"It is much more easier to be critical than to be correct", Disraeli 1860

Editor-the the article starts by, "Kala-azar underrepresented in Indian press..". This is however, not true. It is because, it is not underrepresented but totally misrepresented. Couple of months ago, one of India's leading newspaper in its column known as ‘face off', written by a senior and well known journalist endorsed that kala-azar has long been eradicated from India in 1960s; and there was no need to spend money on it. It is noteworthy that India has pledged to reduce the disease load by 25% till the year 2005 and has planned to eradicate it by 2012. Similarly, another newspaper column wrote that the disease is incurable or drugs are yet to be developed.

Indian journalists are generally hypercritical of efforts, whatsoever, put by the government of India. Unfortunately, even the article seems to have been echoing the same view. It has become amply clear that it is not the government alone; but the non-governmental organizations, social activists, social scientists, local leaders, media, school teachers and the people themselves have to fight for this menace. This is because, for a problem to be as massive as 500, 000 new infections every year; and India accounting for over 90% of cases is unlikely to be tackled by the efforts of government alone. This is due to the fact that overwhelming majority of suffers are poor, and cannot afford the treatment so government has to pay for the treatment also; which means incurring huge financial burden. Moreover, the disease is preventable by taking adequate precautions such as cleanliness and anti-sandfly measures. An important preventive step involves the training of journalists so that at least they report whatever is true and do not mislead the policymakers, doctors, students, social workers and non-governmental organizations.

It is a very good article, but not enough explanation. As a sixth former, i felt that the article is a bit too medical. It would be much easier to read and more interesting if there is a glossary for the medical words, since i am often confused by certain word and therefore found it difficult to understand the article fully.

I think that this problem exists all around the world, including in my country-Romania.

In UK the obesity epidemic might be the result of industrialized food consumption but it is not only the western culture that faces the alcohol problem. Heavy drinking is also common among youngsters in former communist countries where the counterfeited alcoholic beverages are cheap and sometimes the only form of fun/pastime for the young unemployed. Apart from blaming the economic problems and the lack of educational campaigns against drinking and erratic sexual behaviour, the pop culture also has a huge negative impact. At parties it is fashionable to listen some kind of kitsch songs, a combination of folklore pop and oriental music called 'manele'whose lyrics are mainly about the beauty of drinking ('empty your glass 99 times', 'drink when you're sad')or encouraging young males to have multiple sexual partners ('it isn't hip if you don't sleep around,showing how macho you are', 'like I do it with 1000 women'). I am not saying that everyone is buying this music but in the same time a party is not a party without some songs like this. When asked what kind of music they listen, I find 15 old teens answering: manele or 4 year old children that sing explicit sexual lyrics because this is the music that their parents have played at home.

In my opinion this kind of music is also to blame. Does any of you find in the pop music (that has a high audience in UK among teenagers, moulding and guiding in life) the same artificiality and image propaganda that could influence youth?

I am a 17 year old who comes from England, and sadly I have to agree with you.

Today's music and 'hip-hop' influence is taking Britain by storm and I am shocked too by the sexually explicit material on the televsion today, so much so that I am embarassed to watch it alongside my parents.

I feel that it is becoming increasingly difficult to grow up as a teenager in Engalnd without trying a smoke or drink, although I am proud to say that I do not indulge in either of those activities. It is becoming increasingly the responsibility of parents to monitor their children and protect them from the indulgences of 'modern' day life.

I don't think that music is soemthing that can so strongly stand out amoung all the factors that lead to increased alcohol consumption, obesity, drug taking etc. I think what creates this situation is a complex mixture of factors- media( movies, the behaviour of famous people or teenage idols that take drugs and drink loads), individualistic society that brings more loneliness in people's life, the influence of friends or the need to integrate in groups and be "cool", the financial problems or family problems( high rate of divorces, in some countries high incidence of doemstic violence), not enough health education to raise awareness, lack of a value system, or individual factors like emotional instability.

It is, of course, an important problem that needs a multidisciplinary and multistaged approach that should involve all the environments that influence youngsters: family, friends, school, youth organizations etc.

