Issue 33 |  June 2016
Create your future
It is an important time of the year at the moment, with the applications for Interns and PGY2+ positions open. This newsletter contains tips on how to apply for the positions and explanations of the different types of positions available. There are also tips on how to care for yourself while undertaking your career pathway. In addition, we have spoken to two doctors who have undertaken slightly different medical pathways. These doctors are very passionate about their careers, which offer a range of challenges as well as variety.

For junior doctors, the pathways to professional practice are bewildering. Not only are there multiple options, but admission into training programs is now highly competitive. How can a junior doctor see their way through this maze? Unfortunately there are no easy answers. There are a few steps that can be taken however. One is to reflect on your own character and nature, which type of medical practice suits your temperament and style? Which rotations and clinical experiences made you feel most comfortable? Which areas seem a good fit for you? Given that you will likely practice in your chosen discipline for many years, establishing where your natural fit is matters.

Speak to people in potential areas and enquire as to what sort of doctors are needed and what sort of preparation might you do to increase your chance of selection into this area. Advice from those in the field can be invaluable. In all you do, do it to the best of your ability and always be fully professional. Strive for excellence; the paths ahead are mostly easily navigated from a position of excellence in practice, in commitment and professionalism.
Maintain your wellbeing and health in a new role

Dr Roger Sexton, Medical Director
Doctors Health SA

We bring many personal qualities and personal experience into medicine. These include IQ, varying levels of emotional intelligence and resilience, time management skills, motivation and personality traits. Our training hones our inter-personal and professional skills through graded exposure to a vast range of clinical situations as we progress through the course. There are a number of stressful points of transition along the way where our skills and mettle are tested. These include the first year of medical school, our final examinations, internship, competitive entry into training programs, Fellowship examinations and entry into private practice.

This can come at the cost of our mental health. Anxiety can intensify at these times. Burnout with compassion fatigue and cynicism can follow prolonged exposure to severe and traumatic illness and depression may emerge in a system where any sense of control over your personal and professional life is lost. 

It can be difficult to balance your work and personal time to ensure good physical health. Your new role can disrupt good lifestyle habits, deny you sleep, prevent access to the basic existence needs such as food and fluids, deny you vitamin D from sunlight, decondition you through a lack of aerobic exercise and encourage weight gain due to the default option of take-away dieting.  There is little respite within the work environment or a quiet place where doctors can gather and talk.

So, how can you maintain your own wellbeing and health while working in your new role?
  1. Have a GP. You live significantly longer if you do. GPs advocate for you in the health system and connect you with their independent referral networks. They are well-trained to look at all forms of illness, preventive health and provide a safe environment in which you can share your concerns. Use your GP wisely. Take the time to find a GP in a practice you can access and who meets your expectations. Behave yourself when you are there and be helpful. Book longer appointments and don’t expect everything to be sorted out in one visit.
  2. Attend to the basics. Drink regular amounts of fresh water and eat regular meals (take meals to work); build opportunities to be active at work (such as always taking the stairs); sitting is the new “smoking” ; get 10 minutes of sunshine each day and prioritise sleep. 
  3. Interests and hobbies. Have interests outside medicine including art, music, reading, team sport, exercising, cooking, volunteering, coaching etc.
  4. Maintain relationships. Maintain non-medical friendships and re-connect with family and old school friends.
  5. Practise relaxation. Do this at work through mindfulness, meditation, walking whilst having meetings, intermittent music.
  6. Establish a set of advisors. This can be a financial advisor, accountant, GP, personal trainer, psychiatrist or psychologist. Be ready to activate these networks in times of need.
  7. Anticipate stress well ahead. Garner support for stressful times and prioritise sleep, food, water, exercise in advance.
  8. Practise good time management. Do not procrastinate. Use the 3D approach to tasks which works well.
  • Do it (now),
  • Ditch it ( i.e. say NO) or
  • Delegate it.
  1. Plan holidays well ahead. Find restorative value in short breaks such as an overnight stay somewhere.
  2. Have an annual check-up. Ensure preventative health checks are done.
Finding a GP can take time and you may appreciate some help. Doctors’ Health SA is the health program established by the medical profession in 2010, to assist SA doctors with their health. They are here to help you with an initial comprehensive health assessment and to help you find a GP of choice for your future care.

