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R-UK

The magazine from RemedyUK

Issue 3 - October R-UK ISSUE2008 3 www.rukmag.org

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

Time to reclaim our profession? A whiff of foul play at NHS Highlands...

Also inside: Clive Peedell, Scatgate, Phil Hammond, Karol Sikora & Andy Goldberg David Nicholl and Cameron – House Doctor – Dr Beat – Ben Goldacre’s new book www.rukmag.org


R-UK ISSUE 3

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EDITORIAL

R-UK ISSUE 3

Welcome to the October issue of R-UK magazine

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would like to offer my sincere thanks to all the contributors who have provided their time and thoughts for free, asking nothing in return (apart from the odd book plug) and working purely on the basis of goodwill. It has been an enormous effort to get this publication up and running. But now, I hope, its purpose and identity are taking shape. When Hospital Doctor was pulled by Reed Elsevier in late 2007, a yawning gap was left. Nowhere was there a platform for doctors to articulate their views on issues that mattered exclusively to them. This was despite an almost unprecedented dissatisfaction within the profession about their working lives, the fall out from MMC, and the multitude of other issues that appear to have subjugated an erudite and capable group. A disaggregated plethora of blogs and forums have filled the vacuum, but many are fuelled by rumour and lack the reach and robustness of an edited publication. Meanwhile formal journals cater for an international audience and primarily publish academic research. You will see no references or significant articles on academia in R-UK. This is entirely deliberate. Nothing written here will make its way on to Pubmed. This is not a “publish or perish” rag. However, I would like to think that the wit and heritage of individuality within the profession can find a place here, and that debate can flourish. It is true that medicine is a conservative world, but this coexists with a seam of libertarianism that is currently enduring tough times. It is unedifying to see a group of people who care passionately about their work, rendered voiceless and enraged. This magazine is, I hope, the start of a reversal. Unashamedly partisan, it is run by volunteers, takes no pharmaceutical advertising, and is completely free both online and in hospitals. It will survive only if supported by its readers and grows from the grassroots. If you like it, then tell your friends and colleagues. If you would like to contribute, email editor@rukmag.org In the meantime, put your feet up, make yourself a cold beverage, and enjoy. You deserve it.

Jamie Wilson Contact R-UK at R-UK magazine, The RemedyUK Office, 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 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 express permission of the editor. The views expressed in R-UK magazine, in print and online, are those of the authors specifically and are not necessarily those of RemedyUK.

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Contents

Issue 3 – October 2008 4 6

8 10 11 12 14 16 17 18 19 20 21 22 23 24 26 27

RemedyUK on MEE, MRCS, Unfinished Business Lindsay Cooke: Aux armes médecins? The fallout from the Dr Scot Junior affair and history of the medical politician Clive Peedell Silence is Golden: Consultants and CEAs Karol Sikora: Private Medical Schools – a step too far? Deborah Powell: New Zealand Bound? Andy Goldberg on the the future of innovation in the NHS David Nicholl recounts his interview with David Cameron for Panorama Richard Marks decodes the mysterious world of workforce planning R-UK on Medpedia Matt Green gives some tips on a winning CV Nick Edwards: Nun on the run Book Review of Ben Goldacre’s Bad Science Dr Beat on scat Phil Hammond: how not to get sued Diary of an HSMP House Doctor and various trivia Maureen Mull Anaesthetists’ Corner: Neurosurgeon’s sudoku, Competition and Remedy Detectives

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

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REMEDYUK NEWS

R-UK ISSUE 3

The new MRCS Exam: the college responds

Ben Dean poses some questions to the new Head of the Intercollegiate Board of basic surgical examinations

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Ben Dean

hris Oliver, the new chairman of the Intercollegiate Board of Basic Surgical Examinations (ICBSE), has kindly responded to some further questions on the new MRCS.

Question 1:

Does the College anticipate that the new unified MRCS exam will be as rigorous in its selection as its predecessor which was divided into two parts? Does it expect the pass rate to be similar to the old exams combined?

CO: The exam will be as rigorous. The same level

of syllabus is being used as the “Old” MRCS. We do not know what the pass rate of the new exam will be as yet. We await the results next month. There will be a complex standard setting exercise to be performed on the results of the new exam in mid October. It would be expected however that the pass rate may be broadly similar between the old and new exam. The new exam is much more sophisticated in respect of being an assessment tool. No assessment tool can be perfect but the new exam should be much more robust, reliable and defensible than previous versions. Its statistical reliability should be much higher, certainly from the pilot OSCE exam held last April it looks to be a more reliable exam. i.e. for a first time candidate: the combined percentage pass rate for the old MRCS (%MCQ x %clinical/ viva) at first sittings = new MRCS pass rate. – Yes, I would expect to be broadly similar, however we await the results. The final results we be announced early in November.

particular sub-specialty will allow a candidate to be less reliant on marks gained outside of their subspecialty area.

CO: Speciality elements in the new OSCE exam are new. It will not make the exam any easier to pass but will be more relevant to trainees on themed or run through training.

Question 3:

Will the Royal College release statistics detailing the various pass rates for the old MRCS exams so that they can be compared to the new exams pass rates?

CO: An equivalent pass rate would reassure us

that the exams are of similar rigour. One of my wishes as the new chairman of ICBSE is to make the whole MRCS examination process transparent. We will produce data on the new exam in the next annual report. I would expect we will make some preliminary report about the utility and pass rates of the new exam later this year. I will get the Internal Quality Assurance Group of ICBSE to start dissecting this new exam as soon as we get the results in. We will have a detailed meeting to discuss the analysis of the results later in November. We also now are required by PMETB to collect data on Year of training and deanery.

Final comment: Overall I am encouraged by these responses, however I still feel the new speciality elements do represent a dumbing down of sorts. I shall await the new pass rates with baited breath and look forward to a more transparent process in the future.

Question 2:

The new MRCS exam allows for candidates to sub-specialise. Does the College think that this will make it easier for a candidate with less all-round knowledge and skills to pass as the new exam? This question follows the logic that a greater weighting on one

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REMEDYUK NEWS

MEE: a lost opportunity? The devil in the detail reveals a disturbing volte-face

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eaders will be aware that MEE (Medical Education England) is a new board – conceived by Sir John Tooke, nearly shot down by the Health Select Committee, then recovered by Lord Darzi – in whose hands lies the future of specialist medical training in England. MEE represents an opportunity for the profession to learn the lessons of the past and steer the beleaguered classes of 2009 onwards through troubled waters such as dwindling training years and a decimated working week. Even some of the more cynical parts of the profession dared to dream that the recent, very public exposure of UK medicine’s ingrained strategic paralysis might, in the end, result in a long-overdue, fresh approach to structure, representation and accountability through MEE. This week the first signs appeared of what our strong guardian body will constitute. Advertised by the Appointments Committee is the vacancy for the body’s new Chair (Job code DH8087 on their website). The application form reveals a key point that was hitherto unavailable to the casual observer:

MEE is ‘advisory’ rather than ‘executive’ because it does not have executive functions. It will provide independent expert advice and input into the policy-making process. It will not have a staff, but will be supported by a secretariat from the Department of Health. The unimpeachable truth that emerged from the thousands of hours of analysis in the Judicial Review, the Douglas Review, the Tooke Review, and the Health Select Committee was the lack of clarity and direct lines of responsibility in recent training reform. And the solution unveiled to us this week is an advisory board of ‘experts’ to ministers.

R-UK ISSUE 3

Unfinished Business

An update on the accountability campaign

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s this magazine goes to press, the final touches are being applied to the GMC letter that asks for accountability for the fallout of MMC. More than 1600 signatories have added their names and going by the comments submitted to the Remedy website, the feelings are as raw as ever. Some people have posed the question: why not let sleeping dogs lie? Would it not just be better to leave things be? Why rock the boat any further? Of course, that is a perfectly reasonable outlook if you still have a job and your life has not been turned upside down by this debacle. Pretty much every investigation, considered newspaper article, enquiry and more have been scathing and incredulous about this project. A paper trail extends well back into 2006 highlighting serious deficiencies in the project management. Some senior figures have been noble enough to admit the mistakes and fall on their sword. Not so, the others. As Clive Peedell describes in this month’s editorial, the ‘MMC juggernaut’ ploughed on regardless. The Department of Health continues to block Freedom of Information requests for the Sept 2006 Stagegate review, despite the ‘red risk’ warning lights it flagged up. A study published in the BMJ by the Dean of the Royal College of Psychiatrists estimated that 20% of trainees enduring MTAS experienced suicidal ideation. This is 20 times the baseline population rate. Then factor in the mass exodus to other careers, the antipodes and other exit strategies, and you begin to wonder what crime doctors in management positions should be accountable for. No doubt, some people believe Remedy are troublemakers, out to seek revenge through a radical form of politicking. But when you receive emails and phone calls on a daily basis from professional people, who have already made longstanding sacrifices, and are now hopeless, angry, and depressed, it is hard not to think that something needs to change.

Leadership currently seems to be the scarcest resource in English medicine. The MEE envisaged by Sir John Tooke was an opportunity for true leadership to emerge – someone with the courage to take on the responsibility of an executive body entrusted with the future of training. Advisors cannot be leaders. One wonders how this passed by the Programme Board without a struggle. One wonders what Sir John will say.

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OPINION

R-UK ISSUE 3

Aux armes, médecins?

