Seph : Special Circumstances and FPAS

[Several years on from this post and I have successfully applied for Special Circumstances to stay where I trained. For more up to date information please see www.foundationprogramme.nhs.uk]

Some more on the Foundation Programme! Don't ever say that we're not thorough... Here is another guest post by Seph which looks a little more closely at applying for special circumstances within the application process (specifically, reasons you need to stay in your 'home' - read medical school - deanery to work). Thanks Seph =)

In order to tie in with Flo's series on FPAS, I want to write a little bit about special circumstances. This is a process by which you can try to demonstrate that you have a particular need to have a job in a particular foundation school (and deanery). If you are successful, you are allocated to that school ahead of the general allocation process.

I should mention at this point that I did not get special circumstances, because I didn't apply in time, because I assumed I didn't qualify. I was then advised to apply on the basis that I would be more mentally stable if I didn't have to move across the country. Which I would have been. So: make no assumptions! If you think you might benefit from it and you can think of some justification, apply. At the least, email your med school's pastoral support person (particularly if they know you) and ask them what they think.

So, to qualify for special circumstances you need to a) have children, b) be a carer, c) have a medical condition (physical or psychological) or disability for which local follow up is an absolute requirement. There are also educational special circumstances which we will discuss in a minute.

Obviously point c is the more relevant here, and the one under which I tried to apply. Note that their idea of an absolute requirement varies – it may be that your area has a better speciality service than others, it may be that you are used to a psychiatrist or a therapist and would not benefit from being transferred, it may be that you have a surgeon who is taking an interest in your care. It doesn't matter what the reason is as long as you can justify it and get either an OH doctor, a specialist or (at a pinch) your GP to back you up. They have to write a report explaining about your condition, your ongoing treatment and follow up and – importantly – why said treatment has to be local. If you are going to apply, therefore, you need to discuss this with your chosen doctor well in advance and get them to write the letter well in advance so you've got it to hand in. Get your ducks in a row, as soon as you can. If you can get more than one letter backing you up, so much the better, and do it now. It is also worth noting that you can only do this is if you're applying to remain in your current deanery. You can't claim that you need local follow up somewhere else in the country.

Educational special circumstances is a slightly different deal. If you have special educational needs, your medical school will discuss with you what would be the best environment in which to carry out your foundation training. I should point out that the wording of this part suggests that this also includes an assessment as to whether you can “adapt to the working environment”. Make of that what you will. Anyway, your medical school can then put you forward for pre allocation to a particular foundation school.

Applying for special circumstances requires just a short form and the backup stuff. The form and the relevant guidance can be found on the Foundation Programme website at http://www.foundationprogramme.nhs.uk/pages/home/keydocs. The guidance document is pretty good, written in reasonably plain language and fairly straightforward. As these things go.

Special circs is not a certainty. Your application will be reviewed by a local and a national panel and your score still needs to meet the “national allocation criteria”, whatever that is. It won't guarantee you a job, either. You also can't link applications if you apply this way. However, it doesn't hurt (unless you're planning to link) and you might be eligible even if you don't strictly meet the above criteria. As I said above, if you can think of something that would medically justify your need to remain in your own deanery, give it a go.

Good luck!

Do you have experience of applying for special circumstances for the foundation programme? Would you like to write a guest post about any aspect of disability/chronic illness and medicine? Leave a comment or email disabledmedic[funny at thing]hotmail[dot]co[dot]uk

A and E : Compare and Contrast

This is a slightly different style of post. I know that for friends it will be a reminder of a difficult time, and that medics may find themselves acutely aware of the other side of these events. This is my perspective on two A and E visits, one a few years ago and the other a few days ago. This post may be triggering or difficult - please feel free to skip it, or come back later.

I walk into A & E. The waiting room is dark and intimidating. There are several loud, drunk men and I am frightened. Sophie goes to talk to the receptionist because I am too far away to find the words. She barks at her to speak up, and I am dimly aware of the room falling silent when Sophie says that I'm suicidal and not safe at home. Sophie asks if there is somewhere quiet where I can wait, and she is told that I can stay in the waiting room "like everyone else". We sit, and wait for over an hour.

This time I am going alone to a department that I've never been to before. I've been putting it off, because of all the times before, but the pain is too much. The receptionist asks lots of questions, and won't bring me a chair while we talk even though I ask her, I can't lift one myself. Again, my name, address, DOB and telephone number have to be shouted through a screen in a room full of strangers. I sit and wait for 15 minutes.

The triage nurse calls me through and tells Sophie she must wait outside. I freeze. I can't talk, I need my friend to be my voice. Sophie insists, and is eventually allowed in. I'm pretty sure the nurse assumes we've both been drinking. We haven't.

The triage nurse calls me in and smiles at me. When I tell her my diagnosis she writes it down and asks me to explain it to her. She tells me what will happen next. I am called up twice more - for ECG and chest Xray. Getting up and down is painful as is undressing. Both technicians are lovely, and help me to change into the best designed hospital gown I've seen. I return to the waiting room and wait another hour.

The triage nurse is aggressive, and brisk. I am under the "care" of crisis team, I should have called them. Sophie explains that after 2 hours of trying to get through, their advice was to do some washing up. Still, it is not her problem to deal with - "we're not going to admit you, we're not going to give you anything, you could wait to see the medic on call, but they're busy treating people who are actually sick". Apparently if I was really suicidal I wouldn't be seeking help. I can't find the words to tell her that depression this deep feels like and end-stage illness. Death hangs over my head, and I have no control. I'm frightened.

The doctor calls me in and takes a brief history. He knows about my condition, and agrees with my interpretation of the symptoms. He listens to my lungs, and tells me the rib is dislocating with every breath.

Before I know it, the nurse has pulled me to my feet, propelled me back to the waiting room and told me that "if I choose to stay" I'm in for a long night. I want to leave, and when Sophie doesn't try to stop me, I know it must have been as bad as it seemed. I feel small and helpless, and incredibly guilty for "wasting time" and upsetting Sophie. She stays at mine. My friends don't leave me alone for the next 2 weeks as service after service failed me. I am lucky to have friends like these - 20 year olds doing what the grown-ups can't seem to manage.

I get shown my Xray, and talked through the findings. They check my pain meds and I am given lidocaine patches, and told to come back if they don't work.

I have been on both sides of A and E. I know that people get frustrated, and I know it is difficult to feel helpless because you can't "fix" people. I also know that people feel frustrated by the thought of wasting time spent helping "sick people" on people who have "done something to themselves". If only life was that simple.

The difference was in the small things - being smiled at, being believed, receiving treatment. Not being told that as a medical student I should know better than to break a rib...

And if you think that feeling suicidal doesn't count as an accident or emergency, you might want the NHS online symptom checker to change their advice. Because according to them I should have phoned 999. Think how well that would have gone down.

Please also look at my friend Ali's blog here at her posts about A and E, especially this one called 'Getting it Right'

You are welcome to leave your comments, no matter your opinion. I would ask that you bear in mind both that this post leaves me feeling pretty vulnerable, and that I have other readers who have also had similar experiences.

I'm sorry that yesterday's post hasn't materialised. I'm tired, in a lot of pain, and trying not to think about the logistics of getting home.

Round Up

Today's post will cover a few bits and pieces - including Daisy's promised introduction to the NHS couch to 5k programme (she's going to keep us updated on her progress over the coming few weeks). There are also some news stories about disability or the NHS that I would like to highlight.

Hi, I'm Daisy and I'm Flo's fiancee. 4 weeks ago I started couch to 5k using the NHS choices podcast. I would thoroughly recommend couch to 5k to people who are interested in taking up running and don't know where to start. I can't believe I've been running for 4 weeks and I'm excited to tell you a little bit about why I decided to start running and to maybe review some running podcasts/apps for beginners. In my next post I'll explain how the c25k program works and why I started. I look forward to sharing this with you!

