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CYCLING THE SIX: Africa
O THE MAGAZINE FOR JUNIOR DOCTORS
Presenting History JuniorDr 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. Team Leader Matt Peterson, team@juniordr.com Editorial Team Yvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai, Rob Bethune JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 193 6750 Fax - +44 (0) 87 0 130 6985 team@juniordr.com
ne year ago when SpR Steve Fabes wrote for JuniorDr he was in Egypt, and had reached the 16th country on his challenge to cycle the length of six continents. He is currently in country number 27 and gives us an update on his journey from Africa. On the 5th January 2010 I had waved goodbye to friends and family from outside the London hospital where I worked as a Med Reg and started pedaling, I planned to be pedaling for the next five years. When I wrote my first update for JuniorDr in Cairo six months later I was hirsute of face, eight thousand odd kilometres in and several metric tonnes of Cadbury’s Dairy Milk chocolate lighter. Ahead lay a world of tropical heat, all manner of toothsome fauna and the prospect of less salubrious terrain. Ahead lay all of Africa and I couldn’t wait to dive in. First was Ethiopia, a land brimming with both people and livestock and after two and a half thousand kilometres, with barely an incline to test our quads, it was here that we spied our first mountains. Every day gangs of children chased after us, chanting ‘YOU! YOU! YOU!’, demanding money, waving sticks, throwing stones and stealing from our bikes. But I soon discovered that what Ethiopia takes, it also gives back. The same boisterous chancers
STATS FROM STEVE’S AFRICA CYCLE Longest distance cycled in one day: 209 km Cairo to Cape Town: 14,969 km
Health warning JuniorDr is not a publication of the NHS, David Cameron, 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. © JuniorDr 2011. 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.
Top altitude: 3050 metres Top speed: 75 km/hr Punctures: 113 Tyres: 8 Most days without a shower: 8 Crashes: 2 Largest amount of Dairy Milk Chocolate consumed in one sitting: 450 grams
Dr Steve Fabes – Cycling The 6
would push us up the hills, tiny hands pressed against my racks and panniers, propelling me upwards for five or even ten kilometres. Next was Northern Kenya, a region famed for tribal warriors, nomads and ruthless bandits. I pushed my bike through a sandy, desolate wilderness for days - this was the very edge of civilization. Next came the verdant and undulating tea plantations of Uganda and Rwanda, the roadside was full of bright eyes and winsome grins, but it wasn’t long before I found myself immersed in the tropical wet season. The more horizontal the rain and the more punishing the headwind the sunnier my songs became. In the torrential bursts I bashed out an assortment of reggae classics. Finally after 23,215 kilometres, 26 international boundaries, one year and four months on the road, 265 days in Africa and a whopping puncture count yet to be tallied, I rode into the Cape of Good Hope. I studied Belinda, my bicycle. She had scrappy ribbons of electrical tape holding together the handlebar grip, there were scratches on the frame and tie wraps sat where long lost pannier clips should be. She wore the marks and scrapes of those sixteen months on the road, and so do I. The contours of my legs have changed, I’m thinner, there are two small scars on my left knee following an arthroscopy and my hairstyle is bordering on full blown mullet.
If you’d like to keep up to date with Steve’s progress you can visit his blog at http://www.cyclingthe6.blogspot.com or follow him on Facebook. To sponsor his adventure go to http://www.justgiving.com/cyclingthe6. Every penny donated goes to the medical aid agency Merlin.
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TRIAGE
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Tell us your news. Email team@juniordr.com or call 020 7193 6750.
Pensions
Junior doctors could pay £230,000 extra for a worse pension
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hanges to public sector pensions could mean junior doctors paying £230,000 more over the course of their careers for a worse deal on retirement, according to research commissioned by the BMA. The study examined the potential impact of Department of Health proposals to increase the amount NHS staff pay for their pensions. Under the plans, a doctor currently contributing 8.5% of salary would contribute 10.9% by 2012, and possibly as much as 14.5% by 2014. Independent actuaries calculated the additional contributions doctors would need to make over the course of their careers. A junior doctor currently aged 25 pursuing a typical career as a GP and retiring at the future state pension age of 68, could have to make additional contributions of over £230,000 between now and retirement. The researchers also modelled the impact of the proposals put forward by Lord Hutton in his review of public sector pensions, such as a further increase in the normal retirement age and a move from final salary to career average schemes. The modelling indicates that a doctor currently aged 25, retiring as a consultant at the age of 60 could receive a pension around
£19,000 lower than the final salary pension they would receive under current arrangements. Similarly, a GP currently aged 25 retiring at the age of 60 would receive a pension around £20,000 lower under a ‘new look’ public service pension. “These are unjustifiable changes to a financially healthy pension scheme which has only recently been thoroughly overhauled. This isn’t about affordability, it’s about the Treasury looking for yet another quick hit from public sector workers,” said Dr Hamish Meldrum, Chairman of Council at the BMA.
“Doctors pursuing a career as a consultant or a GP will have to pay significantly higher contributions in return for a much reduced pension at retirement.” Dr. Hamish Meldrum BMA Chairman of Council
“Doctors pursuing a career as a consultant or a GP will have to pay significantly higher contributions in return for a much reduced pension at retirement”, the paper concludes. The modelling also looks at the impact of the decision, already implemented, to increase pensions payments in line with the Consumer Price Index rather than the Retail Price Index. A doctor retiring at the age of 65 could be worse off under CPI by £2,000 a year at the age of 70, and by a total of £124,500 by the age of 85. www.bma.org.uk
private practice
Public calls for doctors in private practice to repay NHS training costs
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he majority of British adults believe doctors who carry out private work should have to repay the public funds used to train them, according to a poll by market research firm Populus. 57% of the adults questioned felt that if a doctor trained by the NHS goes on to treat patients privately, they should have to pay back at least some of the cost of their training - a move which could net the NHS £744m.
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NEWS PULSE
A quarter of those polled said the entire cost of a doctors’ training should be paid back if the doctor treats patients privately, 19% said it should be up to half, whilst 13% believe it should be between 50-100% of the cost. It currently costs over £200,000 to train a doctor in the UK. When asked whether doctors should combine public and private work at all, 76% of adults believe that doctors employed by the NHS should be allowed to see private patients
in addition to their NHS role. However, 69% of these believe that the profits doctors make from private work should be regulated. “The study reveals that the majority of British people are largely comfortable with doctors carrying out private work, but feel that there is a deal to be struck,” says Ken Hesketh, Chief Executive of Benenden Healthcare Society who commissioned the study. “They say that doctors’ profits from private work should be regulated, and that those who have had the benefit of public money to help train them for work outside the NHS should be prepared to make a financial contribution to the costs of their training.” bit.ly/nWQCNQ
NEW EDITION
Ethics
Don’t accept patients as Facebook friends, warns BMA
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octors and medical students should not accept Facebook requests from current or former patients, according to the latest advice from the BMA. The guidance ‘Using social media: practical and ethical guidance for doctors and medical students’ also warns against posting personal or derogatory comments about colleagues on public internet forums. Key points in the guidance include: • Doctors and medical students should consider adopting conservative privacy settings where these are available but be aware that not all information can be protected on the web • The ethical and legal duty to protect patient confidentiality applies equally on the internet as to other media • It is inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums • Doctors and medical students who post online have an ethical obligation to declare any conflicts of interest • The BMA recommends that doctors and medical students should not accept Facebook friend requests from current or former patients • Defamation law can apply to any comments posted on the web made in either a personal or professional capacity
August 2011 • £48.00 PB: 978-08153-4243-4
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“Research has shown that while most doctors would not accept Facebook friend requests from patients, a minority said they would consider doing so,” said Dr Tony Calland, chairman of the BMA’s Medical Ethics Committee. “Yet accepting Facebook friends presents doctors with difficult ethical issues. For example doctors could be become aware of information about their patients that has not been disclosed as part of a clinical consultation.” The full report can be accessed at: www.bma.org.uk/press_centre/video_social_media/ socialmediaguidance2011.jsp
gmc
New tribunal service for doctors gets the go-ahead
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lans to establish a new Medical Practitioners Tribunal Service have been approved by the GMC Council which will change the way doctors are investigated about their conduct or their ability to treat patients safely. The new body will take over the running of doctors’ hearings from as early as next year. It will be operationally separate from the GMC’s investigation arm and will be headed by a senior judicial figure who will be responsible for appointing and performance managing panel members. “This is a major reform and will signal clearly the need for panel hearings to be autonomous and to be seen to be autonomous,” said Niall Dickson, chief executive of the GMC. “In the consultation there was strong support for setting up the Medical Practitioners Tribunal
Service - for most respondents the question was simply how best to do it.” The GMC Council also approved plans to hold all hearings in Manchester from next year, rather than running hearing centres in both Manchester and London. The relocation is part of a wider programme aiming to generate savings of around £2.8 million a year.
