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CAREERS
The recent GMC attempt to define ‘unhealthy behaviour’ has placed medical students firmly under the spotlight. In a story picked up by the mainstream press, the BMA have urged caution over these new criteria, which seem to threaten professional censure for ‘bad behaviour’ even before students have qualified. In our inaugural issue, we take a closer look at the new obligations outlined for medical students, and ask what do they mean for healthcare students in general? Those who support the guidelines argue that medical students – and indeed all healthcare students – are afforded specific responsibilities which other students are not, and along with those rights of access and authority comes the added responsibility of early professional behaviour. In a hierarchical system where training consists, in part at least, of a sort of apprenticeship, patients may not be able to distinguish students from healthcare professionals. Thus students should be able to ‘act-up’ in terms of their attitudes and behaviours. Yet how comfortably does this sit with the traditional work-hard, play-hard stereotype of doctors-in-training and nurses-to-be? Critics fear the medical regulators risk “using a sledgehammer to crack a nut.” The GMC is at pains to emphasise that these guidelines are just that, and that they have little jurisdiction over medical school admissions. The hope then has to be that these guidelines are used discerningly by medical schools and universities who hold the careers of thousands of students in their hopefully not-so-heavy hands. Personal and professional attributes are also high on the agenda for those who have just received their F1 allocations. We look at how the system has worked this year and hear from students who have just gone through the process. Did the new weighting of academic achievements disadvantage those in the 1st academic quartile? For the first time it was possible to link your application with a friend or partner but how was this done and what assurances were there? There is also talk of a national qualifying exam being used as a future differentiator of foundation allocations. To unearth the background and issues surrounding this controversial idea don’t miss issue two of the LSJM. Bringing professional attitudes to their training may be less of an issue for those who come to the healthcare sector via a more circumlocutious route. Increasingly, graduate places are being offered on healthcare courses, and a former advertising executive explains why she made the jump from promotion to physiotherapy. We also compare the training of graduate medics at home and away – and look at whether the Australian graduate admissions model, now adopted at some schools in the UK is succeeding in attracting candidates to healthcare. Without a doubt career pathways in all healthcare professions have always been a moveable feast. We anticipate that this will continue. LSJM Careers hopes to guide you through the myriad options that face you from the moment you start studying, and continue throughout your careers. By keeping you up to date with the latest developments in the healthcare sector, and offering tips and insights into paths less trodden as well as the more popular career choices, we hope to make your training time more enjoyable and worthwhile. Illustration: Robert Hare
Rob McGuire and Sonia Damle Section Editors of Careers
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Fitness to Practise - What does it mean for students? Matko Marlais*, Aneurin Young Year 4 Medicine, Imperial College London doi.10.4201.lsjm/car.001
What does fitness to practise mean to you? We all know that committing crimes or engaging in unprofessional behaviour can get us thrown out of medical school, but the remit of fitness to practise spreads much further than that. You may steer clear of drugs, avoid violence and respect confidentiality, but many other issues could call your fitness to practise into question. Can you honestly say that you have never been rude to a colleague, engaged in patient contact without making it clear that you are a student, or embellished your CV a little? These and many other actions could affect your fitness to practise. In addition, illness could strike any one of us and this guidance sets out new ways of dealing with those whose health threatens their ability to be a medical student. In the past, fitness to practise policies have been set entirely by individual medical schools, without clear guidance from external bodies. That is about to change. It has been increasingly recognised that unstandardised procedures threaten to treat students unfairly or to fail in their attempts to protect patients from those who are not fit to practise. As a result the General Medical Council (GMC) and the Medical Schools Council (MSC) has released new guidance: “Medical students: professional values and fitness to practise.”1 Here we explore how these new guidelines could affect you. The GMC aims to “protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.”2 As part of this mission, it defines and polices fitness to practise issues for doctors and has offered the following definition of fitness to practise: “To practise safely, doctors must be competent in what they do. They must establish and maintain effective relationships with patients’ respect, patients’ autonomy and act responsibly and appropriately if they or a colleague fall ill and their performance suffers.” “But these attributes, while essential, are not enough. Doctors have a respected position in society and their work gives them privileged access to patients, some of whom may be very vulnerable. A doctor whose conduct has shown that he cannot justify the trust placed in him should not continue in unrestricted practice while that remains the case.”3
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Whilst it is recognised that students are not doctors, as medical curricula start to include patient contact at an earlier stage it becomes apparent that guidance, similar to that for doctors is necessary. Set out below are some of the main ways in which students might compromise their fitness to practise: Criminal Offences These are some of the more obvious reasons for which a student’s fitness to practise may be questioned. The new guidance gives some examples: assault, theft and financial fraud to name a few. Whilst it is obvious that violent behaviour is unacceptable for a student doctor, other offences such as financial fraud may not be so clearly linked to fitness to practise. Any behaviour which compromises the trust placed in us by patients is potentially a fitness to practise issue. University life provides a vast array of criminal temptations! Medical schools are famed for their culture of drinking and high jinx. But when does this behaviour cross the line into criminality? Many of us have done things we regret after a heavy session at the union, but as medical students we must always be mindful that when jovial pranks turn into violence, criminal damage or theft, our careers are threatened. Unprofessional Behaviour Some examples of unprofessional behaviour in the new guidance include: poor time management, breach of confidentiality, rudeness and poor communication skills. Whilst some may feel it is excessive to review a student’s fitness to practise because of poor communication skills, the new guidance emphasises that it is not just the seriousness of an offence but also repetitiveness of offences which may bring about a fitness to practise review. Hospitals are stressful places and students are constantly placed under pressure to perform. In this context it would be easy for a student to fail to obtain proper consent for a procedure, to become habitually rude to those around you or to fail to maintain the appropriate boundaries between a medical professional and a patient. As doctors-in-training it is our duty to keep in mind the importance of treating patients with respect and acting professionally towards colleagues. Failure to do so could bring into question your suitability for a career in medicine.
