Medical Woman – Vol 37, Issue 2, AUTUMN/WINTER 2018

W EDICAL W MAN

VOLUME 37: ISSUE 2

AUTUMN/WINTER 2018

The Essential Issue www.medicalwomensfederation.org.uk

Editor’s Letter To time: mistakes made lessons learned the essentials of survival & thriving well

F

ollowing the success of The Flexible Issue it brings me great pleasure to unveil The Essential issue. I regard it as the magazine equivalent of a first aid case, and as you leaf through the coming pages you will discover a variety of articles at your disposal.

Media coverage of the gender pay gap in medicine, the discriminatory manipulation of test scores at Tokyo medical school, as well as the multiple cumulative factors implicated in the Bawa-Garba case, have provided much to ponder over the last six months. With this in mind, the current issue strives to engender supportive and supported work practice, strengthening you on an individual basis for your daily roles.

For career guidance turn to lecturer Kathryn Davison who cites the importance of mentorship and valuing the experience of co-workers, as she delves into her transition from community pharmacist to pharmacy education. Farah Bhatti, recounts her inspirational story from medical student to cardio-thoracic surgeon, citing skills in planning and networking as key attributes to cultivate.

Clare Evans, author and productivity coach, provides essential skills and invaluable tips for improving time management.

Talking about time, our central feature in this issue focuses on return to work following time out of clinical practice. Our authors give us their personal perspectives on time out, whether due to ill health, maternity, or to develop their skillset.

Reflecting on the Bawa-Garba case, in conjunction, with our Time Out feature we cover common clinical mistakes and how to avoid them.

I believe in the importance of contributing to a supportive, constructive and productive work environment and Trauma and Orthopaedic surgeon Simon Fleming discusses how we, as individuals, can tackle bullying and harassment in the clinical environment, with a view to generating a more compassionate environment for both doctors and patients.

In another sense, Louise Newson gives her perspective on time out through discussion of the menopause and the complexities of dealing with this, while Charlotte Gath focuses on retirement and explores the intricacies of calling time on a clinical career.

This issue’s A Global Stage introduces you to the commendable work of the Medical Women’s International Association (MWIA). We have intriguing perspectives on medical training in Ethiopia from an Ethiopian and a British doctor.

Continuing along the theme of support, personal instructor Ben Andrews talks finding time for exercise and how pilates can help your strengthen your body and improve your posture.

I hope this issue is as much a pleasure to read as it has been to produce. I look forward to hearing from you – my contact details are below – and to seeing you at our upcoming conference in November.

Fizzah Ali @DrFizzah Fizzahali.editoratmwf@gmail.com

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

News and Events

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Editor-in-Chief: Dr Fizzah Ali fizzahali.editoratmwf@gmail.com

To be an educator

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Career planning: Public health

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Inspiring generations

5

Skills workshop: Time management

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Perfect posters

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Training and beyond: Time out

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Editorial Assistants: Mr Thulani Mutopo Miss Kimberly Murrell Design & Production: Toni Barrington The Magazine Production Company www.magazineproduction.com Cover illustration: rawpixel.com Articles published in Medical Woman reflect the opinions of the authors and not necessarily those represented by the Medical Women’s Federation.

Medical Women’s Federation Tavistock House North, Tavistock Square, London WC1H 9HX Tel: 020 7387 7765 E-mail: admin.mwf@btconnect.com www.medicalwomensfederation.org.uk @medicalwomenuk www.facebook.com/MedWomen

The return journey

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Featured perspectives

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Clinical error

14

Combat bullying: Acorns to oaks

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Spring Conference

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The transition to retirement

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Mental health: Psychosis

22

Registered charity: 261820

Family intervention in psychosis

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Patron: HRH The Duchess of Gloucester GCVO

CBT in psychosis

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President: Dr Henrietta Bowden-Jones

Time out: the menopause

28

President-Elect: Professor Neena Modi

Healthcare: An international stage

30

Ethipia: State of education

32

Postural power

34

Book review

36

Compassionate care

37

Vice-President: Dr Olwen Williams OBE Honorary Secretary: Dr Clare Gerada MBE Honorary Treasurer: Dr Heidi Mounsey

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

South West Local Group Report In the South West, we have made efforts to generate networking opportunities for our members, as well as raising the profile of the Medical Women’s Federation regionally to non-members.

We co-hosted a successful careers evening for medical students with Bristol University’s Medical Women’s Society. The event titled ‘Women in Medicine: the future’ was the student society’s inaugural event and timed to coincide with International Women’s Day. It featured short presentations from senior clinicians about the challenges currently facing women in medicine, support networks available, and how to navigate careers in competitive specialties.

The floor was then opened for questions, leading to interesting conversations over snacks and drinks. The evening provided a lovely opportunity for students and doctors to learn from each other and to network at different levels across the profession.

In August, we enjoyed an evening meal at Professor Bhupinder Sandhu’s home for our regional meeting. We were a diverse group incorporating students, surgeons, GPs, academics and physicians. The meeting provided us with the opportunity to start planning for the MWF Spring Conference in 2019, which we are looking forward to hosting.

Dr Philippa Walker-Smith and Dr Manjit Dhinsa

Scotland Local Group Report It has been a busy year for the Scottish Medical Women’s Federation. We held our first evening meeting attracting nearly 30 people on 31st May. The evening was entitled ‘Making Connections’.

On speaking to fellow medical women in Scotland many are keen to support these types of events but have found it difficult to attend due to distance or getting time away from work and/ or family. The evening was hosted by the Glasgow Women’s Library a fascinating centre steeped in history. We were fortunate to have a tour and find out about all the work they do.

The rest of the evening saw presentations as diverse as ‘Women in the Criminal Justice System’ to ‘Managing Confusion’. We also heard from Edinburgh Medical Student, Izzy Utting, who spoke about the growth of the Medical Women’s Federation locally through the use of social media and a careers speed dating event. Even home baking has been used!

Technology is something that will play a prominent role in the Scottish Medical Women’s Federation going forward as we seek to both recruit new members and support those already in the organisation.

There is another event planned for 1st November that will see our medical students and junior doctors present their research and elective projects.

A ‘Kindness and Excellence’ event is in the early planning stages for 21st March 2019. Please do get in touch if you would like to know more.

Dr Claire Copeland

DATES FOR YOUR DIARY October 2018 3 months extra free MWF membership promotion 18th - 19th October 2018 BMJ Careers Fair 15th November 2018 MWF Council Meeting, London 16th November 2018 MWF Autumn Conference, London – ‘Making Change Happen within Medicine and Beyond’ December 2018 Katherine Branson Student Essay Prize opens January 2019 MWF subscription payments due 8th March 2019 International Women’s Day 17th May 2019 MWF Spring Conference, Bristol 25th - 28th July 2019 MWIA Centennial Congress, New York

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CAREER SNAPSHOT

Learning how to be an educator: from student to teacher Kathryn Davison is a Principal Lecturer in Pharmacy Practice, and Team Leader for Pharmacy Practice and Clinical Therapeutics at the University of Sunderland. With a career currently spanning over 20 years she worked in community pharmacy in the early years of her career, later making the shift to academia in 2010.

She balances her academic career alongside motherhood and practicing the martial art of Karate.

‘My advice… in the early years… is to keep in contact with a mentor and value the experience of the team around you.’

I often find it difficult to label myself when asked what I do for a living. I am by background a pharmacist and indeed I still practise clinically but having worked in academia for the last 8 years I am now also a Principal Lecturer. The transition from one field of pharmacy to another came about without forward planning for me, but it is certainly a career choice I would recommend to peers and one which has brought me endless career satisfaction.

I graduated from the University of Sunderland in 1998 and undertook my pre-registration training within an independent community pharmacy. On qualification I continued working in this arena managing a busy community pharmacy with a team of staff.

In retrospect this was a huge undertaking, considering I was merely 22 years of age with no previous managerial experience.

I do not remember my inexperience being a consideration at the time – I can only attribute this to blind naivety – but it certainly meant I had a steep learning curve in the early years of my career.

Thankfully, I had a fantastic team of experienced co-workers around me and their support was invaluable. My advice to young pharmacists in the early years of their career is to keep in contact with a mentor and value the experience of the team around you.

Having someone to ask a question of or gain advice from is crucial when you are lacking in experience.

Thankfully, those early years of autonomy, were also very successful years, and although my experience was lacking my enthusiasm was not. At that time the role of the Pharmacist was changing from that of a compounder and dispenser of medicines to a more clinically focused role. Today every community pharmacy has a consultation room, but back then pharmacists were being encouraged to embrace the opportunities that the new pharmacy contract offered or perish as healthcare professionals. So that is what I did.

I designed and implemented the construction of a consultation

room in the pharmacy, one of the first in the area, and worked with the local Primary Care Trust to introduce several clinical services into the pharmacy.

It was also around this time that I began to employ and mentor other pharmacy trainees both as undergraduates and as preregistration pharmacists. I loved the teaching element to my role albeit on a one-to-one basis. It felt very rewarding to help mould and inspire future generations of pharmacists. In 2007 I was asked to do some sessional teaching on safe medicines use for the local Primary Care Trust and teach pharmacology to independent prescribers at Northumbria University. This ignited a passion for teaching on a wider scale and served to highlight other potential career options.

In 2010, after the birth of my second child I was offered a maternity cover Academic Tutor post at the University of Sunderland. Although the position was temporary I felt that it was an opportunity I could not miss. Having run a busy community pharmacy successfully for twelve years I was ready for a new challenge. The move to academia was certainly not easy. University life had changed dramatically since my time as a student, even in as much as the introduction of the internet as an educational tool. It was a steep learning curve, but I relished the challenge and undertook a Masters degree in Clinical Pharmacy to help bring my skills and research awareness up to date. Working full time, whilst studying part time and bringing up two young children was not easy. It was in fact the opposite, it was hard work, but teaching in academia is very different from working an 8am-6pm shift. The working hours are flexible (which was invaluable with two young children to consider) and you control your own work patterns. This of course requires self-discipline and commitment. I often found myself working very late at night studying or preparing teaching, but this allowed flexibility to spend time with my children and I valued that hugely.

The temporary post did not last long. Within three months I was offered the role of Senior Lecturer in Medicines Use, which a few years later, following successful module and programme leadership, led to promotion to Principal Lecturer. However, my previous managerial experience was not wasted, and I now manage a team of academics at the University.

Academia has given me a wealth of different experiences and opportunities; from teaching abroad, to autonomy to develop novel academic programmes, and the confidence to publish my own research. It has brought great satisfaction to my working life; I get no greater satisfaction than seeing the young pharmacists of the future grow in knowledge and confidence. Knowing that I play a part in that is the most rewarding part of my career.

Medical Woman | Autumn/Winter 2018 3

CAREER PLANNING: PUBLIC HEALTH

Making a big impression: practising public health medicine Helen Skirrow is a Public Health Medicine Specialist Registrar in London currently based at Imperial College where she also originally studied Medicine. Outside of work, she enjoys adventures with her husband and two young sons in either their campervan or their canal barge. Their barge is called Jemima Puddle Duck and is moored at the bottom of their garden.

Can you tell us a bit about yourself?

I am a Public Health Medicine ST3 in London. After studying Medicine at Imperial College London, I stayed there for my foundation training. I then did my Masters in Public Health from the London School of Hygiene and Tropical Medicine and whilst living in New York helped set up a community health program with the Earth Institute at Columbia University.

Why did you decide to do Public Health?

I have always been interested in the wider determinants of health and how these contribute to society’s health inequalities.

I realised as a junior doctor that my passion lay in improving health and wellbeing at the population level. After my time in New York, I returned to practising medicine alongside a clinical service improvement role at my old London foundation trust. I surprised myself by finding I enjoyed the non-clinical work more.

Choosing public health medicine is a big decision for a clinician as your interaction with patients is very different. For example, it is usually at the end of the phone if they or a contact of theirs has a notifiable infection.

Describe a typical day as a Public Health registrar?

Working as a public health registrar differs depending on where your current placement is, and tends to involve longer term projects. Since the NHS health reforms moved public health into local authorities this is where all trainees start on the scheme.

Local Authority Public Health Departments can be a big change for medics used to hands on clinical care, but they offer really varied opportunities. During mine, I enjoyed working on a local Radon risk project and a new online sexual health testing service. All trainees must undertake placements in local Public Health England Health Protection Units which respond to notifiable infectious diseases and outbreaks. Health protection therefore entails more reactive work providing an acute response service and also being on the out-ofhours rota, though you are usually based at home.

Once you have completed your membership exams and these initial training placements there is flexibility to tailor training to your interests. Placements are possible at acute hospital trusts, Clinical Commissioning Groups (CCGs) or at national health policy bodies such as the Department of Health and other organisations such as Transport for London.

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What do you enjoy most about training in Public Health?

I really enjoyed opportunities in health protection to lead responses to local infectious disease outbreaks. Overall, I relish the varied nature of the training and working with colleagues from a variety of backgrounds. There is a real commitment in public health to improve health as you tackle projects using a multi-disciplinary approach.

I am now exploring academic public health which I had not considered at the start of my training. I am back at Imperial College London working on maternal immunisation uptake research before I go out of program to start my PhD next year. During my PhD I will study Respiratory Syncytial Virus (RSV) epidemiology to understand how a new RSV vaccine may reduce the amount of unnecessary antibiotics prescribed for viral respiratory infections in children.

What are the challenges in your chosen career path?

I would say the biggest challenge is explaining to people (including other medics and my family) what I actually do! Public Health is not well understood within medicine let alone outside of medicine.

Another challenge is that the benefits of investing in some public health interventions may not be seen for several generations, which means they may not represent ‘quick wins’ politically.

Justifying investment in public health is thus a challenge the whole speciality faces.

Personally, I have had to deal with negativity about my choice to train in public health. One hospital consultant told me “You really will be considered the lowest of the low in terms of the medical hierarchy”. I am happy to be considered as such by people who are worried about medical hierarchies – I am pursuing a non-traditional path and I remain passionate and excited about my work.

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

Public Health is a fantastic option for those who are truly passionate about working together to improve the lives of all in society.

However, do not consider it just because you are disillusioned or want to escape clinical medicine rotas! The public health part A membership exam is tough, and training is not the easy option as your career pathway is not as clearly set out as it may be some clinical training paths.

