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S.an "^-<- al2 7 JUL 1989

Bereavement: Who needs counselling?

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Paper, Dear Bob, Bag-EYe And All Your

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BLACK BAGSUMMER 1989

EDITORIALlf we arenl prepared to tackle diflicull issues during the relatively experimental

and responsibility-free years ol our undergraduate training, then when? A@ wemerely clones of our @ntemporaries or imitators of our predecessors?

Every day, as studenls, we come face to face with difficult social and ethicalissues, often for the first time in our lives. Usually we judge critically the beliefs andactions of lhose in charge. But how much further do we go?

Bereavemenl is cerlainly a difficult area to comprchend fully. lt is, however, acentral feature of community and hospital medicine. There are practical andemotional processes that have to b€ worked through and the time we have to thinkon these things now may create the impetus for change later.

ln this issue we open lhe debate on how doctors are trained to deal with andactually do cope with dead and dying patients and thek relalives. There are asmany approaches as there are personalities; and personalities shape theprofession.

Whal is your opinion? What will be your experience?

Editor: Nigel LesterSub-editors: Susan McEvoy (Reviews)

lvladin Plummeridoe (Regulars)Andy Tutt (Features)Kieren Smart (Preclinical)

Business lranager: Sharon DrewetiPhotography: Shauna LongfieldArt Work Andrew DemieTypesetling ancl Printing: lmpress

All articles/enquides should be sent to THE EDITOR, BLACK BAG'

DOLPHIN HOUSE. BRISTOL ROYAL INFIRMARY, BRISTOL 2.

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CONTENTS

Editorial .-........... ..... - . . . . . . . . . . . . . .3lnsight BeGavement l.Life alier Death, Alexander Stemberg . .. ... ...6

2.Communicalion And Caring, Lindsay Shaw . . .73.Death And The Doctor, Dr B. Baker ..........4

Folitics: White Paper - or The End Of The NHS? Dr S. Macara . . . . . .9Siudenb: You Whnt You'd Setde For, You Get . . . . . . . . . . . . . . . . . . . .14

An Arable Parable . . . . . . . . . . . . . . . 15A Day ln The Life: A BRI Patient Rachel Motfat . . . . . . . . . . . . . . . . . . .17Feople Dr. Cole-s, Retiring Clinical Dean . . . . . . . . . . . . . . . . . . . . . . . . . 18Book$ An Aid To Clinical Surgery Reviewed By Proiessor Farndon

. .. -... .. ... ... .. ... ...21Regulars: Competfion .. ... .. .... .. ... ... ..1O

BagFAge - - . . . . . . . . . . . . . . . . . . . . . 1 1

Borborf,gmi.... --. --. - ..........11Auscultalions . . . . . . . - . . . . . . . . . . 1 1

Do-lt-Yourseff . . . . . . . . . . . . . . . . . . 1 1

Bag-Eye -.--.-..--,.. .......12,13Letters . . . . . . . . . . . . . . . . . . . . . . . . 15Dear Bob . . . . . . . . . . . . . . . . . . . . . . 19fuelry comer .. ... ... .. ........22

Now available20th Edition

BAILEY & LOVE'S

SHORT PRACTICE OF SURGERYRevised by

A. J. HARDING RAINS, CBE, MS, FRCSand

CHARLESV. MANN, MCh, FRCSwith 36 specialist contributors

1355 illustrations (236 coloured). xii+ 1406 pp. t3s.00 net.

H. K. LEWIS & CO. LTD

felO'l-387-4282136 Gower Street, London WCl E 685

Telex22607

Insight: Bereavement

Life After DeathAlexander Sternberg looks at one of the most pressing practical issues surrounding the

death of a patient and questions if we are doing enough informing bereaved.lnforming relatives is difticult enough for a young inexperienced doctor but will you be pre-

pared to ask for a gift of organs to give othe. patients the possibility of lite ;ftersomeones deaih?

nurses makes them reluctant to askgrieving relaiives about organ dona-lion. This findinq is confirmed bv lheHoffenberg Report which states that"skill and sensilivity in the approach topatients is variable"- So there are twoprgblems. The first is lhal relatives arejust not being asked. The second is thatwhen they do ask, medical stiaff mavlack lhe techniques frcr obtainino ;posilive answer.

"ln Bristot, if the donolis suitable, the relatives

are alwalE asked"

A number oI solulions have beenproposed. One is a legally requiredrequesl a system pioneered in the USAwhereby there is a legal requirement fordoctors to ask for a gift of organs. Thereis no doubt that this has led lo anincrease in lhe number of organdonations. ln lhe UK however, legaltyrequired requesl is a conhoversial sub-iect particulany amongst a profus,sionwhich relishes its own autonomy- Theidea was dropped by the HoffenberoReport in favour of a syslem oI reterrtand audit Every lime brain stem dealhis diagnos€d, organ donation shouldbe considered and lhe lransplanl teamintormed. ff this is to occur, it has beensuggested, lhough not specifica y bythe Hoffenberg Reporl that ITU staffshould be lrained in bereavementcouns€lling in order 1o facilitate lhe pro-cess of discussion wiih bereav€drelatives- Thus one scenario might bethat when brain slem death is diao-nosed, ihe doctor in ITU informs tierelalives and contacts the transplanla-tion co-ordinalor- Transplant coordinatoG are often fomer ITU nurseswho are particularly skilled in dealinowith bereaved relalives They, in con:junction with lhe ITU nursing staff, dis-cuss the possibility oI organ donationin terms that the relalives can unders-tand. lf the answer is ,\€s", lhehansplant co-ordinator liaa€s with ihesurgical team to set lhe wheels inmotion. There is no rcason for lhe

ln the UK there is a problem withorgan donation that should not existCurrently the potential number o{ organdonors per year outstrips lhe numberof patients on waiting lists for tans-plants. Yet the waiting lisls remain. Howcould this be so?

