Welsh Research and Education Network
Hot topics in research and medical education, in Wales and beyond
Guest post from Dr Laura Potts, Clinical Leadership Fellow, Paediatric Trainee, Wales Deanery
The Medical Women’s Federation (MWF) was founded in 1917. They aim to advance the personal and professional development of women in medicine, to change discriminatory attitudes and practices and to work on behalf of women patients and their families.
This year’s spring conference in Cardiff covered a broad range of topics affecting women from living and working with a disability through to antenatal screening and management of HIV.
The first talk ‘Prenatal testing ; risks or certainty’ was given by Dr Annie Procter, Consultant clinical geneticist. She discussed the evolution of antenatal testing and its future directions. The potential scope of antenatal screening is vast, especially with the introduction of fetal DNA analysis in maternal blood, but routine screening is currently limited to the three major trisomies. This thought provoking talk advised caution; should we test for everything we can, just because we can? It also highlighted the importance of managing families expectations effectively.
Dr Olwen Williams spoke about the progress in HIV and AIDS management in recent years. Huge advance have been made and are now close to enabling affected women to have normal deliveries and breastfeed. Women are however, still presenting with late disease and later in life, with and opportunistic infection and Kaposi sarcoma. She also reinforced the results of the recent PARTNER study which showed that in those with an undetectable viral load, transmission to their partner did not occur. There is a new public health initiative promoting Undetectable = untransmissable.
There were also a number of abstract presentations. Of particular interest was the work being done at Singleton neonatal intensive care unit on family integrated care (FiCare), presented by Dr Rachel Morris (ST5 Paediatric trainee and trainee representative for the MWF in Wales) .
Family integrated care is centred around four main themes – staff education, parent education, creating the right NICU environment and providing psychosocial support. The concept originated in Estonia and was developed by Professor Lee and colleagues in Toronto. It has been shown to reduce length of stay, retinopathy of prematurity and infections and increase breast feeding rates. Singleton have already had a lot of success, receiving excellent feedback from families and demonstrating reduced length of stay and increased breast feeding rates.
During the afternoon there were a number of workshops. I attended Dr Cora Doherty’s session on wellbeing and the healthy team. For optimal team effectiveness and performance mind, body and spirit must be considered, that is to say the team needs a clear vision, good morale and trust and have their physical needs met. The concept of the ‘fitness’ of team members to be part of the team was also considered and how we as team members and leaders have a responsibility to protect our own wellbeing and that of our team.
During the remainder of the afternoon there was an interesting talk titled ‘menopause behind the headlines’. Whilst not particularly relevant to our patients it was a delightful insight into what some of us have to look forward to!
Dr Clarissa Fabre, President elect of the Medical Women’s International Association (MWIA) shared the results of the most recent MWIA members survey. This included some worrying statistics such as 57% of respondents felt that they had been discriminated in their career, with 41% reporting that they had experienced sexual harassment or bullying in relation to their work. Unfortunately younger doctors reported lover job satisfaction, more sexual harassment and bullying and a higher incidence of stress and burnout.
The conference ended with the Dame Hilda Rose lecture, given by Dr Sally Davies, focusing on the importance of stories such as Dr Frances Morgan’s. She was the first woman to receive a doctorate in Medicine in Europe and the first female doctor registered in Wales. She was a pioneer in medical practice and social reform, working all over the world as well as working as a General Practitioner in Wales.
These stories demonstrated how far women have come in achieving gender equality but that there is more work to be done, as highlighted by the recent MWIA survey. The MWF work hard to fight discrimination against women in medicine, for example, challenging Jeremy Hunt on the lack of impact assessment for the new junior doctor contact in England and helping to tackle the gender pay gap. An interesting quote was offered at the end of her talk, ‘good practice benefits all, bad practice affects women more’. I wonder what you all think of this?
The key messages from this lecture and the conference in general were that huge progress has been made by women in medicine and in women’s health and that we all have a responsibility to report and challenge bad practice and behaviour, and make looking after ourselves and each other a priority.
For anyone interested in finding out more about the MWF their website can be found at www.medicalwomensfederation.org.uk
Dr Tim Warlow, Paediatric Palliative Care GRID trainee, Wales Deanery
Few of us can forget recent cases in the press of Alfie Evans and Charlie Gard. Such tragic cases of breakdown in relationship between families and care teams. I’m sure that alongside my own cries you have had the thought ‘Surely things didn’t have to get to this!’ These cases bring into stark clarity the importance of our skills of communication and our ability to put into practice the ethical and legal duties to involve of families and children in decision making. These cases are nightmare scenarios, but at some points in our career we will face similar challenging situations.
