Medical Woman – Vol 38, Issue 1, Spring/Summer 2019

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The Equality Issue

Editor’s Letter Dissecting equality


veryone, it would seem, is a feminist today. Only click on to Twitter, take a profile peak, and you will find yourself face to face - at least digitally - with another who labels themselves as a feminist. Yet, feminism, the role of femininity, and even equality, can mean such different things to us. It can take me a few hours to unwind after a long on-call. Late last night, after a shift on the Hyper-Acute Stroke Unit, I sat down to watch Lady Macbeth, directed by William Oldroyd and based on the short story Lady Macbeth of the Mtsensk District by Nikolai Leskov. The film tells the tale of a woman oppressed within an aged societal structure, peering out from her forced solitude through the bars of patriarchy. The fascinating twist is in her assertion of self - while her tormentors are away, she plays with pleasure and the power of self-ownership. First through the hills and fields the air buffets her, this gives way to an impulsive and reckless lust, eventually transforming into a thirst for blood. She does as she pleases. She is free from consequence. Yet through her ascent there is an irony, she generates casualties out of the vulnerable and socially oppressed - a servant, a labourer, a child, all portrayed by actors of colour - director’s choice. In the end, she returns to her solitude albeit man-free. Truly, if we are to achieve equality in healthcare then cultural change is required. Yet cultural change cannot be a single prong. To change we must think of equality, globally, and in all it’s different forms. The overarching theme of this issue is equality and diversity. As you leaf through you will find a variety of articles; a reflection on the progress of professional women, discussion of pay gaps in medicine, a focus on improving outcomes for minority group students, and the work of refugee doctors. Interwoven into this issue, find articles covering international perspectives on contraception and teenage pregnancy. In Women’s Health the focus is on the pre-menstrual syndrome, and in Mind Matters we cover depression with clinically relevant cultural insight. Along the theme of self-care, we have articles covering physician suicide and a sleep expert discusses how to make the most of your time to rejuvenate. I hope this issue provides a fascinating read, an opportunity to expand thoughts, perspectives and ideas around equality. I look forward to hearing from you - my contact details are below - and to seeing you at our upcoming conference in May.

Fizzah Ali @DrFizzah

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

News and Events

Editor-in-Chief: Dr Fizzah Ali

Career snapshot: Diversifying academia 4

Editorial Assistants: Miss Kimberly Murrell Miss Danielle Nwadinobi

Career planning: Neurology


Skills Toolkit: How not to get squashed


Design & Production: Toni Barrington The Magazine Production Company Cover illustration: Pexels 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: @medicalwomenuk Registered charity: 261820 Patron: HRH The Duchess of Gloucester GCVO President: Dr Henrietta Bowden-Jones OBE President-Elect: Professor Neena Modi


Steps to equality: Improving outcomes 9

Money matters


Refugee Doctors


Learning from loss


Mind matters: Here to help


Mastering mind: Depression


Women’s health: Pre-menstrual syndrome


Global Insight: Access to contraception 32


Honorary Secretary: Dr Clare Gerada MBE

Book review


Honorary Treasurer: Dr Heidi Mounsey

Universal need: Helping hand


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.


Mental health: Cultural insights 26

Sleeping well

this publication may be reproduced or transmitted


MWF Autumn Conference 2018 18

Vice-President: Dr Olwen Williams OBE

Medical Woman: © All rights reserved. No part of





South West Local Group Report The South West Regional group have made efforts to have networking opportunities for our members, as well as raising the profile of the MWF regionally to non-members. MWF medical student members from Bristol University held a careers event coinciding with International Women’s Day titled ‘Women in Medicine: the future.’ 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. Sarah Reeves, medical student representative from Exeter University co-arranged a similar event, ‘Connecting with Clinical Careers’ in December at her University. Clinicians shared their motivation for choosing their specialty and talked about their career paths. The evening provided an opportunity for students and doctors to learn from each other and to network at different levels across the profession. In August 2018, we enjoyed an evening meal at Professor Bhupinder Sandhu’s home for our regional meeting. Attendees from that meeting have formed the basis for the Spring Conference planning committee, and we have been meeting up regularly since then. We look forward to hosting the Spring Conference in Bristol on Friday 17th May 2019. I would like to thank all our local group members for their engagement and support.

Dr Manjit Dhinsa, MWF South West Regional Representative

London Local Event Report MWF London Juniors, Monday 11th February 2019

DATES FOR YOUR DIARY May 17th 2019 MWF Spring Conference (Bristol), ‘Celebrating Success and Preparing for the Future’ and MWF AGM May 18th 2019 MWF Council Meeting (Bristol) June 2019 MWF Junior Doctor Prize opens July 25-28th 2019 MWIA Centennial Congress, New York October 2019 3 months extra free MWF membership promotion October 31st 2019 MWF Council Meeting (London) November 1st 2019 MWF Autumn Conference (London) December 2019 Katherine Branson Student Essay Prize opens

A successful event was run by the MWF London Junior Doctors and Medical Students teams on Monday 11th February at Charing Cross Hospital. Professor Neena Modi, MWF President-Elect, gave the keynote lecture and engaged the audience on their thoughts about the future of MWF and its role for up-and-coming clinicians. Dr Fizzah Ali, Editor-in-Chief of Medical Woman, gave a fascinating discussion on the benefits of a portfolio career in medicine and how to establish yourself as a medical journalist. And last but by no means least, Major Thomas presented her experiences as a front-line army surgeon and the risks and responsibilities entailed in providing medical care in the war zone, as well as the contrast and challenges of returning to NHS work. “Just to say thanks - I had a really great evening, was lovely to meet with other like-minded students” and “Really enjoyed the perspective of very different career aspects” were among the feedback from attendees.

Dr Anna Ryan, MWF Junior Doctor Representative for London

MWF Student Report for the University of Edinburgh The Edinburgh University student committee for the MWF have continued to be increasingly active this year. It is the second year a MWF committee has existed at the University and it has allowed us to host a wide range of exciting events, raising awareness of the MWF within the university student population. Our first event to start off the academic year was a ‘Women in Medicine’ pub quiz, testing our quizzers on their knowledge of all things medical women, including the Edinburgh Seven and Elizabeth Blackwell, the first British female physician. In November we held a ‘speed dating’ careers evening. This was a highly successful event, attracting over 30 female doctors from 15 specialties to talk to medical students about their careers and answer any burning questions. In celebration of International Women’s Day, we hosted a ‘History of Women in Medicine’ evening in the library archives. We explored records from the Bruntsfield Hospital, set up by Sophia Jex-Blake, and the Elsie Inglis Memorial Maternity Hospital, as well as a collection of letters from 1872 which refer to the allowing the admission of female students to the Royal Infirmary of Edinburgh. Finally in May of 2019, we are planning a big celebration to commemorate the 150th anniversary of the Edinburgh Seven.

Hannah Flower, MWF Student Representative, University of Edinburgh 2 Medical Woman | Spring/Summer 2019


MWIA report for Medical Woman

The Medical Women’s International Association (MWIA) is an association of individual members and national organisations, including MWF, from over 70 countries. All members of MWF are members of MWIA. We are celebrating MWIA’s centenary in New York in July this year, where it all began. You are all very welcome to join in the celebrations. MWIA has 8 regions, and MWF belongs to the Northern European region. I was very fortunate to attend the recent Africa and Near East regional meeting in Nairobi last November. A wonderful range of speakers had been assembled, with input from every corner of African life. There were presentations ranging from Dr Joyce Banda, the past president of Malawi, to national politicians, academics, medical students, community workers and survivors of gang rapes. Many problems were highlighted – poverty, corruption, lack of access to healthcare, disapproval of family planning by parts of the church, as well as families themselves (especially husbands), poor maternity care in many areas, gender-based violence (gang rapes occur on a daily basis in some areas), and no access to safe abortions. One particularly harrowing problem was detention in hospital if one was unable to pay for healthcare. We heard from

one woman who was detained in hospital in primitive conditions with her baby for a month after delivery. Her husband and three other children had to bring in food and other provisions for basic sustenance. Detention can last for up to a year. However, progress is being made. The WHO is pushing for Universal Health Coverage, and more of the population is getting Health Insurance, especially via their mobile phones (98% of the population have these). Access to education is improving, and women are becoming empowered. I was very pleased to have the opportunity to visit a primary health care facility in one of Nairobi’s poorer areas, and to speak to two survivors of gang rape in the Mathare district of Nairobi. Despite the poverty, the children were bright-eyed and sparkling. Prominently displayed in a primary school office was an impressive array of cups won by the primary school basketball team. Several children had won sports scholarships to the US. While at the conference, Dr Bev Johnson, a past president of the Canadian Medical Women’s Federation and I met with Drs Michelle Musoga and Yvonne Olwang and discussed issues surrounding teenage pregnancy and contraception in young women in Kenya you will find their story in the coming pages.

Clarissa Fabre, Medical Women’s International Association (MWIA) President-Elect and representative to the World Health Organisation (WHO) Medical Woman | Spring/Summer 2019 3


Diversifying academia Academic medicine is a career which lacks diversity in senior positions. Women and black/ethnic minority (BAME) doctors are under-represented for a variety of reasons. In this interview we meet an outstanding researcher, Mariam Jamal-Hanjani, who has overcome these barriers and achieved an international reputation in Cancer Research. all whilst under the age of 40. Here she shares her experiences and advice for junior clinicians interested in academic medicine. Anna Ryan interviews and reports.


Mariam’s thoughts on diversity

I studied Physics at University College London (UCL), and subsequently Medicine at UCL Medical School. I undertook junior medical rotations in London and entered the Medical Oncology training programme in 2009. I have since worked at St George’s Hospital, Guys Hospital and UCL Hospital. I completed my PhD as a Cancer Research UK (CRUK) Research Fellow in Cancer Genetics at UCL Cancer Institute with Professor Charles Swanton. In 2016, I was awarded a National Institute of Health Research Clinical Lectureship to continue my postdoctoral research alongside clinical training, and in 2018, I became an Honorary Consultant (a role split between clinical commitments and academic research) in Thoracic Medical Oncology at UCLH. I am married, and am part of the ‘sandwich generation’ – having caring responsibilities for my three year old son, and for my parents. To relax I enjoy playing the flute, running, drawing and painting.

Medicine can be fairer than the academic world in terms of career progression, but still the time to progression is influenced by having children. Childcare commitments are likely to have an impact on your progress, for example, the ability to attend early and/or late meetings, which can have an effect on career opportunities and delay progression to senior roles. The research side can be tougher – there is less fixed commitment to clinic timings, but developing a research portfolio takes time and perseverance – you need to establish yourself as an academic clinician, develop ideas and enable effective collaborations. Basic science research, in particular, requires longevity of infrastructure and financial support. In academia there are far fewer female professors – this may be due to women making choices to prioritise family or it may be the inherent prejudices when it comes women – that they may be less knowledgeable than men or focused on other things. I think this problem exists as a society and filters through into whatever profession you are in. I’ve been fortunate enough to have not experienced any direct prejudice, but once or twice when a patient has walked into my clinic room, I’ve felt that perhaps they were disappointed to see me as opposed to a male doctor. With a society that is multi-cultural and multi-ethnic, diversity can enrich and strengthen rather than impede our interaction with patients, and our clinical and academic relationships with colleagues.

Research experiences My research interests are in genetic heterogeneity and the evolution of cancer. Alongside Professor Charles Swanton, and the CRUK & UCL Cancer Trials Centre, I led the set-up as Principal Investigator of two large UK-wide clinical studies. This involved study design, writing the protocols and successful grant applications for £4million (PEACE) and £12million (TRACERx). I manage a diverse research team, providing oversight of recruitment, specimen processing and data management. I have negotiated contractual agreements with collaborators, provide annual reporting to funders and lead the organisation of consortium meetings. I have also chaired and sat on advisory committees for international cancer conferences including for the European Society of Medical Oncology. TRAcking Cancer Evolution through therapy (TRACERx) is the first study to look at the evolution of lung cancer in real time with immense detail, from diagnosis through to either disease relapse or cure after surgery, tracking and analysing how their cancer developed and progressed. The linked Posthumous Evaluation of Advanced Cancer Environment (PEACE) study allows multi-regional sampling of metastatic tumours in the post-mortem setting. PEACE/TRACERx data have already provided exciting insights into the identification of distinct patterns of metastatic spread and the process of tumour evolution in the advanced setting. Professor Charles Swanton has commented: “For the first time we have revealed new insights into how tumours evolve and evade treatment, a leading cause of cancer death”.

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Mariam’s advice for junior doctors interested in academia • Knowledge is power – whatever career path you want to take be knowledgeable, do your research. • Don’t be put off by anyone who makes you feel you’re unlikely to be successful. You’ve got to try, even if unsuccessful - the process and experience is useful. • Take and seek every opportunity that arises. • Be actively involved in writing reviews or publishing, attend meetings and conferences. • Be inspired by other women, if you hear a talk by someone – clinician, politician, anyone – try and talk to them, learn from them. • Seek women mentors. • If you fail, take a moment, and then pick yourself back up and learn from how others have overcome similar problems and persevere toward to your goals.


Cerebral choice: a day in the life of a neurologist Fizzah Ali is a Neurology registrar currently based at the National Hospital for Neurology and Neurosurgery, London. She has interests in promoting flexible working, and is nurturing an interest in journalism and public engagement. In her spare time, Fizzah enjoys yoga and an array of artistic pursuits.

Can you tell us a bit about yourself? I am in my second year of Neurology specialist training (ST4), and I work less-than-full-time. I moved to London fairly recently, having completed my earlier training in the Midlands. Why did you decide to do neurology? I commenced my clinical training in my third year of medical school. Neurology was one of the first specialties I encountered in hospital and I thought it was utterly fascinating. I was fortunate as we received teaching from a consultant who was sensitive in the way he taught us. I appreciated the importance of listening carefully to the patient, detailed history-taking, and how an examination could provide clues to where and what the underlying pathology is. Neurology was the first specialty for which I felt a strong affinity; there were others later - including a brief flirtation with surgery, however over the years the interest in brain persevered. An intercalated degree working with a Behavioural Neurologist was important in shaping my subsequent career steps; however, it was also my rotations through Foundation Year and Core Training which made me feel that my personality type would be best suited to a career in neurology. Describe a typical day as a neurology registrar We rotate every few months over the course of our training through a variety of posts. These include rotations covering, for example, neurology in-patients on the ward, the acute stroke rota, general neurology clinics at district general hospitals, and later a variety of sub-speciality firms such as movement disorders or epilepsy. In keeping with this, a single day will vary. Currently, I am working on a neuro-ophthalmology firm. A typical day will start at 8am with a neuro-radiology meeting where we discuss patient presentations and imaging findings. This is followed by a ward round of our in-patients. Later, clinic is followed up by catching up on some administrative work - whether dictating and correcting patient letters, requesting investigations or arranging admissions. During the week I usually find time to teach medical students, and we also have scheduled registrar case based teaching. What do you enjoy most about training in neurology? The case mix within neurology is broad, ranging a host of disease states, from the very common to the rare, of variable prognosis.

