Syria’s healthcare – started from the top and now at the bottom

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الشعب يريد إسقاط النظام‎(Ash-shab yurid isqat an-nizam) – “The People want to bring down the regime”. This slogan represents the will of the people of not just one country, but of an international movement in the Middle East and North Africa called the “Arab spring”. Beginning with the Tunisian revolution in 2010, the Arab Spring culminated in the toppling of or major uprisings against longstanding regimes in Tunisia, Libya, Egypt, Yemen, Syria and Bahrain. What started as a relatively peaceful revolution in Tunisia (relative to the others in the list), resulting in the successful ousting of Ex-president Ben Ali, turned more heated when the revolutionary fervour migrated eastwards to similar autocratic authorities of Libya, Egypt, Yemen, and the focus of this article – Syria.

To be more specific, this article talks about on the health care workers of Syria, who have been working in the background during the Syrian Civil War to heal people on both sides of the conflict, and the civilians who happened find themselves in the wrong place at the wrong time. This might seem like a challenging task already, and one might think that the government as well as the opposition leadership would support the health care workers, who are serving an important role for their cause – that of healing the injured. However, what we instead see is the systematic targeting of health professionals in both government controlled and non-government controlled areas of Syria. The Syrian Civil War has truly been a destructive experience, and has brought one of the highest functioning health care systems in the Middle East before commencement of the civil war to its heels. Like the revolutionary fervour of the Arab Spring, what happens in Syria does not stay in Syria, and this article will also highlight the plight of the Syrian refugees: the victims and carriers of communicable and non-communicable diseases that place great burdens not only on themselves but also on the governments of the refugees’ host countries.

For the people who watch the news regularly, most would remember the period during which there was regular reporting of the Syrian refugee crisis, showing pictures and videos of boat-fulls of Syrians making their arduous journey across the Mediterranean. This represents an incredibly dangerous part of the migration journey for any Syrian refugee determined to reach the safe havens of Western Europe like Germany, France, Sweden etc. A lot of people tried, and many boats sunk with their passengers. This poses a question – Why did these people risk their lives crossing the Mediterranean?

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It is because the mass exodus of Syrian refugees has posed a very heavy burden on their hosts in the Middle East. There are 3.3 million in Turkey, 600,000 in Jordan, and just over 1.1 million in Lebanon – that’s 1/6 of Lebanon’s population! Although these Syrian refugees have no luxuries to speak of inside the cramped refugee camps or various urban/rural lodgings, they do require quite a lot of expenditure in the way of health maintenance. For example, a survey conducted in 2017 found that 86% of households in Lebanon and 88% of households in Jordan included at least one woman who has had at least one childbirth in the last year. Nearly all of these childbirths happened in health facilities (94% in Lebanon and 98% in Jordan). While this does show the remarkable flexibility of these host countries’ healthcare systems in accommodating the significant influx of extra users, the financial funding for these vital services are do not follow the demand very well – the UN has called for an extra $4.4 Billion funding to be channelled to the neighbouring countries, which in summation host over 5 million Syrian refugees. This under-funding means that the prices of a lot of the services available in the healthcare systems of the host countries may not be affordable for the refugees. Although the UNHCR (United Nations High Commission for Refugees) covers the large majority of the costs, even small contributions demanded from the refugees maybe more than they can pay.

This situation is only made worse by the risks of infectious diseases that comes hand in hand with any mass emigration of people. The unsanitary conditions, poor access to proper healthcare, and the interpersonal contact that occur as a result of moving to foreign places form an unholy trinity that increase the likelihood of outbreaks emerging. Measles, Leishmaniasis and tuberculosis outbreaks have all swept through Syria and onto the neighbouring countries. Even polio, a disease thought to have been eradicated from Syria since 1999 by means of vaccination campaigns, have returned 2 times, most recently in 2017! This is because since the civil war there has been a deterioration of the government polio vaccination programme, with the people in areas controlled by ISIS and other non-government groups being even less accessible to vaccine programmes.  The lack of vaccination and public health systems in Syria as a result of the civil war has turned Syria into a breeding ground for various pathogens that are usually well-contained by effective public health services. As these infections leak to the surrounding countries with the refugees they pose a serious risk to these countries’ public health as well.

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The spread of cutaneous leishmaniasis can result in severe disfiguring

Of course it is not just a matter of treating and isolating people with infectious diseases for the host countries – plenty of refugees have other non-infectious problems. These often chronic problems are also more costly in their treatment than their infectious counterparts – where as you only need to have a proper antibiotic regimen for a case of tuberculosis you need extensively planned regimens of chemotherapy for cancers, or a constant supply of insulin for diabetes. It may surprise you that non-communicable diseases, obesity associated diseases being among them, is the leading cause of death in the Arab world. It may also surprise you that of the Syrian refugee women from the West Bank of Palestine, 30% are overweight, 39% are obese, and 7% are extremely obese. The refugee’s obese condition is not due to over-nutrition – alas, quite the opposite, for the food insecurity of the refugees have pushed people away from the expensive fruits and vegetables to the less scarce supplies of carbohydrate and fat rich foods, resulting in the gaining of weight.

The problem of obesity is a central risk factor to a massive web of different non-communicable diseases – diabetes, depression, heart attacks, metabolic syndromes and so on and so forth. However, it is not the only risk factor experienced by the refugees fleeing Syria. The very act of having to uproot your family and leave the house you grew up in is a very stressful process, and so are the various experiences the refugees have on the road. Some refugees have to walk hundreds of miles only to be turned away at security check points because they lack documentation. Some refugees are insulted by foreigners and are powerless to do anything. Some refugees lost loved ones on the roads or at the sea. The powerlessness of these refugees means the psychological and emotional stress they experience are constant, and they live in constant uncertainty of what might happen tomorrow. Although they have to be concerned more about the immediate future, doubtless many of them also wonder if they might see the loved ones they may have separated from during the trip again; They might think of their home, and wonder if it has since been replaced by a bomb crater. It is unfortunate, and troubling, to think that the refugee health services are too thinly stretched to provide adequate treatments for non-communicable diseases in the host countries, for none require them more than these refugees.

“Turkish authorities have estimated that 55% of the 3 million Syrian refugees there need mental health care, while half of those families believe they need psychological support. In Germany, which has taken in almost 270,000 Syrian refugees, one study estimates 50% have mental health issues and have been victims of violence. Resources to address mental health are scarce, but experts say immediate treatment is needed to avoid long term damage.”

So far I have only talked about the experience of refugees outside of Syria, but as you can imagine, the situation is only more dire inside the war-torn homeland of these refugees. Before the Syrian uprising – and consequentially the civil war – the Syrian health system have been making very respectable progress in improving its health outcomes on a population wide level. Life expectancy from birth was 56 years in 1970 and by 2009 this has increased to 73.1 years. Similar remarkable improvements were achieved in infant mortality and childhood mortality. It also had the leading Pharmaceutical industry in the Middle East. There were issues with the equity, transparency and manpower supply of Syrian healthcare, but the Syrian people didn’t revolt because of their healthcare system.

