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R-UK

The magazine from RemedyUK

Issue 4 – December 2008 www.rukmag.org

Please do not remove from hospital mess or library if a complimentary issue.

What to get the NHS for christmas

Politicians, College presidents and Remedy reveal their stocking fillers. Also inside: Michael O'Donnell on performance artist doctors, Phil Hammond and much, much more.


OPINION

R-UK ISSUE 4

Welcome to the December issue of R-UK magazine The natural inclination at the end of the year is to reflect back on events gone by. What then have been the critical moments of 2008 and what does the future hold? Remedy is certainly at a crossroads, both ambitious and hoping for a better future, but wary of becoming dislocated from its supporters and unclear whether the next generation will emerge. Change is painful and invigorating, but you never know where you will end up. It’s hard not to contemplate the wider events rippling through society and how these will influence the NHS.Yet, I do wonder whether the average doctor is genuinely curious as to how this will impact on them. If there is one overarching purpose of Remedy and its activities, it is to open doctors’ eyes to the external factors that influence our working lives. 2008 will be remembered for seismic shifts in the economic and political landscape catalysed by the credit crunch and the American presidential election. Lindsay Cooke draws the parallels between President-elect Obama’s mobilisation of the ‘net roots’ and asks can the same methods be utilised for universal franchise by the medical profession? Indeed, some may argue that Remedy got there before him, when thousands of pounds were raised in a few short weeks in 2007. Remedy’s barrister remarked at the time that he had never before had a client who fundraised through PayPal. Be sure to tell your grandchildren that you were part of the first internet political campaign. Obama was way behind the curve. And what of finance? I am still paying off my medical school debts and will, at this rate, break even in 2013, 11 years after graduation. I am sure many people reading this are in the same boat. It seems a rather brutal manipulation of aspiration to tell 18-year-olds who have their heart set on being a doctor, that they will graduate with £40,000 debt? The Royal Medical Benevolent Fund offers some advice on page 13. Michael O’Donnell, 80 this year, and former editor of World Medicine teases out the intriguing notion of doctors being performance artists, both as actors for their patients and at the mercy of bland role-play so beloved by the medical educationalists.You will feel human again after reading this. Mental health and psychiatry are facing a crisis. I can assure you of this as this is my own specialty. Neel Burton looks at the blunt truth of doctors and their attitudes and poses some tough questions. Finally, we have some movers and shakers picking out their gifts for the NHS.This type of exercise is always fun, as our front cover hints. Have a restful Christmas,

Jamie Wilson

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Contents

Issue 4 – December 2008 4 6 9 13 14

15 16 18 19 20 21 23 24 26

Remedy News A stockingful for the NHS Michael O’Donnell on the performer in you Finance: advice from the RMBF Richard Marks on the surreal world of preferencing Neel Burton on the crisis in recruitment to psychiatry Lindsay Cooke: kicking off the democracy debate Diary of an HSMP How to get published Phil Hammond in reflective mood How To Succeed At Interview! Dr Grumble on the doc as detective House Doctor Maureen Mull is revolting

Editorial team Lindsay Cooke Ben Dean Idris Harding Matt Jameson Evans Stephen O’Hanlon Jamie Wilson

R-UK magazine, RemedyUK,The Studio, 1 Coach House Mews, 217 Long Lane, London SE1 4PP. Tel: 0845 643 1821 Advertising enquiries: 0845 680 5627 Email: editor@rukmag.org Website: www.rukmag.org R-UK is designed by Cottier & Sidaway 01767 262858 and printed by Crowes of Norwich 01603 403349. R-UK magazine is the magazine of RemedyUK.This issue of R-UK and all of its contents are fully protected by copyright © 2008 and no part of this magazine may be reproduced without the express permission of the editor.The views expressed in R-UK, in print and online, are those of the authors specifically and are not necessarily those of RemedyUK. Cover illustration by Hack

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REMEDYUK NEWS

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RemedyUK committee ‘purge’ needed? On the day we go to press with this Christmas edition of R-UK Remedy will celebrate its second birthday.The arrival of an email in December 2006 from the Royal College of Surgeons (with its serendipitous failure to recognise the difference between CC and BCC) provided 500 email addresses free of charge.This became the seed of an organisation that has now flowered into something very different from an ad-hoc reaction to the biggest ‘Emperor’s New Clothes’ moment in UK medical history. The journey since then has consistently brought into focus the wide gap between the ideas, concerns and experience of ‘frontline’ doctors and those of their grandees.This shows little sign of narrowing despite the overuse of the two words ‘lessons’ and ‘learnt’ in medico-political spheres in 2008. Until there is evidence that this chasm has diminished Remedy will continue to bloom. On the day the gap is extinguished we will press ‘delete’ on our member database and return happily to our day jobs. Over recent years we have all unwittingly been experiencing an active policy, helpfully documented by Government advisors as one of ‘constructive discomfort’ for the medical profession. There is nothing particularly malicious in this concerted effort from Whitehall to shake up and weaken the power of the medical profession. It makes practical sense to implement policy more smoothly.Yet it is up to us to provide a quick-witted constructive counteraction to their approach – an anti-thesis to their thesis. A Chinese philosopher once gave the advice: ‘to lead people walk behind them”The task

Calling all surgical trainees

With the impending introduction of the full limitations of the working time directive to a 48-hour working week, there are many issues that will impact more severely on surgical trainees than perhaps other medical specialties. A lot of problems come from a lack of knowledge as to what is actually happening on the ground in your jobs.The scale of the problem may have been vastly underestimated. ASiT – the Association of Surgeons in Training – are keen to gain insight and knowledge as to what current working patterns and training involves.They have set up an online survey at www.asit.org/news/wtdsurvey.php and they would be very grateful if surgeons-in-training could spend five minutes completing it.

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Remedy sets itself is to outpace the committees of medical leaders so they have no choice but to observe this epigram. Our efforts this year, have been centred on developing an online mechanism to provide an unavoidable barrage of reality into the centre of medico-political decision-making.This will take time to execute, but the fruits should start to be visible in the coming year. But we are also conscious of the dangers of committee institutionalization. We have a fighting fit organization with a strong vision of the future, but we are looking for something of an oldfashioned ‘purge’ within the committee to incorporate new people and perspectives. In front of us lie huge challenges that we are reluctant to leave in the hands of the static institutions that guided us into MTAS, MMC, EWTD, MEE and many other inexorably disappointing acronyms. One of the most unnerving moments of recent weeks has been the re-advertisement of the post of Chair of NHS:MEE – a full month after the deadline closed on applications. Is it possible that we have a bona fide leadership vacuum, where arguably the most important position in securing the future standards of UK medical practice fails to attract any serious candidates? In any such vacuum there is an opportunity to change our whole approach as a profession. Remedy has taken the first steps. Come to an open Monday meeting – email Lindsay@RemedyUK.org for dates – and see if there is something you can do to take it further.

Don’t get ill on February 21st

On Saturday February 21st applicants to General Practice and Core Medical Training will be sitting the CPS exam for entrance into their specialty. It is estimated that up to 9,500 doctors will be involved, most of whom will be FY2s, although the precise number is a matter of speculation.The effect that this will have on delivery of service is also the subject of speculation, especially in A&E departments largely staffed by FY2s. Some hospitals have already drawn up plans to restrict or curtail annual leave over this weekend.

February 21st lies in the middle of half term.

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REMEDYUK NEWS

Unfinished Business

On August 1st 2007 a letter to The Times from Remedy and the HCSA called for a GMC investigation into the process of MTAS an official and thorough investigation on a par with the Bristol and Alder Hey inquiries.The call fell on deaf ears. A year later Remedy wrote to the GMC and asked them to investigate. Our view was that MTAS and Specialist Selection & Recruitment 2007 had been a disaster, that doctors has been partly responsible, and that the GMC had shown it had jurisdiction over doctors in non-clinical roles. Over 1700 people supported this request. In October 2008 we contacted the GMC again in a letter written jointly with our lawyers. So far, we have received only an official acknowledgement of receipt. We have not initiated this action for punitive reasons, but because we consider such preventative action an essential step in maintaining the good reputation of the profession in the eyes of doctors and the public; protecting the public and the public purse against future equivalent mismanagement and rebuilding the shattered trust between the NHS and junior doctors.

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Lost in (White) Space

One of the most criticised parts of the MMC applications process has been the dreaded 'white space' boxes.They fill candidates with fear and dread.They also fill consultant assessors with fear and dead because they can be so difficult to score consistently. Assessors are helped by a marking schedule that lists the essential points that candidates need to include. For example, in dealing with a stressful incident; remaining calm, calling for help, dealing with the matter in hand, then reflecting and ruminating. Including all these points would give a 100% score whether the stressful incident was a lost set of notes or a terrorist attack on the hospital. It seems surprising, then, that the scoring system is being kept secret from candidates. Applicants may not know the importance attached to reflecting and remaining calm and may disadvantage themselves by including such irrelevances as the dose of adrenaline they gave the patient.


OPINION

A stockingful for the NHS

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A while ago, we issued an invitation for people to tell us their ideal Christmas present for the NHS. Here is a selection of responses. Our thanks to all who contributed. “Before giving it a present, I would like a copy of the NHS’s birth certificate, so we can discover its parentage. And in particular, its relationship with its political masters. “Some politicians think that they run the NHS.They take personal credit for every patient care episode, like proud parents, and feel at liberty to micromanage priorities, speak on its behalf and dictate policy. Others keep the service at arms’ length, believing that they are paymasters and commissioners on behalf of the British taxpayer.They see it as their role to crack the whip on this awkward, expensive and demanding offspring. “A loved and wanted conception or an expensive love-child? If only we knew.”

