The Drunk Consultant.

 

depressed doctor

You are a junior doctor and your consultant [your boss, the head of your team] arrives for the morning ward round smelling of alcohol. You confront him and he confides in you that he was drinking because he was upset because his wife left him the day before and asks you not to tell anyone. How would you handle this situation?

It is important to consider this scenario from the view point of all involved.

Your consultant’s point of view: He is going through a difficult period in his personal life and now by coming to work in this fashion he is jeopardising is career and standing in the hospital. However it is much better that he takes sick leave, the stress as well as the drinking would make it hard to concentrate and mistakes which in medicine can have terrible consequences are almost bound to happen. He should not feel that it is a weakness to seek help, we are all vulnerable and there are services such as occupational health, BMA counselling services that are available free of charge to doctors. It is important that he has insight and does not worsen his situation by trying to ‘soldier on.’

The hospital/NHS point of view:  The hospital has a reputation to protect and will be sued for any mistakes made. If the consultant is off hand or rude this may lead to complaints. It certainly cannot have its staff coming to work intoxicated. However the consultant is a very skilled, experienced member of its workforce and has given many years of loyal service so be treated with empathy and compassion. He should be encouraged to use the counselling services available and given time off work but it should be made clear that coming to work in this manner is unacceptable.

The patient’s point of view: – the most important. Patients have the right to be treated safely and courteously by attentive staff  that have their full wits about them. Medicine has the potential to cause serious harm as well as good.

Your view point: As a junior doctor your consultant is your team leader, mentor and teacher. He will also be the person who will give you a reference for future jobs. It is therefore important to still treat him with respect and courtesy. He as a person going through a difficult time deserves sympathy and empathy. However you have a duty to your patients and patient care and safety trumps all – ‘make the patient your first concern.’ It would be going against the GMC rules and probably hospital policy if you tried to cover up, even if no one came to harm. It may be the first time you have seen him like this but other occasions may have occurred and there may be a repeating pattern.

You should ensure that your consultant stops working, that he goes home [by taxi, does not drive]. That all patients he has seen have their notes reviewed, that you inform the relevant authority and seek help with that day’s work.

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A GP in your pocket!

cherry picking

Cherry picking – to selectively choose the easiest or most desirable

Smart phones are being used for most things. You do not need to visit a bank nowadays, most financial transactions can be done online so why not use your phone instead of visiting your doctor? Numerous private companies have already started offering GP consultations online. Babylon is one that has ‘teamed up with the NHS ‘ and can offer patients the choice to register with them and have their consultations funded by the NHS.

We already have ‘private providers’ working along side traditional suppliers for many aspects of health care. The NHS already pays for private companies to offer scans, physiotherapy services and funds private hospitals to carry out operations to shorten waiting lists. These private providers are often accused of cherry picking patients. For example most private hospitals providing NHS operations have exclusion criteria and will not treat the very elderly, the mentally ill and those with complex medical conditions. These will be left for traditional hospitals to treat. Treatments attract an ‘item of service payment’ so a patient with complex medical problems who may take twice as many days to recover from a hip replacement will attract the same fee as a fit younger patient. Private providers have been accused of cherry picking the easier more profitable patients. Babylon’s GP at hand service states that a consultation will not cost the NHS any more than one at a traditional surgery. However it is younger, fitter, more educated patients who do not require an examination that are likely to consult so they are likely to be attracting the easier patients with simpler problems.

There is a lack of GPs. These companies will employ a lot of GPs, who will consequently do less work for the NHS which may pay them less and provide them with more complex more stressful work. This would exacerbate the NHS GP workforce crisis. GP and journalist Margaret McCartney fears that it may ultimately derail our health service. “These schemes may mean that you end up having to wait even longer to see your NHS GP, as the workforce becomes more depleted,”

The NHS was founded to provide ‘free and equal health care for all’. Margret McCartney states.  ”These companies are essentially using market forces to determine access to GPs rather than need. GPs working in these companies will probably make more money and have a less stressful career. However, patients are far less likely to benefit. This might work in your favour if you are basically healthy, need a one-off appointment and have the money to pay to put yourself in the front of the queue. But if you have an ongoing condition, or multiple or complex needs, the research shows that your care will be better if you have continuity and are looked after by a team that can care for you holistically.”