The civil war changed all that, and undermined years of progress in the health sector. Ironically, the government seem to be instituting a policy of war on its own healthcare infrastructure – one of the few achievements that the regime could actually be proud of before the war started. The rationale behind this decision portrays the unspoken belief of the Al-Assad regime that the enemy are within the population which it tries to control. The regime has many enemies in Syria, comprising of ISIS, other jihadist groups like Hayat Tahrir Al-Sham, and various anonymous tribal resistance groups. The war in Syria is a political struggle for some, a religious struggle for others, and a quick power trip for those who have grudges against others to settle. In the end, all these people struggle for peace, yet due to the presence of so many different factions of competing interests, encouraged by international support, peace is still very far off. As such, many sides of the civil war actively prevent the assistance of suspected enemies among the injured and the sick – in other words, civilians – by health professionals. Unfortunately, the Al-Assad regime is not alone in its terrorization of the healthcare system, but it is the most readily accessible one in terms of data collection.

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To work in the Syrian healthcare system in the current time takes a lot of guts and a lot of commitment. There is a lot of intimidation against people working in healthcare as a result of the violence that has been discharged against some of the healthcare facilities. The acts of violence committed that resulted in the deaths of medical personnel include bombings, shootings, tortures, and executions. However, in the aftermaths these acts are not investigated and the guilty brought to justice. In fact although there are statistics on the numbers of different types of attacks, the perpetrators of these acts are hardly known. Nonetheless, in some cases these acts are clearly coordinated by established authorities – the Russian jets most likely knew they were targeting hospitals, the rebel mortar teams most likely weren’t shelling on random, and a few poorly sourced chemical terrorists most likely didn’t get their supply of Sarin nerve gas from the internet. As a result, many health professionals have relocated and separated the different departments of the hospitals as to make it harder for the attackers to find them, and if they do, to minimise the effect they can have on hospital service. However, the targeting of health service is so efficient that some areas cannot sustain the health service in the face of these attacks – such as in eastern Aleppo in November 2016.

As a result of these persistent, deadly attacks, the majority of the medical professionals of Syria have followed the emigration of refugees from Syria. In 2009, there were 29,927 doctors in Syria but by 2015 15,000 doctors had left the country. Turning the guns on the remaining healthcare staff has only worsened their situation, as now the staff not only have to manage the impossible influx of patients, but also contemplate the possibility of dying on the job. You can try to ignore the latter of the two concerns, but it becomes virtually impossible when you hear the sound of explosions just a few yards from the clinic, and are confronted with the consequences of what might happen to you in front of your own eyes. “After a barrel bomb falls we start dancing, the Arabian dancing. We are not dead, and if nobody is dead among us, we start dancing.” says a health worker.

This shortage of willing medical staff has created serious voids in the staffing of hospitals. Thus, working in Syria would be every medical student’s dream, and every medical student’s nightmare. The inexperienced students are given jobs that would normally require many more years of training and experience. However, due to the fact that there would otherwise be no one to do the operation and the patient would literally die, these students are given the best description of the surgery within the limited time available, and rushed off to the operating theatre. If the operation is a success, then the patient lives, and if he dies, then the medical student can at least have reconciliation in their ignorance. Perhaps President Bashar Al-Assad wouldn’t mind stepping into the clinic once in a while and use his ophthalmologist training to help in some operations – I’m sure the staff would all be there to greet him.

The present state of Syria’s healthcare is quite unlike anything I could possibly imagine. The lack of anaesthetics for operations, the amount of amputations one has to do, the need to ration everything available must exhaust the best of physicians. What about the civilians? The primary healthcare system is basically non-existent, so if you don’t have an emergency you probably won’t be treated in the hospital (and going to the pharmacist may not necessarily be the best alternative) and if you have emergency you just have to hope you can get to the hospital soon enough. What about the pregnant women? Obstetrics is one of the sectors in the shortest supply, and pregnant women in rural areas would have to walk strenuous distances to give birth in a healthcare context. It is no wonder that some women are caught out and have to give birth on their way to the hospital, with out professional help, hygiene or dignity.

“Everything is allowed in a field hospital. You can put the intravenous line in with alcohol – we do it all the time. You can do operations without sterilised materials, without anaesthesia machines.” – a healthcare staff working in a field hospital in Syria.

What about the future? When Syria finally becomes united under one political leadership, how can it reconcile with the healthcare services which it sought to tear apart? How can it repair its infrastructure and undo the chronic health problems imposed upon the population as a result of the civil war? These are very tough questions for Syria in the future, and one can only hope that the sectarian tensions currently rampant in Syria and its neighbours will not lead to too much delays in projecting the country’s efforts towards rebuilding instead of destroying, in realms of healthcare as well as beyond.

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My Public Health Internship

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People like to do good, and they like to feel like they are doing good. When I first signed up for an internship at the Health Protection Team at the East of England branch of Public Health England, I was worried that although the job is good, I wouldn’t feel good doing it. I was worried that I would be looking at pages after pages of data, discerning patterns between 2 axis on a graph or 2 bars on a chart or 2 slices of a pie(although no self-respecting professional statisticians would ever use a pie chart). However, the work I found was rigorous rather than tedious, stimulating rather than exhausting, and each new case brings with it stories of people rather than yet another load of data to analyse. I think it is fair to say that similar to the young adults who suddenly came down with measles, because their parents didn’t get them the proper MMR vaccines when they were little toddlers, I was taken by surprise!

I suppose my first surprise is learning on my first day that the department was actually part of a GP surgery – and a very major one at that. This GP surgery included all kinds of fancy equipment and services – it had its own imaging facilities, midwifery services, rehabilitation department etc. It was the Swiss army knife of GP surgeries, and although the outside the building was honestly quite bland, the inside was actually very classy. The lobby looked almost futuristic despite the budget waiting chairs, perhaps due to its openness and the white walls. Perhaps it doesn’t sound very impressive on paper, but think about it – if it wasn’t impressive then would I take the time to write about it? Yes, I probably would just to bulk up my content.

So here I was, standing in this vast lobby, looking for signs directing me to the public health department. I walked around clueless, until I eventually happened upon a very nice public health department administrator, who kindly showed me to the office upstairs.

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“Most members of the public don’t even know that we exist until we phone them to ask them about their condition”. The consultant that managed my placement told me. It’s true – public health exist on the backbenches, not featured on the website of the GP surgery if that is where they are situated, and not noticed in its day to day activities by the general public. When the staff of the public health department need to call the NHS patients about their condition to collect data, they would often ask the patients’ GP or physician to inform them in advance that they should expect a call. Otherwise, the patient may be taken back when a call comes from a department they have never heard of, asking them personal questions ranging from their sexual activity and their recent whereabouts.

Nonetheless, the public health protection team work away in the background, turning the cogs of the NHS, or rather, oiling the cogs. As opposed to dictating policy or targets for the healthcare services, it only checks that there are no serious threat to the health of the public in terms of new infections, environmental disasters/anomalies, or even biochemical/physical attacks on the population. In the background, the staff worked when volunteer healthcare workers returned to the UK from West Africa after the Ebola epidemic, making sure they were free of the deadly virus; they were there recently when the deadly forest fires erupted in Portugal, providing the population with advice regarding the smoke given off; they provided services in the aftermath of the Salisbury chemical attack, ensuring the neural toxin did not escalate into more deaths.