Visit the website at www.doctorshealthsa.com.au for further information. 
Tips for Junior Doctors
Below are some very useful tips for junior doctors to keep in mind during their careers.
  • Be open minded.  Many junior doctors have some idea about where they see their career going but it is important to not close yourself off to other valuable options.
  • Seize the opportunities. In the first few years junior doctors are offered many experiences. You should embrace these experiences the good and the bad, they are all learning opportunities. Seek opportunities to stretch your knowledge and skills – ask to be given responsibilities and to participate in activities or tasks and ensure adequate supervision.
  • Set goals. At the start of each clinical term, work out two to three key goals you would like to achieve during the term.  Discuss your goals with your supervisor.  
     
  • Think and act. Reflect often and record your experiences. Employers like it when you can demonstrate specific skills, not just clinical but communication, management, professionalism and more. If you can demonstrate these skills through storytelling and reflecting, then this adds value to your practice.
  • Ask for feedback and do some practice. Practice doing job interviews to get feedback and ask for feedback after interviews.
  • Show off. Do not forget to show off additional qualifications, research projects, volunteer employment and more. These demonstrate commitment, specifically if you have a specialty that you want to pursue.
     
  • Back it up. Think about how you show evidence of your achievements - letters, testimonials, journal articles, certificates etc.
     
  • Look after yourselves and each other. Junior doctors know what it is like to be stressed; offer to help out others in times of stress and then the favour is invariably returned.
     
  • Make it a habit. Get into good habits of looking after yourself – make sure you eat, rest, maintain social activities.
     
  • Use your mentors. Try and have coffee and meal breaks with your colleagues when at work – it is a good way to debrief about issues that are concerning you whilst developing networks and forming friendships.
     
  • Seek help. If you are troubled by anything, always seek help – there are always people who you can turn to within your unit and also people within the hospital (e.g. Medical Education Officers, Directors of Clinical Training, Employee Assistance Programs).
Internship and PGY2+ Applications
Job applications are now open for Intern and Postgraduate Year 2 and beyond medical officer positions.

The intern year marks the transition from student to medical practitioner. There are four health networks in South Australia where candidates may undertake their intern year. All intern posts are accredited and have staff who continuously oversee the training program.

The purpose of internship is to develop general skills in a workplace environment and also to assist in informing career choices. This indicates that internship is a time for exploration. You are encouraged to see this as an adventure into the medical workforce, and an experience that informs, educates and supports the doctors you will become.

The Postgraduate Year 2 and beyond medical officer recruitment is managed centrally.
 These positions include:
  • Basic Vocational or Pre-specialist Training programs that focus on specific specialty areas.
  • Prevocational (General) Training positions provide further hospital experience. These positions will provide candidates with general rotations through medical, surgical, emergency and other units.
Information on internship and PGY2+ positions can be found through the South Australian Medical Education and Training (SA MET) Unit website with applications for positions coordinated through SA Health Careers website.
Senior and advanced medical officer positions are also advertised through the SA Health Careers website
Internship
Internship provides the experience of applying theory to the treatment of patients as a responsible professional. The Australian Health Practitioner Regulation Agency (AHPRA) issues medical graduates with provisional registration to undertake this period of supervised practice.

The intern year involves at least 47 weeks of supervised clinical experience that includes:
  • A core term of at least 10 weeks in medicine;
  • A core term of at least 10 weeks in surgery;
  • A term of at least eight weeks in a core emergency medicine rotation; and
  • Non-core rotations which make up the balance of the intern year.
These clinical settings provide opportunities to explore additional areas of medicine and surgery, psychiatry, rehabilitation medicine, palliative care and more.  

There are four health networks in South Australia where you may undertake your intern year. During this year you may request, or be required, to undertake one or more rotations in any of the locations within your network.
For 2017 internships, the application process will utilise eRecruitment which is a whole of SA Health electronic recruitment system. All internship applications for positions in 2017 will be completed and submitted online. Further information is available on the SA MET website and SA Health careers website.  ....
Postgraduate Year 2+ (PGY2+)
Recruitment and allocation of Resident Medical Officer (RMO) positions (Postgraduate Year 2 and above) in South Australia occurs on an annual basis. It is undertaken through a centralised process administered by the SA MET Unit on behalf of the South Australian Department of Health and South Australian Local Health Networks (LHNs).  SA MET is not the employing body and does not provide employment contracts. Contracts are provided by the relevant networks.