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PERSPECTIVE What actions can be taken against students? Formal Warning: This is the first option available to the fitness to practise panel. The warning would be placed on record and would have to be disclosed when applying for registration as a qualified doctor. In addition, the student would be placed under supervision so that their progress can be monitored by the medical school. Conditions: This option obliges the student to take defined actions and observe limitations on his or her practise. These conditions aim to protect patients and provide a means by which the student can be supported and guided to becoming fit to practise, either by addressing poor behaviour or returning to good health.
Probity This is an important and under-recognised part of the GMC’s key guidance, Good Medical Practice4. Probity encompasses all aspects of integrity which are essential for doctors to maintain the trust placed in them by patients. As career progression in medicine becomes ever more competitive, the temptation to dishonestly enhance your CV grows. Have you ever considered forging a signature in a logbook, exaggerating your achievements in a CV or application form, or falsifying research to enhance your chance of getting published and earning a few vital MTAS points? Any of these actions would call into question your probity. A few white lies on an application form may not seem like a big deal, but any dishonesty calls into question your integrity. Health The inclusion of health as a fitness to practise issue is a strength of the new guidance. Whilst it is made clear that very few disorders would automatically require a fitness to practise review, there is a broad range of conditions which could potentially impact on a student’s graduation and subsequent fitness to practise. The guidance emphasises the requirement to seek appropriate medical advice at an early stage and encourages medical schools to support students through health problems by making reasonable adjustments. Each student would be assessed individually for the impact that their health problems might have on their ability to practise. This new guidance emphasises the duty students have to listen to medical advice which aims to allow them to practise safely and to observe any limitations which must be placed upon them. For instance, students who are infected with HIV or hepatitis B will usually be allowed to continue in their education as long as they carefully observe the guidance which is given to them to avoid exposure-prone procedures and protect patients. Protecting Students, Safeguarding Patients Fitness to practise policy must balance two important factors: firstly the GMC’s overriding duty to protect patients from poor medical practise, and secondly the need to treat students fairly. As set out in the council’s purpose statement above, these guidelines are formulated to ensure that vulnerable patients are protected from those whose fitness to practise has been called into question. In order to safeguard patients, the guidelines must provide strong tools which schools can use to address concerns or to prevent students from continuing to see patients if the concerns cannot be resolved.
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Temporary Suspension: A temporary suspension from medical school with a resulting delay in graduation can be imposed if it is felt that this period will allow the student to address his or her behavioural issues or health problems. Permanent Expulsion: If the transgression is exceptionally grave or if it is felt that no other measure will sufficiently protect patients, a student can be permanently expelled from medical school. This may be employed in response to serious offences including sexual offences, exploitation of a patient, gross disregard for a patient’s safety or a failure to understand and comply with concerns which have previously been dealt with using less severe measures.
In light of the power of fitness to practise procedures, standardised procedures aim to ensure that students are treated fairly. In line with recent recommendations for doctors and other medical professionals, this guidance incorporates ways to resolve fitness to practise issues without resorting to expulsion from medical school. This is a vital shift of focus, allowing fitness to practise procedures to help students with problems to learn, develop and become better doctors. This guidance integrates with other documents, especially Good Medical Practice, the Doctors’ Guide to Good Practise, and Tomorrow’s Doctors,5 which sets the standards for the expected knowledge, skills, attitudes and behaviours of students. This unified approach provides a firm foundation for students to better understand what is expected of them as a student and when they qualify. Patients, students and medical schools all benefit from clear, effective and fair fitness to practise procedures. This guidance significantly improves and standardises those processes. Very few of us will ever undergo formal hearings, but it is important that we are all aware of the range of problems which could influence our fitness to practise, and how we can expect to be treated if our suitability for a career in medicine is called into question. Reference List •
• • • •
General Medical Council, Medical Schools Council. Medical students: professional values and fitness to practise. 11-3-2009. Ref Type: Report General Medical Council. Role of the GMC. 2009. Ref Type: Internet Communication General Medical Council. The Meaning of Fitness to Practise. 2009. Ref Type: Report General Medical Council. Good Medical Practice. 2006. Ref Type: Report General Medical Council. Tomorrow’s Doctors. 2003. Ref Type: Report
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Career Change Gemma Webb Physiotherapy student, Kings College London
Towards the end of my first degree I studied the psychology of advertising and persuasion, and after a week’s work experience in a media agency, I was hooked. Five years down the line, three agencies and a few promotions later my passion had somewhat evaporated. There I was, working well into the night - talking to target audiences to sell products for other people, yet somehow still penniless at the end of the month. So what’s new you say? Surely, it’s inevitable to feel like this when you spend so much time at work? Well, if you spend an average of 50 hours in the office each week as I did, your working week quickly becomes half your waking week! This excludes the time spent thinking about all the things you have to do on the way to work. In effect, it equates to an awful lot of time in an okay career that no longer excites you. This is how I felt two years ago. After a particularly busy period at work I was knackered, bad-tempered and run down. Over Christmas I thought deeply about whether this was the career path for me. On the plus side, it paid reasonably well, and if I continued to work hard I could have worked my way up the company. However, I looked at my bosses - all overworked and trying to keep numerous work and personal plates spinning - and decided it simply wasn’t for me. I spent time thinking about the aspects of my job that I enjoyed; working in a team, solving problems, negotiating, talking to people. And then there were the things I didn’t like so much; stuck behind a computer, writing powerpoint documents, balancing budgets and sitting in endless meetings. I considered switching to a job in marketing, but would that be any different? It may have offered temporary relief to my situation, but the lack of fulfillment would have inevitably returned. At school I had enjoyed biology at A-level but had been put off pursuing it. My teachers spent their time focusing on the alreadyfuture doctors and vets in the group instead of giving those who needed that extra bit of help to do well. Oddly enough, an interest in human biology had remained, and I had a pile of free New Scientists by the side of my desk at work that I would read for my own pleasure. I’d also taken up running three years earlier to combat stress at work had become interested in training effects on the body and optimising my performance. Could I develop the things I enjoyed into a whole career?
