www.mps-group.org

VO

LUM

E 3 | IS

SU

E 2 | O

CTO

BE

R 2012

VO

LUM

E 3 | IS

SU

E 2 | O

CTO

BE

R 2012 PROFESSIONAL SUPPORT AND EXPERT ADVICE FOR JUNIOR DOCTORS

SO

UT

H A

FRIC

A

SO

UT

H A

FRIC

A

How to work in…radiology

We reveal the top 20 medicolegal myths

Family values: Treating those close to you

Inside this issue:

GETTING A JOB AFTER COMMUNITY SERVICE

You’re hired

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

Helping members in South Africa for more than 50 years

MPS is not an insurance company. All the benefi ts of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London, W1G 0PS. MPS1248:10/12

Leading provider of professional medical indemnity in South AfricaMPS offer peace of mind to more than 26,000 health professionals in South Africa

Just one of the many benefi ts of being a member of the world’s leading medical defence organisation

To fi nd out more call 0800 11 8771 or visit www.medicalprotection.org/southafrica

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

Helping members in South Africa for more than 50 years

More than just indemnityMPS is not just there for when things go wrong. We provide educational workshops, publications and professional support from our expert advisers to help you avoid problems in the fi rst place.

MPS1248_SA_SAMAInsider_Ads_A4_2012.indd 3 09/10/2012 11:21

3C

ON

TE

NT

SJU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rg

Welcome

Dr Graham Howarth – Editor-in-chiefMPS Head of Medical Services (Africa)

Inside this issue of Junior Doctor…

EDITOR IN CHIEF Dr Graham Howarth EDITOR Sarah Whitehouse CONTRIBUTORS Dr Lynelle Govender, Dr Graham Howarth, Professor Zarina Lockhat, Dr Nasreen Mahomed, Dr Michelle Pentecost, Dr Magnus Potgieter, Professor Zephne van der Spuy DESIGN Jayne Perfect PRODUCTION MANAGER Philip Walker MARKETING Mo Khan, Alika Maharaj, Ian Middleton EDITORIAL BOARD Shelley McNicol, Gareth Gillespie Junior Doctor Medical Protection Society, Granary Wharf House, Leeds, West Yorkshire, UK, LS11 5PY Tel: +44 113 243 6436 Fax: +44 113 241 0500

GET THE MOST FROM YOUR MEMBERSHIP

Visit our website for publications, news, events and other information:www.mps-group.org

We welcome contributions to Junior Doctor. Please contact the editor, Sarah Whitehouse via email sarah.whitehouse@mps.org.uk

Opinions expressed herein are those of the authors. Pictures should not be relied upon as accurate representations of clinical situations.

© The Medical Protection Society Limited 2012. All rights are reserved.

GLOBE (logo) (series of 6)® is a registered UK trade mark in the name of The Medical Protection Society Limited.

Cover: © David Leahy, Cultura/Science Photo Library

6

10

12

14

4 UpdateWe focus on the work of SAMA and JUDASA, as well as MPS’s marketing and membership agents in South Africa

5 Medicolegal myths Dr Graham Howarth shares the top 20 most common medicolegal myths amongst junior doctors

6 Family values Sarah Whitehouse and Dr Lynelle Govender look at why family and medicine don’t always mix

8 Termination of pregnancy

Dr Michelle Pentecost considers a junior doctor’s responsibilities when faced with a patient who requests a termination of pregnancy

10 You’re hired Dr Magnus Potgieter offers some top tips on how to improve your CV, whilst Professor Zephne van der Spuy and Dr Nasreen Mahomed explain how to make yourself stand out from the crowd

12 How to work in…radiology

Professor Zarina Lockhat shares her experience of life as a radiologist

14 DilemmaIf it’s not written in the records, it didn’t happen – the importance of detailed records for accurate handovers

As a junior doctor, your intern and community service years can be tough. Not only have you to put your clinical knowledge into practice, you have to get to grips with treating patients whose symptoms – and behaviours – might not always match up to the textbook examples you learnt about in medical school.

Combine these challenges with navigating your way through countless medicolegal and ethical dilemmas and it’s no wonder that planning your next career move may fall down your list of day-to-day priorities.

Remember, though, that your intern years provide you with the vital skills necessary to succeed and it’s never too early to start planning ahead. “You’re hired”, on page 10, offers some useful practical advice on applying for jobs and what you can do to ensure you remain one step ahead of the competition – whether it be taking on professional courses and extra study, or conducting research.

As well as ensuring you get the job you want, keeping your professional skills up-to-date in this way and continually aiming to improve the standard of your performance is the hallmark of a true medical professional.

As you will no doubt be aware, the HPCSA has a strong focus on the importance of professionalism at the moment. Maintaining professional integrity, even when faced with the most difficult of circumstances, is key. In this edition of Junior Doctor, we take a look at times when your professionalism might be challenged – when asked by a friend or family member to “just take a look” and offer an impromptu diagnosis (page 6), or when your personal beliefs prevent you from treating a patient: a situation which, if handled incorrectly, could compromise patient care (page 8).

As ever, do let us know your feedback on this issue – we welcome all comments and suggestions.

4

UP

DA

TE

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

Update

Vaccinating 50 million people against meningitis

A vaccination campaign to protect 50 million people from meningitis will help to save lives in seven African countries.

The scheme, introduced on 5 October by GAVI (Global Alliance for Vaccines and Immunisation), will operate in Benin, Cameroon, Chad, Ghana, Nigeria, Senegal and Sudan – the so-called ‘Meningitis Belt’ of Africa.

Seth Berkley, Managing Director of GAVI, said: “We’ve known for a long time that there are terrible epidemics of meningitis every five to seven years in the ‘Meningitis Belt.’ Nobody really understands why, but there are hundreds of thousands of cases, if not millions.”