Consider doing something public health related either clinical or non-clinical after foundation training before committing to Public Health to gain more experience. I run a taster program in London, Kent, Surrey and Sussex. For those interested in applying, visit the London Public Health website for more information.

SKILLS MENTOR: RESEARCH AND REPRESENTING

Inspiring generations: insights from a cardiac surgeon Farah Bhatti is a Consultant Cardiothoracic Surgeon. As well as operating, Farah enjoys teaching and training. Farah is Chair of the Women in Surgery Forum (WinS) and a Council Member of The Royal College of Surgeons of England, and Welsh Chair for the Medical Women’s Federation.

She enjoys travelling in her spare time.

Make decisions: taking the surgical path My road to becoming a surgeon was a series of realisations of what I wanted to do with my life, culminating in a career as a cardiac surgeon. From my earliest memories, I remember being desperate to be a doctor – my father’s ill health undoubtedly playing a pivotal part. As a Londoner, I aspired to get a place at Guy’s Hospital to train, but was persuaded to apply to Oxford University by my headmistress. At Somerville College, I was interested in all things heart-related for my BA in Physiological Sciences. During my clinical training at Cambridge I really did have a ‘eureka’ moment when I walked into an operating theatre and it just felt right – I felt I belonged there. I decided there and then that I would become a cardiac surgeon. It was as simple, or as naive, as that!

I secured an elective at the world famous Texas Heart Institute where I had the privilege of scrubbing alongside Denton Cooley, one of the pioneers in cardiac surgery. I was lucky enough to be Professor Sir Roy Calne’s first female houseman. After that I set out to gain experience to be eligible to sit the Fellowship of the Royal College of Surgeons (FRCS), which included work at St Mary’s in London doing Accident and Emergency and anatomy demonstrating, six months at Oxford in cardiothoracic surgery and a two year surgical rotation in Bristol. Geographical location was not an issue for me – I wanted to go to the best jobs and was prepared to travel across the country to do so. Having gained my FRCS, I spent time at the Royal Brompton and then Harefield Hospital working for Professor Magdi Yacoub; my training in cardiothoracic surgery had begun.

trainees and those making the decisions affecting our training and job prospects.

Contribute to diversity: encouraging women in surgery It is important to me that I am involved in maintaining standards and supporting the next generation of cardiothoracic surgeons.

I am the Equality and Diversity Lead for the Graduate Entry Medicine Programme at Swansea University Medical School. I am Chair of The Women in Surgery Forum (WinS) and a Council Member at The Royal College of Surgeons of England. These roles make me feel that I am giving back to the profession.

As a young doctor, I was very clear about wanting to be a surgeon, and was only occasionally discouraged from this goal by others. There is, however, a real gender imbalance in the surgical profession. Only 12% of the consultant surgeons are women, and whilst this is better than the 3% figure two decades ago, there is clearly room for improvement. The Women in Surgery Forum at The Royal College of Surgeons of England has a mission statement to Encourage, Enable and Inspire women to fulfil their surgical potential. WinS has a network of over 5000 people and provides practical advice and conferences showcasing role models.

Key directors £

emember what motivated you: hold onto the reason you R chose your career path – it will help you during difficult times.

£

ave a plan of action: plan ahead, know deadlines of exams/ H job applications etc, but don’t worry if you need to change course.

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I f you don’t apply, you won’t get the job: don’t doubt yourself or talk yourself out of opportunities that present themselves.

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on’t forget your other interests: surgery is a challenging D and time-consuming career, but you need to ensure you don’t neglect your own health or take your family and friends for granted.

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ake the most of networking: organisations such as the M Medical Women’s Federation and Women in Surgery provide unique environments where you can speak to peers and senior colleagues and leaders for honest advice and support.

Take chances: research and represent Whilst looking for a training post one day, I happened to see a research post advertised in the British Medical Journal (BMJ). I thought I would apply, although I was not particularly optimistic about my chances. That was how I managed to find myself back in Cambridge researching transplantation. The work was both intellectually stimulating and gave me an insight into the rigours of a scientific approach. I am sure it also helped me secure my training post in cardiothoracic surgery in the North West and ultimately my consultant post in Swansea.

I have always been interested in passing my knowledge on to others, and as a registrar, I was elected by my peers to be a trainee representative to the Society of Cardiothoracic Surgeons of Great Britain and Ireland, probably my first leadership role. My motivation was to improve two-way communication between the

Medical Woman | Autumn/Winter 2018 5

SKILLS TOOLKIT: TIME MANAGEMENT

Controlling clock: tips and tricks for time management Clare Evans is a Time Management and Productivity Coach and the Author of Time Management For Dummies. She works with individuals and organisations in the UK and internationally. She coaches small groups, departments and teams through workshops and seminars for businesses and organisations.

We have a set amount of time each day and it can be difficult to get everything done, especially with different demands or roles in your life. This article covers some specific areas and key advice designed to improve your time management.

Plan your time and create structure to your day if you want to make a difference to your productivity. When people do not plan, they react, feel overloaded, are unable to prioritise and achieve less.

When people do plan, they are productive, use their time better, stay focused and achieve more.

Structure and routine give you control, so you know what you are doing and where you need to be. While structure can feel restrictive, it is important if you want to be organised, waste less time and work more efficiently. Without structure you waste time, re-doing work, looking for things, forgetting meetings, not getting things done, and missing deadlines.

Good habits and routines enable you to look after your physical and mental wellbeing – finding time to exercise, relax and switch off.

Create structure Start by creating clear goals and objectives for the short and longterm. These could be work or personal goals.

Consider the following questions: • What do you want to achieve and where do you want to be in the next few months and years?

• What are your roles and responsibilities – employee, colleague, manager, leader, student, teacher, carer, partner, parent, friend..?

• How much time do you need or have available? Avoid spending too much time on an activity or area that has little impact, when that time could be better spent elsewhere.

At the beginning of each month and each week, plan what you want to achieve based on your goals and objectives.

personal. This way you will not miss important events and avoid last minute juggling or cancellations because you forgot to make a note of parents evening or an early morning work meeting.

Prioritise your tasks Create your to-do list for the day, considering the following questions: • What is important • What is urgent?

• How long will each task take?

• When do they need to be done by?

• Do you need to delegate or ask for help?

Be realistic. Break large tasks into smaller, more achievable steps.

If you have twenty things on your list, you are highly unlikely to get them done. If you think they will only take a few minutes and they take much longer, you will quickly run out of time.

Do the most important task first.

When you feel overwhelmed it helps to prioritise and organise your tasks. Focus on doing what is important rather than trying to do everything.

Block time First, block out time for your fixed time commitments, meetings and appointments. Then block out time for your other tasks – e-mails, in turn leading to calls, preparation time for meetings, follow-ups, writing, research etc. This gives you a more realistic idea of how much time you have available and what you can achieve.

Set aside time for regular tasks – admin, finance, tidying up. Doing little and often saves time and effort in the long run by avoiding things building up.

Set a start and end time. Avoid the temptation to keep going until everything is finished. Remember to take regular breaks and make time for yourself. Time to relax, exercise, socialise.

Take time to plan Get into the habit of setting aside time each day to plan. It takes five to ten minutes to plan your tasks and actions for the day, review progress and what you need to achieve. Many people do this at the beginning of the day, over a morning coffee, while commuting or as soon as you arrive at the office. Some prefer the end of the previous day.

Look a few days ahead so you know what is coming up. You are more likely to remember upcoming appointments and commitments if you refresh your memory each day.

Work from one schedule. Use a planner or diary to provide one point of reference – either digital or paper. Keep all your meetings, appointments and time commitments in one place – both work and 6 Medical Woman | Autumn/Winter 2018

Employ batching Group tasks and work on one type of task at a time.

• Make several phone calls • Read and respond to e-mails • Follow-up after a meeting or phone call This will help you get through the tasks quicker and more efficiently.

Multi-tasking or switching between different tasks, is not an efficient way of working.

Take a flexible approach If you work part-time or from home, you do not have to follow a standard 9am-5pm, five days a week. Plan and organise your

SKILLS TOOLKIT: TIME MANAGEMENT

schedule according to the time you have available and the hours you want to work.

If something changes or comes up, adjust your plan, move things around, change your priorities. With a plan you know where you are and what needs to change and you can reprioritise.

A good structure and routine enables you to switch between different areas knowing that each one is planned and prioritised.

Less unnecessary worrying or feeling guilty about what you have not done.

Avoid multi-tasking You might think you are being more productive but you are not.

When we multi-task we are rarely doing two things at exactly the same time unless one of those things is automatic and we do not need to expend more brain energy on it, such as walking and talking.

When you multi-task you rapidly switch between one task and another, for example writing an email while talking on the phone, or reading a report while listening in a meeting.

It is better to focus on one thing at a time and do it properly, rather than two or more things and doing none of them well. When you multi-task it takes longer to complete both tasks.

Set boundaries I am sure you have received emails or phone calls either early in the morning or late at night. Perhaps you are been guilty of sending them yourself. Technology enables 24/7 connectivity. Just because you can be contacted, read and respond to emails outside of work hours does not mean you should.

You might enjoy the flexibility of working at a time that suits you.

When that flexibility extends to working longer and longer hours

this has a negative impact on productivity, stress levels and overall balance. It is important to create strong boundaries to protect and value your time and ensure a better balance.

Set expectations When you respond to work emails or calls instantly or outside of office hours, you set an expectation. Consider how critical/ important it is that you respond immediately – or can it wait? You may think you are being helpful, when you say ‘yes’ to a request but are you taking on too much? If you accept every request people will make further requests.

Set limits Consider: • What are your office hours?

• What is the best way to contact you?

• How quickly will you respond to emails or phone calls?

• How much work can you actually handle in a reasonable working day/week?

Keep your work and communication to ‘office hours’ – respect and value others time in the same way you want them to respect and value yours. Yes, there will always be exceptions or urgent requests that take priority and need an immediate response but these should be the exception not the norm.

Find out more and check your time habits by taking the Time Quiz – you’ll get free email feedback on your results, on www.clareevans.co.uk Medical Woman | Autumn/Winter 2018 7

SKILLS TOOLKIT: DESIGNING POSTERS

Poster perfect: a guide to designing academic posters Helena Lee is a Core Medical Trainee based at Sandwell General Hospital in the West Midlands.

Here, she divulges her poster making secrets to help medical students and trainees understand what it takes to make the perfect poster.

Having poster purpose It is said that ‘a picture is worth a thousand words’; and this certainly applies to academic posters. A good poster is both a visually attractive summary of your work and can also be used to convey a substantial quantity of information to a reader within a short time period and limited space. Additionally, posters are a means of engaging others into a personal conversation about your work.

Throughout our careers we may complete audits, quality improvement projects, research projects, and case reports. These can all be presented in poster format. Whether at under-graduate or post-graduate level, conferences provide an excellent environment for delegates to design and deliver posters. Conferences also provide an opportunity for feedback from viewers and even prizes for excellence. It is important to check conference specifications before investing time in creating a poster. Conferences may specify the size of a poster (e.g. A1 or A0) and poster orientation (landscape or portrait).

Printing options Designing a poster Posters can be designed on a single slide in Powerpoint. This programme has templates which can be transferable to a poster.

Other templates are also available on the internet.

Considering content The title is likely to be the first element of the poster a reader sees so this needs to grab attention. The title is often in the largest font compared to the remainder of the poster and should outline what your project is. The main authors of the project and any affiliated organisations should also be included. Logos of any affiliated organisations (e.g. university, hospital, NHS trust, funding bodies) can be placed nearby.

Subheadings are used to divide the poster and guide the reader through the main sections of your work. As an example, subheadings for a research project could consist of Background, Aims and Objectives, Methodology, Results, Discussion and Conclusion. Posters often use a separate text-box or column per subheading.

Keeping text short and sweet will allow for an informative and attractive poster. This can be achieved by sticking to absolute key points – if your reader asks for more detail you can elaborate in person while you are standing beside the poster. Ensure the content flows in a logical order guiding your reader through the project story.

Tables and images are used to break up text and embellish the main themes of your poster. However fuzzy, poor quality images do not look good so ensure the resolution is adequate before printing.

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Once the design is complete, if you have the facilities and budget, it may be a good idea to print a draft copy (this can always be a lower quality print) which you can present to your colleagues, lecturers, or housemates. This means you can make changes before committing to the finished product. Ask the printers what kind of finish is best for your poster (e.g. matte or gloss). Always leave plenty of time before the conference to print your poster, as the whole process can often take longer than anticipated.

In conclusion Posters provide a visually appealing way of communicating technical and scientific information and therefore are a perfect medium to present work at conferences and other medical meetings.

Remember to check the conference specifications for poster design, but do not allow this to hinder your creativity and flair. Lastly, enjoy the process of poster making and be proud of sharing your project with colleagues.

References aud D. How to make a scientific poster: a guide for medical students.

D http://cures.cardiff.ac.uk/files/2014/10/NS AMR-Poster.pdf 2 Purrington C. Designing conference posters https://colinpurrington.com/tips/poster-design 3 Powell K. Presentations: Billboard science. Nature. 2012; 483: 113-115 4 Gundogan B, Koshy K, Kurar L, Whitehurst K. How to make an academic poster.

Annals of Medicine and Surgery. 2016; 11:69-71 5 Contemporary Communications Inc. High Resolution Images VS. Low Resolution Images: A Short Primer for Beginners. https://ccideas.com/chatter/high-resolutionimages-vs-low-resolution-images-a-short-primer-for-beginners/ 1

FEATURE: RETURN TO WORK EDITOR’S INTRODUCTION

Time out The incessant grind of clinical medicine becomes routine. The intensity and duration of the shift, the faulty computer system, the absent colleague, the return from twelve months out of programme and out of clinical medicine are shoved to the back of the brain and we get on with it.

I am not sure I ever truly stopped to think about the potential massive impact any of those factors could have on me, a colleague and a patient. The daily grind, despite both external circumstances and internal thoughts, feelings, and motives, provides a sense of the certainty of tomorrow. But what if a combination of the aforementioned factors contribute to a clinical error or even the death of a patient? What will your tomorrow be?

