IELTS Academic Reading Practice Test 323

Elizabeth Blackwell was born in Bristol, England, in 1821, the third of nine children. Her father, Samuel Blackwell, was a sugar refiner whose business suffered a serious fire, and in 1832 the family emigrated to the United States. After a few unsettled years, first in New York and then in Cincinnati, Ohio, the household began to establish itself in a new country, and the children were encouraged to read widely and to argue at the dinner table. Samuel died in 1838, however, leaving his widow and children with very little money, and the older daughters, Elizabeth among them, opened a school in order to support the family.

For several years Blackwell taught, first in Cincinnati and later in Kentucky, where she also studied mathematics, languages and the classics in her spare time. She had no wish to become a doctor; the sight of blood made her uneasy, and she found the idea of medicine faintly distasteful.

What changed her mind was a conversation with a friend who was dying, and who remarked that her suffering would have been far less if she had been able to discuss her body with a woman doctor. Blackwell, then in her mid-twenties, treated the remark as a challenge she could not ignore, and began to study privately with local physicians, borrowing textbooks and reading late into the night.

No medical school in the United States admitted women, and Blackwell was turned away by institution after institution in Philadelphia, New York and elsewhere. One doctor, she later recalled, told her that the only way to obtain a medical education was to disguise herself as a man. In 1847, however, she was accepted by Geneva College, a small institution in upstate New York. The faculty, reluctant to reject so unusual an application outright, had referred the decision to the students, who voted in her favour — a vote that most of them cast as a joke.

The joke turned serious when Blackwell arrived in Geneva and proved an able student. Her presence was not welcomed by everyone. She was excluded from some anatomy demonstrations, sat apart from her male classmates in lectures, and was treated by local families as unfit company for their daughters. None of this prevented her from completing the course, and in January 1849 she was awarded her medical degree, the first woman in the United States to receive one. The local press reported the event with more curiosity than approval.

Further training took her to Europe. In London she attended lectures at St Bartholomew's Hospital and met Florence Nightingale; in Paris she worked at La Maternité, a large maternity hospital, where she hoped to qualify as a surgeon. There she suffered a serious setback. While treating a newborn baby she contracted an infection in one eye, and the sight of it was lost. The injury ended any ambition to operate and pushed her instead towards general practice and public health, causes she pursued for the rest of her career.

She returned to New York in 1851, expecting to be welcomed, and found the opposite. Landlords refused to rent her rooms for a surgery and she was barred from the city's medical societies; her lectures on hygiene drew audiences of women, but patients were slow to come. In 1857, with her younger sister Emily, who had by then also qualified as a doctor, and with a Polish-born colleague, Marie Zakrzewska, she opened the New York Infirmary for Women and Children in a rented house in lower Manhattan. It was staffed entirely by women, treated poor patients without charge, and gave women doctors the hospital experience that no other institution in the country would offer them.

When the Civil War began in 1861, Blackwell threw her energies into the war effort. She helped to found the Woman's Central Association of Relief, which gathered medical supplies for the Union army and pressed for better conditions in military hospitals, and she took part in selecting and training nurses. The women who passed through her hands were among the few in the country with any formal instruction, and she regarded this work as one of her most useful contributions to the war.

In 1868 Blackwell opened the Woman's Medical College of the New York Infirmary. Its course was longer than that of most American schools. It also insisted that students spend time on the wards as well as in lectures, since Blackwell believed that women would never be taken seriously as physicians unless their training was at least as thorough as that of men. The college was one of very few places in the United States where a woman could obtain a complete medical education.

In 1869 Blackwell settled in England, where she spent the rest of her life. She became professor of gynaecology at the London School of Medicine for Women when it opened in 1874, and she campaigned for sanitary reform and against quackery, the sale of useless and sometimes dangerous remedies. Her memoir, Pioneer Work in Opening the Medical Profession to Women, appeared in 1895 and remains a source for historians of medicine. She never married and died at her home in Hastings in 1910, by which time women were being admitted to medical schools in a number of countries. The door she had forced open was not closed again.

