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TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed at trainee doctors from their first day at medical school, through their sleepless foundation years and tough specialist training until they become a consultant. It’s proudly produced entirely by junior doctors – right down to every last spelling mistake. Find us quarterly in hospitals throughout the UK and updated daily at JuniorDr.com.

Team LeaderMatt Peterson, team@juniordr.com

Editorial TeamYvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai

JuniorDrPO Box 36434, London, EC1M 6WA

Tel - +44 (0) 20 7 193 6750Fax - +44 (0) 87 0 130 6985team@juniordr.com

Health warningJuniorDr is not a publication of the NHS, David Cameron, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not neces-sarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual ori-entation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash.

© JuniorDr 2011. All rights reserved.

Get involvedWe’re always looking for keen junior doc-tors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.

What’s inside

04091013

18

20

30

LATEST NEWS

WE LovE THE NHS

THE NhS rEformS

COpING WITH iLLNESS

ARRIvING IN SiErra LEoNE

ExpEDITION mEdiciNE

MEDICAL courSES aNd coNfErENcES

cErTaiNTY IN AN UNCERTAIN NHSO ur NHS isn’t just reforming - it’s transforming into new

national health service that we’ve never experienced before. Not since it was established in 1948 has such a

dramatic change been proposed that will give us a market driv-en service for the first time.

As junior doctors we’ll be the ones leading this new NHS in the future. It’s imperative that we understand what is being proposed so we can make an informed deci-sion about whether we support the government’s plans.

Benjamin Brown summarises what is new, what will change and what will cease under the proposals on page 11. You can also find further explanation about the NHS reforms on our website - including our previ-ous interview with Andrew Lansley himself.

Changes to the NHS will have a huge impact on patients and, as Rosie Puplett reminds us on page 13, we junior doctors are occasionally patients ourselves. We are, however, extremely bad at looking after our own physical and mental health despite the intense demands of our jobs.

As sick leave rates rise among junior doctors we offer some advice about what to do if you become ill and provide a list of the resources available to you. The support section of our DrTribe community has additional resources and the opportu-nity to get advice from your peers.

Further afield our new blogger, FY2 Mikey Bryant, writes on page 18 about his arrival in Sierra Leone where he’ll be spending a year working in a children’s clinic. You can follow his experi-ences online as well as that of our cardiology SpR (page 24) who finally ends her placement before starting a consultant post.

If you’re still looking for holiday plans for Easter or hope to escape the UK over the Royal Wedding wedding check out our guide to Oslo in our Weekend Ward Escape on page 21. If this inspires you to be more adventurous Ivor Vanhegan looks at the career possibilities of expedition medicine on page 20.

Remember, JuniorDr is a magazine produced entirely by you. Get involved and make it your community. We’re planning a special section on junior doctors who have helped improve clini-cal care in June so if you know anyone who we shouldn’t miss out let us know at team@juniordr.com.

The JuniorDr Team

“As junior doctors we’ll be the ones leading this new NHS in the future.”

NEWS PULSE4

Tell us your news. Email team@juniordr.com or call 020 7193 6750.

A lmost one in five UK doctors (19%) has worked with an incompetent or poorly performing colleague in the

past three years, according to a survey pub-lished in BMJ Quality and Safety.

Nearly three out of four of these doctors said they had sounded the alarm, but one in three of those who had not done so gave fear of retribution as the reason. The remainder said they hadn’t sounded the alarm because they thought someone else was taking care of the problem.

Commenting on these findings, Niall Dickson, the Chief Executive of the Gen-eral Medical Council, said:

“Doctors have a clear duty to put patients’ interests first and act to protect them; this includes raising concerns about colleagues when necessary. Our consultation on Good Medical Practice asks what more needs to be done to make sure doctors speak up about anything that puts patients at risk.”

coNfLicTS of iNTErESTThe study of 2,000 US and 1,000 UK

doctors working in primary care and hos-pital medicine also found that only 4 out of 5 respondents in both countries strong-ly agreed that patient welfare should come before their own financial interests.

Less than 7 in 10 of those questioned felt that they should disclose any financial relationships they had with pharma com-panies to their patients despite most having received gifts from these companies.

rEvaLidaTioNWhen it came to the quality of their own

performance, twice as many US as UK doc-tors agreed that periodic revalidation was

necessary. But only just over half of US doc-tors agreed with this, despite recertification having been in place for several years in the US. Revalidation for UK doctors is due to start in 2012.

UK doctors were also less likely than their US peers to completely agree that all the pros and cons of a procedure should be fully explained to a patient, but when things went wrong UK doctors were more likely to agree that significant medical errors should be disclosed.

qualitysafety.bmj.com

ONE IN THREE DOCTORS DO NOT REpORT iNcompETENT coLLEaguES DUE TO FEAR OF RETRIbUTION

ProfEssionaLism

nHs

DOCTORS THINk NhS rEformS bRING MORE RISkS THAN bENEFITS

T he vast majority of doctors are uncon-vinced of the potential benefits of the government’s plans for the NHS in

England, according to an Ipsos MORI poll of BMA members.

The survey of 1,645 respondents found widespread concern about plans to increase competition even among the minority of doctors who are generally supportive of the changes.

Almost nine in ten (88%) think it is likely that the reforms will lead to increased competition between providers, but only a fifth (21%) believe this will improve the overall quality of NHS care.

Two thirds (67%) think closer work-ing between general practice and hospitals

would improve the overall quality of patient care but only a third (34%) believe it likely that the reforms will lead to this.

In terms of the impact on their own roles, three fifths of respondents (61%) think it likely that the reforms will lead to them spending less time with patients.

“This survey shows that the govern-ment can no longer claim widespread sup-port among doctors as justification for these flawed policies,” said Dr Hamish Meldrum, Chairman of Council at the BMA.

“While there are widely differing opin-ions, with many still to decide, there are a number of key issues where the majori-ty have very clear concerns. The govern-ment simply cannot afford to dismiss this

strength of feeling amongst the group they are expecting to lead much of the change.”

Overall the survey suggests that doc-tors’ attitudes to the reform fall into three distinct groups: a third (33%) are broadly opposed, around a fifth (18%) are broadly supportive, and just over a third (36%) say they are waiting to see what happens.

There are also mixed views about the impact of the proposed system of GP-led commissioning. Two thirds (66%) agree it will increase health inequalities and half (49%) that it will reduce the quality of patient care.

www.bma.org.uk

Niall Dickson ChIEf ExECUTIvE of ThE GMC

“Doctors have a clear duty to put patients’ interests first and act to protect them; this includes raising concerns about colleagues when necessary.”

M ost new training programmes designed to widen access to medicine in the UK are fail-ing to increase the diversity of medical stu-

dents, according to a study published in the BMJ.It shows that although historic under-represen-

tation of women and of minority ethnic groups has been redressed, a large proportion of medical stu-dents still come from the most affluent socioeco-nomic groups in society.

Recent years have seen major initiatives to broaden the demography of the UK medical stu-dent population, but it is unclear whether new pro-grammes, such as graduate entry and foundation entry courses, have achieved this.

Researchers at the University of Birmingham looked at whether new routes into medicine have produced more diverse student populations. They found that students on graduate entry courses were, as would be expected, significantly older than stu-dents on traditional courses and were more likely to define themselves as white (84% v 70%).

Two fifths of students on traditional courses de-clared their parental occupation to be higher mana-gerial and professional compared with 27% of stu-dents on graduate entry courses.

In contrast, only 23% of students on foundation

programmes (where entry is restricted to under-rep-resented groups) defined their ethnicity as white and only 8% defined their background as higher managerial and professional. However, the num-bers of places available on these courses are small.

“Evidence of the advantages of increasing diver-sity is emerging, but the implementation of ‘new’ admission routes to the profession does not seem to be bringing significant change,” say the authors.

“In both the US and UK, the most success-ful programmes to increase student diversification seem to be those based on explicit affirmative ac-tion, yet these programmes are not universally wel-comed among the public or the profession.”

www.bmj.com/cgi/doi/10.1136/bmj.d918

NEW TraiNiNg programmES FAIL TO WIDEN DIvERSITy IN MEDICINE

mEDicaL sTuDEnTs

U p to three quarters of hospital tests are not being followed up on discharge, according to a study published in the BMJ.

Analysis of 12 studies showed that between 20% and 61% of inpatient test results, and between 1% and 75% of tests on patients treated in emergency care, were not followed up after dis-charge. This failure can have serious implications for patients, including missed or delayed diagno-ses and even death, the study shows.

The authors base their findings on a systemat-ic review of evidence published between 1990 and 2010 and available on reputable research databases.

Critical test results and results for patients moving between healthcare settings, such as from inpatient to outpatient care or to general practice, were the most likely not to be pursued.

Only two of the 12 studies described fully elec-tronic test management systems and the rate of

missed results was still high in both but the authors point out that this might be because technology makes the issue more explicit and easier to measure. Rates were also just as high in paper-based systems and those using a mix of paper and electronic records.

