Medical Woman – Vol 37, Issue 1, Spring/Summer 2018

W EDICAL W MAN

VOLUME 37: ISSUE 1

SPRING/SUMMER 2018

The Flexible Issue www.medicalwomensfederation.org.uk

Editor’s Letter

To women designing the future

I

t is both a pleasure and a privilege to have joined the Medical Women’s Federation as Editor– In–Chief of Medical Woman. The organisation is at a pivotal point following our centenary celebrations. Already, I have been witness to some interesting discussions, progressive steps, and have met inspirational and talented women who are focused on furthering the interests of women in medicine. For you, I hope this edition of Medical Woman reflects all of this.

By way of introduction, I am a Neurology registrar training flexibly in London. I have a creative streak which I hope will tickle your fancy as you read this first issue.

When I finished university I thought I was prepared for life as a doctor, and life full-stop. Instead, I learnt how life really unfolds with all sorts of unexpected surprises. As I contemplate the future, one of my more recent challenges has been to find a female mentor that I can be inspired by and connect with on both a personal and professional level. Reflecting on this, I realised what a diverse group women in medicine truly are, and how different our needs are in meeting like-minded women. My vision of Medical Woman is one of inclusiveness; representing and appealing to a wide range of medical women, and responsiveness. With all this in mind, this issue of Medical Woman sees contributions from women of diverse backgrounds with varied careers, and covers key issues of balancing professional as well as personal commitments, and building resilience.

With this issue we reach further. Our author range is diverse with women as well as men from varying professions. You will read interesting perspectives and insights from allied health professionals and contributors from outside of the medical field. As healthcare professionals we play on a global field, and in this issue you will sample that as well.

Diversity is enrichment. As reader your journey will begin with inspiring insights from successful women. Professor Gita Ramdharry discusses her steps through a clinical-academic career in physiotherapy. International medical graduates, Dr Farah Jameel and Dr Leila Mebarek provide expertise on negotiation and mentorship. Dr Ngozi Atulomah provides a balanced account of a career in Psychiatry – for A-level students, medical students and beyond – anyone, really, who may be envisaging a career in psychiatry.

This issue is a great reference. Whether a trainer looking to advise or a trainee looking for an accessible resource, dedicated articles on presentation skills and mentorship are geared to help you in your everyday career. In upcoming editions you will read articles on poster making and successful audit.

We cover topical issues. Flexible training is an emerging hot topic and the Medical Women’s Federation believes in supporting flexible trainees to reach the best of their potential throughout their careers. In this key feature we connect with the British Medical Association to deliver the latest state of affairs, alongside personal insights on the trials and tribulations of working flexibly – amusing and, at times, mortifying. These articles cover the realities of working in the current climate, and additionally bridge into the concepts of resilience and bullying. We have dedicated articles on both, in the current issue and up-coming, and I hope they will provide you with information to strengthen you and your practice on a daily basis.

We are interested in connecting with organisations. Mental health is a critical area, and an area that I have much to learn about.

Ellen White, an aspiring student nurse, provides a personal insight into her journey with obsessive compulsive disorder (OCD). Olivia Bamber from OCD Action provides helpful information on resources available to people with OCD. To complete this informative triad, The Secret Illness presents an artistic vision of how symptoms can be expressed through creative means. Our Mind Matters section also includes an extract, ‘Calling Time’, from the recently published Lost and Found, providing a touching insight into the loss of mind and the notion of human identity.

Our vision is national and international. Arthy Hartwell demonstrates that while we may have access to fair-trade chocolate, clothes and coffee; a vast majority of medical supplies in the NHS do not come from as ethical or fair sources. Reflect for a moment on the earth as a closed habitat and the see-saw of life; this leads you to the notion that our actions and interactions impact each other in one way or another.

Lastly, Dr Sarah Matthews wraps up with her book review on Stephen McGann’s ‘Flesh and Blood: A History of My Family in Seven Maladies’, bringing this issue full circle with her reflections on diversity, immigration and the progress that comes with time.

I look forward to sharing all this and more with you, and I hope you will share Medical Woman with all of your colleagues.

Find my contact details below to get in touch, and I look forward to meeting you at the MWF Spring Conference in Cardiff.

Fizzah Ali @DrFizzah Fizzahali.editoratmwf@gmail.com

Contents Medical Woman, membership magazine of the Medical Women’s Federation

News and Events

2

Stepping into academia

3

Career planning: Psychiatry

4

Leading a field

5

Skills workshop: Polished presenting

6

Medical Mentorship

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Editor-in-Chief: Dr Fizzah Ali fizzahali.editoratmwf@gmail.com Editorial Assistants: Mr Thulani Mutopo Miss Kimberly Murrell Medical Women’s Federation

The flexible life

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Training: The case for LTFT

10

Flexible perspectives

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The transition to parenthood

16

www.facebook.com/MedWomen

100 years of medical women

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Patron:

Combat burnout: Resilience

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Reaching out: taking action

22

Professor Dame Parveen Kumar DBE

Breaking barriers and rituals

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President-Elect:

Mental health: A Secret Illness

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Calling time

25

Dr Olwen Williams OBE

Cervical cancer: living well

26

Honorary Secretary:

Labour: the hidden trauma

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Healthcare: Human costs

30

Dr Heidi Mounsey

Forever starts today

32

Design & Production:

Obituary

34

www.magazineproduction.com

Book review

36

Cover illustration:

Finding time

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Tavistock House North, Tavistock Square, London WC1H 9HX Tel: 020 7387 7765 E-mail: admin.mwf@btconnect.com www.medicalwomensfederation.org.uk @medicalwomenuk

HRH The Duchess of Gloucester GCVO President:

Dr Henrietta Bowden-Jones

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10

20

Vice-President:

Dr Clare Gerada MBE Honorary Treasurer:

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The Magazine Production Company

Veronique Chignard Registered charity: 261820

Medical Woman: © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the prior written consent of the Publisher. A reprint service is available. Great care is taken to ensure accuracy in the preparation of this publication, but Medical Woman cannot be held responsible for its content. The views expressed are those of the contributors and not necessarily those of the Publisher.

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MWF NEWS & EVENTS

Edinburgh University Group Report It has been an extremely successful year for the Edinburgh University Student Committee. The committee was formed in September 2017 as a result of the huge amount of interest expressed after the ‘How to have your cake and eat it’ centenary celebration, May 2017. Three wonderful doctors shared how they have managed to balance their careers and pursue other interests, such as travelling, research, hobbies and having a family.

The committee is comprised of 13 students from years 1-6 of medicine. We meet once every two months to discuss events to host and how to inspire and empower other female medical students. We have hosted two events since setting up the committee.

In November 2017, we had an event to promote awareness and educate medical students about female genital mutilation (FGM), with two speakers – obstetrician Dr Carolyn Ford and Bethel Tadesse, a student who

has set up the Hidden Scars Project, a charity that raises awareness of FGM. In February 2018, we hosted a ‘Galentine’s Night’ (the day before Valentine’s Day where we celebrate the women in our lives) speed dating evening. We had 19 doctors from 15 different specialties. The evening consisted of a talk from Dr Tracey Gillies, Medical Director for NHS Lothian, and 14 rounds of speed dating – an amazing opportunity to publicise the huge number of female role models in medicine and providing the chance to learn a little bit more about each specialty.

We are planning our final event of the year which will be a ‘History of Women in Medicine’ event. All of our events have attracted over 40 attendees and we have had some lovely feedback from our peers. We love being part of the MWF, and feeling like a small part of the big move towards gender equality in medicine. Izzy Utting

East Midlands Local Group Report Following our Annual General Meeting in January, we enjoyed a summer lunch hosted by Sue Ward in her garden. This was followed by a meeting hosted

by Jo Jones, on hearing from two of the three successful applicants for elective bursaries from our medical schools. They had contrasting electives, Rebecca in South Africa and Kenya working with street children and HIV patients, and Sara learning surgical neuroanatomy in a lab in New York.

Both described experiencing a ‘culture shock’ and talked about what they had learned during their time abroad.

We spent some time planning an event to celebrate MWF’s Centenary, such that in October 2017, around 30 members and guests met in Nottingham for a tapas meal, socialising and then listening to Anthea Mowat talk about leadership and how she came to be elected the Chair of the BMA Representative Body. She encouraged younger members of the profession to overcome the common “I can’t do that” response, asking instead “why not me?”, and to take up opportunities that come along.

Students in Nottingham, led by representative Rose Soame, have had an active time. They have been involved in organising a surgical careers evening with the Nottingham Surgical Society (SCRUBS) in February 2017. In September, they had a meeting about student opinions on gender equality in medicine to mark the centenary of MWF. In December a meeting on alternative careers in medicine was arranged, reported in the January 2018 MWF newsletter.

I would like to thank local group members who have once again supported our meetings. In particular, Ann Howard who stepped down as local Treasurer after many years and who was a generous host of our Annual General Meetings for several of years, and Sue Ward who continues to be a dynamic and supportive member. Dr Yin Ng 2 Medical Woman | Spring/Summer 2018

DATES FOR YOUR DIARY May 11th 2018 MWF Spring Conference, ‘Women and Health: Aiming for the Wellbeing of Women Doctors and their Patients”, MWF AGM and Council Meeting June 2018 MWF Junior Doctor Prize opens September 6-8th 2018 8th Central Asia Regional Meeting of MWIA in Bangkok, Thailand October 2018 MWF Elective Bursary opens October 2018 3 months extra free MWF membership promotion November 2018 MWF November Conference details TBC December 2018 Katherine Branson Student Essay Prize opens July 25-28th 2019 MWIA Centennial Congress to be held in New York

CAREER SNAPSHOT

Stepping into academia: when curiosity meets enthusiasm Gita Ramdharry is an Associate Professor at St George’s University and Director of Research at the School of Allied Health, Midwifery and Social Care at Kingston University. She trained as a physiotherapist and subsequently specialised in Neurology. Her interests include the management of neuromuscular diseases, orthotics in neurological conditions, analysis of walking and running as well as functional and laboratory measurements of balance and postural stability.

I am a rare breed of clinical academic physiotherapist and took a circuitous route to what I do today. I was born in the UK of mixed heritage. My parents are nurses by profession, my father from Mauritius and my mother from Ireland. I spent a lot of my childhood around hospitals, so that environment plus a love of sport, pointed me towards physiotherapy.

My pre-registration training was at the University of East London, one of the first universities to offer Physiotherapy as a four-year degree course in the early 1990s. After qualifying in 1995, I worked in a number of London teaching hospitals. Early on in my career, I expected to specialise in sports injuries, but I grew to love neurology through working at excellent neuroscience centres. My fascination with neurophysiology coincided with a really important time in neuro-rehabilitation with evidence emerging on how therapists could influence motor recovery and neuro-plastic processes.

In 2001 I went to the National Hospital for Neurology and Neurosurgery, Queen Square, and I’ve never quite left! I was a full time clinical physiotherapist and studied for my Masters at the same time. I started to encounter people with rare neurological conditions, and quickly realised that the evidence for rehabilitation and physical management was almost non-existent. At the same time, I began to collaborate with scientists at University College London (UCL) working in the human movement laboratory. I developed an interest in 3D kinetic and kinematic analysis of balance and gait, using these techniques for my MSc dissertation, assessing the effects of contoured insoles in people with multiple sclerosis.

One of my colleagues in the lab was awarded a Medical Research Council (MRC) Clinician Scientist fellowship that included funding for a research physiotherapist plus PhD fees. I applied for the position and started my PhD in late 2004. My thesis explored gait impairments and potential interventions for people with inherited peripheral neuropathy, or Charcot-Marie-Tooth disease (CMT).

Through the recruitment process, I developed a good relationship with the neuromuscular specialists and provided a physiotherapy service to one of the multidisciplinary clinics.

I completed my thesis in 2007 and decided that returning to a clinical job would probably prove challenging for continued research. I took up a senior lecturer position at the joint faculty at St George’s University of London and Kingston University. My main work was undergraduate teaching, but I was also encouraged to apply for research grants. I kept my links with the Queen Square neuromuscular team and we were awarded a charity grant to undertake an exercise trial in CMT. Later I was awarded one of the newly launched National Institute for Health Research (NIHR) Clinical Lectureships, a fellowship for Allied Health Professionals,

“The rejections make the successes so much sweeter” nurses and midwives. This allowed me to continue to develop clinically at the new MRC Centre for Neuromuscular Diseases, set up a small motion analysis lab at the centre and still teach at St. George’s. Closer working with the centre led to NIHR Research for Patient Benefit grant and other charity grants. I was becoming a principle investigator.

I am now an Associate Professor and Director of Research at the School of Allied Health, Midwifery and Social Care at St. George’s/ Kingston University. My research is still primarily undertaken at Queen Square, and after my fellowship, I was able to negotiate an ongoing clinical day there. This diversity in my role now means I am a true clinical academic physiotherapist, a much rarer model than in other professions, such as medicine.

Research was a draw for me early on as I was continually questioning the theoretical basis for physiotherapy interventions. The catalyst was working at Queen Square, where clinicians and academics work alongside each other, or are in split posts. The scientists were very interested in the clinical questions I had, and that was how the idea for my master’s research became a reality. The career pathway for Allied Health Professionals in the early noughties did not really include research, so I had to grab opportunities along the way. I was fuelled by intellectual curiosity and enthusiasm, so was determined to find ways get projects off the ground. The NIHR clinical academic training route is now more available and is a fantastic opportunity to develop future research leaders. The fellowship opened doors for me and I would encourage others to find out more about them and apply.

Good mentorship is vital plus collaboration with colleagues with differing areas of expertise. Mentors who have worked in research can help you to plan your careers and prioritise opportunities. I have learned not to be precious about my ideas, as others can develop them with you. There is a lot of rejection in research, so developing a thick skin, and using feedback to improve papers and grants is an absolute must. The rejections make the successes so much sweeter!

Medical Woman | Spring/Summer 2018 3

CAREER PLANNING: PSYCHIATRY

Mind matters: a day in the life of a psychiatrist Ngozi Atulomah is a British-Nigerian from Nottingham who studied medicine at Kings College, London.

Ngozi originally moved to Manchester for Foundation Training, and is currently a ST5 in General Adult Psychiatry. She lives with her partner, and for pleasure she prints fabric, she also designs and sews clothing and soft furnishings.

Can you tell us a bit about yourself?

I am a ST5 in General Adult Psychiatry. Originally, I studied medicine at Kings College London and then moved to Manchester for Foundation Training and have worked here for the last 7 years.

Why did you decide to do Psychiatry?

At King’s College, perhaps because of being close to the Institute of Psychiatry, we had extensive medical student attachments in psychiatry. I was impressed by how psychiatrists used skills such as body language and active listening to engage patients, students and colleagues. I wanted to acquire these skills; and that’s when and why I decided to pursue a career in psychiatry. After my 4th year at medical school I decided to intercalate in Psychological Medicine at the University of Birmingham. There, I was able to design and conduct my own original research about patients’ and families’ appraisal of their illness after a first episode of psychosis, and how ethnicity and culture affected that. During this period, I realised that because of the complexity of the mind and newness of psychiatry as a specialty, our current knowledge is only the tip of the iceberg. I could see that in choosing psychiatry I would likely witness some astounding breakthroughs in the field during my career, and that was an exciting prospect.

Describe a typical day as a Psychiatry registrar?

