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TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed at trainee doctors from their first day at medical school, through their sleepless foundation years and tough specialist training until they become a consultant. It’s proudly produced entirely by junior doctors – right down to every last spelling mistake. Find us quarterly in hospitals throughout the UK and updated daily at JuniorDr.com.

Team LeaderMatt Peterson, [email protected]

Editorial TeamYvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai, Rob Bethune

JuniorDrPO Box 36434, London, EC1M 6WA

Tel - +44 (0) 20 7 193 6750Fax - +44 (0) 87 0 130 [email protected]

Health warningJuniorDr is not a publication of the NHS, David Cameron, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not neces-sarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual ori-entation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash.

© JuniorDr 2011. All rights reserved.

Get involvedWe’re always looking for keen junior doc-tors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.

What’s inside

04080915

192830

LATEST NEWS

MEdical TOURISM

GLObAL hEalth

WorkiNg iN bRITISH COLUMbIA

CAREERS IN gENEral practicE

WEEkENd Ward ESCApE

COURSES AND coNfErENcES

O ne year ago when SpR Steve Fabes wrote for JuniorDr he was in Egypt, and had reached the 16th country on his chal-

lenge to cycle the length of six continents. He is currently in country number 27 and gives us an update on his journey from Africa.

On the 5th January 2010 I had waved goodbye to friends and family from outside the London hospital where I worked as a Med Reg and started pedaling, I planned to be pedaling for the next five years. When I wrote my first update for JuniorDr in Cairo six months later I was hirsute of face, eight thousand odd ki-lometres in and several metric tonnes of Cad-bury’s Dairy Milk chocolate lighter. Ahead lay a world of tropical heat, all manner of tooth-some fauna and the prospect of less salubrious terrain. Ahead lay all of Africa and I couldn’t wait to dive in.

First was Ethiopia, a land brimming with both people and livestock and after two and a half thousand kilometres, with barely an incline to test our quads, it was here that we spied our first mountains. Every day gangs of children chased after us, chanting ‘YOU! YOU! YOU!’, demanding money, waving sticks, throw-ing stones and stealing from our bikes. But I soon discovered that what Ethiopia takes, it also gives back. The same boisterous chancers

would push us up the hills, tiny hands pressed against my racks and panniers, propelling me upwards for five or even ten kilometres.

Next was Northern Kenya, a region famed for tribal warriors, nomads and ruthless ban-dits. I pushed my bike through a sandy, des-olate wilderness for days - this was the very edge of civilization. Next came the verdant and undulating tea plantations of Uganda and Rwanda, the roadside was full of bright eyes and winsome grins, but it wasn’t long before I found myself immersed in the tropical wet season. The more horizontal the rain and the more punishing the headwind the sunnier my songs became. In the torrential bursts I bashed out an assortment of reggae classics.

Finally after 23,215 kilometres, 26 interna-tional boundaries, one year and four months on the road, 265 days in Africa and a whop-ping puncture count yet to be tallied, I rode into the Cape of Good Hope.

I studied Belinda, my bicycle. She had scrappy ribbons of electrical tape holding to-gether the handlebar grip, there were scratches on the frame and tie wraps sat where long lost pannier clips should be. She wore the marks and scrapes of those sixteen months on the road, and so do I. The contours of my legs have changed, I’m thinner, there are two small scars on my left knee following an arthroscopy and my hairstyle is bordering on full blown mullet.

cYcliNg thE SiX: AFRICA

Dr Steve Fabes – CyClInG ThE 6

StatS froM StEVE’S africa cYclELonGEsT DisTancE cycLED in onE Day: 209 km

cairo To caPE Town: 14,969 km

ToP aLTiTuDE: 3050 metres

ToP sPEED: 75 km/hr

PuncTurEs: 113

TyrEs: 8

MosT Days wiTHouT a sHowEr: 8

crasHEs: 2

LarGEsT aMounT of Dairy MiLk cHocoLaTE consuMED in onE siTTinG: 450 grams

If you’d like to keep up to date with Steve’s progress you can visit his blog at http://www.cyclingthe6.blogspot.comor follow him on Facebook. To sponsor his adventure go to http://www.justgiving.com/cyclingthe6. Every penny

donated goes to the medical aid agency Merlin.

nEWS PUlSE4

tell us your news. Email [email protected] or call 020 7193 6750.

C hanges to public sector pensions could mean junior doctors paying £230,000 more over the course of their careers

for a worse deal on retirement, according to research commissioned by the BMA.

The study examined the potential impact of Department of Health proposals to increase the amount NHS staff pay for their pensions. Under the plans, a doctor cur-rently contributing 8.5% of salary would contribute 10.9% by 2012, and possibly as much as 14.5% by 2014.

Independent actuaries calculated the additional contributions doctors would need to make over the course of their careers. A junior doctor currently aged 25 pursuing a typical career as a GP and retiring at the future state pension age of 68, could have to make additional contributions of over £230,000 between now and retirement.

The researchers also modelled the impact of the proposals put forward by Lord Hut-ton in his review of public sector pensions, such as a further increase in the normal retirement age and a move from final salary to career average schemes.

The modelling indicates that a doctor currently aged 25, retiring as a consultant at the age of 60 could receive a pension around

£19,000 lower than the final salary pension they would receive under current arrange-ments. Similarly, a GP currently aged 25 retiring at the age of 60 would receive a pension around £20,000 lower under a ‘new look’ public service pension.

“These are unjustifiable changes to a fi-nancially healthy pension scheme which has only recently been thoroughly overhauled. This isn’t about affordability, it’s about the Treasury looking for yet another quick hit from public sector workers,” said Dr Hamish Meldrum, Chairman of Council at the BMA.

“Doctors pursuing a career as a consul-tant or a GP will have to pay significantly higher contributions in return for a much reduced pension at retirement”, the paper concludes.

The modelling also looks at the impact of the decision, already implemented, to in-crease pensions payments in line with the Consumer Price Index rather than the Retail Price Index. A doctor retiring at the age of 65 could be worse off under CPI by £2,000

a year at the age of 70, and by a total of £124,500 by the age of 85.

www.bma.org.uk

JUNIOR DOCTORS COULD pAy £230,000 ExTRA for a WorSE pENSioN

PEnsions

PrivaTE PracTicE

T he majority of British adults believe doctors who carry out private work should have to repay the public funds

used to train them, according to a poll by market research firm Populus.

57% of the adults questioned felt that if a doctor trained by the NHS goes on to treat patients privately, they should have to pay back at least some of the cost of their training - a move which could net the NHS £744m.

A quarter of those polled said the entire cost of a doctors’ training should be paid back if the doctor treats patients private-ly, 19% said it should be up to half, whilst 13% believe it should be between 50-100% of the cost. It currently costs over £200,000 to train a doctor in the UK.

When asked whether doctors should com-bine public and private work at all, 76% of adults believe that doctors employed by the NHS should be allowed to see private patients

in addition to their NHS role. However, 69% of these believe that the profits doctors make from private work should be regulated.

“The study reveals that the majority of Brit-ish people are largely comfortable with doc-tors carrying out private work, but feel that there is a deal to be struck,” says Ken Hesketh, Chief Executive of Benenden Healthcare So-ciety who commissioned the study.

“They say that doctors’ profits from pri-vate work should be regulated, and that those who have had the benefit of public money to help train them for work outside the NHS should be prepared to make a financial con-tribution to the costs of their training.”

bit.ly/nWQCnQ

Dr. Hamish MeldrumBMA ChAIRMAn of CoUnCIl

“Doctors pursuing a career as a consultant or a Gp will have to pay significantly higher contributions in return for a much reduced pension at retirement.”

public callS for doctorS IN pRIvATE pRACTICE TO REpAy NHS traiNiNg coStS

p lans to establish a new Medical Practitio-ners Tribunal Service have been approved by the GMC Council which will change the

way doctors are investigated about their conduct or their ability to treat patients safely.

The new body will take over the running of doctors’ hearings from as early as next year. It will be operationally separate from the GMC’s investi-gation arm and will be headed by a senior judicial figure who will be responsible for appointing and performance managing panel members.

“This is a major reform and will signal clearly the need for panel hearings to be autonomous and to be seen to be autonomous,” said Niall Dickson, chief executive of the GMC.

“In the consultation there was strong support for setting up the Medical Practitioners Tribunal

Service - for most respondents the question was simply how best to do it.”

The GMC Council also approved plans to hold all hearings in Manchester from next year, rath-er than running hearing centres in both Manches-ter and London. The relocation is part of a wider programme aiming to generate savings of around £2.8 million a year.

www.gmc-uk.org

NEW tribuNal SErVicE FOR DOCTORS GETS THE GO-AHEAD

GMc

D octors and medical students should not accept Facebook requests from current or former patients, according to the latest

advice from the BMA.The guidance ‘Using social media: practical and

ethical guidance for doctors and medical students’ also warns against posting personal or derogato-ry comments about colleagues on public internet forums.