Simplify the picture by just consider-ing kidneydonations. The five year sur-vival rate tor a kidney graft is up to 9O%.The mainlenance cost of a transplantpatient is cheaper than for lhe samepalient on dialysisand lhe quality oI litefor lhal palient js dramaticallyimproved. ln shorl, kidney kansplantsare a good thing. The estimaled ne€dtor kidneys in the UK is 5OOO per year.There are 8000 kidneys potentiallyavaihbb each year. But only about onefifth of potential donors beclme actualdonors, so lhat there is a netwailino tistof 34OO patients.

Nrost donors die in an ITU inspite ofartificial ventilalion. What is so intrigu-ing is that some health regions havemuch higher rates for kidney donationsper year than olherc. Clearly it is impor-tant to find out why the one region is somarkedly successful whilst the otherremains suspiciously below average.

Even stranger still is thal some hos-pitals have obtained 90% agreement toorgan donalion whilst others virfuallynever provide organs for transplanta-lion. These kinds of discrepancjes can-nat just be put down to an ill-infomed,poorly educaled public. lll-infomed,poorly educated doctors make theircontribution loo.

ln 1 987, the Hof{enberg Report waspublished in an attempt to explain theshortfalls in organ donation and to pro-vide recommendations to improve thesituation- The primary concem oI thereport was that amongst doctors"knowledge of the criteria for brainstem death, of the anangements fortransplantation and of the benefit oftransplantalion is not unive6al". LePoidevin, from the London Hospital,suggests that one of the main problemsis that the uncedainty and lhe em-barassment about the management oIg ef expressed by some doctors and

relatives of suitable donors to go unas-ked. ln fact, it is unethical not to askbereaved relatives since this may dep-rive them of choi@, meaning andcomfort,

lnslead of making this a legallyrequired reterral, the HoftenberoReport recommends thal hospital;should be audited to record all instan-ces of brain stem death. lhe number ofrequests made, the numberand natureof organ donations and the reason forlhe shortfall. The results lo be collatedby the Department of Heatth. Auditinqbegan in January of this year but there.are no results yet lt is unclear, however,how many hospitals have defined aprolocol lor calling in a transplant co-ordinator in those cases requiringrefural.

ln Bristol, ff the donor is suitable, therelalives are always asked. There isalso a lransplant co-ordinator who isskilled at discussing organ donationwith relatives. ln other areas the pro-cedure for calling in the transplant co-ordinalor seens ill-defined. This meansthat the problem of asking for a gift oforgans may still be left to a dodtorunskillecl in lhe subtleties of counsell-ing lhe bereaved and in the throes ofhis own emotional response to thepatients death.

Whilst public education and opinionis extremely important in increasing lhenumber of organ donations. educationof the medical team shoutd not beforgotten. Such teaching should beginas eady as possible in a doctors career.llshould include the practical legal andelhical problems of death and dyingwith particular refe(ence to the value ofasking for and receiving a gift oforgans. Only then may we expect thetransplant programme to realise itstull potenlial.

Communication And CaringLindsay Shaw writes about one approach to helping doctors deal with the dying. lt is a sub-

,ect all too easily dismissed as untangibleand therelore unteachable. But is nothing really b€t-ter than something when one day we will all be in the hot seat?

Few situations call on lhe necessilyfor "human" skills such as etlectivecommunicalion and caring as much aslhat which faces a doctor whosepatient is dying. Many doctors, ex-perienced or otheMise, find this anexlremely traumatic situation. Theexperience may bring feelings of in'adequacy, guill and rolo conflictwhichin turn may cause more anguish for thepatient and their family.

Hugh l\4cMichael, who occupies thenewly established post of Senior Lec-turer in Pallialive car€ in Brlslol, seesthe care of the dying as a necessaryextenglon of patient care as a whole. lnthe past very llttle of the medlcalcurriculum has been involv€d inwhal isprobably best described as theemotional side of medicine. Perhaps apart of lhe explanation for this is th€ factthat there is no tormal academic modelfor caring. The lntangible nature of thesubject does nol €asily lend ilself to thoformal teaching or gystematic exam-ination charact€riEtlc ot the mgdicalmodel. lt is also possible that inherentin the medical institulion is a notlon lhatthere is conflict between caing andcuring, Doclors are expected to func_tion objectively and are led to believethat they don't have tlme to respond lotheir patients on an emotional level.This mayputa hugoshain on individualdoclors and may mean that expedencoloads them not to cope with death and

dying but simply to avoid the caringrole and the anguish they assume itwill bring.

Hugh McMichael runs seminars on'Death and Dying'forthird year medicalstudents and sees himself not as ateacher but as a facilitator of lho learn"ing process. The seminars were tosome extent allowod to run lheir naluralcourse using experiential oxercis€saimed at allowing studenls to examinelheir own feers associated wilh death.They were also aim€d at forsteringsome posilive attitudes about dealh

"Doctors ar€ expectEd tolunctlon oblectlvely ... theydon't have time to respond

on an emotional level"

and dying, which may in tum rgmovesome of lhe sens€ of lnadequacy whichfaced students al lhe time of thes€minar.

The exerclses were fairly broad-based and many students lelt that theyhad leernl some us€ful lessons aboutcommunioalion in general, suoh as thepower ol eye oontact, listening and,porhaps above all, of silonoe. The idoasthat "lhat sort of thing can't be taught "or "only some people can do it" still

abolnd and perhaps this is partly kue.Nonetheless this short experience hasshown that bY facing hypotheticalsitualions that lear and ignorancewould olheMise lead us to avoid wecan begin to leam how to be effectiveand competent in lhe situalions wemost tear. Clearly third year medicalstudents feel that caring for the dying isan importanl issue. Almost all thestudenls otfered a fuvo day seminarattended and early resulls suggestedthat many felt they gained somethingpositive trom the experience

It we want some Practical kind olcounselling or communicatlon trainingin lhefuturethenthis has to be includedicrmally in the medical curriculum.financial considerations are algoimpodant. The post of S€nior Lecturerin Palllative Car€ is charitv funded andthe money will expire in 5 years timeHowgver pefiaps more important is are-evalualion of the Gquirements ofmedical training. The force to bringabout this chang€ must ultimalelycome from the sludents themselves forIt is them and hopefully thelr patients

who will benefil.

