Medical Woman – Vol 38, Issue 2, Autumn/Winter 2019

W EDICAL W MAN

VOLUME 38: ISSUE 2

AUTUMN/WINTER 2019

the body issue www.medicalwomensfederation.org.uk

Editor’s Letter Choice and Presence

E

veryone has something to say. Particularly when it comes to women’s bodies. Yet, as a society our role is not to dictate one way or another, but to enable choice. Crucially, ensuring the presence of the subject, often absent.

The overarching theme of this issue is women’s bodies. In our career planning article we kick off with perspectives from the world of plastic surgery, moving on in our feature to discuss the sexualisation of women’s bodies. Along the way we touch on healthcare for disabled people, and the human body in the context of organ transplantation. Interwoven into this issue, are articles covering international perspectives on contraception and teenage pregnancy.

Innovation is a key theme in this issue. Our authors provide inspiration and practical tips on how to develop an organisation from the first brick, and how to carry out a successful audit or quality improvement project.

Retreat, reflect and renew with articles centred on well-being in this issue. Read about the Acacia retreat which combines the arts and humanities with medicine to impact on wellbeing. Reflect on the process of taking time out of programme. Lastly, renew your knowledge of anxiety, and stress in the workplace, picking up some tips on how to reduce your stress levels.

I hope this issue provides you with a selection of thought provoking articles to share with family, friends, and colleagues. I look forward to hearing from you - my contact details are below - and to seeing you at our upcoming conference in November.

Fizzah Ali @DrFizzah Fizzahali.editoratmwf@gmail.com

Contents Medical Woman, membership magazine of the Medical Women’s Federation Editor-in-Chief: Dr Fizzah Ali fizzahali.editoratmwf@gmail.com

News and Events

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Women and leadership 4

Editorial Assistants: Miss Kimberly Murrell Miss Danielle Nwadinobi

Career planning: Plastic surgery

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Design & Production: Toni Barrington The Magazine Production Company www.magazineproduction.com

Skills toolkit: Setting up an organisation

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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: admin@medicalwomensfederation.org.uk www.medicalwomensfederation.org.uk @medicalwomenuk www.facebook.com/MedWomen Registered charity: 261820 Patron: HRH The Duchess of Gloucester GCVO

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Skills toolkit: Audit and quality improvement

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Feature: Happy mediums 14

New beginnings: OOPs!

16

MWF Spring Conference 2019 18

Spotlight: Organ transplantation

20

Global Stage: Looking to future priorities

22

Mastering Mind: Anxiety

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Obituary: Dr Lotte Theresa Newman

29

Unwind: Retreat, reflect, renew

30

Honorary Secretary: Dr Anthea Mowat

Book review: Invisible women

32

Honorary Treasurer: Dr Heidi Mounsey

The common commute column

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Vice-President: Professor Chloe Orkin

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

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Global Insight: Access to contraception 24

President: Dr Henrietta Bowden-Jones OBE President-Elect: Professor Neena Modi

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MWF NEWS & EVENTS

MWF Honorary Membership 2019 Winners Announced

DATES FOR YOUR DIARY October 2019 3 months extra free MWF membership promotion for new members 31st October 2019 MWF Council Meeting (London) 1st November 2019 MWF Autumn Conference (London) December 2019 Katherine Branson Student Essay Prize opens January 2020

The Medical Women’s Federation (MWF) recently announced the launch of Honorary Membership to recognise doctors who have demonstrated a unique ability to transfer the MWF vision into living action.

In past years exceptional female colleagues were appointed by MWF but this is the first time in 102 years that exceptional male colleagues will also be able to become Honorary Members. This new development is in line with our President’s mission to bring the vision for MWF into the more modern and inclusive medical world we now live in.

Congratulations to the successful nominees for the 2019 round of awards: Dr Rak Nandwani ~ Dr Simon Fleming ~ Professor Dian Donnai Mr Tim Mitchell ~ Professor Peter Brocklehurst ~ Professor Sir Simon Wessely You are invited to join us for the historical occasion as the successful nominees receive formal recognition of their contribution at the joint MWF and BMA Autumn Conference ‘Working Together: Overcoming Gender Bias in Medicine’ on Friday 1st November 2019.

London Local Group Report In September 2019, Bart’s and the London held their freshers fair, at which the Barts and the London Medical Women’s Federation had a stall. The MWF at Bart’s shares its status with the ‘Women in Healthcare Society’, so it was a joint stall. At the fair we had MWF brochures and flyers. We also had photos that were taken at our events during the last academic year. These events included three talks; ‘Women in medicine’ by Dame Professor Parveen Kumar, ‘Women in surgery’

by Ms Scarlett McNally and ‘Women in A&E’ By Dr Sarah Finlay. The stand attracted much interest and resulted in over 60 students signing up to receive our first newsletter. We told the students of our event taking place in January 2020, a talk by Dr Henrietta Bowden-Jones, this attracted much interest and excitement. Details of the event will be circulated to members shortly.

We informed the students that our next event would be a meeting, in which we will discuss the roles of the MWF in more detail and most importantly find out what they, as students, wanted us to focus on this academic year. I hope it is going to be a very exciting year for the MWF at Bart’s. I hope the freshers fair went as well as ours at other universities.

Lulu Lyons, MWF Student Representative on Council and for Bart’s and the London 2 Medical Woman | Autumn/Winter 2019

MWF subscription payments due 8th March 2020 International Women’s Day 24th April 2020 MWF Spring Conference (Nottingham) and MWF AGM 25th April 2020 MWF Council Meeting (Nottingham)

MWF NEWS AND EVENTS

MWIA report for Medical Woman

The Medical Women’s International Association celebrated its 31st International Congress, The Centennial Congress, in New York City on the 25th-28th of July, earlier this year.

International Congresses are held every three years and are hosted by national associations. Members of MWF are also members of MWIA and ten of us joined over 500 participants at the centennial Medical Women - Ambassadors of Change in a Challenging Global World. Topics ranged from aspects of global health, violence and women, and obesity, through to gender and health, work life balance, as well as skills to thrive, and sexual harassment. The keynote speaker was Gloria Steinem, the celebrated feminist.

Dr Clarissa Fabre from the UK, President-Elect for the past three years, was inaugurated as President of MWIA, a tenure of three years. The UK forms part of the Northern European Region and the next meeting in May 2020 is on a Baltic Cruise organised by our Finnish Vice President, Dr Tuula Saarela.

As UK co-ordinator for the MWF, I was proud to represent the MWF at the Central Asia Regional Congress Women’s Wellbeing: A Global perspective, in Bangkok on September 2018.

This was culturally enhancing, scientifically rich in context and accompanied by an equally active social programme. Ten symposia with 37 speakers addressed a variety of topics ranging from the life course of women, social issues and health promotion, as well as personalised medicine.

Professor Emeritus, Dr Khun Nanta Maranetra, President of the Thai Medical Women’s Association gave the welcome address.

The Thai MWA is a non-profit organisation established in 1951, legalised in 1960 and is under the Royal patronage of Queen Sirkit and has 2140 members.

MWIA President Dr Bettina Pfleiderer of Germany outlined the invaluable work of MWIA in her opening address. Dr Clarissa Fabre spoke on Integrating the healing Power of Humour and Music in your Clinical Practice, as part of the session on Humanism and Clinical Practice.

Work-life balance workshops were held in parallel, examples included the Art of Drawing and Painting, and at a Save the Planet DIY workshop I produced a painted shopping bag with flowers and my name on it!

The Thai art of food carving was taught by a Professor of Obstetrics. The gala dinner was memorable in that we could be dressed in traditional Thai costume and were encouraged to engage in both traditional and line dancing. We had all been appointed a Thai lady doctor companion, so there was an immediate warm exchange of views and opinions and sense of inclusion. A wonderful event!

Amanda Owen, MWIA UK Coordinator Previous editor of Medical Woman, Secretary and President of the London Association.

Medical Woman | Spring/Summer 2019 3

FEATURE: WOMEN AND LEADERSHIP

Consensus statement: MWF priorities in representing medical students and junior doctors

I mproving the education of medical students about issues related to gender equality and women’s health

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Why?

Medical students reported gaps in the curriculum in issues related to women’s health and equality.

MWF Action:

Maintaining the safety and security of medical students

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Why? A student shared an experience of a friend who had experienced sexual harassment on campus and felt the response of the faculty was inadequate.

MWF Action: a. MWF believe sexual harassment is unacceptable and as an organisation pledges to support medical schools to address the situation. b. MWF will draft a written statement to be issued to every UK medical school highlighting this concern and suggesting methods to tackle sexual harassment, including:

i.

S ignposting support mechanisms for students concerned about their safety or wellbeing

ii.

Education of students about unconscious bias and everyday sexism

iii.

E ducation of students about the potential consequences of sexual harassment including mental, physical and judicial sequelae c. If an incident of particular concern occurs, MWF will facilitate a meeting between a senior MWF representative, local MWF representative and a member of the medical school faculty to address local issues and provide dedicated support.

a.

MWF believes that medical students would benefit from learning at an early stage about gender equality and women’s health. b. MWF will recommend to every UK medical school to include subjects in their curriculum such as:

i. Abortion, female genital mutilation, breastfeeding

ii. Equality in the workplace, gender pay gap, less than full time working, parental leave, doctor’s wellbeing and mental health

At the latest meeting of the MWF Juniors group in London, July 2019 a session was led by MWF President, Dr Henrietta Bowden-Jones OBE to understand what attendees thought MWF’s priorities should be for their junior doctor and medical student members.

Students and junior doctors of all grades were in attendance and were enthusiastic in sharing their experiences and ideas. A broad range of subjects were raised and we have six key themes which will form MWF’s priorities going forward into 2020 and beyond.