Key points in the guidance include:•Doctors and medical students should consider

adopting conservative privacy settings where these are available but be aware that not all in-formation can be protected on the web

•The ethical and legal duty to protect patient confidentiality applies equally on the internet as to other media

• It is inappropriate to post informal, personal or derogatory comments about patients or col-leagues on public internet forums

•Doctors and medical students who post online have an ethical obligation to declare any con-flicts of interest

•The BMA recommends that doctors and medi-cal students should not accept Facebook friend requests from current or former patients

•Defamation law can apply to any comments posted on the web made in either a personal or professional capacity

“Research has shown that while most doctors would not accept Facebook friend requests from patients, a minority said they would consider doing so,” said Dr Tony Calland, chairman of the BMA’s Medical Ethics Committee.

“Yet accepting Facebook friends presents doc-tors with difficult ethical issues. For example doc-tors could be become aware of information about their patients that has not been disclosed as part of a clinical consultation.”

The full report can be accessed at:

www.bma.org.uk/press_centre/video_social_media/

socialmediaguidance2011.jsp

DON’T ACCEpT pATIENTS aS facEbook friENdS, WARNS bMA

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August 2011 • £48.00PB: 978-08153-4243-4

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Niall DicksonChIEf ExECUTIvE, GMC

“This is a major reform and will signal clearly the need for panel hearings to be autonomous and to be seen to be autonomous.”

nEWS PUlSE6

D octors entering the UK health service for the first time need better support in order to practise safely, according

to a new report published by the GMC.The State of Medical Education and

Practice report recommends an induction programme for all doctors new to the UK health service.

It concludes more needs to be done to ensure consistency of induction for all doc-tors, and especially for those coming here to work from outside the UK. Every year, around 12,000 doctors from the UK, Europe and countries around the world, start work-ing in the UK for the first time.

The report notes that although there are good local schemes for supporting doctors who are new to practice, there is evidence of

new doctors undertaking clinical practice with little or no preparation for working in the UK, or locum doctors taking on duties for which they have not been appropriately trained.

“‘While there is much to celebrate about medical practice in the UK, the challenges are also clear - we must do more to make sure that all doctors understand the stan-dards expected of them,” said Niall Dickson, Chief Executive of the GMC.

“Developing an induction programme for all doctors new to our register will give them the support they need to practise safely and to conform to UK standards. This will provide greater assurance to patients that the doctor treating them is ready to start work on day one.”

www.gmc-uk.org

bEttEr Support NEEdEd FOR DOCTORS ENTERING UK pRACTICE

TraininG

J unior doctors have no idea what they should be doing when a major incident, such as a terrorist attack or transport

disaster occurs, according to research pub-lished in BMJ Open.

Although every UK hospital has a Major Incident Contingency Plan the survey of 89 junior doctors in three NHS hospital trusts in Wales showed that nine out of 10 (91%) didn’t know what would be expected of them in the event of a major incident.

This knowledge gap could be critical espe-cially as the UK’s current terrorism threat level is classified as “severe”, says the authors.

Current procedure is that once a major incident is confirmed, junior doctors should go to their ward, contact the senior nurse in charge, and compile a list of patients who could safely be discharged while managing the others who can’t. Should they be needed elsewhere, they will be contacted by a senior doctor or the hospital control centre.

However, the survey responses indicat-ed that almost half (47%) would initially go the emergency care department, while more than one in four (27%) had no idea where they should go.

Almost one in three (31%) didn’t know whom they should contact, while 16% said they would contact the switchboard, which would be shut during a major incident.

The junior doctors were also unsure of their primary role, with 16% believing this would be triage of injured patients, and over half (53%) expecting to clerk in patients in emergency care or the medical/surgical assessment units.

bit.ly/ox3qfa

JUNIOR DOCS CLUELESS AbOUT What to do duriNg Major iNcidENtS

TraininG RCp opens to Fy docsThe Royal College of Physicians has

opened membership to medical students

and foundation doctors for the first time.

Two new membership categories will offer

tools and guidance for doctors, including

free web streamed teach-ins and lectures,

access to the Clinical Medicine journal and

discounts on RCP conferences and prod-

ucts. Membership for medical students

is £1 per month, and foundation doctor

membership is £4 per month.

www.rcplondon.ac.uk

UK donor differencesThere are significant variations in the

number and type of organ donations made

across all four UK countries, according to

research published online in BMJ Open.

It found that England, which has the third

highest number of the population regis-

tered, only managed a higher than average

organ donation rate for three of the past 20

years. Yet Northern Ireland, where donor

registration is the lowest of the four coun-

tries, outperformed England and Scotland

in the rate of organ donation.

www.nhsbt.nhs.uk

Stay slim to stay safeThe NHS is poorly prepared to care for

obese patients, lacking dedicated equip-

ment and adequately trained staff, accord-

ing to an analysis of patient safety inci-

dents and published in the Postgraduate

Medical Journal. The study of 555 patient

safety incidents, of which 389 were relat-

ed to obesity, found that one in three inci-

dents (33%) were due to specially adapted

equipment either not being available or not

working. A further one in five of these inci-

dents (22%) were associated with the op-

erating theatre and surgery.

www.pgmj.bmj.com

AbpM 4 bp – NICENew guidelines for confirming diagno-

sis of hypertension have been issued by

NICE. For the first time 24 hour ambula-

tory blood pressure measurement (ABPM)

is recommended for clinic readings above

140/90mmHg. The guidance was devel-

oped in association with the British Hy-

pertension Society. Studies have shown

that as many as 25% of people who are

currently being diagnosed as having high

blood pressure using the ‘old’ method of

diagnosis may not be hypertensive and

may not require treatment.

www.nice.org.uk

Medical MasterclassMRCP(UK) exam revision and preparation materials from the Royal College of Physicians

Medical Masterclass packages are available for both individual and institutional sales and comprise:

• 12 printed modules covering the scientific background to medicine, clinical skills and the range of medical specialties in the MRCP(UK) exams.

• Online access to 3,000 MRCP(UK) exam type questions.

• NEW! PACES screencasts describing the format and stations of the PACES exam, giving examples of common scenarios and cases faced by candidates, and – most importantly – explaining what PACES examiners are really looking for.

• 60 PACES interactive case studies on 2 interactive CD-Roms.

For further details or to purchase online, visit www.medical-masterclass.com or email [email protected]

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edic

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aste

rcla

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om

T he NHS in England has no oversight of whether junior doctors’ rotas are compliant with the 48 hour European Working Time Directive (EWTD), according to a report

by BMJ Careers. This is in contrast with governments in Wales, Scotland,

and Northern Ireland who regularly collect and review data on whether junior doctor rotas are compliant with the “new deal” contract for doctors in training, which is used as a proxy for compliance with the 48 hour limit in the EWTD.

However, in England the data hospital trusts previously sub-mitted on compliance with the EWTD to the Department of Health was cancelled in August 2010 “to reduce bureaucracy.”

As such, the department in England was unable to provide BMJ Careers with information on the proportion of rotas that are compliant with the directive, unlike the health departments in Wales, where compliance of junior doctor rotas is 100%, Scot-

land, where com-pliance is 99%, and Northern Ireland, where compliance is currently 78%.

F u r t h e r m o r e , none of the 10 stra-tegic health authori-ties in England col-lects compliance data from trusts, with many responding

that such information was available only at a trust level, says the report.

“I think we’re talking about patient safety as well as doctor safety, so it would be really useful to see the ministerial returns back in place,” said Dr Shree Datta, co-chair of the BMA’s Junior Doctors Committee.

A spokesperson for Department of Health in England responded:

“As part the government’s commitment to reduce bureaucra-cy in the NHS, the Secretary of State has stopped the central col-lection of new deal compliance data which was used as a proxy to demonstrate compliance with the working time directive. Local organisations are still required to ensure compliance with the working time directive and to monitor that compliance.”

www.bmjcareers.com

coNcErN oVEr WorkiNg hourS AS NHS IN ENGLAND STOpS MONITORING

workinG conDiTions

Dr Shree DattaCo-ChAIR of ThE BMA’S JUnIoR DoCToRS CoMMITTEE

“I think we’re talking about patient safety as well as doctor safety, so it would be really useful to see the ministerial returns back in place.”

MEDICAl ToURISM8

SuN, SEa aNd SurgErYNot long ago the term ‘medical tourist’ was used to describe unscrupulous patients entering the UK to obtain free treatment on the NHS. Today, in contrast, it is used to describe the thousands of British citizens who flee the long waiting lists to seek private healthcare abroad. JuniorDr’s Michelle Connolly looks at the surge of medical tourists travelling abroad for sun, sea and surgery.