With great interest I read D'Angelo's article on radical remedies. I happen to be profundly interested in ancient egyptian and Greco-Roman medicine and I was happy to find a section on ancient egyptian mecicine in this article but my excitement slowly turned into dissatisfaction as I went through it. Not only because I disagree with many of the author's views but also because some of the information was inaccurate.

I would like first to point out that the widespread misconception that settlers along the nile valley considered diseases to come from evil spirits might have been partially true for the lay people in ancient Egypt but completely inaccurate for ancient Egyptian physicians who adopted a scientific method to deal with ailments. for instance , the Edwin-Smith Surgical papyrus contains tens of surgical cases for which the clinical picture, diagnosis , treatment and prognosis described in a puerly scientific manner without any reference or invocation of any sort of supernatural powers except in one case which historians believe to be alien to the original manuscript. In fact the level of scientific precision and accuracy in this papyrus seems to be stunning given teh fact that it was written at the time when the great pyramids where built!. another mis-statement mentioned is that the medical profession was divided into three sections; physicians , surgeons and magicians. well there is plenty of evidence that physicians in ancient egypt were divided according to SPECIALTY, much like our current divisions, this is in part evidenced by the presence of separate scientifc literature for each specialty i.e. the Edwin-smith surgical papyrus for surgeons, the Ebers medical papyrus for physicians equivalent to GPs, or internists, the kahun medical papyrus for gynecologists etc. these papyri are well preserved and are known to be authentic. Not all physicians classified patients prognostically " an ailment I will treat, an ailment I will contend with , an ailment I cann not treat" this calssification was mentioned in the Edwin- Smith papyrus and again support the fact that ancient egyptians adopted a firm scientific basis to treating ilnnesses, I dont think that somone who attributes ailmenst to evil spirits would care to spend that effort to determine the prognosis.I wonder what are the author's sources as no refernces were cited. I do appreciate the author's efforts to bring ancient egyptian medicine into light, I know this is a difficult subject but such misconceptions and inaccurate inforantion should not be tolerated in the studentBMJ which is targeted to medical audience.

I read the article -LIFE Radical remedies and Morris's response to it.

In that context I will like to mention that the practice of medicine has been recorded in India around 800 B.C.Surgery(Shashtra Karma)was one of the eight branches of Ayurveda(the science of longetivity),the ancient science of Medicine.

The oldest treatise dealing with surgery is the Shushruta-Samahita(Shushruta Compedium).

Shushruta,who lived in Kasi was one of the many Indian medical practitioners which included Ahraya and Charaka.He was the first to study human anatomy.In Shushruta-Samahita he has described in detail the study of Anatomy with aid of dead body.His forte was rhinoplasty(plastic surgery)and opthalmology(ejection of cataracts.He has described surgery under eight heads,Chedya(excision),Lekhya(scarification),Vedhya(puncturing),Esya(exploration),Ahlya(extraction),Vseaya(evacuation)and Sivya(suturing).

A typical operation performed by Sushruta for removing cataract has been described in Shushruta-Samahita.

"It was a bright morning.The surgeon sat on a bench which was as high as his knees.The patient sat at the ground so that doctor was at the comfortable height for doing operation on patient's eye.After having taken bath and food the patient had been tied so that he could not move during the operation.

The doctor warmed the patient's eye with the breath of his mouth.He rubbed the closed eye of patient with his thumb and then asked patient to look at his knees.The patients's head was held firmly.The doctor held the lancet firmly between his forefinger,middlefinger and thumb and introduced it into the patient's eye towards the pupil,held a finger breadth from black of eye and quarter of finger breadth from outer corner of eye. He moved the lancet gracefully back and forth and upward.There was a small sound and a drop of water came out."

There will be believers of science and superstition at all times as science is not perfect,it leaves huge voids to let superstition to creep in.What we have to accept is a compromise!

Reference-Ancient India's Contribution to Medical Science-Chapter 8 -Sudheer

I am writing in response to D'Angelo's article Radical remedies.I think it was a very crude way of explaining the ancient Medicine.I do agree that there were very few scientific explanations for the treatment given in olden days but we need to mind that not every headache had a burr hole.There are some of the herbal medications and "grandma's receipes" used even today to cure some ailments.Instead of blaming ancient physicians,we need to acknowledge their abilities to judge and treat patients with no modern aids.

