THE MAGAZINE FOR JUNIOR DOCTORS
Presenting History JuniorDr 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 Leader Matt Peterson, email@example.com Editorial Team Yvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai JuniorDr PO Box 36434, London, EC1M 6WA
Tel +44 (0) 20 8 350 3592 Fax +44 (0) 87 0 130 6985 firstname.lastname@example.org Health warning JuniorDr 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 necessarily 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 orientation, 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 2015. All rights reserved. Get involved We’re always looking for keen junior doctors 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.
DOCTORS AREN’T IMMUNE FROM ILLNESS S ometimes in our busy clinical jobs we forget the impact that illness has on people’s lives. Sometimes we see only the disease and not the person and family behind it. Then sometimes that illness hits one of us. That’s what happened to Joanna Dodkins (page 9) when her medical elective turned into a nightmare, and ended with her lying on a hospital bed asking herself if she’d ever be able to complete her medical degree. Joanna’s story highlights how vulnerable we really are. Our highly respected and relatively secure jobs also require a high level of mental and physical dexterity. A single chance incident can put that all at risk. Although doctors should be experts in illness, we’re notoriously bad at looking after our own health says Rosie Puplett on page 12. Rates of sick leave are increasing amongst junior doctors as changes in working patterns increase stress levels and workload. In this issue you’ll find our guide to ‘Coping with illness as a junior doctor’, which offers advice on putting your health first and includes practical and financial sources of support when things go wrong. Some doctors however, put themselves intentionally at risk of serious illness through their pure dedication to the profession and desire to help the sick and infirm. Sandra Lako is one of those people. Sandra is one of the junior doctors working on the front line against Ebola in Sierra Leone. You can read her experience caring for patients as part of the Ebola Response Consortium on page 22. Often as doctors when we become unwell we seem to find it more difficult to access care and support. It shouldn’t be like that. Share your stories and advice at JuniorDr.com.
What’s inside 04 09 12 18
LATEST NEWS CAN I STILL BE A DOCTOR NOW THAT I HAVE ONLY ONE EYE? SUPPORT FOR DOCTORS HOW TO GET INVOLVED IN TEACHING
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UK DOCTORS UNLIKELY TO BE ABLE TO REPAY STUDENT LOANS
K doctors are unlikely to be able to repay their student loans over the course of their working lives and may have amassed debts of more than £80,000 by the time they graduate, according to research published in BMJ Open. The study also showed clear gender differences in the amount required to service these debts, with women paying more in interest despite earning less than men. Researchers looked at a medical student graduating in 2014 who would have clocked up a debt of £40,000 for tuition fees. If maintenance loans are factored in, this would add £24,000 for a student living at home; an additional £30,000 for a student living away from home; and £42,000 for a student living away from home in London, amounting to a total of between £64,000 and £82,000 by the time of graduation. Responses to their survey showed that average full time salaries rose with age, but then gradually fell after the age of 55, with a wide gap in earnings starting to emerge between men and women from the age of 30 onwards. At the age of 55, male doctors earned 35% more than their female colleagues, which was mainly attributable to hourly
wage rates rather than the number of hours worked. Female doctors pay significantly more The researchers used the average age-salary profiles, projected future repayments, and cumulative debt levels to calculate the total sums required to service the loans. For those borrowing against tuition fees alone, full time male doctors would have to stump up £57,303 to clear their debts over 20 years, while their female colleagues would need to find just short of £62,000 over a period of 26 years. When maintenance loans were factored in, the researchers calculated that the total sums to be repaid added up to £75,786 for an initial debt above £46,000 for women doctors and £110,644 for an initial debt above £65,145 for their male colleagues. For initial debts below £50,000, women repay more, despite earning less, because their debt lasts longer and accrues more interest. But for initial debts above £50,000, men repay more because their average yearly salaries are higher. “It seems reasonable that these repayment variations may actually exist across many graduate careers in the UK,” write the
researchers. “It is also apparent that at the current level of fees, even small changes in the student loan contract will have substantial implications for lifetime wealth across different income groups, across male and female graduates, and on the sustainability of the student loans system.” bmjopen.bmj.com/content/5/4/e007335
TAX RELIEF NOW AVAILABLE ON EXAMS
unior doctor trainees can now claim tax relief on membership exams, such as those for the MRCS and MRCP, following discussions between the Royal College of Surgeons and HMRC. The rebate is applicable to trainees who pay for the exam themselves and are employed on a training contract in either core or specialty trainee posts. To make a claim you will need to complete a form (P87) or do so through their self-assessment tax return if you are already in self-assessment. More information on how to claim can be found on 4
the Gov.uk website: https://www.gov.uk/tax-relief-for-employees/ how-to-claim HMRC have requested that trainees are informed that they should include a receipt or other proof of payment for the exam fees. Claims made without this may be delayed as HMRC may have to contact the trainee to request this evidence. You can claim a tax refund/relief for the current tax year or any of the previous four tax years. This means you can go back four tax years to reclaim the tax deductibility from the exam fees paid. https://www.gov.uk/tax-relief-for-employees/how-to-claim
DANGEROUS WORKING PATTERNS RISK PATIENT SAFETY AS SEVEN IN 10 CONSULTANTS NEVER HAVE REST TIME AFTER BUSY NIGHT ON CALL
he vast majority of consultants never have time off to rest before treating patients after a busy night on call, according to new figures published by the BMA. In the survey of 847 consultants it found that seven in 10 (71 per cent) never have access to rest time following a night spent on call when their sleep had been disturbed; a further one in ten (10 per cent) said that such rest was rare. Only one in 10 (11 per cent) said that they had rest time. Of those questioned almost nine in 10 consultants (88 per cent) reported being on an on-call rota, with just under half being called to attend hospital during the week, rising to two thirds at weekends. With the average call out time at three hours during the week and doubling to six hours at weekends, not having proper rest time compromises patient safety and puts consultants at risk of fatigue and burnout. “Our concerns about consultants’ fatigue and burnout are
SEVEN DAY WORKING
OVER TWO THIRDS OF PHYSICIANS SUPPORT SEVEN DAY WORKING
ver two-thirds (68%) of consultant physicians stated they would support ‘in principle’ a move to seven day working, according to the latest census of doctors in the UK by the Royal College of Physicians. The findings also suggest a correlation between physicians who routinely work seven days and support for the plan (65%) – with stronger support from the specialties that often have to work weekends including acute internal medicine (91%), stroke medicine (84%) and cardiology (75%). The RCP team behind the census said it also underlines the growing need for consultants who can meet the needs of frail older patients. They noted trends from last year’s census where the largest number of appointments were made in geriatric and acute medicine, (113 and 108 respectively) suggesting a move away from specialist working to more generalist roles treating acutely ill patients. “It is clear that a majority of consultant physicians in the UK support the principle of a seven day NHS – however there needs to be much more discussion around how such a plan is implemented,” said Dr Harriet Gordon, director of the RCP’s Medical Workforce Unit. “In order to make the seven-day service a reality, we will need strong clinical leadership and involvement in redesigning services around the patient ... this includes earlier access to specialist opinion within the hospital, and specialist care reaching out into the community to provide seamless services across primary, secondary and community care, as reflected in NHS England’s Five Year Forward View.” www.rcplondon.ac.uk
“We would never allow a consultant under the influence of alcohol to treat patients, but continue to turn a blind eye to doctors who are sleep deprived.” Dr Paul Flynn CHAIR OF THE BMA CONSULTANTS COMMITTEE
well-founded. Sleep deprivation can impair judgement and decision making, skills that are vital for doctors. Studies have shown it can have similar effects to drinking. We would never allow a consultant under the influence of alcohol to treat patients, but continue to turn a blind eye to doctors who are sleep deprived,” said Dr Paul Flynn, chair of the BMA consultants committee. “This has the potential to lead to the same problems that consultants experienced as junior doctors - no one wants to see a return to the dark days of doctors working dangerously long hours. The consultant contract must continue to have robust protections against the acute fatigue that poses risks to patients and the chronic fatigue that risks burnout for consultants.” www.bma.org.uk
A THIRD OF GPS PLANNING TO RETIRE IN NEXT FIVE YEARS - BMA
third of GPs are considering retiring from general practice within the next five years, according to a BMA survey of 15,560 GPs. The results call into question the feasibility of election pledges to dramatically increase the number of GPs. The BMA poll was released as part of their ‘No More Games’ campaign, which calls on political parties to have an honest and open public debate about the future of the NHS.
