JDN_16NL_Oct2019

JUNIOR DOCTORS
NETWORK
empowering young physicians to work together towards a healthier
world through advocacy, education, and international collaboration
Published by the Junior Doctors Network of the World Medical Association
The information, perspectives, and opinions expressed in this publication do not
necessarily reflect those of the World Medical Association or the Junior Doctors
Network. WMA and WMA-JDN do not assume any legal liability or responsibility
for the accuracy, completeness or usefulness of any information presented.
Junior Doctors Network Newsletter
Issue 16
October 2019
ISSN (print) 2415-1122
ISSN (online) 2312-220X
Junior Doctors Leadership 2018−2019
Junior Doctors Network Newsletter
Issue 16
October 2019
Dr Chukwuma
Oraegbunam
Nigeria
Dr Yassen Tcholakov
Canada
Dr Sydney Mukuka
Chileshe
Zambia
Dr Mike Kalmus
Eliasz
United Kingdom
Dr Audrey Chloe
Fontaine
France
Dr Lwando Maki
South Africa
Dr Helena Chapman
Dominican Republic
Dr Chiaki Mishima
Japan
Dr Anthony
Chukwunonso Ude
Nigeria
Dr Caline Mattar
Lebanon
Dr Paxton Bach
Canada
CHAIR
DEPUTY
CHAIR
SECRETARY
SOCIO-MEDICAL
AFFAIRS
OFFICER
EDUCATION
DIRECTOR
MEDICAL
ETHICS
OFFICER
MEMBERSHIP
DIRECTOR
PUBLICATIONS
DIRECTOR
COMMUNICATIONS
DIRECTOR
IMMEDIATE
PAST
CHAIR
IMMEDIATE
PAST
DEPUTY
CHAIR
Page 2
Dr Konstantinos
Roditis
Greece
Dr Jeazul Ponce H.
Mexico
Dr Mariam Parwaiz
New Zealand
Dr Vandrome Nakundi
Kakonga
Democratic Republic
of the Congo
Dr Suleiman A. Idris
Nigeria
Dr Ricardo Correa
United States
Dr Victor Animasahun
Nigeria
Junior Doctors Network Newsletter
Issue 16
October 2019
Editorial Team 2018−2019
Page 3
Table of Contents
TEAM OF OFFICIALS’ CONTRIBUTIONS
06 Words from the Chair
By Dr Chukwuma ORAEGBUNAM (Nigeria)
07 Words from the Communications Director
By Dr Anthony Chukwunonso UDE (Nigeria)
08 Words from the Publications Director
By Dr Helena CHAPMAN (Dominican Republic)
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS
09 Communication and the Junior Doctor
By Dr Bankole OYEWOLE (Nigeria)
11 The Physicians’ Five Keys to Making Lasting Impact
By Dr Anthony Chukwunonso UDE (Nigeria)
14 Health Inequities: Challenges for Doctors in Low- and Middle-Income Countries
By Dr Vandrome NAKUNDI KAKONGA (Democratic Republic of the Congo)
16 Water in a Landlocked Country
By Dr Binet ARYAL (Nepal)
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES
18 Kenya’s Path to Universal Health Coverage: Seizing the Political Commitment
By Dr Lyndah KEMUNTO (Kenya)
20 Surgical Site Infections in Venezuela: Global Call to Action
By Dr Genesis NARANJO (Venezuela), Dr Antonio REYES (Venezuela), and Dr Raymar
ROMERO (Venezuela)
23 CHARTING Study: A Trainee Collaborative Research Study
By Dr Igbokwe MARTIN (Nigeria), Dr Ibisola BABALOLA (Nigeria), and Dr Oladimeji
ADEBAYO (Nigeria)
JUNIOR DOCTORS’ ACTIVITIES
25 Physicians’ Work Style Reform in Japan: Gender Equality
By Dr Daisuke KATO (Japan)
28 Junior Doctors Improve Medical Training Environments in the Republic of Korea
By Dr Jihoo LEE (Korea), Dr Jaehyeon JANG (Korea), and Dr Sei NA (Korea)
32 Fourth General Assembly of Japan Medical Association/Junior Doctors Network
By Dr Ayaka ISHIHATA (Japan) and Dr Kazuhiro ABE (Japan)
Junior Doctors Network Newsletter
Issue 16
October 2019
Page 4
Table of Contents
SPECIAL SERIES: MEDICAL ETHICS
35 Introduction to the Special Series on Medical Ethics
By Dr Lwando MAKI (South Africa) and Dr Aashish KUMAR SINGH (India)
36 Hands that Heal are not Meant to be Broken
By Dr Aashish KUMAR SINGH (India)
38 Untold Stories of Young Doctors from the Land of the Himalayas
By Dr Uchit THAPA (Nepal)
INTERNATIONAL CONFERENCES
40 KMA Young Doctors Network Pre-Conference: Mentorship and Innovation in
Medicine
By Dr Lyndah KEMUNTO (Kenya) and Dr Elizabeth GITAU (Kenya)
43 Health Professional Meeting 2019: Road to Universal Health Care
By Dr Chiaki MISHIMA (Japan), Dr Wunna TUN (Myanmar), and Dr Chukwuma
ORAEGBUNAM (Nigeria)
WORKING GROUPS
46 Medical Ethics Working Group Update
By Dr Lwando MAKI (South Africa)
48 Global Surgery Working Group Update
By Dr Manon PIGEOLET (Belgium)
Junior Doctors Network Newsletter
Issue 16
October 2019
Page 5
Over the past eight years, we have seen a growing interest in the Junior Doctors Network
(JDN) from colleagues all over the world. This is a reflection of the progress that we have
made over the years, ensuring that the JDN remains an avenue for young doctors to gain
the capacity to achieve their professional goals in medicine and public health leadership.
We are appreciative for the World Medical Association (WMA) leadership, which continues
to support the JDN activities, including our attendance and ability to represent the WMA at
various high-level international meetings. As the JDN membership continues to grow, JDN
members are able to become more involved in the decisions that shape our future as well
as the health and well-being of our patients.
Internally, we continue striving to utilize approaches that can increase JDN members’
participation in JDN meetings and activities. We now have an operational ‘Terms of
Reference’ and ‘Strategic Plan’, which aim to help our future generations to understand
where we have come from and the direction we are headed. We also regularly track the
task completion of JDN officers and work groups in order to record improvements as well
as encountered challenges.
As our meetings have had increased attendance and participation, we are gradually
implementing changes that enhance JDN member involvement. In efforts to strengthen our
capacity as the next generation of physician leaders, we have adopted the theme, Gender
Equity in Medical Leadership, for our JDN meeting (October 2019) in Tbilisi, Georgia.
Finally, as we wind up the 2018/2019 term, our progress and direction reflect our stated
mission: “Empowering young physicians to work towards a healthier world through
advocacy, education, and international collaboration”. Increased collaboration and
feedback from all JDN members will allow us to maintain and improve on our past and
present accomplishments, which will dually benefit our future medical leadership and
growing patient populations across the world. It has been an amazing period of my life
chairing the JDN management team, enjoying the support of the management team and
general membership. I most sincerely appreciate our JDN community and hope that our
paths continue to cross in the future. I look forward to seeing many of you in Tbilisi.
Junior Doctors Network Newsletter
Issue 16
October 2019
Words from the Chair
TEAM OF OFFICIALS’ CONTRIBUTIONS
Chukwuma Oraegbunam, MBBS MWACP MRCPsych
Chair (2018−2019)
Junior Doctors Network
World Medical Association
Dear colleagues from around the world,
Page 6
Once more, it is my pleasure to welcome you to the 16th issue of the Junior Doctors
Network (JDN) Newsletter. This newsletter serves as an editorial trademark while we work
together towards a healthier world through advocacy, education, and international
collaboration.
This feature has continued its mission and vision of this totem, which aims to indoctrinate,
inculcate, and fascinate junior doctors worldwide on contemporary issues affecting them.
This effort can encourage junior doctors to share their experiences, become empowered,
and find opportunities to better themselves and their communities via sound apprehension
and grasp of these issues.
My profound respect goes to our wonderful Publications Team, ably led by Dr Helena
Chapman, for their invaluable role in maintaining the high-quality standards of the JDN
Newsletter. I am always delighted and proud of what the Publications Team has
orchestrated on the pages that follow.
I hope that these articles will stimulate informed debate and a lively exchange of ideas. We
look forward to receiving your feedback on this issue. We also encourage your input on
topics to be covered in future issues, especially those local and global subjects that directly
impact the work of junior doctors across the world.
Stay with us, enjoy the read, and expect more!
Junior Doctors Network Newsletter
Issue 16
October 2019
Words from the Communications Director
Anthony Chukwunonso Ude, MBBS MWACS
Communications Director (2018−2019)
Junior Doctors Network
World Medical Association
Dear colleagues,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 7
Junior Doctors Network Newsletter
Issue 16
October 2019
Words from the Publications Director
On behalf of the Publications Team (2018−2019) of the Junior Doctors Network (JDN), we
are honored to present and share the 16th issue of the JDN Newsletter to junior doctors
across the world.
The 15th issue of the JDN Newsletter, published in April 2019, included contributions from
junior doctors from Belgium, Canada, Denmark, Dominican Republic, Greece, India, Japan,
Malaysia, New Zealand, Nigeria, Singapore, United Kingdom, and the United States. These
articles offered summaries of international health conferences, JDN activities, and other
reports and updates on important global health subjects.
Likewise, this 16th issue of the JDN Newsletter includes additional articles from junior
doctors from Belgium, Democratic Republic of Congo, Dominican Republic, India, Japan,
Kenya, Korea, Myanmar, Nepal, Nigeria, South Africa, United Kingdom, the United States,
and Venezuela. These articles incorporated updates on JDN activities, summaries of
international health conferences, narrative pieces on scientific perspectives, and reflections
on community health topics. Notably, a special series on medical ethics was incorporated
into this issue.
As an international platform for the global community of junior doctors, the JDN Newsletter
provides an avenue for junior doctors to share their expertise and reflections about trending
topics in clinical care, research, and community practice. Their dedication to scientific
communication continues to inspire other junior doctors and facilitate communication
between World Medical Association (WMA) and JDN members. Through this network,
junior doctors can learn about emerging global health challenges and advocate for
transdisciplinary collaborations to safeguard population health for local, national, and
regional communities.
We recognize the dedicated efforts of all editors of the JDN Publications Team 2018−2019
as we completed the editorial tasks for this 16th issue. We also acknowledge the continued
support of the JDN management team and WMA leadership for this indispensable resource
for junior doctors across the world. We hope that you enjoy reading the articles in this 16th
issue!
