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 ( 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. 

Thursday, 31 March 2016

Frailty is not a diagnosis, it is a question.

A little while ago, I decided to give Henry James a go. I sat down, in some rented cottage on a week off, curled up on a sofa and settled down with my new copy of The Turn of the Screw. It's rare I buy physical books these days - just my favourites (The Gormenghast Trilogy, The Catcher in the Rye, or The Meaning of Liff), or the ones I think will make me look erudite if seen on my bookshelf......I clearly, therefore, had big hopes for Henry James.

How wrong I was. I rarely hate a writer, but boy, did I hate Henry James. He made me angry. I felt misled, cheated even. How could a writer like him enjoy such a strong reputation after so many years? Surely, we should have worked out by now how sanctimonious and unnecessary his style of prose is. I don't know where the book is now. I may have used it for kindling.

Rarely have I been has my experience of reading a new writer been so divergent from my expectations. I was almost affronted. I was certainly miffed that I had given over good holiday time to him. Some writers grab you, others enthrall you; some flourish language like a paint brush. James clubs you with it, and then filibusters you. His sentences go on for ever. I seem to recall that he does rather like a semi-colon; who doesn't? He seems to use them, however, to link interminable independent clauses, until you forget what he was originally going on about. He approaches meaning tangentially, but never bloody spits out what he actually means. He doesn't seem to tell stories, he seems to mock your linguistic simplicity, while writing his curlicues of sentences, and bamboozling you with his grammatical purity.

If, as I do, the only thing you know about Henry James is the writing of his you have read, then, like me, you may well imagine him to have been some pompous man, who would stand by his mantelpiece telling you why he is forever right, and everyone else is forever wrong. I imagine he didn't have opinions, he had facts, polished out of the granite of his own intellect - unyielding and forever set.

It troubles me that I am so troubled by my experience of Henry James. It's not, I suppose, his fault that I hated reading his work so much: I'm the fool who carried on, when I could have stopped and switched over to something more personally edifying. Yet, I carried on. And I know why I did.

Henry James is part of the lexicon of good writers, and his reputation has persisted over the years, and generations. Writers continue to be read for two main reasons: they wrote something really good, or they wrote something that was loved enough by sufficient people at one time to be included in the teaching syllabus, and never be removed, even when tastes changed. Sometimes it seems as if particular literature continues to be admired in the fashion of some intellectual shibboleth, whereby those who know why it should be admired can seek each other out, and find comfort with each other.

How many writers have been over-read, over-analysed, and under-appreciated by virtue of being included as compulsory texts in English literature courses? If I had been made to read Henry James at school, I might even have given up reading.

You are probably thinking that I need to let this go, and you are right. Indeed, I thought I had done, until I was reminded of my thoughts about Henry James at a recent conference about frailty. Throughout the day, I heard lots of different people tell me stories about how they had adapted their services to better identify their patients with frailty. A lot of work had gone into to what they had done, and to be fair, their services were better aligned now than they had ever been to meet the needs of their patients. Except that I kept thinking 'So what?'

What was happening with this knowledge that they had frail patients? There was some care planning, there were some advanced decisions about what they would do in the event of a crisis, but fundamentally, the services that were available to these frail patients were the same, unadapted services that had been available to them all along. The actual delivery of medical care, and associated services was unchanged. They were still admitted to hospital, they were still expected to go to clinic appointments, they were still subjected to the various and varied inputs of multiple, unaligned specialists services.

Yet throughout the day, we were asked to celebrate the identification of frailty, while people were still unsure as to what they were going to do with that new knowledge, or what difference it makes to patients.

The identification of frailty is important, but only when it makes a difference to how that patient will be cared for. While we have moved a long way in understanding that frailty is an important concept, it seems as if that is as far as we have got. The concept has entered the modern medical lexicon but we are still some way off having a clear understanding of what to do with it. Frailty is not-curable, and only modestly modifiable.

However, knowing that patients are frail gives you the opportunity to frame differently your approach to patients. It is the flag that triggers the question, 'What are we trying to achieve with this patient?', or 'What is important to this person, and how can we help them most to achieve what it is that they want to achieve?' The answers to these questions are as varied as the patients themselves: for some the goal is to improve breathlessness, or to be free of pain. For others, it is to go to their grand-daughter's wedding, or finish the book they are writing. Success might also be not having to see a doctor or go to a hospital.