Most of us can point to the place in our bodies where hunger is felt: a hollow sensation just below the ribs. It is natural to assume that this feeling is simply the stomach announcing that it is empty, and for much of the twentieth century researchers looked for the explanation of appetite in the mechanics of digestion. The picture that has emerged since the early 1990s is far more complicated. Hunger and fullness are produced by a stream of chemical messages, carried in the blood and along nerves, which pass between the digestive tract, the fat stored beneath the skin, the pancreas and the brain. Appetite is less a matter of an empty stomach than of a conversation between organs.

The most important of the hunger signals is ghrelin, identified in 1999 by researchers in Japan and named after a root meaning 'to grow', because it also triggers the release of growth hormone. Ghrelin is made chiefly by cells in the lining of the stomach. Its level in the blood follows a striking daily pattern: it climbs steeply before a meal and drops again soon after eating. When volunteers are given ghrelin through a drip, they report feeling hungry and eat considerably more than usual. This has earned it the popular label of the hunger hormone, though it is only one of several signals that shape our desire to eat.

The opposite message is carried by leptin, discovered in 1994 by a team at Rockefeller University in New York. Leptin is produced by fat cells, and its concentration in the blood reflects the amount of fat a body carries. Mice unable to make leptin eat voraciously and become enormously fat; when the hormone is restored, they lose weight. The discovery was greeted as a possible treatment for obesity, and for the handful of people with rare genetic faults that prevent them making leptin it has indeed been dramatic. For the great majority of people with obesity, however, leptin levels are already high. Their brains appear to have become insensitive to the signal, a condition known as leptin resistance.

A third set of messages comes from the intestine itself. Cholecystokinin, released from the upper part of the small intestine when fat and protein arrive, was the first hormone shown to reduce the size of a meal in laboratory animals, in the 1970s. Two more, peptide YY and glucagon-like peptide-1, are released further down the gut some time after food has been eaten and are thought to contribute to the feeling that a meal is over. Much of this information reaches the brain along the vagus nerve, a major pathway running from the abdomen to the brainstem.

The signals converge on the hypothalamus, a small structure at the base of the brain that governs temperature, sleep and body weight as well as appetite. Within it, the arcuate nucleus contains two populations of neurons with opposite effects. One produces molecules called NPY and AgRP and encourages eating; the other produces a small protein known as melanocortin and suppresses it. Ghrelin switches on the first group and leptin activates the second. The blood vessels here are unusually permeable, so hormones can cross from the bloodstream into brain tissue, which is exactly why this region matters so much to researchers.

The experience of a single meal shows the system in action. As the stomach fills, stretch receptors send signals along the vagus nerve. Cholecystokinin rises as food reaches the small intestine. Only later do peptide YY and glucagon-like peptide-1 appear, and the feeling of fullness they produce can last for hours. Researchers refer to this sequence as the satiety cascade. It explains why the kinds of food we eat matter as much as the quantities. A meal rich in protein and fibre generates a stronger and longer cascade than one made mainly of refined carbohydrate and fat.

Many questions remain. Ghrelin levels rise after weight loss and fall again when weight is regained. This has led researchers to argue that the body defends a preferred weight against both dieting and overfeeding, and it is one reason why lost weight so often returns. Why some brains become deaf to leptin is not understood. Attempts to treat obesity with substances that block ghrelin have had disappointing results, suggesting that other pathways compensate. The bacteria that live in the gut are now being studied; early findings hint that they influence appetite, but the evidence is far from settled. Appetite is also shaped by habit, boredom and the sight of food, which no hormone can explain.

Hormonal research has nonetheless produced treatments. Drugs that mimic glucagon-like peptide-1 were developed for diabetes and later found to produce substantial weight loss; they slow the emptying of the stomach and act directly on the hypothalamus. They are not a simple solution: nausea is common, treatment must continue indefinitely if the weight is not to return, and supply has struggled to meet demand. A drug called setmelanotide, which acts on the melanocortin pathway, has been licensed for a small number of rare genetic conditions. Each of these medicines works on one part of a system that evolved to protect the body from shortage, which is why appetite has proved so resistant to easy answers.