November 2011 • £35.00 PB: 978-0-8153-4441-4
www.gmc-uk.org
“This is a major reform and will signal clearly the need for panel hearings to be autonomous and to be seen to be autonomous.” Niall Dickson Chief Executive, GMC
www.garlandscience.com
GARL1012 JuniorDr Advert (March).indd 9/9/2011 1 10:28:35 AM
RCP opens to FY docs
Training
Junior docs clueless about what to do during major incidents
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unior doctors have no idea what they should be doing when a major incident, such as a terrorist attack or transport disaster occurs, according to research published in BMJ Open. Although every UK hospital has a Major Incident Contingency Plan the survey of 89 junior doctors in three NHS hospital trusts in Wales showed that nine out of 10 (91%) didn’t know what would be expected of them in the event of a major incident. This knowledge gap could be critical especially as the UK’s current terrorism threat level is classified as “severe”, says the authors.
Current procedure is that once a major incident is confirmed, junior doctors should go to their ward, contact the senior nurse in charge, and compile a list of patients who could safely be discharged while managing the others who can’t. Should they be needed elsewhere, they will be contacted by a senior doctor or the hospital control centre. However, the survey responses indicated that almost half (47%) would initially go the emergency care department, while more than one in four (27%) had no idea where they should go. Almost one in three (31%) didn’t know whom they should contact, while 16% said they would contact the switchboard, which would be shut during a major incident. The junior doctors were also unsure of their primary role, with 16% believing this would be triage of injured patients, and over half (53%) expecting to clerk in patients in emergency care or the medical/surgical assessment units. bit.ly/oX3qfa
training
Better support needed for doctors entering UK practice
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octors entering the UK health service for the first time need better support in order to practise safely, according to a new report published by the GMC. The State of Medical Education and Practice report recommends an induction programme for all doctors new to the UK health service. It concludes more needs to be done to ensure consistency of induction for all doctors, and especially for those coming here to work from outside the UK. Every year, around 12,000 doctors from the UK, Europe and countries around the world, start working in the UK for the first time. The report notes that although there are good local schemes for supporting doctors who are new to practice, there is evidence of
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new doctors undertaking clinical practice with little or no preparation for working in the UK, or locum doctors taking on duties for which they have not been appropriately trained. “‘While there is much to celebrate about medical practice in the UK, the challenges are also clear - we must do more to make sure that all doctors understand the standards expected of them,” said Niall Dickson, Chief Executive of the GMC. “Developing an induction programme for all doctors new to our register will give them the support they need to practise safely and to conform to UK standards. This will provide greater assurance to patients that the doctor treating them is ready to start work on day one.” www.gmc-uk.org
The Royal College of Physicians has opened membership to medical students and foundation doctors for the first time. Two new membership categories will offer tools and guidance for doctors, including free web streamed teach-ins and lectures, access to the Clinical Medicine journal and discounts on RCP conferences and products. Membership for medical students is £1 per month, and foundation doctor membership is £4 per month. www.rcplondon.ac.uk
UK donor differences There are significant variations in the number and type of organ donations made across all four UK countries, according to research published online in BMJ Open. It found that England, which has the third highest number of the population registered, only managed a higher than average organ donation rate for three of the past 20 years. Yet Northern Ireland, where donor registration is the lowest of the four countries, outperformed England and Scotland in the rate of organ donation. www.nhsbt.nhs.uk
Stay slim to stay safe The NHS is poorly prepared to care for obese patients, lacking dedicated equipment and adequately trained staff, according to an analysis of patient safety incidents and published in the Postgraduate Medical Journal. The study of 555 patient safety incidents, of which 389 were related to obesity, found that one in three incidents (33%) were due to specially adapted equipment either not being available or not working. A further one in five of these incidents (22%) were associated with the operating theatre and surgery. www.pgmj.bmj.com
ABPM 4 BP – NICE New guidelines for confirming diagnosis of hypertension have been issued by NICE. For the first time 24 hour ambulatory blood pressure measurement (ABPM) is recommended for clinic readings above 140/90mmHg. The guidance was developed in association with the British Hypertension Society. Studies have shown that as many as 25% of people who are currently being diagnosed as having high blood pressure using the ‘old’ method of diagnosis may not be hypertensive and may not require treatment. www.nice.org.uk
working conditions
Medical Masterclass MRCP(UK) exam revision and preparation materials from the Royal College of Physicians
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he NHS in England has no oversight of whether junior doctors’ rotas are compliant with the 48 hour European Working Time Directive (EWTD), according to a report by BMJ Careers. This is in contrast with governments in Wales, Scotland, and Northern Ireland who regularly collect and review data on whether junior doctor rotas are compliant with the “new deal” contract for doctors in training, which is used as a proxy for compliance with the 48 hour limit in the EWTD. However, in England the data hospital trusts previously submitted on compliance with the EWTD to the Department of Health was cancelled in August 2010 “to reduce bureaucracy.” As such, the department in England was unable to provide BMJ Careers with information on the proportion of rotas that are compliant with the directive, unlike the health departments in Wales, where compliance of junior doctor rotas is 100%, Scotland, where compliance is 99%, and “I think we’re talking Northern Ireland, about patient safety as where compliance is well as doctor safety, so currently 78%. it would be really useful Furthermore, to see the ministerial none of the 10 strareturns back in place.” tegic health authorities in England colDr Shree Datta lects compliance data Co-chair of the BMA’s Junior Doctors from trusts, with Committee many responding that such information was available only at a trust level, says the report. “I think we’re talking about patient safety as well as doctor safety, so it would be really useful to see the ministerial returns back in place,” said Dr Shree Datta, co-chair of the BMA’s Junior Doctors Committee. A spokesperson for Department of Health in England responded: “As part the government’s commitment to reduce bureaucracy in the NHS, the Secretary of State has stopped the central collection of new deal compliance data which was used as a proxy to demonstrate compliance with the working time directive. Local organisations are still required to ensure compliance with the working time directive and to monitor that compliance.”
www.bmjcareers.com
Medical Masterclass packages are available for both individual and institutional sales and comprise: •
• •
•
12 printed modules covering the scientific background to medicine, clinical skills and the range of medical specialties in the MRCP(UK) exams. Online access to 3,000 MRCP(UK) exam type questions. NEW! PACES screencasts describing the format and stations of the PACES exam, giving examples of common scenarios and cases faced by candidates, and – most importantly – explaining what PACES examiners are really looking for. 60 PACES interactive case studies on 2 interactive CD-Roms.