Insight: Death And The Doctor

T.E.Adderly on Bereavement.Few who had thegood fortune to work for Mr T.E.Adderly can forget the experience. He bes.

trode the worlds of surgery and the arts like a colossus; Mnemosyne at one hand, a Caduceusin the other. His clinical acumen was legendary, his erudition unparallell. lt is of his views onbereavement that I propose to speak; but first something ot the man.

He was a great showman and lovedto statle by perhaps examining anabdomen with a naked toot or palpat-ing a pulse with the tip of his nose.lndeed in his later years he took to con-ducting ward rounds locked in a largemetal cabinet on wheels from which hewould shout his often obscure diag-noses. "l am a disembodied brain", hewould bellow from wilhin, "you are myeyes and hands, my ears andwhiske6".

He loved also to wilness lhe runninoof the ward in camera'. Often wneicalled to see a patient in the middle ofthe night one mjght find him crouchedunder the bed, carefully noting all. I

recallonce being deep in thought nexttoa particularly conlusing case when aWRVS lady, who had been hovering,slrode up and said "Good pasture'sSyndrome - plain asthe nose on yourface." Adderly, of course, in disguise.

Few things were, indeed, quite asplain as the nose on'lE.'s face. He fre-quently joked aboul his vast appen-dage. "l have a nose for wine," hewould say, "ln fact I have a nose foropening bottles of beer should I sowish". He had a su;table quotation forevery occasion, many of which I havebeen unable to kace to thek originals,but forever apt nonetheless. On beingtold, for instanCe, that a particularpatient came trom Peckham, he wouldsay: "Ahl Peckham! Lovety Arcadia ollhe fair" or "Droitwichl Elysian Grove ol

puresl loveliness! Hopkins, I believe."We, being junior stalf, would of coursegasp and applaud his stupendousknowledge.

lcould recounl endless anecdotes ofNrr Adderlys invigoraling outlook onlife, but I must address myself lo lhetopic in hand. For it is my belief that fewfiner role models exist. On this. as onany topic, he had read thoroughly andhis theory was based on ElizabethKuebler-Boss's treatise. She dividesthe process into five stages. Adderlydiffered only in thetime-scale involved."They said I couldnl whip out a pan-creas in under 11 minutes," he said,

"The chief weaponhe used in his war ongrief was reason"

"and I did. Same with grief". His ambi-tion was to conlract the whole counsell-ing procedure into the same span asdoing lhe 'Times' crossword, at whichhe was highly adept. lndeed he wouldoften perform the two simultaneously. I

once overheard this comic gem: "Yourhusband has died and gone to heaven,MrsSampson.Ah, Heavenl Purcst Ely-sian Arcadia of loveliness! How do youspell Ptarmigan Nlrs Sampson?"

The chief weapon he used in his waron grief was reason. He would takeeach stage in turn and demolish itlike a

sledgehammer would a walnul.'Denial', I think, was his favourite. (,,Ofcourse he's dead, Mrs X.,lookathim -he's stiff as a board"). 'Anger', I believe,lroubled him, but he always took trou-ble to remind the bereaved thal he haclbeen a boxing Btue at Cambridqe.'Bargaining' he dismissed c;n-temptuously. ("God is no usurer,madam, he ente6 no pacts.") As lor'depression' - well, he would pointout, who could beglum in his stimulafing company? At the first hint of'accep-tance', he would be on hjs feet with hishand on the door-knob. He took it as atribute that no'one ever seemed toneed io reiurn for further counsellino

T.E. is, unfortunalely, no longer wihus, but I believe we can all learn frcmhim still. lwouldn't recommend that youcopy his style verbalim bul sortoutsomething suitable of your own. Howamazing it is thal he should havedeveloped such an effortless techni-que without any of the tuition inbereavement counselling that we, asspoonled graduates have taken forgranled. As T.E. oflen said: "The ontvthing that stands between the patieniand the mortuary is lhe relalive".How salulary.

Bob Baker

a

Politics:White Paper

- or The End of the NHS?

Concerned discussion abouttheWhite paperabounds in the press, campaign leatletsand inthe corridors of NHS Hospitals. Dr Sandy Macara, a man deeply involved in many ol the higherlevel discussions, gives us an inside view of the most important medico-political issue ofrecent times.

The aims of lhe government's WhitePaper on the "refom" of the NHS {notethe pejorative word) are admirable:

- the needs ol patients mustbe paramount

- the NHsshould continueto beavailable to all, regardless ofincome

- patient choice should beextended

- those who provide the ser-vices should be resPonsiblefor day to day decisions aboutoper-ational matters

- health authorities shouldensure that the health needs ofthe population for which theyare responsible are mel, thatthere are effective services forthe prevention and control ofdisease and lhe promotion ofhealth. and that their PoPula'tion has ac@ss to a com'prehensive range of highquality, value for moneyservices,

A resounding statement of commit-ment, you might think, and one whichthe proposals in the White Paper andlhe eight working papers could not beb€tter designed to nullify.

For a starl, not a word aboutaddilional resources although our NHSreceives a much lower share of lhenational wealth than any comparablesystem. worse than that, the proposalsare clearly designed io reduce lhe levelof public expenditure devoted to healthcare whilst massively increasing thecosts of management and accoun-tancy, which will inevitably be at theexpense of services to patients, olherthan those who can afford lo insure

privately (notably in lhe case of lheelderly). Proposals for increasingpatient choice include restrictionsupon the freedom of the general prac-titioner to refer palients to the hospitalsand the consultants which in his opi'nion would provide lhe most approp-riate clinical care. Theyalso includetheelimination of every represenlative ofthe community from health authorities,converting them into administrativerubber stamps ilr the application ofcentral govemmental diktats. Withoutthe patient's voice, where is thepatienfs choice?