I have a tendency towards quirky things, and there is always a puzzle in neurology! The diagnostic challenge can be intellectually stimulating. On a day-to-day basis, the specialty has a significant out-patient workload, which means we do a number of clinics each week. I enjoy this clinic based work and find the pace in neurology is better suited to my personality. There is also encouragement to pursue research which I look forward to. What are the challenges in your chosen career path? Specialist training can be lengthy running over a period of years, and this can put some people off, additionally combining this with less-than-full-time training can extend training time substantially. A focus on the journey, rather than the end-point can help counterbalance this. Depending, in part, on where you see yourself training, trainees entering neurology tend to be well qualified even before entering specialty training, perhaps having done research degrees or having developed an interest in a particular area of neurology before embarking on specialist training. On a day-to-day basis the workload can be intense and due to the clinic burden a substantial amount of time goes in to completing clinical administrative work. What advice would you give medical students and trainees deciding on their future specialty? As a medical student it is not uncommon to have a brief neurology rotation, if you feel this taster has whet your appetite, look for alternative paths through which you can explore the specialty and a potential interest further. Within your training, some aspects of neurology may seem complicated, but this is not something to be daunted by early if you are interested - an understanding can develop over time and exposure. When it comes to choosing a specialty, combine interest with practical insight. Be honest with yourself about the sort of lifestyle you want to live and the sort of work-life balance you are looking for. This will include considerations relating to flexible training and length of training, whether you are happy to do evening, night and weekend on-call shifts, as well as the workload and pace of the specialty. Ultimately these practicalities may determine whether way you decide to stick to your choice in the longer run.

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How not to get squashed: leadership for women in the #MeToo era Anna Ryan is a Medical Oncologist at University College London Hospital. She is the London Junior Doctor Representative for the Medical Women’s Federation and has been an invited speaker on Diversity in Leadership for the Faculty of Medical Management and Leadership. She works four days a week, and spends the rest of her time trying to keep up with her two energetic toddlers.

“Woman as a doctor is a conceit contradictory to nature, and doomed to end in disappointment both to the physician and the sick” – the Lancet, 1878

How far we have come since the Victorian era of discrimination against women! Women now comprise over 55% of medical students and 46% of the medical workforce as a whole. Yet male doctors earn on average 15% more than women, 30% of female doctors have experienced sexual harassment at work, and only a quarter of publications in the two highest impact factor scientific journals are authored by women. These dismal statistics highlight that challenges still need to be overcome to achieve true diversity and equality in medical leadership roles. 6 Medical Woman | Spring/Summer 2019

Where have we come from? The first female doctor qualified in the UK in 1865 – Elizabeth Garrett Anderson was the first and only female member of the British Medical Association for nearly 20 years. In 1879 the Association of Registered Medical Women was formed with a membership of nine, this evolved into the Medical Women’s Federation in 1917 with almost 200 members. The year 1918 was marked by women achieving the right to vote in the UK, and in 1935 the Royal College of Physicians (RCP) enrolled their first female


The NHS is the third largest employer in the world, and opportunities for clinical leadership are many and widespread. Clinical leaders not only deliver a service but are forward-thinking and set the direction for future improvements, as well being visible role models for junior staff. Leadership does not always equate to seniority, medical student and junior doctor leaders can be powerful voices in campaigning for change, however career progression is often linked with increasing leadership opportunities. From Clinical Lead through to Medical Director and Chief Executive, leadership within the clinical service is just one of the options available to doctors: research, teaching and non-clinical management positions are alternative avenues of progression.

Individuals: Achieving leadership roles as a female clinician may require a strategic rethink of our daily working practices. Suggestions and advice gleaned from women who have achieved seniority include: • Actively seeking opportunities (not waiting to be invited) • Overcoming internal obstacles (‘imposter syndrome’) • Work ‘smart, not hard’: prioritise personal development • Strategic vision: ‘think like your Boss’s Boss’ • ‘Lift as you climb’: support the progression of juniors • Develop assertiveness, negotiation, networking and personal branding skills: they may not be inherent but can be taught. Male allies: Male preponderance in leadership and executive positions means that engagement of male allies is crucial to achieving equality. The international ‘HeForShe’ campaign has raised awareness of the role men can play - by supporting practical changes at their organisation, but also simple measures such as modelling non-discriminatory behaviour.

Where are we now?


Career progression: Women make up 55% of medical students and 46% of registered doctors in Britain, but in senior roles equality diminishes – 34% of consultants and only 24% of clinical professors are women. Women are under-represented in academia – between 2005 and 2017 females were the senior authors of only 15% of articles published in Nature & Science.1 Equal pay: The Equal Pay Act was passed in 1970 but nearly 50 years later the gender pay gap persists – male doctors earn on average 15% more than women [(basic pay: £67,788 (male) vs £57,569 (female).2 Of the 100 highest earning consultants in the UK only five are female. Despite nationally standardised pay scales the gap in medicine is greater than in most other industries (for example, solicitors 12%, pharmacists 18%, all employment groups 19%). Women are also less likely to apply for Clinical Excellence Awards – only 20% of recipients are females. Sexual Harassment: Around 70% of female clinicians have experienced gender bias, and 30% sexual harassment. Disappointingly, where incidents were reported a quarter of victims felt the incidents were trivialised.3

“You not only have got to do a good job but you have got to do a superior job. What would be accepted from a man will not be accepted from a woman. You have got to do better”. Dr Flora Murray, Founder Women’s Hospital for Children (1912) We have reviewed the background and current situation of women clinician leaders. The challenge of achieving representative diversity in leadership in the NHS has not yet been overcome, despite a legal framework which protects women’s rights and increasing momentum over recent years to change and improve. Action needs to be taken at both the organisational and individual level, and supported by senior leaders of both genders.

fellow, Dr Helen Mackay. It took over 50 years for the first woman to become President of the RCP, and it was only in 1993 that the first female Professor of Surgery was recognised in the UK.

What is leadership in the NHS?

Where are we going? We aim for equal representation of women at all levels of the medical workforce. The Department of Health and Social Care has included gender equality in the Mandate of NHS England and recommended a shift in organisational culture, appointment of a high level champion and task force alongside monitoring and accountability processes to support change.

Personal perspective I have found balancing career progression with family commitments to be a constant challenge – it is the plight of women that the age when we bear children coincides with the time when we tend to be at our most ambitious career wise. There are many challenges I wish to take on, and roles I would like to fulfil at work, but I have learned to prioritise and only accept those which are in-keeping with my personal targets and values. I think that it will become easier over the next 5-10 years; already institutions such as the Wellcome Trust are trialing flexible working as standard, and there are countless campaigns and charities promoting diversity and gender equality. I hope that for the next generation the discussions we are having now will be something they find bemusing – the antiquated idea that women and men would not be equal in the workplace will be as foreign to them as the idea that women would be unable to ride a bicycle is to us.

How do we get there? Organisations: Enabling change at an organisation level is challenging but crucial to supporting equality in the workplace. Strategies for development may include: • Supporting flexible and less-than-full-time working practices • E stablishing clear transparent criteria for promotion and recruitment • Educating employees about stereotypes, implicit bias and the gender pay gap • Encouraging senior staff to vouch for the competence of female colleagues • Providing mentoring for early career female trainees

Further information References S hen, Y.A., et al., Persistent Underrepresentation of Women’s Science in High Profile Journals. bioRxiv, 2018: p. 275362. 2 Appleby, J., Is there equal pay in healthcare? Not if you are a doctor. BMJ : British Medical Journal, 2012. 345: p. e6191. 3 Kane, L. Medscape: Sexual harassment of physicians report 2018. 2018 [cited 2019 28/01/2019]; Available from: 1

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Improving outcomes: for medics from BME backgrounds Katherine Woolf is Associate Professor of Medical Education at UCL Medical School. Since 2004 she has studied differential attainment to improve medical education. Katherine is lead for the NIHR-funded UK Medical Applicant Cohort Study, which aims to help students from diverse backgrounds choose which medical schools to apply to, and ultimately ensure the NHS benefits from the best doctors (see

Medicine is increasingly ethnically diverse: over a third of medical students and doctors in the UK are from black and minority ethnic (BME) backgrounds, and that proportion is increasing steadily.1,2 This is good news. Ethnic diversity within organisations is associated with greater innovation and success.2,3 A national study from the United States found that students from more ethnically diverse medical schools felt more prepared to care for patients from minority and under-served groups.4 The bad news is that despite this ethnic diversity, medical students and doctors from BME groups face significant barriers to success compared to their white counterparts. Students from BME groups are less likely than white students with the same grades to get a place at medical school.5 Once at medical school, students from BME backgrounds have, on average, poorer outcomes in examinations and higher failure rates.6 This is despite that fact nearly 90% of UK medical graduates are British.1 Differential attainment by ethnicity is also present in postgraduate medicine, in examinations, in recruitment, and in Annual Review of Competency Progression (ARCP) outcomes.6,7,8 There is an ethnic pay gap, with black doctors earning significantly less than white doctors.9 It is important to remember that these statistics reflect average differences between groups. There are of course many BME doctors doing extremely well, and unfortunately many white doctors doing poorly. Group differences should not be used to make assumptions about the performance of the individual medical students and doctors we teach, are taught by, or care for us. The fact that these group differences exist is still however deeply concerning. I have spent the last 15 years as an academic in medical education discovering the causes of differential attainment by ethnicity in medicine, and what can be done to address differential attainment, improve fairness, and improve outcomes. This article discusses the importance of ensuring equality in medicine, why ethnic differences in attainment exist, and what organisations and individuals can do to tackle inequality in medical education and enable medical students and doctors from all ethnic backgrounds to thrive and provide excellent patient care.

The need for equality in medical education There is an obvious moral need to ensure medical education is fair for all, and recent research using data from the National Health Service (NHS) Workforce Race Equality Scheme (WRES) found higher patient satisfaction within acute Trusts was predicted by more staff believing their Trust provided equal opportunity for career progression, and fewer BME staff experiencing discrimination.10 But organisations that provide medical education and training

should also address inequalities as part of their Public Sector Equality Duty ( ) see box. Indeed, a recent court case highlighted the need for the organisations responsible for medical education and training to gather and analyse information on differential attainment, but also to act upon what they find.11 The GMC now requires all specialty training providers to report what they are doing to understand and address differential attainment. The 2016 GMC standards for the management and delivery of undergraduate and postgraduate medical education and training have accompanying guidance that make clear how organisations should meet the ‘expectations of the equality and diversity considerations that apply to each standard’.12 Students and trainees themselves are also now much more aware of differential attainment. Across the UK and internationally there are now many student-led initiatives to ‘decolonise’ curricula and make teaching more representative in its content and delivery. In 2018 the National Union of Students and Universities UK launched a national BME attainment gap project ( news/Pages/tackling-gaps-in-bme-students-achievements.aspx ).

Why does differential attainment exist? Differential attainment is now acknowledged to result primarily from institutional practices rather than student deficits.13,14 It remains after controlling for students’ pre-university attainment or socio-economic status,15 and persisted in medical school finals performance after controlling statistically for GCSE and A level results, school type, parental job, language, motivation for being a doctor, study habits, whether living at home, and personality.16 Examiner bias in clinical examinations is also unlikely to be a major cause, although more research is needed to rule out bias in recruitment and ARCP outcomes.7,17,18,19 The learning environment is now considered a major cause of differential attainment. Learning is an inherently social activity and there is strong evidence that interactions between students and teachers, and between students and their peers, critically affect learning outcomes.20,21 An international review found minority medical students ‘experienced less supportive social and less positive learning environments, were subject to discrimination and racial harassment, and were more likely to see their race as having a negative impact on their medical school experiences’.22 BME trainees report poorer experiences of learning.23 BME medical students and graduates can be negatively stereotyped by other students and teachers, can feel they need to work harder to prove themselves, and can find it more difficult to get educational support Medical Woman | Spring/Summer 2019 9


Public Sector Equality Duty (from ) Those subject to the equality duty must, in the exercise of their functions, have due regard to the need to: • Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. • Advance equality of opportunity between people who share a protected characteristic and those who do not. • Foster good relations between people who share a protected characteristic and those who do not. These are sometimes referred to as the three aims or arms of the general equality duty. The Act explains that having due regard for advancing equality involves: • Removing or minimising disadvantages suffered by people due to their protected characteristics. • Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. • Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

from seniors.13,24 Students, white and BME, preferentially form friendships within their own ethnic groups, which can magnify inequalities.25,26 Despite over a third of UK medical students being from BME ethnic groups, students are typically taught about ethnicity as a clinical problem for doctors to deal with.27,28 Teachers are often ill-equipped to discuss ‘race’ and ethnicity, and to deal with racism from patients or colleagues,29,30 and staff can worry about discussing the differential attainment that exists within their own organisations, which itself can act as a barrier to developing interventions to address it.31

What can be done to address differential attainment? The BME attainment gap is a pervasive institutional problem, which requires institutional solutions.32 It is present at undergraduate and postgraduate levels, and across higher education and other professions. There is no single intervention or ‘silver bullet’ that will remove differential attainment, but below is a list of actions that organisations, teachers and trainers, and students and trainees, can take to seek to understand and address the problem. Actions for organisations • Proactively collect, analyse and publish data on learner outcomes and experiences. Include quantitative progression outcomes, and qualitative and survey data on the experiences of BME learners.14 • Treat differential attainment as a systemic institutional problem rather than as a problem learners need to overcome. Make it clear that tackling differential attainment is not about blaming individuals, but about uncovering and changing systems and practices that disadvantage BME learners.14 • Engage staff in tackling the problem. Support staff by providing time and training to enable them to support their juniors. Appoint senior champions to drive forward culture change, while guarding against relying on individuals who may move on.33 Avoid a purely top-down approach: work in partnership with diverse BME learners to co-develop interventions they feel will work for them. • Get advice and support from others engaged in tackling differential attainment. The Office for Students has made tackling the BME attainment gap a priority for higher education institutions, and the National Union of Students and Universities UK have launched a national BME attainment project. Many medical Royal Colleges, Health Education England Local Educational Trust Boards, and medical schools, are developing 10 Medical Woman | Spring/Summer 2019

and piloting initiatives. The British Medical Association, the Workforce Race Equality Scheme, and Advance Higher Education (formerly the Equality Challenge Unit) have freely-available resources. • Create organisational climates and cultures which diversity is valued and racism is not tolerated. This includes training staff and students in tackling racism, setting up reporting systems, creating policies that support equality, and making sure staff, students, and patients are aware of these initiatives (Cf.34 ). • Fund the development, implementation, evaluation, and publication of initiatives. The GMC has published some evaluation guidance to help organisations evaluate (https:// projects/differential-attainment/practical-guide-to-evaluation ). • Be wary of ‘box-ticking’ because it can impede change.35 Actions for teachers and trainers • Spend time getting to know juniors. Asking “where are you from?” can be alienating for people from BME groups, but you can ask about their journey in that morning or what they did at the weekend. • Learn juniors’ names. If you forget their name, ask them again. Find a way of remembering their name, such as making a note of how to pronounce it phonetically, or thinking of something it rhymes with. Never assign somebody a name just because you find it easier to pronounce than their real name. • Notice which juniors you sponsor. Sponsorship (seniors picking out the juniors they think have potential, and then coaching them to succeed) is a strong predictor of career success, and people from BME groups can be overlooked. Notice who gets to examine the patient, or present a case, who you spend time giving extra feedback to. Notice who gets ignored and whose name you don’t know. • Encourage juniors to get to know their colleagues. Ask people to sit next to someone they haven’t spoken to yet, and then do the same the next session. Randomly assign learners to group or pair activities. • Highlight juniors’ shared identities, for example as students of a particular medical school who all need to pass a particular exam, or trainees in a particular specialty who all need to achieve the same competencies. • Consider the representativeness of your teaching material e.g. patient cases and reading lists. Students report only being taught with BME patients when the fact that a patient is from a BME group is the main learning point.

