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A CAREER IN MEDICINE: Do you have what it takes?

A CAREER IN MEDICINE: Do you have what it takes? second edition

Have you ever thought about becoming a doctor but weren’t sure where to start
or what to expect? This book provides a comprehensive resource to guide you
through the various stages involved in becoming a doctor, from deciding whether
medicine is right for you, to choosing and applying to medical school, interview
skills, student finance, plus what it’s like to face your first day as a postgraduate
doctor and beyond.

This revised and updated edition includes 15 easy to read chapters and gives a
clear overview of modern medical training and career pathways, incorporating the
most up-to-date changes to medical education.

Written by a range of experts, from medical students, admissions tutors and

qualified doctors, this book clearly explains what personal qualities and training
is involved in becoming a doctor at each level and offers advice on getting into
related specialties, such as academic medicine and medical journalism.

“An excellent resource – essential whether you are a sixth former, medical
student or junior doctor”
Baqer Sharif, Medical Student, University of Cambridge

“This book is a must for any sixth former seriously considering medicine.
I read it from cover to cover”
Dr Andrew Papanikitas, GP trainee

“My daughter and I would have found this compendium of enormous value
during the difficult decision-making months leading up to her medical school
application. I will make sure she has a copy to guide her though the rest of her
Rameen Shakur

training” Professor David Warrell, Senior Editor, Oxford Textbook of Medicine

ISBN 978-1-85315-633-5

9 781853 156335
www.rsmpress.co.uk
RSM Press
A career in medicine:
Do you have what it takes?
This page intentionally left blank
A career in medicine:
Do you have what it
takes?

SECOND EDITION

Edited by

Rameen Shakur MPhil (Cantab)

The ROYAL
SOCIETY if
MEDICINE
PRESS Limited
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2006 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20121114

International Standard Book Number-13: 978-1-4441-4718-6 (eBook - PDF)

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efforts have been made to publish reliable data and information, but the author and publisher cannot
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Contributors

Editor Abhishek Joshi Graduate

Dr Rameen Shakur F2 Academic Medical Student, University of
Medicine Rotation: Cardiology. Oxford
Nuffield Department of Medicine, Stuart Laverack Final Year Medical
the John Radcliffe Hospital, Student, University of Sheffield
University of Oxford
Kirsty Lloyd Chair, BMA Medical
Authors Students Committee

Dr Kamran Abbasi Editor, Journal Dilshad Marikhar Graduate

of the Royal Society of Medicine, Medical Student, St George's
London Medical School, London

Dr Yasir AI-Wakeel F2 Academic Andrew Pearson Former Finance

Medicine Rotation. Nuffield Chair, BMA Medical Students
Department of Medicine, the John Committee
Radcliffe Hospital, University of Dr Faheem Shakur Fl Houseman,
Oxford General Medicine, The Royal
Preston Hospital, Preston, Lanes
Dr Paul Ayuk Former Clinical
Lecturer in Obstetrics and Dr Edward Shaoul Honorary
Gynaecology, the John Radcliffe Senior Lecturer, Imperial College
Hospital, University of Oxford London

Professor Raanan Gillon Emeritus Professor John Stein Medical

Professor of Medical Ethics, Admissions Tutor, Magdalen
Imperial College of Science, College, University of Oxford
Technology and Medicine, London
Emily Stobbs Medical Student,
Mr Ashok Handa Honorary University of Nottingham
Consultant Vascular Surgeon and Dr Simon Thorn Head of Biology,
Clinical Tutor in Surgery, Nuffield Radley College, Oxfordshire
department of Surgery, the John
Radcliffe Hospital, University of Professor Robin Williamson
Oxford Professor of Surgery, imperial
College London, Consultant
Dr Hywel Jones District Clinical Surgeon, Hammersmith Hospital
Tutor, the John Radcliffe Hospital, and former Dean, the Royal
University of Oxford Society of Medicine, London

v
 About the editor

Dr Romeen Shokur is a 25-yeor-old Cambridge and Edinburgh {clinical)

University graduate currently undertaking a Foundation Year 2 (F2)
academic medical rotation in Cardiology at the NDM (Nuffield
Deportment of Medicine), the John Radcliffe Hospital, Oxford. He is a
Clinical Tutor in General Surgery at the Nuffield Deportment of Surgery
and a Clinical Teacher in Medicine for Green and Worcester Colleges at
the University of Oxford.