For further details or to purchase online, visit www.medical-masterclass.com or email medical.masterclass@rcplondon.ac.uk
www.medical-masterclass.com
Concern over working hours as NHS in England stops monitoring
Sun, Sea and
The Advent of medical Not long ago the term ‘medical tourist’ was used to describe unscrupulous patients entering the UK to obtain free treatment on the NHS. Today, in contrast, it is used to describe the thousands of British citizens who flee the long waiting lists to seek private healthcare abroad. JuniorDr’s Michelle Connolly looks at the surge of medical tourists travelling abroad for sun, sea and surgery.
W
hether it’s for a hip replacement, valve surgery or a simple rhinoplasty medical tourism is booming. Last year alone some £130m was spent on medical tourism procedures outside the UK. However, Britons are still in the Ryanair league compared to countries like the United States where 150,000 Americans jet off each year for long-haul procedures in countries as far away as India, Thailand, Argentina and Malaysia. But the UK is catching up, according to research by analyst Mintel. Their survey suggests that 12 per cent of Britons would consider surgery abroad because of the substantial savings - costing up to eighty per cent less in some cases - compared to private treatment in the UK. Dental surgery is the most common overseas procedure with around 20,000 Brits travelling to favourites such as Hungary and Poland for a better smile at around £2,500 a time. Cosmetic surgery comes a close second with 14,500 of us shelling out for facelifts, breast augmentation and liposuction at a cost of £50 million each year. Those wishing to skip NHS waiting lists for elective surgery, the most frequent of which are joint replacements and cataract surgery, make up a further 10,000 patients spending £36 million. Word-of-mouth is one of the main drivers for overseas treatment. International medical facilities are promoting good service and reward schemes to encourage expatients to recommend to friends. Jacqueline Wilson, a 48 year old Herefordshire
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Medical Tourism
housewife travelled to Gdansk in Poland for tooth veneers after first getting quotes from British dental surgeons. “Poland was nearly three thousand pounds less than the price I was quoted in Harley Street and I combined it with four-day spa holiday too,” she said. “The hospitals were clean, the operation fast and the staff were very pleasant and spoke English. I’d recommend the experience without question.”
Selling surgery Foreign governments and private firms have begun to realise the potential of medical tourism. Brits are being wooed abroad by development agencies such as the Singaporean government’s Singapore Medicine, which describes the UK’s ageing population as “a great potential to be tapped into”. Intermediary brokers are one of the big drivers for overseas treatment in what is a difficult process for potential patients to negotiate themselves. Dipa Jethwa, from the London-based Taj Medical Group,
explained how they try to simplify medical treatment abroad for clients: “We liaise with the patient’s NHS consultant to obtain their clinical records. We then arrange flights, visas and their admission to hospital.” While the mainstay of treatment is joint replacement operations, Taj Medical is also benefiting from the obesity epidemic. “We are seeing an increase in the number of patients, particularly from the US and Canada requiring gastric banding surgery.” And it’s not just small brokers that are benefiting from the public’s new acceptance of private treatment overseas. High street tour operators such as Thomas Cook have realising the potential and have established partnerships with agencies like Taj Medical. Because of these new medical expectations centres in countries targeting medical tourists are no longer typical hospitals - they are ‘resort hospitals’ with enticing names such as Kuala Lumpur’s ‘Palace of the Golden Horses’.
“Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less than they earned in the West.” ANIL MAINI. DIRECTOR OF CORPORATE DEVELOPMENT. APOLLO HOSPITALS GROUP, INDIA.
SurgerY
tourism Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually. To accommodate Westerners it has a specially built Starbucks in the reception and a pizzeria upstairs.
Americans driving the market Americans lead the way in medical tourism partly because of the baby boomer generation and also because of sporadic healthcare cover. With 45 million Americans uninsured overseas treatment is the only way to avoid huge medical debts. Last year, the average healthcare expenditure for a family of four exceeded the total annual earnings of a minimum wage worker for the first time. Howard Staab, a 56 year-old carpenter from North Carolina has become the industry’s poster boy. His local hospital demanded a $50,000 deposit from him for a mitral valve replacement before warning him that the cost of treatment could rocket to $200,000. He got change from $10,000 for a pig valve in New Delhi - and also a trip to the Taj Mahal. Differences in doctor’s salary partly explain why such considerable savings can be made. The average salary of a US family doctor is $161,000, compared to just $35,000 in India.
India With four doctors for every 10,000
MEDICAL TOURISM DOWNSIDES • Little or no aftercare on your return • Often questionable quality of blood transfusions • Weak malpractice laws meaning redress is difficult and malpractice awards abroad are capped at a much smaller amount • Draining away of medical services from local population in order to serve the tourists • The British Transplantation Society has warned medical tourists considering China that they might be receiving the organs of executed prisoners
people, compared with 27 in the US, India is hardly a healthcare model to be copied. Yet India is now seen to be leading the world as a medical tourism destination with the finance minister calling for the country to become a ‘global healthcare destination’. Efforts have been made to improve infrastructure to help smooth the arrival and departure of medical tourists. Import duty on medical equipment has been slashed and the government has introduced a special medical visa which permits tourists to stay in the country twice as long as before. As a result India’s medical tourism industry is set to balloon to $2 billion by 2012, according to a joint
report by the consultancy McKinsey and the Confederation of Indian Industry.
Effect on the NHS Many expected the boom in medical tourism to lead to a reduction in UK private healthcare prices - instead the effect has been largely an efflux of medical tourists. Fiona Harris, head of personal markets at BUPA, the UK’s largest private healthcare provider, denies that their business is threatened by the boom in medical tourism: “Sometimes BUPA customers will seek treatment abroad where it is not available in the UK; in these cases we meet the equivalent UK costs of the treatment.”
Medical tourism
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coSt coMpariSoNS The average procedure in India is one-tenth of the cost in the US. Singapore is a more expensive destination but the savings are still large - a liver transplant which costs $300,000 in the US is just $150,000 in Singapore.
ParTiaL HiP rEPLacEMEnT
India $4,500 • US $18,000 fuLL HiP rEPLacEMEnT
India $3000 • US $39,000 orTHoPaEDic surGEry
India $4500 • US $18,000 knEE surGEry
India £8000 • UK (Private) GaLL BLaDDEr surGEry
India $7500 • US $60,000
Night sweats? It’s four a.m. You’ve been bleeped. You know what to do. But it would be good to get a second opinion – just for peace of mind. That’s exactly what Best Practice provides. A trusted second opinion on the assessment, treatment and management of patients. On call. All day. All night. Just when you need it.
For the best in clinical decision support tools, visit bestpractice.bmj.com
SociAl coStS Often the last thing a patient planning an operation overseas considers is the affect on the local community but it’s one of the key concerns that objectors raise. Many fear an internal brain drain whereby doctors leave small rural practices to work in better equipped urban centres that cater for medical tourists. Anil Maini, director of corporate development at the Apollo Hospitals group India’s largest medical tourism organisation - doesn’t deny this is the case: “There is an internal brain drain but there are enough doctors available to serve both rural and urban populations,” he says. “Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less, than they earned in the West.” There are many who believe medical tourism hails the beginning of a much broader overhaul in the world’s health- care systems - the advent of medical outsourcing. Outsourcing means that it won’t be the patient who decides to travel for treatment, it will be your insurer or government who sends you abroad to save money. Just as manufacturing and call centre operations were relocated to countries such as India healthcare is likely to follow. REfEREnCES
DIAGNOSE • TREAT • MANAGE • LEARN
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MEDICAl ToURISM
Burkett l (2007). Medical tourism. Concerns, benefits, and the American legal perspective. J. leg. Med. 28: 223-45.