 

Good luck in the BMAT ! Some more Essays.

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People injured whilst participating in extreme sports should not be treated by a publicly funded health service. Explain the reasoning behind this statement. Suggest an argument against this statement. To what extent, if any, does the statement justify a change in public attitudes to personal risk taking?

The statement states that people who voluntarily take risks with their health because they participate in extreme sports such as sky diving cannot expect tax payers to pay for their medical care if injured. It is a statement regarding social justice[fairness] because health systems such as the NHS are cash limited so that funds spent on such people will mean that less money is available for treatment for others. In a private or insurance based health system people who take risks would probably have to pay a higher premium.

A person’s autonomy has to be respected. They have a right to decide how to live their life and to do extreme sports if they wish. It is important to be non judgemental and act in the best interests of that patient which means treating injuries. If those participating in extreme sports are denied medical treatment for their injuries a slippery slope may be created in which those suffering from illnesses which may be in part also ‘self inflicted’ such as smoking or obesity related diseases may in future also find themselves excluded from state funded treatment.

At present ethical principles held by most, including the medical profession would value the principles of autonomy and beneficence over the idea that in doing so we would not be fair to others. The statement does put a valid argument to change attitudes to personal risk taking however because of the reasons outlined in paragraph two I disagree with a change of attitudes in this ‘rights versus responsibility debate.’

 

There is money to be made by not curing a disease. 

We spend a lot of money on our health services.The NHS is the biggest employer in this country. The NHS budget is about £120 billion per annum , this is about 8-12% of GNP per annum for most European countries. In the US it is over 18% of GNP per annum. In US today anyone in workforce works about 6- 7 weeks a year to create resources they will then ‘consume’ as health care. Pharmaceutical companies have grown to be the immensely successful giants that they are by providing treatments for long term conditions such as diabetes and hypertension. Long term conditions generate a lot of money for the payment of health workers and for drug companies e.g The treatment of diabetes costs over 10 billion [10% of the NHS budget]a year in the UK. Pharmaceutical companies spend a lot of money on new treatments for diabetes because the financial rewards are so great.

It is unethical and extremely rare for doctors and scientists to withhold ‘cures’ in order to carry on treating the patient. I do not believe conspiracy theories that ‘big pharma’ has cures for conditions but does not want to release them. However when scientists apply for research grants pharmaceutical companies with their enormous R and D budgets will look with more interest at research which is likely to lead to profitable drugs rather than cures which would limit the need for their drugs. The need to generate a profit for share holders may be counter productive  in the quest for cure. In my opinion there it is sad but probable that businesses will focus on treatment rather than cures. Pharmaceutical companies have provided major breakthroughs in the past [eg Sir James Black discovered B blockers and then Tagamet] but over reliance will be detrimental. We face a world threatened by increasing  antibiotic resistance.  Dame Sally Davies the Chief Medical Officer as called on governments to fund research as there is not much incentive for drug companies to fund antibiotics that are just usually taken for a few days while a new blood pressure pill may be taken continuously every day by a patient. Dame Sally said action was needed to overcome this “market failure” and stated that this should be taken up by the ‘Innovative Medicines Initiative’ – an EU funded body whose aim is to promote the development of new medicines. Bill Gates has poured a lot of money into the research of drugs which can cure diseases in the third world where drug companies would not be able to recoup costs. He has also supported GAVI a charity which funds vaccine research to prevent illnesses in the first place. The new rota virus vaccine which kills many children in the developing world has been funded in this way.

We need charities, university research departments and governments to also carry out research, particularly into cures because over reliance on pharmaceutical companies would probably mean more money is spent on research into treatments rather cures.

More BMAT essays.

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a glorious enterprise

 

Science is a great and glorious enterprise-the most successful, I argue, that human beings have ever engaged in. To reproach it for its inability to answer all the questions we should like to put to it is no more sensible than to reproach a railway locomotive for not flying or, in general, not performing any operation for which it was not designed.
What do you understand about the statement above? Explain why it may be argued that science should be expected to answer all the questions that are put to it. Discuss giving examples, the extent to which science has its limits.

Answer

Science has made astonishing progress in increasing our knowledge about how the Universe works. However as the writer points out there are other forms of knowledge as well as the observational and deductive logic that science relies on. A person will use emotional knowledge to tell him whether he likes a piece of music or a painting. The quote tells us critics who complain that science does not have all the answers are right but that does not detract from the value of scientific work.

