The Doctor – issue 1 September, 2018

The magazine for BMA members

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Issue 1 | September 2018

Brexit: why breaking up is never easy Healthcare’s future hangs in the balance Ending the silence The NHS reboot needed to beat the bullies

They come here Celebrating immigrant doctors

Wake-up call Doctors sound the sleep deprivation alarm

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The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499

Email news@bma.org.uk

Call a BMA adviser 0300 123 1233 @TheDrMagazine The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at ÂŁ160 (UK) or ÂŁ225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.

The Doctor is a supplement of BMJ vol: 362 no: 8167

Editor Neil Hallows (020) 7383 6321 Chief sub-editor Chris Patterson e r st r ters Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 t r ter Tim Tonkin (020) 7383 6753 rther re e se news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designer Alex Gay

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Welcome to The Doctor Chaand Nagpaul, BMA council chair

contents

Welcome to the first issue of the BMA’s new monthly member magazine – The Doctor. For 52 years our member magazine BMA News has, in its various formats, been a vital voice for doctors. But as technology has changed and reading habits have evolved it is time for us to do the same. In its place I can proudly reveal a bright, compelling and modern monthly magazine, four times the si e, filled with exciting new features.

This maga ine will provide a fitting platform for our writing team’s award-winning content and much more space for us to reflect on the issues that affect our members and campaign on their behalf.

We will also continue to have a significant online news and analysis platform and regular member messages ensuring you are always up to date. rexit is the issue of our time and a fitting cover feature for this first issue. As this piece, an insight into the vast uncertainty of the process, makes clear, the threat to the NHS from Brexit is very real.

The BMA will continue to be vocal in defence of the NHS against these threats but let me be clear – this is not about

petty party politics. This is about our duty of care to patients and the effect rexit will have on our ability to do our jobs.

Overseas doctors play a crucial part in the NHS – and will be needed even more as we continue to face rising demand and di cult public finances.

In the first of a series of articles we will reclaim the phrase ‘they come here’ – which is so o en followed by reductive, negative assumptions about immigrants – and tell the stories of the doctors who have helped shape our health service.

The BMA’s Caring, supportive, collaborative project – which is looking at what the health service should look like in the future and will be elaborated on in future issues – has further highlighted bullying, with nearly half (49 per cent) of doctors saying they practise medicine defensively because they feel they work in a blame culture.

This first issue of The Doctor starts exactly as we mean to go on – covering the issues that dominate and shape our profession. I am confident our new magazine will allow us to tell your stories and represent your views better than ever before.

4-5

6-11

12-17

r efi

The price rt

silence

Six months to Brexit, and there are precious few Government answers on key health issues

Whether in the form of sly comments or physical abuse, bullying affects thousands of NHS doctors

22-25

26-29

30

Wake-up call

Opinion

Explainer

How doctors are pressuring employers to tackle the causes of sleep deprivation

In your words – the stethoscope as ‘badge of honour’, the impact of ethnicity on mental health, and when does a man become a man?

A key aspect of pensions – in plain English

A belated pay-out for a seriously ill doctor, a new plan for the health service and a possible limit on energy drinks

18-21

the

They come here Celebrating the contribution made by immigrant doctors to the NHS

31 Events on women in medicine, for civilian doctors, and BMJ Masterclasses

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If this is the easiest deal in history...

r efi

Energy drinks or obesity drinks?

Commentary on the latest news events in medicine

A Government plan to ban the sale of energy drinks to children garnered several headlines this month – including the inevitable, ‘Red Bull Ban’.

Its latest public health e o t o te pi e minister Theresa May, focused on the relatively high levels of sugar in them, 60 per cent more than in e la soft i s Her proposal was a si i a t a tio i ta li childhood obesity she said, which she rightly recognised as ‘one of the greatest health challenges facing this country’.

Steps, such as the tax on soft i s a e lo o e e as BMA board of science chair Professor Dame Parveen Kumar said, when the levy came into force in April.

Doctors have been

calling on Government to take seriously the real and escalating dangers of childhood obesity and other public health issues for years.

In the BMA’s latest report, released this month, Securing the Long-term Sustainability of the NHS, it makes the case for prioritising investment across many areas of prevention. t a s t e latest H i ital es s o i t at children in the most deprived areas of England were more than twice as likely to be obese than children living in the least deprived.

‘Despite the wellestablished evidence base and repeated political commitments to prioritise prevention, this has failed to translate into adequate action,’ it states.

GPs tend to be renowned for their earthy realism, but it was one of their number – albeit a former practitioner – who said last year that coming to a free trade agreement with the EU should be ‘one of the easiest in human history’.

Colleagues of the international trade secretary Liam Fox have displayed rather less optimism in recent months and now speculate on the chances of a ‘no-deal’ exit from Europe.

We’ll leave the pundits and politicians to argue about the odds, but the risks of no deal – and many of the possible deals on the table – are everyone’s business. st e s latest ie on the impact of Brexit makes clear, pressure on the UK to forge new trading arrangements could pose a si i a t is to t e sa et and integrity of the NHS. The report warns that the UK is already under pressure from non-EU states to liberalise its trade policy post Brexit, and that Parliament does not have the capacity to scrutinise the negotiation of new free-trade agreements properly.

It calls on the Government to seek to protect the health service by excluding the NHS from being part of future trade deals and resisting any attempts designed to weaken existing safety standards on patient care and medical research. bma.org.uk/brexit

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th s r If you want to make friends in the NHS, unveiling a grand plan isn’t necessarily the best way to do it.

In the same way as ‘strategy’ and ‘IT’ have, in the hands of NHS leaders, gone from being neutral, even useful, concepts to Pavlovian prompts for a roll of the eyes, the promise of a new plan – perhaps to make amends for all the previous plans – does not usually lead to a great unfurling of bunting in the wards and surgeries of the health service.

But at least the 10-year plan for England outlined by NHS chief executive Simon Stevens was expected, in the sense that the Government’s desperately needed promise o a o e i atio i in the summer came with the demand that the health service responded with proposals on how it should best be spent.

e Mr Stevens, speaking at the NHS Expo conference in Manchester this month, hinted that the future would see a much stronger focus on prevention and public health, integration of social care with the health service and a si i a t o s o i p o i mental health services.

‘We have got to look much more intentionally about how, in an NHS that is funded fairly across the country, we use the extra resources for health inequalities more explicitly and programmatically to tackle t ee i i e e es i li e expectancy and health and ell ei et ee i e e t parts of the country and i e e t o ps o people The BMA has long called for the proper integration of health and social care and welcomes moves to join services together. It has highlighted t e a i i ito s e e ts o

ere t

health inequalities.

So a focus on what actually makes people well, or ill, has to be an improvement on previous plans which have been largely structural.

There was an optimistic tone at the conference, but whether these ambitions will be met may depend on an intense and focused political commitment, and rather more investment than the welcome start announced in the summer.

STEVENS : Seeking greater focus on mental health services

A long battle for justice Critical care consultant David Stewart’s life changed beyond recognition following a mosquito bite.

Now, following an eightyear battle, supported by the BMA, the high court has ruled that Dr Stewart should be paid a e e t i is e plo e had denied him.

Having contracted chikungunya virus and dengue fever while at a medical conference in India in 2010, Dr Stewart was unable to o i t s ifts a is pai

hours of work were cut. His trust and the NHS Business Services Authority rejected his application for a temporary injury allowance, which would have covered up to 85 per cent of his normal earnings while on reduced pay.