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At school physiotherapy had been something I had looked at but the high grades had put me off. I am not now and never have considered myself as particularly academic. However, I decided to look into retraining to become a physiotherapist. I assumed that I would need to take science A-levels to be considered eligible to apply, fully appreciating that I may have to do this at night school while continuing to work. To my surprise I learnt that there were a handful of accelerated physiotherapy courses for those who already had a science-based degree. So instead of the traditional three year course I could be qualified within two years and my fees would be covered. Things were looking up. But what about the financial aspects? The accelerated course was full-time so I would have to leave my job. My boyfriend and I had a flat we owned so there would be a mortgage to pay, as well as the balance of my first student loans that I still had to pay off. I had the usual credit card and overdraft debts and no savings to speak of. At this point some might be discouraged, but I did not let this put me off. With the support of my boyfriend and my family, I worked out a realistic plan, focusing on reducing my debts and putting some money aside each month that would help me cover my living costs. I also found out that I would be able to apply for a means-tested bursary which, though not a substantial amount, would at least offset some of the costs. I was lucky because my parents offered to help each month. I also planned to ask my then-employer if I could continue working one day a week. Despite knowing that it would be difficult financially, I remained optimistic and tackled each challenge one step at a time. I did some work experience, I was accepted on to the course at King’s College, London, in March 2007. It gave me the same high as when I completed my first marathon in 2005. Two years later, it is still tough. Whilst in advertising, I had become used to a certain standard of living and three holidays a year. These are all now a thing of the past, and even my student discount won’t justify the monthly shopping trips I used to make! I started to bike to work, I took my lunch in every day, much to the amusement of my colleagues. When I finished work and started at university I negotiated to do a day a week at my old agency. I started babysitting for my friends and I signed up for focus groups. I’ve always been fiercely independent, preferring to pay my own way, but I’ve accepted that for the time being I should accept others generosity.
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PERSPECTIVE *Details correct at time of going to press.
Sources of Funding: A Sunday afternoon surfing the web is time well spent. There is a wealth of financial support available. Here are just a few suggestions to get you started.* 1. The NHS Bursary: What is it? An annual payment which is either income assessed (your own, parents’ or partner’s earnings), or non-income assessed depending on the course you are studying. It includes payment of tuition fees. It will normally be made in equal instalments over 12 months, you will then be required to re-apply if your course is over a year long. Eligibility? To access this, you must have been offered an NHS-funded place on a full or part-time course in an area such as medicine, dentistry, physiotherapy, radiography, speech and language therapy, nursing or midwifery. How much do I get? If you are on an income assessed course it depends. The basic rate for courses in 2008/09 for those living in London is £3,306 and £2,287 for those outside London. However there is a helpful online bursary calculator which can help you get an idea of what you may be entitled to on the website. Pros & Cons: + There doesn’t seem to be a downside! f you are successful at getting a place on an eligible course you should definitely apply for this as they will help towards things like placement costs. Those of you who have children or dependents may be eligible for ‘top-ups’. To find out more visit http://www.nhsbsa.nhs.uk/students 2. Career Development Loan (CDL) What is it? A bank loan for those wishing to retrain or develop skills in their existing career. It will help you fund up to two years of education. The loan is an arrangement between the Learning Skills Council (LSC) and three high street banks. The LSC pays the interest on the loan whilst you are training and then for a month after you’ve stopped training. You then repay the loan over an agreed term at a fixed rate of interest. The loan can help cover cost fees and living expenses.
One of the challenges of going back to studying is accepting that you are starting a career and that you may be treated differently by some. In my previous career I was a senior member of my team, I managed a couple of people. Nowadays I am supervised by senior physiotherapists who are often younger than me. In the early days this was hard for me to accept. I felt that it ignored all I had given up. It’s important to accept that when starting a new career you have a lot to learn and you have to start at the beginning again. However I feel that my age and experience has also benefited me in many ways. In my new career, connecting with people and effectively communicating with them is core to my practice, my previous experience has been invaluable and my supervisors often comment on the ability of older students to establish relationships with patients.
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How do I get it? You must be over 18 and a UK resident. If you qualify for a nonmeans tested bursary or receive a student loan you will not be eligible. Check the CDL website to see if your course is eligible for this product. How much can I get? You can borrow between £300 to £8,000. Barclays, the Cooperative Bank and the Royal Bank of Scotland all offer career development loans. Pros & Cons: + The loan is interest free whilst you study. — However, it is still a loan and you will have to start paying it back a month after you qualify (with interest) so you need to think about the monthly repayments and whether you can afford them. The loan is for courses that are up to two years long. If your course is longer, you can still apply, but be aware that you will need to start paying back the loan whilst you are still studying, (and therefore perhaps not earning). To find out more visit http://www.direct.gov.uk/en/ index.htm and search for “career development loan”. 3. Part Time Work What is it? This could either be work in your former guise, work in your newly chosen industry, or something completely unrelated. How do I get it? Try to stay on your former employer’s good side! You could approach them for part time or freelance work, either on a regular basis or during university holidays. Make use of any contacts Try to find paid employment in your new career sector, for example as a healthcare assistant, or in an administrative role. Upskill before leaving your previous career! Short courses such as sports massage or sports training might be useful services that you can offer, whilst studying. Pros & Cons: + This option will not only provide valuable income, but may also increase your experience of your new work environment. — Remember though, that your course may be extremely demanding at times, so be realistic about how much you will be able to work on top of this. Universities often discourage students from having part time jobs, so be careful if you are asked about how you will be funding your course when being interviewed for a place!
When I left my first career the economy was doing well and it wasn’t until the following summer that things began to slide. I guess despite it being tough financially for me with hindsight I made the right decision at a good time. As my colleagues tell me getting your first physiotherapy NHS post may be competitive but once achieved I‘m hoping that my occupation will be recessionproof. My old colleagues continue to work long hours. Although I’m told business is good the pressure is greater than ever to do what it takes to keep their clients’ businesses afloat, and no doubt salary reviews will be harder than ever to negotiate. Had I not taken this chance, I would have been in a similar position, with similar responsibilities and undoubtedly with more cash in my pocket, but I would still be stressed-out, unfulfilled and frustrated. Don’t be afraid to change an average career into something better. Take that first step, and who knows? It may just be the beginning of an exciting new life.
