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10:32 AM - 6 March 13

TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed

at trainee doctors from their first day at

medical school, through their sleepless

foundation years and tough specialist

training until they become a consultant. It’s

proudly produced entirely by junior doctors

- right down to every last spelling mistake.

Find us quarterly in hospitals throughout

the UK and updated daily at JuniorDr.com

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Editorial TeamYvette Martyn, Ivor Vanhegan, Anna

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What’s inside

0409

12

16

22

26

LATEST NEWS

MEdiciNE IN THE MOvIES

FLyING DOCTORS doWN uNdEr

lEarNiNg to LEAD

DIARy FROM SiErra lEoNE

courSES AND CONFERENCES

C hildren today spend more time watching television, movies and YouTube than in lessons at school by the age of sixteen. It’s the new medium through which they get informed about life and healthcare.

In this issue Alexandra Blackman looks at the impact of film on the public’s percep-tion of medicine (p9) - an influence which can be both positive and negative. As Alexan-dra notes, opinions on mental health have been particularly pronounced with films such as ‘One Flew over the Cuckoo’s Nest’ and ‘Psycho’ being instrumental in skewing impressions of conditions like schizophrenia.

The impact film can have on patients prompted some junior doctors to set-up MedFest - the UK’s first medical film festival. The aims were twofold: to use the power of film to provoke discus-sion of pertinent topics in medi-cine, and to increase interest in psychiatry. You can find out more about MedFest 2014 on p11.

Also in this issue we cov-er some real life excitement with Aarjan Snoek who took an over-seas OOPE in aeromedical retriev-al (p12). Working in Queensland, Australia he offers an insight into this opportunity to learn more about the management of critically ill patients in a unique setting.

We also rejoin our columists Mikey Bryant and Carla Barberio. As usual Mikey is mak-ing the best of it in Sierra Leone where he has been volunteering in a children’s clinic. This issue (p22) he reflects on the potential harm of well-meaning projects supported by gener-ous philanthropic folk back in the UK but lacking some local understanding.

Carla meanwhile achieved all her grades for medi-cal school (congratulations Carla!) and talks about her anticipation and excitement of getting ready to leave home on her journey to becoming a doc-tor (p24).

Wishing you all (and particularly Carla) the best for 2014!

The JuniorDr Team

WHEN MoviES ARE THE bESt MEdiciNE

NEWS PULSE4

A round 27m patients in England will have to wait for a week or more to see their GP in 2014, as a result of

a diversion of doctor posts from general practice to hospitals, says the RCGP.

New research published by the Roy-al College of General Practitioners showed that three extra hospital consultant posts are now being created for every one more GP across the country.

At the same time analysis of the latest GP Patient Survey indicates that the number of people in England waiting for a week or more to see or speak to their GP (excluding

nurse appointments) reached 26.2m in the last year. The College says this is projected to rise to 27m.

The College says the only way to shift this trend is to increase the share of the NHS budget going to general practice from 8.39% now to 11% by 2017, starting with an increase of one percentage point of the NHS budget next year.

RCGP Chair Dr Maureen Baker said:“It is vital to ensure that patients are able

to access their local GP quickly and effec-tively - just as it is important for hospitals to have adequate numbers of qualified consult-ants to look after patients who are in need of acute health care.”

“If waiting times get longer, it will be more difficult for GPs to ensure that problems are caught early, and the pressure on A&E will intensify. This is bad news for patients and bad news for the whole of the NHS.”

Eleven years ago, there were 2,500 more full-time equivalent GPs than hospital doc-tors. However, if current trends continue, there are set to be 22,000 more full-time equivalent hospital consultants than family doctors by 2022.

According to the latest national GP Patient Survey, the proportion of patients in England who are having to wait a week or more for an appointment has risen to 15%, compared to 14% a year ago and 13% 18 months ago. The number of people waiting for a week or more to see or speak a GP or nurse at their practice reached 46.8m in the last year. This is project-ed to rise to 48.4m in 2014.

An opinion poll, conducted on behalf of the RCGP recently, showed that 71% of GPs expect waiting times to worsen over the next two years due to the decrease in resources for general practice.

In response to the report, the RCGP and the National Association for Patient Partic-ipation (N.A.P.P.) have launched a major campaign called ‘Put patients first: Back general practice’.

www.putpatientsfirst.rcgp.org.uk

tell us your news. Email team@juniordr.com or call 020 7193 6750.

27M patiENtS Will Wait a WEEk or MorE TO SEE GP IN 2014, SAyS RCGP

NHs

MEDICAL sCHOOL

A new self-funded undergraduate medical degree programme by the University of Central Lanca-shire (UCLan) will take its first set of students

in September 2014. The UCLan School of Medicine and Dentistry will

offer the 5 year MB BS programme to 35 students. The GMC has committed to work with UCLan to enable the MB BS programme to acquire full GMC recognition.

Students will study medical sciences along with clinical and communication skills at UCLan’s multi-million pound facilities in Preston and Burnley. East Lancashire Hospitals NHS Trust (ELHT) will provide the majority of clinical placements.

“Our market research has highlighted there is demand from overseas students to study medicine at a UK university and our course is aimed predominately at those who have a lack of opportunities in their own country,” said UCLan’s Professor StJohn Crean, Dean, School of Medicine and Dentistry.

“It is priced in line with the overseas and inde-pendent fee paying rates offered at other UK Medical Schools at £35,000 per year, for which students will be able to enjoy outstanding academic excellence, small class sizes, early patient contact, top-of-the-range facili-ties and exceptional practical clinical training.”

www.uclan.ac.uk

NEW privatE MEdical School OPENS FOR APPLICANTS

Dr Maureen BakerRCGP ChAIR

“If waiting times get longer, it will be more difficult for GPs to ensure that problems are caught early, and the pressure on A&E will intensify. This is bad news for patients and bad news for the whole of the NHS.”

I n its first year of operation the new system of checks for doctors practising in the UK has seen nearly 25,000 doctors have their licence

revalidated, says the GMC.When it was introduced in December 2012,

the new system of checks became the biggest shake up in medical regulation in more than 150 years. Every doctor registered with a licence to practise in the UK is now legally required to show the GMC that they are competent and fit to practise, usually once every five years, to be able to contin-ue treating patients.

“These are very early days but we are pleased with the progress made in the first year. This new system of checks is a world first and over time we believe it will make a significant contri-bution towards making sure patients in the UK receive safe, effective care,” said Niall Dickson, the GMC’s Chief Executive and Registrar.

More than 10,000 doctors on the GP Reg-ister and 12,000 on the Specialist Register have

successfully revalidated in the first 12 months.Medical leaders - including Professor Sir Peter

Rubin, Chair of the GMC and Professor Sir Bruce Keogh, NHS Medical Director for England - were among the first to be revalidated following intro-duction of the checks last year.

The GMC expects to revalidate around 30,000 doctors by the end of this year and is on target to check most doctors by the end of March 2016.

www.gmc-uk.org

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P roposals to shorten the length of UK basic medical education could have an impact on patients and the medical profession, the

BMA has warned. Current proposals from HEE, the organisation

responsible for medical education and training, has recommended bringing forward the point at which students fully qualify as doctors by a year so it coincides with graduation.

It says the change will enable all suitable medi-cal graduates to secure full GMC registration and provides a potential solution to foundation pro-gramme oversubscription.

But the BMA medical students committee has said the move could have other, less positive, con-sequences. MSC co-chair Harrison Carter said:

“HEE argues that it will bring improvements in patient safety, but we worry that reducing basic medical education by a year will result in the opposite.”