There are many sub-specialties; Child Psychiatry, Substance Misuse, Later Life, Forensics, Medical Psychotherapy, Neuropsychiatry and Perinatal to name just a few. A typical day varies depending on what area you work in.

I am doing a year in Early Intervention Psychiatry, a service for people in the early stages of psychosis. A typical day starts with a multidisciplinary meeting with nurses, social workers and occupational therapists; we discuss high-risk patients in their case load in the community and on inpatient wards. I usually have a clinic, often with home visits. I finish the day by documenting, and usually finish on time. I also have two sessions per week to develop a special interest.

I was previously doing research, and now I am learning about family therapy and also do an eating disorders clinic.

What do you enjoy most about training in Psychiatry?

Psychological and social wellbeing is intrinsically valued in modern psychiatry. By virtue, there is more space for trainees to pursue their personal, as well as professional growth, compared to many other specialties. There is flexibility within your timetable and protected sessions for professional development. The one hour weekly supervision with your consultant is well respected and pretty 4 Medical Woman | Spring/Summer 2018

much universally adhered to. Breaks in training for professional development, extra-curricular interests and family are encouraged.

There are opportunities to do international humanitarian work, which are integrated into the training program. I recently completed a Masters (MSc) in Psychiatry, which was partly integrated into the training program and then I took a year out of my training to complete it.

I also enjoy the proficiency I have developed for understanding human emotion. Obviously invaluable for a psychiatrist, it is also a highly transferable skill. Through my training I have noticed an improvement in my personal relationships, I think this is due to the acquired greater emotional intelligence.

What are the challenges in your chosen career path?

Treatment of psychiatric disorders can be difficult. Converse to some beliefs, psychotropic medication has good efficacy and response rates; symptoms do often resolve, particularly in psychosis.

Nevertheless, other things in people’s lives, like their social situation or medication compliance can affect longer term recovery. This is difficult, as it is not something as a doctor you have as much influence over.

The biggest challenge in psychiatry is the stigma associated with mental illness. Although this is fast changing, there are still misconceptions about mental health and psychiatry in the wider society and within medicine. Patients often struggle to accept their diagnosis, and they can be discriminated against, affecting access to some services. Professionals in various fields sometimes struggle to conceptualise mental illnesses accurately.

Furthermore, the stigma associated with mental illness often impacts both psychiatrists and other mental health workers. We are sometimes considered as ‘weird’, and our specialist knowledge may not always be viewed with the same respect as that of doctors or nurses in other specialties. Fortunately, there has been progression towards parity of esteem between mental and physical health, largely assisted by the growing societal awareness around mental health issues. I am therefore optimistic that this will not be the case in future.

What advice would you give medical students and trainees deciding on their future specialty?

Do what you love. Whether it is surgery or psychiatry you enjoy, go for it and do not be put off by other people’s opinions. Every field has challenges; your passion will help you get through them. If you are not sure what to do, do not be afraid to take time to explore different options.

SKILLS MENTOR: NEGOTIATION AND LEADERSHIP

Leading a field: advice from a negotiator Farah Jameel is an international medical graduate and GP in London. She is a GP appraiser and a member of the GPC England executive team, through which she has been involved in contract negotiation and representing the views of GP’s on a variety of critical issues. Farah is also chair of Camden Local Medical Committee. She is absolutely petrified of horror movies.

Challenges and transitions It has been 11 years since my journey within the NHS began, a bit like the board game ‘snakes and ladders’, the journey has been a tortuous one. Daunting at the time, I always knew I wanted to come to the UK for postgraduate training because of the high standards and opportunities here. I am also a strong believer in the principles and founding values of the NHS. The concept of accessible healthcare, free at the point of need.

Cultural norms vary between ethnic groups within countries, and this can pose a challenge. In some countries the style of consultation is doctor-centred with much emphasis and respect being placed on the words of the doctor. Coming from a country where the doctor is worshipped, at times, I struggled with the perceived lack of respect for doctors.

Language was also an unexpected challenge. Over time, I have come to understand and value the subtlety of the English language – both written and spoken – along with the variety of meaning, nuance, tone and pitch can bring.

Without friends and family at hand, relocating from a different country can leave one feeling isolated and lonely. We all adjust to situations differently and I feel my easy going nature helped ease my transition from one country to the next, somewhat. As a busy young trainee in a new environment, I saw myself as just another cog in the wheel and kept my head down. There was no time to reflect on awkward responses or unsavoury experiences; yet over time you learn that certain situations are not tolerable.

Inspiration Over the years, I have been inspired by many colleagues, and their quest to do and be more, which has been infectious.

Remember, the world is your oyster, so do not let others’ perception of you define or limit who you become. You can be and do anything you set your mind to. Surround yourself with positive people who encourage you and push you forward. Equip yourself with the tools necessary to develop your whole self. If you are in two minds about applying for a position or a job, put yourself forward – now is always the right time. Skill sets can be developed and honed along the way. I have attended a number of courses over the years, many in my own time, watched TED talks on YouTube, attended talks, listened to speeches, read voraciously, and noted memorable quotes and exchanges. Reflective learning is continuous and lifelong.

Key qualities £

ardwork and discipline: Instill discipline as well as an inner H yearning to do and be more. Discipline is key to being a good leader; it helps focus your mind and enables you to deliver results, which is ultimately what you will be judged on. Be results driven and never lose sight of that.

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tay true to your values: Stand up for what is right, question S authority and put your head above the parapet if something does not fit right with your moral compass.

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L earn to say yes: We are constantly surrounded by opportunities, and what I frequently see is colleagues saying no. They fail to arrive, and fail to put themselves forward when an opportunity presents itself. Perhaps this is because of a lack of self-belief? Or perhaps it is because there is no one to encourage them. Have an open mind, say yes to opportunities.

Apply your energy and passion in areas of interest. This will open doors, and when that door opens – go forth and be ready to conquer.

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he role of sponsors: My husband, my parents, a number T of colleagues gave me the encouragement to achieve my full potential. They actively sought out opportunities, placed them in front of me and suggested I apply. This never-ending encouragement, support and belief in me, was crucial. I was surrounded by numerous possibilities I had never previously considered or appreciated.

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emember the reason why you went into medicine. It is R easy to lose sight of those core values which led you onto the journey you are on now. If you are feeling lost, stop and ask for support.

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e kind, supportive and make time for the important B things. As you grow in your career and your diary fills up, prioritise the people that matter and stay connected with them.

Encourage, support and empower the people you come into contact with. We rise up together.

Each role will bring with it a new niche area that you will develop in to overtime. You will find that, in time, you will employ all the skills that you have accumulated over the years. It is as if everything you have ever done in your life, every interaction, every step you have subconsciously taken, was to prepare you for this role.

So go for it, now, don’t hold yourself back.

Medical Woman | Spring/Summer 2018 5

SKILLS TOOLKIT: PRESENTING

Acting up: the art of polished presenting Lindsay Richardson is a professional classically-trained singer and actor, who co-ordinates the work of the Giles Foreman Centre for Acting in London. She teaches workshops and courses for aspiring actors, as well as coaching performers, private clients and public figures for individual projects.

6 Medical Woman | Spring/Summer 2018

SKILLS TOOLKIT: PRESENTING

At the Giles Foreman Centre for Acting (GFCA), we utilise a system of teaching methods within Realism to help actors bring greater truthfulness and connection into their work. We are one of the very few centres in the world providing detailed training courses in the extraordinary Laban/Jungian technique of Character Analysis / Movement Psychology developed by Yat Malmgren, to develop people’s psychological understanding both of themselves and the characters they are asked to play.

All doctors have to present to some extent; from the local level right through to high-level international presentations. This article offers some tips for delivering effective presentations, and particularly for those who may never have thought about needing this skill. The focus is on making the experience more comfortable, and the result more successful.

Preparation is key, if you want to make an unfamiliar situation work for you. Many people, even actors used to being in the public eye, experience tension at the prospect of speaking in front of a specialised audience, who might be scrutinising not just the content, but the delivery of their words. Once you have put work into the quality of the material that you are presenting, there are a number of strategies to help you deliver on the day, in order to maximise impact.

Setting the stage Firstly, choose a comfortable but structured outfit to wear, so you can move, sit and stand easily – avoid too much visual detailing so that nothing distracts from your message. If you can, take time to check out the presentation space beforehand, even if you already know it as a spectator. Look at the lighting; often, down-lights only provide pools of brightness, and fluorescents can be stark. Consider the following: can you be seen, can you see your notes, and can you easily see people in your audience from different positions? Check the acoustics from different points; temporary staging can be quite noisy to walk on, so it is worth trying it out, in case you decide to move about during your presentation.

If there is a fixed podium, it can be tempting to use it as an anchor – but do not get locked behind it, or it can become a barrier between you and the audience. If there is one, the fixed podium-mic can be adjusted to your height, and this is best done before the audience comes in. Usually it will be reactive to sound-levels, so do not be tempted to lean towards it when you speak. Alternatively, if you are going to be seated, try out the furniture so that you feel confident during your presentation. Keep an open body posture, with some energy in your core abdominal muscles and spine.

Try not to yield completely to the chair – especially if it is cushioned and comfortable! This is particularly important if you are going to be filmed. In which case, always check how close-up the framing is going to be, and adjust the scale and speed of your movements so you are not surprised by the filmed ‘you’ when you see the video afterwards.

Preparing to project well If you are going to wear a clip-on mic, adjust it and test the level so you are not hampered by it. If not, experiment with speaking with different dynamic ranges, in order to reach each corner of the space with your voice, and even a little bit beyond – definitely best done when you are alone! A vocal warm-up will help you check-in with how your voice is working. Any open, sustained sound will help (such as ‘haaah-heyyy’) cycling through a sliding range of pitches starting from the middle of your voice. Focus on connecting down to the lower resonance, rather than allowing it to rise up to the higher end. Shake out tension from shoulders, hips, arms, hands, and aim to centre your breathing lower in the body by focusing on it, to ground yourself.

Taking centre stage All of the above will help, before the audience arrives – then, as people walk in, you have the time to absorb a lot of information about them. Who is in this group? There will always be some who will give you support with eye-contact, maybe an affirmative nod – they are useful to send your key points out towards, while not ignoring the less demonstrative individuals.

As you speak, be aware of using your breath to support your sound; continue to monitor the dynamic of your audience to make sure you are reaching everyone comfortably, and make use of the room’s acoustic.

Women under the lens Are there particular aspects for women to be aware of? Maybe is the answer. You may want to acknowledge that if your vocal pitch rises, it might allow certain people to undervalue what you are saying, because it may sound lighter – so, employ a mid-to-lower pitch range, within your comfort zone. Likewise, using a measured speaking tempo will maintain your right to present your material assertively, with dynamic emphasis where needed. Where you can, enjoy the use of silence too, as it can be very effective to hold or capture attention at a key point.

Effective strategies for a polished performance Give yourself time for preparation Check out the presentation-space beforehand Allow yourself a vocal warm-up and a physical ‘energise’ Utilise the acoustics and make the room work for you Check the technology – whether microphone, PowerPoint, or video Remember that your audience are all individuals Ground the voice – breath, support, and dynamic range are all key concepts Use silence effectively Have an awareness of pitch, range, assertion and eye contact Medical Woman | Spring/Summer 2018 7

SKILLS TOOLKIT: MENTORSHIP

Medical Mentorship: seeking direction and scaling the heights Leila Mebarek is a Core Medical Trainee at Bedford Hospital. She has completed a Masters in Gastroenterology and is an educational representative in the East of England. She qualified in Algeria, moving to London in 2011. Leila enjoys holidays, all sorts of adventures and good food.

Taking steps to find the right compass Mentoring has been defined as a ‘dynamic process where an experienced professional (the mentor) guides and relays his experience to a less professionally experienced individual (the mentee)’.1 Unlike supervision, mentoring is a trainee-centred and trainee driven process.2,3 Undertaken properly it is an effective educational medium that enhances career and personal development.4 My experiences of mentorship begin with a tale of travel, and I journey along with the prospect of further growth.

I left Algeria for London in 2011 to be closer to my husband. I resigned from a highly competitive post as a junior doctor in a teaching hospital within the capital of Algiers, and spent my first year in London acclimatising to life in a foreign city. I still longed to have a career of my own and by then had developed an interest in gastroenterology. I first pursued a Masters in Gastroenterology at Queen Mary University of London and then sat the PLAB exams.

In 2014, I got my first job in the UK as a trust senior house officer (SHO) in Queen’s Hospital, Romford. It was a new experience for me and I needed help in understanding postgraduate medical training in the UK. In 2015, I joined the Royal College of Physicians mentoring programme to seek guidance on entering formal medical training, 8 Medical Woman | Spring/Summer 2018

with the aim of achieving my ambition to become an academic gastroenterologist. As part of the scheme, mentees choose their mentors based on their online mentor profiles. It was through this platform that I was introduced to my mentor. At first, I was more inclined to choose a female mentor because I thought I would have more in common with someone of the same gender. However, after much deliberation, I selected John Ong because we shared similar backgrounds; both of us were foreign nationals working in the NHS and both of us were interested in academic gastroenterology.

John is from Singapore but obtained his medical degree in the UK. At the time he was a gastroenterology registrar in training, and a National Institute of Health Research funded clinical research training fellow seconded to Stanford University.

Our mentor-mentee relationship started off well. John preferred a relaxed approach to our interactions which made it very easy for me to talk to him openly. In the early stages of the mentoring process, it became clear that although I had clear aspirations, I had preoccupied myself with too much and not made significant efforts to achieve objectives that were relevant and important to me. I was encouraged to reflect, prioritise, plan and approach things in a logical and realistic fashion. To my surprise the mentoring process was very interactive, I was challenged to troubleshoot and

SKILLS TOOLKIT: MENTORSHIP Dr John Ong is a ST6 in Gastroenterology in the East of England and a W D Armstrong Doctoral Fellow in Tissue Engineering at the University of Cambridge. He has been mentoring since 2012. Outside of work he enjoys trekking.

A symbiotic process of personal growth Mentoring has been both a privilege and a pleasure. As trainees we sometimes know what we want to achieve, and all that is lacking is the confidence and mechanisms to do so. With positive reinforcement, career guidance and a few lessons on strategic management and planning, a trainee can really break out of his/her shell and find their stride. From a mentor’s perspective, seeing this process bear fruit provides an immense sense of pride and satisfaction. This experience has honed my skills as a mentor, made me a better colleague as well as giving me more confidence to help empower other mentees. I would strongly encourage senior clinicians to become mentors, as it is a rewarding and fulfilling experience.

create my own mechanisms to achieve my objectives. The process made me look inwards and appreciate my own innate abilities and shortcomings. As a result, I have become more independent and proactive in my clinical practice. After experiencing the undertones of being an international medical graduate, perhaps one of the most important outcomes is the realisation and self confidence that I am just as proficient as any other UK trainee.

A testament to our success, are my serial achievements, firstly in joining Core Medical Training in 2016, completion of the full MRCP, and lastly, a national poster presentation. In hindsight, gender differences were never an issue in our mentor-mentee relationship. Our mentoring relationship continues to this day and we are currently working on a publication together. Since it began, this journey has been a great experience and I believe that the key to success has been the open and honest communication that we share. It never felt imposed or time consuming, and I am grateful for the dedicated guidance and support from a mentor who is genuinely eager for me to succeed.

My personal view is that mentorship is crucial in all stages of medical education, but unfortunately, often underrated or neglected.