Richard Marks, Legal & Policy Lead, RemedyUK

“Medical science is going through one of its most exciting periods, where technological advances open the door to new understanding, and new forms of therapy. I think of genome scanning, and the needle-in-the-haystack discovery of disease-gene associations; I think of crystallography, and the elucidation of 3-d molecular structure of receptors and ion-channels; I think of stem cells, antibodies, and the miniaturisation of implantable devices and surgical techniques. “But conspicuously absent from this list is an array of new drugs. It is easy to blame Pharma for this failure. But the mission of translating science into medicines – the goal of the nascent discipline of Translational Medicine and Therapeutics – belongs to all of us. It is our patients who contain the secrets of this translation, whether individually as experiments of nature, or as research subjects in trials.Yet as the funding available for translational clinical research increases, the amount performed drops. Why is this? Because the tiers of obstructive bureaucracy – unashamedly ‘protecting patients from researchers’ but effectively suffocating patients who wish to see benefits from research – mean that only the most optimistic and masochistic investigators can now face the hurdles. “As we discovered with MTAS last year, a vacuum of leadership allows an

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army of do-gooding, jobsworth middlemen to dictate the implementation of policies of whose ultimate purpose they know little and care less. So my Xmas and 60th birthday wish for the NHS is that it reaps the harvest of medical science, and finds wise men for the manger who will speak their mind and lead the way.”

Morris Brown, Professor of Clinical Pharmacology, University of Cambridge and founder of Fidelio “If I had a magic wand this Christmas I would want to give the NHS and its staff the necessary support and resources to enable them to begin to reduce the massive and unacceptable health inequalities that currently exist in populations that live side by side across the UK. “To support this I would also ensure that the NHS could continue to guarantee our doctors of the future rewarding and worthwhile careers so they can strive to do what they do best, treat patients. “A final Christmas wish would be that our medical staff would be a little less busy over the festive period because the public were beginning to heed some of the safe drinking messages!”

Sir Ian Gilmour, President, Royal College of Physicians “My ideal present for the NHS would be to see a fundamental improvement in the way that junior doctors are treated and respected as vital members of the healthcare team. Junior doctors are professionals and must be involved and consulted on all aspects related to their training and employment.

“Juniors can and will no longer tolerate being subjected to poor employment practice. No other professional accepts that they will be employed for two years or more and will not know where they will work, how much they will be paid and even their duty hours until their first day of work. “Junior doctors are the Consultants and GPs of the future and therefore vital for the continuing long-term future of the health service.There must be no further short-term, poorly planned

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OPINION proposals that do not properly take into account the long-term impact they will have on junior doctors, the profession and ultimately the care that patients receive.

Dr Ram Moorthy, former Chair, BMA Junior Doctors’ Committee, writing in a personal capacity

“My Christmas present to the NHS would be an end to health inequalities so that all patients could and would receive the same standard of quality care, regardless of their circumstances or where they live. “When Dr Julian Tudor Hart formulated the inverse care law in 1971 – which demonstrated how you were more likely to receive poor healthcare if you lived in a poor area – I’m sure he didn’t expect that nearly 40 years later there would still be patients in the UK who miss out on vital health services due to their postcode. “GPs have unrivalled access to the heart of communities and we can play an important role in reducing these imbalances and ensuring that all patients receive the standards and wide range of healthcare services they deserve. “By delivering good quality care for everyone, we can then invest our care and resources more wisely in promoting the preventative healthcare agenda and keeping people as healthy as possible for as long as possible, rather than just patching patients up when they are ill.”

Professor Steve Field, Chairman of the Royal College of General Practitioners

“I would give all healthcare professionals mandatory training in mental health. As the College’s new Fair Deal campaign highlights, there is a worrying lack of training and too little collaboration between mental health professionals and those in primary care and hospitals.This means both the mental health needs of individuals treated for physical illness, and the physical health problems of people with mental illnesses, can be woefully under-detected and overlooked. But mental and physical healthcare are inextricably linked, and we need to end the dualistic thinking within the NHS that rigidly separates the two. “If I could choose a second present, I’d give psychiatry a better image within the medical profession. Psychiatrists have long been the subject of jokes and ridicule, but this stigma has contributed to a decline in the proportion of UK graduates entering psychiatry.This year, just 6% of candidates sitting Paper 1 of the MRCPsych were UK graduates. Given that one in four of us are likely to develop mental illness during our lifetime, I’d like to see psychiatry given the status it deserves, and for more medical students and junior

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R-UK ISSUE 4 doctors to realise what a fascinating and fulfilling career the specialty offers.

Professor Dinesh Bhugra, President of the Royal College of Psychiatrists I would ask Santa to reboot the NHS’s risk aversion mindset.The health service is drowning in health and safety regulation, is excessively fearful of litigation, and is staffed by people who are petrified of putting a foot wrong and ending up on the front pages of newspapers. Of course, health care presents unique challenges around safety, but this is different from fostering a fertile atmosphere for staff to develop their ideas without facing humiliation or scepticism. “When I tried to set up a social enterprise showcasing the work of young artists in a psychiatric hospital, it was cancelled two days before the viewing by a manager who thought the chance of a patient smashing a painting over someone’s head was too great.This was nonsense and an exceptionally painful discovery that, for some people, the worst case scenario is the only scenario worth thinking about no matter how unlikely. I believe there are thousands of clinicians who are inhibited from realising their dreams by the cloak of inertia that has descended since many bland elements of management theory were co-opted into the NHS in the past 20 years. We need to reverse this trend.”

Dr Jamie Wilson, MRCPsych, Editor of R-UK

"The NHS really is one of the most precious gifts we enjoy as British citizens, providing a lifeline to families up and down the country.That is why the Conservative Party has made the NHS its number one priority. We back it, and want to build it and improve it for everyone. “But whilst the British people enjoy and appreciate the gift of free healthcare, we understand that many in the medical profession are in little mood to celebrate. “Where once doctors could decide the urgency of a case themselves, they are now subject to a barrage of government diktats. This approach demoralises doctors and erodes their capacity to lead. “A Conservative Government will scrap all those top-down, political process targets which make their life a box-ticking perversity. Instead, we will be clear about what we are setting out to achieve – the best possible health outcomes – and not dictate how it is achieved. That will be based on evidence, with accountability to patients.

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OPINION “The best Christmas present I can offer the NHS is the prospect of a new Government, which will trust the staff of the NHS to fulfil their vocation in providing the best possible care for their patients.”

Andrew Lansley MP, Conservative Shadow Health Secretary

“My choice of Christmas present for the NHS is freedom from central political interference. The NHS is unique for the extent to which it is controlled by Ministers and officials operating behind closed doors in Whitehall. We face rapidly rising healthcare costs with no further significant real term increases in funding for the foreseeable future – a perfect storm. “In these circumstances, the challenge is to make available resources go further. Dismantling the grossly inefficient and ineffective central bureaucracy which pumps out endless initiatives and dictates ill-thought-through organisational change is a necessary pre-condition for achieving a more efficient system. “Freeing up clinicians to exercise their professional judgment, introducing local democratic accountability for the commissioning of healthcare, integrating health and social care and ensuring that financial incentives are designed to keep people healthy rather than simply reward activity are my chosen stocking fillers for the NHS.”

Norman Lamb MP, Liberal Democrat Shadow Health Secretary

“I have seven Christmas presents for the NHS. “Abolish prescription charges — these can never be made fair.The loss of revenue, reported to be £450 million, could be made up by better use of resources, for example by implementation of the Government’s own paper Better Care, Better Value Indicators. “Improve quality across the NHS at no cost through:• Better care – safety, avoidance of errors, consistent use of evidence based protocols for treatment of common conditions • More compassion – dignity and kindness • Better communication – between staff and patients and their families and between all hospital staff and primary care staff • Continuity of care despite shift working. “Fair competition – Where this is obligatory by Government dictat, tendering must be fair so that NHS and non-NHS providers compete on a level playing field “Foundation Trust status for all NHS provider organizations “Accelerate the work of NICE “Make public and patient involvement in health care real “A debate on health care rationing – There must be a full, open public debate on what core services the NHS must provide, eliminating treatments and procedures lacking an evidence base or wide public and professional support. Money

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R-UK ISSUE 4 released could be used to raise the NICE cost effectiveness threshold so that top-up fees or separate provision of partly private health care would be unnecessary.”

Dr Richard Taylor, Independent MP for Wyre Valley

“No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged” – In Place of Fear –Aneurin Bevan 1952 With co-payments, private/public funding, privatisation and market forces as a solution to problems within the NHS, despite all the fine work and high levels of patient satisfaction there are dark forces lobbying and pressurising for even more privatisation. We should be asking how we can make clinically effective treatments available on the NHS. Improving access requires reform of NICE, new initiatives on drug prices, reviewing the exceptional funding process and identifying inefficiencies in the health service. Merry Christmas to all those in the NHS who work every day to listen to and support every patient.

Dr Ian Gibson, Labour MP for Norwich North

“During Virginia’s {Bottomley’s} five years of responsibility for the Department of Health and all the dedicated people in the NHS, she seemed to know how to work to improve the service for patients while caring for the staff. As her Christmas gift, she could take an annual seminar for those who now and in the future are tempted to launch untested computer systems. “She could tell of her respect for those who had the responsibility and the courage to speak up when some bright idea would not work. She could demonstrate how one person spotting the value and the opportunity of a European Medicines Evaluation Agency led to plans that worked. “My gift would be twofold: to ensure Deputy Chief Medical Officers remember the doctors who first warned constructively and persistently of the potential problems in human and financial terms in parts of the NHS IT project and in so much of MMC/MTAS; and to encourage them to have an annual gathering that is dedicated to taking good advice. My Christmas goodwill, year after year, has been pretty well exhausted by unexplained failures to spot early and stop earlier what would go, and then was going, wrong.”

Peter Bottomley, Conservative MP for Worthing

“A refund of the £12 billion wasted on NHS-IT, to be directed to frontline patient care. And some MRSA resistant tinsel.”