FEATURE: IMPROVING OUTCOMES • Don’t use BME juniors as examples of particular conditions that have a higher prevalence in certain ethnic groups (e.g. don’t assume black students know more about or have experience of hypertension). • Engage with and support initiatives to address differential attainment. If you think an initiative won’t work, suggest how it could be improved. If you’re not certain how to manage a situation (e.g. what to do if you witness racism from a patient), ask for training. Actions for students and trainees • Remember that differential attainment is not your fault. It is an institutional problem. • Get involved in initiatives to address differential attainment. Many universities now have decolonisation projects, and many Royal Colleges and HEE LETB’s (deaneries) have differential attainment projects that need developing and evaluating. • Get to know your colleagues. Go to lunch with somebody you haven’t had lunch with before. In teaching sit next to someone you haven’t sat next to before. • Try not to make assumptions about a colleague based on what you think their ethnicity is e.g. don’t assume you know what type of school they went to, where they grew up, what their family/home situation is, or what their values might be. Many BME students report feeling that they are expected to teach others about their culture or background, which can be burdensome and annoying. • Organise inclusive social events beyond going to the pub.

Conclusion Medical students and doctors from black and minority ethnic groups - even those born and brought up in the UK - can face barriers that significantly impede their progression and success. Differential attainment by ethnicity is a serious problem for institutions. It is believed to be caused primarily by institutional practices. The organisations that train and educate medical students and doctors have a responsibility to remove the barriers BME students and doctors face. This article aims to provide a starting point to help organisations and the individuals within them to create environments in which all learners can thrive regardless of their ethnic background. Katherine Woolf is funded by the National Institute for Health Research (NIHR) Career Development Fellowship (Grant Reference Number CDF-2017-10-008). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care. References The state of medical education and practice in the UK. General Medical Council; 2017. 2 Nathan M, Lee N. Cultural Diversity, Innovation, and Entrepreneurship: Firm-level Evidence from London. Economic Geography. 2013;89(4):367-94. 3 Hunt V, Prince S, Dixon-Fyle S, Yee L. Delivering through Diversity. McKinsey & Company; 2018. 4 Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in us medical schools. JAMA. 2008;300(10):1135-45. 5 McManus I, Woolf K, Dacre J. The educational background and qualifications of UK medical students from ethnic minorities. BMC Medical Education. 2008;8(1):21. 6 Woolf K, Potts HWW, McManus IC. Ethnicity and academic performance in UK 1

trained doctors and medical students: systematic review and meta-analysis. BMJ. 2011;342. 7 Tiffin PA, Illing J, Kasim AS, McLachlan JC. Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study. BMJ : British Medical Journal. 2014;348:g2622. 8 Kumwenda B, Cleland JA, Prescott GJ, Walker K, Johnston PW. Relationship between sociodemographic factors and selection into UK postgraduate medical training programmes: a national cohort study. BMJ Open. 2018;8(6):e021329. 9 Appleby J. Ethnic pay gap among NHS doctors. BMJ. 2018;362:k3586. 10 Dawson J. Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015. Workforce Race Equality Standard (WRES), NHS England; 2018. 11 The Queen on the application of BAPIO Action Ltd v Royal College of General Practitioners and General Medical Council. 2014. 12 Promoting excellence: equality and diversity considerations. General Medical Council; 2017. 13 Woolf K, Rich A, Viney R, Needleman S, Griffin A. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open. 2016;6(11). 14 Mountford-Zimdars A, Sabri D, Moore J, Sanders J, Jones S, Higham L. Causes of differences in student outcomes. 2015. 15 Broecke S, Nicholls T. Ethnicity and degree attainment (Research Report RW92). London: Department for Education and Skills; 2007. 16 Woolf K, McManus IC, Potts HWW, Dacre J. The mediators of minority ethnic underperformance in final medical school examinations. British Journal of Educational Psychology. 2013;83(1):24. 17 McManus IC, Elder AT, Dacre J. Investigating possible ethnicity and sex bias in clinical examiners: an analysis of data from the MRCP(UK) PACES and nPACES examinations. BMC Medical Education. 2013;13(1):1-11. 18 Yeates P, Woolf K, Benbow E, Davies B, Boohan M, Eva K. A randomised trial of the influence of racial stereotype bias on examiners’ scores, feedback and recollections in undergraduate clinical exams. BMC Medicine. 2017;15(1):179. 19 Denney ML, Freeman A, Wakeford R. MRCGP CSA: are the examiners biased, favouring their own by sex, ethnicity, and degree source? British Journal of General Practice. 2013;63(616):e718-e25. 20 Eraut M. Informal learning in the workplace. Studies in Continuing Education. 2004;26(2):247-73. 21 Schneider M, Preckel F. Variables associated with achievement in higher education: A systematic review of meta-analyses. Psychological Bulletin. 2017;143(6):565-600. 22 Orom H, Semalulu T, Underwood W. The social and learning environments experienced by underrepresented minority medical students: a narrative review. Academic Medicine. 2013;88(11):1765-77. 23 Gill D. The association between trainee demographic factors and self-reported experience: Analysis of General Medical Council National Training Survey 2014 and 2015 data. JRSM Open. 2016;7(4):2054270416632705. 24 Woolf K, Cave J, Greenhalgh T, Dacre J. Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study. BMJ. 2008;337. 25 Woolf K, Potts HWW, Patel S, McManus IC. The hidden medical school:A longitudinal study of how social networks form, and how they relate to academic performance. Medical Teacher. 2012;31(7):9. 26 Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the gap: the roles of social capital and ethnicity in medical student achievement. Medical Education. 2015;49(1):114-23. 27 Roberts J, Sanders T, Mann K, Wass V. Institutional marginalisation and student resistance: barriers to learning about culture, race and ethnicity. Advances in Health Sciences Education. 2010;15(4):559-71. 28 Nazar M, Kendall K, Day L, Nazar H. Decolonising medical curricula through diversity education: Lessons from students. Medical Teacher. 2015;37(4):385-93. 29 Karani RMDM, Varpio LP, May WMP, Horsley TP, Chenault JP, Miller KHPM, et al. Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference. Academic Medicine. 2017;92(11S) Association of American Medical Colleges Learn Serve (Lead):Proceedings of the 56th Annual Research in Medical Education Sessions:S1-S6. 30 Munn F. Reporting racism on the wards. Student BMJ. 2017. 31 Woolf K, Viney R, Rich A, Jayaweera H, Griffin A. Organisational perspectives on addressing differential attainment in postgraduate medical education: a qualitative study in the UK. BMJ Open. 2018;8(3):e021314. 32 Alexander C, Arday J. Aiming Higher: Race, Inequality and Diversity in the Academy. 2015. Available from: 33 Ahmed S. The language of diversity. Ethnic and Racial Studies. 2007;30(2):235-56. 34 National Academies of Sciences E, Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. Johnson PA, Widnall SE, Benya FF, editors. Washington, DC: The National Academies Press; 2018. 312 p. 35 Ahmed S. On being included: racism and diversity in institutional life. Durham, North Carolina: Duke University Press; 2012.

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NHS pay gaps: gender, ethnicity and other labour market disadvantage Jasjit Kaur Atwal is a salaried GP in the East Midlands, working less-than-full-time, having successfully returned to General Practice after a career break of five years, via the GP Induction and Refresher Programme. She is the mother of three children, the youngest of whom has cerebral palsy.

The gender pay gap is a measure of the difference between average hourly earnings of men and women. It is different from unequal pay which relates to men and women being paid different amounts for the same role. The UK Government aims to eliminate the gender pay gap within a generation. Less well-publicised and discussed is the ethnic pay gap. Traditionally most western employment law frameworks, extending to organisational policy and practice in the UK, have an approach which protects people on the basis of single identities, such as race alone or gender alone. This is problematic as complainants are required to prove each aspect of discrimination separately, necessitating navigation of the single path most likely to lead towards redress. The onus is placed on the individual to identify which identity, out of complex multiple identities, is the source of discrimination against them.2 The single-axis approach is inadequate as it fails to address the realities of discrimination and the interplay between interlacing interactions.2 Addressing discrimination this way assumes the additive nature of discrimination, but in reality, addressing one source of disadvantage alone may not be entirely beneficial for the whole group with the shared protected characteristic. A sub-group within may be left behind. The key concept underpinning this is ‘intersectionality’ and I refer readers to the vital work of black feminists such as Kimberlé Crenshaw3, Healy et al who have used intersectional sensibilities to analyse inequality regimes in public sector organisations in the UK, to reveal that inequalities persist despite over 40 years of equality legislation.4 The Nuffield Trust looked at the NHS gender pay gap with scrutiny of the breakdown according to ethnicity. Essentially, the gender pay gap exists - women’s basic median pay being 8.6% less than men. Also revealed was the ethnic pay gap, varying according to ethnicity and favouring men over women within an ethnic group, the widest gap (21.3%) for Asian/Asian British women.5 Furthermore, an outcome of the 2016 Junior Doctors’ contract dispute was the publication of the Equality Impact Assessment, which highlighted medicine’s gender pay gap in favour of men by 23%. The Department of Social Health and Care subsequently commissioned an independent review, headed by Professor Dame Jane Dacre, the interim findings of which were published on the 31st of March 2019. The research team is being led by Professor Carol Woodhams, whose previous critique of the single-axis approach and research has shown a systematic relationship between multiple disadvantage and pay in NHS trusts. Essentially, people with more than one disadvantage attract lower pay and the more disadvantage 12 Medical Woman | Spring/Summer 2019

the lower the pay, but the penalty rises exponentially not additively.2 The review not only promises to be the most in-depth analysis in the UK to date but seems set to analyse multiple burdens of labour market disadvantage that could result in pay penalties. The outcomes could promote a huge potential for advancement, not just in the NHS but beyond. Possible contributory factors to pay gaps for doctors include differences in distribution of men and women within roles, seniority within roles and then different allocation of salary and discretionary points to those roles. There may be differences in numbers of programmed activities or sessions undertaken and an unequal distribution of leadership positions. There may be an unequal distribution of men and women within specialties. Different career paths, including whether qualified overseas, may attract unequal rewards and there may be an unequal application of Clinical Excellence Awards. There is likely to be unequal distribution of less-than-full-time working, maternity and domestic caring responsibilities which could ultimately result in lower lifetime length of service, compounded further by the impact of race, age, disability, sexuality, marriage, trailing spouse effects and place of training. There is a sizeable group experiencing pay penalties without explanation and therein is the potential for the interplay of discrimination. It is likely that further research will be needed to examine the groups experiencing the widest gaps to better understand the variation within. What are the compound effects of migration history, socioeconomic class and expression or suppression of religious identity? What are the experiences of bullying, whistleblowing, attainment and career progression? We need to broaden our perspective of the confluence of factors that are linked to society and labour market disadvantage via the influence of structural barriers. A reminder that although fewer than 10 of every 100,000 pregnant women die in the UK, black women are five-times and Asian women two-times more likely to die in pregnancy or around childbirth than white women.6 Do issues affecting marginalised women patients translate to marginalised women in the workforce?

FEATURE: MONEY MATTERS References Government Equalities Office 2016 C, Lupton B, and Cowling M. The snowballing penalty effect: multiple disadvantage and pay. British Journal of Management, 2015;26; 63-77. 3 Crenshaw, K. Demarginalising the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1989, pp. 138-67. 4 Healy G, Bradley B, Forson, C. Intersectional sensibilities in analysing inequality regimes in public sector organisations. Gender, Work and Organization. 2011;18:5. 5 Schlepper L, Appleby J. The gender pay pap in the English NHS: how does it vary by ethnicity. Nuffiled Trust, 2018. Accessed at https://www. 6 Saving Lives, Improving Mothers’ Care. Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK), 2018. Accessed at MBRRACE-UK%20Maternal%20Report%202018%20-%20Web%20 Version.pdf 1

2 Woodhams

My personal story is that I am a UK-born and trained GP; the daughter of immigrants, a would-be economist and engineer, but instead they were factory workers who dreamt and taught me to always serve. My undergraduate and post-graduate training on the path to become a GP, plus the advocacy for under-served groups that I sought to undertake, has been fraught with successive difficulties. The personal injustices I faced have been inextricably entwined with the societal and familial conditioning, expectations, pressures and discrimination that I have been subject to. Mastering detachment to these is my current goal and I am achieving this by re-brokering relationships and my perceived and imposed contract with society. Part of this journey has been to understand my personal employment and attainment history and the realisation that my insights, and those of other individuals at the periphery, are essential in ameliorating retention and progression towards leadership within the NHS workforce, by shining a light on the story behind pay penalties. I await outcomes of the current research into NHS pay gaps and I am sure that the review body will enshrine the work of black women academics in their own work. To quote Kimberlé Crenshaw: “The goal of this activity should be to facilitate the inclusion of marginalized groups for whom it can be said: ‘When they enter, we all enter.’”3

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Refugee doctors in the UK: valuable contributions Louise Salmon is a Programme Manager for the Refugee Health Professionals Programme with RAGU (Refugee Assessment & Guidance Unit) at London Metropolitan University. She has 30 years’ experience in careers guidance working with refugee health professionals. All names in this article have been changed except doctors photographed.