“It is clear that incredible pressures on GP services are at the heart of this problem, with escalating demand having far outstripped capacity.” Dr Chaand Nagpaul CHAIR OF THE BMA GP COMMITTEE
Key findings from the survey about the current state of the GP workforce include: • One third of GPs (34%) are considering retiring from general practice in the next five years. • Almost three in ten (28%) who are currently working full time said they are thinking about moving to part time. • Nine per cent would consider moving abroad and seven percent would consider quitting medicine altogether. • Over two thirds of GPs (68%) state that while manageable, they experience a significant amount of work related stress. However, one in six (16%) feel their stress is significant and unmanageable. • GPs cite various factors that have a negative impact on their commitment to being a GP, including excessive workload (71%), unresourced work being moved into general practice (54%) and not enough time with their patients (43%). • Despite the pressures on general practice
just under half (47%) would recommend a career as a GP, but a third (35%) would not advocate working in general practice. “It is clear that incredible pressures on GP services are at the heart of this problem, with escalating demand having far outstripped capacity,” said Dr Chaand Nagpaul, BMA GP committee chair. “GPs are overworked and intensely frustrated that they do not have enough time to spend with their patients, especially the increasing numbers of older people with multiple and complex problems who need specialised care.” “Instead GPs are being taken away from treating patients by pointless paperwork or other work that has often been moved without proper resourcing into the community. Many GPs are facing burnout from increased stress.” www.bma.org.uk
BLAME AND SHAME CULTURE STILL EXISTS SAY TWO-THIRDS OF DOCTORS
ore than two in three doctors believe there is a blame and shame culture in the NHS and that it will be difficult to overcome, according to a survey by the Medical Protection Society (MPS). The survey of more than 500 UK members, including GPs, consultants and non-consultant hospital doctors, found that things had got worse since a similar survey in 2011. Only 16% of respondents thought legislation could be used to improve openness in healthcare. MPS believes that legislative tools - such as the statutory duty of candour now in effect in England and Wales - are not the most effective way of achieving behavioural change. “Legislating to govern the behaviours of healthcare professionals risks creating a ‘tick-box’ mentality,” said Dr Rob Hendry, Medical Director at the Medical Protection. “Mandating actions and threatening sanctions could undermine the intensely sensitive, personalised and patient-centred conversations that should happen with patients and their families when something has gone wrong.” The majority of respondents (72%) felt that education and training would encourage openness in the profession, 65% 6
pointed to the need for better top-down support from management, and mentoring was also considered an important factor for 50% of respondents. www.mps.org.uk
NEWS IN BRIEF I love being a GP The RCGP has launched its first-ever national recruitment video to encourage medical students to choose general practice as a career. It is first time that a college has used a video campaign to attempt to increase the number of medical graduates applying to that specialty. You can view the video at: youtu.be/U2YaT
Appy Happy The Royal College of Physicians’ Health Informatics Unit has produced a factsheet on the use of medical apps, to help doctors protect patients. The factsheet explains what is and what is not a medical app, what to do if you are using or developing a medical app, and how to report issues or problems with apps. www.rcplondon.ac.uk/sites/default/ files/apps_guidance_factsheet.pdf
Scotland falling short Scotland could be facing a shortfall of up to 915 GPs by 2020 according to the RCGP. The numbers are based on Scottish population growth at its highest rate; at the lower predicted rate 563 extra GPs would still be needed. The report comes as a quarter of Scottish people (28%) say they are unable to get a GP appointment within a week.
COMPLAINT DOCTORS FACE SEVERE DEPRESSION AND SUICIDAL THOUGHTS
K doctors that are subject to complaints procedures are at significant risk of becoming severely depressed and suicidal, according to research published in BMJ Open. Those referred to the UK professional regulator, the General Medical Council, seem to be most at risk of mental ill health, the findings suggest. The researchers base their findings on an anonymised online survey of more than 95,000 UK doctors in 2012. Of the almost 8000 (8.3%) who fully completed the questionnaire almost half (49%) had faced a complaint in the past; and more than one in four (28.5%) had done so recently. Around one in six (just under 17%) of those with a recent complaint were moderately to severely depressed, and they were 77% more likely to report these symptoms than doctors in the other two groups, after taking account of influential factors. They were twice as likely as those who had no personal experience of a complaint to harbour thoughts of self-harm or suicide. A similar proportion (15%) of those in the recent/ongoing complaints category were also twice as likely to have clinically significant levels of anxiety as doctors with no personal experience of a complaint. Levels of psychological distress paralleled the type of complaint. Doctors who had been
referred to the GMC reported the highest levels of depression (more than 26%), anxiety (more than 22%), and thoughts of self-harm (more than 15%). The process itself was often an unpleasant experience for the doctors involved. One in five of those who had been subject to a complaint felt victimised for having blown the whistle on poor clinical or managerial practice, and almost four out of 10 (38%) said they felt bullied during the investigation. And around one in four had taken more than a month off work. Most of the respondents who offered suggestions for ways to improve complaints procedures focused on boosting managerial competence in complaints handling; greater transparency; and disciplinary action for vexatious complaints. The researchers emphasised the importance of protecting patient safety and of enabling complaints to be raised as a way of improving standards of care, but go on to say: “However, a system that is associated with high levels of psychological morbidity among those going through it is not appropriate. Most importantly, a system that leads to so many doctors practising defensive medicine is not good for patients.” http://bmjopen.bmj.com/content/5/1/e006687.full
Pause before plastic Doctors who carry out cosmetic procedures must allow patients time to think before agreeing to go ahead with treatment, according to new guidance from the General Medical Council (GMC). The new guidance sets out the standards that will be expected of all UK doctors who carry out cosmetic procedures, both surgical and non-surgical. www.gmc-uk.org/guidance/news_ consultation/27171.asp
WATFORD PALACE THEATRE
lmost everyone enters the world inside it and most of us will experience its healing powers. Many die in its arms and some will have their lives saved by it. It is epic, tragic, joyful, extraordinary and ordinary all the same time. It’s the NHS. Over-worked doctors stitch together broken threads, patients grasp at the uncertainty of their future and cleaners try to wash all the politics away. As the future of the NHS hangs in the balance, Tangled Feet Theatre Company ask: what is it worth to us? And how do we value care? Be swept away as renowned creative maestros Tangled Feet turn the theatre into a hospital: where doctors fly and nurses dance, where you’ll find yourself in the waiting room one minute and the operating theatre the next. Care is a visually stunning piece of political, aerial and thought provoking theatre: a blend of touching storylines and dynamic movement with a beautiful musical underscore from “the masters of physical theatre” (The Independent) Tangled Feet. For more information and visiting times visit www.watfordpalacetheatre.co.uk Credit: Al Orange; Tangled Feet and Watford Palace Theatre.
CAN I STILL BE A DOCTOR NOW THAT I HAVE ONLY
â€œAs I lay in that bed on the first night of my admission to a London eye hospital, this was the question I asked myself. How could this have happened? How would I ever be able to complete my medical degree?â€? FY1 Joanna Dodkins tells JuniorDr her story.
he story behind how I found myself in that hospital bed, the very same evening that I flew back from my elective in Africa, is a complicated one. I went to Uganda for my elective at the end of fourth year to do a placement in paediatrics and it was an incredible experience. Following this, I travelled with a friend around East Africa, seeing everything from mountain gorillas to the beautiful beaches. Essentially I was having the elective I had always dreamt of.