Even now, it makes me nervous to write about the Bawa-Garba case; to consider the family implicated, the emotional, psychological and professional repercussions for Dr Bawa-Garba.

In this feature we consider the important issue of return to work. Here ensues a discussion about the importance of planning return to work and the resources that are available to ease transition back to work.

A number of colleagues tell their stories of time out of clinical medicine, the rewards reaped or the necessity of taking time away out of clinical medicine, the challenges on their clinical return, and what they wish they had known to ensure a less stressful return to work. Their stories give insight into the strength of our colleagues after hardship to re-establish themselves in medicine, and some excellent pointers of where to go if we ever find ourselves in a similar situation.

I took a year out of programme early, in the middle of my core training. For me, a return on a flexible basis was important to ease my transition back, as were the activities I was involved in whilst I was out of programme. Working through the initial parts of the membership exams may not have been the same as practical clinical experience but the revision helped me feel in touch and a bit more confident on my return. I also believe in the importance of supportive educational supervisors, who can help positively direct and inspire us to continue to build our trajectories, after time away from clinical practice.

Medical Woman | Autumn/Winter 2018 9

FEATURED PERSPECTIVES: RETURN TO WORK

The return journey: career breaks and how to make a come-back Dr Helen Fidler is a Consultant Gastroenterologist at Lewisham and Greenwich Trust and has an abiding enthusiasm for medical politics and improving the working lives of all doctors. She is a member of BMA Council, Deputy Chair of the BMA UK Consultants Committee and part of the British Society of Gastroenterology ‘Supporting Women in Gastroenterology’ SWiG steering group. She owns the least intelligent labradoodle in London and has five children.

‘One of the many issues, which resonated with many consultants… was the apparent lack of support on returning from maternity leave.

Having done this five times myself, and survived, I am conscious of the gut wrenching fear that you may have lost competence during those first few days back and how erratically doctors are supported in this situation.’

For many consultants, the responsibility for leading a team and making unsupervised critically important decisions can be onerous.

For those who are coming back to this after a long break for maternity/ shared parental or sick leave, it can be absolutely terrifying. One of the many issues, which resonated with many consultants in the case of Hadiza Bawa Garba, was the apparent lack of support on returning from maternity leave. Having done this five times myself, and survived, I am conscious of the gut wrenching fear that you may have lost competence during those first few days back and how erratically doctors are supported in this situation.

As with everything, the key to this is knowledge and planning well in advance. Even if you think you will not find it stressful, imagine if your first day finds you with absent trainees or an IT failure?

Or if your child has had a sleepless night and you are already exhausted? It is well worth considering a phased return to work and using the arrangements open to all NHS employees – but not widely used by consultants.

There is actually a really good way to do this. As well as maternity leave, you are entitled to request ten ‘keep in touch’ (KIT) days.

If you take these during the unpaid tail-end of your maternity leave you will not lose any maternity pay and most employers will pay you for your time. You can usually expect to be paid at your normal hourly rate; minus the appropriate maternity leave payment you are receiving, however, you need to agree this with your employer in advance. You can take them as half or full days, to attend conferences or departmental meetings or simply to sit in your clinical area and sort out passwords or IT changes. This needs to be agreed up front with your employer, though usually 10 Medical Woman | Autumn/Winter 2018

employers are happy to facilitate this; as it is a positive way of improving your return to work process. Additionally, you and your partner are both entitled to twenty ‘shared parental leave in touch’ (SPLIT) days which can be used flexibly and anytime after the first two weeks from delivery. I would strongly advise everyone to talk to their employer as soon as possible before you go on leave so this can be pre-planned and payment agreed for these days. Your Local Negotiating Committee can help you with this and the BMA has guidance 205 words over on its website. You can also visit the Maternity Action website (https://www.maternityaction.org.uk).

One other advantage of these is that it can demonstrate to the Trust or GP practice how you might work flexibly in the future, if this is something that you are exploring. And remember – you are entitled to return to exactly the same job if returning within 6 months, and the same or a suitable alternative (which must not breach discrimination laws) thereafter.

A carefully planned phased return after a career break can be much less stressful for you, your family and your patients. The Academy of Medical Royal Colleges has produced a return to work guide, which includes practical checklists of what should happen before, during and after your maternity/shared parental leave. In the current climate, doctors risk being held individually accountable for errors that are occurring as a result of unprecedented system pressures and many consultants are concerned about this.

The BMA UK Consultants Committee has issued guidance to consultants, available on our website, and things are moving slowly in the right direction now. Until this is resolved, I would advise all to plan their return to work meticulously so they are free from worry about the return journey.

FEATURED PERSPECTIVES: RETURN TO WORK

Adaptations and Transitions: returning with skill Iona Thorne is a medical registrar, with a special interest in maternal medicine. She has recently completed the National Medical Director’s Clinical Fellow scheme through the Faculty of Medical Leadership and Management. Iona lives in London with her young family - any management or leadership skills gained are put into practice at home, not least the complex art of negotiation with toddlers!

Until recently, I had never had a break in my medical education – going straight from A-levels through to higher specialist training.

In the past four years however, I have been out of programme three times, twice on maternity leave and most recently for a fellowship.

Returning to work after having children posed a mixture of challenges: • Organisationally – it was incredibly complex arranging childcare around erratic work schedules and ensuring that I had reliable back-up plans, alongside overcoming training hurdles.

• Professionally – ensuring I was up to date with a return to clinical practice plan. My local deanery ran a ‘Return to Clinical Practice’ course for medical registrars. This covered recent updates, some clinical skills training and seminars covering the practicalities of returning to work after parental leave. I found two sessions particularly useful – one on negotiating the parttime on-call rota, and another a speed-coaching session on future career decisions.

• Emotionally – adjusting to separation from children who I had been with all day every day for some time, and quietening the ever-present internal voice of Mummy Guilt.

Balancing family and medical training is not easy; it requires planning, resilience and self-awareness. This is perhaps the best advice I can pass on – “there is no perfect work-life balance”. I found that I had to create the best balance for myself and my family, not

allowing any feelings of guilt. I am certain that being a mother has made me a better doctor, and a more compassionate leader. For me, having a professional career makes me a better mother. I have great admiration for full time mothers – I could not do it!

Over the past year, I have also completed a National Medical Director’s Clinical Fellow scheme through the Faculty of Medical Leadership and Management, where I have been working for the Chief Inspector of Hospitals at the Care Quality Commission.

The ‘birds eye’ view of healthcare quality which I have had over this past year has equipped me to pursue quality and support improvement in my clinical practice.

I am planning to return to complete my medical training in October, doing a subspecialty clinical fellowship in obstetric medicine. At my annual review of competence progression (ARCP), we set some very specific training objectives for my final year of training, which I have discussed with my supervisors. I have also had very explicit conversations about enhanced supervision arrangements for my return to clinical practice – for example, until I find my feet, I will be supernumerary in outpatient clinics.

And I will attend my local deanery’s ‘Return to Clinical Practice’ course (for the third time). There are also some useful tools available around developing resilience. Any transition is challenging – but from past experience, time spent in preparation is never wasted.

Medical Woman | Autumn/Winter 2018 11

FEATURED PERSPECTIVES: RETURN TO WORK

Leaning in and linking up: returning with skill Karnathan Jawahar is an old age psychiatry trainee in the East Midlands, with academic interests in the evidence base behind dementia crisis teams. He is hoping to pursue a related PhD in the near future.

His biggest learning curve recently has not been the transition to registrar, but listed building restoration, having bought a ‘project’ in the form of a late 1600s barn conversion.

I am currently in my first year of old age psychiatry higher training (ST4), and also on an integrated clinical academic training pathway as an academic clinical fellow. A few years ago I came to the realisation that all of the extra-curricular medical school activities I did (sport, student support services, various committees etc.) actually helped me greatly as a foundation doctor; the so-called ‘soft skills’ of communication, team-working, leadership and management. In an attempt to pursue medical leadership and management further, I obtained a place on the National Medical Director’s Clinical Fellow Scheme after my first year of core psychiatry training, where I worked on national policy with NHS Improvement. It was a great year, and I was struck by the lack of scientific rigour in places, often driven by political priorities and tight timelines. Subsequently, in a serendipitous moment, an academic clinical fellowship post became available on the rotation I was already on, and it was all about creating the evidence base for services in the NHS – I applied and got the post. After celebrating, a severe case of imposter syndrome arose – how am I meant remember all of the clinical stuff I have now forgotten, let alone bolt on an academic career? To top it all off we had just started a family, so to say I was focused in any way would simply be a lie.

My year out of my training programme allowed a degree of flexibility, so I did my best to meet my future supervisors before returning to practice. This helped alleviate my anxieties as it gave me something tangible to work on. Nonetheless, from a clinical perspective I felt really rather rusty. In my first week I made a basic prescribing error for a sedative – something I had prescribed countless times before my year out. Thankfully no one came to harm, as my consultant picked up the error. He spoke to me about it in a thoughtful non-judgmental way. In hindsight this was key, in how I have subsequently approached my training - from never being afraid to check my working, as it seems as though it is increasingly difficult to openly admit deficiencies the more senior you become.

Perhaps the most interesting challenge on returning to work was the utter bemusement of a minority of colleagues (both clinical and academic) about my year long commitment to building leadership and management skills. Recurring questions included “so did you do a masters?” (no), “did you get any publications” (no), and “so you plan to leave clinical practice?” (no). I was certain that the year away from clinical practice benefitted me immeasurably, both from a personal and professional perspective, yet the recurrent expectation to explain and justify myself became tiresome. I suspect this was because of a failure to see the benefit of the knowledge I gained about the NHS as a system; to consider my enhanced ability to understand how NHS trusts work and the development of my soft 12 Medical Woman | Autumn/Winter 2018

skills to my advantage. On occasions, I even started doubting myself.

On the other hand, those who could understand the benefits of my experiences opened up several new opportunities for me.

Reflecting on my transition back into full-time clinical practice, the following considerations would have eased my transition and hopefully will help you: • Finding out where you will be working on your return before you start your rotation, if possible. I managed to do this and was able to meet my future supervisors. There was more I could have done which leads us to…

• Build in a clinical refresher. Arranging half a day on the shop floor can help you re-develop a feel of how things work in practice. I suspect this would have focused my mind a bit more on refreshing my clinical competencies had I organised this prior to my return.

• Have a spiel ready for when people ask about your year out. I had not given this any thought and when I was asked the first time I rambled incoherently. Soon I communicated this better, and later I was able to dismiss negative comments from people that didn’t get it.

My year developing skills outside of clinical medicine has made me a better doctor, and I do not regret doing it for one moment. There are many opportunities available in postgraduate medical training – the hardest bit is actually figuring out what it is that you want as an individual. It is also important to give some thought to your return before and during your exciting development opportunity.

FEATURED PERSPECTIVES: RETURN TO WORK

ABC: Addiction, Bravery, Coping Our anonymous author has had a varied medical career. She feels fortunate to have had the opportunity to practice medicine both within the UK and abroad. Outside of medicine she is a lover of the great outdoors, and is usually to be found on a bike, in her garden or on a golf course.

I have had a varied medical career, and am fortunate to have had the opportunity to practice medicine both within the UK and abroad.

Outside of medicine, I am a lover of the great outdoors, usually to be found on a bike, in my garden or on a golf course.

I trained as a GP. After several years changed role to a Specialty Doctor. I found the transition easy and preferred working as part of a large team.

After a number of years, I found I was no longer relishing the challenges of life but struggling to stay afloat. I felt unable to ask for help, unable to cope and utterly ashamed at what I viewed as my failure at life. I started using alcohol and other substances to numb terrifying thoughts and feelings.

I was quickly signed off work due to ill health, so thankfully patients were not at risk, but the rest of my life fell apart with alarming speed. Isolation and shame, stigma of my condition, loss of my identity as a respected member of a caring profession, the disgust and frustration of family and friends all led to a worsening spiral of addiction.

I reported myself to the General Medical Council (GMC), was facing bankruptcy, being struck off and drinking myself rapidly to an early death. I hit rock bottom and had all but given up hope. I saw a multitude of health professionals who seemed unable to help. Finally an Occupational Health Nurse arranged an urgent appointment with an Addiction Psychiatrist who told me that I could get better and would return to work as a doctor. For the first time in a year I had hope.

I started a combination of medications, entered a 12 step recovery programme and started attending meetings of the British Doctors and Dentists Group (BDDG).

I was in financial trouble and suspended all non-essential expenses, including British Medical Association and indemnity fees. Initially I attended all proceedings without legal advice or representation. I later discovered I was eligible for assistance as I was a full member during the time I became ill and stopped work. Later still, through the kindness of someone affiliated with the BDDG, I was offered legal help pro bono, which helped immensely in the final stages of returning to work.

Several medical charities helped me negotiate benefits I was entitled to, assisted with the cost of continuous professional development and signposted me to other financial aid to cover basic expenses.

The process of hearings, testing, reviews and reports felt exhausting and overwhelming. Without the support of others who had been through similar situations and survived I am not sure I could have made it.

After a period of confirmed sobriety I was offered GMC undertakings allowing me to return to work under supervision. I am lucky to have an incredibly supportive employer who still meets with me regularly to discuss progress.

Although keen to get back to work I had many fears: how will I cope? What if I relapse? What will I tell my colleagues? I had a phased return to work and although the pace of progress felt frustratingly slow at times, it stopped me from becoming overwhelmed. Many of the anticipated questions did not materialise.

When they did I found brevity in my responses prevented further enquiry. The surprise for me was the kindness I was shown; people missed me during my absence and were happy to have me back.

My colleagues showed unending patience in answering questions as I slowly found my feet and my confidence returned.

I have had two deteriorations in mood since returning. Asking for help is not the weakness I feared. My support system kicked into action immediately. Recovery has been hard at times, my confidence has taken a long time to return, after two years I still have days where I worry about my abilities, feel shame about the past or fret about the future. The difference now is, I am no longer alone and have a way of dealing with these before they get out of hand.

I thought hard work, dedication and trying to be a good person would provide immunity from mental health problems. I now know addiction does not discriminate. If you are concerned about addiction/alcohol problems, I advise you seek help early.

