Sunday, 18 December 2011

Surrogate end points in judging others.


In his book 'Summertime', JM Coetzee takes a novel approach to autobiography- rather than doing a Tony Blair, and outlining to his dear reader what a thoroughly good chap he is, he sets out to achieve the exact opposite through the device of framing the book as a series of interviews by his (fictional) biographer with people who achieve importance and significance in Coetzee's writing and journals.

What follows is a relentless disambiguation of the idea that one can judge an individual from what they publish. Coetzee takes the path least travelled by outlining how ordinary and indeed limited he is, by laying bare his failings as a teacher, son, cousin and lover. In my less generous moods it feels like he is playing for our sympathies by being so hard on himself, as if he somehow expects us to retort by saying, 'But John, don't fret over all those women you disappointed and let down. You're an amazing chap - after all , you wrote 'Disgrace', and if that is not the mark of a truly gifted man, then I don't know what is.'

But we are not going to fall for that ruse are we? 'Disgrace' really is a brilliant book, which asks you to accept that the world isn't fair, and that the good fortune that many of us enjoy is capricious and fragile. But what can we read in to Coetzee the man from the book that he writes? Is it reasonable to extrapolate from the poignancy and rawness of his writing something about him as a person?

In writing 'Disgrace', Coetzee had his moment - this was when for a while his ability to write transected his ability to demonstrate profound insight into a post-apartheid South Africa. Both are significant talents, but they do not necessarily go any deeper. As Coetzee himself tells us, he is a man he with deeply riven flaws (indeed, who isn't?)  - but this is not undone by the quality of his work. Where he asks us to forgive his failings in the light of his other achievements, I reply that one's standing as an individual and member of society is not offset by unrelated actions: his abillity to write books was not made possible by failing to meet the emotional needs of those around him, and as such the one does not negate the other.

I find it difficult not to infer individual traits from books I read, almost as if it is impossible to write something purely as a work of fiction, and that the imagination must always resort to personal experience in order to produce something credible. Never has this been more divisive than in discussions about Shakespeare, and whether Shakespeare the man was the same person as the Shakespeare the poet.

There is a contemporary cultural bias which insists that the man who wrote such game-changing poetry and plays must have been a man of extraordinary talent, experience and standing. The same bias also states that he must have been a solo genius who achieved lofty levels of artistry without the help of others.

The counterpoint to this argument is to ask why those conditions must be met when describing who Shakespeare was. Does the ability to craft the language in the way that he did mean that he must have been equally accomplished in other fields of life? In setting a new direction for English literature, must he have established directions in other walks of life, or might he have been an otherwise ordinary man, who made mistakes, who wasn't very good with money, who was pushed and pulled by the same day-to-day pressures that we all experience?

It is liberating to imagine that Shakespeare was an ordinary bloke, who managed to hit a stupendously rich run of form, and was lucky enough to become the most famous writer that ever lived. Surely that's enough achievement for one individual? Why does he also need to be a noble who travelled, who knew that inner workings of court, and why oh why must he have worked alone?

In his book 'Contested Will', James Shapiro argues that the Elizabethan method for writing plays was highly collaborative, and there is good evidence that Shakespeare was the same - in fact it would have been very odd if he had done things differently, and perhaps, such a biographical detail would have been recorded about him. The fact that he may have worked using the assistance of others in no way detracts from the end product, and probably, in fact enhanced it considerably.

The truth therefore differs from the perception - while people benefit from the assistance of others, achievement is considered greater if it is done alone, and the perception of personal qualities can be skewed by other irrelevant achievements. The factors by which we often judge each other are often surrogates for what we are really looking for - and often poor ones at that. Skewed perceptions about what is important can lead us to over value individuals who do not deserve it, and under value the silent heroes.

Monday, 12 December 2011

Dear Santa

Today I attended a really interesting meeting organised by the directorate I work in, designed to engage with clinicians about how we can meet the financial challenges up ahead.

The only problem was that there weren't many clinicians there. There were some consultants, who are involved in this kind of work on a daily basis, but below that level there was just me and one SHO.

Chatting afterwards to the SHO, she expressed some dismay that there weren't more doctors present, and it was a shame, as we had a really interesting meeting with some managers really keen to hear what we had to say. The question she and I mulled over together was whether this was the fault of doctors for not getting involved, or the fault of the people who organised the meeting for not enticing them.

The issue of how to meet the financial challenges facing hospital trusts is not one that can be met realistically without the heavy involvement of clinical staff. There are two main reasons for this: two thirds of healthcare costs go on salaries, and doctors are the individuals responsible for the majority of spending within the service. Therefore, the inevitability of trying to save 7% a year seems to inevitably involve a combination of reduced staff costs, and reduced spending in the provision of services, given that extra revenue streams are currently very difficult to find: the money available for paying for health services is already being spent, and except for some modest alterations in who provides which services for whom, the money that we currently have is all the money we are going to get.

It can feel as if we have been on an austerity drive for years already, but this has mainly focused on improving pathways, and efficiency; the real pain of reducing costs by the dramatic margins required has not yet begun in earnest.

How many doctors you know have a good feel for this? I sometimes feels as if I somehow ride above the fray on this issue - that the problem of how to streamline the service is someone else's problem, but then I remember that the challenge is to provide excellent patient care with less money, and this is something that I need to care about: without the right kind of clinical input, managers will be forced to guess how best to cut services without the clinical input required to know how the services should be altered.