Everybody has "access to a @m_prehensive range of high qualiiy ser-

"The proposals are clearlydesigned to reduce thelevel ol public expendituredevoted to health care"

And we have other concems. Whatwill happen to medical education andresearch, which receive scarcely amention in all these documents, otherthan the clistressing inabilfty to graspthe importance of lhe currenl link-s bet-ween the health service and medicalschools whose future is now in ques-tion. Whatwillhappen to junior doctors'career planning when self-goveminghospitals are free to employ whomeverthey like, or not, as the case may be?

The govemments proposals willdestroy the NHS as we know it by sub-stituling the ethos of cash for our ethosof care.

There has been no consultation withany reputable representative of themedical or any other health care pro-fession about these proposals at anystage. lMin isters insist lhat they will dis-cuss only implementation of proposals,nol the pdnciples or the proposalsthemselves. Negoliations on generalpractilioner' contracts a@ an entirelyseparate matter, which were clearlyimposed as a smokescreen,

vices", albeit with delaysdue to lack offunds. How can health aulhoritiesensure that the health needs of the pop-ulation are met when it is fragmentedby self-governing hospitals andbudget holding GP's? How free will"those who provlde the sewices" be intheir responsibility for day to daydecisions? Already District N,lanagerc,on shorl tem qontracls and perfor-mance bonuses, are being black-mailed to persuade their hospilal con-ultants to express an interest in optingout of an inlegrated s€ruice so that lheSecretary of State can claim voluntarysupport for his proposals. How can thegovemment expect us to lrust theirintentions when such blatant hypocrisyis implicit in their major proposals?

CompetitionlF YOU remember, we askedyou to supply us with a suit'able caption for a very leveal-ing shot ol our esteemedleader.

There were numerous wronganswers and some lhat were so crea-live we could not possibly print them.(Gedditt?! Ed.) Here is just a s€leclionof lhe wrong ones:

And the winning entry comes from aMr Albed Dorkin, siqnatman withBritish Rail Western diviiion, who hav-mg come across a copy of this maaa_zine left behind on the paddinoionexpress by one of our more las-mopolitan readers, sent us lhis entrvmistakenly lhinkino it was a ohoto oftheir esteemed leader, Mr. Jimmv Naoo(Could they be in somewav relatediEd.):

And here is the next competitionphoto, we thought it better not to reveallhe subjects name in view of the factthai some readers may find lhis picturerather dislurbing (and some of us wanlto pass obs & gynae, Ed.)

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10

Bag-Age:50 years ago

Despite the loss ol staff andcolleagues, and an influx of Pre-clinicals from the lMiddlesex, "BlackBag" managed to keep going, ifirregularly, throughout world war ll,albeit in "utility'' form.

Overhead in outpalients:"Bul whalHitler doesn't know is that lhe whole olStaple Hill's against him."

lvlore regular material wasinterspersed with wartime advice suchas "Blood Transfusion for BattleCasuallies" which concluded:

"This war may well decide lhe realvalue ot blood transfusion and showalso lhe advanlages and uses ofplasma, serum, concenlrated serumand olher substances designed toincrease the amount of tluid incirculation."

"Risks thal some other person pays toput right are regarded as worse lhanrisks individuals have to pay them-selves to remedy." R.P.

lf lhrown by all lhis into a state of"mild neNous disorder" then fore5 5sa week there was a place for You atDorset House Residential Clinic, Cllf'ton Down. Four Guineaswould pay forsimilar lreatment, plus a private golfcourse and fresh oroduce from lhefarm eEtate at Northwoods, Winter-boume,

Do-It-Yourself:Are you one of lhose strange,

deluded people who doosn't relish lheprospect of standing in thealre slaringat a surgeon's back for 6 hours a day?Then why nol make this handy littleinstrumenl so that you can see whal'sgoing on (however, we can't guaranleeyou will be any more enlighlened orentetained by what you see!)

NETT 6SUE:Snellen Chart

Borborygmi"l don't want to go into the ons and outsof reprod uction." K.C.

"Envkonment reters lo all externalinfluenceson man. They may afiect hiswell-being." R.P.

AuscultationsProfessor S.V.Chatteriee sailed

home in tho recent elections which hada record tumout, Still, at least we canfeel proud that more people tumed upfor oureleclions than did for lhe Euro-elections. The other posb were ho ycontesled with almosl as many thirdyears standing as came to the clinicaldlnner (and they wers allstanding thentoo, unllke th€ lourth years and somemember of th€ staff we had befier notmention). And whilstweargon the sub-ject of the Clinical Olnner whoever saidthat onlyAustrallans and Surgeons tellreally dirty jokes was obviously right,Thank goodngss the guest speaker ofthat evening is lrom Newcastle elsesomeone might have had to resussitaleDr Parry.

The frcurth year interviewo passed offwithout a hlnt of ill-feeling, back-stabbing, rule-breaking, hysteria,broken friendships or confusion. ln factit was a thoroughly enjoyable time forone ahd all. N4ay we take this oppor-tunjty to say what a joy it has been todiscover the unknown recesses ofManulife house and we wish them allsuccess in lheir massive task that liesahead: that of trying to sort and tell uswhich jobs we already know we havegot Let's hope Kenneth Clarke neverfinds out about their exislence.

So another academic year is waning.Captain Sensible weighs anchor andsails for pods anew. The sports clubhave demolished their last reslaurantThe final year have trotted off as quietlyas they came, in fact were they everherc? And to the pre-clinicals who arelucky enough to have a summerholiday we say a fond "p**s Ofi!"

Letter E for Your

11 @

Bag-Eye.

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12

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LETTERS:The lastword onfirm gradesDear Editor

I was honified to read in your last edi-tion how haphazard, in the studentsview the firm gradings are assessed.On my firm a completely fak policyoperates. Continual assessment takesthe form of Special-Hourly-lnterro-gation-Tests or SHIT for short. Themore SH lT a student can take the betterhis fkm grade.

Before a student is failed the frrmthere is a Complete Reassessment ofApptitude and Potenlial - or CRAP.Thus a studenl thal can'l take the SHITor handle the CRAP will tail the firm.

Before an A grade is awarded thereis an Assessmenl of SurgicalSpecialities of Uver lnteslines and Kid-neys, or ASS-LIK. Thus a student bothtake the SHIT and be able to ASS-LIKlo get an A grade.