We've been asked to spread around this open letter to Iain Duncan Smith from the Broken of Britain, about how it feels to hear a life changing diagnosis, what it feels like to be ill, what it feels like to be a carer or to worry about a family member or friend and their health. It felt especially relevant yesterday, as we were getting our head around the fact that yet another thing has happened to make us feel vulnerable. Please consider sharing that link on your networks, to encourage people to remember that any of us could become ill at any time.

Today (I think) the Commons will release a negative report on ATOS "healthcare"(Guardian story here), the (IT) company who have been contracted to conduct "assessments" for DLA and ESA. There are some awful stories of bad practice out there, assessors are expected to deny people, and the huge number of individuals who are then granted at appeal shows how ridiculous the system is. Reports are almost always completely inaccurate, but it is hard to refute, as any form of recording is not allowed (without huge effort and expense as they require a trained engineer to examine the equipment beforehand). ATOS and the ridiculous system of computer assessment are the reason I have still not claimed for DLA (once I was aware of it), although I have been eligible at various rates for over 10 years now. And now everything's changing, to make these benefits harder to claim. I'm really scared about what will happen to some of my friends and patients, and to me - especially if the appropriate adaptations cannot be made to enable me to work.

Next, Bendy Girl has posted a great video showing what happened at the first 100 Voices conference (you should watch her keynote speech also, it was very well pitched)- a real first - the Brandon Trust (a Bristol based charity supporting those in SW England with learning disabilities) asked their clients with learning disabilities what they wanted their priority to be for the upcoming year. The video is a really inspiring example of facilitating people to make their own choices, rather than patronising them. It's made me think really hard about how I would try and facilitate an individual who was learning disabled to make decisions about their own care. Employment was the issue voted as most important (the variety of voting methods offered was really cool) and the Trust has committed to taking that forward.

This week, the government slipped out the first wave of privatisation of the NHS in the middle of the Murdoch enquiry. Luckily twitter is wise to that trick. Here Max Pemberton argues that this truly is the end of the NHS - because while any aspect is privatised, it is no longer a national, nationalised service. I'm worried, and mainly because any examples of private contracting of other services by the NHS, such as cleaning, seems to have been linked with a reduced quality, because people are treated like crap (but it's ok because it's not directly the NHS doing it...) and so it's not worth it and they're not motivated to do a good job.

I hope you find something to interest you in there. Following yesterday's A and E trip in my placement hospital, tomorrow I'm going to talk about different experiences of A and E. I also took part in my first twitter-based journal club on Sunday. I really enjoyed it, and will post about it later in the week. (Google for more info, their exact twitter name escapes me, but the tag is #twitjc)

Have you come across any stories this week you want to share?

Just Checking In

Hi,

Just a quick message to say that I'm sorry not to bring you the promised post tonight. I haven't forgotten you, but I've managed to have a fracture-dislocation of my rib today so spent the afternoon in A and E and the evening feeling a bit vulnerable and emotional. Tomorrow's post will be about starting to run, as promised, and also be a bit of a news round up of various disability and NHS stories that have caught my eye.

Foundation Programme : Applying for flexible training

[This post is now several years old. In fact, I am now working as a less than fulltime FY1 on a 50% pro rata basis. The first part of the application process is ranking your preferred foundation schools. When you find out which foundation school you have been matched to, you should contact them about working less than fulltime. They require at least 3 months notice before you would start work. In my foundation school the only official options now for the foundation programme are fulltime or 50%, although I know one doctor working on a supernumerary basis. You can be less than fulltime for reasons of childcare, health or for some professional reasons. I will write more about my experiences now I have the answers to a lot of my questions.]

Again, this is just my understanding, which is not a substitute for actual information being obtained from a proper grown-up, k?

This post has actually been several months in the brewing - that's how hard it is to get any straight answers on this topic. I still have plenty of questions left unanswered, as you'll see.

If you wish / need to complete the foundation programme on a less than fulltime basis, you go through the application process as normal, until you're allocated to a foundation school. Then it gets confusing, because you are then told to contact the Associate Dean for Flexible Training of the relevant deanery, even though you won't know which deanery you'll be in until you've got a job. The first area which needs further clarification.

As far as I understand from conversations with the med school, you wait until you have a job, and then you ask for flexible training. This is good in terms of anti-discrimination-ness, and would be fine if the NHS wasn't as it is. I'm just worried that they won't get anyone extra to cover the rest of 'my' hours, so other juniors will take up the slack, and everyone will hate me. Anyway...

My med school has already had a 'quiet word' with the relevant person in my deanery (with my consent, because it is for his ears only, and so that we can have conversations about the various options early - he is not part of the selection process). This is fine, as long as I get a job in the deanery I want to, otherwise I'll have a frantic few months trying to sort this all out, during my finals.

At this point you have to provide evidence to back up your reason - which are basically health or caring issues (although there are a variety of more unusual circumstances that can qualify). This then goes through the Associate Dean, and then to someone else (hospital, trust...?) who can approve or deny the application. (Apparently my letter of diagnosis from my consultant which the med school has a copy of is enough evidence. I hope this is true.)

That is the sum total of the information that I can find.

Flexible training during other stages is calculated on a pro rata basis (as in, if you're doing 0.6 of a fulltime job, you do 60% of the nights, 60% of the on calls and 60% of the hours. You also, as far as I can tell, get 60% of the pay, and 60% of the annual leave entitlement.), so I imagine this is true for foundation years.

However, there is no information about what would happen for those who cannot work night shifts, or who would need to work half days, for example. I personally need to know if I would be expected to work the same blocks of shifts as other folk (for example 12 days on) with just longer to recover, or if I could work shorter blocks, with more regular breaks.

There is also no information about how the programme works on a LTFT basis. Do I do 4 foundation years? And if so, do I get a 'normal' F1/F2 allocation, and then have to find locum jobs to bring up my hours, or do I get allocated to 4 years worth of job? When in those 4 years do I get my full GMC registration? After year 1, or after I've done a 'normal' 1 year's worth of hours?

There is so little information about this, which is really frustrating. Why should I, as a disabled applicant, have less of an idea of the application process I will go through than a non-disabled applicant? The long and short answer is that so few people do flexible training during foundation years that it's really dealt with on a case-by-case basis. Not helpful.

Yes, we are individuals, and a lot of applicants for flexible training will have different needs, but even a recognition of that would be useful. There is just no indication about how 'flexible' flexible training can be, if needed. This is a real flaw in the one-size-fits-all national application process. Obviously, I haven't been through the system that came before, so I don't know if it was any better...

There seems to be every chance of me pushing my way through the application process, only to get a job and not be able to take it, because the hours will be unworkable. There is also no way to factor in things like travel time or relative accessibility of different wards / hospitals into the process, but that is another conversation entirely.

It just feels very much like disabled applicants haven't been taken into account, or properly catered for at any stage of the planning process.

Does anyone have any more information about flexible training? I've never even met any F1/F2 who aren't training fulltime.

Foundation Programme : FPAS and disability

[This post is now several years old. For up to date information on FPAS, please see www.foundationprogramme.nhs.uk]

Here are some specific things to consider related to FPAS applications as a follow-up to yesterday's post, again with reference to the 2012 applicant's handbook :

- Some with evidence of a good reason they need to be placed in a specific foundation school (for example, school-aged children, staying with a certain healthcare team) can apply to do so. The application and evidence must be submitted by 29 Sept. However, this isn't a guarantee that you will get a job in this foundation school - you still have to have as high a score to be allocated a place as you would otherwise.

- The form does ask if you are disabled or have health problems. This will not affect your allocation to a foundation school (which is based purely on your score), but the foundation school will see it. Bear in mind that it takes time to put adaptations in place so it is probably wise to disclose at the time of application. You can tell them later in the process, but you don't want to give folk any excuse to not adequately deal with your needs.

