Recent eLetters

We are impressed by Dr Jeffery and colleagues' innovative styles of medical education in the context of communication skills, self-awareness and ethical thought1. However, it is difficult to be convinced that short theatre workshop alone would affect the same results across an entire cohort of medical students for reasons we will detail here. The module does however offer a refreshing method in critically engaging students in the complexities of the patient-doctor relationship.

A primary limitation in this study is that selection of the SSC drama module was voluntary. The students who have chosen this drama module are therefore not likely to be reflective of the medical student population in general. In addition the numbers participating are small, with only nine students across two years of enrolment, two students of which had expressed the option to be "a mistake" or their "last option". This highlights underlying obstacles to participation which have not been explored in the context of this article; the ability to engage medical students in what many regard as "soft skills" in comparison to other areas of their curriculum. Furthermore the article details that within this arguably atypical group, the primary concern on the first day was that of assessment criteria. This is reflective of the pervading culture of medical schools which is often focused towards passing exams. Therefore in this case formal assessment may guide input and direct student learning to that which students feel will impress the examiner. It is therefore very difficult to make objective assessments on what the students gained without subjective bias of the module convenors.

We feel this SSC module is a step forward in addressing this deficit within medical education and in a new and enjoyable way. It starts a process of critical thinking amongst the students which if, as the author recognises, can become embedded in clinical practice, will benefit both patients and doctors alike. We believe the focus on increasing self- awareness in this module should form part of the mandatory curriculum. Medical schools as an institution thus need to adopt anthropological approaches, whereby they cultivate young doctors who consider social relationships, cultural norms and the micro and macro politics that influence health and well-being and the experience of illness.

1.Jeffrey E, Goddard J and Jeffrey D (2012). Performance and palliative care: a drama module for medical students [in] Medical Humanities, (38), pp110-114.

Conflict of Interest:

None declared

Ian C. M. Williams' article on the use of comics as a suitable medium for medical narratives is a timely evaluation of the potential of the comicbook form to address several medical issues. For a medium that is roughly over a hundred years old (although some scholar might argue that comics had their roots in the inception of printed cartoons, whereas others trace back their origins as far as the Bayeux Tapestries or even prehistoric cave paintings), comics have surely evolved in content, variety of subject matter and format. As noted, comic studies are relatively new, but a number of books have been published, there are post- graduation courses focusing in comics theory (as the one offered by Opet in Curitiba, Brazil) or literary studies of comics (as the University of Dundee's, Scotland, that began last year), theses, Manchester's University International Comic Conference and even two peer-review periodicals; Studies in Comics and The Journal of Graphic Novels and Comics.

As a practicing neurologist and life-long comics reader I had the opportunity to present last year at the 29th International Epilepsy Congress a poster based on Joshua Hale Fialkov and Noel Tuazon's graphic novel Tumor entitled TUMOR - A GRAPHIC NOVEL REPRESENTATION OF GLIOBLASTOMA MULTIFORME AND MULTIPLE SEIZURES TYPES. This is the story of a private detective who is diagnosed with GB, while solving his last case. A variety of seizure types and other symptoms, such as confusional state and space-time disorientation are presented in graphic form from the standpoint of the main character/patient, providing a layman's interpretation of seizure semiology.

Again, as mentioned in William's article, comics provide a rich source of material for medical studies. Even the so-called mainstream comics have featured characters with multiple medical conditions, such as Barbara Gordon's spinal injury in The Killing Joke, which ultimately led her to become the paraplegic heroine Oracle; David Lapham's Young Liars, where the main female character suffers a bullet wound to the frontal lobe and looses impulse control; or Sue Dibny's death in Identity Crisis as a result of a brainstem stroke caused by the murderous Jean Loring's stepping over her basilar artery in microscopic size.

Also, several characters are Medical Doctors, such as Marvel's Doctor Strange, Gotham City's Dr. Leslie Thompson, the X-Men's Dr. Cecilia Reyes or JSA's Dr. Mid-Nite. There will be more articles on the interaction between comics and Medicine in the coming years for sure.