In an increasingly secular world many people see science as replacing religion. People are attracted to the open values of science and its evidence based approach. They feel that scientific methods could be applied to other forms of knowledge such as psychology and economics. The involvement of science in fields such as the arts has led to the expectation that eventually science will tell us everything, even such matters as why we are attracted to certain people as humans are just products of their biology.

Science will always have limits. Every new discovery will lead to many more questions. In a near infinite universe we cannot know everything. ‘The greater the island of knowledge the longer the shoreline of uncertainty’. Science cannot tell us how to resolve an argument, how to love or what is right or wrong. Empathy, [emotional knowledge] and ethics are different but important forms of knowledge. Science can be used in good or bad ways, for example the germ theory of disease can be used to prevent transmission of disease or in biological warfare. Scientific development should always be within an ethical framework.

We Don’t Live in a World Of Reality, We live in a World of Perception. What do you understand the above statement to mean? Provide examples of how we live in a world of reality and how we live in world of perceptions. What is the common ground between reality and perception.

 

Blind men and the elephant

Answer

Descartes, the famous philosopher imagined a world controlled by an evil demon creating false illusions; he concluded that the only way he could be sure that he existed was because he could think. The film, the Matrix, was based on this idea.  Our view of the world is limited by our perception. Our vision, often regarded as our most important sense only detects a narrow range of electromagnetic wavelengths. Our other senses are similarly limited.

We live in a world of reality to the extent that our senses do not seem to lie. If I touch my desk it feels solid and occupies the space my vision tells me it does. When I call my sister she does hear me. This tells me that we do live in a world of reality. However science tells me that my desk is made up of atoms with enormous spaces between them and even within the atoms there is much more space than solid. Are my senses deceiving me by making it appear solid? We all know of examples of when perception is completely misleading such as in mirages.

It is important to realise that our picture of the Universe is limited by the perception of our senses. We only perceive a small fraction of the Universe. In the old story of the blind men and the elephant, one blind man felt the tail and declared it to be like a snake, another leg and said it was like a tree and so on. All of them were right but all were also wrong. We are stumbling around in the Universe in a similar blind way, reality and perception come together at times but we rarely see the full picture.

Should vaccinations be compulsory? [Ethical scenario of the week and past BMAT question]

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France and Germany are to extend the number of compulsory vaccinations for children. The government in Italy ruled that children must be vaccinated against 12 common illnesses before they can enrol for state-run schools. If children are not vaccinated by the age of six, the school starting age, their parents will be fined. Conspiracy theories about the health risks of certain vaccinations – largely based on the  – have circulated around the world, leading some parents to shun immunisation. Parents in France will be legally obliged to vaccinate their children against measles from 2018, the government has announced.  The French Prime Minister evoked Louis Pasteur and said it was “unacceptable” that children are “still dying of measles” in the country where some of the earliest vaccines were pioneered.

Immunisation may be the most important and life-saving medical invention, arguably saving more lives than antibiotics. A handful of Spanish invaders were able to conquer South America because the majority of natives died from the diseases they introduced [some areas decimated – reduced to 10%]. The 1st World War was responsible for more deaths than any war in history but the Spanish Flu, towards the end of the war in 1918  killed far more – an estimated  50 to 100 million people [3 to 5 percent of the world’s population]. Bill Gates [of Microsoft] has in his wisdom poured billions into vaccinations, via GAVI, as it is one of the best ways to prevent needless deaths and disability. The medical view is clear. There is overwhelming evidence that immunisations are relatively safe procedures that protect populations effectively against the risk of serious disease. When I was young my sister’s best friend’s brother was brain damaged because of measles. It is undoubtedly one of the major causes of the increase in life expectancy in the 20th Century. Bill Gates, with his intelligence, has chosen to invest much of the millions he made in GAVI, which researches into and provides vaccines world-wide. New vaccines are being added all the time for example rota virus and Meningitis B.  

