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The doctor baby boomers 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, Alison Ridley JuniorDr PO Box 36434, London, EC1M 6WA
Tel - +44 (0) 20 7 193 6750 Fax - +44 (0) 87 0 130 6985 team@juniordr.com 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 2012. 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.
I
n just five years time female doctors will outnumber their male colleagues for the first time in the UK - a big change since the 1960s when just 24% of applicants to medical school were female. Whereas the number of men entering medicine has doubled in the past four decades, female recruits have risen ten-fold. They now make up 54% of medical students - a proportion which is continuing to grow. With this rise, medical training has had to adapt to a workforce which more and more needs to balance career development with parenthood. The good news is that deaneries and NHS employers are more open than ever to flexible training and the demands of doctors with families. Experiencing the pitter patter of tiny feet is a life changing, challenging and wonderful experience but how do you manage it if you are also a junior doctor? JuniorDr’s Fareeha Amber Sadiq, recently a new mother herself, invites you to consider some ideas and strategies for planning a family whilst coping with the practicalities of working as a junior doctor (page 9). Also in this issue we look at the troubling rise in the diagnosis of pathological gambling. A quarter of a million new gamblers are expected as the UK gambling laws relax to allow more casinos and the first supercasinos. It has led to fears that the UK’s relatively low prevalence of problem gambling will more than double, bringing it in line with the United States. Michelle Connolly takes a look at pathological gambling, a psychiatric diagnosis, and speaks to Europe’s only professor of gambling studies (page p15). And our content doesn’t end here. Check out our new look website where you can find hundreds of articles and resources. It’s also your opportunity to contribute, share your experiences and be part of the JuniorDr community.
What’s inside 04 08 09 15
LATEST NEWS How to make a human Having a baby as a junior doctor
24 26
Courses and Conferences Dr Who?
Pathological gambling
TRIAGE
3
Tell us your news. Email team@juniordr.com or call 020 7193 6750.
PROFESSIONAL STANDARDS
Complaints against doctors reach record high M ore patients complained about their treatment by UK doctors last year than ever before, according to the latest numbers from the GMC. The number of complaints increased by 23% from 7,153 in 2010 to 8,781 in 2011 - continuing a pattern which has been rising since 2007. It means the likelihood that the GMC will investigate a doctor increased from one in every 68 to one in 64.
Organisations where junior doctors reported below average satisfaction with clinical supervision also had a higher proportion of complaints to the GMC. “While we do need to develop a better understanding of why complaints to us are rising, we do not believe it reflects falling standards of medical practice,” said Niall Dickson, Chief Executive of the General Medical Council. “Every day there are millions of interactions between doctors and patients and all the evidence suggests that public trust and confidence in the UK’s doctors remains extremely high.” Last year the names of 65 doctors were
erased from the medical register and a further 93 suspended. Among the complaints there was a significant rise in concerns about how doctors interacted with their patients allegations about communication increased by 69% and lack of respect rose by 45%. Organisations where junior doctors reported below average satisfaction with clinical supervision also had a higher proportion of complaints to the GMC. GPs, psychiatrists and surgeons attracted the highest rates of complaints. Men, and in particular older male doctors, were also far more likely to be the subject of complaints than women. Doctors trained outside the UK and Europe were less likely to be complained about in middle age but more likely to face allegations when they were older. The GMC is introducing a series of measures to deal with the rise in complaints including a 15-strong team of Employer Liaison Advisors, a confidential helpline
for doctors so they can raise patient safety concerns and a pilot for a national induction programme for doctors new to the register. www.gmc-uk.org
PUBLIC HEALTH
Doctors not taught benefits of exercise
D
octors have ‘sparse or non-existent’ knowledge to enable them to promote physical activity to patients, says a report published in the British Journal of Sports Medicine. The report is based on cirriculum information from all 31 medical schools across the UK. It found that only four medical schools (16%) included physical activity in each year of the undergraduate course and that five schools provided no training at all. Government legacy plans for the London 2012 Olympics placed exercise as a key component of public health strategy but
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NEWS PULSE
this report questions the ability of clinicians to adequately to deliver that plan. The responses showed that the total amount of time spent on teaching physical activity was just four hours on average compared to 109 hours for pharmacology. The authors called for urgent action to train future doctors in how to effectively promote the benefits of physical activity. bjsm.bmj.com
NEW IN 2012
NHS
Acute hospital care on the brink of collapse, warns RCP
T
he demand on clinical services is increasing to the point where acute care cannot keep pace in its current form, says the RCP in a new report Hospitals on the edge? The time for action. The report highlights that there are a third fewer general and acute beds now than there were 25 years ago, but the last decade alone has seen a 37% increase in emergency admissions. This is coupled with an increase in elderly patients - nearly two thirds (65%) of people admitted to hospital are over 65 years. “One doctor told me that his trust does not function well at night or at the weekend and he is ‘relieved’ that nothing catastrophic has happened when he arrives at work on Monday morning. This is no way to run a health service,” says Sir Richard Thompson, president of the RCP. “This is no way to run a health service. Excellent care must be available to patients at all times of the day and night. We call on government, the medical profession and the wider NHS to work together to address these problems.” The RCP has called for: • All health professionals to promote
patient-centred care and to treat all patients with dignity at all times. • The redesign of services to better meet patients’ needs. This may involve consolidation of hospital services and hospital closure. • The planning and implementation of new services must be clinically led. • The reorganisation of hospital care so that patients can access expert services seven days a week. • Access to primary care to be improved so patients can see their GP out of hours, relieving pressure on A&E services.
“Excellent care must be available to patients at all times of the day and night. We call on government, the medical profession and the wider NHS to work together to address these problems.”
978-0-415-68003-5
978-0-415-68416-3
Sir Richard Thompson President of the RCP
GENERAL PRACTICE
GP incomes down by £6K in last five years
T
he average salary for a UK contract holding GP fell last year to £104,100 bringing the total decrease since its peak in 2005/06 to £6000, according to the latest GP Earnings and Expenses report. The figures show that the average income for contractor GPs, which form 80% of the GP workforce, was actually up by 1.5% in the year 2010/2011 but this was offset by expenses rising by 3.5% on average. “From our figures we can see that the fall in actual income before tax for the latest year is influenced by the increase in expenses that practices are facing,” said Health and Social Care Information Centre Chief Executive, Tim Straughan. “While contractor GPs’ gross earnings are continuing to move upwards, this small rise is offset by the bigger increase they face in the cost of running their practices.” The number of top-earning GPs with an income of more than £200,000 before tax fell to 720 (2.2% of the total). The report also shows that around half of all contactor GPs (48.9%) had income before tax of less than £100K. The average income before tax of a contractor
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GENERAL PRACTICE
Extension of GP training gains support of MEE
M
edical Education England, the body responsible for medical education, training and workforce planning in England, has given its support to a proposal to extend GP training from three to four years. The proposals was originally submitted by the Royal College of General Practitioners in 2011 and argued that the increased demands from the growth in community care required a more thorough and extensive training programme. At three years the UK currently has the shortest general practice training programme in Europe and one of the shortest of all medical specialities. “We recognise that the current system of training for GPs has been in place for 30 years and needs to change to adapt to future challenges,” said Christine Outram, Managing Director of MEE.