THE ADvENT OF MEDICAL TOURISM

W hether it’s for a hip replacement, valve surgery or a simple rhino-plasty medical tourism is boom-

ing. Last year alone some £130m was spent on medical tourism procedures out-side the UK. However, Britons are still in the Ryanair league compared to coun-tries like the United States where 150,000 Americans jet off each year for long-haul procedures in countries as far away as India, Thailand, Argentina and Malaysia.

But the UK is catching up, according to research by analyst Mintel. Their survey suggests that 12 per cent of Britons would consider surgery abroad because of the substantial savings - costing up to eighty per cent less in some cases - compared to private treatment in the UK. Dental sur-gery is the most common overseas proce-dure with around 20,000 Brits travelling to favourites such as Hungary and Poland for a better smile at around £2,500 a time.

Cosmetic surgery comes a close second with 14,500 of us shelling out for facelifts, breast augmentation and liposuction at a cost of £50 million each year. Those wish-ing to skip NHS waiting lists for elective surgery, the most frequent of which are joint replacements and cataract surgery, make up a further 10,000 patients spend-ing £36 million.

Word-of-mouth is one of the main driv-ers for overseas treatment. International medical facilities are promoting good ser-vice and reward schemes to encourage ex-patients to recommend to friends. Jacque-line Wilson, a 48 year old Herefordshire

housewife travelled to Gdansk in Poland for tooth veneers after first getting quotes from British dental surgeons.

“Poland was nearly three thousand pounds less than the price I was quoted in Harley Street and I combined it with four-day spa holiday too,” she said. “The hospitals were clean, the operation fast and the staff were very pleasant and spoke English. I’d recommend the experience without question.”

Selling SurgeryForeign governments and private firms

have begun to realise the potential of medi-cal tourism. Brits are being wooed abroad by development agencies such as the Singa-porean government’s Singapore Medicine, which describes the UK’s ageing popula-tion as “a great potential to be tapped into”.

Intermediary brokers are one of the big drivers for overseas treatment in what is a difficult process for potential patients to negotiate themselves. Dipa Jethwa, from the London-based Taj Medical Group,

explained how they try to simplify medical treatment abroad for clients:

“We liaise with the patient’s NHS con-sultant to obtain their clinical records. We then arrange flights, visas and their admis-sion to hospital.”

While the mainstay of treatment is joint replacement operations, Taj Medi-cal is also benefiting from the obesity epi- demic. “We are seeing an increase in the number of patients, particularly from the US and Canada requiring gastric band- ing surgery.”

And it’s not just small brokers that are benefiting from the public’s new acceptance of private treatment overseas. High street tour operators such as Thom-as Cook have realising the potential and have established partnerships with agen-cies like Taj Medical.

Because of these new medical expecta-tions centres in countries targeting medi-cal tourists are no longer typical hospitals - they are ‘resort hospitals’ with enticing names such as Kuala Lumpur’s ‘Palace of the Golden Horses’.

“Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less than they earned in the West.”

ANIL MAINI. DIRECTOR OF CORpORATE DEvELOpMENT. ApOLLO HOSpITALS GROUp, INDIA.

MEDICAl ToURISM 9

SuN, SEa aNd SurgErYTHE ADvENT OF MEDICAL TOURISM

Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually. To accommodate West-erners it has a specially built Starbucks in the reception and a pizzeria upstairs.

AmericAnS driving the mArketAmericans lead the way in medical

tourism partly because of the baby boom-er generation and also because of sporadic healthcare cover. With 45 million Ameri-cans uninsured overseas treatment is the only way to avoid huge medical debts. Last year, the average healthcare expen-diture for a family of four exceeded the total annual earnings of a minimum wage worker for the first time.

Howard Staab, a 56 year-old carpen-ter from North Carolina has become the industry’s poster boy. His local hos-pital demanded a $50,000 deposit from him for a mitral valve replacement before warning him that the cost of treatment could rocket to $200,000. He got change from $10,000 for a pig valve in New Del-hi - and also a trip to the Taj Mahal.

Differences in doctor’s salary partly explain why such considerable savings can be made. The average salary of a US family doctor is $161,000, compared to just $35,000 in India.

indiAWith four doctors for every 10,000

people, compared with 27 in the US, India is hardly a healthcare model to be copied.

Yet India is now seen to be leading the world as a medical tourism destination - with the finance minister calling for the country to become a ‘global healthcare destination’.

Efforts have been made to improve infrastructure to help smooth the arrival and departure of medical tourists. Import duty on medical equipment has been slashed and the government has intro-duced a special medical visa which per-mits tourists to stay in the country twice as long as before. As a result India’s medi-cal tourism industry is set to balloon to $2 billion by 2012, according to a joint

report by the consultancy McKinsey and the Confederation of Indian Industry.

effect on the nhSMany expected the boom in medical

tourism to lead to a reduction in UK pri-vate healthcare prices - instead the effect has been largely an efflux of medical tour-ists. Fiona Harris, head of personal mar-kets at BUPA, the UK’s largest private healthcare provider, denies that their busi-ness is threatened by the boom in medi-cal tourism:

“Sometimes BUPA customers will seek treatment abroad where it is not available in the UK; in these cases we meet the equivalent UK costs of the treatment.”

MEdical touriSM doWNSidES•little or no aftercare on your return

•often questionable quality of blood transfusions

•Weak malpractice laws meaning redress is difficult and malpractice awards abroad are capped at a much smaller amount

•Draining away of medical services from local population in order to serve the tourists

•The British Transplantation Society has warned medical tourists considering China that they might be receiving the organs of executed prisoners

MEDICAl ToURISM10

SociAl coStSOften the last thing a patient planning

an operation overseas considers is the affect on the local community but it’s one of the key concerns that objectors raise. Many fear an internal brain drain where-by doctors leave small rural practices to work in better equipped urban centres that cater for medical tourists.

Anil Maini, director of corporate devel-opment at the Apollo Hospitals group - India’s largest medical tourism organisa- tion - doesn’t deny this is the case:

“There is an internal brain drain but there are enough doctors available to serve both rural and urban populations,” he says. “Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less, than they earned in the West.”

There are many who believe medi-cal tourism hails the beginning of a much broader overhaul in the world’s healthcare systems - the advent of medical outsourc-ing. Outsourcing means that it won’t be the patient who decides to travel for treat-ment, it will be your insurer or government who sends you abroad to save money. Just as manufacturing and call centre opera-tions were relocated to countries such as India healthcare is likely to follow.

REfEREnCES

Burkett l (2007). Medical tourism. Concerns, bene-fits, and the American legal perspective. J. leg. Med. 28: 223-45.

coSt coMpariSoNSThe average procedure in India is one-tenth of the cost in the US. Singapore is a more expensive destination but the savings are still large - a liver transplant which costs $300,000 in the US is just $150,000 in Singapore.

ParTiaL HiP rEPLacEMEnT

India $4,500 • US $18,000

fuLL HiP rEPLacEMEnT

India $3000 • US $39,000

orTHoPaEDic surGEry

India $4500 • US $18,000

knEE surGEry

India £8000 • UK (Private)

GaLL BLaDDEr surGEry

India $7500 • US $60,000

Night sweats?It’s four a.m.

You’ve been bleeped.

You know what to do.

But it would be good to get a second opinion – just for peace of mind.

That’s exactly what Best Practice provides. A trusted second opinion on the assessment, treatment and management of patients.

On call. All day. All night.

Just when you need it.

DIAGNOSE • TREAT • MANAGE • LEARN

For the best in clinical decision support tools, visit bestpractice.bmj.com

WORK

ING

oVEr

SEaS

the gAmbiA

I spent 6 months working in Bansang Hospital as this is where I was posted by the charity MCAI. I chose this charity as it works close-ly with the WHO and the Gambi-an government to strengthen exist-ing emergency medical services and improve maternal and child health. It aims to provide sustainable help to The Gambia and a variety of other countries.

Bansang is in rural Gambia and poorly resourced. My main role is to provide emergency obstetric care whilst at the same time teach-ing the midwives emergency proce-dures and different ways of manag-ing obstetric complications.

The main complications we deal

with are massive obstetric haemor-rhage following big abruptions in already severely anaemic patients and often with a lack of blood in blood bank. I also see very poorly controlled eclamptic patients with limited drug resources. With such limited equipment you have to re-ally think on your feet and adapt your knowledge to the situation.

It’s a wonderful place to work, but clinically and emotionally can be tough. Accommodation is good, but basic. At home and work there is often a lack of electricity and wa-ter and at times the temperature is above 48 degrees. Go with resil-ience and an open mind.

x Sophie Haynes

SierrA leone

When I decided to take a year out after FY2 the first charity I ap-plied to was Mercy Ships, who provide healthcare on boats going around West Africa treating the world’s poorest. Mercy Ships al-so run hospitals on land in some West African countries, and when I was accepted to work in the hos-pital in Sierra Leone I was elated at the chance to be involved in doing simple interventions which lead to a huge impact on so many people.