Lindsay Cooke is talking about a revolution

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began writing this the day after the medic who has become known as Dr Scot Junior returned to work following six weeks’ suspension. His is only one recent example of what could politely be termed an over-reaction to criticism by those in positions of power within medicine. It is not the most shocking incident, hard as that may be to grasp. But it has been pretty much unprecedented in the way it has mobilised grassroots doctors in a manner that hasn’t been witnessed since the heady days of the Remedy march. For those who are unfamiliar with the story, Dr Scot, a surgical Registrar in Scotland, made some derogatory remarks using scatological language about Dame Professor Carol Black, President of the Association of Royal Medical Colleges, on the internet forum DNUK. The remarks were removed after a few hours, but they had allegedly been read by Professor Elisabeth Paice, Dean Director of London, who reportedly found them so objectionable that she contacted Dr Scot’s local Dean, Dr Gillian Needham, who promptly facilitated his suspension. An outcry ensued on DNUK, with speculation as to what he’d written that was so appalling as to expedite such a harsh outcome. The Sunday Times subsequently took an interest, only for the story to fall by the wayside when Dr Scot’s suspension was lifted. Several provincial publications and the BBC’s PM programme ran pieces, and Dr Tim Ringrose, Medical Director of DNUK, was forced into defending his organizationin a radio broadcast. His suspension having been lifted on a Friday and due to return to work on Monday, Dr Scot was then resuspended before he could reach his hospital. There are allegations that the second suspension related not to his DNUK post but to an incident when he was a medical student eight years earlier. As news of the resuspension spread, the DNUK forums were alive with fury and fear. The medical bloggers taunted the architects of Dr Scot’s downfall with language of unparalleled filth and vitriol after the actual words used by Dr Scot were published. They were revealed to be: ‘fucking shit*’. Letters were drafted, signatories sought and expressions of outrage were sent to the CMO Scotland and Scottish Health Minister. Dr Scot has not spoken publicly about the circumstances surrounding these events, apart from stating on DNUK that it confirmed his suspicions that medical leadership was ‘weak’. Dr Scot’s personal nightmare is over, but the underlying issues remain. They relate to principles such as the right to free speech, the nature of leadership, the concept of proportionate punishment, and abuse of power. It would be tempting to imagine that the removal of Professor Paice and her perceived allies would solve the problem. I don’t believe it will. Something is rotten

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in both the culture and structure of the profession. As a result, its soul is slowly withering away. The profession needs to be reclaimed now, or there is a chance that the intellectual autonomy fostered over centuries will be lost forever. As an outsider, here is my analysis of what is going wrong and how it can begin to be put right. Until MMC, the apprentice had always learnt at the feet of the master in a clinical hierarchy based on merit and experience. This was generally respected and most understood their rights and responsibilities. Those at the apex of this clinical hierarchy formed the leadership of the profession, either by acclamation, length of service, or through the selection of their peers. With the founding of the NHS in 1948 a new, powerful partner entered the equation: government, of whatever political complexion. The BMA’s tooth and nail opposition to the founding of the NHS may well have been about protectionism, but time has not necessarily proved them wrong. Medicine could no longer stand apart exclusively on its own analysis and sense of priorities, and a power struggle between the often conflicting aims and values of the profession and incumbent government began. This tension will continue for as long as health care is a public service. Government involvement with the profession has seen the inevitable emergence to positions of authority of a new type of medical ‘leadership’ – the medico-political doctor. Frequently appointed to positions of considerable influence, these individuals came to share the values and ideological drive of the government of the day. Necessarily, these new leaders are increasingly divorced from the realities of clinical practice and the concerns of grassroots doctors. An alternative career path beckoned – their success or failure dependent on their political masters rather than peer recognition. A power structure had been devised, allowing minimal allegiance to the profession to whom they have only secondary loyalty at best. Dislocation between leaders and the led became inevitable.

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OPINION The journey that leads to today, to MMC and to the Dr Scot issue began with what the profession perceived as direct government ‘interference’ in its internal workings under Margaret Thatcher, and continued incrementally almost under the radar until 2006. During this period, the profession’s traditional leadership was infiltrated by medico-political doctors. Those who warned or turned whistle-blower were marginalised or silenced. Control of the profession was gradually assumed by government through legislation and regulation, through the setting up of quangos like CoPMED and PMETB, and by the new ‘leadership’ of government appointees. In the interim, scandals like Shipman and Alder Hey had shaken the profession’s confidence in itself and the public’s confidence in the profession – despite trust in ‘my doctor’ remaining resilient at over 90%. Government response was to legislate and regulate, and the profession’s to keep its head well below the parapet. Subjected to public mistrust and government propaganda, and increasingly policed and punished rather than protected by its new leadership, medicine in the UK became a place where you kept your head down and mouth shut, or you risked the consequences. The paternalism of the past was gone. The schism between the grassroots and medical ‘leadership’ was pretty much complete. And then came MMC. To its architects and fellow proponents, MMC makes perfect sense because it is the product of the dominant ideology they share with their political masters. To the grassroots doctor it is anathema because it tramples on the indefinable but integral art and craft of medicine and the human interaction that lies at the core of every doctor/ patient interface. In its place emerges a mechanistic, disease-defined approach to the alleviation of symptoms, and the notion that doctors and patients are interchangeable cogs in the medicine delivery machine. As a consequence there is now almost no common language between them. The frustration and fury felt by so many, and the protectionism, failure to listen, and good old-fashioned bullying being practised by their leaders are symptoms of this yawning gulf. Even genuine efforts at communication by members of the new MMC Team and decent people at the Department of Health are doomed to failure because no common language exists. Call me old-fashioned, but I have both respect and awe for your profession. What you choose to do seems to me extraordinary. I cannot think of anything more worthwhile than to devote your working life to the service of others. The thought of the responsibility you take on daily terrifies me. But I continue to maintain, in the face of those who accuse me of terminal naivety, that the practice of medicine is a vocation and that to choose medicine as a profession is an act of real nobility. So why is UK medicine and its methods of training, which have evolved over 500 years to be the envy of the world, being permitted to be inexorably dismantled? It is hard, without structures of representative democracy to hold your ‘leadership’ to account. It is

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R-UK ISSUE 3 hard to fight at all after last year with the ongoing traumatic impact on so many lives and dreams. Where do you begin? How do you come together? That’s what Remedy is attempting to provide. The only reason for our existence is to be a voice for grassroots doctors. Our mission statement defines our primary aim ‘to provide a channel for the stifled voice of grassroots doctors’. Our focus for 2008 and beyond is to reclaim the profession and democratise it. The Joseph Rowntree Reform Trust Ltd has enough belief in our determination and ability to deliver that they have made us a grant of £25,000 to begin the process. Last year, Professor Stephen O’Rahilly of Fidelio called Remedy ‘a Prague Spring’ - an epithet that managed to be both flattering and worrying at the same time. After all, the Prague Spring failed when the Soviet tanks rolled in. But the Prague Spring was followed by the Velvet Revolution, which succeeded in establishing democracy. So join us and channel your opinions on the monumental changes taking place through our infrastructure. Venting helpless rage on an internet forum, you achieve nothing. As individuals we are isolated and weak. Together, we can effect change.

Lindsay Cooke is the founder of Mums4Medics and co-chair of the RemedyUK committee. The illustration is Eugene Delacroix’s Liberty leading the People

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OPINION

R-UK ISSUE 3

Silence is golden ...

Clive Peedell, outspoken critic of government health policy, member of the BMA Council and HSCA executive, speculates on why seniors kept quiet during MMC 2007

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he MMC/MTAS debacle has been one of the most damaging episodes in the medical profession’s history. The fact that we had a Judicial review, the Tooke Enquiry, and a Health Select Committee Enquiry into MMC/MTAS is a testament to the gross injustices this process had on the lives and careers of thousands of junior doctors. That senior members of the profession facilitated and promoted this shambles is hard to stomach especially because many doctors, including the BMA JDC, saw the problem coming long before the crash. Unfortunately the dissenting voices were too few, too weak, and too late.

consultants cannot and should not be blamed for the lack of support that junior doctors received during the MMC/MTAS debacle. But what about the Consultants who did know what was happening and were intimately involved in the process? After all, senior doctors were heavily represented as MMC team members, PMETB members, Royal College tutors and officials, Deanery staff, and Programme Directors. One has to ask questions as to why they allowed this unjust and flawed system to proceed. Concerns were raised by some of these doctors, but very little corrective

By the time RemedyUK and Fidelio came along, the MMC juggernaut could not be stopped despite some heroic efforts. I first realised there was a major problem back in 2006 when I heard a lecture by our Regional Tutor explaining the plans for MMC. I was gobsmacked and decided to use the Trust e-mail system to get the views of my Consultant colleagues. I received about 10 responses from about 250 consultants, which immediately made me realise what we were up against. Those who replied mainly agreed that the proposals were problematic ‘the MMC juggernaut could not be stopped despite some heroic efforts.’ and unfair, but the ‘horse had action was taken. Why didn’t they do more to bolted’, and it would be futile to try and stop the stop the MMC juggernaut? I think some of the reforms. This upset me and I decided to use DNUK to explanation lies in due to the fact that Consultants see what others felt around the country. I made my are very well paid, enjoy a high standard of living, first ever post on the 9th August 2006 and entitled it: have excellent job security and are entitled to a “MMC: Message for junior doctors - you are on your generous pension. This just happens to be the own”. I think this turned out to be fairly prophetic. perfect environment for the cultivation of a ‘sticks and carrots’ culture aimed at controlling the I have thought long and hard as to why Junior behaviour of consultants. This culture is bolstered Doctors got so little support from their Consultant by the leverage afforded by the Clinical Excellence colleagues during this period and have come to Awards (CEA) system. This system is supposed to the conclusion that the reasons are complex and reward consultants who can demonstrate that they varied. To be fair to the consultant body, I think have delivered over and above their obligatory that most were unaware of the full implications and NHS commitments through teaching, training and consequences of MMC/MTAS. A lot of the details research, management duties, leadership roles, about MMC/MTAS came out very late on and when service development, and proof of high performance. the message eventually got through about how unfair the system was, many felt it was simply too late A scoring system is used to assess a submitted to do anything to stop it and the best way forward CV and if enough points are gained, a CEA can would be to embrace it and do their best to make it be awarded. There are 12 levels of CEAs (see work. This is why an attempted boycott of consultant below), the highest being the Platinum award interviews failed. I think others were just too busy worth approximately £74,000 per annum on top with their jobs and everyday lives to get a full grip on of NHS salary. These awards are also pensionable. what was going on. Again, I have complete sympathy The last 4 levels are national CEAs and require the with this. There was a lot of MMC jargon that individual to be on the national and/or international increased confusion and turned people off. We also stage in their field. There are regional and national should not forget that some consultants thought that committees that decide on who gets the awards (see MMC was a genuinely good thing, although surveys table 2). Just to put it into perspective, I currently indicated that this was a minority opinion. I have have just 1 CEA point worth £2,900 per year but therefore taken an overall view that the majority of

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OPINION

R-UK ISSUE 3

this will net me £87,000 by the time I’m 65 and will be worth £1,450 a year (40/80ths) as pension! I’ve applied for another point this year. It doesn’t take a genius to work out the long term value of the National awards.

