OXFORD SPECIALTY TRAINING
everything you need for career and membership exam success Oxford Specialty Training is a brand new series and the first to take account of the new training structure and syllabuses, as introduced by the Modernising Medical Careers initiative.
• • • COMING IN SPRING 2009 • • • TRAINING IN SURGERY
TRAINING IN OPHTHALMOLOGY
A complete curriculum guide to specialty training in surgery, covering the material taught during the first two years of training, as well as the topics examined as part of Royal College membership. Written by both trainees who are currently completing their specialty training, and senior practitioners, the information is accurate, comprehensive and at the appropriate level.
This full colour book is the first to take account of the new ophthalmic training structure and syllabus, as defined by the Royal College of Ophthalmologists (RCOphth). As a theoretical and practical aid for trainee ophthalmologists and FY doctors, it is a guide through the initial years of the new postgraduate Ophthalmic Specialist Training. It will also appeal to candidates preparing for the FRCOphth exam.
978-0-19-920475-5 | January 2009 | 448pp | £39.95 | paperback
978-0-19-923759-3 | February 2009 | 480pp | £49.95 | paperback
TRAINING IN OBSTETRICS AND GYNAECOLOGY
TRAINING IN ANAESTHESIA
Accurate and evidence-based, this textbook for junior obstetricians and gynaecologists contains all the material relevant to everyday practice and the new RCOG curriculum. It has been written and edited by inspiring teams that combine juniors, new and established consultants working across a range of settings, and many of the UK's top experts in obstetrics and gynaecology.
Training in Anaesthesia is a curriculum-based guide to the first phase of specialty training in anaesthetics, comprehensively covering the techniques, assessments, and basic medical and physiological knowledge that trainees learn as part of their basic training, and which are examined by the Primary FRCA qualification. The book is authored by both trainees and specialists, and has been comprehensively edited and peer-reviewed.
978-0-19-921847-9 | March 2009 | 528pp | £39.95 | paperback
978-0-19-922726-6 | July 2009 | 672pp | £49.95 | paperback
• • • f o rt h c o m i n g • • • TRAINING IN PAEDIATRICS | 978-0-19-922773-0 | August 2009 | £39.95 | paperback TRAINING IN PSYCHIATRY | 978-0-19-922758-7 | November 2009 | £49.95 | paperback TRAINING IN MEDICINE | 978-0-19-923045-7 | January 2010 | £49.95 | paperback
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available in all good bookshops and directly from OUP at www.oup.com/uk/ost
Time to join the happy doctors overseas? THE MAGAZINE FOR TRAINEE DOCTORS
Presenting History JuniorDr is a free distribution lifestyle magazine produced by doctors for the UK’s Medical Students, Foundation Year Trainees, Specialist Trainees, GP Trainees and Specialist Registrars. You can find us quarterly in hospitals and medical schools throughout England, Scotland, Wales and Northern Ireland, and updated daily at JuniorDr.com. Editor Ashley McKimm, editor@juniordr.com Editorial Team Michelle Connolly, Anita Sharma, Muhunthan Thillai Newsdesk news@juniordr.com Advertising & Production Rob Peterson, ads@juniordr.com JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 684 2343 Fax - +44 (0) 87 0 130 6985 team@juniordr.com Health warning JuniorDr is not a publication of the NHS, Gordon Brown, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. © Copyright JuniorDr 2008. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out juniordr.com.
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t’s not easy being a doctor in December. Outside Britain is cold, wet and gripped by the never-ending pessimism of the credit crunch. Inside, the wards are heaving with norovirus and your wind-chapped hands sting from the constant alcohol gel rubs. You’ll be even more disheartened to hear that hundreds of British trained medics working overseas report they’re having a much better time than you are (page 12). They’re all off for a ‘barbie’ on Bondi beach tonight or busy waxing up their skis for a weekend escape to Whistler. The even sadder fact is that those who have made the move have no regrets about leaving our beloved NHS for greener pastures - or nicer beaches. Since the MTAS malarkey thousands have travelled overseas, initially temporarily, but many fewer have returned. This issue we take an objective view of working abroad and assess the perks and the downsides (page 13). We’ve asked doctors who have made the move to tell us about their favourite new workplaces and offer advice to make your transition easier. If you are sadistically enjoying the cold and the thought of leaving for sunny New Zealand or Australia doesn’t get you excited we hear from Dr Ross Hofmeyr who practises medicine in icy Antarctica (page 9). With nearly 3,000 miles to the nearest hospital it’s perfect for doctors wanting to get away from it all. We hope we’ll provide plenty of ideas to help you dream away those cold winter evenings – and you can find more career options on the JuniorDr.com website. All we ask is that you remember to send us a postcard if you do end up sunbathing on that tropical beach.
“Hundreds of British trained medics working overseas feel they’re having a much better time than you are.”
Ashley McKimm JuniorDr Editor-in-Chief
Correction: In the September issue we mistakenly printed an old version of the MPS advertorial ‘Sticky Business’. We’re sorry if you had read this before. You can read the latest advice on ‘Working Overseas’ from the MPS on page 15 of this issue and find more support at www.mps.org.uk.
What’s inside 04 09 12 16 17
LATEST NEWS MEDICINE IN ANTARCTICA
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SECRET DIARY OF A CARDIOLOGY SPR SANTA GETS CHRISTMAS CHECK-UP
WORKING OVERSEAS Top CARDIOLOGY Websites MEDICAL STUDENTS TO FACE VIRTUAL “ON-CALLS”
TRIAGE
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Tell us your news. Email us at team@juniordr.com or call 020 7684 2343.
working hours
COLLEGES WARN OVER EWTD READINESS
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ver half of hospitals in England are unprepared for the 48-hour European Working Time Directive deadline of August 2009, according to a study jointly published by the Royal College of Anaesthetists and Royal College of Surgeons. Only 49 percent of anaesthetic and 42 percent of surgical rotas were within next year’s limit. Taking Trusts as a whole the situation is worse still – only 18 percent of responding Trusts said their surgery staff were meeting the target; the figure for anaesthesia was 33 percent. Less than 15 percent reported they have
Mr John Black Royal College of Surgeons President
“With the deadline looming, surgeons and anaesthetists are worried that NHS Trusts will be tempted to simply cobble together rotas that fit the law.”
a costed and agreed plan to meet the deadline. Of those who stated they are ready it had taken them between six to twelve months to properly plan and implement the necessary changes. Hospitals face heavy fines if an employee breaches the working hours limit. “If there is one lesson to be drawn from the data presented in this report it is that getting working hours down while offering proper, safe patient care and retaining medical training is not straightforward and takes time,” said Royal College of Surgeons President, John Black. “With the deadline looming, surgeons and anaesthetists are worried that NHS Trusts will be tempted to simply cobble together rotas that fit the law but don’t take proper account of night-time staffing, ensure patients have as few handovers as possible or provide junior doctors with the varied training needed to give us the consultants of tomorrow.” In their report, entitled WTD-Implications and Practical Suggestions to Achieve Compliance, they warned that patient safety and medical training could be compromised unless there is adequate funding and engagement from senior NHS management.