“These particularly include the need to meet the demands of an ageing population receiving an increasing proportion of care close to home and improvements to GP training in relation to the care of children and young people and those with mental health problems.” The RCGP is also recommending that the minimum time spent in general practice training placements be extended from 12 to 24 months which would bring the total time in training to five years for most GP trainees. Plans will now be presented to the Department of Health for approval. www.mee.nhs.uk www.rcgp.org.uk
SURGERY
Trainee surgeons safe in theatres
S
urgical procedures in theatre involving junior doctors in training are as safe as operations performed in which trainees have no operative role, according to a study by the University of Limerick. The project team reviewed data from more than 60,000 surgeries conducted in the US between 2005 and 2008 and found that the rate of incidence of major complication in surgeries with a surgeon-in-training involved was 6% - the same figure for surgeries without a junior doctor involved. “It is now clear that while the involvement of surgeons-in-training was always anecdotally accepted as safe, this has now been formally investigated and the practice proven to be safe,” said Professor Calvin Coffey, part of the Cleveland Clinic based research team that published the study in the journal ‘Annals of Surgery’.
www.ul.ie
No sex please we’re medical students Medical students have fewer sexual partners at university than most other students, according to a poll by website studentbeans.com. The poll of 4,656 student ranked those studying medicine at 30th out of the 43 having an average of 3.43 sexual partners since starting university. Those studying economics came out top with an average of 4.88 partners per student. www.studentbeans.com
GP trainee becomes BMA junior doctors leader London based GP trainee Ben Molyneux has been elected to lead the BMA’s junior doctors committee. He will take over from longstanding chair Tom Dolphin when he steps down at the end of this month. ST2 Kitty Mohan has been elected as JDC vice-chair. www.bma.org.uk
British public lack anatomical awareness The public have a lack of knowledge on the human anatomy and a worrying ignorance of body basics, according to a survery comissioned by the Museum of London. The survey of 2,000 people found that 50% were unable to correctly identify the location of their heart and 62% were unable to explain the purpose of the pancreas. www.museumoflondon.org.uk
1000 suicides from recession 1000 people have committed suicide due to the 2008-2010 economic recession in the UK, according to a report published on BMJ. com. The authors calculated the number of excess suicides attributable to the financial crisis by looking at the total number which were over and above historical trends. It found that suicides rose 8% among men and 9% among women. www.bmj.com
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NEWS PULSE
REVALIDATION
Revalidation to start in December GMC confirms
T
he GMC has confirmed that it will recommend to the Secretary of State that revalidation for doctors should begin in December this year. Between December 2012 and March 2013 it is expected that responsible officers and senior doctors who will be responsible for making revalidation recommendations locally will go through the revalidation process. The rest of the medical workforce will then be revalidated in the following five years, with the majority of doctors being revalidated by the end of March 2016.
“We will be ready to start delivering revalidation from the end of this year and we are confident that the healthcare systems across the UK will also be ready.” Niall Dickson Chief Executive GMC
“Revalidation is on its way. Subject to the Secretary of State’s decision to switch on the legislation, from the end of this year we will begin to tell each doctor the date when he or she will be expected to revalidate,” said Niall Dickson, Chief Executive of the GMC. “We will be ready to start delivering revalidation from the end of this year and we are confident that the healthcare systems across the UK will also be ready. Now is the time to get on with this.” Doctors will need to collect six types of supporting information which they will be expected to provide and discuss at their appraisal at least once in each five year cycle - continuing professional development, quality improvement activity, significant events, feedback from colleagues, feedback from patients and a review of complaints and compliments. For junior doctors in training your responsible officer will be in the organisation that is supporting you with
Timetable for revalidation • responsible officers and other
medical leaders first, by March 2013 • about a fifth of licensed
doctors between April 2013 and the end of March 2014 • the majority of licensed doctors
by the end of March 2016 • all remaining licensed doctors
by the end of March 2018
revalidation - which in most cases is your deanery. The GMC has more information on how revalidation will impact you which can be found at www.gmc-uk.org/doctors/revalidation/12383.asp. www.gmc-uk.org
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7
50
You can get per cent of the nitrogen atoms for your human from industrial fertiliser. In the developed world half the nitrogen components of the body come indirectly from fertiliser factories.
You’ll need
500,000
How to make a
bacteria per square inch for the armpits - and slightly less for his groin and feet. The rest of your human requires a lot less work – just 15,000 for the drier, less bacteria friendly, parts of his body.
Human 02
is the most common element in the human body making up 62.81 per cent.
2.5
Add an extra cm to the height as this is the variation in a normal person’s height throughout a typical day. We all shrink by nightime thanks to the effect of gravity. As we get older the amplitude of daily variation becomes less in addition to spinal column compression and osteoporosis.
£2.75
is the net worth of your man’s most important body part - his skin. The average male has 14 to 18square feet of skin, enough at today’s commercial cowhide rates to put almost three quid in your pocket - but only if it’s cut and dried first. Forget the rest of him - all the remaining dried bits are only worth about 75 pence.
Having a baby as a junior doctor Experiencing the pitter patter of tiny feet is a life changing, challenging and wonderful experience but how do you manage it if you are also a junior doctor? JuniorDr’s Fareeha Amber Sadiq, recently a new mother herself, invites you to consider some ideas and strategies for planning a family whilst coping with the practicalities of working as a junior doctor.
Brought to you by
Having a baby
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Having a baby as a junior doctor
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recent General Medical Council (GMC) report described the number of female doctors as rising and likely to overtake the number male doctors on the General Medical Register in coming years. As medical training is a long process and fertility reduces with age, many are understandably interested in starting families whilst they are in the earlier stages of their careers. Creating a supportive workplace environment and more flexible working patterns is therefore fundamental to supporting this growing number of female doctors. However, as the GMC report describes, some specialties are more flexible than others and female doctors are underrepresented in certain specialities such as cardiology, gastroenterology, anaesthetics and surgery1. More recently there have been increased efforts to retain female doctors in paid employment - examples include the GP retainer scheme2 and Less Than Full Time Training (LFTT)3. Many argue that there is a strong need to change the culture in many areas of the NHS and to remove the barriers which are discouraging women from entering senior leadership positions4. Many female and male doctors will continue to face the constant juggle of parenthood with their medical careers. Combining both of these can be rewarding, however it is important to be aware of ones resources and limitations.