As I looked over the shoulder of the public health protection nurses during their work, I saw them accessing hundreds of NHS patients’ medical data without these patients ever having given them permission to do so beforehand. After reviewing their case, the nurses would phone GPs, labs and patients to gather even more information. This can uncover even more sensitive information, including the people that the patient lived with, whether they regularly injected drugs, their sexual histories etc. As long as the patient was suspected of having a condition that poses significant risks to the health of the general population, the person cannot prevent their data from being held and viewed by the officials in public health protection.

What makes this unconsented access of confidential data pragmatic and tolerable? This question can be answered by looking at one of the many outcomes of what happens when public health protection advice are ignored: The appalling care provided by Mid-Staffordshire NHS Foundation Trust. This was a widely publicised news item when the dismal standard of care at the trust was uncovered. Coupled with the shocking amount of time that this went unreported, this culminated in a gruesome post-mortem figure of 400 to 1200 extra deaths in the trust, as a result of the poor care over the course of Jan 2005 to March 2009.

Although the failings of this particular trust also included clinical incompetence and negligence on the behalf of both nurses and doctors, poor precautions against infections was no doubt a key player in this particular healthcare disaster. The safeguards against spread of infections were simply overlooked by healthcare staff. Patients were left in their own defecate and urine for hours, and the some patients’ families had to clean the toilets after the patient has had a case of diarrhoea. The reasons for these actions? The nurses were so afraid of contracting the infections themselves that they were willing to let the patients suffer the consequences.

This example highlights the importance of the work of public health protection to the quality of healthcare on the wards: If infections are uncontrolled, across the wards sanitary condition can disintegrate to the point that the nurses themselves are afraid of going near the patient and doing their jobs. This can then have a spiralling effect of the wards becoming more unclean, further increasing the spread of infections. The advice provided by public health protection doesn’t just boost the quality of care – it is essential.

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Some of the cases I saw the department deal with were fairly benign. They were your food poisoning, urine infections, and bloody stools. It struck me that we have grown so accustomed to these illnesses that we usually don’t pay attention to just how prevalent they are in society. For these illnesses, we usually accept the symptoms when we get them, knowing that with bed rest and some basic medicines the symptoms will eventually disappear. It is no surprise that our vulnerability to these microorganisms are frequently overlooked. Make no mistake – while the symptoms come and go, the resilient microorganisms responsible are here to stay. If we purge them with drugs, the lucky mutants will survive. If we vaccinate the majority of the population, they will exile themselves to the surrounding environment or other animals, waiting for the right opportunity to return.

In winter, the Influenza virus and Noravirus become public health enemy No. 1 & 2. Every winter, the “winter flu” (Influenza) comes and takes many lives from the most elderly and most young. While the “winter vomiting bug” (Noravirus) only causes a flash of vomiting and diarrhoea in well developed countries like the UK, in the poor countries of Asia and Africa it causes increased deaths every winter. The public health protection staff call winter the “flu and poo season”. Although we try to vaccinate ourselves and to employ efficient antibiotic regimens against these pathogens, every winter they always manage to return with a vengeance. However, the difference in mortality rates between rich and poor countries should show you that good public health protection measures helps us to limit the degree of harm done by these two bugs.

While flu and poo aren’t so scary, there are some species of bacteria that can do a lot more damage to our bodies, and plenty of these live freely in the environment or are carried by non-suspecting individuals. Some microorganisms get to work straight away if given the chance, acting with speed and recklessness. Strep A is one such “hothead”. It is a bacteria found throughout the environment, most of the time being carried around harmlessly on a person’s skin or in the colourful flora of our throat. Even when it is infectious, most of the time it never enters our bloodstream, so it can only give us a sore throat. However, drug users who use unsterilised needles should be very concerned about this bacteria indeed, as I found out in a case of homeless drug users who let loose the bacteria in their blood after sharing unclean needles with each other. If even a tiny dose of the bacteria is transferred from the unclean needle into the patient’s blood stream, the patient can go into sepsis – meaning death within hours if untreated. In some instances  the ambulance is called too late and treatment doesn’t arrive in time. For the homeless intravenous drug users, there could easily have been no one around to call an ambulance for them if they slipped into sepsis, so they can be considered lucky in some respects. Furthermore, those who survive may need to have major reconstructive surgery or even amputation due to complications like “necrotizing fascitis” – a truly horrific condition to witness in real life.

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Alex Lewis, survivor of an invasive Strep A infection. The aftermaths of the incident speaks for itself.

These are the sorts of problems that I saw the public health protection staff deal with in my brief week in the department. Although they only worked behind their desks to deal with these problems, one can almost imagine them as field detectives, because they are the ones that have to chase the leads and connect the cases they are dealing with. They phoned up the clinicians to uncover more information, and frequently “sent for the labs”.  The clinician’s notes or figures from the lab only form only the primary stages of their investigation, and paints a picture of the aftermath of the incident. They have to decide upon the information they collected if the case actually require any intervention from public health: For example, public health protection can do no more to prevent the spread of an infection, if the patient was reported after the period during which the pathogen could spread to another person has passed. The administration of vaccines and prophylaxis to close relations of the patient in the hope of stopping them from developing symptoms would achieve nothing because by that time it would be too late. On the other hand, if the patient is still infectious then action will be taken to prevent the patient from passing the pathogen to others and afflicting others with their condition.

The bread and butter of the detective work lies in asking the right questions to solve the key question to the outbreak – where is the origin of the infection? If I am committed to continuing the criminal analogy, then the spread of an outbreak from a source is like the spread of violence from a gang of criminals – It is not sufficient in public health protection to simply capture and treat one case of infection, two cases or even one million cases because the source of the infection will continue to turn more healthy people into infected carriers. The public health protection officials have to work as quickly as possible to link together the cases they have in order to discern a commonality that all the cases possess. Through this, they can arrive at the source of the outbreak – a number of avian flu sufferers from all over the country could have been found to visit the same bird sanctuary, for example. Only when the source of the infection is destroyed can the cases of infection stop rising (assuming it hasn’t established another source that it can use) and hopefully start to decline.

However, there are often great challenges in pinning down the source of the infection, and sometimes this task can become virtually impossible. I remember one particular gentleman was afflicted with Legionnaire’s disease after an exotic road trip through Italy and France. Legionnaire’s disease is caused by the bacteria legionella,which spreads by aerosolised water from waterfalls, garden hoses, showers etc., and if untreated it has a high rate of fatality. Although the gentleman was fairly unlucky in contracting a relatively rare disease on his holiday, lagging not far behind are the public health protection staff, who have to meticulously research if any of the hundreds of places he visited on his holiday have contaminated water features. Picking out the water feature responsible for his infection would be like finding a needle in a haystack! This is exacerbated by the fact that the numbers of reported cases for an outbreak is usually in the single figures (you would hope, as more reported cases of an outbreak indicates either a more rapid spread, or a lateness of outbreak detection), drastically reducing the reliability of the links between cases – so what if all 4 patients shopped at the same supermarket? The other shoppers haven’t come down with the illness!

