Clinical Career 1 Clinical Career Issue 2 - Spring 2014

ISSN 2053-9649 Clinical Career 1 Clinical Career Issue 2 - Spring 2014

The Journal for Medical Professionals who are passionate about their career success www.ClinicalCareer.co.uk Quarterly in October, January, April & July The Editorial Editor’s Introduction team Welcome to the second edition of the Clinical Career journal. Dr Sara Watkin Editor-in-Chief “Extremely useful.” “A great platform to share advice amongst E: [email protected] T: 01332 821260 colleagues.” “Fills a void that has been present for a long time.” These were just some of the comments we received following the publication of our inaugural edition late last year. They Fraser Tennant Operational Editor clearly demonstrate that Clinical Career has struck a chord E: [email protected] with its stated aim – to inform, educate, and assist in the T: 07941 502512 development of trainees throughout the course of their career.

We have been delighted with the response to our call for FEEDBACK journal participants and many contributions are featured in

Send us your feedback on the this edition. These include an overview of the Shape of Training journal, ideas, suggestions or Review, an examination of the pathway to leadership, the 2023 comments to: challenge to improve healthcare, and the merits of part-time [email protected] working for doctors.

Additionally, our request for your overseas accomplishments has also been well answered with experiences in India, Cameroon, South Africa, and the Himalayas showcased.

Now more than ever, it is vitally important that trainees at all stages have access to independent advice of the highest quality. Advice that will help them make informed choices as they navigate their way through a volatile healthcare environment.

I hope you enjoy reading this edition and I welcome your feedback and suggestions.

Sara

Dr Sara L Watkin Editor-in-Chief, Clinical Career Partner, Insights Publishing

Consultant Neonatologist & Clinical Service Lead University College London Hospitals NHS Foundation Trust Clinical Career 3 Contents

The Big Article 4 The Future is Set 4

Relevant News 10 Taking Shape: the future of medical education and training 16 The Shape of Training Review: What’s the big deal? 19

Articles & Advice 24 Health Education England: A Vision for Education 24

Innovation Feature 28 “A Tidal Wave of Energy and Creativity” 28 Healthcare innovation demands an exquisite balance 30 The story of Rowena - a Craniotomy Simulator 34 The Disruptive Innovation Expectation 38

Career Strategies 42 Investing in your Career Success Early 42 Ahead of the Surgical Pack 44

INTELLIGENT CHOICES, INTERESTING OPTIONS 48 All boxes ticked: In search of happiness 48

Inspiration, Passion & Pursuits 52 “You have to love your patients and you have to love what you do” 52

Rotation Zone 56 Just One Thing - Planning on a CV-enhancing item per rotation 56

OVERSEAS FOCUS 60 Three Weeks in the Himalayas 60 Paediatrics in Cameroon 64 “In India it’s purely about gaining skills and not about tending your ego” 69 Out of Programme Surgical Training Experience in Zululand 73

Work-Life Balance Zone 76 Awesome and Audacious: The Audi Q5 76

Interview & Recruitment Zone 78 Body Language 78

Professional Development zone 82 Less Than Full Time (LTFT) Training 82 Leadership & Management Skills for Core Trainees a Delegate’s View 86 The Pathway to Leadership 90 Depth in Leadership Development 96

WORTH READING 99 Ask Sara 100 Whistle Blowing on Concerns 102 Conferences, Events & Announcement 107 t i c le The Future is Set The Big ar How NHS England is switching to 5 year planning and what this means for professionals

The fact that the NHS landscape has and consequently care providers, would wish to join an employer who is likely to been changing will have escaped be approached. However, from this point stay around by making sensible strategic nobody. However, the implications forward commissioners are required to choices. of this changing landscape have far produce a strategic plan that covers the reaching consequences to the career next five years, with the next two years High Level Changes paths of those currently in training and being specified down to operational Wider use of primary care indeed for every service in the UK. It is detail. With an ageing and rapidly increasing imperative, therefore, that all doctors population, it is no surprise that NHS gain a top level grasp of the nature of This means that shortly we will be able England wants to see the use of primary changes that will occur at the provider to deduce far more clearly how the care beefed up. They describe this as end of the system so that they can make provider landscape is likely to change increasing the use of primary care at absolutely sure that they develop the over the next few years in the face of scale. This strategic agenda is driven not knowledge, skills and insight necessary huge austerity and an increased agenda only by an increasing population but by both to operate successfully in this new for integration across the secondary, the changing nature of that population environment and also to ensure their primary and social care arenas. It and its healthcare needs. With increased attractiveness to new types of potential is absolutely essential that anyone numbers of particularly aged patients, employer. I hope that this article will go intending to have the pick of jobs going the system has to respond to differing some way to providing a starting point forward takes the trouble to research and access requirements. An elderly, frail for just such a top level analysis. understand the true nature of healthcare patient who may also have dementia, provision and how it is changing over cannot be expected to undertake The Big Commissioning Change time. From the provider’s perspective, frequent, often physically brutal, In December 2013, NHS England issued it will mean actively monitoring these journeys simply for routine health care planning guidance for CCGs that had strategic plans for commissioning at a that can otherwise be delivered in a a fundamental change to approach local level to see just how the provider location much closer to them. Equally, contained within its pages. Until this landscape is likely to change and how these patients tend to carry an increase point, commissioners had only been this may affect them. Touching again on level of chronic disease, for which required to produce annual plans of the career implications, if I was applying hospitals are recognised as a less than their proposed activity, which would also for a job today I would want to know ideal location. have contained valuable information just how aware my employer was of this about how the pattern of care delivery, changing landscape, given that I would From a career perspective, this heralds Clinical Career 5

two distinct themes: at their portfolio of care and determine prime or support integration projects. • growth of the primary care/GP what aspects of care are likely to be I think this tells us that NHS England is infrastructure moved into community settings. To definitely serious about integration. • an increase in primary care located continue to expect to operate in the secondary care services traditional hospital-based mode and Again you might want to consider just enjoy the same level of funding, is to which types of long-term condition are The latter theme is an important one place the service at risk of obsolescence likely to be subject to changes in care to consider from a skills and working as community delivery models take hold. delivery as a result of integration. For environments perspective. Whereas The strategically intelligence service instance, are you developing a special many of the secondary care services may should be considering how to adapt interest in an aspect of care that is well be delivered by current secondary its delivery model to match up to this currently delivered in hospital but which care providers, such as hospitals, changing pattern and indeed whether may well switch to a more community although obviously in the community, it needs to partner with a community focused location as an integrated an increasing number will be delivered organisation, in a more integrated pathway approach is adopted? Equally, by new private providers or indeed NHS approach to care delivery. employers may well be seeking providers with a much more limited candidates whose experiences bridge scope, often choosing to address a very The integration agenda the gap between primary and secondary specific type of patient with very specific A consistent theme in the planning care, or perhaps more accurately needs. Going forward, there will be an guidance is the increase in integration between secondary care delivered in the increased need for doctors who are across patient pathways for the delivery community and that which is delivered prepared to work in these limited scope of care to people with long-term in hospitals. This type of approach environments, often independently of conditions. This is also interesting at two is often based around the principles the team and sometimes out of existing distinct levels – the increasing disease of case management, again a useful GP practices in a more integrated burden in certain long-term conditions, addition to a CV for someone wishing to manner. It is worth considering what especially those that are age-dependent, work in this type of environment. might make you attractive to these and having to work in an integrated types of employers that is different from or cross boundary manner. To support Currently clinical professionals within a traditional local hospital job. integration, NHS England is investing services find themselves with so some 3.8 billion in a fund called the much clinical load that the thought of Services need to take a strategic look Better Care Fund, which is specifically to networking and developing shared t i c le The Big ar

services with other providers across a models and an increased number of heightened sensitivity to delivering pathway seems an impossible task that private providers that bring those into surgery without complications, as this there is no time for. However, given the our system. can not only ruin the high-volume other change agendas, to fail to consider finance model but also the reputation of how a more integrated approach may An example that interests the the provider. be appropriate to your patients, could government is the Aravind Eye Care find your service without a chair to sit on Centres in India, where a routine Existing providers would be well when the music stops. As is often so true cataract operation is delivered at similar advised to think deeply about how they and business, the future tends to belong outcomes to the UK but for around $30, streamline elective work by complexity. to the early movers, with the laggard’s around 3% of the UK hospital-based Rather than say viewing care by the type left standing with the DJ says enough. tariff for such an operation. The centres of Department that does it, they might work on the principle of lean efficiency consider starting from the point of view The elective care agenda in the operating model and highly of complexity or reliable repeatability. NHS England is expecting a 20% capable surgeons who only do cataracts Procedures that can be done in volume productivity gain across the next five but in vast numbers. At this point, we reliably and safely, are likely to be years, coupled to an improvement in tend to train ophthalmologists who far more subject to this agenda than outcome and a 20% reduction in the expect to work in hospitals and whose procedures of a more complex nature. resources necessary to deliver that career aspiration would include a variety The Department that fails to think in this care. Whereas this will chill the bones of ophthalmic problems, rather than way may find care, and consequently of current care providers, it also means one specific type of surgery. However, funding, redistributed to new provider that the provider landscape will have cataract surgery is likely to increasingly types that work on this lean efficient to change, both within the existing move to high-volume treatment centres model. providers and also with the introduction and so again the system will be asking of new models of care. It is almost for an increased number of surgeons This is just one example but there will impossible for that level of productivity who are prepared to work in this be many and varied as this agenda gain and resource drop to be achieved environment. To be attractive to these takes hold. One advantage that the without adapting how we deliver types of employers means increasing the new consultant has over a more senior elective care. Consequently, we are likely amount of cataract surgery undertaken consultant is that of a lower wage. to see the introduction of new delivery in training, whilst developing a As this agenda is about productivity The Consultant Special Offer Clinical Career 7 Upcoming Dates: Just £125+VAT 16th May 2014, Manchester 17th Jun 2014, London Usually £245+VAT. Book this course today 9th Sep 2014, London and only pay £125+VAT instead of £245+VAT 18th Nov 2014, London

Insights – Understanding the Evolving Healthcare Landscape 5 Really Important Questions

• Are you 100% confident that you fully understand current healthcare policy? • Do you know the conditions and mechanism for competition entering your locality & the influence you have over this? • Are you completely aware of everything that affects both tariff and your service funding? • Do you fully understand the new choice agenda and just what information will be made available to patients (and how)? • Are you fully conversant with the new commissioning agenda and how this will affect secondary/ tertiary care?

If you answered 'no' to some or all of these questions, it does raise some concern that you and your service may be vulnerable in the emerging landscape, especially if you are trying to influence or set strategy with an incomplete picture.

What’s becoming clear is that the difference between a thriving service and one that struggles and lurches often comes down to depth of understanding and interpretation (leading to confidence to act appropriately). It’s a whole new jungle out there and if you don’t understand it then you are at a disadvantage, in an environment that has stopped looking after its prisoners.

It's now 2013, The Health & Social Care Act is enacted, the Commissioning Guidance released, the payment systems changing. Maybe it’s time to really understand… View the Full Programme

www.NHSInsights.co.uk and cost reduction, we might expect large. To expect to take a specialist be exciting jobs and there will be more employers to seek out new consultants position but with generalist experience routine ones. Most aspire to exciting t i c le in preference, especially those with a is likely to result in disappointment. The position with career progression in an track record of high quality, high volume jobs will most likely go to those people employer that values their employees surgery in a specific area. who have strategically managed their and remained stable in a system that career to end up with a set of both isn’t. It is difficult to ignore that these The Big ar Concentration of specialised services clinical and nonclinical experiences jobs will be fewer and farther between. Currently, there are 143 specialised that set them apart. What these might If you want one, rather than waiting services that are commissioned centrally be will vary according to the nature of until your CCT, only to find that your by NHS England. The strategic guidance the specialised service and where in planned career choice is not nearly on commissioning specialised services the country it sets. A great question to so common, it becomes essential to states that the system should aspire to ask yourself is “if I was the Brompton, make understanding the system an 15 to 30 centres of excellence for each recruiting a specialist in a highly important part of career development specialised service, co-located all linked specialised area, just what would I and as that understanding builds, to Academic Health Science Networks. be looking for that would make that to develop the tendency to adjust Currently, many district general hospital candidate irresistible?” Armed with the your skills development to be more services also deliver some specialised answers to this very enabling question, aligned to these new providers and the services depending on the specific you must then deliberately set out to requirements. interests of the clinicians. Over time gain the skills and experiences. these types of services will be expected My parting words are a reminder that to relinquish these patients in favour of As we view the behaviour of clinical failing to plan is planning to fail. The world centralisation. services, we note with interest the increasingly belongs to the proactive, tendency to resist relinquishing who realise that you must design a From the career perspective, if you specialised care to tertiary centres. career in alignment with the system that aspire to working in specialised services Unless you stand a strong chance of you will be working in. My experience is it means that there is likely to be much being one of the 15 to 30 centres, it that all too many doctors are still basing greater competition for fewer posts and would be better to work out what your their development on a system that is those posts will be centred on fewer new role in the system is and then changing and that many would do well locations than they currently are. In build a reputation for excellence in that to at least consider how those changes many respects, this reorganisation of new area, rather than try to hang on to might affect the traditional career path care brings with it the greatest changes smaller, albeit interesting, bits of work and the opportunities within. to career paths and specifically to career that are likely to be taken away from you strategies. For the most part, trainees at some point. elect to pursue a primary care career or a hospital. When choosing the latter, General Conclusions their expectation is frequently to do I presented just a few of the strategic complex interesting aspects of care in issues emerging from the new a highly respected centre. With care commissioning guidance. Rather than more concentrated, we are going to go this explaining just what to do and how through a period of time in which we to think, I hope it provides a starting Andrew Vincent have more trainees with this expectation point to a very different mindset. That than there are posts. mindset is one of open-mindedness Partner, Academyst LLP towards career path, in a system that and Editor-in-Chief, If your aspiration is to be a specialist will throw up many and varied career Clinical Business in one of these 15 to 30 centres, it is opportunities, many of which will Excellence, imperative that you consider deeply represent a significant departure from what would make you stand out from the traditional view of just hospital or Author Profile the crowd that will become increasingly primary care. In any system, there will Clinical Career 9

Assertiveness without Aggression 1 Day Course 8 CPD Points Assertiveness without Aggression is probably the most comprehensive, practical programme available, designed to help consultants, other doctors and healthcare professionals adopt the right behaviour, communication and approaches to have the desired impact. The resulting effect is greater achievement, more self-control and a greater level of emotional self-mastery. All of this is achieved without ever trying to change the inner you whilst enhancing confidence, self-mastery, impact and interpersonal effectiveness.

Next Dates: • 10th Apr 2014, Warwick • 8th May 2014, London

www.growmedical.co.uk GROWMedical Deadline looms for Clinical Fellow Scheme applications t N ews R elevan

Doctors in training have until 14 February to apply to the Faculty of Medical Leadership and Management’s (FMLM) National Medical Director’s Clinical Fellow Scheme 2014-15.

Sponsored by NHS England’s National Medical Director Sir Bruce Keogh and The Clinical Fellow Scheme is open Shortlisted candidates will have the overseen by FMLM, the Scheme is an to those doctors in training who will opportunity to meet current Clinical opportunity for trainees to develop have completed their Foundation Fellows during an information evening leadership and management skills Programme by the time they take in London on 4 March 2014 and by spending one year in a national up their post as a Clinical Fellow on interviews will be held in London on healthcare organisation, working Monday 1 September 2014. As usual, 12 and 13 March 2014. alongside influential leaders and key the Scheme offers placements across players in healthcare from within the the country, including a number in the More information on the Clinical NHS and the wider healthcare sector. North of England. Fellow Scheme is available on FMLM website at: www.fmlm.ac.uk

Modernising Scientific Careers: HEE publishes Scaling the Heights

Health Education England’s (HEE) of science, technological and service Scaling the Heights document developments. which will assist in the training and development of consultant clinical The Scaling the Heights document the scientists has now been published. full spectrum of HSST, including: • The underpinning academic The document, part of the doctoral programme Modernising Scientific Careers (MSC) • The development of curricula with a comprehensive training and career programme, outlines how Higher scientists, professional bodies and framework for the whole healthcare Specialist Scientist Training (HSST) medical royal colleges science workforce inclusive of the will deliver the consultant clinical • The implementation of these more than 50 different scientific scientists who will provide expert programmes through the National professional specialisms. scientific leadership and innovation School of Healthcare Science for the benefit of patients and health • Certification, registration and the “I commend this document to those services. recognition of previous training, who will be involved in delivering experience and through the and managing HSST training. I wish Consultant clinical scientists have Academy for Healthcare Science. to acknowledge and thank all of a crucial role to play in providing those individuals and organisations scientific clinical advice and care Professor Sue Hill, Chief Scientific who have given so generously of alongside medical consultants across OfficerCS ( O) for England, said: “The their time and for their commitment the healthcare spectrum. They will also Modernising Scientific Careers (MSC) in developing the HSST curricula and support innovation in all its aspects programme sets out for the first time programmes.” Clinical Career 11 BMA Junior Doctors Conference 2014 – the chance to lead change

The British Medical Association’s (BMA) House in London on Saturday 17 May Junior Doctors Conference is a major and will be accompanied by an informal opportunity for junior doctors to have dinner that evening. their say on the major changes that are taking place within the medical And for first-time conference goers profession. who wish to learn more about the BMA and the work of the Junior Doctors Open to all junior doctors in England, Committee, an event is scheduled for Scotland, Northern Ireland and Wales, Friday 16 May (also at BMA House). this year’s event will address a range of issues including the negotiation In a joint statement, Conference Chair “This year’s conference will include an of new hospital doctor contracts and Dr Latifa Patel, and Junior Doctors expert panel and an open discussion postgraduate medical education and Committee Co-Chairs Dr Kitty Mohan on key issues affecting junior doctors. training reforms. and Dr Andrew Collier, said: “The There has never been a better time to Junior Doctors Conference is a major get involved and influence policy.” Conference participants have the option event in the medico-political calendar to submit a motion which, if successful, where the priority work for the JDC Members and non-members of the will form part of the Junior Doctors over the following year is determined. BMA are invited to attend, with places Committee (JDC) policy next year. Negotiations on pay and working hours allocated regionally on a first come, first are underway and sweeping reforms to served basis. The conference will take place at BMA training have been proposed.

HEE and CEM pledge more places for trainees to ease emergency staff crisis

HEE and CEM plan 75 new training posts revealed that they regularly work late to As emergency departments continue to each year for next three years maintain standards. The survey also found face increasing pressure, staff shortages there is a perception that it is difficult are being partly blamed for falling Health Education England (HEE) and the for junior doctors to access emergency standards of care as well as lengthy College of Emergency Medicine (CEM) medicine training posts, leaving too many admission times. Both organisations hope have pledged to create more trainee posts emergency departments understaffed. the new changes will encourage more to tackle the growing staffing crisis in doctors to train in emergency medicine emergency medicine. In a joint statement released with the and, ultimately, ease the pressure in A&E. report, HEE chief executive Ian Cumming Currently, around 50% of trainee posts for and CEM president Dr Clifford Mann “Much has already been done,” said emergency medicine are vacant due to said they have “inherited” a “shortage Cumming and Dr Mann, “and we have the increased view that the subsequent of consultants resulting from poor made considerable progress but we post is unattractive and pressurised. recruitment into middle grade training know more hard work will be required posts. We recognise the difficulties of to develop and implement sustainable This view was recently expressed in a work force development in emergency solutions.” survey of consultants - 60% said their medicine.” workload was unsustainable and 94% Trust to receive PROMPT Birthing Simulator t N ews R elevan A product which has been proven to obstetricians from Southmead Hospital, reduce childbirth injury – a PROMPT Bristol and the Gloucestershire Royal Birthing Simulator – is to be installed at Hospital. The model was designed to Northumbria Healthcare NHS Foundation improve the management of shoulder Trust following an anonymous donation. dystocia through hands-on practice, and as a result has become an integral The simulator has been proven to reduce part of multi-professional training in injury during childbirth and is an integral many maternity units across the globe. part of the PROMPT multi-professional The product provides a realistic platform obstetrics emergency course. for medical staff to acquire the delicate skills required for shoulder dystocia Recent studies have revealed that the management; and allows healthcare number of successful deliveries within committed to continuously improving professionals to build their confidence the training environment nearly doubled training for our midwives, obstetricians and skills to ultimately improve patient from 42.9% to 83.3%1 when medical and all professionals who work on the care as a result of facilitating a training professionals had been trained using the delivery suite. experience close to the real thing. PROMPT Birthing Simulator. “The additional simulator will be a great Dr Shonag Mackenzie, consultant and asset and will help enable us to deliver lead obstetrician and obstetric trainer at training on several sites and continue to Northumbria Healthcare NHS Foundation ensure that every woman and child we Trust, said: “We are delighted to receive care for receives the highest standards of an additional PROMPT Birthing Simulator treatment.” and would like to thank the person who very generously donated it to us. The PROMPT Birthing Simulator (produced by the UK’s leading medical “We have used this excellent equipment skills training product manufacturer, since it became available and are Limbs & Things) was developed in conjunction with the midwives and Kate Fox Evans, Head of Marketing at Limbs & Things said: “The studies using our PROMPT Birthing Simulator have verified the positive impact medical simulation can have on patient outcomes. We are committed to improving patient safety, through excellent product training and are currently working closely with Baby Lifeline - a unique national charity supporting the care of pregnant women and new born babies. As well as providing the Prompt Birthing Simulator for the recent Baby Lifeline charity auction, we are supporting their 2014 Birth 2 training initiative via the provision of our Keele & Staffs Episiotomy Trainers to deliver improved episiotomy repair for mothers post-birth.” Clinical Career 13 Major increase in NHS staff benefiting from health and wellbeing programmes

A major Royal College of Physicians are: “Of greatest importance are (RCP) audit has shown that the NHS • Obesity plans have more than those schemes that provide early has significantly increased support doubled, from 13 per cent in interventions, support networks for the health and wellbeing of its 2010 to 28 per cent and different ways for staff to take staff. • Physical activity plans have responsibility for their wellbeing and increased from 24 to 44 per cent report any concerns in confidence. The RCP report - Implementing • Mental wellbeing has increased NICE public health guidance for the from 48 to 57 per cent “As with so many things in the NHS, workplace – states that 115 trusts are • Smoking is stable at 75 per cent it’s clear that a culture of confidence supporting their 562,723 staff with • Long-term sickness absence and openness is essential and health and wellbeing plans. continues to be 100 per cent that everyone has a part to play in developing this. People who are given This is a significant increase on 2010 Dean Royles, Chief Executive of the confidence to speak up about figures of 70 trusts and 275,421 staff NHS Employers, said: “The NHS their worries and stresses are more members. has maintained an important and likely to highlight issues that could responsible focus on the wellbeing affect their performance or patient The audit also shows significant of its workforce, amid all the other care, and we need this to happen.” increases in dedicated policies that challenges faced by staff and cover specific health areas, and managers. stability in all others. The key areas

BMA’s electives guide offers top tips

Medical students planning their • The kind of experience sought electives can now turn to a new BMA • Whether the student has a resource to help guide them through specialty already in mind. the process. The guide advises arranging an The latest electives guide (which elective early and suggests making first is available on the BMA website) contact 12 to 18 months beforehand. includes a downloadable checklist and a multimedia presentation giving The guide also strongly suggests the students top tips. use of a ‘plan B’ should things not go conditions rarely found in the UK. to plan initially. The guide contains seven questions “But many students underestimate students should ask themselves: Joint Deputy Chair of the BMA Medical the work involved — this updated • Whether to stay in the UK or go Students Committee Samantha guide helps you get the best out of abroad Dolan said: “Medical electives are your elective and provides a valuable • Proposed budget a great chance to broaden your timeline and checklist of what to • If there are visa restrictions medical education and they offer consider.” • If English is spoken the opportunity to travel overseas, • The time of year experience different cultures and see Relevant News Lausanne and S real-time touch sensation from aprosthetic device” saidProf Silvestro from Micera theEcole Pode accident, received thehandfollowing inI surgery lifelike sensations from theirfingers. D An international team ofscientists hascreated abionichandwhichallows the amputee to feel to feel once again Bionic handallows amputee Professor G Educators. oftheAcademykey supporter ofMedical medicine andleadershiphasbeena schemes for inacademic juniordoctors developed many innovative training andD Medical D As Postgraduate D setting bodyfor clinicalteachers. (AoME) -theprofessional andstandard- of theAcademy Educators ofMedical D Professor D G eanery ( eanery President has been elected eanery allen elected AoMEallen elected President C ardiff’s S erek G allen said: “Tomorrow’s ental Education) he has ental Education) he has chool ofPostgraduate allen ofthe Wales cuola Superiore S ean for the Wales ant’Anna, Pisa.hascalled thehand Aabo Mr “amazing.” the UKC Programme andasChairof Director of the UK Foundation Professor G area ofclinicaleducation.” professional excellence inthisimportant andencouragement to develop support arestudents anddoctors given thetime, that trainers andteachers ofmedical As President, Iwillwork to ensure and rapidly changing environment. lifetime inahigh-pressured ofpractice attitudes onwhichtheycanbasea andprofessional knowledge, skills needasolidfoundationdoctors of ennis Aabo, from D ouncil ofPostgraduate Medical allen’s work asNational taly. “I t isthefirsttimethat anamputee hashad enmark, who lost his left handinafirework wholosthisleft enmark, OPMED , , education across theUK the profile andstandards of medical D Prof.D eans, has had a major impact on raising onraising eans, hashadamajorimpact .G allen Clinical Career 15

Presentation Excellence 1 Day Course for Clinical Professionals 6 CPD Points

Effective presentation skills form one of the core backbone elements of a successful career in healthcare. Faced with a diverse range of scenarios, from teaching staff to interview presentations right through to a presentation of an international multi-centre trial or Trust board meeting, it is surprising that few have ever received any formal training in this vital area. This programme takes a single, intensive day approach to dealing with the core elements of effectiveness in presenting with poise and impact.