Helena Chapman, MD MPH PhD
Publications Director (2018−2019)
Junior Doctors Network
World Medical Association
Dear JDN colleagues,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 8
50% of hospital doctors. As junior doctors, we have the unique opportunity to develop
rapport with patients and their families, especially during distressing situations. Patients
may find us more approachable and readily available, compared to more senior members
of the clinical team. Although studies have shown that levels of empathy are highest among
medical students and junior doctors, these levels decline steadily as doctors progress in
training and experience, a term described as ‘ethical erosion’ (1). Burnout, fatigue, high
patient load, time pressures, and lack of senior support are factors that decrease empathy
and lead to inadequate communication skills. This may result in low patient satisfaction,
breakdown of trust, inadequate adherence, and formal patient complaints (1,2).
As junior doctors, we are usually the first clinical team member to evaluate the patient. We
take the relevant medical history, conduct a physical examination, formulate preliminary
diagnoses, and describe the appropriate management plan. Furthermore, breaking bad
news is also a frequent responsibility of junior doctors. Hence, strong communication skills
are essential to delivering effective healthcare services.
Since the bedrock of the doctor-patient relationship is communication, failure in this skill
may result in unintended consequences. Poor communication skills in medical history
taking may lead to misdiagnosis, while miscommunication in conducting intimate physical
examinations could lead to an accusation of sexual abuse. Studies have shown that
inappropriate communication remains a top reason why patients complain about the
healthcare services that they seek and receive (2).
The earliest example where I valued good doctor-patient communication and rapport
occurred during my internship year on the paediatric ward of a teaching hospital in Lagos,
Nigeria. A male child was diagnosed with a kidney tumour that required urgent
chemotherapy. As the most junior doctor on the team, my responsibility included explaining
Junior Doctors Network Newsletter
Issue 16
October 2019
Communication and the Junior Doctor
Bankole Oyewole, MBChB
Foundation Year 2 Doctor, East Kent Hospitals University Foundation
Trust
Kent, United Kingdom
In the United Kingdom, the term ‘junior doctor’ applies to medical
practitioners, ranging from newly qualified doctors to those who are
completing specialty programs. This large cohort makes up more than
Junior doctors are well-positioned to develop cordial relationships
with patients, encouraging them to choose healthy lifestyle
behaviours.
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 9
to his mother the severity of the medical condition, encouraging treatment adherence, and
highlighting possible side effects of chemotherapy. We developed strong rapport through
an open communication channel, where I kept her informed about her son’s response to
chemotherapy, any arising complications, and respective clinical management. She
highlighted that this communication differed to her previous experiences in the paternalist
healthcare system. Unfortunately, her son passed away suddenly overnight from treatment
complications. To my surprise and initial trepidation, I received an unexpected telephone
call from his mother, verbally thanking our team for the high-quality healthcare services that
her son received during his hospitalization.
As a doctor now practicing in the United Kingdom, a different sociocultural environment
from my internship in Nigeria, communication is a recognized aspect of clinical practice and
education, particularly for junior doctors. While some doctors are naturally skilled
communicators and effortlessly develop good patient-doctor relationships, formal training
on effective communication skills is essential to enable all junior doctors to adequately
conduct their roles. This can be done through advanced communication courses,
resources, and workshops, which empower and better prepare junior doctors to have
complex and difficult discussions about resuscitation (e.g., Do Not Attempt Resuscitation
Orders), advanced care plans, palliative care, and end-of-life discussions. Communication
skills, rapport, and genuine displays of empathy can be improved through formal training,
regular practice, feedback, and mentorship within a structured framework. This allows
junior doctors to identify areas of strengths and weaknesses, and work towards self-
improvement to deliver better patient care and healthcare experience (3).
Communication challenges differ across healthcare settings. In low- and middle-income
countries (LMICs), junior doctors may be confronted with difficult discussions relating to
distrust of Western medicine, which may lead to reduced compliance to treatment plans
and poor health-seeking behaviors. Difficult communication may also centre on health
promotion and cessation of harmful traditional practices.
Formal communication training for junior doctors focused on sensitive clinical topics, is
essential for the delivery of patient-centred healthcare, which can improve treatment
adherence and overall patient satisfaction and well-being. This is an area of development,
especially among doctors from LMICs, if global health inequalities are to be bridged.
References
1) Stratta E, Riding D, Baker P. Ethical erosion in newly qualified doctors: perceptions of empathy decline.
International Journal of Medical Education. 2016;7:286–292.
2) Önal G, Civaner M. For what reasons do patients file a complaint? A retrospective study on patient rights
units’ registries. Balkan Med J. 2015;32:17–22.
3) Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clin Diagn
Res. 2015;9:JE01–JE4.
Junior Doctors Network Newsletter
Issue 16
October 2019
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 10
their clinical and community practice. They are trained to understand disease
pathophysiology, complete the diagnostic work-up, and provide the appropriate treatment
plan for patients. As the main drivers of biomedical research, their contribution to medical
sciences can improve population health and lead to potential scientific discoveries.
However, many doctors have underutilized the great potentials of our creative and
intellectual capacity. Some have continued to set goals that are based on financial
incentives, rather than the patient’s satisfaction and self-actualization. The desire to
accumulate financial wealth in the medical field does not lead to lasting impact or fulfillment
in life. Fulfillment is achieved by sharing our lives with others (e.g., leadership or
mentorship roles) and rendering beneficial services to mankind, in order to reach the goals
of self-actualization.
A strong desire to do well is a major key to making a lasting impact, which culminates in a
positive permanent influence and an indelible mark on colleagues and humanity. This
expectation should be placed upon every doctor, which can be achieved if the desire is
appropriately stimulated. To encourage doctors to demonstrate leadership, collaborate with
colleagues, and generate scientific knowledge for the medical discipline, they must follow
five key elements to make a lasting impact. These elements include passion, memory,
discipline with adaptability, favor, and courage.
PASSION
To make a significant impact, doctors must exhibit strong emotions that focus on a dream
and determination to find a solution that benefits an individual or group of individuals.
Without this quality, there would be no will to persevere or reach any significant discovery.
Passion is the key to impact and can sustain enthusiasm despite temporary failures. If
doctors are passionate, the obstacles will seem smaller.
Junior Doctors Network Newsletter
Issue 16
October 2019
The Physicians’ Five Keys to Making Lasting Impact
Anthony Chukwunonso Ude, MBBS MWACS
Communications Director (2018−2019)
Junior Doctors Network
World Medical Association
Globally, medical doctors complete years of classroom education and
clinical training, gaining expertise in the basic and clinical sciences for
“We know what we are, but not what we may be”
– William Shakespeare
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 11
MEMORY
Memory, a process of remembering the past, is the cornerstone of training and learning.
Doctors experience life in three phases: past (memories), present, and future (action). They
must examine the past in order to understand how to conduct present affairs as well as use
the present to learn how to create a more enlightening future. Hence, past experiences
benefit the present and help in proper planning for the future.
DISCIPLINE WITH ADAPTABILITY
Discipline is the act of training where individuals adhere to specific codes of conduct, and
penalties exist for individuals who do not comply. The need to adjust and reflect on
personal beliefs (ethos) incorporates the concept of adaptability. Together, these elements
highlight that learning remains above irrational, emotional or sentimental behaviors. As
doctors must attain a high sense of discipline with adaptability, they can focus on goal-
setting and be intentional and productive with assigned tasks, which can lead to achieving
established goals.
FAVOR
Favor is believed to incorporate attributes of divinity, defined as a belief that external forces
control and direct our activities and efforts as humans. To experience favor, doctors must
exhibit emotional stability and a positive mental attitude. Favor is an advantage in every
position of life, from a subordinate role to every level of authority. Humility, gratitude, and
being at the right place at the right time complement favor toward making a lasting impact.
COURAGE
No pioneer has been recognized by traveling on familiar paths. Courage means taking
action and moving forward, despite the presence of internal or external limitations. Internal
limitations include doubt, shyness, fear, low self-esteem, little or no education, and other
negative self-attributes. External limitations are issues emanating from outside sources,
which include ridicule, opposition, and discouragement from friends and associates.
Courage is the quality of mind or spirit that will prepare doctors to face the aforementioned
limitations without fear. Without courage, they cannot make a difference or initiate the
appropriate conversations that lead to lasting impact.
Junior Doctors Network Newsletter
Issue 16
October 2019
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 12
As junior doctors, how do we want to be defined? Are we motivated to make a positive,
lasting impact on society? Through patience and sacrifice, these five keys will help doctors
identify small observations about reality, demonstrate excitement and motivation through
beneficial pursuits, and exhibit perseverance to explore scientific discoveries. They surely
will guarantee that a lasting impact and an indelible mark are just around the corner.
Acknowledgments: I would like to thank Dr Michael Obaro, Senior Lecturer and Consultant
in the Department of Pharmacology and Therapeutics at the University College Hospital
Ibadan, for his mentorship during the preparation of this manuscript.
Junior Doctors Network Newsletter
Issue 16
October 2019
By dedicating our time, energy, and resources to helping
others, junior doctors can create a deep sense of personal
fulfillment and make a positive impact on those around us.
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 13
Julian Huxler was the first to use the slogan “Health for All” in the Picture Post, a weekly
British Post magazine. He called for “a healthy diet for all, everyone to have a chance to
reach known health standards, public health as a positive service, health put on a family
basis, a real family and population policy…” (1). In 1948, many of these principles were
included in the National Health Service policy in the United Kingdom. Later in 1978, the
World Health Organization (WHO)’s initiative regarding “Health for All”, encouraging each
country to formulate national policies and strategies for health, was emphasized at the
global conference on Primary Health Care in Almaty, Kazakhstan.
The notion of “Health for All” is still far from being achieved in the world, particularly in low-
income countries. Many patients with preventable or treatable conditions cannot easily
access health care services due to geographic distance or financial limitations. Sadly,
some patients pass away right before their doctors’ eyes, with little that can be done by
medical and nursing teams. As a junior doctor, I have cared for children with chronic
diseases such diabetes and sickle cell anemia in clinical practice, where our health center
did not have insulin or hydroxy-urea management, respectively. Other patients required
chemotherapy or surgical procedures, such as surgical repair of congenital cardiac defects,
but were unable to afford these necessary treatment modalities.
As medical graduates, we took the Hippocratic Oath (2), which serves as the pillar of
medical practice, where doctors accept their professional devotion to patient care.