A mentor is much like a mirror and compass, a supervisor is rather like someone making sure you tick all the boxes. In my case, mentoring has helped to shape and define the person, as well as the doctor, that I will be in the years to come. I would advise all trainees to be open-minded and explore mentorship. Choose a mentor with common ground so advice can be useful and make it easier to break the ice. Being passionate about the same subjects makes the relationship more fruitful.

References F rei E, Stamm M, Buddeberg-Fischer B. Mentoring programs for medical students a review of the PubMed literature 2000-2008. BMC Med Educ. 2010:30;10:32.

2 Taherian K, Shekarchian M. Mentoring for doctors. Do its benefits outweigh its disadvantages? Med Teach. 2008;30:95-99.

3 Ackroyd R, Adamson KA. Mentoring for new consultants. J R Coll Physicians Edinb.

2015;45:143–7.

4 Straus SE, Chatur F, Taylor M. Issues in the Mentor–Mentee Relationship in Academic Medicine: A Qualitative Study. Academic Medicine 2009:;84:1.

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Medical Woman | Spring/Summer 2018 9

FEATURE: THE CASE FOR FLEXIBILITY

The flexible life Fizzah Ali is a flexible trainee in Neurology at the Royal Free Hospital, London. She is a representative on the less-than-full-time forum for the BMA. Outside of work Fizzah can be found in a yoga class, and she also enjoys life drawing.

In this issue we deal with flexibility in more ways than one; as you leaf through these pages you will soon share my extracurricular love affair with yoga. So, here is a picture of my rubber-band tutor – and I am flexible too, in more ways than one.

In this feature, with input from the BMA, we update you on the current state of flexible training, the exciting future possibilities and arguments for flexible training in medicine.

In my opinion, flexible training allows trainees to fulfil aspirations, their full potential, and carries the opportunity to diversify; all the while allowing a better work-life balance when and where it is needed. Less-than-full-time trainees are not ‘less’, on the contrary there is potential to be a good deal ‘more’.

The Medical Women’s Federation believes in supporting flexible trainees to reach the best of their potential throughout their careers. In a previous role, as an academic clinical fellow, I was presenting for the BMA on flexible training issues in clinicalacademic careers for a Walport symposium, and in workshops at consecutive annual Clinical Academic Trainees conferences.

More recently, I was part of a series of interviews, available on BMAtv Youtube, and presented at an engagement event in the Midlands. Despite feeling like a flexible veteran, an ‘old hand’, I learn something at these events from fellow trainees every time. Of course, it is interesting to hear a new opinion, a novel experience, but often, there is something important to learn from comments that arise consistently.

Perspectives on flexible training are changing, in this issue we provide a variety of insights based on personal experiences.

Each piece has a different tone, a fascinating insight into the successes and challenges as flexible trainees. The stories are all personal and give an insight to the human underneath the doctor – their possibilities, capabilities, career direction and personal preferences. Their experiences cover caring for children and relatives, caring for one’s own health and psychological well-being, as well as training flexibly in order to develop skills. As a current flexible trainee this will resonate with you.

Alternately if you are contemplating flexible training, it provides food for thought.

In the end, perhaps we should remember that doctors are individuals, and we should represent a profession that is just as diverse as our patients.

10 Medical Woman | Spring/Summer 2018

The case for flexibility Jeeves Wijesuriya is Chair of the BMA Junior Doctors Committee. He graduated from Barts and the London School of Medicine and Dentistry with MBBS and BSc in Medical Education. He is a GP trainee in east London and is completing a Masters in Medical Education.

In the NHS we find ourselves in the midst of a recruitment and retention crisis, with a shortage not just of beds, but of staff. Sadly we also hear reports of increasing levels of burnout amongst doctors who find themselves stretched to meet the demands of the service. The 2017 Doctors and Dentist Review Body1 identified that wanting a better work-life balance is becoming the new ‘normal’ for junior doctors, who will be working for more years than previous generations. For other public and private sector employees, and particularly NHS staff groups, part time working is normal and readily accepted. In this context it is even more peculiar that restrictions have been placed on training on a less-than-full-time (LTFT) basis, and that trainees struggle to access part time opportunities.

LTFT restrictions on working It is a long-held belief that a less-than–full-time trainee represents 50, 60 or even 80% of a ‘whole’ trainee. Yet, in the majority of cases, employers gain an additional trainee that they might not otherwise have at all. These are trainees who might otherwise have left the NHS to pursue other interests, provide care to sick relatives or children, or look after their own health. By thinking more creatively and flexibly about medical training, we are retaining the most valuable of ‘commodities’ – our trainees.

Flexibility in offering different working proportions could make less-than-full-time training even more attractive. This would potentially allow trainees to maximise their available time whilst also contributing maximum service to their employer, benefitting both. Similarly, flexibility to fix working days and on call commitments around predetermined caring commitments can be hugely helpful.

This makes the recent work we have done with the GMC and Health Education England (HEE) to remove restrictions on less-than-fulltime trainees doing additional work all the more important. There

FEATURE: THE CASE FOR FLEXIBILITY

has always been a regulatory barrier to trainees working beyond their agreed percentage, unless for exceptional reasons. The reality is, however, that the need to work flexibly is not static. A person with multiple sclerosis, or a mum of three, is not ‘50%’ for the duration of training. The realities of people’s lives go beyond percentages or slot shares: they are reflected in school holidays, term times and flare ups.

Often this provokes criticism that trainees would then gain less-thanfull-time status and work as locums beyond full time. This criticism simply does not reflect the reality of trainees’ lives. Neither does it bear relation to the robust mechanisms in place for routing out the rare abuse of less-than-full-time working restrictions.

Offering greater flexibility to less-than-full-time trainees is crucial in our understaffed service. It gives the service an additional staff member that knows the team and the workplace, an experienced additional pair of hands, and often prevents the need to recruit expensive external locums. Facilitating additional flexibility is an important indication that trainees are valued; that they, and their contribution, are hugely important to the overstretched, understaffed services they dedicate their time to. Previous limitations on the slot or percentage that trainees can work simply does not reflect either their needs, or, what they can offer. Why can’t a lessthan-full-time trainee in an understaffed service, offer their team support over half term, or when they feel able to? We have made real progress in removing these restrictions to achieve exactly this.

Access to LTFT Working With increasing numbers of junior doctors electing to train on a less-than-full-time basis,2 training authorities and employers realise they must provide more flexible approaches to training. However practical difficulties remain. Trainees often identify a lack of information, a difficult application process and even undermining behaviours from workplace staff as barriers.3 It is exactly these difficulties that prompted the BMA to propose the new flexible training champions to support and advocate for less-than-full-time trainees and raise awareness of their needs in every trust. Our LTFT Forum heavily influenced and improved NHS Employers guidance4 underpinning these roles. We are now working to ensure that less-than-full-time trainees are involved in the appointment of these champions. We’ll also be looking at how effectively the champions are working.

Access to less-than-full-time training still remains an issue. We are working closely with HEE and colleges to introduce training pilots

designed to improve access to less-than-full-time training. By offering staff a better work environment and greater flexibility, we believe that we will retain more staff. Looking longer term, many trainees do not train or work less-than-full-time permanently. Therefore treating them fairly and flexibly helps retain their expertise and potentially enable them to increase their hours in the future. This has to be good for trainees, good for the NHS and good for patients.

Wider Issues We know that there are many issues still to resolve for our lessthan-full-time trainees, who are an essential part of the modern workforce. We continue to work with government and key stakeholders including the MWF, towards a review of the gender pay gap in the medical profession which will hopefully identify the factors that lead to the gulf in pay between men and women in the profession. Part-time working is a key factor in this pay gap. We are also working towards rostering guidance specifically for our less-than-full-time trainees and an Annual Review of Competence Progression (ARCP) system that is fit for purpose for less-than-full-time trainees. With the challenges we face in the NHS, a key part of any solution must be valuing and retaining our lessthan-full-time trainees.

The BMA’s guide to less-than-full-time training provides information about how to apply, what you can expect from your employer and training organisation (LETB or deanery), as well as videos and examples, showing the experiences of doctors who are, or have been, training LTFT. https://www.bma.org.uk/advice/career/applying-for-training/ flexible-training-and-ltft/what-is-ltft References Review Body on Doctors’ and Dentists’ Remuneration (2017). 45th Re-port.

Available from: https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/602319/58665_DDRB_Book_Accessible.pdf 1

General Medical Council. GMC National Training Surveys: 2008-2016.

Available from: gmc-uk.org/education/national_summary_reports.asp 2

Harries RL, Gokani VJ, Smitham P, et al. Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce. BMJ Open 18 April 2016. Available from: bmjopen. bmj.com/content/6/4/e010136.full; Acad-emy of Medical Royal Colleges Flexible Careers Committee (2013) results of the flexibility and equality survey 2012.

Available from: http://www.aomrc.org.uk/wp-content/uploads/2016/05/Flexibilty_ and_Equality_Survey_2012.pdf 3

British Medical Association (2017) State of medical recruitment. Available from: https://www.bma.org.uk/collective-voice/policy-and-research/education-trainingand-workforce/state-of-medical-recruitment 4

Medical Woman | Spring/Summer 2018 11

FEATURE: PERSPECTIVES

Finding a healthy balance Usman Sheikh is a GP Trainee in North London. He commenced flexible training in 2013 as a foundation doctor in Manchester, where he qualified from. He hopes to go in to Medical Education on completion of training. Usman enjoys exploring the many art exhibitions in London and reading a good crime novel when not working.

Baptism of fire “Look after yourself Usman, no one else will” barbed the cynical senior house officer on my first day at work. Being a naive foundation year 1 trainee, I didn’t immediately grasp the significance of what she said; foundation year training soon enlightened me.

As time elapsed, work increasingly felt like a dogfight and trying to balance my bronchiectasis and perpetual aches and pains from hip dyplasia proved challenging.

My initial coping mechanism was to go into overdrive mode and to graft as hard as I could. Unsurprisingly, this set my health back further, quality of life suffered, and work-life balance became a pipe dream.

Changing attitudes One evening, the on-call registrar caught me coughing up blood.

I had kept it to myself as I didn’t think it was anything worrying.

Visibly concerned, she forced me to hand over my bleep, take the evening off, and go to A&E to get checked out. Embarrassed, I duly got myself assessed and was treated for pneumonia. I was advised to take off the remainder of the week.

At this stage I had taken much time off sick, and was duly referred to the Occupational Health department. The Occupational Health Consultant was attentive, sympathetic and keen to explore my physical ailments, as well as my mental well-being and social circumstances. From a biopsychosocial perspective it was pointed out to me: I was suffering. I was advised to think about working flexibly, and I promised to give it some thought.

With the second half of foundation year training looming I decided to broach the subject with my Educational Supervisor. She could not have been any more supportive and encouraged me to apply for long-term flexible training.

Collating the evidence I had from GP letters, hospital clinic letters, and email exchanges with my educational supervisor and occupational health correspondence, I applied for 80 percent lessthan-full-time training through the Associate Dean at my deanery and was successful in this.

Life as a less-than-full-time (LTFT) trainee Switching to flexible training was easily the best career move for me. It has allowed me to truly focus on my health. I can now attend GP appointments and outpatient follow-ups without worrying about taking time off to do so. I have sufficient time to rest after a busy week and, as a direct result, the time I have taken off sick has reduced dramatically.

12 Medical Woman | Spring/Summer 2018

I have enough time to focus on reading and ensuring my e-portfolio is up–to-date with quality reflective entries; something that hasn’t gone unnoticed by my Educational Supervisor.

I have better work-life balance. I have embarked on a family-run business adventure, selling faith inspired art; promoting the beauty of my faith and learning valuable life and business lessons along the way. The business acumen is certainly transferrable for when I start working as a self-employed GP. Flexible working is not without challenges. For example, if you work 60 percent full-time equivalent then your salary, annual leave, sick leave allowance and length of training will reflect this. You will invariably be wrangling with payroll on occasion because they have miscalculated your pay, and there may be three or four people you are communicating with simultaneously to resolve this.

If you are in a hospital rotation and you are not present for half the week. there will be gaps in the continuity of care you provide patients. They will have had investigations, treatments and new diagnoses in the time you have been away. It is important to be cognisant of this, and ensure the care you provide is not compromised as a result.

Advice about going part-time Look after yourself and use the structure you have at work. You are more supported than you think. Get the help you need from your clinical and educational supervisors, your General Practitioner and Occupational Health, and ensure that you are organised, proactive and keep records of communications.

The Medical Women’s Federation website has all the information you need to help you find out if you are eligible for flexible training; it is an avenue well worth exploring.

FEATURE: PERSPECTIVES

Creating a personalised development pathway Tim Yates is training flexibly in neurology at the Royal Free Hospital and Queen Square.

While National Medical Director’s Clinical Fellow at NHS Digital, he was Clinical Lead and Clinical Safety Officer for the NHSmail Programme – one of the world’s largest email systems – and part of the team deploying Skype for Business safely across the NHS.

As repeated policy reviews attest, the NHS badly needs more clinicians experienced and accredited in clinical informatics, leadership and management. But how are they supposed to get there? It is unreasonable to expect them to do so seriously when they already spend an intense 50 hours each week seeing patients. The ideal solution would be GMC Credentials, or other certifications, for which trainees might apply competitively and then undertake as part of their clinical training programmes; but these still seem a long way off. Until then, less-than-full-time training is one way to access important development opportunities alongside ongoing clinical training.

Training less-than-fulltime has eased several important problems I have faced: • Opportunities arise in office hours: most NHS management teams are not available after you finish your shift • Steady, long-term commitment is required: synchronising diaries and attending regular meetings is difficult without the structure flexible training offers • Going out of programme (OOP) is an imperfect choice: stepping out of training risks losing touch with your greatest passion and clinical skills can atrophy; additionally, the defined period of OOP prevents an ongoing development commitment • Waiting until completion of training is not an option: you not only risk losing momentum in your career, but it is more difficult to find the time, headspace and support to build a skill set as a new consultant Only through flexible training could I take on leadership roles fully and, importantly, hold responsibility as a BMA contract negotiator and, separately, the BMA Junior Doctor Committee (JDC) policy lead in postgraduate training. Both included work on information systems. After a year out of programme working at NHS Digital as clinical lead for the NHSmail Programme, I now work in clinical informatics two days a week, alongside higher training in neurology.

Less-than-full-time training for development purposes is not easy

to arrange. When determining eligibility, and whether the training programme can accommodate a flexible trainee, the deanery interprets sections 3.90-3.92 of the 2018 Gold Guide.1 Despite supportive language in the Guide, workforce shortages restrict flexibility and applications for caring responsibilities are prioritised.

Development opportunities must be ‘well-founded’ and even ’unique’. That ‘uni queness’ being a value judgment. I have had to make repeated, lengthy, densely-evidenced written arguments, often enlisting senior individuals to write in support before being successful. However, if you can make a good case your application will always be looked upon favourably.

It is critical to ensure any development opportunity is worth the potentially negative impact on clinical training, and to review this periodically. This is not just the sacrifice of pushing the date I complete my training from 2018 to beyond 2020, which elicits occasional eye-rolling, but the challenge of working in a service not always well-matched to the needs of a less-than-fulltime trainee. Training opportunities are harder to realise and less of the working week is available to smooth out variations in clinical activity. As such, between flexible clinical training and my other job, I work something like 110% full time equivalent, with a pay cut rather than an increase for my trouble.