Next Date: • 6th Mar 2014, Manchester

www.growmedical.co.uk GROWMedical Taking Shape: the future of medical education and training

In recent years, there have been training across the UK. The purpose significant developments in UK of the review was to make sure we postgraduate medical education and continue to train effective doctors training based on recommendations who are fit to practise in the UK, from a number of reports1,2 in the provide high quality and safe care wake of Modernising Medical Careers. and meet the needs of patients and A common theme highlighted in these service now and in the future. The reports is the need for further reform report offers a framework to reshape Professor David Greenaway in postgraduate medical training if the delivery of training doctors and we are to ever meet the evolving maintain continuity of care with laudable, and if implemented would healthcare needs of our rapidly changes to the current system. lead to radical changes in the skills changing society demographics and and experience of all doctors and how the likelihood of greater expectations Several recommendations from the services are delivered to our patients. of healthcare among our population report are: Other recommendations should be now and in the future. However, • Full registration should move treated with caution and do raise these previous reports have been to the point of graduation from many questions. slow to adapt to patient and service medical school needs. Fundamentally the system • Broad based training to achieve In the case of full GMC registration needs to recognise and adapt to these Certificate of Specialty Training at the point of graduation, legislative principles accordingly through a non- (CST) changes will be required to achieve disruptive transition phase to ensure • Develop credentialed this. Universities will need to sustainability and to avoid multiple programmes for some specialty acknowledge and make the necessary redesigns of the system. and all subspecialty training post provisions to undergraduate training CST and education to produce doctors The Shape of Training3 report led • Training providers should be with the skills and confidence to by Professor David Greenaway, the approved and quality assured by undertake the clinical judgments Vice-Chancellor of the University the GMC to provide high quality expected at the early stages of their of Nottingham is an independent training and supervision career. The proposed change may review of the current structure of allow for more doctors from the postgraduate medical education and Some of the recommendations are Clinical Career 17

European Union (EU) to apply for the needed to provide safe and effective regarding the nature of training and UK Foundation Programme, thereby care at the frontline, does not mean competencies that would be achieved increasing competition for foundation we need fewer specialists. With the by their CST. Would this create expert posts. On the contrary UK medical pace of change in medical science and diagnosticians in general care with graduates would be able to apply technology, specialists are essential limited operative ability? for posts within the EU with a fully to the delivery of the highest quality registered UK qualification. There is evidence based patient care. Evidence Individual placements throughout also an opportunity to lift the cap on shows that patient outcomes broad based training will be longer overseas medical student numbers as improve with specialist care therefore than the current four-month rotations once qualified they could return to advanced skills in specialties must to provide better integration within their country of origin again with a continue to hold their place amongst the team, continuity of care and fully registered qualification without the post-generic training. improved learning opportunities having to complete the first year of and training. During broad based foundation training which they are In reducing the length of specialty specialty training, opportunities to bound by within the current system. training to 4-6 years, it is questioned spend a year working in a related whether there would be sufficient specialty or undertaking leadership Following completion of the two time to train. The procedure-based and management or medical year Foundation Programme, which specialties in particular may be further education work will be available. should remain unchanged doctors impacted. These specialties need time Leadership and quality improvement will spend 4-6 years in broad based to acquire the necessary technical, are essential attributes for doctors specialty training gaining experience professional and knowledge based in training. An alternative pathway and competencies in their chosen skills to become independent. Given for trainees undertaking dedicated field. Existing specialties will be that some of these trainees currently time for research to attain a higher grouped together to form patient care report difficulties to train within the qualification must be supported themes for example: Women’s Health, time allocated in the current system and flexible within the system. The Mental Health. Tensions do exist (some state due to the introduction of recommended increased flexibility between generalists and specialists the European Working Time Directive should also enable doctors to gain and although more generalists are 2009), further clarity is required competencies in one broad area and transfer those competencies between learning and training experiences. because as we all know too well, one specialties easily. Assessment of The report fails to mention in detail size does not fit all! training should be reviewed to many pertinent issues for example dispel the impression of paper-based the use of postgraduate membership exercises and form counting. exams, pre-existing curricula and how References: assessment methods would fit within 1. J Temple. Time for Training: A A CST is awarded for those that reach this model. Producing broad based Review of the impact of the the end of broad based specialty doctors who are equipped for hospital European Working Time Directive training to verify that the doctor is and community care must be aligned on the quality of training. May 2010 fully trained and has obtained the to the structures within the NHS competencies and knowledge to healthcare system. Expectations of 2. J Collins. Foundation for practice independently without career ambitions need to be managed Excellence: An Evaluation of the supervision. This replaces the and conveyed at the start of ones Foundation Programme, Professor Certificate of Completion of Training career pathway to help with workforce John Collins. October 2012 and emphasises that education and planning and students entering training are never complete. The medical school should be made aware 3. Greenaway, D. Shape of training: proposal to introduce credentialing of the roles and requirements the securing the future of excellent post CST to acquire specialist profession expects, with a focus on patient care. Final report of competencies in specific areas of population needs. the independent review led by clinical practice provides a way to professor David Greenaway. adapt skills to the prevailing needs On the basis of this proposed October 2013 of the population. However with framework, careful planning is certification of generalist capability required before its implementation. at CST and further specialisation Previous changes have had negative via credentialing do we run the consequences, due to rapid risk in developing a sub-consultant implementation. Further analysis grade? Further levels of complexity of the implications of change need are introduced to the credentialing to be reviewed followed by a phase programme for larger specialties like in approach. This will allow the general medicine that is an umbrella stability of the overall system to be for many complex specialities. maintained whilst reforms are being made. Current doctors in the system Many problems remain unresolved should not be disadvantaged during and need to be address to avoid rapid the implementation of change. A UK- radical changes to the system, which wide delivery group will be formed may inevitably fail. To accept the to oversee the implementation of recommendations in Greenaway’s the reports recommendations with Dr Sonia Panchal report the profession needs to support from the royal colleges, embrace a culture of change Training employers and regulators. National Medical Director’s must be quality assured and the report Clinical Fellow, recommends that training should be The motivations of this review Health Education England & “limited to places that provide high are laudable however, the Academy of Medical Royal quality training and supervision”. recommendations lack detail. We Colleges Local and national organisations should therefore use this opportunity must take responsibility to ensure to influence the finer details of dedicated training time is provided the model including curricula, for trainees and trainers. Service development of broad based training Author Profile delivery must also provide meaningful and credentialed programmes Clinical Career 19

The Shape of Training Review: What’s the big deal?

In March 2013, the organisations a ‘Certificate of Specialty Training’ responsible for medical education (CST). Doctors should be trained to and training in the UK launched a the same level of ability, in a broader review of how doctors were trained, area, but their training should be following their qualification from shorter. Afterwards, they should be medical school. This has now been able to complete more training in published, and makes a number other areas, through ‘credentials’. of recommendations which could radically change how doctors train What’s it got to do with me? in the UK. Future specialty trainees will be expected to spend most of their What are the changes? Dr Sonia Panchal time working in broad areas New doctors should be given ‘full (e.g., general internal medicine). registration’ at graduation. At Trainees who want to work in more present, new doctors (FY1s) are Health could be grouped into specialised areas (e.g., interventional first given ‘provisional registration’ ‘Women’s Health’. Trainees will then cardiology) may need to complete to practice medicine. This imposes train within these broad ‘themes’. additional credentials. They may also some limits on their practice. be expected to work across different Trainees should now be given full Specialty training should be more specialties within their theme. registration when they graduate, but flexible. Trainees should be able to they will be expected to show they transfer freely between specialties Future foundation trainees will are able to work at this level. within a ‘theme’, without having to also work in broader areas and start their training again from the settings. New doctors (FY1s) may Specialty training should be much beginning. be expected to have additional broader. Existing specialties should knowledge and skills, given their full be grouped into broad care ‘themes’ Specialty training will generally be registration. They should be able to with common curricula: for example, shorter, but not ‘completed’. The apply for broader specialty training Obstetrics & Gynaecology and current ‘Certificate of Completion of programmes, however, giving more Community Sexual & Reproductive Training’ (CCT) will be replaced with time to decide on career plans. British Medical Association (BMA) now take place. Most major changes have said that moving full registration are not expected to take place to the point of graduation may allow for 2-5 years, however. It remains more doctors from the European unclear too, of course, whether the Union to apply for the foundation recommendations will be followed at programme in the UK. This could all... lead to more competition for jobs. By Dr Sonia Panchal and Is broader training viable in all Dr Steven Alderson on behalf of the specialities? The Royal College of National Medical Director’s Clinical Surgeons (RCS) have said that it may Fellows 2013-14 be difficult for trainees working in particular broad areas to gain the specialised skills and experience they need. This could lead to much Dr Steven Alderson longer surgical training.

The rise of a sub-consultant grade? Future medical students will have The BMA are also worried that placements in broader areas and replacing the current CCT, and settings. Given that new doctors requiring additional credentials will gain full registration at to work in specialised areas, will graduation, medical students may lead to the development of a ‘sub- also be expected to have additional consultant’. This could lead to more knowledge and skills before they barriers to career progression. qualify. What happens next? Potential controversies... The Shape of Training Review has set Will all new doctors get a job? The out a series of steps which should Clinical Career 21

Editor’s Response

Sonia raises some highly pertinent and controversial issues e.g. the re-emergence of fears around a sub-consultant grade, which open a very specific debate.

The training review clearly attempts to consider how training needs to change in light of how the overall healthcare system is changing and as a consequence identifies changes that might be aligned with the emerging system but unpalatable to those within it. It presents us all (clinicians, educators, trainees, deaneries, providers etc) with Hobson’s choice:

• Is it better to have education aligned with the realities of the new system, even if it heralds professional role changes that we don’t like, or • Is it better to have an educational approach that we all believe in, as doctors, but which may not be aligned with the system, creating workforce issues

The third option – palatable and aligned appears to be highly elusive, as the review makes perfectly clear. That doesn’t mean we should not aspire to it.

By way of an example, a clear system change is that of moving care out of hospitals into the community, often into providers with a limited scope or breadth of responsibilities. This adjustment to the delivery model is completely consistent with Michael Porter’s principles of value-based medicine, promoting a ‘specialist’ focus on very specific value components of care, around which the new system is attempting to organise.

If we consider what this means for doctors, it is likely that we will have an increased need for doctors with a relatively ‘junior’ broad capability and yet a limited scope of specialist capability. If we train lots of ‘traditional’ specialists, we run the risk of massively mismatching three key elements of effective workforce planning:

• Aspiration of the trained workforce – to be a specialist • Nature of the work to be done – limited scope • Workforce numbers – lots of people who there aren’t the right jobs for

However, the flipside is, as Sonia eloquently states, the effective introduction of a sub-consultant grade, ironically akin to a Specialty Doctor – not trained in depth for everything but highly capable in specific aspects of care.

I am not sure there is a right answer but I do think this is something we need to debate more. Consequently, I propose to invite comments in this issue and let’s see where that takes us.

Sara Watkin Editor-in-Chief

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27th Feb 2014, Bristol & 7th May 2014, London 6 CPD Points | £195 + VAT Articles & Advice training. and commissioning education and take greater responsibility for planning providers andclinicianstosupporting behavioursright skills, andtraining by to ensure that the workforce has the inception in2012,HEEhaspledged patient care.good quality Since its remain at theforefront ofproviding and demographical changesand massive environmental, technological intheUKcanbestadaptto services placed to comment onhow healthcare Education England(HEE) is well- leadership organisations, Health of theUK’s keyeducation andtraining As andone aSpecialHealthAuthority haping the skills ofthefuture healthcareShaping theskills workforce for Educa England: AVision Heal th Educa up keyissuessuchasthemove from picking inparticular clinical workload, forthe right numberof doctors the Education Englandwithinthat? what istherole ofHealth orpurpose for medicaleducation intheUKand Clinical to Clinical C and leadershipagenda,asheexplains passionate advocate of the training Programmes, Patrick Mitchell, is a HEE’s Director ofNational areer: What’s your vision areer... to ensure that ithas England (HEE)needs Health Education Patrick (PM): Mitchell tion tion aware ofthedevelopment ofclinical management ofpatient care. We are role that paramedics might play inthe of physician assistants andthewider practitioners, andconsider theuse emerge includingadvanced clinical workforce andthenewroles that with othermembersoftheclinical for the 21st century, how they work we ofdoctors willrequirewhat types PM: Essentially we needto lookat five years orso? changes that we will see over the next is evolving but what are themajor Clinical offer. candidates to thepostswe have on that we thehighestcalibre attract of processes are fairandequitable that the recruitment and selection work that we are doingto ensure (BTBC to our Better Training Better C attentionthis by paying particularly aredoctors trained. We canachieve that we improve theways that our Training R includingtheShapeofmajor reports, care. Alongside to primary secondary ) programme andcontinue the learly thestructureareer: Clearly eview, we need to ensure are Clinical Career 25 leadership, especially in relation to the roles that doctors will play in managing organisations and managing change. We are also aware that of the leadership role that educators and trainers play in their organisations. HEE in particular are very keen to recognise the role of the trainer and the importance of this role in ensuring that health organisations have an appropriate learning environment. We also recognise those organisations that embrace education and training have been shown to be more likely to be patient safe organisations.

Clinical Career: In which areas is your work going well and not so well? PM: We recognise there are some do you liaise with or collaborate with like all paramedics to be trained to major challenges including getting NHS England? degree level so that they can do a lot organisations to look at their clinical PM: HEE works closely with NHS more in the field to stop people being workforce as a whole rather than England. For example, we are admitted to hospital and to support looking at professional silos. We also leading the workforce element for people out in Primary Care settings. recognise the major challenges in the Emergency Medicine Taskforce, HEE have also increased the number attracting candidates to General which is run by NHS England. Our CEO, of GPs we have trained. Practice and some of the acute Professor Ian Cumming, and members specialties such Emergency Medicine. of our executive team, have regular Clinical Career: High quality training meetings with NHS England. And at obviously benefits from a stable Clinical Career: What differences will LETB level, there are early signs that clinical infrastructure. How do you see trainees feel as these challenges are NHS England have recognised that education of trainees being affected met? they need to work with local area by instability and Trust failure in our PM: We need to educate individuals teams. system? entering into medical training about PM: HEE will be joining the Chief the variety of careers they can have Clinical Career: How does the Inspector of Hospitals during visits whilst practicing medicine. It is organisation of Health Education to ensure education and learning is imperative that we highlight those England mirror or align with given the right priority within the who have been surprised moving the changing secondary care inspections programme. Quality into these fields by presenting case infrastructure? Surveillance Committees - Post studies of good practice. For example, PM: We recognise that there are Graduate deans are ensuring where a lot of people that move into General some areas where we need to grow there are poor training experiences, Practice don’t start out in their careers including Emergency Medicine and that organisations are given time to thinking they would become a GP. workforces (such as the community change and turn this around. However, However, statistics show that their workforce) that support and stop if there have been no significant level of satisfaction is as high as those patients getting admitted to hospital improvements or changes, trainees who wanted to be a GP in the first in the first place. We are also aware that will be withdrawn, allowing us not to place. we need to work with the ambulance have any poor training programmes. service on the development of their Currently, HEE is investing in the Clinical Career: How and how closely education. Essentially, we would development of Technology Enhanced Learning (TEL). In the years to come, Clinical Career: Do you think we trainees will receive ‘blended’ learning will see greater polarisation in the opportunities which will allow them development of medical trainees to receive a mixture of e-learning and e.g. into highly specialist doctors

t i c les & A dvi e simulation training as well as physical + generalist doctors + doctors less

A r clinical practise. TEL is proving to be specialist limited scope qualifications? very popular in various areas of the PM: We don’t think the quality of country. HEE are currently working trainees and their qualifications will with the Royal College of Physicians to dilute. However, we do recognise that build a simulation script for the whole we need to move away from specialist of the core medical programme. This requirements except for where it is will mean that core medical trainees needed. This will allow trainees to will have the facilities to use simulation have a broader way of thinking. training as part of the core medical programme. Clinical Career: Do you have any further words of wisdom for the think about their career plans and Clinical Career: Given that we have trainee of today? paths that differ from the historical a rough plan that further centralises PM: We would say make sure you approach? complex work i.e. relocates it from consider all of the options open to PM: The Shape of Training Review is DGHs to major acute centres, how you as the opportunities for a career in likely to challenge trainees to think will that affect the location of training medicine are great and wide ranging. more broadly about the type of numbers and rotations? Think about how you can work with medicine they will be practising in PM: General Hospitals have important other professions to bring about the future. We will be asking trainees opportunities for doctors in training change rather than around what to think differently about their careers and these will be as important as the doctors can do. As HEE gets more and the opportunities that they can very specialist teaching centres. established we will try even harder have. Historically, consultants have to publicise the excellent examples stayed in one organisation during the Clinical Career: Given the growth in of good practice where education duration of their career and not moved. community and long term condition and training takes place across the However, it is now much more likely management, do you see trainees specialties. We will also work to that there will be more movement spending more time in community distribute these across our various as people move to different areas of rotations, of which there are very few channels to make sure those good medicine to further their careers. We at the moment? examples are spread and adopted also believe that trainees need to PM: Though our BTBC Programme we so that others take advantage of see themselves as more than just a have been looking at the foundation what our case studies have shown. doctor. They need to see themselves training programme. We are going to We would also ask trainees to take as leaders, educators and managers. mandate all foundation trainees to do advantage of the opportunities for A key example of this is that one of one community based placement by multi-professional training. our key stakeholders, The Faculty of 2015. We will be asking our LETBs to Medical Management and Leadership, work with their local organisations to www.hee.nhs.uk has over 2000 members and they have identify areas where clinical care can only been up and running for two years. be provided in the community and This demonstrates that trainees are where trainee opportunities will exist. recognising that their medical career isn’t just about managing patients but Clinical Career: With this diversification has a much wider portfolio. in our structure, how should trainees Feature: The Innovation Challenge

Clinical Career 27 Innovation Feature

t i c les & A dvi e Alongside leadership, innovation is a word that you might well

A r hear in every other sentence offered by senior NHS staff. NHS England is acutely aware that it will not be able to sustain the level of service required on the current healthcare settlement unless our system undergoes significant innovation in delivery models and the use of technology. Ongoing financial austerity, coupled to a rapidly increasing and ageing population are placing pressures on the system that it just cannot keep up with. The gauntlet is firmly thrown down – we either innovate or risk the loss of what we currently call the NHS. Consequent- ly, we thought that it was a good idea to run a feature on innovation, although we suspect that innovation will be a topic that runs and runs in many successive issues of Clinical Career. Articles & Advice idea to improve to drugdelivery winning healthcare improvement S with the2023ChallengeAward at the trainee paediatricians, were presented Dr Angus G The winners, DrR Hospital NHSFoundation Trust. fromtrainee Keynes doctors Milton healthcare, hasbeenwon by two forward theirideasfor improving to put which callsonjuniordoctors The first2023Challengecompetition, S Fea aid BusinessS amuel Folkard I I Crea of Energyand “A TidalWa mprove Healthcare ntroducing the2023 Challenge to ture: TheInnova oodson, whoare both chool inOxford. Their hiannon Furr and tivy” tion Challenge and information, andS the multitudeofhospitalprocesses with juniordoctors andsupport induct Trust) withherideafor anApp to help (Oxford University HospitalsNHS The firstrunner-up was DrAsli Kalin England. I S and Wessex Leadership Academy, and Chipperfield, of top judges includingC child patients impressed apanel mprovement and teve Fairman, Director of Thames ve Director of Business R esearch at amuel Folkard aroline V alley NHS said: “We chosethe winners due to Practice BusinessS at Harvard Fund andProfessor ofManagement V Judge Professor R patients across the Thames implementation, for thebenefit of for leadingthe thejuniordoctors package alongside afundedsupport Thames allocated from aHealthEducation assessment andfundingmay be Their ideas willnow undergo afinal prestigious ceremony. of theirpeersandmentors a during pitching to anaudience of around 100 stood in the spotlight for 90seconds, ideas. of theircutting-edge They also they were quizzed onthefinerdetail pitch which during final, face-to-face the finalists were invited to makeone Having from beenselected 57entries, admissionsto hospital. unnecessary surgical device whichcould prevent third place withhisideafor anovel S University Medical (medical undergraduate at Oxford isiting I nternational Fellow, The King’s V alley innovation fund, ichard Bohmer, chool) secured V alley. chool, Clinical Career 29

Dr Rhiannon Furr and Dr Angus Goodson (Right Photo)

the strength of their ideas and the incredible. We’ve had great support been delighted with the response to scope for implementation. The ideas from colleagues back in Milton Keynes the 2023 Challenge which was positive presented were all rooted in day-to- Hospital to whom I am very grateful. not only in terms of the number and day experience of delivering care in the quality of entries, but encouraging in NHS. “We cannot recommend the 2023 the way the amount of talent amongst Challenge highly enough, it’s been a our next generation of innovators has “Furthermore, we were impressed by terrific experience and we’ve all learnt been highlighted. the combination of confidence, passion so much. But this is just the beginning and yet also humility displayed. These – we now have to go on to deliver our “All six of our finalists will now receive a are the core traits needed to make idea into practice.” support package to help them continue a great entrepreneur and to take an to develop their ideas into practice and idea forward into an implemented Caroline Chipperfield,D irector of the we will follow them closely. I cannot innovation.” Thames Valley and Wessex Leadership wait to see how we can grow this Academy, which put the 2023 competition next year and for the next First proposed by members of the Challenge into practice, said: “We have decade.” Trainee Advisory Committee (TAC), an association for doctors in training across the Thames Valley region, the 2023 Challenge gives junior doctors an opportunity to create positive ideas to further improve the NHS. The NHS Thames Valley and Wessex Leadership Academy developed the idea, working with trainees and a number of key partners to deliver the competition for the first time.