www.rcseng.ac.uk www.rcoa.ac.uk www.healthcareworkforce.nhs.uk
health
JUNIOR DOCTOR COUCH POTATO WARNING
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unior doctors are turning into a profession of couch potatoes by taking much less exercise than the national average and well below recommended levels, according to a study published in the British Journal of Sports Medicine. Only one in five (21%) junior doctors met the recommended exercise levels - much lower than the national average of 44 percent. The study of 61 doctors at Bedford and Middlesex Hospitals found that whilst training as medical students almost
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NEWS PULSE
two thirds of the same group had met the Department of Health recommendations of 30 minutes of moderate exercise at least five times a week. 58 percent said lack of time was the biggest single reason for not exercising enough after graduating but almost a third (29%) said they weren’t motivated to exercise, or were too tired after work to do so. “This is very important, not only for the doctors’ own health, but also for the health of the patients. Numerous studies have
shown that students and consultant equivalent doctors who exercise are more likely to counsel their patients to exercise too,” said the study authors. More positively, the study did find that doctors weighed and smoked less than the national average, with only seven percent drinking more than the recommended number of units of alcohol. bjsm.bmj.com
Non-white students reject traditional therapies Non-white medical students are more likely to embrace orthodox medicine and reject therapies traditionally associated with their culture, according to a study published in Medical Teacher. The study looked at over 600 students in the UK, USA and New Zealand and found that Asian and black students had the least interest in complementary and alternative medicine. www.medicalteacher.org
Prescriptions less pricey The government and major drug firms have agreed a 3.9 percent price cut in 2009 followed by a further 1.9 percent from 2010. The deal also sees the genetic substitution of common drugs and introduction of a flexible pricing arrangement which will allow firms to supply new drugs initially at lower prices with the option of higher prices if the value is proven. www.dh.gov.uk
More GPs work late Over half of GP surgeries (51%) now offer patients extended opening hours, according to the latest Department of Health data. In the last six months there has been a 40 percent increase in the number of practices offering more flexible early morning, evening and weekend opening. It meets the government’s target of 50 percent of practices by the end of 2008. www.dh.gov.uk
Get infected with happiness Happiness is infectious, according to a study published in this month’s BMJ. Researchers at Harvard Medical School looked at nearly 5,000 people and found that live-in partners who become happy increase the likelihood of their partner being happy by 8 percent. Similar effects were seen for siblings who live close by (14%) and neighbours (34%) – though they noted that happiness requires close proximity to spread. www.bmj.com
Working Conditions
BMA CALLS FOR 4 PERCENT ANNUAL PAY RISE
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four percent rise in the annual pay of doctors in 2009 would be ‘an appropriate and affordable increase’ said the BMA in its evidence to the UK’s Doctors’ Pay Review Body. They demanded that public sector pay ‘should not be used as a tool to try to control inflation’ and warned that the level of pay is beginning to affect school leavers’ career choices and doctors’ decisions to continue working in medicine. “Last year’s below inflationary rises have failed to keep pace with the increase in the cost of living. Moreover, GPs received no increase in gross remuneration and with practice expenses rising considerably, most of them had a significant pay cut for the second year running,” said Hamish Meldrum, Chairman of the BMA. “The loss of free accommodation for junior doctors also amounted to a pay reduction and a substantial uplift in their basic pay
Dr Hamish Meldrum Chairman of the BMA
“Last year’s below inflationary rises have failed to keep pace with the increase in the cost of living.” is essential to counter the effect this has had on their income.” The Review Body previously used the argument of free junior doctor accommodation for keeping pre-registration doctor pay lower than it might otherwise have been. Hospital Trusts have however called for a rise of no more than two percent in 2009. Last year the government implemented the DDRB recommendation of just 2.2 percent for junior doctors - half that called for by the BMA. GPs received an average increase of 0.2 percent per practice. www.bma.org.uk
MEDICAL STUDENTS
£400,000 of Gunther von Hagens’ body parts bought by Warwick University
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ver 200 ‘plastinated’ body parts from Gunther von Hagens’ Germany laboratory are on their way to Warwick Medical School to aid anatomy demonstration. It will be the first time Von Hagens’ plastinated specimens have been used for teaching by a UK institution. The specimens cost £400,000 and are part of a Strategic Health Authority grant of £1.1 million for the School to create a centre for excellence in anatomy and surgical skills. “Gunther von Hagens’ plastination technique is the most effective and his specimens are of the highest quality,” said Professor Peter Abrahams, Warwick Medical School’s Chair of Clinical Anatomy. “Our students can use these specimens again and again to understand how the body works, they will be a unique and invaluable tool for the training of doctors.” Dr von Hagens’ plastination technique
Gunther von Hagens and his assistants with some of the body parts on their way to the University of Warwick. © Gunther von Hagens.