Clinical Excellence Awards (CEAs) 2008/9 rates. Full Time Platinum L12 – £74,676 Gold L11 – £57,443 Silver L10 – £45,955 Bronze L9 – £34,956 L8 – £29,130 L7 – £23,304 L6 – £17,478 L5 – £14,565 L4 – £11,652 L3 – £8,739 L2 – £5,826 L1 – £2,913 Residing on national committees and working parties is one way of getting national awards. It is common for one important committee position to lead to another which will score more points. Many of the doctors involved in the delivery of MMC are on such committees and have reached national CEA levels. I don’t begrudge them these awards because they have worked very hard to get themselves into these positions. But this brings us to the crux of the matter. As these positions are so financially valuable, then why risk losing them by becoming a dissenter? What would protesting actually achieve if you did it alone? You would need to get a majority opinion to make a difference, but that would mean discussing it with others on the committee – but how could you trust them not to betray you if you were trying to rock the boat? After all, they have their own reputations and positions to look after. This is the culture of the medical establishment, which allows governments to control the medical profession. The Honours system is additional mechanism. I believe this culture of the medical establishment explains why we have seen highly intelligent, well-informed and respected

senior members of the medical profession leaving junior doctors to rot and suffer the grave injustices of MTAS/MMC. This is why we have seen a selection process that resulted in our most experienced junior doctors, with their postgraduate exams in the bag, being the least likely group to get ST posts. The knock on effects of this are truly awful because experienced doctors deliver higher levels of patient care than their more junior colleagues and are also vital for the delivery of medical education. This has also resulted in ‘wasted learning curves’, especially amongst our junior surgeons, all of which has clearly been detrimental to patient care. Having said all this, can you really blame the senior doctors in power? What would you do if you were in their shoes? The bottom line is that if you keep quiet and do as you are told, you’ll reap the rewards. Dissent and protest at your financial, professional, and personal peril. I’ve started praying for my next CEA. Silence is Golden.

ACCEA Main Committee Members 2008 Chair Professor Jonathan Montgomery Medical Director Professor Hamid Ghodse Ex-Officio Members Professor Sir Liam Donaldson Chief Medical Officer, Department of Health Mr David Nicholson, Chief Executive, NHS Mrs Clare Chapman, Director General Workforce Development, Department of Health Professional Members Dame Carol Black, Chair Academy of Medical Royal Colleges, President of the Royal College of Physicians Professor A P Weetman, Dean-school of Medicine University of Sheffield Dr Jonathan Fielden, Consultant in Anaesthesia and Intensive Care Medicine, Chairman of the Central Consultants and Specialists Committee BMA Employer Representatives Mr David Astley, Chief Executive, St Georges Hospital NHS Trust Dr Frank Harsent, Chief Executive, Gloucestershire Hospitals NHS Foundation Trust Vacancy Lay Representatives Mrs Gillian Turner, National Co-ordinator for the CJD Support Network. Miss Jane Kelly, Management Consultant Mrs Madeleine Wang, Patient Advocate and Carer National Assembly for Wales Representative Mrs Ann Lloyd, Director of Welsh Health and Social Care, National Assembly for Wales

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OPINION

R-UK ISSUE 3

Privatising medical education – a step too far?

Karol Sikora, an oncologist and Dean of Britain’s embryonic and only independent medical school, considers the challenge of taking medical education into the private sector

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combination of ageing populations and improved technology has driven a global revolution in healthcare. The demand for skilled doctors is inexorably rising in all societies. Believe it or not medicine is still a popular career, with many more wishing to become doctors than can secure places training, especially at graduate level. The UK has recently seen a remarkable expansion of medical places in its exclusively state funded Universities. But last year only one in six suitably qualified graduate applicants was successful in obtaining a place on a four year programme in the UK.

in previous study and work performance, compared with the complex value judgements inherent in assessing young people from under-privileged backgrounds. During the 1970's the demand for medical school places in the USA far outstripped supply. This led to the development of many off-shore campuses in Caribbean islands. There are now over twenty such schools in operation, mainly catering for US citizens who have been unsuccessful at gaining entry to a school in their own country. Their aim on graduation is to re-enter the US system by taking the examinations for foreign medical graduates to obtain a physician's licence. The course formats are similar to those in the US; an intensive four year course carried out partly in the Caribbean using local healthcare facilities and through further attachments to US and European hospitals.

There is growing global demand for medical training that will far exceed the supply of places. In the developing world there are huge shortages of skilled physicians and many try desperately to leave to more affluent neighbouring countries. There are currently ‘During the 1970’s the demand 21 UK medical schools. The recent expansion has come for medical school places in about by creating extra places the USA far outstripped supply. in almost all existing schools, establishing four new schools, This led to the development of creating four new centres of medical education associated many off-shore campuses in with existing schools, and a Caribbean islands. There are new graduate entry 4 year programme at 13 schools now over twenty such schools in since 2003.

operation.’

Recent government initiatives have concentrated on increasing access to medical education to diversify the social, ethnic and intellectual base of student entry. This is being attempted by the creation of social outreach programmes for the disadvantaged. Another strategy has been to encourage graduate entry to four year programmes - the standard course offered for many years in the US. Graduate programmes are an attractive way of diversifying physicians as success and motivation are more easily benchmarked in those achieving excellence

The business model for these off-shore schools is opaque but the tuition fee structure is broadly comparable to US medical schools, whilst living costs for the off-shore component are significantly lower. Considerable effort is channeled into securing reentry residency appointments at relatively unpopular US hospitals through direct networking. The quality of the staff, facilities and teaching is difficult to assess as the schools make no comparative data available. However, the level of quality is likely to be significantly lower than that found in the mainland US or in the UK. St George's, Grenada, the largest School, has over 3,000 students, well equipped facilities and an impressive array of visiting teaching staff. St George's is a for-profit institution similar to most of the Caribbean schools. They have been created by

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OPINION investor groups that are now reaping considerable financial rewards. One estimate suggests that one of the schools is making more than US$50m profit per year. US tuition fees are considerably higher in the leading private universities compared to State Universities but living costs are broadly equivalent to the UK. Current comparable University of Buckinghamshire Medical School fees and living expenses for a four year course would be £200K. We are planning to create a first class British school, but the very existence of the Caribbean schools indicates global market demand for places. There are several schools in Europe which run specific international programmes in English or German as well as the host country language. The two most established are The Semmelweis University in Budapest, Hungary and the English taught Charles University, Prague, Czech Republic - both with an intake of around 200 foreign medical students. The German course is six-fold oversubscribed and the English course twice. Approximately half the German students leave after the preclinical phase to join German clinical schools whilst the English course students complete a full 6 year traditional programme. The Charles University course is becoming increasingly popular and is now expanding to three sites within the Czech Republic. Fees at both European schools are between US$10 - 20,000 per year. On May 1st 2004 Hungary and the Czech Republic became new member states of the European Union. This means graduates are fully qualified and able to enter the UK physician job market without further assessment or work permit. It would appear that there is a huge opportunity for an independent not-for-profit medical school in Britain, to create an internationally recognised medical training programme in the UK for both domestic and international students. The demand for places in both groups will continue to far outstrip supply. The location will be far preferable than the relative remoteness of the Caribbean islands or the need to learn a second language in Prague, Budapest or Moscow. A first class, fast-tracked, fully GMC approved training programme, is likely to become a global leader, as a UK medical qualification is widely recognised by international health regulators and is valid across the European Union. Independence from the traditional University system and the ability to create imaginative clinical placements around London could lead to new teaching methods to drastically reduce the costs of medical training.

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R-UK ISSUE 3

New Zealand bound?

Deborah Powell, General Secretary of the NZ junior doctors’ union, offers some words of wisdom

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n New Zealand, junior doctors (known here as resident doctors or RMOs) are represented by our own organization, NZRDA. NZRDA aims to protect and enhance the interests of RMOs. We represent our members on many different issues, are a registered union, and negotiate the RMOs’ employment contract. Despite 15 months of negotiation, we have failed to settle this contract which has resulted in national strike action on two occasions – with potentially more to come. This action has taken the form of a complete withdrawal of labour for two 48 hour periods 2 weeks apart.

At the forefront of our problems is the medical workforce crisis. Our reliance on overseas trained doctors was amongst the highest of all OECD countries – making NZ highly dependent on a volatile international labour market. Moreover, we have high vacancy rates which the locum market has responded to. It is unsurprising that many RMOs are leaving permanent employment to locum for fewer hours and more pay – naturally this leaves gaps, and the increasing demand on remaining staff further pushes people towards the locum market Some have commented that our conditions are so much better than the NHS – so why are we complaining? Our conditions have only been gained through collective activity through NZRDA – and as we will never have a ‘perfect’ contract, more work will always need to be done. There has also been some concern from UK doctors based in NZ that the government is heading down the same poorly conceived ‘Modernising Medical Careers’ route. Talk of an ‘employment framework for RMOs to best meet the needs of the public’ sounds worryingly like what has befallen the NHS. If you are thinking of coming 'down under', you might want to keep track of where we are at with this ongoing dispute. You will also have to be careful about what you are being offered: NZRDA has already assisted a number of UK graduates who have arrived in NZ and found things are not as they had been told. NZRDA is available to advise and assist on your request – we have a UK grads section on our website (www.nzrda.org.nz) or you can email us directly at secretary@nzrda.org.nz.