Keeping an open mind Planning when to have a baby will be based on your individual circumstances and how manageable you believe combining medicine with parenthood can be. Parenthood will always throw its own challenges but you can learn to cope with these. With pregnancy it is vital that you keep an open mind. There are many uncertainties and although it can be incredibly rewarding, having children is definitely one aspect of your life that you have very little control over. Doctors are a group of adaptable and resourceful people and therefore this strength can counterbalance the uncertainty that comes with pregnancy. As it can be stressful to look after a young child and work as a junior doctor it is advisable, as much as possible, to mobilise resources and people around you to help. It can be difficult to ask for help when you have been working independently, however having a strong supportive network of connections and caring people can enable you to feel less overwhelmed and for your anxieties to be better contained. This may be family, friends or paid help. It is also worthwhile looking into childcare options prior to having your baby as there are often waiting lists and the more popular childcare places can be over subscribed. When considering childcare, it is also important to speak to other parents and consider the wide range available depending on your preference and budget.
Looking after yourself For any prospective parent it is important to look after your emotional and physical wellbeing as these can be stretched both during and after pregnancy. This may also be the first time you come into contact with hospitals as a service user. Being on the receiving end of care can be challenging and is a different position to manage because of expectations and beliefs that you may have around providing effective care to others. By looking after yourself well you are also preparing for looking 10
Having a baby
after your child. Both of you will benefit from the extra care you take to ensure you remain in good health. One of the key things to ensure is that you attend all your antenatal scans and review appointments. Getting adequate rest and eating a healthy balanced diet is important. These are not surprising messages, however with hectic and pressured working patterns sometimes these vital needs can be neglected. In later stages of pregnancy you may find yourself experiencing tiredness or other health issues which may necessitate coming off your oncall rota. This decision will depend on you and your baby’s health, and the nature of work that you are involved with. It is a personal decision and should be made after discussion with your GP and/or midwife.
“By looking after yourself well you are also preparing for looking after your child.” Attending local antenatal classes can offer helpful support, particularly for non-medical partners, and can also help you meet other parents who live nearby and who could become great sources of support through the coming months and years. Depending on your health, gentle exercise such as swimming, prenatal yoga and massage can aid relaxation and reduce stress levels. Dr Rebecca Viney, Associate Dean of Professional Development, Coaching and Mentoring Lead at the London Deanery suggests: “Step back from the situation, imagine yourself in ten years time from now, what would you be saying to yourself looking back? It might be: get more sleep, more help, stop worrying, have fun and live in the moment.”
Maternity Leave To receive maternity pay you must have had 12 months continual service for the NHS and be still employed at 11 weeks before the baby is due to ensure that you are paid maternity pay. Maternity leave can be up to 12 months and during this time you accrue annual leave and pension benefits as usual. You will receive eight weeks full pay, 18 weeks half pay and then 13 weeks statutory maternity pay. You are not obliged to inform your employer until after week 16. Maternity pay is calculated on the average of your weekly earnings between about 16 and 24 weeks of your pregnancy.
“You are the expert when it comes to your family needs and values, and the balance will change over time.” What you must do when you find out you are pregnant: • Let your HR department and line manager (eg. TPD, consultant) know about your situation in writing, at least 15 weeks before the baby is due. When you provide this information, your employer will also request a MATB1 certificate. This will allow for an adequate risk assessment and also to enable maternity benefits to be put in place. • The risk assessment should be followed by your employer making changes to your work environment as necessary. • Inform your department regarding planned antenatal
appointments in advance. • Discuss your on-calls and how to modify these if possible and/or come off completely in the later stages of your pregnancy. • Decide when you would like to take your maternity leave and communicate this with your organisation. Consider whether you will remain a full-time trainee or you will return as a Less Than Full Time Trainee (LTFT) and apply to work flexibly if this is your decision.
Paternity Leave • Paternity pay is two paid weeks. • Additional Paternity Leave and Pay (APL&P) allows eligible fathers to take up to 26 weeks additional paternity leave. This should provide more choice and a more equitable sharing of leave.
Maintaining a life work balance Life does change dramatically during pregnancy and after the baby is born. As a doctor who is a parent, it can be helpful to remember to keep life in balance and that Winnicott’s idea of “good enough” parenting is key. Rather than aiming for unrealistic ideals, the focus should be more on celebrating parenting’s complexity and enjoying the journey that parenthood takes you on without any guilt or excessive pressure. Dr Rebecca Viney’s advice to those experiencing parenthood and a career in medicine is: “Remember to be present and live in the moment. You are the expert when it comes to your family needs and values, and the balance will change over time. So it is worth creating time to set goals that you value, to work out your unique family priorities and to balance these with your career.” “Coaching and mentoring can help you to achieve this work-life balance. Make sure that you keep your career safe, and find a role model who has reached their potential even with children, just to remind yourself that it is possible to do anything - it just may be that you have a slightly more interesting and different career path.”
Useful resources London Deanery (for London trainees and doctors) offers a mentoring programme for doctors undergoing transitions and requiring extra support. Contact for more information. http://mentoring.londondeanery.ac.uk/ British Medical Association
http://www.bma.org.uk Women’s Medical Federation
http://www.medicalwomensfederation.org.uk
Fareeha Amber Sadiq is a ST6 in Child and Adolescent Psychiatry, London.
Having a baby
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Having a baby as a junior doctor
Coping with Pregnancy as a Junior Doctor
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or my husband and I, making that all-important decision of when we should start our family was something of a balancing act. On the one hand, now that we were both in our thirties, concerns regarding potential fertility issues were increasingly prevalent. On the other, completing my training as an anaesthetics registrar was a major goal, with enormous implications for both my professional development and for our family life. In the end, we decided to let nature take its course and were lucky enough to fall pregnant during my ST5 year. While delighted to be pregnant, this was undoubtedly a time of emotional as well as physical turmoil. My booking scan was unfortunately not entirely the joyful experience that we had hoped for. The amazement of seeing our little bean’s heartbeat was soon tempered with the devastating news that there was a high risk that our little one may have serious congenital or structural defects. It felt as though our world had come to an end. The ensuing weeks awaiting the results of genetic testing and a detailed scan were traumatic, to say the least. All this was compounded by the fact that I was undertaking a Fellowship in Obstetric Anaesthesia at the time. There is no doubt that it was difficult to concentrate on work when all I could really think about was what was happening with my own pregnancy. At the same time, my experience of being a ‘high-risk’ patient certainly gave me a whole new insight into what the hospital experience must be like for many patients. I was under the care of a
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Having a baby
superb obstetrician who kindly and sympathetically prepared me for what to expect at each stage. At the very least, I have learned a valuable lesson in the importance of good communication with patients. Luckily, everything worked out well for us; the chromosome assay was normal as was the 20 week detailed scan. This news certainly alleviated the stress, although the emotional scars remained.
