Tuesday, 16 August 2016

Tilting: the absence of effective team functioning.

I suffer from recurrent earworms. It's an affliction I've had for a long time. I once had to watch Adele's performance of Someone Like You on Jools Holland about 100 times before I could move on. The problem has flared up again recently with Christine and the Queens' 'Tilted'. The traditional management strategy is either to feed it relentlessly until it burns out, or pass it on to someone else. Usually, I have resorted to the former, but more recently, I have tried to share it with my 4 year old daughter. She loves music videos - her favourite is Michael Jackson's 'Beat It'. I don't think she is entirely convinced by Michael's ability to heal gangland rifts through the power of dance, but she does find it terribly amusing. 

For the last week, therefore, I have been exposing her to repeated viewings of Christine and the Queens' 'Tilted', both in video and live performance versions; she particularly enjoys two aspects: the man who walks on his hands and the line 'I am doing my face with magic marker.' 'That's silly, Daddy', she says. She is right, which only leads me to wonder whether a magic marker is the same as a permanent marker, and how worried I should be that she will become a music-lyric-copycat, and be left with ink stains on her face that remain until she grows new skin. She's due to start school in a few weeks - it's a real concern.....

Tilted is a song that first appeared in French. Heloise Letisser (Christine is her alter ego) speaks English with the kind of thought and consideration that allowed Nabokov and Conrad to write beautiful English prose in non-native languages. Tilted in English, is, I suspect, purposefully ambiguous, and contains the delicious line 'I am actually good, I can't help it if we're tilted.'

You make of that what you will, but to me, it invited comparisons with what it is like to work in healthcare. Over my career, there have been moments when I was unable to be the conscientious, well-meaning young man that decided to be a doctor. There have been moments when I found it impossible to be as compassionate as I wanted to be, to be a considerate as I needed to be, or as patient as my patients needed me to be. 

I am not alone in having set out in medicine to be expert, caring and good under pressure. I am not alone in having failed to live up to these objections. I am not alone in having felt the shame of having fallen short. Today, I wonder sometimes how I made it through my time as a medical registrar. 

Feelings of inadequacy in a hospital can be insidious, and undermining. You look around at all the people who manage to be nice all the time, who seem to breeze through the day, while you wrestle with the anguish of feeling inadequate. You exhort yourself to try harder, to be better, because, well, that is how you manage problems in the NHS. 

We have been fostered in an environment that talks about 'no-blame cultures', but which, through every action it actually takes, cements the perception that you are OK as long as you don't mess up. Targets are met through constant cajoling, pushing and exertion. Each day is a full throttle effort to keep up, leaving no time for colleagues to sit down and ask of each other 'Are you OK?'. There is no space to reflect, to learn, to plan different ways of working, or simply to make sense of what has happened. 

It is in this environment of working that staff start to wonder whether they have the stamina to survive. Each day in an acute hospital is run as if it is a crisis. Yet a crisis response is only sustainable if you know that the crisis will end; that one day soon, you will be able to take your foot of the peddle, slow down, catch up, tidy up and recover. 

The recovery time in medicine has disappeared. Recovery used to take place in the mess, in the pub, in the quiet moments of the day. The old way of team building through having the whole firm working together all the time wasn't ideal - machismo and practising on patients are no way to do healthcare, but at least there was solidarity. Now the hours have changed, but nothing has replaced the team structure. Modern working schedules do not allow firm team structures to exist in the way they used to. Without them, however, junior doctors have lost the support networks they used to have, and they have not been replaced with anything. One would have thought that with doctors switching teams so often, that the NHS would be the world leaders in team development strategies. Perhaps we might be, except that the current culture of healthcare seems to view team-building as non-essential. For confirmation, look at the number of junior doctors who started posts this August who still don't have contracts, know what they will earn and didn't get their rotas until a few days before starting. 


I have been musing over this, to the tune of Christine, and various online articles that have caught my eye (here and here, for example). The comments section of the 2nd article is illuminating, including the remark 'You're already a good doctor, and you'll get better.' A revealing insight into the perception that you learn by doing, and by coping. I would hope for more than that. 