involves removing body fat and water and impregnating a polymer to preserve the body or body part. The specimens originate from body donors to von Hagen’s Institute for Plastination in Guben, Germany. www.warwick.ac.uk
NEWS PULSE
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When a fork is faster
Clinical
LIMITING JUNIOR DOCTOR HOURS PRODUCES FEWER GALLBLADDER COMPLICATIONS
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ewer patients undergoing gallbladder surgery had bile duct injuries or other complications when US junior doctor work hours were limited to 80 per week, according to a study published in the Archives of Surgery. The study by a team at the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center looked at 2,470 patients and found fewer experienced bile duct injury (0.4% vs 1%) or any complication (2% vs 5%) following the introduction of a 80-hour work week in 2003. Previous studies using simulators have shown that sleep deprivation has substantial
adverse effects on laparoscopic skills, often resulting in bile duct injury. “We observed improved outcomes in the era of restricted resident work hours in patients undergoing laparoscopic cholecystectomy,” reported Arezou Yaghoubian and colleagues. “Despite the concerns that work hour restrictions may have deleterious effects on patient care and resident education, these results clearly indicate otherwise. Whether the better-rested resident surgeon leads to better surgical outcomes needs further study.” archsurg.ama-assn.org
Working Conditions
Treat burnout among doctors to reduce sick leave
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hort term counselling and a modest cut in work hours can help reduce emotional exhaustion and sick leave among doctors, according to a study published in this month’s BMJ. The one year cohort study of 227 stressed Norwegian doctors found that a programme of psychotherapy reduced the number of doctors on full-time sick leave from 35 percent to 6 percent. Doctors have higher rates of suicide and depression than the general population and are less likely to seek help. “Our findings indicate that seeking a counselling intervention could be conducive to reduction of burnout among doctors,” said Dr Karin Rø and her team at the Modum Bad Research Institute. “Considering doctors’ reluctance to seek help it is important to offer interventions that facilitate access.” The team also found that the use of psychotherapy by the cohort had increased substantially from 20 percent to 53 percent in the follow-up year. A reduction in work hours after the intervention was also associated with a drop in emotional exhaustion. On one year follow-up the stressed
Obese diners tackle ‘all-you-caneat’ Chinese buffets differently than normal weight individuals, according to Cornell University’s Food and Brand Lab. In the study of 213 diners they found that, compared to normal weight diners, overweight individuals sat 16 feet closer to the buffet, were twice as likely to sit facing the food, were three times as likely to use forks instead of chopsticks and were half as likely to browse the buffet before serving themselves. www.cornell.edu
Patients to bypass GP referrals Patients are to be able to self-refer to services such as physiotherapy and podiatry without the need for a GP, Health Secretary Alan Johnson has announced. Many of the UK’s 76,000 allied health professionals fear they may see a surge in new referrals following the change but Mr Johnson insists that it will further empower patients. www.dh.gov.uk
Doctors for doctors A new confidential specialist health service for doctors and dentists has opened in London. The DH funded ‘Practitioner Health Programme’ aims to encourage doctors to seek help rather than managing their own health concerns and self-prescribing. In addition to providing support for physical health concerns the service, based at Riverside Medical Centre in Vauxhall, is also aimed at those with mental health worries or addictions. www.php.nhs.uk
US docs regularly give placebos doctors reported a reduction in emotional exhaustion and job stress similar to the level found in a representative sample of Norwegian doctors. The study followed calls for early intervention programmes to help doctors with mental distress and burnout before their problems begin to interfere with the welfare of patients. www.bmj.com
Many US doctors regularly prescribe drugs, including sedatives and antibiotics, as “placebo treatments” but rarely tell their patients, according to a study published in the BMJ. Of the 679 doctors responding to the survey over half (57%) prescribed “placebo treatments” on a regular basis with 62 percent believing the practice to be ethically acceptable. www.bmj.com
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NEWS PULSE
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Radiographer wearing protective clothing and headpiece, World War I, France. (HJ Hickman, c.1918)
Wellcome Collection
War and Medicine Exhibition
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his groundbreaking exhibition considers the continually evolving relationship between warfare and medicine, beginning with the disasters of the Crimean War in the 1850s and continuing through to today’s conflicts in Afghanistan and Iraq. War and Medicine covers a wide range of subjects - from the pioneering plastic surgery techniques first developed during World War I to treat disfiguring facial wounds through to the recent controversies surrounding Gulf War Syndrome and the diagnosis of Post-Traumatic Stress Disorder. The collection runs until 15 February 2009. For more information visit:
www.wellcomecollection.org
EXTREME MEDICINE:
The Antarctic Doctor Welcome to my A&E Department. Local population: 10 to 100 (dependent on the season). Staff: 1. Nearest referral hospital: 2800 miles (but no referral, transfer or evacuation possible for 8 months each year). Welcome to SANAE IV Antarctica – my home for 15 months and the current year round research station of the South African National Antarctic Expedition.
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outh Africa is one of approximately 20 countries which maintain yearround stations in Antarctica, using the unique conditions as a massive laboratory for research. Nothing in Antarctica is simple however. Research teams across the continent, which is 56 times greater than the UK in surface area, have to contend with living in the harshest environment on Earth. Antarctica is the coldest place on the surface of the planet with temperatures dipping towards -90°C near the South Pole; the windiest, with hurricane force winds an almost weekly phenomenon; the highest, averaging 1860m (6100 ft) above sea level; and despite having more than 70 percent of the planet’s fresh water trapped as 97 percent of the world’s ice, it is the greatest desert with the Dry Valleys area of Antarctica having not seen precipitation in millions of years. In the frigid darkness of the austral winter the sea around the continent freezes for hundreds of miles doubling the surface area of ice. Less than 1000 people are to be found on the entire continent in winter scattered amongst the isolated research stations like tiny candles in the perpetual darkness. During summer this number swells to somewhere over 4000 as the influx of summer
field researchers, support and logistics personnel and a rapidly increasing number of tourists (more than 40,000 in the last year) head south to enjoy the fine weather (‘barely’ subzero) and long hours of sunlight. Stations near the pole experience six months of perpetual darkness during winter and are completely isolated from the rest of the world. Flying into Antarctica in the winter is a near impossibility and it has been suggested that it is logistically simpler to evacuate a casualty from the International Space Station than from Antarctica at this time of year. While many would find providing medical care in this environment incredibly daunting, for a handful of adventurous medics it is a dream come true.
“It is logistically easier to evacuate a casualty from the International Space Station than from Antarctica at this time of year.”
Dr Ross Hofmeyr
The Antarctic General Practice Most expeditions favour a doctor with some surgical experience, particularly with an emphasis on trauma, along with good general practice and general medicine knowledge. Participants in the expeditions are usually very thoroughly vetted prior to departure but still the majority of the medical case load is similar to a general practice. Minor respiratory and GI tract ailments are common. In addition, bumps, scrapes and scratches are regular occurrences. Psychological problems as a result of the isolation and physiological disturbances of working in such an unusual environment for long periods are frequent. Sleep disturbances due to the perpetual daylight in summer and darkness in winter are the most ubiquitous diagnosis. Contrary to expectations cold injuries such as frostbite, hypothermia and other environment-specific illnesses like snowblindness are rare because of the prominent educational programs for expedition staff. The most prevailing concern is that of significant trauma through ice-related falls or injuries from cargo handling hence the preference towards doctors with
EXTREME MEDICINE
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extreme medicine: The Antarctic doctor good trauma experience. Other ‘peripheral’ skills of value on the continent are experience with disaster planning and mass-casualty incidents, aeromedical skills and the ability to use outside assistance via forms of telemedicine successfully.
Meningitis at minus 40 Famously, a Russian doctor removed his own appendix under local anesthesia at the Novolazarevskaya base about 300 miles from SANAE IV using various teammates as assistants. It helps to demonstrate how the expedition doctor in Antarctica has to be many things at the same time and requires the skills of an A&E doctor, general practitioner, psychologist, surgeon, anaesthetist, radiographer, dentist, pharmacist and laboratory technician. Most expeditions include pre-departure training which addresses these needs - particularly the ancillary roles which are not part of most doctors’ experience such as dental work and taking and developing
x-rays. Doctors with an A&E background are good candidates for this type of work where excellent diagnostic skills and a broad understanding of the full spectrum of disease can fill the void created by the absence of advanced imaging and laboratory investigations. For example, the most serious illness I have faced during this expedition occurred when a team member developed clinical signs of meningitis a few days after evacuation of a minor dental abscess. Assisted by a diesel mechanic as my ‘nurse’, I made the diagnosis on clinical grounds then performed a lumbar puncture and started empiric treatment. In the lab using the centrifuge, microscope and some basic equipment I was able to establish a raised white blood count and erythrocyte sedimentation rate. I then performed a CSF stain and identified Staphylococcus as the pathogen. The patient recovered rapidly on the appropriate treatment. The episode reinforced my belief that as doctors we should not allow ourselves to become distanced from clinical and laboratory
procedural skills such as microscopy that form an integral part of acute medicine.
