Social background of medics

“I’ve often gone into [the operating] theatre and they will be grilling you – ‘what are the complications here ? What is the blood supply to that? What school did you go to?’ ”

The school question follows as naturally as breathing. The school was in Finglas, she tells them. “And you can see their eyes widen. I’m never quite sure what it is – is it surprise or admiration ?”

In first year, Lambert was almost overwhelmed, partly by the “outrageously tough” course but also by a sense that she didn’t belong. “I withdrew into myself. I almost felt that I shouldn’t be here. For example, people were milling around with all those notes and I said, where are they getting them from?” (Times) >

Feature on Anatomy Building in Trinity College

My feature on the Anatomy Building in Trinity as published in the Irish Medical Times >>>

Anatomy teaching in Trinity is being re-housed, and Paul O’Connor wonders if anything is being lost in translation.

It’s quiet now, the Anatomy Building in Trinity College, more like it seems in Fionn McCann’s photographs than it was on the day I last visited it in April when a mass of highly animated students, mostly in white coats, occupied every available space while revising for their anatomy exams. Handling a bone, a model or an organ, some students worked alone at various tables, looking from text book to specimen and back again. Others worked in pairs or larger groups, gathering around the cadavers they had dissected during the year, to test each other on the course of blood vessels or the description of features. I thought of Kevin Myers’s sarcastic image of a medical student’s brain: “a cerebral shoebox containing a vast anatomical index, in which you can find the name of every nerve-ending and every follicle, and also, in an un-swept and unvisited corner, a small, withering organ called common humanity.” Meanwhile teaching and technical staff members went about their work, helping when required, offering friendly encouragement and ensuring the other functions of the building continued to be performed.

All these human activities and structural functions are now being relocated to the brand new Biomedical Sciences Institute on Pearse Street, recently opened by An Taoiseach Enda Kenny who declared it, enthusiastically, “another significant chapter in the history of Ireland’s oldest university”. That movement from old to new is universal and often for the best, especially when it comes to scientific research. But in the case of medical education, especially a subject like anatomy, new may not always be entirely good. It’s worth reflecting, I think, on what is possibly being lost in the transition from charming, nineteenth-century, purpose-built Anatomy Building to high-tech institute housing an anatomy department.

Since its construction in the early 19th century, the Anatomy Building has been recognised for its quality. According to Provost Mahaffy in his history of the college, its Anatomical Museum and Dissecting Room were considered to have “none of the dinginess so generally characteristic of rooms of this kind”. In his time as Professor of Anatomy from 1947 to 1984, Cecil Erskine brought to life a personal vision of the building that fused art and function to give it the charm it has to this day. Joint Technical Officers of the Anatomy Department, Siobhan Ward and Philomena McAteer, say that when Gunther von Hagens visited he described it as the best dissecting room he had ever seen. The Trinity Buildings Office is itself fully aware of the historical importance of the spaces and even though their fate awaits an official College review it seems likely they will be preserved in some form.

The building’s interior and contents, as seen in Fionn McCann’s photographs, reflect a time when objects embodied our knowledge, when it was possible to point at much of what was known. Now that our knowledge has penetrated to cellular and molecular levels – giving us physiology, biochemistry, genetics etc. – abstract representations are necessary to explain what we know, visualisation technology plays catch-up, museums are displaced by microchips, and some ask is anatomy even worth studying. But novices benefit from a familiar and tangible starting point that gives a necessary context for what is to follow, so it makes sense that our medical students should begin their health science studies with anatomy. How it is taught, is what is debateable: should we allow first-year medical students, some as young as 17, to dissect the remains of a fellow human being? Perhaps the models, photographs, diagrams and computer generated imagery used in some medical schools would be sufficient and more suitable?

Though there have always been difficulties, from moral to financial, associated with cadaveric teaching, as Siobhan Ward and Thomas Farrell write in a study entitled, ‘Are students of Anatomy adequately prepared to encounter donor remains?’: “Medical schools which have retained the study of practical anatomy with cadaveric specimens are now perceived to have a resource of great value.” Much of the complex stuff that makes doctors’ work different from mechanics’ may take place at a molecular level, but some of it emanates as colouring, texture, swellings, tears, smiles, words and so forth. Doctors need to be trained to notice and interpret the signs, and rightly, as Trinity Professor of Anatomy in the early 20th century, Andrew Dixon, wrote: “A great deal of importance is attached to the surface anatomy of the living body and efforts are made to get students to ‘see’ the deeper parts through the skin in the living subject.” But this can only be fully achieved by way of an intimate knowledge of what lies beneath. Furthermore, the variations between bodies and the differences from textbooks discovered in dissection prepare students better for the particularities of symptoms.