Winners Dr Angus Goodson and Dr Rhiannon Furr said: “It’s unbelievable to have been a finalist, but to win is just Dr Asli Kalin Feature: The Innovation Challenge

Healthcare innovation demands t i c les & A dvi e A r an exquisite balance

Innovation falls into two broad outside established practice. the spread of such advances has categories: incremental and been hampered by reluctance – and revolutionary. The first proceeds The history of healthcare repeatedly even downright refusal – to accept a gradually, step by step, developing shows us how, whereas incremental paradigm shift. and improving from within. The innovation brings value by doing second tends to be more abrupt, better, revolutionary innovation In the 1840s, Hungarian physician breaking new ground, bringing novel brings value by doing differently. We Ignaz Philipp Semmelweis noted techniques and knowledge from can also see again and again how a marked disparity between the puerperal fever mortality rates ¬at Vienna General Hospital’s two obstetric clinics. It was common knowledge that the clinics admitted on alternate days, and some women reportedly begged on their knees not to be treated at the less reliable of the two.

The first clinic was staffed by doctors and their students, the second by midwives. But comparatives skills and experience were not relevant. The explanation instead lay in the fact that autopsies were also conducted at the first clinic but not at the second.

Semmelweis decided a solution of chlorinated lime would address the problem and ordered all doctors and students to wash their hands before examinations. The mortality rate fell Clinical Career 31

from 18% in May 1847 to less than 3% a link between ulcers and the 20 minutes – a time for sufferings so the following month. bacterium Helicobacter pylori. Their acute that was hardly supportable.” initial research was met with extreme (Incidentally, the fact that Madame Yet the clear evidence of this scepticism. Established medical d’Arblay survived for another 28 years breakthrough was not enough to opinion began to soften only after leaves two distinct possibilities: either earn universal recognition from Marshall infected himself and effected the procedure was wholly successful the medical establishment. Many a cure through antibiotics. In 2005 or it had been utterly unnecessary.) shared the reaction of the celebrated Warren and Marshall were awarded American obstetrician Charles D the Nobel Prize for Medicine. Today a mastectomy might last for Meigs, who wrote in 1848: “Those of two or three hours. Twenty minutes you who are contagionists will say Incremental and revolutionary change seems obscenely swift. But speed that he carried the poison from house frequently coexist. An examination of was of the essence in the days before to house. Did he carry it on his hands? the history of breast cancer treatment anaesthetic – which explains why But a gentleman’s hands are clean.” provides a good illustration. James Syme, the surgeon who carried out the first leg amputation at the hip, In 1980 the treatment of gastric ulcers In 1811 the novelist Madame d’Arblay was able to proclaim in a letter written and gastritis was the subject of a vast (née Frances Burney) underwent in 1823: “It is true that the patient body of medical literature. The major surgery. Her account makes grim cannot be considered out of danger, causes were thought to be stress and reading. Whatever sedative she may though I certainly have little fear... I spicy food. Today most of these books have been given was ineffective. did the operation in about a minute.” are redundant: the recommended “I began a scream that lasted treatment for more than 90% of unintermittingly during the whole Innovations in anaesthesia – first duodenal ulcers and up to 80% of time of the incision – and I almost nitrous oxide and then ether and gastric ulcers is a simple course of marvel that it rings not in my ears still, chloroform – fundamentally changed antibiotics. so excruciating was the agony. The evil surgical procedures, while the arrival was so profound, the case so delicate... of antiseptics drastically reduced Two Australian doctors, Robin Warren that the operation, including the postoperative mortality. Yet once and Barry Marshall, had suspected treatment and the dressing, lasted again these advances prompted Feature: The Innovation Challenge

replaces it entirely. For this to happen it is essential to nurture what the great American polymath Carl Sagan described as an “exquisite balance”: “If you are only sceptical then no new ideas make it through to you. If you t i c les & A dvi e are open to the point of gullibility and A r have not an ounce of sceptical sense in you then you cannot distinguish the useful ideas from the worthless ones.”

The sphere of healthcare has been encouraged to learn from the world of business. Again this has not been universally welcomed; but an understanding of the processes of innovation, including the concept of creative destruction, would be useful in an arena where profit and loss are counted in more than mere cash.

Paul Kirkham is a researcher in the field of entrepreneurial creativity with Nottingham University Business opposition (although not, it must led to the use of radium in the School and co-deviser of the be said, from James Syme). Some treatment of tumours. First introduced Ingenuity problem-solving process thought pain a useful indicator that in the 1920s, this genuinely disruptive taught to students at its University of should not be disguised; others raised innovation, despite representing a Nottingham Institute for Enterprise ethical concerns about operating on more conservative approach, was also and Innovation (UNIEI). insensible patients; also, as we have greeted with hostility and was not seen, the suggestion that gentlemen widely acknowledged for another 20 might have dirty hands was simply years. insulting. What we see in all of these examples Subsequently, with surgeons able is that innovation is sometimes met to cut farther and deeper, removing with resistance, even in the face skin, muscle and even bone, radical of manifest evidence of significant mastectomy became the orthodox benefits. This happens to some extent Paul Kirkham treatment. The pain might have been with most innovation but especially reduced, but the disfigurement was so when change is radical. And at the External Research possibly even worse than in Madame heart of this tension is the malign yet Consultant, d’Arblay’s day – which meant women all too familiar effect of a combative Nottingham University were less likely to present for early culture of winners and losers. Business School treatment. Innovation does not always just add to Developments in a completely existing practice: it often challenges, different field – physics – eventually sometimes destroys and occasionally Author Profile LAUNCH NOTICE – Due for releaseClini 2014cal Career 33

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The story of Rowena - a Craniotomy t i c les & A dvi e A r Simulator The passionate pursuit of an interest in innovation

With some astonishing advances in technology over the past decade, the use of simulation as a significant part of surgical training has now become an accepted practice. As with many areas of medicine, neurosurgery involves complex procedures with little margin for error and so the benefits honing planning, diagnostic and surgical skills on a simulator or within a simulated environment are patently obvious. However, the key factor is ensuring that the experience is as close to reality as possible.

This is the challenge that faced Richard Neurosurgical Apprentices) specifically to Ashpole FRCS when developing his teach important surgical techniques. Prior to the creation of Rowena, innovative new neurological simulator Richard’s inventions have included a known as Rowena. As a consultant The background set of surgical instruments to assemble neurosurgeon at the Queens Medical During his career as a consultant, Richard ventriculoperitoneal shunts with a Centre (QMC) in Nottingham, including has developed specific interests in cervical non-touch technique, patented and seven years as training programme spine surgery, particularly the insertion developed during his registrar training, director, Richard is a passionate advocate of artificial cervical discs (arthroplasties), as well as a set of instruments to enable of high quality training as crucial to and the management of hydrocephalus the more accurate and safer placement maintaining a quality health service in adults. Combined with a longstanding of the Discocerv artificial cervical disc, within the UK - and across the world. interest in the design and development combined with a plastic spinal model Demonstrating his commitment to of new neurosurgical instruments and to demonstrate their correct use.It was training neurosurgeons of the future, he technology, branching out into the during the development ofthis spinal developed the Rowena model (Realistic development of inventions himself model that Richard first collaborated with Operative Workstation for Educating seemed a logical pathway. Calibre Models in Wales; a specialised small Clinical Career 35 scale plastic modelling company who helped Richard’s concept of a craniotomy simulator to become reality.

Richard explains the idea behind Rowena: “With the changes in junior doctors’ hours and other aspects of medical training, the exposure to operative neurosurgery (like all other surgical specialities) has decreased, with neurosurgical registrars spending significantly less time in theatre, whilst the necessity of turning out a fully trained and appropriately experienced consultant at the end of training remains. Trying to square this circle is tricky, hence the idea of a simulator.”

Rowena in development “Inevitably, it took some time to get the of different plastics in varying strengths, Almost a year in development, Rowena design right, involving several ‘off the shelf’ thicknesses and degrees of adherence, in consists of a moulded plastic base with trials with a partial head that the model conjunction with similar trials and error internal skull anatomy on which is fixed makers had lying around spare, as well as in order to get the plastic ‘skull’ to cut, drill a replaceable upper cranium with scalp, experimenting with various hemispheres and saw in the same manner as a real one. bone and dural layers. Inside the skull is of layered plastic to see which ones The internal architecture of the skull was a realistic plastic brain. Richard explains behaved most like skull and scalp. Once modelled from a real skull which enabled how his idea for Rowena was realised: we were happy with the basic structure, us to get all the appropriate anatomical “In many ways, neurosurgery lends itself we were then able to add a basic plastic landmarks so crucial for simulating particularly well to the application of ‘brain’ inside and to create a crude working operative surgery. simulation as a significant part of the model. speciality, especially in the early years “Having established the basic viability of of training when procedures generally “The next stage involved mimicking the the idea, the next step was the creation involve getting into the skull and closing overlying scalp and the underlying dura of a full custom made head and neck. For it up again afterwards. (the tough membrane that covers the authenticity and accuracy, it was essential brain beneath the skull). To achieve this, that the model be as close to a real skull as “It was this fact that first spawned the we tried any number of combinations possible, both internally and externally, so idea of making a plastic head with the it seemed logical to base the design on a neurosurgically important bits, i.e. the top real person. or calvarium, made in various layers to mimic the layers of tissue that a surgeon “We approached my 14 year old daughter has to get through in order to gain access Rowena who was happy to act as the to the brain itself. Unfortunately, this model for the fascinating and painstaking ‘tissue’ would inevitably be destroyed process of creating the master moulds. during any simulated surgery. However, in In a session lasting almost two hours, practice, it is only the top piece of the skull the human Rowena had her hair hidden that is drilled/cut/sawn and so the creation under a plastic cap to smooth it down, of a model composed of a high quality after which her entire head was gradually permanent base unit with a replaceable covered with layer upon layer of moulding and inexpensive ‘top’ seemed like the ideal material. This set over the course of a few solution. minutes, allowing the next layer to be Feature: The Innovation Challenge

and opened in various ways to expose the who can use it as refresher training - in soft plastic deformable brain (complete much the same way that pilots do regular with ‘lesions’) beneath. Bone flaps can simulator updates to practise skills that be replaced and fixed with sutures or a can’t always be updated on the job,” variety of plates and screws. The model comments Richard. is compatible with both CT and MRI t i c les & A dvi e scanning, enabling use of the head with Launched on the market in October A r computerised image guidance systems, 2013, Rowena is now being used by further expanding the range of procedures various medical equipment companies that it can be used to mimic, as well as to teach and demonstrate their own applied. Two small straws were popped helping to plan surgical approaches. equipment such as intracranial pressure in her nostrils to allow her to breathe - a monitoring devices and various power great feat of patience if ever there was For closure, the dura is sutured, the tools. An ultrasound variant has also been one. At the end of the process, the plastic bone flap replaced and fixed with any produced and is used to demonstrate mould was carefully cut open at the back proprietary fixation system and the scalp the technique of ultrasound location of and peeled forwards. This mould was stapled. Fractures can be reproduced with intracranial lesions. subsequently used to make the initial a hammer and fragments can be elevated Rowena heads.” and fixed. “I have been delighted with the way that Rowena has been received by the medical Rowena in practice “One of the most useful features is that profession so far,” Richard adds. “There is The completed plastic Rowena consists Rowena can be held using a standard also potential to develop the model still of a permanent head base with internal neurosurgical three point headrest (where further to include even more procedures skull architecture, on which is fixed a top the skull is rigidly held by three small in an increasingly realistic way to ensure or calvarium, consisting of skull, scalp and pins under tension). This keeps the skull that we are providing our neurosurgeons dura. This piece is easily located with a absolutely still during delicate procedures,” with the very best training - and offering lug and a screw for security. Intended to explains Richard. “Putting a head into the patients the very best care.” be replaced once it has been drilled and headrestwithout mishap is another basic sawn to destruction by trainees, it has skill that trainees need to learn. This can www.neurosurgeon.co.uk been designed as a relatively inexpensive be very easily reproduced before they consumable. The scalp can be used with actually get to the nitty gritty of opening Raney clips to turn different flaps as well the scalp and skull.” as standard burr holes and ICP monitoring devices, whilst the underlying dura with Putting Rowena to the test its vascular markings can be hitched up The first real use of Rowena was at the inaugural simulator course at QMC in autumn 2013 which included four neurosurgical trainees from the regional Richard Ashpole neurosurgery unit with differing levels of experience. The course involved trying out Richard Ashpole BSc MB BS FRCS, Consultant a multitude of basic techniques from head Neurosurgeon at Queen’s positioning through to using different Medical Centre in types of power tools and cranial fixation Nottingham, and Royal and repair techniques. College of Surgeons/ Queens Medical Centre “Due to the success of the initial session, neurosurgery course tutor this is set to become a regular four monthly simulation event aimed at newer Profile trainees as well as more senior students Clinical Career 37 CALL FOR PARTICIPANTS & INTERVIEWEES University Leadership & Management Qualifications Feature

• Have you undertaken a programme? • Would you be prepared to be interviewed about your experiences? • Do you have stories to tell – good, bad and ugly? • Could you share your thoughts to help others?

In the next edition, we will be running a feature on trainees pursuing formal qualifications such as Health Management Masters, MBAs and formal certification in all forms. We want to understand more about the value, the relevance, how they performed and whether you would do it again. We are keen o discover what you did with the learning too.

If you would be prepared to contribute, please can you contact me, Sara Watkin (Editor-in-Chief) on [email protected] and we can arrange a mini-interview with either myself or my colleague, Fraser Tennant. Feature: The Innovation Challenge

The Disruptive Innovation t i c les & A dvi e A r Expectation Understanding the nature of system innovation in healthcare

Whereas the requirement that a type of innovation that tends to innovation in health care delivery change the very nature of a market is both expected and accepted by or just how something is done. the profession at large, I can’t help In the technology field, recent but wonder whether the profession decades have brought a whole host has truly grasped the nature of of disruptive innovations, many of that innovation and what it will which leave the existing players mean for existing service providers. in panic mode as the as the new Commissioning has been changed technology takes over from there to support the introduction of established way of doing things. new innovations, in particular the Disruptive innovation is best introduction of what are described understood by looking at a series of as new business models. The examples. music industry, which strongly expectation of NHS England is that resisted this new approach these new business models will Examples of disruptive innovation brought firmly onto the horizon most likely disrupt the existing • the PC disrupted mainframe by Apple provider network by offering computing as the standard entirely new ways of delivering care method of processing data, In healthcare, we also have emerging that have the potential to leave resulting in the demise of technologies that seek to disrupt the existing providers obsolete if almost every large mainframe the traditional way of doing things. they do not adopt them. This short computing company The following represent good article focuses on just this sort of • digital camera technology examples of disruptive innovations innovation, disruptive innovation, disrupted film technology as that are likely to change health care and how it might affect services and the main method for capturing delivery significantly within our individuals going forward. and storing images, very sadly working lifetimes: resulting in the collapse of • Telehealth will enhance our Just what is a disruptive innovation? Kodak ability to care for patients The clue, of course, is firmly in the • MP3 technology has resulted without subjecting them to name. A disruptive innovation is in significant disruption of the cycle of outpatient visits simply Clinical Career 39

to monitor their progress (or disruption. them represent the typical pattern not) of reaction to something that we • Genome sequencing has the The truth is that organisations need see is threatening. Consequently, potential to disrupt traditional to learn to disrupt rather than be it is no surprise that the vast methods of diagnosis by disrupted and yet our psychological majority of treatment centres are identifying patients or reaction to potential disruptive owned and operated by commercial potential patients in advance of innovations is defensive and at odds organisations rather than the NHS. symptomatic development with our likelihood of seizing them or adopting them. An excellent Why do we fall into this trap? Disrupt or be disrupted example of this in healthcare If this tendency to resist disruptive You can’t help notice that in each is the emergence of treatment innovations until such times as they of the examples above, the existing centres for delivering high volume, take over is well recognised just players tended to be displaced comparatively simple elective care. how come we don’t recognise this by those companies promoting The system embraces this disruptive trap early and consequently adopt the new technology. Indeed, it business model because it has the a different approach? The answer is worth considering the well- potential to radically transform lies in the very nature of disruptive known phenomena that disruptive the financial footprint for certain innovation and how it comes into innovations very rarely emerge procedures. However, the profession being. Let’s utilise digital camera from existing players i.e. almost tends to adopt the position that technology as an example. When always come from a new market treatment centres are bad for health the first digital cameras appeared entrants. This suggests that there is care because the results won’t be on the market you would have to something about the R&D process as good, moving routine care into conclude that the technology was of an existing organisation that fails treatment centres will undermine not very good, especially compared to develop or embrace new ways the existing departments and by to today and particularly compared of doing things over and above shifting volume procedures into to the existing way of doing innovating to enhance the existing non-training organisations we will things i.e. film. Consequently in an way of doing things. This should struggle to train the surgeons of organisation like Kodak that had be a clear red flag to organisations the future. Whereas each of these built much success on investing in technology areas at risk of arguments has some merit, all of in film technology, it was easy to Feature: The Innovation Challenge t i c les & A dvi e A r

see digital technology as a fad out in life a bit rough round the to facilitate any provider, new or that would pass and not displace edges, it attracts investment and existing, to come forward and film technology which produced a development and becomes much suggest a better way of treating superior image. So, we commonly better. Consequently, digital images a particular group of patients. discount disruptive technologies today outstripped film technology In the past it was extremely when they first appear. for quality whilst also being of a difficult to get established as a form that is easy to share. Digital new provider, even if what you However, that is not the only part wins. are offering was ground-breaking. of the trap. We also fail to recognise Today, Any Qualified Provider and that alongside a new technology System innovation in healthcare the localisation of commissioning or business model, there is a Currently we have a system that we provide a mechanism for all sorts of change to the desired or expected cannot afford due to poor financial organisations to bring forward their job to be done. Kodak misjudged health in our economy alongside ideas and have them supported that because film technology rapidly growing demand through an into the system, if they hold merit. produced a superior image they increasing and ageing population. However, presently you can’t help would be secure. What they were Consequently if we simply tried to notice that many of the new ways failing to recognise was that the deliver healthcare in the way we of doing things are brought in job to be done with an image was have done so essentially since 1948, not by existing providers but by changing and that image quality we cannot hope to support this in commercial organisations. It seems was rapidly becoming a secondary the face of this increasing demand. that system innovation in healthcare consideration to an emerging Quite simply, the system must is following the expected disruptive primary requirement that images reinvent itself to be able to deliver innovation pathway. This should could be shared e.g. on Facebook. more and different types of care in ring alarm bells loud and clear with What tends to happen is that if a form that is financially sustainable an existing providers. the disruptive technology fulfils a going forward. need that the existing technology An opportunity to be seized doesn’t there even though it starts Commissioning has been changed Given that the system is demanding Clinical Career 41 new, sustainable ways of delivering health care, all providers have immense opportunity to innovate and then use that innovation as a means of expansion and consequently longer term stability for themselves. However, this requires both a change in practice and a shift in mindset.

The change in practice centres around the innovation process. If you job plan people to within an inch of their lives and then puts them under immense and continuous pressure to churn day- traditional manner. As you can see, new innovations both to seize the to-day work, there is precious little success goes to those capable both opportunity laid out before us and mental or physical timespace in of coming up with an innovation also to ensure that we are not victim which to innovate. Unless you create and utilising it to best advantage to new innovations. As with almost the conditions that enhance the from a commercial perspective. anything in life, a new innovation likelihood of innovations emerging, starts out as a seed in the mind but it is highly unlikely that they will Doctors as innovators true success comes from acting on spontaneously appear in our It is easy to see doctors as a rigourous that seed and cultivating it into current overworked environments. followers of clinical and scientific something of value. Good luck with This means that almost by default, evidence i.e. conformist rather than your search. new innovations are more likely to innovating. However the history be discovered by organisations not of medicine and health service is constrained by this overwhelming one of innovation, in almost every delivery requirement. aspect of care. I tend to think that many of the new innovations are The change to mindset means more likely to come not from our learning to think with a commercial most experienced doctors but orientation. Frequently, and from more junior colleagues who NHS service finding a new way have the traditional methods less of doing something results in ingrained at their core. This in no that service doing it only to way means that senior colleagues themselves within their traditional do not have the ability to innovate, existing geographical boundary so much as highlighting that they and consequently cannibalising must recognise the tendency to their own financial stability. A Andrew Vincent discount new ways until proven and commercial mindset would seize develop a healthy view of challenge the opportunity to establish the Partner, Academyst LLP towards traditional methods. new way of doing things not just and Editor-in-Chief, within their own traditional patch Clinical Business I would encourage all to learn across other people’s patches Excellence, far more about innovation, as a competitive move, in effect methods of discovery and most disrupting the organisations importantly commercialisation of Author Profile still trying to deliver care in the Investing in your t egies Career Success Early

Career St ra Creating the perfect CV by starting at the FY level

Okay, so you’re just into clinical roles and the next. So, I would not only health system is a highly complex and already someone is asking you to encourage you to engage in leadership and constantly evolving beast, where consider your future career and what development as early as possible but that complexity is hugely difficult to you can do today to enhance your also then use the insight gained to grasp if you are doing it from scratch chances. Isn’t it a bit early? The answer plan a series of leadership experience in the run-up to applying for posts. is a firm no and what many doctors building activities that demonstrate Consequently, I strongly advise you discover is the closer you get to a true commitment to leadership to become a system detective from actually applying for career posts, the evidenced by stepping up at an early an early stage and make it a passion more difficult it is to ensure that you stage. Such an activity might be to understand why the system is have exactly the right CV at the right leading an improvement project or changing, how the system is changing time. Consequently, it is imperative investigating how a pathway of care and the implications of those changes to get started on career enhancing could be altered to enhance patient to the service providers within. At the experiences as early as possible. This experience. Either of these would be risk of being slightly self-promotional, short article is designed to highlight within the grasp of an FY doctor. a good starting point is to attend our just a few things that we encourage low-cost Insights programme, which FY doctors to consider as early as My second piece of advice concerns will provide you with a solid basis of possible. the importance of developing deep understanding in commissioning, system insight, invaluable both to competition, choice, finance and Although it seems that every future employers and yourself in quality in the new system. last individual is talking about considering just how jobs and career the importance of leadership paths may change going forward My third piece of advice is to seek out development, in our experience most (try reading The Big Article). From the article on how best to approach doctors leave attending the leadership our interview skills work, we know rotations from a career perspective, course until they are within sight that employers are particularly written by my partner, Dr Sara Watkin. of their CCT. Given the likelihood of looking for people who understand In this article she recommends increased competition for the best how healthcare provision is likely to approaching each rotation as an posts, leadership course has become change over the coming years and opportunity to develop just one thing simply a must have to get shortlisted consequently our services need to that enhances your CV for the career but in no way does it provide any adapt. As you start to get into this that you aspire to. The majority of FY differentiation between one candidate topic area you will realise that our doctors focus almost all the efforts on Clinical Career 43 clinical skills development, missing the opportunity of adding significant nonclinical experiences over time. The principal at play is the same one about taking out a pension policy. The true benefit is earned by starting early and investing consistently, leaving you in the latter years with the far simpler task of now adapting your latter experiences to suit the very post but you aspire to.