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Map showing new cases of bovine TB (OTFW = Officially Tuberculosis Free status Withdrawn)

Another challenge of the job is that even when the risk factor for the infection is clear, there can be barriers preventing their amelioration. Quite regularly when public health protection request confidential information regarding customers from organisations suspected of harbouring risks factors (e.g. holiday parks with an outbreak of food poisoning), the organisations refuse to do so on the grounds of the Data Protection Act. They say that under the Act, they cannot hand over confidential issues regarding their other customers, not realising that under the Public Health Act, the public health protection authorities can override the Data Protection Act and demand these organisations to hand over data for the purposes of disease prevention. This one simple legal issue has been the source of many pedantic squabbling when trying to collect data.

Furthermore, public health protection departments have no real power in terms of implementing clinical change – they can only recommend that certain health professionals should do certain things. They cannot make the hospitals hire more cleaners to ensure better hygiene, and they cannot control how clinicians carry out care. There were cases when the clinicians refused to comply with recommendations from public health protection staff, even though their compliance could be essential to the prevention of other people from becoming infected. Under constant pressure to care for their own patients, the implicit attitude of the clinicians is one of “well other people are not my patients”. For example, one doctor refused to ask a married man recently infected with Hep B, a mainly sexually transmitted infection, how he contracted the disease, since the man’s wife did not have Hep B. In the end, the public health protection officials had to phone up the man and interview him themselves. When there is no alternative to getting the cooperation of clinicians, however, the public health protection officials often have to do a lot of manoeuvring in the hospital hierarchy. They may have to inform the clinician’s boss or the boss’s boss just to get the clinicians to do one simple thing in the interest of public health.

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As you can probably tell, although I have tried to make public health protection seem colourful, it is not the most glamorous of jobs, nor does it have the highest prestige or the most lucrative of salaries. However, based on my week here I have become rather infected with the rigorous detective work of public health protection investigations, and I have no doubt as to its importance. It brings together a lot of individual stories and connecting the dots requires a lot of “out of the box” thinking along with experience in the field. I feel obliged to give my own recognition to the creative, careful and very necessary work that this rather anonymous department carry out in the background.

At the moment, travel and novelty is high on my list of priorities, so I am still trying to explore around my interests. However, this is not to say the experience I have had at the Health Protection Team of Public Health England is any less rewarding. Apart from the knowledge this experience has given me, I believe it has affected what I will do in the future. Perhaps I will work in a longer term public health internship next summer, or perhaps I will take a road trip to Italy and France like the gentleman that came down with Legionnaires(I bet it was worth it), or perhaps I can find a role that incorporates travelling with public health. In any case, this insight into a relatively obscure department has made me realise how rewarding internships/placements can be, and I would highly recommend anyone thinking about work related opportunities to spend the time emailing and trying to secure one for themselves, be it in public health or some other weird and wonderful things.

As a general rule, if you want to apply to work opportunities, firstly take the time to look into what the organisation you are interested in actually does and what their goals are. Secondly, tell them in your email what you think they do in the organisation, what they would get from you, and what you want to get from them. Thirdly, keep an open mind when you’re on the job that things might be different from what you expected, though if you made clear your expectations in the email, it shouldn’t be so different that you feel let down by what you see. If you want to ask about something that hasn’t met your expectations, then it is totally appropriate to ask those around you – they don’t expect you to find every aspect of the job perfect! However, do it in a way that shows you have been thinking carefully about your experiences, as opposed to “complaining” about things that don’t meet your expectations. Finally, express an interest in the work and lives of the person that supervises you, because they are expressing an interest in you by showing you around. With luck, they will accommodate you to ensure your time with them is as productive as possible!

Burning out

Causes-of-Work-Stress

When we are charged with duties or tasks there comes moments in which we want to throw in the towel, kick the bucket (the bucket the towel goes in) and call it a day. It happens to everyone, no matter if your collar is white or blue. Some hate the repetitiveness of their jobs; some hate having to constantly meet deadlines or targets. Some become genuinely lost as to why they are in the occupation they once chose – “what am I achieving in this line of work?” While being morally content with a one’s profession is commonly regarded as the highest tier of job satisfaction, they are not necessarily accompanied by other more superficial benefits like long holidays and ludicrous salaries. In fact, usually you can’t have a cake and eat it – your profession either gives you the moral satisfaction of, say, working in a charity to help the poor, but in doing so omit the materialistic pleasures that come with owning your own yacht. Therefore, in healthcare, where the dependence is more on one’s sense of moral duty to look after your patients than the opportunity to go on long holidays(although for most professions the pay isn’t bad), it is important to frequently give yourself a pat on the back and say job well done.

However, we often hear the word “disillusioned” being used in a tone of exasperation in medicine. (“I could have been a great surgeon – I used to play the piano you know. Alas, I became disillusioned with medicine. *looks longingly out the window*). Surely it’s a good thing to be disillusioned in medicine – since it places such a heavy emphasis on he doctor’s philosophy about doing good for the patients. Surely it is better to be disillusioned than to be naive about what medicine is?

However, it is difficult to know if you are doing good, or to be more exact, doing the best you can possibly do. To omit carrying out the best actions is surely comparable to doing harm? Without making a pig’s breakfast of the philosophical debate surrounding the question, it certainly leaves one with a bitter taste if, for example, it turns out that your patient would have lived longer if you gave him drug B instead of prescribing him drug A. I believe that this habit of self-doubt in healthcare is what gives the sense of one being “disillusioned” with health care. Ultimately, I think this sense of self doubt is what principally drives people in healthcare out of the sector. Some people do not know how to cope with being disillusioned – once you take off the glasses you can’t put them back on.

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This feeling of “disillusion” is what I felt when, some years back, I finished my first 9 hour shift in a NHS ward as a patient carer. If my memory serves me correctly, I had 2 sets of 15 minute breaks in the whole course of my shift. “You’ll need it!” The senior nurse that showed me the ward told me, and boy was she right. During each 9 hour shift, my responsibility was to care for the needs of one patient suffering from quite severe dementia, deemed to be suitable for receiving a closer level of care than other patients on the geriatrics ward due to the seriousness of their symptoms and behaviours.

By responsibilities, I mean it in a very loose sense. I was 19 years old, so I couldn’t do much – I couldn’t administer any drugs or feed the patient food. During training I was even told that I didn’t know the correct procedure of how to preventing a patient from falling down. I was not to grab them, for the fear of causing any collateral damage to their fragile bodies, and after seeing patients for myself on the first shift, I realised this was very reasonable. If the patients were falling down, I was to do the best I can of letting them grab onto me and slide down my body. Compare to the other professionals in the ward, even compared to the student nurses/medical students I was more of an optional extra – a mobile warning claxon if the patient was about to come to any harm.

You might think that my day was quite relaxed, and that was what I assumed before I signed up. “This job is going to be totally chill” I secretly thought. It would give me the opportunity to watch other health professionals do their jobs as well as do some relatively stress-free care for patients with the misfortune of late dementia – they would be confused, would struggle to communicate, and be forgetful of physician instructions. As it turns out, there is no stress free work in the NHS – not for me, not for the doctors, not for the nurses. Even the tea ladies seemed to always have somewhere else to be!