The hospital has a maternity unit, a specialist surgical unit for women with childbirth injuries and a clinic for children under the age of 12, where I spend most of my time. My typical day here starts at 8am, when I walk into the chil-dren’s clinic to be confronted by a triage scene which looks a bit like the first half hour of ‘Saving Private Ryan’ - children in various stages of illness ranging from comatose

to sprinting around like jumping beans. I spend the first couple of hours treating the sickest ones, ma-laria is hyperendemic here so we treat some very ill children.

We once had a child with hae-moglobin less than 2! Later on, we treat some of the more chronical-ly ill children, often suffering with conditions such as tuberculosis and sickle cell anaemia. Doing all the consultation in Krio is quite a fun challenge! I usually do an informal ward round of maternity unit in the evening to check on the neo-nates as well.

Working here is a huge pleasure and I would advise anyone inter-ested to get in touch with Mercy Ships. It is a great learning experi-ence for a junior as well as having a chance to do make a huge impact through work that is well within the capacity of an FY2.

x Mikey Bryant

For adventurous junior doctors there are plenty of opportunities to try working overseas - from the coastal towns of Australia to isolated villages in Africa. We’ve asked some of those who have made the move to tell us about the highs and lows of their visit. Read their experiences then join the discussion with other doctors in our ‘Working Overseas’ community at JuniorDr.com.

Current stage of training: ST4 O&GCurrent Location: Bansang, The GambiaBest thing about post: Variety of conditions seen and independent practice increased confidence in own abilitiesWorst thing about post: At times could feel quiet lonely and isolated. In April and May it’s the extreme heat.Length of stay: 6 monthsAverage cost of living per month: £50 (excluding accommodation)Subsistence: Flight and accommodation paid for and living allowance of £300 per month

AFRICA

Current stage of training: I’ve just finished FY2Current location: Freetown, Sierra LeoneBest thing about your post: Watching hundreds of children each week get better and be able to run around againWorst thing about your post: Knowing that so many of the people we can’t treat will still be sufferingExpected length of stay: 18 monthsAverage cost of living per month: Approx $300 to $400Average salary or subsistence: I get $600 each month, with accommodation and food provided 5 days a week. But I did pay for my own flights and travel insurance etc.

WoRKInG ovERSEAS 11

WORKING oVErSEaS

ANTARCTICA

Dr Ross Hofmeyr spent 18 months as the sole doctor at the SANAE IV Ant-arctica research sta-tion. With tem-peratures nearing -90oC and the nearest referral 2,800 miles away it’s cer-tainly one of the most extreme medical posts on earth. For much of the year it’s so isolated that it’s logistically logistically easier to evacuate a casualty from the Inter-national Space Station, so everything from lab work to minor procedures needs to be done on site.

learn more from Ross at - bit.ly/ra0oD2

REpATRIATION DOCTOR

Re p a t r i a t i o n medicine involves the transfer of patients by air, land or sea from overseas hospi-tals back home. It can involve travel to locations around the world and requires a broad range of skills. Tim Hammond, Chief Medical Officer of CEGA Group, offers his experience of repatriation medicine and advice for junior doctors interested in it as a career.

learn more from Tim at - bit.ly/hQZhW4

SHIp’S DOCTOR

Philip Brooks was a senior ship’s doctor with Car-nival UK, a com-pany of well know cruise brands such as P&O Cruises, Princess Cruises & Cunard Line. He has been working at sea since early 2006 and was promoted to the rank of senior ship’s doc-tor in 2007. Philip explains why life on the open seas can be an attractive career.

learn more from Philip at - bit.ly/bp2ccu

ExTREME MEDICINEWant to try something a little more unusual? Check out advice online at JuniorDr.com from doctors who have experienced working in extreme locations around the world.

After completing my medical degree and founda-tion years’ training in London, I decided to do my

OE (Overseas Experience) in New Zealand as I had never heard a bad word said about it. I went through an agency and landed myself a job in Rotorua working in A&E.

The most noticeable difference was that four-hour breach times were not an issue. Patients could therefore be more thoroughly assessed and managed calmly without the harassment and bullying that is often found in the NHS. The only difficult thing to get used to was the rotten-egg sul-phur smell from Rotorua’s geothermal environment!

I then moved to the sunny winery region of Hawke’s Bay obtaining jobs as a Psychiatry Registrar and then as an Ophthalmology SHO by directly emailing my CV to the RMO (Resident Medical Officer) Unit Manager.

Eight months later I found myself working as a Paediatrics SHO in Nelson with such a friendly and supportive team in one of the most stun-ning places I have ever lived in. There are few places where it would be possible to ski in the morning and kayak along beautiful beaches in the afternoon sun!

Even though the annual salary appears less than that in the UK, there are signif-icant financial benefits to working in New Zealand. Medical council member-ship and indemnity insur-ance are reimbursed, all courses and related expens-es are paid for, as are text-books and exams if on a hospital training scheme.

In all the hospitals I worked at I found morale to be higher, the atmo-sphere to be friendlier, and all staff more supportive towards colleagues when compared to the UK. This coupled with the amazing lifestyle that New Zealand has to offer has encouraged me to stay here to complete my training.

x Dr. Tanya Hussein

NEW ZEALAND

“ThERE ARE fEW PlACES WhERE IT WoUlD BE PoSSI-BlE To SKI In ThE MoRnInG AnD KAyAK AlonG BEAUTI-

fUl BEAChES In ThE AfTER-noon SUn!”

WoRKInG ovERSEAS12

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“I undertook my medial training at Glasgow University and worked in the NHS for a few years, but decided to fi ll my gap year with some sunshine and work experience Down Under. I took a job with Queensland Health and relocated to Australia. I’ve now been accepted on to the Queensland Health world-renowned emergency medicine training program which gives me exposure to an unparalleled scope of practice.” Principal House Offi cer, Dr Stephen Elliott enjoys the training programs with Queensland Health.

M30

0811

WORKING oVErSEaSIt had always been a dream of mine to work in Australia and the

reality has proved to be better than expected. My first experience of Australian medicine was working in a rural town called Gympie, in Southern Queensland.

My fiancée and I were part of a team of 12 doctors providing cover to the 90 bedded hos-pital, which included both a maternity and a paediatric ward. On arrival we had a fantastic welcome, even being interviewed for the local paper.

One thing that struck me was the broad skill base of the more senior doctors - local GP’s doubled as anaesthetists, obstetricians and even as pathologists. We dealt with a large range of cases, including plenty that were familiar, but a few that were more exotic, like snake bites! Thankfully a helicopter was available to retrieve the sicker patients.

Working in such a small team made for a good social scene. Among the staff were some real characters, including a radiographer who had bought a very grumpy camel to keep his donkey company.

However if ru-ral hospitals are not your thing, then Australia offers a more convention-al teaching hospi-tal environment as well. My cur-rent position is in a large teaching hospital, and other than the fact that some of our patients are transferred over a 1000 miles to get to hospital it is a bit more like the UK.

Would I recommend Australia? … well as I sit overlook-ing the Indian Ocean sipping a cool ‘tinny’ I guess I definitely would!

x Dr Ben Chandler

AUSTRALIA

“WE DEAlT WITh A lARGE RAnGE of CASES, InClUD-

InG PlEnTy ThAT WERE fAMIlIAR, BUT A fEW ThAT WERE MoRE ExoTIC, lIKE

SnAKE BITES!”

WORKING oVErSEaSAfter more than 20

years of family practice in the UK, Dr. Peter Entwistle and his family were looking to emigrate. “I was dissatisfied with where medicine seemed to be going, and was very frustrated at the constraints that I felt were being put on me to provide the care that I wanted to give. Both Michelle and I want-ed more opportunities for our sons,” he said. “We thought we’d end up in Australia or New Zealand.”

When they were on holiday in Ontario, they first started to think of Canada. They researched various possibilities, and then contacted Health Match BC. They travelled throughout BC and explored communities in the Interior, the greater Vancouver area, and Vancouver Island.

It was Michelle who finally decided on the Okanagan region. “It just felt really welcoming; the physicians and the people generally,” she said. “We loved the lakes and the vineyards; it is all so very beautiful and the climate is so much milder than what I expected.”

Settled into schoolOne question mark was about schools. “We wanted to be sure we

picked the right school. I came over with Tom, my younger son, and we visited several possible high schools before deciding on the best fit,” noted Peter. “We were a bit apprehensive, but they both settled

in to their new schools very quickly. I think their cute English accents may have helped them make girlfriends easily.” Their eldest son, James, has now graduated and, after taking a year off, is planning to attend Dal-housie University in Nova Scotia.

In their free time, the Entwist-les enjoy all that the Okanagan re-gion - and BC - have to offer. “We’ve all started skiing, which we had nev-er done before. The boys really took to it, but snowboarding is their win-ter passion,” said Peter. The family al-so bikes together on the local Kettle Valley Railroad. Their more adven-turous sons mountain bike around the hills of their lake-view home. And this summer, they had an amazing experience sea-kayaking off Vancouver Island.