“There is evidence to suggest that the propor-tion of missed test results is a substantial problem which impacts on patient safety,” say the authors.

www.bmjqs.bmj.com

THREE IN FOUR hoSpiTaL TESTS NOT FOLLOWED Up

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NEWS PULSE6

G Ps need longer training to develop the skills and confidence to manage the increase in complex conditions, says

The Royal College of GPs in Scotland.“High quality care for all our patients is at

the heart of general practice and we want to ensure this is achieved, now and in the long-term” says Dr. Ken Lawton, former Chair of RCGP Scotland and co-author of the new report which looks at the future of general practice in Scotland.

“The introduction of GP specialty training in 2007 was a major advance in medical train-ing. However, the RCGP Curriculum was intended to be a five year programme rather than the current three year programmes that exist, or indeed the current four year pro-grammes in some parts of Scotland.

Training needs to be extended to 5 years, with at least two years based in general prac-tice. Extended training will help GPs and their teams tackle the challenges of the future which include an aging population, increas-ingly complex conditions and greater finan-cial pressures.”

The new document, entitled ‘The Future of General Practice in Scotland: A Vision’ looks at general practice over the next 5-10 years, aiming to ensure that patients receive high quality care through general practice and that GPs are trained to the highest stan-dards possible. Alongside training, the vision document covers the main health issues for general practice in Scotland; health inequal-ities, patient care, professional development and academic research.

http://www.rcgp.org.uk/college_locations/rcgp_

scotland.aspx

rcgp ScoTLaNd: GpS NEED LONGER TRAINING

TraininG

A reduction in doctors’ working hours in the United States from over 80 per week has not affected patient safe-

ty and has had limited impact on training, according to a study published in the BMJ.

The UK-based researchers looked at 72 studies from the US and UK to evaluate the impact of a reduction in working hours on ed-ucational and clinical outcomes and found no significant change in either safety or training.

The medical profession has raised concern about the potentially adverse effects on post-graduate training for junior doctors and the provision of high quality care for patients.

The maximum hours per week for train-ees can range from 37 hours in Denmark to 80 hours in the US. The European Working Time Directive (EWTD) restricted the week-ly hours for trainee doctors in Europe to 48 from August 2009.

Studies on the impact of European legis-lation limiting working hours to 48 a week

were of poor quality and had conflicting re-sults meaning that firm conclusions can-not be made. Further work is now needed to assess the impact of reducing hours to 48 a week in Europe, say the authors:

“Only then can both the public and the pro-fession be reassured that the standard of medi-cal training, and therefore the future care of pa-tients, is of the highest possible quality and will be maintained or improved over time.”

www.bmj.com/cgi/doi/10.1136/bmj.d1580

rEducTioN iN uS WorkiNg hourS HAS LITTLE EFFECT ON SAFETy AND TRAINING

WorkinG conDiTions First female Chief Medical Officer for England

Professor Dame Sally Davies has

been appointed the Chief Medical Offi-

cer (CMO) for England - the first wom-

an to hold the post. The CMO is the Gov-

ernment’s most senior medical advisor

and is responsible for providing expert

advice on a wide range of issues relat-

ing to the health of the nation, including

the handling of health related emergen-

cies. Accepting the post she said, “I am

honoured to be the 16th person and first

woman to join the prestigious ranks of

Chief Medical Officer and I look forward

to working with everyone to improve the

health of the nation.”

www.dh.gov.uk

No job is better than a bad jobHaving a bad job can be just as harm-

ful to your mental health as no job at all,

according to research published in Oc-

cupational and Environmental Medicine.

The study based on longitudinal house-

hold panel survey data from more than

7000 people found that after taking ac-

count of confounders found that the

mental health of those who were jobless

was comparable to, or often better than,

that of people in work but in poor quality,

badly paid jobs.

oem.bmj.com

GMC proposing new tribunal service

A new tribunal service for doctors fac-

ing serious concerns about their practice

is being proposed by the GMC. The Medi-

cal Practitioners Tribunal Service which

would take responsibility for running hear-

ings and for the decisions panels make.

The aim is for the new service to be sepa-

rate from the GMC’s work in investigating

cases and presenting them to the Tribu-

nal. The consultation is open until Mon-

day 13 June. Full details are available at:

www.gmc-uk.org/ftpreformconsultation

prescription charges rise in England

The cost of a prescription in England

will rise by 20p to £7.40 from April 1st.

Scotland will be scrapping charges from

the same date whilst patients in Wales

and Northern Ireland are already exempt

from prescription charges. BMA Chair-

man, Dr Hamish Meldrum, said the move

‘further exaggerates the absurd postcode

lottery that exists in the UK’.

www.dh.gov.uk

Dr Ken LawtonfoRMER ChAIR of RCGP SCoTLANd

“Training needs to be extended to 5 years, with at least two years based in general practice.”

NEWS PULSE 7

www.oup.com/uk

JUST WHAT THE DOCTOR ORDERED

Telephone: +44 (0)1536 741727

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OUP What the Doc Ordered ad v1_Layout 1 10/12/2010 12:01 Page 1

U K trained doctors from minority ethnic groups tend to underperform academically compared with their white counterparts, according to a study published in the BMJ.

Researchers at University College London analysed the results of 22 reports comparing the academic performance of 23,742 medical students and UK trained doctors from different ethnic groups. They found that candidates of non-white ethnicity consis-tently underperformed compared with white candidates.

The effect was statistically significant and widespread across different medical schools, different types of exam, and in both undergraduate and postgraduate assessments. The attainment gap has persisted for over three decades according to the researchers.

A third of all UK medical students and junior doctors are from minority ethnic groups and this attainment gap has persisted for many years and must be tackled to ensure a fair and just meth-od of training and assessing current and future doctors, say the authors.

“Such complex problems are unlikely to have simple solutions - what happens in medical schools is a reflection of wider society,” argues Professor Aneez Esmail from the University of Manchester.

http://www.bmj.com/cgi/doi/10.1136/bmj.d901

I ntroduction of the immigration cap for skilled workers enter-ing the UK has made it extremely difficult for NHS Trusts to fill gaps in hospital rotas, according to the Royal College of

Physicians.It has expressed concern that another route for experienced

international doctors now looks set to be blocked. NHS Trusts are increasingly looking to use the Tier 5 Medical

Training initiative (MTI) to employ highly skilled overseas doctors. The MTI allows non-EU doctors to practise in the UK for a maxi-mum of 24 months before returning home.

Later this year the Home Office intends to cut net migration and reduce the maximum length of stay for doctors on the MTI to 12 months. The RCP warns that such a short stay would remove any training incentives for non-EU doctors and make it even more diffi-cult for NHS trusts to recruit experienced overseas medical graduates.

“Reducing the time limit of the tier 5 MTI will result in an inflexible system and international doctors and health leaders over-seas will lose interest. They will go elsewhere and it will be the UK’s loss,” said Matthew Foster, head of international affairs at the RCP.

“The current arrangements ensure that the UK continues to maintain clinical links around the world, and support the World Health Organization’s code of practice on international recruitment of health personnel.”

www.rcplondon.ac.uk

NoN-WhiTE juNior docTorS CONSISTENTLy UNDERpERFORM ACADEMICALLy

CONCERNS OvER GApS FOLLOWING CAp ON NoN-Eu docTorS

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We love ourF A C T S A N D F I G U R E S

THE pUbLIC IS MORE SATISFIED WITH THE NHS THAN AT ANy TIME

SINCE 1984

1/23ONE IN EvERy 23 OF THE

WORkING pOpULATION

IN THE Uk IS EMpLOyED by NHS.

THE NHS IS THE

FIFTH LARGEST EMpLOyER IN THE WORLD AFTER WAL-MART, pLA, CHINA NATIONAL pETROLEUM, STATE GRID OF CHINA AND INDIAN RAILWAyS

THE NHS AMbULANCE

SERvICE RECEIvES

AppROxIMATELy 360 EMERGENCy CALLS EACH

HOUR

FULL-TIME GpS SEE AN AvERAGE OF

255 pATIENTS A WEEk745 MILLION

pRESCRIpTION ITEMS ARE

DISpENSED EACH yEAR

23 MILLION pEOpLE vISIT THEIR Gp SURGERy OR pRACTICE NURSE EACH MONTH – MORE THAN A THIRD OF THE Uk pOpULATION

THE Uk SpENDS 3% OF ITS

bUDGET ON MANAGEMENT COSTS AS OppOSED TO 17%

IN THE USA

AROUND 77% OF THE NHS WORkFORCE IS FEMALE

ThE NhS REfoRMS10

THE NhS REFORMS

gp coNSorTia

Commissioning is the process of deter-mining what health services a population requires and the purchase of them. This responsibility will be moved out of prima-ry care trusts (PCTs) and strategic health authorities (SHAs) into the hands of GPs working in groups called ‘consortia’ in an attempt to bring decision-making as close to the patient as possible.

