to make the<br />
most of the ones that remain. Often,<br />
both can be benefitted or detrimented<br />
from the same decision; smoking<br />
will lead you to an early grave, and<br />
it will do so from a hospital bed attached<br />
to an oxygen canister.<br />
Ela Karbaron<br />
out every last drop of life at any cost.<br />
In my opinion, to prolong life in this<br />
way, without regard for the way you<br />
spend each day, is to live without<br />
satisfaction. There is nothing about<br />
spending your last days in a hospital<br />
bed attached to countless tubes that<br />
says ‘living’ to me. This may seem<br />
unjust; after all, I’m not living each<br />
day to the fullest. Many people my<br />
age and younger, even adults in the<br />
work force, are unsure of what they<br />
somewhere you have always wanted<br />
to go, to volunteer with the elderly<br />
to give you a sense of responsibility<br />
and fulfilment, or even to make that<br />
extra effort with your friends and<br />
family. One thing all of these examples<br />
have in common is that they encourage<br />
and secure enjoyment and<br />
happiness. These may not be your<br />
goals, but you must have a purpose,<br />
whatever it is, in order to meet the<br />
definition of living: ‘the pursuit of a<br />
lifestyle of a specified type’. It is not<br />
There are those treatments that give you extra<br />
days, and others that give you better days. There<br />
are some that do both and others that, sadly, end<br />
up doing neither. When it comes to make the<br />
choice, if you cannot have both, which do you<br />
decide to take?<br />
To be alive is simply to continue<br />
breathing. It is what you do whilst<br />
you are alive and breathing that<br />
matters. To prolong life, with<br />
no purpose other than to keep the<br />
heart ticking over, would be to completely<br />
disregard the quality of life<br />
a patient desires. They are existing<br />
without any fulfilment or satisfaction.<br />
To prolong living, however,<br />
is to increase the time in which<br />
you can achieve the things you want<br />
to achieve and live the life you wish<br />
to lead. Most of the time, there is no<br />
decision to be made between the two<br />
but, eventually, for many patients,<br />
push comes to shove and we have to<br />
decide; go out in flames or squeeze<br />
are aiming for in life. We are living in<br />
the rigid routine that school or work<br />
forces upon us. We are unable to live<br />
each day exactly as we wish, but that<br />
doesn’t mean to say that teenagers<br />
are not living. Each of us must draw<br />
our own line, but it is rarely a case<br />
of choosing the single best thing in<br />
all walks of life. It is usually other<br />
choices that determine whether we<br />
are truly experiencing enjoyment<br />
and doing things we love, and it is<br />
up to us to make choices that have<br />
a positive impact on our lives, with<br />
whatever spare time we have to<br />
make them. This could be to travel<br />
enough to spend your days without<br />
aim; we talk about a person’s raison<br />
d’être for good reason.<br />
The terminally ill are faced with<br />
the very real decision of what to do<br />
with their remaining days. For the<br />
purpose of this article, I have divided<br />
their options in two: prolonging<br />
living, or prolonging life. There are<br />
those treatments that give you extra<br />
days, and others that give you better<br />
days. There are some that do both<br />
and others that, sadly, end up doing<br />
neither. When it comes to make<br />
the choice, if you cannot have both,<br />
14<br />
15
which do you decide to take?<br />
Cancer patients have been exposed to this<br />
dilemma more than the regular person,<br />
and their treatment is shaped around it.<br />
Chemotherapy is the use of cytotoxic drugs<br />
to target cancer cells. They kill cells very effectively,<br />
but are not so good at distinguishing<br />
cancer from normal tissue and this can<br />
lead to some serious side effects: fatigue, for<br />
example. Tiredness can take over your life<br />
and last for months after the treatment has<br />
finished. Your quality of life is on the line<br />
when you cannot continue to do the activities<br />
that define you as you. When that is the<br />
situation you are faced with, when you are<br />
too tired to seek any enjoyment from life,<br />
which option have you really chosen? Other<br />
rapidly dividing cells such as your hair can<br />
be badly affected, leading to a change in appearance.<br />
This can be horrifying for women<br />
or younger patients as they stand out from<br />
their peers, or feel stripped of who they are.<br />
Maintaining self-esteem is vital, right to the<br />
end of life, in order to go on living the life<br />
you want to lead.<br />
When reading ‘The Other Side’ by Kate<br />
Granger, what struck me as harshly unfair<br />
was the lack of choice the patient (who was<br />
also a physician) had. She had been unintentionally<br />
tasked with making the decision<br />
of prolonging her life or prolonging<br />
her living. After initially deciding to try to<br />
squeeze out all of the extra days she could,<br />
her final decision was to go with the latter,<br />
something I consider a brave choice. It is<br />
not a choice isolated to the patient at hand,<br />
it affects other sick people too. By opting for<br />
palliative care, you usually free up an extra<br />
hospital bed as most of your treatment can<br />
be done at home, leading to better care for<br />
others. Additionally, attempting curative<br />
treatments and further investigations tends<br />
to be significantly more expensive than palliative<br />
care. Those funds can be redirected<br />
to someone with a more positive prognosis,<br />
or that slot in the CT scanner can be used<br />
in an emergency. This is not a case of martyrdom,<br />
nor is it supposed to encourage patients<br />
to give up the fight so that someone<br />
else can have a shot – it is about accepting<br />
when the battle is lost, and moving on.<br />
These reasons are partly why I believe<br />
to prolong living should be a priority. Of<br />
course, how can I, or anyone, put myself<br />
in the position of a cancer patient? It may<br />
seem unfair to spout these beliefs, however I<br />
hope these ideas may help put an important<br />
decision in perspective for others that need<br />
to decide.<br />
In fact, people who do not have a terminal<br />
diagnosis are making these kinds of decisions<br />
for us on a daily basis. QALYs (quality<br />
adjusted life years) are used to determine<br />
the economic benefit of a medical interven-<br />
Think NICE are getting it wrong?<br />
Have a go at<br />
working out QALYs<br />
These may not be your goals, but you must have a purpose,<br />
whatever it is, in order to meet the definition of living: ‘the pursuit<br />
of a lifestyle of a specified type’. It is not enough to spend<br />
your days without aim; we talk about a person’s raison d’être for<br />
good reason.<br />
tion. They allow healthcare funding bodies<br />
such as NICE (National Institute for Health<br />
and Care Excellence) to weigh the benefits<br />
and drawbacks of permitting certain procedures,<br />
or prescribing certain drugs. A price<br />
tag is attached to each year of life saved by<br />
a treatment, and this is amended depending<br />
on the quality of that year (for instance, a<br />
year spent in constant pain is not equal to<br />
a year spent in perfect health). A problem<br />
associated with the use of QALYs is that<br />
they are ultimately assessing the economic<br />
benefit of certain interventions, which fails<br />
to take into account every personal factor<br />
and whether intervention would be in the<br />
interest of prolonging living or prolonging<br />
life. What do I mean by this? Well, if a patient<br />
only ever has one year left to live, and<br />
a treatment would give them near perfect<br />
health for that time, the intervention is still<br />
only going to be worth one QALY. Technically,<br />
a treatment which provides someone<br />
with 20 years left to live, but at only at half<br />
perfect health, is worth ten times the first<br />
treatment. In effect, we are saying the second<br />
patient is worth ten times more.<br />
Fortunately, NICE does not have to directly<br />
choose between two treatments in this way.<br />
They have come up with figures that are<br />
used to determine the viability of intervention,<br />
with any treatment costing less than<br />
£20,000 per QALY as ‘cost-effective’ and<br />
£20-30,000 approved so long as certain criteria<br />
are met.<br />
The problem is still a real one, though, and<br />
it is illustrated perfectly in a documentary<br />
by Adam Wishart. It uses the case of patients<br />
with multiple myeloma to explain<br />
why QALYs disadvantage the terminally ill.<br />
The drug in question was Revlimid, which<br />
would be extremely beneficial in prolonging<br />
living. It saw enormous symptomatic improvement<br />
in a number of patients at trial,<br />
but only increased their lifespan by months<br />
or maybe a handful of years.<br />
There is a lot more to this debate than can<br />
be fit into one article. It is possible people<br />
would never reach a consensus, given all of<br />
the facts and all of the time in the world.<br />
Perhaps no one can truly understand the<br />
magnitude of this decision until they are going<br />
through it themselves. The GMC makes<br />
it clear that it is a doctor’s duty to show<br />
respect for any life, so surely fulfilling this<br />
respect requires allowing patients to continue<br />
or start any treatment that will enhance<br />
their ability to live. In saying this, there are<br />
measures put in place to ensure that every<br />
patient can still live in comfort and with<br />
support. Palliative care provides a truly dignified<br />
end to the dying, whether they are old<br />
or young, active, or bed bound and allows<br />
families to spend quality time together for<br />
months or years before the end. If I were<br />
asked to say what it means to prolong living<br />
in one sentence, my response would be to<br />
live life with intention and meaning, and to<br />
make the most of every situation.<br />
16 17
How do you work out a QALY?<br />
It’s your turn to decide! The last thing that’s important to remember<br />
is that you are supposed to choose assuming you will die at the end of<br />
each scenario, not return to full health.<br />
Health state 1:<br />
Working out someone’s expected QALYs is simply a mathematical equation:<br />
(Length of Life) x (Quality of Life) = Quality Adjusted Life Years<br />
Full health gets a score of 1, and being dead gets a score of 0.<br />
I am in no pain day to day.<br />
I have moderate difficulty washing and dressing myself.<br />
I have severe difficulty walking about.<br />
I have moderate difficulty in my usual day to day activities.<br />
I have no anxiety or depression.<br />
So, if our patient was expected to live for 5 years, with a quality of life of 0.7, that is a total of<br />
3.5 QALYs.<br />
Obviously, it can be hard to predict how long someone is going to live for, but we can use a good<br />
estimate. It is really hard to determine the quality of someone’s life, though.<br />
Would you prefer:<br />
10 years in health<br />
state 1<br />
Health state 2:<br />
5 years in full<br />
health<br />
Or are they the<br />
same?<br />
Quality of life is determined by comparing<br />
different health states and how much we value<br />
them. In practice, this is done by giving<br />
many people many paired scenarios and asking<br />
them to choose one option in each pair.<br />
For instance, would you choose to live for<br />
10 years in a wheelchair or for 1 year in full<br />
health?<br />
That is a crude example, but it illustrates the<br />
point. Have a go at the scenarios across the<br />
page to see what you value most. In reality,<br />
the health states people are asked to choose<br />
between have multiple different factors to<br />
consider.<br />
Once enough data has been collected, the responses are used to apply a numerical value to each<br />
health state (somewhere between 0 and 1). This allows them to be used for QALY calculations.<br />
When you compare your answers to others, you will probably find that you don’t agree on<br />
everything. That’s why these questions are asked to many people from all walks of life to try<br />
and get a better understanding of what qualities people value in general. Of course, it can never<br />
be perfect or accurate for every patient we will ever treat.<br />
I am in severe pain day to day.<br />
I have no difficulty washing and dressing myself.<br />
I have no difficulty walking about.<br />
I have mild difficulty in my usual day to day activities.<br />
I have moderate anxiety or depression.<br />
Would you prefer:<br />
10 years in health<br />
state 2<br />
Health state 3:<br />
I am in no pain day to day.<br />
I have no difficulty washing and dressing myself.<br />
I have no difficulty walking about.<br />
I have severe difficulty in my usual day to day activities.<br />
I am severely anxious or depressed.<br />
Would you prefer:<br />
10 years in health<br />
state 3<br />
5 years in full<br />
health<br />
5 years in full<br />
health<br />
Once you have made up your mind on each scenario:<br />
Or are they the<br />
same?<br />
Or are they the<br />
same?<br />
If you chose the health state, increase the number of years in full health until the options are<br />
equal in your eyes. If you chose full health, decrease the number of years of full health until you<br />
would change your mind.<br />
18 19
Family matters<br />
Kirsten Vizor<br />
TThink<br />
sisters are obsessed<br />
with his<br />
bowel habits. I<br />
“His<br />
mean obsessed.<br />
Every time I go in there I’m trapped<br />
for ten minutes talking them through<br />
it all. They just don’t get how unwell<br />
he is, that he isn’t going to be making<br />
it to his daughter’s wedding no matter<br />
how much they want him to and<br />
no matter how hard we try.”<br />
Quiet smiles of understanding ripple<br />
across the group.<br />
Ward round, palliative care. This<br />
happens a lot. There isn’t really a<br />
sense of resentment from the staff,<br />
but it does highlight an important<br />
issue: many families feel they have<br />
a right to be involved in their loved<br />
ones’ end of life care. Do they?<br />
Should they? In the face of stretched<br />
resources, educated doctors, experienced<br />
nurses, and limited time, do<br />
they really get to be involved to any<br />
real degree? Of course they do. In<br />
the face of many reasons why they<br />
should be kept well clear from any<br />
decision making, kept a little more<br />
than arm’s length from the drug<br />
card, and politely requested to pipe<br />
down when claiming they know best,<br />
of course they should be involved.<br />
Before I go on, I first want to address<br />
the idea of ‘family’. When we ask<br />
how involved families should be in a<br />
patient’s end of life care, we should<br />
be answering it with the patient in<br />
mind. Traditionally, when we all<br />
lived closer to one another in smaller<br />
tribal communities, big life events<br />
(weddings, births and, yes, deaths)<br />
meant having your relatives around.<br />
They saw you grow up, cared for<br />
you, educated you, and loved you<br />
for most of your life, but as UK demographics<br />
shift so must our definition<br />
of family. We scatter across the<br />
world to chase our dreams, but we<br />
still need those close bonds with people<br />
who love us, and whom we can<br />
love. Here, the term ‘family’ will refer<br />
to anyone with whom the patient<br />
has a real sense of love, trust, and<br />
mutual support.<br />
Let us briefly acknowledge the family’s<br />
point of view; a nod to the<br />
blindingly obvious. To face losing a<br />
loved one seems an impossible, and<br />
impossibly cruel, challenge. Dealing<br />
with the enormous grief requires an<br />
endless amount of patience, time,<br />
and support. That support needs to<br />
start before the end of their loved<br />
one’s life. To be shut out by the<br />
doctors only puts pressure on the<br />
situation – pressure for the patient<br />
to be the sole communicator about<br />
their illness, pressure for the family<br />
to learn about the disease process<br />
and prognosis alone, and pressure<br />
for everyone to keep their emotions<br />
in check all the time for each other,<br />
with no professional outlet. Distress<br />
reverberates through a family pretty<br />
quickly. If we can be a source of information<br />
and a source of counselling,<br />
we help families do what they<br />
need to do: be there for each other.<br />
There are many obvious reasons<br />
why keeping people who know and<br />
love our patients nearby might be a<br />
positive part of their care package.<br />
When someone is unwell, particularly<br />
when reaching the end of their life,<br />
there are many difficult conversations<br />
to have and decisions to make.<br />
Which treatment? Any treatment at<br />
all? Where do you want to be when<br />
you die? You’re tired, you’re poorly,<br />
you’re probably on the spectrum of<br />
feeling slightly uneasy to absolutely<br />
petrified, and chances are you aren’t<br />
going to remember every little salient<br />
point the doctor or nurse makes<br />
about your condition and care. Having<br />
someone nearby to listen and<br />
take notes, and who has the time to<br />
go through all the facts again with<br />
you later is hugely valuable. Having<br />
someone else there, ironically, makes<br />
it more likely that any decision you<br />
make is your own.<br />
We scatter across the<br />
world to chase our<br />
dreams, but we still<br />
need those close bonds<br />
with people who love<br />
us.<br />
Family involvement helps us manage<br />
our patients and that is important.<br />
We’re pack animals; for the most<br />
part, we live and work in dynamic<br />
circles and interact with other beings<br />
as part of our basic instincts. We<br />
rely on each other, look out for each<br />
other, look after each other. Why on<br />
earth should that stop right at the<br />
moment that one of our pack needs<br />
us?<br />
For many reasons, actually. I am<br />
not so idealistic as to think family<br />
protection isn’t vulnerable to forcing<br />
massive mistakes on a situation.<br />
Families can pressure their people<br />
to go through invasive and painful<br />
treatments, against medical advice,<br />
because they’re afraid of the in-<br />
21
Fear is a powerful emotion, and our calmer moments can quickly leave us.<br />
evitable loss that will follow if they<br />
do not. Of course they are coming<br />
from a place of love and devotion<br />
but, equipped with fierce emotional<br />
instinct and not enough reasoning,<br />
a family member is often the most<br />
dangerous person in that hospital<br />
bay.<br />
Put bluntly, families can be a massive<br />
problem. They don’t know how not<br />
to be. When you are about to lose<br />
someone you love, you go into fight<br />
mode and shed a detached sense of<br />
perspective. In a situation where you<br />
have very little control, you anoint<br />
yourself the protector. Your world<br />
becomes fighting for their life and<br />
with that comes an understandable<br />
but undeniable selfishness: keep<br />
them comfortable and keep them<br />
alive. Now.<br />
Are patients sensitive to this? Of<br />
course. You’re in bed, you’re exhausted,<br />
you know what is happening<br />
and what is going to happen.<br />
You’ve had the difficult talks with<br />
the doctor and have come to accept<br />
your fate. But you look up from the<br />
bed to see the terrified eyes of your<br />
family and feel that, by ‘letting go’<br />
and saying no to Drug X (despite<br />
its delightful side effects that keep<br />
you up all night in a nauseous daze),<br />
you’re hurting them. Somehow, patients<br />
find themselves in this impossible<br />
situation of feeling guilty, trying<br />
in vain to extend their lives to avoid<br />
disappointing the pack. The wolves<br />
are circling, but they aren’t here to<br />