The vaccine has been produced in association with the Serum Institute of India and the Bill and Melinda Gates Foundation. It has previously been used in Burkina Faso where it led to the eradication of meningitis after a year.

Meningitis can kill within 48 hours and cause brain damage, hearing loss or learning difficulties in 20% of sufferers. In addition to the health benefits the vaccine offers, it also ensures continued economic development. Previous epidemics tended to stop trade as people avoided large meeting places.

The three-month project, due to run until the end of the year, is part of a wider plan to cover 26 African countries. The aim is to vaccinate everyone from babies to young adults up to age 29.

Since its establishment in 2000, GAVI has vaccinated 325 million children and prevented more than five million deaths.www.health24.com

NEWS IN BRIEFFocus on: SAMA and JUDASAWe take a closer look at two organisations that will help you during your junior doctor years – and beyond

We are always looking for contributors for features and articles in MPS publications. After all, as a members’ organisation, we want to see your opinions and concerns reflected in your publication. With a readership of more than 3,000 junior doctors in South Africa, make your voice heard!

If there is anything you’d like to share, be it a debate, a question, or just an account of what it is like to be a junior doctor, please email Sarah Whitehouse, Junior Doctor Editor, at sarah.whitehouse@mps.org.uk.

Any published contributions may be eligible for up to R500 payment in vouchers, depending on length and quality, but just getting published will stand you in good stead.

WRITE FOR MPS IN SOUTH AFRICA!

What is SAMA? – The South African Medical Association (SAMA) is a non-statutory, professional association for public and private sector medical practitioners. Registered as an independent, non-profit section 21 company, SAMA acts as a trade union for its public sector members and as a champion for doctors and patients. On behalf of its members, SAMA strives for a healthcare dispensation that will best serve their needs. Membership is voluntary, with around 50% of public and private sector doctors in South Africa currently registered as members of SAMA. Its head office is in Pretoria.

Mission: to empower doctors to bring health to the nation.

Objectives:■■ To represent doctors with authority and credibility in all matters concerning their interests in the healthcare environment

■■ To promote the integrity and image of the medical profession

■■ To develop medical leadership and skills

■■ To provide doctors with knowledge relevant to the demands of medical practice

■■ To promote medical education, research and academic excellence

■■ To encourage involvement in health promotion and education.

What is JUDASA? – The Junior Doctors Association of South Africa (JUDASA) is a special interest group of SAMA. JUDASA was formed in 1992 and is incorporated under section 21 of the Companies Act, 1973. Its main objective is to address the needs and challenges faced by the junior doctors within South Africa.

Membership of JUDASA is voluntary and is offered to all junior public health sector doctors. This includes clinical year medical students, doctors doing their two-year internship programme, those completing their one year of community service and junior doctors one year after community service.

Mission: To support members by being involved with role-players such as the Department of Health and the HPCSA, both fighting for our members’ rights and providing them with the necessary support for these early years and those beyond.

Objectives:■■ To present the professional and legitimate needs and interests of junior doctors.

■■ To form good relations between junior doctors and other medically associated groups, hospitals, public and private institutions and government.

■■ To serve the medical profession and to promote health for all by striving for an affordable, non-racial, non-sexist, comprehensive and effective unitary health system to which all have the right of equitable access.

Contact us:

www.judasa.org

Twitter: @judasaNEC

Facebook: JUDASA

© C

AT L

ON

DO

N/IS

TOC

KP

HO

TO.C

OM

© S

EA

N W

AR

RE

N/IS

TOC

KP

HO

TO.C

OM

5U

PD

AT

EJU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rg

Medicolegal mythsMPS hears some weird and wonderful excuses from junior doctors as to why their actions have fallen foul of the professional standards expected of them. Dr Graham Howarth, Head of Medical Services (Africa), shares the top 20 most common medicolegal myths:

1. The absence of notes means that the claimant will be unable to prove the case against me.

2. These notes are excellent; I wrote them after the complaint came in but they are based on my recollection of events and the original notes.

3. I only have to tell patients about complications that occur > 1% of the time.

4. You only need to use a chaperone when examining female patients.

5. You only need to use a chaperone when examining patients of the opposite sex.

6. I am a female doctor and therefore do not need to use a chaperone when examining patients.

7. While I recognise that my care was substandard, the patient developed an acknowledged complication, so I cannot be held liable.

8. The expert is supportive so I will win the case.9. They are my notes and the patient is not

entitled to them.10. The expert has let me down by criticising me.11. I want to counter sue for defamation – it

is outrageous that the patient has sued/ complained to the HPCSA about me.

12. If I ignore a letter from the HPCSA/of demand the case will go away.

13. As a community service doctor I am qualified and able to supplement my income by doing GP locums.

14. The patient really wants (whatever) and will sign a waiver, absolving me of any responsibility.

15. I had this nice journalist on the phone, we spoke off the record …

16. I was off duty when (any number of things from drunkenness to common assault) took place, so I was not really a doctor at that time.

17. There is no need to record negative findings.18. The patient signed the consent form indicating

a clear understanding of the risks, and this acts as a disclaimer against legal action.

19. What more do I need to do for consent? I said to the patient I wanted to draw blood and the patient rolled up his sleeve – clearly consenting.

20. Although I took consent I don’t understand the procedure – but I took consent because the registrar told me to.

MPS in South Africa Our operations in South Africa are helped by our marketing and membership agents – who might be familiar faces to some of you.

Ian Middleton, MPS international marketing agentI was born in London, which was still recovering from the effects of the Second World War, to parents that both worked in the medical profession. Yet, despite my medical background, I decided not to undertake a career in the same vein as my parents. As a family we travelled widely, and it was one such family holiday to Barbados that ignited my love for a warmer climate.