However, doctors in low-income countries face significant limitations in providing clinical
care, including inadequate medical and pharmaceutical supplies. Also, widespread poverty
challenges patients’ ability to care for themselves and their families.
Junior Doctors Network Newsletter
Issue 16
October 2019
Health Inequities: Challenges for Doctors in Low- and
Middle-Income Countries
Vandrome Nakundi Kakonga, MD
General Physician
Bukavu, Democratic Republic of the Congo
Variations in health and health care are evident worldwide, but low
household incomes and the lack of social health insurance in low-
and middle-income countries are alarming situations (1). In 1941,
“I SOLEMNLY PLEDGE to consecrate my life to the service of
humanity… THE HEALTH AND WELL-BEING OF MY PATIENT will
be my first consideration… I WILL MAINTAIN the utmost respect
for human life…”
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 14
Where is the actual problem? A political or economic system like capitalism? Inadequate
resource management in Africa? Although a controversial topic, some economists believe
that capitalism is the only economic system viable for the foreseeable future, because there
are no workable alternatives (3). As free markets and consumer choices have led to
competition and creativity, great wealth has been generated in these societies. As such,
more resources have become available to invest in all sectors, particularly in the health
sector.
However, there are still many ethical questions unresolved with capitalism: Are private
property and free markets morally acceptable? Does great wealth enable groups and
individuals to buy political power and influence? Is capitalism compatible with factors that
we value, such as family, community, and friendship? All these values are highly important
for equitable global resource sharing, which can lead to improved health care access for all.
Moreover, capitalist societies still struggle with unresolved issues of exclusion, violence,
political power and influence, environmental destruction, and poverty (3).
Although global poverty has been clearly associated with poor health, we still observe a
significant gap between persons associated with high and low socio-economic levels.
Hence, by promoting health equity, the intention is to sensitize the capitalist class to
reconsider the concept of “profit” in order to facilitate how low-income communities can
increase their household incomes. The low household incomes limit access to health
services and constitute one of the main factors contributing significantly to malnutrition of
children under five years (4). Malnutrition affects the intellectual development of children,
which then reduces their future productivity in society.
Junior doctors expect concrete actions from the capitalist class − our national and
international leaders − including resource allocation to build sustainable primary health care
and social health insurance. With more than 30 years of HIV/AIDS global initiatives, we
have observed the impressive results of participating stakeholders and billions of dollars
mobilized. Hence, real scientific progress requires the same mobilization in order to assure
universal health coverage. This challenge will be the responsibility for our generation.
References
1) Calman KC. Equity, poverty and health for all. BMJ. 1997;314:1187–1191.
2) World Medical Association. WMA Declaration of Geneva. 1948 [updated 2006, cited 2019 Jul 10].
3) Bishop JD. Ethics and capitalism. Toronto: Univ Toronto Press; 2000.
4) Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr. 2010;47:667–678.
Junior Doctors Network Newsletter
Issue 16
October 2019
As health leaders prepare the agenda of the high-level meeting on
Universal Health Coverage in September 2019, junior doctors’
voices should be heard.
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 15
majority of its citizens lacks sanitary water supply. Both rural and urban populations of
Nepal face problems of water scarcity and pollution. While rural populations walk hours to
gain access to natural sources of water, urban populations rely on commercial water
dealers. There are over 250 water bottling factories in the Kathmandu Valley alone. Over-
extraction of groundwater by unlicensed water sellers prevents the government from using
these sources to augment the city supply (1).
Water pollution in Nepal is due to domestic, industrial, and untreated sewage form highly
populated communities. Domestic neighborhood and district water supplies, such as wells,
tanks, and reservoirs, may be contaminated by poorly designed or maintained sewage
disposal systems (2). When toxic water seeps through the ground, it pollutes the
underground water source. With the recent earthquake, continuous flooding, and
landslides, increasing population size has contributed more to this problem (Photo 1).
In 2011, the Nepal Demographic and Health Survey reported findings that the prevalence
of diarrhea in children under five years of Nepal was 14% (3). According to the Asian
Development Bank (ADB), 21% of households in the Kathmandu Valley did not have
access to a piped-water supply in 2009 (4). Due to the exponential rise in population and
failure of national drinking water projects, this rate increased to 34% in 2015 (2).
Junior Doctors Network Newsletter
Issue 16
October 2019
Water in a Landlocked Country
Binit Aryal, MBBS
House Officer, Blue Cross Hospital
Kathmandu, Nepal
Nepal has a population of 29.3 million people. An estimated 42
percent of the population lives below the poverty line, and the
Photo 1. Sewage and household waste dumped
in the river of the Kathmandu Valley.
Credit: Nepalireporter, Binit Aryal.
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 16
Households that had access to piped water, received this supply for fewer than six hours
per week (4).
One study reported that E. coli was detected in 61% of the groundwater samples (5). It
showed that consumers served by an untreated groundwater supply were at risk of enteric
diseases. A high risk of diarrhea from groundwater was estimated in a risk assessment
study conducted in the Kathmandu Valley, and the implementation of risk reduction
programs was recommended (6).
Apart from drinking water, causes of E. coli infection that remain less explored are bathing
and swimming, which contribute to the transmission of diarrheal diseases. People
accidentally ingest water during swimming and bathing, and children ingest higher amounts
than adults (6). Bathers in polluted water sources are exposed to an increased risk of
gastrointestinal infections (7). These outcomes have alerted the public about the need for
researching the role of bathing in disease transmission, focusing on young children.
As a country with high morbidity and mortality rates due to the lack of medical care during
diarrheal illness, sanitary water supply remains a mainstay of a solution to this public health
hazard. Collaborations between government and stakeholders are necessary for tackling
this problem. Water in this landlocked country needs to be purified to open the gates for
improved population health outcomes.
References
1) Sada R, Shrestha A, Karki K, Shukla A. Groundwater extraction: implications on local water security of peri-
urban area of Kathmandu Valley. Nepal J Sci Technol. 2013;14:121–128.
2) World Health Organization. The World Health Report 1996 – fighting disease, fostering development.
Geneva: WHO; 1996.
3) Ministry of Health and Population (MOHP) [Nepal], New ERA, ICF International Inc. Nepal Demographic
and Health Survey 2011. Kathmandu: Ministry of Health and Population, New ERA, ICF International,
Calverton, MD; 2012.
4) Shrestha S, Aihara Y, Bhattarai AP, et al. Dynamics of domestic water consumption in the urban area of
the Kathmandu Valley: situation analysis pre and post 2015 Gorkha Earthquake. Water. 2017;9:222.
5) Shrestha S, Nakamura T, Magome J, et al. Groundwater use and diarrhoea in urban Nepal: novel
application of a geostatistical interpolation technique linking environmental and epidemiologic survey data. Int
Health. 2018;10:324–332.
6) Shrestha S, Haramoto E, Malla R, et al. Risk of diarrhoea from shallow groundwater contaminated with
enteropathogens in of the Kathmandu Valley. J Water Health. 2015;15:259–269.
7) Papastergiou P, Mouchtouri V, Pinaka O, et al. Elevated bathing-associated disease risks despite certified
water quality: a cohort study. Int J Env Res Public Health. 2012;9:1548–1565.
Junior Doctors Network Newsletter
Issue 16
October 2019
Escherichia coli contamination of drinking water is one of the
biggest public health hazards in Nepal.
JUNIOR DOCTORS’ COMMUNITY REFLECTIONS Page 17
‘Big Four’ agenda encompasses food security, affordable housing, manufacturing, and
universal health coverage (UHC) for all Kenyans by 2022 (1). While the ‘Big Four’ priority
areas are all critical in transforming Kenya into a rapidly growing, middle-income nation by
the year 2030, UHC has gained significant traction and popularity. There seems to be more
urgency in achieving essential health care for all, as good health ensures that the
population remains productive, for nations to reap greater economic and social benefits.
The World Health Organization defines UHC as ensuring that all people and communities
have access to needed health services of sufficient quality, while guaranteeing that the use
of these services does not expose the user to financial hardship (2). UHC seeks to promote
equity by providing health for all and is entrenched in the third SDG.
Kenya, a lower-middle income country, has embarked on the path to UHC with
considerable political goodwill. Looking at the history of health reforms in the country and
many other Sub-Saharan African countries, political clamor and skewed priorities have
seen health care trail behind other sectors. This is evidenced by budgetary allocation and
major development projects, where other sectors like defence and education receive more
resources.
The Government of Kenya has also expanded the National Hospital Insurance Fund (NHIF)
pool by including students in public secondary schools, elderly, orphans, people with
disabilities, and other vulnerable groups. All these efforts have increased access to health
care and reduced financial risk to the most vulnerable in society. Albeit fragmented,
improvements in health indicators have been reported (3).
Junior Doctors Network Newsletter
Issue 16
October 2019
Kenya’s Path to Universal Health Coverage:
Seizing the Political Commitment
Lyndah Kemunto, MBChB
General Practitioner, Kisii County Government
Kisii, Kenya
On December 12, 2017, His Excellency Uhuru Kenyatta, Kenya’s
fourth president, announced the ‘Big Four’ priority areas that would
set Kenya on an economic growth trajectory towards achieving Vision
2030 and the global Sustainable Development Goals (SDGs). The
Kenya’s current regime and devolved governance structure has
implemented remarkable reforms in health care – free maternity
services, free primary health care services in all level 1 to 3 hospitals,
and increased autonomy in decision making at county levels.
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 18
On December 13, 2018, the Ministry of Health led by the president, launched UHC pilot
programs, ‘Afya Care,’ in four devolved counties in Kenya. The counties were selected
based on the triple burden of disease prevalence, which includes infectious diseases such
as HIV/AIDS, non-communicable diseases, and trauma injuries. Residents of these
counties can access a range of both inpatient and outpatient health care services at a
subsidized rate. The government hopes to learn from these pilots and minimize failure risks
when the programme becomes scaled-up to the entire country (4).
The Ministry of Health and various stakeholders (e.g., donors) are developing frameworks
for the UHC countrywide scale-up. However, one question is yet to be explicitly defined and
answered: How will the government finance this ambitious, yet crucial goal? The current
health budgetary allocation is 6.7% of the total government expenditures and 5.2% of the
total health spending, as a percentage of GDP. Out-of-pocket spending contributes up to
27.7% of the current health expenditures. Statistics also show that a significant proportion
of Kenyans experience catastrophic health expenditures to the extent that most Kenyans
believe that they are one medical condition away from poverty (5).
