this week SHARED APPOINTMENTS page 87 • FOLIC ACID page 88 • CORONERS’ REPORTS page 89 Whistleblower trainee drops claim A junior doctor who claimed that he was The statement agreed that Day had Chris Day, who worked at unfairly dismissed by an NHS trust for blown the whistle by raising patient safety Queen Elizabeth Hospital in whistleblowing about unsafe staffing concerns in good faith and had “performed Woolwich, fought his claim for unfair dismissal for four years levels and that his career was subsequently a public service in establishing additional destroyed by Health Education England has whistleblowing protection for junior withdrawn his claims part way through an doctors.” But, it added, “The tribunal employment tribunal hearing. is likely to find that both the trust and Chris Day, 33, fought a four year legal HEE acted in good faith towards Dr Day battle to have his claims heard after raising following the whistleblowing and that Dr concerns in 2014 about understaffing Day has not been treated detrimentally on and safety at the intensive care unit of the the grounds of whistleblowing.” The claims Queen Elizabeth Hospital in Woolwich, were “dismissed upon withdrawal.” London, where he was a specialist registrar HEE said in a statement, “We have always in emergency medicine. He claimed that been clear we did not act against Dr Day after he repeated the concerns to HEE it because of his protected disclosures or deleted his training number, making it cause him any detriment. HEE has always LATEST ONLINE impossible for him to continue training. supported healthcare staff blowing the HEE claimed that it was not legally his whistle. It is part of the education and • Physician associates employer, so no case could be brought training we oversee for new clinicians.” will be regulated along same lines as against it under employment law. But in A BMA spokesperson said that it had doctors and nurses 2017 the Court of Appeal ruled that HEE secured legally binding protections, in does employ junior doctors, along with force since August 2016, that “ensure that • Drug companies are incentivised not the trust at which they are placed, opening doctors, whether they are BMA members to improve health the way for junior doctors to bring claims or not, can raise relevant issues in the against HEE at an employment tribunal. workplace, knowing that there is a robust • Number of US children who The tribunal opened this month and was legal apparatus in place to safeguard them are completely expected to last 21 days. Day gave evidence from any detriment that they may suffer unvaccinated has and was cross examined, but after six days from HEE as a consequence.” quadrupled since a statement withdrawing his claims, agreed Clare Dyer, The BMJ 2001 by all three parties, was read out. Cite this as: BMJ 2018;363:k4356 the bmj | 20 October 2018 85 GMC investigators to get training in Flour expected to be fortified system issues with folic acid within weeks GMC staff and clinical experts who ealth experts have welcomed 14 October, though the Department of Health investigate doctors’ fitness to practise reports that the UK is poised for England wouldn’t confirm the move. will be trained in “human factors” so to start fortifying flour with The incidence of neural tube defects in that the context in which doctors have folic acid to help prevent birth the UK is among the highest in Europe, to work is taken into account when the defects such as spina bifida and affecting around 1000 pregnancies a year. regulator takes decisions. Hanencephaly. Experts say that there is clear evidence that The move follows the case of the Nicholas Wald, of the Wolfson Institute fortifying flour with folic acid would lead to a trainee paediatrician Hadiza Bawa- of Preventive Medicine at Queen Mary significant reduction in neural tube defects, Garba, which sparked a widespread University of London, said, “If this is officially such as anencephaly and spina bifida. loss of confidence in the GMC. confirmed, the UK is taking an important step They say such a measure would reach The regulator has teamed up with in preventive medicine and helping to avoid women who are most at risk, including those Oxford University’s Patient Safety disability or termination of pregnancy.” with poor diet and from low socioeconomic Academy to provide the training, and it groups, as well as women who may not have plans to introduce the same approach In line with other countries planned their pregnancy. in local investigations of doctors’ The Royal College of Obstetricians and Official guidance is that women take 400 μg conduct and performance before they Gynaecologists said that such a move would of folic acid daily while trying to conceive, reach the GMC. see a “significant reduction in the incidence until the 12th week of pregnancy. But Peter McCulloch, co-director of the of neural tube defects, for