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ANALYSIS

R-UK ISSUE 3

The Future of Innovation in the NHS

Medical Futures founder, Andy Goldberg, issues a rallying call for entrepreneurship in the health service

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usinesses don’t fail because of the decisions they make. They fail because they don’t deliver the decisions they make. Remember that statement. Andy Goldberg Right now, you are probably thinking that I am some crazy medic who’s just finished a compulsory management course. Not true. To be fair, I have done a management course, a few years back granted, but being taught about management by a manager of a Trust that had been in the red for 2 years wasn’t my idea of inspiration. In business, it doesn’t matter whether ‘The NHS has you decide to start a refuse collection more brains service or a high tech per square foot nanotechnology drugdelivery business; either than any other can be highly successful organisation in or a huge flop. The main differentiator is that the world.’ flops happen because the management team fail to execute the business plan. The reason I urge you to remember my quote is that at some stage in the future, an idea that you are involved in, is likely to flop and it is only then that you will believe what I say is true. Now let’s turn our attention to the NHS. To many, the words NHS and Innovation are an oxymoron. Don’t get me wrong. I am an avid supporter of the concept of the NHS. I dedicate most of my time to it, but you cannot get away from the fact that NHS culture is woven from a patchwork of sub-cultures, power centres and over-inflated egos, where leadership is lacking, blame is an ideal, and risk is a swear word. Innovation is about two words - implementing change. It doesn’t mean that the ideas are new. It doesn’t mean that the changes are necessarily for the better. It simply means daring to do something different. On that score, the Government, the Department of Health, and the NHS executive, deserve a huge award for innovation, as not a month goes by without a new change or directive being fired down to the front line. As I said before, innovation doesn’t necessarily mean it is better, and unless we create an organisation that can evaluate Government directives in the same way the National Institute of Clinical Evidence (NICE) evaluates drugs, then the world will remain an unjust and unfair place. Why do I say this? Well in 2001, the NHS Modernisation Agency was established to

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modernize services and improve experiences and outcomes for patients. Soon afterwards the NHS University was created as was the NHS Leadership Centre. The then Minister of Health, John Hutton stated, “The potential of this organisation to change the culture of the NHS cannot be underestimated”. Actually, John, there was quite a lot of truth in that statement. In 2005, another Minister, John Reid, decided to close down all three organizations as part of an Arm’s length body review, for their complete ineffectiveness. Niall Dickson, Chief Executive of the King’s Fund, was quoted at the time as saying “Too often the government’s solution to every problem has been to establish an agency, with the result that the NHS has been drowning in an alphabet soup of acronyms.” Well done Niall, a victory for common sense. Or was it? Immediately afterwards, a decision was taken to create a new organisation, the NHS Institute for Innovation & Improvement (NHSII). All the same people were offered to reapply for their own jobs and a business plan was written that looked remarkably similar to that of its predecessor. And so on it goes. Remember my quote about executing the business plan. Ideas are two to a penny. Gone are the dot.com days where an idea and a £15 website was valued at £1m. Nowadays, the only thing that matters is delivery. The NHS has more brains per square foot than any other organisation in the world, save the Chinese army and possibly the Indian railway service (maybe I should choose a new metric like weight of neurons per cubic ounce of cortex, so we are on top). I guess what I am trying to say is that the NHS possesses more intellectual capacity to develop services and technologies that improve patient care, than any other organisation in the world. Whilst there are pockets of excellence across the NHS already doing this, the standards of care are not uniform and whilst we thought up penicillin, hip replacements and MRI scanners, it is the Japanese that develop them and the Americans that sell them back to us. The process of generating a new solution is the same whether it is a service, a technology or a new drug. You conceive the idea; you develop the concept; you prove the concept (ensuring that it overcomes whatever regulatory barriers it faces); you make it available to all that need it; and then you use whatever tools you have at your disposal to make it clear that your customers should use/buy it. For a new drug, that process takes 10 years and costs close to a billion pounds. For a service it might not cost too much, but could still take a couple of years and require quite a bit of sweat and buy-in from the powers that be. And as for inventing a medical device, that might be somewhere in between.

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ANALYSIS So why doesn’t the NHS pump out brilliant world changing ideas on a regular basis? Well apathy and aptitude are two of the most common reasons. As doctors we tend to be entrepreneurial virgins. Most of us lack any training or knowledge of how to convert a great idea into reality. The world of patenting, business planning and venture capitalists is alien and best left to someone else. Faced with this ‘knowledge gap’ and a busy work schedule, it’s so much easier to do nothing, than to embark on an unknown journey without a guide or a map. Add in the bureaucracy and red-tape that occurs when you try and change the NHS monolith and it is quite easy to see why change doesn’t happen easily.

‘As doctors we tend to be entrepreneurial virgins. Most of us lack any training or knowledge of how to convert a great idea into reality.’

R-UK ISSUE 3 I’ve decided that the best way to effect this would be through the creation of a new body and I’m going to recommend this to the Government. I believe it should be a sub-organisation within NICE. My organisation would be called the “Innovation Delivery Evaluation and Assessment” Unit. So there you have it NICE IDEA. The potential of this organisation to change the culture of the NHS cannot be underestimated. Andy Goldberg MD FRCS(Tr&Orth) andy@medicalfutures.co.uk

Andy is an NHS Orthopaedic Surgeon and also helped set up the Medical Futures Innovation Awards, which is one of the UK’s highest healthcare accolades catalyzing and rewarding innovation by doctors. Andy regularly speaks at the i2 Events (Clinical Innovation and Insights), which are fora for doctors to learn how to protect, develop and fund their ideas. See www.medicalfutures.co.uk for more details.

I am always amused when top down initiatives are introduced in the NHS. Take ‘18 weeks’. This allegedly stemmed from two ministers sitting down over breakfast and agreeing that something needed to be done about the widely publicised 18 month waiting times. A scrambled egg and de-caffeinated coffee later, 18 weeks was born. “18 weeks sounds like 18 months but much sooner”, I can imagine hearing the Minister utter. Fast forward, three years and three billion pounds and the NHS is just beginning to attain its vision. Hang on, no one stopped to think that the same NHS consultants in their private practice are perfectly capable of running streamlined services in which 18 weeks would be considered long-term follow up. So why is it that no one thought to ask the Consultants to solve the problem? Well they did, but not the medical consultants, a different form of consultant. Management Consultants speak the same language as the civil servants, and hence are much more acceptable. Like most things in the NHS, the reasons relate to politics, bureaucracy, red-tape and, as exemplified here, language barriers. Enough said. I will finish on some good news. Lord Darzi is making more than £100m available to support innovation in the NHS. Compared to the £3bn spent on ‘18 weeks’ and the £12bn spent on Connecting for Health, its unlikely to make a huge difference, I hear you say. However, I am optimist and I believe that the most valuable and important collateral the NHS possesses is its people. They have all the answers, they have all the ideas, they just need a helping hand, and the right motivation to translate them into reality.

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OPINION

R-UK ISSUE 3

Meeting Dave

Consultant Neurologist, David Nicholl recounts his interview of the Tory Party leader for Panorama

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How would he deal with these challenges and how did he feel about NICE, rationing and top-up payments? I got a fairly bland response so I decided to focus on ‘big picture’ NHS stuff. According to his Tory party green paper, we should be aiming for the best quality care in Europe – our 5 year cancer survival figures are 45% (below the European average at 47%) and we should be aspiring for the European best, Sweden, at 60%. I asked how he would achieve this given that his party was offering tax cuts, yet Sweden, the example he cited, had one of the highest tax rates in the World at a staggering 57%. Did he not think there was a dose-response correlation?

n early September, I had the mother of all job interviews. No, I wasn’t applying for another consultant job. Panorama had asked me to interview the leader of the Conservative Party, David Cameron, on his plans for the NHS. Given that, according to the BBC’s chief political correspondent, Nick Robinson, I ‘had twice as long as Humphreys would have had on the Today programme’, I felt very lucky to be able to interview the man who is likely to be the next Prime Minister. So what did I make of him and what did I ask? Clearly, I didn’t feel the Lorraine Kelly/GMTV sofa approach was the right one for a politician. Nope, the Beeb had us both debating it out in the physio gym on our rehab unit for the best part of an hour.

Clearly no politician is going to state they are going to raise taxes, but I kept on at this, as it was not clear how he could offer tax cuts, First of all, David Cameron is a whilst increasing NHS spending nice man and likeable – he does His own experience of his ‘above the level of inflation’. He the politician bit well. Frankly son’s illness has made stated that he would do this by some of the journalist comments being more efficient and cutting about him are irritating. I don’t him adamant that the NHS back in other areas such as give a damn if he ‘once tried should be a top priority scrapping ID cards. He made it Pot Noodle’, but I do care how clear that the NHS should remain he will run the Health Service. and fully taxation based.’ a taxation based system with His own experience of his son’s no role for an insurance based illness (Ivan has severe epilepsy scheme. He plans to scrap ‘all targets including and cerebral palsy) has made him adamant that those for 4 hour waits in A&E’, which some A&E the NHS should be a top priority and fully taxation consultants had indicated to me had proved useful. based. I brought him to meet a patient of mine with Parkinson’s dementia on Rivastigmine, to point out He prefers to focus on health outcomes. I that given the improvements in life expectancy, questioned him on this and pointed out that he one of the major challenges facing us will be the needed to have validated measures of quality. In costs of care and drugs with an increasingly ageing the Tory party green paper, it is stated that this population.

