Medical Sites

1) www.nejm.org
2) www.clinicalcases.blogspot.com--- check this out, it's very interactive site with lots of other useful links...
3) www.studentbmj.com,
4) www.xenomed.com
5) www.who.int.org.--- reach out for who articles, database and free stuffs available for students in developing countries.
6) www.hinari.com--for online research database
7) www.studentconsult.com--- for those students who'd buy elsevier series of textbook and want online reference to those textbooks,, but u must register first.
8)www.pubmed.com-- for indexed american database of medical research around the world.
9)www.healthnet.org.np---it's a good site, specially for nepalese students, u can find out research papers from nepali professors, no less u can still surf for the international health research as well.
10)www.bloodjournal.org
11)www.chemoregimen.org
12)www.medscape.com
13)www.uptodate.com
14)www.bmj.com
15)www.binayfoundation.org
16)www.epernicus.org
17)www.nccn.org for oncology
18)www.thoracic.org of American Thoracic Society
19)www.idsociety.org for Infectious Disease Society of America.

I'm A Surgeon: A perspective

Excerpt from BMJ 2008 february issue.

I’m a surgeon—respect me!
We all know the stereotypical surgeon. Laura Cherrington wonders which personality traits are really necessary and whether there’s room for change
“You can’t sit there, that’s Mr X’s seat,” the scrub nurse calls out to me in the staff room as I’m poised over a chair, identical to the 10 other vacant chairs in the room. I move to another seat. “No,” the nurse stops me again, “That’s where he puts his feet.” I look up at her about to laugh, but just look dumb struck instead when I realise that she’s serious.
What makes people think that surgeons deserve such reverence? He struts into the staff room with an air of superiority and sits on “his” chair, ignoring the hard working team with whom he is about to operate. I doubt he even knows our names.

The stereotypical surgeon
I am a fifth year medical student aspiring to be a surgeon. Last summer I worked as a theatre support worker to get an insight into the world of surgery. Many surgeons I met were kind and sociable, but others came across as arrogant and aloof. If I become a surgeon, will I be one with a reputation among the theatre staff for being a typical surgeon? We all know the surgeon stereotype: decisive, well organised, practical, hard working, but also cantankerous, dominant, arrogant, hostile, impersonal, egocentric, and a poor communicator.
As role models, I prefer surgeons who are friendly and good communicators. One surgeon sticks in my mind. He always described with fascination what he was doing during the operation to all of the team members. He included theatre support workers, whether we were medical students or not. We would be waved over to the table with a smile, “Take a look at this.” He showed no arrogance or hostility and made everyone want to pitch in.
So is it fair to label surgeons with the stereotype? As with all stereotypes, they don’t apply to everyone but often to a considerable number of the group. They frequently stem from some reflection of reality—as the saying goes, “There’s no smoke without fire.”
Thomas wrote a paper entitled “The surgical personality: fact or fiction,” which attempts to provide evidence for the existence of this stereotype.w1 He reported studies in 1997 which showed that surgeons are often described using negative connotations such as “arrogant, dominant, cold, impersonal, impatient, less friendly, aggressive and authoritarian.” He cited Greenburg, who found that surgeons considered being self sufficient, well disciplined, highly motivated, and consistent more important than traits that allow good interaction with others.w2 Thomas also did a small study of 50 non-surgeons, and found that 90% thought that surgeons shared a similar personality and 66% of the terms used to describe surgeons were negative.w1
Thomas’s paper was written nearly 10 years ago. However, from my own recent but limited experience I have to agree that a number of surgeons do fit this set of characteristics. The surgeons I speak of were clearly hard workers, well organised, and decisive, but they were often poor at communicating with other healthcare professionals. Widespread cultural depictions of surgeons also reinforce the negative stereotype. Television programmes (such as ER, Casualty, and Holby City), films, and literature often depict surgeons as arrogant and aloof. The studies that I have mentioned show that the negative attributes stem from limited interpersonal skills. With communication skills having an ever increasing emphasis within medical teaching, does the surgical personality still exist, and is it a necessity to be a good surgeon?

How did the stereotype come about?

