Wednesday, 8 March 2017

Candour amidst all the obfuscation

All 3 diehard followers of my blog will know that I am a cycling fan. I was drawn to it during the ruthless reign of Lance Armstrong, yet even his egregious deceit wasn't enough to throw me off the sport entirely. In cycling, the winner of the race is only one part of a complex narrative - and it is this complexity that makes it such a compelling sport. Much of the enticing texture lies in the little stories that open and close throughout the race, in the shadows of the contenders, vying for the victory. 

While Lance painted a bloody great black mark on the sport, he also provided the chiaroscuro necessary for redemption. Restoration is only possible if there is a context for it. Lance provided the context, and in the absence of a truly great cyclist in recent years, the quest for redemption has become a significant part of the story - and this is where Team Sky came in. 

I liked a couple of things about Team Sky: I liked their disruptive influence on the sport: they clearly didn't mind not being liked, because it probably indicated to them that they were doing something right. I admired their commitment to clean racing. Their was something childishly optimistic about their insistence that cycle racing could be won cleanly if you were on top of every other aspect of performance. They asserted that if you planned every controllable detail and worked hard, then you could do well. It's not particularly artistic, but preparation creates the landscape in which compelling sport could happen. 

Lance Armstrong liked big gestures. There was something brutal and beautiful about the way he stared into the face of Jan Ullrich on the way up the Alpe D'Huez in 2001, before standing up on his pedals and buggering off into the distance. When we thought he was riding cleanly that felt like a big moment. It was also one of the moments that convinced many people that Lance wasn't clean at all. You don't leave someone like Jan Ullrich standing on an 8% gradient the way he did unless you have an unfair advantage. 

In the absence of systematic doping, cycling has become less explosive. The 'Big Bugger Offs' you used to see in racing, when one cyclist would disappear up the road, fueled by a high haematocrit and the Popeye-like influence of testosterone and growth hormone have all but disappeared. Cycling became something more granular, slower-burning, and in many ways more compelling. To understand a recent Grant Tour properly, you had to pay attention for the whole 3 weeks, as the battle played out in small margins over a longer period of time. 

And leading the way was Team Sky. Yet, recently, we have learned that perhaps they weren't leading the way - perhaps they were merely reinventing the way that cheating was done. I don't know if Team Sky has been racing clean or not. I don't know if Bradley Wiggins took delivery of something he shouldn't have in the 2011 Criterium, but I do know that for a team founded on the principles of riding cleanly and proving you could win without doping, they should understand the need for transparency, particularly in the context of a sport about which people still harbour doubts. 

Every time Chris Froome has won the Tour de France he has faced accusations of doping - he even went as far as releasing his training data, and with this in mind, one would have thought that Dave Brailsford would understand the need for good governance and a clear audit trail. Apparently, however, he did not, to the extent that he and his team are unable to account for the medications they ordered (including some rather high quantities of triamcinolone (used for treating allergies by no one except cyclists' doctors.....), and they are unable to say who they were ordered for. None of this proves doping, but it creates a fog of uncertainty. In a sport that has learned to treat fogs as evidence of cheating, Team Sky are guilty of either doping, or monumental incompetence. I hope it's that latter, but my head refused to let me make the assumption that it is. 

Transparency is something we understand well in the NHS. The duty of candour removes the need for discretion in transparency: when something goes wrong, you tell the person it affected. It's really simple. And yet, it continues to be misunderstood. Of course, there is complexity in its implementation, such as what defines 'serious harm' but it can be guided by the cognitive heuristic that asking yourself if you should tell a patient something usually means you should. 

Of course, the ability to be open about anything depends on a culture in which openness is not just encouraged but actively enabled. The trust of staff in their organisations to treat them well when they make mistakes is often low. The perception of scapegoating still exists, and will take time to shift. Even the slightest sense that they will not be supported when mistakes occur will discourage staff from being instinctively open; and the support for this needs to percolate all the way through the NHS, starting at the top. 

Yet what hope is there when one is constantly battling the sense that those at the top do not seem to really appreciate what candour is, and how it is done. Simon Stevens has started to do his bit, but Jeremy Hunt and Theresa May seem to have some form of aversion to it. We shouldn't be surprised  - in broad terms, while the past is no indication of the future, it gives you a sense of where their preferences and tendencies lie. So when Theresa May indicated that A&Es were being over-whelmed through the failure of GP practices to stay open long enough, one has to wonder firstly, where she is getting her information from, and secondly, who's next on her list of people to alienate. And when Jeremy Hunt talks about his frustrations that parts of the NHS are providing unacceptable care, and that he has provided the NHS with extra money, one has to wonder how many times he had to practice his comments in front of the mirror before he was able to say them convincingly. 