Outreach projects into schools improving access to careers in medicine for students from under-represented groups

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Why? Medical students have noted that there is still significant underrepresentation of black and ethnic minority (BAME) students, those from under-privileged backgrounds, and students with physical or mental disabilities.

MWF Action: a. MWF believes in equality of access to medicine, and that the medical profession should reflect the population it treats. b. MWF will promote outreach programmes to encourage and support girls of all backgrounds to apply to medical school. c. MWF will promote existing outreach projects to its members to improve visibility of female doctors to all school children, for example in CPR in schools project.

4 Medical Woman | Autumn/Winter 2019

FEATURE: WOMEN AND LEADERSHIP

Facilitating career progression for female doctors

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Promoting wellbeing and fair employment for female doctors

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Why?

Why?

Junior doctors are concerned that there is persistent underrepresentation of women in some specialties and at senior levels in most specialties.

It is widely recognised that junior doctors are suffering increasing rates of mental illness and burnout.

MWF Action:

a. MWF believes that the health and wellbeing of all doctors is vitally important. MWF promotes concepts which improve work-life balance, reduce the risk of burnout and maintain equality in the workplace. b. MWF endorses access to flexible/less than full time working for all staff who request it (without needing to provide a reason for the request). c.

MWF supports the concept of geographical stability for junior doctors on rotation and will work with Royal Colleges to determine how this can be facilitated. d.

MWF supports ‘return to work programmes’ for doctors who have taken time out, such as for maternity leave, and will signpost to these resources on the MWF website. e. MWF is seeking to address the Gender Pay Gap within the NHS and will post progress updates on the MWF website.

a.

M WF will promote ‘Female Champions’ through its conferences, publications and social media:

i.

Women in male dominated specialties and/or senior leadership positions

ii. Women from under-represented groups

iii. Women who have visibly helped and promoted other women b.

MWF will also promote ‘Male Allies’ – men who have championed women’s rights. c. MWF will act as an umbrella organisation to bring together existing programmes which promote female doctors career progression.

i. MWF will provide a resource on its website including information on all national and local programmes relevant to its membership

ii. MWF will provide an advisory service for any specialty wishing to set up a programme and will signpost this on the MWF website

MWF Action:

Mentoring and coaching services

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Why? There is a great demand for female-to-female support and mentoring within the medical student and junior doctor population. To date there are no national mentoring programmes of this nature.

MWF Action: a.

MWF will create an informal mentoring facility within a ‘members only’ section of the MWF website. b.

MWF members who are interesting in providing advice and support to junior members will be listed with a short biography and junior members will be able to make contact on an individual basis. This will provide additional value to membership of MWF by providing coaching and access to the wisdom and experience of our many senior and retired members. c.

MWF will encourage all interested senior members to undertake training in the mentoring process, such as through the Royal College of Physicians Mentoring Skills Workshop, but this will not be mandatory.

Dr Anna Ryan, Dr Henrietta Bowden-Jones OBE Contributing Authors: Anna Wozniak, Sameerah Abdel-Khaleq, Habiba Shabir, Vaishanja Bhiman, Rose Penfold, Jen Varadarajah, Raji Varadarajah, Zenni Enechi, Jodie Fletcher, Anenta Ramakrishnan, Jaya Roy Choudhury, Sara Hui, Abi Bakare, Shonnelly Novintan, Simran Mann, Narges Mohmand, Maria Nicola

MWF is seeking to expand its junior membership to truly reflect the voice of women doctors and medical students. The meeting has given us lots of ideas and projects to work on, and we are eager to hear more from our membership. If you would like to share your thoughts or any other tasks to our priority list please get it touch via Twitter (@medicalwomenuk) or email admin.mwf@btconnect.com.

Medical Woman | Autumn/Winter 2019 5

FEATURE: CAREER PLANNING

Innovative spirit: a day in the life of a plastic surgeon Nadine Hachach Haram grew up in the US and Lebanon before moving to London to study medicine at Barts and The London School of Medicine. She is currently a Plastic Surgery Registrar at Guy’s and St Thomas’ Hospital, London, and lives in the capital with her husband and three children.

Nadine founded her own company, Proximie, in 2015 to enable surgeons to collaborate virtually using augmented reality tools.

Can you tell us a bit about yourself?

I’ve always been really passionate about how we can improve access to safe surgery for everyone. During my plastic surgery training, I became involved with organisations like Facing the World – a charity for children with facial disfigurement – as well as working with non-profits back in Lebanon, like Global Smile Foundation MENA that provides care for children who need cleft lip and palate reconstruction. Through this work, I saw first-hand that one of the underlying reasons why there is limited access to safe surgery globally is because of a shortage of expertise. From there, I came up with the idea for Proximie whereby surgeons across the world could be brought together to collaborate and share techniques using the live, interactive tools of augmented reality. As Proximie started to develop, I was chosen to take part in the first NHS Clinical Entrepreneur programme in 2016, which allowed me to develop my innovation further.

Why did you decide to do plastic surgery?

When I was a teenager, my family and I returned to my parent’s home city of Beirut. This was in the aftermath of a civil war, and because of the age I was at the time seeing the physical scars that war can leave on a country left a lasting impression on me. I was keen to make a difference and when I learnt how powerful reconstructive surgery is and the positive impact it can have on someone’s life, I knew plastic surgery was for me. I guess, my journey into medicine always had plastic surgery as its end point because of the experiences I had had in my youth.

After this, there is operating, communicating with colleagues about patients, plans for the ward patients, talking to the nurse specialists and teaching. Finally, one of the last jobs of the day is to check on my patients who have undergone operations before leaving the hospital.

What do you most enjoy about training in plastic surgery?

The teamwork is a real plus point as is the impact that I can make on someone’s life. I like that every case may need a different solution or that there may be more than one way of doing things, and that I have to work out what’s best for the patient given their circumstances or expectations. Plastic surgery is also incredibly innovative and is constantly evolving. I like that about it, that it embraces change.

What are the challenges in your chosen career path?

Definitely balancing a full-on surgical career with a family and running my own company, although I do enjoy the variety of my days and the fast-paced nature of the work!

I sit on the Royal College of Surgeons Future of Surgery Commission which is involved in looking at how advances in medicine and technology will change surgical care. The challenges that surgeons will face in years to come is in how well we embrace innovation and how we adapt to a job that is no longer one-dimensional.

Undertaking operations is just one aspect of our careers. How successful we are at communicating with patients, mentoring trainees, collaborating with our colleagues and adopting technology into our practice are all real and present challenges.

Describe a typical day as a plastic surgeon?

No two days are the same, but I generally start with a ward round, seeing patients pre-operation and ensuring I have their consent for the procedure. At this time, I also review patients who had their operations the day before. All members of the surgical team will then meet for a briefing where we undertake a simple checklist, designed by the World Health Organisation as a standard of care.

This helps ensure that nothing is being missed and we have a plan for what we are doing that day and what each patient needs. I am a big fan of this approach which is also advocated by American surgeon Atul Gawande.

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

Be engaged. Ask questions. Talk to those already involved in specialties you are interested in and try and observe doctors already practising in these areas. But most of all pick something that you are passionate about. Ask yourself, would I still be happy doing this in 20 years’ time?

Medical Woman | Autumn/Winter 2019 7

SKILLS TOOLKIT: BUILDING AN ORGANISATION

Motivating Medics: setting up an organisation Sonia Ike is a Core Surgical Trainee in the Kent, Surrey, Sussex deanery, and originally from London.

She is the founder of Motivating Medics. Sonia is pursuing a career in Trauma & Orthopaedic Surgery, with a special interest in lower limb sports injuries. She was also a 2018-19 scholar of The Healthcare Leadership Academy. In her spare time, she enjoys travelling, skincare, reading and the gym.

Speaking about Motivating Medics, University of Nottingham (Sonia’s alma mater), April 2019

The conception Motivating Medics was founded in May 2018. However, the idea was conceived much earlier - around 2012, when I was in my second or third year of medical school.

The organisation was created in order to reach out to young people of lower socioeconomic backgrounds. The primary aim is to bridge the gap and help widen access into medical school.

The idea is to do this via workshops during the school holidays, and where possible, in term time. University meetings, mentoring and school talks are the main avenues of outreach.

Background: my story I experienced a successful widening participation initiative with the Universities of Nottingham and Lincoln. I understand first-hand 8 Medical Woman | Autumn/Winter 2019

how these courses work. I grew up in an under-represented area of London, and attended state school institutions. Thus, I can appreciate the various challenges faced in these circumstances when applying for medical school. Drawbacks included the lack of support and encouragement, very few mentors, variable teaching standards, and greater self-reliance.

Some statistics on widening participation In 2016, a government report on the state of social mobility in the United Kingdom was published, the ’Social Mobility Commission’.

Despite numerous efforts to change the social make-up of the professions at the top of the labour market, including medicine, still, only four per cent of doctors were from working-class origins. I found this figure incredibly striking.

SKILLS TOOLKIT: BUILDING AN ORGANISATION The NHS is made up of a variety of workers and patients of different backgrounds. Medical schools should fundamentally reflect this. This is why widening participation is so important; it allows for greater diversity in medical schools and beyond - including the workplace. No young person should be left behind. If an individual has the academic capabilities and potential for medical school, external factors such as socioeconomic class should have no bearing on their ability to apply and successfully gain a place of entry.

Feel inspired? Want to create an organisation?

When is the right time to start?

Now. Do not hold back. If you have a great idea, and really wish to take things forward, you need to believe in yourself. Start making notes, jot things down.

In the early stages, the content does not need to be incredibly comprehensive; even a few words here and there will suffice. Get creative, and try to think outside of the box.