Knowing what to do with frail patients, therefore, is framed by knowing what that individual wants to achieve, and how you can help them do it. It is underpinned by having an approach to individuals that allows you to be as flexible as their varied ambitions. Identifying that someone is frail is the moment that you can realise that that person's goals probably aren't, or can't, be restoration to full health. And being able to act upon that knowledge is only possible if you and your teams operate in a way that allows them to be flexible in how they help.

The fundamental difference that this requires is a team-based approach centred on problem-solving on behalf of the patient, and doing what it is they need, regardless of what it is that they need. I am not saying that community health teams need to be able to do whatever it is that patients ask, but they should be open to the idea of helping them achieve their goals. We once had a patient whose dog died, and the absence of this beloved dog was having a huge impact on their sense of well-being. We put them in touch with a charity that could help them get another dog. It can be that simple.

So what's this got to do with Henry James? The connection is perhaps loose, but I read Henry James because I had heard that he was a good writer, but I never asked anyone why he was thought to be a good writer. In just the same way, I saw lots of people enthusiastically nodding at the suggestion that identifying frailty is a good idea, but I saw very few people ask why.

When trying anything new, it is important to have a clear sense of what you are doing, and why you are doing it. Without that kind of face validity, you are scrabbling round in the dark, hoping beyond hope, to land on the right answer.

Tuesday, 1 March 2016

This Crazy World

In popular film culture, the character that spends their entire time being mean to people ALWAYS gets their comeuppance. Think Darth Vadar, Hans Gruber (Die Hard), Gordon Gecko (Wall St), Ivan Drago (Rocky IV) Alex DeLarge (A Clockwork Orange). Crickey, even Tony DeVito got found out for being too bad in a world of bad men in Goodfellas.

Not all of life is represented in popular movies, but there is a sense of natural justice, even benign schadenfreude when these bad guys get taken down. Who didn't enjoy it when Biff finally got punched in the face in Back to the Future? There is almost a narrative imperative that their misdemeanours come home to roost - it just wouldn't be right for them to get away with it. How did you feel when Kevin Spacey posted Gwyneth Paltrow's head to Brad Pitt in Seven? It was dramatic, but it wasn't right.

This fantasy of movie justice has played over in my mind over the last week, as I have witnessed numerous counts of meanness in the popular press. From the imposition of the junior doctor contract, to the shameful hectoring at PMQs ( and onwards to swapping of personal insults instead of open debate about the EU referendum. It is in this crazy, mean world that Donald Trump looks like he will get the Republican nomination. Who was the last person to be elected on the mandate to build a bloody great wall, on a ticket of isolationism? Where's the narrative justice?

Was it ever thus, or are we stuck in a rut, unable to remember the benefits of being polite to each other? Is it arrogance, certainty or chutzpah that leads our political leaders to focus discussion around personal inadequacy rather than principle, ideology or ethics? You've got to be pretty confident about yourself when you make a point predicated on the failings of your opposition.

There is the sense that it will get worse before it gets better. Who knows how the refugee situation will play out. Yet in the world of faux-ideology, those leading the charge will try to persuade you that they are on an ideological mission: the 7 day NHS, the recession-proof economy, the elimination of poverty, and the enhancement of social mobility.

I have no doubt that there is ideology involved, and that I can live with. What I find increasingly difficult to stomach is the sense that we are seeing the implementation of an ideology that many people did not know they were voting for.

Is this culture of austerity, ruthless budgetary restraint, European entrenchment what we wanted? Do we feel it is OK to wring as much 'productivity' from hard-working staff as long as it isn't us who is being wrung?

I can't help the feeling that I might be up next. As the terms of the new proposed consultant contract become public, I start to imagine a different future. I don't yet know all the details, but my initial feeling is that it asks a lot of doctors to accept a less bright future, and to start to wonder whether they might be better off working somewhere else, or putting discretionary efforts they currently put into their own services into something else, which allows them to bring home a little extra cash.

Of course, this may be one of the ideological drivers behind the contract: by undermining the motivation of those who work in the NHS to continue working in the NHS, alternative forms of healthcare provision become unavoidable. Increasingly it is difficult to ignore the emerging narrative that the general direction of travel is to take the comprehensive out of the comprehensive health care provided by the NHS.