For people who work in the NHS, who have seen their work-loads ramp up over the last 5 years, (while their pay stagnates without any sign of inflation-indexing), the disconnect between what they know to be happening in the health service, and what those who run the health service say, is so wide, that truth seems to have been the main victim of the spending squeeze. Remaining candid with our patients in an environment in which too few people seem able to talk honestly about what is happening in the NHS is something which continues to take courage. 

And as with many things in the NHS at the moment, it is the courage and commitment of the staff in it that keep us aligned to the values that define the service. In too many places the NHS operates outside of the conditions necessary to optimise the performance of staff. It is galling to hear the problems of the NHS framed in ways that do not match our lived experience, but the problems go deeper than that. The culture I work in is at odds with the culture presented by our political leadership and my current definition of futility involves describing attempts to square that circle. Perhaps, though it was ever thus, and perhaps we are naive to imagine that the culture needed in our health service would percolate down. Perhaps the truth is that it needs to percolate up; perhaps we need to ensure that we support the transparency and candour of our staff in spite of what we hear on the political stage. 

I know that doesn't really help. It never really helps to be told, 'Keep going' in response to a problem you have outlined, but that is probably the best I can do. The reality is that things that shouldn't take courage (like telling our patients that things have gone wrong) require precisely that. This won't change quickly, it may not change at all, but of all the choices we have, the only one that is palatable to me is to keep plugging away in spite of the difficulties. And that is what I will be trying to do. 