I like to pride myself on theamouniofSHIT lgive my sludenls and how they,in turn, handle the CRAP and cannolwait to ASS-LIK. lt is only unfortunateyou do not see more SHII on otherfirms.

Yours,

DCCB

SETTLE FOR, YOU GET

You want to say, "l really haven'l thefaintest idea."You'd settle for saying, "l'm afraid I

haven't reached that chapter in thebook yet Sir."You end up saying, "Well, as I unders-tand it . .."

You want to say, ',1 need a job, andyours will do."You'd settle for saying, ,,1 think I wouldenjoy doing you job.,'You end up s€ying, "lactua ytind look-ing at stool charts fascinaling..,

Students 1: YOU WANT, YOU'D

You want to say, "l've spent three hourstaking blood this moming, and I'd tiketo do something else now."You'd settle for saying, "But he was eafinq his breakfast, and I didn't want todisturb him."You end up saying, "OK, and bloodcultures too?"

You want to s,ay, "The only lhing I canhear is the man in the bed next doorbeing sick"You'd settle for saying, "l've qot a cold,and I can't hear too well at themoment."You end up saying, "Oh )es, middiaslolic."

You want to say, "He's skiing in theSwiss Alps with your youngestdaughter, Sir."You'd setUe for saying, "He's over-slepl again."You end up saying "llhink he,s gotftu;he wasn't feeling too well yesterday."

_ You want lo be a consullantmysrcan.You'd sehle for a 7a hour weeklv slol onGWR talking about .,waierworksproblems"You end up as a colorectal surgeon.

You want to say, ..No I can't se€ anv_thing except your back. Mr X_You d settte tor saying, ..ll I could iustget a little closer "You end up saying, ..Oh ves. thatp'nk thing."

You want to say, '.Whal do you mean'oDvrousty melaDlastic'?"Youd sehle for saying, ,.1 can.t ouiteseem to gel this thing in focus.,,You end up saying, ..Oh, yes, thev,rectearty abnormal, aren't they?"

14

Students 2: AN ARABLE PARABLE

One fine summeds day Mr Joneswent to the maftet to buy some livestock. Mr Jones wenl to the markel withall the other farm hands al about thistime evety year, to buy some animals towork on the farm. However this marketwas a little skange in several ways.Firstly, the animals had to put them_selves forward to be chosen. but eachanimal could only ask to be bought bysix farm hands. Secondly, a farmhandcouldn't take the an imals away from themarket wilh him once he'd boughlthem. lnstead he had to wait for over ayear and a half until the animals hadbeen httened up. This was slrange forthe animals too because some ofthemdid n'l yet know whether they wanted towork in lhe fields, in the farmyard or inthe hay barns. Lastly, and perhapsslrangest of all, both the animals andthe farmhands had lo ask the marketkeepers if, afler they had decided theywanted each other, they could haveeach other. This market ritual hadevolved from an attempt to give themaximum amount of happiness to themaximum number of animals and fumhands, but had turned into somethingquite different. The market keeperslived in a hut near to the largest farmand they were really quile nice peoplewhodid their best to herd the animals inthe right direction. The trouble was thatthey didn't really like farms, farm-hands or farm animals and certainlydidn't relish the thankless task of pleas-ing as many of them as possible.

I\rarket time was very stressful for allthefarmyard animals; some of the chic-kens had gone right off their egglayingand some of the peacocks were strut-ting around, trying to convinceevelyone that they werenl neNous.Some of the animals went to see someo{ the farmhands and were told thatthey would only be bought if theyagreed to the dealrightthere and then.This was untair in two ways. Firsilysome of lhe animals would have Pre_ferred to be bought bY other farm-hands, who would give them more oatsand less beatings, but had to accepttheir first offerfor fear ot being left out topasture. Secondly, because lots ofanimals were being bought eady on,some of the farmers who were late lorthe market could not buy animals forlove or money or plomises of fewerhours in the fields. As if this was notbleak enough the future was beginningto look even more uncertain for thepoor farmyard animalsand the farms inwhich they had been brought {rP-

Everybody had wondered why thepower to run the farms had been takenover by the Griffithson brothers. The

animals used to think the farm handswere bad but at least they were thedevils they knew. Now il was clear whytheGrifiithson brolhers had been putincharge - so that they could carry oulthe evil plans of Mrs Carte Blanche.

However perhaps the most worryingthing lo the farm an imals was the way inwhich the farm hands chose whichanimals they were going to buy.Flumours had been going around ihalsome larmhands liked fillies with wellshaped fetlocks, while others plumpedfor athletic geldings. The farmhandsonly means oI assessing the animalswas when some of the animals hadworked for lhem on the farms for a fewmonths, However the farm grades wereno laughing matter. They were so arbil_rarylhal many ofthe animals wonderedwhelher the farm hands decided after akeg or two of scrumpy. Surely the farm

hands wolld be more discerning whenchoosing animals lo work on the farm?

So, allin all,the market was a bit of ashambles thal day. The farm handswere a little disgruntled, the tamanimals were most distressed and themarket keepers were absolutely livid.But surely lhere was nothing lo worryabout - weren't there more jobs thananimals? Wellthe rumour wenl thai oneofthe chielfarm hands had told alltheanimals thal if you wanted to woft onthe farm in the future then a job in Tr{rrowas about as useful as a pitch fork iormucking out a pig sty.