hunt. No, this pack is here to keep<br />
you alive until the agonising end.<br />
Without wanting to seem completely<br />
heartless, families get it wrong. They<br />
are being selfish. They have forgotten<br />
how to think and function within<br />
their family unit and wider society<br />
with a nuanced sense of intelligence<br />
or responsibility. When we aren’t<br />
in that state of panic I hope we realise<br />
that life isn’t permanent, that<br />
we aren’t owed a certain amount of<br />
time in this world and recognise that<br />
it could be cruel to try and make it<br />
so; that we live in a society trying<br />
to do its best for everyone in it with<br />
restricted resources. In our calmer<br />
moments we can have intelligent (if<br />
sometimes slightly heated) conversations<br />
about quality of life and letting<br />
go when the time is right. But fear is<br />
a powerful emotion, and our calmer<br />
moments can quickly leave us.<br />
It is neither realistic nor helpful to<br />
hope for a world where families<br />
completely shed their selfish instincts<br />
and approach this logically.<br />
Their job is to love and protect, and<br />
most families do this well. So, this<br />
is where doctors come in. Our job is<br />
to learn everything we can from the<br />
families - let them tell us about their<br />
person, about who they were before<br />
they became ill so that we never<br />
once lose an ounce of compassion<br />
or forget about their strong sense of<br />
spirituality. Let the family come and<br />
hold us accountable for absolutely<br />
everything we do. We should also<br />
encourage the families to visit and<br />
be grateful for the time they spend<br />
caring – changing socks, bringing<br />
favourite snacks, reading the paper,<br />
and providing comfort and company<br />
in the final days. Everyone has a part<br />
to play in this tragedy.<br />
I’m asking a lot from everyone here,<br />
because this requires bravery and a<br />
great emotional effort. We have to be<br />
willing to both trust and defy families,<br />
to trust ourselves to know when<br />
to listen to the family and when to<br />
listen to the patient. How? Watch<br />
the interactions between patients<br />
and visitors, listen to the patients<br />
talking, listen to the family talking;<br />
figure out who is really providing<br />
that love, trust, and mutual support.<br />
It might not always be who we think<br />
it is. Not everyone walking into that<br />
bay will be going in with the best intentions.<br />
We’re going to have to engage,<br />
to sort out the voices of grief<br />
and panic from the facts. Try to find<br />
the patient there, somewhere within<br />
the family. Are we adequately taught<br />
these skills as medical students? I, for<br />
one, am unconvinced, but that’s a<br />
whole other article on its own. So, it<br />
is up to us to learn how: you need to<br />
talk to families, talk to patients, talk<br />
to other doctors and it is never too<br />
early to start.<br />
Consider the alternative for a moment.<br />
If we do not let families in, we<br />
lose a huge amount of insight into<br />
our patient. We cripple their support<br />
system and, in the absence of any<br />
real direction from the patient, difficult<br />
decisions are left to the system.<br />
What type of care we provide, and<br />
for how long, and where we provide<br />
it, and where the patient is going to<br />
end up spending their final moments<br />
are decisions that need to be made<br />
and we risk handing these responsibilities<br />
over to a service without the<br />
nuance or resources needed to make<br />
them correctly. We would do our<br />
best to make people as comfortable<br />
as we can, but clinical acumen is not<br />
enough. Patients need their people<br />
and, like it or not, that means we<br />
need them too.<br />
Artwork by Jamie Crawford<br />
facebook.com/idiosinkratic<br />
22
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Is there a doctor in the house?<br />
The rest of the conversation falls away as meaningless chatter. Behind every<br />
pause or slipped sentence I am wondering if this is the face of the disease.<br />
My grandma was diagnosed<br />
with vascular<br />
dementia and my<br />
family do not know<br />
what this means. Not only do they<br />
not understand the definition of the<br />
problem (I partially blame the team<br />
responsible for her care for this) but<br />
also what shape her future is going<br />
to take. What this means for me is a<br />
host of phone calls and difficult conversations.<br />
This is not new to me; I<br />
received them in that proto period<br />
of uncertainty before her diagnosis<br />
took shape. The reason that I am<br />
the one contacted in such an event is<br />
that I’m the go to guy for my family’s<br />
medical problems.<br />
None of my family have any sort of<br />
medical background and, despite<br />
this modern age of medicine overreaching<br />
itself and appearing all<br />
over the media, they do not understand<br />
what is happening. Why is she<br />
behaving in that way? What can we<br />
do to help her? In just five years of<br />
medical training, I’m not sure I have<br />
the answers, but it doesn’t stop the<br />
phone from ringing.<br />
Many of you who are applying, or<br />
who have already applied, to read<br />
medicine will have done so with the<br />
same trouble I had. Medical experience<br />
is invaluable for interviews and<br />
personal statements alike. Of course,<br />
it is only when you think back that<br />
you realise how little you actually<br />
knew. It is not just that you are unaware<br />
of the vastness of the ocean,<br />
you’ve never even seen the sea. All<br />
the same, that modicum of information<br />
is gold dust. However, if you<br />
don’t have a close relative or a friend<br />
who is a doctor or nurse or GP receptionist,<br />
you may find yourself<br />
George Aitch<br />
shut out. I ended up working as a<br />
healthcare assistant for a year (which<br />
I enjoyed very much) to furnish my<br />
CV. It was a leg up but meant I had<br />
to defer my application.<br />
At the other end of things, I expect<br />
to finally graduate this summer. For<br />
my family this means I am basically<br />
a doctor, unless I am telling them<br />
something that they don’t want to<br />
hear:<br />
‘I don’t think you have appendicitis.’<br />
‘What would you know, you’re not even a<br />
doctor yet.’<br />
In August I attended my first family<br />
wedding, which was lovely. All of my<br />
relatives under one roof and a real<br />
chance to catch up. People asked my<br />
sister where she was applying to university<br />
and my brother what it was<br />
like to live in Hungary. When it got<br />
to my turn everyone wanted advice<br />
on their latest joint replacements or<br />
this funny rash which had come up<br />
on their arm. Resisting the urge to<br />
roll my eyes, I dispense advice and<br />
discuss problems. By the way did<br />
you see that article I wrote about<br />
volunteering in Guyana? No? Never<br />
mind, back to your mother in law’s<br />
cataract surgery then.<br />
When it comes to GP visits, my family<br />
fall into two different camps. First,<br />
you have my dad. You have all met<br />
this type; he ‘saves up’ his visits under<br />
the misapprehension that he is doing<br />
the doctor a favour. If you have him<br />
sat in your waiting room, you can bet<br />
that he has a rolled up piece of paper<br />
in his pocket with all of the problems<br />
he has suffered from in the last year.<br />
It is impossible to get him to see a<br />
doctor when anything happens. My<br />
mum is the opposite. Whenever she<br />
gets a blood test or result back, I am<br />
the first to know. Luckily for all of us,<br />
neither of my parents have anything<br />
seriously wrong with them and are in<br />
great health. Part of me is proud that<br />
they put their trust in me (in a really<br />
minor way), but it would also be nice<br />
if both of them had more sensible<br />
approaches to their health.<br />
This won’t stop when I qualify, it will<br />
probably get worse. I already have<br />
an extensive background in telemedicine<br />
via Skype and FaceTime. Has<br />
anyone else had to diagnose a rash<br />
via Whatsapp? If you’re really worried<br />
then why not see a doctor? I say endlessly,<br />
but it feels bad just telling them<br />
to Google it. In fact, I’m sure I saw<br />
something about that in the news a<br />
few months ago…<br />
We’ve long been aware that something<br />
has been wrong with my<br />
grandma; getting to her age tends<br />
to have a few consequences on your<br />
health. However, during a hospital<br />
admission for a fall my parents and<br />
aunt and uncle became concerned<br />
about a change in her behaviour. As<br />
is usual, they called me asking what<br />
might be wrong. Cue an hour long<br />
chat about delirium. Though when<br />
it came to discharge these problems<br />
did not go away. Being at the other<br />
end of the country I asked them to<br />
push for a psychiatry review, some-<br />
And so I explain to my<br />
kind and loving grandparents<br />
the underlying<br />
process behind vascular<br />
dementia.<br />
thing that none of them were keen<br />
on.<br />
Then suddenly, following a review<br />
by the hospital staff, it all came out:<br />
grandma’s gradual decline which<br />
grandad had done everything to<br />
mask. This recent fall was the tip<br />
of the iceberg and he was running<br />
out of his ability to cope. Being the<br />
stoical type that he is, he never mentioned<br />
what was going on and so we<br />
never realised how difficult things<br />
were becoming for both of them.<br />
Now, one month later, grandma has<br />
a diagnosis of vascular dementia<br />
and I am on the phone with them<br />
trying to put a brave face on it yet<br />
give an accurate explanation at the<br />
same time, all the while trying to<br />
keep my emotion out of it. Needless<br />
to say it is difficult.<br />
What can you say? Dementia is as<br />
a good as a terminal diagnosis (the<br />
average life expectancy from diagnosis<br />
is four years). This is the elephant<br />
in the room. They know it<br />
and I know it. Grandma has had to<br />
watch her brother and sister suffer<br />
with the same thing for a number<br />
of years now. She dreads ending up<br />
like them and we both know that it’s<br />
inevitable. This is the curse of medical<br />
knowledge; analysing with terror<br />
every symptom and biopsy result,<br />
scan and blood test. Not only can I<br />
provide a realistic perspective on unfolding<br />
events, but every worst case<br />
scenario also flashes before my eyes.<br />
It’s an extension of hypochondria.<br />
And so I explain to my kind and<br />
loving grandparents the underlying<br />
process behind vascular dementia;<br />
how it is distinct from Alzheimer’s,<br />
how her recent short term memory<br />
loss and anxiety have been caused<br />
by a series of strokes affecting small<br />
blood vessels in her brain. I compare<br />
it to grandad’s TIA which he<br />
had a few years ago. She is quick to<br />
cut across me and point out that her<br />
condition isn’t going to get better. I<br />
can’t think of anything to say.<br />
Already they have begun to plan<br />
for the latter stages of the disease;<br />
today they visited a day care centre<br />
for people with dementia. Grandma<br />
restates her fear of ending up like<br />
those with advanced disease. I try<br />
to reassure her but it’s an acknowledged<br />
truth between us that one day<br />
she will find herself in that position.<br />
The thought of slowly losing your<br />
memories and sense of self is terrifying,<br />
even more so when faced with<br />
the certainty that it will happen to<br />
you. I cannot begin to understand<br />
the place that she must find herself<br />
in. I hope that I may never have to.<br />
The rest of the conversation falls<br />
away as meaningless chatter. Behind<br />
every pause or slipped sentence I<br />
am wondering if this is the face of<br />
the disease. She forgets that I’m not<br />
a doctor yet and in the back of my<br />
mind I turn over how innocent this<br />
lapse in memory might be. I am an<br />
adult and a realist; I know that nobody<br />
is around forever, but I was<br />
hoping for a less cruel exit. The end<br />
of the phone call is austere. Being<br />
cheery seems inappropriate, as does<br />
the usual ‘it was lovely to hear from<br />
you’. Neither of us says it. I mention<br />
that I’ll call back in a week or two<br />
when they know more and we say<br />
goodbye.<br />
I can’t help what is set in stone. What<br />
I can do is make the remaining time<br />
more bearable: call more often and<br />
check how she’s doing, that sort of<br />
thing. It’s very do-able. The news has<br />
destroyed me inside, I knew it would<br />
from the first moment of my mum’s<br />
voicemail message. The worst part is<br />
repeating that same phone conversation<br />
twice later to the rest of my<br />
family.<br />
Herein lies another challenge to<br />
those entering a medical career,<br />
one of many: the puzzling knot of<br />
separating the personal from the<br />
professional. Adopting the cool clinical<br />
manner whilst still empathising<br />
with the person in front of you is a<br />
paradoxical skill which takes experience<br />
to master. Breaking bad news,<br />
discussing serious complications,<br />
possibilities and anything with gravity<br />
or even putting up an emotional<br />
barrier for therapeutic reasons all<br />
require it. The first experience we<br />
might have of this could be in the<br />
dissection room. The body in front<br />
of you is a delicate learning tool but<br />
first and foremost it used to be a person,<br />
one whose generosity should<br />
command respect.<br />
With this in mind, I continue to be a<br />
medical dictionary for my family. As<br />
I write, my mum asks which meningitis<br />
vaccines my sister should have<br />
before going away to university.<br />
When I go home for Christmas I am<br />
sure that it will rear its head. On top<br />
of that, mum will continue to keep<br />
me up to date on my grandma’s advancing<br />
dementia and I will try to<br />
interpret everything that is happening.<br />
Remind yourself that you were<br />
once ignorant of the ocean and then<br />
think how much wisdom you can<br />
impart from just your short voyage<br />
out of port. As a final year student I<br />
have already accrued more medical<br />
knowledge than most will gain in a<br />
lifetime and I should feel incredibly<br />
privileged. My parents have had to<br />
support me, I suppose it is only fair<br />
that they get something out of it.<br />
26 27
No, I’m not a doctor yet<br />
how are you?<br />
oh really? that’s a shame<br />
<br />
it was lovely to hear from you<br />
no, that’s not until next week,<br />
grandma<br />
it was lovely to hear from you<br />
it’s going to rain this weekend<br />
<br />
it was lovely to hear from you<br />
neither of us says it<br />
I was hoping for a less cruel exit
No shame in fat shaming<br />
Recently, a story emerged<br />
out of the usual NHS media<br />
flurry that will seem<br />
particularly pertinent to<br />
an ever-increasingly large proportion<br />
of society. The Vale of York<br />
CCG (care commissioning group,<br />
the people who decide what treatments<br />
the people of York are entitled<br />
to) proposed a restriction on those<br />
with a BMI over 30 receiving nonlife<br />
threatening procedures. The proposal,<br />
which would also have applied<br />
to smokers, could have seen those<br />
falling into these categories being<br />
subjected to delays of up to a year in<br />
receiving their surgery. Workarounds<br />
to these rules were, however, present<br />
(motivation, almost). Those with a<br />
BMI of 30+ would have to lose 10%<br />
of their body weight, and smokers<br />
would be required to cease smoking<br />
for eight weeks.<br />
Shortly after this proposal was announced,<br />
it was met with widespread<br />
criticism from many organisations,<br />
including NHS England and the<br />
Royal College of Surgeons, who<br />
damned the proposal as dangerous<br />
and radical, eventually resulting in<br />
the initiative’s rollout being halted.<br />
Despite this, the topic was a springboard<br />
for polarising debates amongst<br />
many, especially those directly involved<br />
in the healthcare field. Just<br />
what motivated the York CCG to<br />
reveal plans for such seemingly radical<br />
interventions? Is their stance balancing<br />
on the precipice of a greater<br />
societal issue?<br />
India Corrin<br />
If one looks at the situation from a<br />
purely medical perspective, there is<br />
logic behind the proposals. It is well<br />
documented in a plethora of medical<br />
literature that obesity is crippling<br />
people, both at an individual and a<br />
population level. Obesity is just the<br />
first step in catalysing a whole host<br />
of debilitating medical conditions:<br />
hypertension, stroke, diabetes, osteoarthritis.<br />
The list reads like a practitioner’s<br />
worst nightmare.<br />
Once an obese patient has reached a<br />
level of illness for which surgical intervention<br />
is required, whatever the<br />
surgery is for, risks increase dramatically.<br />
Simply anaesthetising an overweight<br />
patient poses significant challenges,<br />
as ventilation once sedated<br />
and supine on a table is significantly<br />
more difficult to achieve (think of<br />
all that weight pressing down on the<br />
chest). This is, of course, in addition<br />
to the greater duration required in<br />
surgery to delve down past the adipose<br />
tissue, the decreased visibility<br />
once the organ or tissue layer has<br />
been reached, and the increased<br />
volume of blood loss throughout a<br />
procedure. If ‘primum non nocere’<br />
is one of the creeds lying at the heart<br />
of medicine, then it would seem that<br />
requiring patients to lose weight before<br />
undergoing surgical procedures<br />
is acting only to preserve this central<br />
notion.<br />
You cannot hope to write an article<br />
on any aspect of the NHS without at<br />
least considering financial implications.<br />
There is constant and consistent<br />
negative press regarding the dire<br />
state of the NHS deficit, and a move<br />
such as the one proposed by the York<br />
CCG is surely designed with an element<br />
of financial motivation. By<br />
reducing non-essential surgical rates<br />
in the excluded groups, it not only<br />
cuts the hospital costs associated<br />
with carrying out these procedures,<br />
but would hopefully prospectively<br />
save money by means of prevention.<br />
Providing motivation for these<br />
high-risk groups to stop engaging<br />
in health-compromising behaviours<br />
would hopefully break the initial<br />
link in the chain of events ultimately<br />
leading to costly medical intervention,<br />
or at least delay the need for<br />
surgery.<br />
So, why the backlash? Central to the<br />
issues clinicians have in simply dictating<br />
what weight patients should be<br />
is the warped modern manifestation<br />
of free choice. Free choice is fundamental<br />
to an increasingly progressive<br />
stance on human rights and equality;<br />
how could such a concept possibly<br />
have sinister connotations? With<br />
time, the phrase has been somewhat<br />
manipulated to fit the seemingly<br />
self-serving choices that individuals<br />
make, especially with regards to<br />
negative health behaviours. It has<br />
become impossible to direct people<br />
on the lifestyle they should be living<br />
without being branded dictatorial,<br />
a ‘nanny state’. Telling people what<br />
weight they should be, or that they<br />
should cease smoking, apparently infringes<br />
on this basic human right to<br />
choose to treat one’s body however<br />
they wish. But are these decisions to<br />
exercise free will in such a manner<br />
really the way we should be using<br />
the responsibility of free choice?<br />
When the actions made by individuals<br />
start to have a negative impact<br />
on society at a greater level, is free<br />