The NHS is short of doctors, in General Practice, A&E and other specialties. Yet several hundred overseas-qualified doctors with refugee status, who live in the UK, with full residency and rights to work, are unable to practice medicine and contribute their skills to the NHS. It is a conundrum. What is stopping them? What challenges do refugee doctors, women in particular, face in gaining registration and how can we support their return to practice? “Why has it taken you so long to come back to medicine?” Ameena, now working full-time in vascular medicine, was asked by her interviewer. “Didn’t she know what I’ve been through? I was a consultant; in the UK I became housewife, mother, breadwinner and student. 10 years on I’m a doctor again; but nothing has changed”. 14 Medical Woman | Spring/Summer 2019

The Building Bridges Programme (BB) has worked with some 400 refugee doctors in London over the last 10 years – more than 50% women - to support them through to GMC registration. Some are recently qualified; many have substantial specialist experience. To date 126 doctors have achieved registration, taking up posts at Trust grade, FY2 and Core training and progressing onto Specialty training.

Who are these doctors? Refugee doctors, as with all refugees, are forced migrants,1 fleeing war, personal threats, gender-based violence, racial or religious discrimination. They face similar challenges in establishing new lives in the UK: poverty and poor housing, unfamiliar healthcare

FEATURE: REFUGEE DOCTORS and benefits systems, and isolation. They may lack social and professional networks and good English language skills. Exacerbated by complex immigration cases and delayed family reunion, it is unsurprising that their physical and mental health deteriorates. Grieving for multiple losses - of family, culture, status and country – and undergoing traumatic experiences, many refugees experience high levels of PTSD.1 Women doctors face additional challenges compared with the male colleagues. With equal proportions of men and women doctors on the Building Bridges programme, only 35% of women doctors achieve registration. Life in the UK challenges entrenched cultural gender expectations: “I come from a restrictive male dominated society; my husband has expectations; even when he was not working and I was, I carried all the childcare,” commented Shazalia, an Obstetrics and Gynaecology consultant in her own country. Married Afghan doctors report pressure to have large families and prioritise husbands’ careers; single women cite pressure from family in their home country to marry rather than study. Strained by conflicting cultural expectations family breakdown is not uncommon, leaving several women doctors as single parents with virtually insurmountable barriers to requalifying while the children are young. The gap since their last clinical experience is frequently greater for refugee women than men.

The long road to GMC registration After their lengthy medical training, refugee doctors are extraordinarily motivated to return to clinical practice: “I struggled emotionally with the reality of starting all over again but I never gave up. It has taken five years to get back on my feet”, reflected Haifa, a Saudi doctor, working in A&E. What helps them? Accurate information is vital – about UK medical pathways, the NHS, the clinical and non-clinical competencies needed to work as a doctor in the UK. Refugee doctors must get to grips with a new legal and ethical framework, a patient-centered care system where patient rights are paramount as well as multidisciplinary team working, often very different from previous experience. They must focus on developing English communication skills and cultural understanding early on and find supporters for their journey. The GMC requires high-level English communication skills before overseas-qualified doctors can proceed to PLAB registration exams, where communication skills are tested again. For decades this was most frequently evidenced through the IELTS (academic English) exam, and presented the greatest hurdle for refugee doctors. Some, experiencing repeated exam failure, nose-dived into despair. In spring 2018, the GMC approved an alternative exam - the Occupational English Test (OET), developed in Australia - which tests language skills within a medical context. OET may transform refugee doctors’ journey to registration. There has been a three-fold increase in OET passes this summer for doctors in the Building Bridges programme as compared with IELTS passes in the same period last year. The BB programme offers refugee doctors OET classes taught jointly by language specialists and newly retired GPs and is also proving an excellent preparation for PLAB exams. Even so, it may take several years before doctors achieve the English requirement. NHS clinicians can help refugee doctors rebuild confidence and feel valued though mentoring and providing work placement opportunities. Doctors working with the BB programme can benefit

from work placements in primary care in health care assistant roles: “I was responsible for NHS health checks, ECGs, phlebotomy, notes summarising and referral letters; communicating with patients and my team is great preparation for OET and becoming a doctor in UK” says Sudanese doctor Mariam. Many find paid work following placements, to support themselves and families: “Gaining my first NHS role I regained my identity and confidence after years” reported Jamila, “I developed language fluency and understanding of the cultural differences. I no longer feel embarrassed if I don’t know the answer, I ask for help.” Work placements are a win-win for GP Practices benefiting from the doctors’ medical knowledge and skills. “In comparison with IELTS, PLAB exams presented little problem”, cites Julia, a junior doctor from Ukraine who registered earlier this year. She attended the Building Bridges GP-led Professional Development Group, where refugee doctors update clinical and prescribing skills and practice communication for the PLAB 2 exam in a safe space. Most pass PLAB exams at first try.

Final steps into the NHS Following PLAB exams, Building Bridges organises 10-week clinical attachments in London teaching hospitals. The differences in cultural and clinical governance, as compared with the refugee doctors’ previous medical experience, are eye-opening. A Yemeni paediatrician noted “I was impressed to see patients involved in the decisions doctors make at every step”. An Iranian haematologist discovered “a culture of learning and support, mistakes are learning points that we are encouraged to reflect on, not punished for”. A Sudanese doctor was surprised “seeing the MDT call each other by first names” and “it’s so so busy, you have to manage your time. EPR systems help but are entirely new for me”. Once the final hurdle of gathering documentation for GMC registration is completed, and for some this can be extremely difficult, refugee doctors embark on their first paid medical post. 70% of Building Bridges refugee doctors join the CAPs Programme, a 6 month super-numerary FY2 post, and experience first-hand the challenges of medical teams coping with the very staff shortages they are helping to alleviate.

Moving forward: Funding and NHS champions For the many BB refugee doctors working in health support roles, and the 126 now working as registered doctors, this represents a massive personal achievement. For the NHS it is a substantial gain. Dr Annie Makumbi, from the DRC, registered five years ago and now works as an AAU Registrar at Whipps Cross: “I could not ask for more, it is an honour.” The BB calculates it costs around £17.000 to support a refugee doctor through to FY2, compared with over £220,000 to train a UK medical graduate to FY1.2 Continued funding for programmes such as Building Bridges is crucial. Above all, every refugee doctor, man or woman, needs champions and supporters within the NHS to hear their story and provide practical encouragement at every stage of their return to clinical practice.3 Could you be an NHS champion or mentor? References Clinical Apprenticeship Placements (CAPs) are run by HEE London Professional Services Unit 2 Building Bridges Refugee Healthcare Professionals project report for HENCEL August 2017 3 Butler C, Eversley J. Guiding Their Way: Assisting Refugee Health Professionals. Medical Teacher 2007;4: 146-152. 1

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Generations ahead: making the future better Scarlett McNally is an Orthopaedic Surgeon who enthusiastically promotes surgery as a career. She also practices what she preaches with her strong belief in the positive impact of exercise.

I had a sudden brush with death over Christmas. Enough to re-evaluate everything. Shortness of breath cycling up hills decompensated into sudden heart failure. I have Myeloma (bone marrow cancer), complicated by AL cardiac amyloid (protein from myeloma cells constricting the heart). It is incredibly rare and incurable, but treatable. Chemotherapy should put the myeloma into remission and my heart may improve. It felt like a triplewhammy: cancer + heart disease + immunocompromise. Through a fog of steroids, chemo, uncertainty and endorphin-withdrawal, some simple concepts have emerged. What can we each do to make the world better? I asked my friends that rather than sending me cards of sympathy, they should contact their Councillor to demand cycle lanes and play parks. My life was great – surgery gets easier with decades of experience. I have my niche as a Council member of Royal College of Surgeons, valued for bringing a new angle to discussions within and regularly speaking on the College’s behalf. I am least worried about returning to work. A veteran of four maternity leaves means that even on a very low day, I know the old skills and doctor-brain will return; though my strength may not. I crossed from the perspective of over-busy surgeon to patient and sedentary weakling. Suddenly life, health and how we value people seem very connected. There are many parallels between how we support each other and how we make the future better, with attention needed at several steps: 1. Knowledge, skills and clarity 2. People themselves being able to adapt 3. People around them supporting the change 4. C hanging structures, institutions, ‘norms’ and what we measure 5. Money

1. Knowledge, skills and clarity Once you have surgical exams or other skills, no-one should question your right to be there. My proudest achievement is leading on the Academy report: Exercise the miracle cure.1 This gave a clear call – exercise at a moderate dose (30 minutes of exercise, 5 times a week) works as primary prevention (reducing the risk of dementia, stroke, bowel cancer and depression by at least 30% each) and as secondary prevention (reducing complications for people already with a condition). Those who do least activity have most to gain. This is a good way of reducing health inequalities. For most people, 16 Medical Woman | Spring/Summer 2019

knowledge is not enough; others around them need to be supportive and the environment needs to be better.

2. People themselves being able to adapt People in under-represented groups sometimes have to ‘fake it till you make it’ to get through the imposter syndrome. I was Chair of Eastbourne’s local cycle campaign group; we went as far as possible with empowering people to cycle safely. We now need more infrastructures and better driver behaviour (eg pass cycles with a good margin and only overtake if there is room).

3. People around them to supporting change Under-represented groups experience ‘micro-aggressions’ and some are challenged frequently. Bystanders have a duty to divert bad behaviour gently at the time: ‘call it out’. Perhaps take the perpetrator for a ‘Vanderbilt cup of coffee’ later and ask if they are okay? Often, the perpetrators of bullying do not realise how they are perceived and are stuck in their own overwork or burnout.2 Conversely, positive input can have a very powerful impact. People in authority need to be aware of their own unconscious biases. Every person should ask themselves – is this what I would say to a man/other in that role? Then try extra hard to make time for those who have do not fit the mould, to listen to how they could be the best they could be. ‘Micro-championing’ should take off. Ideally, patients would be trained not to express their reflex judgements and to be aware that what they are thinking may be unhelpful.

NEW BEGINNINGS: LESSONS FOR THE FUTURE helps other workers and clients see jobs as requiring skills and competencies, not a demeanour. The multitude of inspections undertaken in the NHS should start with staff wellbeing and cycle parking. Resources on www. allow all staff to help patients with improving their uptake of exercise. Exercise is already in most treatment pathways. Perhaps this could be measured too?

5. Money

All those in training need clear tasks and expectations with performance management against these regularly not just at times of impending failure. To improve society, we need children, adults and older people to be active, engaged/involved and studying/working/volunteering. Maybe everyone should “go for a walk with granny”? Committing to a charity bike ride, run or walk is a good way of harnessing our goodwill and social network to keep up our own exercise programme.

4. Changing structures, institutions, ‘norms’ and what we measure Hurdles may be far bigger for one group than another. Practicalities to get through pregnancy should be clear. Access to paternity leave and parental leave should be encouraged – uptake might improve with a ‘use it or lose it’ approach, so fathers become a bigger part of the subsequent gender-neutral 18 years’ of childcare. Less-than-fulltime training needs to be normal for all genders when needed. Employers should be supported or rewarded for retaining people with disabilities in the workforce. Part-time, full-time or volunteering work is (usually) good for health. A heterogenous workforce

There is double-think in the NHS. There is a purported desire to help those going through a tough time, yet insufficient budget. When I was Director of Medical Education, a little extra money for backfill could ease a doctor back into working or training. Now, many doctors in training spend 50% of their time on tasks that do not require a medical degree, most are overworked and there are many vacant posts. I ran a very successful pilot of ‘Doctors’ Assistants’ at Band 3 pay, appointed from HealthCare Assistants with a twoweek training programme and doing work that doctors delegated. Whilst they were funded by educational funds everyone loved them, but the business case to appoint them was tough when the Trust budget-holders did not see the financial imperative for doctors to be less overworked. Happily, four Doctors’ Assistants were made substantive staff (with two more being appointed). The Job Description on has been used in a dozen other Trusts. We can be honest about what we cost and value every single member of staff. Cycle schemes and play parks rely on precarious budgets. There often needs to be a ‘shovel-ready’ scheme for the funding bid that is then shouted down by local residents anxious to maintain car parking numbers as pollution increases. The 2017 BMJ paper I led demonstrated how supporting older people to be more active could massively reduce the need for social care.3 The UK economy will be bankrupted with the projected 10 years of care we will each need (i.e. needing one-three Whole Time Equivalent people). Those maintaining their ability to get to the toilet need far less social care. Just a short walk each day, before it is too late maintains abilities and social interaction. This needs environments and empowerment. I have spent almost 30 years as a Doctor: empowering all staff, supporting good education, information and pathways, explaining prevention and exercise, working on generic, common conditions in Orthopaedic theatres and fracture clinic. Yet now I am now dependent on a super-specialist centre. I fear that this is what politicians and journalists see as health - young (!), articulate and needing heroic interventional specialist care. Most ill-health is more mundane. We need to shed the paternalistic approach to health. As women doctors, we see it all, but patient-centred need not mean passive. The NHS has 1.5 million employees and a culture of regulation. We could change fast with a ripple effect across the UK. Let’s do this: value each person, do the exercise module on and contact your Councillor now, please! References Academy of Medical Royal Colleges (2015) Exercise the miracle cure and the role of the doctor in promoting it 2 Royal College of Surgeons of England (2016) Avoiding unconscious bias: a guide for surgeons 3 McNally S, Nunan D, Dixon A, et al. Focus on physical activity can help avoid unnecessary social care BMJ 2017;359:108-110. 1