Admittedly, we are busy individuals; work, studying, family, friends, relationships can all be time-consuming. However, there will never be a right time. If you feel inspired, get started. As mentioned earlier, you only need a few ideas to begin with.

Most importantly, consider branding. How do you intend to push your organisation forward? Alongside an official website, register and secure social media domain names early. Consider: which social media platforms do you even intend to use? Will you create a LinkedIn page? Are you keen on blogging and content creating?

If so, consider a site like Instagram, for example. Or, are you more drawn towards highlights with microblogging? In which case, perhaps Twitter will suit you.

There are numerous branding experts out there, if the creative aspects are not your forte, then by all means, seek their help.

The people who matter What are your strengths? Name your weaknesses. The latter will help identify the people you need around you in order to complement things.

Consider your target audience, and consider this well, tailoring your content accordingly.

Who can you turn to for advice? Choose your mentors wisely.

They don’t need to possess the highest of accolades, they just need to be sensible and pragmatic. You will need a voice of reason and wisdom.

Promotion and networking Resources and reading around Are you setting up a not-for-profit organisation? A social enterprise?

A charity? What are you trying to achieve? How are you going to get there?

For ethical and personal reasons, I felt that Motivating Medics would function best as a not-for-profit project. Considering the origins, and the demographic the organisation is serving, it only made sense. However, this is subjective.

Take a step back, and consider your ethos. Do not be ashamed to ask for financial help if this is required to further your venture. Apply for funding, contact charities, and seek investors if that is what you need in order to progress.

Quite significantly, you have to understand your subject area.

Dedicate time to researching the field. Read around, ask questions.

Keep abreast of pivotal publications, studies and statistics.

Are there similar organisations out there? Those possessing comparable schemata and principles? If so, try to contact people involved with said organisations; ask for advice, and liaise with them. The information gained may be invaluable. Meet with them.

Troubleshoot. There might even be scope for joint ventures and/or further networking in the near future. Collaboration is key.

Consider and be consistent about your professional development, as this will ultimately play a significant role in how things pan out.

Relevant conferences, events and even small workshops may be available. Consider: what qualities are essential for running an organisation successfully? Do you need to hone your leadership and management skills? Consider your repertoire. What can you add?

Make things official Once you have laid the foundations, conjured up a plan, and picked out a name, you will need to consider the legal aspects. For starters, you must formally enlist your organisation on Companies House – a register of companies. At the time of writing, it costs £12 to do this. This step is paramount. Afterwards, you can delve deeper into aspects such as copyrighting, website domain registration, and logo protection. Get familiar with the relevant law.

On your CV, or if you use social media platforms such as LinkedIn, ensure your organisation is mentioned in the very first introductory statements. This is your passion, treat it like so. Take pride in it, because when you do, it speaks volumes, and people will listen.

Attend events, talks, conferences and put your organisation out there. Advertise it at every suitable occasion. Travel with leaflets/ cards on you - and give them out when the opportunity arises. You never know who you will meet. Sometimes, a significant contact is only one networking opportunity away.

Planning and Perseverance Motivating Medics workshops have targeted more than 100 young people since its inception. A few students I have mentored have gone on to receive medical school interviews and subsequent offers. The workshops have been mentioned in London borough council news. Overall, the organisation is garnering attention from university institutions on a national level.

It has not been an easy feat, and resilience has been essential.

However, planning and perseverance have served me well.

Remember why you started. Keep on going. The success of your organisation doesn’t have to look conventional. There is nothing wrong with an atypical journey. If your objectives are not met the first time, step back, reassess things, ask new questions, and try again.

Recommended resources 1. Setting up a social enterprise - GOV.UK https://www.gov.uk/set-up-a-social-enterprise 2. What are the different types of social media? - Digital Vidya https://www.digitalvidya.com/blog/types-of-social-media/ 3. LinkedIn - for general networking, headhunting, discovering similar organisations, promotion, blogging/article publishing https://www.linkedin.com/

Medical Woman | Autumn/Winter 2019 9

SKILLS TOOLKIT: AUDIT/QIP

Audit and quality improvement: understanding and implementing Nuthana Bhayankaram is an Academic Clinical Fellow in Paediatrics at Royal Manchester Children’s Hospital.

She enjoys research and has an interest in paediatric haematology. Nuthana is the Junior Doctor Council Representative for MWF. When not working, she enjoys dancing, hiking and reading books.

10 Medical Woman | Autumn/Winter 2019

SKILLS TOOLKIT: AUDIT/QIP

Identifying a problem e.g. not all patients having growth charts completed on admission After a set amount of time e.g. 6 months, re-audit to assess if changes have resulted in improvement

Defining standards e.g. Trust guidelines advise all children have growth charts completed on admission

There can be various challenges encountered when designing or conducting an audit. The first can be identifying a problem in the first place! Speaking to a senior colleague such as an educational or clinical supervisor can help you to identify a project which the department will benefit from, so that the work does actually result in improved patient care. There can be challenges with collecting the data and accessing all the electronic and paper notes, be transparent about this in reporting your audit. Implementing changes can be particularly difficult for trainees who move to different hospitals every few months; in these instances, it helps to pair up with your predecessor or successor so that you can complete the audit cycle after changes are implemented.

Quality improvement projects Implement change e.g. tick box on handover and on clerking proforma for completed growth charts

Collect and analyse data to assess how many admitted children do have growth charts completed on admission

Table 1: The audit cycle

Introduction: a familiar sensation The word audit usually results in a heart sink reaction in doctors, but it is something we have to do on a regular basis throughout our training and validation. As such, it can often be treated as a tick box exercise, but a properly done audit can really make a significant contribution to patient care. This article will highlight the important steps in conducting an audit and quality improvement project.

Exploring audit An audit is an integral aspect of clinical governance. The aim of an audit is to compare practice with a recognised standard, for example National Institute for Health and Care Excellence (NICE) guidelines.

We might notice a problem or need to undergo annual reviews of our own practice, so we identify the standard we should be following and collect data to determine how our practice compares with the defined standard. We can then assess reasons for any discrepancies between our practice and the standard and think of practical measures that can be taken to address these discrepancies.

Once these changes have been implemented, we then re-audit to see if we are now meeting the standards. Table 1 is an example of this process in diagrammatic form.

Plan, Do, Study, Act (PDSA)

Plan objectives, data collection plan

Do - documant observations, record data

Study the data

Act on the data to make changes

Quality improvement (QI) is a way of improving care for patients and can be broader and more holistic than an audit as it is not a comparison of our practice against defined standards. Instead, we identify an area we can improve on. Areas for consideration may include a lack of wellbeing support for junior doctors, or the absence of a water machine for patients in an Accident and Emergency.

Once an area is identified, we can then go on to determine how we can improve these services.

Quality improvement projects often follow a cycle of ‘Plan, Do, Study, Act’ or ‘PDSA’. They can be repeated more frequently than audits, from daily to annually to assess for improvement. Table 2 explores the components of a Plan, Do, Study, Act cycle.

Research Many trainees try to use audits or quality improvement projects as a way of showing experience in research and this can be a real bug bear for academics and those on interview panels!

Research aims to further our knowledge, whereas audits are used to assess if we are following standards determined through research.

They are different but important processes used to improve the care we provide for our patients.

How can I get involved with an audit?

All doctors have a General Medical Council (GMC) requirement to show involvement in audit and quality improvement projects. If you are a medical student, do approach a doctor to ask if you can get involved; they will most likely welcome your help.

As a junior doctor with a high workload, it can be challenging to find time within your hours of work to be able to conduct an audit. However, try to bear in mind that an audit that is useful to the department and improves patient care will be a significant and helpful contribution you can make.

Remember to register your audit with your workplace and to ensure that the department has the data you collected before you finish your rotation, otherwise a future trainee may end up having to repeat all of your hard work, or it may not make the positive contribution you intended.

The Medical Women’s Federation conference is a great platform for presenting a variety of audit and quality improvement projects, in a friendly and informative environment.

References Limb et al. How to conduct a clinical audit and quality improvement project.

International Journal of Surgery. Oncology. 2017;2:24.

Table 2: Quality improvement projects and the Plan, Do, Study, Act cycle

Royal College of General Practitioners Quality Improvement Project Guidance for Trainees.

Medical Woman | Autumn/Winter 2019 11

FEATURE: EDITOR’S INTRODUCTION

12 Medical Woman | Autumn/Winter 2019

FEATURE: EDITOR’S INTRODUCTION

Happy mediums Too feminine. Too assertive.

Too fat. Too thin.

Too much clothing. Too little.

Too much make-up. Not enough.

We talk about women belonging in every domain of professional life; from the board room to the lab to the House of Commons.

We talk about women thinking small.

We talk about that prolific disease, imposter syndrome.

And is it a surprise?

Women’s bodies are the subject of commentary, and the language is either one of vulgar corpulence or miserly penury. Interestingly, it is women who are often left out of the commentary to express their own opinions of what exactly suits us, the individual woman.

In this feature we have a hot topic, the female body, with an intriguing angle on how the female form continues to be objectified and sexualised.

Medical Woman | Autumn/Winter 2019 13

FEATURE PERSPECTIVE: HAPPY MEDIUMS

Devotion to difference Hannah Barham-Brown is a GP Trainee, BMA Council member, and gender and disability campaigner.

She is ambassador for disability charity ‘My AFK’, gynaecological cancer charity ‘The Eve Appeal’, and has given two TEDx talks on the need for diversity in the NHS, and being a #RollModel. She campaigns for disability rights on a number of fronts.

As a woman in 2019, one would hope that we were past being sex objects. We have had the vote for 100 years now. We are rising to the top of all kinds of professions, we are saving lives on a daily basis, and yet in the strangest of places, we still see women’s bodies being sexualised.