*Edit : I am investigating this point further, in relation to a comment left below.*

- If you want to link your application to somehow - which may be extra important if, like me, your partner is also your carer to whatever degree - bear in mind two things :

1) You will both be assigned based according to the lower of the two scores

2) Linking applications will limit the number of posts you can apply for, because not all posts have a suitable 'sister' post that will work.

You need to talk this stuff out in advance, to avoid nasty surprises.

- Your referee will be asked if you have any health problems which will have an impact on your work. I think that this is really odd. To be frank, I don't think it is your referee's place to disclose personal information about you. For one, these referees are colleagues/supervisors - and my health, or lack of it, is none of their business to start with. I don't think it's appropriate, but maybe it's a standard questions for employers to ask referees, I don't know.

- The handbook points out that spelling and grammar mistakes can cause you to be marked down in the questions section. I would suggest that if this is likely to be an issue, you ask someone to proofread, which is allowed (and is probably a good idea anyway).

Foundation Programme : FPAS, the basics

[This information is now out of date - please see www.foundationprogramme.nhs.uk]

Hey gang. I'm doing some research about the foundation programme today* because the applications are slowly sneaking up on me, and I need to get some things straight in my head. I'm hoping that Seph's going to help me a little bit, because she's just jumped through all of these particular hoops.

I'm planing to start off with the basics of how applications work (because every time I think I have it straight I end up thinking "but what the hell is a foundation school?"** and that's me back to square one). I'm using the 2012 Foundation Applicant's handbook (available here) for reference. Note, this post should not be considered the final word on anything, this is only a summary of my understanding. Refer to the handbook or other official documentation. Thanks =)

Application Form

You will register on FPAS between 3 and 10 Oct, ready to complete the application form between 10 and 21 Oct. The form consists of :

Personal Information - unscored : includes address etc, but also whether you want to link applications, and if you want to disclose an illness or disability (which I'll discuss tomorrow)

Qualifications - unscored : degrees awarded and such - also what you've been up to if you've not gone straight from med school into F1/F2

Clinical Skills - unscored : a tick list of skills supposedly so that your employer knows what you need to cover during F1/F2. I wonder if anyone actually looks at it?

Equal Opportunities - unscored : for the foundation school to see whether they're getting a good enough mix. Doesn't seem to include sexuality, which is odd as most forms like this seem to.

References - unscored : one doctor who can talk about your clinical skills, and one from someone within the med school (they have from 16 Dec-24 Feb to do it, but basically if you don't have 2 for your employer by August you can't start work). The list of questions they'll be asked is available in the handbook, one is of particular relevance here, which I will discuss tomorrow.

Preferences - unscored : you have to sort every foundation school into order of preference.

Questions - this is the only scored bit : 1) Education Achievements - other degrees, publications etc are scored up to a maximum of 10 points. 2) 5 questions, requiring a 200 word answer, which are related to the "Person Specification", which are worth up to 10 points each. The scoring of these seems to have no rhyme or reason, which will explain why all the people that you think are the best in your year won't get a job in the first round.

Quartiles - as far as I know, these don't go on the form and supplied by your medical school. Basically, you get points out of 40 depending on where you stand within your class, which takes you up to a score out of 100 - you cannot appeal this score. Irritatingly enough for me this will mean that the last assessment which will count towards this is 3rd year exams, which will be more than 2 years ago when I apply. Finals happen after application, and in terms of F1/F2 all that matters is pass/fail.

What next?

If you score high enough to get a place in your favourite foundation school then that's you. Otherwise you move down the list until you end up in your favourite of the foundation schools that you score highly enough to get into. (I believe this is a slightly different system to last year)

By 8 Dec if all goes to plan you will be told you have a place at your favourite foundation school. Otherwise you'll be told that you're on the reserve list, and what will happen next. I don't really understand the explanation of it. Once you have a foundation school, you apply for actual jobs - the system for doing this differs from place to place. Some have interviews, some have to rank every.single.job. in order of preference, some have it easy... You will find out your job on 15 Feb, unless you are on the reserve list, in which case you will find out between May and July.

Apparently, at some point this year we're also supposed to fit in a Situational Judgement Test, as a pilot for next year's applicants. I believe this will be an hour-long written paper. (Will extra time be allowed I wonder?) They're also piloting a new score - the Education Performance Measure - which I think will just involve them doing calculations based on information about us they already have.

*Foundation programme = first two years of postgraduate training out of medical school, aka F1 and F2

**Foundation School = not an actual school - made up of all the med schools, deaneries, hospitals, NHS trusts etc in a given area (Scotland, Wales and N Ireland are all foundation schools, England is split into regions). To be honest, I'm not entirely sure what their role actually is.

Guest post by Seph : how to survive moving house

As you will have noticed, this is a guest post. Assuming Ms Disabled Medic approves it, this will be my first guest post, but I hope to write a few more in time.

So who am I? I'm a medic, although I have now completed my studies and I'm about to start work as a junior doctor or FY1 as it's known. I have just (as in two days ago) moved about a hundred miles, which was, er, interesting.

I do not consider myself disabled, but for a long time I have had an undefined depressive illness. Medical school presented some interesting challenges which I hope to discuss at some point - tips for surviving final exams, special circumstances in MTAS, starting work and so on.
This post talks about moving house, because it's something that medics tend to do a *lot*, and it can use an awful lot of spoons. It's commonly known as one of the most stressful life events to go through. My partner is dyslexic so he and I both tend to get very tired when trying to do certain things. I also have a quite limited capacity for stress and things going wrong before I lose the plot. This post comes from our collective experiences over the past couple of weeks.

1. Know your limits. Figure out what you can do and what you can't. Ask people for help, pace yourself, and if you can, pay removal companies to do some things. If you know you can't shift your worldly possessions up three flights of stairs, don't try. You'll only end up knackered and that doesn't help. Don't feel bad about not doing everything. Everyone has limits.

2. Rest appropriately. If you tend to get fatigued you probably know your limits pretty well anyway, but this can go out of the window when you're trying to get so much done, particularly if you're working alongside someone who has different limits to you. Don't feel guilty if you need to take more breaks. You might feel like you just want to get it over and done with but you know the reality is it will get done faster and better if you're not exhausted.

3. Make a "home" space early. Pick one room – bedroom, living room, whatever you want (although it needs to be comfortable, so maybe not the bathroom!) - and make it as homely as you possibly can as fast as you can. This means unpacking that room first, arranging some of your bits of artwork, photographs, books, cushions, birthday cards or other familiar, homey items, and moving most of the boxes out. This way, even if the rest of the flat is total chaos, you have one area where you can go to rest and relax a little. When you're freaking out because the place is a madhouse and there's loads to do, you can go to your “home” space, take a few deep breaths and feel a bit better. A plant or some flowers might also help, plus your stereo or tv or even just a clock for some friendly noise.

4. Talk. If you have a roommate or a partner, sit down with them well before the move and talk about it. Even if you know each other well, moving will raise unique issues and it is worth going through them. Try to make a rough list of tasks (changing addresses, organising particular rooms, etc) and decide who could do each one. It won't work out exactly that way, and there will always be things you miss, but having a rough plan and a good idea of each others' abilities and limits will help.

The picture shows a variety of cardboard moving boxes taped shut

and stacked up in piles. By skrewtape on flickr.

5. Take your time. Start packing in plenty of time before the move (more than three days. Oops!) and don't expect to have everything sorted out the day after. Be realistic.

6. Figure out what you need. Is your support network largely on the internet? Do you need to have a working phone line for emergencies? Do you need to set up clinic appointments, blood level monitoring or counselling? Whatever it is, make sure you have it in place well before you move. (I suggest looking into these things at least a month in advance because it always takes longer than you expect.)