Working overseas
For adventurous junior doctors there are plenty of opportunities to try working overseas - from the coastal towns of Australia to isolated villages in Africa. We’ve asked some of those who have made the move to tell us about the highs and lows of their visit. Read their experiences then join the discussion with other doctors in our ‘Working Overseas’ community at JuniorDr.com.
Africa
The Gambia
I spent 6 months working in Bansang Hospital as this is where I was posted by the charity MCAI. I chose this charity as it works closely with the WHO and the Gambian government to strengthen existing emergency medical services and improve maternal and child health. It aims to provide sustainable help to The Gambia and a variety of other countries. Bansang is in rural Gambia and poorly resourced. My main role is to provide emergency obstetric care whilst at the same time teaching the midwives emergency procedures and different ways of managing obstetric complications. The main complications we deal
Sierra Leone
When I decided to take a year out after FY2 the first charity I applied to was Mercy Ships, who provide healthcare on boats going around West Africa treating the world’s poorest. Mercy Ships also run hospitals on land in some West African countries, and when I was accepted to work in the hospital in Sierra Leone I was elated at the chance to be involved in doing simple interventions which lead to a huge impact on so many people. The hospital has a maternity unit, a specialist surgical unit for women with childbirth injuries and a clinic for children under the age of 12, where I spend most of my time. My typical day here starts at 8am, when I walk into the children’s clinic to be confronted by a triage scene which looks a bit like the first half hour of ‘Saving Private Ryan’ - children in various stages of illness ranging from comatose
with are massive obstetric haemorrhage following big abruptions in already severely anaemic patients and often with a lack of blood in blood bank. I also see very poorly controlled eclamptic patients with limited drug resources. With such limited equipment you have to really think on your feet and adapt your knowledge to the situation. It’s a wonderful place to work, but clinically and emotionally can be tough. Accommodation is good, but basic. At home and work there is often a lack of electricity and water and at times the temperature is above 48 degrees. Go with resilience and an open mind. x
Sophie Haynes
to sprinting around like jumping beans. I spend the first couple of hours treating the sickest ones, malaria is hyperendemic here so we treat some very ill children. We once had a child with haemoglobin less than 2! Later on, we treat some of the more chronically ill children, often suffering with conditions such as tuberculosis and sickle cell anaemia. Doing all the consultation in Krio is quite a fun challenge! I usually do an informal ward round of maternity unit in the evening to check on the neonates as well. Working here is a huge pleasure and I would advise anyone interested to get in touch with Mercy Ships. It is a great learning experience for a junior as well as having a chance to do make a huge impact through work that is well within the capacity of an FY2. x
Mikey Bryant
Current stage of training: ST4 O&G Current Location: Bansang, The Gambia Best thing about post: Variety of conditions seen and independent practice increased confidence in own abilities Worst thing about post: At times could feel quiet lonely and isolated. In April and May it’s the extreme heat. Length of stay: 6 months Average cost of living per month: £50 (excluding accommodation) Subsistence: Flight and accommodation paid for and living allowance of £300 per month
Current stage of training: I’ve just finished FY2 Current location: Freetown, Sierra Leone Best thing about your post: Watching hundreds of children each week get better and be able to run around again Worst thing about your post: Knowing that so many of the people we can’t treat will still be suffering Expected length of stay: 18 months Average cost of living per month: Approx $300 to $400 Average salary or subsistence: I get $600 each month, with accommodation and food provided 5 days a week. But I did pay for my own flights and travel insurance etc.
WORKING OVERSEAS
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Working overseas
Extreme Medicine Want to try something a little more unusual? Check out advice online at JuniorDr.com from doctors who have experienced working in extreme locations around the world. Antarctica Dr Ross Hofmeyr spent 18 months as the sole doctor at the SANAE IV Antarctica research station. With temperatures nearing -90oC and the nearest referral 2,800 miles away it’s certainly one of the most extreme medical posts on earth. For much of the year it’s so isolated that it’s logistically logistically easier to evacuate a casualty from the International Space Station, so everything from lab work to minor procedures needs to be done on site. Learn more from Ross at - bit.ly/ra0OD2
Repatriation doctor Repatriation medicine involves the transfer of patients by air, land or sea from overseas hospitals back home. It can involve travel to locations around the world and requires a broad range of skills. Tim Hammond, Chief Medical Officer of CEGA Group, offers his experience of repatriation medicine and advice for junior doctors interested in it as a career. Learn more from Tim at - bit.ly/hQZhW4
Ship’s doctor Philip Brooks was a senior ship’s doctor with Carnival UK, a company of well know cruise brands such as P&O Cruises, Princess Cruises & Cunard Line. He has been working at sea since early 2006 and was promoted to the rank of senior ship’s doctor in 2007. Philip explains why life on the open seas can be an attractive career. Learn more from Philip at - bit.ly/bp2ccu
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WORKING OVERSEAS
New Zealand After 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 “There are few places hospital training scheme. where it would be possiIn all the hospitals I worked at I found morale ble to ski in the morning to be higher, the atmoand kayak along beautisphere to be friendlier, and ful beaches in the afterall staff more supportive noon sun!” 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. x
Dr. Tanya Hussein
Australia
Working overseas
It had always been a dream of mine to work in Australia and the reality has proved to be better than expected. My first experience of Australian medicine was working in a rural town called Gympie, in Southern Queensland. My fiancée and I were part of a team of 12 doctors providing cover to the 90 bedded hospital, which included both a maternity and a paediatric ward. On arrival we had a fantastic welcome, even being interviewed for the local paper. One thing that struck me was the broad skill base of the more senior doctors - local GP’s doubled as anaesthetists, obstetricians and even as pathologists. We dealt with a large range of cases, including plenty that were familiar, but a few that were more exotic, like snake bites! Thankfully a helicopter was available to retrieve the sicker patients. Working in such a small team made for a good social scene. Among the staff were some real characters, including a radiographer who had bought a very grumpy camel to keep his “We dealt with a large donkey company. However if rurange of cases, includral hospitals are not ing plenty that were your thing, then familiar, but a few that Australia offers a were more exotic, like more conventional teaching hospisnake bites!” tal environment as well. My current position is in a large teaching hospital, and other than the fact that some of our patients are transferred over a 1000 miles to get to hospital it is a bit more like the UK. Would I recommend Australia? … well as I sit overlooking the Indian Ocean sipping a cool ‘tinny’ I guess I definitely would! x
Dr Ben Chandler
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“I undertook my medial training at Glasgow University and worked in the NHS for a few years, but decided to fill my gap year with some sunshine and work experience Down Under. I took a job with Queensland Health and relocated to Australia. I’ve now been accepted on to the Queensland Health world-renowned emergency medicine training program which gives me exposure to an unparalleled scope of practice.” Principal House Officer, Dr Stephen Elliott enjoys the training programs with Queensland Health.