The moment of expressed crisis in a colleague is not the moment to reflect deeply on what they are doing wrong. It is the moment to reflect on what you as a team are doing wrong. The moment a colleague makes a mistake is not the moment to enquire only on whether they are competent to do their job, but to enquire whether your team is functioning as effectively as it could be. Crises and mistakes are the moments when teams should huddle together in collective responsibility and openly outline the problems, and earnestly offer the solutions they can try. 

Fostering a team environment in which mistakes and crises are taken as opportunities to reflect genuinely on how they can operate better need not be hard. It requires only two commitments: to treat mistakes and crises as the whole team's responsibility, and commit to open, safe discussion of the causes and solutions as a group. 

I am glad I survived registrar training, because I have ended up working in with teams with whom I think I could take on the world. More importantly, I have ended up with teams with whom I feel I can be fragile and vulnerable. I know they will help me, and I wouldn't swap them for anyone. We may be out in West Dorset, but together we are working really hard to offer our patients services that we are proud of; and we are doing this by making sure we have time in our schedules to discuss what is going well, what isn't and what we want to try next. 

Next time someone looks like they're struggling, or they make a mistake, sing yourself the song, and remember, 'They're actually good, but can't help it if they're tilted'. 

Monday, 1 August 2016

Domiciliary admissions

On Friday, a GP phoned the integrated care hub in the community hospital I work in to request an admission for a lady bed bound at home, and in need of medical attention. We took her details, made sure the ward was ready for her and organised transport to bring her in.

Ordinarily, a team would wait for her to arrive and assess her when she was in her bed. Ordinarily, she would be brought on to the ward, sometimes after an interminable delay waiting for transport, and then be assessed by a nurse, then a doctor, and then acclimatise herself to the unfamiliar environment she found herself in.

Ordinary is boring. I wanted to do something a little different. Instead of waiting for her to arrive, I picked up my computer, my bag, and a drug chart, and I drove round to her house. I clerked her in her bedroom. I assessed her medical needs, I had a quick look around her house, and I met her husband. The ambulance arrived while I was still there, and I was able to talk to the crew about her needs. I spoke with her about what I thought was going on, and outlined to her how we would try to help when she arrived in hospital.

After I finished at her house, I popped round to a couple of other patients at home, and by the time I arrived back at the hospital, she was there, at her bed, looking both relaxed and relieved.

Seeing her at home might seem like a small thing. It might seem like a massively inconvenient thing, But it was also very useful. For some time already, I have given up out-patients clinics and only see patients at home. I find it is more relaxing for them, and useful for me. When you see someone in their own home, you instantly get a feel for how they are actually managing. In the same way, by assessing this lady at home, I could instantly get a feel for what she needed from me. It was also, surprising and reassuring for her to meet one of the doctors who would be looking after her in hospital, before she arrived.

I'm not saying that all patients could be assessed at home prior to admission, but I am saying that introducing  new ways of working that are designed around the needs of the patients you are trying to help can have a big impact on their experience and comfort with health services. I also suspect that it allows us to help them more effectively.

Monday, 11 July 2016

What CGA means to me

It worries me when someone talks about 'doing a CGA.' I shy away from CGA evangelism, but comprehensive geriatric assessment is the cornerstone of geriatric practice. Put as simply as I can manage, CGA is the holistic assessment of a patient, to capture all the issues that may be affecting a patient. Done well, it should cover medical, psychological, social and functional domains, creating a detailed picture which helps to explain the presentation of the patient at that moment.

Simple to understand, difficult to implement.

One of the tricks of geriatric medicine is to make sensible treatment decisions for the patient you are dealing. Achieving 'sensible' relies on having a clear picture of what that person is like when they are not ill, and not in hospital.