UHC seeks to reduce household financial burden, mainly out-of-pocket spending by
increasing budgetary allocation to health care services and increasing the proportion of
Kenyans under insurance coverage (e.g., voluntary NHIF). This is both an uphill task,
considering the limitations in revenue collection through taxation and challenges interacting
with the hard-to-reach rural population and large informal economic sector, which has
resulted in lower insurance uptake. Beyond limited financial resources, Kenya also needs
to eliminate corruption. Some experts argue that there are enough resources to implement
UHC, if available resources are put into efficient use, backed with transparency and good
governance.
Achieving UHC is not an easy task, but the health sector needs to collaborate with various
stakeholders and capitalize on the current political goodwill from the highest political office
and global momentum. There has never been a better time for Kenya to lay a strong
foundation to strengthen its health care systems and achieve health for all sooner than
later.
References
1) Towards 2030. Kenya Vision 2030. Nairobi: Kenya Vision 2030; 2017 [cited 2019 Jul 15].
2) World Health Organization. Universal health coverage. 2019 [cited 2019 Jul 15].
3) The National Treasury. Budget. Kenya: The National Treasury; 2019 [cited 2019 Jul 15].
4) Council of Governors. Launch of the universal health coverage pilot. Nairobi: Council of Governors; 2018
[cited 2019 Jul 15].
5) Ministry of Health [Kenya]. Kenya National Health Accounts 2012/13. Nairobi: Ministry of Health; 2015
[cited 2019 Jul 15].
Junior Doctors Network Newsletter
Issue 16
October 2019
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 19
Surgical site infections (SSIs) are a significant health burden for patients and health care
providers. They are the most common postoperative complication and cause pain to
patients. SSIs are universally expensive and could result in catastrophic health expenditure
and impoverishment to patients who are required to pay for their own treatment. In low-
income and middle-income countries (LMICs), single-center retrospective studies have
reported that SSIs could be the most common infection associated with health care service
delivery (1).
New resistance mechanisms are emerging and spreading globally, threatening the ability to
treat common infectious diseases, resulting in prolonged illness, disability, and death. To
address this burden, the World Health Organization (WHO) has supported a standardized
approach to data collection, analysis, and sharing related to antimicrobial resistance at a
global level to inform decision-making and drive local, national, and regional action (2).
Currently, SSIs are used as quality measures for surgical care in health institutions. It
represents a public health problem exacerbated by the growing antimicrobial resistance
with the new generation of multidrug-resistant bacteria (MDR), disabling a wide range of
antibiotics in health facilities.
Junior Doctors Network Newsletter
Issue 16
October 2019
Surgical Site Infections in Venezuela: Global Call to Action
Genesis Naranjo M., MD
Epidemiologist, Francisco de Miranda National
Experimental University
Coro, Venezuela
Antonio Reyes M., MD
General Surgery Resident, Francisco de
Miranda National Experimental University
Coro, Venezuela
Raymar Romero O., MD MSc
Epidemiologist, Francisco de Miranda National
Experimental University
Coro, Venezuela
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 20
Specific to Venezuela, the authors conducted a descriptive study in a local hospital and
reported that SSIs had increased over time, from 10% in 2017 to 12.2% in 2019, with
peaks of 15% and 18% during some months (unpublished data) (Photos 1−2). Since data
on SSIs are not easily accessible or available to clinicians and researchers, working groups
cannot be established to further examine this national health burden. Some challenges
include limited health research data and infrequent publications of epidemiological bulletins
by the Ministry of Health. In fact, one scientific article described that weekly epidemiological
bulletins have not been authorized to be published by the Ministry of Popular Power for
Health since 2015 (3). Ultimately, this scientific isolation may halt scientific advancement
and collaborations with other nations in the Region of the Americas.
Junior doctors living in LMICs face major challenges in their research contributions to SSIs.
First, to detect potential etiologies of SSIs per geographic region, junior doctors need
economic resources and access to specific and high-quality laboratories for diagnostic
procedures. This technology is usually limited or unavailable in LMICs. Second, there are
limited academic platforms and funding opportunities to encourage the call for research
about SSIs and other health care challenges. Finally, limited government funding hinders
opportunities to publish and share data that can inform health decision-making and policies.
Junior Doctors Network Newsletter
Issue 16
October 2019
Photo 1. “Dr Alfredo Van Grieken” University
Hospital, located in Coro, Falcón, Venezuela, where
the latest surgical site infection data were collected.
Credit: Antonio Reyes.
Photo 2. Clinical case of a patient with an
infected wound after exploratory laparotomy
(upper left), culture assay (upper right), and
antibiogram (bottom left), from “Dr Alfredo
Van Grieken” University Hospital.
Credit: Genesis Naranjo.
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 21
Recently, the Global Surgical Outcomes Collaboration (GlobalSurg) and their Global Health
Unit on Global Surgery are working together though annual research prioritization
workshops to set the research agenda based on patients’ needs in LMICs. These efforts
aim to represent surgeons from around the world and support collaborative international
research to examine surgical outcomes, resulting in expanded local, national, and
international research networks (2).
Globally, reducing SSIs will contribute to ensuring safe and essential surgery techniques to
improve patient outcomes. Health care costs of patients living in LMICs are a significant
burden on financial resources and sick leave. Following the WHO’s recommendations, to
address this global burden in resource-limited settings, robust policies should be the
primary dialogue among health authorities. The global call to action must emphasize the
need for high-quality evidence to inform their health decisions that promote population
health (4,5).
References
1) World Health Organization. Global guidelines on the prevention of surgical site infection. Geneva: WHO;
2016.
2) GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in high-income, middle-
income, and low-income countries: a prospective, international, multicentre cohort study. Lancet.
2018;18:516−525.
3) Daley J. Infectious diseases spike amid Venezuela’s political turmoil. Scientific American. 2019 [cited 20
Jul 2019].
4) World Health Organization. Antimicrobial resistance. 2018 [cited 18 July 2019].
5) Meara JG, Hagander L, Leather AJ. Surgery and global health: a Lancet Commission. Lancet.
2014;383:12−13.
Junior Doctors Network Newsletter
Issue 16
October 2019
To address these challenges, junior doctors can support current
global surgery programs and share data through social media, an
innovative tool that has transformed global communication.
In LMICs like Venezuela, SSIs and antimicrobial sensitivity are
infrequently studied, hindering how health institutions obtain
information, manage and distribute resources, and mitigate risk
of infection.
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 22
The Early Career Doctors (ECDs) are medical or dental interns, medical or dental officers
below the rank of principal medical officer, and resident doctors who are in postgraduate
training. ECDs constitute a significant proportion of medical human resource for health in
Nigeria (1). Many of this subgroup of medical or dental doctors in Nigeria are within their
first 10 years of graduating from medical and dental schools. They are represented by the
National Association of Resident Doctors of Nigeria (NARD), which is one of the affiliate
institutions of the Nigerian Medical Association (1,2).
Although the ECDs play a critical role in the country’s health sector, they are faced with
numerous psychosocial, demographic, and workplace-related issues (2−4). Unfortunately,
there are few research studies that have explored relevant themes related to these
challenges (1,2). In January 2019, the 2018−2019 National Executive Council of the
National Association of Resident Doctors of Nigeria, led by Dr Olusegun Olaopa, approved
the newly created Research & Statistics Committee (RSC)’s proposal to investigate themes
relevant to ECDs. The key component of the proposal was the CHARTING study, short for
the CHAllenges of Residency TrainIng and Early Career Doctors in NiGeria Study (1).
Junior Doctors Network Newsletter
Issue 16
October 2019
CHARTING Study: A Trainee Collaborative Research Study
Igbokwe Martin, MB.ChB
Obafemi Awolowo University Teaching Hospitals
Complex
Ile-Ife, Nigeria
Ibisola Babalola, MB.ChB
University College Hospital
Ibadan, Nigeria
Oladimeji Adebayo, MB.BS
University College Hospital
Ibadan, Nigeria
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 23
The CHARTING study is the largest multi-centred and multi-disciplinary research project on
ECDs in Nigerian history (1,5). Driven by the 46 members of the Research Collaboration
Network (RCN) that serves as a sub-structure of the RSC, the study aims to investigate
issues and challenges of ECDs in Nigeria. The key themes the study will explore include
demographic issues (e.g., migration), workplace issues (e.g., practice satisfaction and
dissatisfaction, training and skills acquisition, conflict and conflict resolution, leadership),
and psychosocial issues (e.g., burnout syndrome) (2). The study incorporates a mixed-
methods design with quantitative and qualitative aspects (5). In the quantitative portion, the
RCN will administer structured questionnaires to 1,554 ECDs representing 21 of the 74
branches of the NARD. In the qualitative component, the RCN will conduct four focus group
discussion sessions with nine ECDs per group, for a total sample of 36 ECDs. Study
advisors from the RSC/RCN will include six fellows with multidisciplinary backgrounds who
represent several postgraduate medical colleges within Nigeria (1).
Achievements
So far, the key milestones attained by the project team include securing the necessary
approvals, setting up of the operational structure to execute the project, obtaining funding
from NARD, and publishing preliminary manuscripts.
Future Directions and Conclusions
The team is committed to the gathering and processing of robust data regarding ECDs in
Nigeria, which would lay a solid basis for more advanced research of ECDs at their
workplace in the country. It is anticipated that the study findings would improve the
interaction of the various stakeholders who liaise with the ECDs in Nigeria. Our findings will
also be published in a high-impact peer-reviewed journal in order to permit worldwide
dissemination. Furthermore, we believe that this initiative will greatly enrich the
development of evidence-based policies on relevant themes among Nigerian junior doctors.
References
1) National Association of Resident Doctors of Nigeria. Initiating Trainee Research Collaboration Network: a
NARD Initiative in Nigeria, 2018−2019. Abuja: National Association of Resident Doctors of Nigeria; 2019.
2) Adebayo O, Oluwaseyi O, Olaopa O, et al. Trainees collaboratively investigating early career doctors’
themes: a NARD initiative in Nigeria. Nigerian Journal of Medicine. 2019;28:93−97.
3) Ogunsemi O, Alebiosu O, Shorunmu O. A survey of perceived stress, intimidation, harassment and well-
being of resident doctors in a Nigerian Teaching Hospital. Nigerian Journal of Clinical Practice. 2010;13.
4) Akinyemi O, Atilola O. Nigerian resident doctors on strike: insights from and policy implications of job
satisfaction among resident doctors in a Nigerian teaching hospital. International Journal of Health Planning
and Management. 2013;28:e46−e61.
5) Kanmodi K, Ekundayo O, Adebayo O, et al. Challenges of residency training and early career doctors in
Nigeria study (CHARTING STUDY): a protocol paper. Nigerian Journal of Medicine. 2019;28:198−205.
