Medical Woman – Vol 39, Issue 2, Autumn/Winter 2020

W EDICAL W MAN

VOLUME 39: ISSUE 2

AUTUMN/WINTER 2020

The Viral Issue www.medicalwomensfederation.org.uk

Editor’s Letter The last six months have posed different people, different challenges.

I

remember earlier this year having a catch-up conversation with a friend, reminiscing about some of our past experiences.

We were rooted in routine, planning out our next steps, blinkered to the possibility of mass scale change to come.

The pandemic has had a massive impact individually, nationally and internationally. Often, it seems, these tragedies play out on someone else’s turf, far away, and in our detached awareness we carry on with life as we know it.

There have been many lessons; for me the time has been a catalyst - a time to take stock and consider future directions.

There is change to come in Medical Woman magazine too. I am very much looking forward to continuing as editor-in-chief, and the magazine will continue to uphold principles of inclusivity and support. Moving forward, we also hope to introduce new ideas, involve new perspectives, and ensure the magazine is a sustainable publication.

I hope in the coming months you look forward to receiving our fully digital issues and will welcome an expansion in the editorial team.

In this issue, check out Clarissa Fabre’s inspiring article on her experiences with UN Women. Our central feature is COVID-19 focused, with members commenting on their experiences of working in the National Health Service during the pandemic.

Most recently, October was ‘Speak Up’ month and our article on whistle-blowing certainly makes an informative read. As always, I believe in a healthy dose of personal alongside the professional - and to unwind find a range of articles showcasing creative talent - whether exploring creative writing or our informative book review on the role of medical women at a time of war.

I hope you enjoy our final print issue, and it was a pleasure to see you all at our Winter conference.

Fizzah Ali @DrFizzah Fizzahali.editoratmwf@gmail.com

Contents Medical Woman, membership magazine of the Medical Women’s Federation Editor-in-Chief: Dr Fizzah Ali fizzahali.editoratmwf@gmail.com Editorial Assistants: Miss Katie Aldridge Miss Danielle Nwadinobi Design & Production: Toni Barrington The Magazine Production Company www.magazineproduction.com Cover illustration: Pexels Articles published in Medical Woman reflect the opinions of the authors and not necessarily those represented by the Medical Women’s Federation.

Medical Women’s Federation Tavistock House North, Tavistock Square, London WC1H 9HX Tel: 020 7387 7765 E-mail: admin@medicalwomensfederation.org.uk www.medicalwomensfederation.org.uk @medicalwomenuk www.facebook.com/MedWomen Registered charity: 261820

News and Events

2

Skills Toolkit: Making the most of training

6

Career Planning: General Practice

8

The colour of coronavirus

9

Perspectives: Redeployment and new roles

14

Centrefold: Presidential piece

18

Spotlight: Moving Medicine

20

Vice-President: Professor Chloe Orkin

9

22 Strike a chord: Helping doctors and students

22

Strike a chord: Whistle-blowing

24

Unwind: Creative writing

28

COVID-19 heroines

31

Book review

32

Patron: HRH The Duchess of Gloucester GCVO President: Professor Neena Modi

2

28

Honorary Secretary: Dr Anthea Mowat Honorary Treasurer: Dr Heidi Mounsey

30

Medical Woman: © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the prior written consent of the Publisher. A reprint service is available. Great care is taken to ensure accuracy in the preparation of this publication, but Medical Woman cannot be held responsible for its content. The views expressed are those of the contributors and not necessarily those of the Publisher.

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MWF NEWS & EVENTS

Medical Women’s International Association update Amanda Owen

Dr Amada Owen with Dr Christiane Pouliart at the 30th celebratory reception in Antwerp

Grand Place Brussels, Dr Amanda Owen with Dr Christiane Pouliart, with French and German delegates

Auditorium view of Gloria Steinem speech Belgian Congress

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The Medical Womens International Association is now 101 years old. Our new President is Dr Eleanor Nwadinobi from Nigeria, pictured here with MWF delegates at the centennial celebration in New York, July 2019. Dr Helen Goodyear, UK, is Treasurer and as chair of the Centennial Publications subcommittee she enabled the production of a splendid commemorative book.

Gloria Steinem was our keynote speaker in New York, still sparkling and quoting six life lessons, including dance until the break of dawn. She is pictured with Dr Shelley Ross who has been succeeded as Secretary General

by Professor Padmini Murthy, Global Health Director New York Medical College, who is active within the United Nations Association.

Dr Sonia Adesara, Co-chair Young MWIA, has been proactive during the pandemic championing the NHS both nationally and internationally.

The resolution that all women are entitled to 6 months paid maternity leave has been thoughtfully addressed by Professor Neena Modi, our new MWF President. She has written to the MWIA executive committee advocating that every parent, irrespective of gender, has a fair and equal right to spend the first year of their child’s life with that child, also protecting the rights of the child. This is generating constructive debate.

I attended the Belgian Women’s Congress in November 2019, a celebration of their 30th anniversary in Antwerp and their conference on the ‘Gender Pathology of Disease’ held in the Belgian Parliament in Brussels.

Topics included: Consciousness in all its states: are there gender differences?; Gender gap in depression: nature, nurture and science; The infertile dyad - differences in emotional and sexual experiences; Gender differences in Alzheimer disease and gender sensitive nursing care.

Dr Christiane Pouliart, a co-organiser, played host to members from France and Germany and treated us to a tour of the Grand Place. It was mutually rewarding to meet these colleagues as well as the Belgian contingent.

The North East European meeting scheduled in Finland has been postponed until May next year.

MWIA members remain active during this unprecedented time, maintaining its links with the following International organisations: United Nations – economic and social council; World Health Organisation; Council for International Organisation of Medical Sciences; European Women’s Lobby; World Medical Association; United Nations Children’s Fund; Committee on the Safety of Women; and Conference of Non-governmental organisation in consultative status with the United Nations Economic and Social Council.

The next triennial International congress is scheduled to take place in Taipei, Taiwan in 2022.

The MWIA theme for 2019-2022 is: Young Women Young Doctors – our inspiration our future.

MWF NEWS AND EVENTS

Newcastle University group report President’s perspective Adaeze Chikwe Adaeze Chikwe is a third-year medical student at Newcastle Medical School. She is the current president of the Newcastle Student Branch of MWF and is passionate about promoting diversity and inclusion in the medical school curriculum and beyond.

The Medical Women’s Federation (MWF) is the largest UK body of female doctors and medical students. The organisation was founded in 1917 and, to begin with, the Federation launched campaigns promoting women in the armed forces, focusing on venereal disease, prostitution, as well as maternity and infant welfare.

The MWF is an organisation dedicated to prioritising the well-being of those who identify as women and has done so for over a century.

This is why I am proud to have been elected as the president of the Newcastle Medical Student branch of MWF for 2020 to 2021.

As president this year, I want the focus to be around intersectionality.

Centring attention around the experiences of medics with many diverse identities.

As a woman of colour myself, I have often failed to see myself represented in medicine and healthcare. I want to use this platform to demonstrate to other people of colour that we can fulfil our ambitions despite the box that society wants to squeeze us into.

We have already had our first talk of the year from a medical woman of colour. By bringing in powerful women of colour, women with

disabilities, LGBTQ+ individuals and others to do talks we can inspire students who identify as such. We can give those that are used to seeing the stereotypical doctor the opportunity to see themselves as equally as powerful.

This is my first time being a president of a society so, to begin with, I was very anxious with the size of the responsibility! However, a few of my nearest and dearest have reminded me that being a president isn’t all about having to carry the burden of all the responsibilities on your own shoulders. When we are lucky enough to have a helpful and capable committee (which I am!), tasks can be shared between everyone. In fact, the different ideas and perspectives allows your society to thrive even more.

As the past few months have shown, this is a time when those that have been consistently oppressed by society are rising up and growing into their power. I am so thankful to have the opportunity to be in such a position at a time when people are so receptive to change and hearing from the often less-heard perspectives.

Hopefully, this will be an inspiring and productive year for all!

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NEWS AND EVENTS

UN Women: making a difference This year is the 75th anniversary of the United Nations (UN), the 10th anniversary of UN Women and the 25th anniversary of the Beijing Declaration and Platform for Action, a landmark occasion for women and girls around the world. Clarissa Fabre, a past Medical Women’s Federation (MWF) and Medical Women’s International Association (MWIA) president, and MWIA representative to the World Health Organisation (WHO) from 2012 to 2019, has contributed to a UN Women @ 10 online book chapter on how UN Women has made a difference to our lives.

UN Women has had a major impact on the direction and purpose of my professional life. As the Medical Women’s International Association (MWIA) representative to the World Health Organisation (WHO) from 2012 to 2019, I have learnt first-hand from UN Women the enormous problems women and girls face around the world, and which areas to prioritise to bring about meaningful progress.

UN Women plays a crucial role as an international forum to highlight and discuss issues of vital importance to women and girls, and most importantly, to organise and coordinate solutions. Without UN Women, the world would be a poorer place.

I have been inspired by listening to winners of the Women of Distinction Award, women government leader’s past and present, and meeting with committed groups of women from all over the world. Highlights have included an address by Hilary Clinton reminding us that there has been progress but much remains to be done - more than 30 million girls never attend secondary school, gender-based sex selection is a reality, especially in China and India, and more than half the nations in the world have no laws to prevent violence against women. Even where there are laws, they are not always enforced.

Ruchira Gupta, a former journalist and founder of an anti-sex trafficking organisation in India said ‘We need to address the needs and concerns of the ‘last girl’ - she is 13 years old, poor, works in a brothel, is raped by 8-10 customers every night, does not have a phone to ring a helpline, has no education......’.

Bandana Rana from Nepal, founder of Saathi, the national network against domestic violence, and chair of a worldwide network of women’s shelters, told us that she had to carry out her interviews with women working in the fields at 5am, so that they could talk freely. A 22-year-old Afghan winner of the Woman of Distinction Award, who has promoted education and leadership training for the girls of Afghanistan was memorable, as was a meeting with Huru International, a non-governmental organisation (NGO) which developed and distributes reusable sanitary pads to young girls in low- and middle-income countries, to keep them in education.

The UN campaign ‘He-for-She’ and the Harry Potter actress, Emma Watson’s speech to the UN in 2014 were a landmark. UN Women recognise the importance of fully engaging men and boys for the achievement of gender equality and the empowerment of all women and girls. Justin Trudeau, the Canadian Prime Minister said ‘I am going to keep saying loud and clear that I am a feminist

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Huru International members with reusable sanitary pad

until it is met with a shrug....calling myself a feminist simply means that I believe in the equality of men and women.’ Antonio Guterres, UN Secretary General, a true believer in parity for women, told us that he is determined to achieve equal representation for women on all senior committees in the UN. We need men as our allies, but we as women must remain the principal spokespeople to advance our cause.