THE ATTACK Unfortunately, things took a turn for the worst when we arrived in Tanzania. On arrival in the capital, Dar es Salaam, we got into what we believed to be a licensed taxi to take us to our hostel for the first night. However, once in the car, we immediately knew that something was wrong. Two men, claiming to be friends of the driver, got into the car and we were driven out of the city, in the opposite direction to our
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hostel. The car pulled over into a remote layby and a group of men surrounded the car, swapping places with the original men. They told us “you should not have got into this car, we are the Tanzanian Mafia and we will harm you if you do not cooperate with us”. As requested, we handed over our cash and bank cards which were taken away by some of the group. What followed were the most frightening three hours of my life. We were driven around the outskirts of the city, not allowed to talk to each other whilst the men spoke in Swahili so we had no idea what was being said. Eventually the other men returned to the car and were clearly angry. We learnt that they had managed to get some money from our bank accounts but not as much as they had hoped for. Once we realised they were not going to release us, even though we had done all that was asked, we start to cry and beg to be released. Miraculously, the driver must have had second thoughts. He stopped the car and told us to get out. We managed to get ourselves to the local Holiday Inn and when the hotel staff heard our story they were horrified and gave us a room in spite of us having no cash or credit cards. We reported the incident to the police and the embassy who could not believe we had escaped unharmed. Our friends were horrified by what had happened but encouraged us to continue on to Zanzibar for the final part of our trip. Whilst I was tempted to get on the first flight home, I wanted to put what had happened behind me and enjoy what was left of our trip. How I wish I had stuck with my first instinct to return home.
THEY TOLD US “YOU SHOULD NOT HAVE GOT INTO THIS CAR, WE ARE THE TANZANIAN MAFIA AND WE WILL HARM YOU IF YOU DO NOT COOPERATE WITH US”.
A PAIN IN MY EYE We spent our days in Zanzibar relaxing together, swimming and snorkelling in the sea. I am a contact lens wearer but hadn’t been told that I should never swim or shower whilst wearing them. At dinner one evening I noticed that my left eye suddenly felt very uncomfortable. I put it down to wearing my lens for too long so went to bed early and tried to sleep. However, by morning my eye was extremely red so, I tried a hot compress and took some painkillers. With all that had happened and now the problem with my eye, I decided enough was enough and it was time to go home. This proved to be one of the best decisions I have ever made. With my flight changed to the following day I became increasingly worried about my eye, the pain was getting worse. I went to a local pharmacy where the only antibiotic available was chloramphenicol which I applied, but to no effect. I was unable to sleep the night before my flight due to the excruciating pain. On arrival at the airport, I had to be escorted onto the flight as I could no longer open my eyes due to the pain and photophobia. Once the plane has taken off, I decided to make my way to the bathroom in order to check my eye in the mirror. The memory of what my left eye looked like when I prized it open will haunt me forever – it was completely yellow with pus. The sight of it made me think back to an image I had seen during my recent ophthalmology placement at medical school. Was this a keratitis? I knew it was sight threatening, was much more common in contact lens wearers (like myself) and I knew that I needed help. 10
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The stewardess put out a request for a doctor and by an amazing coincidence there were two eye surgeons on board (they had been attending an ophthalmology conference in Dar es Salaam!). They took a history from me and examined the eye. I remember just asking them repeatedly whether they thought it could be a keratitis and they tried to soothe my concerns by saying that I needed to relax as we still had six hours of the flight left to go. There were no specific antibiotics on the plane but I was given a sizable amount of morphine! The next thing I remember was waking up to the sound of the Pilot’s voice announcing that the plane was coming into land but could all passengers stay seated until the ambulance crew had boarded the plane due to a medical emergency. My heart sank. Was this for me? I sat up in a state of panic. This must be serious if the ambulance has been called. The eye surgeons explained to the paramedic that they suspected ‘a microbial keratitis’ and that I needed to be ‘taken to hospital immediately’. I had been correct in my suspicions all along. Would I be able to see again? Would I lose my eye completely? It was too much to take in.
IN EYE HOSPITAL I was triaged in A&E and was immediately seen by the nurse. She took a swab from my eye but informed me that my eye may not survive due to the extent of the infection. The thought of losing my eye was just too much to comprehend. I was examined by the doctor using the slit lamp. She said that I had what appeared to be a keratitis (most likely to be bacterial) and that I had some of the most extensive amount of damage that she had ever seen. There was a large corneal ulcer but my anterior chamber was still intact and no hypopyon was present. My only question was ‘will I ever be able to see out of that eye again?’ Her response was that the damage would result in me having a large central corneal scar which was not indicative of a good return of vision, but that I had made it to the hospital just in time for the treatment to be started. I was admitted and in the five days that followed I had to have antibiotic eye drops (ofloxacin and ceftazidime) every hour for twenty four hours which meant I could not sleep. I was seen by the doctors every morning and the progress of the infection was monitored. The results of the swab came back as being gram negative rods with polymorphs which confirmed that this was indeed a pseudomonas keratitis.
I REMEMBER THE PILOT’S VOICE ANNOUNCING THAT THE PLANE WAS COMING INTO LAND BUT COULD ALL PASSENGERS STAY SEATED UNTIL THE AMBULANCE CREW HAD BOARDED THE PLANE DUE TO A MEDICAL EMERGENCY. MY HEART SANK. WAS THIS FOR ME?
WHAT IS A ‘KERATITIS’? A keratitis is an infection of the cornea. While severe contact-lens related keratitis tends to be caused by pseudomonas aeruginosa, staphylococcus and streptococcus can also cause it. In contrast, fungal keratitis is very rare in the UK. Of these microorganisms, pseudomonas is the most fulminant and can even cause corneal perforation in just seventy two hours. Although, bacterial keratitis is most frequently associated with
CAN I STILL BE A DOCTOR NOW THAT I HAVE ONLY ONE EYE? contact lens wear (especially if worn overnight), it is also associated with corneal surface disease (for example, corneal exposure or anaesthesia), immunodeficiency, topical steroid use and ocular trauma. The symptoms are exactly as I presented; severe, sudden onset pain with rapid progression. Also photophobia, redness, discharge and blurred vision are common. Signs to be looked for on examination are lid oedema, discharge, conjunctival hyperaemia and infiltration. The interruption of intact corneal epithelium permits the entrance of microorganisms into the corneal stroma where they can proliferate and cause ulceration (as happened in my case). Then there is stromal oedema beneath the lesion and finally endothelial fibrin plaques form beneath the lesion. The diffusion of inflammatory cytokines posteriorly elicits a production of inflammatory cells into the anterior chamber which can cause a hypopyon in severe cases.
HOW DO YOU INVESTIGATE AND TREAT A KERATITIS? The investigations involve doing a corneal scrape and culture to determine antibiotic sensitivities. Slit lamp photography is useful in order to document the progression of the keratitis. The fundamental aspect of management is intensive topical antibiotics (usually a cephalosporin and an aminoglycoside). The microbial response is usually rapid, allowing the rapid stabilisation of the growth of the stromal infiltrate and arrest of further stromal necrosis within forty eight hours. I also received topical steroids once the infection was controlled, in order to reduce morbidity associated with uncontrolled inflammation and to decrease permanent stromal scarring. The enduring effect on the affected eye is the corneal scar (corneal leukoma) and the irregularity of the cornea (irregular astigmatism) which requires long term follow up.
HOW HAS THE ATTACK AND THE KERATITIS AFFECTED MY LIFE SINCE? Following the intensive course of antibiotics and steroids, my eye was finally on the mend. The bacteria had been eradicated but my eyesight was still very poor; I could only see the difference between light and dark, I could not yet distinguish shape or colour. In between coping with my extremely vivid nightmares of the car hijacking and trying to get my eye to heal, I was also dealing with the prospect of starting back at medical school. I informed the staff of the situation I was in and they asked me whether I felt able to start fifth year at that time or did I want to defer. I was very determined to continue and to graduate on the same day as all of my friends - I did not want to miss out! The team at the medical school were extremely helpful and organised my placements to be nearby so that I could walk (driving was not an option at that stage) and the teams that I was working with at hospital were made aware of my situation. One of the main impacts the infection had on my vision was ‘depth perception’; the thought of trying to doing practical skills on the wards, like venepuncture or cannulas, petrified me. Therefore, I organised extra training in order to practice my clinical skills and get used to my change in vision. This process took time but eventually I became a lot more
conformable and confident again in my clinical skills and I began to do successful cannulas for the patients on the wards. The other issue I had was studying for long periods of time during revision. Using computers and reading textbooks to prepare for my exams was difficult as it put strain on my eye and resulted in very bad headaches. I overcame this by trying to take frequent breaks and occasionally using audio revision tools instead of visual ones. My fifth year of medical school was one of the most difficult of my life. Coping with the changes to my vision and the recurrent nightmares, made revising for finals extremely difficult. But I made it. I passed my finals, graduated in summer 2013 and have since been enjoying working as an FY1 doctor.