“The proposal could also mean that medical graduate unemployment is more likely, with more applicants to the foundation programme being possible from those outside the UK and Europe. This would be an enormous waste of both pub-lic and student investment in medical education.”

www.bma.org.uk

ShortENiNg MEdical EducatioN MAy AFFECT HEALTHCARE, WARNS BMA LEADERS

WORKING CONDITIONs

25,000 doctorS SuccESSfully rENEWEd IN FIRST yEAR OF CHECkS

REVALIDATION

Niall DicksonChIEf ExECUTIvE ANd REGISTRAR, GMC

“This new system of checks is a world first and over time we believe it will make a significant contribution towards making sure patients in the Uk receive safe, effective care.”

NEWS PULSE6

N early one in five doctors in training has wit-nessed someone being bullied in their cur-rent post, and more than one in four has

experienced undermining behaviour themselves, according to a major survey from the GMC.

The findings from its annual survey reveal that more than 2,000 doctors in training (5.2%) had raised a concern about patient safety in 2013 and 13.2% said they had experienced bullying at work.

Responding to the survey Dr Kitty Mohan, Co-Chair of the BMA’s Junior Doctors’ Com-mittee said:

“It is concerning that one in ten junior doc-tors reported that they had suffered from bullying

or harassment and that two in ten had witnessed a colleague suffering the same treatment.”

“We must do more to combat any environ-ment that allows bullying or harassment by encouraging NHS staff to share their concerns immediately. Junior doctors have a right to carry out their job in a workplace that is free from any form of intimidation.”

The survey found that:• The number of comments on patient safety

raised by doctors training in emergency med-icine posts have increased since 2012 (from 204 to 287)

• 5,863 respondents had been concerned about patient safety but their concerns had been addressed

• Female trainees and trainees who obtained their primary medical qualification within the UK, are more likely to raise concernsThe GMC says the findings suggest that hos-

pitals need to engage with doctors in training and use their experiences to help change the cul-ture of their organisations.

www.gmc-uk.org

N ew rules on the movement of health profes-sionals across Europe are a major improve-ment in patient safety, says the GMC.

EU ministers have agreed that doctors, nurses and other health professionals moving to the UK from Europe will have to meet new patient safety requirements. The changes mean the GMC will be able to check a doctor’s language skills before he or she is allowed to practise in the UK.

A new alert system will also be introduced, requiring health regulators across Europe to warn each other within three days when a doctor or other health professional has been removed from its register, or has had his or her practice restricted.

“Alongside changes to current UK law in 2014, they will give us the ability to check the language skills of doctors coming to work here from Europe,” said Niall Dickson, Chief Execu-tive of the GMC.

“The new alert system is also a big step for-ward. If we are to protect patients, free move-ment of professionals must be accompanied by

free movement of information.” There are currently 26,949 doctors from the

European Economic Area (EEA) on the UK medical register out of a total of 259,670 doctors.

www.gmc-uk.org

ONE IN FOUR DOCTORS FEEL uNdErMiNEd at Work

WORKING CONDITIONs

gMc WElcoMES NEW rulES ON THE MOvEMENT OF DOCTORS ACROSS EUROPE

WORKING CONDITIONs £41m waste on electricity

The NHS in England wasted

£41.4 million last year simply by

paying more than it should for

energy and water, according to

campaigning group Taxpayers’ Al-

liance. The money wasted annu-

ally on excessive utility bills could

cover the cost of employing 1,350

more nurses they claim. The NHS

in England spent more than £630

million on energy and £80 million

on water 2012-13.

www.taxpayersalliance.com

GMC freezes retention fees

The GMC has frozen its annual

retention fees for 2014/15. Fees

will remain at £390 for registra-

tion with a licence and £140 for

registration without a licence. The

registration fee for newly qualified

doctors will remain at £185 and

the provisional registration fee will

stay at £90.

www.gmc-uk.org

Assaults against staff rise 5.8%

Physical assaults against NHS

staff in England rose by 5.8% in

the year 2012-2013 compared

to the previous 12 months, says

NHS Protect. These figures were

collated from 341 health bodies

across the country. Total report-

ed assaults rose from 59,744 in

2011/12 to 63,199 in 2012/13.

Criminal sanctions following re-

ported assaults also rose by

15.9%.

www.nhsbsa.nhs.uk/protect.aspx

New BMA resources

The BMA has unveiled Make Change Better, a programme of

events, online resources and dis-

cussion forums to keep junior doc-

tors informed as contract negotia-

tions get underway. It includes an

online community which provides

the latest on the contract negotia-

tions and an opportunity to debate

the key issues with colleagues in

real-time.

www.bma.org.uk

Dr Kitty MohanCo-ChAIR, BMA’S JUNIoR doCToRS’ CoMMITTEE

“Junior doctors have a right to carry out their job in a workplace that is free from any form of intimidation.”

NEWS PULSE 7

N ew changes to the GP contract in England will begin to address the issues facing general practice by cutting unnec-essary targets, reduce bureaucratic box-ticking and give doc-

tors more time to focus on the needs of their patients, GP leaders have said.

The changes to the GP contract in England have been agreed following negotiations between the BMA’s General Practitioners Committee and NHS Employers.

“This will not only free up GPs to spend more time focusing on treating patients, but will also mean that valuable resources will be reinvested in general practice to improve frontline care,” said Dr Chaand Nagpaul, Chair of the BMA’s GP committee.

Key changes to the GP contract include:• Introduction of a new “enhanced service” for patients with

complex health needs to avoid them being unnecessarily ad-mitted to hospital or A&E. This will involve easier telephone access for emergency providers ringing GPs to decide whether or not the patient needs to be admitted.

• Reducing the size of the quality and outcome framework (designed to fund general practice) - with 238 QOF points (worth around £290 million) being made part of the core GP funding. A further 100 points will fund part of the enhanced service to help prevent patients being inappropriately admitted to hospital with an overall budget of £162 million.

• That every person aged 75 and over will be assigned a named accountable GP, who will ensure that patients receive coordi-nated care.

• A commitment to monitor the quality of out-of-hours services when used by their patients.

• The introduction of the Friends and Family test from Decem-ber 2014 asking patients how likely they are to recommend a GP practice.

• The introduction of new IT systems including the ability for patients to book appointments online and access their summa-ry care record.

www.bma.org.uk

CHANGES TO CONTRACT WILL FREE gps to iMprovE carE, SAyS BMA

GENERAL PRACTICE

info@IMRmedical.comwww.IMRmedical.com0871 284 7100 (UK)

+61 3 8506 0185 (Int’l)

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H ealth spending fell in the United Kingdom in 2010 and 2011 for the first time since the 1970s, according to a new OECD report.

Health at a Glance 2013 says that spending in real terms per capita fell by 1.1% in 2011, following a 2.5% decline in 2010. It had increased by an average of 5.3% per year over the previ-ous decade.

It noted that the number of doctors in the UK has increased by over 50% since 2000, much more rapidly than in nearly all other OECD countries.

Consumption of certain types of prescribed drugs has also increased significantly since 2000 in the UK - notably the con-sumption of antidepressants and antibiotics - and is now well above the OECD average.

www.oecd.org

NhS SpENdiNg fEll IN REAL TERMS

NHs

Dr Chaand NagpaulChAIR of ThE BMA’S GP CoMMITTEE

“This will not only free up GPs to spend more time focusing on treating patients, but will also mean that valuable resources will be reinvested in general practice to improve frontline care.”

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MEdICINE ANd MovIES 9

MEDICINE: froM cradlE to gravE AND froM caMEra to culturE

WHy FILM IS AS IMPORTANT TO MEDICINE AS IT HAS ALWAyS BEEN

A timeline of medicine and the movies

At its best, film provokes an immediate and enduring bond with the viewer. As they are transported into the reality of the protagonist, there is potential for genuine empathy and great-er understanding of individual experience. This gives filmmak-ers the power to alter our perception of an issue depending on their agenda. In medicine, and particularly mental illness, this agenda has changed over time as more is learned about the complex and ubiquitous nature of many conditions and the clouds of stigma slowly evaporate.