In September, feminist campaigner and author of Invisible Women, Caroline Criado Perez, tweeted the images of two anatomical illustrations – one male, and one female. She accompanied them with the caption ‘Too much to unpack here.’

Next to each other, the images displayed differences that are many and varied; and that’s before one even looks at the anatomy itself.

The male figure’s illustration is simply ‘The Muscular System’; the female is referred to specifically as ‘The Female Muscular System’. The implication being that the male system is the ‘norm’ and does not require identification. Interesting given that women make up 52% of the population! In the image the position of the figures also varies. The male figure appears angry; both fists clenched and a furrowed brow. As one male Twitter follower of mine replied ‘Delighted to learn how hench I’d look without skin, though.’

When we turn to the female figure her pose is verging on coquettish, one leg slightly bent, heel raised off the ground - I suppose we should be grateful they did not go the whole hog and put her in stilettoes. Far from angry like her male counterpart, she is side-on to the viewer, giving a come-hither look, with just a hint of a pout. Her musculature is a paler pink shade; it’s what all the best anatomical models are wearing this season. In other words, even when missing our skin, women are posed looking bizarrely sexual.

Frankly, it’s all a bit bizarre. Why so many differences between them in what is meant to be an educational tool? Why can’t we study a female body in the traditional anatomical position?

Growing up in the 21st century, somehow, this sexualisation of the female form is not a surprise to many women. But it turns out that it’s not just the ‘normal’ female body that becomes sexualised in random, unexpected places.

Since developing a disability myself, I have learnt of the existence of ‘devotees’ – a section of society who are particularly attracted to disabled people. I first discovered this phenomenon when I started receiving unsolicited messages on social media from strangers; but while many women get messages like this, mine suddenly had a disability twist. I wasn’t simply being told I was attractive, or invited for dinner, the messages had specific requests: could I send footage of transferring from my wheelchair to my bed, or photos of my callipers? Aside from being very inappropriate, I actually mobilise around my house on foot and have never needed nor owned callipers.

14 Medical Woman | Autumn/Winter 2019

FEATURE PERSPECTIVE: HAPPY MEDIUMS

It turns out that I am not alone in receiving such requests. In an article for the BBC, Emily Yates, herself a wheelchair user, writes about her investigations into devotees for a documentary.1 She interviewed self-professed ‘devotees’, who were sexually attracted only to disabled people, and chose their partners accordingly.

She also discovered a group known as ‘bad devs’, who become sexually aroused by watching disabled people ‘struggle’. On putting out a direct call for requests, to see what people found attractive, she was also asked for film transferring from chair to bed, but with the suggestion that a few muscle spasms would be a ‘bonus’. She reports being pushed to the verge of tears at the feelings of objectification.

In the context of healthcare, this all becomes rather more concerning, because there are big gaps in terms of the care received by disabled women. If anything, we are often considered asexual beings. A recent report from Jo’s Cervical Cancer Trust into Cervical Screening for women with disabilities highlighted a range of problems, leading to 63% of disabled women reporting being unable to attend cervical smearing.2 20% of respondents reported that “it has been assumed that they are not sexually active because of their physical disability”; and due to the reduced risk of cervical cancer in those who have not been sexually active, that their receiving the smear is considered less urgent. Even if they get to the point of getting a smear, 23% of respondents reported needing a hoist to get onto the couch for the examination – yet only 1% were able to report their GP surgery having a hoist for them to use.

In the 2019 Annual Representative’s Meeting of the British Medical Association, we unanimously passed a motion calling for the organisation to work with the NHS to get every Clinical Commissioning Group (CCG) to ensure at least one of their surgeries has a hoist available. This will not only benefit women needing smears, but disabled men who need prostate examinations, or any hoist dependent person needing a basic abdominal exam – the impact could be huge for so many individuals.

There is still a long way to go in ensuring good healthcare for disabled people; particularly disabled women. To do this, we have to get over the (apparently) awkward truth. Disabled people are sexually active, and need equity of care provision. A year ago, I attended a sexual health clinic in South London. I arrived to two flights of stairs. I can mobilise with a stick, and so I hauled myself up them. But the underlying message was there; people like you don’t need sexual health services. People like you don’t have sex.

As someone who was still relatively new to the world of disability, coming to terms with my new identity, struggling to believe that my disabled body could be attractive to anyone, this was a very hard message to receive.

As disabled people, we tumble from the sublime to the ridiculous.

On the one hand, we are fetishised by strangers, some of whom see us as little else than sexual beings. On the other, we fight against a health system which doesn’t seem to think we could possibly have normal healthy sex lives, leaving us struggling to access even the most basic of investigations and care. I really hope we can hit a happy medium soon.

References 1

2

Yates E. ‘Pretty Cripples’ and the people turned on by disability. Available from: https://www.bbc.co.uk/news/disability-35762887. Accessed on September 2019 Jo’s Cervical Cancer Trust, Barriers to Accessing Cervical Smearing for Women with Physical Disability. Available from: https://www.jostrust.org.uk/sites/default/files/ jos_physical_disability_report_0.pdf. Accessed September 2019.

Medical Woman | Autumn/Winter 2019 15

NEW BEGINNINGS: OOPS!

OOPs! Happy accident or an organised endeavour Fizzah Ali is a Neurology Registrar. She is currently out of programme working at the National Institute for Health and Care Excellence. 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.

16 Medical Woman | Autumn/Winter 2019

NEW BEGINNINGS: OOPS!

Should I take time out of programme?

Clinical training spans a number of years before we reach the finishing line. Along the way, it may be that you develop interests and a desire to develop your skills through an additional avenue, or to focus on other areas of your life that are important to you.

This article covers some of the essential questions that you may find worthwhile to consider before taking time out of programme.

There are a variety of reasons individual trainees take time out of programme. One example is an out of programme experience for research. This could comprise up to three years and lead to a research degree such as a PhD. Another example is an out of programme experience for training, this constitutes time prospectively approved which contributes to the completion of your clinical training.

Conversely an out of programme experience for clinical experience is not approved by the General Medical Council and does not contribute to completion of core training. It may include, for example, a period of work abroad.

Aside from professional opportunities, out of programme periods include those which allow a focus on personal circumstances whether caring for an unwell relative or personal health - and these are termed out of programme experience for a career break. These examples are simplified in Table 1.

How do I apply?

Having considered how you will use your time out of programme, the next consideration is when. The bulk of out of programme applications and approvals come during specialty training, with an expectation that you will have completed one year of training before requesting time out and will re-enter with 12 months (full-time equivalent) remaining on return.

Discussions with an educational supervisor and other trainees who have undergone the application process and successfully completed out of programme time could help facilitate your decisions.

The process of application may vary across regions. During an application for out of programme time you will be expected to complete approval forms with support from an educational supervisor and training programme director.

During this process of approval it is important to be aware of timelines. Discussions about taking time out of programme should commence well in advance, about 12 months in advance. Later, the essential paperwork can be submitted six months in advance.

It is worth noting the notice period employers also require, which is about three months.

Table 1: Four different types of out of programme

Out of Programme Experience for Research - OOPR Out of Programme Experience for Training - OOPT* Out of Programme Experience for Clinical Experience - OOPE Out of Programme Experience for a Career Break - OOPC what plans could be implemented over the few months leading up to your return back to clinical practice.

Ensure you are aware of your Annual Review of Competency Progression (ARCP) dates and requirements. Find out whether there are any useful events hosted by your region aiming to smooth the transition back to clinical work. Remember to give notice about your return to your training programme six months in advance.

As a whole these processes should enable your transition out and back into programme to occur more smoothly, with processes being put into place for your return to work.

Practicalities: Top Tips Plan your return to work This is important from two fronts: psychological and practical.

Envisaging what your return to work will look like can help ease the transition back and reduce stress.

Depending on your needs and availability, some of this planning and preparation can start during your career break. You may wish to consider keeping in touch with your clinical knowledge, and this can incorporate a range of elements whether liaising with educational supervisors, your work hours on your return to work including flexible working, or considering the environment you will return to.

Manage emotion Part of returning from a career break will be about adjustment and managing some of the emotions that we can have in relation to transition. This may relate to a change in pace with regard to flexible working. It can also be useful to develop skills of reflection which can help provide room for growth.

Think money Part of taking time out of programme is about planning financially.

This might include cancelling memberships if they are not needed during the year on a career break or applying for reduced membership fees.

How can I prepare for a return to training?

Prior to taking time out of programme have a pre-absence discussion, and this may be supplemented with a pre-absence form, which can be completed together with your educational supervisor.

Although the reasons trainees take time out of programme may be similar, each individual trainee will have different perspectives and concerns about their return to work. Initial discussion can be helpful in starting to reflect on your requirements and some of the ways in which you might consider keeping in touch during time out of programme. Pre-absence discussions might also help you consider

References and resources Joint Royal Colleges of Physicians Board (JRCPTB) website: Out of programme https://www.jrcptb.org.uk/training-certification/out-programme British Medical Association website: Taking time out of programme https://www.bma.org.uk/advice/career/applying-for-training/out-of-programme BMJ Learning modules: Career breaks and returning to work https://learning.bmj.com/learning/module-intro/career-break.html?locale=en_ GB&moduleId=10060748 BMA TV videos: Less-than-full-time training https://www.youtube.com/watch?v=H_275yYvmRU

Medical Woman | Autumn/Winter 2019 17

SPOTLIGHT: ORGAN TRANSPLANT

Honouring the legacy of our donor: our transplant journey Dr Nighat Arif is a GP with a specialist interest in Women’s Health working in Buckinghamshire, where she lives with her husband and three boys. She works closely with local community projects tackling health inequalities. She is a regular medical contributor for BBC Breakfast and BBC Three Counties Radio shows. She loves to bake and then burn off all the calories at the gym!