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Part of the stress of the job was defining the status of the person you are charged with caring. Easy – he was your patient, you might think. However, gradually it sunk in that the term “patient” describes more a contractual relationship than a personal one. If someone is your patient, you have an obligation to look after him, but you don’t have a personal tie to him that compels you to provide care apart from the sort of tie that exists between two strangers. However the contractual and personal ties are not distinct spheres in healthcare; a doctor doesn’t just care for his patient because he’s a contractual responsibility, but also because he is a person that needs help. Although for each patient I was charged with I was only with them for a day, my contractual obligation to them and my personal attachment to them became more muddled as time passed. At the end of the shift these old men, some of whom could scarcely mumble a few words to me in the whole course of the day while a few others were verbally aggressive to me and the other ward staff, nonetheless became individuals whom I wanted to do more for. They were not contracts anymore, nor strangers, but people whose fate meant something to me.

If in the span of a single day, it is so easy for me to become attached to a patient, then how many patients might a health professional’s mind be tethered to? Some of the patients I had to look after had resided in the ward for several months. There is almost a classic background for the old dementia afflicted patients I had to look after. They come in to the hospital after a fall and gets treated in the orthopaedics ward. Instead of a swift discharge, however, they then catch an infection in hospital that just won’t go away, and so had to be transferred to the geriatrics ward. As they don’t have the capacity to make decisions for themselves, the physicians keep them in the hospital until their infections go away. I didn’t ask, but I suspected that some of the people I was looking after was never going to be discharged. No doubt the staff from these patients’ previous wards also wonder the same thing, even if they no longer look their notes. One of the challenges of healthcare, therefore, is the incomplete severing of ties as patients ingress into and egress out of your care like traffic.

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Related to this challenge of being attached to your patients is another stress that I was fortunate enough in my role as patient carer to not have to manage – the stress of making decisions for your patient. What happens if things don’t go the way intend it to? What if there is a different option? I played the role of the observer when doctors and nurses came around to the patients on my ward and checked upon them. In hindsight, I wish that when it was just me and a doctor, that I had asked the doctors if any uncertainties in their decisions caused them to grow white hairs. However, in the clinical atmosphere of the ward discussions of stress just seemed very out of place. The stress was always there for everyone, so naturally everyone just got on with their jobs. Besides, the mention of hair may have been a sensitive topic for some of the senior consultants I saw.

However, this can have an isolating effect on those who are in need of real support for their sense of stress. The stress of worrying about the clinical decisions one makes is a major cause of “burnout”. In healthcare, if a mistake is made or the best course of action is not taken, then the person responsible will not have the luxury of turning their eyes away. Even if his supervisor does not tell him off, and even if the patient doesn’t make a complaint, it still remains that he has let down the person he was responsible for. Sometimes, very serious consequences may result from a minor loss of concentration in the moment – the slight of hand in an operation or misdiagnosis of an important clue on an X-ray. This is why being a perfectionist is not a good characteristic to have in healthcare. The moment they take their eyes off the ball and fail to make an interception, and it happens to the best of the profession, it won’t be just their reputation that takes a hit, but their sense of achieving what they sought out to do – doing good for their patients. Of course, the personal attachment healthcare professionals form with their patients can only rub salt into the wound when things do go wrong.

This phenomena of “burnout” is a big worry in every healthcare system. There’s even a neat model built around the problem, with defined parameters like “physical energy” (getting out of bed and getting to work), “emotional energy” (empathy, compassion etc.), and “spiritual energy” (serving a purpose). These 3 categories of energy coalesce to form a big pool of energy that healthcare professionals can draw on to get them through the challenges of each shift. The three types are interlinked, of course – if you lose a sense of purpose in your job you probably won’t be very emotionally available to your patients nor would you look after yourself physically. Up to a certain point, you might be able to use your store of energy to push yourself through your shift, but beyond that point, your “energy well” may run so low that symptoms start to appear and you become “burned out”.

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During the course of my shift, there were certainly points when I felt worn out by my attempts to be the “best carer I could be”. Even though most patients can hardly understand what I was saying I still tried my best to talk to them, or explain to them how to eat their food. Sometimes they would forget they are in a hospital and I had to repeatedly tell them where they were until they were finally satisfied with the answer. It simply didn’t feel right to “ration” my patience – surely patience was not some commodity like medicines were. Some patients were very determined to walk around the hospital, and although I wanted to escape the confinement of their ward with them, I had to stop them so that they don’t fall down and break a hip. At several points I wished that I took the night shift, when the patients are worn out by their  daily escape plans, but I knew that the night shift would be draining in its own ways.

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The kind of drain I felt was physical, emotional, and motivational. Pretty soon I caught on that the nurses on the ward felt the same way. Perhaps it’s due to the prevalence of dementia on the geriatrics ward, but the junior nurses that resided on my ward often showed signs of the drain that I felt despite trying to contain them. I could tell how tedious it was for them to explain again and again to the patients why they needed to take their drugs. At the end of a particular shift with a particularly verbally contentious gentleman (he would repeatedly call the female nurse in the ward by a term that rhymes with “hitch”, “glitch” and “ditch”, as well as swear at anyone he didn’t like the look of), I was alone with the nurse in the ward. The gentleman repeated his wish to get out of the bed, as he had wet himself a moment ago. I explained this to the nurse, and she came over to explain that she was administering drugs to another patient on the ward. As I prepared to leave the ward and end the shift, the conversation became heated, and the nurse ended up raising his bed to a position where he is unable to get out, leaving him swearing in his bed and reeking of his own urine. I regret to say that I didn’t act in the best way possible and reluctantly excused myself. I could have tried to calm the patient and the nurse down, and reached some sort of agreement with the both of them, but I didn’t – “I have had enough”, I thought.

The senior nurses, however, seemed almost immune to the tediousness of the activities. It seemed like they walked around with an invisible shield that protected them from the less glamorous sides of medicine. Perhaps they had built up their professional resilience with experience; perhaps theirs is a different philosophy of healthcare altogether; perhaps a mixture of both. Their behaviours were truly admirable and no doubt there is still a long way for me to go until I can reach their level of compassion and dignity in such a stressful occupation.

In my short time of work at that hospital, it didn’t take much for me to see that the NHS is a demanding boss to work for. I was hit with my first dose of the “disillusionment” that I mentioned earlier, and inherited the scepticism that came with the disillusionment – the scepticism regarding my own abilities. Why could I not maintain the sense of patience I went into the shift with? Was there some way I could have been more approachable to patients that didn’t want me there? I discovered that one realises one’s limitations very fast in the health service, because there is no limit and no end as to how much one can care for his patients. When they first come in you treat their immediate problems, when they stay in the hospital you treat their condition as well as their need for attention, and when they leave you worry if you have done enough. This constant worry for each patient dwells for a long time in any health professional’s memory, and some patients are never forgotten. It can drain the staff’s energy to the point of exhaustion.

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The challenge of deciding how to balance the professional relationship for the people I looked after with my personal attachment to them was my primary challenge as a carer in the NHS. How far should I go in caring for them? This brief blog is by no means a comprehensive view of the challenges of a working healthcare professional. The challenge of improving one’s career, the need to make time for one’s family and the carrying of a much heavier burden of responsibilities than the ones I had to bear are just a few examples of the stress factors that I didn’t have to manage. Forget the targets the governments set or the expectations of your superiors, because the majority of the stress in the health service comes from an overwhelming sense of every health professional to make the best actions for the patients under their care. The artificial targets set simply confirm one’s sense of incompetence when one fails to meet them, and makes it hard to say, for example, “well I never could have seen the patient in 10 minutes” when that is exactly what the government/supervisor demands. More could be said, of course, about the negative effects these kind of targets can have on the ability of health professionals to cope. However, from my point of view, it seems that the biggest critic of a health professional is themselves. This is not to say that this is an appalling status quo, but certainly from my point of view the way to a healthy career in the healthcare service is to realise that mistakes are not opportunities for self-blame, but opportunities for future improvement. After all, the history of medicine is built on the basis of trial and error.