It is very easy to demean the lowly things from a heights,but one has to realise that these heights are acheived by starting with a small stumbling step.

Dear Editor,

Yes,I do agree with the author that there were all sorts of remedies being tried in a desperate attempt to cure the ailment,but that also means1)the intention was to relieve the suffering, so they can't be blamed for cruelty what the author tried to bring in and 2)there was a systemical approach to a particular problem.

As the autor says "a hole drilled into your skull" for headache I am sure he does,nt mean to say that a hole was drilled for every headache so that means they had a criteria to operate upon even in those times.

The author also agrees that some of the patients benefited so their techniques were working,though not at all efficient.

As with advance in science,hope not in future someone writes an article about how wrong we were.

Science and superstition will always co-exist.Unfortunately science is not perfect,it leaves enough voids for superstition to creep in.What we have to contend with is a compromise!

I really think this is a very important issue, and most students underestimate its gravity. The alcohol consumption is raising , and i see many medical students drinking far too much. The alcohol consumption in developed countries is worryingly common, both in women and men. Having some drinks at a party is fun and perfectly ok, but when a certain limit is overcome or when this becomes a habit, then it stops being fun. I think students need to be educated not towards a "non- alcohol" or "against alcohol" attitude, but towards an attitude of responsability, awareness and self respect- towards a "alcohol with a limit" attitude, so to say.

sir,i feel that the alcohol habit has made its mark since the students are not monitored by the hostel warden adequately.

I trust the potential of herbal medicine, but if the evidence is "incomplete and confusing", how can we than chose an herbal treatment over classical drugs? In what instances? Does a herbal treatment ever work better than a syntethic drug- it would be good to have an example.

Where in the world is herbal medicine used?

It sounds good, and it is a hope indeed, but at this stage can we make decisions based on traditions, or assumptions?

iam writing this letter in response to Erzard Ernst article on herbal medicine put in context.Herbal medicine in India is termed as Ayurveda,which means the science of life and longevity.Herbal medicine believes strongly in the use of whole herbs.Isolated active ingredients or chemically produced analogues are not equivalent to natural whole plant sources.Herbal medicines though not acts on the target symptoms giving immediate effects as long term benefits.It is defnietily not possible to replace them with modern drugs.each one have there advantages & disadvantages.but use of these ancient remidies saves us some money and also nurtures the same nutrients to body.

Herbal medicines are deeply rooted in the earths energy.plants carry the memory of all times.infinite number of plants &herbs have been energetically evaluated by the ancient seers,who refined there medical values and rendered them into herbs powders oils and so on.At this point it is wise to analyse there knowledge...who knows there could be some remedies hidden in these herbs for not answerable questions of our time.

Its rightly pointed out by the Benjamin Geisler in his artical and being a medical student we should help in fighting againt this deadler disease if untreated called Tuberculosis .

Although a wide modalities of treatment are available on free of cost to people but i think due to the lack of education and knowledge , they are anawar of that.The disease was also seen as Social Stigma and which restrict the people to come forward for the treatment.And if few of then start the treatment ,due to the long course,they will left it in midway soon the symptoms will disapper.This give rise to a defaulters,failure of therapy and problem of multidrug resistance. Which causes burden on the developing country in terms of work and money loss.

Being from India-developing country , it is very important that medical student should take part in the control of the tuberculosis .They should spread the knowledge in each and everway possible(posters,slogen,councelling centre,etc) to the general people about the disease.Student should emphasise on Immunisation(prevention right from the birth), early diagnosis and treatment to prevent the spread of disease.Proper referal center should be set for benefit of patients,which make them to reach the medical set up.Student should make then(patient and general people)aware about the WHO's DOTS therapy and also newer method of treating tuberculosis,which are of short duration with lasser complication.Constant motivation oftuberculosis patients are also important for there complition of treatment.At the end I think Health Educaion and Community Awarness will open the doors of disease free lives .

