Like may of you who work for a hospital, HMO or other organized medical care, I have often been frustrated by the rigidity and dullness of administrators. Many of them go by the rules and seem to be unbending.
Once in awhile one comes across some one who does not fit into that category. A personal example will illustrate this.
After I had retired from my academic position at the University of Miami I was doing intermittent "locums" work. I had just finished a six month assignment in Okinawa, Japan and was in my traveling mode. I needed to find my next "job" and had applied to an add from Mount Edgecumbe Hospital in Sitka, Alaska. That Indian Health Service Hospital was looking for an obstetrician and gynecologist. I was interested, applied and was invited for an interview.
I liked the job and they must have liked me as I was offered a two year contact. However as a new hire they offered me only two weeks of vacation and one week of Continuing Medical Education leave. For someone with my seniority, I thought that that was insufficient and said so. I left Sitka in a sad mood as I really would have liked that job, but was not ready to accept their offer of only two weeks of vacation time. I was told that that was the Company's policy, and that they were not ready to start a precedent.
Some days later, I received a phone call from the medical director of the hospital. She started off by apologizing again that she could not offer me more vacation, as that was the Company's policy for new hires. Right away I felt discouraged, but then she added: "We really would like to have you work for us and what I can do is give you two addition weeks of unpaid leave and raise your salary by two weeks (which, by company rules she was free to do). I was elated and accepted the offer for two years. We liked it there so much that we ended up staying seven years.
I thought that this hospital administrator was using her authority to make a very creative and imaginative decision. We all benefitted.
There should be more administrators like that.
Those interested in reading more about my experiences can download an e book for free from Smashword at: http://www.smashwords.com/books/view/161522 or just Google: "Crosscultural Doctoring. On and Off the Beaten Path".
Last Saturday on ITV’s The Jonathon Ross Show, TV personality and comedian Rufus Hound announced that his candidacy for the European Parliamentary elections in May, standing for the single issue National Health Action, NHA, party. This is something that I think we (those of us who value the spirit of the NHS) should all be grateful for. The government is changing the NHS, big business is coming and no one seems that angry. Well at least Rufus is...
"David and Jeremy want your kids to die (unless you’re rich)"
A provocative title for his accompanying blog post, which of course has helped to fuel discussion. However, I think Mr Hound was right to use this, let’s face it anything that aggravates Toby Young, I am going to look upon gladly. OK, it is dramatised, but based on the evidence we have, it does seem that Misters Cameron and Hunt want an end to the NHS as we know it (an NHS that does indeed do its utmost to prevent any child from dying). We have had top down organisation and privatisation, from parties that promised the opposite pre-election, with an opposition who seem to accept the changes, and had themselves help start the privatisation of the NHS. You can see why Rufus has turned to NHA party, why hasn't everybody else?
What will Rufus achieve? To be honest I don’t think a lot. If he actually manages to be elected, as a MEP his campaigning will be in Brussels not Westminster. There is one key piece of legislation that the NHA will be looking to stop, the EU/US free trade agreement, which if passed including the NHS will mean that privatisation will not be reversible. The health and social care act opened up contracting opportunities in the NHS for multinationals and the free trade agreement will mean that future governments will be powerless to reverse the private contracting of these overseas companies. The three main parties are broadly supporting this agreement. Good Luck Rufus.
Rufus has already achieved something though. He has brought the issue he feels so strongly about to the public’s attention, in a way that no backbencher, lobbyist or journalist ever could. Since his announcement NHA party has been discussed across national media. People realise the NHS is being changed and are starting to speak up. I hate to think of the NHS going the same way as Britain’s utilities. Shareholders and profit should be nothing to do with the health and well-being of the country.
Apparently not all clowns are evil.
Rufus Hound: Comedian, Radio 4 presenter, argumentalist, and now would be politician.
Some further reading:
Trade secrets: will an EU-US treaty enable US big business to gain a foothold? http://www.bmj.com/content/346/bmj.f3574
It’s time to get serious about NHS, says comedian Rufus Hound. http://www.independent.co.uk/news/uk/politics/its-time-to-get-serious-about-nhs-says-comedian-rufus-hound-9086435.html
a person who provides expert advice professionally:
he acted as campaign consultant to the president
[OFTEN AS MODIFIER] British a hospital doctor of senior rank within a specific field: a consultant paediatrician
forming names of inflammatory diseases: cystitis, hepatitis
(Origin - from Greek feminine form of adjectives ending in -it?s (combined with nosos 'disease' implied) )
You may not be surprised to hear that the way in which I recently heard the term 'consultantitis' used cannot be understood to mean 'inflammation of the senior hospital doctor'. Although, I wish it was.
Professionalism, compassion, transparency, teamwork and communication - all terms that appear to be used with an increasing regularity within the NHS. These are concepts that are not merely taught but preached to medical students today. Why? Well it is nit merely the work of a heavily publicised inquiry into a foundation trust, neither is it the upshot of the medical profession's own Voldemort - he who must not be named (except I will name him - Harold Shipman).
Is it then an attempt to heal the wounds within our national health service from within? I hope so. Yet, there are countless more 'isms' and other terms being muttered under the breath of healthcare professionals all over the country. 'Consultantitis' is one that fills me with sadness for one reason in particular: it suggests that those at the top are at the core of some of the problems.
Ponder over that for a while, I intend to explain myself further in my next blog post.
To be continued****.
This anecdote happened many years ago when I was a brand new (read: inexperienced) physician doing my stint in the Colonial Health Service of the former Belgian Congo. I was assigned to a small hospital in the interior of the Maniema province.