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INTERVIEW
Rebecca McConnell, BA (Hons) Year 3 Medicine (GEP), Nottingham University What preparation did you undertake for the GAMSAT? I have A-levels in biology and chemistry and also a degree in physiology. I bought an A level chemistry revision book, a physics GCSE book and the revision papers from GAMSAT (which were really worthwhile).
Describe two positive experiences of your course. - I really liked problem based learning. It forced me to study at home in preparation for a session. - The relationship between GEM students and the teachers was much more adult to adult than my first degree.
To what extent did you find your undergraduate background useful in the GAMSAT? My degree incorporated biochemistry, neuroscience, endocrinology and renal physiology. These subjects are very relevant to medicine but in terms of the GAMSAT they really only helped with the biology questions. Before I did the GAMSAT I had been working for charities for about 10 years and the experience I gained in the marketing and fundraising departments helped a lot towards the essay writing section of the exam.
Describe 2 negative experiences of your course. - Some of my colleagues not quite being the “mature” students that we are supposed to be. - The fear of practical exams. I always hated someone watching me do something.
Did you feel that your prior academic learning and life experience were helpful in the problem solving, critical thinking and writing skills that the GAMSAT is supposed to test? I believe that my prior academic and work experience have given me problem solving and critical thinking skills but I am not sure if they were fully tested in the GAMSAT. Is the GAMSAT in your view a useful appraisal tool for entry into graduate entry medicine (GEM)? I think the science part of the GAMSAT probably helps people who haven’t done science before learn some basics before they start the GEM course. As for the comprehension and essay sections, I guess they test your level and understanding of English but I am not sure what else.
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Do you believe that you will be ready to practice at the end of your course and if not, why? I think we will be well prepared to be doctors. In terms of practical and clinical experience, GEM students get the same amount of exposure as the undergraduates. Our added “life experience” can help with the understanding of social and communication issues but may also make us more cautious doctors, which is not necessarily a bad thing. What sort of reactions towards your graduate medicine degree have you had? From undergraduate students the reaction was really good. They were very curious when we all merged together and seemed glad to have someone with questions they can ask. Both junior and senior health care staff seemed curious about GEM and what we did before. I haven’t really come across any of the stereotyped old consultants who think that graduate students don’t do enough Anatomy.
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Graduate Entry Medicine
Amit Verma*, Ajai Verma Year 3 Medicine, Monash University, Australia amit_verma5@hotmail.com Admission into medicine is traditionally a highly competitive challenge. The ferocious struggle to gain entry has intensified in recent times as institutions seek candidates who are well-rounded and compassionate as well as academically gifted. Such a shift in thinking has meant that many traditionally qualified candidates have missed out, as medical schools seek to test candidates’ abilities through entrance examinations such as the Graduate Australian Medical Admissions Test (GAMSAT) and the Undergraduate Medicine and Health Sciences Admission Test (UMAT). As graduate entry into United Kingdom (UK) medical programs in particular increases1, there has been a similar trend towards supporting these models as a method of establishing the worthiness of candidates. It is paramount that the value of these models in producing multifaceted and balanced doctors is examined, before such a practice is firmly established in the United Kingdom. Since 1997, the intake onto medicine degree courses has increased by more than 60 per cent in the UK.2 This growth is particularly in evidence when looking at the rise in numbers of graduate entry places. This fact alone offers reason to scrutinize the effectiveness of the GAMSAT process in delivering the best potential doctors to medical schools. The GAMSAT is an exhaustive examination designed to test candidates’ problem solving and critical reasoning in the physical and social sciences, as well as written communication.3 While in theory this test is designed to distinguish deserving candidates, there is a stream of evidence, such as a study by Groves et al that suggests that performance in the GAMSAT is not significantly indicative of performance later in medical school.4 This finding is endorsed by a similar study in the United States by Mitchell et al which found that the Medical College Admission Test (MCAT) predictive scores were only slightly higher in Medical School than high school.5 When considering this evidence, however, it must be kept in mind that the study by Groves et al only takes into account candidates who achieved above the required GAMSAT score threshold, so that this data may not be completely indicative of the general population. Studies relevant to the United Kingdom have gone as far as to show that measures of knowledge, such as A-levels, are in fact more predictive of performance than tests of reasoning aptitude.6 However, this may be due to an under-exploration of the personal and emotive factors needed of doctors combining with this finding.7 Such findings reflect the tendency for tests such as the GAMSAT to potentially discriminate against undergraduate candidates, and restrict the talent pool of potential future doctors.1 The recent proposal of a lower age restriction1 upon entry into UK medicine has been rejected as unrealistic due to workforce demands and the pressures of staff turnover. Ironically, this rejection of such a limitation may, in fact, serve to decrease the skill set of
prospective doctors. Evidence showing more mature-aged candidates with prior degrees and a diverse range of life experiences are more suitable for entry juxtaposed against recent school-leavers1, underscores the usefulness of the GAMSAT in this regard. In addition, post-graduate entrants have been shown to demonstrate a high level of inquisitiveness and more emotional maturity than their less experienced counterparts.1 A recent study has also shown that students from non-biological science backgrounds are not at any grave disadvantage to their colleagues and are just as likely to succeed in their graduate medicine programme.4 In fact, it is of note that several clinicians have found teaching and interacting with junior doctors who may be several years older than themselves a daunting experience.8 Despite this possible drawback, the GAMSAT has drawn praise from several sources in its ability to discriminate between candidates, though the level and scope of this differentiation between different regions is unclear.1 The intake of medical students continues to rise throughout the UK and around the world – over seven undergraduate and postgraduate medical programmes have been established in Australia over the past nine years. Before that, no new programmes had been created since the 1970s.9 Such an increase in the number of graduate programmes means the need for entrance examinations which can accurately determine a candidate’s ability in a wide range of reasoning, interpretive and interpersonal domains must be continually reassessed rather than accepting current practices which may not necessarily identify the best candidates. Overall, when seeking validation for the introduction of the GAMSAT based on Australian findings, it is important that selectors keep in mind that the program is still in its infancy overseas9, and that evaluation over a longer period of time will yield more significant and useful results. References 1.