choice as beneficial as it is made out<br />
to be? It may be a person’s right to<br />
indulge in a third slice of cake, but<br />
it is not their right to then incur a<br />
cost on the taxpayer to fund the knee<br />
replacement they eventually require.<br />
Such championing of an individual’s<br />
rights, whilst neglecting to consider<br />
the wider impact one’s actions are<br />
having, is starting to set a dangerous<br />
precedent.<br />
Should the blame be placed on individuals?<br />
It does not take an expert<br />
to see the staggering presence<br />
that unhealthy foods and lifestyles<br />
have in our society. With unhealthy<br />
options costing less than half or a<br />
third of a healthy equivalent, people<br />
are almost constrained to making<br />
poor nutritional choices; hands and<br />
feet bound as they coast through<br />
obesogenic life and straight off the<br />
cliff that is diabetic middle-age. It<br />
automatically creates an exclusive<br />
environment where the ‘haves’ are<br />
blessed with antioxidants and superfoods,<br />
and the ‘have-nots’ are<br />
condemned to a life of additives<br />
and saturated fat. The government<br />
has a responsibility to adopt a role<br />
in preventing obesity-related illness,<br />
and if prevention is the main aim of<br />
York’s controversial proposals then<br />
the CCG is simply fulfilling that<br />
role. This should extend to widening<br />
access to healthy food and providing<br />
education to encourage health-conscious<br />
behaviours. Sadly, this has yet<br />
to come to fruition in any meaningful<br />
way.<br />
Violation of individuals’ perceived<br />
freedom of choice is not the only<br />
criticism of the proposals. Culturally,<br />
the presence of social media in<br />
society has made steady growth, to<br />
a point where it is almost a defining<br />
feature of rising generations. Social<br />
media today is now an incredibly<br />
powerful tool for communicating<br />
one’s opinions on a widespread<br />
scale, breeding various sub-cultures<br />
and trends through which individuals<br />
can share such opinions. Rising<br />
up through the ranks are the ‘selflove’<br />
and ‘body positivity’ movements<br />
which belong to one particularly<br />
prominent sub-culture.<br />
These movements have honourable<br />
aims: to encourage self-acceptance<br />
and appreciation for oneself in the<br />
face of society’s stringent rules of<br />
what constitutes beauty or worth.<br />
This is undoubtedly a step in the<br />
right direction, and such attitudes<br />
need to be broadcast; the prevalence<br />
of eating disorders is rising at a rate<br />
of almost 7% per year in the UK.<br />
Younger and younger generations<br />
are being plagued with vicious mental<br />
and physical health issues surrounding<br />
the need to have the ‘perfect’<br />
figure or face, the attainment<br />
of cachectic physiques or unrealistic<br />
physical parameters.<br />
Whilst being happy in one’s own skin<br />
is laudable and not something towards<br />
which we should be sceptical,<br />
there is a distinction to be made in<br />
the promotion of self-love and a lack<br />
of desire to promote health. There<br />
is a fine line between accepting one’s<br />
appearance and demonstrating apathy<br />
to implement change, and it<br />
is in this balance that social media<br />
has contributed to muddying the<br />
waters. In place of the traditional<br />
skeletal models, there has arisen<br />
a new generation of social media<br />
models inspiring people; models<br />
labelling themselves as ‘plus sized’<br />
are championing curves and ‘more<br />
realistic’ physiques. These new, internet-made<br />
celebrities have been<br />
instrumental in spreading awareness<br />
and acceptance of the self-love<br />
movement, with a cult following on<br />
social media acting to encourage<br />
this message further.<br />
Unfortunately, in promoting body<br />
positivity, the movement has unwittingly<br />
started to spread the message<br />
that it becomes acceptable to be<br />
grossly overweight, as long as you<br />
are content in, and acceptant of, this<br />
state. Even if someone is happy with<br />
their size and appearance, if they<br />
are overweight to a point where it<br />
starts to impose a risk to their health,<br />
should we be promoting the mindset<br />
that they do not need to change<br />
their figure? A difficult environment<br />
is being created in which the ability<br />
of health professionals to advise<br />
patients on lifestyle choices is being<br />
diminished by a feeling that such<br />
changes need not be applied.<br />
Where does progress lie in this maelstrom?<br />
Chasing improvement at one<br />
extreme of the spectrum just pushes<br />
society too far in the other direction.<br />
Using a dictatorial approach in directing<br />
our patients towards better<br />
health runs the risk of alienating<br />
them and decreasing co-operation<br />
and adherence to medical advice. As<br />
prospective and current clinicians,<br />
our concerns must lie primarily with<br />
the safety and wellbeing of our patients<br />
– it would be tantamount to<br />
neglect if we were to simply ignore<br />
these duties.<br />
It cannot be denied that obesity levels<br />
are on the increase and breeding<br />
hosts of co-morbidities with resultant<br />
increasing medical needs. Longitudinally,<br />
the growth of this epidemic<br />
must be stemmed and those<br />
already falling into the obese category<br />
must be helped to find a way<br />
out of such a health-compromising<br />
state. The solution may not lie in denying<br />
certain groups access to surgery<br />
or healthcare, but it is imperative<br />
that we as a medical profession<br />
persevere and keep trying to find<br />
ways to turn the tide.<br />
30 31
I'm all about that bass<br />
'Bout that bass... bass... bass... bass<br />
Yeah, it's pretty clear, I ain't no size two<br />
But I can shake it, shake it, like I'm supposed to do<br />
'Cause I got that boom boom that all the boys chase<br />
And all the right junk in all the right places<br />
I see the magazine workin' that Photoshop<br />
We know that shit ain't real, come on now, make it stop<br />
If you got beauty, beauty, just raise 'em up<br />
'Cause every inch of you is perfect from the bottom to the top<br />
Yeah, my mama she told me "don't worry about your size"<br />
(Shoo wop wop, sha-ooh wop wop)<br />
She says, "Boys like a little more booty to hold at night"<br />
(That booty, uh, that booty booty)<br />
You know I won't be no stick figure silicone Barbie doll<br />
(Shoo wop wop, sha-ooh wop wop)<br />
So if that's what you're into, then go 'head and move along<br />
Because you know I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass<br />
'Bout that bass... Hey!<br />
I'm bringing booty back<br />
Go 'head and tell them skinny bitches that<br />
No, I'm just playing, I know you think you're fat<br />
But I'm here to tell you...<br />
Every inch of you is perfect from the bottom to the top<br />
Yeah my mama she told me, "don't worry about your size"<br />
(Shoo wop wop, sha-ooh wop wop)<br />
She says, "Boys like a little more booty to hold at night"<br />
(That booty booty, uh, that booty booty)<br />
You know I won't be no stick figure, silicone Barbie doll<br />
So if that's what you're into, then go 'head and move along<br />
Because you know I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass<br />
'Bout that bass, no treble<br />
I'm all about that bass
The screening paradox<br />
Rebecca Wray<br />
SStudy<br />
There is pressure on doctors<br />
to deliver screening<br />
regardless of negative<br />
or controversial expert<br />
opinion. When faced with medical<br />
decisions, the public sway towards<br />
the desire ‘to do something’ or adopt<br />
the opinion ‘anything is better than<br />
nothing’. However, this well-received<br />
view, this yearning and enthusiasm<br />
for screening, is not appropriate;<br />
screening is not a miracle cure, in<br />
fact screening is neither a cure nor<br />
a standalone method of diagnosis.<br />
For every survival time improved by<br />
screening there is a hidden figure:<br />
the number of lives disintegrated by<br />
over-treatment.<br />
We fear disease. The idea that illness<br />
may be lurking inside is scary. Many<br />
of us believe screening can put our<br />
minds at rest or at the very least raise<br />
our awareness so we can take action.<br />
However, we may be unaware or<br />
ignore the fact that the subsequent<br />
treatment can be terrifying, even<br />
more so than the disease itself. Charities<br />
have a tendency to promote and<br />
glorify screening programs, but in<br />
reality the outcomes are not all they<br />
are made out to be.<br />
A perfect screening test does not<br />
exist. No test can detect all patients<br />
with a disease and simultaneously<br />
rule out everyone without it. Instead,<br />
there is a trade off between sensitivity<br />
and specificity. Overly sensitive<br />
tests can lead to over-diagnosis<br />
and over-treatment. As well as the<br />
unnecessary expense on the NHS,<br />
over-treatment places strain on the<br />
patient’s body, the effect of which<br />
spirals into anxiety and stress in the<br />
patient’s life. The ensuing tests could<br />
even do damage that is completely<br />
avoidable. Conversely, overly specific<br />
tests often come at the expense<br />
of sensitivity. You are sure to have<br />
the disease if your doctor tells you<br />
so with a perfectly specific test, but<br />
you end up erroneously discounting<br />
many patients with the disease causing<br />
false reassurance. Some doctors<br />
worry patients don’t completely understand<br />
the consequences a positive<br />
test result will have on their lives.<br />
Truly, there is no such thing as an<br />
overly-specific or overly-sensitive<br />
test, just so long as one does not come<br />
at the expense of the other. It is an<br />
important point and one that might<br />
need clarifying: if you take everyone<br />
who smokes and tell them they<br />
could have lung cancer, on account<br />
of that being the greatest risk factor,<br />
you end up catching nearly everyone<br />
with lung cancer because it is rare<br />
to get lung cancer in a non-smoker.<br />
However, many of your smokers will<br />
not have, nor will they ever get, lung<br />
cancer and you have unnecessarily<br />
worried them.<br />
The opposite is also true of very<br />
highly specific tests. You decide to<br />
do a test to try and predict who will<br />
get a cough. You screen your population<br />
for everyone who has just started<br />
smoking and take those people as<br />
your positive result. You plough on<br />
and tell all of the new smokers that<br />
they might get a cough, on account<br />
of that being one of the commonest<br />
causes. In the meantime, you reassure<br />
the rest of the population that<br />
they will not suffer and no one goes<br />
away unnecessarily worried. When it<br />
comes to follow up testing, all of the<br />
smokers have a cough as expected.<br />
None of them are pleased about it,<br />
but they were all warned in advance<br />
and so they are largely content. However,<br />
given the many other causes of<br />
cough, you are inundated with angry<br />
patients who do not smoke and were<br />
falsely reassured; they have all been<br />
coughing with bronchitis for weeks.<br />
Multiple screening programs for<br />
asymptomatic patients are offered on<br />
the NHS with the aim of increasing<br />
lead time (the length of time between<br />
diagnosis of a disease and when it<br />
would ordinarily start showing clinical<br />
signs) to improve outcomes. Studies<br />
into some screening tests uncover<br />
clear positive outcomes, while others<br />
are more controversial. In this article<br />
I am going to discuss three screening<br />
programs that span the spectrum of<br />
screening success: the PSA test for<br />
prostate cancer (no longer routinely<br />
performed in the UK), mammography<br />
for breast cancer (a program<br />
discouraged by many doctors), and<br />
the FOB test for colorectal cancer (a<br />
program with largely positive outcomes).<br />
The PSA (prostate specific antigen)<br />
blood test and the DRE (digital rectal<br />
exam) are used as screens for prostate<br />
cancer. Levels of prostate specific<br />
antigen in the blood are highly<br />
variable, noticeably increasing after<br />
physical exertion or intercourse.<br />
High levels of PSA are associated<br />
with a number of very treatable<br />
and very common diseases such as<br />
BPH (benign prostatic hyperplasia)<br />
and prostatitis, so much so that up<br />
to two out of three men with elevated<br />
PSA levels do not have prostate<br />
cancer. So what does a positive PSA<br />
test mean? In just an ordinary, symptomless<br />
member of society, who is<br />
purely being screened because there<br />
is a screening programme, the test is<br />
35
so sensitive that the result is not hugely significant.<br />
But, after a positive PSA result, the<br />
seed of fear embedded in the patient’s mind<br />
has sprouted and spread. It seems counterintuitive,<br />
even reckless, to shun further testing.<br />
The next stage of screening is invasive, time<br />
consuming and uncomfortable. In short,<br />
it is not an experience patients want to go<br />
through needlessly. The subsequent tests<br />
aiming to determine the cause of elevated<br />
PSA carry a risk of infection, bleeding and<br />
difficulty urinating. The standard next step<br />
is to perform a prostate biopsy. Initially, a<br />
transrectal biopsy is performed under the<br />
guidance of an ultrasound probe. In this<br />
approach both the needle and ultrasound<br />
probe are inserted through the rectum. The<br />
more extensive and invasive approach, the<br />
transperineal template biopsy, is used to<br />
gain additional information beyond that obtained<br />
in the transrectal biopsy if required.<br />
The issue with prostate biopsies is the difficulty<br />
identifying aggressive cancers from<br />
slow growing cancers that may never cause<br />
problems in the patient’s lifetime. Treatment<br />
of prostate cancer is aggressive and<br />
invasive with possible side effects including<br />
impotence and incontinence causing a significant<br />
reduction in the patient’s quality<br />
of life. Many men with cancerous prostate<br />
cells will never require treatment. If they<br />
hadn’t opted for screening the only role<br />
prostate cancer would have played in their<br />
life would be the fear that it may some day<br />
happen. Over-treatment and its effects on<br />
quality of life caused by screening are some<br />
of the main factors that question the effectiveness<br />
of the PSA test and subsequently<br />
have prevented its routine performance in<br />
the UK.<br />
Every three years women aged 50 to 70 receive<br />
an invitation for breast cancer screening.<br />
The initial test is a mammogram aiming<br />
to detect early stage cancers that the limited<br />
clinical examination is ineffective at identifying.<br />
Mammograms pose minimal risk to<br />
patients and, although they are uncomfortable,<br />
they are considered to be harmless. A<br />
study from 1994 to 2009 showed that out<br />
of the 1,297,906 women who had a combined<br />
total of 2,207,942 mammograms<br />
there were 182,340 false positives, which is<br />
roughly 14% of women screened.<br />
The next step for women with a positive<br />
breast cancer result can be more mammography,<br />
ultrasound screening or a breast biopsy.<br />
Like with the tests for prostate cancer,<br />
the biopsy is invasive, slightly painful and<br />
carries a risk of infection. The data from<br />
previous scans is used to target the biopsy to<br />
a suspicious area where cells or fluid is sampled<br />
from. These tests are invasive, but the<br />
fear of disease is an embedded part of our<br />
nature. We feel compelled to go on, choosing<br />
to ignore the fact that another positive<br />
test will lead to the next stage of screening.<br />
In no time at all we have agreed to procedures<br />
that will stall our lives and occupy our<br />
every thought, but the alternative seems unthinkable;<br />
how can I just ignore a finding<br />
that might be cancer?<br />
Similarly to prostate biopsies, it is difficult<br />
to identify fast growing cancers from slow<br />
growing cancers in a breast biopsy. Studies<br />
show that many of the slow growing cancers<br />
picked up by screening would never af-<br />
fect women in their lifetime if left untreated.<br />
About 1 in 5 women diagnosed with breast<br />
cancer through screening will have ductal<br />
carcinoma in situ (DCIS). This is cancer of<br />
the milk ducts. In some women this will never<br />
cause an issue, but if the cancer spreads<br />
from the milk duct it becomes invasive. Unfortunately,<br />
there is no way to tell if ductal<br />
carcinoma in situ will spread. For every one<br />
life saved by screening, roughly three women<br />
are diagnosed with a cancer that would<br />
never have become life threatening.<br />
The treatments of breast cancer are very<br />
aggressive and involve a combination of<br />
chemotherapy, hormonal therapy, radiotherapy<br />
and possibly mastectomy. All of<br />
these therapies can have severe side effects<br />
and greatly reduce the patient’s quality of<br />
life. The main issue associated with breast<br />
cancer screening, like prostate cancer<br />
screening, is over-treatment and the negative<br />
effects it will have on the patient’s quality<br />
of life post-diagnosis. For these reasons,<br />
many doctors in the UK and around the<br />
world do not think breast cancer screening<br />
is effective and there are questions over<br />
whether it should continue to be performed<br />
routinely.<br />
In contrast to the PSA test and breast cancer<br />
screening, the colorectal cancer screening<br />
programme is more specific. Colorectal<br />
cancer screening has been introduced<br />
in the UK for patients between 50 and 74<br />
years old in Scotland and 60 to 74 in England.<br />
Tests are sent via post every two years<br />
and results are usually received within two<br />
weeks of submission. The FOB (faecal occult<br />
blood test) involves the collection and<br />
analysis of a faecal sample, a positive result<br />
occurs in around 2 out of every 100 tests.<br />
A study into a BCSP (bowel cancer screening<br />
program) in England showed that out<br />
of 1.08 million returning tests, 2.5% of<br />
men and 1.5% of women had abnormal<br />
tests. Out of the patients that went on to<br />
have further testing, high risk adenomas<br />
were found in 43% of men and 11.6% had<br />
cancer. In women, high risk adenomas were<br />
found in 29% and cancers in 7.8%. 71%<br />
of the cancers were ‘found early’. Patients<br />
with a positive FOB test are offered colonoscopy<br />
or flexible sigmoidoscopy (camera<br />
tests up the back passage), the first being the<br />
more invasive procedure exploring more of<br />
the colon. These tests aim to look for cancer<br />
or polyps in the colon. If these endoscopic<br />
procedures reveal the patient does have polyps<br />
they are usually removed at the same<br />
time, minimising the number of visits to<br />
hospital. Economic analysis deems screening<br />
for colorectal cancer to be cost effective.<br />
It is important for doctors to ensure that patients<br />
are aware of the risks and potential<br />
outcomes as well as the positives associated<br />
with screening for cancers. A positive result<br />
in any of the tests discussed entails massive<br />
change, anxiety and disruption to a patient’s<br />
life. Furthermore, treatments for the<br />
cancers are aggressive and can often bring<br />
patients’ lives to a stand still; a false positive<br />
result is not only a massive unnecessary expense<br />
on the NHS but, more importantly,<br />
brings needless physical and psychological<br />
suffering to the patient and their family.<br />
36 37
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Ask a<br />
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Artwork by Jennifer. N. R. Smith<br />
www.jnrsmith.co.uk
