SELF-CARE

Chapter 17
SELF-CARE


How are doctors supposed to take care of patients if they don’t take care of themselves? If you overwork yourself consistently sooner or later you will experience burnout. Most of us are not taught much about self-care in medical school. Look after yourself and become a better doctor in the process.


Accommodation


Sadly, the days of doctors being provided with free on-site accommodation are at an end. This used to be available because doctors were resident on-site for long periods of time. However, many hospitals still offer accommodation at favourable rates. Living in hospital accommodation is a good way to meet people that you could rent with at a later date. It is also likely to be within walking distance to the hospital. This may not sound important now but after a week of long shifts the 45 minute commute into work may seem far less tolerable. If a hospital offers accommodation, it must comply with national regulations governing minimum acceptable standards which are non-negotiable:



  • Your room should contain a 3-by-6 foot bed, telephone, cupboards, drawers, desk, chair, washbasin, be carpeted and have curtains. It should be heated and regularly cleaned.
  • There should be a nearby bathroom and toilet, cooking facilities, a common room and on-site laundry facilities. Common areas should be regularly cleaned.

If you have a specific problem with your quarters, contact the designated ‘accommodation officer’ or equivalent through switchboard. There are often websites advertising rooms for rent or check the noticeboard as there are often adverts for rooms to rent.


When you are at registrar level then depending on your speciality you may be contractually allowed to rest/sleep during on calls. However, as a junior doctor this is unlikely to be the case and most trusts stance is that you should not be sleeping at night. So if you decide to rest in an empty on-call room, be aware that this may be against the trust policy. It is not uncommon for a junior to have gotten into hot water when found by the matron or security asleep! Similarly, be extremely careful about leaving the hospital grounds whilst on call unless specific cover has been agreed. Remember that patient care is your first priority so do not put yourself in a situation where you cannot deal with an emergency should it arise.


Alternative careers


What if you have come all this way and decide that you don’t want to be a doctor? Or you like it, but not enough to dedicate your life to it? Little known to many medics, having a medical degree opens many great doors. Chekhov, JPR Williams, Graham Chapman, Harry Hill, Che Guevara and Keats were all once doctors – to name a few:



  • Medical training gives you multiple skills that you probably never even noticed. These include leadership, managerial, communicating, teamworking and observational skills; analytic, mechanical, adversarial skills; and the ability to work within a hierarchy and still get what you want. Sheer endurance and persistence (much prized in the workforce), great people skills and many other talents can be developed through medicine. Never think that these are wasted in a ‘non-medical’ career. Having medical training will enable you to bring something special to whatever you do.
  • However, in general, we would advise completing your Foundation Programme before saying goodbye to medicine. Many people find that they enjoy working more than being a student and having full registration is useful if you ever wish to work in the future.
  • Do not underestimate the breadth of careers available in medicine. Medicine is probably one of the few careers that gives you flexibility to work anywhere in the world, as the skills you have are translational. You can do helicopter mountain rescue in France, research anticancer drugs for pharmaceutical companies in Australia, enjoy office-based occupational health in Dubai, be a sports physician for Olympic athletes or work at the cutting edge of forensic pathology in New York. A good book for inspiration is the Medic’s Guide to Work and Electives Around the World by Mark Wilson.

Bleep



  • Pick up your bleep from switchboard. They will replace the batteries and exchange it for a new one if it breaks.
  • Leave your bleep on the ward and switch it off if you are not on call, as switchboard may call you even when you are off-duty. If you live nearby or on hospital accommodation, this is especially important, as otherwise you may get a rude awakening in the middle of the night by your bleep going off!

British Medical Association


Becoming a member of the British Medical Association (BMA) not only brings you the BMJ with adverts for professional courses but also provides advice and support in all areas of your work, leave, contracts, tax and financial planning. It is also a negotiating body on behalf of all doctors and is definitely worth the subscription costs. The BMJ is an excellent journal in its own right, it is one of the easiest to browse with its almost magazine-like approach, but it also has summaries of up-to-date research that the BMJ has published that week. Specific benefits of membership include:



  1. Personal advice on contracts and terms of service, which DO reap benefits and occasional upbanding, particularly if you are proactive about investigating your contractual terms.
  2. Assistance and representation in disagreements with hospital management. This is becoming more important as trusts and management try to change contracts and reduce pay. For example, the BMA has threatened court action against trust management that has tried to cut pay, now protected under the New Deal terms. The BMA can assist with claims for overtime and additional hours. Simply the knowledge that you are a member of a strong representative organization can often support your case in disagreements.
  3. Independent financial advice by salaried representatives on pensions, income protection, etc.
  4. Insurance services. The personal contents policy is particularly useful.
  5. The fee is tax deductible.

Car insurance


You may buy your first car during your first year. Whilst you may need to purchase it in July just prior to moving to your new job, cars are most expensive around July–August. Most people know where they will be working from January to February, so if you have the funds and the time, consider buying a car around January/February, when you are much more likely to pick up a bargain.