But it’s not the length of your training that counts, nor what you earn, but what you do with the time. Flexible training allows me to be the doctor I want to be: to combine seeing neurology patients with other activities, the outcomes of which positively affect the entire population of patients for whom I and my NHS colleagues care. This undoubtedly makes all the effort in going less-than-fulltime worthwhile.

Tim can be contacted on Timothy.Yates@nhs.net.

References Conference of the medical post-graduate deans of the United Kingdom.

The Gold Guide – 7th edition, 2017. Date accessed February 2018. Available from: https://www.copmed.org.uk/gold-guide-7th-edition/the-gold-guide-7th-edition.

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Medical Woman | Spring/Summer 2018 13

FEATURE: PERSPECTIVES

Maintaining psychological well-being After many years in the wilderness of different specialties, Natalie Nobar is now a less-than-full-time ST1 in General Practice. Eventually she would like to work as a portfolio GP and use her previous experiences to help mentor others. Outside of work, when she is not walking dogs that don’t belong to her, she trains to be a yoga teacher or attempts to learn new skills like upholstery from YouTube.

“What is it that you do on your day off, exactly?” asked my heavily pregnant colleague in front of the rest of the team.

AH-OOO-GA! AH-OO-GA! No, that wasn’t her going into spontaneous labour (although that would have been a welcome distraction); that was one of my oldest friends, the shame klaxon. I clearly thought I was owed a visit since I’d been doing so well, or so I thought. I had been ‘managing’ well since returning to work less-thanfull-time a few months earlier and here it was, undoing all that good work and about to send me down a shame spiral into the pit of misery and inadequacy. It chose a moment when I was vulnerable. I could feel the burning rising up into my cheeks as everyone in the office turned on their swivel chairs to hear my response.

Don’t pretend you don’t have a shame klaxon. Most less-thanfull-time-part-time-couldn’t-quite-hack-it-trainees have them; it just might not go off as often as it does for others. The shame klaxon goes off whenever someone asks you why you’re not full time, or why you’re part time, or whenever you have to decline a request because you don’t work that day. After all, being less-than-full-time is a ‘privilege not a right’, as some of my esteemed colleagues have previously declared.

As if the shame klaxon wasn’t enough, I’m at the very bottom of the hierarchy in terms of reasons to be a flexible trainee. Near the top, if not at the top, is being a carer. Health reasons are at the bottom, and mental health is written somewhere on the back, summarised as ‘couldn’t hack it’.

I couldn’t hack it.

I was showing up for work, I was doing my job, but I wasn’t really there. Some would label it ‘burnout’. My patients weren’t suffering as a result, but everything else was. So I left the coveted training number I had pursued since I was a senior house officer. In fact, I nearly left medicine as I went through a cliché of a grieving process about the loss of my identity as a doctor, and a specialist in that field. However, I then went into a different specialty less-than-full-time. I completed the mid-life crisis with aplomb by training to be a yoga teacher and taking up pottery.

And I’m much better for it.

So what did I say to that seemingly banal enquiry? I wish I had a rousing pre-prepared speech about self-care and nurturing other interests but I didn’t. Instead, with a wry half smile and eyes that said ‘continue to pursue this line of enquiry if you dare,’ I confidently said “I do nothing” as I shoved the shame klaxon into the shredder with yesterday’s list.

14 Medical Woman | Spring/Summer 2018

FEATURE: PERSPECTIVES

Providing care Alison Silver is in specialty training. She writes under a pseudonym, and has previously written about her experiences in training for BMA News’ Voicebox with a piece titled ‘Resuscitation, Remedy and Respite’. She has also written for the BMA’s Doctor for Doctors unit, her piece titled ’There is hope after burnout’ can be found on the BMA website.

Nowadays, when I am asked why I opted for a career in medicine, my answer has morphed into one of a young female doctor who now has several years of experience in the profession. I made a decision to study medicine, like others, in my teenage years. Looking back, I am not sure that we can ever truly know what to expect from a career in medicine until we are here. And so, over the years my response to this question has morphed. Now, I respond with a combination of answers, some of which include an interest in biology and need for intellectual challenge, a caring personality and love of human interaction; but mostly a genuine desire to be useful to others.

In the same way, my writing about the experiences that led me to flexible training has evolved, just as my underlying emotion has ripened. My original writing came from a worried heart – a set of key terminal events leading to an unpredicted and unexpected break from the sprint up Mount Medicine. My subsequent writing was more hopeful; the products of a slower, more patient climb, to a time when I had shed the shock, and begun to face and achieve my aspirations again. Currently, I am in equipoise – an understanding of what being a doctor working flexibly with caring commitments means. I continue to learn how to balance both worlds better, in the face of varying degrees of unpredictability.

I have been very fortunate in having a GP who is both very understanding of my family situation and also willing to support me in my decision to apply for flexible training. She originally asked to see my flexible training forms, and then said she felt I would fit into the ‘caring’ category. We all have different concepts of what our ‘normal’ role as a particular family member encompasses, and funnily, I denied that my life encompassed a caring responsibility.

She explained why she felt I would fit into this category, and over time, with the experiences we have been through as a family, I understand why. The word ‘caring’ can generate all sorts of images, yet it is just as much about being present – including for clinic appointments, providing psychological support in complex situations, doing activities together, and providing guidance through a difficult journey.

It can feel like a vulnerability being a flexible trainee, particularly when you are training flexibly for caring reasons. At a recent Annual Review of Competence Progression (ARCP), faced with a panel of high-flying, seemingly ‘uncomplicated’ doctors, I admit to feeling less, wrongly. Perhaps this was as a result of my own feelings of insecurity in a new area and in a new specialty. I have also been very conscious of slowing down my pace of work, and have feared that I may be perceived as a sort of ticking time bomb or that my future prospects will be stunted because of my flexible status. I sometimes wonder how other medics perceive the idea of a doctor who has caring responsibilities. I suppose I fear sympathy, and perhaps with that, oddly, the possibility of shame. In spite of this, I have coped, balanced and thrived. In fact I appraise, head to bottom, my achievements because they are pretty good-looking.

I am glad for the privilege of being a doctor, and the incredible insight we gain into people’s lives. I admit that I came close to losing all my enthusiasm when I had a lot of stressful events happening simultaneously. I am incredibly glad for the flexible route – it has allowed me to continue to reach a point, once again, where I can aim to stretch as far as my potential.

My advice, on a personal level, regardless of whether you are a flexible trainee or not, is to trust your instincts with your own career path. Also, to remember that we have choice in life – we choose who and what we keep in our lives – so shed the stress. To others, more widely and generally, I would say talk to colleagues instead of slandering them – it makes the work environment more pleasant for all of us. Have tolerance and display kindness to one another, because all of our mountains look different. Remember, flexible trainees are a diverse group, just as the wider doctor body is, and all of us offer our different qualities in varying measures – for the benefit of patient care.

Medical Woman | Spring/Summer 2018 15

NEW BEGINNINGS: MOTHERHOOD AND MEDICINE

Finding a new balance in training: the transition to parenthood Eleanor Parkinson is a CT3 psychiatry trainee in the West Midlands, currently on maternity leave and due to commence higher training in Forensic Psychiatry later this year. She studied medicine at the University of Birmingham following on from a first undergraduate degree in Biochemistry. With two young children, there’s not a lot of free time but she loves getting out in to the countryside and walking, before tucking into a hearty pub lunch.

Growing up, I had always known that I wanted children someday, and if I had written some sort of life ‘to do list’ at the age of eighteen then having babies would have been at the very top. It was a little bit later, during my biochemistry degree, when I became interested in training to be a doctor and soon this became my major focus and passion in life. Fast-forward another eight years, through a medical degree and two grueling foundation years, for the first time in my adulthood life I felt settled and stable. I suppose it was only natural I began to think seriously about starting a family. I had recently embarked on core psychiatric training and I felt happy in my work and well suited to the specialty. I had been aware of flexible training whilst I was still a medical student; amongst my cohort of 16 Medical Woman | Spring/Summer 2018

graduate entry students we often discussed how we might combine postgraduate training with child rearing. During my foundation years I had worked with doctors who were training less-than-full-time and was thoroughly sold on the balance it offered.

I was thrilled to find out I was pregnant towards the end of my CT1 year, and after a healthy pregnancy we were blessed with a daughter. My year of maternity leave passed in a happy blur. During this time I applied to work less-than-full-time and found the process very straightforward. I was helped by my Training Programme Director (TPD) into a suitable post, slot sharing with a very capable colleague. Psychiatry lived up to its reputation of being a familyfriendly specialty and all of the consultants I worked with were

NEW BEGINNINGS: MOTHERHOOD AND MEDICINE

unfailingly supportive and understanding of any difficulties that might arise with childcare and navigating the usual catalogue of childhood illnesses. Returning to work at 60% less-than-full-time, I found having two days off in the week to spend with my daughter was absolutely wonderful. This time spent on outings, meeting with friends, going to classes and just having a bit more time to sit back, enjoy the moment and watch her grow was time that enriched us both. It also allowed me some breathing space in my hectic and relentless role as a working parent and without a doubt gave me a better work-life balance.

However, returning to work after having a baby is not a straightforward process. Balancing a career and parenting young children seemed at times like an impossible challenge.

For any working parent, there are a raft of new responsibilities and complications to cope with. You may have been up since 5am, after a disturbed night’s sleep, running late in the morning due to any

number of minor disasters. When you get to work you are then jumping every time your phone rings in case it’s the dreaded call from the nursery telling you your dear child is unwell. When the working day is done you are panicking about getting out of the door on time to do a nursery pick up, sitting in traffic desperately watching the minutes ticking by. And when you do get home it’s a relentless treadmill of preparing meals, baths and bedtimes before you eventually collapse in to bed yourself, to do it all again the following day.

As if this wasn’t enough to adjust to, being less-than-full-time has another set of challenges. I was now less visible and less available in my job, which meant that I was gaining exposure and experience at a slower rate. I lost count of the number of times I found myself saying “I can’t make that, I don’t work that day”, and undercurrents of guilt and some sort of personal failing grew stronger over time. I certainly felt diminished in my role and a sense of competence and confidence in my abilities was slow to return. It is fair to say that I spent some hours agonising over feeling that I was failing at both being a doctor and being a mother.

Another challenge is coping with the disrupted continuity in your work; handing over tasks you would rather complete yourself or having to rush to tie up all the loose ends because you aren’t back at work for another four days. This clearly did not help with my efforts to leave work on time or my stress levels.

With time and supportive colleagues I began to feel more comfortable with my new identity, mum and doctor, accepting my limitations and setting a new equilibrium for myself. At the end of the day, dedicating extra time to my daughter during her early years has been priceless for me. On a good day I feel truly blessed to be able to balance a stimulating, challenging and rewarding career with my caring responsibilities.

Now on maternity leave after the birth of my second child, I would have the following advice for myself and others returning to work as a parent and a less-than-full-time trainee: • Give yourself time. It will feel strange and scary at first, but knowledge and skills do come back faster than you think.

• Rethink your priorities. I am aware and I accept that my priorities and outlook have changed. My young family comes first at the moment, but I realise this phase of life doesn’t last forever and there will be plenty of time to focus on my career in the future.

• Take on one thing at a time. I found I had to limit the number of additional activities I had on my plate. If I was revising for an exam, I would put doing that audit on hold for a few months. You have an extended training time, use it to make life more manageable.

• Learn to say no. I am a people pleaser and not one to turn down an opportunity when it presents itself. However, I was quick to learn how to politely excuse myself when I felt this was reasonable, as I knew extra projects would directly encroach on my precious family time.

• Be as organised as you can. Use whatever method works for you, but to keep multiple balls up in the air you need to think and plan ahead.

• Ask (or pay) for help. Use whatever practical help you can afford or you have at your disposal to make day to day life just that little bit easier.

• And finally, make the most of the time you have to spend with your little one, everyone says it, but time goes by way too fast.

Medical Woman | Spring/Summer 2018 17

SPOTLIGHT: RESILIENCE

Resilience matters: combat burnout Amanda Howe is a practising family doctor, an academic professor, and a national and international leader in family medicine. She is the Foundation Professor of Primary Care at the University of East Anglia. She served as an Officer of the Royal College of General Practitioners from 2009-2015, previously chairing their Research Committee and the U.K. Society for Academic Primary Care. She is President of the World Organisation of Family Doctors from 2016-2018.

Overworked health professionals are getting cynical about the trend towards psychological coaching as a coping mechanism. Resilience and mindfulness workshops are met with cries of “I wouldn’t be burnt out if you weren’t asking me to do the impossible!” This article braves the same criticism by suggesting that resilience is worth understanding – that the concept needs to be applied at a personal, team and organisational level to be really useful – and that it can be learned and strengthened, even in tough circumstances.

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There are also issues where gender and resilience interact, making it of particular relevance and worthy of recognition, as well as conscious analysis.

Significant parts of the resilience literature come from observations of young children in adverse circumstances, noting that some seemed to find a positive way through despite challenges.1 The value of a secure caring figure in early childhood is well recognised in the psychological literature. As doctors, we recognise the marks in

SPOTLIGHT: RESILIENCE adulthood on those for whom secure parenting was disrupted. The characteristics of individuals who are resilient include a belief that they can make a difference to the outcome of a difficult situation; in other words having self-efficacy and self-confidence. They are also able to take control of areas where they can take control, making conscious choices, and are able to plan ahead, as well as build relationships to help them get through circumstances. Additional characteristics include being pragmatic, managing negative emotions, and being philosophical about the limits of their options.

They also ‘bounce back’ and keep a positive trajectory in situations where others may struggle.

Once we recognise the concept of resilience, how can we learn as adults to become more resilient? Educationalists advocate simulation – graded challenges where we can rehearse things in a semi-controlled environment, building up to rehearsed difficult stages ahead of actually having to do it as independent practitioners.2 Operating on a ruptured ectopic, dealing with a patient who has psychosis, or being part of a significant avoidable error, can all be rehearsed in medical training. A similar rationale underpins professional reflective learning – learning from the experiences of others, as well as our own. This involves recognising what choices we had, where some things were beyond our own control, and also venting negative feelings in an appropriate and constructive way.

The value of rehearsal, or learning by proxy, is also well described in the ‘transitions’ literature.3 This is where changes in personal or professional circumstances have better psychological outcomes if the individual has some chance to rehearse these, take control of some components, and receive practical and emotional support from others through the process.

What are the limitations? Many work situations ask too much, without sufficient ‘safe space’ to relax or review; many workplaces and supervisors do not create time for such rehearsals or reflections; and many doctors do not have the energy or insight to analyse or prioritise their own needs. Another recognised cause of burnout is recurrent clash of values – resilient people often rely on a belief that carries them through, but if the system recurrently acts in conflict to these values, then the long-term ability to make adversity meaningful may be undermined. An example might be – ‘I work crazy hours because I can save people’s lives’, undermined by finding the clinical environment is becoming increasingly unsafe and errors are occurring daily. Or ‘I am a good doctor if I allow people to confide in me’ being undermined by running late, emotional overload and increasing concern from partners about creation of emotional dependence and overall time management.

The latter example brings us to the literature on burnout and gender.

There is some evidence that suggests the cultural upbringing of women enables them to be more emotionally engaged with others, but risks them taking on burdens from others in a way that can become unsustainable. Depression, as a reaction to stress at work, is more common among women,4 whereas men tend to react with aggression and are more likely to have personnel complaints against them. Early upbringing also influences perfectionism, which is a high risk personality type for burnout in health care settings.