Since their arrival three years ago, the family has expanded in number with the addition of Monty, a chocolate Labrador dog. “He made everything feel more permanent,” they both said.

financially better offMichelle, a trained midwife, is working as a birth attendant and is

taking steps toward gaining her full midwifery license in BC. The tran-sition was smoother for Peter, who, after some additional training, is working both on the wards and in the ER, something he did not do in the UK. “The work is great, and I’ve had a lot of support. I really love the way I am able to care for my patients in hospital and find my working day both more varied and stimulating than in the UK.” He added: “Financially, we are way better off than before, and I have a lot more freedom and flexibility in terms of choosing my hours.”

What has been hard to get used to? “Well, I still feel as though I am driving on the wrong side of the street,” concluded Peter. “I have to get up in the middle of the night if I want to watch the Brit-ish soccer games. And I have to remember to call soccer “soccer”, and not football.”

CANADA

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Dr. Shyr Chui & FamilyBritish Columbia, Canada

Please note: Specialists with postgraduate training from the UK or Ireland must hold the CCT/CCST or equivalent. Irish and UK-trained family physicians must have a minimum of two years approved and accredited postgraduate training and may be eligible for certifi cation without examination with the College of Family Physicians of Canada.

Where would you rather be?

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Physicians choose to live in British Columbia (BC) for many

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Snow-capped mountains dominate the vibrant Vancouver skyline. City sidewalks lead to picturesque sandy beaches. It’s no wonder this cosmopolitan city is ranked as one of the best places to live in the world.

To the east of Vancouver lies the sunny Fraser Valley. It is known for its abundant farmlands and scenic valley views. It is just a short drive from Vancouver and offers a wide range of recreational activities including year-round golfi ng, horseback riding and fi shing.

Stroll along the beach. Savour the view. Live the island life. Recently, Condé Nast Traveler magazine ranked Vancouver Island second in the “Top Islands of North America” category.

BC’s interior offers a variety of spectacular landscapes and outdoor activities. Enjoy the open ranches and rolling hills of the Cariboo region, the orchards and vineyards of the Okanagan, and the majestic lakes and mountains of the Rockies.

I’d rather be right here!

PHYSICIANS NURSES ALLIED HEALTH

healthmatchbc.orgHealth Match BC is a free health professional recruitment service funded by the Government of British Columbia, Canada

FIND A JOB IN BC

TEL: 604.736.5920 • EMAIL: [email protected]

ENRICH YOUR CAREER. ENHANCE YOUR QUALITY OF LIFE. Join the hundreds of physicians who have moved to British Columbia to enjoy a quality of life

that is envied around the world. Find out how our physician services team can assist you in

matching your lifestyle interests with exciting career opportunities. Register online today!

After completing my specialist

training and working as a

radiologist in the UK for several

years, I was ready for a new

challenge. Thanks to Health

Match BC, I found a great job

in Prince George, BC. There’s

everything here that we were

looking for as a family.

Dr. Shyr Chui

Dr. Shyr Chui & FamilyBritish Columbia, Canada

Please note: Specialists with postgraduate training from the UK or Ireland must hold the CCT/CCST or equivalent. Irish and UK-trained family physicians must have a minimum of two years approved and accredited postgraduate training and may be eligible for certifi cation without examination with the College of Family Physicians of Canada.

Where would you rather be?

healthmatchbc.orgBritish Columbia, Canada

FIND A JOB IN BC

CAREERS 19

CAREERS IN gENEral practicE

General practice can offer an amazing array of career options. It can bring unparalleled daily variety, a wide spectrum of medical experience and personal flexibility enabling a great work-life balance.

Sophie Park, co-author of ‘A Career Companion to Becoming a GP: developing and shaping your career’ offers some advice on how to get started and considers possibilities for career development.

HOW TO GET STARTED?

Different medical schools vary in how much general practice undergraduate experience they include. Some have extended place-ments, specifically to learn general practice, others include addi-tional placements (perhaps a few days) to extend learning during a particular topic such as child or mental health.

Practices can be very different in the way they are organised, pri-oritise work-load and interact with patients. It is worth, therefore, trying to get as broad a range of experience as possible before mak-ing your career decision. If you are already decided upon a career in general practice, this will at least begin to shape your own ideas about what sort of practice you would like to work in and what you hope to role model in your own practice.

There were plans to offer all F2 doctors a placement in general practice as part of their basic training. GPs still spend lots of their training posts in hospitals, but hospital doctors have not tradition-ally reciprocated. Most trainees who have completed a GP place-ment (whatever their career ambitions), have found it an incredi-bly valuable experience in developing their knowledge, consultation skills and awareness about boundaries of primary and secondary care contexts.

Currently about 55% of F2 posts offer some experience in pri-mary care. This is likely to look favourable on your CV, whatever your career choice.

TRAINING

If you decide to apply for specialist training in primary care, you need to use the existing generic system for trainees http://www.mmc.nhs.uk/ (if applying from abroad visit www.nhscareers.nhs.uk). You may find it helpful to look at the Royal College of General Practice website: www.rcgp.org.uk which outlines details of train-ing, certification and the general practice curriculum. It may also be useful to make contact with your local deanery via www.gprecruit-ment.org.uk.

Most schemes offer a range of primary and secondary care expe-rience (some more than others). No post will cover every speciality and part of your general practice apprenticeship will be about learn-ing how to recognise, manage and develop your own boundaries of knowledge to meet patients’ needs. Currently, schemes are three years (four if including an academic post), but there are plans to extend this to five - the latter years likely to include supported, but independent practice (Tooke, 2008).

Schemes offer experience in general practice, ranging from 12-24 months. This usually involves one to one supervision with your GP ‘trainer’. They will offer educational support within the practice, including tutorials and completing some of your work-place based assessments. You are usually expected to attend one out-of-hours session per month during these placements.

For the remaining time, most schemes insist that you do at least two six month (three four month, or four three month) approved

List a List B

A+E Public Health

Paediatrics or Community Paediatrics Intensive Therapy

General Medicine, Geriatrics or Rehab Medicine Opthalmology, ENT, ENT surgery, General Surgery, Paediatric Surgery, Urology, Trauma and Orthopaedics surgery, or trauma

Orthopaedics

Dermatology Child and Adolescent Psychiatry or Psychiatry of Learning Disability

Obstetrics and Gynaecology or GU medicine Cardiology, Medical Oncology, Clinical Oncology, Gastroenterology, Endocrinology and Diabetes Mellitus,

Haematology, Nephrology, Respiratory Medicine, Rheumatology, Neurology or Infectious Diseases

Psychiatry or Old Age Psychiatry Palliative Medicine

CAREERS20

training posts in ‘list A’ specialities (maximum accepted in one spe-ciality 12 months). Further hospital posts may also include some List B specialities (maximum accepted six months), if providing a reasonable range of experience. If travelling abroad, check with your Deanery (ideally before travel) about arrangements for post approv-al. The Gold Guide has some useful information about taking time out of UK training: http://www.mmc.nhs.uk/pdf/Gold%20Guide%202010%20Fourth%20Edition%20v08.pdf

ASSESSMENT

During their specialist training GPs, like most other specialities, are required to complete an e-portfolio. This includes matching your clinical experience with curriculum statements, case-based dis-cussions and clinical evaluation exercises with your trainer, as well as reflective entries and personal development plan completion. This will be discussed at intervals with your educational supervisor, be monitored and approved by your local Deanery.

You will also need to complete the nMRCGP exam in order to become a member of the Royal College of General Practice. This currently comprises an applied knowledge test, clinical skills assess-ment and work-place based assessment. While in the past, member-ship was optional (only ‘summative assessment’ being compulsory), it is now required for all GP trainees in order to complete train-ing. You will usually attend a Vocational Training Scheme group throughout your training. These are a tre-mendous resource in developing your prac-tice throughout training and are also likely to support your revising for exams through initiation of study groups, or sessions run by the scheme.

SpECIALIST OR GENERALIST?

Many trainees worry about becoming a generalist. In fact, gen-eralism is a specialism! Becoming a GP involves becoming famil-iar with medical knowledge about diseases commonly presenting to general practice. The very nature, however, of primary care as a first point of contact providing a comprehensive and universally available resource, means that you will also frequently encounter a range of less familiar areas, requiring complex consultation skills. This might range from acting as a patient advocate for social or legal issues, or addressing more specialised conditions prevalent within your patient population.

You need, therefore, to develop professional processes which facilitate ways of exploring unknown knowledge in safe ways. This involves using book or internet resources, secondary care colleagues and, most importantly patients, often man-aging your own and the patient’s uncer-tainty (an answer does not always exist!). You also need to refine diagnostic skills and instincts in order to balance identify-ing possible diagnoses against tolerating the unknown; and avoiding the over-investiga-tion and ‘medicalisation’ of all patients. This is partly achieved through ‘safety-netting’ with patients (Neighbour, 2005).