Following a stint as a dealer on the London Stock Exchange,

I decided to achieve my dream of living in an exotic country, and I spent time in both Bermuda and the Cayman Islands. I finally emigrated to South Africa in 1976, after falling for the country on a visit the previous year. I joined MPS in 1993, and take great pleasure in my role. Outside work, I enjoy wildlife, the Bush, classic cars, good food and wine, and, not surprisingly, travel!

Alika Maharaj, marketing and membership agentI was born in South Africa, growing up in Kwa-Zulu Natal where I attended school. After my initial education, I worked for an events management company and continued my studies part-time by completing a Diploma in Marketing and Business Management. After this, I also undertook a B Comm. Marketing and Business Management degree. My career in Kwa-Zulu Natal was a natural progression from my qualifications, and I worked in marketing, events

management and account executive roles.I moved to Johannesburg in 2001 to take advantage of the wider

career opportunities in the vibrant city. I joined MPS in 2008, after 18 years spent in the corporate “rat race”, and now work as a marketing and membership agent. The team I work with at MPS are great, and I thoroughly enjoy my work. My favourite aspect of my role is the different experiences and opportunities it offers.

The Marketing team’s main focus is to interact with medical students during their academic years through to when they qualify as doctors. We communicate with them and keep in contact through written correspondence, events and exhibitions. We are also very keen on attending events and CMEs organised by the new doctors in the public hospitals, as this offers us and them an opportunity to maintain the MPS relationship, and ensure that they understand the importance of indemnity from the start of their new and exciting careers.

Outside MPS, my other interests involve reading, cooking, my religion and enjoying the great outdoors with my family.

We look forward to seeing you at the various medical exhibitions in the future and would welcome invites and offers to attend and/or exhibit at your medical events planned by your hospitals or doctor groups/committees.

© D

ER

EK

LAT

TA/IS

TOC

KP

HO

TO.C

OM

6

FEA

TU

RE

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

When faced with competing demands from friends, family and colleagues

to “just have a quick look”, or to give an opinion, perhaps even on another doctor’s diagnosis, it can be difficult to say no. However, treating those close to you should be discouraged, wherever possible. Sometimes, in an emergency, it might be unavoidable.

Blurring the boundaries The biggest risk in treating those close to you is that you do not treat them as well as you would another patient – despite having the best intentions. Decisions on diagnosis and treatment opinions can become clouded by emotion, by what you feel is best for the patient, or by what the patient feels is best. The HPCSA, in Guidelines for Good Practice in the Healthcare Profession, states that doctors should always have full concern “for the best interests or well-being of their patients as their primary professional duty”.1

Personal ties can complicate a professional relationship. You might have to give straight-talking advice that they do not wish to hear, for example, telling a friend that they need to lose weight if they are obese. Patient expectations may be higher if they know you personally; they may implicitly expect “special” treatment and expect your advice to be right, all of the time.

Off the record Doctors often fail to keep adequate records of requests for treatment by friends and family, as by their nature they are informal conversations, where

records are not to hand. Do not neglect your professional obligations. Medical records must be “complete, but concise” and

“a standardised format should be used (eg, notes should contain in order the history, physical findings, investigations, diagnosis, treatment and outcome)”.2

You might not be as careful to check contraindications when prescribing medicines, or you might not detail common side-effects to watch out for as accurately as for a patient in your surgery.

Dr Graham Howarth, MPS Head of Medical Services (Africa), recalls the tale of a doctor who prescribed treatment for her husband for giardia but he continued to be ill and she did not recognise this. “She then prescribed another treatment, but he became ill again when he took it with alcohol, as she had forgotten to warn him of the side effects of the medication. It was a lesson that she has not been allowed to forget!”

It can be harder to refuse treatment if you know the patient well. Big problems can occur in the area of antidepressants, mind-altering drugs and major pain relief. It can be all too easy for a patient to become addicted to strong pain relief drugs, particularly if they have easy access through your issuing of repeat prescriptions, if you find refusing such requests challenging.

Learning how to say no Early in your career, it is worth developing a technique of gently deflecting requests for a medical opinion in a social environment, by suggesting that the individual makes an appointment with their own GP, as they have a detailed patient history and can provide them with the best standard of care their condition requires.

If you are feeling pressurised into treating someone, you should refuse. An appropriate response would be, “I’m sorry, I’m not the right person to ask. It should be your treating medical practitioner.”

REFERENCES1. HPCSA, Guidelines for Good Practice in

the Healthcare Professions (5.1.1) 20082. HPCSA, Guidelines on the Keeping of

Professional Records (13.1-4) 20083. HPCSA, Guidelines for Good Practice in

the Healthcare Professions (5.1.13)

Family valuesSarah Whitehouse takes a look at the potential pitfalls of treating those close to you

The biggest risk in treating those close to you is that you do not treat them as well as you would another patient – despite having the best intentions

When is it acceptable to treat friends and family?Some exceptions where you may provide care to those close to you are:■■ In an emergency, when doctors may provide treatment to themselves and those close to them until another doctor is available. The HPCSA states that in an emergency, doctors should “provide healthcare within the limits of their practice, experience and competency. If unable to do so, refer the patient to a colleague or an institution where the required care can be provided”.3

■■ If the doctor works in a small community where there are people close to them who are patients because of access issues.

If you treat a family member, you should:■■ Carry out an assessment of the patient’s condition

■■ Keep accurate and clear patient records, including drugs prescribed

■■ Make sure the information about the consultation gets to the patient’s own medical practitioner

■■ Ensure that if a follow-up is needed, the patient knows

■■ Ensure the care is monitored by another doctor.

Remember that all patients – including you – need independent, objective medical advice. Do not prescribe to yourself, other than in emergency situations or when travelling. You are even less objective about yourself than you are about family members. Dr Howarth concludes: “Before treating a family member, stop and think. If you start making exceptions, it can be risky for all concerned.”

7FE

AT

UR

EJU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rg

Dr F is a junior doctor, a few months out of medical school. Her family is very proud of her, and are all eager to have quick

consultations with her whenever they bump into her at family gatherings.