A judge was asked to consider whether Dr Stewart had attended the conference in the course of his employment and whether he could show he was bitten at the conference. The court found in favour of Dr Stewart

Keep in touch with the BMA online at

in both issues, and that e s o l e pai e e t retrospectively, with interest.

Dr Stewart said: ‘The NHS is the caring service – that is its function, its reason for existence. It’s like any institution, the function you get out of your employees is proportional to the way they are treated as individuals. The failure of management to care for its employees is a very dangerous precedent to set.’

Read the full story at bma.org.uk/DavidStewart

instagram.com/thebma

Read more online ‘Pay award disappointing’ ‘Recruitment remedy “not credible”’ ‘BMA urges GPs to consider retention scheme’ ‘No deal would be “catastrophic”’ Read all the latest stories online at bma.org.uk/news

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The price of parting Six months to Brexit, and the Government’s ‘dangerously casual’ attit e to i agreements in vital a eas i a e t patient care is causing alarm in Brussels as well as here – as Peter Blackburn so t

STIHLER: ‘People who are less ell o ill e i e tl impacted’

‘I

f anyone tells you they know what’s happening with Brexit, they’re lying.’

Catherine Stihler, Labour MEP for Scotland, half smiles as she speaks – but there is a very serious side to what she says.

During an hour-long interview discussing the political and philosophical arguments ao e it a its possi le e e ts o t e H it s iftl e o es lea t at e e those at the heart of the European project in Brussels have been given no clear idea what the future looks like – and, as a result, harbour a great deal of concern for the British public’s most-loved institution.

‘The implications of leaving are just so serious,’ she says. ‘I don’t think the people advocating us leaving are being honest about what it really means for people. It will be t e people o a e less ell o t at ill e directly impacted.’

There is no doubting Ms Stihler’s passion.

The EU is, for many like her, a representation of social progress; the foundation of a better future. But this is not just about party politics, personal philosophy or ideology. Brexit poses si i a t estio s o t e ealt se i e It is a vast process which could fundamentally threaten the NHS during one of the most i lt pe io s i its isto Since the triggering of article 50 – the mechanism by which a member state leaves the EU, in March 2017 – the BMA has consistently called for politicians to give the health service the attention it needs during the process of negotiations.

But in so many areas – mutual recognition o p o essio al ali atio s t e relationships with vital bodies such as the EMA (European Medicines Agency) and EURATOM (the European Atomic Energy Community), t e e it e t a ete tio o sta health and safety legislation, public health p ote tio o e e t o e i i es s ie ti research, the coordination of response to communicable diseases – politicians have provided precious few answers. thedoctor | September 2018 07

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HOARDERS: Medicines might need to be stockpiled MAY: A Brexit dividend would help fund NHS investment

‘Brexit poses s fi t questions for the health service’

The risks are many. Even the future workforce of the NHS is in serious doubt – 12,000 European Economic Area doctors work in the UK and many other healthcare professionals play roles in health, social care and a wide variety of other sectors i i e e t e ealt of the public, while leaving organisations such as the EMA and EURATOM could mean issues with the supply of medicines and a disruption in the supply of radioactive isotopes vital for cancer treatment.

This is not ‘project fear’ or hyperbole. Just two months ago, the Government warned medicines might need to be stockpiled in the event of a no-deal Brexit, for example.

It’s a situation which would have been previously hard to imagine outside wartime.

Communication fears There are also concerns about the UK’s ability to share and receive vital data and information, which could help track the spread of infectious

disease outbreaks.

As an article in the magazine Politico e e ts ‘In a worst-case scenario, it could mean Britain receiving o o ial p ates o pai about a person diagnosed with Ebola, or France hitting a wall of silence from Britain about the latest news on bacterial resistance to antibiotics.’

It is a problem Switzerland has faced, being a non-EU member despite its close relationship with Brussels.

Ariane Amberg, Swiss health attachée to the EU, tells s s e a e ot pa t of the EU networks and early warning systems, we don’t automatically get any data. It is a big concern – as Switzerland is like an island in the middle of Europe, having a lot o t a And these day-to-day issues could cripple services before even looking forward to future collaboration in science and research – the innovation that drives improved outcomes.

The concerns seem vast

PA

and insurmountable. But they are a far cry from the public rhetoric of this ‘Brexit means Brexit’ Government, which ofte see s to eal la el in empty catchphrases and promises of clarity.

Prime minister Theresa May – along with several senior cabinet members – repeatedly claims a ‘Brexit dividend’ of up to £400m a week, owing to the UK no longer paying its contribution to the EU, would help fund increased investment in the NHS. This comes despite the Institute for Fiscal Studies, among others, suggesting there would be no immediate post e it oost to a es As Commons health select committee chair Sarah Wollaston put it rather s i tl e e it dividend tosh was expected but treats the public as fools.’

East Midlands MEP Rory Palmer is the Labour Party’s health representative in Brussels and has found the p o ess as a i as a members of the public. ‘It’s i lt to t e o s e

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STIHLER: o a t a e o a e a eat it BMA ARM 2018: o to s ote i a o o a se o eee

HUEBNER: a ot s e et e all sides understand the seriousness of the matter’

WOLLASTON: e e it i i e is tos

PALMER: e lo is ti i e ast

says, speaking to The Doctor i is ssels o e a e i el o e e H a es so e o t e i est alle es it as a e i its ea s e it makes all that worse but we’ve got no answers from t e o e e t ie o l et e o e e t o l a e ee answering some of these questions and setting out sol tio s ea lie e lo is ti i a it s ti i e ast He’s not the only one o e e tt e annual representative meeting in Brighton in June, o to s o e el i l ote to oppose e it a s ppo t a se o eee it o e s o e t e e e ts o t e p o ess o t e H o i ail e as a e t at t e o se e es o a o eal e it o l e pote tiall atast op i ie last o t pointed out the very serious i pli atio s to a e o a eas i l i t e e i al

o

o e ot e ela ealt p ote tio a ealt se it l s a s e es o i l e a is list of European initiatives with i s e ope t e o l ai tai so e o o li i l i t e ( opea e t e o isease e e tio a o t ol) a i e s ie e a esea p o e ts o t e si e t e e is a sense that the Government needs to do a little more than o e p it e e alise as s a ta H e e ai o t e s o stit tio al a ai s o ittee sa s s e elie es t e is a a e o t e i po ta e o o ti e oope atio i a t at oope atio is esi a le t at o t is ill ta e is i lt to see at t is sta e a

Lives at risk t e iss e o o i a le iseases a o i atio s e sa s am not sure whether all sides

understand the seriousness of the matter, but at the e o t e a o ot t i that anyone will be willing to is t e li es o iti e s The issue is far too serious to be used as a bargaining tool, and ultimately, as it t e la e post e it negotiations, a way will be found to ensure that our iti e s li es ill ot e p t at is Some years ago, in a BMA News p o le se io es at t e a o le e t e st o o t i tio t e had made in setting up the European disease networks t at t e e t e o a le e eas o e t e as seen as pioneering, it is now t e s e t o polite t poo o e s ti le s t e la of detail, and inherent o t a i tio s i t e s positio st si o t s o lea i t e to e e t e el o i e o e e t a ts e e t i t e o es us but won’t be part of the sto s io o si le thedoctor | September 2018 09

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CAVALLERI and AMBERG: It has taken a long time to negotiate settlements

FARAGE: ‘A trade deal with the USA is possible in 48 hours’

TUSK ea i up is hard’

‘When you are out, you are out.