Training programs available in South Australian teaching hospitals include:

Basic Vocational or Pre-specialist Training Positions
These programs focus on specific medical and surgical specialty areas. These positions will provide you with experience in specific clinical specialties and are suitable if you know the specialty career path you wish to follow.  In some cases you will need to be accepted by the relevant specialty college prior to appointment and some specialty appointments are made solely by the relevant college organisations, information regarding appointment processes and deadlines can be obtained from the individual colleges

Prevocational (General) Training Positions. These positions will provide you with general rotations through medical, surgical and emergency units and are suitable if you have not yet decided on a specialist training programme or wish to obtain more experience. Training program descriptions for PGY2+ positions have been provided by each Local Health Network (LHN) and state-wide recruitment network. These programs include:

State-wide
  • General Training/General Practice (GP) Training
  • Basic Physician Training (BPT)
  • Surgery
Other
  • Obstetrics and Gynaecology
  • Obstetrics and Gynaecology (6 months) and Paediatrics (6 months)
  • General Surgery Service Post
  • ENT Surgery Service Post
  • Diploma RANZCOG
  • Advanced Rural Skills Anaesthetics
This year, both Port Augusta and Whyalla will be participating in the centralised process for the first time. Port Augusta will offer positions where the Diploma for RANZCOG can be undertaken, while Whyalla will offer positions in General Training/GP Training.

For 2017 PGY2+ positions, the application process will use eRecruitment.  All PGY2+ applications for positions in 2017 will be completed and submitted online. 
Intern Applications
 
Why do you need a copy of my passport?  Applicants are asked to provide a copy of their passport, in order for their application documents to be verified. We need to establish your citizenship in order to ensure that you are assigned to the correct category group for internship allocation.
 
Do my supporting documents need to be certified? No, supporting documentation does not have to be certified.
 
I don’t have a Department of Communities and Social Inclusion (DCSI) check and/or National Police Clearance (NPC). Will this make my application ineligible?  No, if you do not have the required clearances or only have some of these checks, your application will not be marked ineligible. However, you will be required to undergo clearances before you commence working.  If you accept a position offer, we recommend that you contact your Local Health Network (LHN). The LHN will inform you which clearances you must obtain.
 
Can you accept my IELTS results late?  No, we do not accept late IELTS results. The IELTS test results must be attached to the application when it is submitted, before the application closing date.

 
 
Where can I find information about intern rotations? Information about intern positions is available on the SA MET website, under each specific Local Health Network page. Rotation information is available on the Accredited posts page, under the Accreditation tab.
 
Based on the allocation process and past statistics, will any particular order of preferences increase my chances of obtaining an internship in South Australia?  All South Australian intern positions will be offered in the first and second rounds. Any following rounds will only be made if an applicant declines. As SA Health does not know who will decline/withdraw, it’s impossible to judge where positions will become available (e.g. which LHN).

What if I don’t get my first preference?  You will only be made one offer and this will be based on your preferences and availability of positions. You will only receive a single offer from SA Health. Please consider the offer carefully and do not reject on the assumption that you will receive another offer.

What happens if I don’t accept my offer by the specified date? If your response to an offer is not received by the date and time indicated in your offer email, SA Health will withdraw the offer of employment and the position will be offered to another applicant. You will not receive any further offers by SA Health.


PGY2+ Applications
 
What is the state-wide recruitment process?  The state-wide recruitment process includes General Training/GP Training, Basic Physician Training and Surgery. The State-wide recruitment and selection panels have been established to reduce duplication of work across LHNs and increase recruitment and selection transparency.
 
Can I apply for all PGY2+ positions in SA, through the SA Health application system?  All employment opportunities within SA Health are advertised on the SA Health Careers website. Some PGY2+ positions may be advertised outside of the centralised SA Health PGY2+ recruitment process. If you have questions about a position, we recommend you speak to the relevant Local Health Network contact person. The centralised PGY2+ application process allows you to apply for up to three basic or pre-specialty positions. Visit PGY2+ positions to see the positions available through the centralised process.

I am a medical graduate from overseas; can I apply for a PGY2+ position through the SA Health application process?  All applicants must demonstrate that they have or will have General Registration with the Medical Board of Australia by the February start date. If you cannot demonstrate that you have or will have General Registration by the start date, you are not eligible to apply through this recruitment process. All applications are checked to ensure this criteria is met.
 