The White Continent Antarctica is without doubt the most beautiful place I have ever been. Even when the temperature is forty below zero it is a privilege to walk around the mountain or simply sit and listen to the ice crack as the glaciers move imperceptibly onwards. The frequent storms bring both terror and wonder, as the winds scour the landscape and static electricity sparks on every surface. The light is forever changing and it appears as if the stars are so close that one can almost touch them. Simply to journey to Antarctica truly takes one beyond expectations, beyond normality and into that place that ‘transcends reason’. Although not suited to everyone, to be able to use your career as a vehicle to see the White Continent in all her moods is an opportunity beyond your greatest dreams.
The Antarctic A&E Department
‘M
y’ A&E department consists of three main rooms. A consulting room/ office is equipped with the usual items: examination table, basic diagnostic equipment, computer, and modest medical library in a bookshelf. An interconnecting door leads to the clinic area which contains a single hospital bed with non-invasive monitoring. A mobile x-ray machine allows me to perform plain films, which I develop by hand in an adjoining darkroom. Across from the bed is my ‘lab’ which consists of a centrifuge, light microscope and all the paraphernalia to perform smears and cell counts. We are also lucky to have a test strip based machine to perform basic blood chemistry, although unfortunately not blood gases. A small autoclave allows sterilization of equipment. The other corner of the room is dedicated to dental work with a full-sized dentist’s chair, small instrument platform powered by a portable compressor and a mobile suction unit. Leading off from the clinic area is the operating theater which doubles as a resuscitation room. Although austere, there is a basic operating table, a no-frills anesthetic machine (with one vaporizer containing halothane!), non-invasive monitoring and wall gases (oxygen and nitrous oxide). Suction is provided by mobile units and the dental light is used for additional illumination.
SANAE IV Operating Theatre and Resus Room
SANAE IV Doctor’s Office
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SANAE IV
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s suggested by the name, this is the fourth SANAE base. The first three were built on the ice shelf and were gradually buried by snow and crushed in the ice which forced them to be decommissioned. To escape this fate, SANAE IV was built inland atop a nunatak (mountain peak projecting through the ice cap) known as Vesleskarvet in the Queen Maud Land region. Several other nations have bases in this area. The German research station, Neumayer II, and Norwegian station, Troll, are to be found about 125 miles west and east of SANAE. Despite these ‘neighbours’, we are essentially isolated as to make an overland voyage to either station is a journey fraught with danger from crevasses and severe weather conditions. During the brief summer, however, the base population swells from 10 to nearly 100 persons and a local air network is established to move personnel and supplies. As a central location, SANAE is equipped with a larger than average medical facility in order to provide medical support.
SANAE IV on Vesleskarvet
SANAE IV location
The NHS Pension Scheme has changed How does it affect you?
You are probably aware of some of the changes to the NHS Pension Scheme, which came into effect on 1 April 2008. But do you know what they mean to you, and what changes, if any, you need to make to your retirement plans? To find out, book an appointment with your local Wesleyan Medical Sickness Financial Consultant. They have specialist understanding of the NHS pension scheme and can provide tailored advice to help you plan for your future. To find out more call
0800 107 5352
Image © NASA.
You can read the extended version of Dr Ross Hofmeyr’s experience online at JuniorDr.com and follow his Antarctic journey at www.doctorross.co.za. Images used courtesy of (c) Dr Ross Hofmeyr unless otherwise stated. This article first appeared in the Association of Emergency Physicians First Line Newsletter Vol. 5, Issue 3, Fall 2008 www.aep.org
Wesleyan Medical Sickness is a division of Wesleyan Financial Services Ltd. (“WFS Ltd”), a wholly owned subsidiary company of Wesleyan Assurance Society. Registered No. 1651212. WFS Ltd. is authorised and regulated by the Financial Services Authority. Head Office: Colmore Circus, Birmingham B4 6AR. Fax: 0121 200 2971. Telephone calls may be recorded for monitoring and training purposes. HD-AD-5 10-08
Supported by
W o r k ing Overseas Whether it’s Australia, New Zealand or Canada there are plenty of options for doctors wanting to escape the UK. We’ve asked those who have made the move to tell us about their favourite overseas locations and their advice on making the transition. Australia
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worked in Melbourne, Australia, for a year and a half after my house jobs and had the opportunity to do posts in Neurology, A&E and ICU. High staffing levels in A&E meant that we were able to investigate, diagnose and manage patients before referring them on for specialist treatment - in this way, I gained a wide range of clinical experience. On my salary, I was able to live in a shared flat, with a pool and gym in the apartment
block. I also had the opportunity to travel all over Australia my ICU placement was a 1 week on, 1 week off rota, so I went on holiday every other week! My 18 months in Australia has helped rather than hindered my career – it gave me an opportunity to work in a variety of specialties, while I took my time considering what specialty I wanted to train in. It also allowed me to compare and contrast healthcare systems in two different countries. Melbourne has lots to offer – from city living, with access to a variety of sports and cultural
work as a GP in rural Australia practicensw to find out how go to
www.practicensw.com
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WORKING OVERSEAS
events, to the opportunity to see more of the wildlife and geography of the rest of the country. I would highly recommend Melbourne as a brilliant place to work and play. Since working in Melbourne Dr. Amanda Sinai has returned to the UK and is training in psychiatry.
Dr A man da
Sinai
DOWN UNDER COMES OUT ON TOP UK doctors prefer working in Australia and New Zealand to other overseas destinations, according to a survey of 138 British doctors by Wavelength. Most said they valued the change in lifestyle, the similarity of training schemes and the good whether.
Beat the Winter Blues
your experiences
Wavelength International are looking for Junior Doctors with a desire to travel, for a variety of excellent training positions in coastal, city & country locations.
WAV777A
Make the move to Australia & New Zealand
The combination of world class healthcare & unique range of lifestyle options makes Australia & New Zealand a great career move. Our dedicated team give career & salary advice, assist with registration, migration & relocation.