HOW WILL IT AFFECT MY FUTURE CAREER? Even two years later, the destruction done by the bacteria has resulted in my vision still not being as it was before. In fact, there is only a third of the thickness of my cornea remaining in certain places. The treatment option for me, now that the eye is stable, is to wear a rigid gas-permeable lens which I am currently trialling. My one concern was that some career paths may now be closed to me due to having poor vision in my left eye. I had always considered a career in surgery and under reassurance from my eye surgeon that is still an option. That said there are some areas of surgery that I would feel daunted to attempt, for example laparoscopic surgery, due to the minute detail involved but maybe that fear could be conquered with time and experience. There are many doctors who achieve their career aspirations in spite of poor vision and it is incredible to realise that I have come out of the other side of this story knowing that I can still pursue any career that I choose. Finally, in answer to my question lying in bed on that first night in the eye hospital, ‘will I still be able to be a doctor now that I only have one eye?’ the answer is most certainly ‘yes’. As I proved the first day that I walked into my new hospital as a fully-fledged FY1. I hope, in some way, that this experience has actually helped me to become a better doctor. The feeling of being a patient with a serious condition and the trust you place in your doctor is something that I have now seen first-hand and that I hope to never forget throughout, what I hope will be, a fulfilling and exciting career ahead. REFERENCES 1. Weed MC, Rogers GM, Kitzmann AS, Goins KM, Wagoner MD. Vision Loss after Contact Lens-Related Pseudomonas Keratitis. EyeRounds.org. June 24, 2013; Available from: www.EyeRounds.org/ cases/171-pseudomonas-keratitis.htm 2. Al-Mujanini A, Al-Kharusi N, Thakral A, Wali U. Bacterial keratitis: perspective on epidemiology, clinic-pathogenesis, diagnosis and treatment. Sultan Qaboos University Medical Journal June 30, 2009; available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC3074777/ 3. The College of Optometrists Clinical management guidelines; Microbial keratitis. 22 July 2013; available from: www.collegeoptometrists.org/en/utilities/document-summary.cfm/docid/B5A5F28AAC2A-4B8F-918345D87DE1ADA9 4. Eltis M. Contact-lens-related microbial keratitis: case report and review. Next Document J Optom. 2011;04:122-7. Available from: www.elsevier.pt/en/revistas/-/artigo/contact-lens-related-microbialkeratitis-case-report-and-review-90091448
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COPING WITH ILLNESS AS A JUNIOR DOCTOR D
octors should be experts in illness but as a group we are notoriously 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 medical 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 physical 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 FIRST The 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 tiredness, 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 return 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 12
SUPPORT DOCTORS MEDICAL FOR STUDENTS
as your supervisors know what is going on you don’t need to tell anyone else yourself if you don’t want to.
PRACTICAL 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 overdraft until you are back on your feet. Also speak to the
USEFUL RESOURCES The British Medical Association www.bma.org.uk
council or your energy provider if you are envisaging having difficulty paying bills. • Draw up a budget. Look for areas where you can cut costs and reduce unnecessary outgoings. Don’t neglect yourself however - 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 financial 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 financial assistance and advice • Talk to your friends and family - even if they can’t help you financially 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 someone early on. Remember, doctors are not immune from becoming ill, and your health is important!
Doctors For Doctors (BMA Counseling and Doctor Advisor Service) www.bma.org.uk/doctorsfordoctors Royal Medical Benevolent Fund www.rmbf.org and www.support4doctors.org Royal Medical Foundation www.royalmedicalfoundation.org
Doctors Support Network www.dsn.org.uk
The Sick Doctors Trust www.sick-doctors-trust.co.uk International Stress Management Organisation UK www.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
A PERSONAL VIEW
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 fibrillation 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 difficulties 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 supported 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 pointless
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 isolated. 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 illness, 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.”
SUPPORT FOR DOCTORS MEDICAL STUDENTS
YOUR COMPANION AT THE SHOP FLOOR: Through bleary eyes your watch reads 3am as you make your way swiftly through a deserted maze of corridors en route to your next sick patient. It’s pitch black outside, the hospital is eerily quiet and only the repeating echo of your footsteps breaks the silence. The comfort and optimism of the lecture theatre now seem a distant memory. The transition from medical student to junior doctor is always tough – suddenly you find yourself thrust into a world of acutely unwell patients, time-critical decision making and significant clinical responsibility. Pocket On Call is designed specifically for you – the busy junior doctor on the shop floor. Consider it your constant companion for those seemingly endless days and nights spent on call!
THE VISION: Aiming for a succinct yet comprehensive approach, the goal has been to produce a genuinely pocket-sized book which enables junior doctors to approach acutely unwell patients with confidence. With each topic, Pocket On Call provides a clear strategy for the immediate assessment and optimization of the patient, with a particular focus on what would be expected of the foundation doctor. In addition to text, I have worked hard to include ample diagrams and summary boxes that I hope will bring the material to life and assist with rapid recall of key information.
AN EVIDENCE-BASED APPROACH: It can be a challenge for even the most conscientious of doctors to keep abreast of the ever-evolving world of evidence-based medicine. Wherever possible, Pocket On Callstrives to provide information sourced from the best evidence currently available for each given topic.
THE AUDIENCE: Pocket On Call is aimed primarily at foundation doctors and also senior medical students who are beginning to look ahead to their first on-call shifts. In addition, doctors embarking on GP training schemes may also find the content useful as they rotate through hospital specialties.
THE STRUCTURE: Pocket On Call consists of four sections: Section A: ‘Getting set’ – This provides an introduction 14
CALL THE BEDSIDE …
On Call? The only truly pocket-sized guide dedicated to preparing for and being on call
to the logistics of being on call. With detail on necessary equipment, definitions of terminology commonly found on rotas and general guidance on how to make your on call shift pass smoothly! Section B: ‘Acutely unwell patients’ – Pocket On Call’s largest section focuses on the acute assessment and management of a wide range of presenting problems commonly encountered by junior doctors. The beginning of this section hones in on the fundamentals of the ‘A,B,C,D,E’ assessment before embarking on chapters dedicated to topics such as chest pain, shortness of breath, acute stroke, acute collapse, cardiac arrest, sepsis and many more. Section C: ‘Situations and communication’ – This section is dedicated to the ‘non-textbook’ side of being a junior doctor. With guidance on how to go about tackling tricky or simply new situations that may not have been taught in the lecture theatre. Topics covered here include; certification of the deceased patient, activating massive haemorrhage protocols and, how to run an efficient post – including take ward round and presenting patient cases to seniors. Section D: ‘Prescribing’ – One of the major transitions from medical student to junior doctor is the ability to prescribe medication, a task which carries a significant level of responsibility. This section contains information and guidance on safe prescribing, the ‘ins and outs’ of what can be found within a typical hospital drug kardex, followed by sub-sections dedicated to analgesia, anti-emetics and intra-venous fluid prescribing.
SAVE 15% visit: http://bit.ly/JuniorDrPocket to automatically receive your discount and get FREE worldwide delivery. Expires 31/07/2015
MOST IMPORTANTLY…! Above all, I really hope you enjoy using Pocket On Call. It is a book tailored very much to the needs of the junior doctor on the shop floor and, as such, I do hope you find it useful in getting you through those busy on-call shifts we all know so well! Andy Stewart is an ST4 specialist registrar in Intensive Care Medicine and Anaesthesia currently working in South Yorkshire.
ADVERTORIAL Junior Dr - March.indd 1
15 19/02/2015 14:07:08
Medicolegal Advice - in association with Medical Protection
IS THERE A DOCTOR ON BOARD?