A medical note is one of the least public documents a person will ever be the subject of. Written during a ten-minute consultation and typed into a template, it records not only what the doctor observed but what the doctor suspected, feared and dismissed. It is read, if at all, by other clinicians. Patients have traditionally been able to obtain copies by formal request, but the note itself has been treated as the profession's private property. In 2010 a group of primary care physicians in three parts of the United States invited their patients to read their notes online. The doctors expected trouble. Within a few years, the practice they tested had begun to turn into policy.

The results surprised almost everyone. Patients who read their notes reported that they understood their conditions better and remembered what they were supposed to do; some said they were more careful about taking their medicines. A small but significant number spotted factual errors, such as an out-of-date prescription or a mistaken family history. Few reported being confused or upset, and most wanted the practice to continue. The physicians, who had predicted extra work and anxious phone calls, found little evidence of either, and many said they would not go back. The collaboration, which became known as OpenNotes, was later extended to hospitals and clinics elsewhere in the country.

The worries were not imaginary, however. A note is not a leaflet. It is written quickly, in a compressed professional language, and it contains uncertainty: a query here, a possible diagnosis there, a suspicion that will later be disproved. An abnormal result may be flagged for follow-up, and a serious illness may first appear in writing before anyone has had the chance to explain it. A patient reading such an entry at midnight, with no one to answer questions, may take alarm. Doctors also feared that a note written in haste could read as cold or dismissive of the person it described, and on this point the evidence has been more mixed.

The deeper difficulty is that a note is written for other purposes altogether. It is a working document for colleagues who will take over the patient's care, a record for billing, a defence in the event of a complaint, and increasingly a dataset for research. Its conventions are those of a profession talking to itself. Reading one's own note can therefore feel less like a conversation than like overhearing a conversation. The subject is discussed in the third person, in shorthand, by people who know more than the reader does.

Then there is the question of who else is looking. A portal account is a key to a great deal of sensitive information, and a shared laptop or a family phone can give a partner, a parent or an adult child access that the patient never intended. In households where one person controls another, an unexpected notification can be dangerous. Adolescents raise a related problem: the law may give parents access to a child's record at exactly the age when confidentiality matters most. Any system of open records must be designed around these realities, not around the convenient fiction of a patient who lives alone.

The law has already moved. In the United States, the 21st Century Cures Act of 2016 required that patients be given electronic access to their health information. Rules introduced in 2021 then obliged providers to release it without the delays and fees that had long been used to obstruct requests, with narrow exceptions for information likely to cause serious harm. In England, general practices have been moving in the same direction through the NHS app. Several countries, including Sweden and Estonia, gave patients online access to their records well before the United States did. The direction of travel is not in doubt.

Opening the record has begun to change the record. Hospitals have rewritten templates in plainer language, added short summaries at the end of entries and removed the abbreviations and jokes that once passed for communication. Some clinicians admit, however, that they now keep certain thoughts out of the shared note altogether, recording them elsewhere or not at all. This is the strongest argument against blanket secrecy and for careful design: if openness simply pushes information into unrecorded places, the patient is no better informed and the next clinician is worse off.

What, then, should the rule be? In my view the default should be openness. The person who is the subject of a record should be able to read it, and the burden of proof should fall on anyone who wishes to withhold a part of it. That burden must be discharged honestly. There are genuine reasons for withholding a suspected diagnosis for a day or two, for protecting a third party's confidential information, or for holding back an entry that would place a patient in danger at home. Such exceptions should be defined in advance, applied by someone with a duty to explain the decision, and reviewed. What cannot be justified is the old arrangement in which the record belonged to the institution that kept it. A document that the person it describes is not allowed to read is unlikely to be written for that person's benefit.