Sunday, 5 March 2017

The Language of Healthcare

In this world of STPs, flat cash and level 4 alerts, there is a lot of planning about the shape of future healthcare services, and with it comes a string of new terms to learn. It reminds me of the 'language' that I used to share with my siblings: it made perfect sense to us, but to anyone else, it made us sound a little moronic. Indeed, it was the exclusivity of it that kept the 4 of us connected when we reconvened at home after term time at different boarding schools.
The language of families and siblings is a members-only club. Indeed, much of grown-up life is a members-only club, and one of the faux markers of success is which club one becomes a member of. It certainly used to be the case that medicine was a good club to be admitted to, but one has to wonder these days. It is perhaps more advanced that many in its craft-tradition, which is so complex, that one has to attend medical school for 5 years to get to grips with it. Indeed, given how hopelessly unprepared I felt in my first weeks on the wards as a doctor, I have to wonder whether those years at medical school were spent, not learning the knowledge one needs to be a doctor, but rather the language one needs to be a doctor.
Many times medicine has seemed to me to be an exercise in verbal fluency - from clinical exams, where the fluent do better than the knowledgeable, to talking with patients and families, where the key is the distillation of complexity into something more easily absorbed. Medicine often is not about the depth of thinking, but the clarity of it. Good medicine is often indicated by a parsimony of language and a decluttering of terms. The more experienced I become, the less I tend to say.
That, however, is not the case, when talking about the shape of future services, STPs and clinical service reviews. I credit myself with a good understanding of how the NHS works. I credit myself with a particularly strong understanding of how community services for frail, elderly patients work, and in particular, I like to outline the reasonable limits to our expectations and the boundaries beyond which the hopes for community services are fanciful, or even delusional.
I think I can create a clear narrative about a model of care for frail, elderly patients, based in the community, and starting in the patients' homes, with good coordination with GPs. I can share my learning until my voice is hoarse, but too often it seems that my messages gets lost.
And do you know where it gets lost? It is swamped in the language set of commissioning that uses different words, or non-words, to describe a tangentional vision of the healthcare services that has been sketched out by people who have visited services, but never worked in them.
I once remember walking along a tunnel in the Paris metro and hearing a busker sing a song. I knew I recognised the song, but I couldn't make out the words, and I just couldn't quite hang on to what it was, tantalisingly close though it was. A few minutes later, it struck me: it was November Rain by Guns and Roses; what had made it difficult to fathom was that the man singing it clearly did not speak English and had learned not the words of the song, but the sounds of the words. What came out of his mouth, therefore, was not the song November Rain, but an approximation of the noise of November Rain - and that is a very different thing entirely.
This is what meetings about the planning and commissioning of local health services sound like to me: they sound like November Rain sung by sound and not by words. And my response to this is to spend much of my time working out where the overlap between the language I use to describe services and the language I hear services described by is.
Spending time on the language of discourse is important. People from different backgrounds uses different languages to describe the same things. This creates the perception of difference, where the true difference is only one of lexicon. This would appear to boil down to semantics, but it is actually more than that, because it is also about parsimony, which is another personal preference of mine.
During my psychology degree, one of my favourite modules, after I had indulged my passing passion for the evolution of language and intelligence, was behavioural psychology. I do not know the state of psychology today, but at the time, behavioural psychology was the least fashionable area of the subject. Cognitive psychology was where all the interest was - but it didn't really speak to me. Cognitive psychology was all about box-and-arrow diagrams, with little adequate explanation of what happened in the boxes. Behavioural psychology, however, took the view that one couldn't know what was happening inside the box (or the brain for that matter) but one could make a decent stab at understanding what went into the brain, and what behaviours came out. Behavioural psyhcology is pared down, purposefully limited in its scope and wedded beautifully to the idea of parsimony: that is the most simple explanation for a phenomenom is likely to be the simplest explanation for it.
For half a term, I sat for a few hours in the week, listening to one lecturer (the only behavioural psychologist at UCL?) talk without interruption in a rather simple and engaging style about parsimony. And rather like his underlying thesis, everything about this man was  parsimonious - he never deviated from his uniform of blue jeans and off-white T-shirt. I never discovered whether it was the same pair of blue jeans and off-white T-shirt, or whether he had a wardrobe filled with mutliple copies. Behavioural psychology cannot explain all behaviour but it explains some very powerfully and very simply.
Throughout my medical training and practice, my mind has wondered back to my learning from behaviourism, as I have contemplated the possible explanations for a medical presentation. Ockham's Razor is something of a philosophical totem for some physicians and asserts that the explanation with the fewest assumptions or interpolations is likely to be the correct one. It is an argument of parsimony in medical practice that often holds true. In our office at work, a colleague of mine has mounted a 6 foot picture of a zebra, as a warning to the number of times he has ignored Ockham. He gets away with it, because in every way he is a brilliant doctor, and he never ignores the obvious - he just excitedly hopes for something a bit more exotic.
In my recent cognitive ramblings about health service commissioning and service transformation, I keep coming back to the concept of parsimony as a guiding principle  The complexity of the language we use to plan and design our service belies the fundamental simplicity of the concepts that should underpin them. The processes behind transformation are often difficult to navigate, but the principles guiding them are simple, and too often we turn our thoughts about the health service around, assuming that if the processes are complex, then so must be the concepts.
Yet there is something important about turning this habit on its head: too often, we find ourselves lost in service redesign when we lose sight of the destination. Too many conversations I have had about developing community services have happened in abstraction from the simple goal of everything we are trying to achieve. Not enough time is spent understanding where we are trying to get to, in language that is simple, easily recalled, and easily stated. This I take to be the goal of clinicians involved in service redesign: remember what we are trying to achieve, and frame it in a way that anyone can understand. Translate the language of complexity into the broad clinical goals, and repeat. And repeat. And repeat.
It is in that direction, i think, that success lies.

Tuesday, 20 September 2016

Stoicism and hard graft.

Who was not charmed by the sight of Alistair Brownlee giving up his own chance of victory in the World Series Triathlon in Mexico to help his brother Jonny cross the finish line? Jonny hit the kind of athletic wall that would have put you or me into some form of terminal cataplexy. These are tough men - they wonderfully understated, stoical and talented Yorkshire men. They chose to daily inflict on themselves the kind of physical pain that would render me couch-bound for a week, all in the name of sporting excellence.

Jonny Brownlee chose the physical state he found himself in by continuing to push himself when his body was screaming at him to stop. Alistair put it rather more prosaically when he called him a 'flippin idiot' for not pacing it correctly.  Yet, this was an afterthought- his first reaction, instinct, if you prefer, was to help him finish; but it was not instinct that made Alistair gruffly shove his brother over the line ahead of him, in second place. He'd had at least 500m to think about it. That was a choice, and it was borne out of love, and sporting respect. He was rewarding his brother for the race he had run, and the effort he had given.