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:

• • • •

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Cartoons Videos Music downloads Forums and comments

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OPINION

R-UK ISSUE 3

It was much less clear what he could be done at zero cost using would do if he was in the top existing methods such as ‘Google ‘I have my doubts that the job. In summary, he was very and Dr Foster’. This claim could NHS would be significantly nice superficially, but I remain not be taken seriously. Measuring to be convinced as to whether quality of care is something I think different under the Tories he had a grasp of the detail or all doctors will support but know than under Labour.’ how he really would finance the cannot be done at ‘zero cost’. I NHS as his ‘number 1 policy’. I didn’t get a clear answer on this. have my doubts that the NHS Cameron will continue with PFI but would be significantly different under the Tories ‘if the government takes the risk then the costs than under Labour – some may view this as a good should appear on the Treasury balance sheets thing, as the last thing the NHS needs is further and be transparent’. re-organisation. I would give him this though; it was an extremely brave move to be interviewed I asked him for his views on the private sector by a consultant like myself. If there is a challenge, in his own local hospital, the John Radcliffe, it is this: would Gordon Brown be prepared to go by pointing out the ridiculousness of a Ronald through the same process? McDonald House accommodation unit adjacent to the children’s unit. Not surprisingly, he didn’t have a straight answer on that one and how this My interview with David Cameron was broadcast at ties in with the government’s obesity agenda. I 8.30pm on Monday 29th September on BBC1 and can be didn’t get time to ask questions in relation to viewed on the BBC website. training, which I know will disappoint many, but to be honest, it was clear that whenever I asked a question that showed up the current administration’s inadequacies, he would pile in.

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ANALYSIS

R-UK ISSUE 3

Manpower planning – an existentialist approach

Richard Marks unlocks the mysteries of this otherworldly activity

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anpower planning in medicine is a dark and mysterious art that is difficult to get right. This is despite a great deal of time and effort being put into it by some very Richard Marks smart people. Their difficulty, as Harold McMillan put so succinctly, is ‘Events, dear boy’. Manpower planning works with such long timescales that unexpected and unpredictable changes are likely to occur over the years – changes in training, the organisation of health care, immigration policy, demography and the general patterns of disease can all throw spanners into the plans.

training was intended to maximise the efficiency of the learning process. But the introduction of too many non-training jobs into training programmes, coupled with the overriding demands of service and the WTD, has had predictably disastrous effects. A Department of Health ‘Dear Doctor’ letter sent in September summarises the position very nicely. ‘The introduction of run-through training in 2007 highlighted the fact that large numbers of core training posts/programmes exist primarily to support service delivery rather than to train the specialists needed in the future. The MMC Programme Board recognises this as a serious issue and supports the need for core and higher specialty training numbers to be better aligned, particularly, but not exclusively, in surgery.’

We are heading towards a cyclical U-turn in the numbers. During the last years of the 20th century there was expansion in both medical student and specialty trainee numbers. Politically this was encouraged by the drive towards self-sufficiency, without the need to import graduates from abroad, and the need to have patients treated by trained doctors rather than doctors-in-training. In addition the demands for shorter working hours increased the number of specialty trainees, all of whom were flowing towards consultanthood. MMC fuelled this even further. In July 2006 wheels were set in motion to convert non-training Trustgrade posts into training posts. The message seemed to be that all reasonable requests for NTNs would be met, with an emphasis on creating as many training programmes as possible. Again the motive seemed political. This expansion is now coming unstuck, along two separate fault lines. We can now see warning signs that more specialty doctors are being trained than we are likely to need, with the real danger of having too many CCT-holders chasing too few jobs. Having lived myself through the era of the time-expired Senior Registrar I have no desire to see it recreated. But a second problem with this expansion has also become apparent – the lack of adequate training material and the imbalance between service and training. Last week I met two junior doctors reduced to tears because they were not getting the training they needed. Their Trust had forced them to spend the bulk of their time doing work that was clinically necessary but was not part of their curriculum. Their log books were empty. One of the great educational claims underpinning MMC was the introduction of curricula. Streamlined

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‘Manpower planning is a dark and mysterious art that is difficult to get right... despite efforts by some very smart people’ 16


ANALYSIS So not only are there too many trainees but some of them are not being given an educationally sound training. And yet we cannot reduce the number of training jobs because of the service requirements and patient care.

R-UK ISSUE 3 ‘I met two junior doctors reduced to tears because they were not getting the training they needed. Their Trust had forced them to spend the bulk of their time doing work that was clinically necessary but was not part of their curriculum. Their log books were empty.’

An easy solution to this series of problems would be to reclassify some of the present ‘training’ jobs back into ‘service jobs’. The number of training posts could be recalculated based on the capacity to deliver training and the estimated number of consultant vacancies. But making a change like this would require big changes in the way that hospitals and Deaneries were funded. It would also require the creation of a substantial number of middle-grade service posts with a clear division between doctors-in-training and doctors-in-service.

It would also force Trusts to open their eyes. If there was a genuine possibility that the registrars could be taken away from Trusts who were not providing adequate training then we would quickly see a division into ‘training’ and ‘non-training’ departments which would provide a very real incentive to take training more seriously. Darzi’s plan to allocate money to training is only credible if non-training departments are financially penalised.

The political fallout from such a move might be too much for some to bear and they may prefer to place their heads carefully back in the sand. After all, to quote MacMillan once again, most of our people have never had it so good.

Richard Marks is Head of Policy at RemedyUK

Wikimedicine – a disruptive project beckons

R-UK anticipates the impact of a Silicon Valley entrepreneur’s big idea

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he internet has had seismic impact on industries worldwide. But what of medicine? Many hospitals have yet to migrate to integrated systems, and biomedical publishers still have a financial stranglehold on much reliable, peer reviewed medical information. Every doctor is familiar with a patient brandishing an internet print out of an esoteric condition or a long list of rare and unpleasant side effects. But caution is often exercised because of quality problems and the fragmented nature of this data.

was founded by James Currier, a seasoned Silicon Valley entrepreneur. He has enlisted a string of eminent institutions from Harvard, Stanford and Oxford Universities to support the project. Earlier this year he told the Los Angeles Times “Medicine is one of the least developed areas of the Internet, and at the same time, one of the areas that can be most improved by the Internet.’ He was inspired by having trouble finding reliable medical information when his children were in need of medical attention.

‘its ethos is that mass All this may be about to change So what impact will such a with the launch of Medpedia development have? If the parallels collaboration will produce a later this year. Its founders are of Wikipedia are anything to comprehensive, constantly aiming for it to be the largest go by, conventional biomedical collaborative effort on medical updated, instantly accessible publishing could be in for a rough knowledge the world has ride. Encyclopedia Britannica has medical information source.’ seen. Clinicians, researchers, already suffered major losses and medical editors are being since the launch of wikipedia asked to sign up to take part in this massive as the constantly updated nature of this wiki is venture. Based on the widely used site Wikipedia, aligned with the instant gratification needs of the its ethos is that mass collaboration will produce digital generation. It is likely that as soon as any a comprehensive, constantly updated, instantly groundbreaking research is published in the major accessible medical information source for patients journals, this will be integrated into medpedia within and clinicians. The site will be broken down into hours by an assiduous community of editors. Which two branches, one in lay language and one for leaves the question: will doctors, researchers and healthcare professionals. Similar projects are libraries be as inclined to pay their subscriptions with already in existence. Ganfyd.org is run by UK and the costly academic publishers? Australian doctors on a not-for-profit basis and is one of the largest existing medical wikis. Medpedia You can sign up with medpedia at www.medpedia.com www.rukmag.org

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ANALYSIS

R-UK ISSUE 3

Preparing a Winning CV

Matt Green from Apply2Medicine, who deliver Leadership and Management courses for junior doctors, gives his advice on preparing a great CV

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ven in the modern day world of FY1/2 and ST applications, every junior doctor should possess an up to date CV for inclusion in their portfolio. Your CV is your chance to further sell yourself to a potential employer if given the opportunity, such as at interview. Your CV should be a snapshot of your career to date, designed to aid Deaneries to decide whether or not to invite you for a formal interview. As such, your CV should be up-to-date, concise and well-presented in order to engage, and more importantly hold, the attention of someone who will no doubt have viewed countless other CVs.

CV Format and Structure

Whilst your CV should give an overview of your career to date, it doesn’t need to be a 40-page document detailing every one of your daily activities. CV length will vary depending on your level of experience, but we find that no more than 5-8 pages is a good target to aim for. Clarity is vital; use an easy-to-read font – we recommend size 12 Arial or Times New Roman – with slightly larger type for section headings to break the CV up into manageable sections.

What to include in your CV

Although your individual experiences will dictate the content of your CV, you should aim to include the following areas: • Personal details • Career Statement • Education and Qualifications • Present position • Career history (ensure that any gaps in employment are accounted for) • Clinical skills and experience • Development courses and conferences attended • Presentations • Research experience/Publications • Clinical audit • Teaching experience • Management and leadership experience • Personal interests • Referees The above list is by no means extensive or exclusive, but should be used as a good indication of what you should include in your CV. One important point

to remember is not to embellish, exaggerate, or provide false information. You should be prepared to discuss any one of the points listed on your CV at interview. Don’t run the risk of being caught out by a lie; not only will you miss out on a career opportunity, you will also be committing fraud, potentially damaging any opportunities in the future.

Made to Measure

As all applicants will be measured against the selection criteria of the post they are applying for, it is essential that you read the person specification and job description and ensure that your CV addresses all of the desired competencies. Use the career statement at the beginning of your CV to really drive home your enthusiasm and suitability for the position.