So, the donor remains will be moving with the Department, and thanks to good management and benevolent donors the entire donor programme will remain as is, meaning our medics can continue to have this great opportunity: “a true privilege,” as one student put it; “very honored to be given the gift of knowledge by the donors”, another. The success of the programme is down to the sensitive design of each element, from the donation procedure, to the removal to Trinity, from the briefing on respect that the students now receive, to the dignity ensured for each donor in the use of first names, partitioning and in the remembrance service.

Indeed, the Department’s sensitivity in this regard extends beyond the donor to the donor’s family. In research into the impact of donation on bereaved families, Philomena McAteer was surprised to discover that with no graveside to visit for two or more years while they waited for the final burial, family members were meeting outside the Anatomy Building on anniversaries using the grounds of the college as a kind of cemetery: “She is in there, still helping others” in the words of one interviewee. This phenomenon helped the Department secure an additional room in the new building for use a relative’s room, where families will be able to go with the hearse after the removal, and visit at various times afterwards.

But there are other elements of the Anatomy Building which have yet to find a home: the skeletons of various individuals, including that Cornelius Magrath (showing acromegaly); preserved and labelled dissections carried out by Daniel J Cunningham; a pathological collection from the 18th century; and teaching material, including my own grandmother’s Edinburgh Stereoscopic Atlas donated by her son. Although there will be no museum in the new facility, the staff are hoping over time to develop ways of incorporating some of these collections into the new spaces: “we see ourselves as custodians of all the donor remains here … and we feel protective of the specimens too,” Philomena McAteer explains.

The new Institute certainly offers the Department many other improvements. They will finally have enough plug sockets, which is only a trivial matter when you have them, as well as state-of-the-art audiovisual and temperature-regulated lighting equipment beside each donor remains, taking Trinity’s facilities from charming, ‘old-world’ to state-of-the-art, high-tech in one step. This will facilitate advanced surgical training in the future as well as the usual undergraduate learning that will recommence in September. The technological improvements and improved facilities for donor remains are making the move positive for the staff, who have been going through a grieving process of sorts themselves.

Prominent in many of McCann’s photographs, though least practical in terms of the Department’s collections, is the art of Cecil Erskine. His copies of Vesalian illustrations can be seen as an antidote to the somewhat messier business of actual dissection; though they reveal, being classically inspired, they are more celebration than gritty realism. “In medicine anatomy is applied, in art it is transformed,” Erskine wrote.

Fionn McCann’s photographs of the Anatomy Building are quite “applied” in relation to the interiors because they don’t hide much. They are architecturally Anatomical, in that while beautifully composed and lit, and somewhat stylised in their emphasis on historical space over current functioning, they do dissect the spaces to show us the asymmetry as well as the symmetry, the irregularities as well as the patterns. They open up the building, revealing layers, from structure and fixtures, through fittings and layout, to placements and hangings. The photographs are, though, it seems to me, unavoidably transforming in relation to the study of anatomy because they don’t show, as per the Department’s custodial modus operandi, the actual bodies of donors or of students and staff. Without them, so much is left to the imagination that one pictures a version of dissection, amidst these grand sets, that is cleaner and simpler than the reality.

It’s a reality that historically has made us somewhat uncomfortable. Dixon tells us that in the 1920s, at the time when my own grandmother was studying there, the Anatomy Building had, for such reasons, a “special dissecting room provided for women students”. Daniel Shapiro, who teaches in a medical school in the USA, has written about how he felt when he discovered that his mother was donating her body to medical teaching:

I didn’t want her body to reside, naked, under a plastic tarp in a cold room dominated by the hum of heavy fans and the smell of formaldehyde. I didn’t want her to be called cadaver. I didn’t want her name replaced by a table number, nor her body touched intimately by anyone who didn’t know her. (Daniel Shapiro, ‘The Last Gift’, JAMA, November 14, 2007—Vol 298, No. 18 (Reprinted))

