Although most of my experience in this field relates to anaesthesia post graduate exams, I believe it holds firm for other specialities as well - and indeed for undergraduates and teenagers.

It’s not just about what they know. It’s also what they don’t know. If they look blank when coffee room chat turns to Pudsey being the culmination of talent in Britain, or are completely naive of any current affairs, then they are suitably submerged in exam preparation.

This is rule number 1: to acknowledge that significant preparation will be required.

The ones who will pass often look pasty and dull. They are the ones who haven’t been outside for four months. The ones who look worried and who say they don’t know if they will pass but they feel they have prepared as much as possible. While I cannot take credit for it, the phrase “planning and practice prevents poor performance” is absolutely true.

Some people have decided they will fail before they even sit the exam. You only have to ask them how the studying is going. Before they answer they start to shake their head. Rule number 2: to pass exams you need some self belief. Just like putting in a cannula, you have to believe you can do it and approach it purposefully and confidently. The law of diminishing returns applies to exams too. You have to learn that your first attempt is your best attempt, the most likely to be successful, and capitalise on that attempt. Maximise your chances of success, sort your surroundings, get support. Believe you can do it and you will.

Rule 3: know the basics; inside out and backwards. Our trainees from Emergency Medicine and Acute Medicine lament how difficult their new exams are. How little guidance there is. How the syllabus is so far reaching. How there is no guide to studying. This may all be true but these are not the reasons they fail to pass. I have no doubt there is a lot of anatomy knowledge required. I am not surprised they’ve been asked about the pathophysiology of cyanosis. While I don’t know so much about those exams, I do know that if you are a qualified doctor and you don’t know how atropine works you are not going to pass the first exam in any specialty.

Physiology, pharmacology and anatomy are the building blocks of normal body function upon which pathology impacts. I don’t care how many causes of finger clubbing you can name. If you don’t know these basic tools of our trade, you will not get off the starting blocks.

Rule 4: persistence. Sadly there is no short cut to being exam ready. Think marathon rather than 100m sprint. A steady sustained effort is required. Exams are hard work. They are expensive. They are frustrating. They prevent us getting on with our lives. Of course they are hard. If they were easy everyone would pass, they would not be worth having and they would not serve to protect the standards required in our profession.

On the whole I feel sympathetic towards trainees doing their exams. I can see their pain and feel their misery and my overwhelming feeling is one of gratitude that I don’t have to do any more.

Rotas should also be more flexibly and intelligently designed and high quality clinical inductions should be provided for all trainees, according to the proposals drawn up by the Academy of Medical Royal Colleges.

But employers question whether the proposals, designed to improve patient safety and reduce stress on juniors, are affordable and practical.

The first week in August - or the ‘killing season’ as it’s colloquially called - has been the changeover time for most grades of junior doctors since 2007.  But UK and international studies have shown that this is associated with up to a 12% increase in mortality for patients and an increased length of stay of up to 7%.

A survey last year by the Royal College of Physicians of Edinburgh and the Society of Acute Medicine revealed that 58% of juniors believed the August changeover damaged their training, and 90% said it compromised patient safety.

In addition the changeover arrangements place considerable stress on junior staff managing unfamiliar patients in an unfamiliar setting. This is often compounded by having equally new, more senior, trainee colleagues as the first port of call for advice and support.

“Such an unhappy and stressed start to a post is particularly undesirable for doctors embarking on their career and may set the tone for the whole attachment even for those already on a formal career path,” says the AMRC.

The Academy’s recommendations have been endorsed by the Medical Education UK Strategy Group which comprises the chief medical officers and UK medical education representatives. Hospitals, deaneries and college members are being asked to act on the proposals at local level.

But Bill McMillan, head of medical pay and workforce, at NHS Employers, said: “This Academy report is helpful in addressing what constitutes well managed handovers at changeover time. We aim to meet with the Academy soon to explore whether there are issues around terms and conditions, as well as how future developments will support patient care while being affordable and practical for employers.”

Marion Matheson, co-chair of the BMA’s medical student committee, said: “The recommendations offer a logical and practical approach to improving the transition of medical graduates into their first jobs in the foundation programme. It’s a bit disappointing they aren’t already in place and this isn’t already happening and it has had to be explicitly pointed out that this is the best way to get around these problems.