The stereotype is thought to arise for two reasons. Greenburg proposed that it is prominent among surgeons as a result of a selection bias for the so called surgical personality when doctors are recruited for surgical jobs. That is, surgeons normally choose one of their own, someone just like them for the job, so perpetuating the surgical personality.w2
Thomas suggested that the personality may be further encouraged by training methods that promoted certain personality traits.w1 This supports the view that the stereotypical surgeon is more evident in older surgeons, the so called “old school” doctors.
However, this personality may be necessary. The more positive traits associated with the surgical profession, such as being decisive, hard working, well disciplined, and motivated, are essential traits for becoming a successful surgeon and should be retained. This could easily coincide with good communication skills and more sociable traits. Indeed it seems that many of the surgeons I have met have achieved this and do not come across as arrogant, hostile, or egocentric. Is it perhaps more likely that the few who continue to display poor communication skills are tainting the whole profession and perpetuating the stereotype that should be outdated?
Many people feel that poor communication skills lead to a breakdown of teamwork since the rest of the team are no longer motivated to work with the surgeon. As Thomas wrote, “It appears unlikely that one can expect others to support and develop allegiance to a representative of a group of individuals who are characteristically considered to be aloof, arrogant and authoritarian”.w1 This is likely to be counterproductive in ensuring patient safety and the efficiency of operative procedures.
A study by Sexton and colleagues entailed interviewing theatre staff (surgical and anaesthetic consultants, nurses, and residents) from 12 hospitals in five different countries.w3 They found that the most common recommendation for improving patient safety in the operating theatre was to improve communication.
This leads me to believe that the negative aspects of the surgical personality should be strongly discouraged. They could be replaced with good communication with other healthcare professionals, as well as with patients. Improvement could be at three key phases: during surgical training, when selecting surgical colleagues, and in mature practising surgeons. Surgeons are taught technical skills and how to make good judgments. Communication skills are important adjuncts to this training as no surgeon ever works alone in the operating theatre. Charles Vincent, who trained as a clinical psychologist, has done a lot of research into teamwork and patient safety. He has published widely and provides courses for surgeons, highlighting the importance of teamwork to them.

Leading the team
Some people argue that acquiring more sociable traits will diminish the surgeon’s standing as a leader. It goes without saying that surgeons need to take on a lead role. However, Thomas said, “Leadership should be characterized by the ability to engage in productive dialogue and to influence rather than coerce or intimidate those with whom it is necessary to work”.w1 The ability to motivate others and to discuss issues are seen as key to effective leadership.
Some surgeons have a military approach; they command and dominate like an army major. This approach is perhaps necessary in emergency situations that demand immediate action. Parallels can be drawn here with the military, fire service, and airline pilots, where life can depend on the professional. Yet these professions are possibly not as strongly associated with the negative traits seen in the surgical personality. Perhaps this is because of the style of their training, as they are trained in a heavily team orientated manner. More emphasis is put on working together. They also have briefings—meetings before executing the task—where potential issues are discussed and individuals are made aware of their role. This helps the team to understand why, in certain circumstances, the leader has to be so ruthless during the task and may help to keep them motivated to work in the face of this.
These techniques could be introduced to surgical training to diminish the misinterpretation of a surgeon’s abruptness. However, emergency operations are relatively rare. In most surgical cases, leadership could be far more effective if it takes on a more collaborative stylew4—that is, if the surgeon motivates the team, who ultimately share the same goal, as opposed to the surgeon giving a reel of orders.

What about female surgeons?

The surgical stereotype is male, but the number of female doctors is increasing. In the period 1983 to 2003 the percentage of female consultants doubled from 12% to 24%. Surgery remains a male dominated specialty, however, with only 7% of surgical consultants being women, despite being a popular career intention for female medical students.w5 The Opportunities in Surgery Committee of the Royal College of Surgeons is attempting to unravel why this is so. Fernandes writes on their behalf: “We need to understand why some women are attracted to, and go on to succeed in a career in surgery whilst others do not. Are the successful female surgeons similar to their male counterparts, is there a ‘surgical personality’?”w6
Cassell studied female surgeons in the United States and found that they encounter more hostility and conflict from other healthcare professionals because of socially constructed expectations of gender.w7 That is, the surgical personality is less tolerated in women. One woman surgeon commented, “A man who has tantrums is temperamental or high strung; a woman who has them is a bitch.” Cassell believes women surgeons negotiate their feminine gender expectations. Fernandes writes, “To elicit greater co-operation from male subordinates and especially female nurses, many women surgeons are more egalitarian, less authoritarian, and less hierarchical in their behaviour.”w6

Can surgeons change?