One of the issues we discussed today was the difficulty we have in redesigning services that look the way they do because of historical quirks and happenchance. None of the services we were talking about would look the way they do if we started from scratch and built them from the ground up, but working out how to approximate this ideal from the position we find ourselves in now is a really difficult thought experiment.

My argument for the need for doctors to get stuck in to the discussion is not borne out of a desire to see doctors retain their influence, but rather to see doctors roll up their sleeves as part of the team and carry their share of the burden.

I am firmly of the mind that virtually every process in healthcare could be improved, and some of them can be removed entirely. It is crucial that we honestly assess what happens where and why, and what could be done differently, and what can be done away with entirely.

Too often, the efforts of managers to engage with clinicians in reducing costs are undone by the steadfast and unerring belief of the senior doctors involved that the process in operation is already as good as it can be, and that there is nothing that can be done. But if you ask the junior doctors who work for these consultants how the system could be tightened up, you will usually come away with some good ideas.

How then can we improve a system if the people who know what is wrong are not actually at the table?

There are two things that I would like for Christmas - I would like to see doctors in general take seriously their responsibility to get involved in the discussions about how to meet the financial challenges ahead of us, and I would to see junior doctors really believe that their opinion really counts in this process. That would fill a whole in my life that no iPad ever could.

Monday, 5 December 2011

Witching Hour Wariness


Fresh from a night shift, it is always interesting to reflect on the range of behaviours that one sees on display. There is something about the conversation or crisis at 3am that amplifies our reactions and emotions, that lays them bare at our feet as some kind of reflection on the person you are. The hospital at night may be empty of the legions of staff who turn up for the day shifts, but this means that there are fewer places to hide; whatever you may think you have learned from ‘Scrubs’, it is not cupboards that we hide in when we get scared, but behind other people.

The pressure of having to state your opinion and plan of action, all in the midst of sleep deprivation can be a heady mixture. It can also be suffocating - decisions you make in the middle of night rarely look the same in the morning.. Much of this is due to the consensus-basis of clinical decision-making: the post-take ward round is a social construct, in which the practice of validating or undermining others is seen as often as clinical expertise. The nature of the ward round is a spectrum - at one end there is the tendency to support decisions made by the on-call team, regardless of how valid they, and at the other end, there is the tendency to reverse decisions, as some gesture of authority. In the middle, in that Goldilocks zone is the practice of making the right decision, based on what is best for the patient. As obvious as it sounds, achieving these professionals heights is rarer than one might think. The skill of being a consultant running an effective post-take ward round is difficult: the challenge is to balance the needs of the junior doctors, their efforts, their inexperience, and the cognitive effects of being up all night; one also has to make sure that there is scope to change decisions when evidence supports another course of action, and there is also the pressure to remain objective, and not play up to the cameras: these ward rounds often have an element of theatre, consisting of a multitude of junior doctors, medical students, nursing staff and pharmacists; remaining cool with this kind of audience can be difficult.

What then of my midnight learning? The purpose of the paragraph before is to set the scene for the decisions we are asked to make at night: there are fewer people to ask for advice from, achieving the same intellectuals heights at 3am is much harder than at 3pm, and one also knows that in the morning he has to stand in front of the assembled gaggle and justify the actions one took.

There are different ways that one can approach this problem. I have always tried to be confident about acknowledging my uncertainty when it exists, about working on the basis that as long as I am not guilty of slothfulness or sloppiness while working, then what inevitably results is the best that I can offer. I am variably successful in this endeavour: total success relies on the absence of self-doubt about one’s clinical skills and attitudes, and I do not possess either. This inevitably  means that anxiety sneaks through, and what I think I noticed was a form of anxiety peaking through in every other registrar that I dealt with on my night shifts; this anxiety does not seem to exist during the day, as it is borne out of the sense of exposure one feels from being much more alone that usual - let’s call it Witching Hour Wariness.

My own particular foible is to become pointed and direct - not the softest and warmest form of interaction possible. I would have previously argued that this is borne out of my perception that being the on-call Med Reg has a broad remit, and being able to avoid taking on unnecessary work is a good thing, and swerving some of the hassle that swings my way involves being able to say no in a direct and unambiguous way. This is partly true, but a revised truth must acknowledge that this behaviour is also precipitated by the WHW. How does your WHW play out?
I was offered an insight into this by the registrar who had been doing the day shifts this weekend, who fed back to me that she wasn’t sure what I’d done, but one the registrars we had both been dealing with wouldn’t be bothering us unnecessarily in future. It turns out that in the course of one simple phone call, during which I had explained that the extent to which I was prepared to help her was not the same as the extent to which she wanted me to help her. I felt I made a reasonable point, and perhaps I did. What, however, is important is that she came away from the conversation with the feeling that she had definitely been Riazed. That is not always a good place to be, and was certainly not where I either intended or wanted her to be.

So what am I mulling over right now? Well, I am reminding myself that we are responsible for the perception of ourselves that we create in other people, and that often that perception is way off what we either feel or intended; for example, if you accuse someone of being arrogant, they will often retort that they are merely confident. They are wrong - the perception is real, and cannot be refuted. The only course of action is to reflect on how that perception was created.