There is still so much to do.

One of the Millenium Development Goals was to reduce maternal mortality by 75% between 1990 and 2015. Ten countries including Cambodia, Belarus, Lebanon and Rwanda managed to reach the target. Two in three maternal deaths occur in Sub-Saharan Africa.

Visiting a health clinic in one of the poorer areas of Nairobi, I could see that reducing maternal mortality will be difficult to achieve.

Deliveries are done in these clinics by physician’s assistants in very basic conditions, with poor roads, no ambulances, and long distances to well-equipped hospitals should anything go wrong.

There is talk of training physician’s assistants to do Caesarian sections, an approach which is far from ideal. On the other hand,

NEWS AND EVENTS

“We need men as our allies, but we as women must remain the principal spokespeople to advance our cause.�

Dr Fabre with health workers outside clinic in Kenya

preventing and treating post-partum haemorrhage is an achievable goal. At present in many areas there is a shortage of blood, and a shortage or total absence of drugs such as Oxytocin, heat-resistant Carbetocin and Tranexamic Acid which are highly effective in preventing and treating post-partum haemorrhage. These are hurdles which are possible to overcome.

Much has been achieved to reduce cervical cancer. A vital step in prevention is HPV vaccination worldwide. MWIA, with its worldwide networks, is helping with awareness campaigns to provide parents, young people, schools and health workers with fact-based information on HPV and cervical cancer. The majority of unvaccinated girls are in middle income countries, for example Indonesia and India, not covered by GAVI (Global Vaccine Alliance, founded by the Bill and Melinda Gates Foundation). Vaccine hesitancy is also a significant problem worldwide.

Keeping girls in school is the most effective way to protect girls from violence, Female Genital Mutilation (FGM), early child marriage and teenage pregnancy. Relationship education in schools involving both boys and girls is essential. Special youth clinics, partnership

between schools and health clinics, as well as community engagement, involving parents, traditional and religious leaders are all important, so that cultural diversities and sensitivities are considered in legislation on strategies at national level.

Universal Health Coverage (UHC) or the policy of leaving no-one behind is a prominent theme of the current WHO DirectorGeneral, Dr Tedros. The Community Health Worker (CHW) is key to the success of the idea in poorer countries. However, there are problems. Remuneration is ad hoc rather than regular, and most CHWs abandon the job when they realise there is no pathway to progression. There must be a formal rather than informal approach to developing CHW programmes and they must be properly funded.

Many idealistic resolutions emerge from the many meetings we attend. What is now essential is implementation. We all know the important things that need to be done. What is needed now is investment and the political will. It is up to each of us to learn from each other at international events, but then, in our own countries, to influence our governments to bring about change.

Medical Woman | Autumn/Winter 2020 5

SKILLS TOOLKIT: MAKING THE MOST OF TRAINING

Making the most of your time while training: the advice I listened to Katie Wallace is an ST6 in clinical oncology. She describes herself as a fairly ordinary trainee.

She feels that she’s not very good at exams and had her first child as an SHO. Her perspective transformed by a fellowship with the Future Leaders Programme in Yorkshire, which inspired her to become a North Representative to the Faculty of Medical Leadership and Management trainee steering group, Chair of Junior Members Forum at the BMA and various other local roles.

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SKILLS TOOLKIT: MAKING THE MOST OF TRAINING Medical training can feel like a mountain to climb… then towards the end the time rushes by faster than you want. Before you find yourself facing interviews and jobs after completion of training, there are ways you can prepare yourself and make the most of the opportunities that are unique to training roles. People love to give advice; you cannot follow all of it but in this article, I share the advice I have received and want to pass on.

in that you cannot do everything at the last minute. The interview panel can see the dates and distribution of your work and experience.

They suggest doing something every year. It is easier than it sounds if you consider completing and presenting a QIP one year and then the following year presenting the work as a poster at a conference. Be flexible and make the most of the work you have done - every audit or QIP is a potential presentation or publication.

1. Any job becomes routine, find something with flashes of brilliance As a student I had a placement with an anaesthetist who described how the bulk of any role will become routine whatever you do and so you need to find a job where there is a skill, role or opportunity that inspires and motivates you. He explained how, for our orthopaedic colleague, it was second hip revisions which he would only occasionally do but the challenge inspired him.

Medical careers are not easily embarked on or maintained. This advice recognises the need to understand our motivation to be able to nurture and maintain it. All jobs have good days and bad days, but we will be better doctors if we can find a role where the good days maintain us through the bad ones.

5. Make sure you have your cake before you ice it I struggle with this one. This exact phrase was said to a friend. To me I was told to gain my clinical competency to give me legitimacy before pursuing my areas of interest (leadership and retirement in case you wondered). It feels hard when phrased as needing to prove that you have the cake or legitimacy, but it is sensible and that’s why it is being said to different people in different ways. Membership exams are hard. I have failed more than most but once they are done you are free to pursue your interests and have a rounded life. There is a balance and revision is more productive when you are fulfilled and happy but sometimes titles and qualifications open doors to opportunities that you would not have otherwise so it is worth investing the time and energy.

2. Apply for opportunities Go for it. We always imagine the competition is greater and therefore people do not put themselves forwards for awards and opportunities.

I have found myself over recent years repeating this to many colleagues because it is good advice. Colleagues think their quality improvement project (QIP) or audit must be ground breaking to be considered for a conference but I’ve never known a poster abstract to be rejected. The effort does not have to be huge but the benefits for your CV can be great so what is holding you back?

6. Do not be afraid of the scenic route Medical careers can feel like conveyor belts since Modernising Medical Careers was introduced; national recruitment and runthrough training schemes give the impression that you are making a commitment for life and there is no going back or stepping off.

It is not true. You can change speciality, you can retrain, you can even use your skills in different areas. GP’s are perhaps the most forward thinking of these with a vast array of portfolio careers demonstrating that the options are limitless. But there are many ways to gain experience, broaden your options and explore the potential of your career, for example with fellowships with the Faculty of Medical Leadership and Management (FMLM), Harkness and so many other options. I did a leadership fellowship with Yorkshire and Humber Health Education England (HEE) (the future leaders programme); it transformed my career and I would recommend the experience to anyone. While there are arguments for becoming a consultant sooner, I have not met anyone who regretted a year of stepping sideways, yet.

3. Think about what you want to do beyond the clinical A GP partner or consultant is rarely purely a clinician. Whilst our medical training would imply we spend all our time diagnosing cases in a multiple choice question format, the job plan of senior colleagues varies hugely. Once you become a consultant you will need to negotiate your job plan and have a clear understanding of what you want to do and what skills you have to offer. This places you in a better position to take on roles you enjoy. A senior registrar told me at the start of my speciality training that all consultants have an area of interest; research, teaching or leadership. Your training is the ideal time to gain experience and explore what interests you. Once you have found the area that inspires you there are opportunities to demonstrate that enthusiasm through post graduate degrees and local roles. The danger of not exploring this is that as a new consultant you find yourself with a job plan with time dedicated to something you do not like.

4. Do something every year As an ST3, at the start of speciality training, a senior colleague asked to join my project. When I discussed it with my supervising consultant, they advised me to say no because the colleague was trying to bolster their CV at the end of their training using my work. Nowadays as a more senior trainee, I have a more relaxed attitude because we are all trying to boost our CV’s and the service demands, exams, and courses make publications and extra-curricular activities hard to achieve. We are all familiar with the search for a quick and easy QIP to satisfy training requirements. However, the consultant had a point

7. Do not let your preconceptions hold you back A few years back the Medical Women’s Federation, Royal Colleges, British Medical Association and FMLM were among the many medical organisations that I did not understand or think there was a role for people like me to get involved in. I was wrong. There are opportunities for anyone but they are not necessarily well-advertised.

Talk to people, listen, look and be curious and there will be ways you can get involved. The success of medical organisations that represent our colleagues depends on our participation. There is a role for everyone you just need to find it and go for it to get involved.

Key points: Find work you enjoy; it’s where we spend most of our waking hours.

Seize opportunities to explore your interests and shape your role around those interests.

Pass your exams but be kind to yourself and don’t be afraid to take more time or step sideways.

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CAREER PLANNING: GENERAL PRACTICE

A day in the life of an academic GP Sarah Hillman is a GP in South Warwickshire and a National Institute for Health Research (NIHR) clinical lecturer in primary care at the University of Warwick Medical School. She has a special interest in women’s health having trained to registrar level in Obstetrics and Gynaecology and undertaken a PhD in antenatal genetic testing. She now researches women’s health in primary and community care.

Can you tell us a bit about yourself?

I am a salaried GP in South Warwickshire and a clinical lecturer in primary care at the University of Warwick medical school with a clinical and academic interest in women’s health.

Why did you decide to become a GP? I left medical school determined to pursue a career in obstetrics.

I got as far as clinical lecturer level, having jumped through the postgraduate exam hoops and completed a PhD in antenatal genetic testing but I could not stop this incessant feeling that I was in the wrong specialty. I longed for outpatient sessions, feared labour wards, and finally things came to a head one evening. My husband knows me better than anyone in the world, and so when I finally expressed how I felt and he then agreed with me, I had to admit that I needed to change training programmes. General Practice had always been my alternative career choice. I sought out people that could help. A conversation with a couple of, unbeknownst to me, very senior but very approachable GPs (one of which went on to become the next Chair of the RCGP), reassured me that my academic and clinical skills were transferrable. So, I took an almighty breath and stepped sideways into general practice training and I have never regretted it, not for a moment.

Describe a typical day as a General Practitioner I am a portfolio GP, so my day depends on if I am in surgery or at the University, as I divide my time between the two. I also have two primary school age children, so I work two shorter days to do the school pick up.

On my clinical days I drive to the practice which is a converted garden centre in the South Warwickshire countryside. The morning starts with a practice meeting, where we share important information such as safeguarding. I will then spend the morning seeing patients face-to-face. General practice is fast paced, and skilful communication is required to perform a holistic, empathetic and often complex consultation within ten minutes. By the end of the morning session, I will get a well-earned cup of tea and chat with my colleagues. I might discuss a tricky consultation from the

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morning while they do the same with me. Over this lunchtime period, I do a home visit or two. It is a real privilege to be allowed into people’s homes, the medical and social information you gain from doing this is really important. On my return, I will grab some lunch and catch up with my admin. Then, an afternoon of either face to face or phone consultations. More and more we are opening up other ways to communicate with our patients using e-consults or video consultations. My days and cases are varied: anything from dermatology to mental health to family planning and paediatrics and that’s just the first four patients!

What do you enjoy most about a career in General Practice?

I love being a clinical academic, the academic learning that turns into my practice and the questions unearthed by my clinical work that fuels the research. I love the autonomy that general practice brings and the control of my career, including geographical control.