Stephen O’Hanlon, RemedyUK committee

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ANALYSIS

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The doctor as performance artist

Michael O’Donnell, humourist, GP, and former editor of World Medicine details the inner exhibitionist of the jobbing doctor I started doctor watching at an early age. My father, a GP in a Yorkshire village, used to take me with him in his car when he indulged in that strange habit doctors once had of visiting the sick. Occasionally I went with him into a patient’s home and during school holidays was allowed to sit in a corner of his consulting room with my colouring book. When he or his patient sought privacy I was despatched to the treatment room.

At first I was bewildered when my father responded to each patient with a change in character, usually slight, but sometimes dramatic. With one he might be a cheery motivator driving away dull care, with another a quiet unintrusive listener. Delight replaced bewilderment when I realised each character was scarily convincing and every performance different. www.rukmag.org

At first I was bewildered when my father responded to each patient with a change in character, usually slight, but sometimes dramatic. With one he might be a cheery motivator driving away dull care, with another a quiet unintrusive listener. Delight replaced bewilderment when I realised each character was scarily convincing and every performance different. Years later, when I worked for my father as a holiday locum, I discovered that, in the way performers learn from their audience, he acquired much of his

understanding of medicine from his patients.True, he picked up useful knowledge from books and journals but he screened everything he read through the filter of his own experience. I’ve since met lots of doctors who perform in much the same way, and I’ve decided that the empathy they have with their patients – the ability to think themselves into the minds of others – is one of the elusive qualities possessed by doctors whom patients feel better for seeing. I’ve further concluded that the relationship these doctors establish with their patients resembles that which exists between performer and audience and that doctors could learn much about their craft from the actors, writers, and directors with whom I’ve spent the last three quarters of my working life. Practitioners of these crafts need to see the world as their audience sees it.The ability to do so distinguishes performing, which is a creative activity, from the playing of roles which is not. Performers need an audience and are influenced by it. Roleplayers are concerned with satisfying themselves. “I think I handled that rather well,” says the role-playing doctor while next door the patient whispers to her friend, “I don’t think he understood a word I said.” Another essential ingredient of a performance is that it appears to be truthful even if truth exists only in the eyes and ears of the audience.The audience perceives a real person, real emotion; the skill of the performer blinds them to the artifice. Alec Guinness once described the process to me over the relics of a memorable

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ANALYSIS

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lunch. Actors, he said, must devote all of their bodies and nine tenths of their minds to producing a convincing truthful performance.Yet in a tiny corner of the mind – the remaining tenth – sits the pilot with his hands on the controls, coolly monitoring the audience reaction, remembering the lines and the moves, while knowing that a false move on his part could destroy the seemingly impromptu physical performance.

Even the most versatile of actors know there are limits to the range of parts they can play, imposed not just by their physical characteristics but by their personality.The same techniques don’t work for everyone and doctors, like actors, need to nurture their individual gifts rather than try to ape the performances of others. As Samuel Johnson pointed out, “Almost all absurdity of conduct arises from the imitation of those we cannot resemble.”

Performance is not an exceptional activity. Every time we interact with another human being we indulge in it.The poet Philip Larkin wouldn’t go to literary festivals because he found pretending to be himself was too exhausting.Yet doctors remain wary of the word and prefer to talk about Communication.

Take the business of eye contact. Clearly it’s a Good Thing to establish eye contact with a patient.Yet as any intelligent grown up knows, the quality of eye contact – and how long it is held – varies with the age, sex, and cultural and social backgrounds of those engaged in conversation.

Doctors love communicating about ‘communication’. Over the past ten years the BMJ has published 406 articles or letters with the word in the title or abstract. Doctors also enjoy communicating about non-communication. ‘Breakdown in communication’ has become one of the commonest excuses for failure or ineptitude.Yet much of the medical teaching of Communication never gets beyond the Janet and John stage, concentrating on superficial and often banal ‘communication skills’ that have more to do with role-playing than performance.

To accommodate this variance yet maintain the illusion of a mechanical skill, the academic assessment of communication skills is peppered with equivocating adjectives like ‘appropriate’, ‘reasonable’, and ‘proper’. ‘Appropriate’ crops up seven times in the schedule for the MRCGP video exam.These adjectives would be more at home in a guide to Victorian etiquette than to a creative human activity.

Luckily there are exceptions to the depressing norm. Within the University of Birmingham, in the Department of General Practice, lurks John Skelton. Although burdened with the title of professor of clinical communication he keeps asking why we waste precious time teaching the crashingly obvious, the surface skills that have more to with role-play than performance. Like teachers of actors and ‘Establish eye contact writers he encourages at the beginning of the students to learn more about themselves, their consultation and motives, and their attitudes. maintain it at

reasonable intervals to show interest’.

Elsewhere medical students and postgraduates are taught what the gurus call Key Communication Skills. One of the most quoted is: ‘Establish eye contact at the beginning of the consultation and maintain it at reasonable intervals to show interest’. (I love that ‘reasonable’. I suspect I could diagnose unreasonable eye contact but reasonable is a trickier proposition.)

Still, you can’t argue with it – and I advise you not to get drawn into argument with the solemn proponents of this line of teaching. Of course, eye contact is important, as are other Key Skills such as regularly checking that patients understand what’s being said, asking open questions, not interrupting, and so on. But grown ups regard all this as pretty obvious. What worries me about the Key Skills is not just that they’re platitudinous but that they’re a beginner’s guide to role-playing. And when you diminish the art of communicating to the mechanics of role-playing you ignore the limitations imposed by the individual quirks of doctors and their patients.

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Performers aren’t plagued by equivocation. For them the need for and the nature of eye contact spring from a deeper level of sensibility and is not measured by acts imposed by protocol.This distinction has significant implications when doctor meets patient. The notion of communication as a mechanical skill implies that a doctor’s personality makes a minor contribution to the ability to understand and be understood.The notion of performance

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ANALYSIS Doctors are told, not surprisingly, that they should listen to their patients, and are taught techniques to show they are listening. They are less often told that real listening means attending to the meaning of each word, even if they’re words the listener has heard a hundred times before. Each performance has to connect with a new audience so doctors, like actors in a long run, must beware of settling for a routine trot through the role.

R-UK ISSUE 4 acknowledges that a doctor’s personality is sometimes the most powerful generator of empathy and understanding. Take another Key Communication Skill. Doctors are told, not surprisingly, that they should listen to their patients, and are taught techniques to show they are listening.They are less often told that real listening means attending to the meaning of each word, even if they’re words the listener has heard a hundred times before. Each performance has to connect with a new audience so doctors, like actors in a long run, must beware of settling for a routine trot through the role.

Like actors, they must learn not just to pay attention but to respond, and to respond in their own individual way. I recently talked to an aging actor after he’d done a spell in a soap. He’d enjoyed it because he was surrounded by people who knew their craft – with one exception.This was an actor still in his 20s who’d appeared in over 200 episodes of soaps but, maybe because that was the sum of his experience, had one glaring defect.The others found him impossible to play to because they got nothing back from him. Dead eyes, said my chum.That’s all you got. Dead eyes.

As he spoke, I remembered times in my own career when I saw a patient who needed to be understood glancing desperately around the room as if seeking for someone who could provide the response that clearly wasn’t coming from me. The assumption that you can reduce a creative activity to a compendium of technical tricks is a neat example of what the late Bill Silverman called ‘reductionist snobbery’. Bill, one of the founders of American neonatal medicine and a fine provocative essayist, coined the phrase to describe the assumption that the only ‘scientific’ approach to researching complexity is the reductionist one. He – or was it Iain Chalmers? – said it was like suggesting Newton should have sought the source of gravity by dissecting the fallen apple and cataloguing the structures that lay within. There are other ways. In Birmingham John Skelton encourages doctors to learn more about themselves, their motives, and their attitudes. Phil Hammond, who worked with Skelton, says, “For most of us, the usual reason a consultation goes pear-shaped lies deeper than surface skills … It’s attitude rather than skill that determines how we communicate.”

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The practice of medicine is more rational than it was in the days I sat alongside my father on his rounds.Yet murmurs I hear at postgraduate meetings suggest that the pride we take in our ability to provide more evidence-based treatment is tempered by a fear that we deliver it with less empathy and understanding. Why do those qualities matter? Walter Rosser gave one reason in a Lancet article. Some 40 per cent of new disorders GPs see in their surgeries, he claimed, don’t evolve into conditions that meet accepted criteria for a diagnosis. Another reason is that, even when there is a diagnosis, doctors have to treat an illness rather than a disease.The two are not synonymous. Diseases can be defined, their causes sought, organisms or mechanical defects identified. An illness is an individual event belonging to one person whose physical and emotional state determines the way the disease affects that individual life. Clearly medicine has to be evidence-based but, even with diseases where we have compelling data, clinicians have to weigh the generality of the evidence against the particular needs of the individual and seek to understand the feelings of regret, betrayal, fear, guilt, loneliness, and other perplexing emotions that can turn the same disease into a different illness in different people. Doctors trained to diagnose and treat disease sometimes find it hard to cope with the individuality of illness. If they are to become successful at treating both they need to enhance their medical experience with the experience of others who contribute to our understanding of the world in which we all struggle to survive. The Cambridge computer scientist and biographer of the internet, John Naughton, once wrote, “The things that really matter to us – the secrets of the heart, of what it means to be an individual, the depths and heights of human experience – all are accessible, if at all, only through literature and the creative arts. Science has no purchase on them.” Luckily help is at hand from the novelists, poets, and dramatists who sit on bookshelves, ever ready to illuminate areas of life beyond our experience, ever eager to sharpen our appreciation of the humanity we share with our patients. We should consult them more often because, just as the knowledge doctors acquire from observing and investigating their patients can enhance their knowledge of disease, the understanding they may absorb from literature, or indeed any of the arts, can enhance their perception of the nature of an individual illness. The arts don’t just help us understand the world beyond our experience, they also help us understand ourselves, our motives, and our attitudes. A lifetime of doctor watching has convinced me that empathy and understanding – or, as the jargonists prefer, ‘successful communication’ – are as dependent on doctors’ knowledge of themselves as on their knowledge of their patients.