“The amazement of seeing our little bean’s heartbeat was soon tempered with the devastating news that there was a high risk that our little one may have serious congenital or structural defects.” Informing my department of my pregnancy was a task I did not look forward to, but in the end, happened surreptitiously. On one occasion in my first trimester, the consultant I was working with noticed that I was keen to avoid exposure to X-ray while in theatre and guessed that I was pregnant. I planned to formally inform my line manager after the twelve week booking scan. However, following the news of my high-risk status, I found it difficult to broach the subject. In the end, I found myself confiding in a sympathetic consultant colleague who kindly offered to inform the rest of the department on my behalf. This allowed me to then speak to my Lead Clinician in my own time. Informing my lead clinician of my pregnancy was important for a number of reasons. Firstly, it was essential to complete the necessary paperwork to ensure my entitlement to maternity leave and pay, along with arranging a start date for my leave. I initially (somewhat optimistically!) planned to work until 38 weeks gestation. It eventually became apparent that this would not be possible as I was just too big and tired in my third trimester to continue to work effectively in the theatre environment. Following ongoing discussion, it was agreed that I would take two weeks of annual leave after 34 weeks and then commence my maternity leave at 36 weeks. Secondly, I had to have regular scans throughout my pregnancy and required significant time away from my clinical duties to attend these as well as antenatal appointments.
S4D_Ad_Print.pdf 1 30/08/2012 16:40:37
– A Personal View
Support4Doctors is an online portal of information for UK doctors. It offers specialist advice and support for doctors and their families on career, health and financial issues. The site also offers a database of organisations that can provide further help.
Angela Jenkins, ST6 Anaesthetics, Glasgow Thirdly, it allowed a risk assessment to be undertaken which could identify any potential workplace risks to me or the baby, which could then be modified. Such risks included exposure to ionising radiation, dizziness if I had to stand for too long, the need for regular bathroom breaks (unless I wanted to self-catheterise, of course!), difficulties transferring anaesthetised patients and particular problems covering ICU duties, such as having to run to cardiac arrests carrying a heavy bag. A number of small modifications were then made to my clinical duties. Where possible, I could avoid theatre lists involving x-ray exposure, a stool would be provided and (most importantly), I was taken off the ICU rota. This is certainly not possible for all pregnant trainees - I was lucky that my department was able to make it work in my particular circumstances. A helpful tip that I picked up from a colleague regarded maternity pay. I was concerned that there would be no maternity pay for the last three months as I was taking a year off. I was informed that it was possible to request that human resources will annualise maternity pay, meaning that there will continue to be some income all the way through until returning to work. This took a bit of negotiation, but was certainly possible within my health board.
“I was just too big and tired in my third trimester to continue to work effectively in the theatre environment.” Finally, I had to consider my options with regard to returning to work. The decision as to whether to return on a full-time or flexible basis is very individual and can be difficult. I had to balance the desire to finish my training expeditiously with the desire to spend as much time as possible with my baby. It is also important to consider financial aspects of part time training and childcare, along with the impact flexible training may have on the ability to stay engaged with departmental activities. After much deliberation, I made the decision to go back to work on a full-time basis. The best advice I can offer to pregnant junior doctors is to think through your options, talk to people who have been through a similar experience and to keep your line manager and all other necessary parties up to date.
Support4Doctors is a project of the Royal Medical Benevolent Fund. The RMBF is the leading UK charity for doctors, medical students and their families. We provide financial support, money advice and information when it is most needed due to illness, age, bereavement or disability. C
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CM
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CMY
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Each year the RMBF helps hundreds of doctors, medical students and their dependants. The RMBF's help ranges from financial assistance in the form of grants and interest-free loans to a telephone befriending scheme for those who may be isolated and in need of support. For beneficiaries in particular financial need the RMBF can arrange money/debt management advice and in cases where it is appropriate the RMBF may also be able to help with return to work support. The RMBF is committed to leading the way in providing support and advice to members of the medical profession and their dependants. To find out more about our work, or how you can get involved visit the RMBF website.
www.rmbf.org
References
1. General Medical Council. The state of medical education and practice in the UK: 2011. www.gmc-uk.org/publications/10692.asp 2. http://www.londondeanery.ac.uk/professional-development/medicalworkforce-development/primary-care/gp-retainer-scheme/gp-retainerscheme/?searchterm=gp%20retainer 3. Topley R, Ashwell G, Webb J, Brightwell A, Roden R, Corrado O.J. Trainees’ tales of less than full time training” BMJ Careers. 22 Aug 2012. http:// careers.bmj.com/careers/advice/view-article.html?id=20008522 4. Khan M. Medicine—a woman’s world? BMJ Careers. 5 Jan 2012. http:// careers.bmj.com/careers/advice/view-article.html?id=20006082
Registered office: 24 King’s Road, Wimbledon, London SW19 8QN. Tel: 0208 540 9194. A charity registered with the Charity Commission No 207275. A company limited by guarantee. Registered in England No 139113
Having a baby
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eMAil: welcome@healthmatchbc.org
Please note: specialists with postgraduate training from the uK or ireland must hold the CCt/CCst or equivalent. uK and irish trained Family Physicians must have a minimum of two years approved and accredited postgraduate training and may be eligible for certification without examination with the College of Family Physicians of Canada. Photos: tim swanky, Picture bC & tourism bC
Wanna bet? gambling with addiction A quarter of a million new gamblers are expected as the UK gambling laws relax to allow more casinos and the first supercasinos. It has led to fears that the UK’s relatively low prevalence of problem gambling will more than double, bringing it in line with the United States. JuniorDr’s Michelle Connolly takes a look at pathological gambling, a psychiatric diagnosis, and speaks to Europe’s only professor of gambling studies, Mark Griffiths.
PATHOLOGICAL GAMBLING
15
Wanna Bet? G
ambling - ‘the act of risking the loss of something of value on an uncertain outcome in the hope of winning something of greater value’ - isn’t new. Records show the ancient Chinese were placing bets back in 3000BC and even the Egyptians enjoyed a flutter in the shadows of the pyramids. In fact, whole countries have been decided on the roll of the dice. When the kings of Sweden and Norway couldn’t agree on the ownership of land in 1000AD a roll of the dice turned entire towns over to the Vikings. Today the acceptance of gambling varies around the world. Some Islamic nations prohibit gambling and the vast majority impose some form of regulation. In the UK, regulation first started when Henry VII banned his soldiers from gambling when he found they were spending more time placing bets than training.
Betting is the most popular form of gambling, with £47.7 billion staked in 2005; in the same year, £4.9 billion was wagered on the National Lottery. Source: Gamcare. Over the last few years the government has taken the unprecedented step of relaxing legislation.
When is gambling considered pathological? Pathological gambling (PG) was first listed as a psychiatric diagnosis in 1980. It is an addiction to the altered psychological state experienced whilst gambling - similar to the high gained from narcotic substances. Just as a drug addict needs more of a psychoactive substance to get high, the problem gambler must place higher and higher wagers in an attempt to win back lost money - a term known as ‘chasing losses’.