There have been numerous scare stories about immunisations as any search on the internet will show. The last major scare involved Andrew Wakefield who appeared to show a link between the MMR vaccine and autism and a bowel disease [Crohn’s Disease]. It was later revealed that much of his research [which involved risky procedure on children] had been fabricated and he had been paid hundreds of thousands of pounds by lawyers acting for anti-vaccine court cases. The dip in vaccine uptake undoubtedly led to deaths.
However although the risk of harm is very low there are small risks involved. Vaccines like other medical treatments such as antibiotics are not 100% safe, 100% of the time. The risk of most vaccines is comparable with that of crossing roads; for example being seriously affected by measles is about 1/10 of the life time risk of getting struck by lightning[see http://besthealth.bmj.com/x/static/514517/decision-support.html%5D

Reduced uptake of vaccination results in more cases of the disease. If vaccination rates fall below 95% there will be a loss in what is termed ‘herd immunity’. Herd immunity occurs when the vast majority of a population is so resistant to an infection that that infection is undetectable in that population. Those who can’t be vaccinated for medical reasons or those with reduced immunity such as cancer patients are thus protected from the illness. In the USA it is compulsory to show that a child has been vaccinated when it attends school because a non-vaccinated child can be a source of an infectious disease.Donald Trump and other Republican candidates want to change this.

Vaccinations are an emotive subject for many who are anxious not to take any risks with their health of their children. An injection intrinsically seems to cause much more fear than a tablet and as a profession I do not think we explain risks well. Risks are unavoidable in life and the risks from vaccinating are small, certainly smaller than the risk from large numbers not being vaccinated. We need to celebrate the success of vaccinations. They are a vital weapon in our armoury against infectious diseases. A century ago most people died from infectious disease, this thankfully is rare because of antibiotics and vaccinations. As antibiotic resistance grows vaccinations will become even more important

Should we make vaccinations compulsory? They protect a population best when there is herd immunity and the only disease eliminated by vaccination was smallpox which was backed by compulsory vaccination. However patients have autonomy, the right to refuse treatment and often [but not always] to refuse treatment for their children. To deny them this would certainly harm the doctor- patient relationship. So, as long as we are not dealing with an illness such as smallpox or SARS I think on balance it is better to leave the law as it is and put more effort into persuasion.

BMAT essays.

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My advice for tackling the BMAT essay is to practice writing them to time in the space available. You only have a small space to write in so you need to be very disciplined. It is too easy to get carried away with a point and write too much and not leave yourself enough space to make a balanced arguments with lots of different points. I think that time is not an issue so I would write your essay in bullet points in rough before writing it on the paper [you get rough paper in the exam].

I would usually use a the simple format of a three paragraph essay. The first paragraph exploring the question, the second exploring other points and the third paragraph summing up or providing a conclusion. However it is important to be flexible.

Here is an example:

Question;  There is more to healing than the application of scientific knowledge.Explain this statement. What else is important in medicine

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Answer

Medicine is both a science and an art. It has a proud scientific basis;, the application of evidence based medicine and rigor of scientific logic but a consultation with a doctor often involves a lot more than making a diagnosis and treating.

The ‘art’ of medicine renders all appointments interesting and none routine. A good doctor-patient relationship and the development of trust is therapeutic in itself. Patients are much more likely to follow advice and treatment. We are familiar with the term ‘the doctor as the drug’. A doctor’s reassurance has been shown to reduce pain scores, panic attacks and other conditions even if no treatment is given. In General Practice, where patients are seen with many different conditions over a long period of time, even visits for minor conditions can augment an important  relationship where communication skills, sensitivity and empathy all play their part, often subconsciously.

I am reminded of the story of a team of management consultants who were asked to make efficiency savings for an orchestra. They saw that there were a number of violins all ‘doing the same job’ and cut the violins down to one. Then they started to look at other instruments. More and more cuts followed. At the end they had replaced the entire orchestra with a CD player – it did the same job and cost less didn’t it?  But of course something was lost!

Question: Not everything that can be counted counts and not everything that counts can be counted (Albert Einstein). What do you think is meant by this statement?Give examples of things that count in medicine which cannot be counted. To what degree should they count?

This essay question and the one above are describing the importance  of subjective experience such as  ’the art of medicine’. You could do a similar answer for this question. 

Here are a couple more BMAT questions for you to try – remember answer them in a space the same size as the box you will be given to write in.