Canada After more than 20 years of family practice in the UK, Dr. Peter Entwistle and his family were looking to emigrate. “I was dissatisfied with where medicine seemed to be going, and was very frustrated at the constraints that I felt were being put on me to provide the care that I wanted to give. Both Michelle and I wanted more opportunities for our sons,” he said. “We thought we’d end up in Australia or New Zealand.” When they were on holiday in Ontario, they first started to think of Canada. They researched various possibilities, and then contacted Health Match BC. They travelled throughout BC and explored communities in the Interior, the greater Vancouver area, and Vancouver Island. It was Michelle who finally decided on the Okanagan region. “It just felt really welcoming; the physicians and the people generally,” she said. “We loved the lakes and the vineyards; it is all so very beautiful and the climate is so much milder than what I expected.” Settled into school One question mark was about schools. “We wanted to be sure we picked the right school. I came over with Tom, my younger son, and we visited several possible high schools before deciding on the best fit,” noted Peter. “We were a bit apprehensive, but they both settled
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“Dr. Peter Entwistle and his wife Michelle enjoy their life in the Okanagan region of BC, known for its vineyards.”
in to their new schools very quickly. I think their cute English accents may have helped them make girlfriends easily.” Their eldest son, James, has now graduated and, after taking a year off, is planning to attend Dalhousie University in Nova Scotia. In their free time, the Entwist“It just les enjoy all that the Okanagan region - and BC - have to offer. “We’ve felt really all started skiing, which we had nevwelcoming; er done before. The boys really took the physicians to it, but snowboarding is their winand the people ter passion,” said Peter. The family also bikes together on the local Kettle generally.” Valley Railroad. Their more adventurous sons mountain bike around the hills of their lake-view home. And this summer, they had an amazing experience sea-kayaking off Vancouver Island. Since their arrival three years ago, the family has expanded in number with the addition of Monty, a chocolate Labrador dog. “He made everything feel more permanent,” they both said. Financially better off Michelle, a trained midwife, is working as a birth attendant and is taking steps toward gaining her full midwifery license in BC. The transition was smoother for Peter, who, after some additional training, is working both on the wards and in the ER, something he did not do in the UK. “The work is great, and I’ve had a lot of support. I really love the way I am able to care for my patients in hospital and find my working day both more varied and stimulating than in the UK.” He added: “Financially, we are way better off than before, and I have a lot more freedom and flexibility in terms of choosing my hours.” What has been hard to get used to? “Well, I still feel as though I am driving on the wrong side of the street,” concluded Peter. “I have to get up in the middle of the night if I want to watch the British soccer games. And I have to remember to call soccer “soccer”, and not football.”
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Careers in general practice General practice can offer an amazing array of career options. It can bring unparalleled daily variety, a
wide spectrum of medical experience and personal flexibility enabling a great work-life balance. Sophie Park, co-author of ‘A Career Companion to Becoming a GP: developing and shaping your career’ offers some advice on how to get started and considers possibilities for career development. How to get started?
Training
Different medical schools vary in how much general practice undergraduate experience they include. Some have extended placements, specifically to learn general practice, others include additional placements (perhaps a few days) to extend learning during a particular topic such as child or mental health. Practices can be very different in the way they are organised, prioritise work-load and interact with patients. It is worth, therefore, trying to get as broad a range of experience as possible before making your career decision. If you are already decided upon a career in general practice, this will at least begin to shape your own ideas about what sort of practice you would like to work in and what you hope to role model in your own practice. There were plans to offer all F2 doctors a placement in general practice as part of their basic training. GPs still spend lots of their training posts in hospitals, but hospital doctors have not traditionally reciprocated. Most trainees who have completed a GP placement (whatever their career ambitions), have found it an incredibly valuable experience in developing their knowledge, consultation skills and awareness about boundaries of primary and secondary care contexts. Currently about 55% of F2 posts offer some experience in primary care. This is likely to look favourable on your CV, whatever your career choice.
If you decide to apply for specialist training in primary care, you need to use the existing generic system for trainees http://www. mmc.nhs.uk/ (if applying from abroad visit www.nhscareers.nhs. uk). You may find it helpful to look at the Royal College of General Practice website: www.rcgp.org.uk which outlines details of training, certification and the general practice curriculum. It may also be useful to make contact with your local deanery via www.gprecruitment.org.uk. Most schemes offer a range of primary and secondary care experience (some more than others). No post will cover every speciality and part of your general practice apprenticeship will be about learning how to recognise, manage and develop your own boundaries of knowledge to meet patients’ needs. Currently, schemes are three years (four if including an academic post), but there are plans to extend this to five - the latter years likely to include supported, but independent practice (Tooke, 2008). Schemes offer experience in general practice, ranging from 12-24 months. This usually involves one to one supervision with your GP ‘trainer’. They will offer educational support within the practice, including tutorials and completing some of your work-place based assessments. You are usually expected to attend one out-of-hours session per month during these placements. For the remaining time, most schemes insist that you do at least two six month (three four month, or four three month) approved
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Opthalmology, ENT, ENT surgery, General Surgery, Paediatric Surgery, Urology, Trauma and Orthopaedics surgery, or trauma Orthopaedics Child and Adolescent Psychiatry or Psychiatry of Learning Disability Cardiology, Medical Oncology, Clinical Oncology, Gastroenterology, Endocrinology and Diabetes Mellitus, Haematology, Nephrology, Respiratory Medicine, Rheumatology, Neurology or Infectious Diseases Palliative Medicine
Careers
19
training posts in ‘list A’ specialities (maximum accepted in one speciality 12 months). Further hospital posts may also include some List B specialities (maximum accepted six months), if providing a reasonable range of experience. If travelling abroad, check with your Deanery (ideally before travel) about arrangements for post approval. The Gold Guide has some useful information about taking time out of UK training: http://www.mmc.nhs.uk/pdf/Gold%20 Guide%202010%20Fourth%20Edition%20v08.pdf
Assessment During their specialist training GPs, like most other specialities, are required to complete an e-portfolio. This includes matching your clinical experience with curriculum statements, case-based discussions and clinical evaluation exercises with your trainer, as well as reflective entries and personal development plan completion. This will be discussed at intervals with your educational supervisor, be monitored and approved by your local Deanery. You will also need to complete the nMRCGP exam in order to become a member of the Royal College of General Practice. This currently comprises an applied knowledge test, clinical skills assessment and work-place based assessment. While in the past, membership was optional (only ‘summative assessment’ being compulsory), it is now required for all GP trainees in order to complete train- GPs, your responsibility will increase as you move between posiing. You will usually attend a Vocational Training Scheme group tions as locum, salaried and partner (or self-employed) GP. Some GPs develop services (usually in collaborathroughout your training. These are a tretion with their PCO and local hospital) to mendous resource in developing your pracoffer additional specialist provision (such as tice throughout training and are also likely Many trainees worry about Dermatology, Gynaecology, or Opthalmolto support your revising for exams through becoming a generalist. In fact, ogy). This way a GP can develop additional initiation of study groups, or sessions run generalism is a specialism! specialised knowledge useful to both their by the scheme. everyday practice and specialist clinics. Within this role, the boundaries of their work will depend upon Specialist or Generalist? the context in which they are practising and available support from Many trainees worry about becoming a generalist. In fact, gen- secondary care, their primary role remaining to be a GP. If you wish eralism is a specialism! Becoming a GP involves becoming famil- to become a ‘GPwSI’, talk with local colleagues and contact www. iar with medical knowledge about diseases commonly presenting apwsi.co.uk. You may need to gain extra qualifications, at some to general practice. The very nature, however, of primary care as point, in addition to your general practice qualifications. a first point of contact providing a comprehensive