As a medic I had always been aware of organ donation. As a junior doctor, I once witnessed the topic being discussed with a family member who had lost their loved one in a road traffic accident; donation was at the periphery of my consciousness.

In 2015, my husband and I became proud parents for the second time. He was a much awaited baby; our eldest was now approaching five years of age. When our baby, Qasim, was three weeks old I noticed that he had become jaundiced. Although he was feeding very well, putting on weight, and doing all the things a baby should do, I decided I would take him along to the GP. We both agreed that a blood test was needed. I received a call from our local hospital that night and they were very concerned about Qasim’s liver function results. I was told to pack an overnight bag and that the doctors were trying to get us a bed at King’s College hospital, London.

I remember feeling exhausted. I was still recovering from having a newborn and then suddenly terrified that as a doctor I missed something in my own child. The guilt set in quickly. How could I have missed something?

On the ward, the seriousness of Qasim’s condition became obvious.

He had a liver biopsy and then with my husband we were met by a senior paediatric professor.

“Qasim has a rare liver condition called ‘bile salt export protein pump deficiency’ (BSEP) this means he cannot export his bile salt out of his liver. The bile salts are therefore damaging his liver cells, and slowly his liver will get cirrhosis. From our few case studies, the data shows that he will need a liver transplant by age five, until then we can manage the symptoms with medication”.

There was a moment of shock and I went into denial. My son will not have a transplant, was my initial thought. The professor had more to tell me “sadly we know that in some cases. Children with BSEP have a fifty per cent chance of getting liver cancer before transplant”.

The silent car journey back home from Kings was marked by the floods of tears I found were streaming down my face. I was inconsolable.

Qasim never managed to get to age five years old. By four months old, he was scratching himself, he would get recurrent severe nose bleeds, he was oedematous and vomiting. Every review at the liver outpatient clinic was filled with sadness. It was becoming clear that my baby would need a liver transplant sooner rather than later. I was terrified of the prospect of him going through such major surgery, and we also had no donor match.

We waited and waited on the transplant list. Qasim was now 10 months old. The transplant co-ordinator said to me “Nighat, we need 20 Medical Woman | Autumn/Winter 2019

SPOTLIGHT: ORGAN TRANSPLANT

a tissue and blood match for your son. Due to few ethnic minority deceased donors, we have to wait”.

In 2018, there were over 1,800 patients from a Black, Asian Ethnic Minority (BAME) waiting for a transplant. One in five people who died last year waiting on the transplant list were from a BAME background. Due to a lack of deceased BAME donors, patients from BAME backgrounds wait significantly longer on the transplant list for a successful match than white patients.1 I was becoming desperate at the thought of Qasim becoming too unwell to have the surgery and Qasim had also developed growths on his liver which turned out to be cancerous. I was so scared that if he was to become too unwell, the team would discuss palliative care.

As our desperation grew, my husband and I enquired about becoming living related donors. I was a match. I pushed the team to make plans for surgery. The surgeons discouraged this. There is a high risk of complications as few living related liver donations are performed in the UK. I also had another son, a dependant who I needed to care for. But at that point, I did not care. My maternal instinct kicked in, the surgeons could have taken any organ they wanted, if it meant my baby could live.

Qasim deteriorated rapidly. He could not sustain his blood sugars and his International Normalised Ratio (INR) was 6 (normal range 1.1-1.5) despite repeated medical treatment. Every day I waited on the ward agonising whether a donor would be available – also acutely aware that for my son to have his surgery it would mean another mother losing her baby.

A miracle then happened. We got a call to inform us that a match had become available and Qasim would be prepared for surgery.

The next 48 hours were all a blur of me pacing up and down the corridors outside the theatres. My husband trying to reassure me that things will be ok... but what if it isn’t? Being a doctor made the experience no easier. It was tougher. As a medic, I could envisage where conversations were heading before the doctors spoke to me.

Thankfully the surgery was a success. It felt like a weight had been lifted, and my son was recovering very well in intensive care. It was a very emotional time. It was when he was recuperating that I was able to reflect on the fact that someone had freely given an organ of their loved one so that my son could live. It was afterwards that I was told that the organ had been from a young boy, who had suffered a bike accident. The family had been approached about possibly donating their child’s organs, and they agreed. In a world where there are terrible events all over, it is easy to forget that there are kind, gentle souls full of humanity. I will forever be eternally grateful to the family who performed the ultimate selfless act and allowed me the opportunity to take my baby home, at a time when they could not.

Now my son is getting stronger every day. I cannot believe the marvel of the NHS team, and the mother who agreed to donate her child’s liver to us. This anonymous mother is in my thoughts. She has given me the ultimate gift; the gift of time with my baby, the gift to make memories with Qasim. I wonder, how can I ever reciprocate that gift.

I cherish every day with Qasim. Things I used to think mattered now don’t matter. Life truly is too short. As a family we have made a promise that we will encourage our son to live all his dreams just as the donor’s family would have wanted their child to live. Our donor is our hero.

Now, donation is not in the peripheries of my consciousness.

As professionals I advocate discussing organ donation with our families and patients when the opportunity arises. Once we are gone, our organs may provide the legacy for another life to fulfil their hopes and dreams.

As a member of the ethnic minority community, I advocate that we have the much-needed conversations around organ donation. Faith leaders can also help raise awareness and educate the community on the technological advancements that are now available around organ donation and transplant. People across the UK should have the opportunity to make an informed decision, and then share their wishes with their loved ones.

References 1

NHS Blood and Transplant Data. Accessed from: https://www.organdonation.nhs. uk/helping-you-to-decide/organ-donation-and-ethnicity/

Medical Woman | Autumn/Winter 2019 21

GLOBAL STAGE: LOOKING TO FUTURE

MWIA: looking to future priorities Dr Clarissa Fabre became president of the Medical Women’s International Association (MWIA) in July this year in New York, at MWIA’s centennial celebrations. This article is inspired by her inaugural speech.

Young women young doctors: our inspiration, our future This is the theme for my presidency of MWIA for the coming triennium. We must celebrate the outstanding achievements we have made over the last 100 years. Looking to the future, we must remain constantly vigilant to protect the progress we have made, and to identify new challenges. We owe this to our young doctors and medical students and to the many young women around the world who still face major barriers and unacceptable prejudice.

One of my priorities will be to focus on career development and return to work after having children. We must encourage leadership and mentoring worldwide. We must put in place structures which facilitate both career development and good motherhood. It is possible to do both.

Looking at maternity and parental leave in different countries, it is interesting that the United States is one of only three countries in the world where there is no legal right to paid maternity leave. The other countries are Papua New Guinea and Suriname. Moreover, in the US, the period of unpaid leave permitted is relatively small. Employers in the US with fewer than 50 employees are exempt from providing even this basic level of parental leave. Some women go back to work in less than a week, which for many is a highly stressful experience.

The second broad area involves violence against women and girls, and the related issues of sexual harassment, and child and elder abuse. MWIA have developed an online training module on violence which has been used very successfully in workshops at our meetings. I would highly recommend its use at your meetings.

We need to focus on what we as doctors can do, and on the critical issue of prevention. We must ensure that doctors and medical students are trained in detection of violence, and on appropriate referral pathways. And with regard to prevention, we need to begin with boys and girls in schools, to change cultural attitudes.

Partnerships can greatly strengthen the influence and impact of MWIA. We have strong links to the World Health Organisation (WHO) and to the United Nations (UN) through our representatives and collaborative work plans.

There are three key areas of focus where partnerships are valuable: HPV vaccination, contraception and the prevention of teenage pregnancy, and post-partum haemorrhage.

One of the United Nations and the World Health Organisation’s top priorities is HPV vaccination and the elimination of cervical cancer.

It has become clear that HPV vaccination of girls at age 11 or 12 is proving a very effective way of preventing cervical cancer, which is common in low and middle income countries. Ideally, young boys should be vaccinated as well. In Canada and the US, the national Medical Women’s Associations have introduced a very effective HPV Awareness Week.

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As an international organisation, we must encourage our national organisations to engage with government and advocate for HPV vaccination. We can advise on how to organise HPV Awareness campaigns and we can supply appropriate materials (posters, leaflets, videos, webinars, films).

We can educate and support health workers in low and middle income countries, and provide technical assistance where necessary. We can encourage and facilitate cervical screening, including HPV testing. I am confident that MWIA, working with partners such as the United Nations, World Health Organisation and others, can make a real difference in this area, to eliminate cervical cancer.

Contraception and the prevention of Unplanned Teenage pregnancies: In November last year, I attended the MWIA Africa and Near East Regional meeting in Nairobi. It was a life-changing experience. A few facts: one in five 15-19 year old girls in Kenya has a child or is pregnant, 80% of these girls drop out of school, they are often forced into marriage or face great stigma, 95% of pregnant girls did not use any form of contraception. Healthcare staff are often unsympathetic to teenagers’ requests for contraceptive advice and there is a negative attitude from many parents and Church leaders.

Dr Bev Johnson of the Canadian Medical Women and I made many contacts at the conference and have been in touch with many of these groups since. An organisation called RESPEKT, funded by the Danish Youth Council, uses volunteer Kenyan medical students to go into schools to talk to adolescents about sexual and reproductive health. Currently there are volunteers from ten medical schools, and the organisation is growing. They have developed a curriculum for schools, as well as training and action plans. They have approached the government, and have partnered with genderbased violence centers.

GLOBAL STAGE: LOOKING TO FUTURE

Another interesting new development is the use of Apps and social media, for example the LucyBot. This is a Facebook messenger chatbot. It was show-cased at the recent Women Deliver conference in Vancouver at a plenary session chaired by Melinda Gates. It uses Artificial Intelligence and is a reliable source of online information on contraception and sexual and reproductive health.

