Thursday, 28 July 2011

Responsibility and the growth of future doctors

I met the class of 2012 for the first time today, and I rather enjoyed myself. It was refreshing to spend an hour with a group of people who are excited to be learning new skills, and who, in their final year at medical school, are having to grapple with the very real prospect that they will soon be newly qualified doctors.

I guess starting one’s final year at medical school is one of those moments when it becomes real that, however long the training goes on, we all go through the process so that we can become doctors at the end of it. During my six years at medical school there were certainly times when I felt like I was a career student, and those moments where the responsibility of medical practice became real were powerful ones.

I often wonder how well we prepare medical students for life on the job, and much of my thinking about this is tainted by my experiences. Very few of the doctors whom I came into contact with offered me the kind of nurture and guidance that I thought I could do with. In fact, there was really only one consultant who took interest in me as an individual, and I ended up following her into her specialty. I haven’t quite decided whether this was cause and effect, or affinity derived from my pre-existing attraction to her specialty; some questions are unanswerable.

Medical students are tagged on to the bottom of the medical hierarchy. I have never seen this hierarchy in print, but it exists - believe me, it exists. At the bottom (that is the bit we are interested in today) there are house officers, followed by female medical students, followed by male medical students. The distinction between genders is often referred to, and I think derives from the observation that male medical students are felt to be less mature than their female counterparts. This may sometimes be true, but the idea that it is pervasive and universal warrants challenge. But it is the overall attitude to medical students that I would like to throw light on.

At the end of the session I was running today, one of the students piped up and asked whether I would mind signing his attendance sheet. Let me repeat that  - his attendance sheet.

I would have choked on my tea, but no one had made me one. One of my mantras at medical school was that there were high yield learning events, and there were low yield learning events, and life was too busy to waste time in the low yield ones. It turns out, however, that these days, medical students are not granted any autonomy over how they spend their time, and they are not allowed to tailor their own learning to their own specific styles. It doesn’t matter which seminars and tutorials a student turns up to, what matters is how they develop as a doctor in training. Having the time and space to develop as an individual is crucial to one’s growth as a doctor, and that incorporates being able to choose how one learns and develops.

When I graduated, the thing that I missed most was the loss of choice over how to spend my time. As a house officer on a Band 3 job working 90 hours a week, much of my time was given over to the hospital. In particular, I really missed the Wednesday afternoons, when I would usually go and play hockey for the medical school team (if you’re lucky I’ll tell you about my infamously ineffective team talks sometime) - those afternoons meant a lot to me. These days I often say to medical students that they should make sure that they use their Wednesday afternoons wisely - they should takes themselves away from the hospital; they don’t have to play sport, but they should do something other than medicine that really interests them. The best doctors I know have to something to offer away from medicine, and those habits start early.

People expand into the responsibilities they are given. With autonomy, there is great scope for learning, and their is great scope for learning from mistakes. The challenge is to choose the right pace of responsibility, and to offer the right kind of support. This is central to growth as a future doctor, and if our medical schools are not taking the chance to allow their students to take responsibility for themselves and to learn from their mistakes, then they are missing a trick.

It might seem like a small thing to get students to sign into to every learning event they go to, but to them it creates the impression that they cannot be trusted. And these people will be doctors in a year’s time.

I am now going on holiday for a couple of weeks, so I probably won't be posting for a little while. See you after the break!

Monday, 25 July 2011

The Class of 2011

The new house officers arrived today to shadow the people they will be taking over from next week. It was like there was a breeze blowing through the hospital, bringing with it a new season. These are the doctors who have just graduated from medical school, and are just about to embark on their first jobs.

I often try to remember my first day as a doctor, and in all honesty, I can’t remember anything about it. Like being born, your first day as doctor is so stressful that it becomes very difficult to recall it clearly. Day 1 doctoring was ever thus, and nothing I can say or do will prevent it.

However, there are some important themes that more experienced doctors should note. The transition from the old cohort to the new cohort is always bumpy - a group of people who are freewheeling their way through the days depart, and are replaced by nervous novices. That makes life a lot busier for those who do know what they are doing. Over the years, I have realised that the best way to deal with this is to take the first two weeks of August off on holiday, and thus miss the worst of the transition period.

For those who remain, it is important to observe that although much of the time will pass in a blur, the new house officers will recall clearly forever those who take the time to give them the support and guidance they need. I recently bumped into a consultant, who was the registrar the first on-call shift I ever did. The only memory I have of that day is that right at the very start he sat me down for five minutes and explained to me exactly what it was I supposed to be doing. I think I love him for taking that time.