7. Figure out what you need (part 2). If there are any items you absolutely need - splints, meds, hot water bottle, whale song CD, blanket, cat, whatever - make sure you know where they are and that they're not at the bottom of a huge box (particularly the cat).

8. Arrange food. The last thing you want to do after a day's unpacking is cook, so make sure you have something sorted out. You'll be hungry and tired and you need something good to eat that will give you energy, not just junk food. Make some sandwiches or just put some tupperwares of food where you can find them. This is particularly important if you have a specific diet.

9. Get your prescription. If you take any medication, regular or PRN, make sure you have *at least* three weeks' supply before you move, from your old GP. It might take you a wee while to find a new GP and you don't want to run out. Also make sure that you have a copy of your repeat prescription, any relevant clinic letters, and if necessary (e.g. if you take opiate painkillers or odd doses of things) a letter from your old GP explaining your medication regime. Anything which makes it easier for your new GP to give you your medication is good. Your notes will take a while to come through, so don't rely on the new GP being able to access them.

10. Go outside. Being surrounded by boxes is overwhelming and unpacking creates a lot of dust. Go outside at least twice a day. Explore your new area or just sit outside the house and breathe the fresh air. At the very least, open a window. It will help, I promise.

Moving is hard work and it's stressful, but you'll get there.

Have you moved house recently? Did you find that it presented you with any particular challenges? What tips do you have?

This month in the student BMJ

This month's sBMJ had two articles that particularly sparked my interest.

Firstly "People with disabilities face barriers to healthcare"* - a brief article on the first World Report on Disability produced by the WHO and the World Bank. Fine, it's stating the obvious, but even what's included in the wee article seems to suggest that the report will be worth a read. I'll give you my thoughts in a few weeks.

The picture alongside the article however (I'm not sure if it's from the report or not) is the standard wheelchair-user-disabled-logo, pictured at the bottom of a flight of stairs. It's strange because as you'll see if you follow the link, the cover picture is a blurred background with a hand holding the top of a white cane in the middle - quite striking, and not 'predictable'. (There's also an article in the grown-up BMJ, but I don't have an Athens account these and I've forgotten my BMA log-in, so I'll have a look at it later) It's interesting that they've used the phrase "people with disabilities", rather than "disabled people", as the second seems to be more then norm in the UK (I'll explain the difference at some point) but I suppose it is an international document.

(Incidentally, if you're tired of wheelies being portrayed as lifeless, genderless, boring symbols, check out Hannah Ensor's website Stick Man Communications - Hannah is a wheelie herself, and has a huge talent for showing the joyful and ridiculous side of disability. And she's a bendy like me!)

There is another article called "Under Pressure"**, about stress / mental health problems in medical students. It's really quite good - thoroughly outlining the situation, but also offering some examples of good practice under the heading "Preparation and Prevention". I'm really pleased with it. It outlines the spectrum of stress-by-high-pressure, to 'clinical' mental health problems, and deals with the issues surrounding both. This issue is really important, and I don't believe it is dealt with sufficiently at most medical schools. It would be great to have other articles of this quality on other aspects of health and disability specifically for medical students.

All in all, big thumbs up. Both articles managed to penetrate the current brainfog, which is an achievement in itself.

*BMJ 2011; 342:d3618 (this is the citation it gives, confusingly enough)

**Student BMJ 2011;19:d3678

Tailing off

I haven't posted in a few days. Twould be easy enough not to, and to let this project end before it's even started. The thing is - I'm really tired. I don't have anything clever / useful to say. I've been reading back through the Broken of Britain blog, and I remembered this post the "We're fine" update.

I just got an email from one of my best friends who's just got out of the hospital, another has just moved away from home to start work, because the MTAS system is crap. I feel helpless here, so far away. But, let's face it - I've been lying on the sofa for 3 hours, desperate for a pee, not quite able to stand up, let alone find the energy to negotiate the stairs up to the loo - so I'd be as much use as a chocolate teapot even if I was at home.

I'm not really ok. I've had rather an onslaught of symptoms the last few weeks / couple of months, and here I am, exhausted. I'm worried that my mood's not quite behaving, but it's kind of hard to tell, because nothing else is behaving either. I wish I had got signed off sick for my elective as was offered, I can't afford to keep feeling like this.

I'm so happy. Really, deeply happy. This isn't either/or, it's some weird and. I don't understand how deep happiness and deep sorrow can go together, but they do.

I might not post for a few days, unless I type up a few of the posts I've got scribbled in my notebook (so much for modern technology, right...)

In the meantime if you have anything you'd like me to post about, or if you want to write a post about your experience of the NHS - good or bad, as patient, carer, medic or other professional who works in or with the NHS - please send them to my brand new email disabledmedic[funnyAthing]hotmail[dotcodotuk] . Thanks for all of your comments and encouragement so far =)

p.s. I wrote this post some hours ago now, and have since been rescued, had a wee and a cuddle (not at the same time), and am feeling a bit less woebegone.

What's all the fuss about?

When I had a meeting with the head of my year in the medical school this year, he kept saying things like "I think you're being over-cautious, you won't run in to any problems" or "doctors deal with patients with disabilities so they're good at dealing with colleagues with disabilities". I couldn't get through to him that it wasn't that I was worried in case their would be problems at some point in the future, I was there because these problems were part of my daily experience.

So I decided to keep a list of all of the accessibility issues I encountered during one day of placement this week. Obviously things change between hospitals, but this is a fairly average representation.

1) There are 3 steps up from the front door to the entrance hall. There is a level entrance door, but it's not right at the front where I can get dropped off, and it's the other end of the hospital from the paeds ward.

2) The lift buttons are incredibly stiff, so I either sublux my fingers or don't manage to register that I've pressed them every time. I eventually ask a stranger for help.

3) The ward has a keypad entry system, and push button to exit system. If I have one hand on the stick, and one on the keypad, then there's no hands for the door. And the period the door is open is very short so I keep missing it. A nurse takes pity on me and comes to open the door.

4) Once inside the ward, the doors are big, old, fire doors. I can only open the push ones, because when I try to pull them open, my joints give before they do. Again, a nurse helps me out. I would not manage at all in a chair. I'd tip over.

5) The doctors room is not on the ward, but is as often happens, at the other end of the building. This means longer walks backwards and forwards, which add up really quickly to increase pain and fatigue. It also means getting through a tonne of the above heavy doors of evil.

6) The ward has very small cubicles. Each has a bed / cot in for the patient, and an armchair bed for a parent to stay. When there are two doctors, a nurse, and a parent in, there is barely room for me, let alone for me to bring a chair in. By the end of ward round at the start of the week, my seated heart rate was 150.

7) There are very rarely (if ever) staff disabled toilets in hospitals, and this is no exception. I use disabled loos because it saves me getting stuck not able to stand up (as nearly happened in the cinema yesterday). This is an infection control and privacy issue, and often means having to leave the ward and going to the ground floor to find the only appropriate one, especially in a small old building.

8) The toilet door is heavy. The lock is stiff. I nearly can't get out, and there is no alarm cord with which to summon help (not that they're generally heeded anyway).

9) The shortcut from the ward to the dining room involves going down 2 flights of stairs and back up 1, then the same in reverse. This is how the others go to lunch, but I have to go to the lift, and people ask why, and it ends up being a really obvious difference. Consultants also tend to not think before run down 5 flights with a teaching group, too quickly for me to ask where it is they're heading.

10) The canteen is self-service. I asked if someone could carry my tray to the table, because my wrists are prone to giving way, even when one of them isn't taken up with stick. The staff refuse, because it's busy and they "don't do that". The consultant comes over and takes my tray for me, and goes off into a reel of "you're so brave to deal with this" nonsense. I'm not brave. I just get up in the morning and live my life.

11) The consultant was late for clinic, so I had to stand around and wait for him, because the few chairs in the waiting room were full. There aren't enough chairs in the world in general, I've decided.

