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.