Can I change the order of my preferences after I have submitted my application?  No, once your application is submitted your preferences are final.

 

Will my position preferences be visible to all the panels that I apply for?  Yes, your preferences will be visible to the panel member for the positions that you preferenced.
 
There is a state-wide approach to selection and ranking for most disciplines. Each discipline has their own selection and ranking process as the job specifications vary. You may be invited to an interview where you will be asked standardised questions for that discipline and may also be asked to complete assessment tasks. The discipline, or disciplines, that have assessed your skills will each provide a ranked candidates list to SA Health. Using these ranking lists, applicants will be matched to a position in order of their preferences, if positions are available. If you are not ranked or positions for your preference/s have been exhausted, then you will not receive a position offer.
 
In my application, can I provide a print out of my registration certificate, from the MBA website?  Yes, this is acceptable. However, all documentation must show your full name.
 
How will I know when my referee has completed the report?  When two of your referees have completed referee reports, this will be indicated on the home page of your application, you must login to your application to see this information. It is the applicants’ responsibility to ensure that referees complete and submit their reports by the due date. After the application close date, referees have an additional two weeks to submit their referee report.
 
How can I prepare for the interview questions?  It’s recommended that you reflect on your experience as a doctor so far. In the interview you will be asked questions, for example, “tell us about a challenging situation and how you managed that situation?”

Your reflections will help you tell a story to the interview panel. The examples you provide will demonstrate your skills to the interview panel and what you learned from that experience. A reflection could be:
  • A time when something went right or wrong in a situation – what actions did you take?
  • A challenging conversation you have had and how you dealt with this
  • An innovative idea that you have come up with to improve something in your workplace.
Intern and PGY2+ Allocation report

The SA MET Unit administers a centralised application, allocation and offer system annually for intern (Postgraduate Year 1) and Postgraduate Year 2+ (PGY2+, Resident Medical Officer) positions on behalf of the South Australian LHNs. The infographics below provide a visual overview, while the full Intern and PGY2+ Allocation report provides detailed information on statistical data and evaluations for the allocation process.

The full infographics and Intern and PGY2+ Allocation report can be viewed on the SA MET website.
Dr Victoria Cocks
Addiction Medicine Specialist Physician, Drug and Alcohol Services of South Australia

1. What made you choose your career pathway? Is there anything that influenced you? For more than 10 years I worked as a Family Physician medical officer (GP in the state health sector) in South Africa, gaining a vast amount of experience in many different fields including years of emergency medicine, surgery, obstetrics, paediatrics, anaesthetics, rural and remote medicine, and forensic medicine – even doing my own autopsies! In the latter years of my work (as a Family Physician) I gravitated towards the GP sub-speciality of HIV medicine in South Africa – and found it was a field of medicine I loved.

HIV medicine proved not only to be a rigorous scientific field – involving complex medicine – but also a field that addressed the patient in a holistic multi-disciplinary way. My husband, two boys and I immigrated to Australia almost 8 years ago. I had to undertake vocational training in Australia – and due to my love of HIV medicine decided to embark on Physicians Training with the RACP. After successfully completing my basic physicians training, I longed for the holistic approach that my previous years of HIV medicine had offered. I had also realised by this stage that the patient population groups that I loved the most were those that were often marginalised, misunderstood and on the fringes of main stream society – hence I decided to pursue advanced physicians training in Addiction Medicine – the best career decision I have ever made!
 

2. We’ve noticed there aren’t many consultants in Addiction Medicine. Can you tell us a little bit about your training? That’s true – there aren’t many consultants in the field of Addiction Medicine – yet! A relatively newly established and recognised speciality field – is growing and gaining momentum across the country as more and more doctors are exposed to exactly what we do. Traditionally many in the medical field assume that Addiction Medicine is a subspecialty of psychiatry only. Indeed there are Addiction Medicine Psychiatrists – however Addiction Medicine is a speciality in its own right.
 
Training is undertaken through the Chapter of Addiction Medicine, Royal Australasian College of Physicians (RACP). To enter the training pathway you have to have EITHER completed basic physicians training (with success at both the written and the clinical) – e.g. Addiction Medicine is your advanced training pathway in Physicians training OR you can enter as post fellowship training after completing a fellowship in another speciality – most commonly psychiatry, general practice or emergency medicine. It’s a 3 year FTE training program.
 