As someone who has spent the last two and a half years working to provide comprehensive, integrated care to elderly patients at home, this is something of a blow. And I don't know yet whether I am supposed to rage against it, or simply get on with making the best of a bad situation.

I might be prepared to go along with it if I felt that the plan had been implemented on the back of good communication, respectful collaboration and expertise, but I can't see any of those things anywhere I look. I keep hoping for my narrative justice, but suspect this isn't Back to the Future - it's Seven, and I'm just going to have to find my peace with it, or find something else to get my teeth into.

Sunday, 21 February 2016

Niceness in a time of crisis

Is it me, or is there a bit of meanness percolating around the world of healthcare?

Where has your mind taken you to with that sentence? The imposition of the new junior doctor contract, all that talk of healthcare privatisation, the state of NHS finances? All would be suitable examples, but let's think more locally.

Whether you are a user or provider of healthcare, have you noticed rushed, harassed or over-worked professionals wandering around?

I have. Everywhere I go, I see colleagues grinding away at a daily slog of providing good services, and doing their best to make sure that their patients get the care they need. Talking to them, it's not the fact that they are busy that bothers them - it's the feeling that they are swimming against the tide. The feeling that they are being asked and expected to do ever more, with ever less.

Every service I know talks of vacancies: GPs can't replace retiring colleagues; nursing vacancies are high, and junior doctors seem to be wandering off to places where people are nice to them. The remaining staff have to work longer and more often to make up the short fall, yet the message they keep hearing is that we have to do more with less. I bet they go home and wonder how long it will be until they too are broken or simply cannot find the motivation to keep grinding on. It's like a professional depression: you keep going, you keep grinding, pretending that it will get better by itself, until one day you can't get out of bed, get dressed or even stand up.

I worry all the time about my colleagues; I wonder how I can protect them and myself from this funk we're stuck in. Speaking to a management colleague I was disappointed at how unsurprised I was at what she told me: during her hospital's recent rather profound bed crisis, her boss required her to check in every hour to tell her what she had done to find more beds for patients waiting to be admitted. Sounds reasonable? Perhaps, until you learn that these hourly check-ins amounted to little more than a bit of a dressing-down for not doing more to solve the systemic crisis that was none of her doing in the first place.

It doesn't sound like her boss took much time to thank her for her efforts, or remind her how grateful the hospital was for her efforts, or even to empathise about what a difficult time they were experiencing.

And this for me is the rub: every where you look, you will find health and social care professionals working flat out for the benefit of the people they serve. They are driven by compassion and dedication to their jobs. Yet within the workforce, the message they keep hearing is that they must try harder, be better, be more efficient, that they are not doing a good enough job. It simply doesn't ring true. They are working hard, all the time. They go home knackered, they return to work still knackered, and they put in the extra hours to try to get everything sorted. But the same message keeps being repeated: more, better, faster - all the time.

In the midst of this culture, we have forgotten that the starting point for compassionate care is to show compassion to each other. The pugilistic attitude from the top pervades its way throughout the organisation, and becomes normal. We forget to be nice to each other, and succeed in only being a bit mean to each other. It's crazy.

Yet, it needn't be like this, and in lots of places it isn't. I was reminded of how good it feels to work with compassionate colleagues this week. Sometimes, the care we offer patients falls short of our own expectations, and this week, we have been dealing with one such episode.

This week was the culmination of our internal review, in which we presented our findings to our medical director and nursing director, and I was gratified at how useful the experience was. It was allowed to be useful, because we treated it as the opportunity to learn as a team what went wrong, rather than blame particular individuals. Throughout the process, I noticed colleagues being very mindful of their colleagues emotional well-being, and allowing people to learn usefully without feeling like they were exposing themselves to excess blame. As a team, we were prepared to be open, and our senior managers allowed us to be. This allowed us to be open with the family, with whom we have spent time talking things through.

In dealing with this learning process, I have experienced from colleagues sympathy, empathy and support that I didn't even know I needed. I came out of a review of our care failings feeling that I had been part of a team learning exercise that emphasised the compassion of my teams not just to our patients, but also to each other. This week, instead of wondering where the strength to continue comes from, I know that it comes from colleagues like mine.