So perhaps, if instead of outlining the manner in which I was not going to do what she had asked, I had said something along the lines of ‘Actually, I’m pretty busy, and if I’m honest, a little stressed right now - this can be such a hectic job at times, is there another way to solve this problem?’, would I have had such a negative impact?

The trick, however, is to know how to access this kind of insight when you find yourself in the grip, and this is still very much a work in progress.

Sunday, 27 November 2011

Authenticity and vulnerability in the work place


Lana Del Rey seems to be getting people excited and outraged in equal measure. The story runs that she posted a Lo-fi video to her song ‘Videogames’ on Youtube (http://goo.gl/mtN0C); upwards of 7 million people watched it, and she became hugely popular - so popular that when she made tickets available to a gig, they sold out in super-fast time.

The news of such commercial success on top of pro bono internet success has caused some to question her authenticity. Quite what authenticity one is seeking in the world of pop music is a question to which I have not yet found the answer, but it would appear that there are many (who knows actually how many) who feel some form of outrage that the free entertainment they experienced on Youtube was not the work of a talented young woman, working by herself, but rather the work of a talented young woman backed up by a team of professionals, expert in managing young musical talent.

If the concept of authenticity in this context is not exactly modern, then perhaps its interpretation is. Commercial success has always been underpinned by commercial savoir-faire, that usually involves outside input. I question the need to criticise others for seeking help outside of their own skill set, when that is manifestly the right solution to the situation they find themselves. Let us not forget that with the right team of people behind her, Lana Del Rey produced a chillingly good song, with a pretty good video.

All this hullabaloo reminded me of the stories one hears about the Early 20th Century obsession with amateurism in sport, and the idea that sport in its purest sense is the competition between two individuals, calling upon their innate talents, without recourse to anything as crude as training; sport as an aesthetic endeavour, and not one that should ever be used as a means of earning a living. Of course, the agenda in this matter was set by the well-off, who didn’t have to work, so had the time to engage in sporting activities that kept them fit, and to do it all for free. It became an inconvenient truth to discover that ancient Greek athletes trained full-time, and if they weren’t paid for their actual Olympic appearances, there were plenty of money making opportunities that followed their successes.

I have written before about the pressure we exert on junior doctors to be the people they will grow up to be, before they have actually done any growing up; in other words, to turn up to their first jobs as fully capable and competent professionals, who have already completed the maturation required to become a good doctor. As you may recall, I challenged the medical profession on this stance, arguing that it is an absolution of responsibility to young professionals to take no part in their personal growth, and that in reality, we should seize the opportunity to help young doctors blossom and grow, so that they can more easily become the best they can be.

I thought back to such thoughts at a recent conference I attended, where one of the themes I identified was ‘barriers to collaboration’ (it was happenchance - the conference itself was concerned with much loftier challenge) I was particularly struck by one chief executive, who’s trademark style is to disarm others with his openness, and give them the challenge of what to do with his vulnerability. It is powerfully disarming when he tells you something, and acknowledges that in essence if you want to, you could bury him; but actually what he would like you do, is to treat his act of openness as the gesture of comradeship it really is.


Another chap spoke about the work that he does helping teams communicate better together - essentially, his approach is to put the people he is working with in a room together, and make sure they understand that he is prepared to wait longer in silence than they are. Using this method, he either bluffs them or bores them into conversation. I have to wonder how sustained the changes are, but they seem to work in the short term at least.

These two men highlighted that one of the big challenges at work is to get individuals to confess to things they don’t want to confess, to people they don’t want to confess it to. Such reticence is borne out of a fear that they will show something of themselves against which they can be judged, or that they will display feelings and anxieties that mark them down as flawed or weak.

Is it me, or when we expect our colleagues and juniors to turn up for work as polished professionals, and not to expect that we will play any active role in their personal growth, are we sowing the seeds for adversarial, unsupportive, and uncollaborative work places?

Sunday, 20 November 2011

Permission granted


I seem to recall a moment in Don Quixote, when The Don decides that he must stand vigil all night, and wait for daybreak to engage some enemy (it might be the tilting at Windmills escapade, but, then again it might not). As ever he is attended by his faithful batman Sancho Panza.

Sancho illustrates well the perils of voluntary servitude, when he is caught short during the night, and not wanting to question the need for his unbroken presence at his master’s side for the duration of this particular nightwatch, decides there is greater valour in shitting himself where he stands than taking himself off discreetly to do his business behind a bush.

I have no doubt that I have recalled the details of this story incompletely - this was a set text at school (I mean, really - a 700 page set text?), and for much of it, I read the words, turned the pages but failed to divine any meaning from it. I was, however, reminded of it during a coaching session last week, when my coach pointed at the plate of biscuits on the table after half an hour and told me that she had put those there as a leadership exercise. It was perhaps with an undisguised level of smugness that I was able to inform her that I had already eaten two choice-looking chocolate biscuits without her noticing. My implication was that the brand of leadership that I exercised was very subtle indeed; no doubt her inference was that I didn’t like to get caught with my hand in the cookie jar.

The general theme here is permission, when we should seek it, and when we should assume it. Have you ever found yourself oscillating with uncertainty between two courses of action, trying to second guess the response both would elicit in the person you know you will have to answer to? It’s like when you take a multiple choice exam paper, and persuade yourself that the answer you went for immediately cannot be the right one, because you remember vaguely somewhere reading that the opposite is in fact true - thereafter, one enters an irreconcilable spiral of self-doubt, uncertainty, and perhaps also self-loathing. The first answer is always right, about 66% of the time.......