Consortia will be statutory public bod-ies and every GP practice will be mandat-ed to be a member of one. An Accountable Officer and Chief Financial Officer in each consortium will exist and it is thought likely that only a small group of GPs will take a lead role. These consortia will have respon-sibility for buying 80% of NHS healthcare; primary care itself and specialised servic-es will be commissioned by the new NHS Commissioning Board (see below).

Consortia will be able to purchase ser-vices from any willing provider ie. any or-ganisation that meets the required stan-dard for quality and price. Commissioning consortia can decide their own arrange-ments for commissioning support; they will not be forced to use particular types or to outsource to the private sector. Collabora-tion between GPs and secondary care col-leagues will be key for this to work - though

there is currently no mandate for any other health professional other than GPs to sit on a consortium.

Shadow consortia should be in place by 2011/12 with full responsibility for commis-sioning to be taken by April 2013. These re-forms build on previous models of primary care commissioning such as GP fundhold-ing in the 1990s and most recently prac-tice-based commissioning, however, it is on a much bigger scale.

ThE NhS commiSSioNiNg Board

This will be a new statutory body from April 2012 and will take over some func-tions from the Department of Health. It will allocate and account for NHS resources, lead on quality improvement and promote patient involvement and choice.

During transition the board will oversee the establishment of GP consortia and will have powers to intervene with failing consor-tia. It will aim to promote national consistency by setting commissioning guidelines based on evidence from the National Institute for Health and Clinical Excellence (see opposite).

The board and the Secretary of State will both have explicit statutory duties to pro-mote quality, tackle inequalities and pro-mote the autonomy of local NHS organ-isations. The government will publish a mandate for the board with input from the general public every year to set out what is expected of the NHS.

puBLic hEaLTh ENgLaNd

The bill creates a new approach to pub-lic health, which was set out in the white pa-per document ‘Healthy Lives, Healthy Peo-ple’ in December 2010. Public health will have a ring-fenced budget and will include a ‘health premium’ to address inequalities.

Its powers and responsibilities will relate to vaccination, screening, research and management of public health emergen-cies. Local authorities will take on the re-sponsibilities for health improvement cur-rently carried out by PCTs.

The service will jointly appoint a Direc-tor of Public Health with the local author-ity who will be responsible for health im-provement funds allocated according to need. The formation of ‘health and well-be-ing boards’ within local authorities will pro-vide them with a strategic role with respect to joined up commissioning of local NHS, social and public health services. Councils will now have the powers to scrutinise any NHS funded services.

hEaLThWaTch

This network of organisations will act as local patient champions, replacing current Local Involvement Networks (LINks). Na-tionally, HealthWatch England will be estab-lished as a statutory committee within the Care Quality Commission.

What is new?

ThE NhS REfoRMS 11

The coalition government describes the health reforms as ‘evolution not revolution’. Some of the ideas that are being introduced have been around before, such as GP com-missioning and the internal market, though not on such a large scale.

Overall aims of the reforms are laud-able including involving clinicians more

in management and making healthcare more patient-centred. In addition to these reforms, the NHS is also facing its most significant financial constraints due to the global recession.

The reforms are expected to cost £1.4 bil-lion though save £1.7 billion each year from 2014/15 - partly through the government’s

aim to reduce management costs by 45%. Whether both saving money and imple-menting these changes is possible in the time available is yet to be proven.

Dr Benjamin BrownPrimary Care Academic Clinical Fellow,

Manchester

The nHs in England is facing what has been described as the biggest reorganisation since its creation in 1948. These reforms were initially proposed and consulted on in the white paper Equity and Excellence: Liberating the NHS in July 2010 and are now going through parliament in the Health and social care Bill.

much has been said about these reforms - is it privatisation through the backdoor? is it evidence-based? is it too far in too little time?

Despite what preconceptions you may have about the reforms, do you know exactly what is being proposed? JuniorDr’s Benjamin Brown aims to explain the main changes being implemented and split them into three main sections: what is new, what will remain and what will cease.

STraTEgic hEaLTh auThoriTiES (ShaS) aNd primarY carE TruSTS (pcTS)

SHAs - the statutory bodies currently overseeing regional ser-vice commissioning and provision - will be abolished in 2012/2013. PCTs - the organisations currently responsible for local service commission and community health service provision - will be abol-ished by April 2013.

armS-LENgTh BodiES (aLBS)

The number of ALBs will be kept to a minimum. The Health Protection Agency and National Treatment Agency for Substance Misuse will be integrated into the new Public Health Service. Fur-ther information on the overall strategy for ALBs can be found in the white paper supporting document ‘Liberating the NHS: Report of the arms-length bodies review (2010)’.

What will cease?

NhS fouNdaTioN TruSTS

The government will support all NHS Trusts to become Founda-tion Trusts (FTs) by 2013. The bill also reduces the constraints FTs face, strengthens their internal governance and makes them more accountable for their outcomes.

ThE NaTioNaL iNSTiTuTE for hEaLTh aNd cLiNicaL ExcELLENcE (NicE)

NICE’s independence will be secured in the form of a statutory non-departmental public body. It will have a key role in developing a library of quality standards, 150 of which are intended to be pro-duced in the next five years. These standards will form the basis for the new NHS Outcomes Framework

moNiTor

The Bill will convert Monitor - the current regulator of Founda-tion Trusts - into an economic regulator with responsibility for pro-tecting the interests of patients and the public. Its key functions will be to support the continuity of services, drive productivity by regu-lating prices, and promote competition to ensure patients’ right to

choice is protected.

ThE carE QuaLiTY commiSSioN (cQc)

The CQC will continue to inspect the quality of health and so-cial care and have responsibilities under the Mental Health Act. Li-cences for providers will be issued jointly with Monitor.

ThE hEaLTh SErvicE omBudSmaN

The ombudsman will be given greater powers to share reports more widely, strengthening the role of complaints in the system.

ThE dEparTmENT of hEaLTh (dh)

The DH will have some reduced functions but will form a new unit to oversee local authorities’ responsibilities. It will also have specific functions with respect to improving public health (includ-ing tackling inequalities) and reforming adult social care.

ThE SEcrETarY of STaTE for hEaLTh

The Secretary of State will set the mandate for the NHS Com-missioning Board and will also hold it to account. The Secretary will retain responsibility for NHS policy framework but will lose the abil-ity to intervene with individual commissioners.

What will remain?

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SUPPoRT foR doCToRS 13

copiNg WiTh iLLNESS AS A JUNIOR DOCTORD octors should be experts in illness but as a group we are noto-

riously bad at looking after our own health, says JuniorDr’s Rosie Puplett. We often feel pressured into working even

when we are unwell, either by other staff members or (more often) by ourselves.

This is becoming a bigger issue as the EWTD stretches medi-cal teams to breaking point, and rates of sick leave are increasing amongst junior doctors - as recent research by the Royal College of Physicians has shown.

There are many reasons why doctors become ill, from a physi-cal illness to work-related stress. If you feel that you are unwell it is important that you act promptly. This helps your employer and colleagues, but most importantly it helps you to take control of the situation and get back on your feet as quickly as possible.

PuTTinG your HEaLTH firsTThe first - and often most difficult - step is to identify when you

are unwell enough to warrant action. Key things that should make you think carefully about your health are increasing levels of tired-ness, deteriorating ability to cope with work or life outside work, and concern from others about your wellbeing.

The first port of call should usually be your GP. As they are a doctor themselves they can often empathise with your position. Your occupational health department will be able to help too, as they are experts in the complex interactions between health and work and can be a good source of practical advice. The sooner you involve GPs or occupational health, the easier it will be to get on top of things. You could also speak to your clinical or educational supervisor at this stage if you feel able to.

if you nEED TimE off …• Don’t be too hard on yourself! An unwell doctor is the same

as an unwell person and you may well need some time away from work get back on your feet.

• Speak to someone from your deanery - they can help you come up with an action plan with regards to your training. If approached early they can often be flexible. They can also help tailor your return to work to best suit you and can help you to consider your long term career goals.

• Try not to feel responsible for leaving your colleagues to cope

without you. Filling gaps in the rota is the duty of your trust, not you. Hopefully once you are better you will be able to re-turn to work refreshed, and will be far more use to your team than when you were ill!

• Telling your colleagues that you are signed off work can be difficult, but they can be a great source of support. As long as your supervisors know what is going on you don’t need to tell anyone else yourself if you don’t want to.

SUppORT FOR DOCTORS

SUPPoRT foR doCToRS14

copiNg WiTh iLLNESS AS A JUNIOR DOCTORPracTicaL anD financiaL suPPorT

You may well need extra support, financially and practically, while you are off sick. There are a few things you can do to help youself:

• Ensure you are paid correctly - you are entitled to paid sick leave and statutory sick pay once that runs out (currently £79.15 a week). Talk to your pay roll department.

• Speak to your bank manager early on - you may be able to take a repayment holiday from your loan or extend your over-draft until you are back on your feet. Also speak to the coun-cil or your energy provider if you are envisaging having diffi-culty paying bills.