and universally available resource, means that you will also frequently encounter a Combining life and work range of less familiar areas, requiring complex consultation skills. Many GPs’ career decision will have been influenced by the This might range from acting as a patient advocate for social or legal potential work-life balance. Depending on your practice and area issues, or addressing more specialised conditions prevalent within of work, there is likely to be more space for personal preference and your patient population. autonomy in agreeing your place and hours of work. Most surgeries You need, therefore, to develop professional processes which are open to patients from at least 8am to 6.30pm, although there facilitate ways of exploring unknown knowledge in safe ways. This will be opportunities to negotiate when you offer surgeries (includinvolves using book or internet resources, secondary care colleagues ing part-time options). and, most importantly patients, often manThere is, however, a lot of work in addiaging your own and the patient’s uncerDepending on your practice tion to the set surgery times. This includes tainty (an answer does not always exist!). and area of work, there is home visits, checking results, reading and You also need to refine diagnostic skills likely to be more space for acting upon patient correspondence and and instincts in order to balance identifypersonal preference and authorising prescription requests. Surgeries ing possible diagnoses against tolerating the autonomy in agreeing your vary in the way in which they divide ‘reguunknown; and avoiding the over-investigaplace and hours of work. lar’ and ‘emergency’ appointment requests. tion and ‘medicalisation’ of all patients. This Most areas now have ‘out-of-hours’ seris partly achieved through ‘safety-netting’ vices. These are usually staffed during evewith patients (Neighbour, 2005). nings, nights and weekends by local GPs outside their practice Practices work in different ways often utilising expert skills withcommitments. in a mix of GP training and personality. GPs often divide organisational roles within the practice to support development of practice services and quality and outcomes framework (QOF) administra- Teaching in General Practice tion. Your role in organisational and employment tasks will largely depend upon your position within the practice. General practice has traditionally had a very strong affiliation Although most practices welcome offers of involvement from all with education. Many GPs are ‘trainers’, allowing them to supervise 20
Careers
specialist trainees. In order to become a trainer, GPs attend a parttime one year certificate course (the equivalent of a school teacher’s PGCE) and attend ongoing monthly trainer events. GPs can also become involved in foundation and undergraduate level teaching. Most Deaneries require Foundation level supervisors to attend a 1-2 day training course. GPs wishing to get involved in undergraduate teaching should contact their local university and get involved. Some teaching takes place at the university site, but most will be patient-based within a practice setting. These posts rarely require specific qualifications (other than enthusiasm to teach) and ongoing professional development and quality assurance is arranged by the university. GPs often find that teaching and consultation skills have many similarities and involvement in each informs the other. There are a range of courses and events if you would like to pursue this interest further.
Summary In conclusion, there are many opportunities for getting involved in a range of exciting and innovative areas of practice through GP training. From becoming an expedition doctor, getting involved in research and teaching, political activity, work with pharmaceuticals to simply enjoying consulting with patients, general practice offers a breadth of training expanding doctors’ knowledge and future possibilities - enjoy! References Neighbour, R. (2005), The Inner Consultation: How to develop an effective and intuitive consulting style. (Second ed.). Abingdon, Oxon.: Radcliffe. Tooke, J. (2008), Aspiring to Excellence: Findings and final recommendations of the independent inquiry into Modernising Medical Careers [Online]. Available at: http://www. mmcinquiry.org.uk/Final_8_Jan_08_MMC_all.pdf.
A Career Companion to Becoming a GP: developing and shaping your career This inspiring new book emphasises there is no single career path in general practice. Without being prescriptive, its practical approach helps you make life-changing decisions, prompts selfanalysis and equips you with the tools to remain flexible, positive and reflective about your career. Published by Radcliffe. Edited by Patrick Hutt and Sophie Park. (ISBN-10 1846195535). RRP £24.99 Sophie Park is a sessional GP and works at UCL medical school teaching undergraduates and postgraduates. She also teaches with the London Deanery and Institute of Education (IoE) and is studying for an EdD at the IoE.
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Your chance to WIN a new 32GB Apple iPad 3G*. Wesleyan Medical Sickness specialise in providing tailored financial advice to medical professionals. Our iPad competition is exclusive for medics. To enter visit www.wesleyan.co.uk/ipadcompetition *Terms and Conditions apply. See entry form for details. Model shown for illustration purposes only and may differ from actual prize. Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly owned by Wesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Telephone calls may be recorded for monitoring and training purposes. HD-AD-15 (02/11)
Focus on Finance - in association with Wesleyan Medical Sickness
Income Protection I
ncome protection should be an essential cornerstone of financial planning. Wesleyan Medical Sickness answers some key questions about income protection policies. Q: Why do I need income protection? A: As a doctor, you know better than most that people do sometimes fall ill and are unable to work for long periods of time. If you were left without a regular income for a sustained period of time, you could struggle to manage day-to-day living costs and stay on top of debts. Rent, mortgages and other bills, will still need to be paid, and could soon mount up. The BMA has estimated that newly qualified doctors could graduate with debts of at least £37,000. This is considerably more than a junior doctor’s basic salary, so if you fell ill at this stage of your career, you could be particularly exposed financially as debt repayments won’t just disappear, although student loan and tuition fee repayments will be frozen if your income is below £15,000. Q: How does income protection work? A: If you are diagnosed with an illness or injury that means you are unable to work, you will be able to claim on an income protection policy and continue to receive an income. This will be a regular tax-free payment at, typically, around 50% of your gross pre-incapacity earnings. Most income protection plans pay out until you return to work or are no longer suffering from a loss of earnings, for example if you start receiving a pension income, you reach the maximum age for the policy or you die.
Q: Why do I need income protection if I receive sick pay? A: You may initially be covered by NHS sick pay, depending on how long you have been working. A junior doctor in their first year of service is eligible for just one month’s full pay and, once they’ve completed four months’ service, an additional two months’ half pay. This will gradually build up over time but will still only cover basic salary and won’t include other elements that can significantly increase your regular take-home pay, such as salary band uplift. Even consultants are only eligible for a maximum six months’ full pay and six months’ half pay. Therefore you could find yourself living on less than half your regular take-home pay. An income protection policy however is generally based on your full earnings, not just your basic salary. If you were to rely on only the State for help once NHS and statutory sick pay runs out, you could be entitled to a maximum of just £99.85 Employment and Support Allowance a week. Q: What should I look for in a policy? A: Make sure you choose a plan that suits your particular needs. You may have savings or a partner’s earnings to help cover the loss of income and this will have a bearing on the level of cover you require. It is also important to check whether the policy is specified ‘own occupation’, meaning you will still receive an income even if you could do another job apart from your own. Some policies offer an ‘any suited occupation’ definition, which means they
won’t pay out if you can’t do your own job but could carry out other types of work based on your knowledge and experience. The period of time between you being unable to work and the payments starting is also an important factor to consider as you will want to ensure there are no gaps in your income. You can opt to defer income payments for an amount of time that suits you and, in general, the longer a deferred period, the cheaper your income protection policy will be. Conclusion Income protection is important because the right policy can ensure you maintain the level of income you received before sickness or injury. The amount of protection required depends on your own circumstances and lifestyle requirements and while there are a wide range of products available, not all will match your particular needs, so choose carefully. It is sensible to take professional advice to ensure you find the right cover for you, leaving you neither over- nor under-insured.
For more information or for specialist financial advice contact Wesleyan Medical Sickness on 0800 107 5352 or visit the website at www.wesleyan.co.uk/doctors
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0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned by Wesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.