“I used to nip home to place bets until I found out that I could bet on my mobile and even then I was constantly checking results. Colleagues thought I was cheating on my wife.” Patrick - Diagnosed Pathological Gambler
Consequences Afflicting just under one per cent of the UK population, pathological gambling is a chronic, progressive disorder more commonly found in patients being treated for alcohol or drug dependency. The personal and social consequences are obvious (and enormous) - suicide, divorce, bankruptcy and criminal behaviour. Understanding the thought process of problem gamblers is often difficult to grasp, even for doctors. Those affected will commonly gamble their money used for basic needs, such as food, as in their minds this has become the only way to provide more food. It’s common for pathological gamblers to have a long history when they present, up to 20 years in many cases. Men typically start gambling 10 years before women, and seek help three years later. Patrick, a recovering gambler, spoke candidly to JuniorDr about his addiction: “I lived in Curragh, Ireland, an area famed for its horse racing. Gambling is second nature to most people there,” he explained. He started betting on horses, then as lottery fever gripped Ireland in 1987, he increased the amounts he was gambling. “It was turf accounts [horse betting] initially. I’d place up to £5 twenty years ago. Then the Irish lottery began and I would increase my bets to £500,” he says. But it was the advent of online gambling which made Patrick’s gambling addiction worse. “I’d bet up to £5000 online at a time, and larger sums on the horses; I’d bet on anything that moved.”
The Rush Many gamblers are addicted to something specific which influences the type and form of gambling. For Patrick it was the excitement of 16
PATHOLOGICAL GAMBLING
– gambling with addiction the event and chance of a big win. “I had such an adrenaline rush when the events I had bet upon were coming to their conclusion,” he says. “I nearly passed out one day when a horse was involved in a photo finish for £5000 which I lost.” Many gamblers gradually develop a deepset belief that they will win: “I began to make plans for a house by the coast and giving up work. When I went to GA I heard many similar stories of people convinced they’d inhabit their fantasy world once they’d won big.”
On average each pathological gambler will ‘severely’ affect the lives of 15 others to support their gambling. Gamblers Anonymous.
“My work suffered as I was always thinking about my gambling. I used to nip home to place bets until I found out that I could bet on my mobile and even then I was constantly checking results. Colleagues thought I was cheating on my wife,” he adds. “I had got to the stage where I neglected everything. I was at my computer as soon as I came in the door, my wife didn’t mention anything in the beginning, but I started making excuses for not going out; in the end I didn’t even care if she left me. She asked if I was gambling again and I owned up, I had already made the decision to stop though, as I was getting suicidal thoughts and hated my life.” Despite his own experience Patrick is not opposed to the Government’s plans to build a Las Vegas style ‘super-casinos’ in the UK: “Everyone has the right to be entertained by whatever form they wish. It would be foolish to ban any activity to protect the few who don’t know when to stop.” Patrick feels the best way to get a problem gambler into recovery is to try all possible treatments, and to find one that works for them. “After the person has accepted they have a problem, all avenues should be explored: GA, counselling and treatment centres. I don’t think there is one best method,” he says. “I suffered a physical, mental and spiritual decline and am now on the road to recovery one day
at a time.” “Incidentally,” he points out, “I meet a lot of gamblers in Alcoholics Anonymous; I believe it is very common to replace one addiction with another.”
Betting nation It’s not just new casinos, the new act of parliament will see gambling play a more dominant role in Britain’s future landscape impacting everything from restaurants to flying.
Ryanair’s maverick chief executive, Michael O’Leary, has already announced that passengers will be able to gamble midflight as a means to offset airfares. The British Medical Association has warned that the relaxed regulations will
Support in the UK Junior Dr invited members of the GamCare forum to talk about experiences of approaching their GP. Susie: “I sat there in tears saying ‘I don’t know how much longer I can carry on’ and my GP said, ‘See how you feel tomorrow and let me know if we can help’, as he got up, signalling the end of the appointment. I spoke to a different doctor a few days later who signed me off sick and referred me for counselling. I’m lucky in that my company pays for private therapy for ‘addictions’ (even at The Priory if necessary) but you do need a GP referral first. If I hadn’t gone back to the second doctor I wouldn’t have got that referral.” John: “I told my GP that I was suicidal and all I got was a lecture on how gambling was ‘very very bad’, no offer of counselling; he didn’t give me any phone numbers where I could receive help and refused me sleeping tablets and antidepressants. Later that day I was very close to attempting suicide. I won’t be going back there for support; I’ll stick to GA and GamCare for help.”
PATHOLOGICAL GAMBLING
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Wanna bet? gambling with addiction herald a rise in addictions which must be countered by better addiction services, which currently even fail to screen for gambling. Dissatisfied with the act’s aim of raising £3 million annually for the Responsibility in Gambling Trust, the main treatment funding body, the BMA called for a £10 million annual contribution. Culture Secretary at the time of the Act’s introduction, Tessa Jowell, tried to re-assure parliament that Britain wasn’t gambling with its mental health saying that: “Las Vegas is not coming to Great Britain. British casinos will be under the strictest controls in the world. Tricks of the trade will not be allowed. There will be no free alcohol to induce more gambling, and no pumped oxygen to keep players awake.” The government reassured the public that if the loosened gambling law results in an increase in Britain’s relatively low problem gambling incidence, she will shut them down. JuniorDr spoke to Professor Mark Griffiths, a gambler himself, based at the International Gaming Research Unit, Nottingham Trent University. “I do gamble, but only because I am buying a form of entertainment,” he says. “My sole aim is not to win money. If one enters a casino with the sole aim of winning money, then one is much more likely to become addicted than if the evening at the casino is treated as simply a ‘night out’, an alternative to the pub.” When the National Lottery was launched in 1994, it sparked a similar outcry. Medical journals received many letters from doctors worried that we’d turn into an offshore Las Vegas. “That was all very knee-jerk. You cannot become addicted to something that takes place only twice a week,” asserts Professor Griffiths. “You can never ever become addicted to the National Lottery but you can become addicted to buying tickets.” Six years after the Lottery’s introduction the British Gambling Prevalence Survey, in which Professor Griffiths was involved, found that less than one percent of the adult population were problem gamblers but that amongst adolescents, the figure was as high as five percent. “A study found that some 15 year olds got a buzz from buying lottery tickets, which was heightened as they were doing it illegally and it was this feeling to which they were addicted,” he explains. Griffiths wants a loophole in the Act to be closed that allows children to gamble on slot machines in arcades and leisure centres. He feel this is imperative given that slot machines are the most damaging form of gambling: “Slot machines are the crack cocaine of gambling because of the high event frequency - you can gamble twelve times in a minute, and the machine manufacturers build in ‘near misses’ that give the impression that you’re close to winning.”