“If the recommendations came in it would be fantastic but it is questionable whether they are attainable.”

The AMRC and the Conference of Postgraduate Medical Deans also plan to further explore moving to a staggered transition date for changeovers. They propose that higher specialty trainees (ST3 and above) should change jobs between two and four weeks after foundation, core and specialty years one and two doctors start.   Some specialities in a number of deaneries have already adopted this approach with positive results.

The recommendations are:

1. Consultants should be available to deliver patient care and support their trainees at transition dates and should ensure their teams value their trainees and welcome trainees seeking assistance.

2. Rotas should be designed to ensure incoming juniors receive rota protection and additional support when on call for the first few weeks of each attachment.  Doctors continuing in posts should cover the initial on call slots of incoming doctors to give them time to increase their confidence and familiarity with the system before being on call. At the end of attachments departing doctors should not, wherever possible, be on call the night before moving.

3. High quality induction should be provided on all units. Inductions should cover: how the unit works, assessing information, investigations, prescribing, unit protocols and introductions to staff. Every effort should be made to make the incomer feel a valued member of the team.

4. Elective work, clinics and meetings should be reduced at changeover in order to free clinical staff to deliver effective induction.

Of 1,100 social workers surveyed by the British Association of Social Workers 88% said vulnerable lives could be put at risk by cuts to services and 77% are concerned about unmanageable caseloads.

BASW issued a stark warning about the dire state of the profession nearly five years after the death of Baby Peter Connelly, as service cuts prevent social workers spending vital time with vulnerable children and adults.

Despite political pledges to protect frontline services, 85% have seen notable cuts to services in the last 12 months; 46% are afraid to speak out about for fear of repercussions; and 65% are concerned about use of unqualified staff.

The frontline social workers who responded to the survey repeatedly expressed their fears about the potential consequences of a system at breaking point.

One social worker reported: “The team I work in currently is working at dangerous caseload levels in terms of child protection work.”

Social workers spoke of how cuts to back office staff meant they now spend even more time on administration than before, and another described the situation in their social work team as “another serious case review waiting to happen”.

They report having to clean toilets, buy their own stamps and even vacuum their own offices instead of spending the time they need with children and adults at serious risk of harm.

BASW has written to the Secretary of State Michael Gove to emphasise its deep concerns about the state of social work, and is also urging the All Party Parliamentary Committee on Social Work to hold an urgent inquiry into the risks to vulnerable children and adults of an overstretched social work service.

BASW has also issued an immediate call for action, calling on government and local authorities to take three steps:

1. Immediate measures to reallocate local authority administrative staff from less critical roles.

2. Place a moratorium on any further cuts to social work allowances or the introduction of any new charges, which are savagely undermining morale.

3. Ensure that Ofsted and CQC prioritise in all inspections the risks of high caseloads and take steps to uncover bullying.

Hilton Dawson, chief executive of BASW, said: “The survey statistics are damning, and the hundreds of comments we have had from social workers are deeply alarming. The government pledged in 2010 to protect frontline social workers, yet by axing support staff they have turned social workers into glorified typists.

“We cannot afford to wait any longer for urgent action from government. Lives that could be helped will be neglected, and lives that could quite literally be saved, will be lost, unless the response is swift and total.

“Social work services were never beneficiaries of investment in the way other areas of public service were during the so called ‘boom years’, yet now they find themselves facing cuts every bit as deep as those in other sectors. We didn’t have the good times, and now we’re facing even worse times. We simply cannot go on like this.”

Read the survey.

And yet as soon as you have the opportunity to phone ahead and warn your contact that you are running late, all that stress seems to evaporate. You are still at the mercy of the red lights but you have changed your response to the situation.

In the same way, all of us experience periods of anxiety at the end of a bad day or as we contemplate the next rung of the careers ladder. It might be your relationship with your supervisor; how much time you are able to spend with patients; or whether you will get the training post you want. It’s natural to worry about any of these matters but you need to address your concerns and key to this is recognising what is within your control.

