IELTS Academic Reading Practice Test 357

Few institutions of the medieval world were as ambitious as the bimaristan. The word comes from Persian, in which bimar meant sick and stan meant place, and it was adopted in Arabic to describe a hospital in the fullest sense: a building where the sick were housed, fed, examined and treated, very often at public expense. The earliest examples appeared in the ninth century, and over the following four hundred years bimaristans were established in cities from Spain and North Africa to Persia and Central Asia. Their scale and organisation had no close equivalent in Europe at the time.

The first hospitals in the Islamic world grew out of military practice. Armies on campaign were accompanied by tents in which the wounded could be treated and medicines stored, and these mobile hospitals could be packed up and moved with the troops. Permanent foundations followed. According to later chroniclers, the first hospital in Baghdad was established during the reign of the caliph Harun al-Rashid, whose rule extended from 786 to 809, although no trace of the building survives and its site is unknown.

The most celebrated of the Baghdad hospitals was founded by the ruler 'Adud al-Dawla and opened in 982. It was a complex institution rather than a single ward. Its staff included physicians on duty in shifts by day and night, a director, a treasurer, a steward and a pharmacist, and its kitchens prepared special diets for different categories of patient. The hospital took in anyone who came, rich or poor.

Surviving buildings, together with descriptions in geographical and historical works, give some idea of the layout. Most bimaristans were arranged around a courtyard, with vaulted halls on one or more sides and wards opening off them. Patients were separated according to their condition and their sex, so that patients with fever, with eye disease or with a broken limb were not nursed together, and men and women were housed separately. Water was supplied to basins and latrines.

Treatment was normally free. Hospitals were financed not by fees but by a charitable endowment, known as a waqf, which usually consisted of land, shops or mills whose income was reserved for the foundation. The deed that set up the endowment specified in detail how the money was to be spent: how much on bread, how much on drugs, how much on the salaries of the staff, and what was to be given to poor patients when they left.

Bimaristans were also places of teaching. Students attached themselves to a practising physician and followed that physician on rounds, stopping at each bed so that the symptoms of the patient could be discussed and the reasoning behind the treatment explained. Lectures took place in the hospital itself, and some foundations contained a library. Physicians' reputations depended on their teachers as much as on their own books, and ambitious students travelled long distances to study under a celebrated master.

Among the physicians associated with these institutions, the most famous was al-Razi, who worked in Baghdad in the tenth century and whose clinical descriptions of smallpox and measles were still being quoted a thousand years later. A story repeated by later writers describes how, when a new hospital was to be built, he had pieces of meat hung in several districts of the city and chose the site where the meat putrefied most slowly, reasoning that the air there must be the least contaminated.

Al-Razi's greatest work, the Kitab al-Hawi, was an enormous compilation of case notes and extracts from earlier authors, and in Latin translation it circulated widely in Europe. The Canon of Medicine, completed by Ibn Sina in the early eleventh century, became the standard textbook in European universities for several hundred years. In Cairo in the thirteenth century, the physician Ibn al-Nafis went further, describing how blood passes from the right side of the heart into the lungs, an account that anticipated later discoveries about the circulation.

The two largest foundations of the later period were built in Syria and Egypt. The Nuri hospital in Damascus was founded in the middle of the twelfth century by the ruler Nur al-Din and grew into one of the most important medical centres of its age. A century later the sultan Qalawun built the Mansuri hospital in Cairo, which opened in 1284 and was still receiving patients two hundred years afterwards. It contained separate wards, a pharmacy, a library and a hall for teaching, and its endowment paid for the treatment of the poor.

Some bimaristans set aside accommodation for patients whose minds were disturbed, and treated them with a combination of drugs, diet and quiet. In the Ottoman lands the tradition continued after the medieval period: the hospital attached to the mosque complex built at Edirne in the late fifteenth century is often described as having used music and the sound of running water in the care of such patients.

The bimaristan did not survive unchanged. Warfare, plague and the collapse of the endowments on which they depended closed many of them, and the hospitals that later appeared in Europe developed along different lines. Yet the idea that a city should provide care for the sick, regardless of their wealth, owes a good deal to these foundations.