On the occasions I have found myself in this position, I have noticed that I always seem to make the wrong call, and come in for criticism later. To begin with, I took the feedback on the chin, reflected, tried to learn and tried to move on. But a pattern emerged - with certain people, I always made the wrong call, and didn’t matter how well I predicted their preferences and ways of working, they always found scope for criticism. Confidence gets damaged, consistent decision-making is undermined, and it becomes very hard to deal with. The truth of course, is to learn that for certain people, you will never be right, and this is not about you, this is about them.

More generally, knowing how to tackle problems, and trusting one’s own abilities to work through a challenge is the product of many different personal traits, but fundamentally, it relies on the knowledge that one is supported by the people one works for and with.

Within the NHS, one often hears about change fatigue, resistance to change, or griping about the relentless wheel of change turning. My own personal truth acknowledges that change within in the health service is not just important, it is necessary: every healthcare process could be improved, and many of them really need to be. What matters, however, is how those changes are made: I hate being told what I should do and why. I much prefer to find my own way there.

Change within the NHS has followed the traditional forms of leadership that underpin medical practice, with heroic leaders, urging the massed workforce to follow them. This vision of leadership was forged on the playing fields of public schools, in order to be played out on the battle fields of the British Empire. Play up, play up and play the game and all that. But this has no place in a modern health service does it?

Strong leaders are important, but following in the wake of the big characters as they charge forwards means that we miss out on the insightful whisper of the little guy, who knows what the real problem is, because frankly, it affects him every day he does his job.

The daily routine of change is to make small and constant improvements to a service, that deliver a better patient experience, and better quality outcomes. This should be the responsibility of the people who work in that service, and they should be both equipped and empowered to make those changes. This involves, among other things, those members of staff knowing that they will be supported in the actions they take.

Don’t criticise someone who is trying their best; pick them up, dust them off, and set them off again. It makes a massive difference.

Monday, 14 November 2011

Fear of failure, or fear of success?


Leonardo Da Vinci used to be fascinated by ugliness. Legend tells how if he saw a really ugly person, he would follow them, perhaps at a discreet distance, perhaps at an indiscreet distance, and sketch them. I have often wondered whether the resulting sketches were actually of ugly people at all, or whether that is simply what Renaissance folk looked like. Whatever the truth, it can’t ever have been a ringing physical endorsement to find oneself tailed through town by Leo.

I mention this only as a self-indulgent reminiscence, made salient by the new exhibition of Leonardo Da Vinci at the National. This one is off the scales - I haven’t been yet, for one of two reasons: I am either foolishly deluding myself that the hubbub will die down, and in a few weeks time I will be able to visit and have the place to myself, or I know that whenever I go I will have to stick my elbows out and get stuck out, and I am just steeling myself for the scrum. It’s the latter, definitely the latter.

Christina Patterson got me mulling things over this weekend with this article in the Independent (http://goo.gl/PtXZM) : I knew about Da Vinci’s stalking habits (although I will probably find out that this was a lie peddled my way by an harassed teacher at school) but I did not know that he only ever finished about 15 paintings. And his experimental techniques with paints and pigments mean that much of his work has degraded badly, so that what we see today is only a shadow of his original work. And still he managed to be one of the most famous painters of all time. He inspires me and infuriates me in equal measure.

In talking about Leonardo’s propensity to try a lot of different things, and finish very few of them, Christina used that famous Samuel Beckett quotation ‘Ever tried, ever failed. No matter. Try again. Fail again, fail better.’

It’s brilliant. ‘Fail better’. Ballsing up with balls. But its bloody hard to do. Fear of failure is a paralytic; it stops us speculating - it can stop you even trying when it persuades you that it is much better to think you might not be good enough, than to know you’re not good enough.

One of the major hurdles is the definition of success: one of the attitudes we were socialised into at school was the belief that it was much better to achieve something good with indifference than run the risk of being seen to care and failing. I will confess without the need for subpoena that this is not a healthy attitude, but all too often these days, I see the opposite played out for our consumption: I don’t watch X-Factor, but if I did, I might see contestant after contestant pleading how much they want to win, without, apparently, having to spend any time developing the skills requisite for a sustained career in the entertainment industry.

Thomas Edison stated that in inventing the light bulb, he also learnt how not to make a light bulb 1000 different ways. He failed better with panache. Winston Churchill was similarly resilient, achieving his greatest triumphs at the end of a spectacularly long political career. Even Steve Jobs, who even in death defines the current technological zeitgeist was booted out of Apple in 1985, before returning in 1997, with some success.

Failure is not in itself a good thing, but it is an inevitability. Failure is an opportunity to learn something about yourself, something about others, and something about the way the world works. Fear of failure is that thing which stops you chasing your dreams, and forces you to make compromises you don’t need to make. Fear of success is that thing that stops you chasing your dreams because it means confessing the limits of your ambitions.

You are not the only one who has doubts, and you are not the only one who is afraid that one day someone will discover that they mis-marked every exam paper you ever took, and actually you didn’t achieve any of your qualifications. You probably won’t unify physics, and you won’t surpass Shakespeare, but there are a lot of possibilities in between, and it would be a shame to let fear of the what ifs stop you finding where you can get to. Let me know how you get on.