Science is a great and glorious enterprise-the most successful, I argue, that human beings have ever engaged in. To reproach it for its inability to answer all the questions we should like to put to it is no more sensible than to reproach a railway locomotive for not flying or, in general, not performing any operation for which it was not designed.
What do you understand about the statement above? Explain why it may be argued that science should be expected to answer all the questions that are put to it. Discuss giving examples, the extent to which science has its limits.

Answers in a few days – [I will post answers on Wednesday]

We Don’t Live in a World Of Reality, We live in a World of Perception. What do you understand the above statement to mean? Provide examples of how we live in a world of reality and how we live in world of perceptions. What is the common ground between reality and perception.

Answers in a few days.

We Risk Losing Antibiotics

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approached-by-the-antibiotic-resistance

Antibiotic resistance  is according to our Chief Medical Officer, a far greater threat than the terrorist threat. It is already estimated to cause 5,000 deaths a year in Britain. No new classes of antibiotics have been developed for 25 years: the pharmaceutical industry has focused on more lucrative types of drug that are taken daily for years rather than antibiotics which because they are taken as a short course, are therefore less profitable. Dame Sally Davies, The Chief Medical Officer has warned that that resistance could ultimately make major operations and many treatments we take for granted too dangerous, and medicine will be forced back to the dark ages as effective antibiotics will not be available. She suggested last year that governments step in to help research funding. She is attending a conference in Berlin to address the global response to antibiotics resistance.

 

Infections [communicable diseases] used to be the commonest cause of death but now thanks to better sanitation, immunisations, and antibiotics they account for 7% of all deaths. The major causes of death in the UK are now what we call non communicable diseases such as heart attacks, cancers and strokes. [See my book Medical School Interviews The Knowledge p64] It would be appalling if antibiotics stopped working. As Dame Sally said ‘We won’t be able to do a lot of our cancer treatments or organ transplants’. People may die of a simple scratch again.

Why is antibiotic resistance increasing?

1. Over use of antibiotics by people. We do not need to use antibiotics for simple infections, many of which are viral and do not respond to antibiotics. If people do not take the full course or miss tablets it may allow resistant strains to grow by not completely killing all the bacteria. Although doctors in the UK are rightly criticised for over prescribing antibiotics they actually prescribe fewer than in most countries. It is also possible to buy antibiotics from pharmacies in most countries in the world without a prescription.

antibiotics and farmingimages

2. Overuse of antibiotics in farming. Animals actually consume more antibiotics than people. Infections are common in overcrowded dirty conditions so they are often given in small doses in feeds [this is cheaper than providing better conditions]. They are also used as growth promoters; if they are added to feeds they reduce the amount of bowel bacteria and animals put on more weight. In one study of Chinese pig farms Chinese and American scientists detected 149 unique resistance genes. The top 63 antibiotic-resistance genes were found in concentrations between 192 times and 28,000 times higher than “control” samples of manure or soil that were antibiotic-free. Salmonella, a bacterium found in poultry and infects humans who may eat undercooked chicken [barbecues are common culprits] has become increasingly resistant to antibiotics in this way.

3. Antibiotics are expensive to develop. There is not much incentive for drug firms to develop new antibiotics as they tend to be taken for just a few days while a new blood pressure pill may be taken continuously every day by a patient. Dame Sally said action was needed to overcome this “market failure” and stated that this should be taken up by the ‘Innovative Medicines Initiative’ – an EU funded body whose aim is to promote the development of new medicines. David Cameron had a similar discussion with G8 leaders [ the leaders of the richest 8 nations]
Leading microbiologists say that there are only a small number of ways of attacking bacterial cells and these are being exhausted. If we squander the antibiotics we have we will not necessarily have new antibiotics to take their place. There have not been any new antibiotic groups since the 1980s.