It is not a battle likely to be fought and won in solitude. There are many sources of confidential help, such as the Sick Doctor’s Trust, the BDDG, the Practitioner Health Programme (England) and numerous 12 step programmes. I have overwhelming gratitude for everyone who helped, supported and encouraged me‌ you truly saved my life.

Medical Woman | Autumn/Winter 2018 13

FEATURE: CLINICAL MISTAKES

To err is human: clinical mistakes Gareth Gillespie is senior content editor at the Medical Protection Society. He ensures members are receiving timely, engaging and relevant risk management advice and information when - and how - they need it.

Gareth is a journalist by training and has over a decade of experience in newspaper reporting. Here he looks at the six key medicolegal risks that could trip a doctor up and also gives top tips on how you can prevent these errors from happening.

Consent

Confidentiality

No doctor should feel pressurised to do anything beyond their knowledge, experience and competence. This includes seeking consent for a procedure that they are not familiar with. An invalid consent process can lead to medicolegal problems including complaints, claims and disciplinary proceedings.

Consent is a process, rather than a form-filling exercise. General Medical Council guidance emphasises the importance of working in partnership with patients, and the Montgomery ruling in 2015 increased the breadth of information patients now require.

Confidentiality is central to maintaining trust between patients and doctors. As a doctor, you have access to sensitive personal information about patients and you have a legal and ethical duty to keep this information confidential, unless the patient consents to the disclosure, disclosure is required by law or is necessary in the public interest.

Survival tips • Always act in your patient’s best interests.

• Record in the notes what a patient has been told.

• Use your common sense – consent is patient-specific and depends on the individual’s circumstances, including age, lifestyle, occupation, sporting interests, expectations, etc. It may well be that you are not in a position to advise fully, for example, with professional sports people.

• Patients are presumed competent to consent unless proved otherwise.

• Any competent adult in the UK can refuse treatment.

• The law concerning incompetent adults, who are unable to give valid consent, is more complicated, and is different in England, Wales, Scotland and Northern Ireland.

• Remember there are circumstances where a child can give consent without reference to a parent – if in doubt, consult a Medical Protection adviser.

Prescribing Prescribing is fraught with complications – from over-prescribing, transferring incorrectly to new charts and prescribing for the wrong patient, to forged prescriptions and overdoses, incorrect dosages, interactions and allergies.

Survival tips • P rescriptions should clearly identify the patient, the drug, the dose, frequency and start/finish dates, be written or typed and be signed by the prescriber.

• Be aware of a patient’s drug allergies.

• Good handovers require good leadership and communication.

• Refer to the British National Formulary (BNF). It is accessible online if your copy goes walkabout.

• Verbal prescriptions are only acceptable in emergency situations and should be written up at the first available opportunity. Particular care should be taken that the correct drug is used.

14 Medical Woman | Autumn/Winter 2018

Survival tips • Before breaching confidentiality, always consider seeking consent.

• Remember that confidential information includes the patient’s name.

• Competent children have the same rights to confidentiality as adults.

• Doctors can breach confidentiality only when their duty to society overrides their duty to individual patients and it is deemed to be in the public interest.

• Doctors are required to report to various authorities a range of issues, including notifiable diseases (e.g. tuberculosis), births, illegal abortions and people suspected of terrorist activity.

• The courts can also require doctors to disclose information, although it would be a good idea to contact MPS if you find yourself presented with a court order.

• High-risk areas where breaches can occur are lifts, canteens, computers, printers, wards, emergency departments, pubs and restaurants.

• Be careful not to leave memory sticks or handover sheets lying around.

Record keeping Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. The notes will also form the basis of the hospital’s defence should there be any future litigation against your hospital.

Survival tips • Always date and sign your notes, whether written or on computer.

Do not change them. If you realise later that they are factually inaccurate, add an amendment.

• Any correction must be clearly shown as an alteration, complete with the date the amendment was made, and your name.

• Document decisions made in addition to discussions, information given, relevant history, clinical findings, patient progress, investigations, results, consent and referrals.

• Medical records can contain a wide range of material, such as handwritten notes, computerised records, correspondence between health professionals, lab reports, imaging records, photographs, video and other recordings and printouts from monitoring equipment.

FEATURE: CLINICAL MISTAKES

Medical Protection Society (MPS) is a world leading member-owned, not-for-profit protection organisation for doctors, dentists and healthcare professionals. We exist to protect and support the professional interests of more than 300,000 members around the world, helping them to understand and navigate the ongoing challenges of modern practice.

Our philosophy is to support safe practice in medicine and dentistry by helping to avert problems in the first place.

• Do not write offensive or gratuitous comments – e.g. racist, sexist or ageist remarks. Only include things that are relevant to the health record.

other for registered persons. Registered persons being secondary care clinicians, GPs and primary care dental practitioners, will be of relevance to individual doctors.

In relation to a registered person a ‘notifiable safety incident’ means:

Probity Good Medical Practice advises doctors that they must be honest and trustworthy when signing forms, reports and other documents.

It also requires doctors to make sure that any documents they write or sign are not false or misleading. Falling under this category is the requirement for any doctor to inform the General Medical Council (GMC) if they have accepted a caution, been charged with a criminal offence, or if they have been found unfit to practise by a professional body anywhere in the world.

Survival tips • Take steps to verify what you are saying. Never sign a form unless you have read it and you are absolutely sure that what you are saying is true.

• Probity means being honest and trustworthy and acting with integrity.

• Be honest about your experiences, qualifications and position.

• Be honest in all your written and spoken statements, whether you are giving evidence or acting as a witness in litigation.

• You must be open and honest with any financial arrangements with patients and employers, insurers and other organisations or individuals.

• Assume that all records will be seen by the patient and/or others, e.g. GMC, court.

Duty of Candour Doctors should also familiarise themselves with the duty of candour to avoid medical errors. The duty applies to NHS organisations such as trusts and foundation trusts, to secondary care clinicians, and to bodies including GP practices, dental practices and care homes.

Under the terms of the duty, doctors need to make sure that they practise in an open and transparent way with relevant people in relation to care and treatment, and to service users in performing a regulated activity.

After becoming aware that a notifiable safety incident has occurred, doctors must notify the relevant person as soon as is reasonably practicable. Provide reasonable support, such as providing an interpreter for any discussions, or giving emotional support to the patient. Care Quality Commission (CQC) guidance refers to the ten days required by the NHS standard contract.

a) Any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, appears to have resulted in: • The death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition • Impairment of the sensory, motor or intellectual functions of the service user which has lasted, or is likely to last, for a continuous period of at least 28 days • Changes to the structure of the service user’s body • The service user experiencing prolonged pain or prolonged psychological harm b) The shortening of the life expectancy of the service user; or requires treatment by a health care professional in order to prevent: • The death of the service user, or - Any injury to the service user which, if left untreated, would lead to one or more of the outcomes mentioned in sub-paragraph (a).

Doctors who are notifying a safety incident should do the following: £ The incident report should be given in person by at least one representative of the practice involved, and then followed by a written notification £ Provide a true and accurate account of the incident. £ Provide advice on what further enquiries into the incident are required £ Include an apology. £ Incidents should be recorded in a written record, which should be kept securely.

At some point in a doctor’s career they would have made a mistake or they will know of a colleague who has, therefore it is important that doctors are working within their competencies, and adhere to GMC guidance so they can prevent mistakes from occurring. Good doctors apply clinical knowledge in a way that is legally and ethically correct.

They will also know when to consult senior colleagues and avoid working in a vacuum. Simple things like writing concise and accurate records, getting valid consent from patients and knowing when to seek advice can help you practise safely.

Please note that the regulation states that there are two meanings of a notifiable safety incident; one for a health service body and the Medical Woman | Autumn/Winter 2018 15

SPOTLIGHT: BULLYING

Acorns to Oaks: when trainees drive positive cultural change Simon Fleming is a Trauma and Orthopaedic registrar in London. He is immediate Past President of the British Orthopaedic Trainees’ Association and a PhD candidate in Medical Education at Barts and The London Medical School. He has interests in combating bullying and harassment in surgery, through the award winning #HammerItOut campaign. He undoes all his good work in the gym with a love of great food.

16 Medical Woman | Autumn/Winter 2018

SPOTLIGHT: BULLYING The NHS has a problem with bullying, undermining and harassment.

Whenever I find myself writing or speaking about emotive things like ‘bullying’, ‘harassment’ or that most ephemeral of things, ‘undermining’, it is always useful to start with some definitions.

That way, when I mount my soap box and begin to wax lyrical, both I and the reader are on the same page. The GMC National Training Survey (NTS) defines the above terms as the following: ‘Undermining is behaviour that subverts, weakens or wears away confidence.’

‘Bullying is behaviour that hurts or frightens someone who is less powerful, often forcing them to do something they do not want to do.’1 In another powerful document, the Advisory, Conciliation and Arbitration Service (ACAS) further has to say: ‘Bullying and harassment means any unwanted behaviour that makes someone feel intimidated, degraded, humiliated or offended. It is not necessarily always obvious or apparent to others, and may happen in the workplace without an employer’s awareness.’2 Talking about these negative workplace behaviours is, at the moment, very trendy; like the cultural equivalent of quinoa or kale. But there is a reason that these behaviours are the top of a lot of people’s and organisation’s ‘to do’ lists. In 2016, the British Orthopaedic Trainees Association (BOTA) presented the results of a census of Trauma & Orthopaedic (T&O) trainees in the UK. One of the goals of the survey was to shine a spotlight on these behaviours that we all knew existed, knew to be either overt or insidious, but had not revealed to their full extent. 43% of trainees stated that they had witnessed a colleague being bullied in their T&O post; 7% reported that they, themselves, had been the victim of bullying.

70% of trainees had witnessed a colleague being undermined and 25% reported having felt undermined themselves in the last four weeks.3 In fact, 20-25% of all NHS staff report they have been bullied by other staff.4 29.9% of all NHS staff indicated experience of psychological distress due to bullying behaviours5 and 80% believe the state of their health affects patient care.6 So there… consider the obvious stated, and for all the positivists amongst you, I included some numbers. But really, this is more than numbers, statistics and infographics. It is a matter of people, of lives, of mental health and of happiness, in one’s self, in one’s work and in one’s ability to feel powerless in making those things better.

There are a number of initiatives born out of the above data. BOTA launched #HammerItOut, which has led to a pan-College and British Orthopaedic Association (BOA) move to change the culture. Similar commitments from the General Medical Council (GMC) and the Academy of Medical Royal Colleges, who are about to relaunch their own initiative to Mend Medicine, is music to trainees’ ears and will be further supported by similar initiatives from the anaesthetists, with #KnockItOut, and Emergency Medicine’s #CallItOut. But here’s the thing – what can you, the reader of this article, do, if you are experiencing these behaviours or witnessing them? You are only one person. One cog in the behemoth that is the National Health Service (NHS), the fif th biggest employer in the world (after the US military, the Chinese military, Walmart and McDonalds – make of that what you will). It pains me to say it, but, at the time of writing this article, the media is filled with reports of sexual

harassment in Hollywood; a culture of enabling and ignoring; of the ends justifies the means and of ‘don’t ask don’t tell’. Now is the perfect time to remind people that nobody, and I do mean nobody, is required to tolerate being made to feel ‘less’ in anyway; either less human, less worthy, less valued or less able.

Stories of these behaviours in the NHS go from the sublime, to the ridiculous to the heart-breaking; whether it’s a consultant bullying their trainee into skipping meals, to an associate specialist being undermined by a manager, or a trainee harassing another trainee.

These behaviours are everywhere, but we, all of us, can change these behaviours, and here are my humbly offered thoughts as to how to do just that. There are the ‘obvious’ things. Ask them to stop (not easy). Speak up (not easy). Keep a record/diary (not easy and, if it is everywhere, all the time, throughout the system, it may be pointless).

Escalate to your boss/manager/senior colleague (not easy and, as identified by the Australian #OperateWithRespect campaign, often impossible or makes things worse). Exception report (important, so please do it, but not going to change things then and there). So instead, here is an idea. I believe that we, as a community, can make the place we work, the place where we try to make people better, a safer, kinder, easier place to work.

And I think it starts with you... the person reading this. You change you! This is the one person you truly do have control over. I would ask that you be a better you. A kinder you, a more thoughtful you, a more understanding you and because you will start to act a little better, a little more thoughtfully focused, and thus people will role model off you. This will not only relate to those junior to you, but to the other members of your team, both medical and the non-medical workforce, as well as in all directions of the hierarchy we inhabit. I believe that you will slowly notice your colleagues and your team behaving better. I then truly believe that the small change that I am asking you to make will spread. You will hear it in the coffee rooms and corridors, “that team is happier”, “that ward is the place to be” and “the patients love that clinic.’”

I would then hope that, while these changes are happening, those suggestions I mentioned earlier will become easier. It will be easier to ask someone to stop their behaviours. It will be easier to speak up; in fact, I would hope others might even speak up for you at the same time.

And it will all have started with you… little old you, just trying to be a little better.

If the Junior Doctor contract drama of recent memory showed me anything, it is that trainees can both lead and drive change, bringing the health service, our peers, colleagues and patients along with us.

References eneral Medical Council. General Medical Council National Training Survey G Definitions. Date accessed February 2018. Available from: https://www.gmc-uk.org/ help/NTS04 2 Advisory, Conciliation and Arbitration Service. Bullying and Harassment. Date accessed February 2018. Available from: http://www.acas.org.uk/index. aspx?articleid=1864 3 British Orthopaedic Trainees Association. #HammerItOut Campaign Census. Date accessed February 2018. Available from: http://www.bota.org.uk/hammer-it-out/ 4 NHS Staff Survey, National Key Findings Cores 2012-2016. Date accessed February 2018. Available from: http://www.nhsstaffsurveys.com/Caches/Files/20170306_ ST16_National%20Briefing_v6.0.pdf 5 Carter M, Thompson N, Crampton P, et al. Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting BMJ Open 2013;3:e002628. doi: 10.1136/bmjopen-2013-002628 6 Boorman S. NHS Health and Wellbeing review (2009). Date accessed February 2018. Available from: http://webarchive.nationalarchives.gov.uk/20130103004910/ http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_108799 1

Medical Woman | Autumn/Winter 2018 17

“Mindblowing day surrounded by so many inspirational women and new friends.”