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Making change happen within medicine and beyond MFW Autumn Conference 2018 The room was buzzing at Mary Ward House from the moment the doors opened for the MWF Autumn Conference. Students, trainees and senior doctors, grabbing a cup of coffee and pastries, meeting up with old friends, welcoming newcomers from across the UK and as far afield as Malta and Ireland to their first conference. It was happily noisy but President Henrietta Bowden-Jones - “just call me Etta” - soon brought us to order and the day began. The programme was organised by President-Elect Neena Modi who brought in a remarkable range of interesting and challenging speakers. Jane Dacre and Carol Woodhams told us about the culture of inequality in medicine and current work on the Gender Pay Gap in Medicine Review, including a very very complicated mathematical formula for calculating the gap. Victoria MacDonald from Channel 4 News related her 20-year career in health reporting, health secretaries she has known and improved doctor patient relationships. Then it was time for coffee and poster viewing, with topics such as ‘imposter syndrome’, ‘connecting for leadership’ and ‘what should we call junior doctors?’ The session of ‘the two Jonathans’ brought us Jon Ashworth, Shadow Secretary of State for Health, with the ‘Vision for the NHS’ from the Labour Party, tackling health inequalities. Jonathan Cusack, consultant Neonatologist, described his pastoral support for Dr Hadiza BawaGarba during her years of dealing with the GMC. The key lesson is more supportive and timely responses when tragic patient deaths occur. Standing ovation! After lunch it was Medical Memoirs, an absolute treat to listen to the legendary Prof Averil Mansfield being interviewed on her career and top tips for surviving in Medicine. Dr Rachel Clarke, famous on Twitter as @doctor_oxford, talked chronic understaffing as the real challenge to equality in the NHS and her time sitting at a table outside Jeremy Hunt’s office during the junior doctor’s industrial action. Sam Smethers, CEO of the Fawcett Society, gave a fascinating talk on power, gender and politics in contemporary society. There is work to do! The final invited speaker of the day Prof Dame Sally Davies, CMO England, exhorted us to consider servant leadership, community and global health issues and the impact of SoMe on our children. The day was wrapped up with the award of prizes for the best conference poster and best presentation (Support for refugee doctors in Wales) and the Junior Doctor Essay Prize for 2018. You can find all the live comments made during the conference on Twitter, just search for #MedWomen18. The MWF conferences are the most friendly and inclusive, and always with a diversity of topics discussed. If you have never attended, what’s stopping you? See you all at the next conference in Bristol on Friday 17th May 2019. Melanie Jones, Past President


Learning from loss Laurel Spooner is a GP & Community Surgeon, who retired this year. Here she encourages us to focus on the mental health of all our colleagues and the health staff we work with.

Our daughter Sophie had just completed her F2 year. She had never had a gap year and was uncertain what specialty to apply for so she hopped on her bike and with typical energy and determination set off alone to ride the Pacific Way. That done, she returned and took short-term locum posts in paediatrics, got engaged and made wedding plans. In October 2017, when she was 26, she finished a morning outpatient clinic and said goodbye to the nurses but did not reappear for the afternoon session. Her bleep and phone were unanswered but everyone was busy and left it at that. Sophie caught the train home, wrote a note and took a fatal overdose. Her sister found her the next morning after ringing work and discovering she had not gone in. Five months later at the Inquest the Coroner said “We are here to determine how, where and when this young woman died. It is not our job to say why but it is clear that these days doctors are under impossible pressure.” We will never know the exact thoughts that drove Sophie to end her life but she wrote these heart-breaking words: “I think it is 20 Medical Woman | Spring/Summer 2019

for the best. You have loved me more than I deserve….this will enable you all to lead happier lives.” Her hidden and undetected depression had made her believe she was worthless, and she would never be anything but a burden while the reality was that Sophie was renowned for her kindness, and altruism and was a promising young doctor. A conscientious high achiever, she had compassion for everyone else but none for herself when she fell below the high standards she had set. How was it possible that her death was a complete shock? Her sister, brother-in-law, mother and many of her wonderful friends are doctors. Yet none of us, and no-one in the clinic on the day of her death saw how ill she was. At the Memorial Service, her bewildered colleagues described her as the one whose smile lit up the room, the person you knew you could take your troubles to. So many circumstances fed into this tragedy; at first, we could not stop thinking if only one thing had been different she might still be alive. But now we accept our loss and the desire to give her life meaning by making others safer carries us forward.

SPOTLIGHT: LEARNING FROM LOSS We stayed in touch with Sophie’s grieving friends at work who to our surprise were offered no support, so we campaigned with them until the Deanery and the Trust acknowledged her suicide and agreed to discuss the lessons to be learned. There were particular circumstances unique to Sophie’s death but three major ones were issues common to many suicides. I will be focusing on these: stigma, inability to find confidential help and the mismanagement of complaints. Stigma: Sophie’s story illustrates how lethal it can be. She was determined to conceal her illness from others but she kept a journal and from that, together with her phone and laptop, we gained insight into what was happening. She was anxious, out of her depth as a locum, terrified of making a mistake and had great difficulty sleeping. Yet she did not ask for help. Most doctors share her fear of admitting they cannot cope. It is very hard to say you are depressed, addicted, suicidal – or perhaps hardest of all, as in Sophie’s case, that you have a long-term condition to manage. She had had several bouts of depression which had responded well to medication but with a strong family history of bipolar disorder this was the likely diagnosis. So often doctors are paralysed by the fear that their colleagues will find them out and their careers will be wrecked. Sophie certainly was. Shortly before she died she had the insight to look for confidential help outside her area. She contacted the Practitioners’ Health Programme (PHP). Unfortunately at the time only hospital doctors inside the M25 were funded. After that she seems not to have known where to turn and it rapidly became too late. Perhaps a young and inexperienced F3 doctor working in nontraining locum posts across three hospitals was even more vulnerable than other juniors, and locums in general are less well supported. In fact the Deanery was not aware of Sophie’s death when we approached them for counselling for her distressed colleagues. Indeed, Deaneries are not responsible for the wellbeing of locums, non-training post doctors or staff grades. But even so the impact on her colleagues needed to be addressed and it took some months before it was. We automatically expected the Trust to hold an internal enquiry but a year later when we asked to meet the CEO to suggest changes we discovered there had never been one. To us it demonstrated mental illness is as great a taboo for the institutions of the Health Service as it is for individual staff. Since those darkest months we have worked with both the Trust and the Deanery, and as voices within have broken the silence we have seen attitudes transform. We must normalise mental illness for NHS staff as we do for our patients when we say to them depression is a common illness which can happen to anyone and it is not your fault. We know doctors have higher rates of mental illness than the general population but we don’t want to see the wounded healer in ourselves or others. So we must talk about it from medical school onwards, at inductions, supervisions and study days. CPD would also be much better if the solitary ‘reflective learning’ was replaced by ‘collective learning’ giving doctors the opportunity to interact. Wouldn’t all the time wasted reconfirming that we know how to safeguard data be much better spent learning to safeguard ourselves and those around us? Doctors find it notoriously difficult to be objective about their own health, but tools such as the Mental Wellbeing Checklist and apps like ‘Arbour’ are available. Unfortunately, only a few doctors know about them. In contrast at IBM where my son works,

all employees are given a sheet entitled ‘5 unhelpful thinking styles’ and encouraged to question themselves. Every doctor should have it on their phone because it shows so clearly the pitfalls we dig for ourselves. The second major factor: inability to get confidential outside help as her crisis deepened. At meetings with groups of doctors, I find none of them has much idea of sources of help but would search the internet. It is difficult to find the information and in particular a 24-hour phone line in a crisis, on the brink of despair. In Colchester where Sophie grew up Mr James Sheldrick an ophthalmologist, has set up a group called Support of Healthcare Professionals In Essex (touching for us because it abbreviates to SOPHIE) with a website called ‘It’s OK to ask 4 help’, listing a range of support services. Every doctor should put the crucial telephone numbers in their phone: they are given at the end of this article. Finally complaints handling, the third factor for discussion. Sophie received a complaint a few months before she died which really had no substance to it but somehow got through. Unfortunately, she received notice by email from a consultant she did not know saying it concerned a patient she had seen during a single locum shift in paediatric A&E in a different hospital from the one she was working in. Unluckily for Sophie he went on leave while she fretted and lay awake fearing the worst. The complaint was in fact from a relative who had not even been at the hospital but accused Sophie of being a rude and cruel doctor when she had seen a member of his family. Sophie was astounded but with no previous experience of the complaints procedure she also felt panicked. Clare Gerada, Medical Director of the Practitioners Health Programme and champion of doctors’ mental health, has called for a new Code of Practice for Complaints. It can be reviewed on line ht tp: / / / wp - content /uploads /sites / 26 / 2018 / 08 / Complaints-.pdf and we hope it will soon be adopted. Meanwhile if Trusts made the following simple improvements to their in-house procedure it would avoid much of the distress: • Complaints with no substance should be screened out by PALS and consultants rather than automatically forwarded to juniors. • Complaints should be passed on face-to-face rather than by email. • Written information on the steps involved and the timescale for processing a complaint should be made available from the start. • The doctor against whom the complaint has been made should be put in touch with a senior colleague whose job it is to support them through the process. Thank you for reading about Sophie and the changes we are campaigning for. We realise the profession faces deep-rooted problems such as chronic understaffing, exhaustion and burn out. Building the all-important team spirit is hampered by rotations, shifts and loss of safe spaces where colleagues can relax and talk. But 17 months on from Sophie’s death there are heartening signs. The RSM conference ‘The Wounded Healer’ felt like a turning point. In October 2018, NHS England Chief Executive Simon Stevens announced that confidential psychiatric care would become available to all doctors in England. Last month Secretary of State Matt Hancock, launched the NHS Staff and Learners Wellbeing Commission with an apology to the parents of Lauren Phillips, the young doctor who ended her life eight months before Sophie. Although health policy often takes years to change and NHS culture takes decades to change, all of us fortunately have the power to make a difference right now by really meaning it when we ask a colleague, “How are you?”. Medical Woman | Spring/Summer 2019 21


Depression: here to help Rachel Boyd is an Information Manager at Mind, the mental health charity. She works on producing mental health information that is clear, trustworthy and evidence-based. Rachel has been at Mind for more than five years, including time spent working on Mind’s Infoline. She spends most of her time outside of work chasing her toddler daughter around various South London parks.

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STRIKE A CORD: HERE TO HELP Mind provides advice and support to empower anyone experiencing a mental health problem in England and Wales. It campaigns to improve services, raise awareness and promote under-standing. Its network of around 130 affiliated local Minds provides additional services tailored to the communities they serve, such as talking therapies, advocacy and support groups. The Mind Infoline offers phone support to those seeking advice, and is available on 0300 123 3393. Depression is increasingly recognised as one of the most common health concerns, with 300 million people affected globally. Twothirds of GPs in the UK (66 per cent) said last year that they had seen an increase in the number of patients needing mental health support over the previous 12 months and an estimated 40 per cent of all GP appointments involve mental health.1 Governments, businesses and health services are increasingly interested in mental health, and there have been some high profile commitments to expanding services and reducing stigma. In part, this is because we increasingly understand the social and economic benefits of addressing conditions like depression and finding effective treatments. However, there are still gaps in service provision, meaning many people who experience mental health problems like depression are struggling or do not have access to the right treatment. How depression manifests varies from person to person, but some of the symptoms can include: • Feeling sad and tearful, worthless, lonely, detached, demotivated or numb; losing interest in things that you have previously enjoyed; feeling guilty or like a burden; having suicidal thoughts or plans. • Problems around sleep, food and relationships including sleeping too much or too little, eating too much or too little, eating unhealthily, sexual problems, struggling to connect with friends and family, and feeling tired all the time. • Finding it hard to concentrate, feeling confused, agitated or sluggish, struggling to understand or learn. People may also sometimes experience psychosis as part of depression. • Using drugs and alcohol to cope with difficult feelings; self-harming and suicidal feelings. The impact depression has on someone’s life can also depend on how severe or frequent these thoughts and feelings are, and how long they last for. Depression may be diagnosed as mild, moderate or severe, and this will determine what kind of treatment is recommended. Causes of depression can also vary. They might include difficult life experiences, like neglect in childhood or relationship breakdowns in adult life. People who experience physical health problems or disabilities can also be at risk of developing depression. There is currently no clear evidence that depression is caused by specific genes, although this is a popular area of research. Depression can also be seasonal (seasonal affective disorder), ante- or postnatal, or chronic (dysthymia). Mind suggests that people who think they may have depression visit their GP for diagnosis and treatment options. The effectiveness of different treatments varies from person to person and the decision on what course to take should be made collaboratively by both patient and GP, following NICE guidelines. One of the first options may be talking therapy, such as cognitive be-havioural therapy (CBT) or counselling. Underinvestment in mental health services means access to such services can be difficult; while things are improving, services are still struggling to cope with demand and often people

have to wait. Some people may be able to seek therapy from private or the voluntary sector, including many local Minds across England and Wales. Medication is also an option, although it is not a recommended first line of treatment for mild to moderate depression. It is important that anyone prescribed antidepressants or other medi-cation understands what they are taking, the side effects, what withdrawal might be like, and are given options over the type of medication they take. These can include selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclics and tricyclic-related drugs, monoamine oxidase inhibitors and others. GP’s should arrange follow-up appointments so that concerns can be discussed and the dosage and type of medication can be adjusted, if need be. A GP might also suggest alternative options, such as physical activity programmes, guided self-help (usually based on CBT) and watchful waiting, where the patient and doctor can monitor mood over time. Other treatments include arts therapy, mindfulness, peer support and eco-therapy (physical activity in green outdoor areas). There are also plenty of things people with depression can do for themselves, though they may need support to do so. Having a balanced, healthy diet can help, as can trying to keep a regular sleeping pattern. Physical activity is especially important, and can be as effective as antidepres-sants in treating mild to moderate depression. Encouraging people to open up to, and ask for support from, family and friends can also help. We all know the stresses that GPs are under, with only short amounts of time available for each patient. It is estimated that around 50 per cent of people visiting GPs with symptoms of depression do not have their symptoms recognised.2 In response to this challenge, Mind has produced a guide, Find the Words, which can help people with mental health problems to know how to prepare for and best use their GP appointment.3 Mind provides a host of other information as well. Our website,, is a useful re-source for those wanting to find out more about mental health problems, treatments and more, and all of the information is regularly checked and updated. Our information is evidence-based, informed by people’s lived experience and carries the Information Standard quality mark so doctors can feel confident signposting people to us. Our Infoline provides support to people who want to understand mental health problems, find treatment and help, or support someone else. You can contact us on 0300 123 3393 (9am to 6pm, Monday to Friday, except for bank holidays), or via SMS text message to 86463. There are also around 130 local Minds across England and Wales, which provide a range of services.4 Each local Mind is unique and tailored to the community they serve. They can pro-vide support ranging from talking therapies and peer support to arts therapy and exercise groups. People can find their nearest local Mind on our website: References Mind, 2018. 40 per cent of all GP appointments about mental health. Available at: 2 Public Health England , 2018. Common Mental Health Disorders. Available at: E38000010/iid/90647/age/168/sex/4 3 Mind, 2018. Find the Words. Available at: media/23814936/mind-ftw2-eng-web.pdf 4 Mind, 2019. Our Local Mind Network. Available at: about-us/local-minds/ 1

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Depression: diagnosis and treatment Fabida Noushad is a Consultant in general adult psychiatry and clinical director for adult mental health and learning disability services at Leicestershire Partnership NHS Trust. Some of her interests include promoting good mental health, reducing inequalities, transcultural psychiatry and improving physical health in patients with severe mental illness. Her hobbies include walking, playing badminton, travelling and Bollywood dancing.