If we are to address these issues we should consider both prevention and detection/management, which involves working at the personal, team and professional levels. Preventive strategies include developing insight into one’s own strengths and weaknesses – ‘Am I too driven, do I override my warning bells?’ as well as making space to reflect and space to forget. Additional strategies include

team and/or supervisory spaces for reflection and learning, as well as educational strategies to acknowledge potential trouble that may arise and to rehearse these scenarios. Personalised feedback to learners during formal training that explicitly enforces resilience aspects of their responses is also valuable. At a systems level, organisations should rehearse ways to avoid or minimise problem areas, such as unexpected absence of key personnel. Such cases can lead to others in the team being called on a Sunday to come in for an emergency gap in the rota, which can feel different if a team has already agreed how this will be handled and compensated. At a structural level, having sabbaticals, role changes and ‘away-days’ may break the rhythm and allow refreshment. Transitions, such as return to work after a break in service, can also be planned through personnel and organisational policies, which are useful if the break was unexpected, perhaps due to illness.

Detection of problems is a personal responsibility for doctors, and for colleagues. For example, it is important to notice the partner who is becoming increasingly irritable or late in clearing their results and letters files, and to take responsibility to act on this in a sympathetic but also effective way. Additionally, the existence of an explicit organisational health policy, as well as an occupational health service, may promote wellbeing, and provide access to intervention at an early stage when problems start to arise. Legislative baselines for maximum hours or statutory leave can provide a bottom line in terms of adherence, which will prevent feelings of guilt and protect human rights.

Finally, it is necessary to address why resilience matters to modern medical practice, and why it is not just a personal responsibility. This article is designed to demonstrate that resilience is worth investing in, as it may prevent loss from the workforce. However, it cannot just be down to the individual. We have different personalities, different life events, different workplaces and varying work challenges. We have had different educational experiences, and may also face a new challenge at any moment. What we can predict is that unpleasant events (illness, complaints, breakdown of relationships) will happen sooner or later, and we can be prepared for these. Key transitions are pregnancy (an exciting life event, but a threat to current working contract and sense of identity); failure (exams, promotions, errors); illness (‘I let everyone down’), and negative emotions – to name but a few. Colleagues, teams, educators and employers can all take action to maximise awareness and minimise impacts. We can also learn consciously what the experience of others is, and learn to ‘think resilient’.

Through this we may consider: what is the issue, what do I already know about ‘x’, what can I find out, what kind of options are open to me, who can help me, why I am doing this, what can I do if it goes wrong, what else matters, and who else can take responsibility for this. The same checklist may work for the team, your friends or family, and your organisation. It is worth being prepared, or getting prepared, if trouble has already hit. There is ongoing work to address these big issues, and this article provides a taster of what is to come.

References Cyrulnik B. Resilience. London: Penguin 2009.

Howe A, Smajdor A, Stockl A. Towards an understanding of resilience and its relevance to medical training. Med Educ 2012;46:349-56.

3 Bridges W. Transitions : making sense of life’s changes. (2nd ed.) Da Capo/Life Long; Cambridge, MA: 2004.

4 Guille C, Frank E, Zhao Z, et al. Work-Family Conflict and the Sex Difference in Depression Among Training Physicians. JAMA Intern Med. 2017;177:1766-1772.

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Medical Woman | Spring/Summer 2018 21

STRIKE A CORD: MASTERING MIND

Reaching out Taking action Olivia Bamber has had Obsessive Compulsive Disorder since she was 7 years old, but didn’t receive treatment until years afterwards. She began working for OCD Action because she wanted to use her personal experiences of living with OCD to help support others. Olivia is a Youth Service and Communications Manager at OCD Action.

obsessions, in order to build up a tolerance to the anxiety. CBT can be helpful if delivered well.

This article is designed to provide information for anyone who comes into contact with people affected by these disorders so that they may benefit from a greater awareness of the available services.

The services we provide are: Helpline: This is a support and information line for people affected

by OCD (including friends and family), BDD and related disorders.

This is available to anyone in the UK via phone and email. The OCD Action Helpline also provides a service called ‘Next Steps’ which is offered for people whilst they are going through a course of Cognitive Behavioural Therapy (CBT) for OCD. This service will see a caller paired up with a Helpline Volunteer for weekly calls of support and encouragement whilst they are going through their therapy.

OCD Action is a national charity that provides support and information for people affected by Obsessive Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and related disorders, such as hoarding, trichotillomania and compulsive skin picking. OCD Action provides a number of vital services for people affected by OCD and their family, friends and carers.

OCD is a clinically recognised anxiety disorder which affects around 1-2% of the population. It can be debilitating and paralysing. People with OCD experience intensely negative, repetitive and intrusive thoughts, images or urges which cause anxiety. In order to quell the thought and quieten the anxiety, people with OCD will often repeat a physical or mental ritual again and again (compulsions). However, these compulsions only provide temporary relief from the anxiety, but ultimately they feed back into the OCD and make it worse.

Common obsessions include, but are not limited to: fears that you may unintentionally cause harm or come to harm, intrusive thoughts of a sexual or graphic nature, fears of dirt or germs, or a feeling of everything needing to be just right to stop bad things happening.

Common compulsions include: seeking reassurance, avoiding certain situations, excessive washing or cleaning, counting or tapping and hoarding of objects. Obsessions and compulsions are wide-ranging, and can really be about anything. The obsessions are often of a distressing or upsetting nature, and are not in any way in line with what a person wants to think or feel.

The recommended treatments for OCD are Cognitive Behavioural Therapy (CBT) which should include Exposure and Response Prevention (ERP) therapy, and sometimes medication is prescribed.

CBT for OCD works to change the way a person reacts to the thoughts, and gradually reduce the safety behaviours that follow the 22 Medical Woman | Spring/Summer 2018

Advocacy Service: The Charity’s Advocacy for OCD Service is the only service of its kind in the country specifically for people with OCD. It is an issue-based service which has helped hundreds of people access treatment, secure housing, stay in employment and turn their lives around.

Even Better Together Project: This project helps set up and support a network of independent support groups around the country, including numerous on-line groups. Support groups are a vital way of receiving peer support from others in similar situations.

OCD Youth Service: OCD Youth is an OCD Action project, which supports young people under 25 who are affected by OCD or related disorders. The service offers an instant messaging e-Helpline, meet-ups (both in person and online), a website, peer support Forums, and information via a range of social media channels. The Service is run by the Youth Advisory Panel (YAP), a group of eight enthusiastic volunteers under the age of 25, all of whom have personal experience of OCD. Website and Forum: The OCD Action website is the main hub of information for the Charity. It holds a wide range of information for people with OCD, their friends, family, carers and professionals, as well as a large, moderated peer support forum.

If you have OCD or a related disorder, or if you want to point someone towards some support, then OCD Action can be contacted on 0845 390 6232, or by emailing support@ocdaction.org.uk

STRIKE A CORD: MASTERING MIND

Breaking barriers and rituals Ellen White is a 19-year-old who runs a mental health blog called Ellen’s OCD Blog, in which she documents her experience with obsessive compulsive disorder (OCD) and tries to break down the stigma and misconceptions surrounding mental health. She uses sports such as triathlon and jiu-jitsu to help support her recovery. Ellen hopes to become a nurse or work for the police in the future, and when the time is right.

OCD has been a part of my life for as long as I can remember.

As a child, I was haunted by the intrusive thoughts of ‘what if you stabbed your sister in the night?’ and ‘what if you’re actually a drug dealer who spikes people’s drinks?’ Of course, I knew rationally that neither of these things were true or were going to happen, but the intense, crippling anxiety and fear that came along with my OCD always managed to drive any logic out of the window.

With hindsight, I can now identify those thoughts as obsessions (persistent, uncontrollable thoughts, feelings and images), which are a key component of OCD. At age 11, I began to engage in compulsive behaviours, such as repetitive counting up to the number four, avoiding certain foods, and tapping objects. At its worst, it would take me over an hour and a half to complete my night time routine of rituals, as I felt this was the only way I could stop something bad from happening. Of course, in reality, my rituals had no impact on the world around me, but inside my head, I genuinely felt like I had been hijacked by OCD. It felt like the weight of the world was on my shoulders, and that I was indeed the catalyst for all things bad if I didn’t adhere to the rules of OCD. I received a diagnosis at the age of 13 years old when I was referred through to Child and Adolescent Mental Health Services (CAMHS) after a particularly rough patch. I found it quite comforting to receive a diagnosis, as it was good to have a name to put to the torment I had been going through. It was also the start of being able to separate myself from my OCD, a key aspect within my recovery and treatment goals. I spent the next three years receiving treatment.

We focused quite heavily on Exposure, Response, Prevention (ERP), in order to start breaking the cycle. For example, I often worried that if I thought about illness then I would make someone that I cared about ill as a result. To challenge this, I had to wish laryngitis on my psychologist and then sit with the anxiety produced rather than engage in compulsions to counteract the thoughts. I would then see my psychologist and acknowledge that my thoughts had not caused ill health. This did not suddenly cure my OCD, but it was the start of slowly chipping away at the OCD logic.

A big challenge along the way was making sure that I wasn’t seeking reassurance from those around me, as this just reinforces the behaviours. My friendships also suffered during the worst of my OCD. I was often too frightened to go out due to the unknown and not wanting to put myself through the exhausting process of getting ready to go out, as it was so heavily intertwined with numerous rituals.

My journey with OCD has not been all negative. As a result of my experiences I decided to create a blog, to provide a resource for

The Inside Looking Out by Billy from The Gallery, The Secret Illness

others and to help raise awareness about the disorder. I have grown because of these experiences, and whilst having OCD is extremely difficult, I appreciate that it has allowed me to connect with many other people and help make a difference.

Fast forwarding to today, my OCD is now only a very small part of my life. It only crops up if I’m particularly stressed, but even then, I now have the skills to stop my OCD in its tracks. I am currently a student mental health nurse, having been inspired by those I have worked with over the years. I never thought I would get to this point in my recovery, so I hope that my journey provides hope for those currently struggling.

Things do get better. I believe in you.

Tips for doctors encountering patients with OCD • Be understanding – the fear of judgement can be quite significant, especially if the nature of someone’s intrusive thoughts are embarrassing or frightening. Please don’t pass judgement if someone is being open about this, it takes a lot of courage.

• Don’t just tell us to stop – if we could, we would!

• Please don’t say “oh, I have a bit of OCD too” – this is probably one of the most infuriating things encountered. It belittles the condition into something that everyone has and thus can just deal with. It is not a quirk that we all have; it’s a mental health condition.

Medical Woman | Spring/Summer 2018 23

STRIKE A CORD: MASTERING MIND

Creative compulsion: making OCD less of a Secret Illness Becca Laidler co-founded The Secret Illness in 2015 with filmmaker Liz Smith. Prior to this Becca spent 12 years working as an actress and presenter in London, before deciding to step behind the camera and put her organisational skills to good use in an operational role at Minnow Films. Since 2017 she has been working for Total Media whilst exploring the creative arts with an amazing volunteer team in order to expand The Secret Illness into the global project it is today.

The Secret Illness is a global creative arts project that explores the realities of living with obsessive compulsive disorder (OCD). Its aim is to change the often misunderstood or trivialised perceptions of OCD through written, audio and visual expressions of what OCD means to those living with the disorder. The Secret Illness is a space where these creative works can be shared, where people can discover they are not alone and where we can open up conversations that bring a deeper understanding of what OCD is both to the OCD community and the wider public.

My mother has lived with obsessive compulsive disorder for as long as I can remember but was not officially diagnosed until much more recently. I was struck by how much easier both her life and my own could have been if she had received treatment and support at an earlier age. Discussing this with filmmaker Liz Smith, we quickly realised how little was known about the true debilitating reality of living with OCD and set out to create a documentary to raise awareness. As the project developed we realised that a much more flexible approach was needed in order to convey the countless ways OCD manifested itself in the various people we met.

Our first creation was The Wall. People living with OCD could send in as little or as much information as they wished about how OCD had affected their lives. We pixelated their photos and they joined a collective from all around the globe, which now incorporates more than 130 people. The variety among the stories was unbelievable and yet it was the similarities that proved the most powerful.

Countless people wrote about how alone they felt, or how sure they were that no-one could possibly understand what they were going through. Seeing all the pixelated faces side by side was truly striking, and the feedback we received from the OCD community was overwhelming. People were using The Wall to explain their OCD to friends and family who they had previously felt unable to open up to. A lot of people spoke of the shame they felt in others finding out their thoughts and rituals, and how cathartic it was to see those fears down on paper next to others who understood.

There was a thirst for an anonymous platform in which people could share their thoughts and secrets. We were soon inundated as the posts came flooding in. We quickly realised we needed more hands on deck and recruited a fantastic team of volunteers and countless more collaborators. We were sent all types of creative work; sketches, poetry, music, paintings, which we felt needed to be shared and so the Secret Illness morphed into the transmedia creative art project it is today. We are about to launch our Gallery, Salon and Cinema where we will showcase the work we have received as well as co-created pieces where we partner those living with OCD with others with complimentary skills. The Secret Illness 24 Medical Woman | Spring/Summer 2018

is very much a product of the OCD community and is driven by the responses we receive.

Our first film This Old Ghost won the International OCD Foundation (IOCDF) OCD Awareness Week Video Competition in 2016. It was written and voiced by James who had suffered with OCD since childhood. He wanted to get across the pain of living with OCD not only in solidarity with those living with the disorder but also to educate those who think OCD is just washing your hands a lot or liking your stationery to be colour co-ordinated.

The power of creativity helps to connect with people who you may not otherwise reach with a medical article or more traditional information campaign. People with no connection to OCD at all may watch a film and gain insight into the torturous reality of the illness.

Storytelling is a really effective way of communicating a message.

Most of us make decisions based on emotion and post-rationalise with facts, and video is proven to have a higher recall rate than text.

Pairing the emotion of first hand personal stories with memorable creative artistic expression seemed to us a much more effective way to also engage those without a vested interest in OCD. This is so important to us if we are to break the stereotypes and stigma that comes with the trivialisation of OCD in the mainstream media.

We have several more collaborative works in the pipeline and episode three of our podcast series is on the way. We hope that by continuing to turn pain into creative works, we can get people talking and in time, make OCD less of a secret illness.

STRIKE A CORD: MASTERING MIND

Lost and Found: Calling Time Doctor Jules Montague is a Consultant Neurologist in London, a job she combines with medical work in Mozambique and India each year. Jules studied Medicine at Trinity College, Dublin and moved to London nine years ago. She writes regularly for the Guardian. Her work has also featured in Granta, Mosaic, Aeon, NME, the Independent, the Verge, the Lancet, and on the BBC. “Lost and Found” is published on 8 March 2018 by Sceptre, £20

Charlotte had been studying English Literature at university. One Tuesday evening, her mother found her unconscious on the bathroom floor. Her lips were blue. There was no note.

Her mother had performed mouth to mouth. And the paramedics had arrived quickly and of course had known exactly what to do. The emergency room team kept her alive. All of those people fighting the fate that Charlotte had planned out for herself that morning.

Forty-eight hours passed. I was asked to see her in Intensive Care to determine her prognosis. For a moment, it did not feel as if Charlotte had been saved. She was severely brain-injured, unresponsive.

I looked at her brain scan, searching for the normally clear boundaries between grey and white matter; preserved boundaries signal cause for optimism, evidence of preserved function. But no, those boundaries were blurred, almost indistinguishable. The ventilator hummed and infusions ran and monitors beeped; the functions of Charlotte had been outsourced.