My final piece of advice concerns the actual process of planning. Having already made the point that the career of tomorrow may look very different than traditional career paths today, it therefore becomes vital to ensure that your planning process carefully considers just how employment will Armed with the output of this thought juices flowing in the direction of being change over time. We are likely to see process, you can now sit down and highly proactive about your long-term a big mismatch between available work out what the employer might be career at the front-end as you enter candidates and the posts they desire. looking for in terms of both clinical and clinical posts. Whether by design or This will work both positively and nonclinical skills and experiences at by accident, the successful in life tend negatively, with some job types the time you are seeking a substantive to be those that have set themselves having an abundance of candidates post. For instance, will that type of up to be just that. So I hope that this and consequently huge competition, post come with the requirement for article will have been the inspiration whilst other, likely to be new, jobs this and this knowledge and skills, or stimulus to start planning today having an absence of candidates who alongside clinical skills? If the answer for an enormously successful career are perfectly suited. is yes, why not plan in an MSc or MBA tomorrow. in Healthcare Management as part of I encourage you to take a three-step your career strategy to ensure that you approach to early career planning: are perfect for the type of post you • firstly, decide on the type of post will ultimately want. It is abundantly you think is for you e.g. hospital clear that you cannot decide to do specialist in a particular specialty an MBA in your final year before CCT, • secondly, consider whether the if this is the point at which you have specialist area of care will even discovered it might just be the perfect be delivered in a hospital or if it CV item to get you your dream job. is likely to remain so, just how the Andrew Vincent nature of work may change over I have hardly touched on the myriad of time options available to FY doctors wishing Partner, Academyst LLP • thirdly, ask yourself whether to stack the deck in their career favour. and Editor-in-Chief, your choice is simply a reflection Over the coming editions we will build Clinical Business of traditional career paths and on this important aspect of career Excellence, whether you have appropriately strategy, with more examples and considered new or emerging specific advice. However, at this point Author Profile career paths when you made that I simply wanted to get the mental initial choice Ahead of the t egies Surgical Pack

Career St ra Extending your operating experience in short order

Let me ask you a provocative question. If you are presented with two candidates for surgical post, both of which had similar CVs in terms of nonclinical department, projects led, audit, publications and the usual array of career enhancing activities, which one would you choose and how? Now let’s change just one parameter. Let’s say one of those surgeons has vastly more centres who typically do not offer go years without having to treat surgical experience than the other. training posts. Consequently, we gunshot wound... unless you moved Would that make a difference? are seeing an increase in the use of to Baltimore. I am not suggesting overseas appointments as a way of that all trauma trainees should

The reason this is provocative is obtaining a huge volume of surgical plan on a stint in this frankly quite that there has been an increasing experience in a comparatively short attractive US city and if your goal debate about how trainees can space of time. was to work in a trauma centre that gain sufficient surgical theatre would value the skills associated time, as well as participate in all This reminds me of a conversation with treating gunshot wounds, other aspects of a post, since the I had with an overseas surgeon then a rotation in Baltimore would available hours have been cut working in the trauma field who provide you with more experience so dramatically by the European had expressly opted to work in in a year and you could reasonably Working Time Directive. Gaining the downtown Baltimore so that he expect to get in a lifetime elsewhere right surgical experience is made could gain significant experience in the US. I can’t help but think that even more problematic by the rarity of the emergency treatment of what we are starting to see today is of some surgical procedures and gunshot wounds. Whereas we a career strategy very much aligned indeed by the shift of others into might believe from the news that with the small anecdote. high-volume low cost treatment every town in the US has gunmen on every corner, in truth you could Choosing to work overseas for Clinical Career 45 the specific purpose of gaining method of either gaining superior experience that you simply could surgical experience or indeed not get in the UK is becoming a filling gaps where you simply have much more viable option than not managed to obtain sufficient previously. As all health systems, surgical experience of a particular including emerging health procedure already. systems, improve and move towards a relative standardisation We are delighted to feature two of healthcare delivery, surgical articles in our Overseas Section experience gained in overseas focusing on foreign elective terms Dr Sara Watkin territories can be highly relevant undertaken to augment surgical Clinical Service Lead & to UK trained doctors. Of course, it experience. The environment is Consultant Neonatologist, is not simply a case of packing the chosen are very different for each University College London bags disappearing three weeks and and of course the right choice Hospitals NHS Foundation returning with 50 cases under your of environment is critical for Trust & Medical Director, belt. There are important planning the experience to become a CV Academyst LLP considerations to make sure that enhancing activity. However, as you do indeed end up with the a career strategy it is one that cases you seek, as well as issues has increasing merit in the job like indemnity that need to be clear market that is not only changing Author Profile before you embark on operations. but also becoming increasingly That aside, and overseas stint has competitive. become more and more viable as a

Next Edition Enhancing Private Practice Success Just what can you do during training to enhance prospects on qualifying

In the next edition, make sure you check out our article on the sorts of things you can start doing now to ensure that you have a successful en- trance into private practice by accelerating the acquisition of private work. It’s easy to think that this is something for later but we think differently and you’ll see why in the article. Advanced Communication Excellence

Successful healthcare delivery requires exceptional communication skills in a huge variety of contexts, from supervising juniors to successful surgery and from liaising with management to influencing a department of people.T he Advanced Communication Excellence eLearning programme is a designed to take your communication skills to the highest possible levels across the full diversity of contexts, both professional to professional and professional to patient.

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www.NHSInsights.co.uk All boxes ticked: In search of happiness

Guiding Trainees through the Clinical Environment IN T ELLIGEN C HOI ES , ERES ING O PT IONS

“Thousands of people would kill for your job!” - said the Registrar to the SHO who was struggling to control the tears of helplessness, disempowerment and disillusionment.

The moisture overflowed the little available space in my eyes and a huge tear slowly crawled down my cheek. Its bitter-salty taste was surprisingly refreshing. I wiped away this uninvited reflection of the state of my inner world and stared at the stains of mascara on my fingertips. Was it just me who was not finding the fulfilment in “the job of my dreams”? I was so numb and confused that I could not find the words to say. The bleep went off reminding me to put my “commitment to Medicine” hat back on and to stop embarrassing myself in the middle of the ward. The path to a career in Medicine was made the right choice. I experienced I had always known I wanted to be a not only an obvious choice; it was the shock whenever I heard of some doctor. As early as four or five, I had only thing I ever considered. After all I doctor who left Medicine. “What?! Why a pretend hospital in my room where always ‘knew’ I wanted to be a doctor. would anyone do something crazy like I was curing my dolls and teddies of that?” I pitied them for missing out various ailments. Everyone around me At University, I used to be fascinated on what seemed like the journey of a was joyful that this pretty little ‘helper’ whenever I heard of some medical lifetime. was getting good grades at school. student who was unsure they had Clinical Career 49

As doctors, we all have our highs burnt-out doctors who functioned on professional life yet it felt like there and lows. My patients taught me autopilot. was more to life than ticking boxes. many lessons about myself and There was more to life than staying in the world around me. I felt grateful “Is this all my life will ever be?” the box. I was a Registrar in a highly for the opportunity to meet Whenever this thought popped into sought-after specialty, but it was amazing mentors, to go to fantastic my head, I would feel guilty. I felt not feeding my soul. In my hands conferences and events, and to make like I was betraying my patients, my was a fantastic CV listing all the a small difference in other peoples’ colleagues, and even the society that achievements that got me the dream lives. I was one of many who would invested in my medical training. I had job, but no one to hug my empty soul arrive on the ward to prepare the always been “a high achiever” who in my empty flat. An A-star doctor patients’ list well before the ward had passed all professional exams got no stars for prioritising her career round would start. Drawing boxes with flying colours... My multisource above other relationships in her life. next to the hundreds of tasks each feedback forms were complimentary. The nagging feeling that something day and then ticking them off when I made it through all medical fundamental was missing in my life a task was complete had a meaning interviews first time round. A future was getting painful. I lived through and a purpose. More often than not I as an NHS Consultant was only three these doubts alone in the fear that the would choose to tick off extra boxes years away and yet I was longing to medical profession would judge me on my list of jobs instead of a ten minute “natural” break. I would then fail to admit on the Hours Monitoring Exercise that I had not had any breaks. You just play the game that everyone else is playing. I would turn up to work ill because my conscientiousness would not let me call in sick. I would stay late in the evening sorting out endless paperwork in the full knowing that if caught, I would be labelled “disorganised”. I told the guy who I liked very much that I had to take care of my career and did not have time for a relationship. A comforting thought “It’ll get better” made it all seem worthwhile. experience real meaning and purpose as a failure. It seemed ironic to hear in my life. my junior colleagues express their Over time I also learnt that thinking envy over my “dream job”. The story outside the box within the NHS is Like a thief in the night, I would I had heard a few years previously discouraged. So I kept silent, only sheepishly type “alternative careers about a senior registrar who left ever venting my frustrations in The for doctors” into Google. It felt like a Medicine somehow no longer felt Mess with other junior doctors. crime. I could not share it with anyone. all that outrageous. Thousands of The years went by and I was still What was wrong with me? What people probably would kill for my job ticking off boxes on the list of jobs happened to the joy I had the day I yet I was not ready to die over it. instead of taking “natural breaks”. It passed my finals? What happened started to feel less natural. Frequent to my creativity, my enthusiasm, my After many months of soul-searching relocations for job rotations made passion? Was I the only one? and reflecting, I had my epiphany me feel like a rolling stone. I would moment. One Friday evening I look around every day and would see I had ticked off all the goals in my stayed behind after a clinic to do many disillusioned, frustrated and my paperwork. I walked into the Registrar’s office to collect my bag. What I saw was my wake-up call. My senior colleague still in her theatre scrubs sat crossed-legged on a chair staring into a computer screen. She was surrounded by multiple patients’ notes and numerous papers. She was doing an audit. Her partner was on the phone and I could work out from their conversation that he really missed her. It was 8pm on a Friday evening. She kept telling him she

IN T ELLIGEN C HOI ES , ERES ING O PT IONS had to do the audit but would try to come back home soon. In that brief moment I had what seemed like a never-ending string of flash backs to all the relationships fractured by my frantic career pursuit. Eight o’clock on a Friday evening. It was not going to get better. That insight into my future within the NHS gave me the answer. I had to break free.

Did I ever really know that I wanted to be a doctor? I may never know how much the “helper” label in and psychology than I was to reading with the whole world than to follow my childhood combined with my the BMJ, performing surgery or doing the ways of the world and be at war A-star grades determined the path clinics and ward rounds. I know now with your deepest self.” It took some that I chose. Over the years helping that it is neither good, nor bad that courage to listen to the voice inside colleagues and friends with personal prescribing essential medication or and to decide to start all over again and professional development gave administering CPR did not give me and this time to create a life of joy, me great fulfilment. Even more than as much personal and emotional meaning and purpose. Once the the “doctor” label I was proud to be the gratification as did attending decision was made, I started noticing “go-to” person whenever someone personal development seminars and that my health began to improve needed help with preparation for reading books on psychology. and a sense of peace and harmony interviews, exams, public speaking or followed. I could finally breathe. I career management. My heart smiled So it turned out that bringing out felt reborn. There must be a way – I every time I supported someone with the best in people and helping thought - to help others get their lives their job application or gave them them realise their potential was my back and to get them to experience feedback about their research article calling all along. The frequent tears of empowerment, contentment and joy or CV. My soul sang when a school helplessness, disempowerment and while doing the jobs of their dreams. student I mentored through the disillusion were merely drawing my Serendipity played its part and I am Social Mobility Foundation secured a attention to the fact that I was not now doing exactly that for a living. place to read Medicine at Cambridge. aligned with my values and beliefs. I am lucky to know that there are I spent years beating myself up unlimited ways and opportunities to about feeling more emotionally Michael Pastore said: “It is better to live a truly fulfilling life. I am lucky connected to personal development follow the Voice inside and be at war to be creating the life just the way I Clinical Career 51 want it and to experience boundless For me, success is about being true to truly want to become. Everything else energy in the process. oneself. It is not what you do but how is secondary.” you do it. If you don’t feel passionate It is wonderful if Medicine is your about what you do, ask yourself why Until recently, Evgenia followed a true calling and gives you joy and you are doing it. As I started sharing straightforward medical training fulfilment more often than not. my journey with some medics I trust, path: from Cambridge Medical Congratulations if you look forward to it transpired that there are many School through Foundation Years and getting out of bed in the mornings to doctors out there who wish they Core Medical Training to a National do what inspires you! Congratulations could do something that would make Training Number in Dermatology. if you are happy with your work-life their hearts smile. Someone told Throughout her medical career, balance and feel in control of your me her passion was baking and her Evgenia gradually came to be life! There are many doctors out there dream is to open up a bakery. Another aware that clinical practice was not who are less fortunate and Medicine doctor told me she would love to help feeding her soul. She found greatest is just a job, a status, a reliable women look beautiful and would fulfilment in mentoring and helping source of income or a way to prove set up a Beauty Spa if she knew she colleagues to grow and develop something to relatives, friends or could not fail. A third doctor would professionally. Evgenia stepped even society. Be honest with yourself. love to teach dancing professionally. outside her comfort zone to follow What would you do if you knew you They say “I just don’t want my job to her heart and pursue what gives her could not fail? What would you do if be my life”, but stepping out of the a deep sense of purpose in life. She health and money was not an issue box is scary. They are not pursuing now helps doctors realise their full and you had a thousand years to live their dreams because they do not potential and do more of what makes from now? Does it come as a surprise see a possibility that their passions them truly happy. to you that at the recent BMJ Careers could pay off. Heraclitis would say Fair, the workshops on the topics of to them: “Those who are awake have Email: [email protected] Career Change and Work-Life Balance one world in common. Those who are Twitter: @evgeniacoach were sold out? asleep live each in a different world.” Linkedin: uk.linkedin.com/in/evgeniagalinskaya/ Before I am judged for taking up What gets you out of bed in the someone’s place at Medical School, morning? Are you living so fully and a 16 year old “helper” who wanted to presently in every moment that you make a difference in other people’s always feel alive and energized by the lives simply did not know any better gift of life? If not - what’s stopping way to do so than to become a you? Do you love the life you live, doctor. Before the critics say “you just or are you merely making a living? wanted an easy life”, I have to confess Whatever the answers, how honest it was far from easy to leap into the (really) are you with yourself? unknown, out of my lonely but safe box. Doing it all alone poses unique Steve Jobs’ words were the light challenges I had never encountered when I needed it the most: “Your while working in the NHS. Not having time is limited, so don’t waste it living a Plan B means I have to make Plan someone else’s life. Don’t be trapped Evgenia Galinskaya A work. It is a steep learning curve by dogma - which is living with the which often feels like an impossible results of other people’s thinking. Career Development task. Finally being able to really take Don’t let the noise of other’s opinions Coach for Doctors care of myself, to breathe, to live in drown out your own inner voice. And the city of my choice, to create, and most important, have the courage to to rebuild meaningful relationships follow your heart and intuition. They Author Profile are the things that keep me going. somehow already know what you Inspiration, Passion & Pursuits drawn from working-class stockdrawn in from working-class for rise oneoriginallyremarkable surgeon hasbeenasteady one–a tojourney becoming atop plastic S plastic andreconstructive surgery. consultant surgeons specialising in R healthcare environment inspirations behindherpassionforthe Top UKplasticsurgeon RozinaAlireveals the to lovewha p “You have toloveyour trong-willed anddetermined, her OZINA ALIisoneoftheUK’s top a tiens andyouhave from her professional peers, 2013. Alongside suchrecognition Achievement Awards UK&Europe award nomination at thePakistan of aProfessional ofthe Year R level ofprofessional integrity, Liverpool. Testament to her high ozina was recently therecipient t youdo” R ozina as every othersurgeon thiscountryas every drivethe samespirit, andambition and religious background yet Ihad colour’ cultural andfrom aminority S can’t besurgeons you know.’ Iwas merchants saying ‘well, women There were nodoomandgloom found nothingbut encouragement. wanting to beasurgeon and, again Thomas Hospital medicalschool be a surgeon. all around methat Iwas goingto and itwas generally accepted by raised andschooledinLiverpool that nobodysaidno, you can’t. Iwas thingisthink themostimportant not justadoctor, butasurgeon….I I decidedthat Iwas goingto be R surgeon? becoming aconsultant plastic What madeyou taketheroad to the anti-ageing industry. Not to G advice onChannel4’sexpert How most recently seendispensing her appearances ontelevision andwas foris alsomuchsought after couse, class, working female ‘of ozina Ali (R et Oldconsumer guideto A): When S o off I was a child I went to S t

Clinical Career 53

produces. I had originally wanted (where you use someone’s tummy Which of these surgical procedures to be a general surgeon but a to reconstruct a breast). I’m provides the greatest challenge? wonderful mentor in Sidcup called also involved in reconstructions RA: The most difficult, without a John Payne decided I had a good after major gynaecological and doubt, is breast reconstruction. pair of hands and should consider colorectal cancer surgery. The That’s because it’s really difficult to becoming a plastic surgeon. I other thing I am involved in is lower anticipate how the patient is going had my first experience of Plastic limb reconstruction following to feel about it. The art of managing surgery at Billericay hospital and trauma and road accidents. My job expectations is probably what was entirely seduced! So in short, I is to movie tissue from one area to gives patients the most long-term became a plastic surgeon because another, effectively bringing a fresh satisfaction and it is vital to build Surgery was my calling from an blood supply and healthy tissue to a relationship of trust and realistic early age and because those I most massively injured areas. Without expectations with every patient. respected and trusted – my family, this, the underlying structures e.g. my medical school, my tutors, my bones have no chance of healing. For example, if you have someone mentors, encouraged it. What I appreciate most about my relatively young with a high work is that I work in teams with my likelihood of breast cancer due to What kind of work do you undertake colleagues from other specialties genetic predisposition and they are at Norfolk and Norwich University (orthopaedic surgeons, colorectal recommended the removal of both Hospital (NNUH)? surgeons, gynaecologists). breasts….then it is obviously going RA: I’m a reconstructive Together, we do some really to be very difficult to substitute microsurgeon and the majority of significant surgery and we do it for the loss. Some of the most what I do is breast reconstruction, well. challenging yet fulfilling aspects of usually performing DIEP flaps my surgical career are undoubtedly the trauma patients. There’s a huge patients are more knowledgeable. breast reduction or correction of range of possible traumas and There is a tendency in some breast asymmetry. Such procedures accidents and more often than not, patient groups to not take any have more than just psychological less than ideal or sufficient tissues responsibility for themselves. I’m benefits; they have huge physical to move. Other limbs or structures still astounded if someone cannot and social benefits. There are may be very badly damaged so you answer the question as to what studies to show that breast can’t use them; or you can’t violate procedure they had, when they reduction has the same impact certain areas because they are had it and even why they had it. as a major joint replacement… required for rehabilitation e.g. the So I think personal responsibility however these days it’s rare to

ion, Passion & Pursui t s t ion, Passion upper limb because they’re going is essential and I welcome patients secure funding to do those cases. to need it to use crutches, so lots coming in with lots of information I can think of maybe two or three of planning and discussion go into and I will often ask them about patients in the past four years I’ve

I ns p ira such surgical scenarios. what they know already so that been granted funding to operate we can discuss it. I encourage on, for the rest, you can only give It’s immensely satisfying, because and welcome as much knowledge them your understanding, your best those patients are going to be as possible and I am more than advice and wish them well. There’s benefitting from the results of happy to address it. I’m proud no doubt these clinical decisions your surgery for the rest of their of the quality of healthcare we are hard but it’s the inevitable fall- lives. They are also often young, provide at NNUH across all surgical out of a tight financial climate. It is fit patients with really high specialities. also the taxpayers’ money and we expectations. I just relish that. have to respect that, I just think the I think surgery is always pushed The Government’s NHS reforms boundaries and criteria should be forward by functional and lifestyle programme is radically changing more transparent to the public and demands that patients make of the UK’s healthcare landscape with consistent across the country. you. Personally I encourage it and massive financial savings being think it’s marvellous! required over the next few years. How important are training and How has this affected you and the development opportunities to you? Patients are now much more environment in which you work? RA: Training, practicing, personal knowledgeable as to their own RA: I would say we are trying to development are very much an care. Is this a good thing? carry on ‘business as usual’. It’s ingrained part of any surgeon’s RA: It’s a very good thing that still a one-to-one, doctor patient nature. We’re all about personal relationship. As a doctor, you have responsibility, all about learning, to protect and serve and listen to all about achieving and being your patient. You may however completely self-motivated and self- have to tell them what’s available driven. or suitable, and then tell them of what limited procedures you A recent course I attended was called can offer in your Trust. What all Time Management and Personal these changes have meant is a Effectiveness. I was interested huge level of anxiety where we’re in the ‘personal effectiveness’ always anticipating or fearing the component i.e. it’s not enough next political or financial move just to be efficient and to getting that is going to have an impact on things done smoothly or quickly. I clinical care. As a specialty, plastic want to perform meaningful tasks, surgery has been hit hard and I measure meaningful outcomes and have much sympathy for patients lead a fulfilling professional life. At who come in requesting quality- that particular time I was managing of-life enhancing procedures like a full time NHS career, coping with Clinical Career 55 a fast-expanding private practice, honing my communication and business skills and navigating the convoluted, somewhat opaque world of the media, all at the same time.