Car insurance varies a lot. The BMA offers insurance for doctors, but it may be more expensive than you need, particularly if you have bought an old car. Probably the best thing to do is to ring local brokers who deal with many different insurance firms and who can get you the best deal for the cover you need. Alternatively, a thorough internet search is a good way forwards. Many firms give a discount for female drivers. Be aware that you can purchase third-party insurance, fire and theft, if your car is not valuable although this may not build your ‘no-claims’ discount, an important factor in reducing the eventual costs of insurance.


Clothes (laundry/stains)



  • Smart clothes are often touted as helping maintain professional demeanour; this is particularly so since white coats and suits are no longer in line with current infection control guidelines. If your trust has a policy on their professional dress code, be careful not to fall foul of it; these things are rarely worth getting into hot water about. Generally, don’t show too much skin, have comfortable shoes, and don’t wear too much flashy jewellery.

Contacting medical colleagues


After graduation, all doctors are entered into the UK Medical Directory. This is a reasonably reliable way of tracking down friends from medical school and beyond. The Directory is available in hospital libraries and also from the General Medical Council (GMC) nearest you. You can search the register at the GMC website, www.gmc-uk.org. There are now Internet services dedicated to doctors which can supply doctors with contact details of colleagues who have also subscribed. Alternatively, there are lots of professional websites such as Linked In that are popular with doctors to keep in contact. Beware of breaking patient confidentiality on these websites – keep things strictly about yourself and your career.


Contract and conditions of service


Doctors’ working conditions are negotiated by the Junior Doctors’ Committee. More recently, the Junior Doctors’ agreement has altered the rates at which overtime is paid and stipulated the maximum hours for which you can be contracted to work. All hospitals, including trusts, have to abide by these nationally agreed guidelines.


What you need to know about your contract


Your contract is a binding agreement, regulating your hours and conditions of service, pay, holiday and notice. It cannot be altered unilaterally by either you or your employer. In particular, pay protection means that your pay cannot be cut from the time of accepting the job, even if the banding of the job changes. Having a contract is essential to ensure you are on the right pay grade.


Rotas


Virtually all junior doctors now work a full-shift rota with additional duty periods every few days (e.g. 1 in 5), meaning that they work a 40 hour working week and are also on duty every fifth night and/or every fifth weekend. Contracts stipulate the maximum number of hours you work, the amount and type of rest breaks you are entitled to during your working day and the amount of time you must have off, depending on your pay banding.



  • It is important not to get confused by colloquial use of the term ‘on call’ for full-shift duty periods. This is erroneous as it implies you are entitled to sleep during the duty periods.
  • Prospective cover means that when colleagues are away on holiday, the remaining junior doctors cover the duty periods the missing colleague would have done. This works out equitably if everyone takes the same amount of holiday. Virtually all contracts stipulate that you cover your colleagues if they are sick. This provision does not give authorities the power to force you to cover foreseen and notified absences such as annual leave. Similarly, you cannot be forced into doing extra night shifts to cover those that call in sick. It is not a problem if the trust offers you locum rates or pays you at the usual rate, but ensure that you do get the money back. Alternatively, if you cannot work the extra hours, the trust is required to get a locum to cover. Do not cave to pressure from rota coordinators or bullying if you are unable to work. See Table 17.1 for information of the New Deal for Doctors regarding shift patterns.

Table 17.1 New Deal hours.
























Rotation pattern Maximum period of continuous work (hours) Minimum period off duty between work periods (hours) Minimum continuous period of duty
Full shift 14 8 48 hours + 62 hours in 28 days
Partial shift 16 8 48 hours + 62 hours in 28 days
On-call rota 32 (56 hours at weekend) 12 48 hours + 62 hours in 21 days

Working time monitoring


This is a mandatory obligation of your contract. At least twice a year, your medical personnel department will run a diary card monitoring exercise over a period of 2 weeks, where the junior doctors on the same rota will be required to document what they do in hourly time slots. You need to write down on the diary card the time that you started work and the time that you left. You will be asked to write down the number of breaks you had and the duration. This is to ascertain whether the post meets European Working Time Directive requirements and also to determine the amount of pay you get. That alone should be an incentive to take part! The diary card monitoring exercise can be online or a paper exercise. The European Working Time Directive has stipulated a maximum of 56 working hours per week that was cut down to 48 in 2008 (see Table 17.2):



  • Monitoring exercises should not be viewed as ‘checking up’ on you. They are your chance to demonstrate the commitments of your job and get the remuneration you deserve. Never allow yourself to be pressurized into lying on them; you must stand up for what you deserve. It is a good way to get the trust to realize the real hours you work, especially if you are regularly staying late on the ward.
  • There is no need to document exactly what you are doing in each time slot period, just simply whether you are working, resting, eating or studying. Answering a bleep is considered work or simple administrative task. Anything requiring you to be in the hospital should be considered work and must be documented accordingly.
  • It is not your individual working time in a particular week that needs to be in line with the European Working Time Directive. It is the average weekly working time for all the junior doctors on the same rota and in order for changes to be made, at least 75% of junior doctors need to complete the exercise for it to be valid. It is therefore worth completing even if you are working ‘normal’ hours to help initiate change for your colleagues.
  • Monitoring exercises need not be initiated by the medical personnel department. This is significant if there is a dispute over working time arrangements or the running of the exercise. All you need to do is print diary sheets and distribute one to every doctor on the same rota and get them to fill it in. You can request monitoring at any time. It is best to do it when there are enough juniors on the ward to make the exercise valid.