Conclusion

A clearly presented, concise and accurate CV is pivotal in securing an interview. Your interview is your opportunity to really go into detail and show off your knowledge and experience. Ask a colleague to read your CV to ensure it makes sense, and to check for errors in spelling and grammar. Tailor the CV to the job specification, taking into account all of the qualities and skills that are required. Use the CV to demonstrate that you possess those skills and to quantify why you, above all of the other candidates, are the best person for the job.

Key Points: • Points covered in your CV should be clear • • • •

and succinct Always refer to the job specification Don’t exaggerate or include anything which is untrue Ensure your CV is proofed by a colleague Be flexible and update your CV for each job you apply for

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.

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ANALYSIS

R-UK ISSUE 3

Nun on the run

Nick Edwards distils an A&E encounter with Mother Superior

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he ambulance men came in with another Saturday afternoon surprise, but this time a more jovial one than usual.

‘Not sure if she is from a fancy dress party or she is for real. Either way she is absolutely out of her mind.’ Cheers boys,’ I replied. ‘Any other information?’ I called after them. ‘Is she with someone? Has she hurt herself?’ ‘A member of the public saw her lying next to the empty bottle of whisky. No injuries. She is just blotto.’ And off they went. Great, I thought. A few slurry words were said, with an Irish twang to them. She stank of alcohol. I went through her handbag. It contained another half litre of whisky and a bible. Did I forget to mention that she was dressed as a nun? What on earth was I going to do with her? She would take ages to sober up and wouldn’t need to be admitted to our already overflowing drunk tank known as the A&E observation ward. I still wasn’t sure if she had been at a fancy dress party or was a bona fide nun. The more I probed her with questions, the more she told me that God loved me. Knowing that God did indeed love me, I felt I was on a mission. I had to do God’s work and help her. I phoned directory enquiries. What used to be simple matter of dialling 150 and speaking to a reasonable person, was now a lottery. Someone called Maureen from the international calling centre answered. ‘I have a patient here who I am worried about. Do you know the number of any convents near the hospital?’ She didn’t understand. I tried using the word nunnery instead of convent – still no help. ‘I need a Mother Superior.’ She put the phone down, thinking I was a prank caller. I don’t take the Mickey at 79p a minute with a 50p connection charge. People started to gather round the phone laughing. I looked on in despair. ‘Nick, why didn’t you phone the number in the prayer book?’ said a health care assistant who I had a bit of a crush on. ‘Look, on the inside cover is a sticker with the convent’s details.’ I felt a touch embarrassed and went over to check that the name in the book was hers and that she lived at this address. I was reassured that God loved me, but also got a nod to go ahead.

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“Can I speak to Mother Superior please?” I enquired. I wasn’t sure if there was such a thing as a Mother Superior, but it seemed the right person to ask for all things considered. Mother Superior was summoned. I told her that I thought I had one off her nuns and asked if she could come and collect her. I slipped in a ‘nuns on the run’ joke which fell a bit flat. ‘Oh, but it can’t be her. She is cleaning the church graveyard this afternoon, what with it being such a pleasant day.” She also had a lovely Irish accent. ‘Oh I see,’ I said, thinking of damnation. What on earth do I do with this woman? And then had a brain wave. ‘Could I speak to her then please? I am afraid someone has stolen her handbag and bible.’ Mother superior went to find her. It transpired that the graveyard had not had a particularly good weeding that afternoon. ‘I am afraid sister that we have your nun and she is as drunk as a lord.’ Mother superior was a flabbergasted. Her nun had always had a bit of a drink problem but she thought it was getting better, with God’s help. ‘Do you think you could pick her up? She just needs to sober up at home.’ This was a conversation I was used to having with mothers of teenagers, not Mother Superiors. ‘Yes of course doctor, I am so very sorry.’ Within an hour she had arrived with another nun and more importantly a massive box of brownies. God’s angels on earth indeed. She went to see the nun. Looking at her sternly, she said ‘You wait till the bishop hears about this.’ I tried to conceal a smile.

Nick Edwards is the author of In Stitches: The Highs and Lows of Life as an A&E Doctor

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BOOK REVIEW

R-UK ISSUE 3

Quack Quack

Jamie Wilson takes a look at Ben Goldacre’s whistlestop tour of evidence-based medicine, charlatans, and the dubious methods of a new breed - nutritionists

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he first time I remember feeling rabidly angry about a medical story covered in the media was MMR. Since then, I have become cautious about the general tendency to distil unsubstantiated factoids from the ether and lay them down as hard and fast rules. Sometimes, you just cannot win, no matter how hard you try. Two very good friends of mine, one of whom professes to read the Economist on the toilet, still refuse to have their daughter vaccinated. Why? These are intelligent, worldly individuals. What is it that prevents them from making rational decisions about their health? Ben Goldacre’s Bad Science blog and Guardian column have become a font for quack-sceptics, charlatan bashers, and anyone else who takes an interest in the world of science and its representation in the media. He points to the paradox that despite doctors being consistently viewed as the most trusted profession, and journalists the least, we are perpetually in the thrall of sensationalist quickfix narrative, imbibing it as gospel, while ignoring the incremental accrual of knowledge through empirical methods. Doctors too are guilty of this, with considerable evidence that ‘research’ cited in mainstream media makes its way into the references of future academic literature. He reserves his most scathing criticism for the ‘humanities’ graduates who run news desks and parlay a ‘parody’ of science to mask their own intellectual inadequacies and

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prop up readership. Big Pharma and the army of nutritionists who flood our consciousness through dubious public relations conduits are also subjected to a dressing down. He has done little to endear his targets calling homeopathy a ‘useful teaching device’. If you google him, you will find a smattering of bizarre press releases dedicated to undermining his claims and smearing his reputation. Famously, he secured a certified professional membership of the American association of nutritional consultants for his dead cat from the same pseudoinstitution that Gillian McKeith did for herself. The ‘Poo Doctor’ has a millionaire’s mansion in Hampstead, thanks to her lucrative ‘horny goat weed’

Nutritrionists and their wares may be seductive, but the industry is founded on little more than PR, fearmongering and dubious claims

formula that was later banned by the MHRA. Meanwhile, Ben has received threatening text messages, been reported to the Press Complaints Commission (not upheld), and been sued for libel. He was going to write for us this edition, but when I pressed him about submitting, I saw that he was embroiled in a libel action with a German doctor who has made millions from claiming that vitamins are effective in treating HIV, and who has now pulled out of pursuing further litigation. All of this while he continues to work in the NHS as an academic psychiatrist, and tours schools, festivals, and other venues to evangelize about empiricism. If you think this is madness, I would posit he is skirting perilously close to the journalistic holy grail of truth. Finishing with the gold standard of media health dupes, MMR, Bad Science is a whistle stop tour of the evidence-based medicine curriculum. But what he does best is translate complexity into simple language through anecdote and satire. For these reasons, it should be mandatory reading for every doctor and trainee, and passed on to credulous relatives, friends, and, dare I say it, patients. He may be on to something, although is possibly preaching to the converted. The question remains whether the exploitation and hocus-pocus he exposes, is something that can be changed for the better, or is what people really want. To paraphrase the philosopher and logician Bertrand Russell: it has been said that man is a rational animal, but all my life I have been searching for evidence to support this.

Bad Science is out now in all good bookshops.

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COMMENT

R-UK ISSUE 3

A medical maverick

R-UK talks strikes, ‘doctor blacklists’, and health service decline with Professor Paul Goddard

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n the mid 1970s, the parallels were markedly similar to now. Oil prices were sky high, the economy was in a mess, and the Labour Government was wrestling with their old foe, the medical profession. R-UK went to meet the retired radiologist Professor Paul Goddard to discuss. Paul Goddard recently hit the airwaves on the Today programme, claiming that the ill were ‘left starving’ in NHS hospitals. He decided to document his experiences, both as a clinician and carer in his book The History of Medicine, Money and Politics: Riding the Rollercoaster of State Medicine. He took early retirement following a torrid time in Bristol, and then had to endure seeing his own relatives denied adequate care while suffering from dementia.

In many ways a maverick, he was involved in clandestine political activities relating to working hours and salaries in the 1970s, and was involved in organizing the last time doctors took to the streets in 1974. But he was also single minded and typifies the passionate fundraising clinical leaders who did so much for the health service in decades gone by. He saw the emergence of MRI in the United States in the early 1980s and raised money locally by playing in his band to fund an MRI research centre, through which he published hundreds of research articles. Gradually, he saw the sinister tactics of ‘management’ take away his joy of practicing medicine. On one occasion he came in to work to find his office had been inhabited by another

It’s a scat man

Allow Britain’s only practising medicomusicologist to riff away on this month’s hot potato: Scat

department without him being informed. Countless other similar events followed. Much of this he attributes to the impossible straddling that doctors are coerced into: being manager and clinician. He is adamant you cannot serve both masters. The current atmosphere reminds him very much of the dark days of the 1970s where implicit threats and underhand tactics were de rigeur. He claims that the DH held blacklists of troublesome doctors and that parliamentary questions were asked on the matter. When I queried whether this was archived on Hansard [the official record of parliamentary debates and questions], he replied ‘Ah, but they remove information they don’t want on Hansard.’