Medical emergencies can happen anywhere, at any time - if you assist out of hours, you are acting as a Good Samaritan. Charlotte Hudson, Content Editor at Medical Protection, explains.
ou’re on board a flight for a well-deserved rest from the wards, when a passenger falls ill and you hear a flight attendant calling out for a doctor. Your first thought is “should I intervene?” The GMC would say yes - you have no legal duty to do so (in UK law), however you do have an ethical and professional duty to help. A Good Samaritan act is where medical assistance is given, free of charge, in a bona fide medical emergency, upon which a doctor chances in a personal as opposed to a professional capacity. You do not need to be specialised or trained in emergency care to act as a Good Samaritan. The call for a doctor could happen anywhere. In-flight incidents are perhaps the most familiar and dreaded scenarios. At 30,000 feet, if a passenger falls ill, there are limited resources for a doctor to work with - you have to do the best you can, within the limits of your expertise and competence. But what are the chances of an in-flight emergency happening? According to a study published in The New England Journal of Medicine, there is an in-flight medical emergency once every 604 flights - that’s about 44,000 people a year globally having a serious medical problem while on a plane.1 The research also showed that there is medical help on board surprisingly often – with a doctor on the plane 48% of the time, a nurse on the flight 20% of the time, and a paramedic or other health professional 8%. One-third of cases are handled by flight attendants alone. A famous case occurred in 1995, when Professor Angus Wallace used a coat hanger to save a patient’s life during a long haul flight from Hong Kong to London. The passenger complained of chest pains and Dr Wallace recognised that the passenger, who had been involved in a motorcycle crash on her way to the airport, had a collapsed lung.2 Fearing change in air pressure could be fatal, he decided to operate, taking a scalpel and local anaesthetic from the aircraft’s emergency kit, and the rest of the equipment from the kitchen and coat cupboard. 16
Dr Wallace cut into the patient’s chest with the scalpel, while another doctor on the plane, who was one year out of medical school, held the wound open with a knife and fork sterilised in fivestar brandy. They inserted a chest drain made from a urinary catheter strengthened by a coat hanger, which was also sterilised by brandy.
WHAT YOU SHOULD DO IF CALLED UPON: When called into action while off duty, you must remember to: • Make a full clinical record after treatment, and give your contact details to the appropriate official. • Assess your own competence in handling the situation - for eg, you may be under the influence of alcohol - and proceed accordingly. • Only intervene if the situation is an emergency. GMC GUIDANCE IN GOOD MEDICAL PRACTICE STATES: “IN AN EMERGENCY, WHEREVER IT ARISES, YOU MUST OFFER ASSISTANCE, TAKING ACCOUNT OF YOUR OWN SAFETY, YOUR COMPETENCE, AND THE AVAILABILITY OF OTHER OPTIONS FOR CARE”.
MEDICAL PROTECTION ASSISTANCE In the unlikely event that legal proceedings follow, Medical Protection members would be entitled to apply for assistance, no matter which country the legal proceedings are commenced in. Medical Protection considers that a response to the GoodSAM App: www. goodsamapp.org/home, provided it is in accordance with the GoodSAM App Code of Conduct, falls within Medical Protection’s definition of a Good Samaritan act. Contact Medical Protection on 0800 561 9090 or by emailing firstname.lastname@example.org.
More than defence Medical Protection is the worldâ€™s leading medical defence organisation, providing members with more support, more advice and more defence - a lifetime of protection. REFERENCES
1. New England Journal of Medicine, Outcomes of Medical Emergencies on Commercial Airline Flights www.nejm.org/doi/full/10.1056/ NEJMoa1212052#t=articleTop 2. BMJ Careers, Good Samaritan experiences http://careers.bmj.com/careers/advice/viewarticle.html?id=20010202
Medical Protection supports members through the worldâ€™s largest network of medicolegal experts. We have a unique team of more than 100 specialist lawyers and medicolegal advisers (doctors with legal training). We are also committed to sharing our experience with members to help them avoid problems and provide the very best care for their patients. The educational portfolio available includes publications, conferences, lectures, presentations, workshops, e-learning and clinical risk assessments.
Medical Protection members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0800 561 9090. www.medicalprotection.org The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.
HOW TO GET INVOLVED IN
TEACHING D octors have many roles and responsibilities above and beyond clinical medicine, one of which is as a teacher1. Over recent years there has been a renewed focus on medical education, with its importance echoed in documents such as ‘Good Medical Practice’ by the GMC2. Some of you will find teaching a challenge; for others the art of teaching will come more naturally. But whatever your initial experience or capabilities, most doctors find it an enjoyable and rewarding experience that they want to do again! In this article Andrew Pugh, Hayley Coleman and Birgit Hanusch explore the different ways to get involved.
AT MEDICAL SCHOOL Although as a student you may not feel qualified to teach, your time in medical school provides an ideal environment in which to develop your skills. As a more senior student you have recently overcome the challenges of junior colleagues. You should therefore be well equipped to offer advice, reassurance and ‘know-how’ to students in years below. They will be very grateful for any ‘pearls of wisdom’ you can provide. Medical schools are more frequently adopting ‘mentoring’ or ‘parenting’ schemes between more senior and junior students. These schemes are a great way to improve your ability to teach topics with which your mentee may be struggling. They also provide a fantastic opportunity take on and develop your ability to fulfill a pastoral role. Medical schools often advertise teaching opportunities internally. This may take the form of examining on formative clinical examinations. As part of this you should receive examiner training, and you will gain an invaluable ‘alternative perspective’ that will prove useful for your own examinations. There may also be opportunities to deliver teaching sessions under supervision. For example, fourth year students at Newcastle University are offered the chance to deliver small group teaching to first year medical students on Cystic Fibrosis. This provides an invaluable experience in planning a session, delivering to time and answering questions 18
MEDICAL STUDENTS TEACHING
in a safe environment with senior support (not to forget a teaching certificate!). Finally, organising and planning study groups with your peers prior to assessments and examinations is a great way to show initiative and organisational skills. Presenting interesting cases or topics to the group will allow for further development of your teaching skills, as well as being a very useful revision method in its own right. Towards the end of medical school you must take the time to consider whether you wish to embark upon the Academic Foundation Programme (ACF). This is an alternative to the ‘generic’ Foundation Programme. It offers protected time in research or education to allow for teaching, completion of a project or to undertake formal study of an educational qualification.
Top tips Be proactive. Involve yourself in a student ‘parenting’ scheme. Seek the opportunity to teach more junior colleagues and examine on formative assessments. Organise group revision activities. Identify the right foundation programme for you.
AFTER MEDICAL SCHOOL Starting foundation training is both a daunting and exciting experience. It is a busy time where interests such as education can be sidelined whilst you get to grips with the job. However, being a junior doctor provides a perfect opportunity to teach. Firstly, this can be informal on the wards with medical students; observing student-patient interaction, discussing cases or interpreting results. More formally, some Foundation Schools offer teaching posts as part of your foundation training. These tend to be F2 posts and can be competitive, so enquire early. They provide good experience and insight into education as a career, and allow you to see what goes on ‘behind the scenes’ in terms of overall curriculum organisation and delivery. Other opportunities can be accessed
through your local undergraduate department; most offer the chance to help with curriculum teaching. This can range from leading sessions to facilitating small group or bedside teaching. Not only will this enhance your teaching skills and force you to consolidate your own knowledge but observed teaching experience is a mandatory part of you e-portfolio. Increasingly doctors are taking time out after foundation training to pursue specialist interests and strengthen their CV. Many trusts offer twelve month teaching fellow posts; some are purely teaching with no clinical commitments, while others are associated with a specialty and demand a quantity of clinical work. To find out more about available jobs either contact trusts directly or search NHS Jobs3. Create a free NHS jobs account and receive email alerts when jobs are advertised matching your own specifications. This is a great way to identify and apply for local teaching fellow posts. Finally, why not organise and deliver your own teaching day. These are normally well received by final years in the build up to exams. The format is up to you, but this is a good way to demonstrate initiative and looks impressive when applying to jobs in the future!
Top tips Teaching is a mandatory component of foundation training so get involved
can visit the foundation programme website and National institute for Health Research (NIHR) website respectively 4&5. The Academy of Medical Educators are continually attempting to streamline career progression in this field, as well as disseminating best practice standards. Their website provides guidance on pursuing a career in medical education 6. Furthermore, there is an informative interview with Sean Hilton, President of the Academy of Medical Educators on the Foundation Programme website. It can be found by selecting the ‘Rough Guide to the Academic Foundation Programme’ 7.
early. Seek opportunities from the undergraduate department. Enquire about F2 posts in Medical Education. Create your own revision day!