Wednesday, 9 November 2011

Future thinking from enforced confinement



Hitler wrote his magnum opus during a period of confinement for political crimes. One has to wonder whether prison is the right environment to formulate and expound one’s ideas - I haven’t read Mein Kampf, but if the 20th Century was anything to go by, it must have been a pretty poisonous publication.

I too am currently confined, although for nothing like the length of time that Hitler was, and for purely medical reasons - it has become expedient over the last 24 hours to make sure that I don’t stray too far from my bathroom. However, such has been my rate of recovery from this intestinal scourge, that I was thinking about going back into work tomorrow morning, until I was informed by my boss that there is a mandatory 48 hour effluvient hiatus required before I am permitted to return.

This is tiresome for a couple of reasons - by the time I get back, no doubt the person who gave me this pestilence will have recovered, and I will not be able to discover the culprit. Secondly, I am facing the prospect of being in full health, and yet forbidden for discharging the duties for which I am paid, and from which I gain a great deal of satisfaction.

I am not the only one who feels a kind of Catholic guilt at not being at work, even when I am truly too poorly to be useful, so how am I to pass the hours?

Today, I polished the CV, worked on a presentation I have to give in a couple of weeks, and now I’m writing this blog. But somehow, it doesn’t seem meaty enough. I had thought that I might spend some time planning the future, outlining my ideology for consumption by my future followers, and really get a head start in laying out the future direction of travel of geriatric medicine. But then I thought of Hitler, and decided that now is not the time.


Emulating despots is not the name of the game - my goal is to reach a much higher plane of benevolence - indeed benevolence is one of the underpinning ethical principles of medical practice. So let’s bring this back to the real world, and talk about something that impacts on us all.

It recently struck me that in a year’s time, I will be starting the hunt for my first consultant post. This is a strange experience for me - being a consultant has been the professional goal for a long time, but the process takes so long that it many ways it has felt like it might never happen (indeed, it might not), but also, at the same time, part of me is afraid that having arrived at the stated destination, it might be easy to stop travelling.

The quest for qualification is so time-dependent, that intellectually, it has become expedient to develop other parallel, interests, which while they have not taken over from the primary objective, have acquired their own importance. How then does one marry the success of one goal with the potentially subversive pursuit of other goals? I don’t mean to be obscure, so let me elaborate: in the 9 years since I graduated, a number of facets of my life have developed - marriage, hobbies, sporting interest, my desire to write a book, my interest in areas of healthcare not directly associated with Geriatrics. Life gets full, and it becomes difficult to give all of these interests the space they require - the spring cleaning can be ruthless.

However, an easy mistake to make is the desire to be  a different person in the next stage in life. I remember starting at Uni, and thinking that this was my chance to reinvent myself; I lasted a few weeks, before I dropped the facade, exhausted by the effort, and have since spent my time learning to be comfortable with who I really am, and how to iron out the jagged edges that sometimes catch on other people.

However, this reinvention risk re-emerges at the graduation to consultant level - the job is different: you have to wear a suit, you suddenly become responsible for the patients, and worse still, you suddenly become responsible for the professional development of all the doctors now working under you.

I have seen this transition in others many times over, and the transformation can be profound - sometimes it works, often it does not, but most find their feet over time, and what I have noticed is that those who manage the transformation the best, change the least: it is important for us all to remember that we have got where we are by being who we are. Stripping away the aura of mumbo jumbo to that statement, what I mean is that the strengths we have as registrars will continue to be our strengths as consultants, and the same is true for our weaknesses. The aspects of the job that we think are really different, have in fact always been there, just at a slightly less intense level: there has always been the expectation to look smart (consultants needn’t wear suits), we have always been responsible for the patients, it’s just that often that responsibility involves enlisting the help of other doctors, and finally, we all play a role in the development of colleagues - we always have, and always will.

One of my increasingly repeated mantras is that being a doctor is about managing uncertainty, and being an excellent doctor is about managing other people’s uncertainty. This pressure can play out profoundly on arrival at Consultant-ship: one day you are a registrar, who can call for advice when you get stuck, and the next day you are a consultant, and the only people you can ask for help are the other consultants, but you don’t want to look incompetent in front of the people who used to be your seniors, but are now your colleagues.

Many interpret this predicament as meaning that one needs to make confident decisions. However, making paradoxically confident decisions when one is uncertain never works: it leads to inconsistent decision-making, and it infuriates the junior doctors - junior doctors can work with pretty much anyone as long as their approach is consistent, and they understand the underlying reasoning. Inconsistency, or a lack of reasoning, only results in them feeling uncertain, and as if they haven’t got competent back up for when it all goes wrong.

Uncertainty is OK. Indeed, in geriatrics, it must be embraced. And it must be openly acknowledged: a decision made in the face of considerable uncertainty is manifestly open to reversal or significant change, and this does not mean that the original decision was wrong, it simply means that the passage of time has yielded more decision-supporting data.

The trapdoor that is opened for all new consultants is the failure to adopt this approach in their reasoning. Of course, it is easy for me to sit here and say that. Perhaps this time next year, I’ll be asking someone to help me get out of the hole in the floor I have walked in to.

Tuesday, 1 November 2011

I won't be giving 'flu to anyone this year - will you?