New Zealand
Jobs in Medicine, Surgery, A&E and O&G
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fter completing my medical degree and foundation years’ training in London, I decided to do my OE (Overseas Experience) in New Zealand as I had never heard a bad word said about it. I went through an agency and landed myself a job in Rotorua working in A&E. The most noticeable difference was that four-hour breach times were not an issue. Patients could therefore be more thoroughly assessed and managed calmly without the harassment and bullying that is often found in the NHS. The only difficult thing to get used to was the rotten-egg sulphur smell from Rotorua’s geothermal environment! I then moved to the sunny winery region of Hawke’s Bay obtaining jobs as a Psychiatry Registrar and then as an Ophthalmology SHO by directly emailing my CV to the RMO (Resident Medical Officer) Unit Manager. Eight months later I found myself working as a Paediatrics SHO in Nelson with such a friendly and supportive team in one of the most stunning places I have ever lived in. There are few places where it would be possible to ski in the morning and kayak along beautiful beaches in the afternoon sun! Even though the annual salary appears less than that in the UK, there are significant financial benefits to working in New Zealand. Medical council membership and indemnity insurance are reimbursed, all courses and related expenses are paid for, as are textbooks and exams if on a hospital training scheme. In all the hospitals I worked at I found morale to be higher, the atmosphere to be friendlier, and all staff more supportive towards colleagues when compared to the UK. This coupled with the amazing lifestyle that New Zealand has to offer has encouraged me to stay here to complete my training. Dr. Tanya Hussein trained as a junior doctor in London and worked in New Zealand up until November 2008. She is set to return in January to continue her GP training there.
6, 9 & 12 month contracts Refer a friend & earn $500 Flight Centre or House of Fraser gift voucher Apply today – you'll be surprised what's out there! Call Rebecca (NZ jobs) or James (Aust jobs) on 0845 602 1498 or email rdoyle@wave.com.au or jhill@wave.com.au
NEW ZEALAND AND AUSTRALIA HOSPITAL POSITIONS FOR 2009 Variable start dates available from January through to August 2009 - it is not too early! NZ and Australia offer unique and fantastic environments for Junior Doctors to live, work and play. Good supportive orientation programs and positive future career prospects. Talk to us about finding the best jobs in the best locations for you – and the right support and expertise to move internationally. Register today at www.genevadoctors.com call our NZ office on +64 9 916 0150 or email medical@genevahealth.com
Live your dream Work and play in New Zealand for your 2nd or 3rd year ssei ya Hu Dr Tan
n
For more information contact enquiries@nzmedics.co.nz (UK) 0808 234 7853
working overseas: your experience British Columbia
B
orn in England, I went to school and did my medical training in London. Two years ago, my husband and I were looking to leave London when he spotted an advert. I had never been to British Columbia but had enjoyed Seattle, so we attended a Health Match meeting in London. They explained the requirements and since then have facilitated our move with ease. We chose Sechelt because it’s the best of both worlds – you can easily get to Vancouver or Whistler, but it’s still rural. We have fallen in love with the Sunshine Coast stunning scenery, a gorgeous summer, winter skiing and friendly people. We are much better off - I am being paid more than in the UK with rent and petrol at substantially lower prices. We enjoy a good meal and the food is fantastic here, mostly fresh and organic produce. Some things are more expensive - such as car insurance. Being a physician here isn’t that dissimilar to England - there are still waiting lists for
outpatient appointments and MRI scans. I enjoy being self-employed, although I still work within a practice with support around me. I also work in the local ER which gives great variety. We have yet to have any regrets - it is hard to leave family and friends, but easy to fly here. If you are looking for a much better quality of life we couldn’t recommend it more. Dr. Isabelle Hughan moved from London, England to Sechelt, BC, Canada with her scientist husband, Craig, and their infant son, Fraser, in June 2008.
Dr Isabelle
Hugha
n
Enrich your career. Enhance your quality of life. Practice medicine in rural British Columbia, Canada. Variety and challenge, the chance to make a difference in people’s lives, a lifestyle most people only dream about – just a few of the advantages enjoyed by BC’s rural physicians. With its natural beauty, recreational opportunities, clean air and affordable housing, British Columbia offers a quality of life that is envied around the world. Create your future in rural British Columbia. Competitive compensation and benefit packages include signing bonuses, relocation travel, fee premiums, retention bonuses and continuing medical education assistance. For more information and to register, visit our website. Our experienced recruitment consultants can help you match your skills and lifestyle interests to the many exciting opportunities available.
Register today: www.healthmatchbc.org Please note: Specialists with postgraduate training from the UK or Ireland must hold the CCT/CCST or equivalent from the UK Higher Specialist Training Authority (Medicine or Surgery). Family Physicians/ General Practitioners must have a minimum of 2 years of approved and accredited post-graduate training.
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14
WORKING OVERSEAS
JOB # H104-9278 SHIPPING DATE: NOV 3, 2008 CLIENT: HEALTH MATCH BC
Smooth sailing More doctors are jumping ship to work abroad, but uncharted waters present new risks, argues Sara Williams Suitcase in one hand and passport in the other, Dr Ashley Leadbeatter, an F2 from Leeds, walks through the doors of Heathrow Airport to check in for his one-way flight to Australia. As he stands surveying the queue of faces ahead of him, he wonders how many of them are doctors, like him, travelling to the unknown in search of fortune and glory. Ashley will be working in Gold Coast Hospital in South Port, Queensland. So why did he leave? “It is the sensible time to leave, as specialist training is a treadmill that is difficult to get off. If I went later, it would interrupt my training and it would be harder to return. In February I had been a doctor for 20 months; in the UK system I had to decide on what specialty I wanted to do for the rest of my life. I want more life experience before I make that decision.” Ashley is not alone. The GMC has issued 2,266 Certificates of Good Standing so far this year, which is a standard requirement before embarking on clinical work in most countries, and is an indication of how many doctors are going to work abroad. Although the DH could not provide any figures, Remedy UK predicts that the numbers will be significantly higher than last year because of problems with training. Dr Clare Cooke moved to New Zealand last October because she was frustrated with the MMC “fiasco”. “When I was a third year SHO in a busy DGH in the Home Counties, I realised that nothing fazed me anymore; I was working on autopilot. I moved to the Antipodes and found jobs that are without parallel in the UK. You could run a base hospital, work in a clinic 1,000 km from the nearest tertiary referral centre, cruise with the flying doctors, act up a grade, make life and death decisions, and gain infinite clinical skills and life experience.”
Thinking ahead Clare left the UK confident that she could achieve her dreams of working as a foreign doctor, but she now knows only too well the number of boxes she had to tick to realise them. From expensive medicals to police checks, it can take a long time to secure a ticket to work in another country. Thinking ahead is the key to organising a successful trip – getting important factors like travel insurance, flights, vaccinations and professional indemnity sorted early will help avoid problems at the last minute.