Being in the single market is as good as it can get’

market – you can’t have your cake and eat it. ea is all t e i lt issues will be parked until the transition and just not dealt with. If we come out in March 2019 and do not know the direction of travel in terms of what our future relationship actually looks like – what about mutual recognition o ali atio s a t i s like that?’

Mr Palmer agrees: ‘We a t a o to eep aiti for the UK Government to bring forward some clarity and certainty. It’s all been dangerously casual in relation to health and the NHS.’

Sands of time Another major concern with the UK Government’s approach – one which seems to lack transparency and substance – is time. It’s running out. While former UKIP leader Nigel Farage suggests the UK could agree a trade deal with the USA in 48 hours – presumably one which would see warehouses packed with chlorinated

chickens – the reality is likely to e e i ee t Here, there is much that can be learned from the Swiss. Its embassy’s minister for parliamentary a ai s a e it iete Cavalleri, and health attachée Ms Amberg, tell a tale of long and painstaking negotiations.

Mr Cavalleri says his country is now at the stage eei ost el s e a e regulatory alignment where t o i e e t e a is s we try to have the same rules apply in Switzerland as they do in the EU’. There are 120 agreements covering various areas.

Mr Cavalleri adds: ‘If we o a i isto o st most important agreement (with the EU), a free trade agreement, was in 1972.

That was the starting point of what we call today a bilateral agreement.

‘It always depends on at ill e t e el s t at are covered and how much integration is wished. The question is, do you want integration or not, and there is

a price – alignment.’ s e et e e it is even possible, let alone desirable, given the timescale a t e iss e pe ie e Mr Cavalleri smiles, diplomatically.

‘Having done many international agreements, I know time is short.

I wouldn’t say it’s impossible.

You always need two steps – st is t e politi al a ee e t on where you want to go, which is supposed to happen st a t e o o i to the details. If there is an agreement on where the UK and EU want to go by October t at is t e st step

Determined yet vague Predicting what happens e t i t is o ea i process seems impossible.

There is no map for the route the UK Government is taking – there is only a decision whether to forge onward, and see what new world is found, or to take a step back and consider whether the decisions made have been the correct ones.

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THE EUROPEAN PARLIAMENT, BRUSSELS: t s li e at i a ie t e a e a i li e

McGUINNESS: ‘Health should be protected’ isis

The Irish question

For Ms Stihler the latter would be the correct decision spe i all si a se o eee o o o l known as a people’s vote, to i et e p li a sa o t e al eal eli e e s a ‘I back a people’s vote because I don’t think what is ei is sse is i a a shape or form what people t o t o l appe s e sa s still t e lo ti s In Brussels, there is a pervasive mix of e se e t s pat and exasperation from those o a e lo o si e e t e a epe a le all one of the sensible voices i t e oo To them it’s perhaps like at i a oo ie s e a a te i li e isis ollo i t e e it ote the president of the European Council Donald Tusk said: ea i p is a t e evidence of the process so a o l o e t i is e tai o i o t o to ea p is e e a e bma.org.uk/brexit

‘A way will be found to ensure that our citizens’ lives will not be put at risk’

e o t e i est t eats to healthcare post-Brexit is the iss e o t e is o e t is possi le t at lea i t e would lead to a hard border between Ireland and the a p t t e oo i a a ee e t at is Irish MEP Mairead i ess i e p esi e t of the European Parliament, sa s o ela a t e t e e a e st o li s a o s ste s a e pa ti la l losel i te t i e She cites the cross-border se i es s as e e e a iolo ase i e t also se i patie ts a oss t e o e i o e al s i ess is also o e e t at i iti e s leave the NHS, the service i t a its sta e e o e ea il o ela is pti e o o t s ealt a e s ste She adds: ‘There is a a a e ess a o e otiato s o t e pote tial implications, and the a stop optio i t e aft it a al a ee e t references health as an area of north-south cooperation t at s o l e p ote te For most it would seem

o io s t at t is is a e e i iss e o ealt a e i t e a ela t t e o e e t oes not seem to be on the same pa e t e o e e ts latest p oposals s a as at e t a p oposi a solution she knows both si es a a ee o si pl thrown the ball back into the s o t e sai i l t is o o t e to espo ot si pl to all a o to previous positions which a e al ea ee p o e o a le t to e ol e t ei positio i i s s i ess sa s e e a e ee oo o s o a oi i a a border, but we have not see t ose a e p a a ee le al te t i t e it a al a ee e t to provide a fallback in the e e t t at e o ts to o e a close partnership in the t e it t e ail e e is a te e to see the border as a technical question that needs a te i al a te olo i al solution – rather than a broader political and social issue that is so important for t e pea e p o ess

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ENDING THE

SILENCE Whether in the form of sly comments or physical abuse, bullying affects thousands of H doctors. They should not have to suffer in silence, as Keith Cooper reports

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Y

ou would think bullies were everywhere in the NHS from the number of reports, inquiries and newspaper headlines of late. ta at t e a o s itti to Hospital left o e e s llies as a st o e i o The Sun. ll i a its lose asso iate a ass e t a e o ta e se io sl ost ospitals o ials a politi ia s a e a io e ets a a e is o e a t a to e e o t e well-known inquiry into the ‘terrible’ s e i o patie ts at ta o Hospital in 2013.

Ho e e is t so e to e i p all i t e a e i t e o a t le o e i i e as o e o to told us? o a t a e a oo s eo o e e e e i i e o s lta t to a e t t ee p ss ooti ao it ee a e li es are on the line, or lost, at the end of a st ess l s ift a t e loss o a a eall e t eate as ll i at is it e a tl e o to o s i t ai i o o a ollea e o oss o a o a t i to a ass e t at to o e o et ea se o i to s o es o o to s o s a e t ei e pe ie es it t e t is ea it ta es a o s o t e al ost i pe epti le to t e o i t iole t e i telli e t people a e i ol e it a e s tle o e ps iat t ai ee sa s o e pe ie e as o e a o e ts estio i i a i te o ato a e a e to a s e estio s a ai a a ai e ta i pleas e i telli e as o e e ale e e ti o e t ai i e alls ei pi e to a all t e t oat a e e e e i i e o s lta t e too too lo to e ie a patie t appa e tl thedoctor | September 2018 13

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ELTON: e a ti ote to p o essio al p ess es o o to s is a se se o elo i itti

to Hospital

‘During his angry outburst he made r ss fi t t s claims’

fte epo ti it s e as tol ot to a e t o le it i t a e t e e e es e o e to a i e e t ospital e sel o e e est o e s e sa s spe ialt t ai ee as tol to o a e ist a i a oo ll o it esses e sai ot i o o e steppe i to sa t is as i app op iate t e t ai ee a s pa t e as o e e a s o te at a ollea e i i le a iliate i o t o t ai ees t e o e o t ot e pa t e s i e p a ti e ea e o ail t e a o t sa s