Soft tissue infections and abscesses were rather common in this tropical climate, but at one time there seemed to be virtual epidemic of abscesses on the buttocks or upper arms. It seemed that patients with these abscesses were all coming from one area of the territory. That seemed rather odd and we started investigating. By way of background let me say that the hospital was also serving several outlying clinics or dispensaries in the territory. Health aides were assigned to a specific dispensary on a periodic basis. Patients would know his schedule and come to the dispensary for their treatments. Now this was the era of “penicillin.”
The natives were convinced that this wonder drug would cure all their ailments, from malaria and dysentery, to headaches, infertility, and impotence. You name it and penicillin was thought to be the cure-all. No wonder they would like to get an injection of penicillin for whatever their ailment was.
As our investigation demonstrated, the particular health aide assigned to the dispensary from where most of the abscesses came, would swipe a vial of penicillin and a bottle of saline from the hospital’s pharmacy on his way out to his assigned dispensary. When he arrived at his dispensary there was usually already a long line of patients waiting with various ailments. He would get out his vial of the “magic” penicillin, show the label to the crowd and pour it in the liter bottle of saline; shake it up and then proceed to give anyone, who paid five Belgian Francs (at that time equivalent to .10 US $), which he pocketed, an injection of the penicillin, now much diluted in the large bottle of physiologic solution. To make matters worse, he used only one syringe and one needle. No wonder there were so many abscesses in the area of injection. Of course we quickly put a stop to that.
Anyone interested in reading more about my experience in Africa and many other areas can download a free e book via Smashwords at: http://www.smashwords.com/books/view/161522 . The title of the book is "Crosscultural Doctoring. On and Off the Beaten Path"
An email gone astray can provide fascinating insights for an unintended recipient. Written correspondence has undoubtedly fallen into the wrong hands since homo sapiens first put pigment on bark, but never before has it been so easy to have a personal message go awry.
No longer is it a matter of surreptitiously steaming open sealed letters or snooping around in wastepaper baskets. Finding out another's personal business is now just a click away. Even more conveniently, candid opinions can sometimes make an unscheduled landing in your inbox, making for intriguing reading -- as I discovered.
Some time ago, I'd sent out feelers regarding possible new GP jobs and had emailed a particular practice principal a couple of times, expressing interest. When it looked likely that I was going to pursue a different path, I sent a polite email explaining the situation and telling him I wouldn't be seeking an interview for a job at his practice at present. An email bounced back saying that my not wanting to work for him may be "a relief" as I "sounded a bit intense". It was sans salutation but, based on the rest of the content, was obviously intended for one of his work colleagues. It had no doubt been a simple error of his pressing 'reply' rather than 'forward'.
I was chuffed: I've never been called "intense" before, at least, not to my knowledge. Perhaps there are several references to my intensity bouncing around cyberspace but this is the only one my inbox has ever captured.
I've never considered myself an intense person. To me, the term conjured up the image of a passionate yet very serious type, often committed to worthy causes.
Perhaps I had the definition wrong. I looked it up. The Oxford Dictionary gave me: "having or showing strong feelings or opinions; extremely earnest or serious". Unfortunately, I couldn't reconcile my almost pathologically Pollyanna-ish outlook, enthusiasm, irreverence and light-heartedness to this description -- nor my somewhat ambivalent approach to politics, religion, sport, the environment and other "serious" issues.
At least the slip-up was minor. Several years ago, I unintentionally managed to proposition one of my young, shy GP registrars by way of a wayward text message. He had the same first name as my then-husband.
Scrolling through my phone contacts late one night, alone in a hotel room at an interstate medical conference, I pressed one button too many. Hence this innocent fellow received not only declarations of love but a risqué suggestion to go with it. Not the usual information imparted from medical educator to registrar!
It took me several days to realise my error, but despite my profuse apologies, the poor guy couldn't look me in the eye for the rest of the term.
If I was "intense", I would conclude on a ponderous note -- with a moral message that would resonate with the intellectually elite. Alas, I'm a far less serious kind of girl and, as a result, the best I can up with is: Senders of emails and texts beware -- you are but one click away from being bitten on the bottom.
(This blog post has been adapted from a column first published in Australian Doctor).
Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work here.
The NHS is one of the largest employers in the world. It is one of the largest healthcare providers in the world and it is one of the most loved and needed institutions in this country.
The downsides to the NHS is that it is constantly ‘in crisis’ and it is expected to provide better care and newer treatments with less money and not enough staff. Recently, this has caused a significant drop in staff morale and the beginnings of an exodus of trained staff out of the NHS. This needs to be addressed.
If you read almost any management textbook, journal article or magazine, they will tell you that happy staff perform better. This ethos is easy to theorise but less easy to practice. Companies like Google and Apple have taken this to heart but so did some of the old Victorian companies like Cadbury’s and Roundtree. These companies aimed to make a profit but also to invest and look after their staff because of moral and economic principles… and it worked.
I believe the NHS needs to embrace this old fashioned paternalistic concept, if it wishes to continue to be a world leader in excellent, affordable healthcare and professional training. If the NHS invests in its staff now, it will increase staff morale, encourage people to stay working in the NHS and ensure top quality patient care.
Staff canteens open 24/7 (or near enough), that serve good quality, healthy and affordable food. If staff have to work unsociable shifts, it seems unfair not to provide them with the chance to eat a healthy meal at 2am rather than a Domino's. Staff canteens also allow the staff to unwind and socialise away from the wards and the public, they can be unofficial hubs of productivity where the 'real business' takes place away from the meetings.
Staff rooms with free tea and coffee - it doesn't cost much and every appreciates a 'cuppa'.
A** crèche** for the children of staff, on site or nearby. Reduces the stress of having to take children to carers and pick them up, allows greater flexibility for the staff.
Free staff car parking (if they car share). Staff have to get to work and cars are the most practical way for most people, so why punish them by charging car parking?