Gurkhas – army men or economic immigrants?

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As somebody who is not native to Britain but of Chinese heritage, I always notice when I pass by another person whom I suspect to be of Eastern Asian heritage (albeit in 99% of cases it is difficult not to spot). However, in my experiences I have found the Chinese population in Britain to be sparse and lack a certain sense of community spirit, possibly due to the fact that China contains such a wide range of ethnicity and culture that it is difficult for two people to feel truly related to each other. It therefore made a very striking impression upon me when I moved from Southampton to Surrey, as I saw  more and more of people with facial structures broadly similar but also slightly different to mine, with tanned skin that are slightly darker that mine, and speaking English with an accent that was definitely not native, but definitely not Chinese either. “Who were they?”, me and my parents wondered. I suppose we were jealous in a secret way of the sense of community cohesion that these people exuded, even just from observing in a 3rd party perspective. The old couples walked together leisurely side by side, dress in cloaks that are evidently an unashamed expression of their sense of their tradition; The young often huddled together in their own groups in public or at the Sixth Form college I went to, where they constituted a large proportion of the student body.

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“Oh didn’t you know? They are Nepalese!”. Nepalese?! I was extremely surprised when I learned their heritage for the first time. After all, Nepal is not the first country one attributes to mass immigration, and there certainly seemed to be a lot of Nepalese people around the place I lived in Surrey.

“They’re here because their dad is in the army.” Nepalese men in the army? My informants were raising more questions than they answered. It baffled me at first why men from a country that was once dominated by British Colonialism and reaped no benefits from British occupation would continue to fight in the British army. Where do they get their sense of patriotism to lay down their lives in service of a foreign country and foreign people?

How does one in Nepal enlist in the British army? What would happen to their family without its male head at the helm? What could the men gain by sacrificing the life they knew?

As it turns out, the answers to these questions has made me realise that these men, who have spent the majority of their best years fighting for a foreign cause, are actually very family-centric. In the eyes of their family and their country men, their service to the British crown isn’t an act of disloyalty, but actually a very respectable action that is coveted among the Nepalese population. Moreover, these men, the Gurkhas, deserve our respect not just for the fact that they protect the British realm, but also for trying to improve the lives of their family back in Nepal. Their cause should be understood by the British people, so that they will eventually be better understood and accepted into the community.

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The Nepalese soldiers serving in the British army are only a proportion of the Gurkhas in the world, which is simply the name given to Nepalese people who choose to serve in combat regiments under a number of foreign countries/organisations such as Singapore, India, the UN etc. Why Nepal of all countries? Are the children of Nepal bred to become natural soldiers? No doubt if you ask some of the Gurkhas today, they would passionately claim that Nepal breeds tough, resilient children. After all, it takes spirit and determination to not only endure the poverty of the country but also to become of the standards required for becoming a Gurkha.

“Selection Procedure includes – firstly a medical examination, education (somewhat like an IQ test), Fitness (Mile and a half run under 10 minutes, assault courses, sports), and an interview near the end. They must also be able to understand and answer some questions in English. The selection starts from 1500 recruits and thins out to 250. 30 of them go to Singapore, 220 to the British Army. The selection process is a lot tougher than entering the army in the UK.” – experiences of an ex-Gurkha.

Nepalese children are obviously not trained, Hunger-games style, to become natural soldiers when they grow up, even though the lack of infrastructure in the country do promote much more exploration and adventure in their childhoods. As a Nepalese, one also supposedly forms a special attachment to his Kukri – an inwardly curved blade that is very symbolic of the Gurkhas today. In fact the vigour for violence is written into popular history of Nepal itself. It was the Nepalese who fought so resiliently against the British East India Company in their efforts to colonise Nepal, that Brigadier-General Ochterlony decided to get the Nepalese on their side! Nonetheless, I still wouldn’t say that this “culture of violence” is what make the Nepalese want to become soldiers.

What they do have experience in from an early age is the condition of poverty. Nepal is one of the poorest countries in Asia, with the vast majority of the population living a life dependent on subsistence farming. It is similar to most other desperately poor countries in the world, with poor sanitation, undernourishment, poor literacy, infectious diseases etc. It seems like just another country left behind by the economic whirl wind of the 20th century.

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However, unlike other countries that find itself in a similar position, people in Nepal have a more realisable way compared to other countries to escape from the oppression of poverty. The young adults are given an opportunity to enlist in the Gurkha regiments. Not only would they be provided for by the British army in their service, but their family would also benefit. A big part of this benefit comes from the soldiers sending to their families their wages, which can then be exchanged from pounds to rupees (Nepalese currency) – a rate of 1 pound to 90 rupees. This extra financial input allows the Nepalese family back home to make a comfortable living, with a higher level of education for the children. Progress in legislation has allowed the Gurkhas to obtain the British citizenship and passport. Their wives and their children can also be sponsored into the country, creating a massive improvement in the opportunities made available to them should they decide to immigrate. No doubt, this makes the status of being a single Gurkha very difficult to maintain back in Nepal!

To be a Gurkha is a prized status among the Nepalese population, for it not only shows one’s success in the very tough selection procedure with a low rate of acceptance into the ranks, but it also shows your ability to provide a lifestyle for your family that people back in Nepal could only dream of. Perhaps this is why that some of the very best men of Nepal willingly commit themselves to a life of fighting abroad. Perhaps this is why that the Gurkhas have a reputation of being spirited, energetic soldiers. After all, a sense of purpose has to propel the Gurkhas to enact deeds of valour worthy of 26 Victoria Crosses – the highest award of honour.

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However, the status of a Gurkha is not always painted in such a white light in British society. Although the reputation of the Gurkhas in combat is not disputed, to the unexamined eye one might question why Gurkhas fight at all, as I did when I first found out who these Nepalese people really are. Some call the Gurkhas mercenaries, but I think this title is too impersonal. It is true that the Nepalese young men probably didn’t feel a sense of patriotism towards Britain when they enlisted, but their causes are noble and altruistic for a whole other reason. Their cause is not to fight for “their country”, but for a better life for them and their family. After all, is this not the most basic root of the notion of “patriotism”?

Unfortunately there seems to be a bit of a double standard in assigning praise to the Gurkhas as compared to the normal British soldier. To the British people, having someone who was raised in a completely different culture and background to you, not to mention being a different race to you, but nonetheless having devoted their life to the defence of the realm is quite a strange notion. Although this is exactly what they did to the British colonies, people have still not quite adjusted to the idea that although foreign in origin, these people still gave their life in the service of Britain and for the benefit of their families. This is why I believe that the Gurkhas’ sense of patriotism, strange as it may, deserve no less respect than that of any other British soldier.