But mostly, I love understanding whole people and their families in the context of their lives. I have always enjoyed women’s health but some aspects of the job have surprised me; the job satisfaction from helping someone through depression or helping someone to die in their own home.

What are the challenges in your chosen career path?

Dealing with uncertainty can sometimes be tough, but I am learning to share that uncertainty with patients and sometimes colleagues.

Juggling a career as a clinical academic alongside family life is challenging in any speciality, but I am learning to draw borders in my time and diarise everything!

What advice would you give to medical students and trainees deciding on their future career path?

Don’t be scared to follow your dreams, but if things change and they are not your dreams any more don’t be scared to change your plans. Seek out a mentor or two in your early career, they don’t need to be in your training specialty, in time seek out a mentee or two and pay it forward. Being a doctor is an enormous privilege, but it can at times be hard, make sure you keep talking.

CAREER PLANNING: GENERAL PRACTICE

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PERSPECTIVES: RACE AND COVID-19

The colour of coronavirus Hina J Shahid is a GP in London and holds an MSc in Public Health. She is the Chair of the Muslim Doctors Association; a non-profit organisation working to reduce health inequalities and improve inclusion in healthcare. She sits on the General Medical Council’s Black and Minority Ethnic Doctors forum and is co-founder of the NHS Religion Equality Advisory Group. She enjoys travelling, musicals and afternoon tea.

prejudiced and exclusionary attitudes, and direct actions of discrimination and marginalisation. Racism and discrimination are important explanatory factors for the unequal impact of COVID-19 on BAME communities.8 Another key concept is intersectionality; understanding that BAME groups are heterogeneous with important in-group differences and who may simultaneously experience multiple axes of discrimination and oppression beyond racism. Muslims, for example, experienced the highest risk of deaths among all religious groups;9 here religionbased oppression intersects with racism and classism. These multi-dimensional experiences influence vulnerability and demand individualised and contextualised responses.

Why are BAME groups dying more from COVID-19?

Structural factors The majority of health outcomes are structurally determined.

BAME communities are more likely to live in socially deprived and densely populated areas in overcrowded and multigenerational houses10. This makes self-isolation, social distancing and shielding more difficult resulting in increased exposure, transmission and risk of severe complications. They are also more likely to work in key worker roles in the health, social care, transport and hospitality sectors and in low paid or insecure jobs2 with reduced opportunities to work from home and lack of income protection if ill. These increase household viral exposure and transmission11 as well as financial vulnerability, stress and risk of mental health disorders.12

Racism, discrimination and inequities The disproportionate impact of COVID-19 on BAME (Black, Asian and Minority Ethnic) groups is well documented.1-5 On the frontline over 95% of doctors6 and 76% of all NHS staff who have died were from a BAME background.7 These health disparities are not new, they amplify longstanding and intersecting inequalities and injustices.

Racism and discrimination, although used interchangeably, are distinct terms. Racism is a system of oppression, based on racial hierarchies constructed to justify colonialism, that systematically privileges one group (dominant) over another (subordinate) through unequal distribution of power, resources and opportunities. Racial discrimination is the differential treatment of one group by another on the basis of race. This can include biases and stereotypes, 10 Medical Woman | Autumn/Winter 2020

Institutional factors Divisive media and political narratives blaming BAME communities for transmission create alienation and structural stigma. Austerity policies disproportionately impact BAME communities,13 immigration policies create barriers to seeking healthcare due to finances or fear of being deported.14 Security policies, such as Prevent, create fear and mistrust of health authorities.15 These reduce trust and engagement with health authorities and public health messaging.

At work, BAME people face barriers in accessing PPE, testing and risk assessments, and this includes doctors.12,16 This reinforces longstanding institutional discrimination; BAME doctors are more likely to fail postgraduate exams,17 face barriers in recruitment, progression and pay18,19 and are more likely to be referred for fitness to practice hearings and face harsher sanctions.20 This translates into individuals having less autonomy over their work, being more likely to be re-deployed to high risk areas without adequate protective equipment, and less likely to raise concerns.

PERSPECTIVES: RACE AND COVID-19

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PERSPECTIVES: RACE AND COVID-19

Healthcare access BAME patients are less likely to trust and be satisfied with healthcare services and engage with preventative, primary and secondary care services.21 Discrimination by healthcare providers and negative experiences of care form a barrier to accessing healthcare and affect quality of care received.22 BAME patients are more likely to present late to services and with atypical symptoms, which can contribute to misdiagnosis and adverse outcomes.23 These increase risk of adverse outcomes from COVID-19.

Education at undergraduate and postgraduate level: on structural determinants of health, decolonisation of the medical curriculum which incorporates a non-Eurocentric worldview of medicine and examines the impact of colonialism and slavery on medicine and health outcomes. Eliminate epistemic racism which delegitimises narrative and other qualitative-based approaches to knowledge.

Biological and cultural factors BAME groups are more likely to experience socially patterned and stress related chronic conditions such as diabetes, heart disease and obesity, as well as nutritional deficiencies such as vitamin D,24 which are linked to poorer outcomes from COVID-19.

Cultural and religious misconceptions and communal practices such as funerals, burials and congregational prayers can increase risk of exposure and transmission. Fatalistic beliefs and language barriers can create preferences for alternative cultural or faithbased remedies, healers, and media channels, and may reduce engagement with mainstream public health messaging and delay access to health care. These highlight the need for community-led tailored responses.

Make health disparities a high priority organisational problem: this should be at the core of organisations’ healthcare delivery strategy.

Collect and publish data on ethnicity-based health outcomes to monitor for disparities: at primary and secondary care levels as well as for public health programmes.

Create diverse, inclusive and compassionate organisational cultures: enable leadership development and career progression, psychologically safe routes for raising concerns and rigorous implementation of zero tolerance policies against discrimination, bullying and harassment.

Set up Equality, Diversity and Inclusion (EDI) or BAME networks: monitor inequalities in outcomes and experiences of BAME healthcare staff, hold Trust/Clinical commissioning Group (CCG) boards to account and offer formal support, mentoring and skills development.

Training: unconscious bias training is widely used but there is little evidence that it makes impact.

Fund EDI work: to avoid cultural taxation on BAME staff expected to deliver work for free.

Ensure policies, programmes and interventions undergo an ethnic impact assessment: e.g. the use of technology and risk of digital exclusion of BAME patients, dress code policies for staff.

What can be done to reduce health disparities among BAME groups?

The poorer outcomes among BAME groups are due to a combination of increased risk of exposure, transmission and serious disease, and reduced protection. The widespread and deeply embedded inequities can sometimes engender a sense of helplessness among doctors, as well as discomfort on addressing the issue of “race�. As healthcare professionals we should be at the forefront of reducing racially patterned health inequities in our patients, wider society, and our workplaces. The scope, priority and impact of work will depend on a number of individual and structural factors, but everyone can do something.

Addressing wider social determinants Advocacy and campaigning: form networks or join existing organisations, write letters to the government and MPs, create petitions and movements challenging structural inequities.

Community partnerships: Trusts, Clinical Commissioning Groups (CCG) and Primary Care Networks can set up partnerships with voluntary organisations, schools, welfare and housing associations, food banks, faith-based organisations and commission social prescribers, link workers and/or care navigators to support their populations holistically.

Health promotion work: outreach work in under-served communities, creating multilingual culturally and faith sensitive resources.

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Addressing organisational factors

Inner work Become aware: of your own biases and prejudices through educating yourself on race and ethnicity issues.

Authentic allyship: it can be exhausting for BAME people to explain their experiences all the time, avoid assumptions and strive for compassion and mindful communication and connections focusing on practical action.

Self-care and support: dealing with racial injustice either as an activist and/or a victim can create physical and psychological trauma and/or burnout. If you have been affected by this it is okay to take time out for yourself and seek support through friends, family or peer support networks, or formally through coaching, therapy or medical support.

Conclusions The disproportionate impact of COVID-19 on BAME communities and frontline staff is multi-factorial but structural and institutional factors are major drivers. Sustainable anti-racism work is demanding and requires dedicated effort, authentic allyship and adequate support and resources. Denial and de-legitimisation of experiences and knowledge is common, painful and costs lives, as we have seen with COVID-19. Doctors have a unique and important role in eliminating race-based health inequities and there is a moral, ethical, legal and professional obligation on all to create healthier and more equal societies and workplaces.

PERSPECTIVES: RACE AND COVID-19

References 1 ICNARC report on COVID-19 in critical care: 05 June 2020. London: Intensive Care National Audit and Research Centre; 2020.

2 Platt, L. and Warwick R. Are some ethnic groups more vulnerable to COVID-19 than others. Institute for Fiscal Studies, Nuffield Foundation; 2020.

3 Williamson, E., et al. Open SAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv: 2020.2005.2006.20092999.

4 Coronavirus (COVID-19) related deaths by ethnic group, England and Wales London: Office for National Statistics; 2020. Available from: https://bit.ly/3jMg2dH 5 Public Health England. Disparities in the Risk and Outcomes of COVID-19, London; 2020. Available from: https://bit.ly/326NiGz 6 C ook T, Kursumovic, E., Lennane, S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Service Journal. 2020.

7 Levene LS, Coles B, Davies MJ, Hanif W, Zaccardi F, Khunti K. COVID-19 cumulative mortality rates for frontline healthcare staff in England. British Journal of General Practice. 2020; 70:32 8 Public Health England. Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, London; 2020. Available from: https://bit.ly/2HX5ETt 9 Coronavirus (COVID-19) related deaths by religious group, England and Wales: 2 March to 15 May 2020. Available from: https://bit.ly/2THl94t 10 Khan O. A Sense of Place: Retirement Decisions among Older Black and Minority Ethnic People. Runnymede Trust, London; 2012.

11 Li W, Zhang B, Lu J, Liu S, Chang Z, Cao P, Liu X, Zhang P, Ling Y, Tao K, Chen J. The characteristics of household transmission of COVID-19. Clinical Infectious Diseases; 2020.

12 Runneymede Trust. Over-exposed and under-protected: the devastating impact of COVID-19 on Black and Minority Ethnic Communities in Great Britain, London, 2020. Available from:https://bit.ly/35T1qUY 13 Runneymede Trust. Intersecting inequalities: the impact of austerity on Black and Minority Ethnic women in the UK. London, 2020. Available from: https://bit.ly/3oQ7OVC 14 Medact. Patients not passports, published by Medact, London; 2020.

Available from: https://bit.ly/35QiPO8 15 Aked H, False positives: the Prevent counter-extremism policy in healthcare, published by Medact, London; 2020.