Practices work in different ways often utilising expert skills with-in a mix of GP training and personality. GPs often divide organisa-tional roles within the practice to support development of practice services and quality and outcomes framework (QOF) administra-tion. Your role in organisational and employment tasks will largely depend upon your position within the practice.

Although most practices welcome offers of involvement from all

GPs, your responsibility will increase as you move between posi-tions as locum, salaried and partner (or self-employed) GP. Some

GPs develop services (usually in collabora-tion with their PCO and local hospital) to offer additional specialist provision (such as Dermatology, Gynaecology, or Opthalmol-ogy). This way a GP can develop additional specialised knowledge useful to both their everyday practice and specialist clinics.

Within this role, the boundaries of their work will depend upon the context in which they are practising and available support from secondary care, their primary role remaining to be a GP. If you wish to become a ‘GPwSI’, talk with local colleagues and contact www.apwsi.co.uk. You may need to gain extra qualifications, at some point, in addition to your general practice qualifications.

COMbINING LIFE AND WORK

Many GPs’ career decision will have been influenced by the potential work-life balance. Depending on your practice and area of work, there is likely to be more space for personal preference and autonomy in agreeing your place and hours of work. Most surgeries are open to patients from at least 8am to 6.30pm, although there will be opportunities to negotiate when you offer surgeries (includ-

ing part-time options). There is, however, a lot of work in addi-

tion to the set surgery times. This includes home visits, checking results, reading and acting upon patient correspondence and authorising prescription requests. Surgeries vary in the way in which they divide ‘regu-lar’ and ‘emergency’ appointment requests. Most areas now have ‘out-of-hours’ ser-vices. These are usually staffed during eve-

nings, nights and weekends by local GPs outside their practice commitments.

TEACHING IN GENERAL pRACTICE

General practice has traditionally had a very strong affiliation with education. Many GPs are ‘trainers’, allowing them to supervise

Many trainees worry about becoMing a generalist. in fact,

generalisM is a specialisM!

DepenDing on your practice anD area of work, there is likely to be More space for personal preference anD

autonoMy in agreeing your place anD hours of work.

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specialist trainees. In order to become a trainer, GPs attend a part-time one year certificate course (the equivalent of a school teacher’s PGCE) and attend ongoing monthly trainer events. GPs can also become involved in foundation and undergraduate level teaching. Most Deaneries require Foundation level supervisors to attend a 1-2 day training course.

GPs wishing to get involved in undergraduate teaching should contact their local university and get involved. Some teaching takes place at the university site, but most will be patient-based within a practice setting. These posts rarely require specific qualifications (other than enthusiasm to teach) and ongoing professional develop-ment and quality assurance is arranged by the university. GPs often find that teaching and consultation skills have many similarities and involvement in each informs the other. There are a range of courses and events if you would like to pursue this interest further.

SUMMARy

In conclusion, there are many opportunities for getting involved in a range of exciting and innovative areas of practice through GP training. From becoming an expedition doctor, getting involved in research and teaching, political activity, work with pharmaceuticals to simply enjoying consulting with patients, general practice offers a breadth of training expanding doctors’ knowledge and future pos-sibilities - enjoy!

references

neighbour, R. (2005), The Inner Consultation: how to develop an effective and intui-tive consulting style. (Second ed.). Abingdon, oxon.: Radcliffe.

Tooke, J. (2008), Aspiring to Excellence: findings and final recommendations of the independent inquiry into Modernising Medical Careers [online]. Available at: http://www.mmcinquiry.org.uk/final_8_Jan_08_MMC_all.pdf.

This inspiring new book emphasises there is no single career path in general prac-tice. Without being prescrip-tive, its practical approach helps you make life-chang-ing decisions, prompts self-analysis and equips you with the tools to remain flexible, positive and reflective about your career.

Published by Radcliffe. Edited by Patrick Hutt and Sophie Park. (ISBN-10 1846195535). RRP £24.99

Sophie Park is a sessional GP and works at UCL medical school teaching undergraduates and postgraduates. She also teaches with the London Deanery and Institute of Education (IoE) and is studying for an EdD at the IoE.

a carEEr coMpaNioN to bEcoMiNg a gp: DEvELOpING AND

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Q: Why do I need income protection?

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A: If you are diagnosed with an illness or injury that means you are unable to work, you will be able to claim on an income pro-tection policy and continue to receive an income. This will be a regular tax-free pay-ment at, typically, around 50% of your gross pre-incapacity earnings. Most income protection plans pay out until you return to work or are no longer suffering from a loss of earnings, for example if you start receiv-ing a pension income, you reach the maxi-mum age for the policy or you die.

Q: Why do I need income protection if I receive sick pay?

A: You may initially be covered by NHS sick pay, depending on how long you have been working. A junior doctor in their first year of service is eligible for just one month’s full pay and, once they’ve completed four months’ service, an additional two months’ half pay. This will gradually build up over time but will still only cover basic salary and won’t include other elements that can signif-icantly increase your regular take-home pay, such as salary band uplift. Even consultants are only eligible for a maximum six months’ full pay and six months’ half pay.

Therefore you could find yourself living on less than half your regular take-home pay. An income protection policy however is generally based on your full earnings, not just your basic salary.

If you were to rely on only the State for help once NHS and statutory sick pay runs out, you could be entitled to a maximum of just £99.85 Employment and Support Allowance a week.

Q: What should I look for in a policy?

A: Make sure you choose a plan that suits your particular needs. You may have savings or a partner’s earnings to help cover the loss of income and this will have a bearing on the level of cover you require.

It is also important to check whether the policy is specified ‘own occupation’, mean-ing you will still receive an income even if you could do another job apart from your own. Some policies offer an ‘any suited occupation’ definition, which means they

won’t pay out if you can’t do your own job but could carry out other types of work based on your knowledge and experience.

The period of time between you being unable to work and the payments starting is also an important factor to consider as you will want to ensure there are no gaps in your income. You can opt to defer income pay-ments for an amount of time that suits you and, in general, the longer a deferred peri-od, the cheaper your income protection pol-icy will be.

Conclusion

Income protection is important because the right policy can ensure you maintain the level of income you received before sickness or injury. The amount of protec-tion required depends on your own circum-stances and lifestyle requirements and while there are a wide range of products available, not all will match your particular needs, so choose carefully. It is sensible to take pro-fessional advice to ensure you find the right cover for you, leaving you neither over- nor under-insured.

focus on finance - in association with Wesleyan Medical Sickness

INCOME protEctioN

Specialist financial services for doctors

0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

• Savings and Investments

• Retirement Planning

• Life and Income Protection

• Mortgages

• Motor, home and travel insurance

Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

Motor, home and travel insurance is arranged by Wesleyan for Professionals.

For more information or for specialist financial advice contact Wesleyan Medical Sickness on 0800 107 5352 or visit the website at www.wesleyan.co.uk/doctors

24

D r Kamler has treated bear bites in the Arctic, frostbite in the Antarctic and set fractures in the Andes. For-

tunately not all expedition medicine is as extreme. Expedition or remote medicine is defined as the diagnosis, prevention and treatment of injuries and medical condi-tions that occur in remote hard-to-reach areas, far removed from the beaten track.

It is practised in a range of theatres, from rainforests and battlefields, to geographical catastrophes to polar ice caps; if it is off the beaten track, it is expedition medicine. The expedition medic is a generalist, as the role is all encompassing, for they are the radiog-rapher, nurse, porter, surgeon, etc.

Before you go on your expedition•Make sure you have the right indemnity

(see sidebox).

•Ensure that you are registered in the country you will be working in.

• Find out exactly what the medical facili-ties will be, what support you will have, and how you will contact people in an emergency.

•Check that your level of experience is what your team leaders think it is.

•Research the destination and familiarise yourself with local customs.

•Check that you’re happy with the expe-dition company’s risk assessment.

•Training, pre-expedition planning and health assessments are vital to minimise the risk of unexpected, preventable med-ical emergencies.

• Send out questionnaires to find out about current and past medical conditions of participants; drug histories and allergies; detailing appropriate immunisations, an-ti-malarials and personal medical kits.

During an expedition•Remember the same good medical

INTO THE Wild

practice considerations apply however remote you are.

•Work within the limits of your clinical competence (even the most skilled sur-geon could not undertake surgery up a mountain without the right equipment).

• In the UK, the standard of care expect-ed is generally determined by the Bol-am test – that is, what is expected from an ordinary, competent doctor skilled in that particular art.

•When treating patients, you should make it clear that you are giving as-sistance as a skilled first aider, as op-posed to anything more specialized or sophisticated.

•When treating participants as patients, always make sure you have their valid consent and act in their best interests.

•Be aware you have responsibility for the safety of the whole team.

•Keep a record of all consultations and drugs prescribed.

•Be vigilant of professional boundaries as they can become blurred in the setting of an expedition.

•Be sensitive to local customs and cultur-al factors.