Maham Stanyon. GP and course lead at Imperial College.

“What a great meeting! A real feeling of sisterhood. Many thanks to the Welsh organisers.”

Clarissa Fabre. President-elect MWIA.

Women and Health: Aiming for the Wellbeing of Female Doctors and their Patients MWF Spring Conference, Cardiff – Friday 11th May 2018 When it is suggested you might host a national MWF meeting in your region – just say yes. It involves hard work and a few hiccups along the way, but the end-product is a lot of happy people at the end of a big day.

Knowing we would have an audience from all specialties, all ages and career stages, our programme was designed to cover a range of clinical and generic topics. Something for everyone was our motto. Aside from clinical knowledge, we wanted to ensure there was plenty of opportunity for personal development, meeting new friends, catching up on news and networking.

Our invited speakers covered a range of topics: prenatal testing, Hormone Replacement Therapy, developments in HIV treatment, and career management. Rhianwen Stiff’s talk about her loss of sight and her work as consultant in Public Health Medicine was inspiring. Another highlight was Rose Marnell’s talk on being the mother of a child with spina bifida and daughter Carys, aged 12 years old, spoke about her life and aspirations. Carys wants to be a doctor and compete in the Olympics like her role model Tanni Grey-Thompson. In typical MWF fashion, by the end of the day Ilora Finlay had arranged for Carys to have tea with Tanni at the House of Lords. Abstract presentations covered a variety of topics, ranging domestic violence, family integrated care on the neonatal intensive care unit, and issues facing women doctors globally. Similarly, poster presentations covered important issues including homelessness and sanitary products in developing countries.

After-lunch workshops saw Farah Bhatti and Scarlett McNally discuss how to step up and take on national roles, whilst Olwen Williams led a mindfulness group and Cora Doherty discussed wellbeing. Sally Davies delivered the Dame Hilda Rose memorial lecture highlighting work still to be done on the Gender Pay Gap and Dame Parveen Kumar handed the MWF President’s badge of office to Henrietta Bowden-Jones before her inaugural presidential address.

The evening dinner was followed by a speech from Ilora Finlay on working in the House of Lords and finally some rousing singing from the welsh speakers of the traditional Goat Song.

100 women doctors and students came together in May, sharing stories and making new friends. For some, it was the first experience of the friendship offered by MWF. We hope to see you all again in London this November.

Melanie Jones Want to read more about the day? Check out the Tweets for #MWFConf18 and #MWFConf2018

NEW BEGINNINGS: RETIREMENT

Taking time: the transition to an early retirement Charlotte Gath qualified from University College London in 1987. She worked as a GP partner, a medical school GP tutor and as a Consultant in Public Health, based in Warwickshire, until 2017 when she took early retirement aged 55 years old. Since then she has begun doing some of the things she always wanted to do and is having a lot of fun! Charlotte has four adult sons.

My career – just short of 30 years in the NHS and then a local authority – oscillated between public health and general practice in a rather unplanned way. My passion has always been at the interface between the two, in working to reduce health inequalities, and in particular to improve the health of children, and people with long term mental health problems, both in clinical practice and public health settings. I always wanted to be a female Sam Everington and set up another Bromley-by-Bow but somehow bringing up four sons with an often absent surgeon husband meant I never quite achieved that. I did, though, have my share of career highs and lows, and moments of which I am very proud.

I led a fantastic public health team working on dementia and mental health for the last four years of my career, with a significant commissioning budget just short of a million pounds. We were able to demonstrate some real improvements locally for people with 20 Medical Woman | Autumn/Winter 2018

dementia and mental health problems, as well as winning some awards and getting national recognition.

In 2017, after local authorities had undergone 40% reductions in funding due to austerity and the ring fence on public health budgets was under severe threat, I turned 55. A number of senior colleagues chose to leave that spring and so early retirement was on my mind.

More pressingly, the previous year my mother, who was herself a member of Medical Women’s Federation, had stopped coping living alone after several falls, and a new diagnosis of dementia. We made the decision in early 2016 that she would move 80 miles to live next-door to my family. I moved seamlessly from being a working mother as my youngest son left home to go to university, to being a carer – with no gap in between. For nearly a year I juggled GP and hospital appointments, calls from the professional carers who visited at lunchtime, setting up Enduring Power of Attorney, managing

NEW BEGINNINGS: RETIREMENT finances, and continuing to provide meals on a daily basis, with work. I found myself frequently interrupted or distracted at work, in the same way I had been when the children were small. And negotiating the NHS – hearing clinic, eye clinic, dermatology, old age psychiatry, podiatry – was unbelievably time consuming.

I decided to join a small exodus of colleagues in April 2017 and took early retirement the month after my 55th birthday. My surgeon husband – who still loves his job and has never complained about working a one in five rota for his whole working life – plans to continue working for a while longer yet and so I was fortunate to be able to make that choice for myself.

My mother did well for around 18 months – in our dementiafriendly village – but then things went wrong. Insight into her diagnosis made her profoundly depressed and she blamed me for having taken her to old age psychiatry in the first place. When I went away travelling for nearly three weeks to India she refused to speak to me on my return. We had a painful few weeks and then a dementia specialist nurse told me we should consider a respite admission. We did, and things improved, but it became clear that she would not come home again and so after nearly two years next door she became a permanent resident in a lovely care home, where she is mostly settled and happy. I feel slightly heartbroken at the breakdown of the more independent care at home scenario I wanted for her, but greatly relieved that she is as lovely to me now as she always was.

So what happened next? I found myself unexpectedly freed up. Perhaps if I had known that would happen I would have kept working for longer. But I have no regrets! I feel like a bird let out of its cage! I bought myself a beautiful road bike as my retirement present to myself. Influenced by studies suggesting cycling helps to prevent dementia in middle aged women, I began to cycle seriously for the first time. Covering increasing distances – with plenty of coffee and cake stops too – I set myself two targets for 2018. I cycled ‘Ride London’ 100 miles on 29th July in pouring wind and rain, fundraising for the Alzheimers’ Society.

Additionally, in September, I also cycled from London to Paris, 240 miles over 3 days, for womens’ cancer charities, with former Medical Women’s Federation President Fiona Cornish. All the cycling means I am fitter and stronger than I have been for thirty years, which can only be a good thing.

Also on my wish list was more travelling – without having to count days of entitlement to annual leave and negotiate around school holidays. Last year I visited Vancouver, Copenhagen, and India, as well as travelling in France, Spain and Italy.

I have also completed a creative writing module with the Open University, read more fiction and biographies than ever before, and am considering next steps on the way to my best-selling novel!

I volunteer one day a week at our local Food Bank. The fact that people – including children – go hungry in this day and age, as if we were in Dickensian Britain, has refuelled my public health zeal.

For me the decision to take early retirement has been fortuitous and liberating. I have been back to visit colleagues at work and felt no regrets at all about moving on. I hope that this article gives some of you who may be considering a similar step, food for thought. I would have the following advice for others considering retirement: • Keep some structure and routine in your life. A friend of mine who took early retirement from a stressful job was so overcome by relief and cumulative fatigue she did not get out of bed until lunchtime at first. That may be okay initially but then you need to

get back to making the most of the day. I set my alarm for 7.30am with my gentle clock radio to get me going. Have something regular in your diary several times a week – even if it is a yoga or a Pilates class.

• Now that you have the time, I cannot recommend building in regular exercise strongly enough – it helps keep your mood up, joints supple, helps you eat and sleep well, and staves off that dementia.

• Set yourself two or three personal goals based on things you have always wanted to try – make them achievable – based perhaps on a one year time frame at first, and include some travel plans.

• Be open to new friendships – what you did at work before is not really relevant – and make the most of daytime opening for films, exhibitions, classes etc. Become ‘a lady who lunches’ – not every day but sometimes!

Early retirement is a big change but can be a privilege and an opportunity – enjoy it!

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STRIKE A CORD: MASTERING MIND

Psychosis: an overview Tanya Deb is from Wales; she studied medicine in Oxford and moved to London for Foundation training.

She is currently a ST5 in General Adult Psychiatry and has an interest in research and education on reducing stigma towards people with mental illness.

Psychosis is an illness which disturbs thoughts, feelings and behaviour, to the point where those affected can lose touch with reality.

Psychosis can form part of a number of different psychiatric disorders, for example it is commonly seen in severe mental illnesses such as schizophrenia and bipolar affective disorder (BPAD), though can also occur secondary to general medical conditions such as HIV and multiple sclerosis. In addition, both recreational and prescription drugs can induce psychotic symptoms. It can be very distressing, and the most severe forms including schizophrenia will affect approximately 1 out of every 100 people in their lifetime. Stigma can surround psychosis, with some believing that those affected are dangerous, but this is rare, and in fact people with psychosis are more likely to be vulnerable to violence from others.

The mainstay of pharmacological treatment is antipsychotic medication. In general, these medications act to block the receptors of a neurotransmitter called dopamine; excess production and release of dopamine is thought to cause delusions and hallucinations. Dopamine is also involved in the control of muscle movements, and side effects of antipsychotic drugs can include symptoms such as stiffness and tremor. There are two main groups of antipsychotic drugs, typical (referring to older drugs) and atypical (referring to newer drugs). In general, atypical antipsychotics have a lower propensity to cause movement side effects, and these tend to be used first line. Extreme agitation and aggression secondary to psychotic symptoms can be managed with sedating or anxiety-reducing medications.

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Psychological interventions consist of counselling and supportive psychotherapy, cognitive behavioural therapy (CBT) focusing on reducing distress caused by hallucinations and unusual thoughts, and family therapy. Support with practical matters such as finances and accommodation is also an important part of treatment, as well as integration back into education or employment.

Many individuals can be treated at home under the care of a Community Mental Health Team (CMHT) or their GP. If symptoms are severe and pose risks to the individual and/or to others, a period of treatment in hospital might be needed. In situations where individuals are not agreeing to go to hospital, or do not have the capacity to agree to go to hospital, they may be detained under the Mental Health Act. This protects their rights and ensures that they are only admitted to hospital when it is absolutely essential to ensure their safety, or for the protection of other people.

Drug-induced psychoses typically resolve following a period of abstinence from the drug of abuse, whilst psychotic symptoms secondary to medical conditions respond to treatment of the underlying medical disorder. In both cases, there may be a role for antipsychotics in the treatment of refractory psychotic symptoms.

Prognosis depends on the nature of the underlying disorder. For transient drug-induced psychoses, individuals can recover quickly and may never experience further episodes, so long as they remain abstinent. Psychosis in the context of disorders such as bipolar affective disorder and schizophrenia typically have a more chronic illness course, though many people respond well to treatment and remain stable, working successfully as well as having relationships and families.

STRIKE A CORD: MASTERING MIND

Dr Harriet Quigley is a ST4 in General Adult Psychiatry and a researcher at the Institute of Psychiatry, Psychology and Neuroscience. She is interested in the interaction between predisposing genes and environmental factors in causing psychosis.

Presentation can take several forms, with some of the most common symptoms listed below.

• Hallucinations – hearing, feeling, smelling, tasting or seeing something that is not there. Most commonly people experience auditory hallucinations (hearing voices).

The voices often make insulting and upsetting comments about the person, and can also command the person to do certain things.

• Delusions – a fixed belief in something that others are unable to believe, and which appears to be false. Many people affected with psychosis can also firmly believe that they are being persecuted or watched by others, despite no evidence based in reality to support this. People commonly feel perplexed, and often attribute false special meanings to everyday incidents to explain the perplexity. Sometimes people believe they are receiving personal messages via the television or internet. Delusions also tend to be related to the nature of the disorder, for instance individuals may have grandiose delusions in the manic phase of BPAD, believing that they have special powers.

• Difficulty in thinking and disordered thought – people find it hard to think logically and jump from topic to topic, sometimes with incoherent speech. Sometimes people believe their thoughts are being withdrawn from their head, echoed, or ‘broadcast’ to others.

• Delusions of control – people may feel like parts of their body are being controlled by someone else, or that their actions are somehow being influenced by others.

• Lack of insight and self-awareness – people do not recognise that their experiences are not real; leading them to feel frightened and distressed.

There are other symptoms which can occur before or after a psychotic episode, particularly in schizophrenia. These can be more subtle and insidious, such as: • A loss of interest in self-care and daily tasks, such as washing, cooking, cleaning • Less motivation to leave the house and do things • Less emotions, feeling overall ‘flat’ or ‘blunted’ and less reactive to daily events • Feeling less comfortable around other people leading to isolation.

The management of psychosis largely depends on the nature of the underlying disorder. Treatment is usually divided into pharmacological, psychological and social interventions.

“In the early days it was like an angel. I thought I was blessed. Then it became devillike, saying “if you don’t do this I’m going to punish you” Jonny Benjamin – film producer, mental health campaigner and MBE award winner describing his experience of psychosis.

Medical Woman | Autumn/Winter 2018 23

STRIKE A CORD: MASTERING MIND

Family interventions in psychosis: Juliana Onwumere is a Senior Lecturer in the Department of Psychology at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, and a Consultant Clinical Psychologist. Her interests are focused on family issues in psychosis, particularly improving development, training and wider provision of Family Interventions. She developed the first international massive open online course (MOOC) on caring for people with psychosis and schizophrenia (www.futurelearn.com/courses/caring-psychosis-schizophrenia).