12) Spent the whole afternoon in clinic during which the consultant took no rest breaks, so as a consequence I didn't either. 4 hours of near constant sitting in a chair without arms means that I have a wicked headache / neck spasm by the end from trying to hold my head up. It's increasingly hard to concentrate.

13) In the clinic, the examination couches were fixed height, so it was not possible to sit down to examine the patients.

14) At the end of clinic we were taking a pile of case notes up to the secretaries. Case files are heavy, even in paeds, and the fastening are stiff and awkward to use, causing more hand trouble. (The delay in getting paper letters out really disadvantages coordinated care, especially for kids with complex conditions. They're currently typing up letters from January clinics). Junior doctors spend a lot of time acting as postmen for Xray requests, and case files.

14) I get a lift home, as I got a lift in, for which I'm very grateful. The bus stop isn't within my walking capacity from the house, and the bus stop outside the hospital is at the bottom of a steep hill leading up to the entrance (as seems to often be the case).

15) In the middle of this I am trying to keep to a good routine for my meds, and food, because my tummy's been so sad recently. This is really hard when you're not in control of your own timetable.

This is one day of placement, not including what happened before or after at home. It gets very tiring.

Intercalating : A year off the treadmill

Here is my 3rd in the series of alliterative posts this week (small minds, small pleasures...). I took an intercalated degree (BMedSci Honours degree) between 3rd and 4th year, and I'm really pleased that I did. That said, it was far from easy, and I think a lot of people jumped into it without thinking about what it would involve. So, here's the latest addition to the top 10s - some are tips, some more "thinking points". As always comments are welcome, especially if you chose not to intercalate, and can explain the reasons behind it.

1) Think carefully. Intercalating means another year at medical school, with all the costs - financial and otherwise - which that entails. Talk to other students who chose to do one, or not, and ask them their reasoning, and whether they agree with their decision in hindsight. Do your homework about what is actually involved.

2) My opinion would be that if there's a particular subject that you're interested in, want to learn more about, or may need later in your career, then it may well be worth it. Equally if you're interested in the more general aspects of research you can consider it. Don't do one just for the sake of it.

3) Intercal is a year off the treadmill, a year to step back from the inevitability of the medic conveyor belt. It's a great chance for some head space, for re-focussing, and for trying something a bit different. This was invaluable for me.

4) But it is not a year off. For example, my year was composed of a stats course with a final exam, research lectures (e.g. how to run a clinical trial, research ethics) with a final exam, journal club involving presentation and research, writing a research review on a given subject, 3 specialist courses with final exam, and a research project with a final presentation, paper and poster. It's the equivalent of the honours year of a degree. It is a lot of work, and especially towards the end was incredibly busy and stressful.

5) If what you want is a year off, to do some rehab / sort your life out / think about whether medicine's for you, intercal may not be what you need. It's less physical, and it's a change of scene, and you don't have the pressure of ward work, but if a year out is what you need, apply to take one. Most med schools are happy to accommodate this if you have good reason.

6) Intercal will make your brain work. You will encounter more complex ideas that in the normal run of med school. It takes time to remember how to do quality-not-quantity brain work. I really enjoyed this, but I know not everyone enjoys brain ache. It's also very self-motivated (speaking as a PBL student) and that can be very difficult if you are having a bad patch.

7) You will learn a lot. I now feel confident to read and properly interpret papers (a vital skill in an evidence-based service), and I could make a good stab at planning a trial or study. I've also got a good grasp of my specialist area.

8) Myth busting : you will not forget all of your medicine. I was a bit rusty when I came back - I had forgotten some details. But I feel like stepping back for a year allowed my brain to organise and consolidate information. I came back with a better overview of medicine than I'd ever had before. I also grew more confident, and you can notice a big difference in maturity? poise? between those who intercalated and the year below that we have joined.

9) Your access needs may be dramatically different depending on how much clinical work is involved in the early years of your course. Talk to the disability service, and the course organisers early. If you need something to persuade you that access in hospitals is really quite good, do an intercal in a department based over 3 stories, with no lift. See the top 10s tabs for advice on days of lectures and [pending] coping with dissection and lab work for ideas.

10) Before intercal, read Bad Science by Ben Goldacre. Read it again before intercal exams. After intercal run through the main 4 examinations (CV, resp, GI, neuro) and basic principles of history taking. Don't freak out and study all summer!

Anything to add?

Infection Control or "oh, I hadn't thought of that"

Would you believe me if I told you that infection control issues are some of the most challenging that I have to face in terms of access?

It's true, dear readers.

You see, at some point before I started medical school, the NHS decided to promote the use of alcohol hand gel before and after patient contact to reduce the spread of infectious disease. I'm sure someone has proved its effectiveness, and that can only be good, the fact that it has left a generation of staff with allergic dermatitis and that it is not effective against C.diff (which doesn't need any help to spread around) notwithstanding. Personally, I would rather there were more sinks, so that I could properly wash my hands around, but apparently people weren't using them or something.

I think it's good common sense to wash your hands between patients. Folk should wash their hands anyway. It's just nice, and not icky. But, here is my problem, as I explained to the last infection control nurse to teach me to wash my hands (I've been taught 11 times since I started med school...) :

I see a patient, I pick up my stick, I wash my hands, I pick up my stick, thus all the patient germies hang around.

She gave me a look that said "this is not on my algorithm", and then said that I should wipe my stick with a Tuffie wipe between each patient. This makes sense, except that Tuffie wipes all seem to come in tubs of 5 million (and with my stick I already have one less hand to carry stuff), that this means I take longer between patients than everyone else, and the ward round waits for no student, and that I would have to buy them out of my own pocket.

I explained what I had been doing - that is putting a surgical glove (which are all over the wards) over the stick handle each time I wash my hands. This seems an imperfect solution - it's really wasteful, the gloves aren't sterile (people will stick their hands in to the box to get a glove without washing first), and it makes me look silly...

She didn't like this idea (but couldn't explain why) and thought I should use Tuffie wipes. Which hasn't happened for aforementioned reasons.

The other option is to put gloves on every time I see a patient, taking them off before I pick up my stick. This combines two of the earlier problems - gloves not being sterile, and carrying something else around in my one free hand - plus the fact that I don't like making patients feel like lepers from the Bible. I found a newspaper article in the depths of the internet that said that this was the approach taken by a wheelie medic - but on wheels you have more capacity for carrying stuff around.

It's confusing and horrible to feel like I'm not perfectly conforming with a policy that people are so obsessed with. People also comment on it left, right and centre - either telling me off, or telling me I've found an ingenius solution.

That's the major IC issue, but there are others. "Bare below the elbows", brought in in Scotland in 2006, means that I can't wear splints, supports or bandages on fingers, hands or wrists. It's also caused problems for colleagues because of scarring.

I've shown here that I don't have simple answers to these problems, and I don't expect anyone else to - it's just that noone's thought about it. It seems assessing the equality and diversity impact of a policy only relates to patients and not staff. Noone has considered wheelies, or stick users, or splints etc. It's a really isolating feeling when everyone you ask double takes, and says "oh, I hadn't thought of that".

Identity

I know the title "disabled medic" sounds as though I have myself totally boxed off. As with most things in life, it's a little more complicated than that. The reason the blog is titled as it is, is because this is the search I plugged into google on the first day of 4th year after a conversation with my supervisor.

I had mentioned mental health problems to a supervisor before, but not the joint pain, fatigue and fainting that had gradually come to the fore over my intercal year as the worst effects of my 3rd year breakdown faded. It was a bit of an afterthought to mention anything, and so I said something along the lines of "oh, er, um - and I guess that I should tell you that I'm disabled, or something". I can be so articulate...