Information about the training requirements is available on the RACP website, this includes exposure to all of the fields in Addiction Medicine. Theoretically you are required to complete a research project, a detailed case history write up, a public health assignment, directly observed patient interviews, case based discussions – a very busy and well managed training program. The advantage of being a registrar in a small speciality is that you really do receive intensive one-on-one training throughout the training period.
 
Although I have a physician’s background – and am very interested in issues such as alcoholic liver disease, treatment of hepatitis C in a substance using population, liver transplant assessments from an Addiction Medicine point of view, acute care of the unwell dependent patient – my colleagues have a wealth of experience in a variety of fields due to their background prior to Addiction Medicine specialisation – including psychiatry, adolescent health, obstetric medicine, custodial medicine, indigenous health issues. As you can imagine – this provides complete holistic care for our patients – and is a very satisfying way to approach any disease management.

 

3. How different are the medical career pathways in South Africa compared to Australia? As one would imagine – some things are similar, some are vastly different. The overarching pathways are somewhat similar (undertake a 6 year pre-graduate degree and become a doctor).Then, you undertake a yearlong internship – like Australia. In South Africa, all doctors then have to undertake what is called a Community Service (rural and remote) year before the Health Professions Council of South Africa will register you.I did this year many years ago and had a fabulous year! I worked about 500 km from the closest hospital with a registrar. I was supervised by the town’s local GP. I learnt more in that year than I ever have anywhere else.

I took my own X-ray’s, gave anaesthetics for the GP, performed autopsies and all forensic reports, I attended to many multi-trauma victims prior to the 500 km transfer to the bigger hospitals, I delivered twins, managedbreach births, vantouse and forceps deliveries on my own – and then resuscitated the neonates ! It was a very busy year and a huge challenge for a junior doctor – both physically and emotionally – but it was the year that truly transitioned me from a student to a real doctor.
 
Once you are registered as a doctor with the South African Medical Board, you can either work as GP in private practice, continue as a medical officer in the state health system or you could undertake specialist training.
 
Specialist training is quite similar – South Africa has Colleges of Medicine, Surgery, General Practice, Psychiatry, Paediatrics etc.General specialist training takes 5 years of full time training. Once you complete training you are considered ageneral specialist in your chosen field of speciality. You can either continue work as a specialist or specialise further in sub-speciality fields such as endocrine, geriatrics, haematology, neurology, gastroenterology, endocrine or if a surgeon: endocrine, transplant, hepato-biliary as examples. This subspecialising takes a further 3 years. This training model is similar in all fields of speciality. The advantage of this model is that the general specialists (such as the general physicians) - get to do a vast amount of work and procedures such as gastroscopies, angiographies, external pacing, renal biopsies etc. The patients are only referred to the doctors in the sub speciality areas when the general specialist is satisfied they have exhausted all options and as such the sub speciality doctors are not over whelmed by patients that could be managed by general specialist.
 
In South Africa, doctors such as me - who chose to remain medical officers and not specialise – played a vital role in the smooth running of the state health system. We ran what were called primary care clinics and hospitals. Our work included inpatient and outpatient work, surgery, obstetrics, anaesthetics, paediatrics, general medicine and emergency department medicine. We were the initial contact for all patients and referred the patients who needed to see the general specialists on to the relevant department. The general specialists then decided who was referred to the sub specialities. It is a system that created ongoing patients flow, as well as multiple career pathways for those that doctors that wanted to specialise and those that did not.

 

4. What is the one piece of advice you would give to an intern? ENJOY your year – grab every opportunity you can in that year to do everything you can. Accept that as a doctor you have chosen a career with high demands – emotionally and physically. You are going to be exhausted at times – embrace it – that’s part of being a doctor.
 