Table 17.2 European Working Time Directive.

















Maximum working time per week of 56 hours


  • Working time is defined as any period during which doctors are working, at their employers’ disposal and carrying out their activity or duties, and any period during which they are receiving relevant training. This includes time when resident in hospital on call (even if asleep)
The rest requirements which came into effect in August 2004 are as follows:


  • A minimum daily consecutive period of 11 hours


  • A minimum rest break of 20 minutes when the working day exceeds 6 hours


  • A minimum rest period of 24 hours in each 7-day period (this can be averaged to be a 48 hour rest period in 14 days)


  • For occasions when working time is in excess, compensatory rest must be taken immediately following the period of work which it is supposed to counteract (i.e. before commencing the next period of work)
A minimum of 4 weeks’ paid annual leave

Pay


National Health Service (NHS) doctors’ rates of pay are agreed nationally by the Doctors and Dentists’ Review Body, which negotiates the annual pay increase each April. Your pay is calculated on the basis of a banding system. The banding system takes into consideration the type of rota worked, the duration and intensity of out-of-hours work. Your band dictates the supplement received for out-of-hours work as a multiple of your basic salary. Junior doctors in general practice who have an out-of-hours commitment receive an additional 22.5% over and above basic salary regardless of the duration or frequency of that commitment. The BMA website (bma.org.uk) features a band calculator, allowing you to check that your employer is complying with national requirements (see Table 17.3). Alternatively, if you have concerns over your rota and feel the banding does not comply with your rota, you can send the BMA a copy of your rota and ask them to check to see if it is compliant with the EWTD and corresponds to your banding:



  • Your band is specified in your contract. The band allocation is based on the previous working time monitoring exercise, which should be done twice yearly.
  • Whilst the odd hour here or there probably does not warrant special overtime claims, if you are systematically working extra hours (e.g. by starting at 8 a.m. instead of 9 and finishing at 7 p.m. instead of 5), then do not feel ashamed to ask for pay for honest work that you have done. This is best achieved through a working time monitoring exercise rather than an individual claim.
  • Your salary is protected such that even if your banding changes during the time you are working, your monthly salary cannot drop below the banding when you signed your contract. The only exception is Band 3, which is only protected up to Band 2A should the job be down-banded by a monitoring exercise.

Table 17.3 Banding.




































Banding Pay multiple Description
‘Unbanded’ 0 <48 hours per week, sociable hours
1A 1.5 <48 hours per week, high proportion of antisocial hours
1B 1.4 <48 hours per week, low proportion of antisocial hours
1C 1.2 <48 hours per week, non-resident on calls
2A 1.8 48–56 hours per week, high proportion of antisocial hours
2B 1.5 48–56 hours per week, low proportion of antisocial hours
3 2.0 >56 hours per week, insufficient rest (few of these jobs now remain)

Note: Pay protection does not protect Band 3 pay, but it only protects up to Band 2A.


Holiday


Junior doctors are entitled to 9 days of annual leave per 4-month rotation, excluding bank holidays:



  • Do not carry leave forwards, unless exceptional circumstances arise. You are likely to lose the annual leave days and won’t be paid for the extra days you have worked! If you do have extenuating circumstances, contact personnel both at your current hospital and your future place of work to try to ensure you are granted the extra leave.
  • Leave can be supplemented by ‘in lieu’ days. Over the year you are likely to work several bank holidays and statutory hospital holidays. You can take a day off ‘in lieu’ of each holiday worked.
  • Find out the procedure for booking leave early. It may involve simply informing your consultant and his or her secretary, or there may be specific forms to be filled in and signed by your consultant (more likely). Liaise with the rota coordinator early to ensure you get the time off and swaps you want.

Notice


Junior doctors only need to give 2 weeks’ notice of their intention to leave their post. However, to be eligible for full GMC registration you need to have completed 12 months as an FY1 doctor. Although rare, it is not unheard of for trainees to be given notice if the employing hospital is cutting back staff. In this unfortunate circumstance, you will need to discuss the situation with your educational supervisor, the deanery and your representative union, for example, the BMA.


Leave


Compassionate leave

In the event of family or personal bereavement, up to 72 hours paid leave will usually be given. Tell your consultant as soon as possible and the rota coordinator. If there is any difficulty, talk to your clinical tutor and personnel and if necessary escalate the situation to your educational supervisor or the medical director.


Maternity (and paternity) leave

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Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on SELF-CARE
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