Admission to hospital is a cognitive stress-test, which usually takes place in the context of the physiological stress-test of acute illness. Often, the patient in front of you is far from the person they usually are. Imagining your way to that person in their routine is like foraging through a thick forest, looking for clues. The risk is significant: underestimate their usual level of function and deny them treatment that might be effective because we think they are too frail; overestimate them, and subject them to futile, disorientating care that offers them little utility.

I wrestle with the challenge of knowing my patients. I also wrestle with the concept of a CGA done in an acute crisis. It yields important information, but it yields it too late, and often incompletely. Too often it tells me too little about the recent narrative of that patient's life, the trajectory they have been on, and if offers them too little opportunity to take part in planning their care.

Serving a frail, elderly patient well asks that you involve them in their care, that your practice is influenced by their preferences, their style and their goals. These all vary hugely, and practicing geriatrics only one way means expecting your patients to all fit in with your judgments, preferences and biases. This is a certain way of ensuring that you partially serve most of your patients.

In the world of community geriatrics that I circulate in, we have been building services that aim to manage patients holistically, gently and responsively over time. The cornerstone of our adapted services has been the recognition that almost all of our frail, elderly patients are known well to at least one community service. Over time, these services, and key people within them understand in some detail what that patient deals with, what they are looking to achieve, and what they want to achieve from future care as they become more frail.

We base our conversations about how we help patients through periods of crisis or deterioration on the information provided by the person who knows them best. We develop our input around what we have learned about them from their previous care. It is an approach that requires carefully nurtured team cultures that encourage participation from staff of all roles, and it is an approach that demands significant investment of time, to allow for conversations that often swirl and circulate before you are able to focus in on the key issues that have been identified.

What we have yet to achieve is a system in which every routine assessment contributes to a centrally collated CGA, built up over time, and from every healthcare interaction, to which any relevant health professional can refer when they meet a patient. Some people call these care plans - I like to think of it in the narrative sense.

I am working towards a world in which CGAs are not done, but continuously honed. I look forward to a world in which every interaction with an elderly patient is treated as an opportunity to contribute to care when they get sicker or frailer; in which a crisis is just another chapter in the process of caring for frail, elderly patients. We should be able to leverage the opportunity offered by electronic records to collate this information automatically.

The goal is this: whenever a patient presents with an acute illness or crisis, their admission should be underpinned by an holistic care plan, built up over time, honed at every opportunity and able to support critical decision-making at any time.

My great frustration with acute geriatrics before I moved to the community was that I would spend time helping patients recover from their illnesses, understand how their diseases responded to treatment, and then have nothing to do with them until they became sick again.

After three years working in the community, I am much closer to understanding how holistic geriatric care could work effectively in the modern health system. And it's not as far away as you might think it is. 

Tuesday, 5 July 2016

Modern rituals.

Life has a lot of rituals. From the way we organise child-birth, to the day we die, our lives are marked in the stage-posts of periodic rituals. My little girl is due to start school in September, and even that has the hallmarks of a ritual. From the care-free playful days of her first four years, she will embark on a routine that starts to embed in her an understanding of the way that our world works. She will make friends (hopefully), she will learn to read and write. She will take exams - one of my favourite rituals of all.

Perhaps I am being too liberal with the word 'ritual'. Our lives are not governed in the way they once were by religion. That is not true everywhere, but here in the UK, religious practice is a matter of personal choice, rather than compulsory observation. Ritual has become secularised, which is not without its pitfalls.

I see evidence of secular ritualism all over the place, from humanist naming ceremonies, to football matches, summer festivals, graduation, even Christmas. Who can still argue that Christmas remains a primarily religious celebration?

I like rituals. They give us context, grounding and perspective. But primarily, they must have purpose. A good ritual allows us to appreciate where we stand in the world, where we have come from, and where we are going. It is a piece of community history, that encapsulates the learning of the past for the benefit of future generations.

Baptisms introduce a new child into their families and communities. Weddings celebrate the bonding of a couple. Funerals organise the grief over a lost friend or relative. It is always good to forge one's own path, but it is also important to understand from whence you came.