At her mother’s birthday, Dr F’s Aunt S describes stomach pains she has been having for several months, which become worse after eating. Aunt S is convinced it must be “her ulcers acting up again” and asks Dr F to write a prescription for omeprazole, which she had taken previously.

Dr F becomes concerned that without examining her aunt, it would be unethical to simply write the script. However, she isn’t sure how to say no to a respected matriarch of the family.

Aunt S convinces Dr F that she’s had this problem of stomach pains and ulcers previously, but she just doesn’t have the time to get to her usual physician. All she needs is a repeat script.

Dr F eventually concedes and writes a script for omeprazole. Over the next six months, she repeats this script several times.

The following year, Aunt S is noticeably thinner. She complains to Dr F that the medicine is not working anymore and she’s losing weight rapidly. She asks for stronger medicine.

Dr F, alarmed by the symptom of rapid weight loss, urges Aunt S to see her usual doctor and have an endoscopy done. Aunt S, disappointed from not receiving any medicine, takes her advice and has an endoscopy, which shows a suspicious gastric ulcer. A biopsy confirmed a malignant gastric carcinoma.

Learning points■■ Consulting family and friends is playing with the proverbial fire. We often do not examine the “patient” properly, or worse, do not examine them at all. Important diagnoses, as in this case, can be easily missed.

■■ Dr F has to question whether the cancer would have been detected earlier had she refused her aunt and referred to another doctor. More importantly, would this earlier detection have made a vital difference in her aunt’s prognosis?

■■ When consulting family/friends we are often quick to assume the most benign diagnosis. Our professional judgment is easily swayed and we find ourselves assuming that there is simple pathology only because we are emotionally reluctant to entertain a more sinister diagnosis.

■■ Furthermore, the lack of note-keeping leaves us without a medicolegal foot to stand on. As in this case Dr F has no proof that she ever consulted her aunt and even if she did make good notes, she would be found only to be sadly lacking in her clinical examination of Aunt S.

■■ As tempting as it may be, dispensing advice over the dinner table puts not only your own loved ones at risk but you as well. Unless it is a dire emergency, leave the health of those you care about most in the hands of practitioners who have their clinical objectivity intact.

CASE STUDY: EAGER TO PLEASEBy Dr Lynelle Govender, Intern, R K Khan Hospital It can be all too easy for a patient

to become addicted to strong pain relief drugs, particularly if they have easy access through your issuing of repeat prescriptions

© F

ATIH

HO

CA

/ISTO

CK

PH

OTO

.CO

M

8

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

FEA

TU

RE

The provision of safe termination of pregnancy is part of the reproductive

health services offered by the state, and has resulted in a dramatic decrease in the number of deaths and complications from unsafe abortions. Junior doctors are very likely to be exposed to reproductive health services. Every intern in South Africa must complete a four-month rotation in obstetrics and gynaecology, whilst many will also be involved in women’s healthcare during community service and at a primary healthcare level.

The lawThe Patients’ Rights Charter outlines the right to access health services, the right to counselling without discrimination on matters including reproductive rights, and the right to the availability of health services and how best to use such services.

The Choice of Termination of Pregnancy Act (1996) clearly states the circumstances under which a pregnancy may be legally terminated: ■■ Up to 12 weeks – Upon request.■■ From 13 to 20 weeks – If the continued pregnancy poses a risk to the woman’s physical or mental health; if there is a substantial risk that the fetus would suffer from a severe physical or mental abnormality; if the pregnancy resulted from rape or incest; if the continued pregnancy would significantly affect the woman’s social or economic circumstances. ■■ After 20 weeks – In consultation with a second medical practitioner, if

Termination of pregnancy:patients’ rights and doctors’ values

Dr Michelle Pentecost navigates the ethics surrounding an often controversial topic for junior doctors

the continued pregnancy endangers the woman’s life; would result in a severe malformation of the fetus; or would pose a risk of injury to the fetus.

An ethical quandaryWhilst South Africa’s progressive laws are applauded for upholding women’s rights, involvement in terminations of pregnancy may be unacceptable to some junior doctors on religious or moral grounds.

The difficult balance between patient autonomy and physicians’ beliefs is a longstanding topic of ethical debate. Some argue that the primary objective of the health service is to ensure that its users receive the care to which they are entitled, as prescribed by the law, and that doctors should not compromise this duty to their patients based on their personal feelings.

However, it is also recognised that to threaten the integrity of the physician is to threaten one of the pillars of the medical profession: the notion that doctors are moral beings who unfailingly act in good conscience. It is unreasonable to expect the clinician to act according to conscience for the most part, but to ignore this when he does not agree with the delivery of a controversial service.

This dilemma places the junior doctor at the challenging intersection between the professional obligation to provide appropriate and unbiased care, and the personal values on which his sense of self relies.

What junior doctors have to say:

“A woman’s right to govern her own reproductive health is non-negotiable. And this includes her right to terminate her own pregnancy if this has the potential to harm her mental, physical or social well-being. As a doctor, I feel this is an essential (and sometimes life-saving) medical service that should be offered by all healthcare professionals, regardless of their religious or ethical objections. Are doctors allowed to ‘morally’ object to delivering babies, performing Caesarean sections or starting blood transfusions?”Dr J, Community Service doctor

“I have a personal objection to performing terminations of pregnancy based on my religious beliefs and personal morals. Termination of pregnancy is a legal procedure in South Africa and therefore I do not object to providing advice to my patient and if this is her choice, I will assist her up to the point of the termination. This issue highlights the right of a woman to choose. The right to choose should extend to doctors as well.”Dr E, Junior Medical Officer

A satisfactory solutionThe reasonable solution is to accommodate both the convictions of the doctor as well as the healthcare rights of the patient. The HPCSA’s General Ethical Guidelines for Reproductive Health concurs that doctors should not be expected to advise or perform abortions against their personal convictions. Furthermore, conscientious objection should not lead to the