11


BOOK REVIEW

The Meaning of Madness

R-UK ISSUE 4

Neel Burton, Acheron Press Few people have written three books (two award winning) by their late 20s, have three degrees and have worked full time in the NHS as a psychiatrist. Neel Burton is both intimidatingly bright and, as you can see, rather prolific. He is also an MTAS refugee and writes in this issue of R-UK about the attitudes of doctors to the Cinderella specialty of psychiatry. He is the perfect characterisation of the intellectual horsepower shed by the NHS last year, unable to fit into the white space questions of MMC World. What is medicine’s loss is publishing’s gain.

His new book, The Meaning of Madness, draws together the scientific, philosophical and literary influences that have woven the myth and history of psychiatry. Just by being presented with the fact that animals do not suffer from schizophrenia, you begin to be intrigued by the complexities of human behaviour.The book is packed with similar striking insights. Given that Neel belted this book out over a fortnight last summer, his enthusiasm and passion for the subject never slips. He has an elegant facility in allowing access to the generalist reader, while also providing an educational tour de force for doctors who may be drawn to the world of mental health. A grand literary future awaits, I would posit.

The Meaning of Madness is available through the Acheron press or you can contact Neel direct at neelburton@yahoo.com

SAFE IN WHOSE HANDS? From the Bristol Heart Disaster to the Ben Bradshaw Fan Club . . . 17 years of medical scandal, as featured in Private Eye.

Available now at £9.99 or less, including free membership of the Royal College of Patients. The ideal Christmas companion to Medicine Balls (new edition available at £7.99). ‘Hammond has earned the right to kick ass. He blows a good, loud whistle.’ Polly Toynbee Copies at all good bookstores, at Amazon.co.uk or order by phone (free P&P) on 0845 370 0067.

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12


OPINION

Brother or sister at medical school?

R-UK ISSUE 4

The Royal Medical Benevolent fund on a new, free resource to help medical students

You’ll know all about medical student debt yourself. Now there’s a useful resource which probably wasn’t around when you were at medical school. So please pass this on to anyone you know who is still there – maybe a family member or students on placement. www.money4medstudents.org is designed and produced for medical students, in part by medical students. So it recognises how difficult it is to fund yourself through five to six years of study compared with non-medical students on conventional three year courses. And there’s information and advice on issues specific to medical students – like electives, intercalated years, placement travel costs and NHS bursaries. It starts from the premise that unless you’ve got wealthy and supportive parents debt is inevitable but that you can influence how much debt you qualify with; that qualifying with less debt relieves the financial pressure you’re under as a newly qualified doctor; and that the attitude to money you develop at medical school could stay with you for the rest of your life, so…. The user centred navigation provides four key entry points – ‘I need more money’

‘I’m spending too much money’ ‘I need to borrow money’

‘I need to talk to someone about money’ Each leads through to a wealth of relevant, impartial information and advice. For instance ‘I need more money’ will take you through to material on Scholarships, grants and bursaries; Hardship funding;Tips on applying for student support; Money for

Give yourself a treat

your Elective; Financing Medicine as a Second Degree; Part time Jobs; and Benefits and Tax Credits. You can customise the information you receive, to save time, by entering your medical school, year of study and country of normal residence. The News section features imminent funding deadlines plus news of topical money saving ideas.There are online budget and debt calculators and you can e-mail the site’s Independent Money Adviser if you’ve got a particularly difficult financial problem. www.money4medstudents.org was developed by the Royal Medical Benevolent Fund, working in partnership with the BMA Medical Students Committee, the Medical Schools Council and the National Association of Student Money Advisers – so it exists to help medical students not make money out of them. It received 134,000 hits during the last academic year and usage is still rising – so worth suggesting to any medical students you might know.

For just £24 a year, you can now subscribe to R-UK. Every other month for six issues, your personal copy will thud onto your doormat.To sign up via PayPal, visit our website.

R-UK is currently mailed free to Remedy+ members. www.rukmag.org

13


ANALYSIS

Their preference, not yours

R-UK ISSUE 4

Richard Marks, RemedyUK Head of Policy, looks at why the UK is 70 years behind the USA. Back in the 1930s the Americans were grappling with the problem of how to allocate trainee doctors to intern posts – the equivalent of our Seamless Training grades.The dilemma they faced was that hospitals were competing with one another for the best applicants. As a result every hospital moved their offer dates forward, in order to attract the best candidates.The situation got steadily worse Richard Marks until, in 1945, a ‘Cooperative Plan’ was announced by the Association of American Medical Colleges, restricting ever-earlier applications. But this created a new problem – how to deal with the iterative process of multiple offers, decisions and reoffers. In 1945 offers made to applicants had to be accepted or rejected within a 10 day window. By 1949, a deadline of 12 hours was rejected as too long. The difficulty that hospitals faced was that by the time an offer had been rejected it was often too late to reach their next most preferred candidates before they had accepted a rival offer. Hospitals therefore pressurised applicants to reply immediately; offers conveyed by telegram were often followed by telephone calls requesting an immediate reply. In the early 1950s they realised that the only way forward was to have a central matching house to handle the offers and allocations.This would only work if the matching algorithm – the rules and logical sequence governing the way allocations were made – had the approval of all parties.The initial algorithm was rejected by a student group, who proposed an alternative – the ‘Boston Pool’.This was designed to match applicants to jobs based on the preferences of the applicant. Hospitals made their offers to applicants, starting at the top of each hospital’s ranking, and each applicant would be matched Figure 1 with their highest-rated hospital that would take them. With some minor tweaks this process has stood the test of time. It has coped with big swings in manpower demand, from a situation where there were too few applicants to a situation where there were too many. In both of these environments it produced

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matchings that were stable – that is to say that no applicant and hospital were matched when they could have been matched with a higher preference. An unstable outcome, in comparison, would match applicants or hospitals to a lower-ranked preference. Britain had no need for a central clearing house prior to MMC, because the process ran asynchronously throughout the year. But in 2007 all training jobs were brought into line with one another. This will be very difficult to change. Programmes which tried to recruit midway through the year have found it difficult to attract many applicants because the ‘free labour market’ has been depleted; most doctors are tied into jobs that last until August. The changes that were proposed in 2007 made a central matching process imperative.This was appreciated in advance, and MTAS was the proposed solution. Both MTAS and the Specialty & Selection Rules underlying it failed on many levels, and were hurriedly withdrawn.The following year Deaneries were left to compete with one another, but without a central matching clearing process.This is an interesting combination that has raised interesting questions of gameplay for all parties. Recruitment for 2009 is going to be considerably more complicated. Some specialties will be running a single national process. Others will have a locally-led but centrally matched process. And others will be managed locally, with no cooperation between the various regions. England and the devolved nations will be doing things differently.The way in which jobs are offered and allocated will vary. Each of these application units will be carrying out their ranking, allocations and job offers differently. As a result the sequence of matching, preferencing, job offers and acceptance becomes the key determinant in the outcome. Consider for example two Deaneries (or two specialties) that carry out their shortlisting and interviewing, rank their applicants and make offers. I have illustrated this with two hypothetical Figure 2

Deanery ‘B’ after matching and allocations

Deanery ‘A’ after matching and allocations 95 95 94 93 91 90 89 88 87 85 84 83 81 79 78 76 74 72 70 67 66 62 58 54 50 45 38 31 19 0

Continues on page 21

Deanery ‘B’ after dropouts

Deanery ‘A’ after dropouts 70 68 67 66 65 63 62 60 58 56 54 52 50 48 45 42 38 35 31 25 19 11 0 0 0 0 0 0 0 0

95

95

93

94

90

91 90

88 87 83 81 78 73 72 67 66 62 58 54 45 33 31 19 0

87 85 84 81 79 78 74 72 67 66 62 58 0 0 0 0 0 0

14


OPINION

R-UK ISSUE 4

Are psychiatrists mad, bad, or sad? This year, just 6% of candidates sitting Paper 1 of the MRCPsych were UK graduates, evidence if any were needed, argues Neel Burton, that recruitment into psychiatry is facing an unprecedented crisis. In my experience, most medical students enjoy learning about mental illness and talking to mentally ill people, who often have a refreshing knack for saying things exactly how they are. In a fit of inspiration, some medical students tell me that psychiatry is the only specialty that enables them to think about themselves, about other people, and about life in general.They also like the lifestyle: an hour for each patient, ‘special interest’ days, protected time for teaching, light on calls from home, and guaranteed career progression. In medicine they might treat yet another anonymous case of asthma, chest pain, or pulmonary oedema. In surgery they might do one knee replacement after another – up until the day they collapse or retire. But in psychiatry there can be no factory line, no standard procedure, and no mindless protocol: each patient is unique, and each patient has something unique to return to the psychiatrist. I often come across those same students again, months or sometimes years later. After the smiles and the niceties, it transpires that they are no longer so interested in psychiatry. So what happened? The students are never too sure, but I think I have an idea. Whilst I was a medical student in London, an American firm offered me a highly paid job as a strategy consultant in their Paris office. So I gladly left medicine, and the many I had always been inconveniences of working in far too ‘ambitious’ to (and increasingly ‘for’) the NHS. I consider psychiatry, had a great time in Paris, but the job itself turned out to be more but by then it had become clear that I about dealing with personality disorders than about having good didn’t want to ideas. I quit after six months and pursue a career that freelanced as an English tutor to didn’t allow me to high-flying executives, bankers, think and feel, and venture capitalists, and such like. to relate to others As my clients already spoke good and to the world in English and merely wanted to improve their fluency, all I had a genuine and to do was to make meaningful way. conversation. My lessons often turned into something akin to psychotherapy, as I realised that I could make my clients open their hearts and minds simply by listening to them speak. Although they seemed to have everything in life, they were actually deeply unhappy, and had rarely stopped to ask themselves why. I wanted to find out why, so I decided to go back to London, do my house jobs, and specialise in psychiatry. I had always been far too