That night I went home and googled "disabled medic". A lot of what I found that was useful ended up in my "Disability and Medicine" links. The majority seemed to be condition/impairment-specific support organisations, fluffy-but-without-real-answers pages from the GMC/BMA/med schools, a smattering of "wheelchair boy banned from med school" headlines, and forum threads about whether disabled people should be allowed to apply.

The only site that offered any kind of real overview was HOPE for disabled doctors which is definitely worth a read, but I have found very little written from a personal perspective, and very little that specifically relates to mobility impairments, or fatigue.

In offering this blog, I'm not claiming to have all of the answers. For medical students who acquire an impairment, or for disabled folk who become medical students, the learning curve is incredibly steep. My hope is to provide a resource to help people find their feet a little bit. There is a lot that I haven't figured out yet, and all I can write about is my own experience (and no-one will have the exact same experience as me), but here it is, for what it's worth.

There are so many other words that describe me other than disabled and medic - but there are resources out there to address losing weight on a vegan diet, planning a big gay wedding, training cats to bring chocolate when summoned and learning to play the ukelele. So here is a resource about the being-a-disabled-medic bit, so that you can get back to being a vegan, pacifist, crafty, tea-loving, gay, closet-nudist who enjoys reading - or whatever all those other bits of your identity are, that make up the lovely you. Enjoy =)

Elective, wk 1

To update on my week, I managed 2 days of placement out of 5, threw up 3 evenings out of 5, gained 1 ukele, learned to make 5 different kinds of origami flower, passed out 0 times (considerable acheivement) and made 1 banana loaf.

It's been fun, really. I've had a lot of time to rest, enough sunshine that I don't have Rickett's but not enough that I've melted, and plenty of good food. I miss home,  but I've got the mrs, and daft cat, and the 3 of us are taking on the world together.

I had interesting chat about journalling and mental health yesterday, and also a bit about PTSD after major health crises, so remind me to post about those at some point. Also about an article I read in the sBMJ.

I hope you're all enjoying your weekends, and that your week to come involves more origami than vomit... (now there's a blessing for you!)

Posts coming up this week :

- Identity

- Intercal top 10

- Infection control

Confessions of a TV addict

All being well, this should appear when I'm eating lunch at placement tomorrow! Hooray for feeling a bit better =)

I've enjoyed the chat on the tops 10s post (thanks guys for all your suggestions - very helpful for me, and I hope for other folk - keep the comments coming!). I've enjoyed it so much in fact that I think it's time for a new series. This one is slightly less serious, but I think it will be amazing (and the rest of you will just have to humour me!).

I'm sick of being compared to Dr House. Yes, we both have awesome walking sticks, but that is pretty much where the similarities end. Except that I am, also, an excellent diagnostician. In fact, I always beat him to the diagnoses the second time of watching.

I'm especially tired of the comparisons because there is no shortage of disabled doctor-ness with which to compare me. At least one lady at church had the imagination to compare me to Kerry Weaver, who is at least female and gay...

It got me to thinking about disabled doctors in TV dramas. And then I got to compiling a list. So, how about a little content analysis of my favourite TV (read : ER, Holby City, House, Grey's Anatomy, Scrubs and Casualty)? As I said, humour me =)

And if you don't think I'll have much to work with (depending on definitions of disability) :

-Dr Carter, ER, substance misuse

- Dr Stevens, Grey's, metastatic melanoma

- Dr "Thirteen" Hadley, House, Huntington's

- Dr Turk, Scrubs, diabetes

- Dr Hunt, Grey's, PTSD

- Dr Casey (Michael J Fox), Scrubs, OCD

- Dr Winters, Casualty, "breakdown"

- Paul Nathan (medical student), ER, Parkinson's

- Dr Burke, Grey's Anatomy, hand issues

- Dr Howard (doesn't get a surname), ER, OCD

- Dr Lockhart, ER, alcohol misuse

- Dr Adams, Holby, Parkinson's

- Dr Romano, ER, upper limb amputee

- Dr Griffin, Holby, (colorectal / liver) cancer

And, of course, Dr Weaver and Dr House.

And that's only the ones I could think of off the top of my head without bothering to go upstairs and look at the list me and the mrs made on the train on Sunday.

I don't quite know what form it will take, but there are definitely themes (such as the miraculous lack of after effects in all but a vanishing minority following hugely traumatic happenings). It'll be a good excuse for me to watch some boxsets if nothing else ;)

Challenge : who can think of more for the list?

Happy birthday?

Hello gang =)

You won't know you should have missed me, because of my cunning use of that thing what lets you make posts happen from the past (from the future?) when you don't know if there will be internet, but you should have! Don't worry, I'm back...

So, how's this for an I-love-my-life story? I had been in the land of my beloved for a little over 24 hours when I had an unholy puke attack. Charming, I know, but I made a promise with myself to be honest in this wee corner of the blogosphere (not that I'm dishonest in another corner of it, you understand). This means, if you're keeping track, I managed one day of elective, before having two days off sick. How's that for making a good impression? Plus I forgot my meds last night and therefore didn't sleep just to maximise my awake with noone to talk to time.

[pause to give some love to daft cat]

The psych post that should have appeared for you today, combined with a conversation I had with a very-mini-patient's mum the other day have got me thinking.

I know that the post is fairly cheery in tone, and there's no reason for it not to be as I coped with the placements in psych pretty well, my experience of mental health services from the other end was almost universally not good (with the exception of one awesome adolescent consultant, and one equally awesome therapist). Not to mention my recent experience of being diagnosed with a condition that noone's heard of, and everyone's a bit scared of because it doesn't get better, and that makes them feel impotent or something.

This is a not particularly articulate way of saying : every time I think about government cuts, every time I feel the impact of them, every time I see patients hit with them, it makes me angry. We didn't need less of this stuff - we needed more.

More support for psychiatric service users/patients (I realise that I always say patient because I prefer it - if you don't, I apologise) in the community, more provision for pain management courses and ongoing physio for those with chronic conditions, more support for mums who've just been told that their baby will never talk to them. If you want us to work, you need to find us a job that we can actually do before telling us that we are fit for work, you need to not cut funding to groups who working to end discrimination in the workplace, you need to make laws that don't grovel and beg, leaving more loopholes than a rollercoaster.

We needed more, we deserved more, we are worth more. And I can't be coherent, because it doesn't make sense to me. I can't be coherent because I am scared for myself, for my friends - old and new, and for that little baby and his mum.

This is a time when services need strengthening, to build up to deal with our ageing population. We can deal with these people in two ways - primary and secondary prevention, which saves lives, quality of life, and money, or not. If you've only 5 years to persuade people to not vote for you again, the cheaper option is to cut early intervention services. Because the cracks won't show for a few years, and the next guys'll be the ones who end up raising taxes to deal with it.

The NHS turned 63 yesterday. I don't think it's overdramatic to wonder if she'll make 70.

We are living in strange and scary times my friends, but there is hope in the fight, I think.

Tea, biscuits and psychiatry

1) For me, the best bit of psychiatry was that ward rounds involved sitting in a room with tea and biscuits while the patient comes to you. (OK, maybe not the best bit, but it makes a nice change!) They can be very long though, because they tend to be once-weekly, and multidisciplinary.

2) Some wards, especially forensic or intensive care psych wards won't let you work in them if you have mobility problems. There are two main reasons for this - not being able to make a quick enough getaway if somethings kicks off, and the potential for a stick or crutches to be used as a weapon.

Noone mentioned this to me before my placement, but I suppose the people to talk to would be whoever decides which student goes to which ward (to ask them to avoid placing you on secure wards), occie health for the hospital, or your supervisor for the placement to ask if they do any work on a secure ward, and what the local policy is on this.

3) It is worth spending some time with CPNs, to get an idea of how community psychiatric services are organised. House visits may not be possible, depending on issues of accessibility, but CPNs will often run clinics at the CMHT base. If nothing else, ask a CPN to describe their job, and ask a few patients what their experiences are with CPNs.