It is hard to alter behaviour. However, through training in communication skills more sociable traits could become associated with the surgical personality. I believe this would improve the efficiency of teamwork and enhance patient safety. I do not believe it is necessary to have a commanding, military approach to surgery except in emergency situations. Efforts must be made to discourage the negative aspects of the surgical stereotype that have become so ingrained in popular culture. By altering the expectations of surgical behaviour the career may also become more acceptable for female surgeons.
I aspire to be a surgeon myself, and I hope that I can learn to be a great team player, to engage and influence rather than to coerce and intimidate. Surgeons should be happy to collaborate with the whole team and perhaps even share their staff room chair.
Competing interests: None

Medical Student who shook the world

Charles Best and Frederick Banting.

A nice article taken from BMJ 

Students who shook the medical world

One medical student's contribution to medicine nearly won him a Nobel prize, and others have been immortalised eponymously.Sanjay A Pai investigates

Who discovered insulin? Ask any medical student, and chances are that the answer will be "Banting and Best." Some students might even be aware that Charles Best was a medical student at the time he was involved in this exciting research. Few will know of other medical students who were involved in research of historical interest. Research, after all, is usually associated with senior scientists working in laboratories. But the list of students who've made important contributions to science is long-and you'll be surprised to see some familiar names.

Nobel prize, almost

To head the list, of course, is the name already mentioned-Charles Best. Frederick Banting, an orthopaedic surgeon with an unsuccessful practice, decided to switch to research. In 1921, he approached John Macleod, professor of physiology at the University of Toronto, with a project to discover a cure for diabetes mellitus, then a great killer. He asked for an assistant and, after a toss of a coin, decided upon second year medical student Charles Best.

Joined later by James Collip, they discovered and purified insulin. The Nobel Committee, however, awarded the prize only to Banting and Macleod. Irritated, Banting shared half of his prize money with Best. Not to be outdone, Macleod shared his with Collip. Much has been written about the relative contributions of the investigators and it is generally accepted by scholars now that all four indeed made important contributions. The story of the discovery of insulin illustrates many things-the importance of luck and of the selection of an important topic for research; how controversy can follow research and the Nobel prize; and, of course, of student discoverers in science.w1w2

Eponymised and immortalised

Paul Langerhans was also a medical student in 1869 when he discovered the islets in the pancreas that now bear his name. Incredibly, this was his second finding. A year earlier, he had already showed cells in the skin, using gold chloride stain. These cells are known as Langerhans cells.w3 Niels Stensen, too, was a medical student when he discovered the parotid duct in sheep in 1661.

Two other things about Stensen are interesting. He gave up the practice of medicine to become the founding father of the science of geology. And Stensen must be one of the earliest examples of what would be called nominative determinism in the 20th century. Nominative determinism is the term used when one's profession or occupation is reflected in one's name-"sten" is Danish for stone, and "sen" means "son."w4

spl Thanks for the gesture, Banting

One too manY

Other students too have made contributions. In Lima, the capital of Peru, is a statue to the medical student Daniel Carrión. Carrión believed that Oroya fever and verruga peruana were the same disease. To prove this, he inoculated himself with blood from a verruga, developed Oroya fever, and proved his theory. Sadly, he also succumbed to the disease.w5 Other well known student discoverers include Bruce MacCallum, Martin Flack, and Helen Taussig, who made important contributions to pulmonary and cardiovascular anatomy and pathology.w6 Their stories as well as those of many other curious undergraduate discoverers have been documented by the neurologist W C Gibson in his articles and books.w6w9

Other medical students, whose stories are not well known, include some of my personal favourites, perhaps partly because they involve people I know and because they are fairly recent stories. As an undergraduate at Goa Medical College in 1986, Jayant Vaidya, realised while lying in bed one warm night that although he was lying on his right side the left side was sweating profusely. This was surprising because the left side of the body was directly receiving breeze from a fan. He turned, only to find that the left side quickly dried and the right side started sweating. Puzzled, he checked this in his father and brother the next day and found the same effect (J S Vaidya, personal communication). He then performed an experiment on 16 people to confirm the findings and published the findings in a journalw10 and was later quoted in the BMJ's Minerva column.w11

"The mechanism of this effect of posture on autonomic control of sweating, which is controlled by the sympathetic cholinergic outflow, is up for speculation. Perhaps the hypothalamus, from where the sympathetic chains start, has lateralised functions that are dependent on signals from the vestibular apparatus" (J S Vaidya, personal communication). Vaidya is now a senior lecturer in surgery at the University of Dundee.