2. 3.
4. 5. 6.
7.
8. 9.
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Rushforth, B. Life in the fast lane: graduate entry to medicine. BMJ, 16 Oct 2004. http://careers.bmj. com/careers/advice/view-article.html?id=479 Bligh J. More medical students, more stress in the medical education system. Med Educ 2004;38: 460-462. Kulatunga-Moruzi C, Norman G. Validity of admissions measures in predicting performance outcomes: the contribution of cognitive and non-cognitive dimensions. Teach Learn Med 2002; 14: 34-42 Groves M., Gordon J, Ryan, G. Entry tests for graduate medical programs: is it time to re-think? MJA 2007; 186 (3): 120-123 Mitchell K, Haynes R, Koenig J. Assessing the validity of the updated Medical College Admission Test. Acad Med 1994; 69: 394-401 McManus IC, Powis DA, Wakeford R, et al. Intellectual aptitude tests and A levels for selecting UK school leaver entrants for medical school. BMJ 2005; 331: 555-559. Lievens F, Coetsier P. Situational tests in student selection: an examination of predictive validity, adverse impact and construct validity. Int J Selection Assess 2002; 10: 245-257. McCrorie P. Graduate students are more challenging, demanding, and questioning. BMJ 2002;325: 676. Lawson K., Chew M., Van Der Weyden M. The new Australian medical schools: daring to be different. MJA 2004; 181 (11/12): 662-666
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European Working Time Directive Jennifer Turner
Year 4 Medicine, St. George’s University, London m0400240@sgul.ac.uk doi:10.4201.lsjm/car.002
This summer, the NHS is slated to achieve full compliance with European legislation, limiting working time to 48 hours week. The Department for Health is currently considering appeals for the special dispensation of 52 hours to “local services where there remain special difficulties”. Even allowing for such concessions, trainee healthcare professionals are likely to be effected by these new regulations. A recent national news story about the European Working Time Directive (EWTD) and how it may affect the training of junior doctors quoted a trainee orthopaedic surgeon. Speaking anonymously for fear of jeopardising his career, he said did not feel experienced enough in the surgery he will soon be expected to perform solo, as a result of the reduced number of hours he can work under the new legislation. While his blacked out face and actor-disguised voice smacked of sensationalism, his concerns about the impact on professional training and patient safety are shared by many. The issue of working hours and the potential impact on trainee doctors is by no means new. In 1998, Britain finally signed up to the European legislation after much resistance from the previous government throughout the 1990s. Management of the Health Service is becoming increasingly centralised. The European Working Time Directive is set to protect all workers within the European Union from being compelled to work too many hours, and aims to guarantee the amount of rest they get and minimum annual leave requirements. Proponents of the new legislation claim that the new rules will benefit business as well as the individual - as the workforce become increasingly tired, productivity falls. The magic number of 48 hours was determined to be the perfect balance between quantity and quality of work and a contented workforce. Despite the theory, the directive has remained a hotly debated topic, and the implications of this new piece of legislation have already been far reaching. Since signing up to the agreement, all UK employees cannot be compelled to work more than 48 hours a week. Following Government negotiations, which led to a 12 year preparation period, a few exceptions were made. For the moment, doctors and doctors-in-training were permitted to be contracted for longer hours. However, since the legislation was agreed, the NHS is slowly being brought into line. Since 2003, the maximum contract for a trainee became 56 hours. As of this August, the training week
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will be further reduced to 48 hours. But at what cost? Has the Government used their 12 years of easing in time well enough to prepare hospitals for such drastic changes? Most importantly, will the changes ultimately be of benefit to healthcare professionals and those who use healthcare services? As always, arguments have been put forward on both sides of the fence. Stories of junior doctors working for more than 100 hours a week have passed into professional folklore, and even with the aid of rose-tinted glasses, it is unlikely that anyone will claim the old system as perfect. In fact, working conditions for juniors often became so extreme some gave up on their career. Family life became a distant memory, as work began to consume their every being. Working upwards of 80 hours a week led to an overtired population of juniors, who were undoubtedly making mistakes simply through lack of sleep. Nonetheless, many hospitals relied on the huge number of hours put in by the junior doctors to get through the inevitable workload. Some members of the profession consider these unearthly first few years a rite of passage to be endured, however others, often most vehemently, would disagree. It used to be such that time spent on-call was not included as work if you were not actively seeing patients, however any amount of time you are on these duties under new legislation all counts towards the 48 hour limit. This means that for many, there will be lost opportunities to undertake activities such as audits, clinical based education and taught courses with proportionally more time dedicated to non-training duties. It is clear, therefore, that in the same length of time, doctors employed under these new rules will not have had the training that their senior colleagues have benefited from. Many juniors have reported having to undertake training in their free time in order to achieve even the basic competencies expected of them. This is something that has been a particular issue for surgical trainees. Anecdotally, I’m sure many trainees are consistently working over their 48 hour requirements. Reduced hours do not mean fewer patients, and surely cannot mean a reduced level of care? One foundation doctor said “any doctor worth his salt will not leave work as the clock strikes five if there are still patients to attend to”. It’s an attitude commonly echoed, and one instilled from student level onwards. However, overtime that was previously was paid for will no longer being thanks to the curtailment of the working week. A BMA postal survey of showed that 50% of respondents have felt pressure to work beyond their contracted
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INTERVIEW
hours without recompense. Over half of them felt that the reduced hours would be a good thing for both their health and social life. However 64 per cent agreed it would a negative effect on training. Many of those surveyed also believed that trainees should be able to opt out of the directive, that long hours can sometimes be dangerous for patients under their care and that the overall duration of training should be increased to ensure competence before qualification. This clearly means ever-increasing postgraduate training time, but is something that the UK needs to prepare for if we want our doctors to be of the highest standard. How this legislation will affect patient care remains to be seen. More alert, happier doctors can only be a good thing. However, potentially more protected teaching time and increasingly restricted hours will mean fewer doctors in the hospital at any one time. NHS reforms attempting to mitigate this, such as the introduction of nurse practitioners, remain too recent for evaluation. An opt-out scheme seems viable, but would some trainees feel pressured by their employer, or their training demands to do so? Would such an option risk undermining the spirit of protection with which the legislation was adopted in the first place? With the NHS aiming to be fully compliant in less than three months, one thing is clear. Whatever the advantages and disadvantages of the legislation, the directive is here to for the foreseeable future. Changes to postgraduate training are needed fast in order to ensure both short and long-term patient care is not compromised.