• Draw up a budget. Look for areas where you can cut costs and reduce unnecessary outgoings. Don’t neglect yourself howev-er - it is important that you stay warm, well fed and in touch with the outside world! Tools such as budget worksheets can be a great help.

• Look into benefits - if you are receiving SSP you may well be eligible for housing and council tax benefit. The process can be lengthy and you need a lot of documentary evidence so start early. Benefits are there to help people who are unable to work - don’t feel ashamed about claiming them.

• There are several organisations which can help doctors in fi-nancial difficulty - the BMA offers support to its members, and the Royal Medical Benevolent Fund, the Royal Medical Foundation and BMA Charities can all provide a range of fi-nancial assistance and advice

• Talk to your friends and family - even if they can’t help you fi-nancially they can be a great source of support

Overall the best thing you can do if you think you are unwell is to be honest with yourself about your situation, and speak to some-one early on. Remember, doctors are not immune from becoming ill, and your health is important!

SUppORT FOR DOCTORS

The British Medical Associationwww.bma.org.uk

Doctors For Doctors (BMA Counseling and Doctor Advisor Service)

www.bma.org.uk/doctorsfordoctors

Royal Medical Benevolent Fundwww.rmbf.org and www.support4doctors.org

Royal Medical Foundationwww.royalmedicalfoundation.org

Doctors Support Networkwww.dsn.org.uk

The Sick Doctors Trustwww.sick-doctors-trust.co.uk

International Stress Management Organisation UKwww.isma.org.uk

The Citizens Advice Bureau (CAB)www.citizensadvice.org.uk and www.adviceguide.org.uk

DirectGov (information on claiming statutory sick pay and benefits)

www.direct.gov.uk

USEFUL RESOURCES

“It is important to seek help early and to try and behave like any other patient, and seek advice from your GP or occupational health department.”

Dr micHaEL PETErsHead of Doctors for Doctors Unit, BMA

SUppORT FOR DOCTORS

A pERSONAL viEW“I graduated from medical school in June 2010.

This was the culmination of a horrible year. During the run-up to finals, my eldest

son was diagnosed with Henoch Schonlein Purpura whilst my mother was hospitalised with atrial fibrilla-tion and severe COPD. I managed to pass my exams somehow, but was not ready to start work.

My mother had always provided my paid childcare and my carefully laid plans for the summer holidays, which started the same day I started work, were in disarray. This was my first experience of the difficul-ties in combining family life with a career as a doctor and it happened on day one.

I made it through the induction week but on my first day on the ward alone I suffered a panic attack. I hadn’t eaten for over a week, I had lost a stone in weight and I hadn’t slept at all. I couldn’t cope with the overwhelming responsibility of looking after sick patients whilst I had no idea what I was doing. All my training at medical school was useless as I found myself unable to think clearly or function. I was signed off work with anxiety for over two months.

I spent the next weeks crying at home being sup-ported by my family. I tried to forget about work which was actually quite easy as I didn’t really believe I would ever be a doctor. Everything seemed point-less and I felt a complete failure. I was started on anti-depressants and had counselling arranged through the BMA doctors4doctors service.

Over the next few months I gradually began to feel less anxious, and work no longer dominated my thoughts and dreams. I started to attend foundation teaching with my peers whilst on sick leave. The first week was the hardest as I was worried about what the others would think about me. Most had qualified at other medical schools and didn’t know me. I had very few friends in the group and felt lonely and isolat-ed. I had to endure some awkward questions, but in the main my peers have been very supportive of me, despite my absence leaving them short-staffed.

The deanery and my trust foundation programme team have been equally supportive through my ill-ness, which has motivated me to persevere with my training. I am now going to complete my F1 year over two years part-time. I am disappointed with myself that I couldn’t combine full-time work with a family life but I feel that this compromise is the only way for me to continue to work.

My name is Helen Burt and I am an F1 doctor. It still doesn’t feel right and I can’t quite bring myself to introduce myself like this but I am working and I am determined to be a good doctor.”

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LEAdERShIP16

choicE vERSUS TRAININGSubsequent iterations and more detailed explanations of the White Paper place an increasing emphasis on choice for patients. Of course, we have had the concept of choice for a significant time now and it remains a critical component of a healthcare economy driven by market forces and competition. Andrew Vincent and Sara Watkin ask what does choice mean for training and how has this changed at the White Paper unfolds?

T raining in the competition era has always been a contentious issue. NHS services find it distressing that independent pro-viders target the bread and butter caseloads whilst having no

obligations to train the doctors of the future. Some ask “how can we effectively train surgeons if the volume procedures move to institutions with no trainees?”.

In truth, it appears that the reform of training is not running parallel to the reform of healthcare and this is particularly evident in the growing divergence between effective training and service well-being in a competitive market. Lord Darzi described his six basic types of institution and a shift in what type of care was conducted where, with increasing use of the community and re-distributing complex care to fewer but larger centres. We predicted that this would leave local hospitals with a caseload that was less attractive for training and this is now being borne out with some local hospi-tals struggling to fill their middle grade rotas.

What few have realised is that an even greater devil lurks in the more recent detail. The choice agenda is having its heat turned up with the seemingly benign tweak that choice of both treatment and provider will be mandatory for virtually all services funded by the NHS by late 2013/14. However, this tweak to the choice agenda has enormous ramifications for doctors in training that are likely to become apparent as the number of providers and provision of infor-mation to patients both increase.

This concept of being mandatory at all stages of the path-way means that a patient undergoing orthopaedic assessment for knee pain would firstly need to have all treatment options actively

discussed with him/her, including a do nothing option. Assuming that the patient opted for a knee replacement, the diag-

nosing team or GP would then be obliged to explain the options of provider. This latter amendment effectively introduces a breakpoint between diagnosis and treatment that, although has been possible for some time, has been rare in reality. The diagnosing service has got used to providing the care that comes out of their diagnosis.

So what does this mean for training? If the patient has to be offered choice of provider between diagnosis and treatment, then it is imperative that services handle the diagnostic phase with ‘kid gloves’ to ensure that the patient chooses to continue treatment with the same provider, or risk losing patients for the, dare we say it, profitable part of the pathway.

That is going to mean honed and skilled communication skills backed up by a depth of knowledge of treatments and their out-comes, deft application of practical procedures and assessments and a higher attention to the overall patient experience. If a service thinks carefully about who is best placed to do that, it may well con-sider that its senior workforce should be the first point of contact and that trainees, by definition still practising and developing their skills, are a risk to the subsequent retention of patients.

Whether services choose to reform the way they manage their trainees or simply reduce their input at the start of a patient path-way, the impact on a trainees ability to gain experience could be profound. It is not beyond the bounds of possibility that services may even decide that training doctors is simply at odds with busi-ness wellbeing, given that every patient is effectively a customer in a finite pool and that losing customers is at odds with survival.

Ultimately, we need to closely monitor the predictions for their match to reality. However, we’d like to encourage not only more debate about the link between market changes and training but also a push for more clarity on the intentions for training in an environ-ment of standalone, competing providers. Lord Darzi highlighted

Is there a looming time bomb in the development of our future medical workforce?

hoW CAN WE EffECTIvELy TRAIN SURGEoNS If ThE

voLUME PRoCEdURES MovE To INSTITUTIoNS WITh No

TRAINEES?

LEAdERShIP 17

choicE vERSUS TRAININGthat training ultimately would migrate to fewer, larger centres, including Academic Health Science Centres.

However, to date, we see only patchy evidence that tertiary and specialist hospitals are adapting to their increasing responsibility and this is not entirely surprising given the severe financial pres-sure many are under. Simply put, survival trumps everything, effec-tively putting training reform behind business. Although there is an inherent sense about this, it does not address the question of how to ensure an effective supply of competent doctors when the train-ing reform lags so far behind the competition and choice agendas.

Mr Andrew Vincent, Managing Director & Lead Consultant, Medicology Ltd

Dr Sara Watkin, Consultant Neonatologist, UCLH, London & Medical Director, Medicology Ltd

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JUNIORDR BLog

JUNIoRdR BLoG18

Day 1I can’t help wondering exactly what possessed me. Here I am

on February 1st, folded into a BMI economy seat on the way to Freetown, heading away from everything I know and love.

Somewhere in the distant past I remember feeling a little bored of British life and excited about doing something bigger than myself (among other adolescent clichés), so rather than opting for the hazardous sounding career of an army medic I filled in a form for Mercy Ships.

It had been an unusual application process as I had to supply a friend reference as well as a medical one. My friend Kieran had almost attached a picture of me dressed as Britney Spears from a med school pantomime before I managed to coerce him over a few ciders to write something vaguely constructive.

I still hadn’t expected to be accepted. I’d been at a party on a trampoline when a deep southern voice from Texas called me to let me know I was accepted to go. I practically bounced over the fence with excitement.

Right now I would trade anything to be back in the safety of my elderly care ward, telling little old ladies that I am actually old enough to be a doctor and no, they can’t come back to my house for tea.