Schizophrenia disorders, commonly referred to as psychosis, typically include symptoms such as hallucinations and delusions, alongside mood and cognitive disturbances. They often have their first onset during adolescence and young adulthood, and an estimated 20 million people, globally, are living with schizophrenia, the most common form of psychosis.2 One in seven are likely to make a full recovery from a first episode.3 The disorders are mainly longterm, relapsing conditions, where individuals experience high levels of stigma, social isolation and multi-morbidity, along with reduced life expectancy of approximately 15-20 years, compared to the general population.4 Many people diagnosed with psychosis are living with or in close contact with families, who assume ‘informal carer’ roles, which play a key part in helping people to access services, engage with treatments and facilitate recovery. They provide a vital source of support, which is linked to improved recovery and mortality rates.5,6 Unfortunately, the caregiving role can impact negatively 24 Medical Woman | Autumn/Winter 2018

on carers’ own health and wellbeing. Compared to the general population, psychosis carers report higher rates of common mental disorders and reports of burden and ‘burnout’ are elevated, evident soon after initial onset.7-8 Psychosis can be an upsetting and complex condition to witness. The symptoms are confusing and will leave many carers experiencing a range of emotional reactions including fear, anxiety, hopelessness, loss, grief and frustration, which can affect how they think and behave towards their relative and can influence outcomes.7 Close relationships characterised by elevated levels of carer criticism and intrusiveness are particularly predictive of higher levels of relapse and poorer outcomes. In turn, individuals’ own perceptions of carers’ negative attitude towards them are also linked to increases in relapse rates.10 Given the demands that psychosis can make on any relationship, and the importance of informal caregiving to optimsing outcomes, family interventions are a recommended treatment, internationally

STRIKE A CORD: MASTERING MIND

a climate of communication

1

Elizabeth Kuipers OBE is Professor Emerita of Clinical Psychology at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London. She was Chair of the National Institute of Health and Clinical Excellence (NICE). She is a National Institute of Health Research (NIHR) Senior Investigator Emeritus, the 2013 recipient of the WISE lifetime achievement award, and received a lifetime achievement award from the Professional Practice Board of the British Psychological Society.

(e.g. Europe, USA, Canada, Australia), for people with psychosis and their carers. The National Institute for Health and Care Excellence (NICE) for England, Wales and Northern Ireland,11 for example, recommends family interventions to all families in close contact with someone living with psychosis.

Family interventions (FI) are an evidence-based psychological therapy typically offered alongside pharmacological treatments and other psychosocial interventions. It is usually delivered by two trained professionals facilitating sessions in a clinic or within the family home. In the UK, recommended interventions have a minimum of ten sessions, run between three months to one year, and appointments are usually scheduled fortnightly. There are slightly different variations of the evidence based family interventions, with some models meeting with carers on their own and other approaches meeting with families individually or with several families together.12,13 They focus on ‘here and now’ issues that are currently affecting the family, and have an overarching aim to minimise future risk of relapse and improve recovery. Family interventions were developed specifically for psychosis conditions, from a psychosis literature and evidence base, and are offered because an identified family member has psychosis; they are not based upon theories about underlying family dysfunction.12,13 In family intervention, all members are encouraged to be equal and active partners. Interventions are built on having a positive attitude towards families with a normalising and non-judgemental approach to how they respond to psychosis within their family.

The intervention components can include facilitating positive communication styles and patterns of relating to one another, and developing optimal problem-solving and adaptive coping skills, such that relationships improve. They typically include a psychoeducation component to support an individually tailored understanding of psychosis and how it specifically relates to the family, asking the person with the problems, as the expert, to discuss what is helpful with everyone else. Interventions usually include family members completing ‘homework’ tasks outside of sessions to help embed changes.13 The evidence base in support of family intervention efficacy and effectiveness is long-standing and robust.14,15 Key family intervention outcomes include significant reductions to relapse, carer burden and negative caregiving relationships. Individual engagement with, and adherence to, prescribed medication also benefits from interventions as do carers’ positivity and willingness to continue in their roles. Difficulties, however, persist with regards to ensuring adequate and equitable access to family intervention with access ranging from 0-53% in UK services.

Many factors impact provision, including limited access to clinician training and supervision, engagement difficulties with both

individuals and families, and insufficient staff time,16 which can leave families feeling neglected and overlooked by services. There are ongoing efforts to improve provision. Recent initiatives can be seen within early psychosis services within England where families should be able to access recommended family intervention within two weeks of accessing the service.17 Not all families want or need full family intervention, but do require information and support at different stages, given the problems that may arise. Ensuring that the NHS workforce is informed about family issues in psychosis, and can respond positively to their needs, remains an important challenge for service providers.

References ilsen L, Frich J, C Friis, et al. Participants’ perceived benefits of family intervention N following a first episode of psychosis: a qualitative study. Early Intervention in Psychiatry. 2016;10:152-159.

2 leischhacker, WW, Arango C, Arteel, P, et al. Schizophrenia—time to commit to policy change. Schizophrenia Bulletin. 2014;40:165–194.

3 Fusar Poli P., McGorry P, Kane J. Improving outcomes in first episode psychosis.

World Psychiatry. 2017:16: 251-265.

4 Hjorthøj C, Stürup AM, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: A systematic review and meta-analysis. Lancet Psychiatry. 2017;4:295–301.

5 Norman RMG, Malla AK, Manchanda R, et al. Social support and three-year symptom and admission outcomes for first episode psychosis. Schizophrenia Research 2005;80: 227-234.

6 Reininghaus U, Dutta R, Dazzan P, et al. Mortality in schizophrenia and other psychoses: a 10-year follow-up of the ӔSOP first-episode cohort. Schizophrenia Bulletin. 2015;41:664–673.

7 Kuipers E, Onwumere J, Bebbington P. A cognitive model of caregiving in psychosis.

British Journal of Psychiatry. 2010;196:259-265.

8 Onwumere JS, Schulz J, Man E, et al. Understanding the experience of “burnout” in first-episode psychosis carers. Comprehensive Psychiatry, 2018:83:19-24.

9 Bebbington P, Kuipers L. The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. Psychological Medicine. 1994;24: 707-718 10 Tompson, MC, Goldstein MJ, Lebell MB, et al. Schizophrenic-patients perceptions of their relatives’ attitudes. Psychiatry Research. 1995;57:155-167.

11 National Institute for Health and Care Excellence (NICE). Psychosis and schizophrenia in adults: prevention and management, 2014. Date accessed: August 2018.

Available from: https://www.nice.org.uk/guidance/cg178/chapter/Introduction.

12 Onwumere J, Hunter E, Kuipers E. Chapter 13: Family Interventions for psychosis.

In: F. Gaughran & P. Buckley (Eds), Treatment Refractory Schizophrenia – a Clinical Conundrum, 2014.

13 Kuipers E, Leff J, Lam D. Family work for schizophrenia: a practical guide (2nd Edition) London: Gaskell, 2002.

14 Pharoah F, Mari J, Rathbone J, et al. Family intervention for schizophrenia. Cochrane Database Systematic Review, 2010.

15 Claxton M, Onwumere J, Fornells-Ambrojo M. Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis. Frontiers in Psychology. 2017:8:371.

16 Onwumere J, Grice S, Kuipers E. Delivering cognitive-behavioural family interventions for schizophrenia. Australian Psychologist 2016;51: 52-61 17 NHS England, National Collaborating Centre for Mental Health, & National Institute for Health and Care Excellence. Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance, 2016. Date accessed: August 2018.

Available from: from https://www.england.nhs.uk/mentalhealth/wp-content/ uploads/sites/29/2016/04/eip-guidance.pdf 1

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STRIKE A CORD: MASTERING MIND

CBT for psychosis: working with the experience Monica Charalambides is a specialist senior clinical psychologist in the field of psychosis currently working at the National Specialist Psychosis Unit in South London and Maudsley NHS Foundation Trust.

She enjoys maintaining a healthy lifestyle and mind-body balance through her love of fitness and exercise.

Cognitive Behavioural Therapy for psychosis (CBTp) is an evidencebased specialised approach to the psychological assessment and treatment of a severe and enduring mental health condition.

Psychosis features in several diagnoses of which schizophrenia is the most common. The clinical picture can include: • positive symptoms: such as perceptual abnormalities, delusional or paranoid ideation, bizarre behaviour, disorganised speech and thinking • negative symptoms: blunting of emotion, impoverished speech, lack of motivation, loss of pleasure • cognitive: such as poor attention, poor working memory, executive functioning problems Although along a continuum with varying degrees of frequency and intensity, psychosis makes for an often complex and debilitating condition that can impact negatively on functioning and evoke high levels of distress. CBTp has been shown to improve a number of issues including positive and negative symptoms as well as functioning.1,2,3,4 It is recommended within the UK as an adjunct to pharmacological intervention, through at least 16 individual sessions over a period of six months.5 CBTp holds onto the central stylistic tenants, theoretical principles and mechanisms of change of traditional CBT, i.e. an emphasis on the ‘here and now,’ time-limited and structured framework, collaborative and shared formulation, management of less adaptive thinking patterns/behaviours. However, the therapy uniquely centres on normalisation of experience and processes and alleviates distress through working alongside symptoms rather than (necessarily) attempting to challenge them or change their occurrence.6 The structure of CBTp is characterised by three main phases:

James doesn’t feel himself lately, his thinking is slow and confused and he has trouble remembering things.

When people are around his symptoms increase.

James slowly becomes convinced that other people can influence his thinking and read his mind and that he is part of a strange experiment.

When James is in company he looks around suspiciously, stares at people and he starts to feel anxious and angry.

Adopting a curious stance rather than engendering an alternative take on reality brings the therapeutic alliance closer and enables room for working together on issues. People with psychosis may find discussing their experiences and thoughts difficult, therefore assessment should be collaborative, flexible, empathic, and sensitive to where people are in their mental state. It can be helpful to give specific reassurance about fears arising from delusional ideas (e.g. that you, the doctor, do not find the patient ‘evil’). Engagement can be nurtured by understanding how current beliefs act as obstacles to achieving identified goals; disputing evidence rather than beliefs; and encouraging the patient to speak out counterarguments themselves.

The middle phase: formulation and intervention The beginning phase: engagement and identifying issues Engagement and development of a collaborative and trusting therapeutic relationship is pivotal. Greater emphasis on normalisation of thinking processes and experience in comparison to other mental health difficulties is needed; this stems from a stigmatising perception and lack of awareness that psychotic-like experiences are prevalent in approximately 5-8% of the general population.7 Setting goals that guide therapy and a detailed assessment using the ABC model are important:

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Case formulation involves combining clinical information and the theoretical model to develop an individualised version of the cognitive model of positive symptoms.8,9,10 A full description of subjective experiences which link seemingly unconnected events shape an explanation of how symptoms developed and are maintained. Useful clinical questions include: How do beliefs about unusual experiences build on a person’s ideas about themselves and others? How do they make sense in the context of previous life experience? What behaviour or cognitive processes maintain beliefs/distress? The aim of therapy is to provide patients with

STRIKE A CORD: MASTERING MIND

an alternative, plausible and less distressing explanation of their experience. Verbal reattribution and validity testing through behavioural experiments can be helpful tools: Encouraging James to test out his belief that others can influence his thinking by being close to people whilst thinking about a specific topic and looking out for concrete signs they know what he is thinking.

If the patient finds that they cannot accept an alternative explanation, the aim is to be less distressed and disrupted by his/her established belief. Coping strategy enhancement and management of triggers to hallucinatory experiences can be highly effective at this stage. Discussing the validity of voice content and developing an empowering relationship that fosters greater sense of agency, has been found effective in reducing levels of distress.11 Again, the aim is not to alter experience, but develop a way in which one can accept, manage and establish control of one’s symptoms and personal recovery.

Late phase: evaluation and consolidation The final phase is characterised by evaluation and consolidation of gains with a focus on strategies to prevent relapse and nurture longer term goals post-therapy. The therapist may wish to chart illness history and identify a list of stressors and vulnerabilities to relapse, specific to the patient. Early warning signs and a personal ‘relapse signature’ based on cognitive, affective, and behavioural changes experienced by the patient and/or observed by others

when becoming unwell, are useful to outline. Highlighting strengths, areas of progress and resilience, as well as identifying coping strategies and resources to help the patient manage facilitates a positive ending to therapy.

References urns AMN, Erickson DH, Brenner CA. Cognitive-behavioural therapy for medication B resistant psychosis: A meta-analytic review. Psychiatric Services 2014; 65:874–880.

2 Van der Gaag M, Valmaggia L R, Smit F. The effects of individually tailored formulation based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis. Schizophrenia Research. 2014;156:30–37 3 Turner DT, Van Der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: A meta-analysis of comparative outcome studies. American Journal of Psychiatry. 2014;171: 523–538 4 Lincoln TM, Peters E. A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations. Schizophrenia Research. In press. Available at: https://doi.org/10.1016/j.schres.2017.12.014 5 National Institute for Health and Care Excellence (NICE) (2014) Psychosis and schizophrenia in adults: Prevention and management (Clinical guideline 178). Date accessed August 2018. Available at: https://www.nice.org.uk/guidance/cg178 6 Brabban A, Byrne R, Longden E, et al. The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis.

Psychosis. 2017; 9.

7 van Os J, Linscott RJ, Myin-Germeys I, et al. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistenceimpairment model of psychotic disorder. Psychological Medicine. 2008; 39:179-95.

8 Garety PA, Kuipers E, Foweler D, et al. A cognitive model of the positive symptoms of psychosis. Psychological Medicine. 2001;31:189–195 9 Morrison AP. Interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy.2001;29:257–276.

10 Freeman D, Garety PA, Kuipers, E, et al. A cognitive model of persecutory delusions.

British Journal of Clinical Psychology. 2002;41:331-347.

11 Craig

T, Rus-Calafell M, Ward T, et al. AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.

The Lancet 2018;5:31-40.

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WOMEN’S HEALTH: MENOPAUSE

Misdiagnosing my perimenopause Louise Newson is a GP and menopause specialist. She is an editor for the British Journal of Family Medicine and director for Primary Care Women’s Health Forum. She has contributed to various e-learning courses and educational modules for the Royal College of General Practitioners. Louise feels passionately about improving awareness of safe prescribing of HRT to healthcare professionals. She has developed and is the founder of the website www.menopausedoctor.co.uk.

Two years ago, I was convinced I had lymphoma. I was experiencing dreadful night sweats and felt extremely tired. My husband kept telling me how awful I looked and that I needed to see my GP. I was also having worsening migraines and generally did not feel myself.

I felt low in my mood, but I knew I was not depressed. I was also very irritable with my family, especially my husband, which was out of character with me. I had become more forgetful and was finding it more difficult to remember dates and friends’ birthdays. I was also experiencing muscle and joint pains, so I was not doing my yoga practice as frequently. Even when I was not experiencing night sweats, I kept waking in the early hours of the morning and finding it hard to get back to sleep which was incredibly frustrating.