At the foot of the bed there was a slanted desk and across it was stretched a large sheet of paper. A graph plotted the rise and fall of her blood pressure, temperature, oxygen levels and pulse. On the top right was a list of her medications and infusions. Below this, the nurse had written the plan for the day – replace catheter, chase chest X-ray result, supplement magnesium, neurology team review.

The entirety of Charlotte’s day, what had happened that morning, what would happen later, existed on this page.

“Is she still in there?” her mother asked me one morning. This went beyond whether Charlotte could hear us or not, I sensed. It was about whether Charlotte was the same person as before, perhaps even whether she still existed. Charlotte’s identity, or sameness, had irrevocably changed since the moment she ended up on the bathroom floor with an empty bottle of pills next to her.

How could Charlotte’s identity persist when she was unable to respond to her surroundings, when she was unable to have experience of ‘I’ or self or knowledge of existing, unable to impart memories or present her personality to us? What remained? I have never managed to find the answers to these sorts of questions in

the conventional structures of medical education. At Grand rounds we speak of severed spinal cords and ruptured spleens, of malignant masses and multiple metastases. But in my 15 years as a doctor, I have never heard the word ‘identity’ spoken there. Diagnostic labels gathered at Grand rounds speak more to the patient and less to the person. We talk about loss of blood and loss of lung function but we do not contemplate the loss of person and loss of self.

Instead, in Lost and Found, I have returned to the stories we all hear each day in clinic rooms and by bedsides.

The patients we see who tell us of limbs weakened and memories misplaced, of vision blurred and speech slurred.

Because in the midst of those tales, there are also deeper insights into who we become.

There’s Anita, who gets lost on a hill walk along Balscadden Bay in Ireland as amyloid plaques clump throughout her brain. As her family search for her frantically that day, later they will look for glimpses of the mother or wife they once knew, the one who so certainly existed before Alzheimer’s took hold. There’s Martin, whose personality is radically altered by frontotemporal dementia – before he was compassionate and kind; now he staggers down the high street unkempt and hostile. Has neurodegeneration released the ‘real’ Martin, a sinister being that had been lurking all of the years before? I also see what happens when sameness is disrupted in others – Charlotte in her coma, Carol with her traumatic brain injury, Benjamin with his dissociative fugue, and indeed Charlotte, in her coma. There are tales of multiple personality disorder and hallucinogenic drugs and sleepwalking as well as the false memories and enigmatic dreams we all share. The sorts of things that pose a threat to our identities, to our continuity of self, for a moment or perhaps a lifetime.

I shine a light in Charlotte’s eyes now – her pupils dilate. I gently touch the edge of her cornea with a wisp of cotton wool – her eyes blink; the reflex is intact. On I go, searching for signs of recovery, perhaps even searching for her.

For Charlotte, hope remains.

Medical Woman | Spring/Summer 2018 25

WOMENS HEALTH: CERVICAL CANCER

Cervical cancer: living well beyond the disease Rebecca Shoosmith is Head of Support Services and Deputy Chief Executive at Jo’s Cervical Cancer Trust.

Rebecca’s work focuses on identifying ways in which to better support women and their loved ones affected by cervical cancer and cervical abnormalities, as well as investing in volunteers to enable the charity to reach even more women than ever before. Her specialist focus is the cancer patient experience, campaigning for better patient outcomes.

Jo’s Cervical Cancer Trust was founded in 1999 by the family of Jo Maxwell, Jo sadly lost her life to the disease and found a lack of information and support available. Our vision is a future where cervical cancer is a thing of the past. Until then, we want to reduce the impact for everyone affected through providing the highest quality informa-tion and support, campaigning for excellence in treatment and prevention.

Cervical cancer is the second most common cancer in women under the age of 35 years,1 and with nine women diagnosed every day there is an estimated 49,000 women living with or beyond cervical cancer in the UK today.2 Survival is high with over two thirds of women affected living 10 years or more.3 The largest known data set of patients with cervical cancer has shown far higher than anticipated numbers to be affected by multiple, often complex, long term consequences of diagnosis and treatment, which often go unreported.4 Jo’s Cervical Cancer Trust, the only dedicated UK charity for women affected by cervical cancer and cervical abnormalities, has released a report ‘The long term consequences of cervical cancer’, which aims to better understand the profound impact of living beyond a cervical cancer diagnosis. Women who participated in the National Cancer Patient Experience Survey (2010 - 2015) 4 and had agreed to be involved in future research were contacted and an online survey, using the same question set, was available throughout the data collection period for completion. The full report compiles the

26 Medical Woman | Spring/Summer 2018

experiences of 688 women more than a year since diagnosis.

The vast majority of women (88%) reported experiencing at least one potentially life-changing physical problem. Two thirds (63%) reported at least three problems, and a quarter (24%) of women noted six or more potentially life-changing physical problems. These symptoms spanned over aspects such as bowel function (54%), urinary function (54%), pain (52%) and a negative impact on sex life (67%). Many problems presented for the first time a year or more following initial treatment. Time from treatment correlated with a greater number of problems, emphasising the enduring impact of a diagnosis and the requirement for ongoing care.

Psychological repercussions are widespread: 37% of affected women reported depression. Amongst younger women, 79% of 25-34 year olds described feeling blue, sad, down or depressed compared to 57% across all ages.

The impact of cervical cancer permeates every area of life including relationships, finance and occupation. Over half (60%) of those who reported a change to their work life said it was a direct result of their diagnosis and treatment.

One of the most harrowing findings from this survey is that of unmet need. Only half of women who had experienced bowel (41%) and urinary problems (54%) had received treatment. Only 10% of those experiencing negative changes in their sex life received treatment.

High proportions of women described their emotional (75%) and physical (70%) needs not being fully met. Significant numbers affected by each physical problem had not spoken to a doctor about their ailment: lymphoedema (60%), pain (44%) and urinary problems (42%). Women reported simply accepting their condition, being unsure of where to seek help, not wanting to bother anyone and being fearful of finding out what was wrong. Others reported being told there was nothing that could be done to help them.

Laura, a 32 year old known to our charity describes her journey: “I was diagnosed with stage 2b cervical cancer needing chemoradiation and brachytherapy but soon after I received my ‘all clear’ results, my health started to deteriorate. I went to my GP… about fatigue and bladder problems… was told it had nothing to do with my cancer treatment… I felt very low and started to think

WOMENS HEALTH: CERVICAL CANCER

Kate Sanger is Head of Communications and Public Affairs team at Jo’s Cervical Cancer Trust and is responsible for shouting about what the charity does. Kate is always trying to come up with new ways to increase public awareness of cervical cancer and prevention along with ensuring that those affected get the best possible support, treatment and care.

“The aftercare [bowel damage] was very poor although many questions were asked by us to our GP and hospital staff, we were unable to get any answers or help with the problems. This seems once treatment is completed the follow up and help is very poor.”

I would just have to live with it. I was referred to a gynaecologist who explained I was experiencing side effects from my treatments and that I needed further operations. I was so relieved that… someone knew what the problems were… I have been lucky to have had great support but I did find that at times when I was upset, especially in hospital, I would just have the curtain pulled round me or be left to it as people didn’t know how to react. It’s made me anxious about what’s coming next.”

There are many services that exist to treat and mitigate the consequences reported, including those offered through charities and the NHS. Jo’s Cervical Cancer Trust is urging for greater recognition of the long term problems caused by diagnosis and treatment of cervical cancer.

Among those delivering primary and secondary care, increased awareness will ensure clinicians understand the barriers women face when asking for help, especially when problems may be difficult to talk about, including bowel, bladder, sexual and fertility issues. GPs can play a pivotal role in the care of women affected by cervical cancer, therefore understanding how to address these sensitively will create opportunities for women to raise concerns and feel empowered to do so, in turn leading to swifter diagnosis and treatment.

Women reported not being fully aware of some of the more difficult and long term impacts they could face following treatment.

We believe women should feel informed, able to challenge and have the opportunity to voice their concerns. We advocate that a Recovery Package should be available for each patient to support professionals in delivering patient-centred care, helping to identify and address changing needs early. Additionally, a Treatment Summary with details of all treatment received, potential symptoms and key contacts encourages seamless transition from secondary to primary care ensuring a multi-disciplinary approach to long-term care. Examples of these useful strategies are available on our website.

Women must not be simply treated for cervical cancer. Women living with and beyond the disease should have access to the best quality of life possible.

The full report and all its recommendations can be found at: www.jostrust.org.uk/longtermconsequences References ffice for National Statistics, Cancer registration statistics, England, first release, O 2016. Date accessed March 2018. Available from: https://www.ons.gov.uk/ peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/ bulletins/cancerregistrationstatisticsengland/2016 2 Jo’s Cervical Cancer Trust, Long term consequences of cervical cancer and its treatment. Date accessed October 2017. Available from: https://www.jostrust.org. uk/about-us/our-research-and-policy-work/our-research/long-term-consequencescervical-cancer-and-its 3 Cancer Research UK, Cervical Cancer Survivor Statistics, England and Wales 20102011. Date accessed October 2017. Available from: http://www.cancerresearchuk. org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer 4 NHS England Cancer Patient Experience Survey. Date accessed October 2017.

Available from: https://www.england.nhs.uk/statistics/statistical-work-areas/cancerpatient-experience-survey/ 1

Medical Woman | Spring/Summer 2018 27

WOMEN’S HEALTH: BIRTH TRAUMA

Labour: the hidden trauma Rebecca Moore is a perinatal psychiatrist working in London, with experience spanning over twenty years.

Her role incorporates working with and supporting women who have new onset or pre-existing emotional issues through pregnancy and up to a year after birth. Rebecca has worked with one of the pioneers of perinatal psychiatry, Dr Liz MacDonald, as a trainee in London, and she was inspired to pursue work in the field.

An introduction to perinatal psychiatry Pregnancy and the postnatal period are a vulnerable time for women, with many physical and psychological changes occurring.

As perinatal psychiatrists, we aim to keep women as well as possible, so when they leap into motherhood they are feeling mentally well. The risk of relapse for bipolar disorder, for instance, is high in the early postnatal period, so women need highly specialist care and support.

Our patient group includes women experiencing anxiety or depression, women with a known schizophrenia, and women feeling suicidal or those who have experienced birth trauma.

Women are seen at least once a month at home or in clinic, and we draw up a collaborative and holistic plan that incorporates diet, exercise, working life, home life, sense of self alongside biological symptoms, as well as the use of therapies and/or medication.

This is a crucial time period to be working with a woman: empowering a woman at this point impacts her future health as well as the health of her children.

Birth Trauma: an under-recognised entity Birth trauma occurs when women find some aspect of their birth traumatic, distressing, and/or fearful. Currently around 30% of women find some aspect of their birth traumatic, which equates to over 200,000 women per year.1 Yet, it is not well recognised.

Additionally, leaving birth trauma untreated in the long-term can lead to enduring health repercussions both for a mother and her family. Not all affected women go on to develop depression, anxiety or post-traumatic stress disorder, however, a proportion will. In cases with a history of prior anxiety, depression or sexual abuse, 1 in 5 of women will develop post-traumatic stress disorder after birth.2 Trauma at birth encompasses more than life threatening medical emergencies, such as an emergency caesarean or bleeding. Just as often, it can be about the care and language we give to women in labour. This may mean women being spoken about not to, ignored or dismissed by staff, and feeling unheard or not listened to. It may be a lack of kindness or care, staff not introducing themselves or not respecting the woman’s wishes during birth, or women feeling coerced during labour.

Take for example, Emily who comes into delivery knowing her midwife and having had lots of antenatal discussions about her birth preferences. Emily then has a long painful labour ending in a caesarean birth and a postpartum bleed. She perceives her birth as positive, despite it not being the birth she hoped for. Emily had someone by her side throughout explaining to her what was happening, reassuring her, allowing her to raise concerns and fears.

28 Medical Woman | Spring/Summer 2018

This helped in sustaining a sense of control and choice, including for example, immediate skin to skin after birth in theatre.

In a different scenario, Anna comes onto a busy ward to meet a midwife she does not know who is courteous but not especially warm. The midwife keeps leaving the room for long periods of time and Anna is increasingly worried that her labour is progressing quickly and she might deliver on her own. Anna feels out of control and scared. She does not get a chance to ask about pain relief much and by the time she asks for an epidural, which she wanted, she is told it is too late. When the baby is born he is placed on Anna’s chest immediately uncleaned, which she did not want, and when Anna asks the midwife to take the baby and clean him the midwife makes a comment to Anna – “that’s unusual”. Anna transfers to the post-natal ward where everyone comments on how lucky she is to have had such a fast birth but she doesn’t feel very lucky or happy. She starts to ruminate about what the midwife said, doesn’t sleep all night, feels guilty about not having her son on her chest immediately after birth. Anna has a rapid four-hour vaginal birth with no complications or medical intervention, she also has trauma from her birth experience.

It is important to recognise that fathers can be traumatised by birth and that midwives and students in the room can also be traumatised.

Postnatally, the focus is often on the baby and on a mother’s feeding, bleeding or depression. Persistent all day long sadness, tearfulness, low mood, anxiety, fatigue and loss of enjoyment in life, can all indicate depression. In post-traumatic stress disorder or birth trauma we would expect variable mood, fluctuating from sad to angry to tearful to guilty. This can occur alongside recurrent overthinking or re-playing of the birth in dreams, thoughts or visual

WOMEN’S HEALTH: BIRTH TRAUMA flashbacks of moments including a comment made, a doctors’ face, blood on the floor, or the baby not crying after delivery.

weeks, I came to learn that not all colleagues are supportive of long term sick leave. I discovered a shocking lack of professional support on returning after a miscarriage, all the more astounding as I was surrounded by pregnant women daily having just lost my own wanted baby.

As a whole, we must improve on recognising the impact of miscarriage on both patients and staff; with a greater emphasis on the emotional needs of staff.

Being a mother continually influences my work and how I work in a manner of ways.

Looking back, I had always planned to return to work; I love my job and need the mental stimulation. Yet, I initially experienced all the guilt and pressure any woman may feel on returning to work and learning how to juggle motherhood and a career. I believe working makes me a better mum; of course there are weeks where I feel like I am failing at work and at being a mum.

With experience, I operate with a ruthless efficiency at work: I do not stay late; I go home to be with my kids. I try as much as possible to switch off from work and switch off my phone once home.

On returning to be a perinatal psychiatrist after giving birth, I was much more aware of how being a new mum feels. I was able to offer more realistic advice about how to cope with birth, not sleeping or feeding than before. I was definitely able to empathise with the horrors of a colicky baby as both my kids had colic and screamed pretty much consistently for four months!

How can we help?

We should ask all women how their birth experience felt as part of routine care alongside the six-week check. We need to give women enough time to talk through their feelings and tell their story and to know we are really listening and hearing them. Often women are never asked about their birth story and so all these traumatic feelings and emotions remain.

Commonly, I encounter a woman in a second pregnancy with undiagnosed post-traumatic stress disorder as a result of her first birth. It is not uncommon for women to never have another child because their birth experience was so traumatic.

If women feel traumatised by birth we should encourage them to feel able to speak to someone they trust, a partner, friend, midwife, health visitor or general practitioner. If this is overwhelming they can be encouraged to try and write down their story in a blog or use a journal. Online forums can be very helpful as it allows women to speak anonymously; this might be via Twitter or a peer group forum.