4) This isn't actually psych-specific, but this is just where it came up for me. My partner would have been placed with one of the doctors who I saw when I was under the CMHT if she hadn't happened to be on holiday. It hadn't occured to me before that I could end up placed with one of my doctors. There is not really any facility to deal with this at my med school, because allocation of supervisors is handled at the hospitals rather than centrally.

If you do end up in that situation, I suppose there are two options : either get in touch with the med school / teaching administrators and ask to be transferred to somewhere else, or sit down with the doctor in quesion and talk about any issues that might come up. It might even be helpful for your consultant to see exactly how you're managing on placement.

5) During my A and E placement, I found it really difficult how certain doctors talked about / to patients who had self-harmed or overdosed. I reported one particular incident to a consultant because it was so inappropriate. I understand the frustration that doctors feel when they feel like they're getting taken away from people who didn't "choose" to be there, but this frustration should not be taken out on patients.

People will not think of the possibility that you, or members of your close family/friends may have been affected by similar issues. There is an 'us' and 'them' mentality, which feels very awkward as someone who is both.

6) If you are likely to be at all triggered by anything that comes up during placement, make sure your 'support network' - partner, friends, family, minister, disability advisor, CPN etc - know that you are starting the placement, and that it may be difficult for you. Make suggestions about how they can best help and care for you, if you know.

7) I have done two psych placements now, and both times I have told my supervisor that "I have a history of mental health problems" so that they knew in case I was struggling. If this feels too personal, or for whatever reason, you could say that a close family member / friend has mental health problems instead. This will hopefully stop them saying stupid things in front of you, will give you a chance to raise any suggestions e.g. "can you give me a brief run down of each patient before they come in so I don't get surprised by anything difficult?", and will explain away your freak-ish knowledge of little-used anti-depressants.

8) I don't normally journal regularly, but I wrote in a journal every day during my two psych blocks, so I could explore anything that had triggered me, and any emotions that the placement had brought up. Having said that, neither I nor any of my friends with MH problems have found the psych block particularly bad. I still think it's a good idea to prepare for the worst, just in case. Have a think about what you can do to cope if you have a tough time of it.

9) Prioritise your own health. Don't put yourself in any situations that you know are bound to cause problems, such as patients with a similar condition or history to you, or those who are aggressive and intimidating. Focussing on some of the theory (side effects of psych meds seem to make for popular exam questions) can help to take out some of the 'sting' of it

10) That being said, you will have to face some psychiatry in both final exams, and as a junior doctor (and, obviously, you will always find patients with mental health problems popping up in other specialities), so you need to find a way to, for example, assess a suicidal patient, and do it well and thoroughly, without damaging your own health. There are no easy answers to this, but I suspect that, as with many things, the key may lie in practice.

Cheerio 4th year

My year ended in a really positive way. 6 months of placement without a break had gradually worn down my self-confidence, my motivation and my health. I spent a lot of time wandering whether it would be worth it, and more time worrying that I would get so run down that I would have to take time out. In my uni if you take time out you have to complete the whole year again from the beginning, rather than slotting back in at the point you left. I just had this nightmare vision of getting to 3 weeks from the end of the year, getting sick, and having to do the whole thing over again.

The last hoop to jump through of the year - getting signed off in my last placement by the supervisor - went remarkably well. It involved a neuro exam, something that I had been really shaky about until the start of this year, and until the start of this placement i hadn't really known what each part of the exam was looking for with any certainty. I felt really proud when I managed to complete a thorough, slick examination, and to answer all of the questions afterwards. This year has been really difficult, but it's such an amazing feeling to look back and realise how much I've learned - especially how much stuff that I vaguely new before I have now understood and cemented properly in my brain.

One of the (many) things that I love about being a medical student is that there's always more to learn, and that most of it has direct practical applications. It is incredible that the human body doesn't go wrong more often than it does!

Highlights of the year include : picking up my stethoscope after a year of intercal, getting to manage real-live airwaves in anaesthetics - especially putting in an LMA, finally learning my diagnosis, a placement with the community addictions team, feeling a lot more confident on the wards than I did before intercal, rediscovering reading and last but most importantly, moving in with my partner, and getting a cat.

Children are not mini adults...

...A survival guide for paediatrics.

1) If you look "different" in any way, children will ask questions about it, and parents will (for the most part) get embarrassed. You've probably come up against it at the supermarket already, but if you haven't, have a think about what to say to "why is that lady using a stick / chair? etc". Something simple such as "my legs don't work the same way as yours" works for younger children, and simply "I am disabled" for older.

Decide to what extent you will answer follow-up questions as well. To non-medics I tend to say that "I have a problem with my joints", and this seems to work fine with children. (Medics, I tend to tell what I have, purely because it's not well-known and I want more people to have at least heard of it!)

2) I try to be welcoming to questions and curiosity from kids, because I think that's it's a really good opportunity to de-mystify disability. If kids are staring, or parents get embarrassed, I tend to ask the wee ones what colour my stick is. It seems to open up some good conversations.

3) I did talk to a couple of parents who said it was really good for their disabled child to see a disabled medical student. I didn't know what to say to that, but it made me a bit happy. This isn't really a tip so much as something to bear in mind.

4) Depending on your life experiences, some of the issues that are raised in paediatrics may raise some difficult feelings. Recognising non-accidental injury, for example, will almost certainly be raised.The pictures shows a young girl of about 3, dressed in red, kneeling over
a baby, dressed in white, who is lying on the floor. The girl is playing
with a syringe (no needle though, don't worry!), and mum is watching
over them, her left wrist loosely bandaged by the wee doctor.
Picture by uncoolbob on flickr.

5) The MDT is highly valued within paediatrics, and specialist community nurses are the back bone of chronic disease management in kids. Depending on access issues, home visits may not be possible for you, but nurses often also run clinics from a hospital base, or are part of consultant-led clinics (e.g. diabetes clinic).

6) I found it really frustrating how much better coordinated childrens services are than adult. There's no easy answer to this, but it's not just you. Don't be afraid to voice these frustrations, because most paediatricians share it, because they see the anxiety that surrounds the transition between.

7) If you've not spent much time with babies before, and you're nervous around them, get the nurses to teach you how to change nappies / give bottle feeds. If you muck in, you'll get plenty of experience, and the nurses / auxillaries will love you. (If you like cuddles, barter one nappy change for one bottle feed like me!)

8) Spend time in the play room or with play therapists to hang out with some toddlers. Being able to make a child smile will make clinical exams so much easier - a relaxed child is way easier to examine, and a relaxed parent gives a better history. The easiest way to get a child on side is to say "who is that on your Tshirt? / what is your teddy's name? / what colour are your shoes? is that your favourite colour?". Always ask the child their name and age before (if they can't answer) asking the parent (unless they're very obviously 8 weeks old!).

9) But, if you choose to take this kind of hands on approach, remember : have a change of top around in case you get peed or puked on. (Or know where the scrubs live!)

10) Also, know your limits in terms of lifting babies / children. Don't hurt yourself (by lifting a particularly weighty, but tiny-looking 2y/o like me...) and really try not to drop them!

Ready? Get set... Surgery

I am not one of life's surgeons. It's medicine all the way for me. Having said that, I came out of my surgical placement this year feeling smarter, more confident and able to present patients a lot more succintly. And I really enjoyed myself. If I can do it, anyone can. Here are some hard won lessons that I will definitely be bearing in mind next year.

On the wards
1) Surgical ward rounds are fast-paced, which makes it hard to sit down at each patient. Consider sitting out alternate patients, or bays in the doctors room. Alternatively, do your own WR over a day. See each patient and review their notes at your own pace. This is very good for learning, especially if you don't peek at the diagnosis before seeing them (except if the patient answers your opening "what was it that brought you to the hospital?" with "I had a massive heart attack"...)