Indemnity Before practising protect yourself: new countries mean new risks. Having a patient’s best interests at heart will not always protect that patient from harm. Likewise the best intentions will not always protect a doctor from human error and professional scrutiny. This is why having indemnity and access to 24-hour medicolegal advice is vital. NHS indemnity is limited to clinical negligence claims arising from NHS hospital care and the claim is made against the trust. It is essential for all doctors to have additional professional protection for the other medicolegal risks which can arise from practice. The NHS scheme does not extend to doctors working abroad, who will therefore need to make their own arrangements to ensure that they have adequate protection.
Dr Pallavi Bradshaw, MPS Medicolegal Adviser, says that when concerns are raised, having the reassurance that someone will support you and protect your professional interests is invaluable. “Junior doctors must be alive to the ever-increasing risks of clinical practice. Doctors travelling abroad should be alert to the current legal and ethical climate within a particular country. Being aware and managing these risks will safeguard you for the future. “Without a doubt, patients should be protected, but equally, we believe, so should doctors. MPS’s role is to protect the interests of members when concerns are raised about their practice, in any form – claim, complaint, medical council investigation. It is a common misconception that MPS deals mostly with clinical negligence claims. This kind of work represents only about 20% of our caseload.” Clare Wolstenholme is Team Leader for the International Membership Department at MPS. She urges junior doctors to take advantage of overseas membership, as MPS now operates in more than 40 countries. “Some countries have state or government indemnity, but it is usually limited to negligence claims, so it is advised that doctors retain their MPS membership whilst working overseas. Members should contact the membership department with details of their scope of practice and where they intend to work, so we can confirm the correct subscription rate for their work.”
Off the beaten track The Antipodes is a mecca for graduates from all trades, but Clare Cooke argues that a lot can be gained from exploring far-away places. “It depends on who you are, your seniority, your outlook on life and your breadth of experience, but if you really want to, go for it and get a great experience.” Different countries have different requirements for the type of indemnity provision which are acceptable. For example, in Germany and Australia, it is a legal requirement that doctors are indemnified through a contract of insurance and discretionary indemnity is not recognised in these areas. MPS does not offer membership in USA and Canada, or countries operating under their jurisdictions. But it does offer membership for voluntary work overseas for organisations such as Voluntary Services Overseas (VSO), and those who accompany travel groups and expeditions. MPS’s protection allows members to request assistance with medicolegal problems arising from Good Samaritan Acts in any part of the world. This is where a doctor provides medical assistance outside their usual clinical employment or work environment in a bona fide medical emergency, such as when passing a roadside accident, emergencies at public events and on aeroplanes.
Useful links Talk to a membership adviser before travelling, if you are planning to work overseas. Use the helpline number 0845 718 1787, or email international@mps.org.uk.
MPS professional support and expert advice 24 hour medicolegal emergency advice line Medicolegal publications – Casebook and New Doctor Risk Management materials including medicolegal booklets
Online resources including factsheets and case scenarios Educational support through discounts with leading publishers Largest international protection organisation
For more information call 0845 718 7187 Or visit 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. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
MPS0745
In association with
Think you have the flu? Time to ask Google
200
million searches are made on Google every single day. With all this data analysts have been using it to predict everything from the outcome of the US election to the winner of the X-Factor. Now they plan to use your searches to work out where flu will strike next – and outpace current disease surveillance. ‘Google Flu Trends’ is the latest project from Google’s philanthropic arm Google.org. By combining influenza-like search symptoms such as ‘cough’ ‘flu’ and ‘fever’ with a computer’s IP address they are able to locate and plot searches on a city-by-city basis.
cardiology Websites
CRTonline www.crtonline.org
A not-for-profit site created by the Cardiovascular Research Institute at Washington Hospital Center. Check out the CardioTube section for education videos and seminars on the latest in research and cardiovascular technology.
Cardiosource www.cardiosource.com
The website of the American College of Cardiology and the JACC. Homepage includes a useful review of cardiology articles in other journals and a wealth of case studies.
European Society of Cardiology www.escardio.org/knowledge/guidelines Image copyright Google.org
Over the last five years Google Flu Trends has been closely correlated to the flu incidence recorded by the US Centers for Disease Control and Prevention. Traditional flu surveillance has a lag time of 1-2 weeks - the hope is that Google Flu Trends may provide an almost instantaneous early-warning system. “For epidemiologists, this is an exciting development, because early detection of a disease outbreak can reduce the number of people affected,” said Google.org developers Jeremy Ginsberg and Matt Mohebb. “Our up-to-date influenza estimates may enable public health officials and health professionals to better respond to seasonal epidemics and — though we hope never to find out — pandemics.” Currently Google Flu Trends provides data only for the United States but the programme is expected to roll-out across other countries shortly. They also hope to extend the prediction software to track other diseases.
Comprehensive guidelines on pathogenesis and how to treat wide variety of cardiology conditions. Access is free after registration with the option to download a PDA version to carry with you.
Cardiology Site www.cardiologysite.com
Content rich site offering ‘classroom lectures and demonstrations with the use of the latest web-based technology’. Lots of 3D animations, videos and sample questions.
British Journal of Cardiology www.bjcardio.co.uk
Get free unrestricted access to the bimonthly BJC online along with a searchable archive dating back to 2002.
www.google.com/flutrends For more key websites in cardiology - try
16
MEDICAL STUDENTS TECHNOLOGY
Medical students to face virtual “on-calls” I
t’s 4am and sleeping medical students at the University of Central Florida College of Medicine are woken abruptly by a call from a “virtual patient”. The computer-generated patient, speaking like a real human being, complains of chest pain. Bleary eyed students then need to advise and treat their “virtual patients” – the results forming part of their course evaluation. This high-tech teaching program, called MyCaseSpace, is being launched next year at UCF with more than a dozen further universities interested the software. It was developed by UCF Assistant Professor David Segal, who developed the program for his health classes so students could learn how to properly evaluate and diagnose conditions.
MyCaseSpace avatars can age so medical students experience a full spectrum of virtual patients.
“It’s interactive and a way to make it fun for students while they learn to make better decisions,” said Segal. “And they learn. There’s an assessment tool built into this program to validate that the technology is enhancing their learning.” Throughout their four years of medical
school students will have to advise “virtual patients” with symptoms ranging from a common cold to cardiac problems. The system allows tutors to add basic science and clinical cases to each scenario to supplement the curriculum.
Interactive patients The “virtual patients” speak 13 languages with varying accents, can sneeze, cough and even go into cardiac arrest. The symptoms displayed relate to the lesson plan for a particular week or conditions that students have learned recently. Segal also points out that the system can be programmed for the “virtual patients” to make emergency calls to students in the middle of the night or to visit a virtual clinic for a check-up. Patients can even have demanding family members for the students to contend with. “This is an amazing program that brings learning alive for students,” said Jim Wolford-Ulrich, an associate professor at Duquesne University in Pennsylvania. “This model allows for experiential learning for students on line.” The software is due to be rolled out as part of the UCF teaching programme in autumn 2009.
