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 (; 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 ( : 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?