In clinic
2) Surgical clnics are as speedy as the WRs, and doctors tend to walk from room to room as the nurses shuffle the patients so there's not much chance for sitting. Again try seeing alternate patients, or taking regular breaks (starting before you get tired, not after). In certain clinics, for example one-stop breast clinic, it's really useful to shadow one patient through the entire process. This is naturally paced by the queues for each procedure!

Don't always feel the need to stay for a whole clinic. Go to the ward, or the library to read up on what you've seen.

Looking the part
3) Wear clothes that are easy to get in and out of, and compression stockings if you are prone to fainting or getting all oedema-y in the feet when you stand. If you need particularly large, or particularly small scrubs, it's worth snaffling a pair from the hospital buying your own pair (you can get fairtrade ones here).

4) Buy your own clogs if you have musculoskeletal issues. I'm coming to my 6th month of achilles tendinitis and plantar fasciitis after wearing a pair that didn't fit out of the spares bin (even though I was sitting down almost the whole time!). In most places closed toe crocs are fine. You can (at least in my trust) also just wear shoe covers over your normal comfy shoes.

Pictured are a pair of wooden clogs, painted bright orange, against a
grey background that looks like concrete. These would not be practical
for theatre but at all! Picture by garyknight on flickr.

5) I didn't take my stick into theatre, but if I had, I would have made a cover from a pair of old-and-falling-apart scrubs bottoms, or something. I plan to ask a friendly scrub nurse for something suitable next time.
[Update : When I took my stick into theatre, I was just asked to clean it with hard surface wipes. Obviously, I couldn't use it while scrubbed in. When I started using the wheelchair, one hospital let me bring my chair through the changing rooms and just leave it to scrub in, but another made me leave it in the changing room. I talked to theatre sister in advance about when I was going to be where and she helped me sort out a stool to sit on.]

In theatre
6) Scrub in at least once, even if you can't assist. It's a good skill to learn, and it's all kinds of fun. Ask a scrub nurse to show you how to do it properly. If you do assist, don't for more than 10 minutes the first time (even if non-disabled and/or not holding on to a fat flap / retractor). It's harder work than it might look.
[Update : You can sit down while scrubbed in. During my gynaecology placement I assisted for full lists while sitting down.]

7) Ask a scrub nurse or technician for a spare stool if you can't find one (or ask the anaethetist to borrow theirs if they're not using it). Theatre stools don't usually have back support, so it might be worth talking to you supervisor / disability advisor to try and sort something out if that's a problem. [Update : one hospital I had placement in also had higher stools (think barstool height) which are normally used for optho surgery - these were great for being able to see the field while seated. It's always best to chat to the surgeon about where is best or you to sit so you won't be in the way]

If you can't stand at all, or for long periods, then laparoscopic or opthalmic procedures are great because you can sit and watch what's going on on the screen. Most urology surgeries and some breast surgery (axillary node clearance) are carried out seated so you can see the field sitting down. [Update : I was primary assistant on full gynae lists while seated, without any issues.]

8) Pace yourself. Seeing 3 of the same procedure back to back is not the best use of your time. Sit often, for short periods - don't wait until breaking point to have a rest, and between patients go and sit in a more supportive chair in the break room, and have a drink and snack.

9) Drink plenty of water, don't skip breakfast, and don't be embarassed to sit down or leave if you feel dizzy. It's much less embarassing that fainting into the surgical field (luckily I didn't learn that one by experience!)

10) If you don't have a specific anaesthetics placement, spend some time with anaesthetists during your surgical placements. They are very good at explaining physiology (but be warned, they also ask really tough questions about it...), and there are plenty of chances for procedures (venflons, airways etc). Plus there's lots of sitting. Next time I also plan to shadow a scrub nurse for a list.

Questions

Over the next few weeks, I'm going to try and find out some answers to the following questions. If you know the answer, or how I might find out, please let me know in the comments. If you'd like to add something else to the list, then leave a comment and I'll do my best.

- What support is available through the BMA for disabled med students
- How to access the BMA chronic illness matching scheme

- What adaptations have been made for people during their final clinical exams, especially those with pain / fatigue issues

- What some other people's experiences are of being a disabled medical student or junior doctor (if you'd like to write a guest post, let me know)
- What some examples of med schools being good at dealing with disabled students are
- What equipment is available for D/deaf and visually impaired/blind medics (I'm curious)

- How less-than-fulltime FY1/FY2 years are structured, other than the basic nights and weekends on a pro rata basis stuff (for example, will I end up doing 4 foundation years? will I have to apply for the last 2 as a locum, or will they be sorted out for me? etc)
- Whether Access to Work or Occupational Health can be any use in providing adaptations for the workplace, considering how short junior posts are

Written exams : the basics

To celebrate this being the first time in in 16 years that I have had no summer exams (other than an optional mock exam today), here is my exam survival guide. I hope you might find something useful hidden in the depths of it =)

The beginning of the year, or as early as possible :
1) Sit down with someone in the disability service +/- the medical school, and discuss any adaptations you might need. Remember to plan for your worst day. They will be able to tell you what kinds of adaptations they've made for other students. (For example, using a scribe, having rest breaks, or sitting the exam in a separate room)

Before that meeting it would be helpful to think back on previous exams, or to do a past paper in as close to exam conditions as possible, to find any problem areas.

2) Don't let anyone give you the excuse "but when you're working you won't (get extra time, for example)". You might want to say "yes, but it is not your responsibility to make adaptations for me in the work place". This is more relevant for clinical exams, and I'll discuss that another time. It's a tricky one.

Don't let anyone feel like you are gaining an unfair advantage. These are adaptations you need to minimise the impact of your impairment on your exam performance.

The month of the exam :
3) Practice using any unfamiliar adaptations, such as working with a scribe.

4) Learn a quick relaxation technique, and practice is, in case you have a blind panic on seeing the first question (been there, my friend). Some examples are lying flat on the floor and counting slowly to 100, contracting and relaxing muscles working from the feet up, and reciting a funny poem or singing all the way through your favourite song in your head.

The picture shows a window sill, on which are placed a
pile of books, and a big ball of wool with knitting needles
sticking out of it. Outside the window is a lamp-post.

The week of the exam :
5) Make like a marathon runner and tone down your study. Prioritise rest, good meals, stress busting (cinema, craft, coffee with friends, gentle exercise) and some gentle "dotting the Ts" revision. Get your sleep pattern in sync so it's not an effort to be up in time for a morning exam.

The day before the exam:
6) Make sure you know where and when the exam is, and how you're getting there. I get my Dad to phone the morning of every exam to make sure I'm up (not what you might call a morning person...) Give yourself the best chance of sleeping well by using good sleep hygiene (riciculous phrase!) +/- a wee dram.

7) Make sure you've packed the following in 1+ clear plastic bags :
- pens, pencils, rubbers etc
- uni ID badge if needed
- cushions, splints etc
- regular medication and any PRN you might need
- bottle of water (that you can open) and snacks (unwrapped and folded in kitchen roll so you don't rustle)
- lucky charm or something that makes you smile

The morning of the exam :
8) Wake up in time to have a proper breakfast and a drink and leave in plenty of time. Don't look at any work longer than 1 side of A4.

During the exam :
9) Take at least one 5 minute toilet break (if you don't have rest breaks) to stretch your legs, run through a relaxation technique and/or refresh with a snack. I tend to do this after my first plough through, at the switch between types of questions, or if I get a bit freaked out.

10) Think about variety to reduce over-straining any muscles / joints, and to keep your brain engaged. Switch pens regularly so you don't get the dread exam hand cramp, change sitting position (or switch between between sitting / standing / lying down if that is helpful for you) and consider not doing all questions of one type in a block, but rather doing half of one and then starting the other.

What pre-exam routines do you have? Have your med school been helpful in terms of exam arrangements?