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‘ambitious’ to consider psychiatry, but by then it had become clear that I didn’t want to pursue a career that didn’t allow me to think and feel, and to relate to others and to the world in a genuine and meaningful way.There are not many such jobs, but psychiatry – along with general practice, teaching, academia, and the priesthood – is certainly one of them, and is even – arguably – their archetypal form. The following year whilst going about my house jobs I put up with all sorts of abuse from my colleagues in medicine and surgery. One of the other house officers, by then a good buddy, took me aside one day and ‘Why do you want to said with an alcoholic mixture of concern and disdain: ‘Why go into psychiatry? do you want to go into You’re a good doctor. psychiatry? You’re a good Can’t you see you’re wasting your talents?’ doctor. Can’t you see you’re wasting your talents?’ It became very clear, first, that the stigma that people with a mental illness are made to feel also extends to the doctors who look after them; and, second, that this stigma emanates most strongly from the medical profession itself, mired as it is in middle class preoccupations and prejudices and, as a whole, far too grounded in neurosis not to be terrified of psychosis. Of course, it is simply not true that psychiatry is a ‘waste of talent’.The term ‘psychiatry’ was first used 200 years ago in 1808, in a 188-page paper by Johann Christian Reil. He argued for the urgent creation of a medical specialty to be called ‘psychiatry’, and contended that only the very best physicians had the skills to join it.These physicians needed not only to have an understanding of the body, but also a much broader range of skills than standard physicians. Indeed, a psychiatrist can change a person’s entire outlook with a single sentence, so long as he can find the right words at the right time. No protocols, no high-tech equipment or expensive drugs, no pain or side-effects, and no complications or followup. Now that is talent, and one so great that I can only ever aim at it. And each time I fail, I always have medicine to fall back on.

Neel Burton MA (Phil), MRCPsych, is the author of ‘The Meaning of Madness’, ‘Psychiatry’, and three other books.

15


OPINION

Change we can believe in?

R-UK ISSUE 4

In R-UK issue 3, Lindsay Cooke argued that it was past time for doctors to reclaim their profession. Here, she examines how medicine might begin to embrace internal democracy – and why it needs to. I began writing this a week after the election of a self-styled ‘unlikely candidate’ to the Presidency of the United States. We don’t often get the opportunity to witness a paradigm shift.The person who will soon be the most powerful in the world has thrown the old, ‘top down’ leadership models on the scrapheap. Barack Obama is a constitutional lawyer rather than a ‘professional politician’; a listener and a consensus-builder; a personification of ‘leadership with’ not ‘leadership over’. His message is not about ‘what I can do for you’ but about ‘what we can do together’. His use of the internet to produce the largest lobby group in history is unprecedented and perhaps has lessons for other disenfranchised groups including doctors. Despite the many and obvious flaws of representative democracy, universal franchise provides an opportunity for people to influence the general principles under which they are governed. When I first became involved with Remedy, I was more than surprised how little this seemed to exist within Despite the many and the medical profession.There is obvious flaws of no one body which is takes account of the views of all representative democracy, universal doctors – no structure of overfranchise provides an arching representative democracy.To me, that is opportunity for extraordinary.

people to influence the general principles under which they are governed. When I first became involved with Remedy, I was more than surprised how little this seemed to exist within the medical profession.

The perception of grassroots doctors post-MMC is that their existing institutions are out of touch.These institutions have failed to provide them with the support and protection they craved and have, in many people’s view, colluded with the government agenda. Indeed, there is a growing constituency which links the imposition of MMC with a perceived government strategy to de-professionalise and denigrate the profession in order to clear the way for the privatization of the NHS.They see elements of medical leadership as ‘traitors’. Whatever the truth, it cannot it be healthy or productive to feel in a perpetual state of disempowerment.

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It is because of this dissonance between ‘leaders’ and ‘led’ – and only because of it – that RemedyUK emerged.Yet, two years down the line, the circumstances that led to its birth are the same. Despite criticism from sources as diverse as the grassroots rage of the ‘rabid mob’ and the lofty echelons of the Commons’ Health Select Committee, the old hierarchies have changed little. People come and go – or in certain cases, come and stay on a Baker’s Dozen of influential committees – but grassroots doctors are no better represented than they were two years ago. It’s worth saying again because it is so mind-boggling.There is no body that is representative of grassroots doctors. The BMA, the HCSA and the Colleges offer some elements of representative democracy, but the first two are restricted by paid membership and the Colleges by ‘craft’. RemedyUK has begun to put representative structures in place and is committed to providing a voice for grassroots doctors by encouraging participation, seeking opinion and framing consensus but is too new and under-resourced to claim to be representative. Representative democracy is, of course, only the beginning. As the BMA has discovered, the notion of representative democracy alone can lead to an ‘activist class’ and to the institutionalization of the self-selected.The inflexibility and internalization that results could be witnessed during the MMC/MTAS debacle: those negotiating, in good faith and with, I’m sure, the best of motives found themselves out of touch with the interests they were aiming to represent due to inadequate ‘listening’ mechanisms.

16


OPINION With the greatest respect – as my stepfather used to say before being very rude – an apology from the BMA for its failure of political judgment in 2007 could go a long way towards reestablishing trust. Great leadership is characterized by a combination of insight, humility and the chutzpah to acknowledge mistakes. So would the profession really be starting from the constitutional foothills rather than loftier peaks? The advantage of starting afresh is that you can build structures that suit the culture of the organisation and that work. I don’t know what such a body might look like, but here are some starter questions. What would be the electorate? GMC-registered doctors only? Medical students as well? – after all, they’re the doctors of the future. What about retired doctors with, arguably, a wealth of experience and wisdom? How would members be elected? Firstpast-the-post or one of the more proportional systems? Would the entire electorate be voting for individual members or would each section/grade elect someone specifically as their representative? Could the medical profession be the first constituency to develop e-voting to enhance participation and accuracy? What about specific representation for women and ethnic minorities? Or specific regions or specialties? Would this body elect a ‘leader’ or would a leader be directly elected? Should officials be elected to the GMC committees by this method? Is it desirable to have one ‘leader’ mandated to speak for the profession? How would such a body seek and express the views of its electorate? Should it embrace alternative methods of more direct democracy – surveys, polling, whether open or representative? How could such a body ensure that it stayed in touch with its electorate? How could its electorate hold it to account, express its displeasure – get rid of the lot and start again?

R-UK ISSUE 4 If you’ve got this far, you may be feeling a bit prickly about someone’s Mum raising these issues: after all, I’m not even a doctor. I’d argue that I have a right to raise them because I’m “We have had less a patient: like the NHS, I’m 60 freedom than we believed. That which this year and I’m not sanguine we have enjoyed has about the future of the profession I’m likely to have to been too dependent rely on at some stage in the on the benevolence future. And I’m a democracy of our rulers. Our junkie as well as a politics freedoms have junkie.These words are the remained their opening paragraph to possession, rationed Charter88, the call for out to us as subjects constitutional reform which I rather than being our campaigned for in the 90s.

own inalienable possession as citizens. To make real the freedoms we once took for granted means for the first time to take them or ourselves.”

“We have had less freedom than we believed.That which we have enjoyed has been too dependent on the benevolence of our rulers. Our freedoms have remained their possession, rationed out to us as subjects rather than being our own inalienable possession as citizens.To make real the freedoms we once took for granted means for the first time to take them for ourselves.”

I hope this article will begin a debate. Please contribute by writing to me at Lindsay@RemedyUK.org and we’ll pick this up in the next issue of R-UK. The illustration is a detail from Eugene Delacriox’s ‘Liberty leading the people’.

Visit the R-UK website for much, much more Go to www.rukmag.org for more Did you know that this magazine is fully interactive? As well as most of the content of this magazine, there is much more on the website.You will be able to find longer versions of many of the articles, as well as contributions from readers that we couldn’t cram into the magazine. Plus you’ll find the following: • • • •

Cartoons Videos Music downloads Forums and comments

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17


OPINION

R-UK ISSUE 4

Diary of an HSMP

The secret diary of Mei Bo (Mabel) Hwa Smith, aged 33 and 3/4 I was walking down the corridor towards the canteen where I was planning to have the lovely ‘ethnic’ option of curry sauce with chips and spring rolls, when a nurse shouted out to me “Why are your sleeves not rolled up? You are in a clinical area!” I was so shocked that I dropped my latte on the floor. This unfortunately splashed onto her white tunic caused a Health & Safety hazard in the corridor. No one was allowed to go into the canteen for a full ten minutes and a queue built up around us. After I had apologised, filled in the appropriate incident form, rolled my sleeves up, reflected on the incident and considered putting it into my portfolio, I found that the ethnic option had entirely run out and I had to eat the non-ethnic option of pizza and chips as usual. Over dinner that night, I reflected on the incident again with my boyfriend Smith Smith. The waistband of my Primark trousers was feeling much tighter these days and the truth was that I was fed up with my rehabilitation job. I had seen no cardiology at all for four months and the most exciting incident was when Mrs Beryl was discharged after eight months, only to be readmitted four hours later as her 24-hour carer had not turned up and she needed a cup of tea. She had been upset that she had to wait the full four hours in the Emergency department and missed Eastenders. She was so upset that she refused a second cup of tea, which was unusual for her. I had stayed in this country to do cardiology and I wasn’t doing any cardiology. This upset me more than when my hamster mysteriously disappeared one weekend when Smith Smith was looking after it and was replaced by a slightly different coloured hamster with the same name.

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All that I had to brighten up my life was Smith Smith, Primark and curry sauce with chips. This clearly wasn’t enough. “I need to do some cardiology,” I said to Smith Smith. “Yes, you do, darling,” he replied.

“But I can’t get a job in cardiology. I want a training post,” I lamented. “You could marry me instead,” he said.