9JU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rgFE

AT

UR

EThe difficult balance between patient autonomy and physicians’ beliefs is a longstanding topic of ethical debate

Dr Michelle Pentecost is a Medical Officer and Freelance Writer.

clinician’s career being prejudiced in any way. However, the doctor has an obligation to

ensure the patient still receives appropriate and timely care. In order to ensure that neither the individual patient nor the healthcare system is compromised, junior doctors who conscientiously object to involvement in terminations of pregnancy should take heed of the following:■■ Object only if involvement would violate a deeply held conviction central to your moral integrity.■■ Objection is not justified if the procedure in question is required as part of a life-saving intervention. For example, it would be difficult to justify not providing an abortion required for medical reasons where the life of the mother is threatened by the continued pregnancy. ■■ Minimise the burdens placed on the patient as a result of refusing to treat. These burdens may include: additional expenses incurred, a delay in receiving treatment, and the psychological effects that may arise from the perception that you disapprove of the patient’s own choices and convictions. ■■ Ensure that the patient’s access to the required service is not compromised, as she is entitled to this by law.■■ Provide the patient with objective and thorough information so as to assist them in making an informed decision. ■■ Remain neutral during the consultation. Whilst it is acceptable to explain that you cannot offer the service requested, it is unacceptable to impose your moral views on the patient. Similarly, it is not advisable to introduce your religious beliefs into the dialogue. A discussion of religious or moral opinions should only ever be prompted by the patient, who, in that instance, may need to talk around issues as part of the therapeutic process, which can result in making an informed decision. ■■ Mitigate the additional strain that may be placed on colleagues or the facility. Junior doctors who object to involvement in terminations of pregnancy should communicate this to their superiors at the beginning of their rotations or contracts, so that necessary adaptations in the provision of these services at the facility can be made.

The termination of a pregnancy is a difficult situation for both patient and clinician. Whilst personal convictions and religious beliefs should be respected, it is still the ultimate responsibility of the clinician to ensure that the patient receives empathic, objective and uncompromised care.

Dr G is an intern who has just started his gynaecology rotation. He is assigned to gynaecology triage on a busy Friday morning. His second patient of the day is Miss A,

an 18-year-old school pupil from the local area. She has recently discovered that she is pregnant after having unprotected sex with her boyfriend. She is terrified that her parents may find out and is very concerned about having to drop out of school if the pregnancy continues. She has come to the hospital to find out about terminating the pregnancy. She is very conflicted about it, but feels that given her situation it is the best decision to make.

After listening to Miss A’s story, Dr G asks her to wait outside the consultation room. He is a devout Catholic and does not want to be involved in the care of patients who request abortions. He also doesn’t know too much about the services offered at the hospital. He decides to let her wait until his registrar arrives. He continues to see patients as normal, and the fourth patient who presents looks like an ectopic pregnancy that will need theatre. By the time this patient is sent to the OR, it is lunchtime and he takes a break. On his return to triage after lunch, Miss A has left. The sister reports that “a young girl left in tears about an hour ago”.

Learning points:■■ When working in women’s health, acquaint yourself with the services offered in your department and state any conscientious objections at the beginning of your work there, so that you know how to refer patients and do not compromise their care.

■■ The doctor has an obligation to provide appropriate and objective information to the patient.

■■ Every effort should be made to ensure that the patient’s access to care is not compromised or delayed.

■■ Women requesting terminations represent a vulnerable group who should be treated with empathy and sensitivity.

CASE STUDY

© D

AN

IEL

LAFL

OR

/ISTO

CK

PH

OTO

.CO

M©

NE

IL B

RO

MH

ALL

/SC

IEN

CE

PH

OTO

LIB

RA

RY

10

FEA

TU

RE

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

Junior doctors sometimes realise, very late on, that after the comfort zone of internship and community service has passed they are, essentially, unemployed.

When our lives often revolve around long overtime hours and great responsibility, we may forget that we are simply employed for a certain time, at a certain rate – and this contract is not permanent. You will need to apply for a job, with all the administrative stress associated with it.

Junior doctors often have the added stress of moving around the country to get their dream contract. It is not uncommon to grow up in one city, do undergraduate training in another, move for internship, move again for community service and finally (for some) to the area where they will set up private practice or join a registrar training program. We sometimes forget that competition means you are not guaranteed to be appointed (unless you open a private practice, of course).

During your training and community service years, you usually have some form of senior support for advice. The next post you take up may not have anyone available to “come and take a quick look”. You need to stand on your own two feet. Here’s how.

Take up a professional courseThere is a variety of courses to increase your employability – and decrease any work-related anxiety. Professional courses teach internationally accepted protocols based on sound research, so may be of value for doctors deciding to work abroad, either temporarily or permanently. The most popular of these are the Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) courses. Note that the Basic Life Support (BLS) course expires after two years and is a requirement for ACLS.

These courses are often a requirement when applying for work at private hospital groups. Usually the cost is carried by the individual, but some institutions may offer limited compensation and even provide special leave.

Other courses also worth a mention are Paediatric Advanced Life Support (PALS) and Advanced Medical Life Support (AMLS). These courses include written and practical evaluations which you are very unlikely to pass without proper pre-course preparation. The pass rate is often around 84% and includes detail which you may not know, even when you deal with emergencies on a daily basis.

Be aware that protocols and our understanding of patient management changes; the most striking recent example being the paradigm shift in BLS from the time-trusted ABC (Airway, Breathing, Circulation) protocol to a CAB approach.

Consider further study If you are planning to enter into further academic studies

and specialisations, there are some postgraduate diplomas that may be worth considering.