I overheard one of the new house officers say today that she wasn’t worried about the medicine or the knowledge, but was worried about knowing how to get anything done. I didn’t have the chance to check whether her confidence about her knowledge was down to her knowing it all (a worrying sign) or because she knew she would be well supported (a more reassuring sign), but it resonated with a memory that much of the stress was seated in the uncertainty;  as a house officer this manifests in  many ways, and it is only when the sources of uncertainly diminish that one begins to feel at home wandering the corridors of the hospital.

I often think that being a good doctor means being good at dealing with uncertainty, and the mark of an excellent doctor is one who helps his patients and his colleagues deal with theirs too.

Nothing is given in medicine - every time you think you know what could happen, providence throws you a curve ball. Growth is measured not so much by knowing the answers, but rather by knowing how to approach the problem, and for all house officers, this will be huge source of anxiety. Many will deal with the challenge of how to approach problems by cramming themselves with as much knowledge as they can (that is often the medical way), while the really savvy ones will observe that the people they look to for answers often do not know the answers themselves, and will keep their eyes open for the ways that risk is managed and solutions sought.

We all have the chance to forge our own path and develop our own styles. There is no one, right way to practice medicine, and I hope that the new class of 2011 has as wonderful a time as a house officer as I did.

ps - Riaz will be on holiday for the first two weeks of August

Tuesday, 19 July 2011

Health care, social care - do we care?

I spend a lot of time thinking about the care of the elderly; in a way I get paid to. But often my thinking is determined by what is possible, in the context of the services available to my patients, and the input of the family and friends involved. It can often become frustrating having to shoe-horn what you would  like to do, into what you are in reality able to do.

In deciding how to look after patients safely after discharge from hospital, there needs to be considerable overlap between geriatric care and social care. The National Service Framework for elderly care was published the year I graduated, 2003, and observed that many elderly patients ended up in hospital for want of community based services to meet their needs. In the last 9 years, I’m not sure that much has changed: it is still routine to admit patients to hospital when their support networks at home break down, and it is still common for patients to remain in hospital when they are fit for discharge because of delays arranging suitable social care.

Social care is getting people quite exercised at the moment - The Dilnot Report has just outlined how future contributions to social care could work in the future capping social care contributions between £25k-£50k, and only kicking in when people have savings above an agreed level.

What continues to confuse me when talking about social care, is how people seem to class social care and health care under the same banner. What are the responsibilities of the individual to provide for their own old age, and at what level should the state intervene? The whole issue of social care is a massed tangle, so let us try to tease out what the most important questions are:
  1. What is the current role of the elderly in society, and does this need to change?
  2. Is the practice of looking after our elderly in care homes sustainable?
  3. Has our perception of how health care is provided in the UK skewed our views on how social care should be provided?

My answers to these questions remain incomplete, but their nature reveals where I am heading: I think that we make too little use of our elderly, both as sources of experiences and wisdom, and as people who would like the opportunity to continue to contribute to society. I think that the practice of putting our elderly in care homes will end as a result of financial imperatives, and it is as a result of the economical bottom line that we will ask ourselves whether it is the right choice for people we love. I also think that the success of the health service may have contributed to a sense of entitlement in old age. We will probably have to issue ourselves with some challenges on this issue, and we will have to ask each other what the role of the state really is in the situation of social care. More on this over the coming weeks.

Sunday, 17 July 2011

Leadership loose ends, and moral compassing

There are some leadership loose ends that I would like to tie up. I have written recently about everyday leadership, and how there is something we can each do to encourage higher performance at work. It turns out that the Kings Fund agrees: in their report ‘The Future of Leadership  and Management in the NHS’, they argue that there is a need to move away from the ‘old, heroic model of leadership’ towards a ‘focus on developing organisations and and its teams, not just individuals’.

I swear that I didn’t write their report, and perhaps more importantly, I swear that I didn’t copy from it either. The idea that leadership is not something rare is really important for us to absorb - change often fails to take place because we are waiting for someone to give us permission or validate our ideas. A professional world in which we feel empowered and motivated to run with our good ideas, without the need from a nod from above is surely a more rewarding place to be.

And yet there is still a huge need for role-modelling. Recall how good it feels to know that you can bask in the protective penumbra of the boss or colleague who will support you unquestioningly; remember the times that you have asked yourself what that person would do if they found themselves in the position you are in. We seek and absorb the examples of those in a position to influence us, and they influence our behaviours and decision-making in a fundamental way.