It answers questions and points to resources. Users can talk to a doctor directly. We have already begun bringing our Kenyan partners together to expand the use of the LucyBot. We plan to expand the Contraception and Teenage pregnancy project to Ghana and Nigeria in the first instance, and we know there is a similar need in countries like Thailand and elsewhere.

The third partnership, in this case with the World Health Organisation, involves the prevention and treatment of post-partum haemorrhage. This is one area where MWIA could make a significant impact in reducing maternal mortality. Several drugs have been found to be very effective, but are not often available in remote settings. For prevention, Oxytocin and heat-stable Carbetocin (in areas where there is no refrigeration) have been shown to be helpful. For treatment, Tranexamic acid given intravenously within three hours of birth. Working with partners, the MWIA could facilitate the supply of these drugs to those areas where it is needed.

MWIA is a powerful force in advancing the cause of women’s health and welfare throughout the world, as well as improving the lives of women doctors. There are dangers to women’s progress and we need to remain vigilant. Given the nature of men and women, we need a women’s organisation to look after women’s rights. Nothing ever stands still.

Medical Woman | Autumn/Winter 2019 23

GLOBAL STAGE: TEENAGE PREGNANCY IN KENYA

Observations on Teenage Pregnancy and Contraception in Kenya Michelle Musoga and Yvonne Olwang are Medical Officers in Mbagathi Hospital, Nairobi, Kenya. Beverly Johnson is co-chair of the MWIA Prevention of Unplanned Teenage Pregnancy Project Group.

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GLOBAL STAGE: TEENAGE PREGNANCY IN KENYA In Kenya, primary school tuition is paid for by the government, while all other needs such as uniform, food and examination fees are paid by parents or guardians. Secondary school education is accessed after sitting a final exam at primary school, and is paid for by parents or guardians. Many families cannot afford to send their children to primary or secondary school.

The latest data shows that in one year in Kenya, there were approximately 380,000 teenage pregnancies from as early as ten years old. Of these, 30,000 were between the ages of 10-14 years old, with the remainder aged 15-19 years. About 80% of the girls were forced to drop out of school. One in five 15-19-year olds has a child or is pregnant.1,2 There is a pattern to those being found to impregnate the girls: touts who operate public vehicles, motorcycle riders who also act as public server vehicles, and adults who are known as ‘sugar daddies’ who tend to prey on naive disadvantaged young girls offering financial support and lavish gifts. Some girls are forced into prostitution at an early age.

Some girls are impregnated by older boyfriends. In rural areas, the people responsible are mostly relatives and neighbours who prey on young girls.

Once the girls are pregnant, they are often forced into marriage.

In the event that the partner denies any involvement, the child is usually taken care of by the girl’s mother. This creates another financial burden in the home and brings shame to the family.

In some cases, the father of the girl abandons the family because he does not want to be associated with people of ‘loose morals’.

Sadly, a percentage of babies are dumped in garbage sites and left for dead.

The girls face great stigma. Their peers and society regard them as girls with loose morals who took part in sexual activities early in life. They are looked down upon and called names. Other parents discourage their children from associating with them.

As far as abortion is concerned, there has been a steady rise in the past three years. Patients present to hospital with incomplete abortions, septic abortions and sometimes traumatic abortions.

In urban centres, there has also been an increase in the number of safe abortions carried out in private clinics. This occurs when partners and sometimes parents are able to afford these services.

Interestingly even after going through an abortion, the parents may still oppose the girls receiving regular contraceptives. The main reason is that they want to preserve the morality of the girls.

Please note that abortions are illegal in Kenya unless they pose a threat to the physical health of the mother – and they must be prescribed by a qualified medical doctor.

were not using any form of contraception. Most of them reported that they were aware of the risks of engaging in unprotected sex but still did not seek any medical advice or help.

Most young girls in Kenya are afraid to seek advice or help with family planning from the service providers. There is a culture of only seeking help for curative medicine rather than preventive.

Unless a client feels there is a problem, she will rarely go to the clinic.

The girls’ biggest fear was judgement and stigma from receptionists and people offering the service due to an age gap.

Almost one quarter of the girls reported a negative reception at the family planning clinics. They claimed to have been offered subpar treatment because of their age. A number of them reported being told off for having sex at such a young age. The result has been that the young girls prefer not to go to the facilities. They seek help amongst themselves.

Another fear they cited was lack of privacy at the facilities. In most facilities, family planning is located in the same area as the antenatal clinics. Because most of the girls are from the area, they say a neighbour might spot them there and report to her parents or start a rumour in the area.

We also found that the girls had a negative attitude towards contraceptives because of perceived side effects. They feared that long-term use could cause infertility in the future. They also feared weight gain.

A health care worker in the family planning clinic at one of the biggest county referral hospitals admitted that there was stigma and judgement towards young girls amongst the older health care workers. She noted however that they have been undergoing intensive training on sensitisation. This has been going on at the facility level as well as at the community level. She noted also that most parents are reluctant to permit their children to attend such forums.

There is an urgent need for sensitisation and education at the community level (parents, teachers, community, and Church leaders). There is a need also for Continuous Medical Education forums for health care workers. International organisations such as the Medical Women’s International Association could help fulfil these needs. We could also lobby the Kenyan government to provide sex education in schools, and come up with a curriculum that is acceptable to society, and that benefits young people. We could additionally encourage pharmaceutical companies to further subsidise and even donate contraceptives and teaching materials.

Youth contraception perception in Kenya A study carried out by the Kenya Demographic and Health Survey and Performance Monitoring and Accountability showed that most women in rural areas start having sex at the age of 14 years, while in urban centres; the average age is 16 years.3 Currently there is no sexual health curriculum in schools at either primary or secondary school level. Some schools are on the spot over what the government terms ‘illegal sex education’. The government claims that the sex education being offered is illegal, immoral, and unapproved.

We managed to speak to a few girls who have had teenage pregnancies.4 These girls hailed from the urban areas and rural urban slums. We found that up to 95% of the girls we spoke to

References Adhiambo M. Teenage pregnancy becoming a national threat. Standard Media. November 2018. Available from: https://www.standardmedia.co.ke/ article/2001301354/why-teenage-pregnancy-has-become-national-nightmare Accessed Jul 2019.

2 Atieno W. High rate of teen pregnancies is a burden to Kenya: UNFPA official Daily Nation. December 2017. Available from: https://www.nation.co.ke/news/ education/High-rate-of-teen-pregnancies-is-a-burden-to-Kenya/2643604-421861010jwxmd/index.html Accessed July 2019.

3 National Council for Population and Development (NCPD). Insights on Population and Health Issues Affecting Women and Girls in Kenya: Further Analysis of the 2014 Kenya Demographic and Health Survey. Nairobi, Kenya; 2016.

4 Musoga M, Olwang Y. Accounts from interviews with mothers in Mbagathi Hospital, Kenya. 2019. Unpublished.

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Medical Woman | Autumn/Winter 2019 25

STRIKE A CORD: MASTERING MIND

Anxiety: an overview Rahat Ghafoor is a consultant in Child and Adolescent Psychiatry and clinical lead on the transitions national CQUIN at Leicestershire Partnership NHS Trust. Some of her interests include transition of children and young people into adult mental health services and promoting children and adolescent mental health awareness.

Her hobbies include hiking, cycling, Zumba dancing, badminton and travelling the world.

Defining anxiety Anxiety can be described as a feeling we experience when the situation we are in is threatening or difficult. Anxiety can also be described as an unpleasant, vague sense of apprehension, accompanied by autonomic responses like a dry mouth, palpitations, and shortness of breath.1 Anxiety to a degree is adaptive and prompts us to take the necessary steps to prevent the cause or lesson its consequences. It leads to people leaving anxiety provoking situations or avoiding them altogether. We all experience anxiety but it crosses the threshold to become an anxiety disorder when it starts affecting our day-to-day lives.1 Anxiety disorders are amongst the most common psychiatric disorders in youth. Prevalence rates range from 5-15% with 8% of people requiring clinical treatment.2 In adults, the lifetime 26 Medical Woman | Autumn/Winter 2019

prevalence of all anxiety disorders is 14.6%. Anxiety is more common in women than in men. Age at onset varies in different anxiety disorders. Specific phobias are common in childhood.

Generalised anxiety disorder occurs across all age groups. Social phobia, obsessive-compulsive disorder and panic disorder tend to occur in later childhood and adolescence.2 There is a strong genetic component to someone developing an anxiety disorder. Personality and experiencing negative life events do also play a role.

Some medical conditions may also cause anxiety and it is important to rule them out before treating for anxiety. Examples of this include hyperthyroidism and arrhythmias, as well as respiratory and neurological diseases. Some substances like alcohol, caffeine, cannabis, and other drugs may also mimic anxiety.2

STRIKE A CORD: MASTERING MIND Table 1: Generalised anxiety disorder - spectrum of symptoms4

Irritability Restlessness Tiredness Difficulty concentrating Difficulty sleeping Repeated stomach aches or diarrhea Sweaty palms Rapid heartbeat/palpitations Numbness and tingling in different parts of the body Difficulty breathing

Anxiety disorders encompass a broad group of disorders under one umbrella term. In generalised anxiety disorder, the symptoms of anxiety are persistent most of the time and are not restricted to or markedly heightened in any particular set of circumstances.

Panic attacks can be described as unpredictable, sudden and intense attacks of anxiety in which physical symptoms predominate. These physical sensations can be accompanied by fear of a serious medical consequence such as a heart attack.

People with phobias may find they experience the core symptoms of generalised anxiety disorder in relation to certain situations.

Post-traumatic stress disorder is characterised by a triad of symptoms: intrusive re-experiencing of a traumatic event, avoidance, and hyper-arousal. It is common after people experience catastrophic or life-threatening events.