NeonatologyBasic Mamggment, 'on-Call' Problems, Dlseases,DrugsT- L. Co ellaJohn Hopkins U nive rsityM. D. CunninghamUniversity of KentuckyThisnewrompa.tmanurl provid€sessennalinformarionromanaCethenorma rnds.[newrrornchi d.Thefranual sdiv dedintofrves€ct ons Bas. Po.edur€s,sP€.iaPr..cd trPs Dir€ses,ndCoid rionsNeonatal Pharda.olo€y, plus a unique

use rornat s desiened tomakecl'n.acuider n€sreadilya..csrb eforthoseoerforminea soe.if . procedure, diaCnos'nCa Drob em. manaeinsadiseaseor.dfr i. neincand monitor ncdtuetherapy19aa 4oaPages a3a5-66701 spiral

ClinicalPharmacologyB.C. KatzungU niversity of C al ifarni aThisreleren.eprovidcsinlormat onondrugsloruseLn€cncralmed. neand sorC.. scdbvna ordrueeroups,asrheyapp ytodin.a indi.ations and orcan systemd *ases Ea(hdrugdc5d pnon.ov€Epen'npntpdthophysioLoCy rheraF UL !rdronaleandm{hcnsm oha,ma olinPii.rindications,.ontra nd (anons war. ncs,dvcKe reidi.ns r.d'nteradionsl9aa 44apa€€s A3a5 I50l a Spnal

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16

A day in the life of . . .Rachel Mofiat, out-patient turned in-patient, classic case or interesting signs. During her

admissiontothe BRl, shetried to shake ofl the depersonalising labels and after her expefiencegives us her . . .

... GUT REACTION TO WARD 15

My desk at work looks over the BRI

- what a sight! Even from the outside,let alone the inside, it doesn't resemblemy idea (very naive) of a hospital. As achild I watched Angels and GeneralHospital, lexpocted the BRI to besimilar.

I had made the decision to have anoperation after a couple of years sufier-ing from Crohn's dis€as€. My consul-tanl convinced me he wasn't a knifehappy surgeon and lhat I really didneed part of my gut removed. This itselfwas a big enough shock,Itound itveryhard ic understand why'it'had cometolhis - was there nothing else?

"ON THE day I rang up tocontlrm my bed was freeonly to be told lt wasn,t,,

After agreeing lo have surgery I wasbooked inlo ward 15. I didn't thlnk that I

was worried bul as the day app-roached tor me to be admitted (mY

birthday incidently) I began thinking.. . Yet again my naivety showedthrough when I told a friend that I wasterrified of being put to sleep bya maskover my face. I had no idea! I realisedhowwound up lwaswhen onthe day I

rang up to confirm my bed was freeonly to be told il wasn'1. I felt avvful andvery let down afler having built myselfup. Eventually I was told a bed was freeand I set olf for ward 151

My experiences in hospilal I shouldimagine were much the same as anypatient. I had been wamed abouldepersonalisation and became deter-

mined to fight it. Within a couple ofhours of ariving I'd broken the rule ofno more lhan two visilors al one timeand was merrily chatting away with agroup of students (allof which I'm surewill wish to remain anonymousl)

lnitially I was surprised at how little I

camg into contact with both the nursesand doctors. Nurses appoar€d to makebeds and lake temperalures. lt wasn'tuntil after my operallon did I reallyappreciate the extent of 'nursing'n€cessaryl

There is also nothing more intimidat-ing than belng sunound€d byt€n m€di-cal strdents, a houseman, SHO and aconsultant, especlally when I discov€rthat I was such e clesslc case of enileoca€cal rosection I was exhibited to5th years as well as th€ 3rd y€arsl

My deep concern to remaln un-depersonalised continued lhroughoutmy stay at the BRl. My first words aflerwaklng up from the anaesthelic werg'Did I behave myselr.r' and 'Was it allworth it?'! I was so impressed with lTtJthat I am lold I thanked everyone andpractically everything I saw as I wasbeing wheeled back to ward 15.lmustpoint out that by this tihe theimmediale post operative euphoria hadworn ofi and I was doped up to theeyeballs. I was determined to beremem bered not only as anolher sem i-conscious body!

The next few days were spent com-ing to terms with a very sore tummyl I

didn't leellike doing much for a coupleof days. I was dying to eal somethingafter a while but I cedainly.wasn't look-ing forward to hospital food - there isno denying the fact it was disgusting!

"l thanked everyoneand everything I saw,,

As I recovered in re@rd time andwas allowed home. I can't say my stayin ward 15 was enjoyable - the com-panywassllghtlyolderthan I'm used loand the enlertainment, well, what can I

say: the highlight of my 6tay was when I

was invited (or as il was ordered) toattend a lulo al with a lirm of thirdyears. Unfortunalely I had vEry littleic otfer.

I was treated really well by everyone.lstlll can't com€ to terms with thethoughl, however, that if I have anotheroperation in years to come I might wellhave to b€ clerked in by . .. soms-

17

People: Dr. Coles, The RetiringClinical Dean

Some students are under the impression that Dr. Coles is a ligure created bythis publicationforthe sole purpose of poking fun at theteaching establishment. To some he is the man whoseiob it is to provide them with good reasons as lo why not to give up medicine. (l can onlythink ofone - drug lunches, Ed.) To others he is there to change your elective from group C ("1 don'twant to go away right before finals") to group A ("1want to go now"). lt maybe he is simply theman to whom you once said "l've always wanted to study medicine because I really like peo-ple", and then waited for an offer ot AAB. A briefchat with our outgoing Dean and you realise heis in tact all these people . . - and more!

Dr. Coles qualified from Bristol in1951. After an exciting period as aMRC research fellow in Belfast, St.Mary's and Oxford (working alongsidesuch notable figures as Pickedng atOxford) he returned lo Bristol for whalwas to be the rest of his professionalcareer. He was appointed consultantphysician in 1961 by what he calls "anenormous slroke of luck" but it cannothave been unrelated to his obviousded;cation to medicine and his im-portant research in the fields of hyper-tension and vascular disease.

He became clinical dean in 1977. adecision he has never regretted and apositon that has enabled him to helpand influence generalions of Bristolstudents. Whether through personaldifficulties, university politics or simplyat admission, those who have had con_tact with Dr. Coles agree that hisenthusiasm and down-to-earth app-roach have made him an easy personfor sludents to getalong with. He is wellaware, for example, that most havewanted to come here because it is sucha pleasant city (so it really does nol hurtto be honest at interviews) althouoh heconfesses to having experienced amoments hesilation when admitting asludentwho had chosen Bristolon thebasis of its' lce skating rink.