Yet, the ebbing away of religious practice from wider communities has left a big gap in how we deal with death. Today, over half of people die in hospital, yet only 8% want to. The majority would prefer to die at home.

At first glance this appears to be a fundamental failure of the health service to adapt appropriately to the needs of the people it serves; but hold your counsel for just a moment. How many of those people who were asked were actively dying at the time they were asked? I suspect not many.

I have supported a great many people in their final days, and done well, it can be a serene and valuable experience. Many of my patients were ready to die, and tired of life. Yet many were understandably scared and lonely. I try to advise families not to keep vigil, but to keep loving in those final days and hours. To talk, to hold hands, to give space and quiet. I have encouraged them to enjoy final lucid moments, to look out for signs of distress that we can help with, but more importantly to talk openly, honestly and candidly about what is happening, and to take a final chance to say the things they won't ever have a chance to say again.

And sometimes, to me, it feels a little absurd that it is I, a physician in his 30s, who is giving advice to families about how to deal with the process of seeing a loved one die. I never really thought I would become an expert in dying, even as a geriatrician, but then again, who else has the chance to become expert?

Patients often come into one of my community hospitals for palliative care, and we are glad to have them. We are pleased to be able to help. The nurses I work with offer the kind of care I wish everyone could have. With a calm, compassionate simplicity, they tend these patients compassionately, and allow the patients and their families to focus on the things that are important to them.

Many of these patients arrive having had a fraught time at home. Often they are desperate to be at home, and their relatives are desperate to support them. But the challenge of meeting the care needs of some very frail relative, often in pain, or with other symptoms can be overwhelming and incredibly stressful. It is also entirely unfamiliar. What is normal when someone is dying? How do you know what to expect?

Many of us, I suspect have never seen someone die, or even seen a dead person. I remember clearly the first time I was present at the very moment of death. You can tell instantly, and you start to understand why we used to believe in a spirit leaving a body, because that is exactly what it looks like.

It used to be the case that many people died young, or the elderly died at home. It used to happen all the time. Within communities, it was something that most people had experienced.
Vestiges of the past still live on through our hospital chaplains, who minister our patients with grace, calm and compassion. It is through our local vicars that some of this community expertise lives on. The double-edge of the success of modern medicine is that these routine occurrences have passed out of the collective experience. End of life care has been outsourced to hospitals, which means that when it does happen at home, it can be a scary experience for all involved, because there is too little access to people who know how it all works.

Much of the comfort that patients and relatives get from dying in one of my community hospitals is from being surrounded by staff who can help them know what to expect; people who will tend to routine care that is important, so that they can enjoy some tender last moments, without the pressure of attending to basic needs.

Perhaps this was a ritual that we used to have the community expertise to do at home. Perhaps it's something that we still have the expertise to do at home. What I know is that for some patients, being cared for in a calm, expert environment that isn't their home, is often the right thing to do.

Sunday, 22 May 2016

Calm under fire.

I'm a little baffled by the new contract proposal. I don't understand how you can mentor someone who has been on maternity leave to make up the time spent as a mother and not a doctor: equality doesn't mean that to me. Only women can deliver babies - they shouldn't be disadvantaged by that reality. I also don't understand why night shifts that start at 7.30pm don't attract the same pay uplift as shifts that start at 8pm (it is entirely possible I have missed something), and I don't understand why the same contract discussion is still taking place when it has been well demonstrated that not only does this contract not solve the problem the government is trying to fix, but that the problem itself is not a problem. Surely, we do not still linger on the misconception that radical working changes are required to improve survival expectations of patients admitted at the weekends.

Guessing what lies beneath the contract chicanery is a fool's game: we can tell you what the evidence suggests to us - that the NHS is being teed up for greater private provider involvement, but the current political oversight of the NHS is something of an evidence-free zone. Who can reason out the illogical reasoning behind our current situation?

And this is the knuckle-gnawingly frustrating thing about the whole situation. Logic doesn't prevail. Evidence doesn't talk. It reminds me of what it is like trying to explain to my three year old why she can't have more ice cream, while she is having a hissy-fit about not having more ice cream. Nothing gets through.