FINANCE
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Medicolegal Advice - in association
Into the WILD Sara Williams gets off the beaten track and explores wilderness medicine
“One more climber should have died that day, but didn’t, and that’s Beck Weathers. He was able to survive because he was able to generate that incredible willpower; he was able to use all the power of his mind to save himself.” Dr Kenneth Kamler talking about his experiences working as the only doctor during the worst disaster in Mount Everest’s history.
D
r Kamler has treated bear bites in the Arctic, frostbite in the Antarctic and set fractures in the Andes. Fortunately not all expedition medicine is as extreme. Expedition or remote medicine is defined as the diagnosis, prevention and treatment of injuries and medical conditions that occur in remote hard-to-reach areas, far removed from the beaten track. It is practised in a range of theatres, from rainforests and battlefields, to geographical catastrophes to polar ice caps; if it is off the beaten track, it is expedition medicine. The expedition medic is a generalist, as the role is all encompassing, for they are the radiographer, nurse, porter, surgeon, etc. Before you go on your expedition • Make sure you have the right indemnity (see sidebox).
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• Ensure that you are registered in the country you will be working in. • Find out exactly what the medical facilities will be, what support you will have, and how you will contact people in an emergency. • Check that your level of experience is what your team leaders think it is. • Research the destination and familiarise yourself with local customs. • Check that you’re happy with the expedition company’s risk assessment. • Training, pre-expedition planning and health assessments are vital to minimise the risk of unexpected, preventable medical emergencies. • Send out questionnaires to find out about current and past medical conditions of participants; drug histories and allergies; detailing appropriate immunisations, anti-malarials and personal medical kits. During an expedition • Remember the same good medical
practice considerations apply however remote you are. • Work within the limits of your clinical competence (even the most skilled surgeon could not undertake surgery up a mountain without the right equipment). • In the UK, the standard of care expected is generally determined by the Bolam test – that is, what is expected from an ordinary, competent doctor skilled in that particular art. • When treating patients, you should make it clear that you are giving assistance as a skilled first aider, as opposed to anything more specialized or sophisticated. • When treating participants as patients, always make sure you have their valid consent and act in their best interests. • Be aware you have responsibility for the safety of the whole team. • Keep a record of all consultations and drugs prescribed. • Be vigilant of professional boundaries as they can become blurred in the setting of an expedition. • Be sensitive to local customs and cultural factors. • Guides or porters should have access to the same medical treatment as other expedition members. • Bear in mind different environments will present specific risks and associated
with the Medical Protection Society
Getting the right indemnity
MPS advice
Before undertaking any expedition medicine, you should speak to MPS to ensure that you have adequate and appropriate indemnity. Some expedition companies provide expedition cover. Expedition doctors go beyond the scope of Good Samaritan acts, whether a fee-paying member of an expedition or not, doctors are expected to provide medical attention, and so changes to your indemnity cover may be required.
Expedition medics are responsible for the clinical care of the expedition team, risk assessment, medical kits and equipment, and prescribing medicine. Decision-making skills, communication skills and self-reliance are all important. Clinical situations should be assessed in relation to the limited equipment and resources available, the best interests of the patient, and a doctor’s own levels of competence and experience. For more information visit ww.mps.org.uk or call the MPS on 0845 605 4000 or email info@mps.org.uk.
illnesses, eg, on climbing expeditions, altitude starts to have an effect around 1,500 to 2,000m – air pressure gets lower and less oxygen is available. • Remember other medical problems can range from the mundane, eg, stomach upsets, sprains, blisters; to the life threatening, eg, fractures, high-altitude sickness and venomous insect bites. • Remember the scope for comprehensive treatment will be limited, so the emphasis lies on stabilisation of the patient and evacuation to a facility where definitive care is available. After an expedition • The same standards of confidentiality apply; wherever possible, patient consent should be obtained before sharing clinical information with other medical teams. • People who pursue extreme dreams are About MPS info for articles.qxd:MPS Checkup 12/2/10 10:05 Page 1 likely to have accepted that there is a certain degree of risk involved, so are less likely to come back and criticize your skills after the trip.
I’m just on holiday! If you’re going on a trekking holiday and are not attending in any formal medical capacity, remember that in the UK and Ireland, there is an ethical, but not legal, obligation to assist those in need of medical treatment in an emergency. The GMC’s Good Medical Practice (2006) states that in an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care.
About MPS MPS is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world. We actively protect and promote the interests of members and believe that education is an integral part of every health professional’s development. As well as providing legal advice and representation for members, we also offer workshops, conferences and a range of publications designed to aid good practice. 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.
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.
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Assessed by Gil Myers
1
2
Medical Report
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1 More specific than hay fever (10) on 13Series of genes chromosome 6, that 4 Sexual drive (6) 2Small splinter of code for antigens bone (7) 5 Phlebothrombosis (3) including HLA 6 Not a nice guy; sudden muscle 3Any disease antigens (3)contraction in response to a nerve resulting(4) in wasting impulse 14Eardrum (7) of tissues (8) 8 Small communication16Kanner's between tiny artery and vein in the skin of the limbs syndrome 4Presence of fat or oil (6) (6) droplets in urine 9 Inflammation of the uterus (8) to a ligament, 17Injury (7) as a result 11 Tremors or vibrations in part of the of body detected by palpation or 7His disease is sudden staphylococcal auscultation (8) overstretching (6) scalded skin 12 Not mitosis (8) syndrome (6) 15 Voluntary rapid movements of the eyes, e.g. when reading (8) 8Space between the 18 Loss substance two vocaloffolds (7) through pathological or physiological means (10) 19 Indiscriminate 10Organs within the eating of non-nutritious or harmful substances (4) 20 Comon benign body cavities (7) tumour of fat cells (6)
Down
11The association in psychoanalysis (4) 2 Small splinter of bone (7)
Down
the
3 Any disease resulting in wasting of tissues (8) 4 Presence of fat or oil droplets in urine (7)
7 His disease is staphylococcal scalded skin syndrome (6) 8 Space between the two vocal folds (7) 10 Organs within the body cavities (7) 11 The association in psychoanalysis (4) 13 Series of genes on chromosome 6, that code for antigens including HLA
antigens (3) 14 Eardrum (7) 16 Kanner’s syndrome (6) 17 Injury to a ligament, as a result of sudden overstretching (6) You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com Compiled by Farhana Mann
26
HOSPITAL MESS
Dumbo
e may believe that an elephant can fly but I believe that he may be suffering from a number of different conditions.
Temporal lobe aneurysm At various points in the documented life of Dumbo he begins to hear others singing rather than speaking to him. Although that could be a purely escapist fantasy to avoid confronting his own mundane dilemmas, it would be remiss to not think about the possibility of these being auditory hallucinations (defined as sensory stimuli in the absence of external sensory stimuli). These events are rare, but documented, resulting in all voices being heard as song - or maybe for Dumbo it’s as simple as hearing crows “singing” songs about you. A CT should be requested as a matter of course although it would be a challenge to accommodate him into a scanner. Fragile X Syndrome The picture I get of Dumbo’s life is one of psychogenic muteness, repetitive behaviour (the same jump into the bucket of pie filling every night), social anxiety, peer teasing and difficulty with physical feats most recently the elephant pyramid disaster - resulting from poor muscle tone. This, coupled with his appearance, suggests the possibility of Fragile X syndrome - a genetic disorder caused by mutation of the FMR1 gene on the X chromosome predominantly in males. It would also explain why Dumbo’s mother was so secretive about his birth using a stork delivery service rather than a hospital to avoid questions which may have been raised regarding her family history. Vertigo A belief that you can fly is more often than not, incorrect. Even given his enlarged ears, it is near impossible that Dumbo can lift his own body weight off the ground. Add to this the physiological impracticality of “flapping” ones ears and the result is that we must assume that Dumbo cannot actually fly. We are therefore left with an assumption that Dumbo experiences what could be misinterpreted as “flight” - the sensation of swaying while the body is actually stationary with respect to the surroundings. Inner ear problems are often the cause of vertigo as they act to effect the balance mechanisms of the vestibular system - more likely given Dumbo’s distended auricular protuberance. Schizophrenia All of these symptoms could be brought together in a single diagnosis: schizophrenia. Dumbo reports auditory hallucinations, visual hallucinations and delusional beliefs about flying and his famed destiny. There is a suggested family history of odd behaviour: when Dumbo’s mother assaulted those teasing Dumbo, she is judged to be “mad” by the other circus performers (and locked away). There is a strong genetic component to schizophrenia making the diagnosis more likely. A trial of anti-psychotics may be in order - I would suggest Seroquelephant.