Over the years, whilst he has seenthe academie standards rising helhinks the medical sludents commi!ment to humanity still remains: "bigheads will always come to grief - faiFing that they become professors!"("Don't quote thatl") He has fought torelain the 1st N4B and is proud ol themixlure of backgrounds that Bristolstudents can bring to the medicalschool.

As for relirement. the first ruleaccording to Dr Coles is notlocling onto the past and not interferc. Nol such asimple thing when you have been socentral to all that is going on in the clini-cal course for such a long time.

Talkingwith Dr. Coles instillsin you avery old-fashioned, and some would .

say unfashionable, feeling: pride inyour medical school. lf we can hang onto just a little of lhe pride this man hasforthis schoolthen we might alsolakeaway with us some of his committmenlto medical education both here andelsewhere. His farewell speech to theUniversityin October promisesto bean

entertaining memorial to a lifes work,We wish him the very best in hisretkement.

Tell meDoclor. .

Iltttts eqn I be

SIIM?',lc!,se4, t pn4, eql. nolnal ynzal).out bt& ol ,rte !"

'\1i

DoN'r woRR.Y MosTl4EN puT ONWEIGHT AR,OUND YOI,'R AGE.

UNIVERSITY OF BRISTOL

DEPARTMENT OF MEDICINEBRISTOL ROYAL.INFIRMARY

ARIST.)IBS2 IIHW

Telephonc: ({l?72) 2l(xxl0

?*9s'It occurred to me the other day over the mid-moming snack thal I haven't seen you since I popped up to Town lo collect my

gong the olher week. On the whole, it was a thoroughly iolly occasion, allhough the party nibbles were rather on the scanlyaide, I bumped into that perception chappie from the University; the one who bears more thao a passing resemblance lo Pat_

dck Moore, bul without such good clothes sense. Apparenlly he was up to receive an honour similar to mine, and candidly I

think he'd been going rather heavily at the Bristol Cream. There wag a rather slrained silence when, before leaving lo deliver alecture to the Royal Society, he lurched up lo the lady ol the house and offered to show her something her eyes wouldn'tbelieve, Fortunately, his car ardved before she had a chance to send him to lhe lower

Sorry you couldn't make the lrip sp to tho R.C.P., which seems lo havo be€n great fun. They manag€d to smuggle plenty ofbrown ale aboard the coaches, and had quite a time. I still don't know how lhey succaed€d in €xplaining away to the police

ths sight of a usually resen€d and gminenl physlclan displaying his rear end from the back s€al in a lrattic jam on the M4.Only deft work on the spot with thg sigmoidoscope by K,WH. convlnced the officer thal he was preseni at a genuine medicalemdrqency. One man, at leasl musl have b€€n rolieved lo flnd standing room only when they eventually arriv€d al Regsnl'spark,in tr6 end, as you xnow, the post ot Prssidgnt went lo a member of the falrer sex for lhe first lime. I wonder lhe Fellowshad lhe courage, having s€€n whal a similar belng is trying to do to the N.H.S.

lmagine my surpri6e the other day when, lnstead of all trying to avold calching my 9)€ and sllnklng out as quickly as poss-

ibb, o;e of lhe sludents actually half-ralsed an incompetgnt hand following one of my leclu,es. Always willing, if mod€stly, toshare my scanty medical knowledgq I signalled her to carry on. She rath€r floor€d me for a second or lwo by agklng a ques'tion whiCh began: "ls il true that . . . " before proc€€dlng lo make it glaringly obvious that she knew damned well it was. Main-taining an aiiof aulhortly, lsilenc€d lhe impeluous youth with the ever useful Kimmetstiel-Wlsotl kidney. On€ up tothe Prof.

Your's in the fray,

Ar.

A:\qZ-29\@9-

19 -

Churchitl Livingstone $!From your first exam to your first patient -

Ghurchill Livingstone can help...Davidson's Principles and Practiceol MedicineEdited by John iradeod, Christopher

Biochemistry lllustratedPeter N Camobell Anlhonv O Smith@

The new edition of -Gray's AnatomyEdited by P L Wlliams, R Warwick, M Dyson,L H BannisterT*flfity-s*ih ednbo 1600 papes l54o i us

hadbad< EIO.OO O 143 0258A6

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Human PhysiologyShella Jennet

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l 9 19 pag6 n0 ihts ptpebd< etu.95o ztzt3 0a696I

lmmunologyEdited by lvan M Roitl Jonathan Brostotl,David K l,talgtgag Sar'i.tadli,,, 321paga 921 l us (6to it tull@bun p*rb* et7-95 014:lum17

Functional HistologyP B Wheater, H G€orge BurkitlV G Daniels

p4db* e17.95 0113@3117

Essential Orthopaedics andTrauma

er4-95 041' 0100:16

Essential SurgeryH George Burkitt, Clive R G OuiciqDennis T GattNdearbe(1989 Aoopag6 5l7 us Pqe,bad(a&tox 22L o 1t13035934

Ostlere and Bryce-Smith'sAnaesthetics for Medical StudentsThomas Boulton, Colin BloqqAtgusl1989 Tanthaditim apt* t92pagas inus

Churchill's lllustratedMedical Dictionary1989 2l2l Fges illus, with z4-pzge. tullalou ksedhardbad o 443 08691 5

Essentials of Medicine and Surgeryfor Dental studentsA C Kennedy, L H Blumgad, G D O Lowe,J R AndersonAqud 1989 Ffih dilim ovq 2ro ,9fes aad 80 illusDeoeia,.* E12.50 o 4,]t Ao87 7

Basic and Applied DentalBiochemistry

lntroduction to ClinicalExamination

E6.50 0 zUSl @8Zl 6t1750 0 /u3 0i8241

papa{bad< e5.50 O 44) 04)74 A

Essential Clinical Neurology

72 us papeh* t7.6 O44tOgOT 2

Practical Fracture TreatmentRonald K McRae1989 Se6nd 6dition 96

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11166 d!.. s eElablo fon to(rl6l nEdel bo.l€slhr. Fo.tu.lhd hlcmaton d .tt of ,E$ fi$. 6ltct Th€ sd6P@nEds o.pa.h6( ct .c6a l.liEiroe. arobql SLM@Ho@, i-3, B.rb''3 Pla€.!€rlh Wd( E rnbngh EHI sAF.