There was a hard truth to the course leader saying ‘STOP, revise what you can personally do - The course was useful, while it reiterated you could only fit 120 litres into a 120l suitcase…I learned the secret was to have more suitcases! So now, I play to my particular strengths – surgical skills, creative ideas, communication etc but have learned to have a team of like-minded, trustworthy professionals around me who are skilled and experienced in their own fields. Turns out, there’s an art to delegating so that people that are really good at what they do, are left alone to do what they do best! I’m lucky that such good people choose to work with me. I have only succeeded because I work in a team. I have learnt that although you may work faster on your own, you go further as a team. So time management and personal world-acknowledged international be discharged because the whole effectiveness taught me that centre of microsurgery excellence), experience has been life-affirming really worthwhile tasks take effort, that’s at least the equivalent and meaningful. My intention planning and teamwork. of a decade of micro-surgery is to make even an otherwise experience. unpalatable surgical experience What does Rozina Ali offer that into as enjoyable and inspirational a other plastic surgeons do not? In my world, even anxiety, disease, journey as possible for my patients, RA: I try to listen until I understand reconstruction can in fact be made by acting as a trusted guide. That’s and then I would hope to work into a worthwhile experience. what I endeavour to do. It may be with my patient to get the desired You’re wondering if somebody can too strong a word, but it’s true, you outcome. I’m open, I’m honest, really go through an experience have to love your patients and you and I will work very hard and very of having a diagnosis they don’t have to love what you do and if long for my patient. All too often I want, surgery they’d hope never you really dedicated to something, get involved in cases which other to have to undergo and then the I think you’ll start heading in that surgeons deem inoperable or won’t arduous road of reconstruction? I direction. take on, but I figure that since I assure you they can. I have plenty spent 12 months in Taiwan (the of patients who are very sorry to Just One Thing t ion Zone a Planning on a CV-enhancing R o t item per rotation

With consultant posts becoming consistent themes: specialised, delivered in 15- increasingly difficult to obtain, how • For an NHS post 30 major teaching hospitals do you ensure you absolutely stand • Proactive individuals who across the UK. Each will out from the crowd when it comes follow things through require new skills and to your turn to apply for the job • Individuals motivated qualities of your dreams? This is especially towards service redesign relevant when training has become so and delivery of care in Good interviewers recognise that your standardised and everyone has been different ways and settings past is also the best predictor of your on a leadership course (which you i.e. prepared to work and future behaviour. In other words those must, or don’t expect to be shortlisted). think differently individuals who have done some or I’d like to offer an idea or two. • Individuals motivated all of these things are much more towards delivering quality likely to do them again in the future. To truly answer this question it is improvement The individual who says they will do important to consider several factors: • Individuals with specific these things at interview but who • How might the job requirements specialist skills for the post has never done them previously is far change depending on the type of • For a University post less likely to deliver in these areas and post you want? • Proactive people who therefore represents a greater risk to • For example are your are going to deliver high an appointing Trust or service. A track aspirations for a major impact papers and secure record counts. teaching hospital or a DGH significant research funding • Do you want to do be This clearly makes it essential to try an academic or a clinical • How will the job description and and obtain along the way, some of the consultant hence essential and desirable experiences necessary to deliver the criteria evolve over time? specific role you want in the future. It • How have the requirements that • For many, the jobs of still amazes me how many individuals future consultant colleagues the future will fall under apply for a post with a specific interest value in applicants changed over two main banners being; and yet on their CV/application recent years (and how might broader based, delivering form they have made no attempt to they change going forward)? care close to home and in demonstrate that they have developed Job descriptions today have different settings or highly the skills and experiences required Clinical Career 57 in that area. Ironically, the CV is the of person they want, how would they meeting your educational supervisor easy bit. Trying to demonstrate that judge that from their experiences?” in advance of that job and perhaps you are proactive, have lead quality also through soliciting ideas from improvements and small redesign Once you have a clear vision of the juniors presently in the post. projects is almost impossible if you type of job you would like, you can have never done so! begin to develop some high level The type of career enhancing item will goals. For example, if your vision is to vary depending on your present level So, how can you ensure that you do be head of service at the Brompton, of training but at an SHO-level could these things as a junior doctor? It is your high level goals might include include: very easy to use each clinical job solely a high impact academic record, • A good quality audit especially as an opportunity to learn more clinical specialist clinical skills and evidence of where it has the ability to change knowledge. However, side by side to leading quality improvement projects practice this, I strongly suggest you need to and service redesign. Once you are • Publication of a case review which be using each post in your rotation as clear of your high level goals, these demonstrates that you are a an opportunity to develop other skills can be broken down into smaller steps proactive person that help demonstrate these new skills or objectives to be delivered within • Evidence of teaching and and qualities wanted by Trusts today. the context of a single post (e.g. an

I would encourage you to see every post as an opportunity to add ‘just one more thing’ that makes you a stronger candidate in the future. In the same way as most of us would hopefully plan in advance what we want to achieve from a clinical perspective, we need to start planning what we need to achieve to help demonstrate the broader skills and qualities required of new consultants today. Sometimes this is possible to do fully within the confines of a post but to be truly effective goals need to be set well before the first day on the job, before time flies and you realise starting now will not deliver the achievements you audit demonstrating actions taken presenting desire in the time available. to improve quality of care or a small • Evidence of being proactive e.g. but completed quality improvement being the SHO who sits on various Your choice of goals is made easier project) or goals which can run parallel groups or committees if you have a clear vision of the type to your clinical work e.g. undertaking of job you would ultimately like to an MSc or MEd. At a registrar-level the types of goals achieve and the expectations of what will become more specific: will be expected from a successful Your choice of specific goal for any applicant. What is stopping you particular job will also depend on Example 1 reviewing a few job descriptions on feedback you had at the midterm & 1st 6 months - going on a leadership NHS jobs now to get a clear feel for exit appraisal in your present job and course and undertaking quality present requirements for the types of enhanced knowledge of the job you improvement training post you would like to apply for in the are entering, developed by ideally 2nd 6 months - leading a small quality future? Ask yourself; “if this is the type t ion Zone a R o t

improvement project or joining a Chief applying for posts and, be under one embedded thought it is this; for Executive’s shadowing programme (if no illusion, these are the doctors every rotation ask yourself the simple the Trust has one) currently applying time and time question “what’s the one thing I can Year 2 - working as part of a team again but not getting the posts they gain experience of here that makes undertaking more specific service desire. The earlier you start the easier me more attractive for the post I redesign. it is to develop the qualities and skills eventually want”. necessary to be an all-round, great Example 2 consultant today. So, don’t forget: 1st 6 months - doing a train-the- • Start with a vision trainer and teaching course • Research what is needed to 2nd 6 months - Enrolling on an MEd deliver that vision course and being responsible for the • Develop some high level goals SHO teaching programme • In each post aim to achieve some Year 2 - redesigning an SHO teaching smaller goals or actions which will programme and delivering several help you on your way to your high aspects of the training yourself level goals Dr Sara Watkin • Plan these goals early and in Failure to think and behave in this advance Clinical Service Lead & way leads to a phenomena not • Keep reviewing the vision and Consultant Neonatologist, uncommonly seen; a doctor 6 months plan University College London away from CCT with no publications, Hospitals NHS Foundation no high quality audit, no examples The latter point is an important one. Trust & Medical Director, of leadership or quality improvement The NHS is changing and will change Academyst LLP and really nothing on their CV to increasingly rapidly in the future. demonstrate proactivity or drive to be Ensure your plan remains the right a consultant today. By this stage it is one for your longer term aspirations. Author Profile too late without specifically delaying However, if I were to leave you with Clinical Career 59 Overseas Feature

For a medical trainee, the chance to work overseas is an amaz- OVERSEAS F O C US ing opportunity to gain experience that will add immeasurably to their medical development as well as providing an impressive and distinctive entry on their CV.

In our Overseas Focus section we like to focus on the practical and organisational issues that face trainees when they make the decision to take up an elective or contract in a foreign land and the personal and cultural benefits that this provides.

Sharing these experiences for the benefit of others is something we are very keen on and in this edition of Clinical Career we showcase the inspirational stories of four individuals who under undertook training in India, Cameroon, South Africa, and the Himalayas.

As you will discover over the following pages, each benefited enormously from their experience, and each wished to share them with others who may be considering a move overseas... Three Weeks in the Himalayas OVERSEAS F O C US

In June 2013, I spent three weeks in was great. confidentiality for patients was non- the Rupin Valley, Himachal Pradesh, existent. Although when privacy and Northern India, courtesy of the health What we did confidentiality was required, we could charity Himalayan Health Exchange The trip consisted of 5 doctors, one manage it, but it required a team (HHE)1. I had been to Ladakh in dentist, porters, interpreters and lots approach to shepherd other villagers Kashmir with HHE in 2006 during my of medical students. The numbers away. So it was only done if absolutely medical school elective, and had been are simply based on who applies to necessary. Patients were triaged looking for an opportunity to return. come. We would spend a day or two and sent to a tent and seen by the at a village, before moving on to the medical students (most of whom were My motive for going (on both next one in the valley. At each Village American and mostly first or second occasions) was entirely selfish: I we would set up army tents as clinic year). Students would then present wanted the opportunity to trek in rooms and a pharmacy. Villagers their findings and proposed plan a beautiful and remote mountain would crowd into the tents, so to a doctor (one to each tent) who region and have direct and meaningful contact with the people who live in this environment. Having completed MRCPsych and started a higher training post, it was time to treat myself. I was able to secure 10 days of study leave (although no funding!) and took the rest as annual leave for this trip. I applied for study leave through the usual channels, and justified it through stating how the clinical aspects of the trip would link to the curriculum. Then it was a case of emailing HHE and paying up to book my place on the trip. Apart from booking flights and getting a visa, HHE organised everything, which Clinical Career 61

would guide, teach and prescribe. If necessary, a patient would be referred to the nearest hospital (sometimes over a day’s travel).

Challenges faced HHE have been aware for many years that the quality of interpreters is poor. The interpreters would frequently answer questions on a patient’s behalf, especially if it was was excellent though, but planned on scenarios are guaranteed. I remember something sensitive, and clearly ask leaving the organisation soon. It will one doctor washing maggots out of questions that we were not asking. always be hard to find interpreters the wound of someone’s mule. More This especially became frustrating who can speak tribal languages, harrowing though was when we made if clinic was getting busy, the tent drive jeeps on dangerous roads and camp by the side of a river. Those of was crowded and people were be prepared to lift and carry heavy us who set our tents up on the beach impatiently waiting. We had to hone equipment up and down hills and set found our tents to be over-run by clinical examination skills rapidly up camp sites. (mostly pregnant) spiders. It wasn’t to compliment the small history we much fun clearing them out with were able to obtain. One interpreter With these trips, many unpredictable just the light of my head torch and a cup. The next morning, we moved with our environment, has made me our tents further up the hill, which feel calmer in my own environment, solved the problem, but my rucksack whether at work or at home. I can sit (which I had left in the porch) was still more comfortably with uncertainty, weeping spiders for days. It was just and have a calmer approach to as well that we moved our tent up thinking through situations which

OVERSEAS F O C US the hill, as the worst rains in decades are deteriorating. I often find myself came the next day. The river burst thinking back to my time in the its banks, and much of our campsite Himalayas, saying to myself: “well this was flooded. The floods were on the isn’t as bad as then”! Also, by spending international news and there were time abroad, I mixed with people of many fatalities in the region. The different cultures, which only fosters a floods destroyed parts of the road, greater respect and understanding of and it was touch and go whether or people, which is invaluable working in not we would get out in time to catch medicine, in multi-cultural UK. our flights home. Thankfully the rains stopped and JCBs came to fix the road Things I would do differently if I had out. One more day of rain and I don’t my time again think we would have made our flight. Thankfully, as a once-upon-a-time scout, I went prepared for most eventualities; although I’m sure 90% of the people on the trip would symptoms in one patient). Therefore, have wished they had more suitable I wish I had made enquiries with waterproof clothing. Mountains, the organisers of the trip as to what in particular the weather there, is psychotropic medication would be unpredictable. As a psychiatrist, I taken, and what medication and noticed some mental illness, which services were available out there. I everyone else seemed to miss. This should have made some inquiries was everything from somatisation of into cultural understanding of mental psychosocial difficulties, which was illness in the area too (although luckily common, to the cognitive impairment we had a professor of anthropology of schizophrenia (a mental state with us who had made this his examination revealed clear first rank particular area of expertise). Given this

Adam Joiner

Benefits from the trip Apart from feasting on the unbelievably good food that the cooks could produce, it is always going to be beneficial to see how other people live in the world. It is good to remind yourself how much we have, and how we have easy access to so much. Dealing with adversity in the Himalayas, both clinically and Clinical Career 63

lack of preparation, I was essentially unable to help, other than to offer an explanation to patients as to what might be the cause of some of their experiences. And in case you were wondering, we had 10 risperidone tablets, and some weird PRN “anxiety- be-gone” tablets that contained alprazolam and escitalopram!

Dr Adam B. Joiner

Psychiatry Registrar (ST5), Early Intervention Service, Lancashire Care NHS Foundation Trust

Author Profile Paediatrics in Cameroon OVERSEAS F O C US

At 16 I wanted to be an air hostess. program.The RCPCH also appoints I wanted to travel the world, educational supervisors for all elegantly solve my passengers’ fellows, which gives you the option problems and chat to happy to carry competencies obtained families in foreign languages. This during the placement towards your fantasy was quickly shattered when training. my career counsellor told me I was 2 inches too short to meet the The application process was very minimum height requirement for straightforward. After contacting an air hostess. Ten years later I was the RCPCH to express my interest a paediatric registrar and strangely in January, I had a brief telephone enough it suited me. The ever interview and assessment day at the changing rotations satisfied my VSO offices in London where they restless nature. Speaking to people explore whether your personality of all ages from parents to toddlers suits VSO outlook and strategy. to teenagers felt like I spoke many Dr Tamara Bugembe Once accepted, I started pre- different languages in any given country training which consisted of day, and though my elegance online activities and two residential may have been debatable, the job Overseas (VSO) to develop weekends. The RCPCH Committee was all about problem solving. placements for UK based paediatric matched us candidates to the most I thought it was enough for me, trainees to go out to hospitals suitable placement and by April I until I saw an advert on the Royal in developing countries. These was told that I would be going to College of Paediatrics and Child placements are typically 1-2 Cameroon. Health (RCPCH) website for an years but shorter placements of 6 opportunity to work abroad, and it months are available. Since these I arrived in Cameroon in September tickled my curiosity. placements are developed and and was given the task of approved by the Royal College it improving services for children The Royal College of Paediatrics easier to get deanery approval for with chronic diseases at a regional and Child health (RCPCH) works time out of programme than for referral hospital. This involved together with Volunteer Services a placement from an unaffiliated the services for children with HIV, Clinical Career 65

Sickle Cell Disease, Epilepsy and Before getting stuck in, I was the paediatric wards and neonatal Diabetes. Each illness presented encouraged to spend some time unit. The neonatal unit had no a different set of challenges. exploring what it’s like being a ventilators, one oxygen cylinder Children with HIV struggled with child in North West Cameroon. I with capacity to supply up to three social stigma which resulted in spent some time with urban and babies with wafting oxygen and huge losses to follow up and poor rural families gaining insight into six makeshift incubators; but the compliance with treatment. Those the roles of family members, how neonatal nurses were amazing with diabetes had a reasonably decisions are made in a household, and worked tirelessly to keep sick good service with a specialist nurse limitations of infrastructure and babies alive. and free insulin courtesy of the their impact on health seeking World Diabetes Foundation. In behaviours. This was immensely During my 12 months there I light of this, patients with sickle useful in enabling me to empathise developed an epilepsy handbook cell disease and their families, felt with families during consultations. so patients with had handheld ignored and demanded subsidised records detailing their seizure pain relief, access to more The paediatric department types, what to do during a seizure information, specialist services consisted of four doctors, one and their treatment regime. I and more research. Children with consultant paediatrician, myself held some community education epilepsy were largely invisible, and two junior doctors (F1-2 sessions with a local NGO to reduce as many communities viewed it equivalent). Everyday we saw “walk- the mystery surrounding seizures as a spiritual rather than medical ins” with the usual acute infections and we encouraged people to disease and often sought treatment and rashes in a general paediatric come to hospital. On Saturdays I from traditional healers. outpatient clinic. On alternate days did a radio program with a sickle we did inpatient ward rounds on cell activist, discussing health OVERSEAS F O C US

issues and living with sickle cell many of my difficulties, making investigations that were available, disease. The hospital’s HIV team it really easy for me to settle in. I had to carefully consider their was exceptional, and we worked We often had power cuts, water cost, accuracy and benefit of the together to explore the reasons shortages and the internet was test before convincing parents to behind the loss to follow up and extremely slow, but my biggest pay for the tests. Even though I improve things for our patients. source of woe was the absence was in an English speaking region of cheese. Otherwise the fruits my communication skills were On one day a week I worked with the were divine and the local food challenged daily and I got to build VSO health team, which consisted really tasty. I was invited to several on my A-level French. of health care professionals from different cultural celebrations from Cameroon, Canada, Uganda weddings to funerals, giving me a I worked with doctors who had not and UK. We worked together glimpse of many traditional dances, been paid for several years because to deliver community health foods and rituals. Cameroon is of the lengthy procedures involved programs such as HIV awareness unique in having all types of in getting the Ministry of Health schemes, encouraging men to landscapes from the Sahara desert to authorise their salaries. Despite take their wives to antenatal care in the North, to beaches in the this, they turned up at the hospital and training of rural health care South with lush green mountains in and worked without complaint. workers in isolated areas. the middle, including the highest Often they had to take up extra mountain in West Africa. So there jobs and consider alternative It was exciting living in a foreign were plenty of opportunities for sources of incomes to survive country. VSO made sure we always the adventurous types. until their salary was approved. I felt safe, and they provided us with really admired their commitment a monthly allowance. The hospital I was forced to rely heavily on my to their careers and felt ashamed had received previous volunteers clinical skills because of limited at the many complaints I made as in the past and so had anticipated access to investigations. For a registrar back in the UK. Many Clinical Career 67 of these doctors taught me about managing tropical disease, HIV care and creative alternatives to the limitations of working in a resource limited setting. Memorable cases include managing an unconscious child with DKA with no syringe driver for continuous insulin, and the palliative care of a ten year old with a brain tumour.

I also learned a lot about teaching and service improvement. The language barrier, differences of experiences and different agendas led us to keep our training sessions interactive and group led. There were often unexpected tangents and changes and I had to be flexible and creative. The lack of electricity in many of the rural communities we visited quickly weaned me off power point and I learned lots of new ways to facilitate learning.

In developing community projects with VSO I learned how to write a business proposal, recruit staff, monitor and evaluate a project’s impact and sustainability. It opened my eyes to career options outside of hospital medicine, and helped me appreciate the challenges of public health work. I am hoping that this experience will help me be a better doctor, teacher and help me stand follow my own path, and develop out as I apply for consultant jobs. in new areas of learning. VSO has fellowship schemes with the Royal I would volunteer with VSO again. College of General Practitioners The experience is incredibly (RCGP), the Royal College of Dr Tamara Bugembe enriching and VSO and The RCPCH Obstetricians and Gynaecologists go out of their way to place (RCOG) and the Royal College MbChb, MRCPCH, you appropriately and keep you of Paediatrics and Child health MSc, ST8 Registrar safe. In this season where many (RCPCH), I encourage at least look Paediatric Neurology, junior doctors are identical in into the schemes, there might be Alder Hey Hospital training schemes with identical something for you. competencies and portfolios, I am Author Profile grateful to have had the chance to OVERSEAS FOCUS Please DrS contact professional position. experience andachieved itinaUKrelevant to fashionandwithoutrisk themselves ortheir real-life experiences and what peoplehadto doto ensure that theygot notonlytheright placement, sothat trainees considering gainingexperience abroad canread through the meeting. We would ofoverseas be keento buildareference onthesetypes ofarticles section specific reasons associated withgainingtraining experience that you feel theUKwas not We would love withvery to abroad, hearofotherexperiences ofworking particularly Call for comment innovative career strategy butalsoto enter into any adventure withyour eyes open. firmly We hopethat by theirexperiences, sharing you willnotonlybeinspired to consider this specific suchanapproach,reasons. eachwithavery two trainees whoundertook we are section featuring Overseas Our delighted theexperiences to of includetwo articles a highvolume ofsurgical experience by utilisingforeign placements And orelectives soin I U Augmenting Surgical Experience Augmenting SurgicalExperieneUtilisingOverseasPlaemens n ourC tilising Overseas Placementstilising Overseas areer S trategy we highlighted section, anincreasingly common approach to gaining ara Watkin [email protected] Augmenting Surgical Experience Utilising Overseas Placements

Clinical Career 69 “In India it’s purely about gaining skills OVERSEAS F O C US and not about tending your ego” A Neuro-Ophthalmologist’s experience in South Asia

Cataract is known to be responsible learned in India is extremely useful for 50 to 80% of bilateral blindness in training. That’s number one. Number India. Although greater numbers of two is India’s home. Number three, it cataract surgeries has led to a decrease was good to do free work. in prevalence, projected increases in India’s 60+ population is likely to Clinical Career: How would you mean a greater number of those at compare the unit you worked in to a risk of cataract. During the summer similar service in the UK? of 2013, Neuro-Ophthalmologist SS: Basically, they have a fee paying Srilakshmi Sharma undertook an service and a non-fee paying service. elective with a cataract surgery unit at I was working in the non-fee paying the Sankara Eye Hospital in Pammal, service. Only consultants work in the Srilakshmi Sharma Chennai, an experience she describes fee-paying service because patients as “tremendous.” come in and get their cataracts done want to have their cataracts operated by the lead surgeon and the slightly on for free. So there’s none of the hotel Clinical Career: Why did you make the more junior surgeon operates the service that patients are offered here decision to undertake surgical training theatre which is purely for non-fee in the UK and there’s not much time in India? paying patients. It’s totally different for tremendous niceties. There’s not an Srilakshmi Sharma (SS): Firstly, you from the UK in that the technique used onus on personal care at all; patients can get experience in a very particular is far quicker. They can take a cataract are in for one night. cataract surgery technique which is out in under five minutes and then invaluable in helping you deal with do the cataracts back to back. It’s a Clinical Career: How many procedures some complicated cases, and it’s also very high volume cataract surgery, far did you carry out per day? useful if you want to do any kind of higher than in the UK. The surgeons SS: They could have something like 100 relief work in this field in the future. You are exceptionally skilled and their a day. So that would be four surgeons, don’t get that training or experience outcome rates are very good. Another including trainees, seeing a hundred in western countries because we’re key difference is that staffers go out cataracts. That’s about 2 to 2.5 times reliant on an ultra-sound assisted and collect these patients from the the volume of a standard cataract technique. But the small incision rural areas and then bring them back surgeon in the UK. And procedures are cataract surgery technique that I to the hospital if they’re willing and Augmenting Surgical Experience Utilising Overseas Placements OVERSEAS F O C US

carried out under a local anaesthetic purely capitalist. If you can’t pay for it, India. For instance, you can have as they are in the UK. you don’t get it. In India, the pressure theatres running simultaneously, to compete and make money in the with surgeons moving between cases Clinical Career: How do complication private sector is enormous and the instead of sitting down and waiting an rates compare? population is also enormous. So with hour for the patient to make it up to SS: The complication rates for social enterprises like this one and its the operating suite. So efficiency could surgeons working under these sort of network of hospitals, the number of maybe increase in the UK, especially circumstances are no different to that patients coming through your door within hospitals. That’s probably a of the UK. For trainees, it’s probably will be enormous. So that’s one of principle to take away. However, higher, because there isn’t always that the biggest differences in my work there are cultural differences which intensity of supervision. My experience life, the intensity of the workload. would make it difficult for the NHS to was that you’re probably not rescued Personally, as an Indian citizen, the accommodate some of the differences quite as quickly as you would be in the differences are not at all impressive to make for better care. I can’t really UK. But with experienced surgeons, to me because I’m used to India, but suggest many more strategies that it’s really no different. the differences for someone coming aren’t employed anyway. As far as in from the West, who hasn’t had the care is concerned, there’s not a Clinical Career: What was the previous exposure, would be much tremendous amount of difference at experience like from a work and a more obvious. Another difference is all. In India, they have the equipment, personal perspective? in the quality of the equipment used they have all the medications that we SS: The working environment is for non-fee paying patients; they just do, and there’s actually not a whole definitely more intense, particularly if weren’t as good quality as clearly there lot of difference except when it comes you’re in private practice. If you work in was a financial pressure. to rarer conditions which require private care, rather than in this kind of the most expensive treatments. In social care set up, you don’t really see Clinical Career: Do you have any this they fall short, but in the major home until eight or nine at night. It’s thoughts as to how the UK can deliver hospitals, it would be a different story. much more intense but in India a lot of care differently? things are more intense. Education is SS: From a surgical point of view, Clinical Career: What are the long-term more intense because the competition you can certainly deal with a greater benefits of having done the training in is so very high. And it’s no different in volume of patients by employing India? the work environment because it’s some of the methods that I saw in SS: I know that things can be done Clinical Career 71

differently and are done differently heard a lot in the UK about needing greater transparency and a greater in different places. When you may ‘surgeon’s hands’ but in India there’s a acknowledgement that mistakes feel that you’re challenged or limited, much greater openness about people’s occur and you can actually be open there is a sense that there is another surgical ability. My exposure there, about it and gain some confidence way to achieve what you want to talking to the surgeons every single from your colleagues. I’ve never found achieve. I really enjoy exploring new day, the philosophy was very different. that to be the case in the UK. In India horizons and that’s kind of the main You simply apply yourself and you it’s purely about gaining skills and not take home lesson for me, aside from can learn. There’s no such thing as about tending your ego. the surgical skills I gained. Those are surgeon’s hands. I was actually very the main things. There is also a lack of reassured by the attitude that if you blame when something goes wrong. apply yourself with enough diligence, There’s not a tremendous shame you will certainly gain a skill, and about making a surgical error. You surgery is a skill like any other. There’s can actually speak very freely about no real reason to be intimidated by them and talk amongst each other to surgery. There’s a tremendous fear of describe what went wrong and to gain doing something wrong in the UK but opinions from different people. I’ve there isn’t that fear in India. There’s a Augmenting Surgical Experience Utilising Overseas Placements