Dr Beat’s Autumn Top Ten Two little Hitlers – Everything but the Girl Telling tales – Lightning seeds

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t seems a few folk have got a bit hot under the collar in recent weeks about issues of taste - in particular the position ‘scat’ should Dr Beat or shouldn’t occupy in civilized web-based discussion fora. Scat – the ragtime singing style pioneered by Gene Green in 1917, popularized by Louis Armstrong in the thirties and sustained by scatobsessives such as Scatman John well into the nineties – has always courted controversy. Dubbed ‘the Devil’s music’, it was a particular bête noire of the Klu Klux Klan in the twenties. The Nazis came down like a ton of bricks on the ‘degenerate’ lyrical form, banning it entirely from pre-war German

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nightclubs. And right up to the end of the 20th century the anti-scat brigade were deriding Scatman John’s ‘Ski-Ba-Bop-Ba-Dop-Bop’ as ‘the worst trance record of all time’. So forgive me for sounding like a fusty old reactionary, but should it really surprise us that the reemergence of scat in the internet age has brought about such an extreme reaction? Scat has, and always will, divide people. Dr Scot’s scat was destined to land him in trouble as soon as he typed out the fateful words: “skeep-beep de bop-bop beep bop bo-dope skeetle-at-de-op-day!” Nor should the past be ignored by those who were so outraged by his outburst. You can punish, gag, ostracise and humiliate – but history teaches us that scat will always evolve and reappear in ever more creative incarnations. I, for one, wait with eager anticipation.

Pace is the trick – Interpol Nobody likes a snitch – I love New York Highland Tyrant Attack – Absu It’s Tough to be a Bully When There’s No One Left to Bully – Belvedere Gillian’s Escape – John Williams A Medical Silence – Loss of a Child Have you no shame girl? – Solex Where did it all go wrong? – Oasis

Dr Scot Jnr’s Autumn Top Ten Express yourself – N.W.A Bugger off – The Dubliners Doctor Hot Shit – Bravo fucking Bravo The Shit You Talk is Beautiful – Space Bad shit – Scissor sisters Shit can happen – D12 Looks like I’m up shit creek – Nora O’Connor Dirty Rat Bastard – Peace Penguins Every one makes a mistake – Chris Farlowe Let’s Stick Together – Bryan Ferry

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R-UK ISSUE 3

OPINION

How not to get sued

Phil Hammond, our resident litigation Houdini, offers some shrewd advice

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oes good communication stop you being sued? Of course it does. If you say to grieving relatives: ‘he was a corpulent waste of space and he had it coming’, you’re likely to cause offence. But you can get away with acerbic wit by striking the right tone. I once observed a stressed casualty officer upset a particularly demanding patient with: ‘If you want a guarantee, buy a toaster.’ It was a great line, but too harshly delivered and she ended up with a complaint. I’ve since copied the line, but tried delivering it in a lighter way, and I just about got away with it. Next time things don’t quite go as planned, try quoting George Bernard Shaw: ‘A medical degree is no substitute for clairvoyance.’ If you can do it without being punched, you are a master of medical communication. A lot of guff is written about what is, and isn’t, good communication, but anything that keeps you

out of court is a reasonable start. Research comparing the communication of GPs who’ve never been sued for malpractice and GPs who have, found that the former have longer consultations and visits, they make an effort to solicit patients’ opinions and they use humour. Maybe we all start out like that, but after we’ve been sued we’re too bitter to listen and laugh anymore. Recently, I was chatting to a voice therapist called Christina Shewell, who’s writing a book about the art and science in changing voices. She told me of research focusing on the tone of a doctor’s communication. American and Canadian psychologists recorded 114 consultations between 65 surgeons and their patients. Half of the surgeons had been sued at least twice for malpractice, the other half hadn’t been sued at all. Ten second segments of the tapes with the surgeon talking were extracted and judged on a 7 point scale by blinded Harvard undergraduates for criteria such as warmth, anxiety, concern, interest, hostility, sympathy, competence, dominance, satisfaction and genuineness. To rate tone, snatches of conversation were passed through a filter modifier which removed the high-frequency sounds on which wordrecognition depends, but left expressive features such as intonation, speech, pitch and rhythm. After lots of complicated statistics, it turns out that the surgeons identified as being dominant, harsh and uncaring (etc) from their tone of voice were also the ones who happened to have been sued. Again, there’s a bit of chicken and egg here. You can’t say whether the act of being sued turned a surgeon’s tone from empathic to harsh, or whether it was those characteristics in their voice that contributed to them being sued in the first place.

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So, we’re back to ‘it ain’t what you say, it’s the way that you Phil Hammond say it.’ I’m not that surprised, but it’s interesting to see how we go about proving it. I’ve worked with a few German and Dutch doctors over the years and, just occasionally, their perceived harshness of tone and abruptness of manner has been misconstrued by patients as uncaring. The question is, what shall we do about it? We could select surgeons purely on the basis of their voice quality, but then we’d end up with everyone talking like Joanna Lumley. Great at giving you bad news, but you wouldn’t want her fiddling around inside you (well, perhaps only socially). Some brilliantly gifted technical surgeons just don’t have syrupy communication skills. Voice coach Christina reckons that two hours with her could make all the difference, but in my experience of teaching communication, attitude is what drives behaviour and a patient scan smell fake empathy a mile off. Perhaps a better solution is for someone to do the communicating for the few surgeons who can’t quite manage it. This is traditionally what nurses and junior doctors have been doing for years (and not getting the credit for), but it’s a bit unfair to ask them to take the flak for a bodge up and to try to avoid litigation. This is when you really do need Joanna Lumley. Ten minutes with her, and you’d soon forget which kidney was removed*. I wonder what she charges? * If you’re still alive Phil Hammond is a GP and Private Eye Columnist. Amazingly, he’s never been sued but he has just written a book, Trust Me, I’m (Still) a Doctor, that may well land him in court.

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OPINION

R-UK ISSUE 3

Diary of an HSMP

The secret diary of Mei Bo (Mabel) Hwa Smith, aged 33 and ¾ That night I went to see my boyfriend Smith Smith who like me, wanted to be a cardiologist looking after adults with congenital heart disease. I found him frowning and saying a lot of naughty adult words which I had previously only heard my consultant say when he was faced with a particularly tricky rehabilitation case. He was trying to fill in the MTAS form too but could not think of any communication mistakes he had made that did not sound racist or sexist.

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was walking down Lewisham High Street on my way to pay a £50 fine for leaving my dustbin lid 1.5 inches ajar, when I spotted a fellow SHO carrying a large bundle of A4 paper. ‘What are you doing?’ I asked, ‘Oh I’m just trying out different answers for the white space questions on the MTAS form,’ she said. So I decided to find out more about this excellent sounding form. Having applied for one hundred and fifty posts the previous year, I finally ended up with my excellent (training!) post in the ‘rehabilitation of people who other people have not managed to rehabilitate very successfully’. I was very lucky to get this post as I had started out in a non training post, but all of the junior doctors in the department decided o leave at the same time (something about pay and conditions) and no one else in Europe wanted to apply for this job. I had just rewritten my twentieth drug chart when I found some time to log into the MTAS website. I was overjoyed to find out that I could apply for four jobs. I was even more overjoyed to find out that the people marking the form would not find out what my name was, where I went to medical school, what my HSMP status was, or where I had worked before. In fact they would know very little about me at all. This all sounded very fair to me.

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So we used decided to go on a ‘how to fill in an MTAS form’ course and spent nearly £400 each. It was run by a really clever doctor who was actually going to mark the MTAS forms that we were going to fill in. We found out that as long as we wrote the words ‘patient safety’, ‘patient centred care approach’ and ‘ I would reflect on it and review it at a later date’ we would be short listed even if we had no experience at all. What a great deal, I thought. But I was not short listed and neither was Smith Smith. So I decided to Ask BMA why. A lovely man answered the phone and told me that he did not know why, but 1000 people had already phoned him that day to ask him

the same question. He sounded very tired. I then decided to ask my parents. As it was 4 am in Hong Kong and I had forgotten the time difference, they were also unable to tell, but sounded very sleepy. So I decided to ask my consultant. He muttered something about my HSMP status but could not understand why Smith Smith was not short listed. I was a little bit upset but not as upset as Smith Smith who had started looking at adverts in Loot for plumbing courses. To cheer ourselves up we decided to go to central London and try to eat as much as possible in an ‘all you can eat’ restaurant. For some reason we bumped into 12,000 doctors wearing white coats and carrying banners all walking in the same direction. It was such a coincidence that most of them had not been short listed either! A week later, Smith Smith found out that he had been short listed for one job and it was all a big mistake. I was very happy for him and we celebrated by going to the local pub after work. Unfortunately I was not allowed into the pub as they thought that I was a DVD seller. A nice looking man with short hair and a tattoo of a Swastika even told me to ‘go back to my own country’.

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23


LAST RITES

House Doctor

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or those loyal enough to have read the previous issue of R-UK, you may have noticed that House Doctor has now spread his wings on to a double spread. This is not just due to his monstrous ego; it is the unrelenting supply of material with which to take the piss. The House Doctor is being put on a leash by the editor because he wants to page grab the whole magazine. The NHS is a satirist’s wet dream, so perfectly ridiculous and riddled with ineptitude, that he feels like an eager whippet skipping through an orchard, where crunchy fruit offer themselves, and low hanging morsels cry out to be devoured. Eat me! Devour me! Let me loose on this luscious meadow!

R-UK ISSUE 3

On to more sombre matters and everyone’s most loathed quango NICE, never out of the news and always grating anyone with a modicum of fair play and decency. The House Doctor has major issues with NICE and thinks its name should be changed to THUG. NICE is not humane, pleasant, or even workable. It is a government bully that attempts to make scrupulously scientific decisions applying economic rationale, which is then subverted by local market mechanisms and PCT bureaucrats with inert frontal lobe function. The whole point of NICE was to eliminate the post code lottery. This is now worse, doctors are hiding information from patients about possible treatments, other countries just laugh at us, and the NHS is running a £2.5bn surplus. How is this NICE? It is an abomination.