M€&d Ddio. .f Ld€mn Ctup ltd. Resid€cd Office, 5 EenriEk 9d, L'dd WIM 5&1't Regiskrtd No: 872aX Ensh'd

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Essential UrologyNhel Eullock Garv Siblev, Robert WhitakerJuly 1989 352p4.es 169 flluso 1u3 03a41 1

RADwilliaols,JCElliotr1989 Se@ndeditt,,I t36p!gt6 ov.t t@ lu.papehae eu-95 o .us' alu I

Books.Professor Falndon reviews anew students lext.

SCOTT: AN AID TOCLINICAL SURGERYHAF Dudley, BP WaxmanFourth EditionChurchill Livingstone 1989 Pp. 315Price - Cg-95

This book puqrorts to provide "allthat the student needs to know in iac-tlal terms to get through the standardsurgical examinations". The readers ofthis review will know that the surgicalexamination in lhe University ot Bristolis not a "standard surgical exam-ination"!!

The book excludes orthopaedicsand ENT surgery since it assumes lhatthe student will buy lexts covedngthese surgical specialties The bookdoes include some neuroslrgery, !rol-ogy, and vascular, cardiothoracic andplastic surgery These surgicalspecialtes are not always broughtlogether in a single chapter or secliongiving details of lhe disease conditionsnormally seen on such speciahywards.The work of the plastic su€eon, lorexample, usually encompasses bums,reconstructive sutgety, hand surgeryand some head and neck surgery Thereader has to refur to the appropriatechapters dotted around the textbookfor lhese details.

The section on thoracic surgery islimited (8 pages)- The details in lhissmall s€clion are probably inadequateflr the undergraduate curiculum.

Duplication is kept to a minimum butit would have made sense to includethe four pages of infective com-plicatons ol surgery in chapter 6, inchapler 14, which deals with allacute infeclilrs

The figures are mainly line diagramswith lhe o€casi'lal )0ay or CT scan.The slandard od tfle illustatons is adequale in most parts. The st/iis€ddiagram oI the dispo€itir of tfle st'ap

muscles and lhe thyroid gland, whenlooked al by a thyroid surgeon, isenough to take the breath away!Thereis no excuse for such a shoddy illustra-tion (Figure 2O.1). Figwe 2O.2, lotexample, demonstrates the appliedanatomy of the parathyroid glands andthe recurrent laryngeal nerve in a veryacceptable fashion.

For a fourth edition one would havehoped that errors of slyle and useagewould have been eliminated. Fine nee-dle aspiration lor cytology is abb-revialed to FNAC. Subsequent use ofihe abbreviation is as FCNA. N4ultipleendocrine syndromes are betterreferred to as "multiple endocrineneoplasia" ratherthan "multiple endoc-dne adenomas". Not all patienisdemonstrate adenomas and somehave hyperplasia as a precursor of anadenoma. I thought this debate hadbeen settled several years ago andcurrent useage describes "multipleendocrine neoplasia".

I was interested lo read the chapteron biliarydisease and see the use of anew word. I always believed that anXray, taken with a cannula in the cysticduct demonskating the common bileducl, the common hepatic ducl and theintra-and extra-hepatic ducls, was anoperative cholangiogram. We are toldlhat this should be called a "chole-gram". The multiple use of this wordsuggests lhat the authors would likesfudents to use lhis term rather thancholangiogram. Bristol sludentsshould not attempt to use or introducethis term in polile surgical circles!

Another neologism is "Pros-

tatomegaly'- Prostalic hype.trophy hasbeen in conveniional use for manyyears and adequately describes pros-tatic enlargement in the elderly male,without the need to coin an ugly andunnecessary new term.

ln the chapter on breast diseasethere is one herelical statement -"Though cytology cannot be used as afinal means of making a diagnoslicdecision . . . ". I am sure Mr Webb and I

would nol like studenls lo presentthemselves in lhe final Bristol surgicalexam believing lhis statement. Theauthors also suggest that if an elderlypatienl relapses following treatmentwith a first line lherpy Famoxifen) thensurgery has to follow. h is well under-

i slood and described that considerableI remission can be gained from secondand even lhird line endocrine therapy.There may be no requirement lor sur-gery in lhis age group at all. No detail isgiven on breast reconstruction.i The book is relatively shorl and'easily read- lt does conlain many listsbut the editors excuse these by sug-gesting that you might match your ownanalytical diagnosis against thesestrings of words.

This book is not the lop of my list asan undergraduate text You will recallthat lhe final examinalion in surgery inthe lJniversity of Bristol is not a stan-dard surgical exami

21

Back by popular demand

Poetry Corner:UNLIKELY APPUCANTWrote out nry C.V. - d'dnt seern much to me,With no prolec'ts and no pdz98 and no PhO;Feel ralher humblsd - as small as a mous€When I hand the torm ln at Manulib House.

Now evsry lunchtimq I hat s to slt throughpeople going in about lhek inierview;It s€ems to me - or is it a delusion? -That this subjecl blots out oth€rs to iobl exclusion.

lf anlone has lo eiay away tor a day,The rest of lh€ group all expect foul play;A bunch of neurolics - they would interest Freud,The lourth yea6 are all beconing paranoid,

The day ol the inteliet', dawns bright and sunny,But there lsnt a soul wt|o finds it tunnyThat a ftiendly clBt caGes $rch a jam.What will it be like tot the August exam?

So here I am u6iting lor my offers of employnent,Something that is not a source of much enioyment;H they donl come soon - say by Wednesday -I might be reduced to appMng io Frenchay.

Lefs hear it ior lhe people at Medical Sta{fing,Each new enquiry must s€t tlem all laughing;But they wool be so high and mighty,When !w slart lo treat lhem in 199O.

Bernard Stacey

22

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