An onsite gym that is free/reduced price for staff and open 24/7 so that staff can pop in around their various shifts. The physio gym could just be expanded so patients and staff use the same facilities. Providing healthcare is stressful, takes long hours and is antisocial. All these factors make it easy to put on weight, especially with most hospitals only providing unhealthy meals, Costa and Gregs. So, an onsite gym would make it a lot more convenient for the staff to get the exercise they need to burn off all that stress and calories. Healthier, happier staff!
A hospital/ centre social society like a student ‘MedSoc’ to organise staff socials and sports teams etc. This organisation could even organise special events for the staff like a summer ball or sports day. Anything fun that would bring the staff together and let them blow off steam. It could easily incorporate, elected officials from the professional bodies and elected representatives of the different employees and act as an unofficial staff voice.
Regular staff forums that allow each group of employees to raise concerns or solutions to problems with the organisations management and senior staff.
Staff rota’s should not just be imposed by management but should be organised in a flexible manner that allows staff input.
The NHS management should encourage and provide extra learning opportunities for the staff. By investing in staff education they provide people with opportunities to develop them selves which will benefit the organisation and increase their sense of satisfaction with what they are doing.
Team based points systems for good performance and regular rewards for excellent care. These points systems can then be used to promote competition between teams which should raise the level of care. Have a monthly leader board and reward the best team with a day at a spa or something.
These changes may hark back to ideas that are out of favour now with the increased desires for measured ‘efficiency’, but I believe that these suggestions would hugely increase staff well being, which would hopefully improve their attitudes towards the organisation they work for and would hence make them happier and less stressed when they are caring for patients.
If you have any other suggestions for improving staff wellbeing please do leave comments.
The NHS is enormous and has a huge variety. It would be fascinating to survey as many parts of it as possible and see how many places have these services available for the staff already. Please feel free to contact me if you know of any study like this or if you are keen of setting up a study like this with me.
A Tale of Guilt and Woe
June 2012. It was unseasonably miserable. Having successfully fought the battle of Neuro I was all ready for the next onslaught which manifested itself in the form of reproductive and endocrine medicine (us Bristolians have dubbed it EndoRepro which sounds more like an evil Mexican villain). I was making a trip to the library, which, at the time, was around a 30-minute walk away from my student house. This was to do some extra reading. I had my laptop in my bag along with my bags of Haribo for encouragement and when I’d stomached all I could take I began the walk back. It rained. It rained like I have never seen rain before. For 30 minutes, I walked in a torrential down pour and when I arrived at the local Sainsbury’s, they kicked me out because I was dripping that much I posed a health and safety risk on their tiled floor. It was a very miserable day.
When I had eventually gotten back into my room and put all my clothes to dry I stood there and thought – why. Why was I doing this to myself? It wasn’t even necessary and I’d put myself through a monsoon to go get some books and read ahead. The reason was because I’d have felt guilty if I hadn’t – I planned to do it, so I was doing it. Guilt is a very powerful thing and it’s something we all encounter as students on a regular basis. When I used to revise for my pre-clinical exams, if I stopped for an hour or two that meant I would have to extend my evening revision to cover the time. I should imagine everyone can relate to this (even those macho folk that profess to be invincible!). Stopping was not an option. In that rain-sodden day I learnt one thing – cut yourself some slack.
I never believed it when people used to say to me that “down time” was as important as work time. Down time was wasted time. Down time was a period when I missed that all-important sentence that answered MCQ Q22 on the upcoming exam. At the start of that unit I decided to take things differently. I always timetabled work, but this time I was only doing those timetabled slots if I thought it would be productive. If not, the time was better spent doing other things. If I started and felt like it was too much effort, I didn’t carry on in some marathon-like endurance exercise, I stopped. I refused to let the guilt set in. I turned my ears off to all of the talk in lectures about how much work everyone had or hadn’t done – I refused to let myself be intimidated.
So what was the result? I had much better sleep in that time. My head was a lot clearer and I found it about 100 times easier to get up for lectures in the morning. I spent a lot more time doing the things I enjoy which generally upped my motivation.
More to the point, I achieved the best set of results in two years in those exams.
I only wish I could go back to my fresher self and say:
“Cut yourself some slack. Don’t feel guilty. Do your own thing”.
The Birmingham Student’s Medical Leadership Society (MLS) held it’s third and final lecture of 2013 on Thursday December 5th. The final lecture was given by Dr Mark Newbold CEO of the Heart of England NHS Foundation Trust and was a particularly enlightening end to our autumn lecture series on why healthcare professionals should become involved in management and leadership. In contrast to the previous talk by Mr Tim Smart this lecture did not focus on why doctors would be suitable for management roles but rather on why clinical leadership is absolutely necessary to tackle the fundamental problems in our hospitals today.
Once again, the Birmingham MLS heartily thanks Dr Newbold for giving up his valuable time to speak to us and we must also thank Michelle and Angie for video recording this event as well. Fingers crossed, the recordings of both of our last events should be available fairly shortly.
The lecture began with a brief career history of why and how Dr Newbold became involved in hospital management, from front line doctor, to department lead and on to chief exec of a major NHS foundation trust.
The second part of the lecture was a brief history of the recent NHS beginning with the Labour years. Between 1997 and 2010 NHS funding increased enormously, which was a good thing. Targets increased proportionally with the funding, not necessarily a good thing. Expectations to meet the targets at all costs and punishments for failure also increased, not a good thing. Focus became diverted from providing the best possible care to ensuring that the hospital didn’t go bankrupt from failing to hit it’s targets. The “budget culture” was an unintended consequence of overzealous central target setting.
This system did have some major successes, such as overall reduced waiting times and new specialist urgent cancer referral pathways. However, these successes did not necessarily transform into better patient care or higher patient satisfaction. This came to ahead as well all know with the Mid-Staffs Enquiry, the Francis report and the Keogh review.