The most common ones seem to be in anaesthesia, HIV management and child health. These will strengthen your practical work experience with updated, well-researched theoretical data and will inspire some confidence in dealing with patients. Note that some degree of practical post-internship experience (usually six months) is required to take these exams.

It is sometimes possible to take the entry examinations for

You’re hiredDr Magnus Potgieter explains what you need to do to ensure you get the job you want

some specialisations, but this varies between clinical fields. Some now require post-community service experience of varying periods of time in different departments before you can be accepted to take these exams. It’s best to enquire with the examination committee of your chosen field about the current requirements.

Should you conduct research?This is a good idea if you plan to work in an academic setting in the future. You could do some research whenever you encounter unusual presentations. If the case is truly unique, it can be written up as a case report, usually after discussion and supervision by an academic department. With hard work, good luck (and imagination), a new condition may even be named after you! [See ‘Getting into Academic Research’ for more information].

Recognise you have lots of practical experience All the years spent doing internship, community service and medical officer time are sometimes seen to be a waste of time for those eager to specialise and finish their studies. However, these years do provide invaluable experience. Patients do not read our textbooks and regularly (and annoyingly) deviate significantly from classical disease descriptions. The more patients you see, the more accurate, effective and confident you become in your diagnosis.

Keeping a record of all cases seen or operations performed can serve as accurate proof of experience, although not all employers will request this. Proof of employment, eg, “Two years’ Medical Officer experience in hospital X’s burn unit” might be sufficient to convince an employer that you have ample experience in that field.

Getting an interview – now what?When called to attend a formal interview, you need to show that you are smart, effective, hard-working and meet the job requirements. Don’t make the employer later wish you were as good as the initial misconceptions you created – be completely honest with them, on your CV and in the interview.

Remember that a superior attitude, sloppy clothing and poor grooming will not count in your favour. Semi-formal working clothes or scrubs are usually acceptable. Remember, too, that there are factors employers need to consider which might be beyond their control, eg, BEE (Black Economic Empowerment). The process must always be in line with current legislation and blatant discrimination may be challenged in the Labour Court.

Dr Magnus Potgieter is a Community Service Medical Officer, working in the Plastic Surgery Department and Burns Unit at Kimberley Hospital Complex.

Professional courses teach internationally accepted protocols based on sound research, so may be of value for doctors deciding to work abroad, either temporarily or permanently

11FE

AT

UR

EJU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rg

1. Get a good research mentor. 2. Put together case reports on unusual presentations and

pictorial interludes on common conditions to gain valuable skills, eg, doing a pub med literature search, referencing and formatting of articles and electronically submitting articles.

3. Work in groups. This is effective when specific tasks are delegated by a research group leader or mentor. Many hands make light work!

4. Take full advantage of the research courses most universities offer to postgraduate students at nominal costs. Start with basic courses, eg, How to Write an MMED Proposal or Publishing your Case Report, before moving on to advanced courses, eg, Applied Statistics.

5. When choosing a research topic for a master’s degree, choose one you have a personal interest in – this will motivate you and complement your clinical work.

6. Define your research goals and identify a reasonable timeline in order to achieve them.

7. Incorporate research into your clinical practice. 8. Attend congresses, both local and international, and present

your work either as posters or oral papers at the scientific sessions. Congresses are an

excellent opportunity to gain ideas for research projects and meet future collaborators.

■■ Make sure your CV reflects all your experience. Include a short breakdown of your clinical experience in each discipline, including how you were supervised. For example, if you worked in a rural hospital with no or limited supervision, state what input there was into your training.

■■ If you are applying for a post in a particular discipline, state the practical experience you have already gained.

■■ Choose referees who can talk to your clinical, academic and professional skills.

■■ Clearly state what additional courses you have done – all of these contribute to your CV and indeed to your eligibility for many posts.

■■ Give some indication of how you wish to take your career forward and any plans you already have in place. For example, if you are hoping to specialise in a discipline, state when you are planning to do the Part I examination.

■■ If you can gain extra skills within your discipline, try and do so, eg, ultrasound training if you are working in obstetrics.

■■ At job interviews, you may be asked about your research interest. Any audit opportunities need to be included in your CV, or mentioned at interview.

■■ If you have the opportunity to attend a good clinical practice (GCP) course, do take it. The training remains valid for several years and will aid you in your research development. With the new requirements for specialist registration, everyone who elects to specialise will have to complete a research project.

■■ Remember there are many discipline-specific courses, eg, the Basic Surgical Skills course (relevant to all surgical disciplines), and Research Methods courses which you need to complete if you become a registrar. If you can do this ahead of your registrar application, it may be very worthwhile.

■■ Indicate why you wish to be involved in a particular discipline and what you find interesting. This does not have to be a multi-page essay, but a paragraph to indicate your interests often improves your job application.

■■ Be sure that your CV is neatly designed and that your letter of application is typed, unless otherwise requested. If you do have to handwrite a letter, use good quality stationery and do not write on a page out of an examination pad.

■■ Impressions do count. How you present your CV and letter of application and how you present yourself at the interview will have an influence on the selection process.

GETTING INTO ACADEMIC RESEARCHBy Dr Nasreen Mahomed, Consultant Radiologist at Chris Hani Baragwanath Academic Hospital

TOP TIPS FOR JOB APPLICATION SUCCESSBy Professor Zephne van der Spuy, Head of Postgraduate Education and Research, Department of Obstetrics and Gynaecology at the University of Cape Town

Keeping a record of all cases seen or operations performed can serve as accurate proof of experience, although not all employers will request this

© DAVID LEAHY, CULTURA /SCIENCE PHOTO LIBRARY

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

Gone are the days when radiologists were confined to dark reporting

rooms and lightboxes, with the misconception that radiologists do not interact with patients. The modern radiologist has emerged, with an array of digital equipment, to play an active and dynamic role in patient care.