Aware of these issues, the All Wales Paediatric Palliative Care Team received £20,000 of Welsh Government funding to improve the skills of paediatricians in these areas. Our response was to organise a series of free workshops exploring issues of ‘communicating difficult news’, decision making and advanced care planning in paediatrics. April 2018 saw the first of these workshops in the fantastic Copthorne Hotel, Culverhouse Cross. Within a month we had filled all our places and the response on the day from delegates was fantastic.
The truly multidisciplinary event was attended by consultants, community nurses, therapists, trainees and hospice staff, all of whom engaged amazingly in communications skills breakout groups and seminars. There was time to explore advanced communication skills, read and use the Paediatric Advanced Care (PAC) Plan, and consider the views of families and young people in planning. The highlight of the day was without a doubt an interview with one of our parents whose son sadly died under the care of our service. She discussed the value of good communication, of doctors being prepared and sensitive, and the benefit of early and co-ordinated planning.
The good news is that there are several further days being organised, one for each of the health boards in Wales. The next of these is in Swansea where Dr Griffiths will be using trained actors to facilitate what will be an exhilarating day of interactive learning together with other professionals. Please contact firstname.lastname@example.org further information about upcoming days and to sign up. All workshops are free of charge and are in great venues with food provided.
If doing a good job of communicating and parallel planning with families excites your interest, these days are for you. If you want to run a mile, these days are even more for you!
Let’s get to grips with the really difficult stuff of paediatrics, lets help families to live well and for those whose lives are cut short, to live well right to the end.
Dr Annabel Greenwood (ST3), inspired by Dr Ian Morris (Consultant Neonatologist, UHW)
Relevance– How important is the content of the article to me, my patients, and my practice? The title and the abstract will help you answer these questions.
Internal validity– How sound is the study? i.e. how accurate is the study? Look at the methods to help ascertain this.
External validity– How applicableis the article to my practice? i.e how much can I generalize it? The methods and results sections will help you assess the external validity.
Now, with those 3 key principles in mind, let us picture the scene…
You’re an ST7 trainee, approaching the end of your paediatric training, years of hard work and dedication behind you, your CCT within touching distance. You’re at your START assessment, the last hurdle before consultancy, and now for your critical appraisal station. Twenty minutesto read the article AND then appraise?! How on earth am I going to do this I hear you cry?!
Stay calm, take a deep breath, and burst forth the 9 key questions that will help you ace the station!
Describe the study
What is the type of study (principal method)
What type of question is being asked? (e.g. Diagnostic? Therapeutic? Economic?)
Where was the study carried out? (is it multicentred or single study)
What are the key features?
Describe the research question
What is the relevance of the question?
This is usually described in the introduction. Is it an important question? Is it worth reading on? Does it correlate to your clinical practice/scenario?
Describe the methods
Use the PICO template, but expand….
What are the inclusion/exclusion criteria? Is there any masking or blinding?
Are there any secondary outcomes?
Comment on the internal validity i.e. how accurate is the study?
Use various checklists e.g. CONSORT, STROBE, PRISMA
Is there a risk of bias?
Summarise the primary results
Summarise the key secondary results(briefly)
Comment on the External validity– i.e. describe the generalizability of these findings
Were the inclusion/exclusion criteria reflective?
Consider the paper in conjunction with other studies i.e. how does it fit with the evidence out there?
Overall, does this paper help you answer your clinical question? Important to look at the clinical context!
….And just like that, you did it!
9 logical, concise steps to critical appraisal for the START assessment. Of course, this is only a suggested approach, but one which I will most certainly be adopting for future critical appraisals. Now, where did I put that journal?.....
Dr Rebecca Broomfield
Why is it important?
The environment created in the workplace is vitally important to the wellbeing of the staff who work there. In clinical medicine this also translates into the wellbeing of patients and ultimately their safety. So what can you do, as a leader, to ensure that your workplace environment is as positive and functional as it could be?
This topic was first visited during the Faculty of Medical Leadership and Management (FMLM) conference in Liverpool and covered in the Leadership blog in December. It was covered here by Henry Stewart. He runs the Happy company, which has been listed as one of the 20 best workplaces in the UK for five successive years (www.happy.co.uk). Henry Stewart has also written “The Happy Manifesto” He has identified that people work better when they are challenged and given freedom. As a manager we should be enabling people to innovate, and rather than focusing on weaknesses we should develop our strengths. Mistakes should be celebrated and, within the boundaries of clear principles and targets, team members should be given freedom and ownership of projects.
The topic has come up time and time again within the Leadership program I am currently enrolled on. Happier workplaces function better, lead to greater innovation and better results.
What can you do?
Within a quality improvement program provided by Cardiff and Vale Health board, we recieved a afternoon workshop to discover how we can use positive psychology to improve our own happiness and that of our workplace. This was delivered by Mark Hodder.
People tend to currently live with the mindset "I will be happy when....I've lost weight/I have a promotion/I own a bigger house" Thus success creates happiness.