He has won numerous prizes and scholarships, most notably a Churchill

Fellowship for Harvard Medical School for the application of genomic
medicine in Cardiology, a Peter Kirk Fellowship, a Wellcome Trust scholar-
ship for the Songer Centre Genome Campus, Cambridge and a British
Heart Foundation grant for cardiovascular research as a medical student.
His hobbies include playing cricket, football and listening to Indian classi-
cal music.

He studied at Hutton Grammar School and Sixth-Form, Preston,

Lancashire. His research interests include molecular cardiology, immuno-
logical markers of disease and transplantation rejection.

vi
Contents

Contributors v

Foreword ix
Mr Harvey White

Preface x
Dr Rameen Shakur

Acknowledgements xi

1. Medicine: Remembering the past, looking to the future

Abhishek Joshi and Dr Rameen Shakur

2. Entry requirements to medical school 9

Professor John Stein

3. Your school's perspective 17

Dr Simon Thorn

4. The interview 27
Professor John Stein

5. How to choose a medical school 31

Emily Stobbs

6. Graduate entry medicine 39

Dilshad Marikar

7. Student finance 47
Andrew Pearson and Kirsty Lloyd

8. The medical student years and how to survive them 55

Dr Faheem Shakur and Stuart Laverack

9. The foundation years 63

Dr Rameen Shakur

vii
Contents

10. Choosing general practice (primary care) 71

Dr Edward Shaoul

11. Career pathways in medicine and surgery 81

Dr Yasir AI-Wakeel and Mr Ashok Handa

12. Choosing hospital medicine 89

Dr Paul Ayuk
(with Appendix: A week in the life of a consultant physician,
by Dr Hywel Jones)

13. Ethical issues in modern medical practice 97

Professor Raanan Gillon

14. An alternative career in medicine: Medical journalism 103

Dr Kamran Abbasi

15. Academic medicine 107

Professor Robin Williamson

Index 113

viii
Foreword

I om delighted that a second edition of this book has been published.

The first edition, which I edited in 2000, was the child of a study day which
was developed at the Royal Society of Medicine for sixth form students.
The book was popular enough to be reprinted twice in 2003 as it met a
need - namely to clothe the dream of a medical career with the reality
of achieving that goal.

The criteria for student selection ore changing, as ore the methods of
teaching and learning. Even in the lost few years, the expectations of
the public and the work pattern of doctors hove changed. Anyone con-
sidering a career in medicine must be aware of these developments.
These changes and the established ways of the profession ore addressed
in the new edition, which will be invaluable to all those considering
becoming a doctor.

It is good to see that the wisdom and experience of some of the original
contributors, which has stood the test of time, is retained. There ore
welcome new chapters, such as those on the historical background to
modern medicine, student finance, academic medicine and medical
journalism, which broaden the scope and appeal of the book.

The second edition is a more than worthy successor to the first. In addition
to supplementing the study day at the Royal Society of Medicine, it will
stand alone as on essential port of informed decision making for those
considering a career in medicine.

Harvey White

ix
 Preface

Life is short, the art long, opportunity fleeting, experiment treacherous,

judgement difficult.
Hippocrates

Making independent and informed decisions is one of the harder tasks in

life. Some of the decisions you hove to make can affect your own future,
your livelihood and even the future of your family. Choosing the right
career is one such decision, and so adequate time and effort on formu-
lating a realistic and informed choice is important, especially so if that
career is to be in medicine.

Numerous students have found the information in the first edition of this
book very useful in formulating a realistic picture of a life in medicine and
the application process involved. However, given recent changes in
school and medical curricula, the introduction of more graduate entry
schemes and the ongoing financial concerns facing all university students,
it was time to update the book.

This edition has been researched thoroughly to incorporate the most

recent changes to medical careers as announced by the government
through the Modernising Medical Careers committee.