I was reminded of this by the News International saga, and struck in particular by the behaviours of the people at the top. I had come to the conclusion that Rebekah Brooks must know something very important indeed about the Murdochs, but in the light of her resignation, I have been wondering whether the delay was in fact driven by her belief that she had not actually done anything wrong, and didn’t bear any of the responsibility for the people working for her.

Such a position would amount to what I call deranged moral compassing. We see it all the time - Enron, the response of the financial sector to the banking crisis, BPs attitude to safety, North Staffordshire - situations where questionable behaviour continues for long enough without it being challenged for it to feel normal; where immoral decision-making is validated by Group Think and herd behaviour. Often the response to such situations being outed is to exclaim ‘How could they?’, but I think that is the wrong question: I have seen deranged moral compassing so often that I think the question should in fact be, ‘How can we protect ourselves against it?’

Can each of us say with certainty that we would never be liable to moral deviation from our stated norms? Can we all say that if we had work at North Staffs that we would have done something about it? Be honest.

Now the challenge for each of us to ensure that our working and personal lives include the kind of check and balance that will help us maintain the honest path that I think that most people always intend to stick to. Put another way, how can we ensure that our moral compass always points to true north?

This involves honesty and self-reflection, and asks that we invite others to challenge our decisions and our reasoning. Done well, it can be refreshing to know that you are happy to justify your actions, and that in fact you hope that someone does question you on it. It also asks that we seek fresh influence all of the time, and remember why we are doing it in the first place.

Doctors are often a cynical bunch. The experience of co-existing with other peoples’ suffering, and being comfortable living along side it can be poisonous. But every day, I am surrounded by medical students and junior doctors who still feel the visceral joy of learning how to help the sick, and being alongside them is a powerful antidote to the progressive erosion of my hopes and ideals.

Saturday, 16 July 2011

Change in healthcare, and dealing with uncertainty

We’ve been talking about reforming the NHS for a year now. I know that we’ve actually been talking about reforming the NHS for a lot longer than that, but what I mean is that the Lansley agenda has been the topic of conversation now for 12 months. However, for many who work in the health service, it is still the spectre of change that looms, rather than the reality.

We have been kept on our toes, kept in the dark, and kept out of our comfort zones; just as we were beginning to develop a clear sense of what the health service would like after the Lansley Act, we were asked to pause. The pause was a lot like the summer holidays - we entered the vacation with a whole year’s learning under our belts, and managed to forget it all. Since reengaging with the whole topic of health care reform in the last few weeks, I am as confused as I was last July. That does not feel like progress.

The current health bill is a clunky mess. It is not worth building intellectual foundations on what we know so far, as I suspect that we will have to take them down and start again before we have a clear plan to work to. However, this does not mean that we should not have already learned some important themes which we can act on now.

The future of healthcare is tainted by austerity. We have seen how the rate of spending increase cannot continue, and it is widely understood how the pressures of the ageing population, the increasing cost of drugs, technology and patient expectations create a strong driver for efficiency. The concept of efficiency savings creates the impression that we are trying to do less. But we’re not: what we’re actually striving for is technical and allocative efficiency. The latter is something of a hoax- allocative efficiency (the state where is it not possible to increase utility in one place without decreasing it elsewhere - ie everything is as efficient as it could be) is like the 50 year wave or the Yeti: often sighted, but never by anyone you directly know.

Technical efficiency is when a given outcome is achieved at the lowest possible cost. Again, this concept is something of an illusion, but it is a useful goal, and demands that we all ask ourselves the question, ‘How could I have done that better?’ The emerging reality of healthcare is that we cannot do everything we want to do with the money we have. Real and difficult questions will continue to be asked about what healthcare we provide and how. For many people, this will be a new experience, and for a great many it will involve the discomfort of having to work in new ways.

The scope of this new reality has yet to be made real - as I remarked above, the issue of healthcare reform remains largely hypothetical, and not everyone has latched on to the implications yet. Some, however, have, and the contrast is stark.

It is easy to spot the ones who know what healthcare reform means, because these are the people who understand that it doesn’t matter what it is that you actually do, as long as you and the service you provide appear to be indispensible to the people that matter. Services will be judged by outcomes and patient experience, so the service you provide must be the one that delivers something important to patients, in a way that they like. This does not mean that you must drive yourself into the ground every day, but rather it means that your service must adapt to the prevailing circumstances and respond the needs of patients. It has to represent quality, value and patient choice. It has to be the service that patients would choose, and it has to be prepared to change.