The recent NHS reforms have tried to change the NHS management culture away from target driven accounting and more towards affordable, yet excellent patient care – a “quality culture”. The NHS structural reforms have been well meaning but messy and complicated. The NHS culture change has begun, but trying to change something as huge as the NHS is like trying to steer an oil tanker, it takes time for the tiniest change in direction to be noticed. Add to this list of changes, an ever ageing population, an ever growing population, an increasingly chronically ill, co-morbid population and a relative freeze in budget and you can start to see why NHS managers are having such a tough time at the moment.
How can NHS managers adopt this culture?
Put their priorities in order. Quality care + Patient satisfaction > Waiting lists > Budgets
Engage with the public in a more meaningful way. Have a social media presence so that you, your hospital and its staff are more than just a faceless organisation. Have a twitter account and write blogs about your challenges and successes. This will increase patient satisfaction with your hospital.
Ask for and listen to patient reviews regularly. Make sure these reviews are public and this will help ensure that any changes made are recognised.
Better articulate why you are changing a service, e.g. you are not shutting a local A/E to save money but to save lives! Specialist centres have been shown to have better patient outcomes than smaller, less specialised centres. The London stroke service reforms are an excellent example of this principle.
Realise that a budget is a constraint, not an aim!
Create a dialogue with doctors about which targets are important and why they are important. If doctors don’t agree with the targets then they will not try to improve the measures. For example, the A/E 4 hour waiting time target annoys a lot of healthcare professionals, who see it as a criticism of their work. However, this target is in fact not a measure of A/E efficiency but actually a measure of FLOW through the entire hospital. If the 4h target is missed then there is a problem within the hospital system as a whole and the doctors needed to be aware that their service is reaching capacity and that this may affect their practice. They should also consider why the 4h target was missed and what can they do to increase the patient flow through the hospital – are they needed in an understaffed department?
The essence of this part of the lecture can be summarised by saying that “poor hospital performance has consequences for that hospital and its staff, these consequences affect clinical care and therefore, healthcare professionals need to care about the bigger picture otherwise it will affect frontline care”.
The next part of the talk went on to outline some of the recent problems that Dr Newbold has been made aware of and how this affects his hospitals performance.
35% of patients who present to the A/E department have at least 1 chronic condition.
12% of patients are re-admitted within 30 days. Did they receive suboptimal care the first time?
Patients who are re-admitted have a far higher mortality rate than other patients.
Once, a patient has been in hospital for longer than 5 days their mortality rate begins to rise drastically. Being in a hospital is bad for your health and patients are often not discharged as soon as they should be.
A hospital of 1500 people needs to discharge over 200 patients a day just to maintain its flow of patients. If this discharge rate decreases then the pressure on the system increases and beds are no longer available, which starts to decrease the services a hospital can provide, such as elective operations.
Hospitals tend to be managed on 4 layers of alert. When the hospital is on top alert i.e. the most under pressure, mortality rates can be up to 8% higher than when the hospital is at its least pressured.
By not discharging patients promptly, doctors are increasing the pressure on the system as a whole with awful unintended consequences for the patients.
By admitting patients to the wards, who do not necessarily require in-patient care, doctors are also increasing the pressure on the system. Bed blocking has consequences for the patients, not just the budgets.
The list above demonstrates how unintended consequences of frontline staff decisions affect patient outcomes. That is why it is critical that frontline staff are involved with helping to improve some of these problems. Does that patient really need to be admitted to an already full hospital? Does that patient really need to stay on the ward until Friday? Did that man with an exacerbation of asthma get the best acute treatment and has a plan been made for his long term management that will decrease the chance of him re-admitting? Healthcare staff can help by adjusting their practice to the situation and by helping to change the systems overall, so that the above consequences are less likely to occur.
This part of the lecture was really quite sobering. It spelled out some hard facts about how such a complex system as a hospital operates. But more importantly it helped clarify just what needs to be done in the future to make hospital care the best it can be. Dr Newbold quoted the RCP report “Hospitals are not the problem, they have a problem” to highlight his believe that in the future the health service needs to change to be less focussed on acute crises and more focussed on exacerbation prevention. Hospitals should be a last resort, not a first choice.
Hospitals themselves need to change how they deliver care. NHS staff need to explore ways of providing their services in an ambulatory fashion, so that patients don’t need to stay on the wards for any pre-longed period of time but come and go as quickly as possible. This will involve a major shake up in how hospital trusts fund care. They will need to increase their funding for the provision of more services at home. They need to get their employs out of the hospital and into the community. They need to work more closely with GP’s and with local social services. As the previous Chief Medical Officer said “Good Health is about team work”. Only when GP’s, community staff, hospital staff and social services work as a team will patient care really improve.
At the present The University of Birmingham Students Medical Leadership Society is in contact with the FMLM and other similar groups at the Universities of Bristol, Barts and Oxford. We are looking to get in contact with every other society in the country. If you are a new or old MLS then please do get in touch, we would love to hear from you and are happy to help your societies in any way we can – we would also love to attend your events so please do send us an invite.
Email us at email@example.com
Follow us on Twitter @UoBMedLeaders
Find us on Facebook @ https://www.facebook.com/groups/676838225676202/
Come along to our up coming events…
Wednesday 22nd January 2014 LT3 Medical School, 6pm
‘Has the NHS lost the ability to care?’ – responding to the Mid Staffs inquiry’
By Prof Jon Glasby, Director of the Health Services Management Centre , UoB
Thursday 20th February LT3 Medical School, 6pm
‘Reforming the West Midlands Major Trauma Care”
By Sir Prof Keith Porter, Professor of Traumatology, UHB
Saturday 8th March WF15 Medical School, 1pm
“Applying the Theory of Constraints to Healthcare”
By Mr A Dinham and J Nieboer ,QFI Consulting
There are roughly 7000 medical students graduating each year from 33 medical schools in the UK. Medical degrees take either 4, 5 or 6 years depending on the route you take.