Junior Doctors Network Newsletter
Issue 16
October 2019
JUNIOR DOCTORS’ SCIENTIFIC PERSPECTIVES Page 24
The entrance examination into the Faculty of Medicine has irreplaceable value, serving as
the beginning of the journey to becoming a physician. As junior doctors, many believe that
to select competent students for medical education and training, this examination should be
conducted fairly. However, is this a reality?
In Japan, unfortunately, the score adjustment of the entrance examination has become a
controversial issue, after third-party investigations reported that female students’ test
scores were reduced uniformly to minimize their potential to reach the passing exam score
(1). Furthermore, a third-party committee found that some university officials had believed
that female physicians were less likely than male physicians to take important academic
positions and more likely to retire early due to life events (e.g., pregnancy, child-rearing).
This score adjustment of the entrance examination was unjustified and discriminatory
against female students who aimed to pursue a medical career.
To further examine this score adjustment issue, the Ministry of Education, Culture, Sports,
Science and Technology (MEXT) conducted a survey in 2018 of all Faculties of Medicine
across the country (2). Of the 81 Faculties of Medicine, the survey revealed that 57
Faculties (70.4%) had a greater number of male medical students than female medical
students, with a ratio of 1.18 male to female students on average over the previous six
years. In particular, MEXT identified four Faculties of Medicine with prevalent gender
discrimination during enrollment via the entrance examination. It is believed that this gender
discrimination was partly responsible for the imbalance observed among genders.
Gender equality is an important element during the recruitment process as well as formal
employment. In 2018, the World Medical Association (WMA) issued a statement on gender
equality in medicine, which demonstrated support for female medical students and
asserted the need for their encouragement in academia, leadership, and managerial roles.
Following the United Nations 2030 Agenda of Sustainable Development, this statement
emphasized the fifth goal (Gender Equality) of the 17 Sustainable Development Goals
(SDGs).
Junior Doctors Network Newsletter
Issue 16
October 2019
Physicians’ Work Style Reform in Japan: Gender Equality
Daisuke Kato, MD
Japan Medical Association, Junior Doctors Network
Department of Family Medicine, Graduate School of Medicine
Mie University
Mie, Japan
JUNIOR DOCTORS’ ACTIVITIES Page 25
If gender discrimination is not eliminated, more women engaged in the health care sector
may experience gender discrimination in the future.
How can we overcome this gender inequality?
This problem raised the question about how these entrance examinations should be
conducted. In response, the Association of Japan Medical Colleges established a standard
for the entrance examination of the Faculties of Medicine, which aimed to ensure fairness
and equity during recruitment (3). Recently, the Japanese government promoted the
Physicians’ Work Style Reform, to ensure physicians’ health while maintaining high-quality
medical care. The shortage of physicians in Japan has historically led to an increase in
their working hours. In their report, this reform committee highlighted the importance to
create a safe and nurturing environment for female physicians with specific time constraints
related to personal life scenarios (e.g., childbirth, child-rearing). To promote gender
equality, the Japan Medical Association has conducted numerous surveys, presented
forums, and disseminated publications on gender equality.
What should we require for the Physicians’ Work Style Reform?
The physician shortage in Japan has demonstrated the importance to improve work
efficiency and increase opportunities for female physicians to maintain medical care.
Current discussions are underway on a system of childcare leave and shorter working
hours for physicians.
How should our personal perspectives regarding physicians’ work be linked with
public interest?
Junior doctors should reflect upon the meaning of their work and actively seek to reach
established professional and personal goals. These goals can be achieved through
dedicated work and self-actualization, not only material wealth. Previous surveys have
suggested that young physicians emphasize skill development and professionalism in their
career development (4). More research studies should investigate these critical topics for
junior doctors and medical students.
Junior Doctors Network Newsletter
Issue 16
October 2019
Notably, health care became the largest global industry
of young people over the past 10 years, and females
account for more than 70% of health care workers.
JUNIOR DOCTORS’ ACTIVITIES Page 26
In Japan, with few opportunities for young physicians and medical students to discuss their
perspectives regarding working styles, Japanese junior doctors will organize a summer
workshop on advocacy with medical students. Using the theme, Physicians’ Work Style
Reform in Japan: Gender Equality, the agenda will include a description of future activities
based on two lectures: 1) six actions for systematic advocacy by Dr Trevor Shilton (5); and
2) past efforts about the physicians’ work style reform in Japan with a view of management
strategies.
We hope that this summer workshop will provide an opportunity to empower young doctors
to develop their advocacy skills on these essential and timely topics.
References
1) Tokyo Medical University Third Party Committee. Survey of entrance examination of Tokyo Medical
University. 2018 [cited 2019 Jul 4]. Japanese
2) Ministry of Education, Culture, Sports, Science and Technology. Survey of Faculty of Medicine entrance
examination. 2018 [cited 2019 Jul 4]. Japanese
3) Association of Japan Medical Colleges. The standard for the Faculty of Medicine for the entrance
examination. 2018 [cited 2019 Jul 8]. Japanese
4) Abe K, Mishima C, Kato D, et al. Recommendations from young physicians and medical students on the
legislation of long working hours for physicians. 2017 [cited 2019 Jul 4]. Japanese
5) Shilton T. Advocacy for non-communicable disease prevention; building capacity in Japan. Japanese
Journal of Health Education and Promotion. 2016;24:102−114.
Junior Doctors Network Newsletter
Issue 16
October 2019
As junior doctors, we should continue to apply our
leadership to practice, starting with promoting health
advocacy and capacity building.
JUNIOR DOCTORS’ ACTIVITIES Page 27
The Republic of Korea (hereafter, Korea) experienced exponential development over a
short period of time, rising from the ashes of World War II. Currently, Korea stands strong
on numerous public health statistics. The Korean population and residing foreigners enjoy
excellent healthcare services for less than US$10 for any simple visit to a primary health
center. However, these results are made possible by the unreasonable sacrifices of
medical residents. Until recently, medical residents in Korea were required to work more
than 100 hours per week or occasionally 100 days of consecutive duties (1).
However, due to a lack of understanding by political sectors regarding the circumstances of
medical training, coupled with practical roadblocks such as a low medical reimbursement
rate and inefficient healthcare delivery system, collective efforts have advanced slowly.
Thus, KIRA concluded that further legislative action should be considered.
Junior Doctors Network Newsletter
Issue 16
October 2019
Junior Doctors Improve Medical Training Environments
in the Republic of Korea
Jihoo Lee, MD
General Practitioner
Director, Korean Intern Resident Association
Seoul, Republic of Korea
Jaehyeon Jang, MD
Public Health Doctor
Executive Member, Korean Intern Resident
Association
Seoul, Republic of Korea
Sei Na, MD
Obstetrics and Gynecology Resident
Asan Medical Center
Executive Member, Korean Intern Resident
Association
Seoul, Republic of Korea
Established in 1998, the Korean Intern Resident Association
(KIRA) has continuously advocated for the reformation of these
medical residents’ working hours.
JUNIOR DOCTORS’ ACTIVITIES Page 28
In 2012, the death of one medical resident after continuous work duties ignited the debate
and led to the passing of the Act for the Improvement of Training Conditions and Status of
Medical Residents (Medical Residents Act, MRA) in 2015. The four essential elements of
the MRA (Figure 1) also coincide with the World Medical Association (WMA)’s statement
of physicians’ well-being (2,3).
The MRA enactment holds significant meaning for physicians, as medical residents are the
primary focus, and the law enshrines guaranteed basic human rights. The MRA also
ensured direct participation of medical residents on decision-making committees. This
direct participation can improve the training of future medical residents, clarifying the
establishment and operations of the mandatory Training Environment Evaluation Board.
Overall, KIRA aims to refine the MRA and improve its implementation related to three
specific factors.
.
Junior Doctors Network Newsletter
Issue 16
October 2019
Figure 1. Essential elements of the Medical Residents Act (2).
Figure 2. Comparison of changes in the training environment after
the Medical Residents Act enactment, in 2015 and 2017.
Credit: Korean Medical Association.
Working Hours
Since the MRA enactment, the
training environment has slightly
improved (Figure 2), although
the Ministry of Health and
Welfare statistics show that
38.5% of training centers do not
abide by the residency policy.
JUNIOR DOCTORS’ ACTIVITIES Page 29
Quality of the Residency Program
The Korean residency curricula lack detailed syllabi and content, such as mandatory
patient cases and education checklists. Discrepancies among institutions are vaguely
acknowledged and poorly managed, since there are no standardized criteria (4). Moreover,
efforts by the medical societies are limited since curricula reform can lead to practical
strains for hospitals and academic institutions. The MRA mentions national support for
residency programs, but there are no feasible agreements to date. By benchmarking
against other countries’ training programs, Korea could actively improve the quality of
residency programs.
Reinforcement of Residents’ Rights for Safety and Health
Verbal, physical, and sexual harassments were traditionally common in the authoritarian
medical system and unfortunately are still prevalent (Table 1). Gender inequality and
violence in hospitals are also critical issues (5). For example, the results of a KIRA-led
survey indicated that nine of 10 residents in emergency medicine have experienced either
physical or verbal violence from patients and other healthcare workers. Survey results
reported similar statistics for residents working in other clinical disciplines (5). Although
doctors’ safety and health are related to their efforts for population health, the MRA lacks
authority to impose adequate sanctions. Corroborated above, although most of the
physicians admittedly regard the MRA enactment as a milestone that improves the medical
training environment, there is still a long way forward to perfect the environment.
Junior Doctors Network Newsletter
Issue 16
October 2019
Table 1. Percentage of medical residents’ experience on violence, sexual harassment, and assault.
Credit: Korean Intern Resident Association.
JUNIOR DOCTORS’ ACTIVITIES Page 30
Nonetheless, young doctors have a myriad of other reasons for continuing to be proactive
and to advocate for critical topics in their medical training. Korean junior doctors continue to
remain motivated about improvements in their working environments for both doctors and
patients. We remain optimistic and envision a future clinical workplace that is free of any
unjust practices.
References
1) Oh SH, Kim JS, Lee PS. A survey on training and working conditions of residents in 2015. J of the Korean
Med Assoc. 2015;58:1179−1189.
2) Ministry of Justice [Republic of Korea]. Statues of the Republic of Korea: Act for the improvement of training
conditions and status of medical residents. 2015 [cited 2019 Jul 12].
3) World Medical Association. WMA statement on physicians well-being. 2015 [cited 2019 Jul 12].