Putting myself in the pictures, going back in time to 1987 when I was in one of the groups of medical students allocated to a cadaver, I recall the initial discomfort caused by the sticky smell, the formaldehyde-soaked skin, the sunken features and rigid weight of the body we dissected. I don’t think many of us paid a great deal of attention to the interiors of the Anatomy Building, to the reminders of Vesalius, to the elegance of the displays. Some of us were too caught up in our white-coated selves or in medicine or both. But, in the absence of a thorough orientation programme such as is conducted nowadays, perhaps the surroundings took on such a role, and had some impact on us, caught us up in their dignity. Perhaps, unnoticed and despite ourselves, the building’s aged beauty was straightening us out somewhat, putting us in our place, making disrespectful behaviour less likely if not totally eradicating our teenage showiness, before we made the first cut.

The Anatomy Building itself, as clearly seen in McCann’s photographs, at the very least provided a kind of sacred backdrop to that most profane of acts which we were embarking on. The question is can the new setting match it? Perhaps using Fionn McCann’s photographs the way Erskine used the illustrations from Vesalius would be an  appropriate way to help it along.

Or perhaps the newness itself, along with the work of the Department, will release us from our awkwardness around the idea of dissection and help us hear more clearly Daniel Shapiro’s mother whispering:

“Study me hard, and come back to me again and again. You learn everything there is to learn from my body—so that someday you can do something about these dreadful diseases.” (Daniel Shapiro, ‘The Last Gift’, JAMA, November 14, 2007—Vol 298, No. 18 (Reprinted))

Fionn McCann’s photographs are available to buy as prints from his website, Two of the photographs are on display at the 181st RHA Annual Exhibition which runs in the RHA gallery until 30 July, 2011.

Paul O’Connor runs the website Ars Medica. See He would like to thank Paul Glacken, Siobhan Ward, Philomena McAteer and everyone else in the Anatomy Department for the time they gave him in preparing this article.

Literature & Medicine intro

We looked, first, at what makes up this thing we call medicine.  A spider sprawl on the black board based on the group’s contributions to the question What makes up this thing we call medicine? produced the following (give or take):

Accepting that we would not be able to cover all these apsects of medicine in course of a 6-week module, we then read some letters to the Irish Times about the late Maurice Nelligan (here >>>) as an indication of how one (exceptional) doctor’s life can reflect so much of that fuller picture of medicine-in-the-world; while also realising that most doctors will only ever be confronted with most of the issues in passing.

Focussing in a particular aspect of the education/training of doctors, we then read some extracts from a few highly rhetorical Irish Times columns – by a columnist (now with Indo) who shall remain nameless – about the impact of medical training on students: “Possibly the young hospital doctors deserve everything they get. After all, it’s the life that they chose for themselves. Nobody made them do it, and most of them must have had a pretty shrewd idea of what lay ahead from the very first day in medical school, the greatest oxymoron of them all. For medicine and school are antithetical terms.

School for the rest of us means broadening our horizons; but the study required to be a doctor is the precise opposite of that. In what it does your brain, medicine comes a narrow second to placing your head in a piledriver. The latter is, to be sure, a little quicker and somewhat more Hammer-horrorish in special effects, but the net result is the same. Encephalectomy.

Why does the medical profession do this to young graduates? Why are they forced to know the christian names of every single cell of the body? Why do they spend 23 hours a day forcefeeding their brains with vast quantities of useless information which they will never need again? If geese were treated there would be uproar: so why is it acceptable to turn the bright young brains of medical students into cerebral foie gras?” ….

“The very first taks of medical school is the conversion of the brain from a vital ratiocinative organ for analytical thought and speculation into a machine for storing facts – a cerebral shoebox containing a vast anatomical index … and also, in an unswept and unvisited corner, a small, withering organ called common humanity.

This is not the fault of the students. It is almost impossible for the spirit of ordinary sensitivity, of optimistic enquiry, of normal ignorant speculation working its way to enlightened conclusion, to survive the Gradgrindery of medical training. Medical students probably work five or ten times harder than arts students; and correspondingly, they discover five or ten times less about human nature. That discovery is made in casual college discourse, in unstructured debate, in wide and varied and undisciplined reading. It is the very purposelessness of the liberal arts which give [sic] them purpose.”

… and so on.