Nicolas Smoll, BA, MSc Year 2 Medicine Gippsland Medical School, Monash University Australia What preparation did you undertake for the GAMSAT? I completed the Des O’Neill training course, which is a series of workshops and booklets that you can do at home. This course helped a lot and it was extremely useful in the exam. To what extent did you find your undergraduate background useful in the GAMSAT? My background is in physiology, pathology, chiropractic clinical skills and 2 years of radiology. I found this virtually useless for the GAMSAT. Did you feel that your prior academic learning and life experience was helpful in the problem solving, critical thinking and writing skills that the GAMSAT is supposed to test? Not really because the focus of my last course was on research and clinical reasoning. I didn’t find that the exam tested it too well which was surprising since research requires good writing skills. If I were to take a course specifically to prepare for the GAMSAT I would have majored in Organic Chemistry and English Literature. Is the GAMSAT un your view a useful appraisal tool for entry into graduate medicine? I think perhaps, but only because it is a hurdle. Describe two positive experiences of your course. As a whole, the course was well organized. The resources available are extensive. Describe 2 negative experiences of your course. Unlike the rest of the course, the problem based learning groups lacked organization. Do you believe that you will be ready to practice at the end of your course and if not, why? I am sure I will be fine. What sort of reactions towards your graduate medicine degree have you had? The undergraduate students were sometimes apprehensive about having post-graduate students on their course and the senior health care staff were always interested in our backgrounds.
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PERSECTIVE
The Blame Game Nick Lelos Year 4 Medicine (GEP), St. George’s University of London Litigation culture is on the rise, with record payouts and higher profile cases hitting the headlines. What can you do to minimise the risk of it happening to you? In the past decade, healthcare practitioners and doctors in particular have seen the rise of a new phenomenon: the tendency of patients to litigate. The targets of litigation tend to be the providers of healthcare, about perceived damage caused to patients following the intervention they had, or indeed had not, received. Litigation in all employment areas particularly healthcare seems to be rapidly on the rise in the UK,1 though it has not quite reached the status quo of the US.2 There are several reasons for this increase. One reason is because the mystique and glamour of the doctor that older patient generations may have been enthralled by has been worn down substantially through the media. A blame culture is also becoming more prominent, where unmet expectations can be expected to lead to formal complaints. The younger generations have also been raised in a culture where the customer is always right, and healthcare is perceived as a right, extrapolated from the Human Rights Act 1998. The increased emphasis on a patient-centred approach is another factor not to discount. Media effects have been wide-ranging, such as the popularisation of medical jargon and knowledge through television series, by the loss of respect and public trust through scandals in the press and by the well publicised, high damages awarded to successful litigants as seen by the tripling of money awarded to litigants for obstetric cases between 1996 to 2001 to £1.6 billion, or money awarded even forty years after the incident itself, such as in Norfolk with Mr O’Brien.4 An important difference is the technological aptitude of the public. The younger population of patients is more ‘claim conscious’, and also more knowledgeable in how to access information from the internet.2, 3 Perhaps the reason for the rise of litigation against doctors is simply that medicine has become a victim of its own success. Many patients’ now have unrealistic expectations of the power of medicine. As well as this, the number of investigations and tests that can be offered to patients renders the detection of abnormalities almost unavoidable. 5 The end result is that the more expert doctors are, the more likely they are to be sued if something is not detected, when considered in retrospect. An area rich with such examples is the field of antenatal testing which, by improving drastically over the years, has seen a drastic rise in litigations.2 It is almost inevitable to detect abnormalities, and there are also false negatives or false positives possible with every test to consider. With hindsight, the patient can to question the care they received, and if they feel so inclined, sue. While such lawsuits are not yet as successful in the UK as in
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the USA, their numbers are increasing, with certain specifics specialities standing out as prime targets: General Practice, Obstetrics & Gynaecology, and Paediatrics.3 The key to all such litigation claims relies on the medico-legal concept of negligence. In order to prove that a doctor has been negligent, the plaintiff has to establish that there was a duty of care owed to them, which was breached by not achieving the standard of care required, which then led to the damage brought forward by the complaint.5 This is proving particularly harrowing for junior doctors, who may be unsure or not as confident as an understandably worried or anxious patient would like them to be. This in turn may lead to perceived lack of quality in the care they receive. This all begs the question – what can be done to protect oneself as a medical student or junior doctor? Perhaps defensive medicine is the answer. Carrying out medical practices in order to avoid a law suit, as opposed to acting in the patients’ best interest, can have serious consequences. Patients can face unnecessary tests and procedures, at considerable financial cost to the healthcare system, and at increased risk of harm to the patient. Alternatively, difficult or high risk patients may be avoided by nervous physicians. Superfluous radiography, lumbar punctures or unnecessary operations are among the procedures more commonly overordered.2 The irony is that the development of this type of practice, primarily to protect oneself, can be construed as negligence in itself.3 To recognise this fact, and the effect of law suits on doctors’ morale as well as their medical practices is vital, as the fear of litigation can lead to discontent and quitting the profession. 1 If defensive medicine is not the answer, the question remains – what can be done? The answer is simple enough, though trite: candour and communication. Act in the best interests of the patient at all times, use your clinical judgement and if uncertain, always consult colleagues and seniors.6 The current healthcare system in the UK distributes responsibility equally and jointly within healthcare teams. Mistakes are easily made as they are part of human nature and the learning process of medicine. Of course, the stakes are high when considering an individual’s health, but when mistakes are admitted and apologies freely offered, a great deal of anger and a betrayal of trust can be avoided. References: 1.