Out of Programme Surgical Training OVERSEAS F O C US Experience in Zululand

With such competition for higher a medical officer post there I was level surgical training posts and the granted 12 months of approved out difficulty in gaining sufficient clinical of programme experience between experience with the introduction of CT1 and CT2. Having passed my the European Working time Directive MRCS and gained 2 years surgical it can be difficult to gain sufficient experience as a trainee I wanted exposure needed to progress to to use the knowledge and clinical higher training. Many suggestions experience I had gained abroad in a have been made to improve the different setting and culture. efficacy of training during these restricted hours such as dedicated Ngwelezana is a 500 bed government theatre training lists and outpatient run tertiary referral hospital covering clinics to maximise trainees time. a population of over 2 million patients With this in mind, and only two years in north eastern South Africa. It treats to gain enough clinical and academic around 8000 patients a month with experience before applying for ST3 limited facilities and staff numbers. Nicholas Howard registrar posts, I decided seek surgical The orthopaedic department I exposure elsewhere and take an out worked in for 12 months had 2 of programme year to work overseas. full time consultants, 1 part time As a medical officer (middle grade consultant and anywhere between 5 equivalent) your working week Surgical trainees spend time abroad to 10 medical officers depending on comprised of between 4 and 6 for various reasons. I wanted an fluctuating staff numbers including sessions operating, 4 sessions in increase in operative exposure in an 2 other UK based surgical trainees. outpatient clinics, one teaching area of high trauma and with English There were 5 theatres (2 with image ward round and day to day running being my first and only language, intensifiers and radiolucent tables) of an assigned ward of 24 patients South Africa was my destination shared between orthopaedic, with an intern. One day a month of choice. Ngwelezana Hospital in general, dental and eye surgery. you were also part of an outreach Kwazulu-Natal got glowing reports Other facilities included a 9 bed team to a peripheral hospital to from various UK based surgical emergency resuscitation unit, ITU, CT oversee and operate on patients that trainees and having applied for and MRI scanner. Clinical Career 73

could be managed without image Because of this the vast majority of Similar problems were encountered intensification in their theatre. One the workload is trauma and acute in follow up of patients and with session a week was set aside for bone and joint sepsis. There is also the vast majority of patients only academic study and teaching as well an incredibly high rate of bone and speaking Zulu and communication as daily trauma meetings at 7.30am. joint sepsis due to the climate, living taken via an interpreter, histories had On call commitments were shared conditions, poor sanitation and high to be simple and concise. between medical officers ranging rate of HIV infection. Elective or ‘cold’ from 1 in 5 to 1 in 10 days on call. cases were fitted in when possible Supervision and Support On calls were 24 hour shifts often with procedures carried out for Being at a junior level of surgical operating late into the night with a various pathologies such as Blounts, training it was important for me to half day the following day. Rickets, Tumours and resistant club have the support and supervision of feet. seniors. There was always a consultant Kwazulu-Natal is an area of high on call who would happily come and trauma. The reasons for this are Management was complicated in a help day or night. The chief specialist multifactorial including a high large percentage of patients due to or lead consultant (UK trained) had incidence of domestic and non late presentation. Many would visit over 25 years of trauma experience domestic violence, high alcohol the local ‘sangoma,’ or healer before with a specialist interest in paediatric abuse rates, poor road and vehicle presenting for conventional medical orthopaedics. With limited theatre maintenance with a high proportion treatment as well as a delay in patients time, resources and staff however of the population travelling on coming from referral hospitals due you were given a large amount overcrowded public transport. to transport and financial problems. of responsibility and expected to manage your own work load. On call Comparable 6 month periods in UK training and at Ngwelezana commitments included continuing South Africa UK operating on emergency cases well MUA +/- k wires 30 3 into the night independently as well Intramedullary Nails 18 2 as supervising the wards and taking Ankle Fixations 15 4 referrals from A and E. Tendon Repairs 11 1 Dynamic Hip Screw 13 6 Development Forearm Platings 7 0 The learning curve was steep and the Augmenting Surgical Experience Utilising Overseas Placements

during weekends off. With many foreign doctors and South African doctors living away from there ‘home,’ base it was an extremely social year and I have formed many friends both home and abroad from many walks of

OVERSEAS F O C US life. At no point did I feel threatened and we were warmly welcomed from the moment we arrived.

Challenges and Rewards Fortunately I was successful in my application to higher orthopaedic training on my return to the UK. Colleges however were divided in their recommendations of training abroad in 2006. Although they agreed surgical exposure could be beneficial the worries of entering back in to scope for learning about trauma was makes it very difficult to give trainees training in the UK was apparent considerable. The high volume of comparable exposure. especially with the implementation of trauma included a large number of MMC. There is no doubt I benefitted polytrauma patients. Injuries rarely The opportunities were not only and developed hugely from my year seen in the UK such as gun shot restricted to the operating theatre. out of programme both personally wounds and ‘panga,’ or machete With such an interesting range and professionally. My emergency chops were common place as well as of pathologies clinics were full of operative experience has increased road traffic accidents. A baptism of fascinating patients and with this the and there were fantastic opportunities fire on my first on call saw a mini bus opportunities for research were also to be involved in research. crash into a 4 x 4 jeep causing a mass fantastic. Recently the largest study incident with 18 patients admitted of open fractures in HIV patients was Some deaneries have short term with long bone fractures including 6 published in the JBJS and further attachments in overseas units and I open fractures all managed with out papers on the subject are to follow. was very grateful for my deaneries of hours staffing levels (9 doctors and support of my year abroad. If it 2 consultants) . Lifestyle became a more commonly agreed With the high crime rates and press period of ‘out of programme,’ training With 4 to 6 operating sessions a attention South Africa gets in recent I think many trainees could benefit week as well as on call commitments times there was a certain level of hugely from there experiences during the opportunities for operating apprehension in moving there. There a year in which they have the security were fantastic with generally just is no doubt that security lives in the of a further year in training back in 2 people in each theatre sharing forefront of South-African’s minds. the UK and avoid the difficulties of the work load. In comparison to Mtunzinini is a relatively quiet coastal applying for jobs whilst abroad. I the usual one session a week of town an hour north of Durban with would highly recommend such an emergency theatre time in the UK it a large percentage of doctors that experience and the need for foreign is no surprise my logbook was greatly worked at Ngwelezana living there. doctors in developing countries enhanced in comparison. Even with There was always something going is vital in maintaining state health the enthusiastic trainers I have had on in the evening usually in the systems. in this country the volume of work form of a brai (BBQ) and it gave us a and reduced time in trauma theatre fantastic base to travel and explore Clinical Career 75

OVERSEAS FOCUS

If you have read the interview with Srilakshmi Sharma, you will have realised that not only is working overseas is a fantastic opportunity but also that we are keen to share real experiences for the benefit of others. We’d like to focus on both the practical, organisational issues facing trainees taking foreign electives or contracts, as well as the cultural, personal and learning experiences they gained.

CALL FOR YOUR STORIES & ADVICE

In each edition of Clinical Career, we would like to publish 2 to 3 short articles (maximum) of about 1000 words on your experience working overseas either as a junior doctor or a medical student, to inspire others to follow suit. We are particularly interested in:

• What made you decide to go overseas? • How did you organise it? • What challenges did you face? • What did you actually do? • What was it like living in a foreign country? • What benefits has it given you? • Anything you would do differently if you had your time again?

We cannot guarantee to publish all contributions but this is an opportunity to get perhaps your first (hopefully of many) publications which can be added to your CV and help you to stand out from the crowd when applying for that all elusive next post. Please send submissions, or if you just want to discuss further please email me, Sara Watkin (Editor-in-Chief) at [email protected]. Awesome and Audacious: The Audi Q5 W ork- L i f e Balan c Zone

If I had over £35,000 I would happily buy car’s structural elements integrate ultra- chassis of the latest Audi Q5 also adds a the 2.0 TFSI quattro S line version of the high-strength steels; they reduce weight great dollop of refinement and comfort, Audi Q5. and improve crash safety. The result is thanks to changes to the spring, shock that the Q5 handles like an executive absorber and anti-roll bar settings. The You see, the styling of the Q5, with its saloon and takes off like a bat out of hell new power steering system gives you a coupe-like roof line and wrap-around when you dab the accelerator. Indeed, better feel for the road too. tailgate, has been subtly refreshed. the performance totally matches the The design of the headlights has been looks of this Germanic road warrior: The Q5 driving experience is further changed, and the sparkling xenon top speed is 138mph and the 0-62mph enhanced when the optional Audi units are now framed by new-look LED sprint is done in a satisfying 7.1 seconds. drive select system is specified. Audi daytime running lights that form a drive select lets you vary the operating continuous band surrounding more of Another explanation for this awesome characteristics of the throttle pedal, the lens. performance is the updated Q5’s TFSI the shift points of the automatic petrol engine, which combines direct transmission, the degree of power Inside, the Audi Q5 is pure understated fuel injection, while the eight-speed steering assistance and the operation of refinement. The controls are trimmed tiptronic automatic powers the 2.0 TFSI the automatic air conditioning system in chrome, and the narrow panels of Quattro up the cogs effortlessly. The via four modes, including an efficiency the centre console are finished in high- gloss black. The hi-tech central media component, MMI navigation plus, has very few buttons, so you don’t need a degree in Rocket Science to work out how to use it. Other touches such as heated seats, air conditioning and a multifunction steering wheel make the Q5 a dream to drive.

The car is as solidly made as an oak table and yet seems as light as a feather. There’s a reason for this: the bonnet and tailgate are crafted from aluminium, while the Clinical Career 77

mode. In addition, three optional well on rugged terrain. Its maximum components can also be controlled by climbing angle is 31 degrees and its PROS ‘N’ CONS the Audi drive select system if they are approach and departure angles are each • Looks √ fitted. These include adaptive cruise 25 degrees. And you won’t rip anything • Performance √ control, damper control and dynamic off the Q5’s underbelly because the • Build √ steering. During higher speed cornering, vehicle’s ground clearance measures 20 • Expensive X it compensates for understeer and cm. oversteer by intervening with slight steering pulses. This is truly a motor for everyone – FAST FACTS but you’ll have to have a decent bank • Max speed: 138 mph I’m not saying you’ll ever get sick of balance, or a boss who’s nice enough to • 0-62 mph: 7.1 secs driving the Q5, but when you’ve had put this on the company car list to drive • Combined mpg: 35.8 enough of all that commuting to work one. • Engine: 1984cc 4 cylinder and driving the kids to school malarkey, 16 valve petrol the Audi will thrill you off road. It may By Tim Barnes-Clay, Motoring Journalist • Max. power (bhp): 222 at look a bit bling but it actually performs 4500 rpm • Max. torque (lb/ft): 258 at 1500 rpm • CO2: 184 g/km • Price: £35,350 Body Language Mastering matching & other top tips I n t erview & R e c rui t men Zone

With so much focus placed on topics realised that this was his mannerism, the same body language as you would such as how to answer questions posed physically, for indicating that he had with one present. an interview, how to deliver effective not understood, it came across more presentations etc I wanted to focus on a as though he was disagreeing. You can Having established that you may will topic that is important but often under- plainly see that indicating you haven’t have a behavioural trait that is not addressed by candidates preparing understood is relatively benign but the entirely in your best interest interview, for interviews. Regardless of what we suggestion that you disagree can have you can now set about addressing may think about psychological factors further reaching consequences. it. In case you are worried I am not in interviews, body language matters. suggesting any deep psychotherapy You can deliver in almost all regards at I strongly advocate devoting part of and practice a series of simple steps an interview and have your selection your interview practice to establishing is quite sufficient to keep it in check. subverted by mannerism that you are whether or not you have any of these Clearly being aware of it is the first not even aware of. Equally, the effective mannerisms. There are two ways and by far the most important of those use of body language techniques can of doing this, depending on how steps. Once you have established that substantially enhance a candidate’s comfortable you are undertaking it exists the next step is to understand chances of being offered the job. the exercise in company. By far away the circumstances in which it appears. the gold standard method is to find a Again this is best done by using a Avoiding the unseen colleague and have them interview colleague to interview preferably on Almost all of us have body language you but with the specific purpose of multiple occasions so that they can traits or mannerisms of some kind observing you and your body language. recognise the pattern of emergence. or other. Sometimes these are quite At the end of the interview they reflect Once you are confident that you know benign but others can cause problems. back to you what elements of body when you exhibit this mannerism, you One of the biggest problems with language they particularly noticed and can now practice being interviewed these mannerisms is that often we are more importantly what the impact of whilst being conscious and watching blind to them ourselves. I remember those elements was on them. If you for the conditions that trigger it. speaking to a trainee who each time I are unable to do this with a colleague, You will find in most cases that this delivered an instruction that he hadn’t an alternative is to video yourself and is sufficient to stop it occurring. An heard or understood fully reacted then critique yourself afterwards. The enhancement to this is to specifically by scrunching his eyes and forehead limitation of this is that without an remind yourself of the likelihood of it (difficult to convey in text). Whereas I interviewer you may not exhibit quite occurring, immediately before you go Clinical Career 79 into an interview. If you are worried that by focusing on the interview you will lose awareness of the mannerism, you can always take a small object that you can keep in your hand, the presence of which acts as a subconscious reminder of the mannerism i.e. it is the reason you have the item in your hand.

Useful body language strategies One of the most useful techniques that is easy to adopt is that of matching the behaviour of individuals on your interview panel. To be clear we are not talking about mimicking, which will not only not get you to job but also may Assuming the interview is going well, There are a number of decent videos land you with the tag of being distinctly you will start to notice over time that the on YouTube for those of you who wish weird. What I am talking about is the person you have been matching starts to understand the body matching or subtle adjustment of body position to to adjust their body position to match mirroring technique further. A simple better match that of the key people yours. This is a very good sign that you one can be found at: https://www. who may be interviewing you. The have strong psychological rapport with youtube.com/watch?v=rqhSWI4-hnA technique is also known as a mirroring. this individual. The primary difference Allow me to explain further. is that they will not be remotely If you want to discover a bit more about conscious that they are doing this. It how to optimise your body language Let’s say that your new potential head is happening as a direct result of the specifically for the interview scenario, of Department is sat opposite you rapport and is a behavioural reaction try the following: https://www.youtube. with the arms gently folded. Matching seated firmly in our origins as creatures, com/watch?v=rqhSWI4-hnA would result in you gently folding your where matching behaviour was away arms in a manner that just appears of indicating that you were friendly natural. This aligned body stance would towards and not dangerous towards result in far greater feelings of rapport another creature. between you and the department head. Implementation of this technique Further advice must be done in full consideration The whole area of body language is that you cannot appear to just be one with a solid body of literature copying their moves. This track is most behind it but also a huge volume frequently fall into when people make of complete rubbish written on the Dr Sara Watkin obvious and immediate changes to Internet. My advice is to keep it simple. their body position in response to There’s enough to think about in an Clinical Service Lead & someone altering theirs. The best way interview without spending all of your Consultant Neonatologist, to avoid this is to carry on talking for a mental energy on thinking about your University College London moment and then whilst talking slowly body stance. However, becoming Hospitals NHS Foundation and gently adjusting your position. It is aware of adverse mannerisms is vital Trust & Medical Director, highly unlikely with the distraction of to improving your chances of success. Academyst LLP words to listen to that the person you Equally putting a little bit of effort into are matching would notice what you a simple technique like body matching are doing. represents a sensible investment of Author Profile time with a good return on investment. THE GOLD STANDARD FOR DOCTORS WANTING TO GET THE EDGE

Consultant Interview Coaching

Coaching also includes...

Specialty-specific NHS Insights Extensive Online e-Learning Module e-Learning Course Resources Designed to short cut your Included free (normally £150 Gain access to our huge resource preparation and ensure you consider standard fee) to ensure you have base enabling you to prepare in the issues of the day. a cutting edge knowledge of the short order and always be at the top emerging healthcare agenda. of your game

CV Guidance Back Up Coaching

Helping to ensure that your CV has Let’s face it, life is never certain. If the right impact, puts across the key you falter 4 times after doing the messages & gets you shortlisted for programme, we’ll coach you for free the jobs you really want until you get a job!

www.consultantinterviewcoaching.co.uk www.consultantinterviewcoaching.co.ukClinical Career 81

The coaching itself is 2 hours in duration. It commences with a short practice interview to give insight into the areas requiring specific attention, provides direct feedback to help develop and hone key skills, includes exploration of the effects of internal wiring on interview outcome and the opportunity to explore issues specifically relevant to you. At the end of the session there is a further practice interview to help reinforce everything you have learned and to address any outstanding factors that could improve your chances of success.

Following the coaching session you can then access a vast amount of additional material to ensure you turn up on the day fully prepared and ahead of the pack.

About Sara Feedback

Sara is Consultant Neonatologist and Clinical Dear Sara, Many thanks for your time last Service Lead at University College London week for the coaching session! I am glad Hospitals NHS Foundation Trust, with over 14 to say that they have offered me the job years as a consultant and more than 8 years in after the interview I had yesterday! senior service & network leadership roles. She “ has appointed (and rejected) many consultants On reflection, the coaching session was in that time. absolutely fantastic and I only wish that it happened a lot more earlier in the course Sara is also author of the prestigious title The of my preparation. Consultant Interview, published by Oxford University Press and has a formal coaching Hi Sara, I just wanted to let you know I training from the country’s leading coaching was successful at the interview for the school, The Coaching Academy. Consultant job. Thank you for your expert coaching, it definitely gave me an edge. It Besides her unbeatable credentials in interview “ was a unanimous decision and I actually insight and preparation, she is also a very active almost enjoyed the interview at one point. member of the leadership faculty of Academyst LLP and Editor-in-Chief of two journals; The Consultant and Quality, Governance & Definitely worth every penny. Gives you Experience. This depth and breadth of relevant every chance you need to be successful at experience is undoubtedly why she has such an interview enviable success rate. “ Professional Development zone on themedical register sometime that women willoutnumbermen and current suggest predictions are now entering medicalschool, I some ofthem. trainees. seeksto addressThis article less thanfulltimedoctors, including many misconceptions remain over 5). However, ithighlighted justhow including hisown college (2, 3, 4,and from many individualsandbodies, comments rebuttals prompted angry andretirework part-time, early. His female intend often doctors to taxpayer more money. Why? Because man, thuspotentially costing the would needto betrained for every on theNHS,astwo female doctors was having a detrimental effect the feminisation oftheworkforce theNHS hurting having somany women is doctors I surgeon inanational newspaper (1). controversial by acancer article storm, thanksto anoutspokenand recently ofamedia beenthesubject D Training Full Time(L Less Than General Issues n theopinionpiece, entitled “why t istrue that more women than men octors who work part-time have whowork part-time octors ”, heclaimedthat D (EWT EuropeanWorking Time medical careers (MMC implementation ofmodernising changed dramatically thanksto the last 10years. training has Medical the medical workforce over the the onlychangeto happento 2017(6).However,after thisisn’t hours, and today’s generation of excessiveof working andantisocial being ahospitaljuniormeant years Dr SusannaC ). G one are thedays are when

rowe TFT) ), andthe Directive,

proportions ofpeopletraining LTFT,proportions that somedisciplineshave higher down by speciality, it’s widelyknown didn’tthe survey break thesefigures which 86.4%were female (7). Whilst respondents were training LTFT, of showedtraining survey that 9.1%of time, year onyear. I therefore considerably risen inthis training LTFTof doctors has other commitments. The proportion combine acareer inmedicinewith aredoctors usedto beingableto n 2013,theGMC

Clinical Career 83 partly reflecting the gender balance in that speciality. However, once you look at the medical workforce as a whole (not just trainees), only 66% of the part-time medical workforce are female (8), and a survey in 2011 by the Royal College of Surgeons (2) indicated that 30% of all consultant surgeons would like to work part time at some point in their career, thus indicating that flexible working is something that both sexes may consider at some point in their careers.