FORMAL QUALIFICATION Although experience is essential, more formal qualifications in education are becoming desirable. There are numerous courses available across the country. These range from postgraduate certificates to doctorates, all with flexible study options. Most universities offer programmes in clinical or medical education; broadly they involve gaining an understanding of recognised learning theories and teaching methods. The key is to identify a programme that suits you. This means considering whether you prefer face to face or distance learning; and the level of study. Most start with a certificate or diploma. To find out more about individual courses visit the Universities’ website. Some trusts can also help with funding of qualifications, so it may be worth speaking to your employer.
Top tips Identify a course that suits you and your schedule. Start with a certificate or diploma. Speak to your postgraduate department about possible available funding.
KEEPING YOUR PORTFOLIO UP TO DATE A career in medical education is attractive. Over the years its importance has been recognised with a growing number of associated posts. However, with increasing demand comes increasing competition. Demonstrating an interest early in your career is important and taking every opportunity to gain experience is imperative. A portfolio of evidence to highlight your commitment, experience and skills is essential, so ensure you gather this. This could include certificates of teaching, student feedback, lesson plans and direct peer observation.
Top tips Create a teaching portfolio. Keep it up to date.
MAKING TEACHING YOUR CAREER There is currently no clearly defined pathway to a career in medical education. A possible route would include completion of the Academic Foundation Programme (AFP) followed by an Academic Clinical Fellowship (ACF). Both the AFP and ACFs allow a mixture of clinical and academic work. ACFs are particularly competitive with a variety of entry points between CT1 and ST4 depending on the region. To learn more about the AFP and ACFs you
Seek advice from senior medical educators at your institution. Investigate whether the AFP or an ACF would be for you. Stay up to date with careers in medical education via the Academy of Medical Educators.
SUMMARY Teaching is an important activity for Doctors today. Opportunities to teach, ranging from informal sessions to accredited qualifications, make themselves available as early as Medical School. Be proactive in finding and taking these opportunities! Andrew Pugh, Hayley Coleman and Birgit Hanusch. James Cook University Hospital, Middlesbrough.
REFERENCES (ACCESSED FEBRUARY 2015)
1. General Medical Council (GMC). Tomorrows Doctors 2009. www.gmc-uk. org/education/undergraduate/tomorrows_ doctors.asp 2. General Medical Council (GMC). Good Medical Practice 2013. www.gmc-uk.org/ guidance/good_medical_practice.asp 3. NHS Jobs. www.jobs.nhs.uk 4. The Foundation Programme. Academic Programmes. www.jobs.nhs.uk 5. National Institute for Health Research (NIHR). NIHR Academic Clinical Fellowships for Doctors. www.nihr.ac.uk/ funding/academic-clinical-fellowships.htm 6. Academy of Medical Educators. www. medicaleducators.org/aome/ 7. Geeky Medics. http://geekymedics.com
MEDICAL STUDENTS TEACHING
THE EVOLUTION OF MEDICAL EDUCATION FOR
The days of sitting in a lecture theatre learning the intricacies of the Krebs cycle or the insertion points of the latissimus dorsi are numbered, according to doctors.net.uk - the UK’s largest professional network of doctors. Medical education is evolving, and it’s becoming digital. Here’s why it’s time to leave In association with those textbooks on the shelf and get logged on instead.
014 marked a tipping point when the majority of doctors became ‘digital natives’ - a term popularised by education expert Marc Prensky to describe those who are native speakers of technology and fluent in computers and the internet1. In five years time ‘digital natives’ are expected to comprise two-thirds of all healthcare professionals. ‘Digital natives’ work and learn differently from their ‘digital immigrant’ counterparts. They prefer interactive online videos to traditional text based book chapters; discussion forums to library based self-study; and simultaneously learning from different media rather than sticking to a single source. This shift is no surprise. Doctors across the EU now spend 15.9 hours per week online for professional purposes in addition to the 5.1 hours for social use2, meaning that we’re all becoming much more comfortable with information in a digital format. It does however mean medical education will need to adapt, and learning in the future is going to look very different than it does today.
FLIPPED EDUCATION The good news is that adapting to the needs of ‘digital natives’
should make medical education more instantaneous, relevant and fun - even for ‘digital immigrants’. Undergraduate medical education has already been pioneering this transition with streaming lectures, online learning and ‘flipped classrooms’. The ‘flipped classroom’ has been implemented in many medical schools across the UK. It is a form of blended learning in which students learn online by watching video lectures first, with classroom time then dedicated to more active learning activities. It allows the lecturer and peers more time to interact and collaborate. At a postgraduate level, medical education is moving closer to the point of care in hospitals and other clinical settings. 60% of EU doctors surveyed said that it was on the job clinical challenges, such as unknown signs and symptoms, which were most important in identifying learning needs3.
RELIABLE AND TRUSTWORTHY After research and clinical guidelines, medical education has the next biggest influence on a doctors’ choice of treatment so it’s important the information is trustworthy and reliable. Doctors.net.uk found that of the 72 hours a group of cardiologists ARE YOU A DIGITAL NATIVE OR DIGITAL IMMIGRANT? Digital Natives prefer:
• • • • • • •
Receiving info quickly from multiple sources Multitasking and parallel processing Pictures, sounds and video before text Hyperlinked sources Interacting in “real time” User generated content Learning that is instant, relevant and fun
Digital Immigrants prefer:
• • • • •
Controlled release of info from limited sources Single or ‘focused’ tasks Often prefer to get information from text Greater need for private and personal space for introspection Like info presented in a linear, logical and sequential fashion
Source: Institute for Alternative Futures
had spent engaging with online CME a third of this time (27 hours) was on self-study. Of the remainder, professional association sites (11 hours) and independent websites (12 hours) got significant use. It is these independent websites which often cause doctors great concern about whether the content is current, accurate and valid for use in their clinical setting. With medical information doubling every five years it’s a problem that’s only going to become more pressing. BARTS HEALTH NHS TRUST BEGAN BROADCASTING LIVE LAST MAY WITH THEIR FIRST OPERATION STREAMED LIVE TO 13,000 TRAINEES IN 115 COUNTRIES.
It’s this credibility that is increasingly the issue as more and more content appears online. In the Doctors.net.uk survey CME content written by a recognised expert was seen as much more credible and likely to be used than content produced by an independent author (88% versus 49%). 65% of doctors ranked ‘accuracy and relevance to daily practice’ as the most important factor, closely followed by ensuring the information was ‘unbiased’. In the decision to use it those surveyed felt that this was more important than whether it actually met their education needs.
Looking for your next role? FIND IT WITH DOCTORS.NET.UK CAREERS Our Careers service allows you to:
DIGITAL INNOVATION One major benefit of this shift to cater for the ‘digital native’ is the innovation in medical education this new technology allows. This new thinking goes beyond classroom learning to postgraduate conferences and symposia - frequently cited as the most valued CME activities. Over a third of medical associations (34%) believe virtual meetings will take over from physical congresses and conferences4. This means we’ll soon be swapping flights to far flung events for live streaming at home in our dressing gowns. And this isn’t just speaker presentations, in 2013 Ohio State University became the first to stream live surgery via Google Glasses worn by the surgeon giving you a live view from their perspective. Since then live surgery broadcasting has spread globally and live shows take place daily. Barts Health NHS Trust began broadcasting live last May with their first operation streamed live to 13,000 trainees in 115 countries. Questions can be submitted by Twitter which appear in the bottom left of the surgeon’s vision which were then answered.
THE FUTURE The accessibility of the internet also means individual medical students and doctors are sharing their own education resources in huge numbers. Thousands of peer learning videos, revision notes and practice questions are now accessible online. Online education is allowing us to learn and share in new, more efficient and effective ways - and innovation is only just starting. It’s time to nurture that ‘digital native’ inside you and embrace the evolution in medical education.
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www.doctors.net.uk/jundr Already a member? Check out Doctors.net.uk Careers today.
