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.


Monday, 18 April 2016

Crowd-sourced trust

I have a snippet of a memory from many years ago. Aged 3 or 4, I am sitting in the back of a car - my parents are up front. There are novelties for all of us: it smells different, it is beige, it runs on diesel, it is Montego hire car. Remember the Montego? Outside it is foggy, snowing even, and it is bitterly cold. I hear my parents whisper to each other about it being too cold for a diesel car, that the fuel will freeze and we may well end up stranded on the side of the road.

For the rest of the journey, I am petrified. I give myself a pep-talk, telling myself how brave I am going to be if we break down and have to walk home. It never occurred to me to ask my parents if we were going to be OK - I had heard enough. And I dealt with my own fear by myself, because the last thing my worried parents needed was to have to deal with my own, small, child worries. Surely aged 3 or 4, I should be able to manage those for myself?

In the end, there was no crisis - the Montego defied expectations and carried on going, and we returned home without further incident.

I was thinking about that memory recently, as I drove to work on a cold, cold morning. And two things struck me: firstly, was it even a thing that diesel cars in the 80s would freeze if the ambient temperature dropped too low? I never saw it, I never see it now. Or was it that my parents had enough experience of British Leyland cars to know that if conditions fell off optimal then you could never be sure what the car would do. It's like the memory that in the 80s, whenever someone had a new car and you asked them how it was, they would always say 'It's too soon to tell.' You had to give them a couple of months to find out where all the gremlins were, which panels weren't properly fitted, which electrical components had been botched, and which bits of paint were going to flake off first.

I still see this in lots of my patients: the tacit acceptance that something brand new won't necessarily work well straight away. I think it might be why they take so much better care of their cars. They have the hard won knowledge from years of suffering well-designed, but terribly-made British cars, which unless they were cherished, polished, waxed and oiled, would seize up. They would look at the tide-mark of Dorset mud on the side of my car and shiver, I'm sure.

The second thing that this memory triggered was the realisation that my parents at that time had no idea how worried I was, and if I had mentioned it to them, they would have talked me through it, reassured me, and let me know that it would all be all right.

I often wonder how much I understand about what is worrying my patients. Sometimes I get a sense of what they aren't telling me, when one of them asks me a question, or does something so ordinary but unusual, that I begin to wonder whether a lot of their concerns never get asked, or aired. A man the other day interrupted my ward round review of him because he needed the loo. He was clearly desperate, but couldn't stop apologising afterwards. I couldn't reassure him enough that it was OK, that nobody should have to have an important conversation while bursting for a wee.

Another lady shyly asked me how her recent injury would affect some deeply personal aspect of her life. I was happy to advise her, but she was clearly mortified to have to ask, but still determined enough to do so.

This all begs the question, how do we give patients the confidence to ask, the time to be heard, and the confidence that they will be treated with compassion? I notice that so much emphasis is placed on my ward rounds by the patients that they get performance anxiety, and forget some of the things that they meant to ask. I encourage them to write their questions down when they occur, so that they don't slip their minds. But more than that, the thing I try to do now is to be present less formally. A ward round is quite a formal time: I go round the ward and see each patient in turn. They see me walk into the bay, and they wait their turn. Sometimes it must have the sense of an inspection, or progress report.

I have previously commented that my most fruitful relationships with patients are when we have a relationship on equal terms. They are them, and I am me, rather than a patient and a doctor. Honesty, to some extent, thrives on informality and familiarity; these are aspects of relationships that take time to build. and time is the one thing that we are not given enough of. I have 80 in-patients. If I spend just ten minutes with each of them, that is 13 hours a week.

Over time, I have learned that although my own relationship with my patients is important, it is not the only important relationship they have. They have close friends, and families; they have strong relationships with district nurses, therapists, their GPs. There are many people who have spent time with my patients over the years, and they are often well ahead in the trust-stakes with them.

Each moment I spend with them counts, but they are not the only moments that count. There are countless other opportunities to learn and understand. Effective team working enables this learning, and flat team hierarchies mean that it doesn't matter whether important conversations take place with a doctor, a nurse or a healthcare assistant - they can all be brought to bear for the patients' benefit as long as you have the trust in all the people you work with.


Tuesday, 12 April 2016

Crafting Care Plans

Legend has it that Voltaire wrote Candide in three days. Academic enquiry suggests it took a great deal longer. The idea that talent and perfection is innate has a peculiar traction, but it is perhaps lucky for most of us, that great works are more often the function of graft than inspiration. It is something that can give us all hope.