Then hastily retracted and mumbled something about not knowing me long enough, too much commitment, wanting to wait until he was 45, and went red. It was at about this time that I changed my name by deed poll to Mabel Smith to see if that would help my job applications as it sounded more English. I applied for every single Cardiology post I could find in London and the Home Counties apart from the one that was only advertised for 48 hours which I missed by ten minutes as my brother phoned me to say that he wasn’t going to be made redundant from his investment bank after all. However, I still could not get a training post. On the plus side, I made friends with five other doctors who were also doing the London interview circuit. One morning at work, my boss called me into the office.

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“Don’t tell anyone I told you, but there will be an FTSTA advertised in the North East in Cardiology for 48 hours tomorrow. It will only be advertised in one place. The Head of Department there used to be my SHO.” “Is there a Primark in Manchester?” I asked. In the next installment: Mabel and Smith Smith try to rent a flat halfway between Manchester and London and both commute for over four hours a day, leading to another hamster incident.

Take out a Remedy+ membership for just £15 per month – and every pound will be matched by the Joseph Rowntree Reform Trust Ltd. Help us deliver maximum bang for your buck – and grow – on 0.06% of the BMA’s income. • • • •

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18


ANALYSIS

Getting published – standing out from the crowd

R-UK ISSUE 4

Matt Green and Sarah Silvester from Apply2Medicine, the UK’s leading provider of career progression support and non-clinical development, provide a valuable insight into how doctors can become published. Why be published?

There are many options open to doctors to become published but many overlook the option of writing or contributing to a book. As a busy doctor why would you want to write a book? There are personal as well as career-driven factors that will influence your decision to want to be published. Whilst there are many motives, most doctors write primarily to gain recognition from their peers, enhance their CV and improve their career prospects. Although some may consider it less academically prestigious than peerreviewed papers, books usually appeal to a wider audience and give the author credibility. Besides the prestige factor, there are also the financial rewards; advance payment, author royalties, or a combination of the two. Hence, there are many benefits of being published, namely to: • Enhance your CV, professional and career prospects • Hone your writing and research skills • Raise your own profile and reputation • Share your life’s work, ideas and medical experience with others • Benefit financially i.e. advances/royalties

How do you get involved?

Successful authors have certain qualities; they know their subject, understand where their book fits in the market, and write well. Once you have decided on your subject you need to submit a proposal. It is fairly rare for a publisher to accept a complete

manuscript for publication on spec. In your proposal you should demonstrate that you understand the commercial market and readership your book is aimed at.You also need to define what makes your book unique and how it is better than the competition. Your book proposal should contain some or all of the following: • • • • • •

Brief summary of contents Description of target audience What is unique about your book List of chapters Sample chapter Your CV

Besides the sole author approach there are other possibilities which include: working with one or two colleagues, dividing the subject up according to their interests and expertise; or editing/coediting a multi-contributor collection. An editor of a multi-contributor book would have additional responsibilities such as chasing contributors, editing and suggesting rewriting to fit the book’s tone and style.

The publishing process

Just as authors seek publishers, publishers also seek new authors.The publisher will already have an exact idea for a book, series of books or project they would like you to develop. If you do not have an immediate idea for your own book, it is still worthwhile registering your interest with a publisher.You can do this by submitting your

CV or an outline of your subject specialism, experience, qualifications and anything else you think may be relevant. Publishers are always looking for experts in a particular field and you may fit their profile. The publisher’s decision to publish your book will be influenced by considerations such as: Is the focus right? Is there scope for it in the market? Is it profitable? The book should not date quickly and, ultimately, should be appealing to the reader. Once your proposal has been accepted the publisher will issue a contract (intellectual property rights), agree payment (advance or royalties) and set a schedule for submission. It is important that the final manuscript follows your original outline closely, and does not exceed the agreed word count.

How to become one of our authors

Apply2Medicine is committed to publishing high quality books that support career progression for medical students, practitioners and allied healthcare professionals. We welcome proposals from new authors with specialist knowledge that adds value to our publishing portfolio. If you are interested in submitting a book proposal or would like to become involved with one of our existing projects we would like to hear from you. Please email your CV together with your area of interest, brief outline of your book (if you have one) to author@apply2.co.uk and we will contact you shortly.

RemedyUK has teamed up with Apply2Medicine, the UK’s leading provider of medical career support and advice, to offer an exclusive 20% discount to RemedyUK users. Visit www.rukmag.org and click on the Apply2medicine advert to take advantage of this offer, and get advice on management skills, interview preparation, communication skills, skills for teaching the teacher, and much, much more.


OPINION

The good old days?

R-UK ISSUE 4

Phil Hammond takes a nostalgic look back …

Christmas is allegedly a time for reflection, so here is a precis of the programme notes we wrote for Struck Off and Die, a militant junior doctor double act , for the Edinburgh fringe in 1990.

Struck Off and Die are two tired and surly junior doctors,Tony Gardner and Phil Hammond, who got together to publicise our working conditions and wage a war of ridicule on the medical establishment. We encourage criticism (and chocolates) and are especially keen to hear from anyone who has felt the rough end of the NHS pineapple (confidentiality assured, all letters answered, photo appreciated). Concessions for this show are available for NHS staff and the relatives of anyone we’ve killed. Sorry.

Phil Hammond

Thought For The Day: Is killing patients when you’re tired – and then killing yourself – the only way to learn? Two years on, and I clearly wasn’t happy with the pace of change, so here’s what I reeled off in The Observer.

Junior, Behave Yourself 28 June 1992 –The Observer Should you feel sorry for junior doctors? You don’t see many of us with rickets. Most come from cosy professional backgrounds and go on to earn healthy sums of money in secure jobs with satisfaction and respect. And a few are so insufferably arrogant, it’s hard for the rest to engender mass sympathy. True, I could fill this column with horror stories of patients dying at the hands of tired, abused and unsupervised doctors, or of promising careers ending prematurely in alcoholism or suicide, but how much of that is self-inflicted? It’s easy to blame ‘the system’ for a doctor’s lot, but the system is largely composed of other doctors and we never were very good at accepting the buck. ‘Bury the notes and burn the X-rays’ is the stock solution to another tired cock-up. After five years fighting a futile hours-reduction battle that started when I was in nappies, one question still perplexes me. How can a profession that purports to care for patients have so little regard for its own? The vast majority of consultants are not knowingly abusive towards their junior staff.True, there is a countrywide smattering of childishly malevolent surgeons who could do with an empathy infusion, but many more wellmeaning specialists still suffer from a huge reality gap. Most of us communicate badly with patients because we’ve never been poor, sick, black or even female. But even when we’ve experienced the iniquities of medical training first hand, it’s all too easy to progress into consultant-hood with the misguided air of ‘it didn’t do me any harm.’ Besides, if you’ve sacrificed your marriage and your liver to make it to the top, you don’t want the bastards beneath you to find an easier route.

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And after a few whiskies in the clubby locker-room atmosphere of an all-male common room, you tend to view your formative years through blood tinted spectacles: ‘We used to work for weeks on end . . . never saw daylight . . . and I enjoyed every minute of it.’ Blah, blah, blah. Long hours weren’t quite so onerous when the only therapeutic options were Horlicks or extra potatoes. Technology, turnover and patient expectation have risen so sharply that few consultants have any idea what life’s like on the bottom rung today. And with the administration, intimidation and uncertainty of the reforms, none of them has the stamina to find out. Perhaps junior doctors deserve the mess they’re in.Too many of us would rather sacrifice our own and our patients’ wellbeing than stand up for ourselves.The combination of apathy, fear and fatigue has never allowed us to present a united front. ‘Give us what we want or a handful of us will get in a strop’ is unlikely to cut much ice with the Tories. It would be nice to have a well-organised union behind us but we’re stuck with the BMA.The traditional public school bias of medicine has bred a self-perpetuating profession of sheltered, spoon-fed sycophants with as much independent thought as a de-cerebrate baboon. Though medical schools now accept students from a broader base, the mould remains to be broken: you don’t see many black or female faces in a Royal College of Surgeons’ group photo. Assured of success, the ‘white, male and hearty’ brigade have no need to rock the boat. Anyone else dare not. ‘You’re only as good as your last reference’ is the familiar cry of the downtrodden doctor. Moving from job to job every six Continues on page 27

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OPINION

R-UK ISSUE 4

Their preference, not yours (continued) Deaneries, one of which is more popular than the other. (See figure 1) After the allocations have been made, some of the successful candidates will withdraw.The number who will do this is unknown. Previous experience suggests that some will be lost to other specialties, especially to general practice, but previous experience is unlikely to predict future behaviour. Candidate behaviour is likely to be altered by perceived competition ratios and risk ratios, and cannot yet be considered as having reached steady state.The impact of this will predictably be higher amongst the stronger candidates, since they are more likely to receive multiple job offers. (See figure 2) The net result will be that there will be a low fill rate in the more popular programmes, while simultaneously there will be applicants given their second-choice placement when a vacancy exists in their first choice. In 2008 the Obstetricians & Gynaecologists pioneered a single national matching system for all their jobs. It went well, and their experience gives a good indication of how the process can work. But they have the organisational advantage of being an oversubscribed specialty (competition ratios were around 7:1) so their drop-out rate would be relatively low.They also managed the process of making offers to candidates very efficiently.

There are many issues of detail that can affect the final outcome, but the most important is the timing of the offers. Programmes or specialties that go early in the process will get the stronger and better candidates initially, albeit with more dropouts. Specialties or programmes that go late will be at a disadvantage. It does not seem right to me that major decisions affecting junior doctors’ careers are made by quirks of the recruitment system. In the long term the only fair and equitable solution is to have a single centralised matching process, allocating all jobs at a given entry level.This is the only solution that is fair to candidates. It is also an inescapable consequence of the move to once-a-year rotations.The Americans realised this in the 1940s, and they rejected the concept of an ‘offers’ week’ in favour of a national Resident Matching Program. We need to learn from their experience. We are living under the spectre of the ghost of MTAS. "We’ve tried it, it didn’t work," seems to be the reflex answer. If we want to be fair to applicants it will be necessary to think the unthinkable and to start looking at a central matching and allocations process through fresh eyes.