There was a certain comfort about knowing exactly where your next pay check was coming from. For all the hassles and whing-ing about life as a beleaguered junior, there was a certain comfort in knowing that I could always call someone more senior if I got muddled - and that at some point the shift would end and I could head to my local in Cardiff and chew everything over with some trusted friends. Where I’m going I really don’t know what these people are going to be like, or whether there will be anyone more senior than me.

As the aeroplane dips down towards Sierra Leone, I can’t help noticing how dark it is. Where are all the landing lights? Still, we make it onto solid ground and my least favourite part of the

journey begins as I try to do battle with all the customs officials. Thankfully, most of them have heard of Mercy Ships and I clearly don’t look like a diamond miner so I manage to breeze through it all with surprisingly little trouble.

The next part of the journey is a huge challenge as I try to nego-tiate my way across the river to Freetown. I don’t know whose idea it was to put the airport on the other side of the river from the capital but it makes life incredibly difficult. Honestly, pilgrim’s progress has nothing on this! I eventually manage to stumble onto a water taxi which gets me fairly safely across albeit leaving me a little soaked and nauseated. I’m met at the gate by a gentle young New Zealander called Anya who seems to have been here for ages.

As we come through the gates Anya shows me where the children’s clinic is. I get a brief glimpse of large gates, Noah’s ark painted on the wall and various Krio health education posters telling people that malaria can be cured. Impressions are difficult to make in the dark and I’ve been up since before 5am this morning so I head straight to bed under a mosquito net ready to start in a few hours at seven am.

Day 2Dr Mandy looks at me as though she’s a fisherman who has

just caught a jellyfish when she thought she had a barracuda. “I thought you were older … never mind,” she trails off as the first patient of the day comes through the door, a seven year old girl carried in by her mother looking frighteningly pale and in need of some rehydration.

She can’t stand up and her eyes are rolling back inside her head. Mandy springs into action like a defibrillated patient and grabs the child, barking orders to various nurses. They stay alarmingly calm, as though these are the sort of things they deal with all the time. Soon the child has had a stat dose of IM ceftriaxone and is sent off round the corner to be admitted.

The rest of the day is a blur of Krio voices and medications long disused back home, wailing children carried in and out by grate-ful mothers and confused fathers. Nearly everyone seems to end up getting a malaria test and rehydration solution. There is a lot of malaria here, often the children aren’t conscious or seem to be in respiratory distress.

The mums start every consultation with extreme drama and end either smiling encouragingly or confused while I try to explain

ARRIvAL IN SiErra LEoNEAs you inhale your lunch and grab a couple of minutes of calm in the mess between bleeps, FY2 doctor, Mikey Bryant, is in Sierra Leone with the charity Mercy Ships. He is volunteering in a clinic for children aged 12 and under, in a country where 1 in 5 children don’t live to see their 5th birthday.

Mikey will be blogging his experience for us at JuniorDr.com. Here is the account of the first two days of his arrival.

“I CLEARLy doN’T Look LIkE A dIAMoNd MINER

So I MANAGE To BREEzE ThRoUGh IT ALL WITh

SURPRISINGLy LITTLE TRoUBLE.”

why they need to come back next week. Some of them get it, some don’t seem to understand anything and sit there blankly gazing into space. I find myself wandering around the clinic a lot looking for my blasé nurses to try and translate.

There is no time for a tour of the hospital and there seems to be a blur of people coming in and out introducing themselves to me who end up all merging together. The nurses seem friendly and quite switched on. They all have specific roles in the clinic and often come and ask me if I’m sure I want to prescribe certain things - frighteningly similar to the pharmacists in Wales.

The flow of patients seems to be constant, as soon as some-one leaves, another three or four mums are battling to get into the office, shouting in Krio about how their children’s bodies are ‘warm like fire’. Mandy tells me some of them have been queuing outside since 5am in the morning.

Eventually the room settles down and some of the mothers leave, vaguely satisfied by my prescriptions and attempts at talking

in simplified English. There is no pause for lunch or even for water for that matter - which is a bit of snag as I’m sweating a lot.

In the end everyone has left and a strange hush falls. Mandy smiles at me and thanks me for ‘making her day easier’. I can’t imagine what this must have been like with just one doctor here.

We head over to the welcome tea the international staff have put on for me, again there is a blur of faces, it certainly seems as though they were expecting someone a little older. To everyone’s credit, they do well at being welcoming in a place where the turn-over must be very quick.

There seem to be a couple other 20-somethings as well, one smiles especially nicely and pulls out a chair for me in what she calls ‘the children’s corner’. I smile back as I realise this isn’t going to be quite as bleak as I’d been expecting.

You can follow Mikey’s journey online at JuniorDr.com by clicking on ‘Blogs’.

ARRIvAL IN SiErra LEoNE

“ThERE IS No PAUSE foR LUNCh oR EvEN foR WATER

foR ThAT MATTER - WhICh IS A BIT of SNAG AS I’M

SWEATING A LoT.”

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CAREERS20

ExpEdiTioN MEDICINERepatriation medicine involves the transfer of patients by air, land or sea from overseas hospitals back home. Juniordr’s Ivor Vanhegan asked dr Tim hammond, Chief Medical officer of CEGA Group, about his experience of repatriation medicine and advice for junior doctors interested in it as a career.

Dr Sean Hudson is the Medical Director of Expedition and Wilderness Medicine - a organisation which runs courses for expedition doctors who work in remote or inhospitable environments. They train over 250 medics a year in diverse areas such as polar, jungle and desert medicine.

JuniorDr’s Ivor vanhegan asked Sean about his experience of expedition medicine and advice for junior doctors interested in it as a career.

A fter training in the UK I decided to work abroad for a while to experience medicine in a more remote environ-

ment. It was an early stage in my career but even at this point it was apparent that the broader my knowledge base, the more like-ly I was to be employed. Expedition Med-icine is approximately 60% general prac-tice, 30% environment specific and the remainder trauma. I worked for a year with Raleigh International in Africa, on a ski field in New Zealand and climbed through Central Asia and the Himalayas.

Working as an expedition/wilderness medic I often find myself working alone and without the usual infrastructure we all rely upon on a daily basis. It can sometimes be terrifying and exciting but ultimately extremely satisfying. Furthermore, the skills you develop as an expedition medic are increasingly becoming recognised and val-ued in other fields of medicine.

Over the last 2 years, I’ve worked in many varied locations and roles throughout the world. This has included: in Antarctica setting up and running one of the remot-est clinics in the world, running training courses in Iraq for close protection officers and providing medical cover for production companies in a number of remote locations. I also provided the medical support for a fashion shoot in Southern Africa and have worked as a consultant for the foreign office. In addition to these roles I have also trained a number of private individuals before they head off on exciting, often solo, expeditions.

The future for medics wanting to work in this field is increasingly bright. The spe-cialty is gaining recognition and with that comes remuneration. Soon we may arrive at the stage where medics can choose this as a career pathway rather than a stop gap to a more traditional specialty.

In recognition of this, a postgraduate qualification is now available in Wilder-ness Medicine. The Fellowship of the Acad-emy of Wilderness Medicine (FAWM) is a postgraduate qualification which recognises experience and learning in the field of Expe-dition and Wilderness Medicine. It is over-seen by the Faculty of Wilderness Medicine in the US.

For more information on Expedition and Wilderness Medicine and the Fellowship of the Academy of Wilderness Medicine visit www.expeditionmedicine.co.uk.

ANNAPURNAEvEREST

GettinG thereBA (www.ba.com) fly direct to Oslo but

check out Norwegian, Norway’s low cost operator, where you can pick up return flights for under £80 (www.norweigan.no). Ryanair also serve Norway but use Torp airport, a three hour bus journey away, so isn’t a great option for a weekend trip.

Getting to the town centre is simple. Flybussen (www.flybussen.no) operate a coach service in 45 minutes or you can get there in half the time with an express train costing around £10.

WHErE To sTay?

Norway is ridiculously expensive and you’ll struggle to find affordable accom-modation anywhere. One of the cheap-est, P-Hotels (www.p-hotels.no), offer very basic double rooms for under £70. Breakfast is a baguette and carton of juice in a bag hung on your door, howev-er the location is excellent just off Oslo’s main street, Karl Johansgate.

A little more expensive and ten min-utes tram ride from the town centre is the Gabelshus Hotel (www.gabelshus.no). Situated in a residential area it offers ren-ovated rooms, a huge buffet breakfast and free use of spa facilities in the base-ment for around £100 a night.

EaTinG

For a traditional Norwegian meal take the metro 40 minutes up the mountain

to the log and stone restaurant Holmen-kollen (www.holmenkollen.no) but get there while it’s still daylight to enjoy the view. Reindeer, a tender meat, with a taste between beef and liver, is a top choice.

Alternatively if you crave a more swish Scandinavian dining experience try Sult – which means ‘hunger’ (www.

sult.no). This trendy venue attracts the fashion consciousness Oslo-ites and offers controversial but tasty foodstuffs like whale steaks.