Novels take time to appear. I like to apply the Michelangelo idea to a book: the idea that a book starts as a solid block of paper, and the novel is chiseled out of the block in a process of rough outlining, correction and laborious polishing. It starts with the idea of what book is contained within, and the application of labour and skill to reveal the story concealed within. Reading Steinbeck or Nabokov or Conrad, one can certainly appreciate the process of refinement, and sense the bloody determination and brain-aching effort taken to phrase each sentence just so. 

Perfect prose has some of the hallmarks of a wonderful goal, or a breathtaking try. Before it happens you have the hope that it will work out the way you want. Afterwards, on the replays, it has the aura of something that always was, and was in some way always meant to be. 

My friend Charlie has written a wonderful (and beautiful) book (http://charliemaclean.co.uk/). It is actually more than just a good story, it is wonderful to hold and flick through. In the hand, there is the suggestion that it could only ever have been the way it turned out. But to know Charlie is to know the hours and the years that he put into crafting his first novel. It was a sacrifice to write, and a true labour. 

I know something of the commitment required: I have 70,000 words of almost complete twaddle sitting on my hard drive, waiting for me to find the courage to erase, and start again. Such is the experience of writing: one can go for miles and miles down one path before realising that it's the wrong one, and you need to go all the way back and start again. 

I thought of the creative process this afternoon, while engaged in a lively twitter discussion with David Oliver (@mancunianmedic) and Claire Solomon (@geridoclondon) about the wisdom of screening for frailty, without a clear plan of what to do with the knowledge that someone is frail. 

Within the world of geriatrics, it seems to be de rigeur to set up projects that screen patient groups for frailty. At a couple of events recently, I have listened to project after project describe how they are screening; but I have heard very little about what they do with that information. In many instances the process of screening is conflated for an actual comprehensive assessment, and what results from the whole process is a care plan, produced in one day, that is never updated, and almost certainly, rarely referred to again. 

Geriatricians deal with advanced frailty, and as David Oliver told me this afternoon, mild frail is about self-care and prevention, while  moderate frailty is about good primary care coordination. 

The question this poses me, as a community geriatrician, is what my role in all of this frailty management is. In reality, this question answers itself when I reflect on the patients that my capable and excellent local GPs ask me to see. Their referrals to me can be divided into three groups: those in whom they can't quite figure out what is going on (diagnostic uncertainty), those with complex symptoms in the context of multiple medical problems and those for whom the limits of medical intervention and treatment need to be considered (ie ceilings of care). 

The rest they mostly manage themselves. However, I have found that there is a useful role for me in this routine work, through the time I spend with GPs and MDTs, contributing to the discussions about patients and how we can best support them. 

Over the last two and a half years, I have learned a couple of important things about helping frail and vulnerable patients at home. 

The first is that success is defined by what the patient wants to achieve, and this can vary hugely. Some want to be pain free, others want to be able to breathe a bit easier. Some want to live long enough to go to their grand-daughters wedding or celebrate their ruby wedding anniversary. Others want never to have to see a doctor or go to hospital. And some simply want to die in comfort. There is no standard definition of success for these patients, and we can only know if we have done our jobs properly if we understand what it is that they wanted to achieve in the first place. 

Understanding patients to this kind of details takes time, and can't be achieved in one assessment or home visit. It takes patience, and commitment. 

And it takes something else: it requires you to listen, not just to the patient, but also to all the nurse, therapists and carers who have spent time with the patients, and formed a deep understanding of their issues and needs. 

Community MDTs need to function in a way that allows all team members who know the patients to be heard and to have the confidence to contribute; and care plans for these patients need to capture this information, and to evolve over time, as our understanding of individual patients grows and deepens. 

Care plans are not works of literature, but some of the same principles apply. Start at the beginning with a guiding concept, and over time, rework it, hone it and polish it. Make it a living document that everyone can refer to, contribute to and refer again to. 

Of course, behind every good book is a good editor, and perhaps the same is true of care plans. 

There is something of the chicken and egg about care plans: health professionals won't rely on them until they are readily accessible and contain useful information. GPs can be reluctant to spend much time on something that people can't access and don't use. 

Where I work, we have gone a long way to solving the accessibility issue. We just need to commit to both producing them, and using them. Of course, there are still barriers, but we won't get anywhere if we let that put us off.