Also, for the first time, chapters relating to academic medicine, careers
in medical journalism, graduate entry and medical student funding have
been included, alongside updated versions of the chapters that had
made the book a clear favourite among students in the post. The second
edition continues the tradition of the first in providing independent,
concise and thorough information relating to aspects of a career in
medicine and how to achieve this goal.

We envisage this book to be of great value not only for candidates who
are thinking about entering medical school, but also for current medical
students and junior doctors alike. Please visit the website which accom-
panies the book for more information on aspects of the book's content:
www.acareerinmedicine.net.

Rameen Shokur
Oxford, 2006

X
Acknowledgements

This book has required much effort on the part of the contributors and
the RSM Press staff. I would like to thank all of the contributors for their
time and effort in producing their chapters and for researching their topics
so thoroughly. I would like to thank in particular Harvey White, who gave
me this opportunity after the great success of the first edition. A very big
thanks should also go to Peter, lan, Hannah and Laura from RSM Press for
their support and hard work during the production of the book.

Thank you also to all my colleagues at the John Radcliffe Hospital for their
support during the writing of this book, namely Dr AKM Muktadir, Dr Dalia
Wahab, Dr Hywel Jones, Dr David Holdsworth, Dr David Nasralla, Mr Ashok
Handa, all the staff of the Postgraduate Centre at the John Radcliffe, and
my consultants Professor Warrell, Dr Dwight and Professor Becker.

Finally, I would like to thank my family - my mother, father and brother -

for their unabated love and support during the whole of my student life.
They have been inspirational in my development. I would like to say a big
thank you to my mother and father for instilling my thirst for knowledge
and my passion to ask the question, why?

I would like to dedicate this book to my grandparents {Abdul Wazid and

Abdus Shakur), neither of whom are here to read this book, but were it
not for their blessings, this and all my achievements thus far would not
have come to fruition.

xi
This page intentionally left blank
Medicine: Remembering the
past, looking to the future
1
Abhishek Joshi, Graduate Entry Medical Student University of Oxford
Dr Rameen Shakur, F2 Academic Medicine Rotation: Cardiology. Nuffield
Department of Medicine, the John Radcliffe HospitaL University of Oxford

Doctors practising today can call on a huge body of knowledge and

experience when they treat their patients. There are thousands of journals
to read, hundreds of guidelines to follow and an almost unlimited number
of scientific ideas to be used. Practising as a doctor involves applying new
scientific discoveries and inventions to some old problems.
Yet it was not always like this. Every time a doctor takes a blood sample
or listens to a patient's heart, he or she is utilizing thousands of years of
thought, experiment and experience. There have been doctors, or
people like them, for thousands of years, but their methods have been
evolving and only very recently have they started to use the techniques
that we are familiar with. The first doctors knew nothing about cells,
organs or drugs. You might very well wonder how they managed to treat
people at all, but they did. This chapter explores some of the major histor-
ical advances in medicine and those that helped shape the ethos of
medical practice.

The spirit of medicine

Much of modern Western medicine stems from the ancient Greeks, where
the main practitioners of medicine were priests. The ancient Greeks
originally thought that diseases were caused by the gods deciding to
punish the patient. The treatment was prayer, and many priests would
prescribe patients potions that would make them enter a state of shock.
The idea was that a god could then appear before them and they could
ask to be made well again. Medicine was closely associated with magic
in the very early days, and the Greeks used combinations of 'magic
numbers' in their treatment of diseases. For example, patients who were
ill were quarantined for 40 days, because the number 40 was considered
to be magical!

The idea that illness is some sort of punishment from God or the gods, and
that it can be cured by prayer and ritual continues today. In fact, some
scientists are now engaged in researching whether prayer actually works
to improve people's health.
A career in medicine

Hippocrates
After a while, the Greeks began to think differently about the world around
them, and also about disease and health. In particular, Hippocrates
(460-377Bc) introduced a number of new ideas, and is now known as the
'Father of Medicine'. Hippocrates taught
his medical students how to recognize
the outward features of disease, and
encouraged them to learn which
features suggested the severity of
the disease. This brought about the
ideo that doctors could make a
diagnosis and a prognosis for a
person based on observation, and
helped Greek doctors to begin to
classify illnesses.