In 1960, the film ‘Psycho’ was released. Norman Bates’ creepily oedipal character slashing A-list celebrities in the shower (not to mention hiding his mother’s skeleton in the basement) undoubtedly perpetuated misinformed opinions about the dangerousness of mental illness, and the confusion between schizophrenia and dissociative identity disorder.

The classic example of ‘One Flew over the Cuckoo’s Nest’ (1975) suggests that psychiatric hospitals are akin to prisons, inhabited by patients with no autonomy and robotic staff com-pletely devoid of empathy. Measures such as restraint and ECT are sensationalised and shown as a means of control.

Fast-forward 23 years and a very different perspective is seen in ‘Patch Adams’, highlighting the importance of humour and humanity in healthcare, whilst promoting medics as individu-als complete with human complexities and flaws. Who could forget Patch’s line “You treat a disease, you win, you lose. You treat a person, I guarantee you, you’ll win, no matter what the outcome”2.

It has been said that ‘no other art form pervades the consciousness with as much power as film’ 1.

Film is omnipresent, crossing boundaries of age, culture and time. Despite this, there is little conscious awareness of the medium’s profound ability to influence our opinions - particularly about emotionally charged topics.

The impact of film on the public perception of medicine - especially mental illness - has been notably pronounced. As Alexandra Blackman describes, this influence can be positive or negative, and even be used for recruitment.

MEdICINE ANd MovIES10

Similarly the 2004 film ‘The Aviator’ can be considered a valid attempt at exploring the debilitating effects of a men-tal illness from the individual’s perspective. The portrayal of the descent into obsession and compulsion of the billionaire genius Howard Hughes, clearly attempts to provoke an emo-tional reaction from the viewer that only comes with genuine empathy.

Films such as ‘Psycho’ and ‘One Flew over the Cuckoo’s Nest’ must take partial responsibility for the pervading stigma of mental illness, not to mention public opinion of treatments such as ECT. This stigma is undeniably one of the reasons that a small proportion of people access healthcare for their mental health problems.

In fact, when the UK charity MIND surveyed 515 people with a diagnosed mental health problem, half of them reported that media coverage of mental illness had a negative impact on their own mental health3. Worryingly a quarter felt they had experienced hostil-ity from neighbours follow-ing such reports3.

However, when the media portrays illness and healthcare in a more sym-pathetic light, the reaction can be just as profound. It is perhaps reassuring that

although critics hold ‘The Cuckoo’s Nest’ in great esteem, ‘Patch Adams’ is by far the more popular of the two in public rating-scales4,5.

So how can we tackle the residual elements of mental health stigma? ‘Bedlam’, the Channel 4 documentary series on mental health in South London and Maudsley NHS Foundation Trust (SLAM) attempted to do just that. By closely following specific people this highlighted the individuality of mental illness and the realities of healthcare.

We met James, a young man with severe anxiety, and were invited into his family home to see the true impact his symp-toms have on their daily life. We also met Helen who had recur-ring thoughts that she had put passers-by in the bin. Despite having insight into the absence of logic in this worry, the wor-ry persisted none-the-less, and Helen shared the impact her symptoms have had on her intimate relationships.

James is a university student, Helen works at a prominent London museum. We could pass either of them in the street, or have a drink with them, and not realise the torment either

of them suffers on a daily basis. They could so easily be us, or someone we care about, and that is how they are portrayed. Reviewed in the Guardian as “a fair portrayal of a fascinating place”6 this will hopefully have a positive impact on public per-ception of mental illness.

A short history of ‘Medfest’

Medfest was founded in 2011 by Dr Kamran Ahmed, a psy-chiatry trainee in SLAM, as the UK’s first medical film festival. The aims were twofold: to use the power of film to provoke dis-cussion of pertinent topics in medicine, and to increase inter-est in psychiatry.

Evening events were held in nine universities across the country, showing a selection of short-films, documentaries and animations on the theme ‘The Image of Doctors in Film’. These

fILMS SUCh AS “PSyCho” ANd “oNE fLEW ovER ThE CUCkoo’S NEST” MUST TAkE PARTIAL RESPoNSIBILITy foR ThE PERvAdING STIGMA of

MENTAL ILLNESS.

JAMES IS A UNIvERSITy STUdENT, hELEN WoRkS AT A PRoMINENT LoNdoN MUSEUM. WE CoULd PASS EIThER of ThEM IN ThE STREET, oR hAvE A dRINk

WITh ThEM, ANd NoT REALISE ThE ToRMENT EIThER of ThEM SUffERS oN A dAILy BASIS.

MEDICINE: froM cradlE to gravE AND froM caMEra to culturE

MEdICINE ANd MovIES 11

were then discussed between the audience and expert panel-lists, who included Max Pemberton and actress Shobna Gulati.

Although coordinated nationally with identical pro-grammes, each event was organised and chaired by a local psy-chiatry trainee or ‘Psychsoc’ lead. The programme included ‘Shadow Scan’ - a BAFTA winning short film documenting a medic’s first-hand experience of healthcare, starring panellist Shobna Gulati. The events were well received at all sites, and as the first festival of its kind Medfest caused a small sensation in the medical and psychiatric communities, culminating in a review in the Lancet7.

Over the next two years Medfest continued to expand, although the for-mat has remained the same. Featuring the celebrated ‘Animated Minds’ series of films, the 2012 ‘Healthscreen’ festi-val included 16 universities and host-ed 1000 attendees. 2013 reached an impressive 21 universities - appropri-ately enough discussing ‘the Power of Medicine’.

Films were diverse and included a clip of the contemporary documentary ‘Rus-sell Brand: From Addiction to Recov-ery’ and the BAFTA winning animation ‘Mother of Many’ - examining the ben-efits of a good doctor-patient relationship. The 2013 event also saw the advent of the Medfest: Music event at the National Psychsoc Conference, and culminated in a showcase event at the Royal Society of Medicine.

Medicine: from cradle to grave

The theme of Medfest 2014 is ‘Medicine: from Cradle to Grave’. The programme will be split into three sections rep-resenting the main stages of life - namely childhood, middle-age and old-age/death. The concept of health is a constant that affects us throughout our lives for better or worse.

The lesser discussed fact is that this includes our mental health, a reality which can become apparent at any stage in life. In our early years we are exposed to ‘predictive factors’ for mental illness, many of which are decided for us. As we travel through middle age, most people will have come face to face with the fragility of mental health in some way.

Finally we end with the natural breakdown of that which makes us human - our cognition, to say nothing of the psy-chology surrounding death. Physical and mental wellbe-ing are so intrinsic within the lifecycle that exploration of this journey through film cannot fail to evoke a reaction in the audience, be it emotional or edifying. That is, at least, the hope.

So far there are thirty confirmed events at medical schools in the UK and Ireland. This will be the first International Medfest festival as we also look to hold events in America, Africa, and continental Europe. The Medfest: Music event will once again form part of the festival, and we will also see the first Medfest art exhibition in London. Excitingly, the gala event this year will be held at the Royal College of Psychiatry, which hopefully will be the first of many.

The 2014 festival will hopefully prove to be another enter-taining event that inspires the budding psychiatrists in the audience to carry on the crusade against stigma. As Norman

Bates said himself, “We all go a little mad sometimes”.

If you would like to know more about Medfest, or to get involved in Medfest 2014, please visit www.medfest.co.uk.