Obsessive compulsive disorder is characterised by recurrent timeconsuming obsessions and/or compulsions that cause distress or interference in functioning.3 Anxiety disorders can exist in isolation, but most commonly occur with other anxiety and depressive disorders.4 The ensuing portion of this article will focus on generalised anxiety disorder. In this instance worry and apprehension are more prolonged. Someone suffering from generalised anxiety disorder might feel as though their worries are widespread and difficult to control. They may become irritable and forgetful. Table 1 illustrates some of the symptoms that are associated, such as a dry mouth, muscle tension experienced as restlessness, and an inability to relax. There may be difficulty falling asleep and persistent worrying thoughts. Some people may experience night terrors. Early morning wakening is not a feature of generalised anxiety disorder, but its presence may suggest depressive disorder. The symptoms of anxiety should be present for at least six months for the diagnosis of generalised anxiety disorder.4

Treating anxiety The treatment of generalised anxiety disorder comprises a stepped approach. This is illustrated in the National Institute for Health and Care (NICE) guidelines which can be accessed through the NICE website.4 The different strands for a holistic approach to treatment are considered below.

Self-help resources A self-help resource might be the first treatment option offered and is available fairly rapidly. It can be delivered through:

• Workbooks: A healthcare professional may want to consider recommending a particular title from a scheme called Reading Well Books on Prescription. This scheme is supported by the majority of local libraries, so the books can be checked out for free. More information can be found on the Reading Well website. • A computer-based cognitive behavioural therapy (CBT) programme. There are several app-based cognitive behavioural therapy courses recommended on the NHS apps library, these can be searched by anyone to locate an app that may work and suit them.5 Psychological therapies In the absence of improvement and the presence of marked functional impairment, individual high intensity psychological intervention should be tried. Cognitive behavioural therapy is treatment of choice in children and adults. It links feelings, thoughts and behaviours. It can help the individual affected by generalised anxiety disorder to understand his/her anxiety and generate ways of dealing with the symptoms effectively.

Pharmacological treatments Pharmacological avenues could be considered by general practitioners if cognitive behavioural therapy or psychological intervention is not successful. Selective Serotonin Re-uptake Inhibitors (SSRIs) and Serotonin Noradrenergic Reuptake Inhibitors (SNRIs) are the medications of choice in adults. Table 2 lists some of the pharmacological treatments available.4 Using specialist services A referral to a specialist psychiatric services should be considered if anxiety is severe with marked functional impairment, in conjunction with risk of self-harm or suicide/significant comorbidity, self-neglect, or an inadequate response to treatment.4

Stress and anxiety in the workplace: Most of us spend the majority of our waking hours at work, so it is important to be able to recognise stress and anxiety at work and deal with it effectively.

We can all relate to feelings of stress at work. Perhaps you have a deadline looming. Perhaps there are too many personal and professional tasks to cram into the day. Perhaps you fear making a clinical mistake. All of these elements raise stress levels and anxiety at work.6 Work-related stress in NHS staff has reached alarming levels.

Recent figures show that in 2016, 15 million working days were lost because of stress, anxiety or depression. Frontline healthcare staff in the NHS, particularly those supporting clinical staff (5.5%) have the highest absence rates. Overall, stress, depression and anxiety are the fourth most common reasons for absence; affecting female staff (7.8%) slightly more than male staff (7.6%).6 Doctors are particularly prone to stress and anxiety due to the demands of the job. We can also struggle to maintain a decent and consistent work-life balance. Generally, doctors do not have a 9am to 5pm job; the shifts are longer with a complement of unsocial hours of the day or night. On-call commitment commences with the start of foundation training and continues through to retirement. Increasing pressures in the NHS mean that doctors from all specialties struggle to obtain relief from the pressures of their workload. This is complicated by the high expectations individual Medical Woman | Autumn/Winter 2019 27

STRIKE A CORD: MASTERING MIND Table 2: Pharmacological options for Generalised Anxiety Disorder4

Medication used

Time period for use

Key adverse effects to keep in mind

To be prescribed in primary/secondary care

Benzodiazepines such as Short term use only Diazepam, Lorazepam

Tolerance and dependence, sedation, dizziness

Both, but use is not advised

Buspirone Short term use only

Higher risk of discontinuation due to side effects like nausea and dizziness

Secondary care

Selective serotonin reuptake Long term use The effect is not seen immediately inhibitors (SSRI) by the patient. Discontinuation

symptoms on abrupt withdrawal

Both, but secondary care to commence in children/ adolescents. This is the first line treatment in children

Serotonin noradrenaline Long term use reuptake inhibitor (SNRI)

Both. First line treatment in adults like SSRI

Can sometimes elevate blood pressure. Sexual dysfunction, and urinary retention

Tricyclic antidepressants, Long term use Dangerous in overdose examples include Imipramine

Secondary care only.

Not commonly used in the UK due to a risk of overdose in high risk patients

Anti-epileptic drugs such as Pregablin

Headaches, weight gain, severe dizziness, hallucinations

Secondary care

Movement disorders, sleepiness, weight gain, higher risk of getting diabetes and increased prolactin levels.

Secondary care; to be prescribed by specialists only.

Short term and long term

Atypical antipsychotics, Short term such as Quetiapine, and long term Olanzapine, Risperidone

doctors hold for themselves, striving to deliver and provide best possible care for their patients.

Stress and anxiety can, in part, be combated using some simple actions on a daily basis. Getting enough sleep, eating a healthy and nutritious diet, as well as regular exercise are important for our general well-being. Taking regular breaks and time away from work such as a short break or a holiday can also relieve stress. It is important to give time to friends and family, as spending quality time with them can help us feel more relaxed.

It is important to acknowledge that phones, laptops and other electronic devices can also feed into unhelpful habits of never switching off. I also advocate boundaries between work and personal life as a lot of people find it difficult to switch off from work after working hours.

References Gelder M, Harrison P, Cowen P. Shorter Oxford textbook of Psychiatry.

7th edition. Oxford University Press, 2018.

2 Semple D, Smyth R. Oxford handbook of Psychiatry. Oxford University Press, 2007.

3 World health organisation. The International Classification of Diseases (ICD 10).

Classification of mental and behavioural disorders. Accessed at https://icd.who. int/browse10/2016/en#/F40-F48 Accessed August 2019.

4 Generalised anxiety disorder and panic disorder in adults: management. Clinical guidelines (CG113). National Institute for Health and Care Excellence, 2019.

Accessed at: https://www.nice.org.uk/guidance/cg113 Accessed August 2019.

5 Mind website. Accessed at: https://www.mind.org.uk/ Accessed August 2019.

6 Mental Health Foundation website. Survey: Stress: are we coping? Accessed at https://www.mentalhealth.org.uk/publications/stress-are-we-coping Accessed August 2019.

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28 Medical Woman | Autumn/Winter 2019

OBITUARY

Dr. Lotte Theresa Newman CBE, PPRCGP MWF Past President 1987-88 Dr. Lotte Theresa Newman CBE, PPRCGP (aka Mrs Aronsohn) died on 26th April 2019 aged 90. She was a champion of women’s roles and rights both as a doctor and patient in Primary Health Care nationally and internationally.

Her parents Tilly Meyer and George Neumann met in Frankfurt and both qualified as doctors. George had the foresight to travel to Glasgow (1933) and requalify as a doctor, to allow his wife, son, daughter and a cousin to travel to England in 1938 and escape the fate of many. She said “I remember the night we went. We were woken up, I presume it was after midnight, and dressed and told to be quiet and not make a noise and taken to the train. I don’t remember saying goodbye to anybody and I don’t remember all that much until we were on the train near the frontier and I presumed it was a normal stop and my mother was taken off the train and then, I presume I was about eight, between seven and eight, and I was very conscious of the fear that my mother wouldn’t come back. I didn’t really quite know what it was all about.”

With her father established as a GP they avoided internment and she started at a local school speaking little English. Two years later at 11 she obtained a scholarship to North London Collegiate School. Lotte studied at Birmingham, King’s College London and Westminster Hospital Medical Schools.

Gaining a BSc in 1951, an MB BS and LRCP in 1957, MRCS in 1957 and her FRCGP in 1977. Initially working as, a casualty officer and Paediatric House officer at Westminster

Children’s Hospital she went on to work in general medicine at St Stephens’s hospital.

In 1958, as a qualified GP, she assisted her father George Newman in his Edgware practice before setting up her own practice the Cholmley Gardens Medical centre, as this practice grew her assistant Dr Tony Antoniou became her partner and they started an additional practice, the Abbey Medical Centre, in 1968.

Their NHS practice served patients in Kilburn, West Hampstead, St John’s Wood, Swiss Cottage and Hampstead and Lotte ran the practices for 45 years.

During this period, she developed national and international medical interests. Lotte was an examiner for the RCGP; president of the Medical Women’s federation 19871988; president of the International Society of Medicine 1988-1989; Vice president of the World Organisation of the National Colleges of family physicians 1992-1994; Member of the GMC 1984-99; council BMA 1985-1989; lecturer at the Royal Army medical college 1976-1989; advisor to the WHO and several Home Office tribunals 1990s; Chief Medical advisor to St John’s Ambulance 1999-2002 and a member of the parole Board 1992-94.

Lotte was a mother to four children and a wife to Norman Aronsohn for sixty years. Lotte was a practising Jew and a representative on the Board of Deputies. As a mother she didn’t espouse feminist politics but her actions spoke her beliefs. She publicly expressed that as a woman there were only two options: “If you speak out you’re a shrieking harridan, if you keep quiet you’re a shrinking violet.”

Lotte was made an OBE 1991, became the President of the Royal College of General Practitioner’s (RCGP) 1996-1998 and awarded CBE in 1998.