Medicalisation Pathological gambling is a specific psychiatric diagnosis. It falls into a similar category as schizophrenia and depression. Many argue, however, that the medicalisation of gambling is a step too far. “I’m not trying to medicalise gambling,” he says. “But this behaviour is pathological. I receive lots of calls from the media about gardening, internet and sex addicts - that’s the medicalisation of society for you! But with those ‘addictions’, they’re not addicted in the pathological sense, as they don’t exhibit the classical signs of dependency.” “Gambling is particularly debilitating, as there is a big financial 18
PATHOLOGICAL GAMBLING
loss involved; if one is addicted to the internet, the only loss is time. Furthermore, problem gamblers often engage in criminal activity to recoup losses. The same cannot be said of being addicted to the internet or sex. And very few video games addicts fulfil all the criteria of addiction, i.e. they do not suffer withdrawal, nor do they become tolerant.”
Addictive personalities Many gamblers excuse their actions stating that they simply have an ‘addictive personality’, but it’s not something Griffiths believes in: “I don’t believe in the concept of an addictive personality,” he says. “People who are addicted to gambling exhibit traits that are not unique to addiction. There is no evidence that there’s one personality trait that points to an addictive personality. Addicts often use the addictive personality as an excuse for their behaviour.” “Problem gambling shows all the traits of addiction to alcohol or psychoactive substances. In addition, studies have shown that SSRIs such as fluoxetine are effective PG therapies.”
NHS Treatment Questions remain on how well the NHS is prepared for an increase in problem gamblers. Professor Griffiths recalls how, on registering with a new GP, he was asked whether he smokes, drinks or takes illicit substances, but not whether he gambles. “Doctors certainly do not receive enough training in tackling addictions. The NHS urgently needs to put gambling on the same footing as other forms of addiction. People understand that you can be addicted to a substance,” he says. “But they find it hard to see how someone can be addicted to the high that the action of gambling causes.” “I am not anti-gambling,” he emphasises. “I even gamble myself, but I believe that the protective mechanisms need to be enhanced and the intoxicated must be stopped from gambling. People are owed an informed choice: they should be told the chances of winning.”
References Professor Griffiths authored the BMA report Gambling addiction and its treatment within the NHS, which can be downloaded here www.bma.org.uk/ap.nsf/Content/gamblingaddiction Beaudoin, C & Cox B (1999) - Characteristics of problem gambling: A preliminary study using DSM-IV based questionnaire. Canadian Journal of Psychiatry, June 1999. Lesieur HR, Rosenthal RJ: Pathological gambling: a review of the literature (prepared for the American Psychiatric Association Task Force on DMS-IV Committee on Disorders of Impulse Control Not Elsewhere Classified). Journal of Gambling Studies 1991;7:5-39.
Resources Gamblers Anonymous gamblersanonymous.org.uk
Offering support since 1964.
Gam Anon www.gamanon.org.uk 08700 50 88 80
For those affected by another person’s gambling.
GamCare www.gamcare.org.uk 0845 6000 133
Provides online chat rooms as an outlet for problem gamblers to talk to others, and residential programs.
A full body of knowledge Acute and General Medicine 2012 offers a visionary new approach to medical training. Physicians across the UK – from core medical trainees to consultants – have a unique opportunity to get up-to-date with latest practices and thinking in acute and general internal medicine for practically nothing. Update your knowledge in Cardiology, Respiratory Medicine, Diabetology, Care of the elderly, Neurology, Nephrology, Rheumatology, Gastroenterology and much more… Up to 11 CPD points accredited by the RCP. Great value with two days of training for just £99 including refreshments and lunch. Register online or call 0207 348 4906
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Medicolegal Advice - in association
Don’t miss the All doctors have a responsibility to protect children and young people from abuse or neglect. Charlotte Hudson explores guidance surrounding child protection.
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hild abuse hit the headlines almost 40 years ago when the death of Maria Colwell shocked the nation, after which there were several high profile cases, including Heidi Koseda and Jasmine Beckford, before the Victoria Climbie findings generated the government legislation Every Child Matters. But, children are still being put at unnecessary risk because professionals involved in their care do not recognise the signs, or fail to take appropriate action. The most prominent recent case was that of Baby P who was killed by his mother, her boyfriend and his brother after months of abuse, in 2007. All the healthcare professionals involved in Baby P’s care were scrutinised, including Baby P’s GP. He was found guilty of a serious breach of professional duty for missing the signs of abuse, when he failed to properly examine Baby P or refer him for an urgent assessment after finding bruises on the child’s head and chest after apparently falling down the stairs. Had he taken the appropriate steps such appalling abuse – and his death – could have been prevented. An Ofsted report released in 20111 looked at hundreds of cases in which babies and young people suffered death or serious injury at the hands of their parents – known as serious case reviews, between 2007 and 2011. In one case, a depressed mother suffocated her baby, after doctors and health workers had been so worried about protecting her privacy that they failed to report that she could be a risk to her child. The inquiry found ‘repeated examples of agencies underestimating the risks from parents’ background and lifestyle’, including drug or alcohol misuse and being abused as a child. New guidance from the GMC, Protecting children and young people: The responsibilities of all doctors (2012)2, states that if doctors are treating an adult patient, they must consider whether the patient poses a risk to children or young people, and they must be able to identify risk factors in a patient’s environment that might raise concerns about abuse or neglect.
What should you do if you suspect child abuse? The GMC guidance reinforces the message that doctors must communicate their concerns. It states: “You must tell an appropriate agency, such as your local authority children’s services, the NSPCC or the police, promptly if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect, unless it is not in their best interests to do so”. “It is vital that all doctors have the confidence to act if they 20
believe that a child or young person is being abused or neglected.” NICE guidance When to suspect child maltreatment (2009)3 states that doctors may sometimes come across many different obstacles in the process of identifying maltreatment, including: discomfort of suspecting or wrongly blaming a parent or carer, divided duties to adult and child patients and breaching confidentiality, and fear of complaints. It says that these should not prevent you from following the appropriate course of action to prevent further harm to the child or young person. The GMC now makes it clear that doctors should follow up concerns and take them to the next level of authority, if they believe the person or agency to who they have referred the issue
with the Medical Protection Society
signs NSPCC statistics reveal that there were 50,552 children on child protection registers or the subject of child protection plans in the UK as at March 2011
has not acted on them appropriately and a child remains at risk of abuse or neglect. There is now an obligation for all doctors to be aware of services in their locality that can help parents and children if a child is potentially at risk, including services provided by voluntary groups. The GMC also expects doctors to develop an understanding of the practices and beliefs of the different cultural and religious communities that they serve – presenting a challenge for doctors who work in ethnically diverse areas. In hospital, paediatricians and emergency medics are in a prime position to pick up signs of abuse or violence and refer to other agencies when young people present with injuries, or signs of grooming when young people present with alcohol or drug related issues. If you suspect abuse, you should highlight your concerns to the designated lead for child protection in your unit. You need to be aware of the trust policy on child protection, and who to contact and how. Junior doctors should make sure they seek advice from seniors when appropriate. It is your professional responsibility to act if you suspect child abuse or neglect. You will be able to justify your actions if a complaint is made about you – provided your conclusions are honestly held, have been pursued through the appropriate channels and in accordance with the GMC guidance.