Angry outbursts e e al elt llie ei e i e o i o a a e ollea es t as e ea i o e espo e t sa s ot e a ale o s lta t as e i e a a i alise a o e se io a a e i ollea e is l i ate i e a i a ole e o e it o t o s ltatio ea s s a o to s elt llie alse a satio s as e i i e a io s i is a o t st e a e ossl titio s lai s a o t a lette a itte o e s eo ote s e ot a ie e a e al e til it e e it a

t eat to a ee e e ale t ai ee elt se all a asse o sta t o e ts o a o s lta t a o t t e le t o e le s He tol e e is e e as a i a a ai t elt li e e as t i to p t o t eele s ot e alle e i to is oo to sit i a ai lose to is o o o l t sit i it it o t o le s to i is ai ees it isa ilities elt llie e easo a le a st e ts o o e e ot o o e o e e e see as a ea li t ai e s a o so e ollea es o t see to e sta t e li itatio s o isa ilit o at easo a le a st e ts ea o e sa s o i o itio s a e t a p ote tio s e to isa ilit sa s a ot e t ot e se io o se o e s e e o st ti e a si e o ot p lli ei t ese epo te e a io s a e te p o essio al a pe so al li es to a i e ees a elt isolate o e to ta e si lea e o i so e elt p is e ai ees s it e spe ialt t e s it o elt t appe o l ta e a tio t o st et a so ote a e to o it t ese ollea es o t e est o a ee o e e ale s eo sa s e e al st le to e o e a

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no one to turn to,’ one GP said. ‘My mental health started to deteriorate and my family relationships were s ei ose to esi One trainee felt bullied by their e atio al s pe iso o a ea t st pi l pe se e e t i i e e t all it ill pass t osts e a lot o sleepless i ts st ess e tal a p si al health problems.’

Inclusion matters Hostilit o ollea es la o o passio a isolatio it o to s pa ti la l a o sa s a oli e lto a o patio al ps olo ist ose oo Also Human: The Inner Lives of Doctors, a s o e a ee s ppo ti t o sa s o people e antidote to professional pressures o o to s is a se se o elo i a i ollea es o a tal to a espe t o s e sa s solatio o t at t e is pa ti la l to i o ll i is a p o le o o to s it see s t s o espe te o a e o e e o tol s t see s to it all a es o p a ti e a spe ialties The Doctor heard from o to s i la otla ales a ot e ela e H sta e e last as e in 2017, one in four said they had felt llie o a asse ollea es pe t o e i o e isa le o a la o i o it et i a o les ia a o ise al t e o ial es sa a lie t is ea t e s e e thousands of members to inform its a i s ppo ti e olla o ati e p oe t i ai s to e elop a positi e isio o a ette ealt a e system. o ft s sai t at ll i e i i o a ass e t as a p o le i t ei pla es o o o o s lti it e es i l i t o a e o e e ts t e is o i o p a ti al solutions to address the problems in i lt e a o o e i o ot e se ll i e a io s

Bullying and harassment – what you told us e ollo i a e a o a o li e po tal The Doctor ope e last p il as i o to s to s a e e pe ie es o ll i o a ass e t Consultant anaesthetist a e ee llie o t e last ei t ea s a se io ollea e t sta te it i i i e o e o all ties t ot e la i t e totals as se t e te ts afte o plai i a i a totall elpless positio a o sia o i i He is ite oo to a ot e s

Specialty trainee t sta ts it o s lta ts t eati o as t o o ea i ele a e e li i al i e to tol e t e si pl o ot a e ti e to tea s e a e o tea i a a e loo e o o

GP trainee o t e e e t e e a t poi t t i s sta te o ill t it st a e ee ea l o He e e i to is o e o a ail asis o so e pe is e ea o o ot e e ail e ati s i i se e it to t e poi t e e ea o a He as e e t ee ti es o o t i a o elt p ess e sai o

oi a alli ei e ease ll i

Surgeon as i esti ate a a asse e essa il t o l a e ee so te o t it a o e satio at e t a p tti et o t e i e t a t a et e so ll a e to a e sel to t i to t e s ste o t a t t e to a ot e i i a o ts o se t i s appe to ot e people

Consultant and medical academic o se io o to s t e lt e is still e t at o s it p ese t i s appe a i le a e ite i l s ess l ot so eo e o a o l o si e to e at is t es e e ist ess e e ts o pe so al li e a a ial a

GP as llie as a e l ali e t sta te e t ie to a e o es to a s pa t e s ip a i te si e e a e appea a e i a o a e it spi it al e plo atio atte pts to see pea e l esol tio e e laste o t o t e ate t as ee ea s a a e st le to e il li e a e e te e e al p a ti e thedoctor | September 2018 15

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‘When intelligent people are involved, it can be subtle’

READ: ‘Bullying and harassment has been a i i

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but may sometimes help exacerbate them.

Although it can seem intractably i lt t e e a e also a tio s i t ose o eel t e sel es llie can take.

BMA members can call an e plo e t a ise t s est to all at t e st i li t at o e ei llie sa s ea o e e e plo e t elatio s ill e a o o e sees t e se i e ‘Sometimes people do come to us e it s a it late a it s a e to esol e t i s o eel o a e ei llie pi up the phone. A specialty doctor did st t at a as la s e i e tol t e a t to si e el t a o o o elp a o s ppo t at a pa ti la l i lt ti e o a elpe e ai a o e ti e pe spe ti e e elt eall elpless This is supported by guidance o t e e plo e t a iso a o iliatio se i e i sa s t e e s a ette a e o so ti t i s o t a p e e ti ll i sp ea i i it is ealt it ea l i e e at e i is e s e a a s it o t it esses it a e o e pe so s o a ai st a ot e s o to s a e a ise to eep ia ies

o i i e ts a t e ee to e tal e t o t e p o ess o aisi o e st o o ial a els a they need to be supported through a i i ies o issio e t ei employers. s a io a ise s s ppo t o to s a se o ll i too s ases s e a sa s t e e a e st i t se it alls aise a i ee t a ise s o ea si e la o to s a a a ass e t a o o sl i t e is it ee o to spea p a ia s o i t e ea e e s a at least o e i ea ospital t st a ie ea a i e iat i e i i e at i e sit Hospitals l o t H st as t e st io o to to e appoi te to t e ole e atio al a ia s e i o e sees i is ee o o e t ai ees to si p ‘Bullying and harassment has ee a i i a oss all o t e a ia s ea sa s o e people sa t i a ei llie e i e o a asse t es o t se t e ll i la el tt o o e satio s it loo s li e t at is at s ei es i e t te s to e e i i at e t a s o ti o a essi e e a io e a s t s a o t people ei tol t e e ot oo e o s i e

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GUARDIANS OF THE REALM: Plymouth Hospitals (left) is one of the few to have a junior doctor in the role of ‘freedom to speak up guardian’

comments in rooms full of people. That nothing you ever do is good enough.

There’s nothing you can do about it, even if you work really hard.’

Trainees felt undermined by senior doctors, including those in charge of their training, according to the experiences some shared. More than 140 reported ‘belittling or humiliating’ behaviour to the GMC last year.

Such behaviour is ‘absolutely not acceptable’, says Health Education England’s GP dean for the eastern region Vijay Nayar.

‘These allegations are followed up and investigated.’ He said feedback to trainees should be given in a respectful way which is sensitive to their needs.

If relationships broke down, GP trainees could seek help from their programme directors, associate deans or heads of school.

So help is there to address immediate concerns. For the longer term, the BMA is leading a campaign to change the culture of medicine and is holding a conference in November.

‘I don’t believe that bullying and harassment is all in the game of the medical profession, as some still do,’ says BMA representative body chair Anthea Mowat, who is leading the campaign. ‘You’ve told us you want an end to it. We won’t stop until it does.’