“Daily life for them included: waking up before dawn no matter winter or summer to go collect grass and water to feed the family livestock, which would normally be in pitch black darkness. The majority of people in the mountain side wouldn’t have adequate clothing nor footwear, so they would be cold and have no protection against any sharp foreign objects on the ground. After coming back from that, which would take good couple of hours, they would have to rush for school after eating whatever the mother of the family had made – normally rice or ground corn made into like a sticky dough, nothing like the breakfast we have here in the UK.
Sometimes there wasn’t enough harvest and not enough money for the family, so they would go to school without food and would have to wait until school finished. Even school was a privilege as the family would have to pay for admission fees too, so some wouldn’t have access to education, which young students here in the UK don’t understand the value of.
After school, they would then return home so they can help out in whatever possible means for the family household, which may be taking care of the livestock or taking care of the crops.
They would then finally have dinner which would most likely consist of rice, lentils and some sort of vegetable curry; maybe a meat curry once in a while. Sometimes, I’ve heard from my mums side, they wouldn’t actually have enough food for everyone.
And I guess it’s just a repeat of that every single day.”
A Nepalese friend speaking of the experiences of his parents.

Although the Nepalese community in Britain is by no means small in size and is very close-knit, I believe the British population should be making a more pro-active move in welcoming them into their community. It took me far too long to fully learn about who these Nepalese people were and why they are here. The British population, even around the areas when the families of the Gurkhas cluster together, seem unaware of the fact that the Nepalese people walking past them in the streets have fought for Britain. As a result, these Nepalese people feel a sense of frustration that they are not being recognised for their abilities. If Britain was to truly represent a United Kingdom, not only inclusive of England, Wales, Scotland, and Northern Ireland, but also of the various ethnic minorities that contribute to it, then improving the public awareness of who the Gurkhas are would be an excellent place to start.

Hoping for a medical miracle

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Based on the brief year I have spent in my medical school, it is safe to say that just about everybody in my year has had some kind of post hoc revelation about the degree they signed up for. Although existential crises are part of every university students’ experience, suppressed by the various activities ranging from sports to drinking to sex, from my perspective it does seem like medical students has been given less liberty to participate in these types of stress-relieving activities. Of course it’s still possible to get these things in, but it is much more challenging for us to find the time to sustain these things on a regular basis. The sense of playing a zero sum game between academic performance and having the “university experience” is a very frustrating feeling, particularly when the deprivation concerns the last of the recreational examples given above!

So is it all worth it? Do most medical students find the degree rewarding despite its challenges, due to the nature of what it will amount to – working as a doctor in the NHS? The rigorous selection process which we medical applicants hear so much about are entrusted with selecting the applicants who are not only have the brains (and you do feel like you need more than one brain sometimes) but also the vision to see past their degree to realise that everything they are doing is so they will be of service to the NHS.

I cannot stress how important this process of applicant filtering is to the future efficacy of the NHS.

The NHS is an organisation that is becoming more and more strained year by year. It’s due to factors like an ever ageing demographic, an ever higher expectation for the NHS to take on more services, the ever progressing field of technology etc. It’s a big melting pot of factors that places the NHS on unsteady grounds for the future. Even the health professionals, the ones who love the NHS enough to give their careers in service of it make no concessions about the stress of their jobs. It’s not just in the news – some of my friends who are near graduation from medical school have said they have been given advice by NHS doctors along the lines of “well working as a doctor is not for everybody – there are plenty of other opportunities to pursue as a medical student”. This kind of attitude among the would-be doctors would deprive the NHS of doctors while the demand on having more doctors is increasing.

Therefore we must ensure that the successful applicants of these medical schools don’t just possess a higher level of intellectual capacity, albeit important, but also that they are stubborn enough about their reason for going through this degree that they will actually go through with it instead of dropping out or switching to a degree like biomedical studies. My university is quite tolerant of people switching courses if medicine is not for them. While this is fortunate for those people who did not find their calling in medicine, it certainly does no justice to the roughly £30,000 per year it cost the tax payer to sponsor a medical student’s education (from statistics showing it costs the tax payer 185000 to put a medical student through medical school after discounting student loans). The effect is similarly damaging, if not more damaging should the student complete all 6 years of medical school and then decide, as the doctors above suggests, to steer clear of the NHS. Even if they transition into private sector care it is still not fair on the taxpayer because those who can’t afford private don’t get private.

The unsuccessful medical student is not to blame – the degree is stressful to the extent that even the most on track students sometimes feel a lack of confidence in the degree. Most of the medics in my year, myself included, went into medical school with an almost standard trio of altruism, good academic grades, and the want of prestige. The balance between these factors, at least based on what people claim to admit, are varied.

It is obvious that the type of candidate the medical schools should aim for would be one that has a good balance between these 3 factors; Should I become disenfranchised with physical activity, of alcohol, of sex, then at least I can rely on the interplay between my altruism and my prestige to carry me through.

However, the process of medical school selection is imperfect at filtering these sorts of candidates out from the rest. I know of many personal friends who I have found lacking their commitment to healthcare. They are very clever people, living a normal student life that is incompatible with the seriousness of the medical degree. When I talk to them about why they are going out clubbing for days in a row or are drinking an absurd amount, the unspoken logic they convey is “Medicine shouldn’t have to get in the way of my student life”. Clearly they had no preconceptions about the amount of worked medical school involve, or thought of the sacrifices they might have to make to be successful in their studies, rather than trying to manage a pass at the end of the year. I believe the fault in this lies in the process of medical school application, or rather in the external influences on the students that are outside of the control of the application officers.

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It is a topic that people often moan about, but never get around to discussing. Whenever I do get around to discussing this topic with someone, we often end on a note of “yes it’s a shame”. After all, those who were successful gain little in looking back, those who were unsuccessful just seem bitter in their challenge, and those who are applying are afraid of challenging the people who control their future. Thus, the problem stands clear in the daylight without much action being taken. As a result, people continue to enter into the degree without truly knowing what they signed themselves up for.

The problems lies not in the lack of stringency of medical school admission processes. The admission process, while it is in many areas a subjective exercise (I believe the official word is holistic), is a fairly rounded assessment of the applicant’s academic abilities (assessed by academic record), their motives for the degree (assessed by interview), and their ability to think critically (assessed by admission tests).

The problems lies in what the students can do to prepare for such interviews. The sheer volume of medical students competing with one another for these much coveted spots has generated a sense of entrepreneurship that crooks the spine of the interview process. It is the case today that a hopeful medical applicant can aspire to his/her dreams by signing up for special classes and events that essentially shapes them into the ideal candidate by telling them what to say, rather than providing genuine educational information about the true nature of studying medicine. This is damaging to the integrity of the admission process in many ways.

Firstly, these “special classes” are incredibly damaging to the equity of opportunity for these highly competitive places. These classes cost a lot of money, and they attract a high proportion of medical applicants. The exact proportion no one can really be sure due to lots of different “businesses” providing these services. However, the price floor is high enough to place at a disadvantage students from poor backgrounds. They offer services ranging from things like providing students help with interviews, admissions tests, personal statements etc. These services became popular because the students have the opportunity to learn from people who are supposedly knowledgeable about medicine. Some are medical students, some are doctors, and some are even consultants. While the experience of talking to a doctor is no doubt very valuable to aspiring medical students, how anyone is supposed to learn what it truly means to work in the NHS from a 5 minute dialogue from a doctor on an interview circuit is beyond me.