Conflict of Interest:

None declared

I read with interest Caruncho and Fernandez postulation of Chopin possibly having temporal lobe epilepsy, and resultant complex hallucinations. I was struck by a few other explanations which could account for these bizarre phenomena. He was in a state of poor health, and could have had a few subacute confusional state in clear consciousness. Secondly it is not uncommon for truly gifted people such as Chopin to have synaesthesia, a a process in which one type of stimulus produces a secondary, subjective sensation( for example when some color evokes a specific smell)What could be in favour of this is considering that in some of the accounts these events happened while he was playing music. What isn't in doubt was that these "hallucinations" did not impede him from being one of the greatest musicians of all time.

Conflict of Interest:

Nil

One of the best episodes (and probably most shocking to thousands of people of all ages)of a medical programmes in UK dealt exactly with the need to reassure people about the huge variation in genitalia. Shocking because genitalia are so taboo that a penis still cannot usually even be shown on TV. The programme continues to run a web site so that people can see different genitalia for themselves and also to share experiences and worries . It simply does not work for healthworkers to assume it is reassuring to somebody being examined that they 'have seen hundreds of them, it means nothing...' when there is such a strong taboo about exposing private parts of the body. This programme gave people of all ages the chance to look at real human beings who were at ease with their different bodies including their genitalia. It is to be expected that reactions would be different and they did range from shock, disgust, curiosity, embarrassment to positive acceptance and healthy interest instead of secretive voyeurism or anxiety. It was also the case though that even after seeing how much variation is normal, many youngsters, boys and girls,preferred a cosmetically enhanced version of the stereotypical most ideal bodyshape to variations on that,including a majority preference for certain size and shape genitalia. Some would still choose surgery to conform. Hopefully when the issue is so complex, as many healthworkers as others will access the programme and web site as well as using what are often rather dehumanising descriptions or photographs of parts of bodies. The doctors who ran the programme are to be congratulated for breaking the taboo which causes so much distress.

Conflict of Interest:

None declared

Caruncho and Fernandez interpreted Chopin's hallucinations as temporal lobe epilepsy.(1) Recently, Karhausen examined the 140 causes of death of Mozart that have been proposed in the medical literature.(2) These studies on both composers nicely illustrate how a mechanistic view of death and disease still dominates modern medicine.

Identifying the cause of death can be difficult. Many physicians will share the experience that one is sometimes uncertain about the cause of death. In these instances, cardiac arrest is often written on the death certificate, which almost seems true by definition; the heart stopped beating. Intuitively, physicians realise that the mechanistic view of a single cause and a single effect is not always appropriate. Death certificates and national statistics however demand the identification of a single cause of death.

In a seminal paper, Rothman has argued that death and disease seldom have single causes.(3) His model of causation identifies multiple components. Sufficient causes are subdivided into component causes. This model illuminates important principles as multi-causality, the dependence on the strength of component causes and interaction between component causes. In his view the death from a fall is caused by the combination of e.g. visual problems, a loose rug, osteoporosis and sarcopenia. This has important consequences, since it is therefore recognised that intervention with any of these component causes is important to prevent the formation of a sufficient cause for the fall.

In the next century, people will live longer lives without disabilities.(4) The challenge in the future will be to manage elderly patients with multiple chronic diseases. A mechanistic view of single causes of death and disease is not appropriate for our growing population of elderly patients. A more widespread appreciation of the multi-causal nature of death and disease could be an important step to successful ageing in the next century.

1. Caruncho MV, Fernandez FB. The hallucinations of Frederic Chopin. Med Humanities 2011 doi:10.1136/jmh.2010.005405

2. Karhausen LR, Mozart's 140 causes of death and 27 mental disorders. BMJ 2010; 341:c6789. doi:10.1136/bmj.c6789

3. Rothman KJ, Greenland S, Stat, C. Causation and causal inference in epidemiology. Am J Public Health 2005; 95:s144-s150. doi:10.2105/AJPH.2004.059204

4. Perenboom RJ, Van Herten LM, Boshuizen HC, Van Den Bos GA. Trends in disability-free life expectancy. Disabil Rehabil. 2004 Apr 8;26(7):377- 86.

Conflict of Interest:

None declared