I read with great delight Peter Cross' article on age and medical student selection. However, I think a point that was not discussed was on the number of years a physician will work once trained. As we all know, physician shortages is a major issue globally. Large amounts of tax dollars are invested in training physicians. It is important to realize selecting students in their 40's and 50's inevitably means that these physicians will not be able to work as long as a physician trained in their early 20's on average. I feel this is a point that needs to be considered in this interesting discussion.

Pavi Kundhal

Medical Student, University of Toronto

As someone in their forties who has applied for entry to medical school in 2004, I question Pavi Kundhal's argument that younger graduates will repay the tax dollars spent on their education via years of service to medicine. Any student who obtains a vocational degree, regardless of their age on graduation, may later decide that the day to day reality is not for them. However, mature students usually enter university having made personal and financial sacrifices that indicate a firm commitment to their future profession. Mature students often bring to the study of medicine a broad range of life experiences which hopefully encourages them to treat patients as they might wish to be treated themselves. Presuming that younger students will remain in the profession for a longer period of time may well turn out to be a false economy. Medical students ought to be selected not merely because they are young, but because a university selection panel strongly feels that an individual has the makings of a caring and committed physician.

Susan Gibbins

Pavi,

I am a management consultant who intends to study graduate medicine next academic year.

As a management consultant, a fair chunk of my large salary goes goes to the tax man.

Therefore, not only am I supporting your medical school studies, but am paying my dues (before I start).

You will find that the majority of graduates going into medicine are in the same situation.

Try and think out of the undergrad box.

Kind Regards,

An old man

I am being taught during my medical school years one thing. To practice Evidence Based Medicine. I have spent my fair share listening to the teachings of Arthur Cochrane. I have been taught to consider a treatment or plan of action ineffective until there is a proven benefit*. My school taught me this. Our schools taught us this. Which is why I find it unbelievable the extent to which political correctness is sweeping through our institutions.

There is no evidence that age at matriculation has any bearing whatsoever in performance as a doctor (as measured by grades in the final year of medical school/first year postgrad). Not only that, studies have shown there is no difference.

I would direct you to [http://www.nzmsa.org.nz/archives/A%20policy%20on%20Medical%20School%20Admissions%20-%202001%20(html).htm ] which has a very interesting article on the subject of criteria involved in acceptance to medical school.

But don't let a little thing like fact get in the way of your dreams to use your 'life experience' to the betterment of patients.

References; (straight from the quoted website)

• Neame RL, Powis DA, Bristow T. Should medical students be selected only from recent school-leavers who have studied science?. Medical Education 1992 Nov;26(6):433-40.
• Herman MW, Veloski JJ. Premedical training, personal characteristics and performance in medical school. Medical Education 1981 Nov;15(6):363-7
• Rolfe IE, Pearson S, Powis DA, Smith AJ. Time for a review of admission to medical school? [see comments]. Lancet. 346(8986):1329-33, 1995 Nov 18

As a hopeful mature student with 20 years of management and engineering experience I feel that the extra skillsets I can offer medicine easily balance the deficit of service years I have to offer.

It is also important to consider that the value of mature students does not stop with the skills they possess but also in the new skills that will be passed on to other doctors and the medical profession.

I think the combination of young and mature students will bring a rich mix of abilities that will help to improve the standards of medicine and the care profession. After all medicine is a team sport!

The article written by Mr.Peter Cross is interesting and stimulating. Well I can't help thinking why should this age restriction be present only in medical schools? Why not in other professions? Often many mature students choose their profession by choice and hence may perform better. Younger students may be influenced by the peer group pressure, money, etc., in deciding what they want to do. Ofcourse a lot of money is spent in training doctors. But I don't think this should restrict ones interest. A few years of dedicated work is better than many years of uninterested work. How could we explain the near 12% drop out rate in medical schools in UK?(1) It will be quite interesting to study the drop out rates in mature students and younger students from medical schools. Perhaps this will provide a answer to the debate- Does age matter?