Unfortunately eating cheap is impos-sible in Oslo where a Big Mac meal costs over £7 and you’ll struggle to pick up a bottle of water for less than £2. Do as the locals do and jump on a free bus to Ikea where you can munch without needing a to arrange a mortgage.

kEy aTTracTions

Fjords: Oslo sits on a rather flat piece of land so you have to travel pretty far

to get a glimpse of the spectacular fjords. A package called Norway in a Nutshell (www.norwayinanutshell.com) offers full-day train, bus and boat passes to get you there. If you’ve got time take the train one-way from Oslo to Bergen, ranked as the most picturesque in Europe, and catch a flight back to the UK from there.

Vigelandsparken: 200 human sculp-tures, some mildly pornographic, fill this park on the outskirts of Oslo. Contain-ing the world’s largest granite sculpture it’s a relaxing retreat from the city and a great way get some amusing holiday photos too.

Edward Munch Museum: Famous for his Scream painting, which was even more famously stolen a few years ago. Worth a quick look.

Find the full Oslo guide at JuniorDr.com.

There are two facts everyone should know about the vikings. first, they never wore helmets with two horns, and second, they’ve progressed pretty far from their club-welding, rape-and-

pillage period. Today Norwegians are hoping that you’ll flock to their fjords and rave about their reindeer in the hope of making their country one of the hottest destinations this year. Just don’t

come back with a horned helmet - you’ll just look a fool to those in the know.

21

OSLOWEEkEND WARD ESCApE TO

kEy FACTS

•PoPULATIoN: 500,000

•LANGUAGE: NoRWEGIAN

•CURRENCy: 1£ = 9.2Nok

22

I t is the start of your first three-month placement and you are cannulating a patient. After four attempts you still

cannot find the vein and the patient starts to complain. You ask for help but, instead, the specialist registrar sends a tirade of abuse hurtling your way and performs the cannulation, but leaving you and the patient feeling stressed and anxious.

Medical professionals are a heteroge-neous group, so differences of opinion and personality will be inherent at every grade from medical student to senior consultant. But it is not acceptable to be the subject of public and unfounded criticism. It is nor-mal to feel clumsy, ignorant and uncertain as an F1; unfamiliar settings full of new staff who require you to perform tricky proce-dures you have only read about – you will feel out of your depth.

The GMC’s guidance states that all doc-tors must challenge their colleagues if they are not treated fairly and respectfully regard-less of colour, culture, disability, ethnicity or gender (Good Medical Practice, par 46-47). But this is easier read than acted upon. The skill in tackling a difficult relationship lies in understanding why you are experienc-ing bad relations and in working towards a solution that will benefit the patient, your-self and the team.

CLASHES OF pERSONALITy

In any relationship, people influence each others’ behaviour, so appropriating

blame is not only difficult; it is unproduc-tive. Your objective should not be to ‘win’ but to improve the situation and fix the problem, and the first step to achieving this is to take your share of the responsibility.

When Dr Quendo, Course Director and Professor of Clinical Psychiatry at Colum-bia University in New York, was inter-viewed by Medscape’s Editorial Director, she described the experiences that an Afri-can-American resident had with a white medical student who used street slang to address her. The student ended up label-ling the resident a difficult person who was hard to work with. This could have been avoided if the resident had followed this four-step approach:

1) You have no control over your col-league’s behaviour but you do control your own, so consider if your behaviour contrib-utes to the bad relationship.

2) Approach the colleague in a non-accusator polite and firm way. By being dip-lomatic you avoid any dramatics: this will

RAISING CONCERNS aBouT coLLEaguES

MPS is the leading provider of comprehensive professionalindemnity and expert advice to doctors, dentists and healthprofessionals around the world.

We actively protect and promote the interests of members and believe that education is an integral part of every healthprofessional’s development. As well as providing legal adviceand representation for members, we also offer workshops,conferences and a range of publications designed to aid goodpractice.

MPS is not an insurance company. All the benefits ofmembership of MPS are discretionary as set out in theMemorandum and Articles of Association.

About MPS

MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.

www.mps.org.uk

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.

About MPS info for articles.qxd:MPS Checkup 12/2/10 10:05 Page 1

enable you to discuss the problem in a dig-nified way.

3) Actively listen to the other person’s per-spective rather than just fighting your corner.

4) If this fails bring in a senior colleague and work out a plan to set behavioural lim-its. You two may never get on but abusive behaviour and bullying should be stopped immediately.

kEEpING Up GOOD RELATIONS

Overcoming clashes of personality is a challenge, but it can be overcome more easily if you have the support of your team. Medi-cal students and new doctors will have a more comfortable ride if they get on with their extended team and their immediate team, from physiotherapists and phlebotomists to ward clerks and nurses. Doctors who are good communicators who work well in a team . have fewer complaints made against them.

Dr Richard Stacey, MPS Medicolegal Adviser, recalls advice he was given when he began his Vocational Training Scheme: “When I started my SHO post in obstet-rics and gynaecology, the first thing every-one said was ‘don’t upset the midwives’. If you get on with them they will more like-ly than not suture episiotomies themselves rather than disturbing you!”

He adds: “Starting out as a new doctor is an exciting time – you have just graduated and are bursting with knowledge. But you’re going into an environment where you don’t have the practical experience and you’re work-ing with nurses and medical colleagues who have a wealth of experience. It is vital you tap into that and make friends rather than adopt-ing the attitude of being all-knowing.”

A COMMON pRObLEM: SELF pRESCRIbING

A common problem among junior doc-tors is self-prescribing. MPS receives a high number of calls from new doctors concerned about their colleagues’ self-prescribing. Dr Stacey says: “Although a colleague who was self-prescribing antibiotics for an ear infec-tion would cause less concern than a col-league who was self-prescribing benzodiaz-epines, analgesics or the morning after pill, doctors should not prescribe for themselves.”

The GMC places an obligation on doc-tors to register with an independent general

medicolegal advice - in association with the Medical Protection Society

RAISING CONCERNS aBouT coLLEaguES

practitioner and expressly states that doctors should not treat themselves (Good Medical Practice, par 77).

HOW TO RAISE CONCERNS

Good personal conduct, effective commu-nication and respect for colleagues will avert most problems; however, what if the actions of your colleagues could harm patients?

A recent survey in BMJ Quality and Safety found that one in five UK doctors has had direct experience of an incompetent

or poorly performing colleague in the last three years.

So how should you handle colleagues who are underperforming? The stress of the clini-cal workload means that mistakes are inevi-table, but a distinction needs to be remem-bered between matters of personal conduct, poor performance and where a doctor’s per-formance may be affected by a health issue (eg, depression, substance abuse etc).

GMC guidance says you should sup-port colleagues who have problems with performance, conduct or health, but action

should be taken if this compromises patient care. The GMC recommends that you raise your concerns to the medical director or a senior colleague. Local guidelines will be in place to deal with these situations should they arise. If in doubt, contact your MDO for specific advice.

Dealing with difficult colleagues is a nec-essary part of any job, but not every job deals with life and death. Learning to work as a team is a skill that you learn by practis-ing and making mistakes; successful doctors empathise with their colleagues and take any problems by the hand and guide them to a solution.

SUppORT SERvICES FOR DOCTORS

• MPS tel: 0845 605 4000 | www.mps.org.uk

• Doctors Support Line. Tel: 0870 7650001 | www.doctorssupport.org

• National Counselling Service for Sick Doctors. Tel: 0870 2410535. www.ncssd.org.uk

• The BMA Counselling Service. Tel: 0845 9200169 (BMA MEMBERS ONLY).

Sara is a senior writer and editor at MPS. She writes for Casebook and edits New Doctor magazine. Her contact details are sara.williams@mps.org.uk.

medicolegal advice - in association with the Medical Protection Society

Sara Williams explores where a junior doctor’s priorities should lie when dealing with challenging colleagues.

SECRET dIARy24

SECRET DIARy OF A cardioLogY Spr

* Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!

monDay If you’ve been following this column then you’ll know that my

days as a cardiology registrar are numbered. All that remains are two ward rounds, one angio clinic and an office full of notes resembling the Manhattan skyline to process.

I’d like to say I’m apprehensive and unprepared like all my peers - but honestly, I can’t wait until this post ends. I feel I’ve reached my nadir as a registrar. Each day has become a routine with a few minor bursts of interest interspersed.

The Monday afternoon ward round goes as usual. The two FYs run around frantically delaying the round. I tell them to slow down but they reply that they want to be away by 5pm. I consider launch-ing into my usual tirade about how I never left before 8pm - even on a good day - but as it’s my last few shifts I keep quiet.

I leave around 7pm after working through the Chrysler Build-ing and Empire State stacks of notes in the office. The juniors are nowhere to be seen. Back home I celebrate my impending depar-ture with a glass of Merlot and some Thorton’s chocolates given to me by one of the patients.

TuEsDay Angio clinic today. Everyone seems a little too pleased that I’m

leaving. The clerk has already emptied my pigeon hole leaving all the papers in the cath lab with a Post-it note saying ‘Your things’. I take offence to this and remain in a bad mood throughout the morning.