Lotte attributed her remarkable success to: “Luck, very good support from my family, being prepared to be unpopular at times – and always being at least as well prepared as the men at meetings!”

Lotte is survived by her husband Norman, children Simone, Simon, David and Alexander and seven grandchildren.

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UNWIND: RETREAT

Retreat, reflect, renew Sandy Miles is a GP and Medical Educator in Hampshire. She has an MSc in Medical Humanities from King’s College, London and promotes the important role that the arts and humanities can play in the wellbeing of both patients and healthcare professionals. To this end, she co-founded Acacia Retreats for Doctors and is developing social prescribing as Clinical Director of Eastleigh Health Primary Care Network.

Beginning with burnout We, Sandy and Sam, are two GPs and medical educators in Hampshire who developed the shared vision of Acacia Retreats for Doctors. A few years ago, we both hit low points in our careers, suffering burnout and disillusionment with our work. At the time we both found attending retreats to be hugely valuable opportunities to reflect and find new energy for both work and home life. Sandy subsequently completed a Master’s in Medical Humanities at King’s College, London. This reignited a love of literature, suppressed during her medical career and inspired her to use more creativity in her work and self-care. Sam, already qualified as a master of neuro-linguistic programming (NLP), went on to complete mentoring training which expanded both her self-awareness and her breadth of work opportunities, leading to a diverse portfolio career.

We both felt strongly that creating a retreat specifically for doctors – of all specialties – was important, especially at this time of increasing 30 Medical Woman | Autumn/Winter 2019

work pressure and reduced opportunities, for doctors to meet up and share their experiences. While one day refresher courses and educational events also provide spaces in which to pause and ponder, we felt a three-day residential retreat would allow a greater opportunity for introspection, with plenty of time to unwind and relax. We planned to nourish doctors with good food and fun, as well as provide plenty of opportunities for thinking, talking and exploring whatever they individually needed in order to flourish. We would provide useful tools to do so from our own experiences, using NLP techniques, art and poetry to delve deeper and create long lasting practices to nurture and sustain us all going forward.

Retreat: an avenue for renewal Acacia trees symbolise renewal in many cultures. It therefore represents our key aim of the retreat – to enable personal renewal for doctors in both their work and home lives.

UNWIND: RETREAT

Reflect: an opportunity to build skills After we acquired new skills of event planning and marketing – and coped with a last minute change of venue – our first Acacia retreat was fully subscribed in March 2019. Five doctors from four different specialties formed our pioneering group in a rural hideaway.

We built the plan for the retreat around the framework of The Hero’s Journey. It is a universal tale that has been exploited by writers through the ages from Homer’s Odyssey to J.K. Rowling’s Harry Potter series. The common themes can be applied to all of us as we venture into new realms such as changing roles, developing new areas of interest or battling with the challenges of working for a cash-deprived NHS. Feeling a call to action, identifying our internal and external friends and foes, understanding our values and encountering the ‘dark night of the soul’ before emerging triumphant is a well-worn path which anyone who has sought personal development, worked in a team or even run a quality improvement project will recognise!

We offered the group a range of optional activities; to use music, poetry, art and literature to express themselves and further their understanding of their own journeys. Sam led sessions on how to implement simple neuro-linguistic programming techniques for self-management and we experienced the joys of group drumming. Some wild and windy walks, excellent cake and plenty of opportunity for rest and relaxation added to the sense of truly retreating in order to emerge renewed. On the final day we used simple but very effective tools to help clarify what changes, if any, needed to happen to perpetuate our wellbeing once we re-entered the real world. Everyone accepted the offer of a one-to-one coaching session and we rounded off by sharing our thoughts and reflections with each other.

really useful as the different perspectives challenged some of my thinking.” Another mentioned that the “co-mentoring of each other was unexpected and a real benefit of a retreat for doctors.”

In summary, participants felt “calmer and more appreciative of family and home” and “validated by other people listening and accepting my story”. One doctor was delighted that the retreat “exercised bits of my brain and creativity that don’t usually get exercised” and one summed it up as “a worthwhile and restorative few days, led by amazing and insightful women!”

We reflected back on three days of laughter, fun and powerful emotional insights and hope that these insights and the sense of renewal will carry our well rested doctors forward to more fulfilling days ahead. Follow up interviews three months after the retreat revealed that all our participants had made significant changes to their working lives with improved sense of wellbeing and credited the retreat as the catalyst for these changes.

Renewal: validation and valuing variety

Looking to the future

It was agreed, by all, that being a group of doctors had enabled a really shared understanding of the challenges and joys of our work, allowing us to get to know and trust each other quickly and easily.

Everyone’s motivations for coming were different and this was respected and celebrated by the group. Most had not been a on a retreat before. As one participant noted “Our group was from a variety of backgrounds, geographically and medically. I found this

We have a few places left on our next retreat, planned for the 30th Jan – 2nd Feb 2020, in beautiful Barton Stacey in Hampshire. We believe it is an important offer to all doctors, to be able to rest and unwind with supportive colleagues and explore their own needs.

If you wish to join us please find details at www.acaciaretreat.org Medical Woman | Autumn/Winter 2019 31

BOOK REVIEW

Invisible Women:

exposing data bias in a world designed for men

by Caroline Criado-Perez Nicola Davis is a Clinical Oncology Registrar trainee in the South East.

She is currently on maternity leave looking after her two boys. She is an avid reader striving to plough through her constantly increasing pile of books! Nicola helps run the twitter book club @BookOncology.

You will undoubtedly be aware of the gender pay gap, but have you heard of the gender data gap? Invisible Women by Caroline CriadoPerez, a British feminist, award winning campaigner, and journalist, explores this intriguing concept.

The book has received significant media attention, as well as several mentions on the Medical Women Federation’s twitter feed. As a doctor practicing evidence-based medicine I thoroughly enjoyed the book; it is well researched with arguments consistently supported by relevant data. I was fired up by Criado-Perez’s central premise; that there is a failure to account for half of humanity and ‘when we say human, on the whole, we mean man.’ The book covers a variety of issues including employment, sexual harassment, politics, healthcare, technology, urban planning and government policy.

Consequences of the data gap were also covered, which in some situations can even be fatal.

As a less than full time trainee, and mother, facing the usual worklife balance struggles, there was much to identify with in this book.

Criado-Perez frequently mentions the significant amount of unpaid care work that women do. She explains that globally this amounts to three times as much as that which men do, with twice as much childcare and four times as much housework. I was struck by her statement ‘there is no such thing as a woman who doesn’t work.

There is only a woman who isn’t paid for her work’. How many of us identify with this?

In the chapter ‘The Myth of Meritocracy’ the author focuses on the difficulties that women in academia face, noting that ‘female students and academics are significantly less likely than comparable male candidates to receive funding, be granted meetings with professors, be offered mentoring or to even get the job’. There are many other relevant points relevant that I could relate to. One example is voice recognition software, which does not recognise women’s voices resulting in higher transcription error rates for women than men.

32 Medical Woman | Autumn/Winter 2019

I appreciated the author’s light-hearted approach, highlighting what may appear as minor issues, yet simultaneously emphasising the utter frustration of a world designed for men. Would you be surprised to learn that the average smartphone is 5.5 inches which is too big for the average woman’s hand, or that there are no female crash test dummies? She also mentioned the frustrating lack of adequate pockets in women’s clothes!

The book also includes numerous important learning points for clinical practice with a particularly interesting chapter about medical issues affecting women. I was fascinated to learn about ‘Yentl syndrome’, the ‘phenomenon when women are misdiagnosed and poorly treated unless their symptoms or disease conform to that of men’. Criado-Perez illustrates her point by discussing the striking differences between men and women with heart disease.

For women, common preventative regimes may not be as effective, they tend to present with atypical symptoms and investigations may be less conclusive. There is also a lack of research into medical issues that mainly, or only, affect women. She summarises that ‘bodies, symptoms and diseases that affect half of the world’s population are being dismissed, disbelieved and ignored and this is the result of the data gap and the belief that men are the default humans.’

Invisible Women was a fascinating read. There were many occasions while reading that I was truly astonished at not only the scale of the problem, but also the devastating effects of the data bias in a world designed for men. I was relieved that the book closes with an uplifting homage to women already leading the way across the world in closing the gender data gap. There are inspirational examples across the fields of politics, academia, science and the film industry. Criado-Perez’s passion for her subject matter shines through and the book is a powerful manifesto for change.

I encourage you to read this book, and to take action to close the gender data gap – not just for the sake of women, but for the benefit of the whole of society.

EDITOR’S COLUMN: COMMON COMMUTE

Common Commute Choice and Presence

One evening I found myself procrastinating, and - as often it is - Twitter was the worthy subject. I scrolled through a number of replies to a discussion post on women’s appearance, peeping at who had posted what. Amidst the long list of replies, it occurred to me that despite a vast number of strong, no grey area, opinions, a woman who might identify with the topic was… nowhere to be heard. I briefly wondered how this absence could be extrapolated to numerous other ‘discussion points’ relating to women’s bodies and autonomy.

Why are women’s bodies up for grabs? Really, it’s difficult to point to a single causative seed. Of course, there will be an overarching cultural influence that varies and directs discussion, of essentially the same issues, in seemingly different directions. Really, this performs the function of a distractor. Regardless of whether we talk about beach bodies or burkhas the end point is the same. An opinion being dictated, loaded with presumption and preference, ultimately forgoing a woman’s choice.

Perhaps, there is an unsaid and subconscious belief that a woman’s body is not her own. That the biology of receiving, incubating and nurturing has perhaps signalled a deputising of choice to other investors. Thus, giving permission to label a woman as too much of something and too little of another.

Choice is the key word, and in its absence, we offer a false empowerment in our feminist discourse and wider discussions.

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