Interviews: how to keep your sanity and succeed

The clocks have gone back, the nights are drawing in and it’s getting cold outside. Winter should be a good time for the junior doctor – you’ve settled into your job, you’ve worked out the new hospital system, the FY1s are starting to find their feet. But then the emails start coming … Round One … Deanery X has already put their application form on NHS Jobs … Deanery Y has decided not to use NHS Jobs. Or BMJ Careers. Where are we advertising? It’s a secret … Please hand-deliver 12 copies of your application form to HR between 12am and 2pm last Wednesday.

For the last four years I have been interviewed for jobs in different specialties up and down the country, pre and postMTAS, so I consider myself battle hardened. Last year I got offered two different run-through jobs, and I believe, without sounding too much like Paul McKenna, that you can do it too.

It’s hard not to be perturbed by the randomness and sheer unfairness of the jobs process in the UK. By the time you’ve finished the application form you feel like you’ve completed a work of art. So when the invitation for interview comes through the door, it’s easy to think ‘Well, I’ve done the hard part.’ Not so.The interview is more important than ever.

Don’t pay any attention to the MMC league tables. OMG they’re interviewing five hundred people for two jobs for ST1 Paeds in Huddersfield! Ignore these tables – they are very silly.

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Here are my tips for the interview process.

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Take time off work.Your employer has an obligation to give you the day off for an interview. If your interview is on the other side of the country take the day before off as well. Get a hotel, wake up in the morning fresh and ready. Interviewers don’t give points for being tired.

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Don’t take it too seriously. At every interview there will be a locum consultant from Poland who has been doing the job for longer than most of the interviewers; and if that’s what they are looking for you can’t do anything about it.

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Warm up.You will be parked in a waiting area with other nervous junior doctors. Chat with them.Talk about the weather or something equally irrelevant.This will get you in the talking mood, and more importantly, it will prevent you from repeating in your head the answers to those questions you’ve heard come up in all interviews. Being relaxed and chatty is key to the good interview.

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Tell them everything.Your interviewers may have no idea who you are, as a lot of the time they don’t have access to your application form or CV.You may notice that they are furiously scribbling down everything you say because of that. Offer any random piece from your application form, repeat yourself ad infinitum – you may be bored by ‘describing your favourite chill out strategy’ but for them it is fresh beats.

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Now for The Big Secret.Your interviewers may well be quite cynical about the MMC interview process and not that interested in your first thoughts when you see a picture of kittens! They will probably include a consultant in the speciality you are interviewing in, and will want you to show... them that you are passionate about what they are considering you for. So tell them about everything you have done.

An example.

Interviewer:Tell me about a time when you felt happy. Me:There was this patient who arrested, and because I had done my Advanced Life Support course I was able to follow a CPR algorithm. In fact after I did my ALS course I wrote a case report which was published in the… If they are not interested, they will guide you back and you can talk about kittens some more. But always be ready to offer real information.

7 was being asked to ‘describe what makes a good multidisciplinary team.’ I’d stayed up the night before trying to You can’t win them all. My most embarrassing moment

memorise a list, and that – along with the seven pillars of clinical governance – had screwed my head. All I could remember was the fact that ‘the ideal team should have less than twenty people.’ So that’s what I told the interviewer. Three times. The only advice I can give is to move on to the next question, keep confident, try and forget your moronic answer and hope the interviewer does too. I have yet to meet anyone who can memorise and recall the seven pillars of clinical governance.

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Walk away. Once you have left the interview room, you possess ‘the knowledge’, and there will be an unscrupulous group of junior doctors who will use every trick in the book to get you to open up. ‘Hey mate, how did it go? You must be exhausted. Put your feet up and tell me everything ...’ So keep your head down, pick up your portfolio and get the hell out of there. And that’s it. Some places will let you know that day, some will tell you next week, others will make you wait for months, others will offer the job to someone who’s not interested and will call you in a panic in the first week of August. It’s a junky process, and it deserves not to be taken seriously.

Enjoy your interview, and for God’s sake don’t accept a job that you don’t want.

www.rukmag.org

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LAST RITES

Dr Grumble channels Sherlock Holmes

R-UK ISSUE 4

In case you don’t know, Dr Grumble is a blogger. He likes to call himself a top medical blogger. It’s not really true but you can call yourself what you like on your blog. Dr Grumble’s latest batch of medical students are very green.Very bright but no knowledge. Everything clinical is new to them. It’s rewarding to teach bright students who know very little.The less they know the more you can teach them. It’s like starting with a blank canvas and painting a masterpiece. Maddeningly Dr Grumble has his students for only a month. It’s crazy, of course, but nobody listens to Grumble. He used to have them for eight weeks. In that short time, if students and Grumble worked hard, the rudiments of history taking and examination could be taught.The beginnings of a masterpiece could be created. Some of these students will end up much greater and more important than Grumble. Amongst them may even be the Lord Darzis of the future. And, hopefully, some really good GPs. The job of teaching is important but there’s little reward. Nobody in the hospital hierarchy really cares about how well you do your teaching.They say they do but they don’t. Small group teaching is essential when it comes to clinical work but only the small group even knows you have done it.These days they report back online on the quality of the teaching. But sometimes they do not quite know how good their teaching has been.They do not know that the notes they write will forever be better structured than the notes of those who were not taught properly.They do not know that those difficult questions were not to make them look stupid or to check their factual

knowledge but to get them thinking in the right way to be a decent doctor. They do not know what they don’t know, what they really need to know and where they are heading. Eventually Grumble’s students do realise what he was trying to do. Sometimes, anyway. Just occasionally Dr G will get an email from a student or doctor thanking him for teaching that took place years earlier. Sometimes in these emails they explain that it was only later they came to realise the importance of the Grumble style of bedside teaching.This is Grumble’s only reward. It’s his greatest reward. It’s the only reward he wants. Dr Grumble had teachers he appreciated, teachers he wanted to emulate. He hopes he thanked them. Some years ago Grumble used to teach Japanese medical students. Don’t ask why. Even Grumble does not know.They just turned up and Dr Grumble just taught them. He used to ask them who wrote Sherlock Holmes.They always knew. Home-grown students can look bewildered if you ask them a question like that.They certainly don’t see its relevance. But it is relevant. In a way. Because the next question is about how Sir Arthur Conan Doyle got the idea for Sherlock Holmes. And the answer, which they rarely know, is from Dr Bell who used to teach Sir Arthur when he was a medical student. Dr Bell, like all physicians, was a detective. Sometimes he could tell what parts of the world his patients had visited and what

Nobody in the hospital hierarchy really cares about how well you do your teaching. They say they do but they don’t. Small group teaching is essential when it comes to clinical work but only the small group even knows you have done it.

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jobs they were in. Dr Grumble can do some of this. It impresses students no end. The other day Dr Grumble met a patient for the first time and told his students in front of the patient that he thought he had been in the army, that he had worked in the past as a coal miner and that he had given up smoking about six weeks earlier. The patient dutifully confirmed all this.The students were visibly impressed. Dr Grumble thought that from then on they would be taking him seriously. How did Dr Grumble do this? It isn’t that difficult. Patients who call the doctor ‘sir’ have usually been in the armed forces, coal tattoos in old cuts are common in previous coal miners and if fingernails grow at 3mm a month it is easy to work out from the tar staining when the patient stopped smoking. Now doesn’t that sound like Sherlock Holmes explaining his deductions to Watson? It’s easy to see how medicine laid the foundations not only for a series of good books but also for modern detective work. As Sir Arthur says himself in the only surviving recording of his voice.The recording is a bit stilted and there is only a hint of the admiration and gratitude Sir Arthur showed for his teacher, Dr Bell, without whom there may never have been a Sherlock Holmes. Visit Dr Grumble at his website, drgrumble.blogspot.com

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OPINION

House Doctor

R-UK ISSUE 4

The House Doctor is in typically ebullient mood this festive season. While the rest of the world is trimming back and embracing austerity, the House Doctor has been raiding the nooks and crannies of our wonderful health service, plump and brimming with all manner of endless parody. Pour yourself a glass of sherry, put on your toe warmers, and indulge yourself in a festive smorgasbord of harebrained infuriation, egomaniacal positioning, and breathtaking stupidity. Bah humbug.

What then to make of the maniacal scramble for Foundation status by NHS trusts around the country? The House Doctor has had his ears pricked and sources primed on this issue. He recently sat in at one such when all consultants were impelled to attend a briefing by the Key Performance Indicator manager, a bean counter par excellence, whose sole duty was to capture data for submission to Monitor, the Foundation Trust regulator. The consultants, infuriated at being faced with yet another tick box exercise for every patient they see, demanded to know why such an exercise was necessary. Would they be remunerated accordingly and what benefits would it provide to their service? The carrots on offer were sparse.