Writing in the Notes er
A doctor as a lead
earning to Dear Editor, st the article ‘L re te in h uc m l-embracI read with excellent and al an is It . 5) p1 achieve lead’ (Iss 21, on the way to ew vi er ov e, is as a leading, yet conc ills. A ‘doctor sk ip sh er ad le odern day much-needed zzword in the m bu a y bl na tio ugh evoluer’ is unques S is going thro H N ur O e. at r creating medical clim constant need fo a ith w n tio lu g ones to tion and revo rganising existin -o re as l el w as ery. Consenew services healthcare deliv in t en ci effi e ng leaderbecome mor need of possessi e th d an e lu va phasised. quently, the d never be overem ul co or ct do a ning these ship skills as r you start lear ie rl ea e th at th e will be. The truth is tter the outcom be e th , er re ca r featuring skills in your niorDr team fo Ju e th d au pl ence at the I warmly ap r the right audi fo le tic ar nt va such a rele l done! n right time. Wel Aung Zaw Wi
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:
Sausages and chips
A ball pen
s (not animals)
r’s copy read my partne to ed st re te in am I was very ’ (Iss 21, p9). I mals in Training e ni dg ‘A le r D ow or kn ni ur Ju of much of yo e se u yo as it re a vet and whe animals we see ing coming from actice is on par nd ta rs de un d an ry pr Today’s veterina y casthe other way. ls - and in man ita sp ho in er liv de erations with what you mplex cardiac op co do e W . or ri e many es is even supe that would mak es tr ea th ile er st brag about in high-tech ould go on to w I s. ou al je s rts of the NHS doctor operate on all pa so al n ca ts ve t want to the fact that ns but I wouldn’ eo rg su an m hu body unlike hts! ndall start picking fig Michael Ke
3 doctor) ner of an ST Vet (and part
‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.
Strathclyde Hospital, Lanarkshire
Too expensive to write a complaint at:
£1.99
Neath Port Talbot Hospital, Port Talbot
Doodle-tastic:
e’re better
Tested on human
King’s College Hospital
£2.40
More because w
GP trainee , Newcastle
£3.65
More banger for your buck at:
n Deanery ST5 North Wester
Dear Editor, I was a little di sappointed by yo docs prescribe ur article ‘Young more’ (Iss 21, p6). It suggests younger doctor that s over-prescribe and do not offer style advice to be lifetter manage card iovascular diseas would argue th e. I at another explan ation is that youn doctors have a ger better understa nding of newer and so can offer drugs these where appr opriate. Today th is much emphas ere is on cost-effect ive prescribing an outcomes in the d on NHS and from my experience yo doctors are appr ung opriate and effec tiv e prescribers. Sangita Sin gh
Less sizzle for your cash at:
49p Pint of milk
Royal Victoria Hospital, Belfast
Expensive enough to make it curdle at:
79p
Royal Free Hospital, London
Moo-velous prices at:
59p
Yeovil District Hospital, Somerset
Next issue we’re checking the cost of a bowl of porridge, an A4 B/W photocopy and a jotter pad. Email prices to hospitalconfidential@ juniordr.com
Queen’s Medical Centre, Nottingham 42” TV with Sky Digital, 10 PCs with Internet Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table. Complimentary tea, coffee, toast, newspapers and magazines are provided daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.
JuniorDr Score:
★★★★✩
HOSPITAL MESS
27
Weekend Ward Escape to the
Lanzarote There’s a myth that the Lanzarote locals coined the slang ‘Lanza-grotty’ to keep rowdy tourists away from this year-round sunshine island. Lanzarote however, is more ‘art’ than ‘all-day English breakfast’ and an ideal choice for a long relaxing weekend ward getaway. Getting there Despite being a Spanish island Lanzarote lies closer to Africa, situated just 100 miles off the Moroccan coast on the same latitude as the Sahara desert. Flying time is a little over 4 hours from London. For flights check out ThomsonFly, Monarch or the other package operators for cheap lastminute deals. Alternatively BA offer direct flights from many UK airports with Easyjet offering a summer service.
in Playa Blanca at £140 per night offers a spa and uncrowded beach (www.princesayaiza.com). For a more exclusive and individual experience try the very private Lagomar guesthouse with seaviews over lava craters and access to an eccentric underground cave bar (www.lag-o-mar.com).
Eating Lanzarote cuisine is similar to that on the Spanish mainland but you’ll find excellent fresh seafood most commonly served grilled. There’s a small number of local dishes including salted potatoes in a hot local mojo sauce. Try Caserio de Mozaga (www.caseriodemozaga.com) in San Bartolomé which is recommended for perfect Canarian grilled fish and local produce.
César Manrique, this site contains a subterranean garden, restaurant, pool and concert hall built into a network of volcanic caves. Reserve a table in advance. Fundación César Manrique - Understand the island’s world famous artist, architect and sculptor who worked with the likes of Andy Warhol.
Car hire is highly recommended to allow you to experience the extreme island landscape and visit the more remote villages. Alternatively, taxis on the island are cheap and coach tours to the main attractions operate from the major resorts towns year-round.
Where to stay? The two main tourist resorts on the island are the low-rise developments of Puerto del Carmen and Playa Blanca on the south coast. Both are relatively inoffensive with only a splattering of ‘all-day English breakfast’ cafes and beer guzzling Brits making them a good base for those without a car. Try the cheap and cheerful Atalaya Apartments in Puerto del Carmen for a good location and access to the beach at £50 per apartment per night (+34 902 50 53 50). For a more luxurious 5-star experience the Princesa Yaiza Suite Resort Hotel 28
Tourism
Another great Canarian restaurant with a modern twist is La Tegala in Mácher (+34 928 524 524). Here you can sample Tapas style dishes and enjoy a fantastic panoramic view of the volcanic landscape.
Key attractions Timanfaya National Park - This massive 20-square-mile site of lava and volcanic craters is spectacular and the island’s top attraction. After the tour you can refuel the with food cooked directly off the volcanic surface. Jameos del Agua - Designed by the islands most famous architect, sculptor and resident,
Find the full Lanzarote guide at JuniorDr. com.
Key facts • Population - 130,000 • Language - Spanish • Currency - 1£ = 1.15 Euros
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29
THE MEDICAL COURSE AND CONFERENCE DIRECTORY
A
s doctors we hate scouring the web to find where and when we can attend the next exam revision course, training event or conference.
We think they should all be in one place - which is why we launched EventsDr.com as part of the JuniorDr network.
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31
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