After the break, we moved on to looking at what literature is & where it might fit into a medical student’s & doctor’s life. I pointed out that I was not limiting the course to fiction but including poetry, scripts, memoir, essay and journalism; only looking for fresh & interesting perspectives being offered on any aspect of medicine.

Wanting to take an extreme perspective on what use literature might have in the life of a medic, I read an extract from Rita Charon’s Narrative Medicine:

This led to a discussion on how far one could go in treating a patient (and in taking a history, in particular) using one’s imagination. The thesis that “clinical imagination” should be used by doctors was seen as perhaps going too far, in that mistakes could be made; the antithesis that it’s all about facts misses out on the fact (!) that people tell stuff about themselves in stories that don’t always give up their facts neatly. The sythesis emphasised that a sensitivity to how narratives work, how stories are told, might help a doctor get to and unearth the important facts in patient’s situation to aid a sound diagnosis and treatment.

Finally, I quickly mentioned some other benefits of reading outside the course:

  • It can enthuse you about a topic
  • It can provide new perspectives
  • It can lead to a deeper understanding
  • It can put you in your place (in society) both in the usual meaning of that word (as in keep you real!) but also in a more positive sense (as in boost your confidence)
  • It can show you that your situation or stuggle is not a first, that others have gone through similar
  • It can make everything new & fresh again, giving you the eyes of child in a sense
  • It can help you get a rapid second-hand insight into particular issues without you having to go through them

We discussed the next session’s text: William Carlos Williams’ stories.

Studying medicine with dyslexia

(From the British Medical Association

Medicine is a demanding subject, requiring a lifelong commitment to learning and hard work. Its practice is a combination of science and art. Knowledge of science forms the foundation for understanding the cause of the illness. The art is combining this knowledge with clinical judgment to determine a diagnosis and management plan.

Studying in a competitive field such as medicine can be a daunting challenge. For individuals with a learning disability, such as dyslexia, the ability to cope with the transition to an independent learning style can carry additional difficulties. However, it is important to remember that dyslexia is not a barrier to becoming a doctor and these difficulties can be overcome with appropriate support.

These guidelines aim to answer questions, provide information and quash myths. They are relevant for students already at or applying to, UK medical schools; or for medical students who think that they may be dyslexic.

Preparing TY for the ER

Full article in Irish Times here >>>

ROYAL COLLEGE OF SURGEONS IN IRELAND: Live operations, crime investigation, clinical trials: all in a day’s work for budding TY medical students

‘WHOSE BODY was this? How did he die?” State Pathologist Prof Marie Cassidy asked 150 Transition Year students at the Royal College of Surgeons Ireland (RCSI). The body was found in Dublin’s Grand Canal, and the students had no idea of the dead man’s identity or what had happened. Prof Cassidy talked the group through the clues, until a picture was eventually formed.

The State Pathologist was delivering a lecture to the TY group as part of a special week-long course at the RCSI, designed to give secondary school students a realistic taste of life as a medical student. Around 80 schools were represented at the event, held during the week of January 18th.

The course, now in its third year, brought students to Beaumont hospital on three days. Here, they were introduced to stood out. One of these was about to undergo a gall bladder operation, while the other was preparing for gastro-intestinal surgery.

Continue reading “Preparing TY for the ER”

Getting into medicine: a user’s guide to the HPAT

MEDICAL education has been transformed by the Health Profession Admission Test (HPAT), which allows all Leaving Cert students with more than 480 points to apply for medicine, writes LOUISE HOLDEN

Under the old system, only those scoring very high Leaving Cert points (in the region of 570) were guaranteed entry to medicine.

Former education minister Mary Hanafin hailed the new system when it was unveiled three years ago. From now on, she said, students would no longer need a “perfect Leaving Cert” to enter medicine.

Under the new system, all students with more than 480 points can apply. Entry is decided by a combination of your CAO points and your result in the HPAT.

Essentially, the test, which examines spatial and logical reasoning, problem-solving and interpersonal skills, allows candidates with lower scores in the Leaving Cert to make up the difference and get into medicine. On the flip side, high CAO scorers who perform poorly on the HPAT are kept out.

The introduction of the test has whipped up a flurry of debate.

Students are caught in the middle. The following is an objective guide to the exam that 3,000 Irish students will sit in February 2010. >>>>