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Matters became more heated at another Trust where the dreaded four-hour wait was rearing its ugly head.The Trust, within touching distance of being granted Foundation status, had put all managers and service heads on red alert for any breaches of this vital gauge of efficiency. It seems that the pressure transmitted down to the coalface was even more febrile than usual. When a junior doctor clerked an intoxicated patient – feeling, in his opinion, that a period of observation and drying out was justified – he was then ‘manhandled’ into intravenously washing out the patient to speed up discharge. Needless to say, this questionable intervention provoked controversy within the said Trust leading to a stand off between clinicians and managers. Not very pretty.

developing key hole methods. Funny then, that the Independent on Sunday (19th October) carried a ‘Visionaries’ feature with Lord Darzi quoted as saying:

Everyone knows that Lord Darzi is an expert in robot-assisted rectal laparoscopic surgery. But pioneer and inventor of the key hole technique? Surely a step too far? A tap of the keyboard and one is rapidly familiarised with the work of Kurt Semm, the German gynaecologist who dedicated his professional life to

As you will have gathered by now, the House Doctor does not shirk from establishing the facts. He was soon on the case to Roger Alton, editor of The Independent, who promised him that his colleague at the IoS would clarify this matter. Despite repeated attempts, the House Doctor has fallen short. Perhaps the

"I developed the keyhole technique during an era when, from a surgical perspective, the bigger the incision, the more macho the surgeon. I recognised that an incision was probably the biggest component of pain for a patient, so what was driving me was how to reduce that. I started with keyhole operations for gall-bladder surgery and you could see patients recovered much quicker. I had a lot of critics so I had to turn them around. You bring people with you not by saying ‘because I say so’, but by taking them through the entire process. I worried I’d be singled out as a maverick, but I always remembered why I was doing it: Not to be different but because it had an impact on patients. I pushed the boundaries in using keyhole surgery.The more I wrote about the subject, the more patients expressed a desire to have the procedure done that way and 15 years on, it has become common practice."

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OPINION impending round of job cuts at The Independent impacted on editorial scrutiny or journalistic standards. But then again, this seems to be a verbatim quote from an individual who seems very sure of himself. Perhaps Lord Denham could furnish R-UK readers with a clarification? The House Doctor remains puzzled.

R-UK ISSUE 4 Caldwell’s letter to Sir Liam of September 2006 which implores delays, adequate testing and customisation of the Cerner system. Dr Caldwell is Director of Medical Education at Worthing Hospital. “Please remember that in Bristol it was a lone voice that spoke out.You may hear a lot of reassuring words from IT and Training staff, but until there has been real end user testing in near real simulations, showing that the system ... does not significantly delay clinical and administrative processes of care by more than say 3% at go live, it would be foolhardy to proceed with such haste.” Crash bang wallop.

Forgive the House Doctor for a moment while he pays homage to the far-sighted ‘lone voiced’ doctors who have anticipated logistical and financial catastrophes of the type seen at the Royal Free in North London.The implementation of Cerner’s Millennium system is in chaos, yet could this have been avoided? The House Doctor does not feel what follows is an unreasonable abuse of hindsight. For those familiar with the Chief Medical Officer’s adoration of airline safety, you may be aware of the concept of early warning systems – now a critical component of clinical governance. Indeed it is beholden on clinicians to forewarn senior managers if problems are likely to arise.You may think we have been here before with MMC. According to E-Health Insider and Computer Weekly, the Cerner care records system at the Royal Free is now subject to a 90 day rescue plan to remedy 22 major faults which have so far cost the Trust £7.2million. It can be a bitter pill to swallow to then read Dr Gordon

It’s time for the House Doctor to get personal and tickle your fancy with some anecdotes of NHS Human Resources practices. Logically, one would imagine that to keep staff motivated, enthused and loyal to their employer, some emphasis would be applied to providing timely documentation, clear communication and a personal touch. This may make staff feel ‘wanted’. Fine to rule with iron in a velvet glove, but there should be some velvet to soften the blow in the first place. Is that not a reasonable starting point?

“Please remember that in Bristol it was a lone voice that spoke out. You may hear a lot of reassuring words from IT and Training staff, but until there has been real end user testing in near real simulations, showing that the system ... does not significantly delay clinical and administrative processes of care by more than say 3% at go live, it would be foolhardy to proceed with such haste.” www.rukmag.org

When the House Doctor fashioned his exit strategy from the NHS in September 2007 following the intolerable dramas of the oft-mentioned MMC training debacle, he made considerable efforts to inform all relevant parties of his departure so that all loose ends could be tied up. In a round of emails, telephone calls and letters, he informed his Consultant, educational supervisor,Trust HR department, training scheme coordinator, Deanery staff and Royal College educational coordinator of his self-imposed exile for reasons of alternative ambition, mental health, and unremitting frustration. Done and dusted. Time to move on to the – garumph – private sector. Six months later, feeling fairly relaxed, slightly shocked at strange quirks of office culture and ruthless corporate types who do body stretches around the photocopier (yes, anthropologically it does bear a resemblance to a watering hole), the House Doctor receives a contract of employment to sign and return from his previous NHS Trust. ... six months after leaving their employment. The photocopier lurkers shake their heads in disbelief. But how can they expect to keep you if they treat you like that, they say? The House Doctor feels vindicated. Stuff ‘em. Several weeks ago, the House Doctor, having moved on to pastures new and projects other, returns to his old flat to find a personally signed letter from a Deanery Head of Department (and coincidentally a consultant on his previous training scheme) cc’d to another old consultant demanding to know why the House Doctor hasn’t filled out some shitty form.This, a full 13 months after escaping the clutches of the said Deanery and a period punctuated by various emails in which the House Doctor has outlined, on at least two occasions, his career plans and change of address. The letter finishes with a suggestion that, "We suspect this trainee may have resigned." How perceptive.

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A NEW YEAR’S REVOLUTION

R-UK ISSUE 4

“I will provide a Public Service, not a Public Convenience.”

I will not open all hours, happily available to be dumped on by any passing, pissant politician or patient with the inclination. I will not have pennies, or anything else, shoved in my mouth, smile cheerfully and open my doors or my legs to order. I will certainly not pretend that I like it. I will not be handily available to deal with any and all bodily fluids man or woman may be heir to. Friends, I will not swallow.

I will not provide hand-washing facilities. It is not my problem to supply solutions, soapy or otherwise, to every grubby member, be these Members of Parliament or MRSA-ridden nether regions. Pontius Pilate can find another scrubber. I will not provide sanitary disposal devices. The elderly may well take up a lot of medical care but so they should. They are old; they are owed.They are people, not bed-blocking tins of beans. I will not help dispose of them nor help them dispose of themselves. BMA Ethics committee take note.

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I will not provide a mirror for morons. I will not reflect and reinforce their pathetic, self-pitying views of themselves in the bogus name of empathy. I will not provide medical validation of their assumed victim-status at the expense of the sick. I will not be society’s sympathysump. I will monotonously remind anyone ducking under my radar who isn’t patently ill, that they can choose to get a life. Maybe not the exact life that they feel their uniqueness deserves, but a life. I will not provide or become a ‘Speak-your-Weight’ machine. Fat people have generally noticed they are fat. Telling them the obvious, in the absence of any effective medical intervention short of bariatric surgery, is not my job. Lifestyle dictation and regulation are not my reasons for being. I will no more weigh and turn away the overweight in need of surgery than I would deny them antibiotics. I am not God, or more secularly, the external locus of control for an entirely screwed-up Western world. I will not allow Bill Posters to stick anything up, in or on my pristine surfaces. In particular, I will not allow him to advertise services that cannot be, should not be, or are not provided. Unless of course this is a strictly private arrangement

between me and my conscience. French classes after dark, maybe. An inadequate replacement for yet another trashed GUM clinic or the supervision of DIY abortions at home? No. I will not provide, or be, a shoe or soulcleaning apparatus. Wipe your clay feet on me and I will wipe the floor with you. I will not be dumped on. I will not clear up your every mess. I will not be used or abused.

I am a doctor. It takes the best part of 20 years to make a good one of me. So here’s a New Year’s message the MMC mafiosi might like to ponder as they continue to grind Junior Doctors into the dust. I am the only person qualified to define and delimit my remit. I am certainly the person best placed to decide how this remit could be fulfilled in a resourcelimited system. Love & kisses, A Public Servant

DISCLAIMER: The fact I am on call throughout Christmas and New Year has not in any way coloured my world view. That was Comrade Brown, in the library, with broad sloppy brushstrokes and great big buckets of hogwash.

Maureen Mull is a GP. For the last 25 years she has chosen to practice remotely. Patients are rarely allowed in the same building let alone the same room. She is on-call all of the time. This gives her much too much time to brood. She has a husband, three grown children, one of whom is a graduate medical student, an Art Gallery and decided opinions – lots of opinions. It is only the last of these she actively wants to share with you...

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The good old days? (continued) months, our futures depend on the vagaries of successive consultants.Tough luck if you end up with Sir Lancelot Spratt. The only possible way out of this mess is for the profession to accept its share of the blame.The problem isn’t simply one of hours.There’s a long-standing cycle of self-inflicted abuse that has become so ingrained into junior doctor culture that even patients cease to be shocked by it. The cycle will be impossible to break without a simultaneous overhaul of our training.The restrictive and secretive practices of the Royal Colleges must be replaced with openly restructured and team-based training, so that a whimsical prejudice doesn’t mean the end of a promising career. Consultant selection must have more to do with clinical competence and less to do with trouser legs. Training should be centred on one area, so doctors can establish a home base and a low-alcohol social life, and learn to fight their ground with consultants and managers alike. And working conditions should be well publicised so juniors can shop around for humane jobs while unpleasant ones remain unfilled.

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None of this is likely to happen overnight.The Government, too, has become so blinkered that many long-term improvements are being sacrificed on the ill-advised altar of waiting lists uber alles. But only tradition bars doctors from being supportive of each other. And if we swallowed our egos, we’d get a lot more sympathy. So, what can we learn from all this? Firstly, I guess, to be careful what we wish for.The junior doctors’ hours campaign was actually pretty effective to the extent that many trainees are deliberately now flouting the law and working longer hours than they’re paid to get the experience. Clearly the pendulum, with the EWTD behind it, has swung too far the other way. But the need for humane attitudes, team based training in nearby locations and a life outside medicine remains as strong as ever.The one thing I’ve learned as a journalist is that you have to keep banging away at the same story for years to get things changed. I’m a long way past being a junior doctor, but the cause remains close to my heart so if you fancy venting your spleen in Private Eye, drop me an email. Confidentiality assured, all letters answered, photo appreciated. Happy Christmas.

Phil Hammond hamm82@msn.com

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R-UK Issue 4 - What to get the NHS for Xmas  

The Christmas issue of R-UK

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