Depression is a mental health problem that many people are affected with at some point in their lives. Though the awareness of depression has increased considerably, it can be often misunderstood, and some people still feel reluctant to ask for help and tend to struggle for long periods on their own. Depression should not be confused for normal sadness, which is something everyone has at times, and are able to overcome. Depression is a mood disorder where the central features include depressed mood, negative thinking, lack of enjoyment, reduced energy and slowness.1 They need to be present for at least two weeks. Whilst no-one can guarantee that depression is completely preventable; self-care, managing stress, and having a good worklife balance can all help one’s mood. Sports, hobbies, activities, meditation, mindfulness, yoga all have roles to play in self-care. Social media, whilst having some negative repercussions; can also be helpful for people to prevent isolation and many support groups are present online.

Diagnosing depression The criteria for depression are listed in Table 1. Symptoms needed for depressive episode according to ICD 10 A Depressed mood Loss of interest or enjoyment Reduced energy or decreased activity B Reduced concentration Reduced self-esteem and confidence Ideas of guilt and unworthiness Pessimistic thoughts Ideas of self-harm Disturbed sleep Diminished appetite Mild depressive episode - at least 2 of A and 2 of B Moderate depressive episode – at least 2 of A and 3 of B Severe depressive episode – 3 of A and at least 4 of B The symptoms need to be present for at least 2 weeks Table 1 (taken from Oxford textbook of psychiatry,1 listing International Classification of Diseases criteria for depression)2

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Biological symptoms include sleep disturbances (early morning awakening, delay in falling asleep, waking at night), diurnal variation in mood (usually worse in mornings), loss of appetite, loss of weight (though sometimes people may gain weight), constipation, loss of libido and amenorrhoea in women.1 Depression is more common in people who have other chronic health conditions. A systematic review and meta-analysis to provide a comprehensive estimate of the prevalence of depression or depressive symptoms among outpatients showed that the highest numbers (53%) were in otolaryngology clinics, followed by dermatology (39%) and neurology (35%).3 Another study looking at prevalence of depression in inpatients on medical and surgical wards varied between 5% and 34%.4 All professionals can help patients by asking about their mental health and how it affects their physical health.


Focus of the intervention

Nature of the intervention

STEP 4: Severe and complex [a] depression; risk to life; severe self-neglect

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

Medication, high-intensity psychological interventions, combined treatments, collaborative care [b] and referral for further assessment and interventions

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression for further assessment and interventions

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

STEP 1: All known and suspected presentations of depression

Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions

[a] Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors. [b] Only for depression where the person also has a chronic physical health problem and associated functional impairment (see: depression in adults with a chronic physical health problem: recognition and management [NICE clinical guideline 91]).

For those people who are not trained in mental health, it can be worrying to know how to talk to and support people who may have depression. Listening and offering support can make a big difference. Telling them it is okay to get help and fostering hope is also beneficial. Encouraging them to eat healthily and regularly, maintain regular physical activity and connecting with people can also help. People with depression may be unable to take on board any of these and understanding this is important, as they may feel under pressure and guilty. Depression can also cause a person to have suicidal thoughts and this needs intensive support and help. Sometimes there is a fear of asking about suicidal thoughts, however most often when asked, a depressed person will disclose these if they feel able to share it with the person asking. It is important to ask about passive wishes of not wanting to be alive. Looking for protective factors are also important, such as family, loved ones, pets. Professionals need to be aware of past history, family history including of completed suicide. Trust your instinct, sometimes people may take a few tablets with an intention to die and other times serious overdoses may not have been taken with intent to die. Sometimes a patient is higher risk during treatment as their motivation to end their life returns once they are treated from a severe episode and have more energy. Some people choose negative coping strategies, such as drinking alcohol, using illicit drugs, indulging in unhealthy dietary patterns or lifestyles. These can make depression worse. If, despite help, depressive symptoms are persistent, then encouraging them to get more professional help is important. People with depression may feel negative, guilty, worthless, hopeless and helpless. They neglect themselves, and don’t feel they deserve anything. Some patients may also have psychotic symptoms (severe depressive disorder with psychotic symptoms) such as believing their insides are rotten (nihilistic delusions) and may also not eat and drink to such an extent that it may be life threatening. In such instances and other instances where appropriate, it may be necessary to consider use of antipsychotics and electroconvulsive therapy.

Treatments for depression A stepped care model is in place to treat depression, as per NICE guidelines, illustrated in the table above.5 For sub-threshold symptoms - treatments include psychosocial interventions such as self-guided help, physical activity, computerised cognitive behavioural therapy and group based cognitive behavioural therapy.5 Medications are considered for those patients who have moderate or severe depression, and where mild depression has not improved despite repeated interventions and have been persistent for two years.5 Antidepressants are not effective for everyone, and some patients may need switching to other antidepressants, augmentation or adjunctive treatment. This will need to be done under the guidance of secondary care and patients are referred after two failed trials of antidepressants. Occasionally antidepressant combinations are used.5 Psychological treatments are useful and are available in most secondary care Trusts – they include cognitive behavioural therapy, interpersonal therapy, psychodynamic psychotherapy.5 For some patients, both medications and psychological interventions are used together.5 Treatments such as retrograde transcranial magnetic stimulation are considered in certain individuals where other treatments have not worked.5

References Shorter Oxford textbook of Psychiatry, 7th edition, Oxford University Press, 2018. from ICD -10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, 1992. World Health Organization. 3 Wang J, Wu X, Lai W, et al. Prevalence of depressions and depressive symptoms among outpatients: a systematic review and meta- analysis. BMJ Open 2017;7. 4 Walker J, Burke K, Wanat M. Psychol Med. The prevalence of depression in general hospital inpatients: a systematic review and meta-analysis of interview-based studies. Psychol Med. 2018;48:2285-2298. 5 Depression in adults: recognition and management; Clinical guideline[CG90] Published date: October 2009 last updates: April 2018. Access https://www.nice. 1

2 Data

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Understanding mental health and culture Yasir Abbasi is a Consultant Psychiatrist and Clinical Director for Addiction Services at Mersey Care NHS Foundation Trust and an Honorary Senior Lecturer at University of Liverpool. In 2017, he was shortlisted for psychiatry communicator of the Year award by the Royal College of Psychiatrists. He likes to star gaze with an amateur telescope at home and enjoys photography and trekking when not working.

“I have been diagnosed with a low blood pressure illness” said a woman of South Asian origin in a session. Even though ‘low blood pressure illness’ does not exist in the medical textbook, I reflectively asked “But what does that mean to you? What is it that you experience?” What the women went on to describe in detail were the symptoms of mild to moderate depressive episode. She described in her language a phrase which roughly transliterated in to “my heart sinks”. A usual phrase used to describe low mood. She then went on to explain how she struggles to sleep, has lost interest in her children, lost appetite and started to lose weight. She was quite surprised when I suggested depression as a possible diagnosis and worried that people might label her as ‘being mad.’ We hear more stories of psychotic patients being beaten to death by witch doctors in the process of ‘driving the spirit’ out of them or vulnerable girls with depression being abused by ‘religious pirs’ (Holy person). This makes it even more pertinent to understand the interaction of culture and mental health.

What is culture? One in four people in the United Kingdom will experience a mental health problem every year. Mental disorders manifest in a diverse manner among different cultures and societies. Culture can be broadly defined as a set of beliefs, norms and values that form the basis of our behaviour and interactions with other human beings. However, it is prudent not to narrow down culture to the restrictive domains of religion and language only. The definition of culture is still open to interpretation and with more and more globalisation; the definition of culture is becoming more fluid. Culture is multifaceted with many intricate spheres making it challenging to have systematic approach.

So what is Transcultural Psychiatry? Some people refer to this as cross-cultural psychiatry. Since the modern construct used to explain mental health problems are described as mental and behavioural disorders, hence the behaviours expressed for the same type of illness can vary from person to person and culture to culture. Traditionally, transcultural psychiatry was comparing mental health disorders across various cultures. However, more recently there have been views which suggest the models of mental illness are embedded in research done in the Western population. Hence it might not be generalisable, therefore we need to have a broader scope of defining what it is including and not restricted to developing cultural relevant diagnostic criteria as well as interventions. This is to ensure there is a better sociocultural understanding of mental health problems. For 26 Medical Woman | Spring/Summer 2019

example, in some cultures it might be a sign of weakness to say that you are depressed hence the presentation of low mood is expressed in various psychosomatic symptoms displayed over a period of time.

And why does it matter? There are many reasons why we need to have a better approach to culture and psychiatry. This includes and is not restricted to promoting mental health well-being, understanding the prevalence of mental health problems in a cultural context, reducing barriers to treatment, reducing mortality and morbidity and ensuring the interventions are better equipped to address the unmet need in Black & Asian Minority Ethnic (BAME) population in the UK. Anjum Memon et al published a paper in 2016 looking at the perceived barriers to treatment for BAME communities1. They identified that this population are more likely to have poorer health outcomes, a shorter life expectancy and have more difficulty in accessing healthcare than the majority of the population. They further explained the population from the BAME community was less likely than their white British counterparts to see their general practitioner for mental health issues, be prescribed an antidepressant or to be referred to specialist mental health services, despite relative high levels of anxiety and depression in South Asian women (63.5%: 28.5%) and psychotic disorders in Afro-Caribbean men (3.1%: 0.2%). This does signify there is a need within this community for more mental health input.

Understanding barriers In a meeting, when asked of people from the South Asian community to describe what depression was, they used one word in Urdu “Pagal” which translates as ‘mad’. In another meeting when a group of people from the Afro-Caribbean background were asked to describe psychosis, they said “voodoo”. This raises the two-fold issue of stigma interlaced with lack of awareness. The stigma of being diagnosed with a mental health problem plays an important role when it comes to lack of engagement. The added pressure of being judged by others coupled with feeling low and having poor self-esteem acts as a double whammy and prevents people from rightfully asking for help and intervention. The lack of awareness leads to people misunderstanding the symptoms of mental health problems, which sometimes results in seeking intervention from unqualified professionals who profess to have the power of treating such problems. There might be other issues such as lack of interpreting services, lack of cultural sensitivity on behalf of the clinician, inability to mobilise to mental health services which are far from home which act as barriers to seek treatment.


Building bridges If the modern National Health Service (NHS) is serious about tackling this issue, then we would need to have a three pronged approach. There needs to be increased awareness around mental health problems at the grassroots level of the BAME population. This would not only reduce stigma but also help family and friends identify the problem. Second, the staff working in the NHS would need better training in understanding various cultural sensitivities and presentation, in order for them to engage better with the BAME population. Lastly, we need to ensure bespoke interventions are offered which should be culturally competent and meet the needs of those it is delivered to. Reference Memon A, Taylor K, Mohebati LM, et al, Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England. BMJ Open 2016:6.

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Pre-menstrual syndrome: urban myth or a well-kept secret? Rachel O’Donnell is an NIHR Clinical Lecturer and subspecialty Fellow in Gynaecological Oncology based at Newcastle University and the Northern Gynaecological Oncology Centre. Alongside her translational research Rachel specialises in patient-centred research with interests in shared decision making, pathway and behavioural healthcare change.

Introduction Premenstrual syndrome (PMS) is a condition first recognised in the 1950s when Dr Dalton observed resolution of PMS symptoms with progesterone administration.1 Some have described it as a ‘socially constructed disorder’, serving to ‘pathologise’ women by mislabelling them as suffering from a mental illness, whilst others regard it as basic physiology.2 Perhaps it is these extreme and diverse views which have historically deterred health professionals 28 Medical Woman | Spring/Summer 2019

from further researching this classically under-recognised condition. In recent years, there has been a shift in recognising PMS as a distinct entity following increasing evidence from epidemiological and clinical studies.

What is PMS and why is it so variable? The term PMS describes a range of psychological, behavioural and physical symptoms of variable severity. It is this diversity that


Fong Kwong is a Specialist Trainee in Obstetrics and Gynaecology in the Northern Deanery with interests in pre-menstrual syndrome and the psychological impact of disease.

Patients presenting with possible symptoms of PMS Core PMS • Cyclical • Recur in luteal phase • Relieved by menstruation • Symptom-free week

Variant PMS • Premenstrual exacerbation (pre-existing non-menstrual condition significantly worsen Premenstrually

Not PMS • Non-cyclical • No symptom-free week • Constant imapce on quality of life

is at least partially responsible for under-reporting and lack of formal diagnosis for many women, also making quantification of the true incidence of PMS challenging. As many as three in four women report PMS symptoms at some point in their lifetime.3 The prevalence of PMS is estimated to be approximately 40% and that of severe PMS is between 5-8%.4 Symptoms are numerous and diverse with physical symptoms including gastrointestinal disturbance, breast tenderness, abdominal cramping and even clumsiness.5 Psychological symptoms can include low mood, irritability and depression with the most severe form of psychological symptoms known as premenstrual dysphoric disorder (PMDD). It is widely accepted that PMS occurs following ovulation and this theory is supported by the absence of symptoms prior to puberty, during pregnancy and in postmenopausal women.4 Absolute levels of sex steroid hormones are not different between those with and without PMS but those with PMS may be more sensitive to the downstream neurotransmitter effects. Estrogen is an agonist of serotonin and dopamine, modulating cognition and motivational drive, whilst progesterone, mediated through its metabolite (allopregnanolone), is a GABA agonist regulating mood and anxiety. 6

How can PMS be diagnosed? In the absence of a diagnostic laboratory test, the diagnosis of PMS/ PMDD is clinical. The wide range of associated symptoms pose a diagnostic challenge and the International Society for Premenstrual Disorders (ISPMD) has divided symptoms into ‘core’ and ‘variant’, Figure 1.7 For an accurate diagnosis, symptoms must occur regularly in ovulating women during the luteal phase of the cycle, with resolution by the end of menstruation.8

Is PMS measurable? The Royal College of Obstetricians and Gynaecologists (RCOG) recommends prospective completion of the validated Daily Record of Severity of Problems (DRSP) to aid diagnosis.9

What is the impact of PMS? PMS and PMDD can affect mood, work, and social activity. These effects are complex to quantify but there are several validated quality of life tools. Studies show relationships between disease severity and the extent of associated disease burden which includes effects upon relationships, physical and psychological health, lower work performance as well as financial consequences.10,11,12 Medical Woman | Spring/Summer 2019 29


How can PMS be managed? There may be significant delay in the accurate diagnosis of PMS or PMDD. The first essential step in successful management is therefore recognition of symptoms and impact, and an accurate diagnosis. This, for some, may be sufficient. Referral to secondary services may be required and a stepwise approach, managed by a multidisciplinary team consisting of a GP, gynaecologist and mental health professional should be followed.