16 BMA. Analysing the impact of coronavirus on doctors, London 2020.

Available from: https://bit.ly/3jPNHU3 17 Rimmer A. Ethnic minority and non-UK doctors are more likely to fail exams, GMC data show. 2016.

18 Linton S. Taking the difference out of attainment. BMJ. 2020;368.

19 Appleby J. Ethnic pay gap among NHS doctors. BMJ. 2018;362: k3586.

20 GMC. Fair to refer; 2019. Available from: https://bit.ly/3mPRKlb 21 Hunt KA, Gaba A, Lavizzo-Mourey R. Racial and ethnic disparities and perceptions of health care: does health plan type matter?. Health Services Research.

2005;(2):551-76.

22 Laird LD, Amer MM, Barnett ED, Barnes LL. Muslim patients and health disparities in the UK and the US. Archives of disease in childhood. 2007;92:922-6.

23 Szczepura A. Access to health care for ethnic minority populations. Postgraduate Medical Journal. 2005;81:141-7.

24 Khunti K, Singh AK, Pareek M, Hanif W. Is ethnicity linked to incidence or outcomes of covid-19?. BMJ 2020;369:m1548.

Medical Woman | Autumn/Winter 2020 13

PERSPECTIVES: NEW ROLES

Redeployment to intensive care: A viewpoint from an Obstetrics and Gynaecology trainee Kate McCallin is an Obstetrics and Gynaecology trainee (ST1) working in the South Yorkshire area.

COVID-19 may well provoke permanent changes to healthcare delivery in the UK. From video consultations with patients and online multi-disciplinary team meetings, to extensive phone based triaging systems – we have had to adapt national practice significantly to reduce face-to-face contact and help prevent virus spread.

As for my personal role, seven months into my speciality training programme of Obstetrics and Gynaecology, I was redeployed to the unfamiliar territory of Intensive Care. To say the workload was different is somewhat of an understatement. No longer was I helping to deliver new-born babies by caesarean section, the new focus was to prevent death in critically unwell patients.

Daily life now consisted of a prompt eight o’clock morning handover led by the night senior registrar and attended by the full cohort of doctors working that day. Each patient was discussed in minute detail, ordered logically by organ system and cardiovascular status, blood pressure support medication requirement, respiratory system and ventilator settings and so forth. Initially, I felt as though I was listening to a different medical language. The vast majority of the patients on the unit were COVID positive, sedated and requiring a ventilator to breathe. Most had been on the unit for days and some up to four weeks. It was difficult not to blur patients all into one.

Following morning handover, it was time for the daily patient reviews. We donned our stiflingly hot personal protective equipment (PPE) including surgical gown, sterile gloves, non-sterile gloves, surgical hat, FFP3 mask and visor and entered the unit. After being assigned a patient, the in-depth analysis began. Each system was closely evaluated using detailed charts meticulously kept up-to-date by the nurse looking after that patient. Ventilator settings were monitored. The three or four drug infusions that the patient was on were carefully assessed. When was the patient last proned? When did they open their bowels? What were their most recent blood oxygen levels?

Proning was new to me. I had never before come across this in my ten years of being at medical school or a doctor. It involves turning the patient, complete with central line, endotracheal tube, and arterial line onto their front in order to improve oxygen levels.

Patients remained prone for approximately sixteen hours per day.

14 Medical Woman | Autumn/Winter 2020

Coming from a specialty where patient communication is of upmost importance – breaking bad news of a second trimester miscarriage or metastatic ovarian cancer diagnosis – not being able to talk to patients was one thing, but not even being able to see their faces?

Proning was not the only barrier to effective communication.

Wearing a voice muffling FFP3 mask which covers half your face also effectively conceals the majority of muscles used for facial expressions. Dressing all staff in identical outfits also provides issues. Each worker had a sticker placed on his or her surgical gown detailing that person’s name and job role. These small additions to enable cohesive team working in a new, stressful environment should not be underestimated.

There were tough days. And this was despite the amazing support of the intensive care consultants, anaesthetic trainees and experienced nursing staff. To watch a previously fit and well man in his fifties die despite the consultant giving him every last drop of available treatment possible is hard. To watch the grieving relative in full personal protective equipment (one family member allowed only) say goodbye after not seeing her husband for three weeks was harrowing.

Towards the end of my time there, I saw a patient that I had become familiar with over the past few weeks, walk unaided out of the unit with staff providing a poignant round of applause. He no longer had to communicate via miming nor breathe through a tracheostomy.

During his stay he told me of the mental struggle he had struggled to overcome. He felt imprisoned in his single room with no daylight and much to his annoyance, a clock that showed the wrong time and could not be fixed. His mental and physical recovery provided the much-needed moral boost that the wearied staff needed.

For many specialties within the NHS, particularly surgical based, work may be currently less busy than usual, with many elective surgical lists cancelled. However, at a time like this, spare a thought for intensivists and anaesthetists, working tirelessly for each critically unwell patient.

My contribution was miniscule but it has taught me the importance of adaptability, resilience and teamwork in the face of the unknown.

I hope that the lessons we learn during the COVID crisis will continue to benefit the National Health Service (NHS) for many years to come.

PERSPECTIVES: NEW ROLES

Medical Woman | Autumn/Winter 2020 15

PERSPECTIVES: NEW ROLES

A new role in COVID: Experiences of a retired returner Anthea Mowat is a recently retired Associate Specialist Anaesthetist in Lincolnshire. She is Honorary Secretary of the Medical Women’s Federation. She has a strong interest in supporting doctors, having been a Chief Officer of the British Medical Association, as past Chair of the Representative Body. She is former Chair of her Trust Local Negotiating Committee (LNC) and was Lead Appraiser until her retirement.

When the COVID-19 crisis hit, there were 2500 recently retired doctors who answered the call to assist the NHS. Frustratingly many who came forward to volunteer did not end up back in the workforce, some due to departments having sufficient resources that they managed to redeploy staff, but others who were stymied by bureaucracy, in both primary and secondary care.

Having retired in the latter part of 2019, I was keen to help, but also aware that a recent health issue would put me in a higher risk category. Nevertheless, when I applied using the necessary link, NHS England assured me I could have a useful role. The day the General Medical Council (GMC) announced they would be granting temporary registration to returners, I also had a phone call from my old department and a generic letter from my old employing Trust, both asking if I was prepared to come back.

Due to enquiring about a non-patient facing role, I was asked by the Trust if I would consider being a driver, porter or domestic (which is where I started my original job in the NHS as a student so a certain symmetry there!). Though it did puzzle me that these roles were seen to not have interaction with patients! Meanwhile, NHS England suggested NHS 111 as a possibility.

Having provided identity checks, health declaration and other paperwork for NHS England they assured me it would be forwarded to my old Trust. I was pointed to the hours of online learning expected (dutifully completed), and also used online learning provided, with impressive speed, by my Royal College and specialist associations. More Continuing Professional Development (CPD) done within a week than normally done in a year, it was an emergency after all. Then nothing seemed to happen! Frustrating, as I was ready and raring to play my part.

Having heard nothing for nearly three weeks, I contacted my previous Medical Director to ask how I could help and, with no hesitation, was offered the role of Medical Examiner, to do the amended role permitted under the Coronavirus Act 2020. There were 26 necessary online modules to complete before the role could be done. So, even more CPD undertaken. Trust induction specifically for returners was planned. Mine was held on a bank holiday with some necessary departments not there (IT and occupational health). I was the only person on it, and the trainers

16 Medical Woman | Autumn/Winter 2020

who were there were all staff I had trained when they started in the Trust: we were surprised and amused by the role reversal. I was also required to confirm my identity (ID) again to three different departments despite having NHS England approval. However, I soon acquired the all-important ID card, had departmental induction for the new role, alongside three other retired returners, and off we go! Only one short delay when occupational health would not accept the health declaration done for NHS England and wanted their own format, but we got there in time for me to start.

The role has been both rewarding and poignant. It was based in bereavement services, and involves completing Medical Certificate of Cause of Death (MCCD) after scrutiny of the whole of the final admission for all deaths, irrespective of cause. Having not been involved in the care of the patient, it required detailed scrutiny of all the results and entries by any professional in the notes to determine cause of death but also to look for any clinical governance issues.

It also involved speaking to the bereaved relatives, to check their understanding, give them the chance to ask questions, and also to find out if they had any concerns. This was a sad privilege as so many were stunned by the speed of events but also their grief was magnified, as in many cases they had not been able to visit and may have only had a facetime call with their loved one.

We also liaised with the coroner and completed the initial forms necessary for cremation. This took pressure off all the amazing clinical staff who no longer had the pressure of doing this work at a time when new rotas, long shifts, redeployment, use of Personal Protective Equipment (PPE), and sheer exhaustion were taking enough of a toll.

It has been a fascinating role using professional skills but very different from being in my former clinical role seeing patients.

As things gradually started to return to restoration phase, I and my three new colleagues came to the end of the fourth month of the role and were stood down, and while we will miss the all wonderful staff who welcomed and valued us in our return, we all hope we will not be called upon to return.

I was lucky I have been able to help, albeit this quiet background role, but also feel for the many retired doctors who wished to come back but have not been enabled to do so.

PERSPECTIVES: NEW ROLES

Medical Woman | Autumn/Winter 2020 17

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INSIDE: INSIDE: Clinical Commissioning what’s next?

Women At The Top Olwen Williams Women in Leadership

by Penny Newman

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Pension Tension how do the changes affect you?

How I got here: Dame Carol Black

Women At The Top Professor Jenny Higham

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Women At The Top Hilary Cass

Twitterview Dr Helena McKeown

How I got here: CMO Professor Dame Sally Davies

100 Leading Ladies

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Whistleblowing: Dr Kim Holt

The Forgotten Women Dr Jodie Smythe

Sexual Health in the older population

Charity Focus: Daughters of Eve – Leyla Hussein

Freezing Eggs the facts

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Ready Steady Mums Medical Women in World War 1

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SEXISM IN MEDICINE

JUST HOW COMMON IS IT? WHAT KIND OF PATIENT WOULD YOU BE?

10 Steps to Success...

THE LILANI WAY

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From strength to strength: the many faces of Medical Woman magazine. Each Editor has delivered their unique perspective, and as the magazine grows and moves forward into the future it will continue to support, hope and diversify.

It is a tremendous honour to be president of the Medical Women’s Federation. Thank you, the membership, for having voted for me. It is also a humbling and enormous privilege to be following in the footsteps of so many inspirational women, most recently, Etta Bowden-Jones, who has carried the baton magnificently for the last two years.

The Medical Women’s Federation is 103 years old, but still has work to do. We have striking gender disparities in pay, career progression, and opportunity. These factors alone justify the need for the MWF, but there are also other personal, professional, and societal challenges for women.

This year, the year of COVID, has brought additional difficulties and revealed fundamental weaknesses in structures and society.