The government via the Student Finance Company will pay for your tuition fees for the first 4 years of any undergraduate degree. After this the NHS will pay for the last year or 2 years of the undergraduate medical tuition fees.
The maintenance loan depends on family income. The figures aren’t easy to find for the background of most UK medical students but a ‘guestimate’ based on my medical school is that 50% went to a private school, 30% went to selective state schools and 20% went to a comprehensive. Of the private school kids probably about half had a scholarship or bursary. So, a rough guess would be that 70% of med students come from a “middle class” family who have a decent income but not huge wealth and are therefore eligible for a ‘maintenance loan’ above the minimum. This majority therefore rely on there loan to get through the year.
An average student income is between £1000 and £1500/term (£1200 average-ish). Most university terms are 10 weeks, hence average income is about £120/week. As a preclinical medical student this is fine and we are on par with everyone else. As soon as we become clinical med students the game changes!
Clinical years are far longer, more like 40 weeks a year rather than 30. Students are on placement, have to dress professionally and travel to placement daily. This adds additional costs and requires the money to stretch further. Doubly bad!
Once, the NHS starts paying the tuition fees, the Student Loans Company starts reducing the maintenance loan, by half! Why?
A final year student or a 4th year who has intercalated now has to survive at University for one of their course’s longest years with half the money they had previously. >40 weeks on a loan of roughly £1500/year. This situation is pretty much unique to medical students.
Some students are lucky enough to have parents who can afford the extra couple of thousand pounds required for the year. Some students get selected into the military and get a salary. A greater proportion find part time jobs to help cover the cost and the rest have to resort to saving money where they can and taking out loans.
When I was a member of the BMA medical student committee I did a project as part of the finance sub-committee investigating the loans available for medical students. Many banks used to “professional development loans” which allowed medical and law students to borrow money for a year before they had to start repaying the loan. Hardly any banks now offer this service, so the only loan available is an overdraft or a standard loan that requires you to have a regular income.
This means that final year medical students with limited family support may have to live for a year on less than £2000. Does this seem fair? Does this seem sensible government policy?
Medical students are 99% guaranteed to be earning over £25 thousand pounds within a year. We will be able to repay any loans. So why isn’t the Student Loan Company allowing us to continue having a ‘normal’ maintenance loan? And why aren’t banks giving us the benefit of the doubt and helping us out in our time of need?
When I was on the BMA MSC there was talk of having a campaign to lobby government and the banks to rectify this situation but I can’t say I’ve been aware of any such campaign. Are the NUS, BMA, UKMSA or anyone else doing anything about this?
Please do leave a comment if you do know if there has been a progress and if there hasn’t why don’t we start making a fuss about this!
Book of the week (BotW) = The Darwin Economy by Prof Frank
Being a medical student and wanna-be-surgeon, I am naturally very competitive. I know exactly where I want to end up in life. I want to be a surgeon at a major unit doing research, teaching and management, as well as many other things. To reach this goal in a rational way I, and many others like me, need to look at what is required and make sure that we tick the boxes. We must also out-compete every other budding surgeon with a similar interest.
Medicine is also a dog-eat-dog world when it comes to getting the job you want. Luckily you can head off into almost any field you find interesting, as long as you have the points on your CV to get access to the training. In recent years, the number of med students has increased, but so has the competition for places. The number of FY1 jobs has increased but so has the competition for good rotations. The number of consultant posts has increased, but so has the competition for the jobs.
To even be considered for an interview for a consultant surgeon post these days a candidate (hopefully my future self) will have to demonstrate an excellent knowledge of anatomy, physiology, pathology and demography. They will need to have competent surgical skills and have completed all of the hours and numbers of procedures. To further demonstrate this they will need to have gone on extra-curricular courses and fellowships. They will also need to show that they can teach and have been doing so regularly. They must now also have an understanding of medical leadership and have a portfolio of projects. Finally, they will have had to tick the research box, with posters, publications, oral presentations and research degrees.
That’s a long list of tick boxes and guess what? It has been getting longer! I regularly attend a surgical research collaborative meeting in Birmingham. Many of those surgeons didn’t even get taught about research at medical school or publish anything until they were registrars. Now even to get onto a good Core Training post you need to have at the very least some posters in your chosen field and probably a minimum of a publication. That’s a pretty big jump in standards in just 15 years.
In two generations the competition has increased exponentially. Why is that?
Prof Frank explains economic competition in Darwinian terms. His insights apply equally well to the medical training programme. It’s all about your relative performance compared to your peers and the continual arms race for the best resources (training posts). However, the catch is, if everyone ups their performance by the same amount then you all work harder for no more advantage for anyone, except for the first few people who made the upgrade. The majority do not benefit but are in fact harmed by this continual arms race.
I believe that this competition will only get worse as each new year of med students tries to keep up and surpass the previous cohort. This competition will inevitably lead to a greater time commitment from the students with no potential gain. Everything we do is relative to everyone else. If we up our game, we will outperform the competition, until they catch up with us and then relatively we are no better off but are working harder.
Why is this relevant?
I know everyone will want to select “the best” candidate, but in medicine the “best” candidate doesn’t really exist because we are all almost equally capable of doing the role, once we have had the training. So there is no point us all working ourselves into the ground for a future job, if all our hard work won’t pay off for most of us anyway. But we can’t make these choices as individuals because if one of us says that “I am not going to play the game. I am going to enjoy my free time with my friends and family”, that person won’t get the competitive job because everyone else will out-perform them. We have to tackle this issue as a cohort.
How do we ensure that we don’t work ourselves into the ground for nothing?