4) Wang K-C. Reformation of post-graduate medical education system in Korea. J of the Korean Med Assoc.
2011;54:352−354.
5) Song SH. Pregnant trainees worried over 40-hour work limit. Korea Biomedical Review. 2018 [cited 2019
Jul 12].
Junior Doctors Network Newsletter
Issue 16
October 2019
In February 2019, another medical resident
was found deceased in the on-call room
during his night shift, after working 110 hours
per week for four consecutive weeks. In order
to address this growing concern for Korean
medical students and trainees, KIRA held a
press conference and alerted the public about
the MRA enactment and unacceptable
tragedies of 2012 and 2019 (Photo 1).
Photo 1. Korean Intern Resident Association press
conference after medical resident’s death in 2019.
Credit: Korean Intern Resident Association.
By collectively sharing our medical training experiences with other
junior doctors from all over the world, we hope to create an
international dialogue and expect to break through the various
challenges that young doctors face in today’s medical society.
JUNIOR DOCTORS’ ACTIVITIES Page 31
The Japan Medical Association and Junior Doctors Network (JMA-JDN) held the 4th
General Assembly on July 20-21, 2019, in Tokyo, Japan. Using the theme, The Role of
Junior Doctors in the Current Trend of Global Health, the purpose of this meeting was to
provide JMA-JDN members, other junior doctors, and medical students with opportunities
to identify global health challenges, discuss potential approaches to minimize these
challenges, and form professional networks.
Day 1: Symposium
Using the theme of the 4th General Assembly, this symposium included presentations by
four panelists who were members of the JMA Global Health Committee. First, Dr Hideko
Yamauchi, Director of Breast Surgical Oncology of St. Luke’s International Hospital,
highlighted that comprehensive patient care should incorporate medical care and health
promotion activities related to the social determinants of health. As a surgeon and clinical
researcher in the United States, she recommended that junior doctors establish their
dreams and develop a plan to achieve those dreams.
Second, Dr Mari Urabe, President of Uzawa Kokusai Gakkan, introduced the concept of
“social common capital”, which was developed by her father, Professor Hirofumi Uzawa, a
Japanese economist. This concept “provides members of society with those services and
institutional arrangements that are crucial in maintaining human and cultural life” (1). She
emphasized that the existence of the hospital and primary care doctor are important for
social stability, and that physicians should view patient care in a holistic manner.
Junior Doctors Network Newsletter
Issue 16
October 2019
Fourth General Assembly of Japan Medical Association/
Junior Doctors Network
Ayaka Ishihata, MD
Senior Resident, Emergency Department Center
Tokyo Metropolitan Hiroo Hospital
Tokyo, Japan
Kazuhiro Abe, MD PhD
Project Researcher, Department of Public Health
Graduate School of Medicine
University of Tokyo
Tokyo, Japan
Junior doctors serve as advocates on diverse issues, including
challenges related to health care systems’ adoption and
implementation of remote medicine.
JUNIOR DOCTORS’ ACTIVITIES Page 32
Third, Dr Yasuhide Nakamura, President of the World Health Organization’s Association
of Japan, mentioned the importance of equal relationships related to international
humanitarian efforts to achieve the Sustainable Development Goals. He urged junior
doctors to carefully think about how their training could positively influence the delivery of
primary healthcare services to all.
Fourth, Dr Hiroki Nakatani, Director of Human Resource Strategy Center for Global
Health, described that domestic medicine has been affected by globalization, including the
increase of international patients and healthcare workers in Japan. He emphasized the
importance of becoming involved in global health opportunities and highlighted the
possibility of harmonizing medical careers at both domestic and international levels.
In the discussion period following the lectures, participants shared experiences and
perspectives and discussed the future roles of junior doctors in global health topics. They
suggested creating e-learning opportunities for Japanese junior doctors on global health
topics, including using innovative technology to develop surveys.
Day 2: Skill-based Workshops
Two skill-based workshops were coordinated to provide learning opportunities for
symposium participants. First, the 2nd Annual Advocacy Skill Workshop was held for
Japanese junior doctors to learn about the concept of advocacy and how to use advocacy
as an effective strategy (2). Dr Masamine Jimba, Professor in the Department of
Community and Global Health Graduate School of Medicine at the University of Tokyo, led
the workshop and educated participants on the use of advocacy frameworks, which were
developed by Dr Trevor Shilton to construct the strategy for effective advocacy (2). He then
provided personalized tutorial sessions, while participants formed small groups for the
simulation of these advocacy strategies.
Second, the Localize, Centralize Workshop was organized by medical students of the
International Federation of Medical Students’ Associations (IFMSA-Japan), Asian Medical
Students’ Association in Japan, and the Japan Association for International Health
Students section. Workshop participants included junior doctors and medical students.
They formed two small groups to discuss challenges related to healthcare service delivery
in rural and urban communities across Japan. Then, they developed potential solutions and
identified how junior doctors could collaborate to minimize these described challenges.
Collaborative learning was observed as junior doctors were inspired by the innovative ideas
from medical students, and medical students were exposed to the challenges of clinical
practice and influence of health policy through junior doctors’ experiences.
Junior Doctors Network Newsletter
Issue 16
October 2019
JUNIOR DOCTORS’ ACTIVITIES Page 33
References
1) Uzawa H. Economic analysis of social common capital. Cambridge: Cambridge University Press; 2005.
2) Abe K. Junior doctors’ challenges of advocacy for physicians’ well-being in Japan. Junior Doctors Network
Newsletter. 2019 [accessed 2019 Aug 20];15:20−23.
3) Shilton T. Advocacy for non-communicable disease prevention; building capacity in Japan. Japanese
Journal of Health Education and Promotion. 2016;24:102−117.
Junior Doctors Network Newsletter
Issue 16
October 2019
Photo 1. Participants and panelists of the 4th General
Assembly of the Japan Medical Association/Junior
Doctors Network, held on July 20, 2019.
Credit: JMA-JDN.
Their continued leadership can provide
new insights into the use of innovative
technology, methods, and resources to
solve global health challenges.
Through the symposium and skill-based workshops, junior doctors
demonstrated enthusiasm to collaborate on health initiatives that
can minimize risk to future health threats to the global population.
JUNIOR DOCTORS’ ACTIVITIES Page 34
INTRODUCTION FOR ENTIRE SECTION
Dear JDN members,
We are pleased to announce that the Junior Doctors Network (JDN) Medical Ethics
Working Group has taken an initiative to highlight the problems faced by junior doctors
around the globe.
The JDN Newsletter will now have a dedicated space for JDN membership, in efforts to
share unique experiences and challenges faced in the workplace. In early 2020, the
Working Group plans to prepare one special edition of the JDN Newsletter that focusing on
the Medical Ethics challenges faced by junior doctors.
Stay connected, and let your voice reach the world!
Junior Doctors Network Newsletter
Issue 16
October 2019
Introduction to the Special Series on Medical Ethics
Lwando Maki, MD
JDN Medical Ethics Officer
Chair, Medical Ethics Working Group
Aashish Kumar Singh, MBBS
Project Lead
Member, Medical Ethics Working Group
SPECIAL SERIES: MEDICAL ETHICS Page 35
of the noble working class. Over the past few years, however, numerous global incidents of
violence against doctors in the workplace have instilled anxiety and fear among doctors.
These actions have led to suffering of doctors and patients alike, where doctors often leave
health institutions to strike within the medical community, and patients are devoid of timely
treatment.
India, with a population of 1.3 billion, is on the verge of a health crisis as there are not
enough doctors to manage the population health priorities. According to Medical Council of
India, there are 529 medical colleges, with more than 75,893 graduates per year (1). Many
of these medical graduates work as junior doctors in remote areas of the country,
experiencing limited basic infrastructure of health facilities. Hence, these junior doctors are
the torchbearers of the health care delivery system in these remote areas, yet may suffer
physical or emotional abuse by their patients.
A study conducted by Indian Medical Association reported that nearly 75% of doctors have
faced some form of violence in the workplace, and most of these assaults occurred in
emergency services and intensive care units (2). A large portion of these violent assaults
happens within government hospitals, where medical services are provided gratuitously to
patients. With limitations in proper infrastructure, medications, and supportive materials,
doctors are frequently blamed as the root cause for these health care challenges.
A recent example from June 2019 exemplifies this current challenge facing doctors in India.
In West Bengal, one doctor was brutally assaulted and was transported to the intensive
care unit with a lacerated wound on his head. Following this incident, 800,000 doctors
across India participated in a national strike, demanding that security be improved in the
workplace (3).
These shared stories about violent assaults among doctors are not isolated to India, but
rather have become a global epidemic. For example, in Nepal, doctors have been
Junior Doctors Network Newsletter
Issue 16
October 2019
Hands that Heal are not Meant to be Broken
Aashish Kumar Singh, MBBS
Junior Resident Doctor, North Eastern Indira Gandhi Regional Institute
of Health and Medical Science
Shillong, India
Since the advent of human civilization, the medical profession has been
a respected field. Doctors have been revered, well educated, and part
Recently, assaults on doctors have caused physical and emotional
pain, hindering the delivery of medical services to patients.
SPECIAL SERIES: MEDICAL ETHICS Page 36
experiencing these same challenges and are forced to work in a constant state of stress
and fear of violence. Attacks on doctors are a daily phenomenon, and people often
vandalize hospital premises and demand exorbitant compensation for any harm produced
during the course of treatment. These factors have motivated doctors to unite and demand
for safety and stricter legal provisions to higher authorities. Likewise, these incidents have
occurred in other nations, such the United States, where one study showed that nearly
78% of doctors working in the emergency department have faced physical violence and
verbal threats (4).
The overall solution to prevent assaults lies with the government, hospital authorities,
doctors, and the general public. First, the government should make stricter laws to prevent
future attacks on doctors, like categorizing assaults on doctors as a non-bailable offense
and establishing sanctions such as fines or imprisonment. Second, hospital authorities
should improve their basic infrastructure by adding more hospital beds and confirming that
treatments are available. They can recruit more medical personnel to enhance the delivery
of high-quality health care services to patients. Third, doctors should collaborate to
strengthen trust and transparency in the medical community and emphasize robust
communication skills that foster positive doctor-patient relationships in clinical practice.
Finally, the public should be educated about medical ethics and protocol, where
communication with doctors is essential, and violence is not tolerated. Hospitals and
medical personnel should coordinate meetings with the public, which will instill faith in the
responsibilities and actions of health professionals.