There are many reasons people train less than full time. All trainee doctors are eligible to apply, provided they can demonstrate that they are involving training for a rising. Reflected in these changes unable to train full time for “well particular religious role which is an increasing demand for non- founded individual reasons” (EC requires a specific amount of traditional working hours to fit directive 93/16/EEC). These reasons time commitment. around childcare commitments, and are divided into two categories: • Non-medical professional men and women in many industries development such as now work flexibly. With this, and Category 1 management courses, law LTFT training in medicine becoming Doctors in training with: courses, fine arts courses or more common, maybe we’ll see a diploma in complementary lessening of the gender divide over • Disability or ill health (this may therapies. the coming decade? include those on in-vitro fertility programmes) Category 1 applicants are usually People sometimes assume that • Responsibility for caring (men given first priority. doctors training LTFT will always and women) for children stay that way, but in practice doctors • Responsibility for caring for ill/ Of note, both men and women can often change their hours as their disabled partner, relative or train LTFT for childcare reasons, individual circumstances change, other dependant although typically, it’s still women and they work out the balance who choose to do so. We have had that’s right for them and their other Category 2 just one male visitor in the last three commitments. For those training Doctors in training with: years to the LTFT advice zone at my LTFT for ill health, or category 2 own college’s annual careers fair, reasons, their eligibility may change • Unique opportunities for their which is aimed at medical students over the course of their training own personal/professional and foundation doctors who are programme. development, for example interested in joining the speciality. training for national/ There are considerably fewer men The GMC requires that people international sporting events, going into O&G these days, but this should undertake no less than 50% or short-term extraordinary does still reflect the GMC training of full time training (9), unless there responsibility, for example a survey’s results. However, society are exceptional circumstances. In national committee is changing, with the proportion practice, the proportion of full time • Religious commitment – of two working parent families General Issues

and burnout. Anecdotally, LTFT trainees often say that for them, working less enables them to be a better doctor; less tired, and less prone to compassion fatigue. There has been much criticism over recent years of the reduced training hours required before achieving CCT, and whether the consultants of the future will have the necessary skills, both medical, and managerial. LTFT trainees, whilst training for the same amount of time as their Pro f essional D evelo p men t z one full-time colleagues, have more indirect exposure, as their training programmes last longer, thus hours offered (e.g. 60%, 70%, 80%, debating the relative contributions contributing towards their overall and 90%) varies depending on of doctors working for the NHS. experience. speciality and region. Some LTFT trainees work in supernumerary There is also an argument to be had Training LTFT isn’t without its posts, although in the bigger that two LTFT trainees in a slot-share difficulties, though. Juggling a specialities they often slot-share is equivalent to more than one full demanding medical career with with each other in full-time training time trainee. The GMC requires that other commitments is challenging, posts. How much they get paid LTFT trainees complete work-place and it can take time for LTFT trainees depends on the number of hours based assessments pro-rata over the to work out how to combine the worked and the proportion of anti- course of a calendar year; to expect two. Trainees in specialities with social hours undertaken, with a them to complete the same amount practical procedures can find them completely different pay structure of paperwork as their full time difficult to learn whilst working to full-time trainees (10). The colleagues would be unnecessarily at 60% or less, as realistically proportion of on calls worked often burdensome (12). However, over they perform them infrequently, varies from post-to-post, depending any given calendar year, LTFT and therefore often need to work often of the service needs of the trainees often contribute towards out solutions to overcome this. department. For example, some teaching, departmental meetings, In some specialities trainees feel 60% of LTFT trainees undertake audits, and quality improvement as less rewarded as their ability to 100% of the on call commitment, much as their full time counterparts. provide continuity of care suffers; in and some 80% LTFT work 50% of Many LTFT trainees (and indeed specialities with full-shift patterns the out of hours shifts, even in the consultants) find that working LTFT and the loss of the firm structure, same speciality in the same region. actually facilitates them to take on this is less of an issue. Prejudice Many LTFT doctors therefore work leadership roles, both within their against LTFT trainees remains, in excess of 30 hours a week, a fact departments, and on wider levels. At with 58.6% of 251 respondents supported by the results of the a recent regional meeting I attended, in the aforementioned Academy Academy of Medical Royal Colleges’ with specialty representation across of Medical Royal Colleges Survey 2012 survey of doctors working many disciplines, the proportion (11) replying that they had been flexibly (11). Whilst this may be of LTFT trainees in attendance was subjected to persistent undermining part-time for a doctor, this is close much higher than the expected behaviour as a consequence of their to full time work for most members 9%. Part-time work also enables LTFT working. Whilst the numbers of the general public, which is an greater work-life balance, which are too small to draw meaningful important point to remember when arguably protects against fatigue conclusions, it does highlight a Clinical Career 85 cause for concern. However, as References: flexible working becomes more (1) http://www.dailymail.co.uk/debate/ (11) http://aomrc.org.uk/publications/ commonplace, and LTFT trainees article-2532461/Why-having-women- reports-a-guidance/doc_details/9736- start to take up consultant posts, doctors-hurting-NHS-A-provovcative- results-of-the-flexibility-and-equality- maybe attitudes will gradually powerful-argument-leading-surgeon. survey-a-report-of-the-academy- change. One way to counter this html flexible-careers-committee.html is with strong leadership for LTFT doctors within trainee bodies, (2) http://www.rcseng.ac.uk/news/ (12) http://www.gmc-uk.org/LTFT___ clear representation at training presidents-response-to-daily-mail- WPBA_and_ARCP___Additional_ programme / college / national article-by-professor-j-meirion- position_statement___Feb_2012. levels, and the development of thomas#.UtaUK2RdVvW pdf_48095387.pdf mentorship schemes (11). (3) http://www.rcpe.ac.uk/press- (13) https://www.gov.uk/government/ Undermining behaviour can release/rcpe-comment-women- publications/implementation-of- certainly contribute however, to medicine tariffs-for-education-and-training the loss of confidence expressed by http://www. some LTFT trainees. This can also be medicalwomensfederation.org. caused by the period of LTFT training uk/about-us/news-blogs- being immediately preceded by competitions/353-response-to-daily- a career break (e.g. maternity mail-article-why-having-so-many- leave). It’s therefore important for women-doctors-is-hurting-the-nhs educational supervisors and college tutors, as well as LTFT trainees (5)http://www.nhsconfed.org/ themselves, to recognise this, and Documents/The%20importance%20 put strategies in place, such as of%20LTFT%20employees%20to%20 Dr Susanna Crowe graded returns to acute disciplines. the%20NHS.pdf Senior Registrar

Where does the future lie? In (6) http://www.rcplondon.ac.uk/sites/ in Obstetrics and Gynaecology, England, the introduction of the default/files/documents/women-and- Bart’s Health, London postgraduate tariff (13) currently medicine-summary.pdf scheduled for April 2014, is going to signal huge changes for the (7) http://www.gmc-uk.org/National_ Author Profile funding for full-time training posts, training_survey_key_findings_ with the funding for LTFT posts report_2013.pdf_52299037.pdf still subject to negotiation. What impact, if any, these changes have (8) http://www.hrmagazine.co.uk/hro/ on the availability and provision of features/1141324/dean-royles-people- LTFT posts remains to be seen. The women changes to postgraduate medical training contained in the Shape (9) http://www.rcog.org.uk/files/rcog- of Training document, if applied, corp/LTFTT-GMC-18th-October-2011. could herald huge changes to the pdf profession, for all trainees. However, with more demand as a society for (10) http://www.rcpch.ac.uk/sites/ flexible working for both women default/files/asset_library/Training/ and men, it seems likely that less Less%20Than%20Full%20Time%20 than full time training will be here Training/doctorstraining_equitable_ to stay, in one form or another. pay11.pdf Professional Development zone our training, rather thanrealise we lack required to onin beagoodleaderearly vital that we develop andusetheskills run. I how ourNHSwillactually withfuture plansfor to keepup-to-date to engagewithNHSreformdoctors and forchange, junior itisimportant I a Delega for CoreTrainees Management Skills Leadership & non-Clinical ProfessionalDevelopment n theenvironment ofNHSstructural t isalso course to gainmore experience inall for C Skills Management level. Iattended the Leadership and patient care, rightfrom thejunior improvement projects, andimprove howto to know leadandrunquality for consultant posts. We alsoneed at the time of interviews these skills te’s View ore Trainees This course is run by Who organises itandwhoisfor? trainees ofalllevels.specialty how itwould benefit core trainees and of theseareas, andthisreview explains R G to 5.30pm;bothdays were heldat S 8.30am to 7 pm and day was aS one day ofstudyleave asthesecond trainee. The course only required 4th May 2013asaC I attended the course on 3rd and When and where didIdoit? refundable fee to attend. and otherdoctors, whopay a£200non- outside thistraining programme area deposit) butisalsoopento trainees (who pay only a £100 refundable West London training programmes mainly targeted at trainees inS aimed at C London C of the Hospital as part of trainees at and hence attendees mostlyconsisted and D efreshments andadaily£6lunch eorge’s Hospital in Tooting, London. ental Foundation Year 2trainees, ore Training Programme. I ore Medical, C aturday. Day 1was from C T1/C Day 2 from 8.30 am T2/DF2 level. T1 core medical S ore Surgical S t outh West G eorge’s outh I t is t is t Clinical Career 87 voucher to use at the hospital canteen were included.

Why did I do it? I went on this course as it provided an excellent opportunity to cover a wide variety of important and topical areas in a two-day, focussed environment. With lots of courses and conferences on offer, and limited study leave available, this was important. I particularly wanted to update myself on NHS reforms, clinical commissioning and the future structure of postgraduate medical education, which, as a busy junior doctor, I have found difficult to • Leadership qualities and MBTI examples of good and poor leadership do. I also wanted to learn more about and the practicalities of leading and how various personality qualities can Although most sessions were lectures, managing teams. On the second day we affect clinical leadership and to gain they were always interactive. They were split into small groups to plan quality insight into how my personality could delivered by a large variety of experts in improvement projects, practising help or hinder my ability to develop their field, ranging from trust medical the principles we had learnt in earlier into an excellent clinical and academic directors to professors of medical sessions. The MBTI workshop enabled leader. I felt that feedback from the education or public health, and from us to explore a spectrum of personality short Myers Briggs Type Indicator leaders in general practice to heads of qualities, and we used our own pre- (MBTI) assessment, which the course quality and safety. Despite the prowess course MBTI assessment results to includes, would be a useful way to do of the speakers, sessions remained develop awareness of how we could this. relaxed and there were plenty of become both better team members opportunities for sharing experiences and team leaders.

What did it cover? and asking questions. There were Each day consisted of 6-7 sessions (lectures, workshops and group discussions), which covered a different topic within the following areas:

• Structure and reforms of local healthcare environment and the wider NHS • Future hospitals and public healthcare • Clinical commissioning, healthcare finance and funding flows • Future medical education and breaks for tea, coffee and lunch, and Was there an exam? training structures the refreshments were excellent. No, but participants are required • Patient safety, risk management to carry out a short online MBTI and serious incidents Two workshops focussed specifically assessment before the course, which • Quality improvement projects on leadership qualities and how to they receive feedback on during the • Leadership, mentorship and carry out a good quality improvement MBTI workshop. A certificate of course management in practice project. On the first day we analysed attendance is provided. non-Clinical Professional Development

Would I recommend the course? Top tips: Consultant I would thoroughly recommend this • This course is popular so book course. The quality of the speakers early Interview and the range of topics covered made • Make sure you do the MBTI online it an excellent learning experience. I assessment well in advance to give Preparation learnt more from this course in two time for your feedback report to days than I could envisage learning be produced, as some participants from weeks of self-study. I am much left it too last minute more informed about and interested • Think of an idea for a quality Open Course in the current structural and political improvement project that you wish Structured perfectly changes within the NHS, and more to carry out before the course, so passionate about keeping myself up you can use the various workshops for success to date as things develop. NHS change to develop your strategy Pro f essional D evelo p men t z one will affect us and we need to know elearning about it. All the speakers and sessions Further information brought home the importance of The next course will take place on Prepare while taking the time to develop the non- 4th and 5th April 2014 at St George’s on the move! clinical attributes inherent to being a Hospital. For further information good doctor and leader, which often please email Paula Fernandez, MDECS get forgotten in the daily busy routine Administrator at St George’s Hospital: of shift work. It inspired me to get CoreMedical.TrainingCMT@stgeorges. 1-to-1 Coaching more involved in quality improvement nhs.uk or telephone 02087254026 projects and to get started with making 70% success rate at a real difference to patients – not only Competing interests key next interview those currently on the wards, but in the I have no competing interests or longer term and on a bigger scale. It personal or financial connections with did this by giving me some skills and the organisers of this course. Definitely worth confidence to start being a leader and every penny. manager at a local level. Gives you every chance you need As a result I am now leading a quality “ to be successful at improvement project to improve the interview patient experience for Haematology cancer inpatientsat my trust, meaning I liaise with patients, nurses, doctors, Understanding how managers, patient information teams, to ‘sell’ yourself and Dr Ione Woollacott quality improvement teams, printers working through and funders to work together on this specific examples ST2 Academic Clinical project! Before this course this had “ with someone with Fellow in Neurology, seemed a massive and unachievable Dementia Research so much experience goal, but now, my initial ideas for Centre and Department of definitely accelerated change are becoming a reality. All of Neurodegenerative Disease, the learning process these experiences and skills will have UCL Institute of Neurology, for me and also a major impact on my training and London made me much more practice for years to come. confident that I’d Author Profile done the right sort of preparation. Clinical Career 89

Core Skills in Clinical & Service Audit Audit is a fundamental tool for improving both quality and performance in health and yet many healthcare professionals have never had any formal audit training, often resulting in a loss or dilution of the significant benefits it offers. Invaluable for getting the “ underpinning knowledge and skills for audit. ” Find out more about this course

Finding the right leadership course for you!

Take a look at our helpful guide on choosing the right leadership course today. Professional Development zone academic interview. a ‘national’ programme was programme compared interview to differed from an academic foundation pathway. I my peersapplying for anon-academic of questionsto answer, nodifferent to were inexistence, again,Ihadacouple At that time, space questions”“White foundation programme application. etc. muchlikeyou would inanational prizes, publications, degrees extra I I hadto list alltheacademicactivities foundation programme application; compared to themore traditional wasn’t anoverly different application year ofmedical school. I foundation programme my during final management, Iappliedfor anacademic could include astint inleadershipand When Isaw that academicmedicine ofmy career.developing these parts BMA rep asastudent, progressing and asacourse representativeelected and since medical school, having been medical leadershipandmanagement I to Leadership The P non-Clinical ProfessionalDevelopment ’d completed asastudent- posters, ’ve hadalongstandinginterest in felt that Ifelt ndeed, theonly part n many ways it a had an I had an thw fortunate tofortunate begiven anoffer, up and took unscathed from theinterview. Iwas any odd, questionsandemerged abstract Idonotrecall beingasked the interview; questions were ascould for beexpected that makefor anacademic, andagain,the healthcare. Iwas askedaboutqualities medical leadershipandmanagement in and how I perceived thefuture of ambitions for thefoundation programme prepared presentation, about my talking involvedthe interview pre- giving a short difficult colleague. The ‘academic’of part ethics behindhow Imight dealwitha by discussingthecommunication and might alter my management, followed chest painandhow eachdifferential differentials for thegentleman with witha fewto an emergency sensible students. R applicants were allfinal year medical andethics, in anemergency given the if askedaboutyour approach to apatient were what you might realistically expect demonstrate. The clinicalcomponents wards andotherpersonal qualitiesIcould scenario, anethicaldilemmaonthe consider approaching anemergency competencies, how Imight asking focussedThe on interview ‘clinical’ eeling offthe “ABC ay ” approach

Dr Jonathan Mills FY1 year, there to isexpectation complete protected academictime. Again, likethe with aboutonethird ofthewholeyear rotations, eachof6months duration The programme comprises of two Clinical Leadership andManagement. award ofaPostgraduate C the University ofLeicester, leadingto the ofpostgraduateworth assignments from I dedicated to developing theseskills. with aboutathird ofmy wholeFY2 year for leadershipandmanagement activity, Foundation postincludesprotected time any otherFY1doctor. Academic My achieve thesame competencies as (i.e. 100% ‘clinical’), to andexpected being muchlikeany otherprogramme my firstjobasanFY1,withtheFY1 year t alsoinvolves completing 60credits ertificate in in ertificate Clinical Career 91

the competencies expected of an FY2 fellow participants are undertaking the you to consolidate leadership and doctor, but with a reduction in time to degree, one a senior registrar and the management theory and applying it complete this. Perhaps arguably helping other a newly appointed consultant. to your situation, helping increase its demonstrate your time-management The teaching is to help consolidate relevance, rather than be some abstract skills in juggling these two competing knowledge and gives a chance to discuss concept of no use to you. The first demands? areas that aren’t clear, and you should assignment was completed about 3 allow time to read around the subject months into the course, and required The degree involves a number of contact matter. There are a number of excellent application of theory to a topic of your days with the university, attending choosing. Writing 3000 words was not courses relating to differing leadership something I’d practiced since GCSE and management theory. The sessions English some years prior, so it was a are very interactive, with little of the challenge to get the rusty cogs of writing content being didactic. Instead, the tutor moving again. At first, it was daunting, leading the course provides a number of but as I became more emerged in the activities helping you consider leadership reading and considered how the theory and management as applicable to your could be applied, where theory could own situation. The small-group activities work and where it would falter, the help share experiences and provide a writing became a little easier, setting different perspective to how you might aside a few afternoons to complete it. The proceed with an objective, and plan second assignment was a management for handling challenges that present report; this involved some project work, themselves. The pace is maintained which early in the course you identify and the teaching enjoyable with the a project you’d like to work on with the approach employed, and the tutor has support of a tutor (usually someone with considerable experience in delivering textbooks, web articles and published an active management or leadership the course. Having about 10 days papers on leadership and management, role). Colleagues have worked on projects spread throughout the year certainly though as with anything, some are more relating to doctor’s morale and sickness, makes it manageable, and with notice interesting and readable than others. responding to clinical warnings and my and commitment, could be completed There are three assignments on the own project relating to memory clinics by those not on the programme- two Leicester programme, each helping following the national dementia strategy. non-Clinical Professional Development

news, medical journals and trust emails, and it’s not going to go away anytime soon. Adopting a more proactive role in management and leadership roles as a doctor in training has been rewarding. It has increased my appreciation and perspective of how political, economic and other ‘non-medical’ demands all need to be addressed for something to succeed. If at the end of completing a leadership and management qualification you decide you don’t want to be driving the frontier of change, you’ll Pro f essional D evelo p men t z one have a qualification useful to your CV, develop a useful skill set and hopefully enjoy learning. There have been times where I have felt out of my depth, but through it all, I have absolutely no regrets about applying, and convinced it was the right thing for me to do. The final assignment comprising 50% of work out (I initially had some problems, the credits is a portfolio of smaller articles requiring modification of the project). In Jonathan Mills is an Academic Foundation and reflections, covering a wide spectrum fact, some of the things I’ve learnt have Year 2 Doctor in the Leicestershire, of your experiences; from times you’ve been through the experience of them Northamptonshire and Rutland Deanery observed someone lead well and learnt not going correctly first time and the (LNR) and is currently completing an from it, to a situation you have failed. measures I took to rectify them. It’s also academic post in Medical Leadership I’ve yet to complete the assignment, important to recognise what you might and Management as his Academic but if you’ve managed to write a few- feasibly achieve during the time you’ve component. thousand words and a report, writing got, and negotiating with your supervisor shorter articles shouldn’t pose a problem. what is and isn’t going to be achievable Remember, you have peers completing it is imperative to success; something alongside you, with university study days smaller and more manageable is likely interspersed and the tutor available to to succeed. There are a number of other guide you if you’re struggling. organisations dedicated to medical management and leadership such as I’ve not quite finished the degree, and this the Faculty of Medical Leadership and is certainly a target to complete before Management, which offer a wealth of Jonathan Mills the end of my FY2 year. However, I have advice and opportunities to develop found setting aside blocks of time to write and showcase medical leadership and BMedSci (Hons) BMBS a section of the assignment is helpful, management success, a number of PGCME DRCOG, alongside reading of publications. Writing resources I have used and found to be Academic Foundation 300-400 words at a time over a couple of helpful. So I guess you could say I was a Year 2 Doctor, weeks makes it a lot more manageable convert to the importance of developing Leicestershire, than setting out to write 3000 words in management and leadership skills Northamptonshire and one go. Contacting your project tutor to from the beginning. The importance of Rutland Deanery (LNR) try and agree goals in advance is helpful, medical management and leadership as well having a ‘plan B’ if things don’t regularly makes it into the national Author Profile Clinical Career 93 eLearning for Junior Doctors

• Advanced Communication Excellence • Consultant Interview Skills • Core Skills in Patient Experience Excellence • Foundation Course in Leadership & Management for FY Doctors • Leadership Fundamentals & Core Principles • Management Excellence for Junior & Middle Grade Doctors • Presentation & Teaching Skills for Clinical Professionals • Time Management & Personal Effectiveness for Junior & Middle Grade Doctors • Understanding People

www.emedicus.co.uk Leadership & Management Masterclass for Latter Year Trainees & Newer Consultants

The Leadership & Management Masterclass is for individuals who are determined to take their leadership & management ability to new heights with the intention of leading and 14th - 16th catalysing the very highest levels of service or organisational success and change. Built on the principle that true excellence May 2014 or mastery is a journey of learning, discovery, self-insight and 3 Days 29 CPD Points doing, it provides a tailored programme with all the backup you’ll need along the way.

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Additional training days are just £95 - £125 +VAT per day

And Much More, all included with this course Clinical Career 95

The attended programme is designed around application of learned leadership & management principles into some extremely challenging contexts, just the sort of issues facing leaders today. The 3-day programme utilises a case study approach to apply transformational leadership principles and robust management frameworks, providing an experientially rich analysis of very real scenarios.