What are the signs? The Royal College of Paediatrics and Child Health (RCPCH) work to prevent
References: 1. Ofsted, Ages of concern: learning lessons from serious case reviews – www.ofsted.gov.uk 2. GMC, Protecting children and young people: the responsibilities of all doctors 2012 – www.gmc-uk.org 3. NICE, When to suspect child maltreatment CG89 www.nice.org.uk/cg89 4. NSPCC, Child protection fact sheet, The definitions and signs of child abuse – www.nspcc.org.uk/inform
and respond to abuse and neglect. They state that the four types of abuse are: physical, sexual, emotional and neglect (as defined in the UK government guidance Working Together to Safeguard Children 2010). NSPCC guidance4 states that there are a number of physical signs that may indicate abuse, including unexplained bruising, marks or injuries on any part of the body or human bite marks. Changes in behaviour can also indicate physical abuse, eg, flinching when approached or touched. Changes in behaviour which can indicate emotional abuse include neurotic behaviour and self-harm. Usually, in cases of sexual abuse it is the child’s behaviour that may cause you to become concerned, although physical signs can also be present. Neglect can be a difficult form of abuse to recognise; signs can include constant hunger, poor personal hygiene, along with changes in behaviour, such as being tired all the time. MPS Director of Policy, Communications and Marketing, Dr Stephanie Bown, said: “On the one hand doctors can be condemned if they don’t spot abuse or neglect, but on the other hand, they could also find themselves subject to a complaint if they raise concerns about parents or carers. “What the GMC’s new guidance makes clear is that doctors have to put the interests of the child or young person first, and this of course is what they will be judged against.”
How to identify child maltreatment NICE guidance says: • Listen to and gather information to create a full picture • Seek an explanation in an open manner • Record in the child’s medical record what is observed and heard from whom and when • Discuss your concerns with a more experienced colleague or named professional for safeguarding children. Further information on child protection can be found in the MPS factsheet, Safeguarding Children – http://www.medicalprotection.org/uk/england-factsheets/safeguarding-children.
MPS is the world’s leading medical defence organisation, putting members first by providing professional support and expert advice throughout their careers. MPS supports members through the world’s largest network of medicolegal experts. We have a unique team of more than 100 specialist lawyers and medicolegal advisers (doctors with legal training). We are also committed to sharing our experience with members to help them avoid problems and provide the very best care for their patients. The educational portfolio available includes publications, conferences, lectures, presentations, workshops, E-learning and clinical risk assessments.
MPS members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.
www.mps.org.uk The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.
21
WIN an iPad
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
A
Kick start your savings habit
s a junior doctor, your finances may not be in the best of health with loans, overdrafts and credit cards to pay back. While saving may not be a priority at the moment, as you move through your career and start earning more, it will become increasingly important. It is also worth noting that research carried out by Wesleyan Medical Sickness showed 41% of doctors wished they had started putting money away earlier in their career, so it is never too early to start.
Build up an emergency fund
One of the first things you should begin saving for is an emergency fund – essentially a reserve of cash that will keep you going in the short term. This should tide you over if you are unable to earn for any reason or face any unexpected expenditure, if the car breaks down for example. The amount you save will depend on your lifestyle and circumstances, but we usually recommend the equivalent of three months’ net income. Keep this money where it is easily accessible - in a bank or a building society account for example. Don’t let inflation eat into your savings
It’s easy to let your savings build up in your current account or a low interest savings account, but if the return on your savings isn’t outpacing inflation, the buying power of your money will erode over the long term. For example, if you have £10,000 in an account today paying interest at the Bank of England base rate of 0.5%, in five years this would be worth the equivalent of just £9,018* today and in ten years’ time it will be worth £8,132. To learn how inflation could be impacting on your savings, try out the
online calculators on the Wesleyan website at www.wesleyan.co.uk/investments. Saving for the short term
If you’re saving for the short term, for something like a car or a holiday, you will probably want to keep your money easily accessible. In this instance it’s worth considering setting up a Cash ISA, which is like a normal savings account but you won’t have to pay income or capital gains tax on the interest or on your money when you come to withdraw it. Up to £5,640 can be paid into a Cash ISA in the current tax year, and the government has pledged to increase this allowance in line with inflation each year.
might want to consider share, or equity, based investments. When investing in shares you should be prepared to leave your money in for at least five years. You should also be clear about how much risk you are prepared to take with your money – can you afford to get back less than you put in? Many people choose to invest in a fund which is a collective investment, where lots of people put their money together to access a wide range of investments. Spreading money in this way reduces the impact of loss from a single investment and funds are usually managed by an expert manager. There are also ISAs that invest in stocks and shares in a tax efficient manner, such as Wesleyan’s with profits ISA. You can invest a total of £11,280 into a stocks and shares ISA this tax year if you don’t use your Cash ISA allowance. By investing in a with profits ISA you are investing in a fund that has been designed to smooth out the highs and lows of the stock markets. The amounts paid out are therefore less volatile than the stock markets, which is an attractive feature of these policies. As you build up your savings and investments portfolio you should look to keep your money in a range of assets so that if one type performs badly another may perform well during the same period. Also remember to review your portfolio on a regular basis so you can identify any underperforming funds. Conclusion
If you’re new to savings and investments or want expert guidance, talk to a financial adviser who understands the medical profession and can help you build up a savings portfolio that suits your needs.
Saving for the long term
If you have a long term saving goal, you
* Based on the current inflation rate of 2.6%
The above information does not constitute financial advice. If you would like more information or need specialist financial advice, call Wesleyan Medical Sickness on 0800 358 6060 or visit the website at www.wesleyan.co.uk/doctors.
Specialist financial services for doctors • Savings and Investments
• Mortgages
• Retirement Planning
• Motor, home and travel insurance
• Life and Income Protection
Motor, home and travel insurance is arranged by Wesleyan for Professionals.
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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THE MEDICAL COURSE AND CONFERENCE DIRECTORY
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Making the best of it in
Sierra Leone FY2 Dr Mikey Bryant is in Sierra Leone with healthcare charity Mercy Ships. He has been volunteering in a children’s clinic for a year in a country where one in five children don’t live to see their 5th birthday. In this regular column he gives us an update on his experience.