Being from a poor background, I did not want to go to any of these classes, but due to the sheer popularity of these programmes I was made to feel like I had to ask my  parents to go to these courses, that these courses were a necessity, not an optional extra. At the end of each one I felt a sense of frustration that I did not earn back in knowledge what my parents paid for me in cash. “It was worth the risk; even if one of these tips helped you get into a medical school it will be worth the money” my parents would say. It just made me cling onto what the people at the classes taught me to say even more, and gradually I felt I had no real freedom of expression to say why I truly dreamed of going to medical school. Sure, I wasn’t all altruistic, sure I had a head full of pride to make my parents proud, but these are genuine reasons why I toiled through medical school today, and why I want to be the best doctor I can be. Looking back I feel utterly exploited by these corporations, taken advantage of because I had no one to turn to when I was worried about what medical school was about, why I was doing it, or if I was going to make it. I felt utterly ashamed when my parents would let me attend one of these events – they knew even less than I do about medicine and were constantly worried. Therefore I had to drag myself to these classes, my dignity sagging behind me. I would listen to repetitions of what everyone tells me to say but each time always finishing with “but say it in your own words”. Thanks, you’ve really helped me to figure out why I want to do medicine.

This brings me on to my second criticism of these preparation classes – they corrupt the process of differentiating the candidates, particularly on their motive to do medicine. They have made people’s wishes to do medicine textbook, that is to say, to make your passion and your dream sound cliche. I want to help others and feel like I’m doing a public good! Too cliche, you don’t want to say that. I’ve always had a passion for science! Okay they can already see that from your grades and personal statement, think of something else. I want to do it because I want to make my family proud! Sure you can mention that but don’t focus on this factor. It wasn’t even that they said these were not worthwhile goals, and if they did I wouldn’t have taken their advice, it was that they made me worry and fret about creating the answer to “rule them all”. You add a little bit of scientific intrigue, a pinch of public duty and finish it of with a dash of personal story. Why don’t I just put my passion in a grinder instead?

A final criticism I have is that these enterprises ignore how important it is for medical applicants to take a measured choice in their decision to pursue medicine. As a person who just finished his GCSEs, arguably the first hurdle in British children’s lives that really matter, they are forced to confront a decision as big as what they want to do in the future. I was a bright lad with a very respectable set of GCSEs who was more interested in making my parents proud than having a specific career goal. When my parent talked up medicine to me – good salary, rewarding work, very respectable, of course I would take it. Why wouldn’t I? Marine biologist? Sounds like a fun life, but then why did I make such an effort in my GCSEs? I was not fit to make a decision to embark on a vocational career, yet that’s exactly what I did – I decided to aim for medical school.o-TABLE-570

The sources of information I was given to make this decision involved the university websites on medicine, of which the most captivating bit was the three letters under “grade requirements”. I was not recommended to read books about working as a doctor. I was not told anything apart from the fact that medicine was hard, that most of us (students sitting in on a class about doing medicine) was not going to get in, and that we needed to get work experience. As before, these are things which I knew already, and everybody else knew I knew, but I worried that others knew more than me.

In come these so called “experts” in getting into medical school. As I previously said, I felt I had no choice but to trust in these experts, who were so expensive to get hold of yet so unoriginal in what they had to say. It wasn’t just me that felt this desperate need to trust in their advise; Everyone else in the room were clinging on to every word because they too are ambitious, clever teenagers who have spent the money and effort to gain some sense of order in their calamitous struggle to get into medical school. I knew their desperation, and everybody else knew I knew, but I worried that others didn’t feel as desperate as did I.

What’s the government’s proposal to educate these ignorant young wannabes? Work experience! I was told from the beginning that I needed work experience, and it was portrayed almost like some sort of bargaining chip – the more chips you had in your pocket, the more advantageous you will be. What remained illusive to me was what form this bargaining chip took. Repetitive emphasis on needing more of it made me think it was time, but then it was work experience. Time is only one necessary condition. You need to actually take away some insight.

I was not given advice about what to expect, or what to look for, or what to do to maximise my experience. I was given a tour of the various departments of a local hospital, and made to sit in consultations, various imaging procedures, and even some operations. I was certainly stimulated visually, but I didn’t know what it meant to be a doctor when I left. If you were paraded through a factory production line, you would get the over grandeur and complexity of the operation, but you wouldn’t learn the various intricacies that are the nuts and bolts of everyday service. I was juggled from one doctor to another, from an imaging department straight to an operation. I was supposed to ask them questions, but which ones? “Don’t bother the doctors too much! They’re very busy people!” My mother kept reminding me before I went in.

In the end the work experience left me in a similar frustration as did the preparation courses. They were both things that was talked about as the “envy of many” but they were underwhelming to say the least. The doctors are of course very generous in allowing me to spend time with them, and they answer all my questions with patience, but I couldn’t find the right questions because I hadn’t the faintest clue how a hospital worked. I kept asking scientific questions because it was the only thing I knew about medicine. Perhaps my attitude that this wasn’t a factor of much consideration tells you something about the unpreparedness of some of the other applicants for medicine!

How can the system be improved would be the next logical thing to address. How can we make sure that the applicants entering into a course of vocational commitment are applicants that actually care about the health of the community?

Well for a start the applicants themselves need to be true to their reasons for pursing medicine. They shouldn’t be told to shy away from declaring their interest to make their parents proud or fulfilling the goal of achieving a high social standing. Having this kind of self respect is what gets you through the various lows that come and go in medical school.

Secondly, they should be told what their sense of helping others would truly entail in the NHS. I don’t mean showing them snippets from Tomorrow’s Doctors telling them the importance of being empathetic and maintaining trust with patients etc. I mean a genuine concerted movement to increase awareness of what medicine involves. This means that the university open days should emphasise on the need for prospective applicants to read around the subject, stress the challenge of being a doctor and draw attention to the less pleasant side of studying medicine or having a medical career. At the moment they are more promotional events for why students should choose one university over another, with particular stress on the entry requirements, not realising that by focusing on textbook criteria for idea applicants, they are sabotaging the quality of the applicants they get.

Thirdly, there should be major denouncement of the actions of companies that take advantage of the applicants’ confusion about the application process in order to profit, in the process making the application a miserable process of conformity rather than originality.

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The medical application process is in need of a miracle. The corruption of the application has been a travesty that has been  not only allowed to continue, but indeed promoted by web, print, word of mouth. There should be a realisation that the real way to get genuinely passionate medical students that make no reservations about their commitment into the places they deserve, is the emancipation of medical students from a culture of widely accepted “norms” that a successful medical student should have. Everyone have their own reasons, and while they are similar, they should be encouraged to go beyond simply reiterating their interests. It should be the universal emphasis that medical applicants should liberally explore areas of medicine that interest them, not just be given rough skeletal points on which to show shallow knowledge. An end to the tradition of you must say this and this, and oh no you must not say that. An end to the perception that just because your parents cannot afford to send you to certain extra classes or just because your college cannot provide you with mock interviews, that you are at a significant disadvantage with respect to the other competitors, and that you need external help, lest you should look upon them with envy when they are successful and you are not. I feel I have done my part in correcting this imperfection, and I hope that others will heed my words so that future applicants will feel that at least amongst the competition, there is a true sense of self liberty to explore the area of medicine before you go into it.