Collectively as medical students and trainees we should ask the BMA and Royal Collages to set out a strict application process that means once candidates have met the minimum requirements, there is no more points for additional effort. For instance, the application form for a surgical consultant post should only have space to include 5 peer-reviewed publications. That way it wouldn’t necessarily matter if you had 5 or 50 publications.
This limit may seem counter-intuitive and will possibly work against the highly competitive high achievers, but it will have a positive effect on everyone else’s life. Imagine if you only had to write 5 papers in your career to guarantee a chance at a job, instead of having to write 25. All that extra time you would have had to invest in extra-curricular research can now be used more productively by you to achieve other life goals, like more time with your family or more patient contact or even more time in theatre perfecting your skills.
If you were selecting candidates for senior clinicians, would you rather pick an all round doctor who has met all of the requirements and has a balanced work-life balance or a neurotic competitor who hasn’t slept in 8 years and is close to a breakdown?
Being a doctor is more than a profession, it is a life-style choice but we should try to prevent it becoming our entire lives.
As a hospital doctor, surgeon or GP we encounter death frequently. We quickly learn to cope. It helps when we know that we have done everything within our power to prevent death. When death is close we have the ability, medication and specialists services to make the process as 'comfortable' as possible. In the final moments it is rare that the patient is alone; whether in the company of family, friends or health care professionals.
When an individual dies on expedition it may have been avoidable, you have very little kit to prevent it, they may be alone and they probably were your friend.
No one prepares you for the potential of a client dying. But it happens.
First of all, I am not trying to put you off doing an expedition. I love expedition medicine and have dedicated the last five years of my life to it. But I was not prepared for my first near death experience and I want to make sure you are.
During an expedition injuries, near misses and deaths are sometimes avoidable. There may have been a faulty bit of kit, medication which wasn't packed or route marker that fell down ... Hindsight is a wonderful thing. You, the team and the organisers work within what is feasible and normal health and safety don't and can't apply. I am NOT saying it is ok to be negligent, but a degree of pragmatism is need. What you need to remember is the competitors/ clients are aware of the dangers and, as medics, we should be too.
Many medics are shocked by the lack of kit taken on expedition. But you need to think about the environment you are in and then think rationally. If your nearest decompression chamber is 3 days away by boat, is there much point taking oxygen on a diving expedition? If you are on expedition in the middle of the jungle is there any point taking a defib if any client in need of a defib is unlikely to survive extrication. You have to work within the limits of your environment and with the kit you have. As the medic you need to be aware of the nearest hospital and their facilities, the nearest large hospital with surgical and ITU facilities and the casevac plan.
During expeditions the clients often become good friends. You will experience their highs and lows and share incredible experiences. This makes it especially hard when unfortunate events occur. At this point our role as medic often broadens to counsellor and bereavement officer. The other clients, organisers and medics need support during this time. Try to start this process whilst you are out there.
Even with near misses, the psychological effect on people can be huge. Signs and symptoms are generally easy to spot, but screen for them at clinics. Be aware during race events that grief may manifest though clients pulling out, loss of performance and increased injuries due to lack of sleep, low mood or poor concentration.
No matter what happens when you are on expedition my advice is; you can only work within your skill set and with the equipment you have. As a foundation doctor, if you’re faced with an unresponsive client - you are not expected to perform RSI and intubate. Work through your ABCDE and work within your limitations.
If you would like to suggest any other blog topics or have any questions please post below.
Imagine a world where procrastination became a productive pastime…
Procrastination, as it stands, is a core feature of the ‘human condition’ and most would argue that it is here to stay. However, what if we could hijack the time we spend playing Candy Crush saga and trick ourselves into contributing towards something tangible. Today, I wish to explore this possibility with you.
The phrase ‘gamification’ is not a new or made up word (I promise) although I agree it does sound jarring and I certainly wouldn’t recommend trying to use it in a game of scrabble (yet). The phrase itself refers to the process of applying game thinking and game mechanics to non-game contexts to engage users in solving problems. For our purposes and for the purposes of this blog ‘problems’ will equate to promoting healthy living for our patients and maintaining our own medical education.
For one reason or another, most people show addictive behaviour towards games especially when they incorporate persistent elements of progression, achievement and competition with others. The underlying psychology won’t be discussed here; call it escapism, call it procrastination, call it whatever you will. What I want you to realise is that every day millions of people spend hours tending to virtual farms and cyber families whilst competing vigorously with ‘online’ friends. If we can take the addictive aspects of these popular games and incorporate them in to the non-game contexts I indicated to above, we could potentially trick ourselves, and even perhaps our patients, into a better way of life.
The first time I heard the phrase ‘gamification’ was only last year. I was in Paris attending the Doctors 2.0 conference listening to talks on how cutting edge technologies and the Internet had been (or were going to be) incorporated into healthcare. One example that stood out to me was a gaming app that intended to engage people with diabetes to record their blood sugars more regularly and also compete with themselves to achieve better sugar control.
People who have the condition of Diabetes Mellitus are continuously reminded of their diet and their blood sugar levels. I am not diabetic myself, but it is not hard to realise that diet and sugar control is going to be an absolute nightmare for people with diabetes both from a practical and psychological standpoint. Cue the mySugr Compainion, an FDA approved mobile application that was created to incorporate the achievement and progression aspects of game design to help encourage people with diabetes to achieve better sugar control. The app was a novel concept that struck a chord with me due to its potential to appeal to the part in everyone’s brain that makes them sit down and play ‘just one more level’ of their favorite game or app.
There are several other apps on the market that are games designed to encourage self testing of blood sugar levels in people with diabetes. There is even a paediatric example titled; “Monster Manor,” which was launched by the popular Sanofi UK (who previously released the FDA / CE approved iBGStar iPhone blood glucose monitor).