The human hand contains 27 bones, and almost every one of them can be moved independently of the others. Eight small bones, the carpals, form the wrist; five long metacarpals form the palm; and fourteen phalanges make up the fingers, three in each of the four fingers and two in the thumb. What distinguishes the hand from the limb of any other primate is not the number of bones but the shape of the joint at the base of the thumb, which allows it to be brought opposite each of the other fingers. The fingers themselves are richly supplied with nerve endings: the fingertips contain one of the densest concentrations of sensory receptors in the body.

The eight carpal bones are arranged in two rows and held together by short, strong ligaments, so that the wrist can bend and twist while remaining stable. The most vulnerable of the eight is the scaphoid, which lies at the base of the thumb and is the carpal bone most often broken in a fall onto an outstretched hand. The injury is easily mistaken for a sprain, because the pain is felt in the wrist rather than at the site of the break, and this matters: most of the scaphoid's blood supply enters through a single narrow channel near one end, so a break can cut off the blood reaching the larger part, which may slowly die.

Across the front of the wrist lies the carpal tunnel, a passage formed by the curved arch of the carpal bones and closed at the surface by a tough band of connective tissue called the flexor retinaculum. Nine tendons pass through this narrow space, together with the median nerve, which carries sensation from the thumb, the index and middle fingers and part of the ring finger, and which also supplies the muscles at the base of the thumb. Because the walls of the tunnel are unyielding, anything that narrows it or swells inside it presses on the nerve, producing numbness, tingling and weakness in the hand.

The movements of the fingers are produced largely by muscles situated in the forearm, not in the hand itself. Long tendons run from these muscles across the wrist and into the fingers, and it is the pull of these cords that bends the joints. The hand contains its own muscles too, the intrinsic muscles, which are small and lie in the palm. Those at the base of the thumb form the thenar eminence, the fleshy pad that makes the thumb's opposition possible; those on the little-finger side form the hypothenar eminence; and a set of slender muscles between the metacarpals, the interossei, spread and close the fingers.

A tendon that simply ran straight from the forearm to the tip of a finger would fail. When the finger bends, the tendon would lift away from the bone and the joint would bow, in the way that a bowstring curves. The hand prevents this with a series of pulleys: bands of fibrous tissue that strap the flexor tendons to the bones of the fingers. Five annular pulleys, numbered A1 to A5, encircle the tendons like rings, and three cruciate pulleys, C1 to C3, cross them diagonally. Together they keep the tendon close to the bone, so that the muscle's pull is converted into a smooth and powerful curl.

A tendon is not a passive cable. It is composed of bundles of collagen fibres, aligned along the direction of pull, together with a small population of cells called tenocytes and a matrix that binds water. This structure gives tendons great tensile strength, but it is also why they heal so poorly. Torn tendons repair themselves with scar tissue, which is disorganised and weaker than the original, and the repair tends to stick to surrounding tissue. Surgeons therefore encourage patients to move a repaired flexor tendon gently within days of the operation, because movement helps the fibres to align and discourages adhesions, while complete rest invites stiffness.

Three nerves serve the hand: the median, the ulnar and the radial. The radial nerve, which runs along the back of the arm, controls the muscles that straighten the wrist and fingers; the median nerve powers most of the thumb's muscles and provides feeling in the thumb, index and middle fingers; and the ulnar nerve, which crosses the elbow, controls most of the small muscles between the finger bones and gives the little finger its sensation. The ulnar nerve is what allows a pianist or a surgeon to make fine, independent movements of the fourth and fifth fingers. Sensation, too, is divided: the fingertips contain different kinds of receptors, some responding to steady pressure and others to vibration.

Much current research aims at replacing or repairing tendons more reliably. Surgeons have tried grafts of tendon from elsewhere in the patient's own body, and more recently scaffolds made from collagen or synthetic polymers, which are seeded with the patient's cells in the laboratory and are intended to break down as new tissue forms. The results are promising in animals, but they have not yet transformed practice in people. Other questions remain open. Why some people develop a thickening of the palmar fascia that curls the fingers, a condition known as Dupuytren's contracture, is still not understood, although it runs in families and is far more common in people of northern European descent. Ordinary trigger finger, in which a swollen tendon catches as it passes under a pulley, is common, but why it appears in one finger rather than another is usually unexplained.