•Guides or porters should have access to the same medical treatment as other ex-pedition members.

•Bear in mind different environments will present specific risks and associated

Medicolegal Advice - in association with the Medical Protection Society

Sara Williams gets off the beaten track and explores wilderness medicine

24

“One more climber should have died that day, but didn’t, and that’s Beck Weathers. He was able to survive because he was able to generate that incredible willpower; he was

able to use all the power of his mind to save himself.”Dr Kenneth Kamler talking about his experiences working as the only doctor during the worst disaster in

Mount Everest’s history.

MPS is the leading provider of comprehensive professionalindemnity and expert advice to doctors, dentists and healthprofessionals around the world.

We actively protect and promote the interests of members and believe that education is an integral part of every healthprofessional’s development. As well as providing legal adviceand representation for members, we also offer workshops,conferences and a range of publications designed to aid goodpractice.

MPS is not an insurance company. All the benefits ofmembership of MPS are discretionary as set out in theMemorandum and Articles of Association.

About MPS

MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.

www.mps.org.uk

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.

About MPS info for articles.qxd:MPS Checkup 12/2/10 10:05 Page 1

illnesses, eg, on climbing expeditions, altitude starts to have an effect around 1,500 to 2,000m – air pressure gets low-er and less oxygen is available.

•Remember other medical problems can range from the mundane, eg, stomach upsets, sprains, blisters; to the life threat-ening, eg, fractures, high-altitude sick-ness and venomous insect bites.

•Remember the scope for comprehensive treatment will be limited, so the empha-sis lies on stabilisation of the patient and evacuation to a facility where definitive care is available.

After an expedition•The same standards of confidentiality

apply; wherever possible, patient con-sent should be obtained before sharing clinical information with other medical teams.

• People who pursue extreme dreams are likely to have accepted that there is a certain degree of risk involved, so are less likely to come back and criticize your skills after the trip.

I’M JUST ON HOLIDAy!

If you’re going on a trekking holiday and are not attending in any formal medi-cal capacity, remember that in the UK and Ireland, there is an ethical, but not legal, obligation to assist those in need of medical treatment in an emergency.

The GMC’s Good Medical Practice (2006) states that in an emergency, wherever it aris-es, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care.

Medicolegal Advice - in association with the Medical Protection Society

25

gEttiNg thE right iNdEMNitYBefore undertaking any expedition medi-

cine, you should speak to MPS to ensure that you have adequate and appropriate indemni-ty. Some expedition companies provide expe-dition cover. Expedition doctors go beyond the scope of Good Samaritan acts, wheth-er a fee-paying member of an expedition or not, doctors are expected to provide medical attention, and so changes to your indemnity cover may be required.

MpS adVicEExpedition medics are responsible for the clinical care

of the expedition team, risk assessment, medical kits and equipment, and prescribing medicine. Decision-mak-ing skills, communication skills and self-reliance are all important. Clinical situations should be assessed in rela-tion to the limited equipment and resources available, the best interests of the patient, and a doctor’s own levels of competence and experience.

For more information visit ww.mps.org.uk or call the MPS on 0845 605 4000 or email [email protected].

hoSPITAl MESS26

duMboH e may believe that an elephant can fly but I believe that he

may be suffering from a number of different conditions.

tEMporal lobE aNEurYSMAt various points in the documented life of Dumbo he begins to

hear others singing rather than speaking to him. Although that could be a purely escapist fantasy to avoid confronting his own mundane dilemmas, it would be remiss to not think about the possibility of these being auditory hallucinations (defined as sensory stimuli in the absence of external sensory stimuli). These events are rare, but doc-umented, resulting in all voices being heard as song - or maybe for Dumbo it’s as simple as hearing crows “singing” songs about you. A CT should be requested as a matter of course although it would be a challenge to accommodate him into a scanner.

fragilE X SYNdroMEThe picture I get of Dumbo’s life is one of psychogenic muteness,

repetitive behaviour (the same jump into the bucket of pie filling every night), social anxiety, peer teasing and difficulty with physical feats - most recently the elephant pyramid disaster - resulting from poor mus-cle tone. This, coupled with his appearance, suggests the possibility of Fragile X syndrome - a genetic disorder caused by mutation of the FMR1 gene on the X chromosome predominantly in males. It would also explain why Dumbo’s mother was so secretive about his birth using a stork delivery service rather than a hospital to avoid questions which may have been raised regarding her family history.

VErtigo A belief that you can fly is more often than not, incorrect. Even

given his enlarged ears, it is near impossible that Dumbo can lift his own body weight off the ground. Add to this the physiological impracticality of “flapping” ones ears and the result is that we must assume that Dumbo cannot actually fly. We are therefore left with an assumption that Dumbo experiences what could be misinterpreted as “flight” - the sensation of swaying while the body is actually station-ary with respect to the surroundings. Inner ear problems are often the cause of vertigo as they act to effect the balance mechanisms of the vestibular system - more likely given Dumbo’s distended auricu-lar protuberance.

SchizophrENiaAll of these symptoms could be brought together in a single diag-

nosis: schizophrenia. Dumbo reports auditory hallucinations, visu-al hallucinations and delusional beliefs about flying and his famed destiny. There is a suggested family history of odd behaviour: when Dumbo’s mother assaulted those teasing Dumbo, she is judged to be “mad” by the other circus performers (and locked away). There is a strong genetic component to schizophrenia making the diagnosis more likely. A trial of anti-psychotics may be in order - I would sug-gest Seroquelephant.

Assessed by Gil Myers

MEDICAL REpORT1 2 3

4 5

6 7

8

9

10 11

12 13

14

15 16 17

18

19

20

Across

1More specific than hay fever (10)

4Sexual drive (6)

5Phlebothrombosis (3)

6Not a nice guy; sudden muscle contraction in resopnse to a nerve impulse (4)

8Small communication between tiny artery and vein in the skin of the limbs (6)

9Inflammation of the uterus (8)

11Tremors or vibrations in part of the body detected by palpation or auscultation (8)

12Not mitosis (8)

15Voluntary rapid movements of the eyes, e.g. when reading (8)

18Loss of substance through pathological or physiological means (10)

19Indiscriminate eating of non-nutritious or harmful substances (4)

20Comon benign tumour of fat cells (6)

Down

2Small splinter of bone (7)

3Any disease resulting in wasting of tissues (8)

4Presence of fat or oil droplets in urine (7)

7His disease is staphylococcal scalded skin syndrome (6)

8Space between the two vocal folds (7)

10Organs within the body cavities (7)

11The association in psychoanalysis (4)

13Series of genes on chromosome 6, that code for antigens including HLA antigens (3)

14Eardrum (7)

16Kanner's syndrome (6)

17Injury to a ligament, as a result of sudden overstretching (6)

2 Small splinter of bone (7) 3 Any disease resulting in wasting of tissues (8) 4 presence of fat or oil droplets in urine (7)

7 His disease is staphylococcal scalded skin syndrome (6) 8 Space between the two vocal folds (7) 10 Organs within the body cavities (7) 11 The association in psychoanalysis (4) 13 Series of genes on chromosome 6, that code for antigens including HLA antigens (3) 14 Eardrum (7)

16 Kanner’s syndrome (6)

17 Injury to a ligament, as a result of sudden overstretching (6)

1 More specific than hay fever (10)

4 Sexual drive (6) 5 phlebothrombosis (3) 6 Not a nice guy; sudden muscle contraction in response to a nerve

impulse (4) 8 Small communication between tiny artery and vein in the skin of the limbs (6) 9 Inflammation of the uterus (8) 11 Tremors or vibrations in part of the body detected by palpation or auscultation (8) 12 Not mitosis (8) 15 voluntary rapid movements of the eyes, e.g. when reading (8)

18 Loss of substance through pathological or physiological means (10)

19 Indiscriminate eating of non-nutritious or harmful substances (4)

20 Comon benign tumour of fat cells (6)

You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com

Compiled by Farhana Mann

ACRO

SSDO

WN

hoSPITAl MESS 27

Less sizzle for your cash at:

£3.65 King’s College Hospital

More banger for your buck at:

£2.40 Strathclyde Hospital, Lanarkshire

Too expensive to write a complaint at:

£1.99 Neath port Talbot Hospital, port Talbot

Doodle-tastic:

49p Royal victoria Hospital, belfast

Expensive enough to make it curdle at:

79p Royal Free Hospital, London

Moo-velous prices at:

59p yeovil District Hospital, Somerset

Next issue we’re checking the cost of a bowl of porridge, an A4 B/W photocopy and a jotter pad. Email prices to [email protected]

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular

column of the best and worse hospital essentials you’ve reported:

42” TV with Sky Digital, 10 PCs with Internet Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table.

Complimentary tea, coffee, toast, newspapers and maga-zines are provided daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.

JuniorDr Score: ★★★★✩

Sausages and chips

pint of milk

‘Writing in the notes’ is our regular letters section. Email us at [email protected].