I can often see among junior doctors that they have a vision of what their career will look like, and for them, their first consultant job represents their arrival at their destination. They settle in to their new office chair, and look forward to spending the next 30 years making sure that that it moulds perfectly to their backside. They have no intention of moving, and if you need them, you know where to find them. I have also noticed that many of the most influential and inspiring people I have met have travelled in an unusual direction, and their arrival at wherever they end up is not so much a matter of choice and planning, but much more a manifestation of kismet. For them, it is not about the arrival, it is definitely about the journey.

It is this example that we need to learn from over the next ten years. The conclusion that I have drawn is that I have no idea what my career or the health service is going to look like over the next decade, and the challenge is to make sure that my own personal role in the process is challenging and effective. I don’t mind what the NHS looks like in 2020, but I will mind if the patient experience is worse than it is now, and I will mind of the quality of care isn’t better than now.

Sunday, 10 July 2011

Everyday leadership - start today!

In my last blog, I wrote about Bernhard Hinault and the Tour de France as an exemplar of leadership. I had wanted to make the point, that sometimes being a leader might involve putting yourself second, but I’m not sure that I made the point terribly well. Ho hum.

Leadership in medicine is a complicated beast. We often get distracted by the challenge of creating change in the NHS, and forget that a lot of leadership involves enabling people to perform at their best. I was reminded about how bad we can be at supporting each other during a conversation I had with some colleagues: we were talking about doctors who struggle with the different pressures that the job entails, and one of them said that when working for consultants who don’t provide enough support, some doctors flounder, while others just deal with it and get the job done. I pointed out that not doing anything about an unsupportive consultant did not amount to ‘dealing with it’ and that it is a shame that the language of contemporary medical practice in the NHS labels it as such.  

Leadership involves a great deal of personal reflection. It is very difficult to change and improve an organisation if you are not prepared to change and improve yourself. This is based on the observation that it doesn’t matter how effective you are, there are always elements that can be improved. This involves developing the language, knowledge and wherewithall to identify your personal preferences and challenges, and being able to deal with them. In every success and failure you experience - in fact, in every conversation and argument you ever have - there is a great deal of you playing a part. Leadership asks that you have the self-awareness to examine what you contribute to each of those situations, and learn from it. Leadership is about examining your ability to help other people reach higher, from the ordinary and the mundane, to the truly gifted; it is not just about talent spotting, it is about nurturing your colleagues every day.

Leadership in clinical practice is not just about what you go on to achieve in your senior career, and we can all be successful leaders without all having to achieve some stellar professional orbits. There are decisions we can make now that can have an impact straight away: we can all take the time to support our colleagues and help them achieve as much as they are able to; we can all be the ones who look for those small and constant improvements to the services we work in, and we can all be the ones who, no matter how shitty a time we are having at work, remind each other that it is, and always should be about the patient, and the care that they receive.

Leadership is not just about strategy and vision, it is about being the person who helps everyone else perform better and reach higher, and that is something that we can all strive to achieve from toda

Saturday, 9 July 2011

He who cannot obey cannot command

Last Tuesday, I gave  a talk on Change Through Leadership (not sure if the capitals are necessary, but judge for yourself) at a small conference organised by NHS London. It felt like a big deal. It wasn’t. But it felt like one - mostly, because Andrew Lansley was due to turn up. He didn’t hear my talk, so I thought I would blog about it, so that he can catch up on what he missed.

When he did arrive, it was to announce the launch of a new NHS Leadership Academy, to build on the various Leadership programmes that are in place throughout the country, and particularly London, and to give a national profile to leadership and its development. The details are still to be established, and I have to admit, that I still do not have a particularly clear idea of what this academy will look like, and what gap it will actually fill.

I spoke about what I had achieved on the clinical leadership programme, both in terms of improving patient care and experience, and personal development. The timing of the talk has coincided with a couple of big things in my life: one is a personal crisis, which I am not yet ready to talk to you about, and the other is the Tour de France, which I am always ready to talk about.

The Tour de France is the Grand Opera of sporting events. Dismiss it as an event at your peril  - it has everything. The one thing you need to understand about cycle racing is that up to 30% of your energy is spent overcoming wind resistance, and that when you are cycling behind someone, they do this work for you. This very simple principle plays out in a number of ways, and means overall that no one man can win the Tour de France by himself. Every man who has won the race in the modern era has done so with the considerable backing and support of his 8 team mates.