Consider a patient with type 2 diabetes who attends a clinic every three months. The consultation lasts half an hour, blood pressure and blood sugar are measured, and the dose of one medicine needs adjusting. Until recently, the nurse conducting that consultation could explain, advise and telephone a doctor for a signature; the doctor might never have met the patient at all. In the past two decades, in a number of countries, that has changed: nurses who have completed the required training can now write the prescription themselves. Whether they should be allowed to do so is one of the more interesting arguments in health policy, and it is not really an argument about whether nurses are competent.

The change came gradually. In Britain, a small group of community nurses was given the right to prescribe from a limited list in the early 1990s, and the list was extended over the following decade. From 2006, nurses who had completed an approved course were permitted to prescribe any licensed medicine for conditions within their competence, with a few exceptions. In the United States, nurse practitioners have had some form of prescribing authority in every state for many years, but the degree of independence varies widely: some states allow them to prescribe without medical supervision, while others require a formal agreement with a collaborating physician.

The argument in favour begins with access. In many places, the doctor who would once have signed the prescription is simply not available, and a patient who must wait three weeks for an appointment may go without treatment altogether. Nurses are often the clinicians who see people with long-term conditions most regularly, and they are well placed to adjust doses, review side effects and explain why a medicine matters. Reviews of the research have generally been reassuring: nurses with the appropriate training appear to prescribe safely for the conditions they treat, and patients report high levels of satisfaction.

The objection is that a prescription is not an isolated act but the last step in a chain that starts with a history, an examination and a differential diagnosis. Deciding which of several possible explanations is the right one, and noticing the rare condition that does not fit, is the hardest part of clinical work. Nurses who prescribe have usually completed a course in pharmacology and physical assessment rather than a full medical degree. That does not make them unsafe, but it does mean that the system around them has to catch what an individual consultation may miss.

There is a second and less obvious risk. Once several clinicians can prescribe for the same patient, the list of medicines grows. Each addition may be justified on its own, yet the combination may interact, and elderly patients in particular may end up taking eight or ten drugs whose effects on one another nobody has considered. The safeguard is not to withhold prescribing rights but to insist that one clinician remains responsible for the whole list, and that every prescriber can see what the others have done. Shared records matter more here than professional boundaries.

Training, then, is necessary but not sufficient. An independent prescriber's course in Britain includes the study of pharmacology, the principles of assessment and a period of supervised practice with an experienced doctor, and candidates are assessed both by examination and in the workplace. What such a course cannot do is give a nurse ten years of diagnostic experience. Competence is therefore better understood as something specific: a nurse may be entirely competent to manage asthma and quite unprepared to assess chest pain.

It is here that the debate most often goes wrong. Supporters cite the absence of evidence that nurse prescribing causes harm; opponents reply that the absence of evidence is not evidence of safety. Most of the research measures what is easy to count — the number of prescriptions written, the length of consultations, the patient's opinion — rather than whether people became healthier, and much of it comes from services in which nurses work closely with doctors who can be consulted when something is unclear. Remove that support and the findings may not hold.

My own view is that the question should be reframed. It is not whether nurses are as good as doctors, a comparison that cannot be answered in general and invites defensiveness on both sides, but what arrangements make it safe for a wider range of clinicians to prescribe. The right to prescribe should be tied to a defined scope of practice, so that a nurse prescribes for the conditions they have been trained and assessed to manage. Decisions should be open to review, through audit and clinical supervision. Records should be shared. And where diagnosis is genuinely uncertain, the pathway to a doctor should be quick and without stigma.

None of this argues for a return to the old arrangement, in which capable clinicians had to hunt for a signature. It argues for care in how the change is made, and for honesty about its limits. Access to medicines is not improved by making prescribing harder; it is improved by making it available where it is needed and supervised where it is risky. The argument, in the end, is not about status.