AS NoRMAN BATES SAId hIMSELf, “WE ALL Go A LITTLE MAd

SoMETIMES”.

rEfErENcES

1. ‘Movies and Mental Illness’ d. Wedding, M Boyd, R Niemiec. 3rd edition, hogrefe publishing, 2009

2. ‘Patch Adams’ 1998, screenplay Steve oedekerk

3. Mind survey ’The daily Stigma’, february 2000

4. http://www.boxofficemojo.com/movies/?id=patchadams.htm

5. http://www.boxofficemojo.com/movies/?id=oneflewoverthecuckoosnest.htm

6. Sam Wollaston ‘Bedlam – Tv review’, The Guardian, friday 1 November 2013

7. holmes, d ‘falling from their pedestal - doctors on film’ The Lancet. 2011, 377 (9780),1825

MEDICINE: froM cradlE to gravE AND froM caMEra to culturE

fLyING doCToRS12

FLyING DOCTORSdoWN uNdEr

AN OvERSEAS OOPE IN AEROMEDICAL RETRIEvALWhen Dr Aarjan Snoek wanted to develop his skills leading a multidisciplinary team in the management of critically ill patients he realised there could be no more fun way than by becoming a flying doctor down under. Now back in the UK he tells us how taking to the air has helped him develop some unique skills.

T he land area of Queensland in Australia is vast at over seven times greater than that of the UK and relies heavily on aer-ial medical transportation to cover distances quickly. The

Aerial Medical Service, the precursor to the Royal Flying Doc-tor Service (RFDS), was established in Queensland in 1928 to do precisely this.

Since then the air transport system has developed signifi-cantly and today Careflight Medical Services (CMS) supply Queensland Health with doctors who undertake emergency medical retrievals and interfacility transfers through the RFDS and other organisations.

Despite not performing terribly well on a 6am telephone interview I was fortunate enough to be offered a position as part of the team. Here is my experience.

cliNical ExpEriENcE

Throughout my time primary responses, such as road traf-fic accidents were most exhilarating, and occasionally required a technical winch job. Primaries were an opportunity to implement ATLS and pre-hospital emergency management first hand, as well as principles unique to retrieval and transfer medicine. These included pre-arrival planning, ensuring scene safety, obtaining 360 degree access, prudent utilisation of bystanders, positioning of team members and equipment, use of checklists1, performing a kit dump2, and minimising the therapeutic vacuum.

The unique working environment allowed for the opportu-nity to implement cutting-edge techniques and procedures such as finger thoracostomies, hypotensive resuscitation, and coexis-tent high-flow nasal cannulae preoxygenation3. We had access to modern equipment so that I also gained experience with the use of a McKesson prop4, stretcher bridge, Rapid Infusion Catheter (RIC), trauma tourniquet, and FAST scans.

Interfacility transfers from remote and rural hospitals to ter-tiary hospitals could also be challenging. The medical work-up on these patients was often minimal, with special investigations like basic X-rays sometimes being unavailable, meaning that clinical skills became all the more crucial. The retrieval flight physician

was generally regarded as the ‘expert’ this did sometimes lead to tasks being delayed until my arrival. Interfacility retrievals to ter-tiary and quaternary centres often involved more complex cases such as a patient on intra-aortic balloon pump support.

The relative predominance of one task type over another depended on the base location, with some bases more common-ly tasked for primaries compared to others where interfacility retrievals were more common. Involvement in search and rescue missions, for example to a British holidaymaker bushwalking in the outback5, occasionally became necessary. Scenes with mass casualties fortunately are rare, but when they do occur, can pro-vide valuable leadership experience in a major incident situation.

NoN-cliNical dEvElopMENt

Induction week certainly wasn’t the typical UK fire safety lec-ture. We were trained in major incident management, basic tech-niques for vehicle extrication, Helicopter Underwater Escape Training (HUET), and winching.

This training can form part of a Certificate in Aeromedical Retrieval6, although the cost for non-Australian residents might persuade one to consider the Diploma in Retrieval and Transfer Medicine of the Royal College of Surgeons of Edinburgh7 instead.

Working in small teams and hearing about the colourful (often military) career histories of other doctors developed a sense of camaraderie, but the aviation environment also intro-duced some new ideas such as principles of ‘pilot fatigue’, com-plexly defined with an algorithm based on the number of hours worked versus rest time.

The fatigue concept also applied to doctors and meant that a scheduled shift might commence later if a previous day’s shift had overrun for example. The Drug and Alcohol Management Plan (DAMP) - usual for aviation crew8 - also applied to doctors, and there was always a potential to be subjected to random test-ing at work.

Weekly clinical governance meetings allowed for opportu-nities for in-depth retrospective case analysis with consultants. The formalised professional conversations stimulated reflection,

fLyING doCToRS 13

and contributed to the depth of understanding and subsequent improved clinical care.

A weekly statewide teaching programme by teleconference covered topics unique to Queensland such as Irukandji syn-drome and snakebite, but also topics pertinent to retrieval medi-cine such as the use of ketamine for sedation of the psychiatric patient undergoing air transport9.

There were also plenty of opportunities to develop non-tech-nical leadership skills and effective communication skills when collaborating towards a common goal, for example in discus-sions with pilots on the merits of flying at sea level pressures or with helicopter rescue aircrewmen during winching or with fire-men (‘firies’) at a car accident scene.

challENgES

Hypobaric hypoxia at altitude causes even one’s own SpO2 to dip as low as 90% but fortunately the panoramic landscape views alone are able to fend off any potential hypoxic fatigue for doctors at least. Helicopters are not as comfortable as they might appear: the limited ‘office space’ can cause aches, and vibration and noc-turnal lack of lighting means the need for detective work on note deciphering the following day.

The full body fireproof flight suit in the Queensland summer heat is akin to wearing a swimming costume in Antarctica for its comfort. Vigilance and situational awareness are particularly rel-evant in an environment that is so noisy that syringe driver and monitor alarms become useless.

Working without direct supervision, with only telephonic

backup availability, leads to clinical maturity but does also make a very isolated environment if things start to unravel. The crash team that you might usually fall back on could be hundreds of miles away.

Diseases unfamiliar to us in the UK - such as melioidosis, den-gue fever, and chikungunya - are endemic in Queensland. Austra-lia also has some vicious animals including marine stingers, croco-diles, sharks, poisonous snakes (that seem to enjoy sleeping under helicopter skids), giant goannas, mosquitoes and tarantulas.

But other than that, if you think Ashes jibes won’t get to you, I can’t recommend an Australian retrieval medicine OOPE high-ly enough.

rEfErENcES

1. Mackenzie R, french J, et al. A pre-hospital emergency anaesthesia pre-procedure checklist. Scand J Trauma Resusc Emerg Med 2009; 17(Suppl 3): o26

2. http://www.uk-hems.co.uk/Rapid%20Sequence%20Intubation.pdf

3. Weingart S, Levitan R. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2011; 20(10): 1-11

4. Murphy AP, doran hJ, et al. The Mckesson prop: an essential tool for the emergency physician? Emerg Med J 2010; 27(2): 156-8

5. http://www.bbc.co.uk/news/uk-england-21490782

6. http://www-public.jcu.edu.au/courses/course_info/index.htm?userText=76511-&mainContent=subjects

7. http://www.rcsed.ac.uk/the-college/news/2012/march-2012/diploma-in-retrieval-and-transfer-medicine-(2).aspx

8. http://casa.gov.au/aod

9. Le Cong M, Gynther B, et al. ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J 2011; doi:10.1136/emj.2010.107946

hoW do i apply to Work With thE royal flyiNg doctorS?Applications are generally considered from trainees coming from a background in anaesthetics, intensive care, or A&E that have passed their primary exams. other specialties, for example trauma and orthopaedics, have been recruited in the past.