• Cognitive Behavioural Therapy (CBT) CBT forms the cornerstone of management of severe PMS. It reduces the frequency of irrational thoughts, provides coping mechanisms, and has been shown to result in better treatment maintenance.4 In some instances CBT can eliminate the need for pharmacotherapy, with its associated side-effects.

• Non-hormonal therapies Non-hormonal therapies are aimed at stabilising the effects of sex hormones on neurotransmitters. Controlled clinical trials have consistently demonstrated good effect of SSRIs such as fluoxetine, 30 Medical Woman | Spring/Summer 2019

citalopram and sertraline used in luteal phase with overall response rates of 50 – 90%.4

• Complementary therapies Multiple complimentary therapy modalities including supplemental calcium, vitamin B6, and primrose oil have been evaluated in clinical studies with conflicting results.4 The lack of conclusive evidence means recommendations are absent from guidelines however, complementary therapies remain an attractive option for women who decline hormonal therapy and who are informed of the available evidence. Research to date has shown a 36-43% placebo effect.

• Hormonal therapies Hormonal therapies target ovarian suppression. Drospirenonecontaining combined contraceptives should be considered as a firstline hormonal intervention with clinical trials demonstrated a 50% reduction in symptoms, using the DRSP.7 Alternatively, transdermal estradiol provides effective suppression of ovulation. Caution should be exercised in women with a uterus,

WOMEN’S HEALTH: PRE-MENSTRUAL SYNDROME as unopposed estrogen is a recognised risk for the development of endometrial hyperplasia and atypia. The RCOG recommends a cyclical course of concurrent oral, vaginal or intrauterine progesterone and a low threshold to investigate abnormal bleeding. Gonadotrophin releasing hormone (GnRH) analogues are a highly effective alternative. Due to the resulting iatrogenic menopausal side-effects, they are reserved for refractory cases or as a short-term diagnostic test with the expectation that simulating the menopause should cause resolution of symptoms.

• Surgical Surgery is a radical approach but may be necessary in severe PMS or PMDD. A bilateral oophorectomy with or without hysterectomy provides complete relief of PMS symptoms in severe cases. Clearly the surgical risks as well as its impact on fertility should be extensively discussed and gold practice would be to undertake these discussions over several consultations with involvement from psychology. A short course of GnRH agonists to confirm the diagnosis first is advocated prior to definitive surgery. With uterine preservation (perhaps to retain the possibility of future embryo transfer) is controversial. Cyclical HRT with progesterones would result in iatrogenic reintroduction of PMS. A continuous combined HRT preparation would minimise this risk. Following hysterectomy, a continuous estrogen preparation only is needed to reduce the cardiovascular and skeletal side-effects of a premature menopause, as advocated by the British Menopause Society based on data from the Million Women Study on HRT.13

Does this demand an ICD reclassification of PMS? PMS was first added to the World Health Organisation’s International Classification of Diseases (ICD) in 2015. It is possible that the diagnostic criteria has deliberately remained vague to preserve the fine line between ‘reinforcing negative attitudes’ towards menstruation via over diagnosis, and leaving women untreated.14 There is a pressing need for diagnostic uniformity in the light of increasing evidence of the impact of PMS. The recognition of PMS as a formal condition would facilitate the prescription of efficacious therapies, tailored methodologies during clinical research, and acknowledging PMS as a socially acceptable diagnosis for affected women.15 PMS (under the subheading of ‘premenstrual tension syndrome’) and PMDD are labelled as physical disorders of gynaecological aetiology.16 The significant overlap between PMS with other physical and psychiatric disorders renders its classification ambiguous. These conditions include hormonally driven disorders such as postnatal depression, as well as other major depressive disorders. Similarly, there is an increased incidence of physical disorders such as endometriosis and systemic lupus erythematosis in women with PMS. A tighter reclassification of PMS is hence elemental distinguish it from co-existing conditions whose symptoms can mimic those of PMS.17

Reflections and future directions? There is little doubt that for a proportion of women, PMS and PMDD can be a debilitating condition with significant impact upon quality of life. It is likely that reporting PMS is variable across different populations with varying cultural, healthcare engagement behaviours and socio-economic factors. How many women are

experiencing an unrecognised debilitating condition? Can we expect women to engage with healthcare services to evaluate and treat this condition if the workforce is not equipped with the knowledge to recognise it, and furthermore if there are insufficient specialist secondary referral centres providing holistic multidisciplinary care? Before further interventions can be implemented and evaluated, intervention is needed to ensure that healthcare professionals and women alike are empowered to seek advice and assessment. References Dalton, K., Menstruation and acute psychiatric illnesses. BMJ, 1995. 5115: p.148-149. 2 Browne, T.K., Is Premenstrual Dysphoric Disorder Really a Disorder? Journal of Bioethical Inquiry, 2014: p. 313-330. 3 Steiner, M., Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. J Psychiatry Neurosci, 2000. 25(5): p. 459-68. 4 Management of Premenstrual Syndrome: Green-top Guideline No. 48. BJOG, 2017. 124(3): p. e73-e105. 5 The American College of Obstetricians and Gynecologists. Clinical Guidance for Premenstural Syndrome. 2015; Available from: FAQs/Premenstrual-Syndrome-PMS?IsMobileSet=false. 6 Spinelli, M.G., Depression and hormone therapy. Clin Obstet Gynecol, 2004. 47(2): p. 428-36. 7 Nevatte, T., O’Brien, P.M.S., Bäckström, T., Brown, C., Dennerstein, L., Endicott, J., Epperson, C.N., Eriksson, E., Freeman, E.W., Halbreich, U., Ismail, K., Panay, N., Pearlstein, T., Rapkin, A., Reid, R., Rubinow, D., Schmidt, P., Steiner, M., Studd, J., Sundström-Poromaa, I., Yonkers, K., Consensus Group of the International Society for Premenstrual Disorders, ISPMD consensus on the management of premenstrual disorders. Arch Womens Men Health, 2013. 4: p. 279-291. 8 Kadian, S. and S. O’Brien, Classification of premenstrual disorders as proposed by the International Society for Premenstrual Disorders. Menopause Int, 2012. 18(2): p. 43-7. 9 Endicott, J., J. Nee, and W. Harrison, Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health, 2006. 9(1): p. 41-9. 10 Wallenstein, G.V., et al., Development and validation of the Premenstrual Symptoms Impact Survey (PMSIS): a disease-specific quality of life assessment tool. J Womens Health (Larchmt), 2008. 17(3): p. 439-50. 11 Schiola, A., et al., The burden of moderate/severe premenstrual syndrome and premenstrual dysphoric disorder in a cohort of Latin American women. Value Health, 2011. 14(5 Suppl 1): p. S93-5. 12 Kahyaoglu Sut, H. and E. Mestogullari, Effect of Premenstrual Syndrome on WorkRelated Quality of Life in Turkish Nurses. Saf Health Work, 2016. 7(1): p. 78-82. 13 Hamoda, H., S. British Menopause, and C. Women’s Health, The British Menopause Society and Women’s Health Concern recommendations on the management of women with premature ovarian insufficiency. Post Reprod Health, 2017. 23(1): p. 22-35. 14 Mai, M., Reed, G.M., The ICD-11 classification of mood and anxiety disorders: background and options. World Psychiatry, 2012. 11, Suppl 1. 15 Halbreich, U., Backstrom, T., Eriksson, E., O’Brien, S., Calil, H., Ceskova, E., Dennerstein, L., Douki, S., Freeman, E., Genazzani, A., Heuser, I., Kadri, N., Rapkin, A., Steiner, M., Wittchen, H., Yonkers, K., Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies. Gynecological Endocrinology, 2009. 23(3): p. 123-130. 16 ICD-11 for Mortality and Morbidity Statistics (ICD-11 MMS) 2018; Available from: 17 Connolly, M., Premenstrual syndrome: An update on definitions, diagnosis and management. Advances in Psychiatric Treatment, 2001. 7(6): p. 469-477. 1

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Access to contraception: a key element of effective humanitarian aid Christina Wegs is an Advocate for reproductive rights, refugee rights and gender equity. She leads global advocacy for sexual and reproductive health and rights at CARE, one of the world’s leading humanitarian organisations. Christina brings over 20 years of experience in global health and development, with a focus on rights-based approaches. She has Master’s degrees in public health and social work from the University of North Carolina, USA.

CARE International is an international humanitarian agency delivering emergency relief and long-term international development projects, with a focus on the rights, need and leadership of women and girls. Imagine that you have been displaced from your home because of war or natural disaster. You may have lost everything you own, you may be separated from your family, and your social support systems have been torn apart. You do not know what the future holds from you. Imagine if, with all this uncertainty, you cannot control your own body. Right now, there are 65 million people displaced by conflict or crisis – more than at any time since World War II. Almost half of all people affected by humanitarian crises are women and girls: it is estimated that 32 million women and girls are in need of humanitarian assistance.1 32 Medical Woman | Spring/Summer 2019

Despite this, the needs and realities of women and girls are often overlooked in humanitarian assistance - including their sexual and reproductive health needs. A key persistent gap in humanitarian response is access to contraceptive services. A 2014 global evaluation found many humanitarian funding requests did not include contraception, and where family planning was provided, women had very little access to the highly effective, long-acting methods many women want and need. Emergency contraception was almost entirely unavailable outside post-rape care.2 Consequently, many women and adolescent girls are forced to contend with unplanned pregnancies and experience entirely preventable suffering and death from complications of pregnancy and childbirth, in addition to the traumas of conflict, disaster, and displacement.

A GLOBAL STAGE: ACCESS TO CONTRACEPTION CARE Here is what we know: The need is acute. Most preventable maternal deaths take place in fragile countries, many of them affected by conflict, violence, displacement, and natural disasters.3 Fulfilling the unmet need for effective contraception could avert a third of these maternal deaths. Women’s sexual and reproductive health needs do not go away when emergencies strike. In fact, the need for sexual and reproductive health services often becomes more acute in emergencies. During crisis and conflict women are at increased risk for sexual violence, increased risk of unintended pregnancy, death or disability during pregnancy and childbirth, and unsafe abortion.4,5 The demand is fierce. Many women whose lives have been upended by conflict and displacement want to avoid becoming pregnant or delay pregnancy until their lives have stabilised and they can take care of themselves and their families. Across diverse contexts, 30% to 40% of women experiencing displacement did not want to become pregnant in the next two years, and 12% to 35% wanted to limit the number of pregnancies. 6 The proportion of women who want to prevent pregnancy can be even higher in some contexts. Nearly three quarters of pregnant Syrian refugee women surveyed in Lebanon wished to prevent future pregnancy, and more than one half did not desire their current pregnancy.7 It is doable. Evidence and experience from leading humanitarian agencies show that it is possible to provide sexual and reproductive health care - including contraceptive services - in even the most challenging settings. Since 2011, the combined efforts of CARE, the International Rescue Committee, and Save the Children, with the support of Columbia University’s Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, have delivered contraceptive services - including long-acting reversible contraceptive methods (LARCS), to more than 1 million women and girls affected by crises.8 We can deliver with quality. In a wide range of settings - from post-earthquake Nepal, to the conflict-affected areas in the Democratic Republic of Congo, and refugee camps in Bangladesh, CARE provides high-quality contraceptive services. These services include counselling to ensure free and informed choice and access to a wide range of contraceptive methods, including LARCs. Providing contraception to women affected by crisis and conflict is not a luxury or an ‘extra’, it is a fundamental part of a basic healthcare package that should be provided in every humanitarian response. It saves lives, and it helps ensure that women can make autonomous decisions about their bodies and their lives. There is great need and there is great demand. We have evidence and experience that shows it is possible to deliver contraceptive services with quality and respect. Above all, it is a human rights’ imperative: every person, everywhere should have the same right to decide whether to have a child and to survive pregnancy and childbirth. It is time for us to demand that donors, governments and humanitarian actors commit to ensuring universal access to quality contraceptive services for all women and adolescent girls affected by conflict and crisis. We achieved an important breakthrough at the Global Family Planning Summit in London in 2017- an event co-convened by the British Government where crisis-affected settings was recognised for the first time as a priority by the global contraception/family planning community, and where 21 powerful donors, governments, civil society and private sector actors made

concrete commitments to ensuring access to contraceptive services in crisis settings. CARE continues to work alongside key partners to secure the commitment of more donors and governments, monitor progress and ensure accountability. Most importantly, we are working to make sure that women and girls affected by crisis have leadership roles in shaping humanitarian programs and policies so that they respond to their real-life needs, priorities and realities including high-quality, non-discriminatory sexual and reproductive health services. References United Nations Office for the Coordination of Humanitarian Affairs (OCHA), (2016), ‘Global Humanitarian Overview 2017’. Available at: http://docs.unocha. org/sites/dms/Documents/GHO_2017.pdf. It is estimated that 128 million people are currently in need of humanitarian assistance and 1 in 4 are women and girls of reproductive age according to UNFPA ‘State of the World Population 2015’ report. Available at 2 IAWG Global Evaluation (2012-2014). Available at 3 Save the Children, (2014), ‘State of the World’s Mothers 2014: Saving Mothers and Children in Humanitarian Crises’. Available at: content/dam/usa/reports/advocacy/sowm/sowm-2014.pdf; Calculations represent the share of global maternal deaths that occur in the 51 fragile states identified by OECD. This list does not include the Philippines or India, both stable countries with pockets of fragility. Maternal deaths are sourced from the WHO [Levels and Trends for Maternal Mortality:1990 to 2010. (Geneva: 2012)]. 4 Ahmed et al. Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet 2012;380:111-125. 5 Cleland et al. Family planning: the unfinished agenda. The Lancet, The Lancet Sexual and Reproductive Health Series 2006. Available at: reproductivehealth/publications/general/lancet_3.pdf 6 McGinn et al. Family Planning in Conflict: Results of Cross-sectional Baseline Surveys in Three African countries. Conflict and Health 2011;5:11. Available at: http://www. 7 Benage at al. An assessment of antenatal care among Syrian refugees in Lebanon. Conflict and Health 2015;9:8. 8 Data from RAISE Initiative, Columbia University (forthcoming). Available at https:// reproductive-health-access-information-and-services-emergencies-raise-initiative 1

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Sleeping well for doctors and patients Hugh Selsick established the Insomnia Clinic at the Royal London Hospital for Integrated Medicine/University College London Hospitals where he is the Lead Clinician. He is also a Consultant in the Sleep Disorders Centre at Guy’s Hospital. He founded the Sleep Special Interest Group in the Royal College of Psychiatrists and is currently the president of the Sleep Medicine Section at the Royal Society of Medicine.