2. 3. 4. 5.
Mulcahy, L. 2003, Disputing doctors: the socio-legal dynamics of complaints about medical care, MaidenheadPhiladelphia, Open University Press. Pp. 30-149. Jauhar, S. 2008. “Eyes Bloodshot, Doctors Vent Their Discontent.” July 18 2008 THE NEW YORK TIMES Harpwood, V. 2007 Medicine, Malpractice and Misapprehensions, New York: Routledge-Cavendish. Sources: http://news.bbc.co.uk/1/hi/england/norfolk/3216151. stm, http://news.bbc.co.uk/1/hi/health/7033658.stm Harpwood, V. 2001 Negligence in Healthcare: clinical claims and risk, London, InformaUK Limited, pp. 5-64. Capsticks, J.B. 2004 Making amends—the future for clinical negligence litigation, BMJ 328:457-459 (21 February), doi:10.1136/bmj.328.7437.457
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PROFESSIONAL BRIEFING
Professor Nigel Leigh, BSc, PhD, FRCP (UK), FMedSci Professor of Clinical Neurology; Director, King’s MND Care and Research Centre; Co-Director, MRC Centre for Neurodegeneration Research, King’s College London As an undergraduate, getting your head around neurology is no mean feat. As well as a detailed anatomical knowledge of that most complex of organs – the brain – as well as the whole network of nerves and synapses leading to and from it, a proper understanding of this system also requires a certain talent for logic, deduction and detective work. Is it a fascinating discipline, with many research opportunities and diagnoses to determine, or is it more often a case that’s too hard to crack? For award-winning consultant neurologist Professor Nigel Leigh, who has spent a lifetime trying to unravel the mysteries of Motor Neuron Disease, it is clearly the former. And he has some advice for students who suffer from a little documented, but well-known condition that he terms “neurophobia”. “There is a core and basic set of skills to learn in Neurology”, He says, rather reassuringly. “Once you have that, and you have disposed of your fear, you have the makings of a very interesting subject.” Professor Leigh is a world renowned specialist in motor neurone diseases (MND), a group of disorders in which motor neurones – which control muscle activity such as movement, walking, speaking, swallowing and breathing – are progressively destroyed. These disorders have held his interest for more than a quarter of a century. But what inspired him to pursue neurology in the first place? “The brain is the most interesting organ in the body”, He said. “Neurology includes the mind and the whole gamut of nervous system disorders, and all aspects are fascinating.” The Professor’s curiosity began at an early age, and he comes from a dynasty of neurology giants. The eponymous Leigh’s Disease – a rare neurometabolic disorder – was discovered by his father, who was also a neurologist. “When I was growing up we had books, phrenological heads and skeletons around the house and so I developed a young and unhealthy interest in the human brain”, he said with a twinkle in his eye. In 1986, Professor Leigh became particularly interested in MND. He said that there was “pitifully little” in terms of treatment available before the 1990s. “In hospital a diagnosis would be made and then there would be a big black hole. The patient would just be handed back to their GP”, he said. When a colleague voiced the same concern to him over coffee, he decided that there was a need for change in the way that MND patients were treated. Alongside an already burgeoning clinical practice, a research career was born. When it comes to research, the Professor admits to thinking “big and ambitiously”. Today, as well as being Professor of Clinical Neurology at King’s College Hospital, he is also Director of the King’s MND Care and Research Centre and until recently Deputy-Director, MRC Centre for Neurodegeneration Research, also at King’s. Together with his teams, he continues to explore MND at a clinical and molecular level. “Developing an understanding the neurofilaments and structural proteins of the nervous system is a step towards to finding different treatments – and perhaps one day a cure – for MND,” He said optimistically, before being careful to qualify his statement. “We are nearer to finding a cure, if you can believe any cure is possible, but we are still not close.”
He spoke passionately of his research. The latest includes a large randomized controlled trial for Parkinson Plus Syndrome and Riluzole treatment he carried out, which was published in the journal Brain last January.1 He said: ”It was a big trial, which involved follow up of blood, DNA sampling and collecting and analysing over 100 brains.” The trial took place in France, Germany and the UK. Leigh is also preparing a large scale drug trial looking at the effects of lithium treatment on the progression of the disease. With so many irons in the fire, he admits that balancing the demands of home and the office is sometimes tricky. “It’s a difficult one,” He said, sounding momentarily troubled, but any doubt was swiftly swept away by an enthusiasm and energy for his patients, which is easily evidenced. A lot has changed since he began his career. Professor Leigh talks of a revolutionary change in the attitude towards neurology as a whole. While there remain few cures for many of the neurological conditions suffered by patients, greater emphasis is now placed on appropriate patient care. He believes that this can make a real difference to the quality of people’s lives. “Palliative care and multidisciplinary teamwork is highly valued within neurology today. Not only is a team essential for good patient care, but as a consultant you have to have a good team to support you in the work you do.” In determining the appropriate course of care for often terminally ill patients, he often finds himself having to make difficult decisions. He gives an example of the constant round of choices which dramatically influence a patient’s quality of life. “To give you an example, most weeks we’ll have to weigh up the pros and cons of using a PEG (percutaneous endoscopic gastrostomy) compared with a non-invasive technique.” The PEG enables patients to have a fluid diet through a tube that is placed directly into the stomach via the abdominal wall. It prevents anxiety and difficulties the patient may have with swallowing food and it also reduces the risk of aspirating food into the lungs. However, Professor Leigh points out: “Just because there is a gizmo or technique available, it is not always the best decision to go ahead and use it. To have the PEG can be painful and when a patient has 3 months to live it might be better that one is not inserted.” He added, “Palliative care is all about death with dignity”. He explains that although patient autonomy is an ideal concept, it is not always as simple as asking the patient what they want. Often the patient will not want to think about the situation or be the one to make the final decision. He added, “The patient and family will always be given a proper consultation but often the decision is pushed back on to you. You cannot run away from those decisions.” Despite the difficult decisions, he remains positive about his patients, and finds that his patients remain optimistic also. “Working with MND you do get terribly tragic situations, but by and large patients are very positive, courageous and grateful. “I can never remember a time when I didn’t want to do neurology.” Laura James Year 3 Medicine, King’s College London Currently intercalating in medical journalism References 1.