Send an email to recruitment@careflightmedical.org.au

AdvERToRIAL14

THE SINGLE bESt aNSWErORIGINS

The single best answer book series began as a means of revi-sion during the challenging year of medical finals. Construct-ing realistic vignettes for colleagues and providing comprehen-sive answers to the correct and incorrect answers soon became one of the most useful study aids and from this the SBA series was born.

We sought to create not only a successful question and answer book but also a useful revision textbook. Unique from other available materials the SBA series ensures valuable principles could be garnered from explanations of both correct and incor-rect answers. The single best answer series reflects the changing emphasis of examination methodology but more importantly provides optimal educational value.

Every question challenges the readers’ depth of learning whilst the answers provide greater breadth across the subject areas. Every area of the medical curriculum is thoroughly explored including diagnosis, investigation and management.

FROM STUDENTS, FOR STUDENTS

We published our first book as medical students along-side doctors, consultants and professors. Each of our vol-umes brings a valuable blend of authentic student insight alongside relevant experience. Our team have published 4 successful textbooks covering medicine, surgery, the clinical specialties and our latest addition in clinical pathology.

ExCELLENT ExAMINATION REvISION

Each volume ranges from 250-500 carefully constructed examination style questions in accordance to UK medical school guidelines covering the most relevant areas of the medical school curriculum. Each chapter is organised by subject area allowing the reader to direct their learning.

INNOvATIvE LEARNING AND vALUE FOR MONEy

With analysis of every UK medical school curriculum and examination styles each question is prepared with real life sce-narios and reflective question options that tests the vertical

AdvERToRIAL 15

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SERIESlearning of students. The reasoning behind correct and incor-rect answers is provided for every question stem ensuring hor-izontal learning across topics. This principle ensures that for every question our readers optimise their learning potential. Each of our published texts contains a large array of ques-tions and priced competitively to ensure you receive excellent value for money.

We hope you enjoy the challenge of using these books and wish you all the very best for you finals exams.

Written by Dr Sukhpreet Singh Dubb on behalf of Single Best Answers team.

MEdICAL STUdENTSSUPPoRT16

lEarNiNg to lEad

Many of the challenges facing new consultants in the emerging NHS lie in the realm of leadership and yet junior doctors often report feeling unprepared to lead.

The time when the sole function of a doctor was to provide clinical care has passed.

A s a junior doctor you can develop your leadership compe-tencies by being proactive and consciously assuming great-er responsibilities around leadership activities; the Medical

Leadership Competency Framework provides a range of practi-cal examples of opportunities for learning and development.

Clinical training might include a higher degree in a subject allied to medicine and might also count towards your certificate of completion of training (CCT). In the past, these have includ-ed leadership positions, vocational or academic qualifications and overseas posts that are not part of an approved programme. OoPTs require prospective approval from the General Medical Council (GMC) and candidates can retain their national training numbers during this period.

Establish clinics, participate in management meetings and vol-unteer to undertake additional leadership responsibilities; closely observe selected role models in order to identify effective leader-ship behaviours; attend a postgraduate leadership course so as to gain exposure to unfamiliar scenarios and new theoretical models and identify your personality and leadership styles by completing self-assessment questionnaires.

Additional opportunities for leadership development, both pre- and post the transition to consultant grade are outlined below and learners are encouraged to blend learning opportunities. Each development tool and method has its own advantages and disad-vantages and the right approach will depend upon individual and organisational circumstances and goals.

Opportunities for leadership development•Action learning - working as part of a small group of peers or

an ‘action learning set’ to address real life problems, develop solutions and take action

•Coaching - a time-limited, goal-orientated, one-to-one devel-opmental relationship based on real work issues

•Developmental work assignments - learning from ongoing work initiatives and integrating these experiences with each other and strategic organisational imperatives

•Mentoring - a long-term, open-ended, one-to-one develop-mental relationship in which a senior colleague supports the personal and professional development of a junior colleague

•Leadership within a team - motivating team members, leading

Brought to you by

FROM JUNIOR DOCTOR TO CONSULTANT

MEdICAL STUdENTSSUPPoRT 17

Support4Doctors is an online portal of information for UK doctors. It o�ers specialist advice and support for doctors and their families on career, health and financial issues. The site also o�ers a database of organisations that can provide further help.

The Royal Medical Benevolent Fund is the leading UK charity for doctors, medical students and their families. The RMBF provides financial support, money advice and information when it is most needed due to age, youth, ill health, disability and bereavement.

The RMBF aims to make a real di�erence to the lives of doctors and their families in times of need. The role of the RMBF is to help beneficiaries to become independent and self-su�cient again wherever possible, whilst maintaining longer term support for those for whom this is not possible.

The RMBF also aims to make a real di�erence in the lives of medical students and their dependants facing financial hardship due to unforeseen di�cult circumstances.

The RMBF is committed to leading the way in providing support and advice to members of the medical profession and their dependants. To find out more about the work of the RMBF, or how you can get involved visit the RMBF website.

Registered o�ce: 24 King’s Road, Wimbledon, London SW19 8QN.

A charity registered with the Charity Commission No 207275. A company limited by guarantee. Registered in England No 139113

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through change, confronting poor performance, delivering re-sults (by achieving objectives) and encouraging and supporting the professional development of team members

•Networking - creating interdependent and often mutually ben-eficial relationships

•Self-directed learning - taking responsibility for finding, man-aging and assessing one’s own learning eg. basic internet re-search, reading leadership books and journal articles, attending and contributing to networks and forums

•Shadowing - provides opportunities to observe and understand an unfamiliar part of a system without being required to act

•Workshops and masterclasses - time limited learning sessions focused on specific topics which provide opportunities to gain up-to-date information, develop particular skills and to share learning

•Workshops delivered by experts in their field are called masterclasses

Developmental experiences are likely to have the greatest impact when they can be linked to or embedded in your ongoing work. You should adopt a cumulative approach to learning, con-sidering basic concepts and local systems early on in your training and complex concepts and wider systems when more established.

Regular, accurate and honest appraisals, grounded in the Medical Leadership Competency Framework, can offer insight into your leadership strengths, abilities, gaps and developmental needs as you progress in your career. Seize opportunities to reflect, individually and with colleagues, and to promote deep learn-ing as a means of realising positive changes in your thinking and behaviour. When confronted by a new leadership framework or approach it is helpful to ask “how does this apply to my situation” and “how can I do things differently in the future?”.

A significant temptation for a newly appointed consultant is to accept every leadership role and opportunity that is offered; this approach, however, is an inappropriate use of resources, limits teamwork and team development, fails to foster the skills of oth-ers and may increase levels of stress. Conversely over-delegation risks establishing unrealistic expectations and stretching individu-als beyond their competencies to the detriment of patient care and team well being.

Dr Michael HobkirkMichael is the Lead Consultant for Chichester Child and Adolescent Mental Health Service and the Specialist Advisor for Leadership Development at the Royal College of Psychiatrists

rEfErENcES

NHS Institute for Innovation and Improvement, Academy of Medical Royal Colleges (2010) Medical Leadership Competency Framework, 3rd edn. http://www.institute.nhs.uk/images/documents/Medical%20Leadership%20Competency%20Framework%203rd%20ed.pdf

SuMMary

•LEADERSHIP IS A KEY COMPONENT OF YOUR PROFESSIONAL DEVELOPMENT AND AN ONGOING PROCESS

•REFLECT UPON YOUR LEADERSHIP COMPETENCIES AND LEARNING NEEDS USING THE MEDICAL LEADERSHIP COMPETENCY FRAMEWORK AS A GUIDE

•THERE ARE NUMEROUS INFORMAL AND FORMAL OPPORTUNITIES FOR LEADERSHIP DEVELOPMENT

•STRIKE A BALANCE BETWEEN TAKING ON NEW ROLES AND DELEGATING WORK TO OTHERS

18

1. CONSENT

Junior doctors should not feel pressurised to do anything beyond their knowledge, experience and competence, this includes obtaining consent for a procedure that they are not familiar with.

failure to take consent properly can lead to medicolegal problems including complaints, claims and disciplinary proceedings.