Baby, it’s cold outside<br />
Editor’s Prize for<br />
Alistair Roddick<br />
One of the greatest<br />
achievements of the human<br />
race has been our<br />
ability to colonise vast<br />
swathes of land across a full house of<br />
continents, irrespective of climate,<br />
from the Tuareg people of the Sahara<br />
Desert to the Inuit of the arctic<br />
circle. From the Steppe plain to the<br />
thickest rainforest, humans have settled<br />
most everywhere at some point<br />
in history. This is in part due to our<br />
ingenuity. Not to blow our collective<br />
trumpet, but we invented clothes,<br />
mastered fire and continue to build<br />
ever more complex and efficacious<br />
shelters. This has allowed us to survive<br />
in climates that otherwise would<br />
not permit a dwelling. However, being<br />
clever can only get us so far. To<br />
survive in the most unforgiving of<br />
climates, the human body has been<br />
crafted and fine tuned by millions of<br />
years of evolution into the tall (usually),<br />
imposing (sometimes) survival<br />
machine that we see today.<br />
Even the human body has its limits,<br />
though. In the previous issue we discussed<br />
the physiology and danger of<br />
extreme heat. This issue, we will go<br />
to the polar opposite: the physiology<br />
of extreme cold.<br />
The human body has evolved to<br />
function as efficiently as possible,<br />
and this can only be achieved within<br />
a very narrow temperature range<br />
(around 36.5-37.5 o C). As a result,<br />
just as with an increase in temperature,<br />
the body has a variety of mechanisms<br />
to respond to a decrease in<br />
environmental temperature, ranging<br />
from the highly effective to the completely<br />
useless to the highly effective.<br />
I like extreme adventurers, so let’s<br />
use an explorer on a cold day in<br />
Antarctica as an example. Our adventurer<br />
wakes from sleep and leaves<br />
their tent to begin the day. Almost<br />
instantaneously, a drop in blood<br />
temperature is detected by cells in<br />
the hypothalamus. Interestingly, cells<br />
cannot determine body temperature<br />
beyond a fairly narrow range and,<br />
whilst we have both heat-sensitive<br />
cells and cold-sensitive cells, no cells<br />
can detect both. These cells trigger<br />
activation of the autonomic nervous<br />
system, this time driving a set of unconscious<br />
responses that act to either<br />
generate or conserve heat. At the<br />
same time, the hypothalamus signals<br />
to the cortex of the brain, activating<br />
behavioural pathways that are executed<br />
via conscious sensation and<br />
complex neuromuscular programs<br />
with environmental components.<br />
Or, explained more practically, you<br />
will feel cold and put on a jumper.<br />
So, about those unconscious responses;<br />
let’s start with the useless.<br />
The sympathetic nervous system<br />
(that is, the fight-or-flight part of the<br />
autonomic nervous system) signals to<br />
tiny muscles distributed throughout<br />
the skin called arrector pili. Each of<br />
these little muscles attaches to the<br />
base of a body hair in a hair follicle<br />
and when activated they heave<br />
all the hairs into an upright position,<br />
producing characteristic goosebumps.<br />
In our furrier ancestors, this<br />
would serve to trap a warm layer of<br />
air against their skin, keeping them<br />
warm in chilly weather. In humans,<br />
whose fur is somewhat less impressive,<br />
this response does, well, basically<br />
nothing.<br />
Probably the best physiological method<br />
for preserving heat that is useful<br />
to humans is the process of vasoconstriction<br />
– constriction of blood<br />
vessels around the body. In particular,<br />
the body loses loads of heat due<br />
to blood flow through the skin. We<br />
saw this in our desert explorer last<br />
time. To combat this heat loss on a<br />
chilly morning in Antarctica, sympathetic<br />
nervous system signals will<br />
be sent via nerves to major arteries<br />
and smaller arterioles supplying the<br />
skin, causing them to constrict. This<br />
reduces the blood flowing to the skin<br />
and therefore minimises the amount<br />
of heat lost into the surrounding air.<br />
These same signals are sent to the<br />
veins at the surface of our explorer’s<br />
arms and legs (like the veins that<br />
you may be able to see in your own<br />
arms after exercising), causing them<br />
to constrict. As a result, cold blood<br />
coming back from the fingers and<br />
toes towards the heart is diverted<br />
along deep veins that run alongside<br />
the major arteries. Because heat always<br />
moves from hot to cold, hot<br />
blood reaching the hands and feet<br />
would normally conduct its warmth<br />
out into the cold atmosphere. Instead,<br />
the hot blood transfers its heat<br />
into these deep veins carrying cold<br />
blood back from the limbs, which<br />
become warm, while the arterial<br />
blood becomes colder as it heads<br />
off towards the fingers and toes.<br />
This system means that the blood in<br />
the extremities stays cold while the<br />
blood in the body core (where all the<br />
important stuff is) stays warm. This<br />
process is known as counter-current<br />
exchange, and is one of the most<br />
important mechanisms of holding<br />
on to that precious heat in freezing<br />
climates.<br />
Everything we have mentioned so<br />
far is a means of preserving heat, but<br />
artwork 2016<br />
Congratulations to Jamie Crawford who has won this year’s Editor’s Prize for an<br />
artwork contribution. His work can be seen on page 21 of this issue.<br />
Jamie will receive £100 in book vouchers.<br />
Highly commended goes to Jennifer Smith, whose work can also be seen throughout<br />
this issue. In particular, the artwork attached to “Unprepared for autopsy” on<br />
page 40.<br />
________________<br />
All submissions in a calendar year are eligibile to win the Editor’s Prize. The award<br />
goes to the piece of work deemed to be of the highest quality; taking into account<br />
the originality and polish of the final piece, as well as the steps undertaken to achieve<br />
it. The winning piece is chosen by the editorial team.<br />
42 43
Counter-current flow<br />
is also how fish breathe,<br />
except gills exchange<br />
oxygen instead of heat.<br />
the body has another way to keep<br />
warm. Ditch the vest and do some<br />
press-ups. Most metabolic activity in<br />
the body will generate a little bit of<br />
heat. In particular, muscle contraction,<br />
which involves a whole host of<br />
metabolic processes, is a particularly<br />
‘hot’ activity. This is where shivering<br />
comes in: the ‘shivering centre’ (a<br />
little bit of brain located at the back<br />
of hypothalamus) causes coordinated<br />
muscle contraction; firing up all<br />
of those cold, dormant muscle fibres<br />
throughout the body. Since muscle<br />
activity increases blood flow to the<br />
active muscles, more blood is delivered<br />
to the warmest muscles, where<br />
it collects the heat and transports it<br />
back to the body core. Shivering is a<br />
great way to warm up, and can increase<br />
the body’s heat production by<br />
up to five times. Now we’re cooking<br />
with gas.<br />
Until recently it was believed that<br />
shivering was the only way that<br />
adults could generate their own<br />
heat. However, there is another way<br />
that we can produce heat. Brown fat<br />
(or brown adipose tissue) is a type<br />
of fat that is widely distributed in<br />
new-born babies and hibernating<br />
mammals. The cells in brown fat go<br />
through the same process of energy<br />
production as every other cell in the<br />
body, but with one important difference:<br />
at the very end of the energy<br />
production line, instead of producing<br />
ATP, brown fat cells release their<br />
stored energy as heat. This is, in<br />
normal circumstances, a massively<br />
inefficient use of all that glucose and<br />
fat that the cells use to produce energy.<br />
However, in very small babies<br />
(who have yet to fully develop their<br />
shivering centre), this inefficiency<br />
can be crucial, providing a means<br />
to fight off the elements. Although<br />
brown fat tends to decrease with<br />
age, it has recently been shown to be<br />
important in adults for maintaining<br />
heat in extreme cold weather (my favourite<br />
kind of cold weather). Also<br />
great for hibernating through long<br />
winters, if that’s your cup of tea.<br />
As with everything in the human<br />
body, our capacity to keep warm,<br />
although impressive, can be overwhelmed<br />
in extreme scenarios.<br />
Maybe our Antarctic explorer gets<br />
lost, and can’t get back to the tent<br />
in time for the bitter cold of night.<br />
Before long, their body temperature<br />
will drop beneath the 35 o C mark –<br />
the cut-off point for hypothermia.<br />
This is where things begin to go<br />
wrong. In the early stages of hypothermia<br />
(roughly 32-35 o C) the cold<br />
heart begins to weaken, pumping<br />
out less blood with every beat. In order<br />
to keep blood circulating around<br />
the body, the heart must speed up<br />
to compensate. This means blood<br />
is pumped through the lungs more<br />
rapidly, so breathing has to speed<br />
up as well in order to maintain adequate<br />
oxygenation. In the extremities,<br />
blood vessels shut down to<br />
maintain heat within the core, cutting<br />
off circulation to the fingers and<br />
toes (and in really bad hypothermia,<br />
the nose too). This is the first step on<br />
the path to frostbite, which causes<br />
severe damage and can require amputation<br />
of the affected digits.<br />
As the explorer starts to get colder,<br />
things begin to get progressively<br />
worse. The heart rate, initially increased,<br />
begins to drop. Breathing,<br />
too, slows down as metabolic processes<br />
throughout the body become<br />
sluggish. More worryingly still,<br />
mental function slows as the brain<br />
becomes affected by the cold, causing<br />
confusion and tiredness. The<br />
cold also plays havoc with the hypothalamus<br />
(as with hyperthermia),<br />
making regulation of body temperature<br />
even more difficult. Often the<br />
hypothalamus can send incorrect<br />
messages to the conscious parts of<br />
the brain, creating a sensation of<br />
warmth. This causes a phenomenon<br />
known as ‘paradoxical undressing’,<br />
where severely hypothermic individuals<br />
start stripping off their clothes,<br />
becoming even colder in the process.<br />
Once body temperature drops below<br />
around 28, nearly ten degrees<br />
below normal body temperature,<br />
the outlook begins to look bleak.<br />
Breathing becomes so slow that carbon<br />
dioxide begins to build up in the<br />
blood. This causes the blood to become<br />
more acidic, which promotes<br />
dysfunction of multiple organs. In<br />
particular, acidic blood makes the<br />
heart very unstable, and prone to<br />
trigger fatal heart rhythms. At this<br />
temperature, the heart is very unstable<br />
anyway due to failure of the<br />
vital enzymes that keep it beating;<br />
together, the cold and the acid will<br />
bring the heart to a gentle halt.<br />
Is this the end for our brave (and fortunately,<br />
hypothetical) explorer, lost<br />
and alone in the dark of the Antarctic<br />
night, with dwindling brain function<br />
and a cold, motionless heart?<br />
Well, not quite. Dangerous though<br />
hypothermia is, there is still hope for<br />
this explorer.<br />
Every cell in the body must balance the<br />
amount of energy it produces (in the form<br />
of ATP, made using glucose and oxygen)<br />
with the amount of energy it needs to carry<br />
out its functions. During exercise, for example,<br />
muscle cells work harder to contract<br />
and therefore must produce more energy<br />
to fuel this process. The brain, however, is<br />
active all the time, and must always have a<br />
constant supply of energy to fuel the many<br />
neural impulses criss-crossing through the<br />
white and grey matter 24 hours a day. If<br />
the brain loses blood supply (say, in a stroke,<br />
or in a cardiac arrest) then the brain cells<br />
cannot generate enough energy to remain<br />
active, and they will begin to die.<br />
However, in a cold brain, all the enzymes in<br />
each cell move at a snail’s pace, slowly doing<br />
all the work needed to send the neural<br />
messages around the brain. These messages<br />
may be moving so slowly that the brain is<br />
not functional (i.e. the owner is in a coma).<br />
At this pace, however, the brain cells are<br />
not working very hard, and do not need a<br />
lot of oxygen or glucose supplied to them.<br />
In our plucky explorer, even though their<br />
heart is not beating and not supplying the<br />
brain with blood, their sluggish, cold brain<br />
can survive on what little oxygen is left in<br />
the stationary blood for a long time.<br />
This means that severe hypothermia can actually<br />
protect the brain, and can save lives.<br />
Take the inspiring story of Swedish doctor<br />
Dr Anna Bågenholm, who became trapped<br />
in an icy stream during a skiing outing in<br />
the frosty mountains of Norway. After 40<br />
minutes, the freezing cold overwhelmed her<br />
heart and her circulation stopped. 40 minutes<br />
later, she was pulled from the stream<br />
and airlifted to the nearest hospital an hour<br />
flight away. Here, over three hours after<br />
falling into the water, Dr Bågenholm’s heart<br />
was restarted and she was revived. She suffered<br />
no permanent damage from her incident.<br />
Since this incident, and many similar others,<br />
we have begun to realise the power of<br />
hypothermia. Research has begun to show<br />
that cooling dying patients in ambulances<br />
can increase their chance of survival, while<br />
so-called ‘therapeutic hypothermia’ is used<br />
in operations such as open heart surgery<br />
in children, allowing surgeons to stop the<br />
heart completely and repair it, all the while<br />
protecting the child’s brain from damage.<br />
So, hypothermia: is it bad?<br />
The answer is a resounding maybe. It depends<br />
on when you are cold, and why. But,<br />
despite its benefits, in most cases hypothermia<br />
is a highly dangerous situation, with serious<br />
risks and consequences. So, don’t turn<br />
down those gloves or ditch the scarf just<br />
yet. Instead, dress appropriately, wrap up<br />
warm and, unlike our hypothetical explorer<br />
(who luckily was rescued by their team<br />
and returned to full health), when exploring<br />
the cold and dangerous wilderness, bring a<br />
map.<br />
44 45
Unprepared for autopsy<br />
Lok In Lam<br />
After badgering my fellow<br />
medical students about<br />
what their post-mortem<br />
visit was like, I had a rough<br />
idea of how the visit to the mortuary<br />
would go. I was to remember<br />
my name badge, remember to wear<br />
socks, remember to get signed off.<br />
There was to be blood, new smells,<br />
new sights, and all kinds of sensory<br />
overstimulation. Having gone to a<br />
medical school that performed fullbody<br />
dissection, I (wrongly) thought<br />
I would be prepared for what I was<br />
going to see.<br />
The first thing that hit me when I<br />
walked into the autopsy room was<br />
how peaceful the bodies looked, as<br />
though they were sleeping. In the<br />
world of medical school, we learn<br />
about the wonders of modern medicine<br />
and technology every day, often<br />
forgetting to reflect on its limitations.<br />
The autopsy can be a way of promoting<br />
positive attitudes towards<br />
death and bereavement and can help<br />
us come to terms with the harsh reality<br />
that all patients must eventually<br />
die; an essential for medical students.<br />
The series of events leading up to<br />
the person’s death and why the autopsy<br />
needed to be carried out was<br />
explained to us as we watched the<br />
procedure. This allowed a greater<br />
appreciation and understanding of<br />
the legal framework applied when<br />
working with patients after they have<br />
died. As medical professionals, contact<br />
with the dead and medico-legal<br />
aspects are inevitable, and as such<br />
it was beneficial to learn about the<br />
laws and regulations.<br />
As the bodies were opened and organs<br />
removed, again I was amazed<br />
at how different the procedure<br />
seemed to dissection. The embalming<br />
process reserved for cadavers<br />
produces a completely new specimen.<br />
The post-mortem procedure<br />
has been set up to allow the viewing<br />
of three-dimensional anatomy in its<br />
original space and appreciation of<br />
the relationships between structures<br />
in a more ‘realistic’ form.<br />
The examination of the organs was<br />
fascinating; the careful slicing and<br />
scrutinising of each organ in order<br />
to determine the cause of death was<br />
something completely different from<br />
any other medical specialty. Pathology<br />
can be a specialty that medical<br />
students have little to no contact<br />
with, and the post-mortem was a<br />
good opportunity to learn about the<br />
role of a pathologist. This can allow<br />
further exploration of future career<br />
options, as well as fostering an appreciation<br />
for other healthcare professionals<br />
such as anatomical pathology<br />
technologists.<br />
After the autopsy, the body was<br />
washed and made presentable. This<br />
was a sharp reminder that this person<br />
was somebody’s partner, relative,<br />
friend. It made me consider the<br />
wider clinical context of this patient,<br />
and the life they must have lived<br />
before I met them in the mortuary.<br />
This consideration of other people<br />
is important in order to prevent<br />
clinicians from becoming distanced<br />
from their patients, and from losing<br />
the empathy which is so important<br />
in providing good care. Of course, it<br />
is well and good saying that autopsy<br />
benefits career choices and anatomical<br />
knowledge, but the downside<br />
is that we are, for a brief while,<br />
exposed to a body not a person. It<br />
seems as though that patient’s personhood<br />
is put on hold from the moment<br />
the pathologist makes the initial<br />
incision until the body is closed<br />
and dressed. For that short period of<br />
time, a doctor who otherwise only<br />
deals with patients, not organs, who<br />
deals with diseased people, not the<br />
disease itself, is allowed to think of<br />
their patient as just a body.<br />
These patients are all somebody,<br />
not just some body, and giving doctors-in-training<br />
a glimpse of the<br />
other side of the curtain could have<br />
disastrous effects. To allow medical<br />
students the opportunity to think<br />
they are treating the lungs, that<br />
the disease stops with whatever is<br />
cut open and diagnosed at autopsy,<br />
when really they are treating the<br />
breathless patient at the end of the<br />
corridor, may lead to a workforce devoid<br />
of human awareness.<br />
Despite my initial fears about the<br />
visit, overall the benefits of attending<br />
a post-mortem were numerous<br />
and unique. I gained knowledge and<br />
attitudes that I would be unlikely to<br />
achieve in other settings. However, it<br />
must be mentioned that post-mortem<br />
visits can be very emotionally<br />
distressing. As such, students undertaking<br />
the sessions should be adequately<br />
supported, and their time<br />
there should be well structured in<br />
order to fully reap the benefits of a<br />
visit.<br />
Artwork by Jennifer. N. R. Smith<br />
www.jnrsmith.co.uk<br />
47
with the end of the Liverpool Care<br />
Pathway, we can look forward to an era<br />
of compassionate palliative care<br />
Daily Mail 2015<br />
The LCP is dead.<br />
Long live the LCP.<br />
The Liverpool Care Pathway (LCP) was<br />
introduced in the late 1990’s at the<br />
Royal Liverpool University Hospital,<br />
along with the Marie Curie Palliative<br />
Care Institute, with the goal of ensuring<br />
dignified and peaceful deaths.