1. Source: LBI Health: www.lbi.com/uk 2. Survey with 1,848 doctors across EU5, July 2014, medeConnect and M3 Global Research 3. M3 EU5 survey of 155 Cardiologists – March 2015 4. Research presented at ICCA World Congress, 25 Oct 2011 (study surveyed 27 European and 3 International medical associations)
Part of M3
JUNIOR DOCTORS ON THE FRONT LINE AGAINST EBOLA
FY2 Dr Mikey Bryant is in Sierra Leone with healthcare charity Mercy Ships. He has been volunteering in a children’s clinic in a country where one in five children don’t live to see their 5th birthday. This is his regular column.
oday I’m leaving the limelight of my column to a woman far more deserving. I’m interviewing Dr Sandra Lako who has been working in Sierra Leone since 2005. She works with an NGO called Welbodi Partnership, who have been at the heart of transforming care in Freetown’s largest paediatric hospital, Ola During. Welbodi has been working with Sierra Leonean frontline staff during the Ebola outbreak.
What is your role with Welbodi? I work as the Country Director for the organisation. I am involved in strategy and guideline development during the Ebola outbreak both at a national and hospital level, and also engage with partners to improve training of health workers and strengthening the resources available for hospital staff to safely provide care to children.
It sounds like you have been busy! How did you come to be in Sierra Leone? I grew up overseas as my parents worked on one of the Mercy Ships travelling around West Africa. Since then I have been passionate about improving healthcare in Africa. I came to Sierra Leone and started an outpatient clinic for children in 2005. I was only going to stay for a year, but I loved the work and the people, so stayed, and then joined Welbodi in 2010 to help build capacity in the government’s health system.
So what has Welbodi been doing during the Ebola outbreak? We found that there was a gap in the training of hospital staff in how they can safely provide general health services, so we have been organising training for hospital staff. I am a member of the national case management pillar and have helped develop various standard operating procedures for managing suspected cases, setting up Ebola care facilities, and centres for highly exposed asymptomatic children. This helped standardise treatment protocols across the country and has led to improved outcomes in several treatment centres. Welbodi is a part of the Ebola Response Consortium, a group of NGOs working to improve infection control in government hospitals, amongst other things.
Do you think Ebola has affected other aspects of healthcare for Sierra Leone’s children? There have been a few set-backs, for example in Ola During we had just reached the point where we were doing testing every patient with a fever for malaria rather than just treating everyone who walked through the door automatically. There are now almost no testing facilities due to the risk of potential transmission of Ebola virus. Sadly, some of my medical and nursing colleagues have died due to the Ebola virus, including a paediatrician and a (paediatric) surgeon. 22
MEDICAL STUDENTS DIARIES
Other aspects of healthcare have also been affected. Uptake for childhood immunisations has been reduced, so there is a chance that we could see a measles epidemic. Some children have been lost to follow up in the tuberculosis and HIV clinics, so could become unwell very quickly or develop resistance to medication. There is a risk that children who are sick are not going to be brought to the hospitals for fear that they will catch Ebola so instead they may die at home due to a common childhood illness.
What are your thoughts on the future for Welbodi in helping Sierra Leone’s children? In the short- and long-term, there is a lot of work to be done to rebuild the healthcare system. The outbreak highlighted a gap in infection control in Sierra Leone’s hospitals, so we need to work to address that. This has been a wake-up call for the hospital. As an organisation we will expand our work to include other hospitals, including the maternity hospital in Freetown, so that infection control is improved there. We will continue to facilitate training for doctors in Freetown looking to specialise in paediatrics and want to support the college of medicine in setting up a postgraduate diploma in paediatric nursing.
It’s great to hear that you still want to push things forward! How can doctors and other health workers in the UK help to support your work? At the moment we are recruiting IPC mentors to work with national IPC leads in the hospitals we will be supporting, a WASH engineer to help with water and sanitation improvements at the hospitals, a paediatric nurse educator and a UK doctor who could help co-ordinate the paediatric postgraduate training for doctors. If people are interested in making a donation to support the hospital, that can be done via our website. Sandra Lako’s blog can be found at: http://sandralako.blogspot.co.uk/ Find out more about Welbodi Partnership at: http://welbodipartnership.org/
Focus on Finance - in association with Wesleyan
PROTECTING YOUR BIGGEST ASSET - YOU!
s a junior doctor, it could be easy to dismiss the prospect of being unable to work because of illness or injury as something that only happens to older colleagues. However, as a doctor, you know anyone could be struck down by illness and be unable to work at any time of their life – with the risk obviously increasing if they are working in dangerous places – which could have serious implications for their finances. An income protection policy, which pays you a tax free sum each month if you are unable to do your job because of injury or ill health, should be an integral part of any financial plan right from the start of your career, as it will enable you to maintain your standard of living should anything happen to you. WHAT KEEPS DOCTORS OFF WORK?
Wesleyan has analysed income protection claims made by doctors from 2004 to 2014. It found mental health issues were the most common complaint that kept doctors off work over the past ten years, accounting for 40% of claims in 2014 alone. This is well ahead of the next highest causes, led by cancer at 11%, problems with the nervous system and sensory organs at 10% and circulatory conditions at 9%.
you a regular tax-free income, typically up to 50% of your pre-incapacity level. Most policies pay out until you are well enough to return to work, are no longer suffering from a loss of earnings (such as if you start receiving your pension), you reach the maximum age for your policy, or you die. Without an income protection policy, once your sick pay stops you may have to draw upon any savings you might have or, if eligible, rely on state support. The Employment and Support Allowance currently pays out a maximum of £105.05 a week, which is likely to be some way short of your regular income. WHAT TO LOOK FOR WHEN BUYING INCOME PROTECTION
WHY YOU NEED INCOME PROTECTION
If you work in the NHS and fall ill, the maximum amount of sick pay that can usually be claimed from your employer is six months full pay, followed by six months half pay after five years continuous service. Remember, this only takes into account your NHS work, not any private work. If you work wholly in the private sector, any sick pay you are entitled to will be determined by your employer. Income protection policies are generally based on your full earnings and will pay
When buying income protection you should ensure the policy is specifically tailored to your needs and provides all the key benefits you require if you need to claim. For example: • Ensure the policy includes an ‘own occupation’ definition, meaning it will pay out if you are unable to carry out your specific job. If the policy states ‘any suited occupation’, it won’t pay out if you are able to carry out other types of work based on your knowledge and experience.
• Check the insurance offers ‘permanent’ protection, meaning the terms on which it is offered will remain unchanged until the policy expires or you retire, whichever comes sooner. • Think about how long you can wait before it pays out. Premiums are normally cheaper if you wait longer before benefits are paid, so you might choose to defer payments until other sources of income, such as sick pay, have expired or reduced. • Review your policy regularly to make sure it provides the right level of cover. As your income and financial commitments change over time, you may want to change your insurance to match. Wesleyan has recently launched a new income protection policy that includes guaranteed options to increase cover without providing further medical evidence, as well as an option to suspend, reduce or continue cover on an own occupation bass during career breaks such as maternity or paternity leave. There is also access to Wesleyan’s Health & Wellbeing Scheme, which has been set up to support policyholders while they are healthy, rather than waiting until it’s too late. It provides a range of specialist health treatments and services to help them stay fit, including chiropractic and physiotherapy, face-to-face counselling and health checks. CONCLUSION
Any time you are off work without receiving an income could leave you financially vulnerable. In the worst case, you could lose your home or build up substantial debts. A financial adviser with understanding of the medical profession will help ensure you are protected and have adequate cover in place.
The above information does not constitute financial advice. For further information please speak to a financial adviser. For more information call 0800 980 2277 or visit the website at www.wesleyan.co.uk/incomeprotection.
Advice is provided by Wesleyan Financial Services Ltd. ‘WESLEYAN’ is a trading name of theWesleyan for Professionals are trading names of Wesleyan Group of companies. Wesleyan Financial Services Ltd (Registered in England and Wales No. 1651212) is authorised and regulated by the Financial Conduct Authority and is wholly owned by Wesleyan Assurance Society. Wesleyan Assurance Society is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Incorporated in England and Wales by Private Act of Parliament (No. ZC145). Registered Office: Colmore Circus, Birmingham B4 6AR. Telephone: 0845 351 2352 Fax: 0121 200 2971. Telephone calls may be recorded for monitoring and training purposes.