Refernce:

1. James Parkhouse. Intake, output, and drop out in United Kingdom medical schools. BMJ 1996;312:885

Thanking you

Yours Sincerly

I read with great delight Peter Cross' article on age and medical student selection. However, I think a point that was not discussed was on the number of years a physician will work once trained. As we all know, physician shortages is a major issue gI was delighted to read the article highlighting the possibility of transferring between medical schools1. In my experience this is a taboo subject both for both the individual wishing to transfer and between medical schools themselves. Having completed two years of preclinical study at a London medical school, I have transferred to the University of Bristol to complete an intercalated degree in addition to my clinical studies. While this was the most frustrating, difficult and stressful action that I have ever undertaken, I can wholeheartedly say that the trauma has been worth it. Rajakumaraswamy correctly points out that in order to make a successful application, one must cite extremely strong academic or personal reasons. An individual medical student may, however, have perfectly valid reasons for wanting to transfer which do not amount to the strong academic or personal reasons required by the medical schools.

At the age of 18 the typical medical student has just completed two of the most academically demanding years of one's life. Together with academic pressure, there is pressure to achieve in all other aspects of life from the sports field to the care home where one carries out weekly work experience. It is unlikely, therefore, that every medical student has thoroughly researched the establishment where they will spend a minimum of the next five years. Undoubtedly some get it wrong. For these few students there are three options. Firstly one could 'stick at it' in the knowledge that five years down the line there may be the option of moving. Secondly one could consider 'dropping out' and reapplying. Thirdly, transferring is a feasible alternative. Since the ethos of most medical students is to 'make things right immediately', the latter option should rank most highly.

Thus, in the absence of any family adversity or strong academic reason, a medical student may feel that they have chosen the wrong institution and may quite justly decide to attempt to transfer to a different university. The mere fact that one does not have a specific and strong academic or personal reason should not be a deterrent. The best advice is to honestly evaluate one's reasons for wishing to transfer. These reasons may seem insignificant to others but ultimately, if the motives for transferring are sufficiently meaningful to oneself, it should be possible to convey this importance on to others.

Olivia Kingston

1. Rajakumaraswamy N. Transferring between medical schools. StudentBMJ 2004;12:20-21. (January)

In the above article, 'Queen Mary and Westfield Medical School' is a misnomer at best, non-existant at worst. The correct name is Barts and The London.

Best Wishes,

Hassan Elhassan

The article is a very interesting read however a major flaw in it is the use of reference 5 (McIntosh and McCrory; Impact energy attenuation performance of football headgear, Br J Sports Med 2000; 34:337-341) which is one of the major arguments used about headgear. Looking at the reference closely it has been written by Australians refering to Australian Football League (which is also known as Aussie Rules Footy) and not about English Football (Soccer).

McCroryhether mentions that head to head contact can cause enough forces to cause brain injury and that the commercially available soft helmets have little protective role. As this statement has been made used on the basis of information from a game that is similar to Rugby or American Football (and different from English Football (Soccer)) - this totally invalidates the argument. This is because in English Football (Soccer), one of the aims is to head the football, where the brain injuries may occur when two players are leading with their heads in the air attempting to head the ball but instead colliding head to head with eachother. Whereas in Australian Football League, players do not head the ball and instead the injuries occur during the game through other means.

Although this now means that head gear may be protective in English Football (Soccer), although not proven - it is highly unlikely that we will see English Footballers (Soccer players) wearing head gear for protection in the near future.

From time immemorial the medical proffession has been thought of as a nobal proffession.i agree.there is no one who elects to study medicione in order to look for ways to kill patients quickly.therefore the analogy between medicine and careless driving does not arise for the simple fact that if someone is driving while drunken can not be compared to the dutiful doctor going about his work whose forgotten to give an I.V. injection but given I.M. dose/intrathecal injection for a cancer patient.

am of the opinion that this many litigations will impact negatively on the profession because a patient may miss an important treatment which works, just because the doctor is hesitant as he consults with others or feels its beyond him for fear of litigations!

Dear Sirs,

I read the above article and I fail to understand why the debate should arise at all if there is clear understanding of legal terms and their application in the cases mentioned.

Manslaughter is the unlawful killing of a human being without premeditation.When the author defends the case of Mulhem saying "he was not trying to harm the patient" he should realise that that fact has already been taken into consideration making him worthy of manslaughter and not murder.Secondly when he mentions that the increasing prosecutions for medical negligience reflects society's changed attitude towards notion of gross neglience,it would be wise to note that(1) the success rate for medical manslaughter prosecutions is much lower than for manslaughter generally. The reason is simply that for a manslaughter charge to stick, it must be proved that the defendant caused the death. The cause of death is much harder to state with certainty in medical cases than in more ordinary manslaughters, such as a death after a fight got out of hand.