Various other factors can help birth trauma, such as diet, exercise, sleep, social support, meditation, breathing, psychological or physical therapy and/or medication.

The prognosis is very good once identified and most women feel significantly better within 12-18 months with the right care.2 It can seem never ending and terrifying to be traumatised by birth but women do get better and we must always try to engender hope about recovery.

Reflections from motherhood I am a mother of two gorgeous kids. I have also experienced two miscarriages and hyperemesis. Whilst lying in bed unwell for 16

Birth Trauma Resources http://blogs.plos.org/mindthebrain/2016/08/24/perinatal-psychiatry-birth-traumaand-perinatal-ptsd-an-interview-with-dr-rebecca-moore/ Websites: Birth Trauma Trust and Birth Trauma Association References 1 Cook N, Ayers S, Horsch A. Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. J Affect Disord.

2018;225:18-31.

2 Dikmen-Yildiz P, Ayers S, Phillips L. Longitudinal trajectories of post-traumatic stress disorder (PTSD) after birth and associated risk factors. J Affect Disord.

2018;229:377-385.

Medical Woman | Spring/Summer 2018 29

A GLOBAL STAGE: ETHICS

The human cost of healthcare: protecting labour rights Arthy Hartwell is the Head of International at the British Medical Association, and leads the BMA’s international work on fair and ethical trade. She provides expert advisory support on global health and international development matters to international organisations such as the UN Sustainable Procurement in the Health Sector taskforce. Arthy sits on the editorial board for the BMJ Global Health journal.

Glove manufacture, Sri Lanka

Healthcare is a big business. The global market for medical goods runs into the billions and the supply chains that service this business are vast, employing millions of people worldwide.

If asked to put a human face to this market, who would you imagine?

Could you imagine a seven year old child working on a grinding mill, or a migrant worker working more than 80 hours a week?

Evidence shows that many supplies used in the healthcare sector are produced in unhealthy, unsafe, and unfair working conditions. Wide scale abuses have been reported in numerous manufacturing sites – from uniforms, to latex gloves, to disposable surgical instruments – where international labour core conventions are persistently disregarded, and the use of child labour is widespread.

Awareness of campaigns for fair and ethical trade of consumer products such as coffee, chocolate and clothing is high, but the same scrutiny is not applied to commodities used every day in healthcare.

The operating room is the largest user of medical supplies within the hospital, typically accounting for a third of all hospital supply costs.

When making purchasing decisions for healthcare consideration 30 Medical Woman | Spring/Summer 2018

is given to value for money and quality, but consideration is rarely given to the conditions in which these supplies are made.

Research carried out by the British Medical Association (BMA) has exposed unethical working conditions in the manufacture of a number of high-throughput supplies used routinely in the operating room.

Thousands of surgical instruments are used every day in operations throughout the UK. The global market for surgical equipment was valued at USD $10.5 billion in 2016, and expected to rise to USD $20.5 billion by 2025, due to the increasing number of minimally invasive surgeries across the globe.1 A growing proportion of the simple surgical instruments, such as scissors and forceps, that reach healthcare providers are manufactured in Sialkot, Pakistan. The manufacturers in this area produce more than 150 million surgical instruments every year, with a global market value of £200 million in 2013-2014.2 Outsourcing the manufacture of surgical instruments to developing countries can help boost income in local economies and support development, but outsourcing often involves seeking the lowest price, risking exploitation of workers and abuse of labour rights.

A GLOBAL STAGE: ETHICS While the healthcare industry plays a critical part in building the economy of many of these countries, labour laws often remain weak and government enforcement weaker still. In addition, we are increasingly witnessing global demand and competition turning human labour into a commodity; where labour standards become secondary to price.

There are an estimated 50,000 manual labourers working in the surgical instrument industry in Sialkot. A typical labourer will work twelve hours a day, seven days a week and earn around $2 per day. Taking a look at the medical gloves industry, much the same can be seen. This industry has a market value of more than USD $5 billion3 with most of the production of medical gloves outsourced to factories in Malaysia and Thailand, and a handful of other Asian countries. Many factories in these regions are reliant on migrant workers, where serious labour rights concerns have been documented including excessive working hours, retention of passports, and anti-union activities.

Workers often lack personal protective equipment

Employees such as women workers are especially vulnerable and often suffer human rights abuses in supply chains, ranging from wage differences to inhumane working hours.4 The garment industry, which produces uniforms for the healthcare sector, employs a large number of women workers. Nearly eight out of ten workers within this industry are women and they are increasingly recognised as the backbone of the Bangladeshi economy – an industry which generates billions of dollars (USD) each year. Female-led industrialisation of this type, has given millions of women the opportunity to provide for their families. It has been shown, this does not lead to improved life quality of the women, instead low wages, long working hours, and the exposure of harassment and abuse gives rise to women who are exhausted, undernourished, and deprived for their human rights.5 This creates a distressing paradox, set against the core of what the healthcare sector is built on and throws into the foreground the moral and ethical responsibilities of this sector.

Modern approaches to addressing labour rights abuses focus on models of ‘ethical trade’. This model aims to make international trade work better for poor and otherwise disadvantaged people.

Ethical trade is a top-down approach, and refers to the steps that purchasing organisations, such as hospitals take to improve the pay and conditions of people involved in the supply of goods and services. It asks purchasers to systematically assess the risk of labour rights abuses in the goods they procure, and to push for improvement where necessary. This includes working with companies throughout the supply chain to help workers exercise

© M.Bhutta

Teenagers wielding laryngoscopes, Sialkot

fundamental rights such as the right to safe and decent working conditions, and how to consider effectively issues of gender, vulnerability and marginalisation.

There is a huge opportunity to leverage the significant purchasing power of the healthcare sector to foster improvements in the working conditions for workers globally, promote decent work for all, and eradicate modern slavery from within its supply chains.

Further pressure and accountability is added by the UN Guiding Principles on Business and Human Rights.6 Businesses have a responsibility to minimise human rights violations in their supply chains, irrespective of whether the business contributed directly to the violation, and a duty to adequately address any abuses that do occur. Together with the UN Sustainable Development Goals,7 and the prominence procurement has been given, this has trigged a shift in focus towards labour standards in global supply chains.

The regulatory environment is closing in and shaping the market, bringing with it the opportunity to embed a zero tolerance principle towards labour and gender rights abuses.

There is of course much more that needs to be done. A clear signal must be sent that is it not business as usual – that healthcare organisations around the world want the goods it uses to not be at the expense of the health of workers in the global community.

References Grandview Research 2017, Global Surgical Equipment Market. Date accessed February 2018. Available from: https://www.grandviewresearch.com/press-release/ global-surgical-equipment-market 2 Swedwatch & British Medical Association 2015, Healthier Procurement – Improvements to working conditions for surgical instrument manufacture in Pakistan. Date accessed February 2018. Available from: http://www.swedwatch.org/ wp-content/uploads/2016/12/healthier_procurement.pdf 3 British Medical Association 2016, In good hands; tackling labour rights concerns in the manufacture of medical gloves. Date accessed February 2018. Available from: http://library.sps-consultancy.co.uk/documents/reports-and-reviews/in-good-handsmedical-gloves-report-web.pdf 4 UN Sustainable Procurement in the Health Sector 2017, Human Rights and Gender Equality in the Global Health Supply Chains. Date accessed February 2018. Available from: https://savinglivesustainably.org/knowledge-practice/contribution/sphswebinar-series-human-rights-and-gender-equality-in-the-global-health-supply-chains/ Dp777B.html 5 Swedwatch 2012, A lost revolution? Empowered but trapped in poverty. Women in the garment industry in Bangladesh want more. Date accessed February 2018.

Available from: http://www.swedwatch.org/wp-content/uploads/2015/04/ swedwatch_-_a_lost_revolution.pdf 6 UN Guiding Principles on Business and Human Rights 201. Date accessed February 2018. Available from: http://www.ohchr.org/Documents/Publications/ GuidingPrinciplesBusinessHR_EN.pdf 7 UN Sustainable Development Goals 2016. Date accessed February 2018. Available from: https://sustainabledevelopment.un.org/?menu=1300 1

Medical Woman | Spring/Summer 2018 31

UNWIND: YOGA

Forever starts today: a Jivamukti journey Dioulde Diallo was a cigarette smoking and fur wearing fashionista living the fast-life in the city. After trying out a Jivamukti yoga class in New York, she commenced her journey of commitment to yoga practice.

Dioulde is currently based in London, teaching both Jivamukti and Vinyasa Flow yoga. She believes yoga is more than physical exercise, she advocates yoga because of the sense of lightness and stress release achieved after each class.

I initially started practising yoga on and off in 2006, then, four years after my initial encounter in New York City, an opportunity to explore the Jivamukti yoga path presented itself in India. It is natural to feel apprehensive when embarking on an adventure.

The prospect of a new beginning generated a concoction of emotions; excitement, fear, an awareness of the many unknown and unanticipated challenges, as well as questions. Would I be fit and flexible enough for that yoga course? Who would help if I was injured or unwell?

Fear was a predominant emotion as I began sacrificing the fundamental securities of life; leaving a job without another lined 32 Medical Woman | Spring/Summer 2018

up, financial investment, and the prospect of being a newcomer in a potentially saturated field.

In the end, motivation and fitness were not the only key ingredients to success along this chosen path. Discipline was essential; acquiring this quality posed as both my quest and my propeller on a daily basis. Discipline got me on my mat for practice every day, it got me meditating for twenty minutes daily, and eventually it helped me stop smoking and adopt a healthier lifestyle – until it became routine.

A key lesson I learnt through my yoga journey, and now live by, is that change has to be self-directed. One needs to be ready,

UNWIND: YOGA and as you take the first steps of letting fear go – you realise you are prepared.

One of the founders of Jivamukti Yoga, Sharon Gannon, has shown me what it really means to walk the path of Yoga and the key is to remain a committed student, always. I have now transformed my life, and although the lifestyle aspects of Jivamukti yoga may, at first, appear daunting, I am determined to make the teachings more accessible to everyone curious and/or interested.

Diouldé’s tips for Yoga Here are two poses to get you started.

Tadasana (Mountain Pose) is the posture that invokes Samasthiti (Equal Standing). It is the practice of standing with equal, steady, and still attention. This asana (pose) is like the base or the mother of all asanas, from which the other asanas emerge. Most of the standing poses are shifts in a certain part of your body or an individual joint that spring from the Tadasana, while the other parts remain neutral.

In yoga, we believe there are some amazing benefits of the Tadasana. These include an overall improvement in body posture.

With regular practice of this asana, you will find your legs strengthen and it tones your buttocks and abdomen. It also improves the flexibility of your spine and improves sense of balance. In yoga, we additionally believe the pose helps regulate the digestive, nervous, and respiratory systems.

They say that if there was ever a blueprint pose, it was Tadasana. We believe that this asana works on your muscles so that your posture is not only better, but also pain-free while you are at a sedentary desk job. It works to align your skeleton and bring it back to a neutral stance. When this happens, your body comes in to the starting point for all the other asanas to follow.

However easy this might sound, owing to our excessive smartphone usage, unhealthy sitting postures at work, or when waiting for the bus or tube, and carrying heavy hand bags, there is always a tight muscle or an alignment amiss. We believe this asana corrects them all. It is the muscular effort that it takes to get into this asana that helps strengthen the core and straighten rounded, weak backs.

This asana, when taught in the right way, enables you to understand how much effort is required to come to the neutral position before you try the more complicated asanas. If you get this right, it will be quicker and easier to take on the more challenging poses.

Performing Tadasana (Mountain Pose) • Stand erect, and place your legs slightly apart, with your hands hanging along-side your body.

• You must make your thigh muscles firm. Lift your kneecaps while ensuring you do not harden the lower part of your belly.

• Strengthen the inner arches of your inner ankles as you lift them.

• Now, imagine a stream of white light or energy passing through your ankles, up to your inner thighs, groin, spine, neck, all the way up to your head. Gently turn your upper thighs inward. Elongate the tailbone such that it is towards the floor. Lift the pubic area such that it is closer to the navel.

• Look slightly upward.

• Now breathe in and stretch your shoulders, arms, and chest upwards. Raise your heels, making sure your body weight is on your toes.

• Feel the stretch in your body right from your feet to your head.

Hold the pose for a few seconds. Then, exhale and release.

The second pose to get you started in yoga is Adho Mukha Shvanasana (pronounced A-doh MOO-kah shvah-NAS-anna) or Downward facing dog pose.

Adho Mukha Svanasana looks similar to how a dog looks when it bends forward. This asana also has numerous benefits that make it an essential pose. The best part is, even a beginner can get the hang of this asana with ease.

In yoga, we believe some of the benefits of this pose include strengthening of the abdominal muscles and also of the hands and feet, as the body weight is on your hands and feet. Additionally, the downward facing dog is actually an inversion. The hips are lifted, and the head is dropped below the heart, such that there is a reversal in the pull of gravity. We also believe it prepares the body for better balance. The pose can also help in reducing anxiety, helping to relax and calm your mind. We believe that as the neck and cervical spine are stretched, stress is released.

Performing Adho Mukha Shvanasana (downward facing dog) • Stand on four limbs, such that your body forms a table-like structure.

• Exhale and gently lift your hips and straighten your elbows and knees. You need to ensure your body forms an inverted ‘V’ shape.

• Your hands should be in line with your shoulders, and your feet in line with your hips. Make sure that your toes point outwards.

• Now, press your hands into the ground and lengthen your neck.

Your ears should touch your inner arms, and you should turn your gaze to your navel.

• Hold for a few seconds, and then, bend your knees and return to the table position.

If you are in your early days of practicing yoga, it is easy to know whether or not you are doing this asana right. If you feel that your joints are stressed, or you are unstable, you need to check your alignment. Start over, and make sure your knees are right under your hips, and your hands are beneath your shoulders. Also, make sure that the creases on your wrists and elbows are aligned with your mat.

Diouldé’s tips for Meditation: Choose your seat: on a chair, cross legged on the floor, on a zafu or blanket; making sure your hips are higher than your knees • Be still: commit to your seat, so make sure you are comfortable and warm • F ocus on your breathing: make your inhalations and exhalations equal, counting to four with each inhalation and exhalation can help Perhaps, start with five minutes a day, building up to 20 minutes.

An alarm clock with a soft ring tone can be used to help your meditation. You will have many thoughts entering and leaving your mind. Let them in and let them go by refocusing on your breathing.

Practice, practice, practice!

Diouldé extends her gratitude to Hachi Yu, Yogeswari and Jules Febre, Sharon Gannon and David Life, for their continued inspiration and guidance.

May all beings everywhere be happy and free and may the words, thoughts and actions of my own life contribute in some way to that happiness and to that freedom for all.

Medical Woman | Spring/Summer 2018 33

OBITUARY

Dame Beulah Bewley A physician who blazed a trail for female doctors to follow B: 2nd September 1929 D: 20th January 2018

Dame Beulah Bewley was born into an upper-middle-class family, the second daughter of Ulster Bank Official John Knox and wealthy heiress Ina Charles, in 1929.

As a child, Beulah thought that she would marry a clergyman and be a great musician.

She also dreamed of being a doctor. Her ambition was fuelled by her experience of diphtheria and an appendix operation – and by the deaths of two schoolmates. Naturally, such an announcement in those times was met with resistance and Beulah recalled her Uncle Joe suggesting that she do dentistry so that she could meet a husband and have children. “Dentistry would be more suitable for a nice girl like you,” he told her.