AND
 
Don’t rush career choices. Give yourself time to decide what you like and don’t like. It’s awful to be stuck in a 6 year training program when you’re not sure of what you want to do. Work as a general trainee for a year or two, before making a commitment to a training pathway. When you decide to enter a training pathway, make sure you have a definite end goal in site – it’s that dream that keeps you going through many long sleepless nights
.
Dr Andrew Pearce
Senior Emergency Physician and Clinical Director of Training & Education - MedSTAR

1. Can you tell us about your role as the Senior Emergency Physician and Clinical Director of Training and Education at MedSTAR Emergency Medical Retrieval Service? I think I have one of the best jobs in the world, doing what I enjoy, having multiple roles in different organisations and being able to do clinical work, education and training, management, clinical coordination as well as recruiting and interviewing new doctors for the South Australian Ambulance Service (SAAS) MedSTAR, South Australia’s emergency medical retrieval service. Working in the Emergency Department at the Royal Australian Hospital is a challenging role with the number of sick and injured patients who attend every day (around 220 per day).  
There are a number of roles as an Emergency consultant whether running resuscitation, looking after our short stay ward, supervising trainees on the floor seeing patients, running the minor injury and those cases unlikely to need admission to the hospital or overall duty emergency physician ensuring the department runs smoothly with patient admissions, discharges, phone calls from General Practitioner’s and liaising with the hospital executive. Every day is completely different.

My role at SAAS Medstar is an extension of what I do in the ED; just doing it in a helicopter, fixed wing plane, road ambulance all over South Australia and even further into the Northern Territory up to Alice Springs or Darwin, into NSW Broken Hill! Our cases comprise of 20% primary trauma to the scene and 80% inter facility transfer from rural medical centres with sick and injured patients requiring a higher level of care or treatment in Adelaide. The training to do the role is extensive as we are sending a small specialised team to retrieve a very sick or injured patient from a long way from Adelaide. You get to see a lot of the countryside and meet some amazing people.


2. Was there a specific reason why you chose your career pathway? Was there anything that influenced you?
Originally I thought I was going to be a cardiothoracic surgeon and started the long training program in Adelaide. It wasn’t until I met my mentor Professor Chris Baggoley (currently Chief Medical Officer of Australia) who introduced me to Emergency Medicine and the opportunities it offered in looking after all kinds of sick and injured patients, all ages and an ability to work all over the country. I was able to do training in the US, UK, NSW as well as all of the hospitals in Adelaide. At an early stage in my emergency medicine career I became interested in retrieval medicine and also joined the Royal Australian Air Force (RAAF). 

I would highly recommend having a mentor to discuss ideas, ask questions and talk with openly to help you get the right information to make decisions which in a medical career is really important.


3. What was a highlight of your training?
Spending time in the UK at Plymouth as a specialist registrar in emergency medicine. I did a number of important courses, became involved with motorsport medical teams at the British Grand Prix, sailed to Antarctica as the doctor for the British Antarctic Survey and spent time on Rothera Base and worked with the Royal Air Force search and rescue teams.

On returning to Australia I spent a couple of years in Sydney flying with the Westpac Surf lifesaver rescue helicopter and working at St George Hospital to gain experience in pre-hospital and retrieval medicine and prepare for my fellowship exam.


4. What is one piece of advice you would give to an intern, considering their future career pathways?
Take your time; it is all about the journey and not the destination. There is no need to rush through your training because when you are a consultant things change and your flexibility is somewhat diminished.
Upcoming workshops in 2016

Professional Development Program for Registrars (PDPR)
PDPR aims to improve leadership and management performance in the workplace via a sustainable, national professional development program for Vocational Doctors (Registrars).
  • 22-23 September 2016
  • 24-25 November 2016
Register for PDPR through the online registration form available on the SA MET website.

PERMA+
PERMA+ is a framework concept for individual action to build wellbeing. PERMA training was developed by TechWerks in America from positive psychology, to provide resilience.
The PERMA+ program includes the key domains of Positive Emotion, Engagement, Relationships, Meaning and Accomplishment plus physical activity, nutrition, sleep and optimism. The two day course is being facilitated by SA MET. 

Watch the SA MET website for further updates.


Alcohol and Other Drug Use and Intimate Partner Violence workshop
9.00am-4.00pm on 17 June 2016
Clinical Education Centre, The Queen Elizabeth Hospital (TQEH)
Registration via email: Lynne Burn or Natalie Hickman

Sapmea workshops and training

The 2016 sapmea calendar is now available online. The calendar contains various workshops and training. View the sapmea calendar now!
 
Feedback
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   Upcoming newsletters ... Keep an eye out for our next newsletter, which will be focusing on the impact of different cultures in the workplace.
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