I’ve just had my ‘flu jab. I’ve got to be honest - I had to work quite hard to get it this year. Normally, occupational health beg us to turn up and be immunised. Not this year.


The ‘flu jab often gets a hard press - how many times have you heard someone say that the ‘flu jab gave them ‘flu? Alarmingly, how many times have you heard doctors say it? I have clerked in many patients who have said to me that they were doing fine until they had the jab. It took me a while to work out what was going on, because if you believe the patients, the ‘flu jab is responsible for a range of ills, from lung fibrosis, through strokes to road traffic accidents. There is, of course, no causality here - the jab is merely an innocent bystander in the chaos of illogical reasoning.

In rather the same way as Christmas seems to run from the beginning of November to the middle of January (‘How long have you been poorly?’ ‘Since Christmas.’), the memory of the 'flu jab tends to linger, and we tend to have the ‘flu jab when lots of colds are going around. Perhaps it still instinctively feels like a risk to purposefully go looking to spark up the immune system.

I am not fastidious about many things, but I am about my annual immunisation. There are two reasons for this: I am tired of seeing my elderly patients laid low or killed by infections they pick up in hospital. If by having the immunisation I can reduce their risk of a potentially fatal viral infection, then I can see no plausible reason for not having it.

Secondly, I got married last December, in the middle of a raging ‘flu season - many of the guests at my nuptials turned up with streaming, influenzal upper airways, and many of the other guests caught it, and spent the next week laid up in bed. I, however, was smugly immune to their pestilance, and not only had a wonderful day, but also had a wonderful honeymoon, uninterrupted by seasonal viruses.

I am often disheartened by how many of my colleagues decline to offer themselves up for the ‘flu jab, and the discussion usually centres on their low risk of getting ‘flu. As you know, I think that this argument misses the point, and the main reason for the jab is patient protection. But it goes further than that: we work in a health service where many of the employees fail to avail themselves of an effective prophylaxis against a nasty illness. It’s almost like being a chef who won’t eat his own food: by failing to use our own therapies and best practices, we are visibly failing to endorse the service we offer. How does this impact on patients?

Tuesday, 25 October 2011

Supervision on the night shift


This week, I am relaxing with the wife in a beautiful cottage in the countryside, in that hinterland between England and Wales, just outside Hereford. One can get a real sense of the fluctuating identity of this area, that has inevitably led to high tensions over the years - the boundary between England and Wales around here is often indistinct: the names often share common heritage, and it is easy to imagine how neighbours would have tested each other’s resolve by creeping into each others’ territory, stealing, pilfering and generally making a nuisance of themselves. Imagine how tested poor old Offa must have felt to decide to dig a bloody great ditch to stop his Welsh neighbours pinching his sheep. I can only imagine that the presence of the Dyke was viewed as a challenge, rather than a deterrent by many potential sheep rustlers.

In the time and space afforded to me by this week off, I have been reflecting on the night shifts that I did last week, and what kind of experience they were for the people I was working with. In many ways, these shifts were also a new experience for me: for the first time I can remember, we were shadowed by medical students, many of whom actually managed to stay up with us all night. They seemed to enjoy the extra attention that one has the time to offer students during the night, and they seemed to enjoy the buzz of being up at 4 in the morning on a hospital ward. I have to admit that the physical sensation I get these days from being asked to make decisions in the witching hours of the night tend to verge more on physical pain than real excitement, but I remember how thrilling it used to be to have the time and space to make decisions for myself as a house officer on nights.

And this brings me on to my point for today: I am one of those chaps who thinks that the level of supervision and support that house officers gets today is as good as it has ever been, and medical training in the modern age recognises the need for demonstrable progress, graded exposure, and a constant and clear commitment not to let medical education ever undermine the quality of patient care. We do this now better than we have ever done this before, but one of the challenges of supervision is the process of graded responsibility: allowing junior doctors to take on more responsibility when they are able to.

One of the issues is that house officers become so used to having every decision they make checked and ratified, that they can quickly become accustomed to not having any decision-making autonomy. Undoing this mindset can be difficult, painful and scary if they arrive at their F2 or CT1 year with it still in place.

And this is where night shifts come in: I know that in some places, house officers have been taken off the night shift, as some feel that it does not offer a good enough training opportunity. I would however, like to challenge this view and offer the opinion that while house officers on night shifts do not get the level of clinical supervision that they might receive during the day, by virtue of the fact that there are fewer doctors around, what they do receive is the opportunity to learn what it feels like to take responsibility for decisions. In truth, there is always someone around for them to ask should they need support, but for simple, small scale decisions, this is often their first chance to assess patients, decide on the problem and what its solution is completely independently. At first this is terrifying and disconcerting, but even over the course of four shifts, I have seen house officers grow, and more importantly start to experience what it means to be a doctor.

Being a doctor these days is less about being a knowledge expert - all the information is freely available. Among other things, being a doctor is about having good decision-making skills, and also about managing uncertainty. Good doctors manage their own uncertainty well, while excellent doctors manage other people’s.

Night shifts allow house officers to experience uncertainty and to start to learn how to manage it. And it is from helping these doctors learn about that, and from watching them grow as professionals that I gain my enjoyment from those achingly tiring night shifts.

Sunday, 16 October 2011

The tenuous link between sport and neglect.