Restoring faith in doctors is the urgent need of our society. As the common phrase, “Love
conquers everything”, junior doctors should aim to be empathetic and develop rapport with
patients and their families. As such, Dr Morgan Martin has beautifully described the
importance of communication in the health care setting.
References
1) Medical Council of India. List of colleges teaching MBSS. 2017 [accessed 2019 Aug 7].
2) Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Natl Med J India.
2017;30:97−100.
3) TT Bureau in Calcutta. NRS Medical College junior doctors assaulted. The Telegraph. 2019 [accessed
2019 Aug 7].
4) Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med.
2016;374:1661–1669.
Junior Doctors Network Newsletter
Issue 16
October 2019
“The physician treats with words; within the physician-patient social
system, the patient is moved by fears and other sentiments, and these
are modified by the physician’s words and phrases. Physicians
dispense not only medicines but words that influence medicines or, all
by themselves that affect the patient more than the medicine.”
SPECIAL SERIES: MEDICAL ETHICS Page 37
the Nepal Medical Council and licensed to practice medicine in Nepal. The doctor to
population ratio is 1:1,360, which falls short of the World Health Organization (WHO)’s
recommendation of 1:1,000. This number further suffers a huge setback when we consider
that only 30−35% of them have attained a post-graduation degree, and the majority
practice medicine in the capital city of Kathmandu.
There are two main challenges that medical graduates encounter in their training. First, in
recent times, a number of private medical colleges has been established in different
geographic regions, resulting in 2,000 medical graduates annually. With only 200−300
post-graduate seats available per year, the competition for a medical residency spot has
become fierce. Second, different government quotas have resulted in an even further
reduction of available seats for individuals applying without having a government job.
However, the process to obtain a government job seems to be an uphill task, as only
80−100 doctors are recruited annually, and they become eligible to apply for a medical
residency spot only after a minimum of two years of service. Hence, each year brings more
medical graduates who are added to the competitive wait list for medical residency spots,
with the numbers often reaching 8,000 to 10,000 applicants.
While awaiting their medical residency, young doctors work as medical officers in hospitals
and frequently encounter workplace-related challenges and stress. For example, they may
observe or experience violence, which has become a major arising issue in the Indian sub-
continent. While a substantial number of cases is being reported on a weekly basis, the
government has failed to acknowledge this burden. Doctors have also become an easy
target for the media, and the government and policies (e.g., life imprisonment, monetary
reimbursement amounting to US$30,000) have been imposed on them due to patient
deaths during treatment, irrespective of the prognosis. After many protests made by the
Junior Doctors Network Newsletter
Issue 16
October 2019
Untold Stories of Young Doctors from the Land of the Himalayas
Uchit Thapa, MBBS
General Physician, Kantipur Hospital Pvt. LTD.
Kathmandu, Nepal
Nepal, a small country enriched in cultural diversity, is known as the
land of mountains with a population of 29.94 million. Doctors are
scarce in number, accounting to approximately 22,000 registered with
“An educated workforce is the foundation of every community
and the future of every economy” − Brad Henry
SPECIAL SERIES: MEDICAL ETHICS Page 38
medical societies, these policies were abandoned, leaving doctors feeling rejected and
isolated. Unfortunately, following numerous defaming articles and rumors spread by the
national media, the general population has lost their trust and respect for doctors.
Furthermore, Nepalese doctors receive minimal financial compensation for their job
responsibilities, which challenges their ability to support household expenses. While
monthly living expenses in Kathmandu reach approximately US$361 (excluding rent), the
monthly salary ranges from US$220−500. In order to overcome this struggle, doctors join
multiple institutions and work overtime, which has consequently resulted in lower quality of
life, limited family time, and substandard patient care. While the general public may view
these actions as doctors’ “greed for money”, only few seem to understand the challenges
doctors face in Nepal.
This has resulted in a generation of young doctors who prefer to embark on different career
paths, pursuing medical training in other countries, such as the United States or the United
Kingdom. Every year, these numbers are increasing exponentially, as around 200 doctors
have applied for the United States Medical Licensing Examination (USMLE) match in 2018,
and hundreds are planning to apply in the future. This trend demonstrates that nearly
20−30% of annual medical graduates are opting for a career in a foreign country. This
highlights the “brain drain” phenomenon in its true form. Our country is losing skilled
manpower at an alarming rate, alas with few concerns demonstrated by the government. In
a few years, Nepal will be facing an acute shortage of doctors, which will lead to countless
preventable deaths.
In the end, it comes down to the saying, “You reap what you sow”. Forward steps call for
creating an environment where young doctors can thrive and inspire younger generations
to follow their footsteps, and not the other way around.
Junior Doctors Network Newsletter
Issue 16
October 2019
In summary, the lack of educational opportunities, workplace
insecurities, and financial limitations have significantly degraded
the quality of life experienced by doctors across Nepal.
SPECIAL SERIES: MEDICAL ETHICS Page 39
In April 2018, while celebrating their 50th year anniversary, the Kenya Medical Association
(KMA) commissioned the Young Doctors Network (YDN) as a standing committee of the
association. KMA sought to increase participation, mentor, and champion the welfare of
junior doctors in Kenya.
One year after the commissioning, the YDN held its inaugural event in Naivasha, Kenya.
The KMA YDN Pre-Conference was a one-day meeting held before the KMA Annual
Scientific Conference on April 24, 2019. Under the theme, Mentorship and Innovation in
Medicine, the pre-conference was well-attended with over 100 participants, including
medical practitioners, residents, specialists, and students from Kenya and East Africa. The
agenda included invited speakers with diverse backgrounds in entrepreneurship,
innovation, advocacy, academia, and leadership, who aimed to mentor and inspire the
young doctors and participants.
Mentorship
The keynote speaker, Dr Andrew Odhiambo, a young respected medical oncologist and
lecturer, emphasised that mentorship is an essential component of medical education. It is
especially critical in medicine, where training moves each young doctor to the next level,
and then this position is replaced by the next trainee. Dr Odhiambo highlighted that
mentorship needs to be continuous and bilateral, adding that a mentee can indeed mentor
the mentor. Likewise, other speakers, including Dr Jacqueline Kitulu, the KMA president,
stated their overall appreciation for younger tech savvy doctors, who mentor older
colleagues on technology and innovation.
Junior Doctors Network Newsletter
Issue 16
October 2019
KMA Young Doctors Network Pre-Conference:
Mentorship and Innovation in Medicine
Lyndah Kemunto, MBChB
General Practitioner, Kisii County Government
Kisii, Kenya
Elizabeth Gitau, MBChB MBA-HCM
Chief Executive Officer, Kenya Medical Association
Nairobi, Kenya
Since medical education and practice can be demanding,
having a good mentor can guide medical trainees and
junior doctors to survive this dynamic journey.
INTERNATIONAL CONFERENCES Page 40
With technology, e-mentorship becomes a feasible option, where mentor-mentees can
uphold a relationship beyond physical presence. Dr Ahmed Kalebi, an entrepreneur and
experienced pathologist, demystified the need for physical presence for mentorship to
occur, recognizing that distant and virtual platforms facilitate a productive mentor
relationship. He also encouraged participants to draw inspiration from hard-to-reach role
models.
Innovation
Innovation is the art of joining the dots by efficiently utilizing available resources to solve
problems. In Kenya, the devolution of health care services has resulted in structural
changes and emerging challenges such as unemployment among doctors. The
conversation is moving from traditional roles of practitioners in health care service delivery
to offering potential solutions in other spheres of health care, such as entrepreneurship,
policy, and advocacy.
Entrepreneurship was featured with significant discussions around how to tap into health
care as a business. Health care needs are largely unmet locally, presenting future
opportunities that strive to increase economic productivity and improve population health.
Dr Maxwell Okoth, founder Ruai Family Hospital, shared his entrepreneurial journey that
started with a one-roomed clinic and grew to a chain of health care facilities, including a
specialist hospital. In a comical manner, he narrated his encountered challenges and
described taking small and large risks, such as selling his wife’s car to finance the next step
of his career path.
Junior Doctors Network Newsletter
Issue 16
October 2019
Seasoned entrepreneurs provided their insights on what
approaches were successful in their work, underscoring the
element of courage, resilience to push through challenges, and
passion to acquire new knowledge and skills.
INTERNATIONAL CONFERENCES Page 41
Overall, pre-conference participants listened to high-quality presentations, engaged with
speakers, and gained insight about key lessons in mentorship and innovation in medicine.
First, forming professional networks within and beyond KMA can serve as an important
support and mentorship group during medical training and practice. Second, seeking
entrepreneurial and innovative solutions for the delivery of health care services, coupled
with consistently upholding ethical standards, can refine and advance current clinical
practices.
KMA YDN looks forward to engaging more young doctors and providing interactive
platforms to share experiences, challenges, and solutions that promote high-quality health
care. The next YDN Pre-Conference will be held on April 24, 2020, and KMA’s Annual
Scientific Conference will occur on April 24–26, 2020, in Kisii, Kenya.
Acknowledgment: The authors acknowledge the Kenya Medical Association for supporting
the Young Doctors Network Inaugural Pre-Conference in April 2019.
Junior Doctors Network Newsletter
Issue 16
October 2019
Persistent and intentional actions to maintain lasting
relationships with mentors and role models can facilitate
valuable career advisement.
Photo 2: KMA YDN Pre-Conference participants.
Credit: Kenya Medical Association.
Photo 1. KMA YDN Pre-Conference speakers: Dr Elizabeth
Gitau, Dr Rowena Njeri, Dr Paul Yonga, Dr Nyachira Muthiga,
Dr Ryan Nyotu, Dr Thomas Kirengo, Dr Elizabeth Wala, Dr
Lyndzie Wanjiku, Dr Lyndah Kemunto (Left to Right).
Credit: Kenya Medical Association.
INTERNATIONAL CONFERENCES Page 42
The Health Professional Meeting (H20) 2019, which was organized by the Japan Medical
Association (JMA) and the World Medical Association (WMA), was held from June 13-14,
2019, in Tokyo, Japan. Using the theme, Road to Universal Health Coverage, this event
served as a physician pre-conference to the G20 Summit in Tokyo, with the attendance of
220 participants representing 38 countries. These representatives included medical
students of the International Federation of Medical Students’ Associations (IFMSA) and
junior doctors (Dr Chiaki Mishima, Dr Chukwuma Oraegbunam, Dr Wunna Tun) of the
Junior Doctors Network (JDN), providing an opportunity for the voices of the next
generation of physicians to be heard (Photos 1−2).
Notably, this meeting aimed to implement the April 2018 memorandum and reinforcement
of emergency disaster control, between the WMA president and the Director-General of the
World Health Organization (WHO).