What can we do?
1. We should reserve antibiotics for serious infections. I often think of Tolstoy who said ‘Time and patience cures most things’- unfortunately many patients don’t have the time to be ill and certainly not the patience! MRSA[methicillin resistant staphylococcus] and clostridium difficile rates in hospital have decreased in hospital since better practices were introduced but unfortunately there has been a rise in E coli and other infections.We need to look very carefully at farming practices. Antibiotics should not be used to make up for shoddy, dirty farming practices.

antibiotic resistance staph
2. Value our ‘good bacteria’. About 90% of the cells in the human body are supposed to be bacteria. We have trillions of bugs living in our gut and on our skin. Most of these cause no harm and some are helpful. Their presence stops bad [pathogenic] bugs growing by depriving these pathogenic bacteria of space to grow. We know that over washing can lead to more rather than less skin infections and it is common after a course of antibiotics to get other infections such as thrush [a yeast infection which grows into the space that had been occupied by good bacteria now killed off by antibiotics.]
Many teenagers may be taking antibiotics for acne. These work against Propionibacterium acnes bacteria which cause inflammation in sebaceous glands of the skin leading to spots. Recent studies seem to show that those teenagers without acne still have Propionibacterium acnes but of a strain that does not cause inflammation. Perhaps in the future a treatment using this ‘good strain’ may become available. [J. Bacteriol. January 2012 vol. 194 no. 1 202-203]
Probiotics– These have been shown in some studies to be helpful in treating diarrhoea. They contain harmless bacteria like lactobacilli which are supposed to displace harmful bacteria. Studies have shown that taking capsules of ‘healthy faeces’ known as a ‘faecal transplant’ also helps certain types of diarrhoea by re-colonising the gut with normal healthy bacteria!poop_by_a_ufo_lost_in_flames-d5qoq873. Bacteriophages are viruses that infect bacteria. They have been used for over 90 years as an alternative to antibiotics particularly in Eastern Europe and the Soviet Union. They are usually very bacteria specific – only acting on one type of bacteria. There has has been increased interest in them because of antibiotic resistance and since 2006 several types have been licensed including one against MRSA! However they are still not in common use

bacteriophage

There must be a global, coordinated campaign. In some parts of the world antibiotic resistance is much greater. New Delhi Metallo-beta-lactamase-1 (NDM-1) is thought to have emerged in India where poor sanitation and antibiotic use have helped resistance to spread. This multi-resistant bacteria has been found in the Delhi drinking water but due to international travel, cases have been detected around the world including in the UK. Britain misuses antibiotics much less than many countries where they can be bought cheaply without prescriptions. Drug resistance cases of bubonic plague have also been discovered in Asia raising the spectra of recurrence of a disease that some estimate to have wiped out a third of the population of Europe.

Personal Statements

UCAS logoPersonal Statements – you should have these ready to go off. I am re-blogging this to help you make those final touches.

Look up the the medical schools you want to apply to and list ‘key words and phrases’ that come up in their prospectus such as ‘appreciation of the human story’ ‘proven commitment’ and the ‘knowledge of the reality of becoming a doctor’  and bear these in mind when you write your personal statement.

My advice is to put everything you can think of down on paper at this point. You can edit and summarise and précis  everything later. It is important to get started.

  1. Introduction –Why you want to be a doctor. The hardest bit. Try to write something original but it is so hard to say something that is not a cliché as admissions staff see thousands of applications. Do not hyperbolise the virtues of doctors. Statements such as ‘Medicine is the only career that combines a love of science and caring for people’ are just not true and denigrate other professionals. Graduates should describe a “eureka” moment that made they decide that they wanted to medicine.
  1. Work experience – don’t list places or procedures. Remember they are most interested in what you learnt ‘from you experience not what you did. Medical schools say that they are looking for students with the ability to reflect and learn. Did you notice that doctors required any special qualities such as ‘courage’, ‘good communication skills’? Do you have these and are there any examples that prove that you have these? Perhaps mention the downsides of being a doctor  and why that does not put you off.  Remember doctors are dealing with human beings- it is no longer considered correct to refer to patients by their disease such as ‘the diabetic’ in bed 4 or the ‘asthmatic’ in bed 6 – it dehumanises them. Remember the ‘patient story’ is important. Referring to this shows empathy.
  1. Voluntary work; Again be brief about what you did and write mainly about what you learnt. It is probably good to mention a few of those ‘key qualities’ such as good communication skills, any leadership skills teamwork etc in this section as well as the next.
  1.  Extra curricular  activities.  Universities are looking for people who excel in  non academic fields in addition to getting good grades. What ever your passion or hobby always relate it back to how the skills you have learnt will help you in a medical career.

As in the previous paragraph mentioning how you demonstrated ‘competence skills’ such as teamwork, leadership skills, coping with stress or challenging behaviour, compassion and empathy.