I have no idea what is going to happen to the NHS over the next few years, and I am still worried about it. The one thing I do know, though, is that I work with the kind of people, in the kind of organisation that you want to face a time of uncertainty with.

So perhaps, individually, we all need to take a leap of faith: be nice to the person next to you, and perhaps they will pay it forward. And who knows, in time, perhaps there will be a cultural reset, and niceness will percolate in the way that meanness currently does. 

Tuesday, 14 April 2015

Community Geriatrics: The Way In. Biography-Based Medicine

In the last blog I talked about the real nature of the challenge that faces community geriatrics: that of meeting the expressed and felt needs of the elderly, rather than their supposed or assumed needs. I talked about this in terms of biography, and I hope that I conveyed the sense that what is valuable to an elderly patient moves away from the objective to the phenomenological. The experience of being frail and elderly is something I can only appreciate vicariously. I have seen it hundreds or thousands of times, but I have never lived it; and while there are themes and commonalities, it is the differences between my patients that distinguishes them.

I recently told an elderly man that he had metastatic bowel cancer, involving his spine and liver. He painted me a context of that news, which took him back to reflections of his experiences of the 2nd World War in Burma. He recalled the men he’d left behind, who with him had endured very difficult conditions, but unlike him, hadn’t survived. Being told he had an incurable illness was of little moment to him, when every moment he had lived since 1945 felt like both a bonus and an undeserved privilege.

These are the narratives that frame the context in which we deliver care to the elderly. Where are they now, where have they been? The biography of the elderly sits at centre stage of our efforts to serve them well. It is our guide, and our obligation to them. Let’s call it biography-based medicine – medicine that fits poorly on protocols, medicine that urges you to understand deeply with whom you are dealing, and what it is that you can do to most faithfully serve them.

I still feel that I know my patients only superficially. There are moments when they let you in, and give you a real glimpse of what you can do for them. The challenge for creating conditions for their trust and confidence are the trickiest part of community geriatrics. It is the creation of these conditions that is one of the key challenges for a community team.

For a while I scratched my head about how to do this – but then a realisation crept in. The more I spoke to district nurses, community therapists and GPs, the more I realised that there already exist whole teams of people that know these patients well, and understand where they are in their lives. I heard vivid narratives of patients struggling on at home, and these teams struggling on to support them. These nurses and therapists are not just committed to their jobs, they are trusted by the patients they help, in relationships that have been forged and nurtured over time.

The more I listened, the more I realised that these teams were the way in. They have almost everything: skill, knowledge, commitment and the trust of patients. What they were lacking was the medical support to manage complexity, to deal with uncertainty, and to seek support rapidly and easily. My role started to become clear.

I have a running debate with a local practice manager. Her question to me is whether we know who all the frail and vulnerable patients are locally. I can’t yet give a definitive answer yet– we are still looking into that – but it is my sense that in a town like Bridport, it is rare for a frail, elderly patient in need of support and care not to be known to at least one of the health or social care services. I might be wrong, but I intend to find out. But if I am right, then it means that we have broad coverage of our local elderly patients, and the challenge is to ensure that if one of the teams notices a deterioration, or requires additional help in the management of a patient, then that help is easy to come by.

This is what we have been ramping up – the cross-support and co-ordination of community teams. We met every week to discuss our patients, and we coordinate our actions for the patients. It starts with the person who knows the patient best describing their situation, and continues with the team members clarifying, suggesting and offering actions to help the situation. Anyone can bring a patient up for discussion, and we keep the patient under review until we are happy that things are back on track. We discuss what to do in an emergency, we agree appropriate actions, and we follow it up.

It feels right, because it is based on a narrative of the patient from the team member who knows them best. It feels right because everyone who needs to be there is there, and we have a breadth of experience and expertise to call upon, from social services, safeguarding, GPs, nurses, therapists, and mental health services; there is an old-age psychiatrist, and of course, me.

Someone who came to the meeting told me that they thought it should be more structured. I could see their point, but I argued that too much structure can stifle. Not everyone in that room speaks the same form of descriptive narrative, and nor should they. What emerges from the description of the situation is an ever-more detailed picture, and it needs space to emerge.

What really matters is that these dedicated members of the team have the opportunity to enlist support with patients they know well, and that the team gives them the airtime to outline their concerns, in the context of the knowledge they have of the person. That’s the starting point from which everything else can follow.