So applying aspects of game design into disease management apps has anecdotally been shown to benefit young people with Diabetes. However, disease management is just one area where game-health apps have emerged. We are taught throughout medical school and beyond that disease prevention is obviously beneficial to both our patients and the health economy. Unsurprisingly, one of the best ways to prevent disease is to maintain health (either through exercise and / or healthy eating). A prominent example of an app that helps to engage users in exercising is ‘RunKeeper,’ a mobile app that enables people to track and publish their latest jog-around-the-park. The elements of game design are a little more subtle in this example but the ability to track your own progress and compete with others via social media share buttons certainly reminds me of similar features seen in most of today’s online games. Other examples of ‘healthy living apps’ are rife amongst the respective ‘app stores,’ and there seems to be ample opportunity for the appliance of gamification in this field. An example might be to incorporate aspects of game design into a smoking cessation app or weight loss helper. Perhaps the addictive quality of a well designed game-app could overpower the urge for confectionary or that ‘last cigarette’…
The last area where I think ‘gamification’ could have a huge benefit is in (medical) education. Learning and revising are particularly susceptible to the rot of procrastination, so it goes without saying that many educational vendors have already attempted to incorporate fresh ways in which they can engage their users to put down the TV remote and pick up some knowledge for the exams. Meducation itself already has an area on its website entitled ‘Exam Room,’ where you can test yourself, track your progress and provide feedback on the questions you are given. I have always found this a far more addictive way to revise than sitting down with pen and paper to revise from a book. However, I feel there could be a far greater incorporation of game design in the field of medical education. Perhaps the absolute dream for like-minded gamers out there would be a super-gritty medical simulator that exposes you to common medical emergencies from the comfort of your own computer screen. I mean, my shiny new gaming console lets me pretend to be an elite solider deep behind enemy lines so why not let me pretend and practice to be a doctor too? You could even have feedback functionality to indicate where your management might have deviated from the optimum.
Perhaps more sensibly, the potential also exists to build on the existing banks of online medical questions to incorporate further aspects of social media interaction, achievement unlocks and inter-player competition (because in case you hadn’t noticed, medics are a competitive breed).
I have given a couple of very basic examples on how aspects of game design have emerged in recent health-related apps. I feel this phenomenon is in its infancy. The technology exists for so much more than the above, we just need to use our imagination… and learn how to code.
The Cardiff University Research Society (CUReS) held its second annual student research symposium on the 13th of November 2013 at the University Hospital of Wales. Medical students were invited to submit posters and oral presentations for the symposium. The event also launched this year’s INSPIRE program, a joint effort between Cardiff, Bristol, Exeter and Plymouth to give students connections to research groups through taster days and summer research programs. CUReS is a research society for medical students in Cardiff. All events and projects are completely free and available to all years. The research society has a particular focus on developing close bonds between researchers and students. In addition to INSPIRE, the society also releases a yearly list of summer research projects where medical students can find researchers interested in hosting projects over the summer.
The purpose of the conference was to mark the launch of the INSPIRE taster days and display some of the impressive work that has been accomplished from the taster sessions and the funded summer projects. The symposium aims to give Cardiff medical students valuable experience in presenting their research and to motivate students interested in pursuing an academic career. CUReS president Huw Davies gave the opening speech, while INSPIRE lead Colin Dayan introduced the INSPIRE program. Previous INSPIRE students gave talks on their research and experiences gained from the program. Three successful applicants were invited to give oral presentations that were judged by the Cardiff Dean of Medicine Professor Paul Morgan, Professor Colin Dayan and Professor Julian Sampson, who also gave the keynote speech on his research.
The symposium was a great success thanks to the enthusiastic medical students who presented posters and gave oral presentations on their research. First prize for an oral presentation was awarded to Georgiana Samoila for her work on Histological Diagnosis of Lung and Pleural Malignancies, while Lisa Roberts and Jason Chai were awarded runner-ups. The award for best poster was given to Thomas Lemon. Two further awards sponsored by Meducation, assessed by Peter Winter, were given to George Kimpton and Ryan Preece for their poster presentations. There was also a Meducation stall and the Cardiff University Research Society greatly appreciates the support.
To get in touch with the CUReS, please email firstname.lastname@example.org or
visit our website at www.cu-res.co.uk for more information.
Written by Robert Lundin
As more and more knowledge about our health is becoming evident, people everywhere are looking at new and innovative ways like Health Evangelism as a means of treatment. Getting a clean bill of health is a challenge for many people these days. For that reason many people are looking at different types of health care options that may stray a bit from the traditional but still give the patient needed relief from their physical problems. This is where new approaches have come in to help gain control of many of the medical issues that many people have to face.
What is Health Evangelism?
The expression ‘health evangelism’ is defined as an applying of the principles of healthful living in a way that includes physical laws that have been set forth by God to act in our lives. This is simply recognizing that God, as the provider of life, created us to function in a very specific way. Many of the physical health problems that we face are a direct result of going against those inborn laws that he set forth. Health Evangelism is a means of identifying those laws and not only using them within but passing them on to others in an evangelizing work.
Benefits of Health Evangelism
Your knowledge of the physical laws that he has set in motion have been instrumental in helping to improve a number of major health concerns of many people. For example, just coming to an understanding of your diet and how certain foods were designed to nourish your body can help to improve blood sugar health, cholesterol levels, cardiovascular conditioning, and your immune system among other things.
Higher Spiritual Plane
As you see how this understanding has had a major impact on the improvement of your health you will reach a point where, you will develop a personal relationship with your creator and the things he’s provided. Your care for your health and physical well-being will not be just taking care of yourself but you will come to view it as a part of your worship to your spiritual benefactor. By doing this, you will have reached a higher spiritual level that you may not have discovered otherwise.