They also want to know that you are sociable ‘well rounded’ person who knows how relax and ‘de-stress’. It is always an advantage if they think you may be able to contribute to University life eg the rowing team or drama society.

5. You may want to write about something you studied and enjoyed. It is not necessary to list every subject. Again focus on one or two points and avoiding listing. Perhaps mention books [or journals] you have read and why you found them interesting.

6. ‘Love of science’ it may be important particularly for Oxbridge entry to refer to    this. Say what it is about science that interests you – ‘scientific logic’ for example.

7. The Conclusion . Sum up and try to end with a flourish.

NEVER DISPLAY A HINT OF ARROGANCE BUT NEVER PUT YOURSELF DOWN!

Assisted Dying – Noel Conway loses his case.

Noel Conway.

Noel Conway, 67,  has motor neurone disease,  a condition that results in progressive  weakness of the muscles including respiratory muscles. He was a fit healthy man who used to enjoy a range of sports such as skiing however he now has virtually no movement and needs a ventilator to help him breathe. He argued that he wanted a doctor to be allowed to prescribe a lethal dose when his health deteriorates and does not want to be entombed in his body.

Noel skiing

Before his illness Noel Conway was a keen cyclist, skier and climber

Currently any doctor helping him to die would face up to 14 years in prison. He argued that the alternative would be pulling out his breathing apparatus which would lead to an uncomfortable and distressing death by suffocation. He said he could either bring about his own death while still physically able to do so, or await death with no control over how and when it came.

Assisted suicide is in the news a lot and is often the subject of ethical scenarios at medical school interviews.

Arguments against assisted suicide
1.‘Thou shalt not kill’ is one of the oldest moral commands. It has been a key part of medical ethics for centuries. The original Hippocratic oath states ‘I will give no deadly medicines to anyone if asked, nor suggest any such counsel.’ Many religious people contend that only God has the right to give or take life.
2. Those that are infirm may be pressurised to die or made to feel selfish or a burden if there was this option. Peter Saunders, from the Care Not Killing Alliance, said the decision was right “because of the concern that vulnerable people might be exploited or abused by those who have a financial or emotional interest”.
Slippery slope arguments. The ‘slippery slope’ argument holds that if assisted suicide was practised for people like Mr Conway then it would become acceptable to allow it for less clear cut cases and eventually you may end up with a situation as in Nazi Germany where those deemed to be defective were killed.
4. With good pain control and counselling, suffering will be minimised.

Arguments for assisted suicide:
1. The person’s right to autonomy, control over his or her life. According to polls most people in the UK feel that they should be able to have some control over when and how they die. In many philosophical traditions ‘egoistical suicide’ [death for one’s own reasons such as to avoid pain] is considered selfish and wrong. However the aim of ‘altruistic suicide’ which is carried out for the love of others or for the religion [eg Jesus praises a man who lays down his life for others [John 15;13] ] is more acceptable to most religions. It can be argued that someone who wishes to die in order not to be a burden is following the same principles.
2. Some, such as Debbie Purdy, who had multiple sclerosis, have argued that if her husband faced prosecution for helping her to commit suicide she would travel to Dignitas earlier while she could do so alone. However if the law permitted her to have help she would delay dying.
3. Even with the best palliative care [treatment of the dying] suffering and pain are common. Dr Ann McPherson, who set up the charity and website ‘Teenage Health Freak’ and supported a change in the law on assisted dying, died recently from pancreatic cancer. Her daughter wrote in the BMJ ‘our mum died slowly and in pain. …The law needs to change to allow terminally ill but mentally competent people the right to a more dignified death than my mum’.

Euthanasia
Active euthanasia is when death is brought about by an act – for example when a person is killed by being given a deliberate overdose of pain-killers.
Passive euthanasia is when death is brought about by an omission – i.e. when someone lets the person die. This can be by withdrawing or withholding treatment. Eg stopping a ventilator.
Active euthanasia is illegal while passive euthanasia is legal. ‘Thou shalt not kill but need’st not strive officiously to keep alive.’ [Arthur Clough 1850’]. It has been argued that often the moral difference between acts and omissions is tiny. The Catholic Church for example sees no difference between the two – ‘The act or omission which, of itself or by intention causes death in order to eliminate suffering constitutes a murder.’ [Catechism of the Catholic Church] NB In common language euthanasia is often used to mean active euthanasia.

