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.

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