“Virtual patients make emergency calls to students in the middle of the night or to visit a virtual clinic for a check-up.”
Assistant Professor David Segal. University of Central Florida College of Medicine.
www.ucf.edu Images courtesy David Segal and Thomas Alan Smile
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Secret Diary of a Cardiology SpR Monday If you’ve been following this column you’ll realise that I only have six months before I become a consultant. Try as I might I can’t put it off any longer. This, plus I found out that my last boyfriend, David, has ended up married with children has led me to seriously evaluate my life. When I left medical school I was convinced that I’d have my own family by this time, be working in a small district hospital, own a land rover and maybe even a dog. I always wanted to do cardiology but somewhere along the way between my MD and the angio lists I forgot to get the husband and three children. On Monday morning I made it through the ward round relatively painlessly. Surprisingly the FY1 didn’t mess up too much and had even arrived early to type up a nice list of the troponins on CCU. Bless his little heart. I spent the afternoon dictating letters and doing paperwork. I left by five and went home for a long bath and an early night.
* Names have been changed to try to keep our cardiology SpR in a job though she’s doing a pretty good job of trying to lose it without our help!
Tuesday On-call today. Shockingly I’m on with my own team which has never happened since I’ve been working here - I feel like checking with the BMA to make sure we’re not violating some sort of rule! The morning is spent doing rubbish but in the afternoon we get a little busy. I send a fifty-year-old lady with sepsis secondary to a UTI up to intensive care after much argument with the ICU consultant. He suggested we take her to CCU as, in his own words, all she needed was ‘a little drop of noradrenaline to make her happy again’. Not on my watch. Later we had a Guillain-Barré who needed non invasive ventilation and a young man with a good going infarct that we took straight to the cath lab. By the time I got home at eleven I ate a slice of cold pizza and crashed into bed. I’d always told myself that I would stay away from general medicine but if I did end up in a teaching hospital doing pure cardiology then I’d definitely miss it.
Wednesday I have an angio list this morning. Douglas, my boss, is nowhere to be seen. I know he’s around somewhere though so I start and subsequently end the list without him. After lunch I do a quick ward round and a couple of echoes. I finish off a paper I’m writing on the use of drug-eluting stents before Douglas calls me into his office. We start chatting about jobs and how things are in general when he suddenly drops a bombshell. The hospital, now a foundation trust, has been given funding for a new consultant post starting in six months. Am I interested? If I were I’d be the only woman on a team with five men, not to mention the youngest by more than two decades. I tell him that provisionally I am before asking him whether his question was a polite enquiry or a firm job offer. He smiles as his mobile goes off. One of his private patients has developed chest pain post cath. As he leaves he tells me to give him a firm answer by the end of the week. That’s the problem with being a cardiologist. You feel the pressure to do private work and then as the money rolls in the problems stack up and you soon find yourself on call 24 hours a day, seven days a week.
20
DIARY
I get home by six and spend the evening making calls to all the friends I’ve been neglecting over the past few weeks. I tell no one about the job offer.
Thursday The day goes by pretty quickly. None of the bosses are around apart from John who’s a complete idiot having a permanent mid-life crisis. He puts his arm around my shoulder and tells me to give him a call if I have any problems. This is pretty unlikely as he knows less cardiology than me and even less general medicine than my FY2. I spend the afternoon doing echos before going out with the team for a drink. It’s the monthly mess night and they persuade me to follow them to a dingy bar. Peroni, red wine and vodkas with grapefruit juice are a bad combination for anyone - but disastrous for me. I end up pulling two guys one of whom looks suspiciously like a cardiology HCA. I go home alone and fall asleep immediately but not until I have thrown up in bathroom.
Friday Surprisingly I only have a little hangover but I guess that’s partly due to the fact that much of the alcohol ended up in the toilet. I get through the ward round with two litres of Evian and spend the afternoon reviewing patients on CCU. One of them decides to have another MI so I take him to the cath lab and do the angio myself. He should make a good recovery. That’s why I love cardiology. Unlike much of medicine where you have to wait to see if your potions have worked, when someone comes in with chest pain you open up their heart vessels and they’re cured - at least until they have their next one. But I’ve always told myself I’d never end up in a teaching hospital mainly as working here wouldn’t be the best environment to meet someone and settle down. I spend rest of the afternoon in a nearby cafe drinking lots of coffee and even more water. I go back to see Douglas before the end of the day. I knock on his door and as I walk in he looks up and smiles. I’ve made my decision.
Focus on Finance - in association with Wesleyan Medical Sickness
NHS Pension Scheme Changes What they really mean A new pension scheme was introduced for members of staff joining the NHS from 1 April 2008. The original pension scheme continues, with some modifications, but members will have the option to switch to the new scheme if they prefer. Is there a change in the retirement age?
For members of the original scheme, normal pension age remains at 60 with the option to retire earlier on reduced benefits. Under the new scheme the normal pension age is 65 and early retirement is only allowed from 55. Do I get a higher pension if I work beyond my normal retirement age?
Under the new scheme you receive extra pension if you continue working beyond normal pension age. Under the existing scheme there is no enhancement in your pension if you delay your retirement, other than normal pension accrual. Do I have to pay higher pension contributions even if I stay in the existing pension scheme?
Yes, both schemes cost the same. Instead of the previous flat rate contributions, a system of tiered contribution rates based on earnings now applies - 6.5% if you earn between £20,225 and £66,789. The new contribution rate will apply to the whole of your earnings. Do I get more pension for my money?
The accrual rate of 1/80th of final salary
for every year of service remains the same for the existing scheme. The accrual rate under the new scheme is 1/60th. How is the tax free lump sum calculated now?
Under the existing scheme there is an automatic entitlement to a tax-free lump sum of three times your annual pension. You can now top this up to a maximum of 25% of your total pension benefits by ‘commuting’, or giving up, part of your annual pension for cash. For every £1 of annual pension you give up, you will get £12 of lump sum. Under the new pension scheme, there is no automatic lump sum entitlement but you can also commute your annual pension and take up to 25% of your benefits as cash. Are there any changes in the way that my final salary is calculated for pension purposes?
Under the existing scheme, your pension is still based on your best year’s pay within the three years prior to your retirement. Under the new scheme, it is based on the average of the best three consecutive years’ pay within the last 10 years. This makes it easier to reduce your responsibilities and take a lower salary in the run-up
to retirement without damaging your pension. Under the existing scheme this has also been made easier through new “step-down” arrangements. Can I still buy added years to top up my pension if I stay in the old scheme?