That brotherly shove encapsulated a great deal: it was a practical solution to the problem of negotiating a limp body over a finish line; it ensured his brother finished by himself (kind of) and ahead of him. It was also a payback for a finishing 500m that Alistair hadn't counted out: presumably he had held enough to get himself over the line but hadn't counted on having to do it for two. He was also making sure they weren't overtaken by the man behind them. It was practical, unfussy and unceremonious. I found it all rather tender. And inspiring. When Alistair Brownlee says that he would have done it for anyone, I believe him.

I have something of a soft spot for understated excellence. I am inspired by success through endeavour, and it often makes me rather emotional to see someone succeed on the back of hours of graft, pain and commitment. I outrageously interpolate unjustifiable conclusions about the type of person a sportsman or woman is from their performance. It's why the outing of Lance Armstrong was so bitter for me. Today, when the provenance of sporting performance is so murky, it is the Brownlees who help me keep my faith.

I want to think that they must have been terrible at school, such was the challenge of persuading them to sit still for long enough to learn something, but that might be my desperation to find a chink in these otherwise amazing athletes. These are not lime-lighters. Every interview with them seems to have the forebearance of someone under obligation. They were recently in an episode of Top Gear, but they seemed to use the challenge as a training exercise.

I suppose we find inspiration in different places. I find mine in sport, and in particular, I find it in sportsmen and women who practice, and train for the chance to win, but without the fear of failure.

I need that inspiration at the moment to counter-balance the clagging tribulations of being a doctor in the NHS right now. Today, it has been announced that the Consultants are to be expected to publish their private earnings (£0 for me - job done) which is one thing. Quite another is the manner of portrayal, as Nick Triggle on the BBC website reports that it is 'certainly not uncommon' for consultants to earn 'in excess of £500,000': this 'fact' can only be explained in 3 ways: it is either a loose representation of reality, a lie, or it is true -in which case my wife will probably tell me to pull my thumb out. Yet it taps into something important: many non-medical acquaintances of mine assume I work short hours for lots of money, with loads of lovely leisure opportunities at a golf course, which I drive to in an expensive car.

In itself, this is a small moment, but death by 1000 paper cuts appears to be looming, as the drip-drip of undermining reporting about doctors eventually makes you ask yourself whether you really are the earnest, hard-working person you try to be. I was bowled so far over by Theresa May suggesting that junior doctors were 'playing politics' that I did wonder whether I'd Rip van Winkled it and woken up in another world. The endless repetition of £10billion of extra investment in the NHS, with the highest number of doctors and nurses in the health services history, and the need for the NHS to be more efficient has been a prevalent, endlessly repeated riposte from the DoH at every marker of NHS crisis, syncophantically repeated by every news outlet that reports on it.

Yet every day, we doctors, nurses, therapists, managers and social workers go to work and know the realities of those pressures. We know that we are not so inefficient that savings will make up the shortfall. We know that we work flat out so much of the time that there is never any time to think about how to do things differently. And we know that no one is really listening, or think we are exaggerating.

Frustrating, isn't it.

So ask yourself this: what would the Brownlees do? Tapping into my habit of detailed character profiling from minimal robust psychological information, I have decided they would:

  1. Keep working as hard as ever, to do the best with what they have. 
  2. Not complain, but plough on
  3. Wait until someone asks them for help sorting the mess out
  4. When they do get asked, they would have a list of practical, sensible measures ready to implement.
So, from watching a brother help his hobbling brother finish a race, I have decided that I can finish this race by continuing to work on the things I do best (being a doctor) and spending time with my teams working on how we can continue to provide good care for our patients with what we have. We will be honest about what we can't do, and then just get on with it. Right now, no one wants to hear anything different, so we'll have to wait for someone that does.

If, in the meantime, you need cheering up, then perhaps you can watch the clip of Alistair and Jonny. Or perhaps you could watch this one, or this one, or even this one. 

Tuesday, 6 September 2016

Timeline melancholy

My Twitter time line is a forlorn place right now. The dominant theme is the Junior Doctor's strike, and there are three prevalent themes:

  1. Junior doctors are striking because of their concerns about patient safety
  2. Junior doctors are striking and are threatening patient safety.
  3. This person says Junior Doctors shouldn't strike, and this is why they are wrong. 
In the last couple of weeks, David Oliver (@mancunianmedic) has been asking doctors close to CCT how they will behave when they are consultants (#whenimaconsultant), and he sparked my current train of thought. 

