The objective of this study was to determine the extent of medical students' experience of death and dying. A questionnaire was given to two groups of Birmingham medical students at the beginning of clinical studies (third year) and in the final year which was designed to estimate their experience of death and of dying people. The questionnaire also explored the students' attitudes to their own future deaths. Questionnaires were returned by 119 third-year and 143 final-year students. Students had little experience of death and what they did have was largely acquired before entry to medical school or in their social rather than medical lives. Where they did have experience of death this was often traumatic and there was little chance for them to have counselling about it. There is need for increased teaching about death and dying particularly before clinical training and at the time of graduation. Another time may be at the beginning of human dissection.
A method of comparing the referral of patients by general practitioners to medical outpatients departments at teaching hospitals in Amsterdam and Birmingham was devised. This was applied to 89 referral letters to medical specialists at the Free University Medical School Policlinic in Amsterdam and to 88 referral letters to clinics at Birmingham University Medical School, UK. The standards of referral were lower in the Netherlands than in Britain, and this may be related to differences in the health care systems, in the culture, or in the organisation of general practice. The delay between the general practitioner's referral and the consultation to the outpatient department was four times greater in Britain than in the Netherlands.
Doctors in different countries completed a questionnaire relating to the importance they attributed to eight possible sources of information about a new drug, their estimation of patients' expectations of the doctor prescribing drugs under specific circumstances and their therapeutic response to common clinical general practice situations. There were major differences between the stated behaviour of doctors in different countries with regard to the importance they attached to the eight sources of information on drugs. While doctors agreed on the importance of books and journals and on the unimportance of patients, nurses and other paramedicals, there was a major disagreement about the importance of drug company representatives: this source of information about new drugs was rated high in Sweden and Yugoslavia and low in Britain and Belgium. Doctors also differed in their estimation of patients' expectations of how they would prescribe and how they responded to the clinical problems. The differences, which might be due to differences in education about therapeutics or to cultural differences between countries, are important because of the high cost of drugs bills in all countries.
bifurcations and bends and may be related to low velocity low shear areas forming.'4-'6 This might result in local accumulation of lipids and other constituents, and activated platelets and white cells might spend longer at the site, promoting their interaction with the endothelium. Smoking is associated with an increased packed cell volume, increased circulating fibrinogen concentrations, and blood viscosity'" 18 and hence might encourage further blood stagnation in these areas.'9 Thus a combination of smoking and haemodynamic factors might promote atherogenesis in specific sites of the arterial tree and perhaps more in peripheral than in coronary arteries.
FGRFOWKES Senior Lecturer in Epidemiology
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