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http://brain.oxfordjournals.org/cgi/content/full/132/1/156
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PERSECTIVE
UK Foundation Programme Anna Mead-Robson Year 4 Medicine, St George’s University of London m0502048@sgul.ac.uk
“ This summer will see the UK Foundation Programme enter its fourth year; having negotiated an updated online application system, over 7,000 medical students have now been allocated to F1 programmes around the country. In previous years, criticism of the allocation system has arisen from both technological difficulties and controversy around the suitability of ranking candidates ‘by computer.’1 However, while some students this year may naturally have been disappointed by the outcome of their application, the process seems to have run more smoothly and to have attracted fewer objections than in the past. As in previous years, a candidate’s score and subsequent placement depends on several factors: their academic ranking whilst at medical school, other academic achievements - such as additional degrees, national awards and publications - and their answers to a series of questions that aim to assess the personal attributes necessary to become a foundation medic, as laid out by the GMC’s Tomorrow’s Doctors.2 Such attributes include good communication skills, the ability to prioritise and work effectively as part of a team, the ability to cope under pressure and, above all else, the recognition of the importance of patient-centred care. This year, changes made to the online form meant that, for the first time, candidates were able to link their application with someone else’s – such as a partner or close friend – although this option is not without pitfalls: the foundation school to which any pair are allocated is dictated by the lower-scoring candidate, and while a couple may be placed within the same deanery this does not guarantee they will be working within the same hospital. Nevertheless, the introduction of linking is likely to remain popular, especially with students in long term relationships. In addition, the weighting given to academic achievements was once again altered this year. While candidates are still divided into
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For me, medicine is a vocation ... deep down, it doesn’t really matter where I end up
”
quartiles by their medical school on the basis of exam results, their academic ranking provided a maximum of 40 points, as opposed to 45 points last year.3 The gap between higher and lower scoring medical students was also narrowed – meaning that those in the bottom quartile scored just 6 points less than those in the top. While there is still some debate around how much weight exam results should carry, especially given the lack of a national qualifying exam for all medical students4, most students seem to feel that the current balance is acceptable. ‘Technically everyone who graduates is safe to practise, no matter what their academic ranking at medical school’ said one final year student at St George’s, University of London. ‘I can see it irritating some people that you can do well academically and still get a low score, but it wouldn’t be fair to allocate people on the basis of their exam results alone. Your priority in medical school should be becoming a safe clinician – not one who excels in written exams.’ Although this year’s statistics are not yet available, in the past two years over 90% of candidates were allocated to their first choice foundation school. However, some may end up many miles from where they had hoped to work. Allocations are made on the basis of preference rather than score5; if an applicant does not gain a place in their first choice foundation school, regardless of their score they will be allocated to the next school on their list that has remaining places available – which for some candidates may turn out to be one of their last choices. The Foundation Programme website provides data from the last two years which give a rough idea of which foundation schools are the most competitive – although candidates are reminded that these figures fluctuate each year, and it is impossible to predict which schools will be oversubscribed, although traditionally the London deaneries have always been the hardest to get into.
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PERSPECTIVE Source: Wellcome Images
In the past, the overall number of posts available in the UK has exceeded the number of candidates, and in an attempt to correct this and to divert candidates to some of the less popular foundation schools, an announcement was made after this year’s application deadline that 120 posts would be scrapped across the country – including a loss of 24 posts in London. This sparked some outrage and was criticised by the BMA medical students committee, and it is likely that as a result a greater percentage of students will not be allocated to their first choice school.6 However, candidates should be reassured that there will still be enough posts to achieve a 100% employment rate, despite a recent surge in foreign applications. Nevertheless, following this year’s application round many students remain positive. ‘For me, medicine is a vocation,’ explained a final year student at St. George’s, ‘deep down, it doesn’t really matter where I end up, especially at this stage when I do not know what I want to specialise in,’ while another St. George’s fifth year medic pointed out, ‘In medicine we are very sheltered – in this current economic climate we are all lucky to have jobs – wherever they may be’. References: 1. 2. 3. 4. 5. 6.
Hawkes, N. 2006 ‘Pick a doctor by computer ‘fiasco’’ The Times, March 4th Tomorrow’s Doctors. 2003, available at: http://www.gmc-uk.org Kelley, T. and Finnigan, E. 2008 ‘Foundation Programme 2009’ sBMJ; 16:398-399 Kelly, C. and Burke, K. 2008 ‘Should UK medical students sit a national qualifying exam?’ sBMJ; 16:184 FP 2009: Foundation Applicant’s Handbook. 13th October 2008, available at: http://www.foundationprogramme.nhs.uk Lelos N. 2008 ‘120 Posts Axed’ Medical Student Newspaper, December
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Box 1: 2008: foundation school rankings Most oversubscribed... 1. North West Thames 2. South Thames 3. North Central Thames Most under subscribed... 1. North Yorkshire and East Coast 2. Northern 3. East Anglia
Box2: Foundation Programme applications – Top Tips 1. Refer to the Foundation Applicant’s handbook for advice – it becomes available online each October. Visit http://www. foundationprogramme.nhs.uk/pages/home/key-documents for more details. 2. Most universities will offer some sort of support in the form of lectures or one-to-one guidance – ask for help if you need to. 3. Make sure that you read each question very carefully. Be prepared to spend time forming considered and relevant answers – it may take several hours before you are satisfied with your response to a question. 4. Get a friend or tutor to proof-read your answers – poor spelling or grammar can result in a poorer score. 5. Remember to save your answers as you work your way through the form. 6. Don’t leave applying to the last minute!
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