Why we shouldn’t have got rid of the<br />
Liverpool Care Pathway<br />
Katie Faulkner<br />
You matter because you are you, and you matter until the last moment<br />
of your life. We will do all we can, not only to help you die peacefully,<br />
but also to live until you die - Dame Cicily Saunders<br />
The Liverpool Care Pathway<br />
(LCP) was introduced<br />
in the late 1990’s<br />
at the Royal Liverpool<br />
University Hospital, along with the<br />
Marie Curie Palliative Care Institute,<br />
with the goal of ensuring dignified<br />
and peaceful deaths. Produced<br />
according to best practice and evidence<br />
based research, the intention<br />
was to recreate the care received<br />
by patients in a hospice setting and<br />
apply it to hospital wards as well. It<br />
was not long before the pathway was<br />
attacked for being used to catalyse<br />
deaths, clear beds and save money. A<br />
series of articles were written on experiences<br />
of patients’ families watching<br />
their loved ones dying “an awful<br />
death” on the pathway, with news<br />
headlines depicting the pathway as<br />
“the road to death”, “a one-way ticket”<br />
and, most commonly, “the death<br />
pathway”.<br />
Whilst unethical in itself to display<br />
such a sensitive topic so tastelessly,<br />
the impact of the media meant the<br />
minority of cases where the pathway<br />
was not well carried out over-shadowed<br />
the massive benefits the pathway<br />
had to offer. Enough so that in<br />
2013 the Department of Health and<br />
NHS commissioning board instigated<br />
an independent review of the<br />
LCP establishing a table of 44 recommendations<br />
and, finally, the withdrawal<br />
of the pathway altogether.<br />
For this reason, I will establish two<br />
major principles of medical practice<br />
to explain why it was not only<br />
unnecessary, but unwise to have rid<br />
ourselves of the LCP, whilst also<br />
drawing out what we should learn<br />
from the mistake we have made and<br />
demonstrating why the LCP was an<br />
effective tool in managing dying patients.<br />
The first principle is this: we should<br />
never replace an effective and<br />
well-established practice because<br />
some doctors don’t know how to<br />
use it. The LCP provided beneficial<br />
treatment for patients who were dying,<br />
with numerous stories of good<br />
practice. It is partly because of the<br />
LCP that the care of the dying patient<br />
in Britain was ranked by the<br />
Economist Intelligence Unit as best<br />
in the world in 2010, with quality of<br />
care and public awareness of palliative<br />
medicine recognised as our<br />
main strengths. Likewise, in the independent<br />
review of the LCP, Baroness<br />
Neuberger herself stated,<br />
“there is no doubt that, in the right hands,<br />
the Liverpool Care Pathway supports people<br />
to experience high quality and compassionate<br />
care in the last hours and days of their<br />
life”<br />
The main recommendation given in<br />
her review was simply the use of the<br />
word “pathway” in the name, which<br />
she believed might suggest that patients<br />
are on an unstoppable road<br />
that they cannot step off. These indications,<br />
and many more, demonstrate<br />
that the pathway itself was not<br />
the problem but the application of<br />
the pathway by doctors untrained in<br />
how to use it. It is thought that there<br />
was a great discrepancy in its use;<br />
implemented properly under hospice<br />
circumstances where the staff<br />
are trained to offer the pathway in<br />
its intended holistic nature, versus<br />
the hospital environment where the<br />
pathway was too often regarded as a<br />
tick-box exercise, by staff who were<br />
as impermanent as the patients.<br />
Therefore, should we not have kept<br />
the pathway (in which the problem<br />
did not lie) and improved training<br />
and staff-turnover on wards working<br />
with those managed under the<br />
guidelines of the LCP?<br />
Just as we would not stop giving insulin<br />
as a treatment for diabetics or<br />
anticoagulants for those at risk of<br />
stroke simply because some doctors<br />
do not know how to use them, discarding<br />
the LCP for dying patients<br />
simply because some doctors misused<br />
it denies us of a great tool for<br />
providing very good quality care.<br />
Secondly, it is never acceptable for<br />
the pressure of the public and the<br />
media to dictate how the NHS operates.<br />
In a typical Hippocratic Oath<br />
style, we agree to “provide a good<br />
standard of care, uninfluenced by<br />
political or religious pressure”. We<br />
had been using the pathway for years<br />
and the LCP itself had not really<br />
changed. So, where did this sudden<br />
pressure come from that terrified us<br />
into removing the pathway? Maybe<br />
society’s expectations of practitioners<br />
had increased causing a limited<br />
acceptance of the fact that illness<br />
cannot always be cured which led to<br />
more friction than before between<br />
health professionals and relatives of<br />
dying patients. Maybe increasing<br />
financial and time pressures put on<br />
the NHS meant doctors were less<br />
able to fulfil their roles as previously.<br />
Or maybe the media just love to find<br />
any fault in doctors which they can<br />
use to stir up an emotional response<br />
amongst the public and sell papers.<br />
Whatever the cause may have been<br />
for the pressure put on us to change<br />
our approach towards care for dying<br />
patients, we should never have been bullied<br />
by the medically unqualified to change current<br />
practice. If there is an obvious fault<br />
in the current procedure which needs to<br />
be addressed, it is logical and good to address<br />
it. Yet, withdrawing such a vast set of<br />
guidelines as the LCP without any evidence<br />
to suggest harm caused directly by them is<br />
sadly testifying to the fact that we are unable<br />
to stand strong as a body for what we<br />
have determined is good for public health.<br />
Further to this, by changing current practice<br />
we have actually appeared to agree<br />
with the outrageous claims made in the<br />
newspapers and have confirmed people’s<br />
doubts in our ability to care for their dying<br />
relatives and have given them a reason to<br />
suggest that doctors lack genuine concern<br />
for these vulnerable patients. Instead, we<br />
ought to have spent our time reassuring the<br />
public of the benefits of the LCP and why<br />
it was practised, highlighting positive experiences<br />
such as that of a family spoken of in<br />
the Neuberger Report stating:<br />
“They spoke to us as a family in a sensitive way...<br />
She died with my mother holding her hand, surrounded<br />
by the people she loved in the place where<br />
she wanted to be... I believe we could only do this,<br />
because the LCP provided staff with the guidance<br />
to prepare us for her death and also gave them the<br />
confidence to provide the right care at the right time”.<br />
This brings me on to my final point: the<br />
LCP represented best practice in managing<br />
terminally ill patients in their final moments<br />
and so should not have been removed. Supported<br />
by literature review which showed<br />
that using the LCP promoted better care<br />
for dying patients, it brought the ‘gold<br />
standard’ care found in hospices into a conventional<br />
healthcare setting. Evidence supports<br />
the fact that symptoms could be adequately<br />
managed using the LCP guidelines,<br />
that the LCP provided staff with assistance<br />
in communicating with patients and their<br />
relatives about the patient’s condition and<br />
their eventual death and the pathway recognised<br />
that views of patients and relatives<br />
should be listened to and documented appropriately.<br />
In all ways, the LCP brought<br />
excellence to the care of patients. That is<br />
not to say that the pathway was perfect, but<br />
its problems should have been addressed<br />
individually and corrected; what a waste to<br />
throw it all out and return to the drawing<br />
board.<br />
Dame Cicely Saunders, the founder of the<br />
hospice movement, said,<br />
“You matter because you are you, and you matter<br />
until the last moment of your life. We will do all we<br />
can, not only to help you die peacefully, but also to<br />
live until you die.”<br />
Certain doctors and nurses weren’t doing<br />
all they could do, but the Liverpool Care<br />
Pathway should not be made a scapegoat<br />
for them.<br />
We should never replace an effective and well-established practice<br />
because some doctors don’t know how to use it.<br />
50 51
We’re going through changes<br />
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<br />
Medic Mentor family? Well, some pretty big changes have taken place in the latter months of 2016 that we<br />
wanted to share with you.<br />
Perhaps the most exciting of all is the arrival of a swathe of fresh faces; the new scholars. It’s out with the<br />
old and in with the new as we come to terms with handing over the projects that have become our babies<br />
to our Medic Mentor Scholarship successors.<br />
You may have already felt the presence of the company’s wisest new recruits; the Medi Council. The pun<br />
is bound to split opinion but their expertise is indisputable. These junior doctors hold a previously unheard<br />
of level of insight and, in the absence of dark forces to be fought, will be keeping the scholars on their toes.<br />
Weak minds need not apply.<br />
Drs Dhakshana Sivayoganathan and Iain Kennedy have a new arrival of their own on the way. At minus<br />
three months old and already drafted in as Medic Mentor’s youngest member, have we finally found a job<br />
that Dhakshana cannot take in her stride? No. Dr Sivayoganathan is moving from CEO to Director of<br />
Communications to allow for greater flexibility, but she remains just a phone call away if you need help.<br />
Conference attendees will still get time with our best known mentor, but she now comes equipped with<br />
bump or baby boy. Iain is currently trying on Dhakshana’s very large CEO boots; I think he rather likes<br />
them but there’s a lot to learn and Medic Mentor’s 2017 diary is filling up fast.<br />
That would leave Dr Kennedy’s role as Director of Education open but it is being filled by Dr Rebecca<br />
Yates, last year’s Widening Access Scholar. Dr Yates is currently working as an FY1 in Wales and will add<br />
taking care of the incoming scholars to her long list of responsibilities.<br />
The more attentive amongst you may have realised that this makes the November edition my last as Publishing<br />
Scholar and therefore my last as editor. Do not fear, I’m moving on up but I’m not moving away. At<br />
the beginning of December I hand over the magazine’s production to its new editor (the new publishing<br />
scholar) and I become the Director of Publishing. You should still see my articles and know that I’m somewhere<br />
behind the scenes, making sure we get a great magazine to you every quarter. My fan-mail should<br />
now be directed to publishing@medicmentor.org.<br />
GGet involved<br />
We’ve profiled the new lot below, be on the lookout for their faces at upcoming events.<br />
53
The Medi Council<br />
Dr Rebecca Yates<br />
Director of education and leader of the medi<br />
council<br />
I don’t want to sound mushy but being part of Medic Mentor<br />
is really awesome. Being able to use your own experience<br />
of applying to medical school to help others in their applications<br />
is incredibly rewarding. Medic Mentor provides the opportunity<br />
to design and create resources distributed to prospective and current<br />
medical students; the company really goes above and beyond.<br />
“No” isn’t a word that is used very often and I love that.<br />
I’ve been involved with Medic Mentor for just over a year, initially<br />
as a scholar working with school societies and then as a Fellow.<br />
Now in my role as Director of Education I will be working alongside<br />
the Medi Council to support our team of talented scholars<br />
and mentors.<br />
I’m hoping that we will complete some incredible projects that will<br />
benefit many current and prospective medical students. I’m also<br />
excited for our first ever national mentors conference, Mastering<br />
Medical School, designed to give our mentors all the info they<br />
need to make the most out of their time at university.<br />
I decided I wanted to become a doctor around the age of 14 however, despite my best efforts, I didn’t<br />
get any interviews when I first applied. Not wanting to accept defeat, I decided to study for an<br />
undergraduate degree and apply to medical school as a graduate. I read molecular medicine<br />
at the University of Sussex and had a fantastic time, but I was still determined to go into medicine.<br />
I applied to four graduate entry medicine programmes, was lucky enough to be offered places on three,<br />
and decided to study at Keele University. I graduated in July 2016 and I’m now working as an FY1.<br />
Dr Claire Gillon<br />
Lister Hospital - aspiring surgeon<br />
My first degree was in anatomical sciences at the University of Manchester which also involved<br />
studying Japanese. After this I opted to do an undergraduate medicine course in Manchester so that<br />
I could do the European Studies Programme - this enabled me to complete a 16 week elective in Berlin<br />
in 2016 before graduating. I found doing a degree beforehand to be incredibly useful; I had developed<br />
graduate skills whilst gaining a broader knowledge base in the biological sciences.<br />
I have practised tai chi for over ten years and am a qualified instructor; at university I set<br />
up and ran a society for tai chi. I particularly love travelling, and went to Japan in the summer and even<br />
more recently to New York. I can frequently be found reading and watching movies, although asking<br />
which are my favourites is an impossible question.<br />
I first got involved in mentoring when I started 6th form, mentoring younger pupils who, for whatever<br />
reason, were struggling at school. From there I developed my teaching skills whenever the opportunity<br />
arose - usually on an informal basis. During my medical degree I was involved in the Scalpel society<br />
which aims to further the knowledge and experience of those interested in surgery. My role primarily<br />
was organising and running weekly lectures but I also helped teach at various day courses and supported<br />
the running of the annual conference.<br />
Make the most of the wide array of opportunities available to you: get involved in societies, especially<br />
non-medical ones and build up a variety of non-medical interests and activities. In doing so you will<br />
improve your transferable skills and at times they can help you to stay grounded. Remember, there<br />
isn’t just one way to do medicine.<br />
Dr Husay Janebdar<br />
Ipswich Hospital - Core surgical trainee<br />
My journey of getting into medical school was one of the classic straightforward ones (boring I<br />
know!). I had straight As and A*s at school and college, gained work experience at a variety of different<br />
places, a few other extra curricular activities and achievements … and then just took my passion<br />
for medicine to the interview! It worked.<br />
Being part of the Medi Council I look forward to mentoring the Medic Mentor Scholars, I am particularly<br />
excited about organising the Mastering Medical School conference this year and generally<br />
being part of an enterprise and group of like-minded intellectuals who feel passionate about teaching,<br />
mentoring and widening access to medicine.<br />
I love the concepts and values of Medic Mentor. I love that with us, anybody from any background<br />
with a slight passion or interest in medicine can have all the support, information and access<br />
to opportunities they need to nurture and blossom.<br />
My advice to current medical students? Enjoy the journey, and make the most of every Christmas and<br />
New Year you have off as it won’t always be the case once you start working.<br />
Dr Sarah Bassiony<br />
William Harvey Hospital - aspiring surgeon<br />
Throughout medical school I have had multiple mentees and had the opportunity to help them develop<br />
and see them blossom to the doctors they have now become. As an FY1 I was the teaching lead for<br />
final year medical students and arranged a year-long teaching programme which combined a mixture<br />
of lecture-based and bedside teaching.<br />
Simulation is being increasingly used to train doctors and I love it. I have always thought it was a<br />
brilliant way to learn. Since FY1 I have been part of the faculty team in organising simulation session<br />
for medical emergencies using SimMan and helping them reflect on their performance. I realised that<br />
a lot of the students were worried about their first on calls, so this year I launched “HotlineBleep” (if<br />
54 55
you don’t get the reference, we can’t be friends). This virtual on-call programme allows students to<br />
develop their confidence in dealing with common calls they are likely to receive, and helps them to<br />
recognise when and how to escalate to their seniors<br />
When I was at school I remember being torn between wanting to study clinical psychology and medicine.<br />
I am not going to lie and say that getting into medical school was an easy ride. I came from a<br />
school where not all of my teachers believed I would get into medical school, let alone graduate. My<br />
performance in the interview meant that the University were willing to overlook me<br />
slightly missing out on my grades, which I am really grateful for. So, I would say getting experience<br />
in and out of medicine is key in helping me develop as a person. To me, medicine is more about<br />
being a well-rounded, caring individual, and less about being a book worm.<br />
The 2017 scholars<br />
James Everson - Leadership Scholar<br />
University College London - sixth year<br />
I’m hoping to start my career in August 2017 with the Academic Foundation Programme in clinical<br />
leadership, moving on to train in emergency medicine and, later, to sub-specialise in the rapidly<br />
developing field of pre-hospital emergency medicine. I love teaching too, so I am very keen to keep<br />
this up throughout my career! I have taught other medical students in various capacities at UCL, and<br />
through my experience with the Army Reserve I have spent a lot of time mentoring juniors, which I<br />
find really rewarding and is a fantastic way to help people develop. I have also been a presenter with<br />
Medic Mentor for the past year, which necessarily entails a great deal of teaching.<br />
Only since joining Medic Mentor have I realised how lucky I was with my journey to medical school.<br />
I applied straight from school, and after interviews at St Andrews and UCL, I got an offer from UCL.<br />
It turns out that you only need one opportunity to make it in! Looking back, I think taking a gap<br />
year would have been a fantastic idea, and I really encourage everyone to consider it.<br />
In the coming year I would like to try and focus some attention on our medical students and start looking<br />