So the 14 men of Wales lost by one point to the 15 men of France, after Allain Rolland sent off  Sam Warburton for a dangerous tackle - a decision which is a bit like the rugby equivalent of sending Gary Lineker off, such is Sam’s reputation for fair play. Mr Rolland is a referee who rarely offers any sort of apology for his on-field decisions, and I am sure that this time will be no different. Conspiracy theories will no doubt abound: Rolland hails from Ireland (the team Wales beat in the Quarter Finals) and his father is French. I would prefer not to blame the heritage but rather offer the individual time to reflect on the impact he has had. No matter, I may feel rotten now, but I shouldn’t like to be in his shoes next time he goes to Wales: I would advise him against ordering any food or drink in any Welsh-run establishment for the rest of his life - the ingredients may well veer off those stated on the menu.

Perhaps therein lies the only real gain from the whole debacle: Welsh solidarity often seems to rest on a sense of shared injustice. We can be heartened that we now have a real episode of sporting robbery to unite us. For too long our failures as a rugby playing nation have been entirely our own. Having just got off the ‘phone to my brother and my Mum (the proper Welsh person in the family) I can already feel the guilty satisfaction garnered from having something meaty to moan about. Of course, this does not compare to what it would be like to actually have got to the final, but in many ways, talking about failure is our daily bread, so being able to blame it on someone else is like Christmas come early for the chippy Welshman.

In the run up to this match, I felt unprepared for the concept of a truly gifted, performing Welsh side: we have spent so long talking about past achievements that it has become ingrained that such performances and successes can no longer be expected from current and future Welsh teams. What we have learned over the last few weeks is that high performance can be earned, and that the past does not necessarily indicate how the future will look.

And this brings me on to my main point for today: Wales losing a rugby match because of a cheating, biased referee is only a sporting event - it has resonance for many reasons, including collective identity and heritage, but playing and watching sport are pastimes, and they only reflect the real fabric of society, and never truly replace them. These matches sometimes feel so important that it can be easy to forget that they are not. One of the reasons that Wales have been playing so well is that they seem to get this: they recognise that playing sport is important for the national sense of well-being, but that the position in society of what they do is brought into sharp relief by miners dying in pit accidents, or mass unemployment back home. They see their performances in the World Cup as a salve for the real world going on back home, and this really shows.

How then should we react to the news that we continue to abuse and neglect our elderly patients in hospital? This is a theme that crops up with regularity, and it is the same issues every time. Ann Abrahams published the excellent report ‘Care and Compassion’ earlier on in the year, and who was surprised to find out this week that in many hospitals, the same issues are still there?

Radio 4 wheels on individuals to relate what happened to their vulnerable relative, and we shake our heads, wring our hands, and talk about staffing levels, attitudes to caring, the qualifications of nursing staff and health care assistants. We talk about how we need to do better, and yet I go to work every day and pretend it’s not happening on my patch,

And here’s the rub - I am prepared to get exercised about the questionable call of a well-meaning referee when I see it, but do I roll up my sleeves in the same way when I see the abuse and neglect of elderly patients. I happen to work on wards where the care my patients receive from nursing staff is superb, but I still see patients admitted to hospital bearing the scars of sub-standard care every week. We always initiate the relevant reviews and safe guards, but it is my perception that neglect particularly of the elderly is so endemic, that we are less sensitive to it.  

Mistreatment of the elderly has relevance to me because I work with them; for others, the conversation strikes a chord because of their experiences with their own relatives. What we are lacking is for the elderly to have relevance in the wider society, and for them to be integrated in to the daily workings of their communities. Many elderly folk do not have the physical robustness they used to have, but they have experience, acquired emotional intelligence, and a perspective on life for which there is no short cut. The reality for many pensioners is social isolation and isolation.

The treatment that we afford them in hospital is a function of this bigger picture. The treatment that our elderly receive when they are ill is the best that our society has decided they deserve. We should be careful of criticising the standards of service that are offered to them by statutory services that are paid for by a society that clearly feels that the elderly are not that important.

The solution to their mistreatment in hospital lies partly in addressing staff training and attitudes, but it also lies in addressing societal attitudes. I fear that our elders will continue to experience poor standards of care until we as a society value them, both for what they have done in the past, and for what they continue to offer.

So next time you read a story about the poor treatment of the elderly in hospital, as yourself whether you individually contribute to the solution, or whether you are part of the problem.

Monday, 10 October 2011

Teamwork and the revolving doctors.


There is of course only one thing to talk about this week - the Welsh rugby team are in the semi finals of the rugby world cup. As you may recall, Mama Dharamshi is in fact Welsh, and she got in there early with my sporting education, and I have been watching Wales mostly lose for as long as I can remember.

The range of emotions I have been through watching Wales play have ranged from ecstasy and exhilaration (I have twice seen them win the Grand Slam in the Millennium Stadium) to despair (virtually every year they haven’t won the Grand Slam).

I learnt about disappointment watching Wales, and I learnt what it means to really invest emotionally in something, only to find oneself disappointed. Therefore, the experience of seeing Wales win, and win well, is doubly good - they haven’t just won, they have won by playing with skill and with enjoyment.

This contrasts starkly with the England rugby team, who have spent the last month playing badly, behaving badly, and failing to reflect honestly on the way they have performed. That bunch of lads have clearly forgotten how to enjoy playing the game.

Now I know that many of you will be switching off and tuning out, but bear with me - it has been a few months since I used a sporting analogy, and this one does work.