Hippocrates also popularized the ideo of the

'humours' in medicine. The Greek theory of the humours was that every-
thing in the world was mode up from a combination of the four elements:
air, water, fire and earth. Hippocrates associated these elements with
humours (or fluids) in the body: air with blood, green bile with fire, block
bile with earth, and phlegm with water. He believed that if someone hod
too much of one of these humours, the resulting imbalance, or dyscrasia,
caused illness. The obvious cure, then, would be to remove some of the
humour, so he suggested sneezing or vomiting as cures for diseases.
Interestingly, Hippocrates also believed that doctors should try to do as
little as possible and let the patient recover naturally.

These theories of humours ore 'holistic', in that they treat the energies of
the person rather than the specific disease, but people like Hippocrates
did begin to recognize the importance of individual organs in the body,
suggesting that they hod a role in producing the different humours.
Hippocrates was also credited with writing the Hippocratic oath, the
ethical code of conduct that doctors swear to follow, although a number
of similar oaths existed before his time. Interestingly, the Hippocratic oath
separates doctors from surgeons, as surgeons were considered unedu-
cated servants of the doctors.

Ayurvedic medicine
The ideo that illness was characterized by on imbalance in the patients'
elements was not exclusive to the Greeks.
Early Indians practised the Ayurvedic method of medicine over 3000 years
ago, and the practice still survives in Indio today, often allied to modern
'biomedical' practice.

2
 Medicine: Remembering the past, looking to the future

The system teaches doctors to maintain a balance between the five

elements of ether, air, water, fire and earth. Early Hindus believed that the
knowledge of Ayurvedic medicine come directly from the god Brohmo,
and the main texts were the Charaka and the Sushrata, which were
written down after a period of word-of-mouth. The system is very complex,
and divides the mind, body and soul into separate systems. There ore
detailed explanations of how disease occurs and specific medicines for
each disease, aimed at restoring the patient's balance. Ayurvedic physi-
cians hod to learn eight different disciplines: internal medicine; surgery
and anatomy; eye, ear, nose and throat diseases; paediatrics (and
embryology); demonology (or psychiatry); toxicology; rejuvenation; and
fertility.

In addition, the physician would hove to master the study of chemistry,

so he could make his own medicines, which were usually mode from
plants. Training took seven years, and at the end doctors were required
to toke on oath promising to put their patient's core above all else.

The Egyptians
Hippocrates' teaching remained popular in ancient Greece, and was
refined over generations. As Alexander the Great spread his influence
across the Mediterranean, his scholars took the Hippocratic model with
them. When the great library of Alexandria was founded in Egypt, the
Greek methods met with the (much older) Egyptian doctrines. This
meeting was particularly fruitful.

The Egyptian method of practising medicine dotes

bock to 3000Bc. The Egyptians, too, believed that
illness was due to the influence of gods and
spirits, and they used on array of potions and i'
spells to heal their patients. The Egyptians
worshipped one of the first royal physicians, .,
lmhotep, as the god of healing. lmhotep
wrote what has become known as the
'Edwin Smith Papyrus'. This documents, in
exquisite detail, the Egyptian methods for
examination, diagnosis, treatment and
prognosis of a number of diseases. The
Egyptians were also aware of public health,
and by 1150Bc (the 19th Dynasty), they were
providing medical insurance and sick leave for
workers building the pyramids.

The crucial difference between the Greeks and the Egyptians was in their
study of anatomy. Whereas the Greeks considered the body sacred and

3
A career in medicine

so did not dissect cadavers, the Egyptians dissected cadavers as a matter

of course. This led to a better understanding of human anatomy. The
Egyptian understanding allowed surgical practice to develop, and the
Egyptians also had a better understanding of things such as the pulse and
the functions of different organs.

Some scholars at the school in Alexandria attempted to use an empirical

approach to medicine. This meant that they listened to the patient's
complaint (a history), examined the patient and then made a diagnosis
-just as doctors do today.