Writing in the Notes

a doctor as a leader

Dear Editor,I read with much interest the article ‘Learning to

lead’ (Iss 21, p15). It is an excellent and all-embrac-

ing, yet concise, overview on the way to achieve

much-needed leadership skills. A ‘doctor as a lead-

er’ is unquestionably a buzzword in the modern day

medical climate. Our NHS is going through evolu-

tion and revolution with a constant need for creating

new services as well as re-organising existing ones to

become more efficient in healthcare delivery. Conse-

quently, the value and the need of possessing leader-

ship skills as a doctor could never be overemphasised.

The truth is that the earlier you start learning these

skills in your career, the better the outcome will be.

I warmly applaud the JuniorDr team for featuring

such a relevant article for the right audience at the

right time. Well done!AUnG ZAW WIn

ST5 noRTh WESTERn DEAnERy

More because we’re betterDear Editor,

I was a little disappointed by your article ‘Young docs prescribe more’ (Iss 21, p6). It suggests that younger doctors over-prescribe and do not offer life-style advice to better manage cardiovascular disease. I would argue that another explanation is that younger doctors have a better understanding of newer drugs and so can offer these where appropriate. Today there is much emphasis on cost-effective prescribing and on outcomes in the NHS and from my experience young doctors are appropriate and effective prescribers.SAnGITA SInGh GP TRAInEE, nEWCASTlE

QuEEN’S MEdical cENtrE, NOTTINGHAM

A ball pen

tested on humans (not animals)

I was very interested to read my partner’s copy

of JuniorDr ‘Animals in Training’ (Iss 21, p9). I am

a vet and whereas you see much of your knowledge

and understanding coming from animals we see it

the other way. Today’s veterinary practice is on par

with what you deliver in hospitals - and in many cas-

es is even superior. We do complex cardiac operations

in high-tech sterile theatres that would make many

NHS doctors jealous. I would go on to brag about

the fact that vets can also operate on all parts of the

body unlike human surgeons but I wouldn’t want to

start picking fights!MIChAEl KEnDAll

vET (AnD PARTnER of An ST3 DoCToR)

ToURISM28

getting there

Despite being a Spanish island Lanzarote lies closer to Africa, situated just 100 miles off the Moroccan coast on the same latitude as the Sahara desert. Flying time is a little over 4 hours from London.

For flights check out ThomsonFly, Mon-arch or the other package operators for cheap lastminute deals. Alternatively BA offer direct flights from many UK airports with Easyjet offering a summer service.

Car hire is highly recommended to allow you to experience the extreme island landscape and visit the more remote vil-lages. Alternatively, taxis on the island are cheap and coach tours to the main attrac-tions operate from the major resorts towns year-round.

wHErE To sTay?

The two main tourist resorts on the island are the low-rise developments of Puerto del Carmen and Playa Blanca on the south coast. Both are relatively inoffen-sive with only a splattering of ‘all-day Eng-lish breakfast’ cafes and beer guzzling Brits making them a good base for those with-out a car.

Try the cheap and cheerful Atalaya Apartments in Puerto del Carmen for a good location and access to the beach at £50 per apartment per night (+34 902 50 53 50). For a more luxurious 5-star experi-ence the Princesa Yaiza Suite Resort Hotel

in Playa Blanca at £140 per night offers a spa and uncrowded beach (www.princ-esayaiza.com).

For a more exclusive and individu-al experience try the very private Lagomar guesthouse with seaviews over lava craters and access to an eccentric underground cave bar (www.lag-o-mar.com).

EaTinG

Lanzarote cuisine is similar to that on the Spanish mainland but you’ll find excel-lent fresh seafood most commonly served grilled. There’s a small number of local dish-es including salted potatoes in a hot local mojo sauce.

Try Caserio de Mozaga (www.caseriode-mozaga.com) in San Bartolomé which is recommended for perfect Canarian grilled fish and local produce.

Another great Canarian restaurant with a modern twist is La Tegala in Mácher (+34 928 524 524). Here you can sample Tapas style dishes and enjoy a fantastic panoramic view of the volcanic landscape.

kEy aTTracTions

Timanfaya National Park - This massive 20-square-mile site of lava and volcanic cra-ters is spectacular and the island’s top attrac-tion. After the tour you can refuel the with food cooked directly off the volcanic surface.

Jameos del Agua - Designed by the islands most famous architect, sculptor and resident,

César Manrique, this site contains a subterra-nean garden, restaurant, pool and concert hall built into a network of volcanic caves. Reserve a table in advance.

Fundación César Manrique - Understand the island’s world famous artist, architect and sculptor who worked with the likes of Andy Warhol.

Find the full Lanzarote guide at JuniorDr.com.

There’s a myth that the lanzarote locals coined the slang ‘lanza-grotty’ to keep rowdy tourists away from this year-round sunshine island. lanzarote however, is more ‘art’ than ‘all-day English breakfast’ and an ideal choice for a long relaxing weekend ward getaway.

WEEKEND WARD ESCApE TO THE

LanzaroTE

kEy facTs

• POPULATION - 130,000

• LANGUAGE - SPANISH

• CURRENCY - 1£ = 1.15 EUROS

ClASSIfIED 29

The Medical Journalist’s Association brings together medical writers, the media, health professionals, and health charity workers.

> Meetings on major health and medical topics of the day> A forum to meet colleagues> Recognition and cash awards for distinguished work> A website with your own address. Visit www.mja-uk.org> Professional advice when you need it

Wish to join? For more information visit www.mja-uk.org

2012 Specialty Training Recruitment

Get ReadyThe provisional timetable for Round 1 and Round 2 recruitment is as follows:

CT/ST1 Round 1 - August/September 2012 intake• Applications open on 25 November and close on 9 December 2011• First offers issued by 9 March 2012

ST3+ Round 1 (and readvertised CT/ST1 posts) - August/October 2012 intake• Applications open on 17 February and close on 5 March 2012• First offers issued by 25 May 2012

Note: Round 1 includes recruitment to run-through specialties and CT2 for most of the uncoupled specialties. The exception is Anaesthesia - where CT2 posts will be advertised with ST3 recruitment.

Set...Visit the SMT website over the summer for more information on the application process.Subscribe to the SMT e-Newsletter via the website for the latest updates.

Go!http://www.scotmt.scot.nhs.uk

GET yOUR NEURAL INpUT TO JUNIOR DOCTORS. ADvERTISE HERE. CALL US ON 020 7684 2343.

jourNaliSM

From little acorns mighty oaks grow To make sure your career grows strong

and true, and always on an upwards trajectory, join:

The Society for Acute Medicine

“The most important body championing the cause of acute medicine” SAM member, 2011

To join or to find out about the many benefits SAM members enjoy visit www.acutemedicine.org.uk or email [email protected].

rEcruitMENt

rEcruitMENt

EvEnTSDR.CoM30

THE MEDICAL COURSE AND CONFERENCE DIRECTORY

A s doctors we hate scouring the web to find where and when we can attend the next exam revision course, training event or conference.

We think they should all be in one place - which is why we launched EventsDr.com as part of the JuniorDr network.

We’re aiming to build the most comprehensive database of medical events. Below you’ll find just a selection of the full listings at EventsDr.com.

MEDicinE

MrcP PacEs

Sat 15th oct(2 DAyS)

£680 london

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Mon 23rd Jan(4 DAyS)

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£1499 london

MrcGP

Sat 22nd oct(1 DAy)

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MRCP 1

Mon 5th Dec(5 DAyS)

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hammersmith MedicineMon 5th Dec

(5 DAyS)£495 london

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EvEnTSDR.CoM 31

MrcPcH cLinicaL skiLLs

Sat 14th Jan(2 DAyS)

£820 hillingdon

Sat 21st Jan(2 DAyS)

£820 Kingston

MRCPSyCh PaPeR 1

Superego CafeSat 5th nov

(1 DAy)£195 london

Sat 12th nov(1 DAy)

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surGEry

Mrcs ParT B

fri 20th Jan(2 DAyS)

£365 Cardiff

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fri 20th Apr(2 DAyS)

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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

The best protectionMPS members have access to a wide range of benefits designed to help with the legal and ethical problems that can arise from professional practice.

� Medicolegal advice – available in an emergency 24/7

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We encourage members to get in touch on 0845 605 4000 if they are in any doubt overa medicolegal issue.

MPS Educational ServicesWe have developed a range of highly rated publications, workshops, conferences and e-learning resources to help promote good medical practice and minimise the risk of clinical mishaps. More than 4,000 doctors in the UK have already benefited from attending an MPS workshop. www.mps.org.uk/education

Working overseas?MPS has over 270,000 members in more than 40 countries. If you are planning to work overseas we can usually help.

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.

Supporting you throughout your careerMPS understands the importance of giving members access to a reliable, high quality service, and a range of educational services designed to meet your needs.

3921 MPS A4 Advert V2.indd 1 10/03/2011 10:47

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