Consent is a process, rather than a form-filling exercise. Recent GMC guidance emphasises the importance of working in partnership with patients.

TOP FIvE MEdicolEgal hazardSMedicolegal Advice - in association with the Medical Protection Society

Good doctors apply clinical knowledge in a way that is legally and ethically correct – but all doctors can slip up. Here are survival tips for the top five medicolegal risks for junior doctors.

•Always act in your patient’s best interests.•Record in the notes what a patient has been told.•Use your common sense – consent is patient-specific and depends on the individual’s

circumstances, including age, lifestyle, occupation, sporting interests, expectations, etc. It may well be that you are not in a position to advise fully, eg, professional sportspeople.

•Patients are presumed competent to consent unless proved otherwise.•Any competent adult in the UK can refuse treatment.•The law concerning incompetent adults, who are unable to give valid consent, is more

complicated, and is different in England, Wales, Scotland and Northern Ireland. If you are in doubt consult senior colleagues or your MDO.

•Remember there are circumstances where a child can give consent without reference to a parent – if in doubt consult a senior colleague.

SURvIvAL TIPS

2. PRESCRIBING

Prescribing is fraught with complications – from over-prescribing, transferring incorrectly to new charts and prescribing for the wrong patient, to incorrect dosages, interactions and allergies. It is imperative that you have a good knowledge of the pharmacology and the legislation surrounding drugs, and the Trust protocols and controlled drug routines – if unsure, ask.

•Prescriptions should clearly identify the patient, the drug, the dose, frequency, route of administration and start/finish dates, be written or typed and be signed by the prescriber.

•Be aware of and document a patient’s drug allergies.•Good handovers require good leadership and communication.•Refer to the BNF. It is accessible online if your hard copy goes walkabout.•Verbal prescriptions are only acceptable in emergency situations and should be written

up at the first available opportunity. Particular care should be taken that the correct drug and dose is used.

SURvIvAL TIPS

3. CONFIDENTIALITy

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

•Before disclosing confidential information, always consider obtaining consent.•Take advice from senior colleagues.•Remember that confidential information includes the patient’s name.•Competent children have the same rights to confidentiality as adults.•Doctors can breach confidentiality when their duty to society overrides their duty to

individual patients and it is deemed to be in the public interest.•Doctors are required to report to various authorities a range of issues, including notifiable

diseases (eg, TB), births, illegal abortions and people suspected of terrorist activity.•The courts can also require doctors to disclose information, although it would be a good

idea to contact MPS if you find yourself presented with a court order.•High-risk areas where breaches can occur are lifts, canteens, computers, printers, wards,

emergency departments, pubs and restaurants.•Be careful not to leave memory sticks or handover sheets lying around.

SURvIvAL TIPS

5. PROBITy

Good Medical Practice advises doctors that they must be honest and trustworthy when signing forms, reports and other documents. It also requires doctors to make sure that any documents they write or sign are not false or misleading.falling under this category is the requirement for any junior doctor to inform the GMC if they have accepted a caution, been charged with a criminal offence, or if they have been found unfit to practise by a professional body anywhere in the world. It also includes the requirement to take up any post that you have formally accepted.

1919

FOR JUNIOR DOCTORSMedicolegal Advice - in association with the Medical Protection Society

MPS is the world’s leading medical defence organisation, putting members first by providing professional support and expert advice throughout their careers.

MPS supports members through the world’s largest network of medicolegal experts. We have a unique team of more than 100 specialist lawyers and medicolegal advisers (doctors with legal training).

We are also committed to sharing our experience with members to help them avoid problems and provide the very best care for their patients. The educational portfolio available includes publications, conferences, lectures, presentations, workshops, E-learning and clinical risk assessments.

MPS members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.

www.mps.org.uk

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.

4. RECORD kEEPING

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. The notes will also form the basis of the hospital’s defence should there be any future litigation against your hospital. Notes are a reflection of the quality of care given so get into the habit of writing comprehensive and contemporaneous notes.

•Always date and sign your notes, whether written or on computer. Don’t change them. If you realise later that they are factually inaccurate, add an amendment.

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

•Making good notes should become habitual.•Document decisions made, any discussions, information given, relevant history, clinical

findings, patient progress, investigations, results, consent and referrals.•Medical records can contain a wide range of material, such as handwritten notes,

computerised records, correspondence between health professionals, lab reports, imaging records, photographs, video and other recordings and printouts from monitoring equipment.

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

•Patients have a right to access their own medical records under the Data Protection Act.

SURvIvAL TIPS

•If you are uncertain double check your work with a senior.•Take steps to verify what you are saying. Never sign a form unless you have read it and

you are absolutely sure that what you are saying is true.•Probity means being honest and trustworthy and acting with integrity.•Be honest about your experiences, qualifications and position.•Be honest in all your written and spoken statements, whether you are giving evidence or

acting as a witness in litigation.•You must be open and honest with any financial arrangements with patients and

employers, insurers and other organisations or individuals.•Assume that all records will be seen by the patient and/or others, eg, GMC, court.

SURvIvAL TIPS

Read the full version of this guide in ‘Avoiding easy mistakes: Five medicolegal hazards for junior doctors’: www.medicalprotection.org/uk/booklets/medicolegal-hazards

fINANCE20

Could you describe to everyone who missed out on your award-winning presentation what it was about and its key findings?

Patients with coronary artery disease often present with chest pain. As cardiologists we may be able to treat these patients with coronary stents. However, it is not always clear which artery is causing the problem. Cardiologists have developed several ways of trying to decipher which arteries need stenting. However, the existing tests require the administration of potent vasodilators during their measurements.

The administration of these drugs, causes discomfort to patients and in some countries are prohibitively expensive or simply una-vailable. During my research I helped to develop a new way of assessing coronary stenosis severity that circumvents the main lim-itations of the tests available to clinicians today. Our new index, the instantaneous wave-free ratio (iFR) uses equipment already available in catheter laboratory but samples haemodynamics in a particular part of the cardiac cycle most suitable for stenosis assess-ment. By doing this we avoid the need to administer potent vas-odilator drugs. This means our new test will enable a physiologi-cal approach to stenting to be available to more patients globally.

rSM yOUNG TRAINEE 2013focus on finance - in association with Wesleyan Medical Sickness

Dr Sayan Sen has been named the 2013 winner of the Wesleyan RSM Young Trainee of the Year. Sayan, who works at Imperial and specialises in Cardiology was the overall winner against 50 other doctors, already RSM prize winners within their respective specialties.

Sayan was shortlisted alongside five other doctors, representing a variety of medical fields from across the country. Each of them had to make a detailed presentation on their specialist subject to a panel made up of eminent medical professionals including Professor Parveen Kumar, Professor John Betteridge, Dean of the Royal Society of Medicine and Ben Attwood President of Wesleyan Medical Sickness’ Junior Advisory Board.

We interviewed him to find out what winning the award meant and how the £3,000 prize money will be used to help him progress his already successful career.

fINANCE 21

This is such a breakthrough in medicine that is already in use – what impact do you think this will have going forward?

The benefits of using physiology to guide stenting have been established extensively over the last twenty years. In randomised trials such an approach has been demonstrated to improve patient outcomes and reduce healthcare costs. Despite this physiology guided treatment is only rarely performed (<6% of all stenting procedures). One of the reasons for this is the need to administer potent vasodilators during the measurements of the current tests. These drugs add cost and time to the procedure, cannot be given to all patients and in some countries are simply unavailable.