Of the 21 doctors charged between 1970 and 1999, 10 were convicted, but three of them had their conviction quashed on appeal. Of the six doctors charged with manslaughter between the beginning of 2000 and mid-2002, only one, an anaesthetist,was found guilty. At least three of the remaining five were acquitted on the direction of the judge, after the prosecution case collapsed. In another, the judge had nudged the jury towards its decision by summing up for an acquittal. By comparison, Home Office figures for manslaughter cases generally in 2001 show that of 278 defendants who stood trial,238 were convicted and only 40 acquitted.

Of the 21 doctors charged between 1970 and 1999, 10 were convicted, but three of them had their conviction quashed on appeal. Of the six doctors charged with manslaughter between the beginning of 2000 and mid 2002, only one, an anaesthetist,was found guilty. At least three of the remaining five were acquitted on the direction of the judge, after the prosecution case collapsed.

In the end it should be noted that accidents can be prevented by care and care can be learnt,by reward or by punishment.

1. Doctors face trial for manslaughter as criminal charges against doctors continue to rise- http://bmj.bmjjournals.com/cgi/reprint/325/7355/63/a.pdf.

Over the holiday period, I had a long chat with a friend who has recently given up a career in anaesthetics. He reached the level of registrar in anaethetics, having quickly progressed through the system after qualifying. His main reasons for giving up, were related to fear over litigation and the possibility of criminal charges being brought against him, as had happened to several of his colleagues recently. Some of these problems were due to being put in positions where he was out of his depth without more senior support. This could be resolved by ensuring that the system does not allow this to happen. However, no matter how good the system is at controlling these errors, genuine mistakes will always be made and this is part of life and learning for a junior doctor.

When a loved one has a bad 'car accident' we want a highly skilled and experienced anaesthetist to look after them when they reach hospital. we've just lost one largely due to this culture of blame. Unfortunately, no amount of litigation can bring dead people back.

There may come a day when there are not enough anaesthetists, obstetricians or midwives due to fear over litigation or the inability to get adequate insurance. what do you say to people then?

Just yesterday a portion of my class was discussing in seminar the exact same issue of medical mistakes. The idea of charging a hematologist with murder for mistakenly injecting the wrong drug is a frightening prospect that does not occur, to my knowledge, in Canada. The principles outlining medical mistakes and how I understand them from our discussions are as follows:

1) A health professional that commits a medical mistake, and is honest and upfront about his mistake from the getgo, is not a criminal by virtue of the fact that he intends no harm. Medical mistakes that result from honest incompetence are dealt with by the professional regulating body, as they provided the license in the first place.

2) Putting blame on one individual will not prevent the mistake from recurring in the future. Rather, an examination of the system that allowed such a mistake to occur should be examined. For example, where are the safegaurds to ensure that wrong drugs are not administered, such as the pharmacist that checks what the drug is for and makes appropriate labels, the nurse that is standing by and who may know the drug is supposed to be i.v., the junior doctor who should similarly have some knowledge of the drug he is injecting? Where are the supervisors of Dr. Mulhem, who allowed him to work on his own after being on the job for only 2 days and not having had any prior experience with chemo? These are questions that are not intended to shift blame, but rather to identify the 'holes' in the system that allowed a chain of mistakes and assumptions and bad luck to coalesce into a fatal event.

3) The poor patient's family has every right to be angry at a mistake of such fatal consequences. But will it comfort them more to know that a doctor who had no intention to harm was thrown in jail, or that something is being done via a systems-based approach to prevent someone else's family from losing a son?

4) The result of this prosecution and the trend towards punishment of mistakes is to drive fear into health professionals' hearts. Instead of being honest with patients and colleagues, health professionals will feel the pressure to cover up their mistakes in order to avoid punishment. In that sort of environment everyone loses out.