Another medical student you should know is Manu Kothari, a retired professor of anatomy from King Edward Memorial Hospital, Mumbai. In December 1955, having just passed his first year bachelor of medicine-bachelor of surgery exams (MBBS), he was perusing Hamilton Bailey's Physical Signs in Surgery. He was yet to enter the hospital wards and start seeing patients. Seeing the pictures in the book, two thoughts occurred to him. He wrote, "In inflammations of hip, the fixed adduction deformity can be measured visually without having to move the patient's painful limb as the text advised. All that involved was to measure visually the angle between lines joining anterior superior iliac spine and the deformed position with a line drawn bang horizontally from the spine on the normal side." He says, "Inguinal hernia in the male and the female can be differentiated from the femoral hernia by inspecting the inguino-scrotal or inguino-labial curve. This curve loses its concavity in inguinal hernia but does not do so in femoral hernia" (M L Kothari, personal communication).

He wrote this to Hamilton Bailey and was rewarded, in 1959, when, in the 13th edition of Demonstrations of Physical Signs in Surgery, a method was described, named after him and with a footnote on his biographical data.w12 Kothari's findings are an excellent example of how simple and logical observations, in a field of clinical medicine unexplored to him, made discoveries that were not obvious to trained surgeons for many years.

Topfoto Guess I'm ambidextrous...

Medical students can also have fun while doing research, as shown by Chris McManus. In 1973, McManus wrote the first of his many papers on laterality, a topic on which he is today one of the world's experts.w13 Later, he examined 107 antique statues in Italy to see which testicle was larger and higher and whether the art of ancient Greek sculptors had imitated real anatomy.w14 He discovered that right handed people have higher right sided testicles-which, surprisingly, is the heavier. This led to a paper in Nature in 1976, and to his being awarded the IgNobel prize in 2002 for research that "cannot and should not be repeated."w15

21st century

Many of these discoveries by students were done in the 18th and 19th centuries, when medical science was young and much was remaining to be discovered, especially in anatomy and dissection. Similar opportunities may not easily be available today. But a significant number of findings have been made in the past 50 years. Often they involve common sense observations followed by a hypothesis or experiment, as the last two examples prove. Thus, it is not entirely impossible for many medical students to do or to contribute to research. Research opportunities exist in many universities. For instance, at Birmingham University, in England, the department of public health and epidemiology has run numerous projects involving students over the years.w16 Many of these result in publications in journals.w17w18

Colin Ross, a medical student who worked in a laboratory at about 1980, says that experience in a research laboratory will not provide answers or any new dogma. Rather it provides an education and will better equip the physician to adjust to and shape a better future.w19 Of course, the research need not be restricted to laboratory work but may include diverse fields such as epidemiology or clinical medicine. Working on research projects teaches students the importance of a systematic approach to a problem, something that could well be of use in clinical medicine later on. Working with thinkers or researchers exposes different ways of thinking or tackling an intellectual problem.

Come come, students

The benefits of the student-scientist interaction are many. Students, of course, benefit from working and learning from experts in the field-but senior researchers may also benefit from intelligent students with their "out of the box" thinking and lack of preconceptions. A research paper in a journal can be tremendously encouraging and, indeed, may even lead to the foundation of a future professional interest and career. At the least, students will learn how to search the scientific literature and to evaluate it properly, lessons which should stand them in good stead for the future. Working on research projects may help expose students to areas such as medical statistics or laboratory research and would contribute to their increased understanding of these fields.

Mentors thus have the responsibility of encouraging medical students, the "medical comets," to use Gibson's phrase, to contribute to medical research-a duty which may be beneficial to the student, the teacher, and, ultimately, to science itself.

I thank Drs Jayant Vaidya, M L Kothari, Tim Marshall, and Chris McManus for information and clarification.

Sanjay A Pai, consultant pathologist and head,Department of Pathology and Laboratory Medicine, Manipal Hospital, Airport Road, Bangalore 560 017, India Email: s_pai@vsnl.com

Competing interests: None declared.