The clinic finishes early. It’s strange treating a bunch of patients that you will never be responsible for again. I suspect in the near future this will be the norm with shift based care - which is bad for both doctors and patients.

I stay late again. I debate whether any of these discharge summaries will actually be useful for the GPs after the two months they’ve sat on the shelves. At 8pm I go home, watch re-runs of CSI and go to sleep.

WEDnEsDay My final day. We were on take last night and, rather ironically

(though unsurprisingly given my history), we had one of our busi-est this year. When this happens the post-take round degenerates into one slow treasure hunt to find patients which are now scattered throughout the hospital.

We’re joined by the SpR who will be covering until my successor arrives. He looks rather perturbed by the number of patients we’re accumulating. Then, out of the corner of my eye, I see the FY2 doc-tor collapse to the ground.

She has always looked a little fragile to cope with prolonged standing up so it’s no great surprise. What is more of a surprise is that, despite her being back on her feet within a few seconds, our overly emotional consultant Professor Dean sends her home.

With the FY1 away and the ST post-nights I am reduced to one of the team’s least senior doctors on my last day. I get angry, text my SpR colleagues to cancel leaving drinks and spend the rest of the day completing forms and answering bleeps.

At 7pm I consider finishing the notes still stacked in the office which was my plan for today. I don’t. I leave without saying good-bye to the remaining staff and head for a drinks with a select few of my friends. We drink whiskey until 11pm then I head home still feeling feeling angry about how I spent my final afternoon.

THursDay This morning my frustration from yesterday has been replaced

by guilt - not just from my failure to clear the notes backlog but also not saying good bye to the staff.

After a quick shopping excursion, where I end up spending a small fortune on gifts, I drop off chocolates for both the nurses and admin staff. They wish me the best for my next job but seem more relieved that I’m going. We never got along terribly well so it’s not a surprise.

One senior nurse tells me she thought I was one of the most ‘clinically astute’ doctors she had worked with. I suspect she means that I’m better dealing with the disease than the patients (and the staff for that matter). I make a mental note to try and be nicer to people in future.

I work through the notes and finish surprisingly quickly. I make a special point of asking the FY2 if she’s feeling better. She looks embarrassed and starts to offer a long explanation of familial hypo-tension but I interrupt. I join some friends for dinner and it ends up being a late night.

friDay I wake early and lie there thinking about what is happening on

the wards. I contemplate that from next week I’ll probably do this every morning. Being a consultant should bring a new feeling of responsibility for my patients that doesn’t get handed over at 6pm.

The comments from the nurse yesterday pop back into my head. I realise that as a consultant I will be confident treating patients - it’s managing the other doctors and clinical staff that causes me stress. I contemplate whether this is because of the high standards I set myself or just a dysfunctional personality trait. I decide on the latter.

I reason that today should be a day of shopping. New clothes and shoes for a new me; a consultant cardiologist who will be less cynical, less sarcastic and more of a ‘people person’.

Goodbye cardiology SpR slavery. Bring on my consultant post. Perhaps I am just a little more unprepared and apprehensive than I was at the beginning of the week - but just a touch! See you on the other side.

fINANCE 25

W illiam Shakespeare advocated “Nei-ther a borrower nor a lender be”. If he returned to modern day Brit-

ain and had to put himself through uni-versity, he would probably want to retract that piece of advice. According to the Brit-ish Medical Association, medical stu-dents beginning their degree in 2006, can expect to graduate with an average debt of £37,000 but of course for some this figure will be much higher.

With rising tuition fees and an increase in the cost of living, debt is becoming a fact of life for many young people. You at least have the satisfaction of knowing that you have a career that will bring good finan-cial rewards. However you still shouldn’t be complacent about money. We all have to keep our spending and borrowing in check, regardless of what we earn now or in the future, to ensure our financial security. Tak-ing a sensible approach to financial plan-ning today will put you in good stead for the rest of your life

hoW To maNagE Your dEBTSThe first step in building a financially

secure future is to manage your debts. Don’t be tempted to put your head in the sand as ignoring them will only make matters worse. Certainly don’t carry on adding to the debt because you feel it’s all so unman-ageable and another loan won’t make any difference.

A good way of dealing with any debts is to make a list of everything you owe includ-ing unpaid bills, money you owe on credit cards and loans from family and friends.

Then sort your debts according to prior-ity; it’s not the size of the debt that makes it a priority but what creditors can do to get their money back. So priority debts include mortgage or rent arrears. If you’re struggling to pay these, talk to an agency who can offer free impartial debt advice such as the Citi-zens’ Advice Bureau.

Once you know exactly what you owe, draw up a realistic budget for yourself. Work out how much money you’ve got coming in and how much you need to keep aside for bills, rent, food and other key expenses such as travel. Then you’ll have a clearer idea of how much money you’ve got left over at the end of each month once all of your main expenses have been met. You can use this to start reducing your debt.

If you’re not yet in a position to reduce your debt and in fact need to borrow more remember these key points:• Don’t run up an overdraft without first

talking to your bank as you may be charged for an unauthorised overdraft.

• If you use credit cards check the interest rates and the small print on any offers – some cards that offer 0% balance trans-fers charge a transfer fee.

• Try and pay off the whole balance of your credit card in full each month or at least clear the interest.

• Never buy goods on hire purchase unless you can afford the monthly repayments.

• If you buy goods on interest free credit make sure you pay off the balance before interest starts to kick in because it’s likely to be at a much higher rate.

• Be very careful about taking out loans es-

pecially if you still have your student loan to re-pay.

• Make sure you understand the terminol-ogy around loans, particularly the dif-ference between secured and unsecured lending. If you take out a secured loan, you are using your house as surety and you may lose it if you cannot make the loan repayments.

• Take out solid income protection cover as soon as you can and with a reputable pro-vider – this will form the foundation to your financial health.

Having debt is inevitable for most of us these days. It’s not the debt that’s neces-sarily the problem but how you manage it and your ability to repay it. Consider tak-ing regular advice from a financial services specialist who can guide you through the process of managing your money both now and in future.

Specialist financial services for doctors

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Motor, home and travel insurance is arranged by Wesleyan for Professionals.

focus on finance - in association with Wesleyan Medical Sickness

DEALING WITH dEBT

The above information does not constitute financial advice. If you would like more information or need general financial advice you can call Wesleyan Medical Sickness on 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

hoSPITAL MESS26

TiNTiNGROWTH HORMONE DEFICIENCy – AN INITIAL DIAGNOSIS

I have taken this referral from Claude Cyr, a professor of medicine at Quebec’s Sherbrooke University asking for some differential diagnoses. Professor Cyr has already

hypothesised that: “Tintin never aged during his 50-year career because the repeated blows he took to the head trig-gered a growth hormone deficiency. This intrepid Belgian reporter has suffered 50 significant losses of consciousness during his many adventures. I hypothesise that Tintin has growth hormone deficiency and hypogonadotropic hypo-gonadism (a disorder of the pituitary gland) from repeat-ed trauma. This could explain his delayed statural growth, delayed onset of puberty and lack of libido.” Although this opinion appears on the surface to be valid, it fails to take into account some of his other symptoms.

pSyCHOGENIC AMNESIA

People have described Tintin as ‘a well-rounded, yet open-ended character, noting his rather neutral personality - sometimes labelled as bland’. In fact, even the name ‘Tintin’ remains a mystery and whether it is a first name or a surname is unknown. It may not actually be his real name, but rather a pseudonym that the character uses to protect his identity. At this point it is worth considering his early upbringing. Tintin was raised by his mother who died of illness when he was a child. He never knew or met his father, whom Tintin believes to be dead. Early trauma is thought to be a major risk factor for Psychogenic amnesia, a disorder characterized by abnormal memory functioning in the absence of structur-al brain damage or a known neurobiological cause. Here, a patient can lose their autobiographical memory and person-al identity even though they are able to learn new informa-tion and perform everyday functions normally. Professor Cyr points out there is a history of head injury, however these symptoms were present prior to these.

HOOkWORMS & IRON-DEFICIENT ANAEMIA

Tintin shows growth deficiency, pale skin and thinning

hair. At times he has remarked about the bright lights (Tin-tin in Tibet) and has often felt faint (Tintin - The Blue Lotus). This could clearly be a result of this simple but untreated condition. Because it tends to develop slowly, adaptation occurs, and the disease often goes unrecognised for some time. Iron deficiency anaemia can be caused by parasitic infections, such as hookworms, with the intesti-nal bleeding leading to faecal blood loss and iron deficien-cy. In his travels it is likely that Tintin would have been exposed to such parasite given that they are rife in Sub-Saharan Africa (Tintin in the Congo) and India.

CRANIOpHARyNGIOMA

A rare, usually suprasellar, neoplasm that develops from the nests of epithelium derived from Rathke’s pouch (an embryonic precursor of the anterior pituitary) and grows very slowly along the pituitary stalk. They usually are clas-sified as benign and comprise 9 percent of all paediat-ric brain tumours - occurring in children between 5 and 10 years of age. On light microscopy, the cysts are seen to be lined by stratified squamous epithelium with kera-tin pearls. The cysts are usually filled with a yellow, viscous fluid that is rich is cholesterol crystals. This would account for a reduced growth hormone release. It is much like the original diagnosis made by Professor Cyr but sounds much more medical and uses some great long words.