at getting formal mentoring and teaching for the vast number of medical students in our ranks.<br />
George Huntington - Publishing Scholar<br />
University of Sheffield - fifth year<br />
I had to work hard to get into medical school. I’m not the most studious student. Unsuccessful on my<br />
first application, I was told that it wasn’t worth applying a second time. After getting my A levels I<br />
concentrated extensively on getting medical experience to line my application. A friend of the couple<br />
who I used to babysit for introduced me to an ICU consultant at a barbeque. I ended up spending<br />
a month shadowing him. After that I worked as a healthcare assistant on a trauma and orthopaedic<br />
ward. In this time, I resubmitted for medicine. When it didn’t seem as though I was going to<br />
be successful, the ward began training me as a nurse via the diploma that was available at<br />
that time. Out of the blue, I received a Sheffield interview and here I am.<br />
In medicine I would like to work towards the marriage of the two specialities which interest me most:<br />
mental health and acute medicine. Ideally, working as a mental health specialist. My wider ideal career<br />
would also involve teaching and academic medicine. Outside of healthcare, I write short fiction<br />
to relax. It has always been a dream of mine to see this published as a collection.<br />
I have written for this magazine since its inception. I like the accessibility of the articles and also<br />
the writing process itself; I have seen essays written by physiologists, interviews with medical course<br />
directors interspersed with articles by contemporaneous medical students and future applicants to<br />
the course. What a wide perspective on things! The previous editorial team have worked so hard to<br />
produce the Medic Mentor magazine. The very least that I could do in my role would be to carry<br />
the fire and continue to put out such a quality publication.<br />
Oluwafunto Ogunleye - Work Experience Scholar<br />
University of Sheffield - second year<br />
When I was about 17, I really was not sure what I wanted to do as a career but I loved my biology<br />
practicals at school. I was passionate about anatomy so I went to Bristol and studied anatomical<br />
science. During my final year I was able to carry out an independent research project in the field of<br />
56 57
orthopaedic surgery - shoulders, specifically - in which I became very invested. I loved every minute<br />
of operating on fresh cadaveric shoulders. I also found my supervisor, an orthopaedic surgeon, to be<br />
inspiring and I think it was a combination of those factors that made me begin to seriously consider a<br />
career in surgery or medicine. From there I organised work experience, got a job as a hospital healthcare<br />
assistant, gained some real life insight into medicine and made an informed, calculated decision.<br />
Two years after I graduated, I started my medical degree at Sheffield.<br />
Medic Mentor is unique. Gaining admission into medical school is no easy feat and it is certainly not a<br />
level playing field. I like that Medic Mentor brings the<br />
real, uncoated truth and information to keen school<br />
students directly from motivated medical students and<br />
doctors. Additionally, the medical students benefit<br />
from the increasing list of opportunities such as scholarship<br />
roles with challenging projects that make driven<br />
medical students stand out.<br />
It is easy to get bored and end up going through the<br />
motions as you go about your work experiences. Try to<br />
pay attention at every experience or scenario you encounter.<br />
Don’t be afraid to ask ‘why’ to the people<br />
you’re observing or working with and try to reflect on<br />
what you’ve witnessed at the end of each day while<br />
thinking of how it could be important.<br />
Lauren Quinn - Medical Schools Compendium Scholar (Research)<br />
University of Birmingham - fourth year<br />
Research and academia is real passion of mine and so I devote much of my time to getting involved<br />
in projects, hosting events and endeavouring to engage students in research. I was awarded a Nuffield<br />
Science bursary between year 12 and 13 during which I undertook a research project looking at risk<br />
factors and preventative measures for diabetes. This was my first exposure to academic (research)<br />
medicine and I loved it and knew I wanted to further this interest during my time at medical school<br />
- and I have done!<br />
My first involvement with Medic Mentor was at a medical careers day when I had the opportunity<br />
to present a poster and deliver a lecture on my organisation, the Birmingham Academic Medicine<br />
Society. It was a very inspiring day to see young people who were so engaged with medicine. I later<br />
invited the medic mentors to attend our national student conference in January 2016 and they were<br />
delighted to attend. They made a huge impact and were very well received by medical and prospective<br />
students alike.<br />
The passion and vocation for medicine has to stem from yourself. Medicine is a long haul, it’s a marathon<br />
not a sprint and you have to be the driver! Also, you must not compare yourself to those<br />
around you, not now or in your future career; you must endeavour to be the best you can be<br />
and continually strive to improve yourself, rather than feeling inferior to those around you. This way<br />
you’ll be much happier!<br />
Caitlin Gibb - Medical Schools Compendium Scholar (Education)<br />
Queen Mary University - third year<br />
Having enjoyed sciences all the way through school, I wanted to keep my options broad and decided<br />
to study biology at university. During my degree, I did work experience and internships in career<br />
paths such as finance, event management, and teaching. I enjoyed all of them but I couldn’t imagine<br />
myself doing them for the rest of my life. In my third year we got to choose a module and I choose<br />
mine on ageing - it was one of the few human modules and I thoroughly enjoyed learning about age<br />
related disease. I think I shocked myself and the people around me when I told them I wanted to<br />
study medicine! But having found out that there were graduate medicine courses, completed some<br />
work experience in a hospital, and spent some time researching it, I felt I had found what I wanted to<br />
do as my career - it had just taken me a bit of time!<br />
Medic Mentor is unique in that it offers an opportunity to link up doctors, medical students and<br />
pre-medical students in one place. Forming this sort of network is invaluable as we can all learn so<br />
much from each other! It’s great that it enables everyone to access advice and guidance that can be<br />
hard to get if you don’t have certain contacts. This allows students to be better prepared with the help<br />
from people who actually have been through it. The brilliant thing about Medic Mentor is that it is<br />
the people who really make it what it is!<br />
I work for the widening participation team at Queen Mary University and regularly work on events<br />
for students who want to get into medicine and dentistry. These have included one day events where<br />
they get to have a go at practical skills and have talks on a specific area of medicine. I have worked<br />
on summer schools for years 11 and 12. I have immensely enjoyed these and it has been great to see<br />
the students progress and watch their confidence increase over the week. I was a mentor for a small<br />
group of students on the summer school who had to complete a presentation. It was great to coach<br />
and support them through the planning and presenting of their work.<br />
Angela Yan - Research Scholar<br />
University College London - fifth year<br />
I started medical school straight after finishing my A Levels. I went to a grammar school where medicine<br />
was a popular option to study for university but there was a lack of information and support.<br />
This, coupled with the fact that my parents were non-medical and had no experience of higher education<br />
in the UK, meant I made some ill-informed choices when applying for medical school.<br />
I like how Medic Mentor aims to help everyone make an informed choice about whether medicine<br />
is right for them. It caters for the entire spectrum and does not exclude any group. I’m<br />
looking forward to creating a work experience workbook in the coming year that will enable students<br />
to get the most out of their work experience and hopefully help them decide whether medicine is truly<br />
for them.<br />
I am also interested in creative writing and classical music (I have achieved Grade 8 in both the cello<br />
and the piano) and in my first three years at university I was an officer cadet in the University of London<br />
Officers’ Training Corps. Take good care of your physical and mental health; medical<br />
students need to be able to look after themselves before they can take care of others.<br />
Raymond Diallo - Widening Access Scholar<br />
University of Nottingham - fourth year<br />
I have been involved in medical education and mentoring since my first summer holiday in medical<br />
school. This took place in the form of MedSoc teaching, anatomy revision lectures and teaching<br />
58
Medic Mentor<br />
National Weekend<br />
Summer School 2017 & 2018<br />
5-Day Super Intensive Residential Course<br />
Sat 18th - Sun 19th March<br />
Locations:<br />
*London *Lancaster<br />
*Birmingham<br />
What<br />
you<br />
get:<br />
*<br />
Making it into Medicine (UCAS Lecture)<br />
MASTERCLASS (wider reading & interview prep)<br />
2 days of Personal Statement Tutoring<br />
UKCAT and BMAT Crash Course<br />
MMI and Panel Mock Interviews<br />
8 Medical Application Textbooks<br />
Insight into Medicine (Saturday)<br />
Making it into Medicine (Sunday)<br />
Dates:<br />
Location:<br />
24 th – 28 th Jul 2017<br />
31 st Jul – 4 th Aug '17<br />
7 th – 11 th Aug 2017<br />
23 rd – 27 th Jul 2018<br />
30 th Jul – 3 rd Aug '18<br />
6 th – 10 th Aug 2018<br />
University of Nottingham<br />
Call us now<br />
07738914395<br />
or book online<br />
www.medicmentor.co.uk<br />
Call us now<br />
07454 704204<br />
or book online<br />
www.medicmentor.co.uk
clinical skills for medical students. I also mentored A-level students in Lincoln and assisted in running<br />
mock interviews and tutorials that prepared students for medical school application. Furthermore, I<br />
have featured in OSCE-style clinical skill videos as a mock patient as well as a medical student.<br />
Demystifying MMIs<br />
I took a very unusual route into medical school. After finishing high school, I started studying economics<br />
at the university of my hometown in Hungary. However, I soon realised that it wasn’t a genuine<br />
interest of mine and I moved to Paris where I have some family. I got a part-time job and I spent<br />
my free time trying to figure out my next step in life which is when I came across medicine. I got some<br />
work experience in France and in Hungary, and I started building my CV towards medicine. I was<br />
working hard but I hadn’t left myself enough time to put together a strong UCAS application and I<br />
started to lose faith by the time the application deadline had come. I ended up applying to only two<br />
medicine courses and three pharmacology ones as this was (and still is) another interest of time. I got<br />
into pharmacology at King’s College London but I was forced to quit after a year and a half due to<br />
financial hardship. I spent the next year working full-time, volunteering, gaining work experience in<br />
the UK, in Hungary, and in Gabon, taking private lessons, resitting high school exams, the IELTS<br />
and the UKCAT. My hard work was eventually rewarded by three interviews followed<br />
by three unconditional offers.<br />
Do not make the mistake of leaving CV-building extra-curricular activities to the end of medical<br />
school. Stick your head out and get involved early. There are countless opportunities to network and<br />
collaborate with professors, doctors as well as other medical students. Take advantage of the fact that<br />
you are in such an inspirational environment and focus on your personal and professional growth.<br />
Oluwafunmilayo Nofisat Abari - Student Anthology Scholar<br />
University of Leeds - second year<br />
At present, I am quite interested in women’s health and holistic healing methods. As a Muslim, there<br />
is a lot of emphasis in my religion on natural health and wellbeing practices, and I would really like<br />
to explore this further; marrying my understanding of medicine and biological sciences with traditional<br />
practices. I appreciate that my current interest in obstetrics and gynaecology may well change<br />
throughout my time at medical school, though, with so many other specialities to venture in to.<br />
Prior to working with Medic Mentor, I set up a social enterprise called TIMS - The Institute of Mad<br />
Science. Through this organisation I set up projects to teach children aged 7-14 STEM subjects (science,<br />
technology, engineering and mathematics) beyond the scope of the curriculum. I also provided<br />
mentorship to college and secondary school students aspiring to study medicine. I applied for medicine<br />
after college and was unsuccessful. I went on to study chemistry with biochemistry and<br />
after graduating applied to study medicine. I worked for a year as the Curriculum Associate at The<br />
Challenge, a charity committed to bringing different people together to develop their confidence and<br />
skills and understanding in connecting with others, through designing and delivering programmes.<br />
Medic Mentor is a safe haven. It is a family that is so welcoming and completely committed to supporting<br />
everyone that is involved: current medical students, aspiring, doctors, volunteers and families!<br />
I am so grateful to be a part of something so rich and so special.<br />
I’m Angela,”<br />
I smile, holding<br />
out my hand<br />
“Hi,<br />
to the nervous-looking<br />
year 13 student who has<br />
just sat down in front of me. She<br />
takes it.<br />
“Hi,” she stutters. “I’m Clara.”<br />
“It’s very nice to meet you, Clara,” I<br />
replied. “This is the communication<br />
skills station, i.e. the roleplay scenario.”<br />
I watch her face drop like her five<br />
predecessors had done. “You are<br />
the captain of your medical school’s<br />
hockey team. I am your best friend.<br />
Please tell me that I did not make it<br />
onto the final team this year.”<br />
She stares at me in response, frozen.<br />
I decide to help her start.<br />
“Hi Clara,” I relax back into my<br />
seat, acting like we had just met up.<br />
“How are you?”<br />
“Hey Angela,” she mumbles back<br />
awkwardly. “I’m OK. How are<br />
you?”<br />
“I’m still recovering from the hockey<br />
try-outs last Wednesday,” I laugh.<br />
“They were exhausting, weren’t<br />
they?”<br />
“Yeah,” she fidgets with her hands.<br />
“Um, look Angela, I know we are<br />
friends and all but I’m going to have<br />
to tell you that you didn’t make it<br />
onto the team.”<br />
I pretend to act shocked. “What?” I<br />
gasp, starting to look upset. “What<br />
do you mean I haven’t made it onto<br />
Angela Yan<br />
the team? I’ve been on the team<br />
for two years, you know how much<br />
hockey means to me!”<br />
The student cringes in response to<br />
my outburst and for the next five<br />
minutes I’m unable to get anything<br />
else out of her apart from being<br />
repeatedly told I hadn’t made the<br />
hockey team.<br />
This is a common performance by<br />
a prospective medical school student<br />
at this station which I have seen<br />
more often than not during my past<br />
year of volunteering for mock medical<br />
school interviews. At first my initial<br />
response had been one of sympathy;<br />
these students remind me of<br />
my 17-year-old self. Five years ago<br />
when I had found myself in the same<br />
position, I can recall the sinking feeling<br />
in my stomach as I panicked over<br />
what to say. I had no idea how to<br />
break bad news to someone, or how<br />
to talk about a sensitive topic like<br />
weight-loss to an obese patient. All<br />
the pre-reading I had done on my<br />
personal statement, current medical<br />
news and ethics had not been able to<br />
help me in this situation.<br />
It is only five years later that I really<br />
understand what the interviewer<br />
had been looking for in this scenario.<br />
I had to show that I was empathetic,<br />
that I could treat the actor<br />
with respect and sensitivity. Sure, at<br />
17 years old I was able to rattle on<br />
about how communication skills are<br />
an essential trait every good doctor<br />
must have, integral for creating good<br />
patient-doctor relationships and<br />
therefore good patient care. I had<br />
no doubt that Clara knew how important<br />
communication skills were,<br />
but how could I get her to be able<br />
to use her knowledge and put it into<br />
practice? It had earned me my first<br />
rejection and it was only then that<br />
I began to understand what the interviewers<br />
were looking for. I didn’t<br />
want Clara to make the same costly<br />
sacrifice I had to.<br />
“It’s OK,” I smile gently at Clara.<br />
“Remember this is only a mock interview;<br />
any experience, good or bad<br />
will help you in the real thing. Now,<br />
let’s change the scenario. Imagine<br />
that you have just been told you got<br />
rejected from your favourite medical<br />
school. How would you feel?”<br />
“Upset,” she replies, her face paling<br />
at the mere thought. “I’d be really<br />
upset.”<br />
“Exactly,” I nod. “How would you<br />
like to be treated if you found yourself<br />
in that position? “I’d want someone<br />
to comfort me,” she replies. “I’d<br />
want someone to tell me it’s OK.”<br />
“Anything else?” I press her. “From<br />
the medical school perhaps?”<br />
“Feedback,” she starts to realise what<br />
I’m getting at. “I’d want to know<br />
how I can improve.”<br />
“Of course you would,” I reply.<br />
“Now let’s apply it to this situation.<br />
It’s never a good idea to just give<br />
some bad news straightaway is it?”<br />
She shakes her head. “You want to<br />
broach the subject gently. Start by<br />
talking about what she’s good at or<br />
why she’s a good friend. She’s going<br />
to be feeling very low after you break<br />
the news to her so it’s important you<br />
remind her of her other skills and<br />
good qualities. When you tell her she<br />
didn’t make the team, it’s important<br />
62<br />
63
you give her a reason. It’s important that<br />
she knows where her weaknesses are so she<br />
can improve for next time. You can make<br />
up any reason but you have to give her a<br />
reason.”<br />
“Any reason?” she repeats. I nod, this is a<br />
common misassumption students make;<br />
there is no set script for the station and the<br />
actor will follow the student’s story unless<br />
it’s inappropriate.<br />
“Finally,” I reply, “in real life, if I was your<br />
best friend, you’d want to help me make it<br />
onto the team again, because you’d want to<br />
support your friend. For example, if the reason<br />
I hadn’t made the team was because of<br />