Matters relating to medical litigation often seem to be confused with the issue of whether or not doctors should be immune to criminal prosecution simply on the basis of their holding a medical qualification. I doubt anyone could convince me that this should be the case.

However, I remain unconvinced that doctors should be labelled criminals for making a genuine error in their daily work. The Collins Concise English Dictionary defines a crime as "an evil act" - surely not a description that can be applied to a genuine clinical error?

Investigations into this area should look for the presence of any malicious intent in committing the mistake, and if proved to be appropriate, criminal action can then follow.

In the absence of criminal ("evil") behaviour, it should be sufficient for incidents to be dealt with by medical regulatory authorities such as the General Medical Council.

This is indeed an exciting opportunity for the students of the University of Canberra. Near to the completion of my B Applied Science (Medical Laboratory Science) [now known as B Medical Science],I was fortunate to be offered a place at the University of Sydney. Many of my lecturers were unaware of the graduate medical programs available, and it was only by luck that I discovered this degree.

How wonderful it is to have this option offered to the future students of U Canberra, not only for the students but also for the faculty. The program offered when I was a student was fantastic but unfortuately poorly subscribed. This will hopefully encourage more students to undertake their studies at what is a fantastic University in a beautiful city.

I only wish it was available when I was a student.

Perhaps I'm a cynic, but this Hungarian adventure merely sounds like the opening up of the 'export medical education', most popular for American graduates who can't enter medicine, into the Australian market.

It is well known that, at present, graduate entry programmes are generally far less competitive than the respective admission requirements for high school leavers.

If, after graduating from university, an applicant is still unable to enter any medical school in Australia - perhaps we should be asking two questions; (i) Is this applicant suitable for a career in medicine? (ii) Are the admission requirements for medicine reflective of the required abilities in future practice?

I find it especially worrying that an applicant not even deemed suitable for a 4 or 5 year graduate course in Australia is then offered a 3 year course in Hungary.

Nicola Cooper provides a useful discussion of how to recognise patients who are critically ill in her article "Recognising critical illness" (1).

This is particularly appropriate as the Department of Health have raised concerns over junior doctors' ability to recognise these very patients (2).

In response to this, Doctors.net.uk and the National electronic Library for Health have launched a series of electronic education modules, available free of charge to all UK doctors and medical students. These, and many other modules, can be accessed at www.doctors.net.uk. It is hoped that as many colleagues as possible can benefit from these resources.

Scott Oliver

Intercalating medical student, University of Glasgow and Medical Student Co-ordinator,
Doctors.net.uk

Dr Tim Ringrose

Medical Director
Doctors.net.uk

1. Recognising critical illness, StudentBMJ 2004; 12: 12-13 (January)
2. Knowledge of aspects of acute care in trainee doctors. Postgraduate Medical Journal 2002;78:335-338

I agree with Nicola Cooper that the recognition of critical illness is a fundamental aspect of medical training that is too often neglected (1). Any House Officer unable to distinguish a stable from deteriorating patient and act appropriately needs to seriously reconsider their clinical competence. Early Warning Scores (EWS) and other Patient-At-Risk criteria provide simple measurement tools that can be utilised by a range of health care workers. Evidence of their efficacy in the medical setting is growing (2), but it can be argued that they are a cumbersome replacement for what should be basic common sense.

Having audited different EWS during attachments in both Accident and Emergency and Medical Admissions, I found Respiratory Rate (RR) was clearly the most sensitive parameter in any score applied. RR as a predictor of significant deterioration has been well documented (3,4). One study observed that increased RR was four times more likely in patients preceding cardiac arrest (5). Documentation of such a potent indicator of critical illness by doctors is unacceptably poor, and this is a problem that could be addressed at medical school. The message that simple measurements really do matter must be highlighted from the first day of clinical skills training. For those who currently don't take the time to measure respiratory rate, the introduction of scoring systems will necessitate consistent documentation of all vital signs, and ultimately reduce suboptimal care through the improved recognition of critical illness.