A ‘tradition’ which must end You’ve probably heard quite a lot about bullying already.

How bad it is for patient care.

About being strong and speaking up. Here’s a leaflet, there’s a phone line. Let’s tick that box and move on.

But I want the BMA’s anti-bullying campaign we’ve begun to be different. We need to start a conversation with everyone, including the bullies. We need to end the silence. To not stop until everyone knows where to find help and feels safe to do so.

We need to help those who harass us to change. Some of us might have to admit that we’ve been bullies too.

We know there’s a problem.

We’ve listened to your experiences of being isolated, frozen out and marginalised by colleagues. Those feelings of being trapped, forced to work alongside your aggressors; how it harms your career, your health, your home life. The false accusations.

In cold, hard facts, one in five doctors are bullied or harassed in the NHS. As a staff, associate specialist and specialty doctor, I was regularly informed of my

‘junior’ status by a colleague.

Into my anaesthetic room he’d come, twiddle the controls on my perfectly balanced machine. Nothing said. Just changed it, then walked away.

I was so stunned.

We must do something about the bullies, too.

Some don’t recognise their patterns of behaviour and the damaging effects they have.

They might be horrified, they might not. Or what if it’s out of character? Is there trouble at home? Even doctors get ill, of course. We must think of the future, of changing the culture. About how we treat and train the next generation.

How to put paid to the unproud tradition of training by humiliation, which some still pass on. We need to find role models for doctors and team leaders, an alternative to belittling power plays.

I don’t believe that bullying and harassment is ‘all in the game’ of the medical profession, as some still do.

You’ve told us you want an end to it. We won’t stop until it does.

Anthea Mowat is BMA representative body chair

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A passage from India ‘They come here…’ And so goes the age-old rant about immigrants. In a new se ies a o t t e i al la le e e ts overseas doctors have brought to the NHS, The Doctor thinks it’s time to take that phrase back and put it to good use instead.

He e s t e st p o le o so t ales Hasmukh Shah. Tim Tonkin reports ‘Overseas doctors e r in the areas here one else te to go’

T

e alle s o so t ales a e see unimaginable change.

In two generations the pits have gone and the heavy i st as la el ollo e But while slag heaps have become nature reserves, and tough jobs replaced by no jobs, there has been a remarkable constant. e s o ae o t e miners, the ex-miners, their children and grandchildren will, more likely than not, a e ee o sia o i i During the last decade it was estimated that around t ee a te s o si t e

Rhondda and neighbouring valleys were Asians.

Many at that point were still t e st e e atio immigrants who answered t e all o s essi e ealt ministers – including Enoch o ell o all people o o to s to elp ll t e aps in UK medical provision.

The doctors came not just o so t sia t also east i a pa ti la l a a ollo i i i s e p lsio o t e sia pop latio a Kenya. e a as o i western India in 1947, Britain was about to lose the jewel in

COMMUNITY SPIRIT: a o t e community in the Rhondda (pictured) ‘so nice. They e e illia t a espe t l

its empire but gain the jewel i its el a e state He would have grown up knowing much about the o e olo ial po e t less a o t t e els valleys where he has spent the last 30 years. at e i o t a s to his parents, was that his destiny was to become a doctor. ot e a at e told me as a child “you have to become a doctor”,’ says Dr Shah. ‘Back in India, being a o to is a o le p o essio to the point where you are almost worshipped by people.’

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‘Because I was an overseas graduate, the first preference for jobs tended to go to UK graduates’

Planned to return He came to the UK, aged 27, with a plan. He would spend some time in the NHS, complete his training to become an ENT consultant, then return to India. As with so many other NHS ‘lifers’ who have come from overseas, he didn’t mean to stay.

‘Initially, when I came, the main reason was that if you gain your postgraduate medical degree and experience in the UK, and then return home to practise, you do very well.

‘UK medical education was, and still is, seen as the

best in the world.’

It was 1975. Dr Shah arrived alone at Heathrow Airport. He had £3, as there were limits on the amount of currency people could leave ia it t as t e st time he had visited Britain.

He had no family here, no professional connections.

Fortunately, he knew one colleague from university in Gujarat, who collected him from the airport and was his host while he applied for a job. i a ts ofte spea of the new sensations they encountered on arriving in a new country. The feeling

Dr Shah had, which he had never previously experienced, was loneliness.

‘It was very lonely. I was on my own practically the whole day while my friend was at work, the only company I had was the TV. This isolation was something that I had never experienced when back in India.’ It was six weeks before he spoke to his parents by telephone.

Money woes The three pounds did not last long, and he had to borrow money from his friend while e sea e o is st o thedoctor | September 2018 19

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SHAH: ‘My mother and father told me “you have to become a doctor”’

e o a e afte a o ple o o t s a lo positio at a istol tea i ospital i i e as e o a e a st alia se io e ist a He as so i p esse it e pe ie e a espe te o le e t at e tol e to ot aste a ti e a o plete o t ai i as i l as possi le a t at o l e o e a o s lta t very quickly.’ t espite t is i itial e o a e e t e o o l a s essio o lo o s at e t a pe a e t oles e a se as a o e seas a ate t e st p e e e e o o s te e to o to a ates et e t e a t e sa e a o t o t ai i as e o ot espite ai i e pe ie e o i o al ost ea s i e sa o ope o e o i a o s lta t alt o e app

HOME FROM HOME: Dr Shah came from Gujarat (pictured), India, to the UK, where a friend from university helped h fi h s eet

i

is o e li e a ie it t o il e e as i easi l espo e t o e is a ee p ospe ts afte al ost a e a e i t e o l see t at i ot have any chance at becoming a o s lta t e a se as a o e seas a ate t as e e o alisi ‘I knew that going back to ia to sta t i p i ate p a ti e it o t a si i a t a o to o e e i e o l ot e eas ot il e e e also o i t e s ool s ste a my family and I were happy li i i t e t s a e te e t ai i a o t at e loved it.

‘I knew I could not make a a ee o sel i a t at o l t to esta lis sel i e e al p a ti e a t at i o i t e o it I would go back [to India]. t e st a e e al

practice training] I met a brilliant trainer – Dr Walker.

Coming home I told my wife how much I had enjoyed it.’

He is e is t ai i ti e iatel st le to se e a o i t e a e o extremely high competition. e o see e to a e to appli a ts e e getting a locum job in general p a ti e as i lt

Happy and settled it pe siste e a patie e a e e t all la e is st ole as a setti p is p a ti e i Llwynypia in the Rhondda Valley. He quickly fell in love it is e s o i s a p o essio al ole e people e e so i e a a e still i e e e e so illia t a espe t l espite ei a elati el s all al o it a sa s its ealt a e ee s e e ofte o ple a lti pathological in nature.

‘The unemployment rate a o t e o it as e e i e sa s e o a as a i i a ea a at t at ti e s a lot of people were unemployed. lo it iss es s as ep essio st ess p o le s it al o ol a a se o l also see a lot o patie ts it espi ato p o le s es lti o t ei ti e o t e i es ei t e lea i a lose it al a ea ea t becoming one of the local o it s lea i a ost e o isa le es a ole a espo si ilit t at a sa s e eatl el o e s ell as ei t e lea pa t e o is p a ti e a se e as a e e o is lo al ealt oa o ea l ea s

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‘He fell in love with his role’

became an executive member of his local medical committee, and served on the BMA Welsh GPs committee.