The following exercise may help…

Select a career objective that you decide is important and achievable (see my previous blog) and make a list of the things you fear will hinder you from reaching your target. Then consider these points in terms of what you can and cannot change and make a list of the three things you can do to help you reach your goal. For example, if you are an F2 doctor who eventually wants to be a cardio-thoracic surgeon, the list of points that you can address might include: participating in clinical audits, joining the SCTS, and seeking out a mentor from the specialty.

On the other hand, the principal obstacle outside your control might be the fierce competition for core surgical training posts in your preferred location. In my experience, it can be enormously difficult for academic high achievers to accept that there are situations where hard work and dedication may not lead to the desired outcome. Worse, many feel they will have failed if they do not achieve their objective, cranking up the pressure still further.

Recognising you cannot change the situation doesn’t mean giving up. Instead, it should prompt you to focus on what you can do yourself, from attending a communication skills course, to formulating a ‘plan b’ such as applying for a training post in another part of the country or perhaps getting experience overseas after your core surgical training.

By acknowledging what is outside your control and changing your response, you will give yourself the best chance of success and be ready to seize any other opportunities which come your way.

Next time: Your career to-do list

Healthcare Performance was established by two doctors with over 30 years’ experience of clinical governance and medico-legal work. It specialises in careers coaching, professional development and organisational trouble-shooting within the healthcare sector.

The group, set up by disgruntled junior doctors in 2006, came to prominence with the introduction of Modernising Medical Careers.

MTAS was an online application system for allocating NHS trainees with jobs. But the system was dogged by security breaches and the poor assessment of applicants. Many juniors were left disillusioned - and indeed in some cases jobless - by the experience.

Its implementation was heavily criticised both in the press and within the medical profession, and it led to the resignations of key staff and apologies from the then health secretary Patricia Hewitt.

Remedy provided a rallying point for juniors, 12,000 of whom attended a march in protest. The pressure group was the driving force in forcing a judicial review into MTAS and its relentless campaigning played a significant part in leading to the eventual shelving of the project.

It went on to pursue the architects of MTAS, pressurising the GMC to use its fitness to practise powers to investigate those responsible. The GMC declined and it resulted in a high profile court case which Remedy ultimately lost.

However, the pressure group struggled to maintain its profile in the ensuing years, with more recent pronouncements being seemingly out-of-step with the profession’s views. Remedy representatives sat on the controversial Future Forum, which advised the government on its Health Bill reforms. And, more recently, it urged doctors not to take industrial action over the NHS pension proposals.

The BMA is this week balloting the profession on potential industrial action.

In a statement, Remedy said: “With much regret we have to inform you that Remedy is no longer able to exist as an organisation.

“After five years of campaigns, direct action, courtroom battles and the occasional march we are unable to sustain the management and leadership that an effective Remedy needs. We have therefore decided to close with immediate effect.”

It concludes: “Remedy was about providing the legitimacy and security to passionate medics who wanted to challenge the views of the establishment.”

Read more.

Abiraterone, marketed as Zytiga, can extend the lives of late-stage cancer sufferers by more than three months.

NICE revised its recommendations after fresh information from the manufacturer, Janssen. Experts welcomed the draft guidance.

Read more in The Guardian.

As an increasing number of countries introduce taxes on unhealthy food and drinks, Oliver Mytton and colleagues at the University of Oxford examine the evidence on the health effects of food taxes on bmj.com.

Evidence suggests that taxing a wide range of unhealthy foods or nutrients is likely to result in greater health benefits than narrow taxes, they say, although the strongest evidence base is for tax on sugary drinks.

For example, a US study found a 35% tax on sugar sweetened drinks (£0.28 per drink) in a canteen led to a 26% decline in sales.

Ideally, they say, taxes should be combined with subsidies on healthy foods such as fruit and vegetables.

Their views come ahead of the 65th World Health Assembly taking place in Geneva on 21-26 May 2012 where prevention and control of non-communicable diseases will be a key issue for discussion.

Meanwhile modelling studies predict a 20% tax on sugary drinks in the US would reduce obesity levels by 3.5%, and suggest that extending VAT (at 17.5%) to unhealthy foods in the UK could cut up to 2,700 heart disease deaths a year.

Opinion polls from the US also put support for tax on sugary drinks at between 37% and 72%, particularly when the health benefits of the tax are emphasised.