These symptoms occurred around the time of setting up my menopause website and also opening a menopause clinic. I presumed all these symptoms were related to me pushing myself too much at work and also having three children, but I was inwardly really worrying about the night sweats. I decided to delay seeing my doctor as I did not want any bad news at a time when I was trying to be very productive with my work.

After a few months of feeling like this, one of my daughters made my diagnosis. She told me she had had enough of me constantly being so irritable and she asked if my period might be due (as her friends often became more irritable before their periods occurred).

I then realised that I had not had a period for around four months!

All my symptoms clearly were related to me being perimenopausal – but I had not related these symptoms to this. I was 46 years old at the time – the average age of the perimenopause is 45 (51 years for the menopause). I am often teaching and lecturing other healthcare professionals to think about other potential symptoms, especially psychological symptoms that may occur in addition or instead of the classic vasomotor symptoms during the perimenopause and menopause, but had missed my own! There are so many potential symptoms that can occur during the perimenopause and menopause (Figure 1).1 I have prescribed Hormone Replacement Therapy (HRT) for many women over the years and I was very encouraged when the National Institute for Health and Care Excellence (NICE) guidance was produced, showing that the benefits of HRT outweigh the risks for the majority of women.2 Fortunately, I saw a menopause specialist and I started using oestradiol patches and taking micronised progesterone. After three months, I was advised to use testosterone. I was rather apprehensive initially, but I was desperate for my brain to be engaged again and my wellbeing to improve. I also wanted my reduced libido to return.

I now feel the best I have felt for many years and I realise that I probably had been experiencing symptoms related to my fluctuating hormones for a long time.

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Figure 1 - Greene Climacteric Scale Please indicate the extent to which you are bothered at the moment by any of these symptoms by placing a tick in the appropriate box

I was fortunate because I only experienced symptoms for a few months. Every day, when I run my menopause clinic, I feel sad and horrified with stories from women telling me that they have had symptoms for many years and never received adequate help, despite often seeing numerous doctors. Around 70% of women who come to my menopause clinic have been inappropriately given or offered antidepressants in the past by their GPs as their only form of potential treatment for their menopause. There is no evidence for the use of antidepressants in this way.2,3 Many women tell me that their doctors have even actively refused to give them HRT, some telling them it will give them cancer, others saying that it is purely a lifestyle treatment, and some simply informing their patients that they do not know enough about the menopause and HRT. I have even seen women who have been sectioned in the past, having been incorrectly diagnosed with bipolar depression and who have tried to commit suicide, all as a direct result of their psychological symptoms of their menopause, which subsequently improved with taking HRT. Clearly the menopause is a natural process rather than an illness.

However, as we go through the menopause there is an increased risk of cardiovascular disease, osteoporosis, type II diabetes, osteoarthritis and also probably dementia.4 Taking HRT can reduce the risk of these very significant conditions and the evidence supports that the earlier HRT is started, the more effective it is at the reduction of risks of these chronic diseases.5 It is a sobering thought that one in two women over the age of 50 will have a fragility fracture, yet many guidelines do not mention the effectiveness of oestrogen in reducing fracture rate and improving bone mineral density.

WOMEN’S HEALTH: MENOPAUSE

Figure 2- Menopause and body identical HRT • Body identical HRT (same molecular structure as a woman’s hormones) is the safest way of a woman having HRT • Oestrogen through the skin as a patch or gel is the safest way of having oestrogen and is body identical • Micronised progesterone is body identical progesterone which is given as an oral capsule and is safer than older types of progestogens • Testosterone is a female hormone that can improve libido, mood, energy and concentration There is still so much stigma associated with the menopause. Many of my friends were shocked to hear me telling them I had started HRT. Imagine being 26 or 36 years old and having Premature Ovarian Insufficiency (POI) – menopause under 40 years – which affects around one in a hundred women in the UK.6 These young women have to have hormones (either in the form of HRT or the contraceptive pill) as they have an increased risk of chronic diseases and early mortality. Yet many women I have seen in my clinic, I have been told that they are too young to be menopausal, and are not offered any hormones. It would be a potential medicolegal case if a woman presented with an osteoporotic fracture and was found to have been menopausal from a young age without it being properly managed.

I work closely with West Midlands Police and the impact of the menopause in the workplace should not be underestimated.

Research we undertook showed that around 30% of menopausal women had considered giving up work and nearly 80% of women had experienced menopausal symptoms which had negatively affected their ability at work. The three most common symptoms affecting them at work were fatigue, memory problems and anxiety.

So offering menopausal women a fan in the workplace is not going to help!

I have undertaken some research looking at training and education on the menopause for healthcare professionals.7 Sadly, the results highlighted that there is a huge need for improved menopause education, especially in primary care where the majority of menopause care should be delivered.

Clearly, I am not advocating that every woman should consider taking HRT but I do feel that women should be given an informed choice regarding taking HRT. Body identical HRT, the oestradiol given as a patch or gel and micronised progesterone is by far the safest way of prescribing HRT (Figure 2).8 This type of HRT can be given to women with an increased risk of venous thromboembolism and obese women.

Women, who have had a hysterectomy and receive oestrogen only HRT, do not have an increased risk of breast cancer. Women who have micronised progesterone are likely to have a lower risk of breast cancer than women taking other progestogens.9 However, the risk of breast cancer is similar to the breast cancer risk that a woman has if she is overweight, does not exercise or drinks a couple of glasses of wine a night.

Taking HRT is not a choice or option for every woman. Eating a healthy, balanced diet which is rich in calcium is very important for bone and cardiovascular health. Women should also exercise regularly and work to improve their sleep hygiene. For some women, medications such as antidepressants or gabapentin can improve symptoms, but their use can be limited by side effects.

With the menopause work I am involved in, I want to encourage more healthcare professionals to be educated on the current evidence and guidelines on the menopause to help more women make this a positive rather than negative experience of their lives.

References reene J. A factor analytic study of climacteric symptoms. Journal of Psychosomatic G Research. 1976; 20:425—430.

2 N ICE. Menopause: diagnosis and management. NICE Guideline [NG23]. 2015.

Date accessed July 2018. Available at: www.nice.org.uk/guidance/NG23.

3 Baber RJ, Panay N, Fenton A. IMS Writing Group. IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric. 2016;19: 109-50.

4 Lobo RA, Pickar JH, Stevenson JC, Mack WJ, Hodis HN. Back to the future: Hormone replacement therapy as part of a prevention strategy for women at the onset of menopause. Atherosclerosis. 2016;254:282-290.

5 Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health. 2016: 22: 165-183.

6 Maclaran K, Panay N. Current Concepts in Premature Ovarian Insufficiency.

Women’s Health. 2015;11:169-182.

7 Newson L, Mair R. Results from the menopause survey. British Journal of Family Medicine. 2018;6:12-22 8 L’Hermite M. Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal. Climacteric. 2017;20: 331-338 9 Stute P, Wildt L & Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018;21:111-122.

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Medical Woman | Autumn/Winter 2018 29

A GLOBAL STAGE: AN INTERNATIONAL VOICE

Making progress: lending an international voice to women doctors Clarissa Fabre is the Medical Women’s International Association (MWIA) President-Elect and representative to the World Health Organisation (WHO), and a past-president of the Medical Women’s Federation (2010-2012).

After undergraduate training in Australia, she trained in Paediatrics and Adult Medicine in Canada and the UK. Clarissa was involved in research in Oxford. After having three children, she turned to general practice, and is a senior partner in a semi-rural practice in Sussex.

Central Asia MWIA regional meeting: ‘Women’s Well-Being: A Global Perspective’

The Medical Women’s International Association (MWIA) is a powerful international force in advancing the cause of women’s health and welfare. MWIA also aims to improve the professional lives of women doctors all over the world. We have members from over 70 countries and will be celebrating our centenary on July 25th-28th 2019 in New York.

All members of the Medical Women’s Federation are automatically members of MWIA. There are 8 regions, and the UK is part of the Northern European region. Each region has an elected Vice President, and these, together with the Officers, form MWIA’s Executive Committee.

Last year MWIA conducted an online survey on various topics, to guide our future priorities. 1150 women doctors and medical students responded.

Here are a few of the findings: • Over 50% of our sample felt they had been discriminated against, with over 40% of these more than once • Over 40% of our sample had suffered sexual harassment or bullying related to their work, 25% of them more than once • Around 60% of younger doctors, under the age of 40, had suffered stress, and 25% from burnout, with lower figures for the over 40s • The majority of doctors with children took less than three months maternity leave. Younger doctors were more likely to take more than three months maternity leave, as well as parental leave, than the older group.

Additionally, members were asked what the five most important areas were for MWIA to address. Work-life balance came out on 30 Medical Woman | Autumn/Winter 2018

top, followed by violence against women and girls, leadership and mentoring, career progression, sexual harassment and bullying.

MWIA’s greatest strengths were felt to be excellent networking opportunities and giving women doctors a political voice.

Here are some of our plans and priorities for the future: To continue our focus on violence against women and girls. We have developed a training module (https://mwiaviolencemanual. wordpress.com/) which contains about 35 case studies from all over the world, and we plan to use this module in workshops at future meetings.

To continue our project on sexual harassment (#MedToo), which is led by Professor Jan Coles from Australia. An online MWIA survey has just been completed, with over 1100 responses. Here are some preliminary findings: • 35% respondents had personal experience of sexual harassment • 22% felt that their job depended on performing sexual behaviours • 5% experienced attempted or completed rape One of my top priorities as MWIA president from next year will be a focus on young doctors, looking at women doctors’ career development and return to work after having children. The United States is one of only three countries in the world where there is no legal right to paid maternity leave, and no job protection after taking leave. The other countries are Papua New Guinea and Lesotho. Some women go back to work in less than a week.

Another will be to focus on leadership, mentoring, sponsorship and empowerment. We plan to encourage mentoring in each country, with loose international links, and support for those countries where systems are less well-developed.

A GLOBAL STAGE: AN INTERNATIONAL VOICE

MWIA members attending the UN, including 10 Australian medical students

There will also be a greater focus on international partnerships: • For the last 5 years I have been the MWIA representative at the World Health Organisation (WHO) and attend the World Health Assembly in Geneva every year. One example of collaboration with the WHO is the Safe Childbirth Checklist. The aim is to reduce maternal and perinatal morbidity and mortality. One of our MWIA members in River State Nigeria, Dr Rosemary Ogu, was involved in the pilot scheme for the Checklist.

• Working with the WHO we aim to promote HPV vaccination for boys and girls to eliminate cervical cancer. In Canada, the Federation of Medical Women has been at the forefront of a very successful HPV Awareness campaign. We plan to replicate this worldwide.

• MWIA has two representatives at the United Nations. A small group of MWIA members attend the Commission on the Status of Women in New York every year.

• A Fistula Hospital in Ethiopia was established by two obstetricians from Australia and New Zealand, Drs Reginald and Catherine Hamlin in the 1970s. The hospital repairs 1,500 fistulae every year at no cost to the patient. I recommend strongly that we support this venture in any way that we can. It is a fantastic example of what can be achieved.

I recommend that you all consider becoming more actively involved in MWIA. As president, I plan to work with all the different MWIA regions to deliver practical advances in every part of the world. Do come to our centenary in New York on July 25-28th next year and submit an abstract https://amwa-doc.org/mwia100. It would be brilliant to have you all working with us.

Dr Ogu (top row 2nd on left) and team Young girl with her brother arriving at the hospital

Medical Woman | Autumn/Winter 2018 31

A GLOBAL STAGE: EDUCATION

Ethiopia: State of Education Catrin Morgan is a Foundation Year 2 doctor in London. As a medical student she was the student lead chair for the Aksum-Barts partnership and travelled to Ethiopia as part of this project. She has a keen interest in global surgery and outside of medicine enjoys playing tennis and travelling.

Akusm-Barts Partnership: a partnership between Barts and the London Medical School and Aksum University Medical School in Northern Ethiopia was established in 2013. The aim of this partnership is to provide opportunities for students and staff in Barts and Aksum to develop innovative medical education projects and further curriculum development, alongside supporting undergraduate teaching and later postgraduate training. The partnership is funded by the Tropical Health Education Trust through the Department for International Development (DFID) Health Partnerships Scheme.

Ethiopia is a country with a severe shortage of doctors, especially in the rural areas. According to the World Health Organisation (WHO), in 2010 the doctor to patient ratio in Ethiopia was 1:42,706, which is among the lowest in sub-Saharan Africa.1 The WHO established a critical threshold of 23 doctors, nurses and midwives per 10,000 of the population as a minimum to enable the delivery of essential maternal and child health services, yet they found this figure to be 3 per 10,000 in Ethiopia.2 Furthermore, it is estimated that 43% of doctors work in Addis Ababa, the capital of Ethiopia, despite only 5% of the population living there.3 The severe shortage of doctors in Ethiopia could be attributed to several reasons including the emigration of qualified doctors, limited number of medical schools, and difficulty in accessing education.

In 2012, 12 new medical schools were opened, including the University of Aksum Medical School to tackle the significant shortage of doctors in Ethiopia. The New Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. There have been four years of clinical students on the course, with the first cohort of students graduating in 2016. The curriculum is designed to train biomedical science graduates to become doctors in four years, with a focus on the healthcare needs of rural people living in poverty. Once graduated, the doctor must work in Ethiopia for at least three years.

The number of female medical students and doctors in Ethiopia remain low in comparison to males. Interestingly, the admission policy states the cumulative Grade Point Average (GPA) required for male applicants is 3.0 compared to 2.75 for females and applicants from emerging regions.4 If a female scores the same as their male counterparts, then priority will be given to the female applicant. This was initiated by the government, with the aim of encouraging more females into the profession.

Here, in two reflective accounts, we describe experiences of being educated and working in Ethiopia.

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Catrin Morgan: from the outside looking in

As a final year medical student, I travelled to rural Ethiopia as part of the Aksum-Barts partnership. The aim of this project was to evaluate the real clinical experience of medical students undertaking the New Innovative Medical Curriculum (NIMC). I undertook this research with a female General Practitioner working in Aksum, Dr Meron Teshome. From interviewing and observation of the students, it was clear that these students were highly motivated and eager to learn. However, the intended curriculum did differ from the real experience. One of the most striking observations was the lack of doctors with specialist postgraduate training and the amount of responsibility these medical students had.