I want the Medical Women’s Federation to be a strong advocate for progressive policies that empower women and girls, end genderbased stereotypes, and create a better, fairer society for everyone. I want to see the Medical Women’s Federation contribute to the larger, wider debates of our time, as “the voice of medical women on medical issues”. Above all, the Medical Women’s Federation is here to offer you a friendly ear, networking, educational and development opportunities, and support.

We have an exciting programme of new work in addition to our established activities, and growing representation from medical students and young doctors, bringing new ideas and a thriving vibrancy. Please encourage your friends and colleagues to join us, consider applying for one of our representative roles, and contact me, one of our executive team, or office staff if there is an issue you want help with, or want to bring to our attention.

Stay safe, and stay strong!

Neena Modi President, Medical Women’s Federation

SPOTLIGHT: MOVING MEDICINE

Moving medicine Helen MacMullen has been a Medical Women’s Federation (MWF) member since 2007: previously a MWF Student Representative and member of the South East Committee. As well as working in Accident and Emergency, she loves travel, adventure and meeting inspirational people. She manages to combine all of these with providing medical cover for multi-day, ultra-marathon races and expeditions internationally.

Most importantly, she loves hanging out with her husband and daughters Anna (11) and Lydia (13).

Just imagine if you could help your patient change just one thing that will radically alter the course of their health and, therefore, life. One thing that could save a stretched to breaking point National Health Service or your General Practice without costing a penny? What do you think it would be?

My first hospital job was as a phlebotomist at the age of 21. I took blood, for a year, after my first degree and before I started medical school.

It was a great education. What I experienced was a lot of unhealthy people sitting on the wards. Unhealthy, not just because of the pathology that had brought them into hospital, but often also because of the choices they had made about aspects of their lives – smoking, nutrition, exercise specifically – had put their bodies in a vulnerable state making them more likely to get sick. I know about their choices because I spent that year observing a lot and talking with my patients.

What I also observed was us ‘patching’ them up and sending them home with the ‘real’ underlying issues remaining, unaddressed.

My feeling at that time, and now, nearly 20 years on still is, ‘What is the point?’ of us treating ‘X’ if, fundamentally, nothing else is going to change?

Looking at physical activity alone - the scale of the inactivity epidemic is colossal. We have decreasing activity levels in the UK with adults now more than 20% less active than they were in the 1960s. By 2030 this figure is estimated to rise to 35%.1 And what we know is that low activity levels lead to poorer health, which in turn leads to reduced activity, leading to poorer health…. and the cycle goes on. It brings with it a huge financial impact on both individual health and on health services: an estimated annual UK cost of £7.4 billion.2 Although I went on to attend one of the most highly regarded medical schools globally, there was nothing during my five years of education that even attempted to equip us, the next generation of doctors, with the skills and understanding to address this issue of inactivity 20 Medical Woman | Autumn/Winter 2020

SPOTLIGHT: MOVING MEDICINE

that is, unarguably, fundamental to optimal health. I understand, thankfully, that this is now changing in some medical schools. But can we afford to wait for the next generation of doctors to come through before the face of medicine changes to address some of the real issues around health?

I am an Emergency Medicine doctor and my current role as an Emergency Medicine Fellow at Oxford University Hospitals (OUH) Trust also sees me working with our Sports and Exercise Medicine Team on the Active Hospitals project. This project is supported by Public Health England (PHE) and Sport England (SE) and aims to embed more physical activity conversations and interventions into secondary care settings.

We have embedded conversations about physical activity throughout clinical pathways and are sharing our tools, insights, evidence and learnings in our online toolkit to help support other hospitals to become active. It also contains a whole host of useful resources, for designing pathways, training and support, posters and flyers for you to use in your hospital or GP practice. We want to empower patients to lead more active, healthier and happier lives. It is free of charge and safe!

As part of this project, we decided to talk to our hospital staff – our nurses, therapists, nursing assistants, doctors and managers – about why conversations about physical activity with patients might or might not happen. What we learned was that across the different groups of staff, similar themes emerged.

Firstly, it seems that we need to identify the moments of opportunity to talk about physical activity. Staff highlighted that there are a number of reasons that some moments are less good than others for approaching the conversation and there might be many reasons for this: patients are already at risk of information overload; their immediate priorities are elsewhere; they are working through powerful emotions; coming to terms with new identities; or because they are just too sick. But those moments of opportunity do exist, we just need to recognise them.

Secondly, staff told us that they lack the confidence to have these conversations. They worry about saying the wrong things and about patients coming to harm from being more physically active. There was concern about how patients might react to this conversation and, also, uncertainty about how effective it would be talking to a patient about physical activity. In fact, we know that healthcare professionals are well placed to provide physical activity advice with 25% of patients saying they would be more active if advised by a GP or Nurse.3 That is a Number-Needed-To-Treat (NNT) of four.

Thirdly, it was clear from what staff said that physical activity was usually only raised when it directly supported team priorities. For example, directly contributing to clinical outcomes, helping people get back to baseline or speeding up discharge.

And lastly, they told us that it would help if the physical environment supported them in encouraging and facilitating patients to move more.4 For our full findings please visit www.movingmedicine.ac.uk/active-hospitals/design These are the responses from our staff in our hospital, but I wonder whether this sounds familiar to you? The question then is, how do we address these issues?

Moving Medicine has the answer. It is an award-winning5 online resource that aims, quite simply, to get people moving more. It has been developed by the faculty of Sport and Exercise Medicine in partnership with Public Health England (PHE) and SE. It recognises that healthcare professionals are short on time and perhaps also on confidence. It offers solutions for people with one minute, five minutes and more minutes to spare. It guides you through a simple conversation and provides specific information about the benefits of exercise on a whole range of common conditions, from arthritis, chronic obstructive pulmonary disease (COPD), depression and many more thus educating us, and our patients, as we use it. It also has a paediatric section. It is fully evidenced based and referenced.

Maybe some of you are thinking, ‘it’s not my job to talk to patients about inactivity’. Perhaps we think it is not our job because we were not taught to value it. Or maybe we do not feel confident enough in our abilities to make a difference, as we discovered talking to our staff? The huge gaps in medical education around the importance of lifestyle factors in determining health and the current practice we see around us cannot fail to influence our own values and behaviours as doctors.

We are not talking about that one conversation being the one that changes someone’s behaviour. We are talking about creating a culture change within healthcare that sees us valuing movement as a powerful tool to keep people healthy.

In the Emergency department, I frequently see people that would benefit hugely from moving more. Perhaps a young person with diabetes or on medication for high blood pressure or someone presenting with symptoms of anxiety. And yes, often, this is not the right opportunity to talk to them about it but, sometimes, it is, and so I do, because I can, and I understand that that five-minute conversation might have more impact on their health and the rest of their life than anything else I can do for them today.

So, perhaps the question we need to ask ourselves, every time we see a patient is ‘What opportunity is there in this moment?’

References 1 Health Matters: getting every adult active every day. Public Health England. 2016.

Available from: https://www.gov.uk/government/publications/health-mattersgetting-every-adult-active-every-day/health-matters-getting-every-adult-activeevery-day 2

Health Matters: getting every adult active every day. Public Health England. 2016.

Available from: https://www.gov.uk/government/publications/health-mattersgetting-every-adult-active-every-day/health-matters-getting-every-adult-activeevery-day

Health Matters: getting every adult active every day. Public Health England. 2016.

Available from: https://www.gov.uk/government/publications/health-mattersgetting-every-adult-active-every-day/health-matters-getting-every-adult-activeevery-day 4 For our full findings please visit: www.movingmedicine.ac.uk/active-hospitals/design 3

5

Moving Medicine has won an Excellence in Patient Care award 2020 from the Royal College of Physicians for the category ‘Person-centred care’. This recognises projects that have placed patients’ needs, views, and involvement at their heart.

Medical Woman | Autumn/Winter 2020 21

STRIKE A CHORD: HELPING STUDENTS AND DOCTORS

Helping doctors and medical students in times of need Professor Dame Parveen Kumar DBE has been the President of Royal Medical Benevolent Fund (RMBF) for over 7 years. A former President of the Medical Women’s Federation, she is currently Professor of Medicine and Education at Barts and the London School of Medicine and Dentistry, and an honorary consultant gastroenterologist and general physician.

Professor Kumar steps down this September when Professor Sheila the Baroness Hollins takes up the post. Baroness Hollins is Professor Emeritus of Psychiatry of Intellectual Disability at St George’s University of London and Honorary Professor of Spirituality, Theology and Health, University of Durham.

Reflecting on her time at the RMBF, Professor Kumar comments: “What stands out is seeing the very real, life-changing impact that RMBF support can make. We have helped prevent families from losing their homes in a crisis. We have helped medical students in difficulty to qualify and take their first steps as doctors. And we have helped hundreds of doctors get back to work as, otherwise, they would have been lost to the profession”.

22 Medical Woman | Autumn/Winter 2020

STRIKE A CHORD: HELPING STUDENTS AND DOCTORS

The Royal Medical Benevolent Fund (RMBF) is a UK registered charity.

Every year we help hundreds of doctors, medical students and their family members who are in serious hardship due to age, illness, injury or bereavement. We provide support to doctors of all specialties and at all stages of their careers. In addition to financial assistance, we provide money advice and mental health and wellbeing support.

Helen’s story illustrates the life changing support we provide: Helen had only just started her first Foundation Year training post when she suffered a relapse of Crohn’s disease requiring extensive surgery. Without having time to build a financial safety net, she was not only faced with the prospect of significant time out of medicine, but also the impossibility of being able to support herself financially.

“When I first approached the RMBF, I had been in hospital for a few months and I knew I was going to need a prolonged period of recuperation.

I didn’t have any savings at the time as when I became sick, I was just two months into Foundation Year 1. I didn’t have anything I could fall back on, and was told I would need to take six months off work, which was terrifying.

As a newly qualified medic you aren’t entitled to very much sick leave. And because I have a longterm illness, I couldn’t get insurance. So, when this happened, I was left in a really difficult situation.

I didn’t know whether to stay local to where my condition was being managed, or try to move home to my parents who live in another country. I felt very isolated.

While there is a huge amount of support when you are in hospital, once you get out of hospital that support isn’t there to the same extent. Everyday issues that you haven’t thought of while acutely unwell come to the forefront and it is a challenge to figure out how to deal with them. I could turn to friends for a lot of things, but I couldn’t ask them to support me for six months financially.

For those first couple of years of working, I felt particularly vulnerable. There is more pressure, more stress, and you don’t want to be seen to show weakness. When you have a chronic illness, it’s not the kind of thing you want to talk to your colleagues or boss about. That reluctance to show weakness is often a Catch-22, as you can run yourself into the ground, often compromising your ability to do your job and return to work properly.