Being a team leader and persuading your team mates to ride for you is more complicated that just being the best rider - you have to have leadership, and you have to have it in spades. The work that the team does for its leader involves team members physically burying themselves. The suffering, sacrifice and commitment that these chaps show is often superhuman, and half hearted efforts get you nowhere.

I think that I have learned a lot about leadership from watching the Tour de France, and one of my favourite examples was Bernard Hinault, the patron of the race in the late 70s and 80s. He won the Tour five times, and it was clear that his team mates would walk through hell for him. There were a number of factors that led to this, but key to his approach was reciprocity - he struck a deal with them: they would ride for him to win the big race, the Tour de France, but in other races, and on quiet days in the Tour, he would ride for them. It wasn't always about him. He represented and protected his team mates, organising protests with race organisers and making sure that they were treated well.

But there is one picture that I want to share with you

This is a picture of Hinault leading Greg Lemond up the murderous Alpe D’Huez in the 1986 Tour de France. Remember, it is always easier to ride behind someone else. In leading Lemond up this climb, he was in fact leading Lemond to victory in that year’s race. That in itself says a lot about the man Hinault. What however, speaks even louder about him is the fact that at the time this photo was taken, Hinault had won the previous year’s race, and in doing so, had equalled the great Jacques Anquetil and Eddy Mercx in winning the race 5 times. In 1986, the French public were quite clear -they wanted their hero Hinault to go for a record breaking 6th title.

There are of course many subtexts to this story, but in the two weeks that preceded this stage, Lemond had proved to Hinault that he was the man that the team should ride for, and up this legendary climb, Hinault did the hard work for Lemond.

This anecdote captures for me something about leadership that we don’t hear often enough - that leadership is not about the leader, it is about the outcome. Benjamin Franklin said it well when he said that ‘He who cannot obey cannot command’

Tuesday, 5 July 2011

A thought on vulnerability and the health service

Sometimes we lose sight of what is important; sometimes we never see it, and sometimes we wilfully ignore it. Ask yourself, when was the last time you were blindsighted, and what can you learn?

The other morning, as I was approaching the main entrance of the hospital, I noticed a police cordon. As I got nearer, I saw people pause and stare; approaching the centre of attention, I saw that the ground was covered in shards of glass. When I got near enough, I was able to track what people were looking at, and follow their gaze to a set of screens which had been placed in the street. Although the screens had been placed carefully, so that they fully encircled what lay inside, they did not fully reach the ground:  underneath, I could see a pile of sheets, roughly conforming to the shape of a body. Up above, on the 8th floor, there was one single, broken pane of glass.

One does not fall out of an 8th floor hospital window by accident.

There are perhaps many questions that could be going through your mind right now, but there was one that kept playing through my mind: what must be going on in someone’s life that they decide that jumping out of a window is better than all the other options?

I have often felt that the mark of a charmed life is not so much avoiding personal or family crises, but rather being able to call upon all sorts of help and support when they do happen. It is wonderfully self-affirming when you realise that you are not dealing with your problem alone, but that you are backed up by unconditional love.

It is also sobering to realise that there are many people we meet who don’t have families and friends who can take  up the strain for them when they can no longer manage, and we often meet these people in hospital.

These are the people who present with symptoms we cannot explain, or present with symptoms they cannot describe. In the highly pressured environment of the acute medical take, it can be easy to miss the people calling out for help, because these are not people who ask for help, they are people who do not know the language required to access it.

I have noticed a few patients recently, with both psychiatric and medical diagnoses, who repeatedly present to hospital with symptoms related to their medical diagnosis, but with problems underpinned by their psychiatric diagnosis. What I mean by this is that the language of their medical diagnosis becomes very familiar to them - they hear it, the use it and they remember it. The language of their psychiatric diagnosis is less well known, as flare ups with these problems impair their perception and memory of those experiences. And when they ask for help with their psychiatric problems, they are used to getting a poor response.

Patients with psychiatric diagnoses are hard to deal with. Sometimes they are infuriating; they do not give clear histories, they do not respond appropriately, and they take up a lot of time. They can really test your resolve. And yet we do not criticise the man with pneumonia who coughs up phlegm; why should we criticise the patient with schizophrenia who cannot articulate what he is feeling and thinking, or presents with chest pain, whereas what he is actually experience is paranoia and suicidal thoughts?

These patients present to A & E often because they do not know how to access help in other way. Their inability to articulate is often the main symptom of their illness, so for these people having to ask for help means that they do not get help. For the frail, the vulnerable and the mentally ill, this can mean that the healthcare service fails them.