Recent studies have highlighted that patients do not actually know what a radiologist does, and how a radiologist fits into the medical discipline. A radiologist is a medical doctor who interprets and analyses digital images of patients, takes into account the clinical history and examination given by the referring clinician, and proposes a diagnosis. The images are obtained through a variety of specialised medical imaging equipment or modalities.

A radiographer works with the medical imaging equipment and acquires and processes the images for interpretation by a radiologist. Thus, radiologists, radiographers and clinicians work as a team, together with other allied healthcare professionals.

Radiologists may be primarily involved with diagnosis and follow-up; however, interventional radiologists may perform therapeutic procedures,

particularly in patients who may not be suitable candidates for surgery or anaesthesia.

Radiology, as a field of medicine, can be regarded as a “melting pot” of pathology. Patients present with a myriad of symptoms and signs and after having a clinical evaluation often require additional biochemical tests and radiological investigations to confirm a diagnosis, or to assist in complex problem solving.

The medical imaging investigations include ultrasound, general radiography, mammography, contrast studies (such as barium, intravenous contrast agents used in fluoroscopic studies and angiography), computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound and MRI do not have associated radiation hazard; however, the other modalities do and this should always be considered when requesting radiological investigations, particularly in children.

Training as a radiologistIf you are interested in training as a radiologist you should have an interest in physics, anatomy and physiology.

Specialists in training (registrars) will eventually be expected to write the national College of Radiology Examination and may acquire the Master in Medicine (MMED) in Diagnostic Radiology as an additional qualification. The training consists of a minimum period of four years with rotations in all aspects of general and

subspecialty radiology. The examination has a Part One component with evaluation of medical imaging physics, imaging anatomy and radiographic techniques; and a Part Two component with evaluation of all aspects of general radiology, with a focused research component. Specialists in training are constantly supervised and mentored by consultant radiologists.

Working as a radiologistMost of the time, working as a radiologist is like putting together the pieces of a puzzle, assimilating all available clues and solving a problem.

12

FEA

TU

RE

How to work in…radiology

Seeing is believing. Radiology is a field rich in imagery, visual perception and the quest for creating the perfect digital image, says Professor Zarina Lockhat

If you are interested in training as a radiologist you should have an interest in physics, anatomy and physiology

13JU

NIO

R D

OC

TOR

| VO

LUM

E 3 | IS

SU

E 2 | 2012 | S

OU

TH A

FRIC

A w

ww

.mp

s-gro

up.o

rgFE

AT

UR

E

Professor Zarina Lockhat is Professor and Head of the Department of Radiology at the University of Pretoria and Steve Biko Academic Hospital.

Elective patients are usually pre-booked for radiological investigations and radiologists perform the relevant radiological procedures applicable to the patient’s clinical presentation and referring clinician’s request. Analysing and reporting plain radiographs, ultrasound, CT scans and MRIs are generally part of a day’s routine. Urgent patients are accommodated during the course of the day. Reports are communicated to the referring clinician for further management.

In an academic environment, sufficient time has to be allocated for teaching and inter-departmental academic meetings. Although service delivery usually takes priority, radiological research is vigorously encouraged at most academic institutions.

Working hoursRadiologists are virtually attached to their reporting areas and computer workstations. Working hours may vary in different institutions. In the public sector, apart from normal working hours, radiologists have to be on call for emergency radiological investigations. In the public sector the calls can be quite busy with emphasis on ultrasound and CT examinations, particularly for trauma.

In the private sector some radiologists may have access to teleradiology and can report from home, or from mobile devices.

RemunerationBoth nationally and internationally, radiologists are highly sought after. Public and private sector remuneration is relatively lucrative; however,

this must be viewed against a background of investing in highly-specialised and expensive medical imaging equipment.

The future of radiologyAdvances in radiology and diagnostic imaging are directly proportional to technological advancement, which is progressing at a phenomenal rate. The Picture Archiving and Communication System (PACS) allows for digital imaging archiving. The newer fields of cloud storage systems can archive patient electronic health records, including patient demographics, biochemical and pathological results, clinical notes and radiological imaging results, to allow clinicians and relevant medical personnel access to patients’ data, in the hospital and remote settings.

Constant image refinement by medical imaging vendors, exquisite imaging detail and advanced computer post-processing allows intricate and detailed viewing and interpretation of anatomy and pathology of the human body. This undoubtedly makes imaging a superlative adjunctive diagnostic tool in overall patient care and management.

The clinical examination is the cornerstone of all diagnostic and therapeutic decisions, and it is important to listen to and treat a patient according to the clinical findings. Therefore, despite innovative technology, mobile devices and fantastic mobile apps, as in life, in a medical environment and in radiology the words of my mentors always come to mind: “You only see what you look for, and you only recognise what you know.”

With the progressive technological advances in medical imaging and detailed anatomical imaging, subspecialty imaging in radiology has spiralled and accreditation is currently under review.

The major subspecialty areas include systemic divisions such as: ■■ Neuro-imaging■■ Head and neck■■ Chest ■■ Cardiac■■ Musculoskeletal■■ Gastrointestinal ■■ Genitourinary ■■ Paediatric imaging.

And also modality specific imaging such as: ■■ Mammography■■ Angiography and intervention ■■ Ultrasound ■■ CT and MRI.

Increasingly, hybrid imaging is also being researched, with huge strides in Positron Emission Tomography (PET)/Computed Tomography (CT) and PET/MRI.