Despite the government initiative to try and encourage more females into the profession, the number of female medical students on the NIMC remains low. In Aksum, there were 28 females out of 210 students. On further discussion with the female students, they felt this was due to the responsibility and commitment required to become a doctor. They commented a large proportion of the male medical students were married with children in comparison to the females who were mostly unmarried.

A GLOBAL STAGE: ETHICS

Meron Teshome was born and raised in Addis Ababa, Ethiopia. She graduated from Addis Ababa Medical School in 2013. As part of her postgraduate training she moved to Aksum in rural Ethiopia and is currently one of the few female General Practitioners work-ing there. In her spare time she enjoys swimming, reading and travelling.

Meron Teshome: from the inside looking out

I was born and raised in Addis Ababa. I am the eldest child in my family and was raised by parents who strongly believe in the importance of education, and subsequently, I have always taken my education seriously. I graduated from high school as one of the top students and later on I was able to join medical school at Addis Ababa University medical faculty. Joining medical school was not only my childhood dream, but also fulfilled my passion to help those in need. In a developing country like Ethiopia there is a high disease burden particularly of communicable disease. I was inspired to become a doctor as this role is of great value to the society I live in and I felt a responsibility to serve my society.

I was given some mentorship from senior medical students before starting university; this included specific advice for women.

Although my expectations of medical school were somewhat different from the reality, I always knew that I had to be strong to achieve my goals. There were 20 females out of 150 students in my class.

Despite a shortage of reading materials, I spent my time reading to score the best..

After I graduated from medical school, I went to Aksum University hospital and College of Health Sciences, which is located 1000 kilometres away from Addis Ababa, where my parents are living. The first few months were difficult, due to having to adapt to a new environment. Over time, I, however, found this gave me an opportunity to learn about myself, gain confidence and start living my dream. This has been balanced alongside my desire to spend time with my family. I am 28 years old now and it has been four years since I started living here. During my stay I have attended a postgraduate study program, a Masters of Public Health (MPH) at Aksum University.

Currently, I am working as a lecturer and general practitioner. I am working in the department of internal medicine. I am also an assistant professor engaged in various research activities. On average I work 45-50 hours per week.

Being a female doctor can be particularly challenging, as some patients, especially in rural areas, do not consider female physicians as fit to treat patients in comparison to their male counterparts. This is due to a number of cultural reasons and misunderstandings.

In the future, I hope to specialise in cardiology. Additionally, I hope to create a program that helps improve the leadership capacity of female physicians. Ultimately, this will improve aspects of women’s careers and help educate the community, thus, hopefully, bringing changes in the attitude towards female physicians.

References 1

2

3

4

African Health Observatory and World Health Organisation. Ethiopia: Analytical Summary 2014. Date accessed March 2018. Available from: http://www.aho.afro. who.int/profiles_information/index.php/Ethiopia:Analytical_summary_-_Health_ Status_and_Trends World Health Organisation. Ethiopia Health Workforce 2014. Date accessed March 2018. Available from: http://www.aho.afro.who.int/profiles_information/index. php/Ethiopia:Health_workforce_-_The_Health_System Abraham Y, Azaje A. The new innovative medical education system in Ethiopia: Background and development . Ethiopan Journal Health Development 2013;27: 36-40.

Federal Ministry Of Health of Ethiopia and Ministry Of Education.

The New Innovative Medical Curriculum for Ethiopia. 2010.

Medical Woman | Autumn/Winter 2018 33

UNWIND: PILATES

Powering through: improving posture and preventing lower back pain After suffering with a ligamentous knee injury, Ben Andrews developed an interest in injury rehabilitation and dedicates his working life to helping people prevent injury through exercise, mainly pilates. He has always had an interest in sport and sports performance. Ben’s hobbies include running and tennis. His small miniature dachshund accompanies him sometimes as a running buddy! He also enjoys travelling and music. Ben can be found on Instagram: benandrewspt.

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UNWIND: PILATES As a personal trainer who focuses on pilates, I see people who are ambitious to get in good shape, and also to feel free of pain and potentially overcome injury. This led to my particular interest in injury prevention; which allows us to learn how to train safely and effectively, and as a bonus, look good too! Understanding how to gain and maintain good posture, allows us to be injury free and prevent injury.

Finding the time to work out in the modern day can be challenging.

The modern era has given us technology that, for a lot of us, in relation to medicine, is a revelation! Yet it has also made us lazy. We have always been designed to move, to hunt, to run and for some that instinct appears to be disappearing. The thought of moving to some people is fearful. Additional to this, when life does get in the way, it can be hard to find the time to exercise – perhaps you have left work late after planning a run? Or have been stuck in your office far longer than you hoped?

A key awareness to have is that your body is the most important tool you have. You cannot work without it. Once you come to this realisation, firstly, congratulations, welcome to the club! Secondly, you now need to learn to enjoy exercise. You do not have the requirement to hunt for food or run away from lions, so find a sport you enjoy playing. Perhaps go for a walk with your friends and family, or go to an exercise class where a trainer can help motivate you to look after your body. Appreciate nature, there’s nothing better than being outside.

Now how do you fit an exercise programme into your busy day to day schedule? Sometimes you must be brutally honest with yourself and realise you can get up half an hour earlier, you can make time in your lunch break, you can fit in half an hour after work or before bed. If being too tired is an excuse, yes, an excuse, understand that exercising boosts your metabolism, and makes you more alert.

This busy lifestyle that the agricultural revolution has created for us has caused us to live in a seated position, or the opposite, where you are on your feet all day. The position you sit in becomes the norm for your body, and as a result, the aches and pains increase, most commonly in my practice, lower back pain. The drawbacks of conditioning your body to sit for long periods of time are tight hips, an over stretched and weak back, and zero gluteal activation.

Here are a few exercises which can be done anywhere to counteract the daily side-effects of your workplace.

‘Finding time to work out in the modern day can be challenging…

We have always been designed to move, to hunt, to run and for some that instinct appears to be disappearing… A key awareness to have is that your body is the most important tool you have…’

Shoulder bridge

A perfect exercise to create extension in the back, activate your gluteal muscles and engage your core.

• Lie on your back, with the head and shoulders placed down on the floor, and heels pressed into the ground under your knees. Start with your back and tailbone down on the floor.

• Breathe out and lift up your hips, squeezing your buttocks, so that you form a line from your knees to your shoulders. Maintain a flat position on your abdominals, and making sure your rib cage does not poke up.

• Breathe in and in a controlled fashion bring your hips back down to the floor, squeezing your buttocks and hamstrings.

• Try three sets of ten repetitions.

The aim is to strengthen the core, so it can maintain a good posture when sitting or standing and maintain the natural curve that we all have in the lower back.

Abdominal crunch

• L ie on your back with your head, shoulders and feet on the floor.

• Breathe in. Slightly tucking your chin in towards your chest so you can still fit a full fist between your chin and chest.

• Breathe out. Lift your head and shoulders off the floor, reaching your fingertips towards your heels. Make sure the ribcage lifts off the mat.

• The lower ribs should always stay connected to the mat.

• Breathe in and return to the start position.

• Attempt 3 sets of 10 repetitions.

Although there are many exercises that focus on developing your strength in the core and lower back region, we must not neglect the rest of the body.

I do these two exercises daily – normally with my puppy jumping over me trying to interfere! So it is worth making time, even if it means lying on the floor at work. We can make time for our body, it is vitally important.

Medical Woman | Autumn/Winter 2018 35

BOOK REVIEW

A Fortunate Man: the story of a country doctor

by John Berger and Jean Mohr

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.

One of the books which influenced me the most as a GP trainee back in the mid-1990’s was A Fortunate Man. My trainer, David Jewson, was then a young GP, new to training and with some alternative ideas as to how to go about things. As part of his brief, every week in the tutorial he would give me a book of his choice for me to read for discussion the following week. Some of these were narrowly focused (I remember the ABC of Alcohol for example); some emphasised communication skills (The Inner Apprentice taught me a lot in this regard) and others were more general.

A Fortunate Man belonged to this last group.

On reflection, I think the question my trainer was trying to address with me that day, and one which I have often raised with both students and registrars since is, “What sort of doctor do you want to be?”.

The book certainly describes a different time (1967) and a style of medicine which would not be possible to achieve in NHS general practice today. Dr Sassall works by preference as a single-handed GP; on-call all year round to his patients. He has no modern sense of work-life balance and on his off hours involves himself in community projects and village affairs.

The continuity of this way of working is much emphasised, with consultations which open “Do you remember when…?” and a description of the doctor as ‘clerk of the records’; someone who is able to hold and retain the history and sequence of the lives of those around him in a truthful and reliable way.

36 Medical Woman | Autumn/Winter 2018

He is seen as ‘a good doctor’ by John Berger ‘because he meets the deep but unformulated expectation of the sick for a sense of fraternity.’ Despite acknowledged differences of background, class and education, Sassall is able to meet with his patients and hear their stories with honest openness. Sometimes he is able to deliver difficult truths which may be hard to hear, such as his statement to the husband recently bereaved, “It would have been worse for her if she’d lived. It would have been worse.” This was meant with compassion and to free the husband from any sense of responsibility for inaction or failure on his part in the events which had occurred.

Sassall himself believes the good doctor to be ‘in command and composed – whereas everybody else was fussing and agitated.’

There is no reduction in authority based on time of day, or whether he is wearing his work trousers over pyjamas at 3am; authority is invested in his position and aspect.

The most striking line in the book is that Sassall offers his patients his ‘unfeigned positive regard.’ This is the attitude which I have tried to embed into my practice. It comes to mind when a patient offers challenge in some way; either medically or in their attitude or interaction. Not only are we entreated to look positively upon the patient; but this is to be really our view, no matter the circumstance.

This is a challenging approach to consulting but very rewarding.

In tandem with Berger’s description of Sassall and his methods, Jean Mohr took a series of black and white stills which interweave with and illustrate the whole. These are sometimes of individual patients or of the doctor himself, both in his consulting room and the wider community. Both Berger and Mohr lived with him and his family for six weeks to create the work and get a detailed insight into all aspects of his life.

The authors do not flinch from the hardness of the life or the fact of the intense emotional impact which it had on the doctor. There is an unwritten assumption that the support of his wife was integral, although she appears neither in the text nor the photographs.

Certainly after her death in the early 1970’s Sassall did leave the practice, and there is evidence that even during his time working there that he suffered from deep episodes of depression, sometimes for months at a time. He sadly ended his own life in 1982.

The book, however, lives on, with the power to influence a new generation of doctors. We may not want to be completely in his image, but he still has plenty to teach us as we sift through that tricky question – “What sort of doctor do you want to be?”.

And as for Dr David Jewson, my trainer, he retired a year or so ago, but continues to teach the next generation of students and no doubt is working with them on just that same question.

BLOG: COMPASSIONATE CARE

Caring counts: unexpected outcomes Heidi Mounsey now works for a medical indemnity organisation, but for a while she was a palliative medicine registrar. During that time, her aim was to provide a good quality of life, for the rest of life.

Here Heidi talks to us about two influential characters, who inspired her attitude to care in clinical practice.

Case 1

Mr P was elderly, with a likely primary hepatocellular cancer. He came to us after his family had stopped visiting him or providing any help, and a neighbour had raised concerns. His appetite was poor; he had experienced profound weight loss and dreadful diarrhoea. He had no energy to wash himself, and was in a sorry state when he arrived.

He was apathetic, disengaged, and appeared to have simply given in to feelings of abandonment and loneliness.

It was felt his prognosis from cancer was a short few weeks, but that his demise was likely going to be accelerated by his disinterest and withdrawal from his surroundings. It seemed there would be little we could do about that.

It turns out we were wrong.

With medication to control the diarrhoea, a bath, and some choice morsels from the kitchen (it turned out he had a love of salmon), it took only a couple of days for Mr P to show a lot more interest in the world. His appetite increased hugely, he expressed (loudly, in no uncertain terms, but somehow endearingly) his wants and needs, and he claimed a favourite spot in the day room, settling himself there in the sun and grumbling at anyone who dared to take the seat first.

He stayed with us for two months, with a quality of life that had not been thought possible on his first presentation, before gradually deteriorating and dying peacefully; knowing, we hope, that he was cared for and would be missed.

Case 2

Miss D came to us with severe respiratory problems following sepsis.

She had not been expected to survive, and to put it harshly, was simply taking too long to die in the acute setting. She was very young to be so sick, and there was a lot of speculation (out of her hearing) about whether surviving long-term would even be the best outcome for her; she would have significant permanent respiratory impairment and had also suffered a marked degree of visual loss.

A ceiling of care was set, and we were prepared for a rocky road and a bleak ending.

Miss D, though, appeared to be blissfully unaware of this. Her limited vision and poor breathing did not stop her engag ing as much as she could, and as she regained some strength and independence she pottered around the place interacting with whoever she found. She did manage to get herself lost a number of times, and every so often there would be a plaintive cry for help as she found herself somewhere unexpected and could not remember how to get back to her room.

She had further chest infections, which were successfully treated with oral antibiotics and symptomatic management. There were some perilously close calls, but she gradually improved until the point she was clearly no longer in need of palliative care, although her respiratory impairment remained.

She was deemed fit enough to undergo surgery which restored a degree of vision, and now lives a happy and active life.

Both Mr P (Paddy) and Miss D (Daisy) are cats who were fostered with me and my partner, via a local cat shelter, specifically with a view to providing a loving home for end of life care. Paddy had been abandoned by his owners when he became unwell at 17 years of age, and Daisy was a three month old stray suffering with severe cat flu which, as well as causing respiratory difficulties, resulted in corneal damage. Even after surgery, she remains blind in her right eye.

Although euthanasia was offered in both cases, it was declined as it was felt that there were no symptoms which could not be managed, and despite their poor outlook it would be unfair not to give them the opportunity for as good a life as possible for as long as possible.

Both cases display the importance of good, committed, palliative care – regardless of species – it is not always about treating the disease with the intent of a cure or restoring perfect health and function.

It is about maximising quality of life. And, sometimes when we make this our aim, the outcome is not always what we might predict.

Much progress has been made, but much more remains to be done!