AN ADDENDUM

As a side-note, Tintin is remarkable in that he is appar-ently devoid of sexual or romantic feeling. In the last adven-ture a female, Martine Vandezande, flirted with Tintin and appeared to ask him out on a date towards the end but nothing ever happened. He, however, describes Snowy, a Wire Fox Terrier who travels everywhere with him, as “hav-ing a bond that is deeper than life”. This would not impact on his growth but it may necessitate a detailed psychosex-ual history - including fantasy exploration - and a psychi-atric referral.

Assessed by Gil Myers

MEDICAL REpORT

hoSPITAL MESS 27

Sends a shiver down your spine at:

£2.95 Ulster Hospital, Dundonald

Lick-tastic prices at:

£1.49 Royal Free Hospital, London

Priced for an emperor at:

£4.25 Royal Manchester Children’s Hospital

Affordable for chickens at:

£3.49 Ipswich Hospital

More likely to turn you green at:

60p Whipps Cross Hospital, Leytonstone

Vitamin-C-tastic at:

40p St bart’s Hospital, London

Next issue we’re checking the cost of a packet of Maltesers (37g), toothpaste (approx 100ml) and 4xAA batteries. Email prices to hospitalconfidential@juniordr.com

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular

column of the best and worse hospital essentials you’ve reported:

Sky HD on 42in High Def plasma, wireless 16Mb broadband, leather sofas, lava lamps. Three computers in separate computer room: two for all access broadband. Kitchen with dishwasher, microwave, basic food bread, tea, coffee, biccies etc usually topped up. Separate chill out/quiet room (with a few old sofas!). £10/month.

JuniorDr Score: ★★★★✩

Tub of ice-cream (small)

An orange

‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.

Writing in the Notes

absence of consultants at weekends is no

revelation

Dear Editor,Finally, everyone has realised what we as junior doc-

tors have known for years - that hospital A&E depart-

ments are manned (often entirely) by junior doctors

at weekends and at night (Hospitals need more senior

doctors at weekends; Iss 19; p4). The fact that none of

the hospitals surveyed provided more than 12 hours of

consultant on-site cover is just staggering. Hopefully

we can soon look forward to a service where consul-

tants review sick patients within a few hours of admis-

sion - no matter when that is. It does mean that our

futures are more likely to include resident on-calls,

even as a consultant, but I personally think this is a

price worth paying for safe patient care.NIGEL xIoNG

fy2, WESSEx dEANERy

gmc cuts nice, but why now?Dear Editor,

I am keen to know how the GMC has managed to cut fees (GMC cuts fees for newly qualified docs; Iss 19; p5) at this point in time - not that I’m objecting. When every organisation from local councils to the Royal Colleges seem to be increasing their charges I’m surprised they have managed this. I have always felt the £420 I pay annually is excessive. I’d happily not receive their glossy magazine and feel that bad doctors should repay the costs of their investigations rather than this being funded by the rest of us. Moreover, with oth-er public employees such as the police and teachers having their ‘revalidation’ funded by the government shouldn’t we be in this situation too?ANoNyMoUSST3 PAEdIATRICS, LoNdoN

priNcESS aLExaNdra, harLoW

Chicken caesar salad

good on leadership - just not on working

overseas

Dear Editor,I was impressed with the recent JuniorDr Issue 19

focusing on medical leadership and MBAs. It pro-

vided a useful insight into this new atypical medi-

cal career and produced some stimulating thoughts.

Well done. I much prefer this than the previous issue

featuring overseas careers which was too superficial.

That issue failed to explore more complicated mat-

ters like training post competition in popular over-

seas destinations for example.SAMUEL yUEN

MUSGRovE PARk hoSPITAL, TAUNToN

CLASSIfIEd28

The Medical Journalist’s Association brings together medical writers, the media, health professionals, and health charity workers.

> Meetings on major health and medical topics of the day> A forum to meet colleagues> Recognition and cash awards for distinguished work> A website with your own address. Visit www.mja-uk.org> Professional advice when you need it

Wish to join? For more information visit www.mja-uk.org

Specialty Training in Scotland 2011

Get ready... Round 2Applications for recruitment to Scottish Medical Training higher level training programmes (CT2/ST3 and above) are underway. Some specialties are currently open for applications until 7 March 2011. ST3 Medical Specialties open from 4 March 2011 to noon 23 March 2011.

For full details on the recruiting specialties and the corresponding opening and closing dates go to:

www.scotmt.scot.nhs.uk/applying-to-specialty-training-(hospital)/how-to-apply

Set...Check the SMT website regularly for detailed information on the application process, person specifications, interview schedules and vacancies. Remember to subscribe to the SMT e-Newsletter.

Go!Visit: www.scotmt.scot.nhs.uk

GET yOUR NEURAL INpUT TO JUNIOR DOCTORS. ADvERTISE HERE. CALL US ON 020 7684 2343.

jourNaLiSm

JUNIOR DOCTORS NEW ZEALAND/AUSTRALIA 2011

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Check it out on www.genevahealth.comRegister your interest today www.genevadoctors.comFreephone 0800 051 6743Email: ruthm@genevahealth.com

rEcruiTmENT

rEcruiTmENT

CLASSIfIEd 29

Experience Drama

Experience Satisfaction

Junior Doctors – Christchurch NZ

You’ve always been the type to challenge yourself - always up for adventure; keen to do more, see more, achieve more. And it’s a philosophy that applies to every facet of your life...work, play, whatever comes your way. So that said, there’s simply no better way to stay true to yourself – and to truly maximise your career and quality of life, than to join us at Canterbury District Health Board.

Imagine it now...living in Christchurch, in New Zealand’s stunning South Island. With the ocean a couple of minutes away, and snow-covered mountains a couple of hours away, you’re literally in the middle of life at its best. Then there are the professional advantages. The variety, training and opportunities you’ll have at our leading tertiary hospital are world-class, so your medical career is set for serious enhancement.

If you’re a qualified Junior Doctor looking to ramp up your career and really enjoy life, we can make it happen. To learn more about this unique opportunity, and to apply, visit

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• Careeradviceandsolutions• Permanent,ContractandLocumoptions

• Professionalmigrationadvice• RegistrationandWorkVisasfullymanaged

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Manchester19-20 March 2011London26-27 March 2011

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?? ?

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ProfessionalAdvice

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Fill your gap yearDOWN UNDER

If you have completed your foundation years and are looking to advance your career and experience some of the best training and practice in the world then Queensland Health has you in its sights. We offer appropriately skilled junior doctors competitive remuneration packages and an adventure like no other. Talk to us today.

Adventure.>n. an unusual or exciting experience

M270810

“Although I originally hale from Wimbledon, I undertook my medical training at Glasgow University. I worked in the NHS for a few years but decided to fi ll my gap year with some sunshine and work experience Down Under. I took a job with Queensland Health and relocated to Australia in 2009. I’ve now been accepted on to the Queensland Health world-renowned emergency medicine training program that offers me exposure to an unparalleled scope of practice and an extraordinary case mix in a major tertiary hospital.” Senior House Offi cer, Dr Stephen Elliott enjoys the training programs with Queensland Health.

iiiiicalcalcalcalcalca trt tr trtrainainainainainainingingingingingingn at atatatt ata hehehheheee NHSNHSNHSNHNHSNNHS fofofoff r ar aar a fefefefef w yw yw ywwwwwwww earar bbbs bs bbutututut decdecdecdedecideideidedded td td td td o fio fifio fifio fifillllllll mymymymmy

Senior House Offi cerDr Stephen Elliott, Royal Brisbane & Women’s Hospital, Queensland Health

EvENTSdR.CoM30

THE MEDICAL COURSE AND CONFERENCE DIRECTORY

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Take MPS on your travelsValuable protection if working overseas

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

MPS is the world’s leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals.Medicine is an increasingly mobile profession, with doctors travelling the world to work.

MPS is the world’s largest mutual medical defence organisation operating internationally. We have members in more than 40 countries, so if you decide to work overseas, membership can be arranged easily. It is one less thing to worry about.

The main jurisdictions where MPS operates besides the UK are Ireland, South Africa, New Zealand, Hong Kong, Singapore, Malaysia, West Indies, and Kenya. However, we do have smaller numbers of members in other countries, so it is

often possible to continue your membership, even in unlikely places, for example if you are doing voluntary work overseas.

MPS has also made arrangements with Australian insurance company, MIPS, to cover members practising in state indemnified hospitals for up to one year (extended to a maximum of 24 months on request).

MPS prides itself on being a flexible organisation with membership designed to suit you.

If you are thinking of working outside of the UK, please contact membership services.

To find out more: Call Membership services on 0845 718 7187 Email member.help@mps.org.uk Visit www.mps.org.uk

MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London, W1G 0PS.

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