Author Archives: Thuvaraka Ware

Thuvaraka Ware

About Thuvaraka Ware

Thuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

The merits of time off from practice

Thuvaraka Ware

Thuvaraka Ware

Thuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.
Thuvaraka Ware

photo-1460398495418-62c9b5d79fbfAlthough we would otherwise think and hope it, there remains a culture within medicine that disincentivises time off for anything, from parental leave to sabbaticals. The reasons for this are myriad, from concerns about de-skilling to the fear of the unknown and coming off the conveyor belt of speciality training.

There is, of course, security and contentment in knowing where you are heading and following a chosen and well-trodden path, weathered by many before us. But what are we denying ourselves by racing to the end without exploring the diverse options available to us? Despite being a motivated, intelligent and compassionate workforce, with many transferable skills, it sometimes feels like our choices are limited.

During my maternity leave, I did not have the time to do much more than nurture my children, both of whom are intent on removing themselves from the gene pool in interesting ways. But the time away from clinical practice let me breathe, reflect on my career so far and derive meaning in my role as a doctor. I was able to explore ideas I would not have normally, like writing; I also got back to doing art, using skills developed during the warm haze of my grammar school years, but left languishing in some part of my mind not regularly used for analysing blood results and honing consultation skills. I optimised this period of reflection further by making use of a fantastic mentor, who helped me realise my strengths and the aspects of my work that gave me real satisfaction. On my return to the practice, I felt better able to direct my training with purpose and creativity.

I do not think that I would have achieved this without the time off, as the emotional and mental strain of work leaves little room for fanciful ideas at the end of each day. It is no surprise that the mental health of medics is one of the poorest of any professional in the country, as we so rarely give ourselves a break. Taking time off may be very useful to check in with our inner id, to ensure we are happy on the path we find ourselves – or give us a stimulus to find another one.

This experience has also spilled over into other aspects of my life. By feeling like I am doing something meaningful at work, I am able to take this personal sense of value and make the limited time I have with my family richer and more colourful. And the newfound purpose adds to the feeling that hopefully I will leave behind something grander and more significant, than the day to day tasks of reassurance, negotiation and docman reviews.

So be brave and take a break from work! Take pause and stock of your place in it all. You only get one chance at this and after all, as they say, its all about the journey.

Have a little faith: trainee view of audit and paint-by-numbers medicine

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

The audit process is an important part of clinical governance to ensure standardised, high quality care.  It is encouraged by medical schools and a necessity of training programmes.  But for our generation of paint-by-numbers medicine and algorithm based practice, clinical audit has become another hoop to jump through for the eportfolio.  I recently completed an audit looking at the prescription of statins in patients with chronic kidney disease (CKD).  The standards were taken from the 2014 Lipid Modification NICE guidelines which advised all patients with CKD to be on atorvastatin 20mg or an equivalent regardless of age, comorbidity or qrisk.

My search revealed several high risk vasculopaths who weren’t on statins.  Yet, the largest proportion was octogenarians for whom improving 10 year survival seemed questionable.  The guidelines did not make allowances for multiple morbidity, polypharmacy or compliance in this cohort.  I marched on nevertheless as per my ARCP requirements; however, it became clear that patients are particularly astute at nuance and picking up indecision on the clinician’s part.  I found it difficult to convince those on the fence to take the statin because of my own ambivalence about its benefit.  The implementation of change was therefore weak leaving the audit suboptimal.

The need to complete an audit for the sake of it is just one facet in the NHS and its increasing ‘obsession with grip’ (as Keith McNeil, former chief executive of Addenbrookes Hospital, puts it).  The benefits of good patient care and effective training is secondary to outcomes, stringent documentation and rigorous regulation; the art and apprenticeship of medicine is being eroded.  Yes, regulation is important and safety paramount. But experience, skill and judgement – those things we only ever learn through autonomous practice and reflection – appears to have little value in the current climate.

In this context, one thing we can do to make clinical audit more relevant than just a CV exercise, is to bring a bit of ourselves into the process and have a little faith in the cycle.  Find something that piques curiosity and is not just a recent topical guideline; an idea that makes tangible sense to you as something that could actually improve practice rather than promising to do so. This belief and commitment will be visible to and appreciated by patients and other relevant stakeholders; which in turn will provide the real impetus to complete an effective audit, one that will maintain relevant clinical standards or effect real change in order to do so.

Junior doctor dispute: The politicisation of a generation

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

I am a junior doctor. I went through medical school, foundation and speciality programmes with relative ease and multiple accolades.  I married a guitar playing, Aston Villa supporting historian I met at university who entered policy work.  I would scoff at his insistence that politics was important – I truly believed that I was doing the only true and noble job in the world. Politics was beneath me.

Experiencing the furore of our contracts dispute I now realise how completely and naively politically illiterate I was.  To disengage with this process and say it does not concern us for we are public servants has proved detrimental.  If the health secretary has done nothing else, he has at least caused a political awakening amongst our generation and I am not ashamed to say that at times this has been thrilling.  I have attended marches, canvased local support, given interviews, written and appeared in newspapers and journals and signed numerous group letters to various news outlets.

Social media has played a central role in this. Facebook groups have allowed us to feel connected to almost every other junior doctor in the country in some way, answer queries, debate responses and celebrate victories. The twittersphere, has enabled rapid dispersal of information and opinion.   Both these have helped nurture and spread the message of an essentially grass roots campaign, like #meetthedoctors, to fight the imposition of a contract that is unsafe for patients and unfair to us.

The unravelling of this dispute in the media has strengthened the resolve of many of my peers to become more politically active.  Many believe that the media have to take responsibility for their role in exacerbating this dispute – you may recall the now retracted 1998 Wakefield study and subsequent rise in incidence of measles as an example.  Indeed the online national survey by Gan et al1 to explore the ‘Hunt effect’ suggested that in the months after reporting of Jeremy Hunt’s irresponsible interpretation of the Freemantle epidemiological study2, there were patients presenting later than they would have to emergency services, afraid the weekend care would be suboptimal.  Patient care was potentially compromised as a consequence.

By engaging with the press, we are able to project our concerns whilst also being able to hold them accountable to what they write – my peers have written letters to the Independent Press Standards Organisation (IPSO) and a complaint about a report on our pay was recently upheld by the BBC.  This increased engagement between our media and the scientific community can only be a good thing, hopefully leading to an improved relationship long term.

As we enter the next chapter of this dispute with a clear mandate for industrial action it is life affirming to realise that we are not alone.   Many patients, allied health professionals and other emergency staff understand the nature of this fight and stand with us.  Becoming politically aware does not have to mean just engaging with politicians and the status quo.  It is also the way we connect on a meaningful level with those around us to make our immediate and extended social, cultural and economic environment relevant and bearable.

Although I am yet like a child taking my first steps in this new landscape, my feelings of political apathy are diminishing and I sense that change is possible.  I’m aware that our contracts debate will take many months to resolve.  But I am hopeful that our political awareness and social responsibility will survive the crest of this campaign post crisis, whatever the outcome.



1. Gan HW in response to BMJ 2015;35:h4596. Available online:
2. Freemantle et al., Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351:h4596