Junior Doctors Network Newsletter
Issue 16
October 2019
Health Professional Meeting 2019: Road to Universal Health Care
Chiaki Mishima, MD
Past Chair, Japanese Medical
Association/Junior Doctors Network
Tokyo, Japan
Wunna Tun, MBBS MSc MD
Secretary (Organization and Communication),
Myanmar Medical Association
Yangon, Myanmar
Chukwuma Oraegbunam, MBBS MWACP
MRCPsych
Chair (2018-2019)
Junior Doctors Network
World Medical Association
In conference sessions, participants shared experiences and
perspectives, discussed challenges, and identified potential
solutions to implement universal health coverage (UHC) across
nations and improve access and availability to high-quality health
care services without any financial barrier.
INTERNATIONAL CONFERENCES Page 43
The opening ceremony counted with the attendance of the Crown Princess Kiko of Japan,
top members of the Japan Ministry of Health, and key medical leaders including Dr
Yoshitake Yokokura (JMA president and immediate WMA past president) and Dr Leonid
Eidelman (WMA president). Three medical leaders delivered outstanding keynote
speeches for the conference sessions. Sir Michael Marmot (WMA past president and
professor of epidemiology at the University College in London, United Kingdom),
highlighted the social determinants of health that influence health inequities. Dr Naoko
Yamaoto (assistant director general, UHC and Health Systems), described the WHO
efforts and plan toward achieving UHC. Dr Mukersh Haikerwal (WMA past chair of
council) discussed primary health care as the unit of effective health systems and
discussed the roles and functions in primary health care teams.
In his presentation titled, Invest in Young Doctors Now, Dr Chukwuma Oraegbunam
spoke on the health workforce aspects of UHC. He described the impact of poor job
satisfaction, little or no incentives to accept jobs in rural areas, and the quest for better
work-life balance. He suggested these factors as reasons that have inspired junior doctors
to move from low- and middle-income countries to more developed countries. As a result,
this transition has produced significant negative impacts on the UHC goals of stakeholders.
Junior Doctors Network Newsletter
Issue 16
October 2019
Photo 2. Mayo Clinic Caring Physicians of the World
Alumni Group: Dr Wunna Tun (JDN past
communications director), Dr Chiaki Mishima (JDN
membership director), Dr Otmar Kloiber (WMA
secretary general), and Dr Jacqueline Kitulu (KMA
president) (Left to Right) at H20 2019.
Credit: Dr Wunna Tun.
Photo 1. Dr Chukwuma Oraegbunam (JDN chair), Dr
Batool Al-wahdani (IFMSA President), Dr Daisuke Kato
(JMA Japan), and Dr Wunna Tun (JDN past
communications director) (Left to Right) at H20 2019.
Credit: Dr Chukwuma Oraegbunam.
INTERNATIONAL CONFERENCES Page 44
After these conference sessions, the Memorandum of Tokyo was adopted. This declaration
reinforced the understanding of high-quality primary health care as the core element of
UHC. It also highlighted the scarce human resources available for health care across
countries, motivated governments to invest in the education and retention of health
professionals to promote UHC, and encouraged physicians and their associations to play a
significant role in the advocacy for UHC.
In summary, junior doctors from all over the world, in line with WMA policy and
Memorandum of Tokyo, must now join the global dialogue to ensure that high-quality
primary health care systems are prioritised as the core of UHC, with adequate attention
given to the training and retention of physicians (Photo 3).
Junior Doctors Network Newsletter
Issue 16
October 2019
Photo 3. Participants at H20 2019. Credit: H20 2019 staff.
Dr Chukwuma Oraegbunam encouraged world leaders to invest
in the appropriate training and incentives of doctors to serve in
primary health care centres in rural communities, as one strategy
to achieve high-quality UHC systems.
INTERNATIONAL CONFERENCES Page 45
Medical Ethics forms the foundation of the medical profession and comprises an integral
part of global health. Over the past decade, health professionals have encouraged and
stimulated discussions on diverse topics related to medical ethics, including clinical
competencies and responsibilities, human and animal research, patient confidentiality, and
end-of-life care.
To address this important global health issue, the Junior Doctors Network (JDN) formed the
Medical Ethics Working Group on June 22, 2019. Chaired by the medical ethics officer of
the JDN management team, the Medical Ethics Working Group is geared to strengthen a
global network, where junior doctors can share essential information, resources, and
activities on Medical Ethics topics with the JDN membership.
The Medical Ethics Working Group has three main objectives. First, it aims to increase
awareness about Medical Ethics amongst junior doctors through innovative and scholarly
activities. Second, it plans to encourage the active participation of junior doctors in policy
analysis, policy review, and research collaborations related to Medical Ethics topics.
Finally, it seeks to foster collaborations that can lead to junior doctors’ exchange for
professional experiences related to Medical Ethics in clinical and community settings.
Junior Doctors Network Newsletter
Issue 16
October 2019
Medical Ethics Working Group Update
Lwando Maki, MD
JDN Medical Ethics Officer
Chair, Medical Ethics Working Group
Public Health Medicine Resident, University of Pretoria
Pretoria, South Africa
Junior doctors should be engaged as active leaders,
encouraging continued dialogue amongst the global health
workforce on these diverse themes.
WORKING GROUPS Page 46
During the inaugural meeting on July 27, 2019, the Medical Ethics Working Group
formalized the first set of projects. Over the next nine months, junior doctors will be focused
on five main activities (Figure 1).
The Medical Ethics Working Group has a vibrant and diverse membership. Members
represent the majority of World Health Organization regions as well as various medical and
surgical specialties. If you are interested in Medical Ethics and would like to participate with
other JDN colleagues in numerous activities, please contact our team (Dr Lwando Maki,
Chair of the Medical Ethics Working Group) to learn about more information.
Junior Doctors Network Newsletter
Issue 16
October 2019
Activity Projected Date
Implementation of a Medical Ethics activity at the JDN
Annual General Meeting (Republic of Georgia)
October 2019
Preparation of an article series for the JDN Newsletter,
focusing on Medical Ethics topics such as work-life balance
and challenges encountered by junior doctors
October 2019
Preparation and dissemination of an online survey to
examine Medical Ethics challenges faced by junior doctors
December 2019
Preparation of an activity at the 14th World Conference on
Bioethics, Medical Ethics, and Health Law (Portugal)
May 2020
Development of a Medical Ethics database as a resource for
learning, training, and exchange opportunities for junior
doctors
October 2019 –
May 2020
Figure 1. Description of five main activities with projected dates for the JDN Medical Ethics Working Group.
WORKING GROUPS Page 47
persistent belief (however, incorrect) that surgery is not cost-effective in low- and middle-
income countries (LMICs). Various professional surgical associations created working
groups or even new separate organizations to help address this burden of surgical disease
in LMICs. The International Student Surgical Network (InciSioN) was founded a few years
ago to represent the voices of medical students in a unified manner at various fora and
events. However, the unified voice of junior doctors and residents has remained absent on
the international level. It is exactly this gap that created the opportunity for the Global
Surgery Working Group to be created, and it is exactly this gap that we aim to fill.
The Global Surgery Working Group is the youngest working group of the JDN, formally
established in February 2019, with 25 members from 20 countries. We have truly grasped
the opportunity to create a platform where junior doctors can contribute to Global Surgery
within the JDN. Led by Dr Manon Pigeolet and Dr Victoria Von Salmuth, this Global
Surgery Working Group aims to provide a platform for residents and young doctors alike to
increase professional networks, exchange essential information about global surgery,
advocate for surgical patients at the local level and effective surgical health systems at
international meetings, and provide opportunities for collaborations on policy or scientific
papers on global surgery (Photo 1).
Junior Doctors Network Newsletter
Issue 16
October 2019
Global Surgery Working Group Update
Manon Pigeolet, MD MSc
University Hospital Center of Charleroi
Charleroi, Belgium
Surgery has historically been a neglected and absent specialty in the
global health sphere. Various reasons can be named for this
unfortunate course of history, ranging from the rise of HIV to the
Photo 1. Dr Manon Pigeolet and Dr Victoria Von
Salmuth are the co-chairs of the JDN Global
Surgery Working Group. Credit: Manon Pigeolet.
This working group was charged with creating a
statement on the Access to Surgery and
Anesthesia Care, to which various members of the
working group provided feedback for the final
content. The statement has been sent to the World
Medical Association (WMA) Secretariat for further
consideration and should be voted upon at the
upcoming WMA General Assembly in the Republic
of Georgia.
WORKING GROUPS Page 48
Within the working group, members continue to collaborate on several projects related to
research, education, and advocacy in Global Surgery. To further our efforts in research and
advocacy, various contacts have been established with the G4 Alliance (an organization
grouping over 75 surgical and anesthesia organizations worldwide) as well as the Alliance
for Surgery and Anesthesia Presence (ASAP) from the International Surgical Society (ISS-
SIC).
The Global Surgery Working Group plans to coordinate four upcoming projects for JDN
members (Figure 1).
If you are interested in Global Surgery and would like to participate with other JDN
members in the Global Surgery Working Group, please contact our team (Dr Manon
Pigeolet, Co-Chair of the Global Surgery Working Group) to learn more information. This
working group is open to all interested junior doctors who are working in surgical fields,
completing subspecialty training, or training in other medical disciplines. We welcome new
members on a rolling basis and are open to discuss ideas for future projects and
collaborations.
Junior Doctors Network Newsletter
Issue 16
October 2019
Activity Description
Peer-reviewed
Letter to the
Editor
Members will prepare a collaborative letter with InciSioN titled,
Junior Doctors: The Missing Piece in Global Surgery.
Informational
Brochure
Members will develop a two-page summary about global surgery
within the JDN framework. This document intends to provide an
introduction of activities that support global surgery advocacy and
increase awareness about the work of the JDN Global Surgery
Working Group.
Survey Members will prepare a survey titled, Mapping of Exchange/Elective
Opportunities in Global Surgery for Residents and Junior Doctors.
After survey pilot testing (August 2019) and launch (October 2019),
members will disseminate the survey to National Member
Associations, JDN members, universities, teaching hospitals, and
national and international professional organizations.
Webinar
Series
Members will prepare a webinar series titled, What is Global
Surgery, and How can Junior Doctors Contribute?, to be launched
in October 2019. Dr Kathleen Casey (ASAP) will present the first
webinar titled, An Introduction to Global Surgery.
Figure 1. Description of four activities for the JDN Global Surgery Working Group.
WORKING GROUPS Page 49