References

1. Cooper N. Recognising Critical Illness. StudentBMJ 2004;12:12-13 (January).
2. Subbe CP. Kruger M. Rutherford P. Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM 2004;94(10):521-6.
3.
3. Fieselmann JF. Hendryx MS. Helms CM. Wakefield DS. Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients. Journal of General Internal Medicine 1993;8(7):354-60.
4. Schein RM, Hazday N, Pena N, Ruben BH. Clinical antecedents to in-hospital cardio-pulmonary arrest. Chest 1990;98:1388-92.
5. Hodgetts TJ. Kenward G. Vlachonikolis IG. Payne S. Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2004;54(2):125-31.

However, the tone of Mr Goldie's original opinion article, if not the title ("Religion must not enter medical practice") did not give me the impression that he was merely trying to "explain that even those without religious faith can still care for patients" (2). If this were the case, I doubt there would have been such an outpouring of response. Instead, as the title suggests, Mr Goldie's opinion appeared to be that religious faith in medicine risks good and fair clinical practice, and should therefore be discouraged in all doctors. He further states "Religion has no place in the practice of any healthcare professional. The same standard of medical care must be provided equally by all doctors and must be based on evidence and not on personal beliefs."(2) This is a very bold assertion, and it is not surprising that many readers found such easy criticism of their beliefs to be deeply offensive. However, the criticism is an important one. Biased and superstitious practice of medicine should not be tolerated; and if religious faith is truly a real liability to our patients, then something ought to be done about it.

Having said this, I feel that several further points are relevant to the discussion.

Firstly, Mr Goldie suggests that Biblical texts are of the same evidential calibre as anecdote (1). This is not true. There is significantly more evidence for the textual reliability of the New Testament documents than for that of any other ancient text (3). The truth of the gospel accounts is, of course, another matter. But to dismiss the text as nothing more than anecdote is effectively to throw all ancient writings into doubt, including those of Plato, Caesar, Tacitus, and Pliny.

Secondly, the attitudes and practices advocated by Mr Goldie (that "everyone must be treated with equality, respect, and non-judgemental care"(2)), are identical to those encouraged by the Bible. Thomas Sydenham, a founder of modern clinical medicine and known as the "English Hippocrates", provides a well-phrased explanation: "It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things:- First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care. Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for His glory, and the good of mankind, and not for mere gain or ambition. Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with His divine dignity, and far more than this, died to redeem it. And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer." Thomas Sydenham (1624-1689) (5)

So, far from encouraging biased, prejudiced, or sloppy care, Christian beliefs concerning the nature of God actually provide a powerful rational for striving to be as fair and clinically competent as possible.

Finally, Christianity was and is central to the lives (including the working lives) of many notable doctors, past and present. A list of such people could include Edward Jenner, Thomas Hodgkin, Joseph Lister and C Everett Koop (4). Given that Christian beliefs can be founded on rational principles, encourage and motivate good clinical practice, and continue to positively influence the lives of many doctors, it is difficult to imagine why it might be a good idea to try to force a dichotomy between belief and action in clinical practice.

Sincerely,

Ian MacCormick

References:

1. Goldie SJ, Religion in medicine: author's reactions to responses. StudentBMJ 2004;12:39. (January)
2. Goldie SJ. Religion must not influence medical practice. StudentBMJ 2003;11:435. (November.)
3. McDowell J, The new evidence that demands a verdict, Thomas Nelson publishers, 1999.
4. Graves D, Doctors who followed Christ, Kregel Publications, 1999
5. Thomas Sydnam, quoted in Patrick J, Hippocrates and medicine in the third millenium. http://www.johnpatrick.ca/papers/jp_hippoc.htm/ (viewed 5.01.04)

Rebecca Hope asks us to "jump off the conveyor belt" and stop putting pressure on ourselves to acheive. To illustrate this, in her few months off, she has published her first paper, written a guide for medics on elective, learnt to play the guitar, and improved her Portuguese. If this is Ms Hope when she is relaxing, her list of achievements when she is pressurising herself must be truly frightening.

Whilst I applaud and agree with her sentiments, I find it vaguely patronising that she urges us to relax and slow down when she has so patently not achieved that herself. Relaxation is essential for a medic to prevent burnout in a long and arduous career. As a student, I have usually found relaxation to be synonymous with daytime television. I suggest that Ms Hope starts watching double doses of Trisha and Neighbours now.