I can't count the number of people who have shaken their heads patronisingly at me, and said that junior doctors are being naive, that this is politics. The implication is that politics goes by different rules, and we should be OK with that. We should be OK with a world in which reason, evidence and grown-up dialogue are usurped by the diaphanous concept of 'winning'.

Where the sad reality leaves us that is that there is no clean way out of this. Jeremy Hunt talked, the morning after a proposed contract was agreed, about this not being about who won, but how long will that last. Can junior doctors trust him not to go crowing about winning the day after they agree what has been proposed? Could they stomach what would come after if they rejected the new contract?

The Department of Health keeps reminding us that this is about providing a 7 day service to patients. I suspect many are not convinced about their real understanding of what this means. But we do. We all know the areas of our service that we want to improve, we all understand the limitations to achieving what it is that we want to achieve; yet I imagine many of us still have plans for what we are going to do next.

In this crazy world of doctors having to play politics, understand the nuances of PR and social media, we are all still going to work, delivering the best we can for our patients today, and thinking about making our future services better still. There are elements of the service we work in that we have no control over. We can't predict what the current Health secretary wants to do next, and we can't predict how the next one will want to make his or her impact. What we do know is that they will want to do something, because when was the last time a Health Secretary trusted the people who run and deliver healthcare services to know what the best thing to do next might be?

And it was ever thus. We have been tinkered with, reorganised, and in some cases catastrophically buggered around with, all in the name of improving what we do now, since the NHS began. And yet we have continued to deliver better healthcare. The care we deliver now is not perfect, but our outcomes are better now than they ever have been.

There is also a silver lining. When was the last time that consultants and junior doctors felt so connected? The sense of solidarity pervades the NHS. Consultants now have a better grasp not only on what the problems of being trainee are, but what the day to day frustrations they experience are. They may only have walked a few days in the shoes of their juniors, but it has been enough to erase the rose tint from their own memories of being a junior, and focus on the reality of that life today, in the current NHS.

So we have solidarity, but we still have the threat of imposed change. Of course we do - and it won't go away. But in reality, it doesn't change very much. We always operate within the limitations of our current framework, yet great change is always possible.

The system may be telling junior doctors that they aren't appreciated, but we don't need to toe that line. Consultants, nurses and therapists are all capable of creating teams that any junior doctor would want to work in, and of delivering better services together.

It's not much, I know, but perhaps we would do well to remember that any framework creates opportunities, and however down-trodden we feel right now, we can still hang on to the prospect of creating something better for our patients.

While the metaphorical mortar shells are flying overhead, we must keep calm under fire, and do what it is that we have always sought to do: put the patient first. 

Saturday, 14 May 2016

On a raft without a paddle

Werner Herzog's cult movie 'Aguirre, the Wrath of God' opens with a shot of a Spanish baggage train weaving it's way down some steps cut into an Amazonian mountainside. As the shot zooms back, the scale of this path carved into the hillside becomes apparent - they start at the sky, and seem to weave their way into the bowels of the earth.

Aguirre is a notable movie with for a number of reasons- it is dark, weird, beautiful and atmospheric; Klaus Kinski is terrifying - up there with the Child Catcher from Chitty Chitty Bang Bang (you know I'm right). He doesn't do or say very much, but there is always menace, and an ominous verbal tick punctuating the movie foretells all manner of darkness. But what has always grabbed me is the story of its making: I was told (who knows how reliably) that Herzog wanted to recreate the reality of the conquistador's progress through the Amazon rain forest by undertaking a conquistador's progress through the Amazon rain forest. Let's call it Method Directing. Those steps on the mountain in the opening scene weren't there before the movie was made: Herzog got the cast and crew to carve them. They weren't very happy about it, but what could they do? They were marooned in the jungle with a maniacal director and a scary actor fully absorbed in a scary role. 