Rather than this way of looking at happiness what would happen if we looked at it from the opposite direction, shifting our paradigm and focusing on happiness bringing success? Learnt helplessness is a huge problem, but now we know this we can challenge this and learn positivity.
When driving home from work try thinking of 3 positive things which happened that day. They don't have to be big things, just build it into your daily routinue.
In work in order to build positive relationships we need 3 positive interactions to every negative one. Can you within your workplace build in positive feedback or interactions.
How often do you praise people or say thank you? Could you do this more?
Think about how you motivate your team. For praise to be most beneficial it should be given for effort rather than ability. By praising for ability you run the risk of creating a fixed mindset which then has the potential to cause a drop off in performance. Effort and recognising hard work by saying "Thank you" or "I can see you have put a lot of work into ..." A growth mindset is created promoting positivity and providing motivation.
When you encounter a problem or a difficulty could you
Dispute, Distract, Distance?
This technique creates a mindset that setbacks are tempory, local and changeable rather than spiralling into a negative perspective or allowing negative feelings to dominate a workplace. Problems are actively dealt with.
What about your face?
Consider who your face is for? .... (clue it's not for you!)
Your face and body language are ways of communicating to other people. Faces have so much to give away we just have to focus on them and see it. In the same way, we need to be aware of what our face is saying about us and how we can use this to our advantage - smiling is contagious! When we are interacting with people often their facial expressions and body language mirror our own, therefore our behaviour and attitude matters. Think about what your daily facial expressions project about your emptions onto your team.
And finally ..... helping other people will help you. 5 random acts of kindness a day have been shown to reduce cortisol levels and thus reduce stress, see how many you can build into your day.
The Happy Manifesto: Make Your Organiszation a Great Workplace By Henry Stewart
The Chimp Paradox: The Mind Management Programme to Help You Achieve Sucess, Confidence and Happiness By Prof Steve Peters
http://www.markhodder.net/ - Links to articles from the workshops and contact details for Mark Hodder.
Guest Post: Dr Roisin Begley
Preparing for RCPCH Progress: What you need to know
2018 is the year of huge change in paediatric training with the introduction in August of the new RCPCH Progress Curriculum.
All trainees will move from the current curriculum to RCPCH Progress, unless they are due to CCT before 15 September 2019.
You will not need to re-demonstrate achievement of training levels already completed under the old curriculum ie Level 2 trainees will not need to evidence again that they have met the requirements of Level 1 training.
Preparing for Progress: guidance and resources
What is different about RCPCH Progress?
The new curriculum is based on a framework of learning outcomes as opposed to the current list of competencies, and incorporates the Generic Professional Capabilities the GMC expect of all doctors. Collecting evidence for an outcomes based curriculum will be very different from getting a competency signed off. This new approach will allow greater flexibility for you to demonstrate achievement.
The curriculum comprises:
Example: LEVEL 1:
Curriculum Learning Outcome 2
1. Effective working relationships:
• Demonstrates skills and strategies for effectively consulting with babies, young children, adolescents and their families in such a way that the child or young person and their family feel able to talk about difficult or emotional issues.
• Manages disruptive or antisocial behaviour in children, adolescents and families in clinical settings if it occurs.
• Applies knowledge of how different factors influence a patient’s journey and how they may impact effective communication and cause anxiety about treatment and illness.
• Communicates, with support, with parents and the rest of the family of a patient who has an acute or chronic illness, is hospitalised, or has died.
• Discusses the indications, benefits and possible risks associated with a procedure to obtain informed consent from patients and parents or carers for a procedure that the trainee is competent themselves to perform.
A comprehensive range of materials have been produced and are now available from the RCPCH Progress webpage.
This webpage, www.rcpch.ac.uk/progress is regularly updated with additional resources and information.
Opinions from those using Progress
Dr Sophie Con, Wales Deanery Paediatric SHO
"The new curriculum is certainly more succinct than the last. It does take some time to find your way around it though. Sometimes you wish it would be more specific! I think it is more achievable to find an illustration for each point than the previous curriculum"
Dr Tim Warlow, Paediatric Palliative Medicine Trainee, Wales Deanery
“Our speciality was chosen alongside a small selection of others to trial the new RCPCH progress curriculum. You will be pleased to know that this is an immeasurable improvement on the old curriculum. There are key learning objectives within which are ‘key capabilities’. We link these to our portfolio entries. They are far fewer in number and much better worded than in the previous version.
The whole layout and menu selection is much more intuitive, with submenus relating logically within their categories. This is a refreshing change from what was a baffling and frustrating previous system. In combination with what is a much better new portfolio in ‘kaizen’, it feels as through the portfolio might be becoming fit for purpose as a way of signposting our learning, helping us to monitor our progress, and enabling our supervisors to see a clearer picture of what we have been doing. Well done RCPCH!”
Dr Annabel Greenwood