You also rotate all the time making things particularly difficult. You don’t really have anywhere to turn.

Fortunately, I was encouraged to contact the RMBF by a friend at just the right time. The charity was external, and not linked to anyone in hospital, so it was a safe space to talk about what was going on. The caseworkers were also really helpful and took most of the major pressures and worries away at a time when I wasn’t able to deal with them properly. It was a really difficult time.

Knowing that the RMBF was not only going to support me for the here and now, but also for at least six months of my recovery, really meant that I could focus on getting myself better with the realistic goal of getting back to work again as a trainee. I can’t really put into words how having that security for a period of time made such a difference.

Even after restarting Foundation Year 1 the following August, I remember the charity making it clear that if I was to ever find myself in that situation again in the future, I could always reapply for their support and there would be no need to feel that I was on my own again. It really felt like there would always be someone there who would listen, appreciate what you were going through, and be there to help you.

Thanks to the RMBF, I’ve been able to return to medicine and complete my foundation years – and now I’m training to be an anaesthetist. I still have a chronic illness, but I’m far better now. If I was ever in a similar situation again, I wouldn’t feel scared to approach the charity for help. It makes me feel much more supported in my day-to-day life just knowing the RMBF is there.”

If you, or a doctor or medical student you know needs help, please refer to our website for full details of the support the Royal Medical Benevolent Fund can offer: www.rmbf.org

Medical Woman | Autumn/Winter 2020 23

STRIKE A CHORD: WHISTLE-BLOWING

Blowing the Whistle: changing culture Mary Higgins qualified in Ireland and has been a consultant in Emergency Medicine for twenty years.

She currently works at East Cheshire NHS Trust where she is Medical Appraisal Lead and Local Negotiating Committee (LNC) Chair. Mary has undertaken a Masters in Employment Law and has interests in equality, discrimination, exible working and the gender pay gap. She runs for headspace and has run several marathons!

24 Medical Woman | Autumn/Winter 2020

STRIKE A CHORD: WHISTLE-BLOWING

Jenny Vaughan is a neurologist in London. She is a leading campaigner for reforming the law on gross negligence manslaughter and was instrumental in getting the conviction of surgeon David Sellu overturned.

She is a council member of the Medical Women’s Federation and the Royal College of Physicians and Learn not Blame lead at The Doctor’s Association UK. She campaigns for a “just culture” in healthcare and seeks to highlight the importance of speaking up in patient safety.

Whistleblowers play a vital role in society and are the first line of defence against criminality and corruption.1 Effective whistleblowing protection could return 2 billion pounds of misused public funds to the UK annually in the area of public procurement alone.2 Numerous scandals in the NHS were brought to light by whistleblowers, notably a whole-system failure at Mid-Staffordshire NHS Foundation Trust.3 There is a clear relationship between lower levels of bullying and harassment in the National Health Service (NHS) and better Care Quality Commission (CQC) ratings.4 Yet, 56% of whistleblowers suffered negative treatment during the recent lockdown: 26% were victimised or disciplined, 21% were dismissed, 2% were bullied by co-workers, a further 6% resigned and 2% were suspended.5

Tension exists between healthcare professionals’ contractual duty of confidentiality to their employer and the right to disclose information. The Public Interest Disclosure Act (PIDA) 6 allows a ‘protected disclosure’ provided certain conditions are met – the right information must be disclosed in the right way to the right person or organisation.

‘Right type’ of information 1. Information that is disclosed must be in one of six categories: a. criminal offence b. failure to comply with legal obligation c. miscarriage of justice d. health and safety – the most relevant in a patient safety context in the NHS e. environmental damage f. attempts to cover up any of the above7 2. A disclosure must be of information rather than mere allegation or opinion.

3. The whistleblower must have ‘reasonable belief’ that the information disclosed is correct. It is irrelevant if this is subsequently proven not to be the case. Healthcare workers would not be expected to have an in-depth knowledge of health and safety legislation if whistleblowing about lack of personal protective equipment (PPE).

4. The information disclosed must be in the public interest.

Concerns about patient safety clearly qualify here.

Making a disclosure in the right way to the most appropriate individual Whistleblowers must make the disclosure to the relevant individual or body in order to have legal protection. A tiered approach exists, with more exacting requirements with progressive tiers. The first tier is to the employer or through the employer’s whistleblowing policy. NHS organisations have a statutory requirement to have a whistleblowing policy called ‘Freedom to Speak Up (FTSU)’. FTSU

is acknowledged by the National Guardian for the NHS, as being central to patient safety.

The second tier is to organisations known as Prescribed Persons8 and include MPs.9 Whistleblowers must have reasonable belief that the subject of the disclosure is within the remit of the Prescribed Person and that the information is true.10 Organisations are chosen for expertise or authority in their field and are frequently regulators. Relevant organisations in the context of the NHS include the Care Quality Commission (CQC), the General Medical Council (GMC) and the Health and Safety Executive. Of note is that Trade Unions are not Prescribed Persons and although they can offer advice, they are unable to act directly. A whistleblower is not legally protected if information is disclosed to their Trade Union.

The third tier is external, directly to the public and to mainstream or social media. The legal requirements for making such a disclosure are complex and are difficult hurdles to overcome. Certain conditions must be met to enjoy protection. Whistleblowers are strongly advised to seek legal advice from their Trade Union if contemplating such a disclosure.

Who is covered to make a Protected Disclosure?

All NHS employees are covered under PIDA. Cover also extends to student nurses and midwives, agency staff and, uniquely to the NHS, job applicants. Trainee doctors did not come under the scope of PIDA until the case of Dr Chris Day, a trainee in Anaesthetics who raised concerns about safe staffing levels at the Trust where he worked. It was initially held that Health Education England (HEE) could not be regarded as an employer despite having significant control over junior doctors’ training and paying the bulk of their salary.11 This was overturned by the Court of Appeal and so extended whistleblowing protection to 54,000 junior doctors,12 though with considerable consequences for him personally and for his career. The NHS and HEE spent £700,000 of public money defending this case, as highlighted in the House of Commons (Table 1).13 Chris Day relates his personal experiences in Table 1.

Medical Woman | Autumn/Winter 2020 25

STRIKE A CHORD: WHISTLE-BLOWING

Table 1 Due to a discovery made by a Telegraph journalist in 2019, it has now become clear that the law allowed junior doctors to have whistleblowing protection from Health Education England all along and that the rulings in the Day case were a result of misleading arguments and a failure in disclosure of a key contact governing junior doctors’ employment (the Learning and Development Agreement). This was a subject of much debate in the House of Commons by two MPs who are former employment lawyers. First, Justin Madders: “Health Education England effectively sought to remove around 54,000 doctors from whistleblowing protection by claiming that it was not their employer.”

Sir Norman Lamb stated: “Is the hon. Gentleman aware that the contract between Health Education England and the Trusts, which demonstrates the degree of control that Health Education England has over the employment of junior doctors, was not disclosed for some three years in that litigation?

It was drafted by the very law firm that was making loads of money out of defending the case against Chris Day. I have raised this with Health Education England, but it will not give me a proper response because it says that the case is at an end. Does the hon. Gentleman agree that this is totally unacceptable and that it smacks of unethical behaviour for that law firm to make money out of not disclosing a contract that it itself drafted?”

Due to a payment of £55k to Dr Day and a questionable settlement agreement these issues were never explored in Court. There is now a legal regulator investigation that is now over a year old. Dr Day commented: “What I’m worried about is the message this case sends which is that public bodies can gang up to stop a whistleblowing case being heard and that medical leaders and regulators will turn a blind eye. If they can get away with this, what message does that send to someone who is considering speaking up or someone who is considering supporting or listening to someone who speaks up to them?”

Detriment The use of Non-Disclosure Agreements (‘gagging clauses’) as part of Settlement Agreements to prevent whistleblowers from discussing the subject of a protected disclosure is illegal.14 Examples of detriment include intimidation, bullying, harassment, exclusion, denial of training opportunities, bogus performance management, disciplinary action and demotion.15 There is no protection under PIDA for ongoing detriment and no statutory duty for employers to take measures to prevent it. This is a significant gap in current legislation, as evidenced by the experience of Dr Kim Holt, a community paediatrician at Great Ormond Street Hospital in the ‘Baby P’ case. Her personal experience is outlined in Table 2.

26 Medical Woman | Autumn/Winter 2020

Table 2 Dr Kim Holt was part of an effort by the Trust to rebuild paediatric services following the death of Victoria Climbie and the subsequent inquiry. Concerns were raised by her and the paediatric team about staffing resources and an oppressive culture. Over 60 clinical incidents were raised related to systemic issues, such as, lost follow up, missing notes and lack of robust Child Protection systems between 2004 and 2006. Two of Kim’s colleagues resigned in 2006 and she became increasingly isolated. Despite this she continued to raise concerns to the highest level in the Trust – directly to the Chairman, Chief Executive and Medical Director. The outcome was increased hostility, removal of support and increased isolation. Kim was advised to go on sick leave by her doctors due to work related stress in February 2007. During this period the consultant workforce had been reduced to two: Kim and one other substantive consultant. Dr Al Zayyat was recruited as a locum and started work in 2007. On a fateful day in August 2007 Dr Al Zayyat was asked to cover a clinic and Peter Connelly (Baby P) was brought by his mother and a friend for assessment. Two days later he had been killed by his carers. Dr Al Zayyat was pilloried. Despite having recovered from her work-related stress Kim was not permitted to return to work as Occupational Health believed workplace culture was risky to her mental health. GOSH placed Kim on special leave and in November 2007 offered her a year’s salary to leave (and sign a confidentiality clause). The saga dragged on for a further four years before Kim was reinstated and received an apology. Dr Al Zayyat has been pressured to take voluntary erasure and became seriously unwell. She was unable to continue to work for the Trust.

Kim says “Once I realised that the systemic issues and problems that we had raised concerns about within Haringey were being airbrushed from any inquiry I had to escalate my concerns. I reported them to the highest level internally and to the CQC, NHS London GMC and my Member of Parliament (MP). I spoke up largely because I saw unjust treatment of an inexperienced locum but also because a vulnerable child needed someone to ensure lessons were learned. I refused to sign any confidentiality clause as morally this was akin to taking a bribe. In many ways I was lucky to survive and be reinstated and I thank my MP Lynn Featherstone and the press. No health care organisation supported me. They all acted to worsen the situation and try to persuade me to move on, accept a payoff and go quiet. Government ministers who had been made aware also sought for me to be silenced.

I definitely suffered detriment with severe bullying, impact upon my mental health and loss of opportunity to fulfil my potential.