Latterly, he has been elected as secretary of the British Association of Physicians of Indian Origin Wales, and been appointed as visiting fellow at the University of South Wales.

Earlier this year, he received the British Empire Medal, and was invited to Downing Street as part of the NHS 70 celebrations.

Still a practising GP, his experience matches that of thousands of others who have come to the UK to lend their skills to a service in acute need. He has overcome hardship and rejection in the process.

The Asian GPs of south Wales are one part of a remarkable story of immigration, which is not just a source of pride for the UK but a source of survival for its health service.

The Doctor hopes to tell other such stories in the months ahead.

It is a scenario from which Dr Shah believes everyone stands to lose out.

He says: ‘These [overseas doctors] are the backbone of the NHS,’ he says. e ofte o i t e areas where no one else wanted to go and in understa e a eas s as e e al practice, geriatric medicine, psychiatry and emergency medicine and GP out of hours. t is i t is a t at e ll up the gaps, and I think the NHS would have struggled without overseas doctors.’

Working in the UK Doctors and medical students from outside the EEA (European Economic Area) looking to work or train in the UK have to meet certain requirements: – Non-EEA students looking to study medicine will need a Tier 4 visa – To be eligible for a Tier 4 visa, applicants need an o itio al o e o a e i al s ool a visa letter from a licensed sponsor and evidence of s ie t s to o e t ei o se ees a li i costs for up to one year – Non-EEA doctors who wish to work in the UK will need a Tier 2 visa – Eligibility for a Tier 2, requires that doctors have a job o e i eets t e esi e t a o a et est and receives an appropriate salary ppli a ts ill also e i e a e ti ate o spo so s ip provided by an employer or deanery.

Until June this year, the Government imposed a cap on the numbers of Tier 2 visas, which could be issued each month.

The cap saw hundreds of non-EEA doctors who had secured jobs in the NHS prevented from starting work in the health service.

Following lobbying from the BMA and other organisations, o e se eta a i a i lifte t e ap bma.org.uk/immigration The BMA has this month launched a free online information sharing resource aimed at non-EEA overseas o to s loo i to o i t e o a ess t e se i e which requires registration with the BMJ, go to: bma.org.uk/overseasdoctorsadvice thedoctor | September 2018 21

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Wake-up call Doctors who are constantly tired risk their own health and that of their patients. The BMA is pressuring employers to address the causes of sleep deprivation.

Tim Tonkin reports

he e e ts sh r s st t rs t r

re

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DRIVEN: Trusts are increasingly o e i ta i services to get tired doctors home

‘W

hen I was a foundation year 1 and F2 I remember having to drive home exhausted was quite a common thing,’ says Daisy Yates, a junior doctor.

‘I remember driving and my eyes starting to go and having to open the window [to wake myself up].

‘If you’ve done a 12-hour s ift t e a o s i e to get home, you will have been awake for a large amount of time.’

Dr Yates, now a specialty trainee 5 in old-age psychiatry, is recalling the dangerous levels of fatigue s e ofte elt i a previous commute.

‘Once you go home you obviously have your sleep, but by working nights you are changing your whole [sleep] cycle,’ she says.

‘You’ve also got to consider t at o i o all is ofte busier than a normal day s ift Tackling workplace fatigue resulting from sleep deprivation has been one of the BMA’s objectives during 2018.

A paper on sleep ep i atio a t e e e t o i e e t o i patte s

on doctors was published in January, revealing the sta tli e ati e e e ts that fatigue can have on a doctor’s health and professional performance. t o t at t e e e ts o s ift o i e ea ‘substantial risk factor’ for fatigue, with doctors among the most at risk owing to the ofte i e la a a tiso ial hours of their work.

Encourage employers Following up on this paper, the BMA produced a fatigue and facilities charter to a ess t e o ti e e ts of sleep deprivation, fatigue and burnout on members of a profession who are having to sta a i easi l under-resourced and overpressured NHS. At its core, the charter attempts to support employers in upholding good practice, through a set o lea l e e actions.

It stresses the importance o oo ota esi e e ti e induction and training to elp p epa e sta se to working nights, and to i i ise t e e e ts of fatigue resulting from working on call.

It says mess, catering and rest areas should be p o i e to o all sta a that the facilities of these areas should adhere to a basic standard, such as a bed, towels, clean sheets, telephone and power sockets.

The charter also calls for employers to ensure there is reserved parking o sta o i o all a when providing rest facilities is not possible, that taxis and alternative travel services be p o i e to sta at t e e o t ei s ift Since its introduction in March this year, uptake has been encouraging.

Data gathered by the BMA has found that 88 per cent of relevant English trusts have adopted the charter in principle, and 17 per cent in full.

In line with recommendations made in the charter, 82 per cent o t sts o e i tio s a t ai i to sta e to working on call, 78 per cent have rest facilities for on-call doctors, while 81 per cent have travel arrangements such as a taxi service to get tired doctors home at the e o a i t s ift Despite these successes thedoctor | September 2018 23

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COSTACHE: ‘There are very few doctors covering the hospital at night’

‘There are two bedrooms, an area to sit, a TV, a fridge and an area to make food’

there are areas where improvements are still needed.

While 74 per cent of trusts provide mess or commonroom facilities for on-call sta pe e t o ot a only 2 per cent have an action plan in place to rectify this. ea ile pe e t have redesigned rotas to i i ise ati e t o per cent have not and 5 per cent have plans to change this.

The trusts with no immediate plans to make changes to promote doctors’ health and patient safety a e i a i o it t they collectively employ t o sa s o sta ates o is ase at London Road Community Hospital i e sa s t at while the trust signed up to the charter at one of the most recent local negotiating o ittee eeti s a aspects set out by the charter are already in place.

‘The good thing about our trust is that [for those on call] t e e a e t o e oo s a a ea to sit a a i ea

an area to make food.

‘I know somebody who when they did a weekend onall t e e e a le to sta o site the whole weekend.

‘If you’re in the position where you are too exhausted to get home again between o all s ifts a i a ess to a room for the duration a es a eal i e e e ‘The sleep charters are a e i po ta t iss e especially in trying to reduce levels of burnout and improving general well-being among doctors.’

Hampshire paediatrics ST1 Cristina Costache says that the introduction of the a te ile still a o i p o ess as ee a i po ta t step i t e t to tackle fatigue and sleep deprivation in the workplace. e sa s ati e a o i ile ti e a e ofte ‘hidden subjects’ among members of the medical p o essio it o to s ot wanting to admit or discuss when they’ve been pushed beyond their physical limits.