The index we have developed at Imperial College avoids the need for such drugs and therefore has the potential to permit the use of physiology guided revascularisation in far more patients across the globe. Prior to our findings it was thought that such assessments could only be made with the administration of potent vasodilators. Our findings therefore challenge a dogma that has prevailed in this field for over 30 years.

What does winning the award mean for you?

It is a great honour to have won this prestigious award especial-ly with the high standard of the other entrants. It is hugely benefi-cial for an aspiring investigator at my stage to have my work evalu-ated by such an esteemed panel.

What made you go into cardiology as a specialty?

The specialty is constantly evolving and tries to take a very objective and scientific approach to patient therapy. Interventional cardiology combines a practical aspect which is particularly appeal-ing to me. The specialty also lends itself to clinical research.

What are your next steps for this research and your career?

The next step for this research is to validate our new index in a large randomised trial. This will be the purpose of the FLAIR

trial; an investigator lead study that aims to recruit 2500 patients. This will be the largest study of its kind ever performed. I will be the clinical lead of this trial so I envisage being very busy over the next few years!

What has helped you to get where you are today?

I have a competitive nature and always want to produce my best. This gives me the drive to work hard and persist despite set-backs. However, I would not be here today without the support of my parents and my family. In particular, my wife, who has been fantastically supportive during my training and research.

In terms of medicine, cardiology and research I am indebted to Dr Justin Davies, Prof Darrel Francis and Prof Jamil Mayet. Not only have they have taught me invaluable lessons in medicine and research but also life in general.

What are your top 3 tips for a successful career in medicine?

1. Work Hard2. Don’t hold yourself back or be afraid to think differently3. If at first you don’t succeed, don’t give up!

For those who want to apply for the young Trainee of the year award - what advice would you give?

I would definitely recommend submitting your work for this prestigious award. It enables you to showcase all your hard work and expose it to critical appraisal - invaluable for any aspiring investigators!

RSM provides over £60,000 a year for trainees in prize money to find out more visit http://www.rsm.ac.uk/academ/awards/

Specialist financial services for doctors

0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

• Savings and Investments

• Retirement Planning

• Life and Income Protection

• Mortgages

• Motor, home and travel insurance

Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the . Wesleyan Financial Services Limited is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

Motor, home and travel insurance is arranged by Wesleyan for Professionals.

Financial Conduct Authority

rSM yOUNG TRAINEE 2013

The above information does not constitute financial advice. If you would like more information or need specialist financial advice, call Wesleyan Medical Sickness on 0800 358 6060 or visit the website at www.wesleyan.co.uk/doctors.

focus on finance - in association with Wesleyan Medical Sickness

MEdICAL STUdENTSdIARIES22

I ’ve taken a couple of days out of clinic work this week to spend a bit of time at an information sharing and planning

meeting with some of the major govern-ment and organisational people in Sierra Leone. The talks are largely inspiring and enthusiastic, and it is great to realise that our small hospital is part of a much larger movement all over the country.

Some of the discussions about the pro-gress on reducing HIV transmission are very motivational, and I make a mental note to take some of the ideas back to our hospital, particularly the thoughts on involving local staff more in the counselling process.

Unfortunately, the breaks in between the talks are far from encouraging. I find myself accosted by a wild-eyed lady with hair that looks like it got caught up in an electrical explosion at a chemical dye factory, who spends the entire coffee break waxing lyri-cal about her pet project. She has clearly just

flown in from the UK, her pressured, fran-tic speech is a clear give-away. I am almost envious of her child-like wonder at a coun-try which I have loved and hated equally at times.

When I ask her about what it is she actu-ally does, the conversation runs something like this:

“So tell me about your organisation.” I ask, doing my best to sound like a keen development worker looking for a network-ing opportunity the way a toddler hunts down a chocolate biscuit.

Her eyebrows shoot up like a high-pres-sured geyser, “We have a sustainable pro-gramme of community health empower-ment!” None the wiser, I ask, “How does that work?”

The woman’s tone doesn’t drop at all as she replies with fierce energy, “I am facilitat-ing a locally-led programme of stakeholders who are working in resource-poor settings

to ensure health-equity”. Still baffled as to what is actually going

on here, I ask who the stakeholders are. The answer is as oblique as a politician on ques-tion time.

“They are grassroots small-holders in a range of public-private partnerships, dedi-cated to community-sensitisation using col-laborative healthcare outcome programmes. My role has been to ensure that the inclusive growth generated through this leads to post-2015 capacity-building!”

T hankfully, I manage to hold my tongue until the end of the meeting, and again some of the conversations about

expanding the tuberculosis program in the country sound much more promising. I manage to network enough to get hold of some more firm promises that we will soon have our own proper supply of anti-TB drugs, and it feels as though the DOTS programme is suddenly taking shape.

I make it back to the hospital in time to catch the end of the day’s clinic and to see the last few children. As usual, there are no

MAkING THE BEST OF IT IN SiErra lEoNEFY2 Dr Mikey Bryant is in Sierra Leone with healthcare charity Mercy Ships. He has been volunteering in a children’s clinic for a year in a country where one in five children don’t live to see their 5th birthday. In this regular column he gives us an update on his experience.

GLOSSy BUZZWORDS

HARM WITH GOODWILL

oN REAdING WhAT IS GoING oN, My CoNfUSIoN SLoWLy

TURNS To hoRRoR. ThE LEAfLET dESCRIBES, IN NAUSEATING

dETAIL, hER oRGANISATIoN’S MISSIoN STATEMENT.

MEdICAL STUdENTSdIARIES 23

I feel like a lost patient in a foreign hos-pital. I try to focus and ask, “How do these partnerships benefit the local Sierra Leone-ans?” The woman still resembles a Duracell bunny as she replies, “It involves local part-ners in resilient micro-financing initiatives!”

I give up trying to break through the gobble-de-gook and decide to pick up one of the lady’s many leaflets. On reading what is going on, my confusion slowly turns to horror. The leaflet describes, in nauseating detail, her organisation’s mission statement.

The plan is to get hold of as much mag-nesium sulphate and misoprostol as possible from whatever benevolent health boards in the UK are willing to donate, and then give it to whoever in Sierra Leone wants it. There seems to be no audit trail mentioned, nor is there any record of which health centres are getting the drugs. Instead, there are lots of photos of smiling mothers with cute babies in well-knitted woolly hats.

The “micro-financing” seems to involve drugs and money being given at random to a collection of dubious people who are accountable only to themselves. I had

wondered why the black market had been so full of magnesium sulphate last weekend, and now I know.

children who are at the healthy weight they would be, and the last one makes me partic-ularly sad, even a little angry. A tiny-look-ing three year old (called Asiatu) is brought in by her exhausted Mum. She clearly has Down’s syndrome, but that doesn’t explain the protruding ribs and gasping breaths.

As the story unfolds, I realise that she has been coughing for the last few weeks and she has been breathing frighteningly quickly over the last three days. Her head is bouncing up and down like a basketball and Mum’s weary eyes tell me that they have tried all sorts of things to cure the child before finally turning up here.

We persuade her to let us take care of Asiatu here overnight and try to help her breathing, and thankfully she stabi-lises a little on oxygen and becomes a lot more alert as the night goes on. Mum lets me look through the bag of medicines she has bought, and sure enough, a bottle of

magnesium sulphate is sitting in the bag attached to a giving set. Exactly how or why the mother was expected to give this to her child, I can’t fathom.

Our Sierra Leonean lead nurse has a long chat with Mum about where best to find medicine and help for her child, and once again I question the value of some of the work being done by international organisations.