Added years contracts are no longer available although existing contracts will continue to run. Instead, under both the old and new pension schemes, you can buy a fixed amount of extra annual pension up to a maximum of £5,000 in blocks of £250. The extra pension is increased in line with inflation but it won’t be related to your final salary. Any other changes?
Survivor pensions are now also payable to common-law spouses or same-sex partners where a relationship has lasted at least two years and are payable in all cases for life, regardless of any future relationships. Children’s pensions will be paid until age 23 in all cases or indefinitely if a child is disabled. Members of the existing scheme will have the option to switch to the new one between July 2009 and June 2010. Once the transfer terms have been published, discuss your options with a financial consultant before making a final decision.
The above information does not constitute financial advice. Wesleyan Medical Sickness provides specialist financial advice for doctors. Telephone 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk
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21
Medical Report
Mr S Claus Obesity Assessed by Gil Myers
S
anta isn’t just big-boned. He isn’t ‘jolly’. He is obese, with a BMI of well over 35. Obesity, especially central or waist-predominant obesity, is an important risk factor for ‘Syndrome X’ - the clustering of a number of diseases and risk factors that heavily predispose for cardiovascular disease. These include diabetes mellitus, high blood pressure, high blood cholesterol and combined hyperlipidemia. Apart from metabolic syndrome, obesity is correlated with a variety of other complications (all with TLAs), ranging from cardiovascular (CHF) to gastrointestinal (GoRD) and psychological (BDD). The answer is clear: Diet or Die Santa.
Cyclothymia
S
anta locks himself away from the world for the majority of the year, not speaking to anyone (except for his ‘elves’) and then appears incredibly happy, overjoyed with everything and unable to stop laughing. He doesn’t sleep, excessively spends his money buying presents for all and then jumps in his vehicle and speeds off - all the while dressed in bright colours. A word of warning, high mood such as this is followed by irritation, recklessness and sexual disinhibition – so watch out Rudolf!
Albinism
H
2504 magazine ad 190x60
is head, beard and eyebrows are white as snow. The most likely diagnosis would be Albinism, a genetic abnormality where no pigment is found in human hair, eyes or skin, making the eyes blue, the hair white, and the skin pale. It would also explain why he is only seen at night - he lacks melanin, a protective pigment in his skin, burning eas10/11/08
13:55
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ily from exposure to the sun and suffering from photosensitivity.
Red Face
A
ll those years of children leaving out ‘a little glass of whiskey to keep Santa warm’ may have left him with a problem. Long-term alcohol use causes cirrhosis of the liver. As this stops working and begins to shut down the results are multi-systemic signs. The tiny blood vessels in his face burst leaving a permanent red face, nose and cheeks. This would go well with his jaundice, clubbing and gynaecomastia. It would also explain why he always wears gloves and baggy clothes - and why the glass you left was always empty in the morning.
Haemorrhoids
S
anta’s sleigh doesn’t look very warm and cosy. Assuming he starts off from snow-covered Lapland and travels all across the world he must spend an awful lot of time sitting on a cold, hard seat. He doesn’t appear to have much time for toilet breaks either. Too much pressure on the rectal veins due to poor muscle tone or poor posture, coupled with obesity, sedentary lifestyle and postponing bowel movements has been proven to cause haemorrhoids. It must also be very difficult for Santa to get help - he can’t exactly pop down to his local chemist for a tube of Anusol.
Sexual Fetishes
H
e is a grown man who is always seen in the company of elves, children or a red-nosed reindeer. But just in case he happens to be reading this I’m not saying anything else. I wouldn’t want to go on his naughty list ...
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Writing in the Notes Fewer hours but
falling salaries
Dear Editor, licy suggestions troubled by po ly ed at pe re I am further (‘Fewould be reduced sh s ur ho s’ or ct duce mistakes’ that do d dramatically re ul co s ur ho ng training slashed er worki D has seen our T EW e Th ). p4 whether that Iss 10, any analysis of ed tic no t no ve octors should be and I ha tients at risk. D pa g in tt pu is eek – those who alone ith a 56-hour w w ly ’t si ea pe co able to sewhere. Haven employment el ek e se fin ld as ou w sh It ough? cannot ries plummet en la sa r psa ou di en se lly we also this gradua banded but as . That alone is when we were ot and unm ivated ed lu va un el fe I pears t our care. enough to affec on Sarah Lidd y, London ST3 Surger
Hard to find bad
Coca-Cola (500ml bottle)
a fake!
r Fairytale Dear Editor, en fooled (‘D be ve ha u yo ated that Dr I think Nick Riviera st . 3) p2 10 s Is Simpson is a fake’ assessed Homer ve ha t no d ul As is evident Fairytale co nded a doctor’. te at ce on ot ‘n ition he has as he has or physical cond po ’s on ps m Si derwent a from Mr least when he un t no – s or ct do h Season). I seen many (Episode 11, 4t n io at er op ss himself is triple bypa Dr Nick Riviera at th t ou t in po gree hanging should also Med School’ de b lu ‘C a s ha d a fraud an all. clearly on his w vanathan Thanam Vis s fan) (and Simpson nt ude St Med
‘Writing in the notes’ is our new regular letters section. Email us at letters@juniordr.com.
Enough to make your top pop at:
£1.20
UCH, London
Fizz-tastic prices at:
90p
doctors?
hire
Dr Nick Riviera is
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:
Chocolate flapjack
Dear Editor, As a GP I was in itially worried by website that allo the launch of a wed patients to post negative co ments about th meir doctor’s care (‘Doctors fear ab of ratings websi use te’ Iss 10 p4) bu t after visiting th I am more worri e site ed that they are not! There is an whelming lack overof critical comm ents and the cy side of me feel nical s that patients views are either censored or do being ctors are rating themselves. Th could be a usef e site ul resource but it shouldn’t be for doctors to in a way flate their egos. Name Withh eld GP, Worcesters
W
Royal United Hospital, Bath
Prices to get you in a flap at:
£1.10
Mayday Hospital, Surrey
Fill yourself up at:
75p Banana
Bronglais Hospital, Aberystwyth
Slipping up on healthy eating at:
60p
Whipps Cross Hospital, Leytonstone
Potassilicious:
30p
Royal Free Hospital, London
Next issue we’re checking the cost of Celebrations Chocolates (460g), Bic ball pen and a ‘Get Well Soon’ card (cheapest). Email prices to hospitalconfidential@juniordr.com.
Royal Free Hospital, London Our own staffed lunchtime kitchen serving hot food. A bar (yes, an alcohol serving bar!). A balcony to enjoy the summer sunshine when it arrives. Newspapers. A stocked machine dispensing Marks and Spencer sandwiches and ready meals. Tea/ coffee. Reasonably comfortable sofas for on-calls. £10/month.
JuniorDr Score: ★★★★★
HOSPITAL MESS
23
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