There's a moment in the film when the group needs to make its way down the Orinoco on rafts. There's no CGI here, and from I can work out, he put the cast on one wooden raft, the cameramen and crew on another, and pushed them down the river. He clearly didn't get much footage from it (he repeats certain shots), but the picture of fear on the actors faces is not faked: they were being pushed down some rapids in full 16th Century attire on hand-made wooden rafts. 

I thought of this scene recently at the British Geriatric Society conference, during a conversation about leadership. Herzog displayed the form of leadership that involves putting your team on a raft and sending them over the white water, while waving at them from the bank. This reminded me of some of the leadership behaviours I have witnessed in the NHS over the last 10 years. It seems to be particularly prevalent at the moment at the top of the health tree. 

I wonder if Herzog was angry that he got so little footage from this escapade, and gave his crew a bollocking. Let's imagine he did. Perhaps his crew could have pointed out that on a wooden raft, they didn't have appropriate camera rigging to get steady shots, that they couldn't capture decent sound while being on a different raft to the people they were filming. Perhaps, they argued that they spent so long worrying about their personal safety, whether they would be OK without life-jackets, that their minds weren't entirely focused on the job at hand. In fact, one could argue it's a miracle they captured any footage at all.

Sound familiar?  Ever get the feeling that we've been put on a raft, pushed down the river, while people shout from the safety of the river bank that we need to work harder and be better? Look after an ageing population with increasing complexity? You can have some more money, but we want you to save even more through being more efficient. Provide elective and emergency care across 7 days? You can't have any more money for this, but we will magically pay you more, while keeping the overall salary budget the same. 

The NHS is currently Herzog's crew on the raft. The major problem with this whole situation is that the patients are the cast on the other raft, and they too haven't had much say in how the whole process works. It's not hard for them to act the role of scared explorers on a raft, because the only difference is that they didn't know they were explorers.

The scenario I describe relates to a still prevalent leadership style within the NHS that is counter-productive. You can push people down a river, but usually, you only to do it once. Next time you go near water with them, they will keep you between the river and them. Perhaps you can argue that the end justified the means, but you'll have to make your own assessment of the price of art (or happy healthcare workers).

Sunday, 24 April 2016

Everyday crises

Death and taxes - the great unavoidables in life. Except, perhaps, if you have the phone number for a lawyer in Panama. Yet even the rich have yet to cheat death - it remains the great equaliser.

If 2016 is a bad year for celebrities, think for a moment about what it is that grabs us when one of them dies. The death of a celebrity prompts a bout of intoxicating nostalgia, that is not possible when they are alive. The loss of someone we feel we know (but haven't met) triggers some intangible emotions related to the fact that we have lost someone who didn't know they were important to us. Perhaps some of the grief is wrapped up in the realisation that they will never have the chance to know how important they were to us. Celebrities must have some abstract sense of the role they have played in other people's lives, but I doubt that they really grasp how resonant their song, book, film or art was to all their fans. Perhaps the sense of loss is more selfish - that the death of a celebrity reminds us of a bit our past that has gone for ever: reminds us that we are relentlessly marching in the same direction. I tie myself in knots thinking about it.

The manner of dying also has resonance: Bowie orchestrated a most stylish exit. Alan Rickman and Victoria Wood seem to have died privately, with friends and family around them. Prince was found in a lift. Marvin Gaye was shot by his father on his 45th birthday. Sean McGrotty died trying to rescue his family from a sinking car, after he had taken his 4 month old baby safely to the surface. The moment of dying is not just an ending, it is an epilogue to a life. It is the last thing you read in the book of someone's life, and it can colour or enhance everything that went before. 

I thought about this recently, when I heard that the body of Rose Polge had been found. All I know about her is that she was a junior doctor in Devon, and had last been seen in February; a note was found in her car. Who knows if being a doctor had anything to do with her death, but it sits there in the biography of her life as an emblem.