I reflect when I get home on how easy it is to do a great deal of harm with a lot of goodwill and a few handy international

development buzzwords. I think of all the well-meaning projects supported by gener-ous philanthropic folk back in the UK, sup-ported by people who really believe they are making a difference.

I think about all the children and preg-nant mothers who are going to be injected with inappropriate doses of drugs over the next few months, and I realise that the only way to decide what to support and who to put time and energy into is by looking past the glossy photos and grandiose mission statements and working out what is actu-ally happening.

Something that is near impossible to do without having been there and seen it. Something that, unfortunately, far too few international decision-makers and funding bodies understand.

Read Mikey’s blog online at www.juniordr.com

MAkING THE BEST OF IT IN SiErra lEoNE

GLOSSy BUZZWORDS

HARM WITH GOODWILL

I REfLECT WhEN I GET hoME oN hoW EASy IT IS To do A GREAT dEAL of hARM WITh A LoT of GoodWILL ANd A fEW hANdy

INTERNATIoNAL dEvELoPMENT BUzzWoRdS.

dIARy24

I t was 6am on the 15th August and my heart was pound-ing. The day had finally come when I would find out if I had reached my offer to secure my place at medical school. With

my usual lack of self-belief, all I could think of was what would happen if I hadn’t made the grades. How would I tell all my fam-ily and friends who had put their hopes into me getting in? What if I didn’t get in the second time round? How would I cope know-ing that I had missed out on my dream career at the last hur-dle? I truly thought that I hadn’t done well enough in the exams so there was nothing I could tell myself to stop these negative thoughts racing through my mind.

After what seemed like an eternity, the UCAS page loaded. I logged in with fumbling fingers, terrified of what it might say… “Welcome back Carla Grace…”, I was holding my breath with all my fingers crossed, “Congratulations! Your place for Medicine has been confirmed”. My breath rushed out in a scream of joy, while my family were hugging me and screaming too. I was ecstatic, I had finally reached my goal. After going into school I found out that I had not only reached, but surpassed the offer, so all my worrying was for nothing.

However, little did I know what I had let myself in for. Peo-ple had told me time and time again how hard medical school was, how much work it involved and how little free time it left you with. I had naively believed they were exaggerating and took what they said with a (quite large!) pinch of salt. But even just after the first week there, I realised that I previously had had no idea of how demanding it would really be. Having 9-6 lectures each day, needing to write up those lectures and prepare for the tutorials of the next day, along with all the content seeming a thousand times harder than that of A-levels felt gruel-ling to say the least. Trying to con-tend with the dreaded ‘Fresher’s Flu’, caught from celebrating a bit too much in Freshers’ Week, probably made eve-rything seem worse too!

The first few weeks seemed to be endless com-plex science, fascinating and enjoyable, but with-out a patient in sight. Biochemistry, cell biol-ogy, genetics, endocri-nology, anatomy, phar-macology, neuroscience and, I mustn’t forget,

the dreaded histology. Every week another sheet of pink images was thrust my way to try to decipher for the next session. How anybody could make sense of them, I could not understand.

All in all, during the first few weeks, I felt quite run down and although the science was really interesting and enjoyable too, I longed for some patient-contact or clinical relation. Seeing my flat-mates and friends from other courses having time to relax, go out and have a good time didn’t make things seem much better, but thankfully my medic friends felt exactly the same as me.

Then, in the third week, came the light at the end of the tunnel - my GP placement. Despite having to wake up at 6am (not a typi-cal student waking time!) in order to get there, I absolutely loved it. I met and chatted to real life patients, observed consultations, learnt how to take blood pressure, various pulses, palpate and per-cuss. We even have our own student consultation room, just like a GP’s room, where pre-booked patients come for us to practice tak-ing histories. I felt enthused by chatting to patients and finding out how their problems affect them and how the doctors had helped them. I was reminded of why I wanted to go into medicine in the first place, and I felt motivated to keep ploughing through the first two pre-clinical years, whilst keeping in mind that in only two years’ time I would be on placement, interacting with patients and putting the science to good use, every day. Thankfully, we are lucky enough to have the placement day once every fortnight, something of which I am only too glad!

After that first placement, things seemed to pick up. I recovered from the ‘Fresher’s Flu’, and settled in to university life. After discus-sion with older students, I found that nearly everyone thought that the first semester was difficult in terms of the content, and that they

found the subsequent semesters more enjoyable, which I

found encouraging. I even, believe it or not,

worked out how to interpret histolog-ical images. Well, sort of!

My biggest fear now is the upcoming prosec-tion sessions … but I’ll leave that for my next col-umn, if I survive my January ex-ams first, that is!

rESultSMy JOURNEy TO BECOMING A DOCTOR:

Sixth former Carla Barberio dreams of being a doctor. We were all there once struggling with

exams, trying to perfect UCAS forms and longing to swing a stethoscope around our necks. In this column we join Carla as she awaits to hear if she

has an offer for medical school.

After what seemed like an eternity, the UCAS page loaded. I logged in with fumbling fingers, terrified of

what it might say…

Carla Barberio

hoSPITAL MESS 25

Who’s been a bad junior doctor this Christmas,

£1.20 Guy’s and St Thomas’ Hospital, London

Ho ho ho’s all the way at,

40p Cumberland Infirmary, Carlisle

Burns your pocket as well as your mouth at,

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Chocolicious at,

40p Barnet Hospital, Hertfordshire

Just stay in bed at,

£4.95 Royal London Hospital, London

Sneeze that cold away at,

£3.99 Barnet Hospital, Hertfordshire

Next issue we’re checking the cost of a ballpoint pen, birthday card and a Twix (50g). Email prices to hospitalconfidential@juniordr.com

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular

column of the best and worse hospital essentials you’ve reported:

Colchester Doctor’s Mess has a flatscreen TV with Sky, microwave, dishwasher, and coffee maker. Off the main mess is a room with three

computers. The usual tea, cof-fee, toast and cereals are pro-vided along with daily news-papers. One plus is having a cleaner. Mess fees are £10 a month with occasional subsi-dised mess nights out.t

JuniorDr Score: ★★★✩✩

Mince pie

Lemsip

‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.

Writing in the Notes

doctors need to take more sick leave

Dear Editor,I was interested to read your published study

which shows doctors take the least amount of

sick leave each year (Hospital doctors least like-

ly to take sick leave of all NHS staff; Iss 30; p4).

Your article didn’t address whether this was a

good or bad thing. From my experience there

are many junior doctors who turn up for work

unwell (and infectious!). Surely it’s not always a

good thing if we have sick doctors in our hospi-

tals working beyond the call of duty primarily

because there are no appropriate cover arrange-

ments in place?RoBIN (SURNAME WIThhELd)

fy2 hERTfoRdShIRE

career change considerationsDear Editor,

I have been trying to understand why a high number of junior doctors are considering a career change (Third of junior doctors considering career change; Iss 30; p4). I suspect the figure quoted in the article is realistic but I wonder whether it is higher than other careers? And if not, is it a con-sequence of embarking on a long medical degree at an early stage before we truly understand the implications? I think the commentator’s com-ment about the not having enough time to give patients the care they deserve is a real problem. We go into medicine because we want to care for patients - not spend our time constantly battling against a never ending jobs list.dR BANERJEE LoNdoN

colchEStEr gENEral hoSpital

Stigma of sick leave

Dear Editor,I think one of the reasons doctors take less sick

leave than other NHS professions (Hospital doc-

tors least likely to take sick leave of all NHS staff;

Iss 30; p4) is related to the view senior staff have

of this. Until consultants no longer see juniors

who take sick leave as weaker or not pulling their

weight things we’ll continue to turn up to work

with colds, the flu and other infectious conditions.

NAME WIThhELd

By EMAIL

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