my lack of fitness, you could have offered to<br />
go to the gym with me, or do extra practice<br />
sessions with me. In this station, the interviewer<br />
wants to see that you are a caring<br />
person who is aware of the feelings of her<br />
friend and wants to help her. These are all<br />
desirable qualities a good doctor should<br />
possess.”<br />
The list of possibilities that can come up in<br />
the communication skills station is almost<br />
infinite. Sometimes they can be very obviously<br />
medically-related; for example, talking<br />
about a sensitive topic like obesity, but<br />
sometimes not, like comforting a distraught<br />
stranger. It can be very difficult to think of<br />
what to say and do in these situations, especially<br />
when you will be given very little time<br />
to prepare for these stations. My one piece<br />
of advice would be to put yourself in the<br />
actor’s shoes, and start thinking about how<br />
you would like to be spoken to and how you<br />
would like to be treated. That way, you will<br />
be able decide what would be appropriate<br />
to say and not to say in this situation, and<br />
formulate your response accordingly. Don’t<br />
forget that this is an unscripted role play as<br />
well and you are allowed to put your own<br />
twist on the setting. Good luck to all our<br />
readers with upcoming MMIs!<br />
Our February edition will be themed ‘Hate your body’ and will<br />
feature a number of articles on mental health, exercise, the media<br />
healthy living and more.<br />
As well as this, we are looking for articles on the following topics<br />
specifically:<br />
-Your journey into medical school.<br />
-Your perspective as a parent.<br />
Thinking about writing?<br />
-The things you have done with Medic Mentor and what you thought of the company<br />
and its events.<br />
-Current affairs: many seemingly non-medical things affect the medical world.<br />
-Is there someone you could interview that you think our readers would like to hear<br />
from?<br />
-Letters discussing the previous edition’s content.<br />
We want more of you to get involved with the magazine, no matter who<br />
you are or where you’re coming from. Our writers are mostly medical<br />
students but that is only because those of you who are still at school don’t<br />
get in touch! Three of this edition’s articles were written by pre-university<br />
students.<br />
mag@medicmentor.org<br />
64<br />
65
Respiratory crossword<br />
Everything in this crossword is to do with lungs, their physiology, and the diseases<br />
that affect them - It’s quite tough!<br />
maangras<br />
Anagrams<br />
granamas<br />
Sangrama<br />
Namagras<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
8.<br />
7.<br />
9. 10.<br />
DOWN<br />
1. The name for something that moves in the blood, normally<br />
a blood clot from the veins in the leg to your lungs (7).<br />
ACROSS<br />
4. A common respiratory disease of childhood. It gives you a<br />
wheeze (6).<br />
1. High blood pressure<br />
2. A vital sign that you can count from the end of the bed<br />
6. Hormone released by the ovaries<br />
7. Medical term for heart attack<br />
2. The name for a cancer of lining (epithelial) cells. In the<br />
lungs, there are two broad types: ‘small cell’ and ‘non-small<br />
cell’ (9).<br />
3. Phlegm (6).<br />
4. The smallest unit of gas exchange in the lungs (7).<br />
9. A bacterial infection. There is a rise in multi-drug resistance,<br />
especially in Eastern Europe. It causes you to cough<br />
up blood, and used to kill a lot of people. It is more common<br />
in people who live in crowded houses and who have weak<br />
immune systems (12).<br />
10. The largest tubes in the lungs (7).<br />
3. The tract that digests food<br />
4. A very strong painkiller<br />
5. Respiratory condition<br />
8. Your brain, spinal cord, and nerves make up your…<br />
9. Wear and tear of the joints, more prevalent in older<br />
populations<br />
10. An endocrine disorder characterised by high glucose<br />
5. The medical term for fast-breathing (10).<br />
6. The device used to deliver medication for 4ACROSS.<br />
When using 7DOWN it is made of blue plastic (7).<br />
7. The gas that we breathe in which diffuses into red blood<br />
cells and is carried around the body. It is used by cells to<br />
perform respiration and produce ATP (6).<br />
8. The mainstay of treatment for 4ACROSS. It dilates the<br />
airways over a short period of time. (10).<br />
11. The small hairs lining the respiratory tubes that move<br />
mucous. Burned when you smoke cigarettes (5).<br />
12. The commonly used acronym for a crippling, chronic<br />
disease in people who smoke all of their life. In the developing<br />
world, cooking on indoor fires and inhaling the smoke is a<br />
common cause (4).<br />
13. The medical term for things to do with the lungs (9).<br />
Answers to all of the<br />
Puzzles<br />
can be found on page 4<br />
66<br />
67
Dear reader,<br />
Early report<br />
EARLY REPORT<br />
If you have something to say, arrive early, stand<br />
up, and speak clearly.<br />
-<br />
There are articles printed in here that, despite my best efforts, may contain mistakes. It is<br />
also realistic that some of you will disagree with some of the opinions. In fact, I would encourage<br />
you to do so.<br />
If you spot a mistake, or you want to discuss an issue further, or you plainly want to call out<br />
an author on the tripe they have written that, somehow, I have allowed to be printed, I want<br />
you to write in and tell me.<br />
The worst that can happen is that your e-mail remains in my inbox; I give it one look and<br />
decide it isn’t worth printing. That shouldn’t be a concern.<br />
The concern should be that you’re sitting on knowledge that we all need to hear, because if<br />
an article gets printed, that means I think it’s correct, and our readers will think it’s correct.<br />
What does a mistake like that mean? Probably nothing, but it might cost someone their<br />
interview when they reel off a ‘fact’ that is ten years out of date. More likely, an opinion<br />
will go unchallenged when really there ought to be people begging me to<br />
print a counter piece.<br />
The best that can happen is you enlighten our readers, get a letter printed in a national<br />
magazine and improve your writing skills, articulation and logical reasoning - all in time<br />
for your interview or for writing your personal statement. These are transferable skills that<br />
graduates need in abundance; start working on them now.<br />
So, I have picked two articles waiting to be argued with and printed them below. Have<br />
a think about how you might respond. Across the page lies an example of what happens<br />
when we are mislead; thankfully someone spoke up.<br />
Faithfully yours,<br />
The Editor<br />
Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and<br />
pervasive developmental disorder in children<br />
A J Wakefield, S H Murch, A Anthony, J Linnell, D M Casson, M Malik, M Berelowitz, A P Dhillon, M A Thomson,<br />
P Harvey, A Valentine, S E Davies, J A Walker-Smith<br />
Summary<br />
Background We investigated a consecutive series of<br />
children with chronic enterocolitis and regressive<br />
developmental disorder.<br />
Methods 12 children (mean age 6 years [range 3–10], 11<br />
boys) were referred to a paediatric gastroenterology unit<br />
with a history of normal development followed by loss of<br />
acquired skills, including language, together with diarrhoea<br />
and abdominal pain. Children underwent<br />
gastroenterological, neurological, and developmental<br />
assessment and review of developmental records.<br />
Ileocolonoscopy and biopsy sampling, magnetic-resonance<br />
imaging (MRI), electroencephalography (EEG), and lumbar<br />
puncture were done under sedation. Barium follow-through<br />
radiography was done where possible. Biochemical,<br />
haematological, and immunological profiles were<br />
examined.<br />
Findings Onset of behavioural symptoms was associated,<br />
by the parents, with measles, mumps, and rubella<br />
vaccination in eight of the 12 children, with measles<br />
infection in one child, and otitis media in another. All 12<br />
children had intestinal abnormalities, ranging from<br />
lymphoid nodular hyperplasia to aphthoid ulceration.<br />
Histology showed patchy chronic inflammation in the colon<br />
in 11 children and reactive ileal lymphoid hyperplasia in<br />
seven, but no granulomas. Behavioural disorders included<br />
autism (nine), disintegrative psychosis (one), and possible<br />
postviral or vaccinal encephalitis (two). There were no<br />
focal neurological abnormalities and MRI and EEG tests<br />
were normal. Abnormal laboratory results were significantly<br />
raised urinary methylmalonic acid compared with agematched<br />
controls (p=0·003), low haemoglobin in four<br />
children, and a low serum IgA in four children.<br />
Interpretation We identified associated gastrointestinal<br />
disease and developmental regression in a group of<br />
previously normal children, which was generally associated<br />
in time with possible environmental triggers.<br />
Lancet 1998; 351: 637–41<br />
See Commentary page<br />
Inflammatory Bowel Disease Study Group, University Departments<br />
of Medicine and Histopathology (A J Wakefield FRCS, A Anthony MB,<br />
J Linnell PhD, A P Dhillon MRCPath, S E Davies MRCPath) and the<br />
University Departments of Paediatric Gastroenterology<br />
(S H Murch MB, D M Casson MRCP, M Malik MRCP,<br />
M A Thomson FRCP, J A Walker-Smith FRCP,), Child and Adolescent<br />
Psychiatry (M Berelowitz FRCPsych), Neurology (P Harvey FRCP), and<br />
Radiology (A Valentine FRCR), Royal Free Hospital and School of<br />
Medicine, London NW3 2QG, UK<br />
Correspondence to: Dr A J Wakefield<br />
Introduction<br />
We saw several children who, after a period of apparent<br />
normality, lost acquired skills, including communication.<br />
They all had gastrointestinal symptoms, including<br />
abdominal pain, diarrhoea, and bloating and, in some<br />
cases, food intolerance. We describe the clinical findings,<br />
and gastrointestinal features of these children.<br />
Patients and methods<br />
12 children, consecutively referred to the department of<br />
paediatric gastroenterology with a history of a pervasive<br />
developmental disorder with loss of acquired skills and intestinal<br />
symptoms (diarrhoea, abdominal pain, bloating and food<br />
intolerance), were investigated. All children were admitted to the<br />
ward for 1 week, accompanied by their parents.<br />
Clinical investigations<br />
We took histories, including details of immunisations and<br />
exposure to infectious diseases, and assessed the children. In 11<br />
cases the history was obtained by the senior clinician (JW-S).<br />
Neurological and psychiatric assessments were done by<br />
consultant staff (PH, MB) with HMS-4 criteria. 1 Developmental<br />
histories included a review of prospective developmental records<br />
from parents, health visitors, and general practitioners. Four<br />
children did not undergo psychiatric assessment in hospital; all<br />
had been assessed professionally elsewhere, so these assessments<br />
were used as the basis for their behavioural diagnosis.<br />
After bowel preparation, ileocolonoscopy was performed by<br />
SHM or MAT under sedation with midazolam and pethidine.<br />
Paired frozen and formalin-fixed mucosal biopsy samples were<br />
taken from the terminal ileum; ascending, transverse,<br />
descending, and sigmoid colons, and from the rectum. The<br />
procedure was recorded by video or still images, and were<br />
compared with images of the previous seven consecutive<br />
paediatric colonoscopies (four normal colonoscopies and three<br />
on children with ulcerative colitis), in which the physician<br />
reported normal appearances in the terminal ileum. Barium<br />
follow-through radiography was possible in some cases.<br />
Also under sedation, cerebral magnetic-resonance imaging<br />
(MRI), electroencephalography (EEG) including visual, brain<br />
stem auditory, and sensory evoked potentials (where compliance<br />
made these possible), and lumbar puncture were done.<br />
RETRACTED<br />
Laboratory investigations<br />
Thyroid function, serum long-chain fatty acids, and<br />
cerebrospinal-fluid lactate were measured to exclude known<br />
causes of childhood neurodegenerative disease. Urinary<br />
methylmalonic acid was measured in random urine samples from<br />
eight of the 12 children and 14 age-matched and sex-matched<br />
normal controls, by a modification of a technique described<br />
previously. 2 Chromatograms were scanned digitally on<br />
computer, to analyse the methylmalonic-acid zones from cases<br />
and controls. Urinary methylmalonic-acid concentrations in<br />
patients and controls were compared by a two-sample t test.<br />
Urinary creatinine was estimated by routine spectrophotometric<br />
assay.<br />
Children were screened for antiendomyseal antibodies and<br />
boys were screened for fragile-X if this had not been done<br />
THE LANCET • Vol 351 • February 28, 1998 637<br />
68<br />
69
Bad parenting<br />
Last year, history was made<br />
when a couple were arrested<br />
on suspicion of neglect<br />
and narrowly escaped jail.<br />
The reason? They allowed their<br />
11-year-old boy to balloon to a<br />
shocking 15 stone. The couple were<br />
detained on the Children’s Act 1933<br />
and held on bail. Do you believe<br />
they should have gone to jail?<br />
This is an extreme example, but<br />
childhood obesity is a global epidemic<br />
and an intervention is needed<br />
as soon as possible. According<br />
to the Lancet, there are now more<br />
obese people in the world than underweight<br />
and this should worry<br />
everyone. In order to solve the problem<br />
we need to find the cause. What<br />
I’m wondering is: are parents at fault<br />
here?<br />
A recent government study found<br />
that more than 30% of children<br />
aged 2 to 15 were classed as either<br />
overweight or obese, 10% of 2 to<br />
5-year-olds are overweight and, since<br />
1980, the proportion of overweight<br />
children aged 6 to 11 has more than<br />
doubled. These are shocking figures<br />
that show a dramatic increase in<br />
childhood obesity. The question is,<br />
what has caused this increase and<br />
how can we stop this epidemic progressing?<br />
Obesity is a complex problem with<br />
many drivers, including our behaviour,<br />
environment, genetics and culture.<br />
However, obesity is ultimately<br />
caused by an energy imbalance:<br />
taking in more energy through food<br />
than we use through activity. When<br />
we talk about tackling obesity, all we<br />
are really talking about, in essence, is<br />
tackling this energy imbalance, one<br />
Rebecca Vere<br />
fat person at a time.<br />
Childhood obesity is such a worrying<br />
epidemic as it is extremely likely<br />
to progress to adult obesity. Lifestyle<br />
patterns from our early years persist<br />
over time, with childhood obesity<br />
continuing into adulthood. Obesity<br />
during childhood has been found<br />
to be associated with significant<br />
medical co-morbidities, and excess<br />
weight in childhood independently<br />
increases the risk of mortality related<br />
to cardiovascular and metabolic<br />
disease. It is important that we also<br />
consider the psychosocial impact of<br />
obesity as it has been linked to adverse<br />
effects on social, psychological,<br />
and academic development. Obese<br />
children are more likely to experience<br />
bullying, lower health-related<br />
quality of life, and impaired mental<br />
health. Therefore, it is clearly in the<br />
best interests of parents to prevent<br />
childhood obesity.<br />
Although it may be tempting for parents<br />
of an overweight child to blame<br />
‘bad genes’ for problems managing<br />
excess weight, in reality genes have<br />
less to do with the problem than<br />
we would like to think. Whilst they<br />
do contribute to a child’s ‘natural<br />
weight’, a large part of obesity susceptibility<br />
remains down to their<br />
lifestyle. Such a dramatic rise in<br />
childhood obesity in such a short<br />
space of time cannot be attributed<br />
purely to genetic factors, as these do<br />
not change in any substantial way<br />
year on year, or even between generations.<br />
There are many other factors,<br />
such as diet and exercise, which<br />
make a much greater contribution to<br />
weight than genes. These are, arguably,<br />
under the parent’s control.<br />
Obviously parents influence their<br />
child’s diet. Who feeds you before<br />
you learn to feed yourself ? Your parents<br />
do, and children eat what their<br />
parents eat. If parents consume fast<br />
food regularly, their children are<br />
more likely to do the same, which<br />
can result in obesity. Unhealthy eating<br />
habits can result in serious health<br />
complications for the children such<br />
as diabetes and high cholesterol,<br />
which will affect them throughout<br />
adulthood.<br />
So, of course it is the responsibility<br />
of parents to monitor the nutritional<br />
value of the foods their children<br />
consume. Which means it is essential<br />
that parents are knowledgeable<br />
about nutrition and are able to identify<br />
what is healthy and what isn’t.<br />
Many parents simply don’t know<br />
how to provide their children with<br />
a healthy, balanced diet. All too often<br />
parents are over-feeding their<br />
beloved child because they feel it is<br />
what they need to do to be a good<br />
parent, ensuring their offspring grow<br />
big and strong. Ironically, the reality<br />
is that they are providing their children<br />
with health problems that will<br />
stay with them throughout their life.<br />
In order to make healthier choices,<br />
families need to be presented with<br />
clear information about the food<br />
they are buying. The UK has led the<br />
way, working with industry to implement<br />
a voluntary front of pack traffic<br />
light labelling scheme, which now<br />
covers two thirds of products sold in<br />
the UK in response to recent government<br />
guidelines.<br />
Similarly, schools are making a<br />
conscious effort to tackle the problem,<br />
and parents need to do the<br />
same. School dinners have already<br />
been modified thanks to Jamie Oliver.<br />
Unfortunately, I remember<br />
the year that turkey twizzlers, fizzy<br />
drinks and ice buns were confined<br />
to the history books; a secondary<br />
school lunch that the older years<br />
would speak of fondly (although<br />
now I appreciate their true damage).<br />
Food isn’t the only problem. One in<br />
five children aged 9-13 were found<br />
to engage in no free-time physical<br />
activity. This is a shocking figure and<br />
obviously parents can make a difference<br />
to this. Recent developments<br />
in technology mean the easiest way<br />
for a parent to keep their child occupied<br />
is with an iPad rather than<br />
a physical activity. Just go to any<br />
family restaurant and you will see<br />
children glued to a screen to keep<br />
them occupied throughout the meal.<br />
This also extends into the home, an<br />
environment which is undoubtedly<br />