We have all been wonderfully made and our appreciation for our creation is a demonstration that we are part of something that extends far beyond our own personal world. Learning the details of Health Evangelism can open our eyes to many of the things unseen from the world around us.
For more information, visit http://www.pambrarmd.com/contact.php.
Ironically, it seems the health products with the least evidence are coming with the greatest assurances. A few years ago, a package holiday company advertised guaranteed sunny holidays in Queensland (Australia). The deal went something like this: if it rained on a certain percentage of your holiday days, you received a trip refund. An attractive drawcard indeed, but what the company failed to grasp was that the “Sunshine State” is very often anything but sunny.
This is especially so where I live, on the somewhat ironically named Sunshine Coast. We had 200 rainy days last year and well over 2 metres of rain, and that was before big floods in January. Unsurprisingly, the guaranteed sunny holiday offer was short-lived.
There are some things that really shouldn’t come with guarantees. The weather is one, health is another. Or so I thought…
“Those capsules you started me on last month for my nerve pain didn’t work. I tried them for a couple of weeks, but they didn’t do nothin'.”
“Perhaps you’d do better on a higher dose.”
“Nah, they made me feel kinda dizzy. I’d prefer to get my money back on these ones an’ try somethin’ different.”
“I can try you on something else, but there are no refunds available on the ones you’ve already used, I’m afraid.”
“But they cost me over 80 dollars!”
“Yes, I explained at the time that they are not subsidised by the government.”
“But they didn’t work! If I bought a toaster that didn’t work, I’d take it back and get me money back, no problem.”
“Medications are not appliances. They don’t work every time, but that doesn’t mean they’re faulty.”
“But what about natural products? I order herbs for me prostate and me heart every month and they come with a 100% satisfaction guarantee. You doctors say those things don’t really work so how come the sellers are willing to put their money where their mouths are?”
He decided to try a “natural” treatment next, confident of its likely effectiveness thanks to the satisfaction guarantee offered.
Last week I had a 38-year-old female requesting a medical certificate stating that her back pain was no better. The reason? She planned to take it to her physiotherapist and request a refund because the treatment hadn’t helped. Like the afflicted patient above, she didn’t accept that health-related products and services weren’t “cure guaranteed”.
“My thigh sculptor machine promised visible results in 60 days or my money back. Why aren’t physios held accountable too?”
Upon a quick Google search, I found that many “natural health” companies offer money-back guarantees, as do companies peddling skin products and gimmicky home exercise equipment. I even found a site offering guaranteed homeopathic immunisation. Hmmm…
In an information-rich, high-tech world, we are becoming less and less tolerant of uncertainty. Society wants perfect, predictable results — now! For all its advances, modern medicine cannot provide this and we don’t pretend otherwise. Ironically, it seems the health products with the least evidence are coming with the greatest assurances. A clever marketing ploy that patients seem to be buying into — literally and figuratively.
I think we all need to be reminded of Benjamin Franklin’s famous words: “In this world, nothing can be said to be certain except death and taxes.” We can’t really put guarantees on whether it will rain down on our holidays or on our health, and should retain a healthy scepticism towards those who attempt to do so.
This blog post has been adapted from a column first published in Australian Doctor http://www.australiandoctor.com.au/articles/11/0c070a11.asp
Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/
BOXING Day, 1.30am. “Are you the doctor on call?” I wrenched my reluctant brain from its REM state. “Yes.”
“I’m worried about my wife. She’s 16 weeks pregnant and very gassy.”
“Burping and farting. Smells terrible! It’s keeping us both awake. I’m worried it could be serious.”
By the time I ascertained that there were no sinister symptoms and that the likely culprit was the custard served with Christmas pudding (the patient was lactose intolerant), I was wide awake. My brain refused to power down for hours, as if out of spite for being so rudely aroused.
I have a confession to make. When the Australian Federal Government announced that it was planning to abolish after-hours practice incentive payments, I was delighted. I know, I know, I should have been outraged along with the rest of you. After all, the RACGP predicted that after-hours care would be decimated if incentives were removed. Comparisons were made with the revamp of the UK system in 2004, which led to 90% of the profession opting out of after-hours work. Much as I sympathised, I was secretly rubbing my hands together with selfish glee. Surely this would mean that our semi-rural practice would stop doing all of our own on-call and free me from my after-hours responsibilities?
I detest being on call. I loathe it with a passion completely out of proportion to the imposition it actually causes. I’m on call for the practice and our local hospital only once a week and the workload isn’t onerous. Middle-of-the-night calls aren’t all that frequent, but my sleep can be disturbed by their mere possibility, leaving me tired and cranky. If I’m forced suddenly into “brain on, work mode” by a phone call, I can kiss hours of precious slumber goodbye.
I love to sleep, but, as with drawing and tennis, I’m not very good at it. I gaze with envy at those lucky devils who nap on public transport and fight malicious urges to disturb their peaceful repose. If I’m not supine, in a quiet, warm room, with loose-fitting clothing, a firm mattress and a pillow shaped just-so, I can forget any chance of sleep. Let’s just say I can relate to the Princess and the Pea story. I bet she wouldn’t have coped well with being phoned in the middle of the night either.
If these nocturnal calls were all bona fide emergencies, I wouldn’t mind so much. It’s the crap that really riles me. I’ve received middle-of-the-night phone calls from patients who are constipated, patients with impacted cerumen (“Me ear’s blocked, Doc. I can’t sleep”) and patients with insomnia who want to know if it’s safe to take a second sedative.
The call that took the on-call cake for me, though, was from a couple who woke me at 11.30 one night to settle an argument.
“My husband says that bacteria are more dangerous than viruses but I reckon viruses are worse. After all, AIDS is a virus. Can you settle it for us so we can get some sleep? It would really help us out.”
I kid you not.
Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com