However, they point out that understanding the overall effect on health is complicated, and that policy makers need to be wary of negative effects, like changes in other important nutrients and compensatory behaviour that may increase energy intake or reduce energy expenditure.

The food industry also argues that the taxes would be ineffective, unfair, and damage the industry leading to job losses. And from a legislative point of view, it is still unclear how such taxes are best introduced and enforced.

Meanwhile, others have advocated that the taxes be used to raise funds to treat diet related diseases, subsidise healthy foods, or to stimulate industry reformulation of food (such as removal of salt, sugar, or saturated fats from foods).

In a second analysis paper, Corinna Hawkes from the Centre for Food Policy at City University London says that, although governments are beginning to implement food policies to encourage healthier eating, “there remains a long way to go for food policies to reach their full potential.”

She points out that changes to the food supply system since the 1980s have “coincided with rises in obesity and non-communicable diseases” and argues that health must be made a priority for the modern food economy.

Read more.

Their report says part of the problem is drugs being bought cheaply in the UK then sold at higher prices elsewhere in Europe.

The MPs say the government needs to “up its game” to tackle the acute and disproportionate impact on patients. The Department of Health says it has issued new guidelines and is working with every part of the supply chain.

At any one time between 30 and 40 medicines are in short supply. These have included treatments for Parkinson’s disease, some cancers and depression.

The All Party Pharmacy Group of MPs says the main cause is some medicines being exported by smaller wholesalers to make a profit, not the supply from pharmaceutical manufacturers.

Read more at BBC Health.

In my blogs I’d like to unpick the doctor-manager relationship, to better understand why it is frequently a strained one. To start, let’s examine why doctors and managers often seem to have different agendas.

This is a fascinating question. I commented in my last blog that the ‘real’ agenda was not one created by managers or politicians, but one that had arisen through evolution - of the consumer society, of medical advance, of disease patterns, and of the economic climate.

What have been created though are targets. These, and the ‘target culture’, are generally unloved. But are doctors opposed to targets per se? Few feel it is right for people to wait over 4 hrs in ED, or over 18 wks for a hip replacement, or over 2 wks for cancer fears to be checked out? I suspect what doctors oppose is unintelligent target chasing in ways that set aside the interests, rights, and dignity of patients. Box ticked but point missed.

Look at Mid Staffs I hear you say? The issue there was not targets, or the need to balance budgets or achieve FT status - it was that clinical safety and patient dignity were allowed to fall by the wayside in pursuit of these aims. The system never mandated this, but it happened because the trust board felt an imperative to achieve and then allowed themselves to make bad decisions. They failed to recognise what was right, and to keep that as their guiding principle.

Management must manage rigorously, and must be prepared to take difficult decisions, but it must also be strong enough to do what is right. And doing what is right might be, in some circumstances, the hardest thing of all. Especially if you feel culpable for getting into a difficult situation in the first place.

Easy to say? Sure, but management is not easy and neither is leadership, which is called for on such occasions. Boards have a non-executive majority to provide challenge, and they have people senior and strong enough to challenge the wider system if it seems to be requiring the wrong things to be done.

Of course, the aim is to avoid getting into a ‘no win’ situation, by managing effectively and being clear about values, aims, and priorities. If these are the right ones, and they are adhered to consistently, then there will surely be alignment with the medical body? Then, if matters deteriorate, managers and medics will be together, and positioned to address difficulties jointly, in a way that doesn’t compromise those values and priorities.

It’s clear what the NHS is for, so it takes some doing to break the natural alignment of all those working in it, be they doctors, managers, or anybody else! It reflects poorly on management that it happens so frequently.

A final point - we often blame ‘the system’ but the best way to improve it is from the ground up. A consensus amongst doctors and managers would be a powerful way of creating a strong enough movement to do this. We are too passive. We should seize the initiative and shape the system so it always acts in the patient interest, because we know this is right.

Fresh fears over the future of the department were raised after maternity was axed at the site in February. But chiefs at Pennine Acute Trust have agreed to spend £2.25m to improve facilities and say that will secure its long-term future.

The A&E was originally designed to treat 45,000 patients a year - but last year saw more than 65,000 people and bosses say it needs to expand to meet the demand.

Read more in the Manchester Evening News.