the benefit of many women do not take the supplements, academy, said, “Our aim in this work women and their babies and families.” especially if a pregnancy is unplanned. is to ensure that context and systems Leading medical organisations and issues are always fully taken into charities have long been calling for account when evaluating a doctor’s mandatory folic fortification, which would OFFICIAL health performance, allowing doctors to have bring the UK in line with other countries, guidance is that all women take confidence in the fairness of the GMC’s including the US and Canada. procedures.” Ministers have now been persuaded of the 400 μg of folic acid daily while Clare Dyer, The BMJ scientific case and will introduce the policy, trying to conceive, until the 12th Cite this as: BMJ 2018;363:k4295 possibly within weeks, said the Guardian on week of pregnancy. Doctors’ conversations with dying patients need to improve perceived as a failure and that modern prioritised time for conversations, and medicine was expected to cure all the need to be sensitive to different ailments. However, evidence from cultural and religious beliefs. patients and carers indicated that many One key issue identified by the report people wanted to talk about death and was that healthcare professionals that planning helped them feel more needed to begin conversations about empowered about their care. planning for care at the end of life care nearer to when patients were given a Lack of privacy terminal diagnosis, to give patients a A range of clinicians interviewed for the better experience. report said that they were uncomfortable RCP president Andrew Goddard said, with initiating conversations about “This report is a big step forward in Training did Doctors need to speak to patients the future with patients. Students and helping patients, relatives, and doctors not prioritise with terminal illnesses in a timelier junior doctors had little practice with to talk honestly about death and dying. the “soft” way and handle conversations with real patients and said that their training “We must minimise the barriers in skills needed greater compassion and confidence, did not prioritise the “soft” skills they our systems and culture that prevent says a report from the Royal College of needed. this happening. This is not just about Physicians. Other barriers to talking about death palliative care in the final days but about The report, which examined why included confusion over whether having a series of conversations much clinicians find it difficult to talk to hospital doctors or GPs should be earlier after a terminal diagnosis.” patients about dying, found that some having the conversation, workforce Adrian O’Dowd, London doctors thought that death could be pressures, lack of privacy, lack of Cite this as: BMJ 2018;363:k4330 88 20 October 2018 | the bmj FIVE MINUTES WITH . Nicola McKinley The surgical trainee discusses why she is conducting a nationwide survey of doctors’ resilience urrently, the only study on how resilient NHS doctors are is our pilot study. Our team at Queen’s University Belfast ran a survey Experts say that folic acid fortification will help prevent birth defects such as spina bifida in a single NHS trust in Northern Ireland“ in CAugust 2016. Overall, 283 doctors Wald led research that found that affairs for the British Pregnancy were surveyed, and we found that, despite being there was no need for an upper limit Advice Service, said that fortification resilient, 37% of them were still really burnt out of folate intake and was seen as “will spare hundreds of women the and 72% had high traumatic stress from their job. removing any final barriers to folic heartbreak of receiving the news that “These findings gave us limited information, acid fortification of foods such as flour. their baby has a serious condition.” which is the reason for the nationwide survey. He said that if the government She said that the measure should be “There is no universal definition of resilience, but action was confirmed, “there will brought forward “as soon as possible.” I think it would be generally accepted that it’s the undoubtedly now be discussion The Labour MP Owen Smith, ability to recover from stress or bounce back from an over the level of fortification, which who has campaigned on folic acid adverse incident. should be high enough to prevent an fortification, said, “I have today “We are using three questionnaires that have estimated half of cases of spina bifida written to the health minister seeking a good evidence base. The Connor-Davidson and anencephaly. “Fortification of confirmation that this measure will Resilience Scale asks clinicians flour with folic acid provides a safety go ahead and called on him to make to think about the past 30 days net; it does not mean that women a statement in parliament ahead of and rate themselves on a scale.