On the plus side, I discovered a strength I didn’t know I had – we worked hard to bring about increased awareness of the failures in the system and lack of any real protection for whistleblowers. I am proud to have given evidence to the Health Select Committee, Public Accounts Committee (on gagging clauses) and supported many colleagues going through bullying experiences. ‘Learn not Blame’ is definitely the way forward but I strongly believe in tougher accountability for executives who suppress the truth. I’m certain that the Department of Health to date have not ensured adequate protection exists. This disappoints me.”

STRIKE A CHORD: WHISTLE-BLOWING

Claims can be brought to Employment Tribunals but only once detriment has occurred and the success rate is only 4%. Cases pre-Coronavirus typically took 20 months to complete and the median compensation award was £17,422.16 This can dwarf actual losses. Costs can be prohibitive – whistleblowers were ordered to pay costs of £753,135 in total in one year whereas employers had to pay £183,992.17 There is no protection for costs under PIDA so whistleblowers can find themselves subject to costs orders and, like Dr Chris Day, can feel pressurised to abandon their claims.18 Whistleblowing in the time of COVID The COVID crisis first came to the world’s attention due to the brave actions of Dr Li Wenliang at Wuhan Central Hospital. He warned colleagues about a new SARS-like virus in December 2019.

He was summoned to the Public Security Bureau where he was ordered to sign a letter in which he was accused of ‘making false comments’ and that he had ‘severely disturbed the social order’.19 In the UK, many clinical staff raised concerns about the ability to speak out about workplace issues in relation to PPE and other matters and have felt silenced and ‘gagged’ in doing so.20 The campaigning whistleblowing charity, Protect, advises that if an individual believes that their employer’s protective measures are insufficient and if there is concern about health and safety of oneself, colleagues or the public, concerns can be raised as a whistle-blowing disclosure. The GMC have issued guidance in support of doctors and will take into account the special circumstances of the pandemic during their investigations.21 Proposed developments in legislation While ground-breaking for its time, PIDA no longer provides adequate protection for today’s whistleblower. Legislation should be consolidated into a Whistleblowers’ Act and should be updated to cover current gaps. A Private Members’ Bill22 and the APPG recommendations are timely.23 An Office for the Whistleblower is proposed with statutory powers to protect and advise whistleblowers and to enforce protections.24 Ultimately, the best protection for whistleblowers in the NHS is an open and fair workplace culture. Legislation will not of itself facilitate this. The Doctors’ Association UK (DAUK) launched a ‘Learn not Blame’ campaign in November 2018.25 This advocates for transformational change of the culture of fear and blame that still prevails in parts of the NHS. It promotes a culture of learning and of enabling staff to speak up in a constructive way when things go wrong.

Notwithstanding, individuals who whistleblow deserve better protection and legal reform is urgently required. Our MWF manifesto calls for action to ensure that everyone makes as full a contribution to patient care as they are able to.26 Freedom to speak up is a fundamental part of this as it is a part of how we keep our patients safe.26

References 1 Halford-Hall G, Pasculli L. All Party Parliamentary Group (APPG) report on Whistleblowing. July 2019. Available at www.appgwhistleblowing.co.uk Accessed March 2020.

2 European Commission ‘Estimating the economic benefits of whistleblowing protection in public procurement’. July 2017. Available at https://minhalexander. files.wordpress.com/2018/06/estimating-the-economic-benefits-of-whistleblowerprotection-in-public-procurement-et0117799enn-en-1.pdf Accessed September 2020.

3 R Francis. Mid Staffordshire NHS Foundation Trust Public Inquiry, HM Government.

February 2013. Available at: https://www.gov.uk/government/organisations/midstaffordshire-nhs-foundation-trust-public-inquiry Ac-cessed April 2020.

4 Care Quality Commission. ‘Equally Outstanding’. October 2017. Available at https://www.england.nhs.uk/wp-content/uploads/2018/01/EDC03a-equallyoutstanding-presentation.pdf Accessed April 2020.

5 Whistleblowers deserve better – join Protect in campaigning for legal reform.

Available at https://www.transparency.org.uk/whistleblowers-deserve-betterjoin-protect-campaigning-legal-reform Ac-cessed July 2020.

6 Public Interest Disclosure Act, 1998 c23. Available at https://www.legislation.gov. uk/ukpga/1998/23 Accessed March 2020.

7 Employment Rights Act, 1996 s43B(1)(a)-(f). Available at https://www.legislation. gov.uk/ukpga/1996/18/section/43B Accessed March 2020.

8 Public Interest Disclosure (Prescribed Persons) Order 2014, Statutory Instrument No. 2014/2418 Available at https://www.legislation.gov.uk/uksi/2014/2418/pdfs/ uksi_20142418_en.pdf Accessed April 2020.

9 Public Interest Disclosure (Prescribed Persons) (Amendment) Order 2014, Statutory Instrument No. 2014/596. Available at https://www.legislation.gov.uk/ uksi/2014/596/introduction/made Accessed April 2020.

10 Employment Rights Act 1996 s43F(1)(b)(i)-(ii). Available at https://www. legislation.gov.uk/ukpga/1996/18/section/43F Accessed April 2020.

11 Day v Lewisham and Greenwich NHS Trust and another [2016] ICR 878. Available at <https://swarb.co.uk/day-v-lewisham-and-greenwich-nhs-trust-and-anothereat-9-mar-2016/ Accessed March 2020.

12 Day v Health Education England and others [2017] EWCA Civ 329, [2017] IRLR 623.

Available at https://www.bailii.org/ew/cases/EWCA/Civ/2017/329.html Accessed March 2020.

13 Hansard: House of Commons Debate 3 July 2019, vol 662, col 1273. Available at https://s3-eu-west-1.amazonaws.com/public-concern-at-work/wp-content/ uploads/images/2019/07/09175924/Backbench-MP-whistleblowing-debateHansard-.pdf Accessed March 2020.

14 Employment Rights Act 1996 s43J. Available at https://www.legislation.gov.uk/ ukpga/1996/18/section/43J Accessed March 2020.

15 Halford-Hall G, Pasculli L. All Party Parliamentary Group (APPG) report on Whistleblowing, July 2019, pg 21. Available at <www.appgwhistleblowing.co.uk Accessed March 2020.

16 S Dreyfus, S Wolfe and M Worth, ‘Protecting whistleblowers in the UK: a new blueprint’, Blueprint for Free Speech 2016, pg 6. Available at https://www. blueprintforfreespeech.net/wp-content/uploads/2016/05/Report-ProtectingWhistleblowers-In-The-UK Accessed April 2020.

17 Public Concern At Work, ‘Is the law protecting whistleblowers? A review of PIDA claims’ (Protect, May 2015). Available at https://www.bdbf.co.uk/arewhistleblowers-being-protected/ Accessed March 2020.

18 House of Commons Debate 3 July 2019, vol 662, col 1273. Available at https:// s3-eu-west-1.amazonaws.com/public-concern-at-work/wp-content/uploads/ images/2019/07/09175924/Backbench-MP-whistleblowing-debate-Hansard-.pdf Accessed March 2020.

19 Hegarty S. The Chinese doctor who tried to warn others about Coronavirus. BBC News website, 6 February 2020. Available at https://www.bbc.co.uk/news/worldasia-china-51364382 Accessed February 2020.

20 Campbell D, ‘NHS staff ‘gagged’ over coronavirus shortages’, The Guardian, 31 March 2020. Available at https://www.theguardian.com/society/2020/mar/31/ nhs-staff-gagged-over-coronavirus-protective-equipment-shortages Accessed March 2020.

21 General Medical Council. How we will continue to regulate in light of novel coronavirus (Covid-19). 3 March 2020. Available at https://www.gmc-uk.org/news/ news-archive/how-we-will-continue-to-regulate-in-light-of-novel-coronavirus Accessed March 2020.

22 Public Interest Disclosure (Protection) HC Bill (2019-21). Available at https:// services.parliament.uk/bills/2019-21/publicinterestdisclosureprotection.html Accessed April 2020.

23 Halford-Hall G, Pasculli L. All Party Parliamentary Group (APPG) report on Whistleblowing, July 2019, pg 45-49. Available at www.appgwhistleblowing.co.uk Accessed March 2020.

24 Baroness Kramer’s Office of the Whistleblower HL Bill (2019-21) 66. Available at https://publications.parliament.uk/pa/bills/lbill/58-01/066/5801066.pdf Accessed April 2020.

25 The Doctor’s Association. Learn not Blame. Available at https://www.dauk.org/ learnnotblamedauk Accessed April 2020.

26 Medical Women’s Federation. Available at https://www. medicalwomensfederation.org.uk/our-work/our-manifesto Accessed April 2020.

Medical Woman | Autumn/Winter 2020 27

UNWIND: CREATIVE WRITING

Creative Writing Roshni Beeharry is a London-based portfolio Medical Educator, ex-NHS consultant in rehabilitation medicine, poet, writer and Creative Writing for Wellbeing Facilitator. She is a keen advocate of the medical humanities and arts in health movements. Her academic interests are reďŹ&#x201A;ective practice, inter-professional education and professional identity formation, and the roles the Arts can play in these areas.

28 Medical Woman | Autumn/Winter 2020

UNWIND: CREATIVE WRITING

If you had met me as a child, I most likely would have had a book or notebook, or both, under my arm; the rest of the time you would find me on my typewriter, tapping away happily, writing stories and making mini-books.

For some of us, including myself, pursuing a medical career has meant that much-loved creative and other hobbies, have often taken a ‘back seat’ to sciences at school, and then all the studying that is involved at medical school.

It was not until I was a first-year senior house officer (SHO), two years after my brother died, that I started writing again; and not just fiction, but reading and writing poetry too for the first time since school. I feel the relative concision of poetic form as opposed to my favoured prose form, helped me articulate emotions and thoughts I had hitherto found difficult.

This experience went on to spark my interest in Arts in Health, Medical Humanities, and in using writing for wellbeing and reflective practice with others, and I am trained formally in the latter field.1 I now run workshops in my local women’s mental health drop-in group, ran a public ‘Nature as inspiration for wellbeing’ workshop at Keats House Museum London and I have run my own Special Study Component (SSC) Creative Writing for ‘Personal & Professional Development’ with medical students at Trinity College Dublin Medical School and Brighton & Sussex Medical School.

I will be running Writing for Wellbeing Workshops and Writing for Wellbeing for Healthcare Professionals online from September 2020.

I joined my first writing group in 1998 and now belong to two others, and these are an enjoyable way of connecting with like-minded people and writing to timed prompts, sharing work, receiving and giving feedback, which along with open mic performances of my poetry and fiction, are all valuable transferable skills to a medical and academic career, whilst doing something fun.

In our fast-paced outcome-dominated clinical and academic worlds, we can sometimes forget about the process of an activity, and focus on the product or outcome. What I love and endeavour to convey about writing, is that it is very much a process, and the ‘bonus’ is a piece of writing that you create yourself, from that ‘mysterious’ world – your imagination.