an important setting in preventing<br />
overweight and obesity. Television<br />
viewing has been identified as an<br />
independent risk factor for obesity<br />
and, as a result, might in fact be<br />
more dangerous than playing in the<br />
woods or climbing a tree – activities<br />
which do not seem to belong in the<br />
digital age.<br />
There’s also the matter of loading<br />
children’s days with activities that<br />
preclude kids from exercising more.<br />
Given a choice — and the opportunity<br />
— it is highly likely that children<br />
would opt to spend more of<br />
their time engaging in physical activity,<br />
but they’re not being allowed<br />
to choose freely. Rather, adults are<br />
choosing for them. Parents, in the<br />
most loving and mollycoddling way<br />
imaginable, are over-scheduling<br />
their children to ensure they provide<br />
them with the ‘best possible’ childhood.<br />
But what value is there in being<br />
grade 5 clarinet if you’ve been<br />
left with metabolic syndrome? Parents<br />
are indeed partially responsible<br />
for over-scheduling their kids, but<br />
there’s also the matter of teachers<br />
assigning copious amounts of homework.<br />
Obviously, this will reduce the<br />
amount of time they spend outside.<br />
In a bid to tackle this, the Department<br />
of Health are working to ensure<br />
that from September 2017,<br />
every primary school in England<br />
has access to high quality sport and<br />
physical activity programmes, both<br />
local and national. As part of this,<br />
national governing bodies will offer<br />
high quality sport programmes to<br />
every primary school.<br />
However, it is ultimately the parent’s<br />
choice if their children walk,<br />
cycle or drive to school. Although<br />
initiatives are set in place by schools<br />
to encourage walking and cycling,<br />
parents have the final say. Too often,<br />
overly anxious mothers are driving<br />
their children to school because they<br />
believe it is unsafe to let them walk<br />
or cycle themselves.<br />
School is also tackling the problem<br />
of lack of exercise since new PE<br />
initiatives have already been put in<br />
place. Following changes in recent<br />
government guidelines it has been<br />
recommended that all children and<br />
young people should engage in<br />
moderate to vigorous intensity physical<br />
activity for at least 60 minutes<br />
every day. Many schools already offer<br />
an average of two hours of PE<br />
or other physical activities per week.<br />
However, we need to do more to encourage<br />
children to be active every<br />
day. At least 30 minutes daily should<br />
be delivered in school through active<br />
break times, PE, extra-curricular<br />
clubs, or other sporting events.<br />
The remaining 30 minutes need to<br />
be provided by parents, outside of<br />
school time.<br />
So, schools are making a conscious<br />
effort to make the lunches they provide<br />
healthier and to engage children<br />
in more frequent physical exercise.<br />
Educating parents is the next step<br />
required to tackle the issue. There<br />
are several factors that will contribute<br />
to childhood obesity, however<br />
the two most important are diet and<br />
exercise and these are usually under<br />
the parent’s control. The solution is<br />
to tackle all of the problems simultaneously,<br />
but ultimately parents must<br />
change their offspring’s eating habits<br />
and they need to be educated in how<br />
to look after their child’s health. We<br />
need to improve awareness of this<br />
horrendous epidemic and education<br />
will follow. Otherwise we will be failing<br />
our children with only ourselves<br />
to blame.<br />
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Dope article, bro<br />
I<br />
have felt the anger and bafflement<br />
experienced by many fans<br />
of sport upon discovering that<br />
a successful athlete has cheated<br />
their way to the top. The ‘top’, as<br />
if they have actually ascended the<br />
ranks of their profession. Rather,<br />
they have just switched sports, the<br />
same way boxers switch weight categories,<br />
and are now competing only<br />
with other like-minded dopers. Why<br />
go to such lengths to win when the<br />
victory is hollow? They must know,<br />
deep down, that what they have<br />
done is not just wrong, but a waste of<br />
time. A gold Olympic medal is worth<br />
much more in pride than it is in metal,<br />
so you’re depreciating its worth<br />
by defrauding the system.<br />
This is a hard line to take and you<br />
can’t walk down it for long before<br />
you reach an unpalatable conclusion:<br />
we need to ban coffee. It is often<br />
an unwelcome voice that pipes<br />
up to remind ‘true’ sports fans that<br />
the line we have drawn to delineate<br />
doping and competing is a completely<br />
arbitrary one. We needn’t look<br />
far back in sporting’s history to find<br />
unacceptable practices that are all<br />
but necessities today, but only those<br />
completely blinded by tradition<br />
would argue that sport is in worse<br />
shape now than it was 50 years ago.<br />
It seems, to me at least, that doping<br />
is only a problem so long as we keep<br />
saying it is.<br />
Developments in training have made<br />
a much greater contribution to improvements<br />
in sporting outcomes<br />
than anything that can be implemented<br />
at the race, on the main stage, on<br />
the night. I’m not talking about performance<br />
enhancing drugs, either.<br />
In Chariots of Fire, one of the main<br />
Michael Houssemayne du Boulay<br />
characters is lambasted for hiring a<br />
coach. Indeed, historically, athletes<br />
were discouraged from training at<br />
all, relying instead on ‘natural’ ability.<br />
Fast forward and we have personalised<br />
nutrition programmes, where<br />
nothing passes the lips of a top athlete<br />
without it being logged. The<br />
very idea of natural ability is such<br />
a weak concept that it struggles to<br />
stand up under its own weight. The<br />
near interminable variables are too<br />
many to even list, let alone control<br />
in a desperate and futile attempt to<br />
create a perfectly balanced competition<br />
of raw talent. All we can hope<br />
to do is provide equal access to performance<br />
enhancement across the<br />
board, but tell that to athletes from<br />
underprivileged backgrounds (have<br />
you ever enquired into the cost of<br />
tennis coaching?).<br />
To cheat is to garner an unfair advantage<br />
over your competition. Unfair<br />
implies that others do not have<br />
access to it, but that cannot be the<br />
only distinction drawn. Nutrition<br />
has surely had the greatest impact<br />
on physical prowess in history, but<br />
even that is unequal amongst today’s<br />
athletes. We would not turn<br />
around and deny a sportsperson<br />
their dietitian because the team from<br />
Equatorial Guinea haven’t heard of<br />
MyProtein yet, and rightly so. We<br />
complain about our performance<br />
in the Winter Olympics and blame<br />
it on our lack of snow, but no one<br />
is suggesting for a second that we<br />
should be given a handicap because<br />
the climate in Great Britain is not<br />
conducive to developing a first rate<br />
ski team. So, too, if you come from a<br />
poor country you should be afforded<br />
no privileges.<br />
After all, the purists argue, hard work<br />
is always available in abundance, no<br />
matter where you originate. Certainly,<br />
but how efficacious is hard work<br />
when you have to devote most of<br />
your day to going to your job and<br />
feeding your family? What time is<br />
left to train? Contrasted with the<br />
sponsored athlete who is paid to go<br />
to the gym our penniless underdog<br />
can barely be consider a contender.<br />
Doping this may not be, but it is certainly<br />
more of an unfair advantage<br />
than taking steroids which athletes<br />
the world over have access to. What<br />
do you think is more expensive: a<br />
high altitude tent to sleep in every<br />
night and a personal physician to direct<br />
its use, or some make-me-hench<br />
‘roids that you got from Gary down<br />
the gym?<br />
While we’re talking about drugs,<br />
we ought to just touch on the medications<br />
mentioned in this article.<br />
Meldonium is an old Eastern European<br />
treatment for ischaemic heart<br />
disease. It is not licensed for use in<br />
the UK and it was brought into the<br />
spotlight following the scandal surrounding<br />
Sharapova, one of the<br />
highest grossing tennis players of all<br />
time, who was banned for using it<br />
by the World Anti-Doping Agency.<br />
EPO stands for erythropoietin, the<br />
hormone responsible for stimulating<br />
red blood cell production. It is most<br />
famous in sport for its widespread<br />
abuse in cycling, in particular the<br />
Tour de France where a number of<br />
previous winners have been stripped<br />
of their titles for its abuse (as well<br />
as other substances). Most notable<br />
of the disgraced Tour cohort is<br />
Lance Armstrong who deceived the<br />
competition organisers, fans and<br />
sponsors for many years. Anabolic<br />
steroid is the generic name given to<br />
androgens that mimic the effects of<br />
testosterone in the body, well known<br />
for rapidly increasing muscle mass<br />
and giving body-builders the Arnie<br />
makeover.<br />
What, then, does it mean to cheat?<br />
The only answer I can reason is<br />
that it means to do what your sport<br />
says you can’t, and what your sport<br />
says you can’t do is arbitrary and<br />
open to change. Largely, the line<br />
seems to be drawn on a feeling of<br />
wrongness alone; we’re noticeably<br />
uncomfortable with players taking<br />
a perceived shortcut to success. To<br />
take two football examples to illustrate,<br />
Peter Shilton and Lionel Messi<br />
were both too short as children to be<br />
seriously considered for professional<br />
careers. The would-be England<br />
goalkeeper reportedly dangled from<br />
the bannister in his home, with increasingly<br />
heavy weights attached<br />
to his feet (house bricks, apparently)<br />
in order to stretch him out. Whereas<br />
the world’s greatest player, diagnosed<br />
with a growth hormone deficiency<br />
in childhood, was prescribed<br />
human growth hormone and he<br />
has now reached average height in<br />
adulthood. Suppose Peter Shilton<br />
had decided to skip the undoubtedly<br />
arduous process of drawing<br />
his own legs, opting instead to have<br />
his bones surgically fractured and<br />
then positioned to promote growth,<br />
or pressured his doctor to prescribe<br />
him human growth hormone, like<br />
Messi. It certainly doesn’t feel as if<br />
we should allow the latter options to<br />
go ahead, but they achieve the same<br />
outcome, and put the player’s body<br />
and mind through different, but still<br />
difficult, ‘training’.<br />
You’re all shaking your fists at the<br />
thought, but what about the malnourished<br />
child whose growth improves<br />
in leaps and bounds when<br />
they’re given a proper diet? Now,<br />
what about the well-nourished child<br />
who, when given a personalised<br />
diet programme, reaches their full<br />
potential instead of falling short<br />
by an inch? Now, what about the<br />
well-nourished child, with a personalised<br />
diet programme, but without<br />
the same testosterone producing capacity<br />
of their peers? By no means a<br />
disease, but they would undeniably<br />
gain benefit from the use of anabolic<br />
steroids. You might argue that it’s<br />
just genetic variability – some people<br />
are naturally predisposed to be taller,<br />
stronger, faster – these aren’t diseases<br />
to be corrected, so it’s wrong<br />
to try and fix them with a medical<br />
intervention. The only difference<br />
between child two and child three,<br />
dangers of their treatment aside, is<br />
that we consider anabolic steroids<br />
to be an unfair sporting advantage,<br />
whereas dietary advice is well within<br />
the boundaries of acceptability.<br />
The dangers don’t really factor into<br />
that ruling, either. In the grand<br />
scheme of the perils of sport, blood<br />
doping is relatively safe, especially<br />
if it is above board and well controlled.<br />
No one threatens to bring<br />
an end to sport over the injuries,<br />
sudden cardiac deaths and the psychological<br />
trauma that goes into<br />
training. (Youth rugby aside – although<br />
look at the public outcry<br />
when it was suggested!) Why has the<br />
line been drawn, then? I believe it<br />
boils down to the same feeling and<br />
fear of the unnatural. Herbalism is<br />
natural, meditation is natural, injecting<br />
steroids into your eyeballs<br />
with a big syringe isn’t natural. But<br />
in the same way that you shout at<br />
a patient for not taking aspirin because<br />
they don’t like tablets, we’re<br />
shouting at athletes for embracing<br />
technological advances that move us<br />
away from the roots of sport. People<br />
swim in pools, not lakes, we have<br />
carbon fibre everything and multiple<br />
spares rather than one wooden<br />
racquet, bikes weigh less than the<br />
food a cyclist consumes in a day and<br />
with each progression we step away<br />
from naked Greco-Roman wrestlers<br />
and towards e-sports, bionic super<br />
humans and athletic competition<br />
which requires a team and a holistic<br />
strategy not just a go hard or go<br />
home mentality.<br />
Yet we have die-hard fans talk about<br />
how doping is ruining sport. The<br />
only thing ruining sport is a desperate<br />
attempt to cling to the days<br />
of yore in the face of unstoppable<br />
change. Look no further than Sepp<br />
Blatter’s repeated refusal to introduce<br />
goal line technology for the<br />
sake of nostalgia versus tennis and<br />
cricket’s willing adoption of hawk<br />
eye as the perfect example. When<br />
will cycling realise that EPO is only<br />
a problem because the organisers<br />
say it is a problem? Crop dust EPO<br />
over fields of cyclists and put testosterone<br />
in their porridge and any unfair<br />
advantage is gone.<br />
We have all been getting outrageously<br />
upset with the Russian state-sponsored<br />
doping programme. The gall<br />
of it! It is so obviously cheating and<br />
so perfectly Putin. However, if we<br />
look instead at a state-sponsored<br />
training programme, pumping millions<br />
of pounds into the development<br />
of athletes, perfecting their<br />
nutrition, designing the best bikes,<br />
hunting down the perfect players<br />
from all four corners of the globe,<br />
no one bats an eyelid at its morality.<br />
These were all new practices once,<br />
and they all attracted disapproval. I<br />
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would suggest that if we made sure athletes<br />
were not put at harm, a goal much easier<br />
to achieve by allowing widespread, above<br />
board doping, all we are witnessing is the<br />
next big development in sport.<br />
Why are we so concerned about this<br />
change? Some people cry that it takes away<br />
the enjoyment of watching the competition,<br />
but this is inconsistent with our love of the<br />
performers and artists in every other walk<br />
of life. I reach peak coffee about half an<br />
hour after I neck a cup. It’s like carb loading<br />
but for writing ability and as I type this I<br />
feel warmed up and well stretched. It won’t<br />
last, and when you spot a good paragraph<br />
you can be assured there was an espresso<br />
to thank. That’s performance enhancement<br />
for you. Similarly, athletes gain a significant<br />
benefit shortly after ingesting caffeine, so<br />
much so that you would be a fool to not<br />
take some tablets with you to a competition.<br />
Of course, we cannot ban caffeine because<br />
we would reduce our eligible pool of sportspeople<br />
to a handful of post-menopausal<br />
women with weak bladders who, in anticipation<br />
of their call-up, have been avoiding<br />
caffeine for years. But that is the conclusion<br />
we have to reach if we keep up this Luddite<br />
witch hunt for progressivists. The Olympic<br />
Committee might as well revoke every<br />
world record created after Starbucks was established<br />
because all of them were created<br />
unnaturally, on drugs. We should be fighting<br />
the return to sport’s origins, not actively<br />
seeking it. The only difference between<br />
caffeine and Sharapova’s recent ban due to<br />
meldonium is that we started banning drugs<br />
after caffeine was discovered.<br />
The same argument stretches to so many<br />
walks of life. Would you deny The Beatles<br />
LSD? Because I’m not a big fan of Sergeant<br />
Pepper’s Lonely Hearts Club Band<br />
but I hear they have a few followers out<br />
there. The album wouldn’t be the same,<br />
for sure, and their competitive status as the<br />
greatest band of all time might have been<br />
challenged. It frees my mind, man. Well,<br />
EPO frees me from the crippling pain of<br />
cycling up a 1 in 3 hill, friend. As the public<br />
continuously clamours for the greatest<br />
spectacle since the last time they turned on<br />
the TV, the pressure on athletes and artist<br />
to perfect their form builds. ‘Natural’ development<br />
can only take us so far - if you keep<br />
demanding entertainment then we need to<br />
allow our entertainers to source new means<br />
of improvement.<br />
The competitive element is obviously fundamental<br />
to the argument. Drugs tilt the<br />
field quite significantly but that only matters<br />
if you’re playing for spoils. This is not<br />
so applicable to artists who are just trying<br />
to achieve personal greatness, rather than<br />
outdo each other as sportsmen and women<br />
are. But let’s re-level the playing field: give<br />
everyone on the Tour EPO and the problem<br />
disappears. If you’re still uneasy with<br />
its use, I suppose you must be unhappy with<br />
them outdoing their historical counterparts.<br />
Who else is being cheated? Though, as we<br />
have seen, this is a not a problem of our<br />
generation, nor a problem of illicit and<br />
controlled drugs. Future generations will always<br />
outdo their ancestors.<br />
Purists of sport are frothing at the mouth<br />
in rage, without stopping to consider what<br />
they’re angry about. It’s just easiest, I suppose,<br />
to shout about banning cheats loud<br />
enough to drown out any progressive thinking,<br />
but where do we end up? Like all angry<br />
mobs, they will quieten down when no<br />
longer stoked by reactionary voices and<br />
slowly, but surely, sport will progress to its<br />
natural end: giant, bionic humans on cocaine<br />
battling each other to their simulated<br />
death. I, for one, can’t wait.<br />
___________<br />
Originally published in North Wing Magazine,<br />
available here:<br />
http://northwingmagazine.com/<br />
I look forward to reading your letters.<br />
Fewer than 300 words, received no later than 14th<br />
February 2017.<br />
For submissions and enquiries:<br />
mag@medicmentor.org<br />
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M E D I C<br />
www.medicmentor.co.uk