You’ve probably realised by now that doctors can have weirdest names. Here’s the world’s most appropriate (and inappropriate!). They’re all real, you can check them for yourself on Medline. Cardiology
Dr Trulove, Dr Love, Dr Hart, Dr Valentine, Dr Everhart Dentistry
Dr Pullman, Dr Chu, Dr Cheek, Dermatology
Dr Spot; Dr Rash, Dr Frye (burn specialist), Dr Tanner, Dr Skinner, Dr Whitehead ENT
Dr Klotz (Clots); Dr Wax General Practice
Dr Kwak; Dr Killer, Dr Yau (“yeow”); Dr Blood, Dr Coffin, Dr Patient, Dr Payne, Dr Slaughter, Dr B. Sick, Dr Stasick (pronounced stay sick); Dr A. Sickman, Dr Deadman, Dr Pulse; Dr.Ill, Dr Uhren, Dr Doctor, Dr Howard Hertz (pronounced HOW-it HERtZ) Gastroenterologists
Dr Grunt, Dr Puppala (pronounced Poop-a-la), Dr Butt Hand Surgeons
Dr Hand; Dr Palmer, Dr Nalebuff, Dr Watchmaker Neurology
Dr Megahead, Dr Brain, Dr Head Renal
Dr Wiwi, Dr Ono, Dr Risk, Dr Fear, Dr Dibble, Dr Fillerup Obstetrics and Gynaecology
Dr Hyman, Dr Love, Dr B. Savage, Dr Pillow, Dr Storck, Dr Semen, Dr Hatch, Dr Born, Dr Hatcher, Dr Yell Opthalmology
Dr Peek, Dr Glass, Dr See, Dr Seymour Landa Pain Management
Dr Neupane, Dr Pain, Dr Ow Paediatrics
Dr Donald Duckles, Dr B. Softness; Dr Childs, Dr Jelley, Dr Bunny, Dr Tickles, Dr Elfman, Dr Toy, Dr Kidd (4 so far) Psychiatry
Dr Alter, Dr Reckless, Dr Brain, Dr Strange, Dr Wisdom, Dr Dippy, Dr Moodie, Dr Nutter, Dr Nutt, Dr Bummer, Dr Looney, Dr Dement Surgery
Mr Butcher, Dr Deadman, Mr Yellin 26
HOSPITAL MESS
I
t’s Thursday morning. I am standing on a plank of wood trying to balance on a puddle of mud feeling a bit like a condemned sailor. John and I are doing our best to squeeze between two tin shacks on an expedition to find as many children as we can. We have started a new initiative. Several weeks ago, Colin and I realised that most of our patients were coming from two or three areas of Freetown. There were many areas where children have heard of our hospital but can’t make it to our clinic because they can’t afford the 1000 leones (17 pence) to get a bus ride to come and see us. Our solution was simple - we decided to try to take the hospital to them. John (my local guide to Kroo Bay) and I manage to push our way past the community centre and into a little honeycomb of metal roofs supported by small wooden sticks. There are children everywhere, all of them waving, there skinny arms thrust into the air like eager sunflowers, mouths open wide screaming “Alle alle!”. Except for some of them. The most unwell are ominously quiet, the first one I see is lying on the veranda with a cannula in her elbow, her eyes sunken and tired. She is trying to stay awake. Her Mum just looks confused, tears streaming down her face and she is looking quite “There are lots of sick children around lost. John tells me she every corner, many of them need can’t speak any Krio. hospitalisation.” I can tell enough from the dehydration and bits of history from her younger sister that this girl has cholera. There has been a bit of an epidemic in the last few weeks and it has been tearing through the slums. We manage to get her to start swallowing oral rehydration solution and John explains to the family what they need to do to try to stop it from spreading around the bay. I move on and have a look at another child. There are lots of children with pneumonia and malaria. They’re usually fairly easy to diagnose as the presentations are so florid. I ask a couple of the mums why their children haven’t had any medicine. The answers always the same - they don’t trust the local clinic and some say that they can’t afford the registration fee. So much for free health care! As we walk around, rain starts coming down and the bay fills up like a bath. We see families trying to bail water out of their houses and I wonder why there has been no effort to re-house these people - then realise the answers will only be the same depressing cycle of poverty and corruption. As I trudge away from the bay feeling like a fisherman caught in a cyclone, I can still allow myself a little smile, relieved in the knowledge that at least something good was done for a few people today. If nothing else, the children will remember we were there and hopefully next week word will get out and we will see a few more. Read Mikey’s blog online at www.juniordr.com
Writing in the Notes A painful remedy? that RemDear Editor, ppointed to read I was very disa Remedy was ed (Iss 25; p4). edyUK has clos TAS chaos fighting the M instrumental in ning posts and plying for trai when I was ap have held the no-one would without it I fear t. I don’t have Health to accoun Department of which appears e in the BMA much confidenc react to issues slow moving to too large and ll have another in the future we’ but I hope that ough to standdoctors brave en group of junior tment. up to poor trea withheld
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:
Toothbrush
omas
Dear Editor, I found the ar ticle ‘Practice in scribing’ (Iss 25 safe pre; p20) in the su mmer edition of your magazin e a useful remin der of how to manage patie nts with a raised INR. However I can see th at morphine an d cyclizine are prescribed as in tramuscular inje ctions on the PRN side of th e sample drug chart. I would suggest an INR of 6.5 as these ca n lead to significant intram uscular haemat om as. Matt Cates CT2 Haemat ology, Torb ay Hospital
ve for the NHS
Olympic sized lo
sor Mike ur author Profes I agree with yo cy of Lonticle ‘Is the lega ar e th in d ee W p9) that the y lost’ (Iss 25; ad re al 12 20 n do ysical activOlympics on ph e th of ct pa im . What I am be determined ity has yet to ceremony w the opening sure about is ho S. I’m sure love of the NH cemented our rre that our s found it biza other countrie ngly, but no featured so stro health system ntastic comever had such fa other host has about - even thcare to shout prehensive heal people exerit does not get Beijing. Even if s strengthen pefully it help cising more ho e NHS. the legacy of th eld
Name withh on Health, Lond blic Pu 2 FY
‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.
£2.69
Nottingham Hospital, Nottingham
Teeth-tastic at,
£1.29
Name , London GP Trainee
Avoiding haemat
A trip to the dentish might be cheaper at,
Chocolate chip muffin
Royal Free Hospital, London
You’ll choke on the price alone at,
£1.49
Southampton Hospital, Southampton
Buy one for your favourite patient at,
80p Portion of chips
Newquay Hospital, Cornwall
Skip it and have a salad instead at,
£1.10
Royal Marsden Hospital, London
Just remember the cholesterol at,
80p
Belfast City Hospital, Belfast
Next issue we’re checking the cost of a 165g tube of Pringles, a plain doughnut and a 500ml bottle of Sprite. Email prices to hospitalconfidential@juniordr.com
Princess Alexandra Hospital, Harlow What it’s got - Sky HD on 42in high def plasma, wireless 16Mb broadband, leather sofas, lava lamps, 3 computers in separate computer room: 2 for all access broadband. Kitchen with dishwasher, microwave, basic food bread, tea, coffee, biccys etc usually topped up. Separate chill out/quiet room (with a few old sofas!). £10/month.
JuniorDr Score:
★★★★★
HOSPITAL MESS
27
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