It is wonderful to give oneself permission, time and space to drift off into that world.

So, if you have been wanting to try writing or get back to writing, or are just curious, here are some tips to get you started: • Firstly, cast off any doubts of whether you can write or not – you can!

• Writing is a cheap, accessible and portable hobby – all you need is a notebook and pen, or your laptop/device if you prefer.

• Doctors like writers, are curious people and great observers, so we have a head start! Jot down words and snatches of conversations (anonymity preserved of course) – these can trigger ideas for a piece of writing later.

• You might like to record any thoughts that come to you, on your mobile phone or an inexpensive voice-activated Dictaphone.

• The process of journaling2 can be helpful for many, and if you keep a diary of some form, then you might find re-reading it, and

noting phrases and words can be a source of ideas for a creative piece, memoir or a reflective piece.

• Find a place to write where you can focus on your writing – you may prefer peace, or some ‘noise’ around you; indoors, outdoors, in a public place, or you might prefer to stay at home. You can experiment.

• Now, write something. Anything – even it is a shopping list for dinner! That could turn into your first found poem.3 • Most importantly, keep writing. Because you never know where your writing might take you. Enjoy it!

Useful resources There is a plethora of writing resources in print and online, but a few I have used, include: • T he Artist’s Way by Julia Cameron, Souvenir Press (April 2020) – one of the seminal books for writers and artists; discusses ‘morning pages’ and the principles of free writing •W riting Magazine and Writers’ Forum magazines, are available is available in print and on online https://www.writers-online.co.uk https://writers-forum.com • There are many resources and writing communities on social media, such as Twitter and Facebook, and this is a great way to connect with like-minded people • If you enjoy writing and other creative activities, I would heartily recommend joining cRxeate. This is a warm and welcoming community uniquely for doctors, dentists and vets at all stages of their career, who wish to foster their creativity and share work and ideas.

• You can find writing groups by searching online, looking for adverts in local libraries, local papers and writing magazines • Literary festivals, author readings and one-off workshops, are a sociable way to meet others whilst hearing published writers discuss their craft. These are also helpful if you are not quite ready to join a writing group.

• If you are interested in the arts for wellbeing, LAPIDUS International https://www.lapidus.org.uk, has many links to other organisations, or contact me, I would be very happy to help.

References 1 I trained on the MA Creative Writing & Personal Development, Sussex University in 2003-5, the first UK degree of its kind, but the department has sadly since closed down, but similar diploma and degree level courses exist at the Metanoia Institute www.metanoia.ac.uk and Teeside University www.tees.ac.uk 2

American Psychotherapist Dr Ira Progoff, pioneered the Intensive Journal Process https://en.wikipedia.org/wiki/Intensive_journal_method

3

There are a multitude of books /online sources on how to write and read poetry, but Stephen Fry’s ‘The Ode less Travelled’ (published in 2005, Hutchinson), is very readable, thanks to his renowned wit.

Medical Woman | Autumn/Winter 2020 29

UNWIND

30 Medical Woman | Autumn/Winter 2020

UNWIND

COVID - 19 Heroines Dabota Yvonne Buowari is a member of the Medical Womenâ&#x20AC;&#x2122;s Association of Nigeria and Vice-Chair of the MWIA Work Life Balance special interest group.

This poem is dedicated to all women doctors working on the frontline during the COVID-19 pandemic.

They say we are the weaker vessels They say we are not physically strong Just because we have oestrogen and progesterone We encounter discrimination Wherever we go Discriminated in medical school Discriminated at the workplace Discriminated during clerkship rotation Discriminated during residency selection Then comes the SARS-CoV2 pandemic We are at the frontline Women doctors in the battlefield of coronavirus disease 2019 Fighting to save the lives of our patients Irrespective of their gender Not minding if they are males or females Some women doctors have fallen Some are gone Some have lost their lives In the COVID-19 war Some of us are still standing Even with the global shortage of personal protective equipment We are not discouraged The battle continues Combatant soldiers at the warfront Of the SARS-CoV2 battle Women doctors, we shall conquer Medical women, we shall win the war Because we have what it takes

Medical Woman | Autumn/Winter 2020 31

BOOK REVIEW

Fact and fiction: Medical Women at War

Wendy Moore is a prize-winning journalist and author of five non-fiction books on medical and social history. She writes for the Lancet, Guardian and Times Literary Supplement. Her second book, Wedlock, was a number one Sunday Times bestseller. Endell Street: The trailblazing women who ran World War One’s most remarkable military hospital (Atlantic Books, £17.99) was published in April.

Headshot credit: Colin Crisford

Elizabeth Garrett Anderson battled discrimination to become the first woman trained in Britain to join the UK Medical Register in 1865. But almost 50 years later there were still only about 1,000 women doctors registered in Britain and almost all of them worked in hospitals run by women to treat only women and children. Women had won the right to qualify in medicine but they were still barred from training in most medical schools and from working in most mainstream hospitals.

The First World War changed everything. When war broke out on 4 August 1914, women doctors immediately offered their services to the country. While they were just as keen as men to do their patriotic duty, medical women also saw war as a unique opportunity to gain experience and prove they were equal to their male colleagues. The Association of Registered Medical Women, forerunner of the Medical Women’s Federation (MWF), was at the forefront of this drive. Ten days after the outbreak of the war, the MWF collected the names of more than 60 women doctors willing to volunteer at home or overseas. Others approached the War Office directly with offers of help.

At first the government was adamant that women doctors were not wanted. The Scottish surgeon Elsie Inglis was famously rebuffed with the words, ‘My good lady, go home and sit still.’ Determined they were not simply going to sit out the war, women such as Inglis took matters into their own hands and immediately began organising allfemale medical units to serve abroad. The first such unit, which set out for France on 17 September 1914, was the Women’s Hospital

Detail from staff photo at Endell Street, showing Louisa Garrett Anderson, centre with black dog, and Flora Murray on her right - credit Women’s Library LSE

32 Medical Woman | Autumn/Winter 2020

Corps led by Flora Murray and Louisa Garrett Anderson.

Anderson, a surgeon and daughter of Elizabeth Garrett Anderson, and Murray, a physician and anaesthetist, had more than 10 years’ experience apiece. Both had trained at the London School of Medicine for Women (LSMW) although Murray finished her degree at Durham.

Both had been active suffragettes – Murray was Emmeline Pankhurst’s doctor and Anderson had served time in prison for breaking a window – and they were also life partners. Knowing it was pointless approaching the War Office, they volunteered their services instead to the French Red Cross.

Within weeks Anderson and Murray had raised £2,000 for medical supplies and recruited a unit of 18 personnel comprising of three more women doctors, eight nurses, three female orderlies and four male helpers. Kitted out in military-style uniforms, they sailed for France where they established a hospital in a luxury new hotel, Claridge’s, in Paris. Two days later they accepted their first wounded – British and French soldiers from the nearby frontline – and within days Claridge’s was full. Army officials who came to visit were initially sceptical but were so impressed they invited the women to run a second military hospital near Boulogne under army authority.

Then in early 1915, Anderson and Murray were asked by the War Office to run a major military hospital in the heart of London.

Ward at Endell Street - credit Cook-Dickerman Collection, National Park Service, US.

BOOK REVIEW Operating theatre credit Cook-Dickerman Collection, National Park Service, US.

‘War had changed everything. Despite their complete lack of experience in treating men, or dealing with war injuries, the two women had decided to set up their own emergency hospital to treat wounded soldiers plucked from the battlefields in France. Gathering together a team of young recruits, including three more women doctors, eight nurses, three women orderlies and four male helpers, they were bound for Paris. It was a gamble. They were not only heading for unknown dangers in a war zone with eighteen young people under their command but their medical inexperience meant they were seriously unprepared for the challenges ahead. As committed to the women’s cause as they were to each other, Murray and Anderson saw the unfolding drama in France as their first chance to prove that women doctors were equal to men.’

Endell Street Military Hospital opened in May 1915 in a former workhouse in Covent Garden with 520 beds, later expanded to 573.

By now other medical women had set up hospitals and medical units in warzones across Europe. Led by Elsie Inglis, the Scottish Women’s Hospitals founded hospitals in France and Serbia and later worked in Russia. But Endell Street was, and would remain, the only hospital run and staffed by women under the authority of the British Army.

Apart from 20 male orderlies, later reduced to 13, the entire staff of 180 was female. These included 14 doctors, 29 trained nurses and more than 80 orderlies.

Endell Street stayed open throughout the war, treating more than 26,000 wounded – most of them men – and performing some 7,000 major operations. Since the hospital was close to major railway stations, many of its patients were serious casualties who arrived in convoys of up to 80 at a time, often in the middle of the night.

As news of this unique hospital spread women flocked from across the globe to work there, including four surgeons from Australia and one from Canada. Endell Street was declared a triumph by the press, the public and the profession.

Suddenly medical women were in demand. Spurred by the success of Endell Street, in 1916 the army appealed for 40 women doctors to join the Royal Army Medical Corps. The response was so large that 85 women sailed for Malta that July and the following year more followed them to work in Greece, Egypt and India. At home, women doctors took up posts left vacant by men in hospitals, private practices and factories. Dr Jane Walker, the MWF’s first president, became consulting physician at the Ministry of Munitions and Ministry of Food while Dr Florence Stoney took over the X-ray

department of Fulham Military Hospital. In 1916, the magazine of the LSMW noted that ‘at present practically every appointment is open’ to women. Many medical schools opened their doors to women students for the first time.

Yet acceptance was a double-edged sword. Women doctors in the army were denied commissions, uniforms and privileges and paid lower rates. Without proper authority, their orders were ignored; they had to travel third-class on trains as ‘nurses’ and were turned out of army messes. One described the experience as a ‘daily humiliating annoyance’. Worse still, when the war ended women doctors were no longer required.

Winston Churchill, Secretary of State for War, told the MWF that women doctors were no longer needed in the army since it was ‘beyond refutation that medical women cannot perform all tasks which are at present undertaken by Medical officers’.

Hospitals, which had relied on women doctors throughout the war, ended their contracts and refused to appoint them to new posts. Medical schools, which had only survived in wartime due to women students, shut their doors again.

The war had proved the worth of women doctors – but peace brought their value to an end.

Endell Street remained open for a year after the war ended, treating the victims of the 1918-19 influenza epidemic, before closing in December 1919. Most of its women doctors returned to low-status jobs treating women and children or retired. Murray died in 1923 and Anderson lived on alone for another 20 years. The hospital building was demolished in the 1970s and today the only reminder is a plaque on the wall.

Medical Woman | Autumn/Winter 2020 33

Much progress has beenwomen made, The voice of medical but much remains to be done! onmore medical issues