Working hours may vary in different institutions. In the public sector, apart from normal working hours, radiologists have to be on call for emergency radiological investigations

THE SUBSPECIALTIES

© P

HO

TOD

ISC

© H

AYD

EN

BIR

D/IS

TOC

KP

HO

TO.C

OM

© M

AU

RO

FE

RM

AR

IELL

O/S

CIE

NC

E P

HO

TO L

IBR

AR

Y

14

JUN

IOR

DO

CTO

R | V

OLU

ME

3 | ISS

UE

2 | 2012 | SO

UTH

AFR

ICA

ww

w.m

ps-g

roup

.org

DILE

MM

A

Forty-five-year-old bus driver Mr B attended casualty following an

episode of central chest pain that resolved spontaneously while he was at work. The pain was severe and radiating to his left arm and it lasted about 15 minutes. Mr B had no previous cardiac history, but had several risk factors: he was a heavy smoker and somewhat overweight. By the time he arrived in casualty, brought in by a colleague from work, the pain had subsided.

Junior doctor Dr O was working a day shift at the department. He took a comprehensive history and performed a thorough examination, which was normal. Dr O looked carefully at the ECG carried out on arrival and documented that the ECG appeared within normal limits. Dr O arranged for Mr B to have his troponin levels first tested one and a half hours later. He explained to Mr B the importance of the blood tests and suggested admission to the casualty observation ward, for repeated blood tests and ECGs, but Mr B declined. Dr O documented this.

Dr O’s shift finished before the troponin test results were ready, so he handed over the case to another junior doctor, Dr W, and asked her to make sure the patient didn’t leave before the test was proved to be normal. However, Dr O did not document his plan of action or the name of the doctor he had handed over to.

Two hours later, Dr W discharged Mr B, and noted “Non-specific chest pain. Home”. She didn’t sign her

notes. Unfortunately, the troponin levels were raised but Dr W failed to check the test results. Mr B suffered a further episode of severe central chest pain 24 hours later followed closely by a fatal cardiac arrest. The postmortem confirmed the presence of an acute myocardial infarction.

A claim was made alleging substandard care by both

Dr O and Dr W. During the course of the investigation, Dr O insisted that he had handed over to Dr W and specifically suggested that the troponin tests had to be checked, but Dr W denied any knowledge of the patient or the handover. The documentation was very limited, but some nursing notes supported Dr O’s account of the events.

At the subsequent inquest, both doctors were called to give evidence. Dr O’s version of events was accepted on the basis of the nursing notes and some of his documentation; his management was considered to be acceptable. However, Dr W’s was considered inappropriate. The hospital settled the claim for a substantial amount.

Don’t drop the baton

This dilemma is a reminder of the need to take detailed medical records to ensure there is continuity of care and is based on a case dealt with by MPS that first appeared in Casebook, Vol. 17 No. 3 – September 2009

LEARNING POINTS

■■ Working shift patterns means that careful handovers are vital for patient safety. When referring a patient or making a handover, it is always useful to document the time, the name and the specialty of the recipient doctor.

■■ Documenting a clear plan of action, with specific instructions, makes handing over safer. It is important to emphasise the need for good communication within teams, particularly with the increasing use of flexible working patterns.

■■ Leaving written records of what has been said to the patient and relatives is also good practice.

■■ The discharging doctor is ultimately responsible for the actual discharge of a patient and its consequences. It is important that care is taken to ensure

that discharge of a patient is managed appropriately and that the patient is aware of the risks and when to seek further advice. If in doubt, deal with the patient as if no other doctor has seen him/her before.

■■ Readable and clear notes will lower the multiple dangers of handing over and will save time and effort to the receiving doctor, particularly in an environment such as casualty, where time is precious. Avoid using unusual abbreviations.

■■ Employer indemnity is generally limited to claims but does not usually extend to representation for a doctor for the consequences of an adverse outcome at an inquest. Dr O was represented by MPS and avoided criticism. Dr W was not a member of a defence organisation and was not independently represented.

MPS publishes medicolegal reports as an educational aid to members and to act as a risk management tool.The reports are based on issues arising in MPS cases from around the world. Facts have been altered to preserve confidentiality.

© T

OM

MA

RV

IN/IS

TOC

KP

HO

TO.C

OM

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

Helping members in South Africa for more than 50 years

MPS is not an insurance company. All the benefi ts of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London, W1G 0PS. MPS1248:10/12

Leading provider of professional medical indemnity in South AfricaMPS offer peace of mind to more than 26,000 health professionals in South Africa

Just one of the many benefi ts of being a member of the world’s leading medical defence organisation

To fi nd out more call 0800 11 8771 or visit www.medicalprotection.org/southafrica

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

Helping members in South Africa for more than 50 years

Clear advice on medicolegal and ethical issuesIn the internet age, it can be diffi cult to fi nd the right information quickly. Our expert advisers offer personal, focused advice on all your medicolegal and ethical queries.

MPS1248_SA_SAMAInsider_Ads_A4_2012.indd 4 09/10/2012 11:22

SOUTH AFRICA MEDICOLEGAL ADVICE

www.mps-group.org/za-mla

To help us to provide you with assistance as quickly as possible please use the medicolegal contact form on our website.

The form is secure and confidential – allowing you to give us your MPS membership details and provide a brief explanation of an incident. The information you provide comes directly to MPS and the receipt of the form will be acknowledged by email immediately.

On the next working day we will open a new case for you and we will contact you as soon as possible to discuss the matter.

T 0800 982 766 (toll-free within SA)E medical.rsa@mps-group.org

In the interests of confidentiality please do not include information in any email that would allow a patient to be identified.

SOUTH AFRICA MEMBERSHIP ENQUIRIES

Ian Middleton T 0800 118 771 (toll-free within SA)E mps@global.co.za

Alika Maharaj T 083 277 9208 (cell phone)E mps@iburst.co.za

South African Medical Association T 0800 225 677 (toll-free within SA)

www.mps-group.org

VO

LUM

E 3 | IS

SU

E 2 | O

CTO

BE

R 2012

VO

LUM

E 3 | IS

SU

E 2 | O

CTO

BE

R 2012

The Medical Protection Society is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world.

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.

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

How to contact us

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

ISSN 2042-2369

SO

UT

H A

FRIC

A

SO

UT

H A

FRIC

A