The problem was that these doctors did not understand the diseases they
were studying well enough to relate the symptoms and signs to a disease,
and when they could, they did not know what to do about it. This meant
that the perfectly rational idea was out-competed by the 'methodic'
school, who were obsessed with the state of patients' pores. This school
of doctors thought that the pores on the skin were a direct reflection of
the patient's health, and so they suggested a number of ways in which
a person should wash in order to maintain healthy, open pores. The theory
was popular because doctors could see the direct results of their treat-
ments, even if they did not actually cure any diseases.

The Romans
As the Roman Empire began to take its hold in the 1st century AD and the
Greeks became poorer, many Greek doctors continued to ply their trade
as Roman slaves. Being a doctor in Rome was seen as a socially un-
desirable job. However, a number of doctors were successful and were
able to buy their freedom. One of the most successful Roman doctors was
Galen (AD 129-200), who was the son of a wealthy architect. He was never
a slave, but instead studied at Alexandria, where he learned the
Hippocratic theories of medicine, which he then brought to Rome. He
developed these ideas and furthered the study of anatomy through public
dissections of pigs and Barbary apes, which he considered to be
anatomically similar to humans. He showed that the kidneys produced
urine and demonstrated the importance of the spinal cord, but despite
these useful experimental findings, Galen's effect on medicine was
effectively to halt any real progress for over a thousand years after his
death.

Galen recognized the importance of blood in sustaining the body, but

thought that it was produced by the liver and then consumed by the rest
of the body. He thought that blood was given a 'natural spirit' in the liver,
a 'vital spirit' in the heart and an 'animal spirit' in the brain. Blood was
then supposed to travel through the nerves to nourish the rest of the body
with its spirits. The theory's flaw was not so much that it was inaccurate,

4
 Medicine: Remembering the past, looking to the future

as that it unfortunately fitted so well with the Christian ideas of the time.
This meant that Galen's theories were promoted and protected by the
Church in Europe, which ensured that his anatomical findings and theory
of medicine were not challenged for over a thousand years. For example,
people believed that the humerus bone in the arm was curved because
Galen said so, and dismissed the straight bones they saw as 'tricks of
nature'.

Galen's teachings thus survived virtually unchanged well into the 17th
century. The main change over this time was the introduction of patron
saints for each disease. These saints were petitioned for cures, in a return
to the earlier ideas and superstitions that God or spirits intervened in man's
health. For example, St Fiacre was supposed to protect the patient from
haemorrhoids. There were few practical advances - medicine had
entered the Dark Ages in Europe.

The Middle East

While European medicine had come to a virtual standstill, the Arabic
world began to flourish. In the 6th century AD, King Khusraw of Persia
began to welcome Christian refugees from the Byzantine Empire in the
West and scholars from India and China in the East to Gondeshapur (in
modern-day Iran). There they translated their texts and shared their
accumulated knowledge, founding the first medical school. This cross-
pollination of medical cultures allowed students in Gondeshapur to
combine the different strands of medicine and to develop their ideas
further, which provided fertile ground for the development of a number
of eminent Middle Eastern medics.

AI-Razi (865-925) and Ibn Sino (Avicenna) (980-1037) were two major
Arabic physicians, who wrote over 600 books between them. They both
studied medicine alongside philosophy, mathematics, and other sciences
and arts, and are credited with keeping the tradition of rational thought
and discovery in medicine alive. Most of their work found its way to
Europe, where it formed the basis of medical teaching.

AI-Razi lived in what is now Tehran in Iran. Despite being strongly influ-
enced by the Hippocratic way of thinking, he described the symptoms
and signs of diseases and did not try to explain them in terms of spirits or
humours. He wrote about the diseases of smallpox and measles, and was
careful to mark the differences between them. He relied on rational
thought and observation, and this helped him make his discoveries. He
also began to publish the first doubts about some of Galen's teachings.

Ibn Sino qualified as a doctor by the age of 18, and came to live in Tehran
as the court doctor to the emir (king). He wrote almost constantly, and
consolidated everything he knew about medicine (which in those days was

5
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Asia

Alexandri Aristodemus

Mercurius summum etsi

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