Inspired by her spinster aunt who said “no woman should be entirely dependent on a man,” Beulah ignored her uncle’s advice and went to Trinity College, Dublin to study medicine. In her fourth year she met a young doctor, Thomas Bewley, at Adelaide Hospital in Dublin. He was from a Quaker family that owned Dublin’s celebrated Bewley’s coffee shops. The couple married in 1955, when he was training in psychiatry.

Beulah qualified in 1953, and it was the first year that the General Medical Council (GMC) insisted that every doctor do two six month periods of medicine and surgery 34 Medical Woman | Spring/Summer 2018

before registration. She described her working life between the ages of twentyfour and thirty-eight as a “zigzag career”, doing some paediatrics, some psychiatry and some family planning, around her growing family. This changed when she saw an advertisement in The British Medical Journal in 1969 for a new MSc in social medicine at the London School of Hygiene and Tropical Medicine, which was being launched by Jerry Morris, a respected epidemiologist who discovered the connection between exercise and health. She was the only woman on the course, but it was the start of her distinguished work in public health, which included groundbreaking research into the effects of smoking on children.

Beulah went on to become a pioneering doctor who rose to the top of her profession in the face of entrenched sexism and broke barriers for the generation of women who followed her into medicine.

Beulah became a member of the Medical Women’s Federation and was later elected President in 1986, dedicating her time trying to get female doctors into positions of power in the 1980s. She achieved fellowship of three medical royal colleges, Paediatrics and Child Health, Physicians, and Public Health Medicine, and mentored many young doctors.

After asking, in print, why there were so few senior women in medical organisations, she stood for the GMC in 1979. Beulah served for 20 years at the organisation. As Honorary Treasurer of the GMC (1992-99), the highest rank any woman has achieved there, she encouraged the organisation to take on more women – and lobbied council members of royal medical colleges to increase their previously insignificant female intake. As her daughter, Professor Susan Bewley, an obstetrician at King’s College London, once observed, Dame Beulah Bewley was a woman ‘leaning in’ long before the phrase was even invented.

Beulah retired in 1994 as emeritus reader in public health medicine at the University of London, but remained on the GMC until 1999. In 2000, Beulah was honoured with a DBE in recognition of her services to public health and in promoting equal opportunities for women in medicine.

As she grew older she developed dementia, but started to write her memoir with the help of her family. Her autobiography, My Life as a Woman and Doctor, was published in 2016. She died from the effects of dementia and heart disease on January 20th, 2018, aged 88. She is survived by Thomas and her children Susan, Louisa, Henry and Emma. Sarah predeceased her.

OBITUARY

Dr Catherine Harkin B: 21st November 1956 D: 12th June 2017

After completing a degree in zoology and forensic science Catherine Harkin applied and was accepted to study medicine. She practised for nine years in Bellevue Medical Practice before moving to Edinburgh Homeless Practice in 2004, developing good relationships with both patients and staff.

She worked as a volunteer doctor with Medical Justice and Freedom from Torture, medical liaison officer for the Royal Medical Benevolent Fund, and Scottish Secretary for the Medical Women’s Federation. Catherine represented colleagues on both Lothian GP subcommittee and the BMA’s Equality and Diversity Committee. Catherine had a natural

way of reaching out and providing comfort, sanity, wisdom, and hope. She had utter authenticity and a belief in the rights for all, of justice, in all walks of life, for all people.

Diagnosed with bowel cancer in February 2015, she fought for her life and cherished each day.

Catherine was grateful to the MWF which she stumbled across at a difficult time, late on in her medical career. Her first experience of the MWF was a conference addressed by Dr Kim Holt, she returned with her faith restored and inspired after seeing the courage of sharp, clever and courageous female colleagues.

Catherine was the MWF representative on the BMA Equality and Diversity Committee and co-organised the MWF Spring Conference in Edinburgh in 2016. She was also the author of a witty column in MWF’s magazine Medical Woman, based on a fictional character called Dr Iona Frock.

Catherine was a volunteer with Medical Justice and Freedom from Torture. She was also a passionate supporter of Scottish Independence,

a member of the Iona Community, a soprano with Aria Alba Opera Group and a Dragon with the Port Edgar Dragons Paddlers for Life.

Something that most MWF colleagues will not know is that Catherine was a member of Alcoholics Anonymous for over 20 years, and her gratitude to AA and to Al-Anon was enormous. Her experience of alcoholism and recovery, combined with her doctor’s knowledge and practice, gave her a deep understanding of addiction and recovery, and a love for people struggling on the journey.

Catherine was overjoyed by the passing of Civil Partnership and Equal Marriage legislation, and was among the first in Scotland to publicly join her life partner, Caroline Gooch, in a civil ceremony in 2007, before going for the ‘upgrade’ in 2017.

Catherine had a catastrophic stroke on 6th June 2017 and never recovered. She is survived by her wife and soul mate, Carrie, cats Katisha, Kitski and Montezuma, 50,000 honeybees, a pond full of frogs, and an enormous family of friends and colleagues.

Dr Patricia Anne Burton B: 21st June 1937 D: 17th February 2018

Pat Burton was a student at Blackburn High School for Girls and qualified as a doctor in 1961 after training at the University of Manchester Medical School. She completed Senior House Officer posts and a period as a Demonstrator, before taking on the position of Assistant Lecturer in the Department of Pathology in Manchester. This was followed by lecturer posts at UCL and Edinburgh, and she completed training in pathology at Newcastle.

Academically able, her first paper was in the Lancet in 1966, and she was awarded the David Dickson Research Prize in 1973 from the Newcastle Regional Health Authority on ‘Brown fat in the human adult’. She continued to be active in research and to publish throughout her working life and beyond.

Following her work in 1973, her collaboration

with biochemists in Nottingham led to a further publication in 2017 when she was 80 years old; a remarkable contribution.

In 1973 she moved to Bristol as her husband John had been appointed Senior Lecturer in Medicine, and after several years of undertaking short term locums in general practice, dermatology and histopathology, she was appointed at Southmead Hospital in Bristol as a Consultant Histopathologist, and was Head of Department from 1984-8.

At that time she was one of a handful of female consultants working in the city, and she provided a superb role model. She was active in the Medical Women’s Federation (MWF) as the regional representative for many years, and many young doctors benefited from her encouragement, kindness and generosity of spirit. As Careers Co-ordinator for the MWF she gave evidence to the Department of Health on part-time postgraduate training in medicine, and was passionate about ensuring equal opportunities for women doctors. It is hard to envisage now how controversial the notion that female doctors might wish to work parttime for a few years whilst they had child care responsibilities might be.

She arranged many career’s evenings for junior doctors, always encouraging and with great energy and warmth. This was the time when I first met her, arriving in Bristol in 1987 pregnant and no job. Her support and belief was very helpful. Needless to say she then persuaded me to become the MWF South West representative and thus began my involvement in MWF. This generosity of spirit was recognised by her daughter Jane who has commented, “Mum was so proud of the MWF group and really enjoyed championing younger women and encouraging them to reach their fullest potential in medicine”. She retired in 2000, characteristically delaying her retirement due to the premature death of a colleague.

After retirement she and John moved to North Perrot in South Somerset, and they continued to spend three months of every year in their house in South Africa for over 20 years. She leaves three children – working variously as an eye surgeon, at the Home Office and Christie’s, and nine grandchildren and her beloved husband John, to whom she was married for 54 years.

Professor Selena Gray Past President, MWF Medical Woman | Spring/Summer 2018 35

BOOK REVIEW

Flesh and Blood: A History of My Family in Seven Maladies by Stephen McGann Sarah Matthews is a GP in the Midlands who trained at St Mary’s more than a few years ago. She has developed an interest in medical humanities and, more latterly, medical politics. She considers herself poorly read, but is working on that agenda.

Stephen McGann will be well known to some of us as the doctor in the BBC1 series ‘Call the Midwife’. In my house, we refer to this as ‘warm bath TV’; what you might choose to watch for a relaxing hour on a Sunday evening when you have everything in hand for the coming week. The themes may be taxing, but the characters are engaging and we follow them through their ups and downs hoping that another tricky delivery comes right or sister Julienne says the perfect words to calm a situation. However, nothing comes right in Stephen McGann’s new book. He looks back into the history of his own family to examine various deaths which have occurred, and uses these as themes to consider the broader social and cultural history of the time.

As the descendant of Irish immigrants to Liverpool, this gives him the opportunity to consider The Great Hunger of the Irish Famine in the late 1840’s and how this led to mass migration both to England and America; living in poor tenement apartments in the Liverpool dock area was not much of an escape and the rate of infant mortality remained very high. The death certificate for Teresa McGann, age one, in 1868 gives the cause of death as ‘marasmus’ for which McGann reasonably paraphrases ‘starvation’. He ably draws the scene of a child wasting away in a filthy hovel despite being born in love and hope. He documents the illiteracy of her parents, marking the registration of her death with a cross on the certificate.

36 Medical Woman | Spring/Summer 2018

McGann works his way through a smallpox death, reveling in the great leaps we have made in the elimination and control of some diseases and the availability of vaccines to the working poor. He also portrays a young death from pneumonia in a great-uncle who had survived hypothermia after being in the Atlantic after the Titanic sank; his own asthma, likely linked to panic attacks, and his father’s heart disease.

In the section on Trauma, McGann discusses the Second World War and his father’s part in Operation Overlord. Although his father survived the experience, a stick grenade caused multiple shrapnel injuries and he was invalided back to England, waking up at the Leicester Royal Infirmary. The author suggests that his life may have been saved by the use of penicillin, which was available only to the troops of the time in such life-threatening circumstances. This allows an interesting comparison to modern day, with the more recent and inappropriate use of antibiotics for coughs and colds: we move towards antimicrobial resistance.

As a reader, the true value of the book was not inside the covers, but in reflecting on the themes of death and illness, and extending these thoughts to my own family historically and how things may, or may not, have altered our paths today. Of my two grandmothers, one arrived from Ukraine but died in 1921 of puerperal sepsis in the East End of London; an environment for another group of first generation immigrants, probably not far removed from that of McGann’s family in the 1860’s. Subsequently, I never met either of my father’s parents and a significant part of his childhood was spent in a south London orphanage, which he left at 14 years old to make his own way in the world.

My maternal grandmother was born to a military family at Colchester barracks and our first family photograph of her is aged two years old in India with the company. She contracted polio in childhood and walked all her life with a leg brace on one leg. This did not prevent her from having a normal life; she married and had seven children of whom my mother was the youngest.

Our family history is also one of disease, that in modern times may be prevented, treated, or eradicated, linked to the movement and renewal that comes with immigration. My practice in Coventry reflects a wide variety of ethnic backgrounds from around the globe. Every family has a story to tell, whether recent arrivals or the children of patients who have been with us for 60 years.

As we see the pictures of boats trying to make the crossing over the Mediterranean, or of children travelling alone and arriving in the UK, I hope we will all reflect on the generations of immigrants who have contributed to the diversity and prosperity of the country we call ‘home’.

Finding time

EDITOR’S FLASH FICTION

An inspired solution for organisation, multi-tasking, and time-keeping...

A long, black hand ticked. Loudly. Incessantly. Progressively. Eventually rewarded by an eager chime emanating from the pearl face. I watched the gold pendulum, planted in the tall wooden body swing, as steadily as time. The worn leather squeaked gently as I shifted on the brown couch. I looked ahead to the panelled blue door. There was a tarnished black sign over the top; I could make out a ‘P’, ‘lice’ and ‘Box’. I wondered momentarily what it could mean? The receptionist’s desk lay abandoned. Externally, the hospital had looked similarly aged.

Months ago things had begun to unravel. I thought it was my fault. I felt as though I had been losing my humanity. I could have explained more to the patient. Spent longer with his family. Fed him a little more yoghurt because he couldn’t reach. But I couldn’t – my bleep, the nurse, a meeting – there wasn’t time. There were long hours and late nights. There was sickness in the family. Love.

Lost. Friendships. Fizzled. And eventually the passion that had sustained me began to waiver. In the end, I had done the best I could to wrap up the situation.

“Talk” said the GP. It would help expel the buildup of love, that turning stale had morphed into guilt. I searched unconventional methods to help re-instate the human I was. I had spotted the advert in a local newspaper: ‘Humans will face grave difficulties in life. I can help with time, travel, therapy.’

Beside it stood the dishevelled looking figure of a tall, wiry man. This ‘Doctor’ as he had called himself, was clad in tweed.

The clock chimed again. I looked, expectant, to the blue door. I took a few steps to the reception desk and rang. A shrill electric sound punctured the air. Silence. Ensued. Nothing.

“Ah-Ha!” My body twitched with surprise at the accusation, I had thought I was alone.

I looked up into the narrowed blue eyes, messy brown hair and red bowtie of the eccentric stooping over me. His striped shirt, unchecked, spilled over his belt buckle. Damn. I always attract mavericks.

“Hi, I was due to see you at -” “Never mind…” he appraised me from head to toe, stuck his hand into his left trouser pocket, and after some suspicious fiddling pulled out an odd-looking gadget. Not a tendon hammer. Not an ophthalmoscope. Certainly, not a stethoscope. I followed its gentle buzzing sound, mesmerised by the blue glowing tip. He bought his hands to my face, curled his index fingers under my jaw and with each thumb pulled down my lower lids.

“I know this trick” I said gently, “I’m not anaemic.”

“Right” he puffed ‘“you’ll have to do!”

Until this point I had been under the impression that I, the patient, had selected the ‘Doctor’, so I pulled out the newspaper cutting to show him why I was in attendance.

“I’m here for your…time, travel, therapy…” I hesitatingly pointed to the phrase on the advert, “is it …like… a retreat.”

He looked at me for a second, then snorted with laughter.

“They did it again! They got it wrong, too many commas… Doesn’t matter… you’re here to join me in time travel?”

I was astounded. Time travel? Was someone filming secretly? Did someone want a reaction worth a few laughs?

“I need advice from an insightful and empathic individual who can understand my predicament and help me build my future, like a mentor.”

He perched on the edge of the desk, pulled his leg up across his knee and rubbed a thoughtful hand across his chin. I took this as a cue – the session had begun – I resumed my place on the couch, stretched out my legs and closed my eyes.

He sighed deeply, “Prioritise, delegate, never stay late, try your best and stop feeling guilty.”

I scowled, “I know that stuff.”

“Then put it into practice… Eat lunch, empty bladder at regular intervals and take up some extra-curricular activities.”

I opened my eyes. He rolled his.

“Actually, I know exactly what to prescribe you, a gadget all doctors ought to have, look here… “ He paused, tugged a pink pocketsquare out of his jacket, made his way to the blue door and thoroughly wiped the black sign: ‘Police Box’ it read. He pointed his probe to the blue door so that it began to whir and pulse frantically.

“This!” the blue door flung open, ”This is how I do…er… time travel therapy.”

“Travel where?”

“Travel what, you mean: time.”

“This is the gadget all doctors need?” I laughed, disbelieving.

“Well what do you want – Bond’s x-ray desk, Spock’s probe, Inspector Gadget’s hat, the KGoal for your pelvic floor? TARDIS is the only gadget that’ll give you what you need – time. Tempted?” His eyes twinkled merrily as I peeped inside, contemplating my past, present and future.

Medical Woman | Spring/Summer 2018 37

Much progress has been made, andmuch muchmore moreremains remainstotobe bedone! done but