One's first years of practising medicine are an intoxicating mixture of pride, exhilaration, fear and exhaustion. While experiencing the thrill of diagnosing, prescribing and helping, there is also the worry, pressure and intensity. People always say that medicine is a tough job, but nothing prepares you for the reality of it. It is an odd and overwhelming feeling to be a doctor after the years spent chasing it. However, I found myself, for a time, hating parts of the job, and feeling wretched about it. It eased with time, but whenever I thought I had it sussed, something came along to unsettle me. Even now, I'm not quite sure how I made it through five years of being a medical registrar.

As I experienced self-doubt, and negative thoughts, I would look around me. All around me, I would see my peers seemingly sailing through with charm and style.  For a while as a house office, I went through some particularly hopeless periods. I wondered how I could feel so bitter about the people I was helping. I started to wonder if I cared enough about people to be a doctor. Interestingly, I started to find some perspective when I read 'House of God'. Samuel Shem's dark satire portrays a world so fancifully unrealistic, it is easy to dismiss it simply as black humour. But every hospital has a Fat Man,, who boils the world of medicine down to 13 simple rules. I had mine, and it was through him, I started to realise that I wasn't a bad doctor, I was simply a young doctor being asked to find his way through medicine without enough help. I wanted to be a Fat Man when I grew up. I guess we all do in a way: he is the one who makes it look easy. Yet even he went through his black periods, and perhaps the one thing that teaches us is never to trust the person who has never found it difficult.


There is nothing wrong with medicine being a challenging job. It is probably the lure of the challenge that draws so many in. It is therefore, unsurprising that many find it hard along the way: if we all found it easy, it would mean that it isn't that hard. What troubles me when I see it, is the failure to recognise and deal with stress and anxiety when we come across it at work. Who of us can truthfully say that we always help a struggling colleague whenever we find them? I often think about a house officer of mine who found the going tough when I was a registrar. I wanted to help her, but was barely keeping my head above water myself. I worked for a consultant who expected me to cope with everything that came my way. I often wonder what happened to her, and whether she made it through.

The challenge of supporting junior doctors gets confused because of how we think about junior doctors. The fact that we call them junior doctors illustrates the point. We treat them as students, and trainees, rather than fully functioning professionals. I prefer to think of them as colleagues. I prefer to think of them exactly as I think of other consultants, nurses and therapists. Of course, there are differences, but we shouldn't use these as an excuse for unjustified differences in how we treat them.

The hardest thing about dealing with junior doctors is their transience: they spend a few months with a team before moving on. There is little time to develop deep and trusting relationships. By the time you have understood how they are doing and what help they need, they are moving on. And this is the problem: we work with colleagues on the understanding that normally everything works well, but sometimes, we have to deal with problems.

The reality is that there are problems all the time. Dealing with challenges and stress is a daily part of the job, and should therefore be a daily part of the way we work.

From experiencing deep personal crises, I have learned that one of the most useless things to say to someone is 'You can ask me for help anytime.' One of the hallmarks of a crisis is not knowing how to ask for help, or how to approach a problem. The most helpful thing you can do for someone, is well, something helpful. You may not be able to solve the problem, but you can take away other things unrelated to the problem and increase their capacity for meeting the challenges ahead of them. I remember my Mum helping a neighbour who had lost her husband by doing her ironing. I thought it odd, but later realised, instead of offering sympathetic platitudes, she was doing something useful.

The most helpful thing that teams can do for junior doctors is to function in a way that allows the open contribution and discussion of problems and aspirations as part of the routine.

Personal sustainability in medicine is all about having the routines and habits that make a difficult job easier to bear, and teams who share the load. None of these skills is currently taught to junior doctors - they are expected to learn from people who themselves have never learned the good habits of personal sustainability. Is it any wonder then, that nothing seems to get better?

My goal is to ensure that the teams I work in communicate openly and honestly all the time; that we talk regularly about what is going well and what isn't; that we discuss what we want to do next, and we do it all together. I think, if we can do this, then any new member of staff, be it a junior doctor, healthcare assistant or nurse will join a team in which they know that they can learn, and struggle, and that all they support that they might ever need will not just be there when they ask for it, but given to them freely from the start.