‘People don’t like to talk

‘Nirvana’ – a good on-call room My on-call room – all hospitals should have a good on-call room, it makes all the difference. #FightFatigue #YouMatter @MunchkinDr Carpet? blinds? sheets?! What is this, nirvana? @ncl_medic Is that... an ironing board and iron? @DanBeale1 PC connected to intranet for results and imaging? Surely not? Fridge either broken or full of mouldy food. @jtg_baoms

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about their weaknesses. It is e i lt as a o to to a ept t e a t t at o a e ea e o li it e a se e e all pe e tio ists a it s t e ost st ati t i to ealise o e ea e o li it ‘It makes you worry [when o e t at ti e e a se o ealise t at t e e a e e e o to s o e i t e ospital at i t t a es o o e a se o t e o e a o a e espo si ilit o t e sa et o o patie t a se o l espo si ilit o o o sa et t a e ts t e a o eel as a o to a ot ei a le to eet t e pote tial t at o e e pe te to e a se o ei ti e osta e sa s t at ile a o to s a e a le to a a e t ei ati e le els o s o t pe io s o ti e a a latio o ti e ess a e e t all et t e ette o e e t e a iest i i i als o ts to ta le a ses o sleep ep i atio a ati e a i p o e o i sta a s o o to s o i o all a e ot li ite st to la ales is also e ta i e o ts to i t o ea sleep a a ilities a te it e otiatio it t e els sse l a H o e e atio e a s it its lis o te pa t t e els a te ill e o ise t e ee o a i e sal sta a i o to s a ilities it a o s o ota esi a i a e to e plo e s o ette p a ti e o a essi sleep ep i atio a ati e io o to s o ittee ai ee es i es i a sa s t e

Core elements of the BMA’s charter WIJESURIYA: e a te as ee o e o t e ost i po ta t pie es o o t e asso iatio as p o e

a te is o e o t e ost i po ta t pie es o o po e t e a el o es t e e te t to i t sts a oss la a e so a e a e it it He sa s e ati e a a ilities a te as ee o e o t e ost i po ta t pie es o o t e asso iatio as p o e i e e t ea s t ies t e a i epe e t o ies a e o siste tl i li te t e s ale a se e it t at ati e poses to t e e i al o o e io o to s o ittee ep t ai ete a p ell a s t is positi e that so many trusts are o i to a opt t e te s o t e a te a ta i steps to i p o e o itio s eit e t o p a i a ilities o app op iatel o i i otas e ill o ti e to s ppo t o to s lo all to e s e t at t e a e a le to a ess t e i alit a ilities t e ese e p o oti oo p a ti e a i li ti e e a ilities a e ot p to s at bma.org.uk/fatigue

Rostering and rota design otas s o l e t a o lo s o se e o se t a o si

esi e it ifts i a o a ti e s ifts a a o pe

o oe a i o oe io

Induction and training sts s o l e s e t at a asi e atio o sleep a o i i ts is p o i e to sta i t ei i itial i tio

Common room or ‘mess’ easil a essi le ess a ilit it app op iate est a eas s o l e a aila le to sta o s a a se e days a week.

Catering e a te states t at sta s o l a e a ess to so e o o ate i a ilit a s a ea it a ilities s as i o a es a aila le i i sta es e e t e a tee is lose

Travel plo e s s o l p o i e s ie t pa i o sta a alte ati e t a el a a e e ts o o to s o a e too ti e to i e o e ollo i a s ift

Rest facilities for doctors working on-call sts s o l e s e t e e a e sleep a ilities eeti e e i i sta a s a aila le ee o a e o all sta o a e oste e o ol ta il esi e t o all at i t

thedoctor | September 2018 25

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on the ground Highlighting practical help given to BMA members in i lt

spe ialt o to o ta te t e o a i ea s ppo t as s e elt llie a a e lo a a o se e tl o e o si lea e e as a o pa ie a ep ese tati e at e et to o eeti where it was agreed, in future, that there would be better a o e s o lo s e as also ass e o a sa e o i e i o e t po e et to o

sta asso iate spe ialist a spe ialt o to as tol she had been overpaid because of a duplicate retention pa e t espite atte pti to esol e atte s o se e al o t s s e a aile to a e ea a it e t st eeti it t e o to s e plo e t e representative found that the doctor was being paid for 10 s a ee t a t all o i a as o e a la e s t a s e a ee o e pai e e plo e a ee to o set t e e pa e t a ai st t e o e pa e t

A consultant had become aware that when she started e st o s lta t post s e a ot ee e ite it e o se io it He e plo e a ot ta e i to a o t t e ti e s e a spe t o t e e i le t ai i s e e e as s ppo te t o a le t ie a e process, and at an appeal hearing, and has since been i e a a itio al sala poi t a ate se e al ea s

A junior doctor had been given an ‘outcome 4’ at the annual review of competence progression, which would have prevented them from continuing with their training.

A BMA adviser gave support and guidance which, in the o s o t e e e elpe t e sail t o a i lt appeal process’. The result was changed to an outcome 3, which means additional training time is required, but without losing a place on the programme.

The BMA helped a consultant in arranging a phased return to o ollo i a pe io o si lea e e o to as ee a le to e e e o pla pe a e tl o s (programmed activities) down to seven PAs, with some e i ilit to e a le e to o o o e e s e ee s to e o epo ts s e is e e all eeli ette a e i i e es o si lea e a e e e

26 thedoctor | September 2018

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the secret doctor

opinion

Our badge, our security, our identity

‘Jesus, that’s a long time to be in training!’

We’ve all heard this one.

Given medical training takes between nine years (for a graduate-entry GP) and 16 (for a neurosurgeon who intercalated), it’s fair comment. And precisely because it is so long, there are plenty of opportunities, over the years, for all kinds of people to tell us so.

This time, the remark came o t e il e i landlord’s bathroom. He’d o e o o a tea ea and it had seemed only polite to have a chat.

I pointed out that, actually, most trades and professions have long training, even if an i o al o e o e a ple didn’t he himself have to eep lea i a o t i e e t building techniques, or maybe new materials?

He agreed enthusiastically.

There was always lots to learn in the building trade – so many new things to keep track of, so many skills to brush up.

‘But for you,’ he said,

‘there’s one main thing, isn’t there?’

‘There is?’ I asked, puzzled. Did he mean human physiology? Surgical technique? Bedside manner?

‘That thing,’ he said, s appi is e si irritation at his inability to bring the word to mind.

‘That thing you wear round your neck.’

Finally I grasped it. The stethoscope. For this man, the stethoscope was not only the symbol but the actual locus o e i al e pe tise e could master that central tool, and all its mysteries, we were doctors indeed.

OK, I had to rely on those many years of training to suppress a smile. Few adults with much formal education would share the builder’s view o at least e o l e p ess it so unselfconsciously. But the stethoscope does have a special place in medicine, which goes far beyond its practical utility.

I use my stethoscope on a daily basis, to check

for bowel sounds, to assess air entry or to listen for a murmur. That’s not all I use it for, though. I use it as a badge of identity, wearing it round my neck when I meet a new patient, even if I have no plans to auscultate anything.

I use it to reassure family members, as they watch me go methodically through the it al o e a i atio se it to e a i e a e o s il starting with their chest, even if I’m really looking for a cerebellar lesion – because that’s how Dr Brown Bear e a i es eppa i It’s by no means only theatre. For now, the stethoscope is still genuinely useful. But even when it’s been well and truly superseded – by ultrasound, genomics or even the tricorder – will we be ready to leave the time-honoured emblem of our profession behind?

By the Secret Doctor bma.org.uk/ thesecretdoctor @TheSecretDr thedoctor | September 2018 27

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it happened to me

opinion

Sorting the men from the boys When is a child not a child?

When you want an opinion on a 16-year-old in August, apparently.

I phoned the on-call medical registrar recently.

Not too worried but a little out of my depth – and thinking a chat with a colleague might help.