What society thinks is usually reflected in the laws of a country. Assisted suicide is presently illegal but the view of the general population seems to be shifting with about three quarters of the population now reportedly backing assisted suicide. This is reflected by the lack of prosecutions of those helping loved ones go to Dignitas [the clinic offering assisted suicide in Switzerland].‘The law has a stern face but a kind heart’ is how Baroness Finlay described the present situation. However Lord Falconer has said:
‘No one has the stomach to enforce the current law, because it is inhumane and further provides no protection for the vulnerable. The threat [of prosecution] forces some people to die alone and earlier than otherwise for fear of what may happen to those who accompany them.’

The Director of Public Prosecutions was asked by Debbie Purdy a multiple sclerosis sufferer under what circumstances her husband would be not be prosecuted if he helped her travel to Dignitas. He produced a set of guidelines in 2009 in which he stated that the patient had to have shown that they had come to a ‘clear, settled and informed decision’ to commit suicide and that the loved one who aided them was entirely motivated by compassion.

Abortion should not be a crime.

assisted suicideAbortion is in the news again. The President of the Royal College of Obstetricians and Gynaecologists said that abortion should continue to be regulated and the 24 week upper limit retained but it should be decriminalised.

The Republic of Ireland has announced that voters will be asked to decide whether to change the Irish constitution under which abortion is only allowed if the life of the mother is in danger. The penalty for having an illegal abortion faces up to 14 years in jail. However thousands go abroad each year to obtain an abortion.The planned referendum could be held in May or June during or just before the planned papal visit to Ireland.

The Eighth Amendment of the Irish constitution, introduced in 1983, gives an equal right to life to a pregnant woman and an unborn child. This referendum is partly due to the death, four years ago Savita Halappanavar, an Irish dentist. The 31-year-old dentist was told that she was miscarrying, she asked for a medical termination a number of times of the nonviable foetus over a three day period, during which she was in severe pain. But her husband said these requests were denied because a foetal heartbeat was still present and they were told at one point: “This is a Catholic country.” Medical staff removed the dead foetus days later after the heartbeat stopped but Halappanavar died of septicaemia on 28 October 2013.

Northern Ireland has similar laws. Women are only allowed an abortion [termination of pregnancy] if there is a severe threat to their life.  Rape, incest and fatal foetal abnormalities are not circumstances in which they can be performed legally. This summer Parliament agreed to fund abortions for women in Northern Ireland coming to England but they still cannot have them in their own country.

The Abortion Act 1967 [UK but not Northern Ireland] makes abortion legal if one of the following criteria are agreed by 2 doctors.

[a] If the pregnancy has not  reached 24 weeks and there is  greater physical or mental risk of harm to the mother or her existing children and family by continuing the pregnancy.

[b]. At any stage if there is serious risk of permanent injury to the health of the mother

[c] that the continuance of the pregnancy would involve risk to the life of the pregnant woman.

[d]  At any stage if the foetus is likely to be born with severe physical or mental abnormalities.

Pregnancy and delivery are more dangerous than a termination so reason number one suggests that provided the pregnancy has not gone far there is effectively abortion on demand. However late terminations, beyond 12 weeks are rare. 90% are before 12 weeks in the UK.

Abortion is a very emotional subject. It is the only procedure that a doctor can opt out off. But the GMC advises that your personal beliefs should not affect your treatment of a patient. Even if you disagree with a patient who requests an abortion that patient should be treated with consideration and empathy. It may be reasonable to ask her to consider other options if she does not seem completely sure but that should not result in any significant delay. The patient should be quickly referred to a colleague who is willing to help her.

The major organs are formed by 12 weeks. The vast majority, 90% of abortions take place before 12 weeks in this country.  We think that the foetus may begin to feel pain at 20 weeks when the nervous system begins to mature.  When can they think, when does sentient life begin? Philosophers and ethicists and religious leaders have endlessly debated  when recognisably human life truly begins. The Pope and Catholic Church argue that even contraception is wrong because it prevents human life. The law in the UK argues that it is when independent life outside the uterus is possible. Medical science has advanced and many now argue that we should bring down the 24 week limit but the Royal College and BMA argue that while life outside the uterus is possible below 24 weeks babies born this young usually have  permanent disabilities.