Buried deep in this summer’s Darzi workforce review was a choice nugget from the lexicon of a dying government machine. ‘Modular credentialising’ is an awful assault on the English language, evoking similar vomitous dismay to ‘skills escalator’ and ‘choice agenda’. Where do they source these neologisms from? Is there an army of blindfolded monkeys in the DH throwing scrabble pieces at a wall of honey? Just leave our language alone, it is part of our heritage, and not to be pillaged at will. What is more, such a proposal represents a further knife twist in the gut for

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the assimilation of experience by initiative, enthusiasm and intrigue. Deconstructing a vast range of expertise into discrete pick and mix categories is reductionist and futile. What a vacuous load of crap. A recent news article in our sister publication the BMJ highlighted the pervasive spread of management jargon into the previously unfettered field of public health. The House Doctor can exclusively reveal that the Department of Health has the stranglehold on infuriatingly inane corporate word salad. If you wish to baffle yourself with a whole new language, you should go to the DH website for a peak. It is breathtaking and, for any doubters, demonstrates that these galeks are indisputably from a parallel universe.

The House Doctor knows there are a bunch of old timers in the medical community who are straining at the leash to speak out, but understands they are only months away from taking their pension, and don’t feel able to man the trenches. In his detailed research on this matter, the House Doctor perused the archives of the Wellcome library and found an old publication titled World Medicine. Remember this, old skool dudes? Its pages revealed a mind blowing array of subversion, satire, and medical wit, that has not been seen until the launch of R-UK. Staggeringly, the House Doctor turned the page to find Polly Toynbee sneering at him from the 1982 June issue. Given that the House Doctor had only just gained control of his bowels at this point in time, he could barely believe that the intervening 26 years had been spent slagging off the

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LAST RITES

es Pr s:

Update on everyone’s favourite IT consultant – Richard Granger. Bathing in the luxury of nearly 12 months off, Granger has shrewdly identified the land mass geographically least reachable from Whitehall to continue his career. He is to take up a post in Melbourne to oversee global health operations for KPMG, the accountancy firm. The House Doctor would like to extend his sincere gratitude for all the diligent cost controls that he implemented. The door is always open, particularly if he would like to contribute some of his pension pot to the wedge of public sector debt that he left us and the other credit crunch victims.

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You will also be glad to know that when the House Doctor was working on the wards, he pilfered most of the nurses’ chocolate stash and hid the wrappers behind the crash trolley, particularly when his blood sugar was running a bit low on night shifts. It is possible there is karma somewhere amongst this, but then again, the nurses seem to be getting a raw deal. Plus ca change.

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Last issue, the House Doctor reported on the barely believable salary re-structuring at the top of Connecting for Health. ( 1x old NPfIT – Richard Granger = new NPfIT + GDP of small sovereign state). I am glad to report that DH has searched far and wide for suitable a candidate and come up with a gem. In fact, not just one but two priceless diamonds in the rough at, yes, thrice the cost. Goodness knows how much was spent on the recruitment agency who managed to be this creative. A former Cadburys-Schweppes executive is now at the helm. The House Doctor is convinced this is a shrewd appointment. The cocoa inventory management capabilities of a chocolate industry executive are the perfect antidote for a nation of morbidly obese, type II diabetics.

Last issue, the House Doctor reported on how Fujitsu had been given the push by CfH, leaving the whole of South England in digital darkness. The Japanese IT giant was clearly not amused and is reportedly suing the NHS for £700million. Does the government really think it can act with impunity and treat large powerful organisations with contempt? Well of course. According to Hansard, Ben Bradshaw, the only health minister with his own Botox contract, is adamant that the DH is only liable for £50m per contract year. We are glad that doctors are not alone in feeling stitched up. If any Fujitsu employees are feeling a aggrieved, Remedy is always looking for new supporters. We have no shame and will get into bed with anyone. Perhaps we could set up a club, buy a few packets of custard creams, and sit round holding hands in a seance with the BMA.

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Left work at 5pm. Could have sworn I saw someone lurking round the corner with a telephoto lens. Walked to bus. Had unnerving sense that people were giving me funny looks. Felt a bit paranoid. Got home. Logged on and skirted around some DNUK forums. Scatology, facile humour, rage. Not exactly my cup of tea. Eminently reportable though. Computer starts making whirring noise and begins to merge with my stomach. Think it might now have seized my autonomous streak. Possible I have now lost free will faculties. Next thing I know, whole medical profession hates me. What do you do?

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medical profession. What a waste of perfectly good life.

R-UK ISSUE 3

The House Doctor is shocked to report on a recent case of dodgy maths and dubious advertising practice by Remedy’s friends in Tavistock Square. According to the Hospital Consultants and Specialists Association, a flood of complaints were received about a mailshot from Tavistock HQ stating that your chance of incurring litigation was 1 in 2. Thus, the searing logic continued, a saving of £3,463 would accrue if you signed up for membership with Tavistock HQ after the £387 forked out on membership. At this stage, the Advertising Standards Authority became involved and Tavistock HQ agreed to alter its claim that 50,000 ‘enquiries’, not ‘cases’ were made per annum. Do you see the gossamer thin differentiation? The ASA replied stating that: ‘We think this assurance addresses any concerns about the ad causing fear and distress without good reason.’ Isn’t it great to know that someone is on your side?

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MULLED WHINE

R-UK ISSUE 3

Doctor on a role

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ouGov have recently emailed me a questionnaire on behalf of the MMC Board. Apparently, last year I ‘kindly’ responded to the MMC Inquiry Consultation. Following this random act of kindness, Recommendation 5 of the Tooke Report was that ‘a consensus be reached on the Role of the Doctor before the end of 2008’. In advance of the ‘Consensus Conference on the Role of the Doctor to be held in London from the 21-22nd October (tickets by invitation or lottery if I tick the right box) I am asked to reply to all questions ‘as a medical professional’, but importantly, ‘from the perspective of a recipient rather than a provider of medical care’. Leaving aside the matter of who sold my medical records to YouGov, is this exercise in transubstantiation possible, rational or useful? For the record, I AM a doctor. I have been labouring under this particular delusion for 34 years. Imagine my surprise then to discover that I may not have the rudiments let alone the refinements of the role adequately defined?

being given to medical students everywhere, neither the unwhole nor the unholy need me to make direct eye-contact with them, put one of my heads on one side like a demented budgie and gently ask, “Do you have any concerns you wish to share with me about that?”

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 oncall 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...

Admittedly, my generation are routinely referred to as dinosaurs - but isn’t that the species that successfully ruled the world for millenia until the going got rough, when they smartly evolved into birds and survived?

There are though, more invidious thought-disorders at work in my being required to put my patienthead on and then answer questions about doctors’ integrity, communication, risk management, team working, leadership, wisdom and so forth. And I don’t mean the obvious one; these terms are notoriously ill-defined and any answers are likely to have the dubious significance of runes. No, the crass assumptions that really brass me off are that I will have separate doctor- and patientheads and that these will in all likelihood think, look and behave differently. Whatever the rumours to the contrary, I have only one head. Why would I need two? Sick people are primarily people. There is no evidence they have special communication needs that are not met with in other human interactions. Despite the impression

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And then there’s the other problem. If I’m widely assumed to need a special doctor-head because I eternally relate to ‘special cases’, then someone else, apparently a committee, are going to have themselves a meeting to define the ideal such head. We are all going to be given something else to conform to. With luck I may then be given a limited time to re-educate my old head before recourse to brainwashing or surgery is considered.

All this presupposes that those who know best have already toiled up the mountain and come back down with an itemised list of cardinal doctor virtues. We all know the ones I’m talking about empathy, selflessness, humility, reasonable to the point of being suicidally irrational, a team-worker par excellence but not necessarily the leader, a willingness to work for peanuts outside the box across professional boundaries. Now, it seems, the Thought & Behaviour Police will screen qualified doctors for compliance with their deranged behavioural ideal. Too late. An unholy alliance of politicians, managers and, sad to say, nurses have long since decided what the role of junior doctors should be. They are not, as many feel they are, cogs in the machine. They are the grease that is expected to oil those cogs. They were sent to earth to be scutmonkeys, scapegoats, rota-fodder, experimental objects - eternally emollient no matter what the garbage thrown at them. This has gone far enough. Morale out there is getting a bit on the low side. Speaking as a patient if I must, I don’t want a downtrodden doctor. They are dangerous. Speaking as a doctor as I must, I will not be downtrodden. Whether you be patient, admindroid, politician, or a deluded colleague in a position of self-importance, step on my dignity and you won’t get a leg-up. You’ll get a leg over.

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ANAESTHETISTS’CORNER

R-UK ISSUE 3

R-UK Sudoku Difficulty level: neurosurgeon

anaesthetist

dentist

orthopod

Win a year’s subscription to R-UK magazine Send your completed sudoku answers by text or image to editor@ rukmag.org and the first correct one we receive will win a year’s free subscription to R-UK magazine. The same prize will go to the winner of this issue’s competition below. If you are already a Remedy+ member, you will win a special prize instead.

The Remedy Detectives need you! Competition This issue’s combined competition and Detectives special is for the most ridiculous sartorial dictat from your Trust. Remedy has been informed that the tunic is making a return to the medical haute couture calendar, but is concerned there is no opt-out clause for conscientious objectors. Evidence exists that ‘tunic enforcers’ are stalking the wards for non-compliant FY1s. Clearly, in the interests of best taste, this cannot go on. If any mandatory tunics (see below) are hung in your wardrobe, we need to know to avert a perilous decline in medical style. Send us your tunic pics or be a baggy polyester basket case forever.

The new Third Edition is in full colour, with fully revised and updated contents and dozens of photographs of clinical signs. A must have for all students! – International Journal of Clinical Skills Concise, informative, and comprehensive... anyone who has mastered its content will sail through the final OSCE. – Professor Sir Cyril Chantler Only £20 from www. scionpublishing.com Enter discount code REMEDY08

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R-UK ISSUE 3

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R-UK Issue 3 -Time to reclaim our profession?