As an aside, one of the peculiarities of general practice is the door. The mighty and powerful door that closes when you sit down with your patient, shutting out all other eyes and brains and medical input, so that sometimes the consulting room can be a lonely place. e afte all t ese ea s the thing I most miss from hospital jobs is talking about cases with colleagues; the

Doctors’ experiences in their working lives

ward rounds and the various meetings, where brains can be stormed and management pla s a e oate o e all alone in GP Land, unless you refer.

In times gone by, we used to tal i o ee a lunchtime, and I believe there are still practices where colleagues discuss patients and unicorns peacefully graze the sunlit uplands outside.

But most of us are just too busy, and the queue of patients in the waiting room just too long. So you plough a lonely furrow in general practice, and refer when truly stumped. And just occasionally, you phone a friend.

As on this occasion. ot i ite ts a t e la looks OK, but some blood results are a bit o a really want to talk to someone. And the lucky someone I pick is the general medical registrar.

And now the games sta t e st question is his precise age.

That’s easy; 16 and one month.

Ah-ha! In that case he’s paediatric and for the oncall paediatrics registrar.

This seems a moot point, as the problem really isn’t a paediatric problem.

I parry; he’s a big lad, and I’m happy that this is an adult case. The

quick comeback: what if it’s a paediatric condition of which the adult medical registrar has no knowledge? What?

Really? No. I don’t think so.

OK – but is he still at school?

No! He’s an apprentice, which makes him an adult! Surely this trumps all? But no; the coup de grâce – has he had his GCSE exam results?

This is a new one on me.

In all my conversations with my hospital colleagues I have never before been quizzed on the educational milestones of my patients. I turn to the bemused lad and his father; well? Has he?

No. And I lose. I know that GCSEs are responsible for much stress in life but who knew they carried such profound medical implications?

I call the paediatric registrar who refuses to discuss him, patiently explaining to me that this is an adult case.

The patient remains undiscussed.

Later that night, dad turns up with him in the emergency department and he gets seen, one way or another. We all live to t a ot e a a all is well that ends well.

Further enquiries with the powers-that-be reveal that the hospital policy is that you are in fact a child until you are 17 – except for on some occasions when it’s 16 and a day. So that’s clear.

Meanwhile the queue outside my door grows longer.

Beatrice Duck is a GP. She writes under a pseudonym

28 thedoctor | September 2018

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the consultation

interview

The Doctor will see you now

LINTON: ‘Comments, the small looks, the everyday things that eat away at people’s sense of self-worth’

As a black woman, Samara Linton felt isolated at medical school. Now a junior doctor, she has co-edited an anthology exploring the mental health experience of black, Asian and minority ethnic people in the UK We moved to the UK from Jamaica when I was seven.

When I was 14, my parents talked about moving to Canada. I said, no, I want to go to Cambridge. I was very oal o ie te a it pai o In my second year, I wrote a blog about cheeses. It had a rant about people going o a o t t e i e e t a es as if any ordinary person would know. It was just little things like that, adding up to make you feel out of place. When you’re already feeling low, it makes you feel even more isolated and alone.

I saw a university counsellor. I talked about feeling disconnected from the predominant culture there but they struggled to understand.

It wasn’t her experience.

People don’t necessarily understand what it’s like to be an immigrant or a

black woman in a majority white institution.

I ran an event about intersectionality and mental health. People talked about o t ei i e e t i e tities their race, sexuality, gender and religion, interacted with their mental health. It was what I was experiencing personally, what was coming through in my studies. It was clearly something people wanted to talk about more.

My schoolfriend asked for help with The Colour of Madness. She’s my co-editor.

It’s a glimpse into having e tal ealt i lties i o are not white, through writing, poetry and artwork.

There are some common threads. It’s the small things, though not really small.

The microaggressions and othering. Not necessarily overt racism, or sexism, or

Islamophobia, or homophobia.

It’s the comments, the small looks, the everyday things that eat away at people’s sense of self or self-worth.

Some are quite hard to read because they are really critical. Some feel unfair.

We put them in anyway.

It’s what people actually feel.

It’s really challenged me to e e to p o essio Last year, I was like, psychiatry, yes, it’s what I want to do. But you’re stepping into people’s real, messy lives. Even if the o te ts a e i e e t t e e are small, unexpected things that trigger you and make you feel exposed or shaken up.

It’s still a contender. Right now, I don’t know. I still have some ti e to e it o t The Colour of Madness is published this month thedoctor | September 2018 29

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explainer NHS jargon, political changes, and contractual intricacies – explained in plain English

Tapered annual allowance h e e t

es h e te re r t e t

e s rete t

r

th h

s

fi

t

What is the pension annual allowance?

What are the concerns about the TAA?

This is a threshold which limits the amount your pension can grow each year before tax charges apply. When this growth exceeds the threshold, the charge seeks to ‘recover’ the tax relief on your contributions. The annual allowance is set at £40,000, applies to all your registered pension schemes and has been ‘tapered’ since April 2016.

The BMA, along with other unions, is concerned that the TAA is having a si i a t e e t o e it e t a ete tio t pe alises o to s a iall when they get pay rises for promotions, take on extra work, or receive clinical excellence awards for innovative work. The TAA is deterring doctors in the armed forces from rising up the ranks. It may also encourage doctors to opt out of the NHS pension scheme or retire early.

What does tapering mean? is a a e t o to s ea i i e ess of £110,000 ‘threshold’ income if their ‘adjusted income’ exceeds £150,000. For each £2 that your ‘adjusted income’ is above this amount, you lose £1 from your annual allowance. So, if your adjusted income is more than £210,000, your personal annual allowance drops to £10,000, the lowest amount under the tapering arrangement.

What is ‘adjusted income’?

This is your threshold income (your taxable income minus your pension contribution that year) plus your employer’s contribution ( e e o t i tio s e e) pe sio growth attributable to your employer ( e e e e t s e e) ta e o

Is the BMA doing anything about this?

We have written to chancellor Philip Hammond to ask him to increase the allo a e a o e o e t e tape ot make complex pension schemes even more confusing. We have asked the chancellor to review the entire pensions tax relief system to ta e a o t o t e e e t o e it e t and retention of doctors.

For more information go to bma.org.uk/pensions Is there anything you’d like to feed through our explainer? Contact news@bma.org.uk

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what’s on

October

November

01 Pensions taxation and retirement planning seminar, 7pm, London

02 Medico-legal expert report writing course, 9.30am, London

04 Women in medicine conference, 9.30am, Devon

02 BMJ Masterclasses: neurology for physicians, 9.30am, London

04 Managing the business of general practice workshop, 9am, Glasgow 16 CESR seminar for SAS grade doctors, 9am, Manchester 17 Civilian doctors conference, 9.30am, London 19-20 BMJ careers fair 2018, 9.30am, London

08 Trainee doctor LNC reps conference, 10am, London 14-16 Leaders in healthcare conference, time TBC, Birmingham 22 Practical skills... leadership and management course for doctors, 9am, London 29 BMJ Masterclasses: GP general update, 9.30am, London

December

January

05 Practical skills for self-management course, 9am, London

18 Planning for retirement seminar – delivered by the BMA, 9.15am, York

07 Planning for retirement seminar – delivered by the BMA, 9.15am, Oxford

Visit bma.org.uk/events for full details

Doctors’ notes From unexpected emergencies to embarrassing medical school moments, each month, doctors from across the UK share their stories and experiences.

If you’ve got a story to tell, a suggestion for future episodes, or have some feedback, email podcast@bma.org.uk

To find out more, visit

bma.org.uk/podcast Available on

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