What we have seen from the Wales team that we haven’t seen from the England team is a sense of collective - they respect each other professionally, they enjoy each other’s company socially, and it clearly matters to them all how they as a team are perceived.

Tuckman describes the stages of team work with the terms ‘forming, storming, norming and performing’. Any new team that comes together has to go through a formation process, where they learn about each other, behave well with each other and avoid conflict. Guess what happens when teams start storming? This can be a rough ride, and this is where a lot of the behaviours play out.

The goal of course is performing, which is the team that results when the individuals have a clear grasp of what each person brings to the group: everyone is motivated, capable and autonomous. This frankly is where the Welsh rugby team is, and why they have exceeded the expectations of even their most ardent fans. They have developed a trust in each other, by sharing some pretty painful experiences together (there was a famous training camp in Poland, where they all stood in freezers after training sessions to help with the recovery and thus allow them to do more training), and spending a lot of time together.

But I work in a system that almost precludes ‘performing’ teams by virtue of the fact that some of its members rotate every 3-4 months. It can be disheartening and exhausting to start again with new house officers and SHOs so often, and I have often wondered whether such frequent rotations undermine the level of performance of the team as a whole.

It’s a difficult question to answer but what I have noticed is that when there are highly performing teams in a hospital, that level of performance is usually a function of the more senior doctors working well with the nursing staff and therapists. A far more common experience, however, is to work in poorly performing teams, where the communication between members is either absent or unhelpful, and where team members do not value the contribution of their colleagues.

I have no doubt that my most productive and effective periods have been made possible by the people around me. The question I constantly ask myself is whether I have returned the favour. We each have a responsibility to do what we can to help our colleagues reach higher, and in turn, we can reasonably expect a leg up in return. It does not take long for new comers to a team to recognise when they are working in an environment in which individual contributions are valued. So when I think about how to incorporate new junior doctors in to the team, I think about what my relationships are like with the nurses and therapists are like. If I have paid enough attention to these relationships, then my new house officer will have no trouble settling in, because a conducive team environment will have already been created.

But rather like following the Welsh rugby team, one’s fortunes can turn in an instance: these relationships need constant nurture, and there is no such thing as completed work in maintaining the performance of a team.

Monday, 3 October 2011

I wasn't listening before, but I promise I am now.


Last week, I was having a chat with my consultant. Forgetting that this is the chap that I may someday need a reference from, I took the opportunity of his monologue to check some emails on my phone, and fire off some quick replies. ‘Don’t stop,’ I said to him, ‘I’m still listening.’

‘No you’re not.’ he replied

I mumbled some platitude about being one of those blokes who could actually multitask, but he was right - I had decided that I didn’t need to listen too closely because I already knew what he was going to say.  

The following day, I gave a talk, and experienced the satisfaction of knowing that it had gone down pretty well. After the end of the session, one lady came up to me and told me that she had enjoyed my presentation thoroughly, and that she knew that everyone else had too, ‘Because you could feel it.’

I know what she means - there is a certain feeling you experience when you are talking to a room of people who are paying attention, but I have always thought that it is more of a sound: you hear it rather than feel it. I think it has something to do with the fact that attentive crowds fidget less, cough less, tap on their phones less, and consequently achieve a silence that one rarely hears. The point, however, is that it is a very nice experience. And one, apparently, that I am not prepared to extend to my boss.

This realisation has got me thinking about what it means to be heard, and what it means to listen. I have been struck by the number of bad habits that I seem to have developed. For example, when I am on-call (this is a euphemism for being busy) I often use the time that the patient is talking to think about how I am going to investigate and treat them, which patient I am going to see next, what I might have for dinner, how I might try to win my next squash match and so on. It was disheartening to realise that I use very little of that time to actually listen to the patient and give them my full attention.

A medical maxim is that the diagnosis is always in the history and rarely in the examination. This is true, but in my case, the diagnosis is often in another doctor’s history, which they then tell me.

The way we work in medicine means that there is often a lot of duplication of effort. Let me explain - I send a house officer or SHO off to see a patient, and they come back and tell me what has happened and run over what the plan should be. Sometimes I will have to go over certain aspects of the history with the patient myself, and partially repeat the process that the other doctor has already gone through. My consultant will then repeat this process with me. Even when I see the patient from the beginning myself, that patient has already been seen by a doctor in A and E or their GP - those are the entry criteria for the attention of the on-call medical registrar, so it must seem like Groundhog day for them.

Between presenting to a doctor with a problem and being treated for the problem, a patient can expect to be seen by upwards of 4 doctors, often all asking the same questions. This must be insufferable.
We all know the importance of asking opening questions, and it can be a particular skill to resist the temptation to ask more specific, closed questions when one is busy, but I guess that it doesn’t matter what kind of question that one asks if one is not actually listening properly. Speaking to a patient doesn’t only have to involve finding answers, or monitoring progress - there is therapy in the conversation itself, and there is reassurance in the being heard.

Doctors in general, and this one in particular, have a habit of being goal-orientated, and trying to ensure that each particular experience achieves an outcome. What I have realised is that a goal in itself is allowing people to know that they have been heard. It does not matter if nothing they tell you has a material difference on what you do for them, the experience of knowing that you have been listened to is a powerful and important one.


This week, therefore, I am planning to shut up and listen. Even on Thursday, when I am on-call.