A mole could be skin cancer. A headache could be a brain tumour. A cough could be pneumonia.
n the pre-clinical years of Medical School we study the basic body systems: Respiratory, Cardiovascular, Neurological & Digestive. And in these years, I have been utterly convinced that I have had horrific diseases. Respiratory, Cardiovascular, Neurological and Digestive diseases. Luckily for me, I was wrong and I am still alive to tell the tale. The disease which I actually have contracted is Medical Student Syndrome. Medical Student Syndrome is a phenomenon striking fear in the hearts of medical students worldwide. It is a form of Hypochondriasis or Nosophobia (an irrational fear of contracting a disease). Once afflicted with this syndrome, students believe that they are suffering with the diseases that they are studying. They may notice a benign twitch or pain and perceive it as a life threatening symptom and sign of impending doom. A mole could be skin cancer. A headache could be a brain tumour. A cough could be pneumonia. Doctors and medical students are trained to be so observant of Secondly, stopping reading media scare stories on how deaths signs and symptoms in patients but, in my experience, this has led could be avoided if symptoms were detected earlier is definitely a to ‘oversurveillance’ of my own ‘symptoms’. Once I think I have good way of escaping the syndrome! noticed something unusual, I keep on noticing it. In the Autumn, Thirdly, know that the more you stress, the worse it seems. I noticed my legs and arms twitching when trying to sleep… Was Especially around exam time! I’ve found that relaxing and taking it benign? Was it just in my head? Or was it something worse…? time away from Medicine to spend time with family or friends Thankfully, my patient GP reassured me that I shouldn’t worand get back to the real world helps to put things in perspective. ry and that it was just another flare up of Medical Student SynHowever, the best thing to do is to see a medical professional to drome. Which was a relief! rule out anything sinister and put the mind at rest. And if it is just Medical Student Syndrome is a source of many jokes among Medical Student Syndrome, they usually say they suffered from it medical students and is often seen as humorous. However, accordtoo and that it diminished with time! Here’s hoping, but for now I ing to the University of Buckingham, 70-80% of us experience it am just thankful for narrowly escaping so many diseases! at some point in our studies. So how can we cope with or avoid it? Apart from this, my Second Year at Medical School is going Here are some top tips! well, although I am eagerly awaitFirstly, being aware that learning the third year when we ing about hundreds of illnesses start the hospital placein a short period of time unments! However, with der immense pressure is very this new term comes likely to lead you to believe new diseases to pothat you have one of them. tentially knock Thinking rationally will me down… So, help to avoid this. So inyour tips on how stead of diagnosing myself to avoid Mediwith Hypothyroidism due cal Student Synto lack of energy, I’ll redrome tweetCarla Barberio dreams of being a doctor. We member that Medical Stued to @juniordr were all there once; struggling with exams, dent Syndrome and the would be greatly fact that I didn’t go to bed appreciated! trying to perfect UCAS forms and longing to early enough are probably swing a stethoscope around our necks. We’ve the explanation.
been following Carla since sixth form and in this column she contracts the dreaded ‘medical student syndrome’.
Writing in the Notes Demand versus
ture of Dear Editor, last issue (The Fu the ur yo in l ria ito The ed ) laboured on UK; Iss 32; p3 ringly low. Doctors in the morale is stagge or ct do or ni ju on the sitfact that don’t see any reas I t bu ue tr be no driver That may ere is currently th as ge an ch ill gret their uation w e doctors may re m so le hi W it. , there’s no to make medical school to y pl ap to at elusive decision ing up to seek th eu qu le op pe of doctors dries shortage s the supply of es nl U e. ac pl the 1990s, training industry did in ng hi ac te e th rrect the up, like any reason to co be to g in go t g a doctor there’s no e appeal of bein th ar fe I y dl sa ime soon. wrongs is to happen anyt th r fo ng ro st o O is just to ERPOOLORTH LIV
.CO VIA JUNIORDR
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:
Box of tissues
NAME WITHHELD VIA JUNIORDR.COM COM MENTS
BMA pay bungle Dear Editor, ng the governMA condemni d The irony of B B (Doctors an ving the DDR gi t ed no fe r fo to t ity en m rtun Body) the oppo Dentists Review MA condemns (B y pa on decision into next year’s Iss 32; p4) whilst e year ‘pay cut’; sixth consecutiv bers feed into own BMA mem rdian.com/ not letting it’s egua y (http://www.th their board’s pa ion-secret-payun sor ct do 7/ /0 un /j society/2015 t lost on us! hikes-bma) is no JIJ1979 .CO VIA JUNIORDR
‘Writing in the notes’ is our regular letters section. Email us at email@example.com.
St Thomas’ Hospital, London
Prices not to be sneezed at,
80p Bottle of water
Quantity not quality Dear Editor, The article ‘Half of junior doctors have concerns about quality of care’ (Iss 32; p4) focuses on fears over the quality of jun ior doctor care being delivered. There’s a bigger problem which seldom gets discussed - the quant ity of care. In my job I’ve had to accept that I’ll never be able to deliver the quality of care I wo uld like, so the decision is what’s acceptable to meet the quantity of the workload. Frequently I deliver a poor patient experience just so everyone gets the basic level of care - if I had to deliver a ‘service with a smile’ every time it would mean blood tests wouldn’t get done and real clinical care would suffer.
Expensive enough to weep at,
Ayrshire Central Hospital, London
You may want to collect rainwater at,
King’s College Hospital
Makes your recommended 1.6l affordable at,
60p Jacket potato with cheese
Salisbury District Hospital
Maybe just stick to butter at,
St Thomas’ Hospital, London
Say cheese at,
Newham General Hospital
Next issue we’re checking the cost of a ballpoint pen, KitKat (45g) and a pint of milk. Email prices to firstname.lastname@example.org
TRAFFORD GENERAL HOSPITAL, MANCHESTER The Mess has a newly decorated lounge, which includes a television and snooker table. Adjacent to the mess, a quiet area for study is available with PC, printer and Medline Search facility and CD-ROM texts (a laptop and CD-ROM can also be borrowed). The doctors also have their own dining area where Barbara the waitress serves breakfast and lunch. In the restaurant foyer vending machines sell snacks, drinks and chilled foods. The latter may be reheated in the adjacent microwave ovens.
JuniorDr Score: ★★III
THE MEDICAL COURSE AND CONFERENCE DIRECTORY
s doctors we hate scouring the web to find where and when we can attend the next exam revision course, training event or conference.
We think they should all be in one place - which is why we launched EventsDr. com as part of the JuniorDr network.
We’re aiming to build the most comprehensive database of medical events. Below you’ll find just a selection of the full listings at EventsDr.com.
MRCP Part 1
Number 1 for Medical Interviews & Applications Courses in small groups for a more personal approach We offer a range of medical interview courses and services to optimise your chances of success at medical interviews
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GOT AN EVENT TO ADD?
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MRCPCH IMPERIAL COLLEGE
Gantz’s Manual of Clinical Problems in Infectious Diseases, 6e Myers, Moorman & Salgado November 2012
Fri 17 JULY
656 pp • 8 illus. & 207 tables Paperback
PSYCHIATRY MRCPsych SUPEREGO CAFE
Handbook of Nephrology Leehey & Moinuddin March 2013
Management and leadership skills
234 pp • 72 illus. & 30 tables
Pocket Medicine, 4e Sabatine August 2013
SCOTTISH MEDICAL CAREERS FAIR
ISBN: 978-1-4511-8887-5 280 pp • 92 illus. Paperback
Available from www.lww.co.uk
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MORE THAN DEFENCE FOR DOCTORS IN TRAINING Medical Protection is the world’s leading provider of professional protection for doctors. We’re here to support you through the challenges of your career.
Rachel Eyre, foundation doctor
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Make the most of your membership or join us now… Visit: www.medicalprotection.org/uk/join-mps
The Medical Protection Society Limited (MPS) is a company limited by guarantee, registered in England with company number No. 36142 at 33 Cavendish Square, London, W1G 0PS. 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. ‘Medical Protection’ is a trading name of MPS.
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