Actual Programme Elements

DAY 1 & 2 – Leadership, Strategy & Context DAY 3 – Management of People, Projects & Performance • The context of leadership today - setting the scene • The management imperative for modern services • Strategic leadership of services and organisations • What is management really? • The leader as catalyst • Key differences between management & leadership • Understanding medical management responsibility • Transformational leadership • 4 Cornerstones of Management Effectiveness • The WILL, SKILL, CAPACITY, AUTHORITY model • Management pitfalls and their clinical implications • 6 Core Components of Effective Leadership • Management planning and organising • (an application model) • Developing robust performance management systems • Inspiring trust & confidence • Introducing a measurement-feedback-correction cycle • Clarifying purpose and direction • Robust framework for managing people • Aligning systems & processes • What does the team around you need from you? • Knowing the people • The people in organisations - essential understanding • Releasing potential • Deploying people for maximum effectiveness • Influencing, communicating and engaging • Assigning responsibility and fostering accountability • Understanding each component in depth • Setting compelling goals for self and others • Practical application of each component • Core principles in effective delegation • Applying the principles to change and culture • The SMART plus framework for goals, objectives and • Overcoming inertia and paralysis delegation • Leading through consensus • Planning your shifts appropriately • Creating distributed leadership & responsibility • Utilising team members based on skills & preferences • Leadership in challenging circumstances • Creating an environment for effective teamwork • Motivating your team to better performance • Management styles and how to apply them • Communicating effectively with your team

The programme focuses on practical application of knowledge, skills, insight & principles across a series of typical care scenarios. It is challenging, provocative and highly hands on. You will not find finer preparation anywhere for the true rigours of today’s environment. Professional Development zone that leadership development, something an individual’s truecommitment to these answers tell memuchabout shortlisted”. Whereas both may be true, ofmy orto get curriculum, as part Ineedto“because goonacourse of years ofcompleting theirCC intrainees withinacouple particularly an increasingly common answer, course delivers for them. However, Icanensurethis knowledge that the with becausearmed course, inpart whyearly peopleare attending the leadership programs Itend to ask capacity. ourWhen conducting of individuals in a development groups withdistinct annum working I spendupwards of150days per The course versus thetruecommitment Development Depth inLeadership non-Clinical ProfessionalDevelopment before and even beingshortlisted going to have to applyfor many posts without thisevidence, theindividualis programme at all. We that know attended aleadershipdevelopment for postswithnoevidence of having we findindividualsabout to apply We are constantly dismayed when The minimum versus theideal aswell.in theirCV I know will most likely be reflected T, is

your CC untiladdress thiseven iftimeisshort to providing advice onhow bestto trainees, we specificallydevotes time management program for latter year leadership and on ourthree-day thatthis to besufficiently important how you’ve utilised it. We consider evidenced by what you’ve doneand level ofleadershipcapability, properly would beto develop awhollydifferent but also that a sensible career strategy the choice of individuals interview in factor only isleadershipaprimary in healthcare, thissuggeststhat not andseniorperson agency about every word leadershipisonthelipsofjust I hasthesame.interviewed stands to being reason that everybody course isessential, on your CV thenit However,that important. if having the guaranteeing noselection. Yes, it’s the absence ofwhichcomes closeto isanessentialon your component, CV today that having aleadershipcourse at all. shortlisted There isnoquestion there isnoguarantee that theywillbe f we consider from moment that the T. Leadership Framework is that of One ofthedimensionson NHS example. facets ofleadership. Let’s lookat an commitment to developing distinct thator projects emphasiseyour development activity then undertake through theframework lens, you can clinicians. understandingleadership By of whichare aimedspecifically at into dimensions, seven five distinct framework breaks leadership down NHS Leadership Framework. This good example ofthisisthe(outgoing) which you yourself. can benchmark A of whichhave assessment tools against number ofmodelsleadership, some in your training) willdemonstrate a Imeanonethatearly occurs early leadershipcourseA goodearly (by steer your downstream development. a framework that you can utilise to aspossibleandadopt asearly journey that firstpiece ofadviceMy is to start S experience. options for deepeningyour leadership Let’s consider then,someofthe teering deeperdevelopment

Clinical Career 97

setting direction. Setting direction has activity would not only be a perfect which is often most valuable in always been one of the fundamental demonstration of setting direction but gaining a wider perspective on the components of leadership activity. also an indicator of a modern mindset impact of your behaviour on them. Many trainees often consider that valued particularly by good Trusts. Although the feedback can sometimes they have little involvement in setting be uncomfortable, a good leader direction, given that it mostly comes Understanding yourself recognises that whether it is good from more senior staff. However, One of the most frequently or bad it is a gift that allows them having established that this is an area misunderstood aspects of leadership to develop behavioural approaches where skills must be developed, it development is that there is no that have maximum impact but is perfectly possible to adopt career formula the leadership. Different with minimal adverse consequence. stage specific strategies to focus on the individuals adopt different leadership To help motivate you to undertake specifically. For instance, at FY level you approaches, which should be tailored this process, I would offer you the could lead an improvement project, in to the circumstances in which they are comforting thought that someone’s which case the success of that project leading and the nature of the people feedback actually tells you far more will be partly dependent on how they lead. However, it is rare to find an about them than it does about the well you set an articulate direction to exceptional leader who also appears inner you. What I mean by this is that the other people involved. Not only to have little insight into themselves the feedback is far from personal and should your CV highlight the project and how they think and act, as well much more a reflection of how they that you undertook and the outcome as the impact of their actions on like to be treated, rather than a direct achieved but also the leadership others. What we are saying here is criticism of what you get wrong (even learning that you experienced in the good leadership starts from within, if it doesn’t feel that way). However, area of setting direction. If you are a by developing a deep understanding what a good leader appreciates is latter year trainee, you could extend of self and how that influences your that although the feedback does not your direction setting experience to a decisions and actions. necessarily mean you do something whole new dimension by undertaking wrong, it is an accurate reflection a strategic review of the service’s To address this very specific of how you make that person feel. strategy, perhaps in conjunction development requirement often Consequently, if there is consistency with an established consultant, to requires undertaking 360° assessment in feedback across those providing it evaluate how it needed to change in so that you can receive direct then this becomes an important area response to changing system. This feedback from other individuals, for development. non-Clinical Professional Development

create a development plan specifically for them. This cyclical approach to understanding, assessing, addressing and then evidencing different aspects of your leadership pathway will result not only in an exceptional leader but also one that looks exceptional on paper. The end goal is to ensure that you move from being shortlisted in spite of only having a leadership course on your CV to being shortlisted because of your clear and exceptional commitment to leadership evidence Pro f essional D evelo p men t z one by a systematic approach over time to self-development in this area.

Another important piece of leadership In summary development is that of gaining a As you have probably gathered by picture of your psychological make- now, the journey of true leadership up. The reason behind this is that your development has many components. individual psychology can heavily More importantly, my advice is that influence the leadership styles that you you undertake these components as adopt and more importantly can result early as possible so that you may put in a default leadership style that you them into practice with sufficient time utilise whether or not it is appropriate to provide considerable evidence of to the circumstances. Psychological your leadership commitment by the Andrew Vincent assessment can be undertaken in a time you need to demonstrate it to Partner, Academyst LLP number of forms, each of which has somebody. This represents, for many, and Editor-in-Chief, both merits and disadvantages. In and almost complete reversal of their Clinical Business the NHS by far the most common is leadership development approach, Excellence, MBTI (Myers Briggs Type Indicator), which typically involves concentrating although there are a number of other on clinical development in the early tools such as the Strength Deployment stages and then a leadership course Author Profile Inventory or Insights that are equally towards the back end. I am advocating as good, if not better under certain putting a good leadership course circumstances. What is important at the front-end to provide a solid is that the feedback is provided in leadership framework from which conjunction with a good mentor or you can base subsequent leadership coach who can help you understand development. just what the feedback is telling you. A really good coach will help you identify Once you have a framework in place, examples of behaviour that are linked you can then systematically assess to your underlying psychology and yourself against that framework then develop an understanding of the over time and select either areas of implications of this behaviour and its weakness or areas that you believe impact on others. will be particularly important and Clinical Career 99

T H READING WOR

Redefining Healthcare: Creating Value-Based Competition on Results This insightful and thought-provoking book depicts a scenario of a U.S. healthcare system in crisis.

structured differently. on competitive strategy and the competitiveness of nations and regions. In redefining Healthcare: creating Professor Porter’s work is recognized in Value-Based competition on results, the governments, corporations, non-profits, and internationally renowned healthcare academic circles across the globe. experts Michael E. Porter and Elizabeth Olmsted Teisberg examine the challenges Elizabeth Olmsted Teisberg is Professor facing the US healthcare system and reveal of Community and Family Medicine at their prescription for change. Many of the Dartmouth’s Geisel School of Medicine, ideas are relevant to the UK and we think and a Senior Institute Associate at Harvard’s it’s worth a read because the Government Institute for Strategy and Competitiveness. places much stock in its authors – coming to Professor Teisberg has developed a system near you! frameworks and cases to enable the implementation of health care delivery The authors lay out a framework for transformation by physicians, provider redefining health care competition based systems, employers, health plans and Purchase on patient value over the full cycle of care— governments. from prevention and diagnosis through It is a system that is on a collision course with recovery or long term disease management. patient needs and economic reality, where The book has something for all and provides the need of the patient is secondary to the a great perspective on how we may see our pursuit of revenue or the affordability of system change. Don’t be put off by its US healthcare provision. At stake is the quality baseline. of care for millions of Americans, the financial A 90 minute presentation by Professor health of individuals and employers, and the About the Authors: Porter on Value-Based Healthcare Delivery is stability of government budgets. This might Michael E. Porter is the Bishop William available to view on YouTube at: http://www. be the US but we have the exact same set of Lawrence University Professor at Harvard youtube.com/watch?v=Z3fKyWydweo issues, even though we have a system that is Business School and a leading authority A sk S ara

Ask Sara Providing answers to your burning career questions

This section of your journal is devoted to direct assistance in the form of advice and answers to specific career questions. You can submit these questions to [email protected] with ‘Ask Sara’ as the first bit of the subject line. Clinical Career 101

About Sara

I am a Consultant Neonatologist and Clinical Service Lead at University College London Hospitals NHS Foundation Trust, with over 15 years’ experience as a consultant and more than 8 years in senior service & network leadership roles. I have been an educational supervisor for many years, college tutor and mentored more trainees than I could possibly remember. I am author of The Consultant Interview, published by Oxford University Press and I have a formal coaching training from the country’s leading coaching school, The Coaching Academy.

Ask Away!

As this is the first edition, I don’t have any submitted questions yet. But we’d like some!

Ask questions in the following areas:

• Career strategy advice • Career dilemmas • Problems you are experiencing • How to… questions • Options and opportunities • Worries and fears • Almost anything else career focused

We’ll try to answer as many as possible and publish the best ones for the benefit of all (anonymised, obviously). Again, you can submit these questions to [email protected] with ‘Ask Sara’ as the first bit of the subject line. Ask Sara or hasstruggledto getthemheard. Iamreally keento know: I aminterested whoelsehasraised to concerns know andeither ‘eventually’ hadthemheard C I When andwhocanadoctorturntoforhelp? on Concerns Whistle Blowing feel itrequires widerwork. asaguidebutIamalsointeresteding article, to gaugewiderexperiences inthismatter asI implications for safe care are sogreat. Iamaddressing thisonesubstantially withthefollow concerns heard. However, ofmy thisisthesubject Ask S be heard onaS S As always, insomethinglikethisandfullyrespected. anonymity isimportant n thepost-Francis era itissadto findthat individualsare stillhaving trouble gettingsafety • • • • • • all for R ara was asked: What doIwhenamstrugglingto What finallytippedthebalance when you didgetheard How you responded to the Trust attitude How itaffected you (personallyorprofessionally) What happenedinresponse What you didto raise itandgetheard Nature oftheconcern esponse afety Issue? ara section thisedition,givenara section that its

- Clinical Career 103

Whistleblowing is the popular “You must also protect patients if you want to be protected under the term used when someone raises a from risk of harm posed by another Public Interest Disclosure Act 1998 concern regarding quality or safety to colleague’s conduct, performance or (PIDA).The policy itself usually involves someone in a position to and willing health by taking appropriate steps raising the concern with someone to do something about it. As a doctor, immediately so that the concerns are senior in your department (usually whether junior or senior, we have a investigated and patients are protected your line manager). If this does not duty to protect patients and colleagues. where necessary.” deliver the expected outcome the As such every trust has a policy on concern should then be raised with the raising concerns. Furthermore we are This sounds straightforward but Medical Director followed by the Chief protected in law from harassment and where do you actually turn for good Executive. bullying when we raise a concern. independent advice if your concerns do not appear to be being listened to? As a junior doctor it can be hard to Good Medical Practice states: And perhaps how far are you prepared know whether a situation should be “If you have good reason to think that to take your concern as a junior when raised as a concern. The BMA suggests patient safety is or may be seriously your future may depend on a good that you should be guided by the compromised by inadequate premises, reference from the very people you following question: equipment, or other resources, policies have concerns over. or systems, you should put the matter “If you let the situation carry on is it right if that is possible. In all other All employers should have a likely to result in harm to others?” cases you should draw the matter to formal policy for raising concerns, the attention of your employing or which will usually be known as the If in doubt, you should always err on contracting body. If they do not take ‘whistleblowing policy’, and you should the side of raising the concern with adequate action, you should take familiarise yourself with this at an early your manager/ immediate superior, independent advice on how to take the stage when tackling a concern you and you should do it as soon as you matter further. You must record your have. This can usually be found on the can. They suggest a number of issues concerns and the steps you have taken Trust Intranet site or by contacting the that you might have concerns about to try to resolve them.” HR department or if this fails your Local and examples include: Negotiating Committee Chair or BMA Protecting patients can also mean representative. • Systemic failings that result in raising concerns about your colleagues. It is important that you follow the patient safety being endangered The GMC states: organisation’s whistleblowing policy e.g. poorly organised emergency A sk S ara

response systems, or inadequate/ (http://wbhelpline.org.uk). Established local workplace policies and procedures broken equipment in December 2011 and commissioned should you consider raising your • Poor quality of care by the Department of Health but run by concern externally. If the concern is • Malpractice MENSA this provides free, independent about a colleague the most appropriate • Welfare of subjects in clinical trials advice and support to staff within the place would be the GMC and if about a • Acts of violence, discrimination or NHS and Social Care. The purpose service or organisation the Care Quality bullying towards patients of the helpline is to help individuals Commission (CQC), although the CQC • Acts of fraud clarify whether they actually have a advises first getting advice from your • Health and safety violations – whistle blowing concern; talk through professional regulatory body (GMC) or blocked fire exits, dangerous the process of raising a concern; and your trade union (BMA). structures, etc. provide advice on how to escalate a • Illness that may affect a doctor’s concern if you feel the issues raised In December 2012 the GMC launched ability to practise in a safe manner have not been addressed appropriately its own confidential helpline (tel 0161 • Substance and alcohol misuse by the organisation. What it is not is a 923 6399) which offers both advice and affecting ability to work disclosure site although it can advise enables doctors to disclose concerns re • Negligence you of your rights under the Public safety. At the same time the GMC also • Fraud or corruption Interest Disclosure Act 1998 (PIDA). This launched an online ‘decision aid’ to help • Deliberate attempt to cover up act is aimed at protecting those who doctors report patient safety concerns. any of the above raise a patient safety, or other issue Depending on the disclosure made, the in the public interest by following the GMC may take it forward themselves Some organisations have arranged correct procedures. or if it is about an organisation, refer access for their staff to free, the doctor on to the Care Quality independent, confidential helpline The helpline can be contacted on Commission. facilities where staff can seek further 08000 724 725 by emailing enquiries@ advice on reporting a concern. wbhelpline.org.uk. The Care quality commission can be Alternatively you may wish to approach contacted by telephone on 03000 the National Whistleblowing Helpline Only when you have exhausted your 616161 or by email at enquiries@cqc. Clinical Career 105 org.uk . All concerns are dealt with Act. Under the act as long as you acted by a local Compliance Inspector for honestly and responsibly when raising Consultant the service in question. He or she will a matter internally or to a regulator (e.g. use the information along with other the GMC and CQC you are protected). Interview information they may already have to This protection exists even you’re help decide what to do next. Again, your contract appears to contain a Preparation like the GMC, they will notify another gagging order. Wider disclosures e.g. regulator or official body if it is more to an MP may be protected in some appropriate for them to look into your circumstances but are subject to more concern. rigorous test. If your career as a doctor Open Course suffers as a result of raising a complaint Structured perfectly The CQC have produce a Quick guide you can bring a claim for compensation for success to raising a concern with CQC booklet in the Employment Tribunal where that has useful advice and a step-by- awards are uncapped and based on the step approach to raising concerns with losses suffered. elearning them. It’s accessible at: Finally, in the post-Francis, Keogh and Prepare while http://www.cqc.org.uk/content/ Berwick era and with changes to the on the move! whistleblowing-quick-guide-raising- CQC inspection regime it is hoped concern-cqc that all organisations are developing cultures which are open to listening 1-to-1 Coaching If you are hesitating about reporting a to staff concerns and responding concern in case it has a negative effect appropriately to them. If this is indeed on your career, working relationships the case then hopefully the need to 70% success rate at or results in a complaint about you, you whistle blow externally will become a key next interview should bear the following in mind as feature of the past and all from medical stated by the GMC student to consultant will feel safe in raising concerns about patient safety. Definitely worth • You have a duty to put patients’ every penny. interests first and act to protect Gives you every them, which overrides personal chance you need and professional loyalties. “ to be successful at interview • The law provides legal protection against victimisation or dismissal for individuals who Understanding how reveal information to raise to ‘sell’ yourself and Dr Sara Watkin genuine concerns and expose working through malpractice in the workplace. specific examples Clinical Service Lead & “ with someone with Consultant Neonatologist, • You do not need to wait for proof University College London so much experience – you will be able to justify raising Hospitals NHS Foundation definitely accelerated a concern if you do so honestly, on Trust & Medical Director, the learning process the basis of reasonable belief and Academyst LLP for me and also through appropriate channels made me much more confident that I’d The protection the GMC describes is Author Profile done the right sort of through the Public Interest Disclosure preparation. 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Time Management & Personal Effectiveness for Junior & Middle Grade Doctors

4 Hour eLearning course with 4 CPD Points N on- S pecific Featured eLearning Featured

Description PROGRAMME Aimed specifically at doctors in training, this is probably • Understanding the key determinants of personal effectiveness the most powerful course in personal effectiveness you will • Learning to avoid the performance pitfalls find anywhere. The successful junior or middle grade doctor • Interpersonal performance & interdependency - everyone’s agenda needs a unique-combination of skills combining a high team • Developing the qualities of consistently high performers orientation with strong time management & organisational • Mental processing of consistently high performers skills coupled with a delicate balancing act between learning • Understanding people, their beliefs and how this affects you and delivering. There is an ever increasing demand for results, • Developing behavioural flexibility to influence others with more ease as well as a low tolerance of mistakes. Packed full of practical • The power of personal vision and a goal-focus strategies to plan & prioritise effectively, manage the never • Deciding what you want, clinically & professionally, and achieving it ending influx of work and regain effective work-life balance. • Doing the most important things, consistently This is probably the most powerful personal effectiveness • Utilising a priority grid to balance importance & urgency course you will find. • Physiological strategies for high performance • Continual evolution - improving your performance incrementally • Act, evaluate & adapt - strategy for ultimate success Cost • Essential time management strategies for successful people £72 + VAT • Achieving work-life balance and career success

www.medmeetings.co.uk www.emedicus.co.uk Assertiveness without Aggression Cost: £195.00 + VAT Event Type: 1 day Course CPD Points: 8 Provider: Grow Medical LLP ourses Assertiveness without Aggression is probably the most comprehensive, practical programme available, designed to help consultants, other doctors and healthcare professionals adopt the right behaviour, communication and approach to have the right impact. The resulting effect is greater achievement, more self-control and a greater level of emotional self-mastery. All of this is achieved without

Open C ever trying to change the inner you whilst enhancing confidence, self-mastery, impact and interpersonal effectiveness.

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Consultant Interview Skills Session 1 - Strategy, Skills & Techniques Cost: £125.00 + VAT Event Type: Half day Course CPD Points: 3 Provider: Grow Medical LLP

With training becoming more standardised and competition for consultant posts getting ever greater, it is vital that you stand out from the crowd in order to secure the perfect post for you. That means getting the edge. The edge consists of having the right insights and demonstrating it, adopting the right overall strategy and how well you perform on the day.

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Management Fundamentals & Core Principles £195.00 + VAT Event Type: 1 day Course CPD Points: 6 Provider: Academyst LLP

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Presentation Excellence for Clinical Professionals Cost: £195.00 + VAT Event Type: 1 day Course CPD Points: 6 Provider: Grow Medical LLP

Find Out More http://www.medmeetings.co.uk/training/all/presentation-excellence-for-clinical-professionals Insights - Understanding the Evolving Healthcare Landscape 109 Cost: £95.00 + VAT Event Type: 1 day Course CPD Points: 6 Provider: Academyst LLP ourses Our ground-breaking, renowned Insights programme is designed to take individuals from an inadvertent state of naive vulnerability to one of informed insight, allowing you to set a sensible strategic direction, seize opportunity and mitigate the myriad of risk in the emerging system. Going well beyond just information and facts, it provides a deep level of interpretation and insight as to how our new system is likely to play out in reality. Open C N on- S pecific

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Leadership & Management Masterclass for Latter Year Trainees & Newer Consultants Cost: £585.00 + VAT Event Type: 3 day Course CPD Points: 29 Provider: Academyst LLP

Aimed primarily at those within sight of their CCT or recently into their first consultant post and specifically at those who recognise the unquestionable importance of true leadership and management effectiveness both in demonstration of your personal value to a prospective organisation and operationally in post.

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Leadership Fundamentals & Core Principles Cost: £195.00 + VAT Event Type: 1 day Course CPD Points: 6 Provider: Academyst LLP

Our Leadership Fundamentals programme is aimed at taking those with no formal leadership training to the point of a thorough understanding of leadership, what really makes it work and how to start applying it in every day practise. It is designed to build very solid foundations on which individuals can build ever greater leadership expertise over time. It’s thoroughly people-focused and designed to sit in the context of our very challenging times.

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www.clinicalcareer.co.uk Students Academic Meeting Cost: From £35 + VAT Event Type: Evening CPD Points: - Provider: Royal Society Of Medicine ourses Good medical leadership is vital in delivering high-quality healthcare. All medical professions (students to consultants) should be able to identify situations where things could be done differently, and have the initiative and the skills to improve them. No doctor should “leave it for others to sort out”. Open C

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Speciality applications: Clinical Radiology Cost: From £15 + VAT Event Type: Evening Course CPD Points: - Provider: Royal Society Of Medicine

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The RSM Trainees Committee is proud to host this trainee event aimed at informing prospective candidates wishing to apply into Core Surgical Training about the application process, portfolios and interviews. The event is primarily aimed at FY2 trainees, although more junior trainees are welcome to attend.

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Speciality Applications: Core medical training Cost: From £15 + VAT Event Type: Evening Course CPD Points: - Provider: Royal Society Of Medicine

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Find Out More http://www.rsm.ac.uk/yf/tre05.php Future surgeons conference orthopaedic (FOSC R R Teaching for Smallgroup doctors: skills teaching Find More Out Find More Out Find More Out Find More Out C C C C examples of common, important andinterestingexamples ofcommon, important cases, taught tostandard.P/MRCS MRC C The for objective thisoneday course isto cover radiological topics relevant themostimportant to foundation doctors. A joint meetingwiththe Trainees C V Friday 15November 2013 V S poor design orexecution thatrandomisedUnderstand theprinciples underlie controlled andrealise trials how by orsubverted easilytheycanbeundermined which itisappropriate to usethem Understand thestrengths ofthedifferent andweaknesses knowresearch thecircumstances studydesigns inobservational and in http://www.rsm.ac.uk/academ/ore03.php http://www.rsm.ac.uk/academ/rpe01.php http://www.rsm.ac.uk/yf/tre08.php http://www.rsm.ac.uk/yf/tre07.php aturday -Sunday 7-8D enue: R enue: R ost: ost: ost: ost: ourse participants willbeprovided for withusefultipsandtricks ourse participants systematic interpretation ofradiological casesaswell asmultiple esearch appraisal methodsandcritical course adiology for foundation doctors From £35+ From £35+ From £105+ From £90+ oyal S oyal S ociety Of Medicine, 1 Of ociety Wimpole S ociety Of Medicine, 1 Of ociety Wimpole S V V V AT AT AT V AT ecember 2013 Event Type: Event Type: Event Type: Event Type: ommittee 2 day C 1 day C 1 day C 1 day C onference ourse ourse ourse treet, LONDON, W1 G 0AE treet, LONDON, W1G 0AE CPD Points: CPD Points: CPD Points: CPD Points: - - - - ) Provider: Provider: Provider: Provider: R R oyal S oyal S R R oyal S oyal S ociety Of Medicine Of ociety Medicine Of ociety ociety Of Medicine Of ociety ociety Of Medicine Of ociety

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