I struggled emotionally through registrar training, and my overall synopsis of those 5 years could be presented in the motif  'I was a happy geriatrics registrar and miserable med reg.' Too much of my time was spent worrying about why I was finding the role difficult. I spent way too little time articulating to myself and others what made the role unnecessarily hard, and what could be done to improve it. I spent a lot of time feeling bad about feeling bad. I felt guilty that it mattered to me that I felt unsupported, over-worked and stressed. 

I would go to talks about leadership and hear platitudes about embracing the leadership potential of junior doctors, and about improving training. In the end, there were two things that made all the difference to me. The first was taking a year out to do a leadership programme that taught me all about reflective practice, and the habits of personal sustainability. The second was working for a consultant who offered all of his registrars the opportunity to help him develop his service and develop beyond the delivery of clinical services. He was fun, energetic, kind and restored my faith. 

A great many consultants I worked with over my junior doctor career were guided by the ethos of 'telling not asking', and 'bollocking not understanding,' and for them it was easy pickings: the entire focus of my junior doctor training, until I wrestled some control back, was entirely focused on clinical skills. None of the other essential skills of stress management, team working, team building, reflection, or understanding behaviours featured on my curriculum. 

Junior doctors now, as then, find out their rotas the day they start a job. Contracts never appear, pay not confirmed until you are actually paid. I once presented myself at induction, only to be told to go home as I was starting nights that evening. One hospital tried to be organised, and demanded that I take a day off work before I started there to visit their HR department. I refused. The consultant I was working for told me not to make trouble and to go along. 

There is something very akin to bad schooling about how we treat junior doctors. Publicly, we encourage them to question, to enquire, to be open about mistakes and feedback, but in private, our behaviours scream the exact opposite: we expect them to do as instructed, to mask their independence and intelligence until they are consultants, because until then, they are someone else's responsibility, and cannot be trusted to use all of their clinical skills, common sense and social skills effectively. I found it infuriating then - it still is now. 

Too little trust and autonomy is placed in these capable, effective men and women who staff our wards and clinics. Too little time is spent on helping them develop the habits and skills that will help them navigate stressful and demanding jobs with happiness and satisfaction. 

Twitter is currently reminding me of how toxic this kind of culture can be. The GMC has escalated the rhetoric about the risks junior doctors run by striking; the Association of Medical Royal Colleges has decided to discount the value judgement behind the decision to strike. Everyone seems to have an opinion about the justification of strike action, or the risk to patients, but with each comment we mark ourselves as dissociated and out of touch with the very doctors we are supposed to be mentoring. The debate around the strikes has turned into conversations with them, advice given to them, instruction given to them. No one would know we are all part of the same professional family. 

Imagine you are part of a rugby team, and you are planning a foreign tour somewhere, but your forwards don't want to go because of the poor human rights record of the country you are planning to visit. Do you tell them not to be silly, that they are putting in jeopardy the whole tour, upsetting the sponsors, and anyway, all the tickets have been booked? Would you go without them and try to beat a 15 man team with your 7 man team? Or would you listen to them?

In Bowling for Columbine, Marilyn Manson was asked what he would say to the children from the school, and marking himself out as something of a sage for our times, he replied 'I wouldn't say a word to them. I would listen to them.' Who knew that occasionally you need to consult a Shock Rocker to get any sense of a situation? What he realised about Columbine is that rock music wasn't the problem, it was a symptom, and that when kids feel like they're shouting and no one is listening, the shout louder, and more violently. 

Our junior doctors are shouting loudly, and instead of listening to them, we keep bollocking them. They are shouting loudly because no one seems to be listening properly, and those that do come up with childish put-downs which clearly misunderstand the point being made. Junior doctors are people who articulate complex problems for a living. They interpret a raft of symptoms into neat, precise sentences. They have analytical skills, deductive and inductive insights, and they have the verbal fluency. They are telling us there is a problem. That means there is a problem. 

Remember, junior doctors all learn when to ask for help. Good ones take the problem they are dealing with as far as they can, then call their consultant. These juniors have called their consultants, and now it our job to help them find a solution. It is our duty because they are part of our professional family, because they are crying out for support, and because they clearly recognise that they cannot fix this current impasse by themselves. They are doing all the things we have taught them to do. 

Perhaps with this round of industrial action we can do more than either support them or criticise them. Perhaps we can engage with the discussion both at our own trusts and more broadly about how we move forwards. Perhaps we can demonstrate to our junior colleagues that times have changed, and not only do we trust them, but we also believe them, and we value them. 

That was what I promised to do when I became a consultant. 

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.