Sleep is central to our physical and mental health, yet we learn almost nothing about it in our training as doctors. Given that we spend a third of our lives sleeping, there is a lot of time for things to go wrong and there are over 60 sleep disorders. Many of these disorders are common but are often undiagnosed or untreated. Poor quality sleep and insufficient sleep are risk factors for depression, they increase the risk of car accidents and medical errors, impair cognitive function and productivity, and have an enormous impact on quality of life. As doctors we need to understand sleep and sleep disorders, not only so we can look after our patients, but also to ensure that we are sleeping well enough to provide safe and effective patient care! Female doctors often have two additional challenges when it comes to sleep. The first is that sleep is profoundly affected by the menstrual cycle, pregnancy, childbirth, breastfeeding and menopause. This means that the physiological and social factors that impact on sleep are constantly changing for women. The second challenge is that many doctors do shift work, having to stay awake when the body expects to be asleep and then trying to catch up on lost sleep when the body expects to be awake. Almost inevitably this leads to poorer sleep and impaired performance when awake. In this article, I will outline some simple strategies to manage insomnia that you can use with your patients and yourselves. I will also give you some tips on how best to manage your sleep when working shifts. 34 Medical Woman | Spring/Summer 2019

Before discussing insomnia, it is important to point out that many people who are good sleepers experience chronic sleep deprivation. Sleep time is often sacrificed to other demands and, as a result, people do not give themselves enough time to sleep. If you sleep more than an hour longer on a weekend than you do on a weekday, you are probably not getting enough sleep in the week. Although you can catch up on lost sleep on the weekend it does mean you will be sleep deprived and not at your best the rest of the week. So prioritise your sleep! It is tempting to put off going to bed in order to catch up on household tasks, social media, and the latest episode of your favourite show. But if you miss an hour of sleep tonight you will feel tired for all 16 hours of your waking time tomorrow.

Treating Insomnia Insomnia is a very common and debilitating condition, yet it is seldom adequately treated. Often behavioural interventions will entail little more than sleep hygiene advice, which research tells us is very rarely effective. On the other hand, there is a well-proven cognitive behaviour therapy for insomnia program that can lead to significant improvements in sleep, mental health and quality of life. What follows are some simple and effective techniques that you can use with your patients. 1: Get up at the same time every day, seven days a week, no matter how much or how little you have slept. One of the common myths about sleep is that it is essential to go to bed at the same time


Categories of Sleep Disorders with examples • Breathing disorders e.g. obstructive sleep apnoea. • Central hypersomnias e.g. narcolepsy, idiopathic hypersomnia. • Parasomnias – unwanted experiences and behaviours in the night e.g. sleepwalking, night terrors; REM sleep behaviour disorder, nightmares. • Circadian rhythm disorders – body clock out of sync with outside world e.g. delayed sleep wake phase disorder, jet lag. • Movement disorders e.g. restless legs, periodic limb movements. • Insomnia – not able to get enough sleep. The range of sleep disorders means that Sleep Medicine is one of the most multi-disciplinary areas of medicine, drawing people from psychiatry, respiratory medicine, neurology, ENT, maxillofacial surgery, dentistry, anaesthetics, neurophysiology and general practice.

every night. In insomnia, actively trying to keep a constant bedtime can be counterproductive. However, if you get up at the same time each morning, you will start to feel sleepy at the same time each evening and your bedtime will naturally become more consistent. 2: Go to bed later. This seems nonsensical – surely if one is not sleeping enough one should spend more time in bed? But, in insomnia patients, extra time in bed is generally spent awake and this makes the insomnia worse. A good rule of thumb is to try matching your time in bed with your actual time asleep. So if you are only sleeping six hours and you get up at 7:00a.m. then you should set your earliest bedtime at 1:00 a.m. However, if your sleep time is less than five hours then set your earliest bedtime at five hours before your rising time. Once you are consistently falling asleep quickly and sleeping through most of the night you can experiment with moving the bedtime earlier by 15 minutes a week. 3. In addition to the rule above, only go to bed when you feel sleepy. In other words, you need to reach your earliest bedtime and feel sleepy before you go to bed. It is worth discussing with patients what sleepiness feels like. Insomnia patients are tired most of the time, but this is not the same as sleepiness. Sleepiness is difficulty keeping your eyes, open, your head nodding forward and difficulty staying awake. 4. The bedroom is for sleep and intimacy only. The more time you spend in the bedroom awake the more you come to associate the bedroom with wakefulness. This association means that when you go into your bedroom you automatically become more awake. Therefore, do not read, watch TV, listen to the radio, relax, exercise, work, study or do anything else in the bedroom. In addition, if you go to bed and it becomes clear that you are not going to fall asleep in the next few minutes, get out of bed and out of the bedroom. Do something pleasant and relaxing such as read, do a puzzle, listen to a podcast etc. and only go back to bed when you feel sleepy (again, sleepy, not just tired). If on returning to bed you do not fall asleep then repeat the process. Note: many people will have tried this for a few nights and they will say it does not work. What they often don’t realise is that this technique is not designed to help them get back to sleep on the night that they do it. It is designed to ensure that they spend no

Shift work is an unavoidable part of the medical profession in many specialties. It is unrealistic to expect you to be as alert at night as you are in the day or to be able to sleep as well in the day as you do at night. However, there are some strategies you can use to better manage your shifts: • Try to increase your sleep time for several nights prior to your night shift. Unfortunately, you can’t ‘pre-sleep’ and bank your sleep in advance of the night shift, but by sleeping longer you can at least ensure you don’t start the night shifts with a sleep debt. • Reduce your caffeine intake for a few days before the night shift. You develop a tolerance to caffeine, so by reducing your intake you make yourself more sensitive to its effects and therefore will get more of a kick from it when you need it. • If possible, take a nap during your night shift: A 40-minute nap opportunity in the middle of a 12-hour night shift improves reaction time, alertness, fatigue, and performance. But it does not improve alertness on the post-shift drive home. • Have a caffeinated drink at the start of the shift if you feel you need it and then have another at around 3 to 4 a.m. This will give you a boost to get through the 4 to 7 a.m. period where your alertness is at its lowest. • Avoid driving home after the shift – your risk of accidents is significantly increased! • If you have another night shift go to bed as soon as possible on getting home. You will probably not sleep through the entire day, so try to also have a nap in the late afternoon or early evening before you leave for your shift. • When you have finished your night shifts have a brief recovery sleep when you get home and then try to avoid sleeping until the evening. If you sleep too long in the day you may struggle to sleep that night. Go to bed early that night to catch up on your lost sleep so you will be ready for your day shift the next day.

time in their bedrooms awake. They may spend a lot less time in their bedrooms, but almost all that time is spent asleep. As a result their association with the bedroom will gradually change until eventually the act of going to bed makes them sleep. Most patients have built up their dysfunctional association with the bedroom over many years or decades and it won’t change overnight. A good rule of thumb is to stick with the technique for two months before evaluating if it is working. 5. Don’t end your day at bedtime. Working or studying right up to bedtime doesn’t leave any room for you to process any thoughts and feelings that have built up during the day. As a result, those thoughts and feelings will overflow into your bedtime and disrupt your sleep. You should finish your work, study etc. at least 30 minutes before bedtime, and ideally even earlier. The last portion of the day should be used to wind down and do things you enjoy. This will also give you an opportunity to take stock of your day, plan what you have to do the next day and to process and ‘park’ your thoughts so they don’t need to be processed when you get into bed. Medical Woman | Spring/Summer 2019 35


The Mind’s Eye by Oliver Sacks

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.

Many of you may be aware of Oliver Sacks, the New York neurologist who came into the public eye with the 1990 film version of ‘Awakenings’ starring Robin Williams, documenting the encephalitis lethargica epidemic and the initial use of L-dopa in the mid-1960’s for this group of patients. I was privileged to see him at Warwick University where he gave a talk about his life in medicine in the early 2010’s. At that time, he was certainly an old man, slow to respond to questions and I recall him shuffling on to the stage wearing comfortable trainers and a baseball hat. Initially it seemed unlikely that he could be an inspiration… until he started to speak about that period of his life at Beth Abraham Hospital and what he had learned from that group of patients. How they had initially ‘woken’ after many years of a suspended existence of very little movement or interaction of any sort. How it was to look back in time to the 1920’s when they had first become unwell - as for many of them that point in time was where they were still situated. So they might sing a song from that time, or demonstrate a dance move. He talked of the frustrations of the ‘on-off’ effect with L-dopa; that patients generally had only a period of time when they improved before being cast back into the static existence from which they had come. He was totally engaging as he developed the narrative of particular patients with whom he had been most involved over an extended period. ‘Awakenings’ is not a typical example of Sacks’ writings. Mainly he is interested in the patient as an individual as well as an example of disease type and so his diverse case studies in both, ‘The Man who Mistook his Wife for a Hat’ and this book, ‘The Mind’s Eye’ are full of individual details. His interest extends to the living circumstances of the patient; their ability to cope at home and outside of it; the impact of pathology on the relationship with their husband or wife. He takes time to build up his knowledge of a patient and the development of a pathology; both in terms of recovery and deterioration. He is never limited by what the textbooks tell him if his experience of the individual tells him the opposite.

36 Medical Woman | Spring/Summer 2019

Sacks documented his young life, and particularly his obsession with chemistry in his book ‘Uncle Tungsten’. He had a whole room set up adjacent to the family home in which to perform chemical experiments; and we are rather lucky that he survived a (single) significant explosion when he was developing some experimental techniques. He often refers in his books to neurologists who have developed the specialty historically. He is naturally aware of the great advantage we now have in terms of imaging, my sense is that he was never reliant on this but prefers to make inferences from his history taking and the signs present, with imaging used as a confirmation of his suspicions, rather than as a starting point. In ‘The Mind’s Eye’ he concerns himself particularly with patients who, due to trauma or disease, find themselves lacking a particular ability e.g. alexia (the inability to read). He locates this problem in the brain (the visual word form area); the fact that it is not always associated with an inability to write (alexia sin agraphia); the historical context (Charcot described this previously in the nineteenth century); and the personal. He always names his patients, which draws us closer to them and provides enough context about their profession or the particularity of the challenge that their disease brings them that we can feel as though we are in the room. Sometimes his books feel like an extended neurology ward round where we move from bed to bed learning about the unusual which we might meet in the course of clinical practice, examples include prosopagnosia (face blindness) and the very rare, such as visual agnosia. Despite his slight tendency to fascination - the patient as interesting rather than of intrinsic value - he does come across as a very compassionate doctor. He wonders about the coping strategies of patients, both emotionally and in terms of overcoming their clinical difficulties. He is full of praise for the extended team of therapists who support patients and can make such a difference to recovery, for instance after a stroke. Having seen him lecture, I found myself unexpectedly moved when I heard that he had died in 2015. I have read various of his books over 30 years; you could do worse than pick up one or two.


Universal Need: A Helping Hand Sometimes we all get tired. Sometimes we all need a bit of help. I was having one of those starts to the day. The fatigue that sometimes seems to precede an inevitable viral illness. The muddle of things still to be done as the week progressively ticks by. The feeling that I need and should get home to my family soon. Sometime later after the usual hustle of the district general commute, I started my general neurology clinic. The line-up of headache, blackouts, and memory problems is not uncommon in a clinic list for a neurology registrar. Being a curious creature of habit, a systematic individual who enjoys a bit of planning, in times of uncertainty I like to go back to the basics of medicine - asking a few questions, using my tendon hammer, and making a list of what to do next to find out what is wrong. But consultations, as you will know vary, some require a greater focus on explaining a disease process, some a greater consideration of treatment avenues, some a greater focus on responding to emotion. The emotion, for example, that comes with the painful adjustment to a new diagnosis, a life-long neurological condition, which carries with it uncertainty and the possibility of significant disability. This received at a youthful age of career success, flat buying, and moving in with a partner - is hugely unwelcome and requires difficult and progressive psychological adjustments. Or, for example, when a consultation takes an unexpected emotional turn. Towards the end of the afternoon, I found myself sitting opposite a man who alongside his neurological problem, had also developed a recent addiction. I asked him some questions, and after, in the usual fashion I whipped out my tendon hammer. Then I shared what I was thinking about the cause of his symptoms, he told me what he thought and asked a few questions. We then discussed a plan of action, involving some allied specialties to help with some wider problems and I asked him if he would be comfortable taking some medication. I told him that it was important we got him the help he needed. He started crying. I almost reciprocated. Poking my face into a blood form helped. There was an old and bespectacled professor of psychiatry when I was a medical student at Birmingham, and he seemed exceptionally wise. The sort of wisdom I would love to emulate and emanate one day. During a ‘psychiatry and the arts’ small group session, I remember him sharing the one occasion he thought it was acceptable to cry with a patient. Bereavement. I am not sure what my view is. Is it acceptable? If so, when is it acceptable to cry in front of a patient? Perhaps, it will vary according to the patient and what they expect from their doctor. I think it was what tears can mean. Perhaps an unsaid and silent thanks for being taken seriously, for being given help, for the possibility of the future. At the end of clinic today I got a thank you and a handshake - well - I was only running thirty minutes late. But I take away more for the next time. Words matter. A lot. So does kindness. But. Time.

Blog authored at

Medical Woman | Spring/Summer 2019 37

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

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