Sunday, 29 January 2012

Love the skin you're in

This week, I have been thinking about what it means to help my team develop as individuals. The circumstances in which I work with house officers and SHOs can be challenging: junior doctors often rotate after a very short time, they are often away from the wards doing on-calls, and they join the team I work on from other teams, which may have demonstrated to them ways of working that are different to the way that we do things. On top of this, is the need for them to satisfy us enough that they are competent for us to assess them favourably as part of their training programmes.

What then is the best way to help them develop?

The temptation is to try to portray the specialty that one works in as the best one to do, and to treat the time junior doctors have with you as a prolonged sales pitch. Another approach is to try to embed in them your way of doing this. It is very easy to begin to believe that the way that you practice medicine is the way that everyone should practice medicine, but it does not take a long period of reflection to realise that even if we all implement the current best practice, that there is significant scope for individual preferences and styles.

What I have recently recognised is that junior doctors are asked to develop some idea of what they would like to specialise in very early in their careers, which is a new kind of pressure that I never really had to deal with: when I was an SHO, it was usual to either get a training rotation in the relevant field, or to cast around for a specialty that suited by taking on short term contracts in different specialties. The beauty of this system was that it allowed different people to either go quickly or slowly in their chosen direction, on the basis of their own aspirations and experiences. These days, junior doctors are asked to have some idea of what they would like to do, when they do not necessarily have the experience they need.

The risk, therefore, is that young doctors hedge their bets, and go for specialties that they are poorly suited for, and will not thrive in. However, I have been wondering recently, how real this risk is. One issue in medicine that I have written about before is the problems associated with socialisation of junior doctors and medical students, so that they mimic the behaviours of senior doctors, and a certain pattern of behaviour becomes embedded in the way that particular specialties conduct their business.

I suspect that for most specialties, there is the scope for a range of different approaches and character types, and perhaps the distinctions we traditionally make about the types of people who become surgeons or physicians or paediatricians are in fact arbitrary. If we break down the stereotype then maybe the whole of medicine would reap the benefits of new approaches.

Of course, I imagine when doctors think about what specialty to apply for, they look at the people who do it now, and make some form of assessment of affinity. So it may be that the new pressure to choose early will actually entrench old fashioned stereotypes, but what if our young doctors are choosing specialties before they have had a chance to know what kind of doctor they will be in the future? This is a process of discovery that we all have to go through, and it is true for me, and therefore I suspect others, that I have turned out differently to how I both hoped and expected. Asking doctors to make career choices early may, therefore, result in the erosion of traditional stereotypes, if and where they still exist.

If my arguments here feel a little forced, then hopefully what it has persuaded me of will not, for it occurred to me, that what is important for junior doctors is not necessarily what specialty they choose, but rather how they approach it. It is perhaps plausible that any doctor could be happy and successful in any specialty: medicine is a sizeable place, and there should be scope to accommodate all sorts of different character types within its walls.

It is crucial for doctors to recognise that both they, and the people they work with, have particular preferences about the way that they go about things, and that these preferences are not universal and equally shared: some people are really focused on the details, others on the broader strategic aspects: some like practical procedures while others prefer to specialise in the decision making required to know when to do what. We all have a slightly different pattern of preferences, and while it is important to recognise what appeals to you, it is also important to recognise how the people you work with view the world.

Every doctor that I work with brings with them certain strengths (things they are simply good at) and areas that need a bit of work. With junior doctors, the temptation is to spend the most time working on the things that they need to improve, but my recent realisation is that where they have strengths, then we ought to spend some time developing them, and putting them to the best use of the team.

By emphasising the positives that all team members bring to work, you foster an atmosphere of collaboration and also of learning. By first defining colleagues by their talents, they are immediately valued team members, and not just trainees. This shift in emphasis makes the point that there is no one ‘right way’ to practice, and acknowledges from the start that there is no expectation that a trainee on my firm should work in a particular way. Done well, this approach would mean that every new job a trainee goes to is a chance to both shine, and develop, by adapting their approaches to a new arena.

And that is what I have been mulling over this week.

Sunday, 22 January 2012

Timing is everything

A man invited me to his funeral the other day. I would very much like to go.

We had had a brief conversation about something that we had both noticed: that he was going to die soon.

The realisation that your body is giving out on you must be both powerful and incredibly lonely. In my practice, it is rare for my patients to have a clear recognition of their own impending death - most of them suffer significant confusion and drowsiness in the days leading up to it, so I am much more familiar with having to talk their families through the process.

Watching an individual come to terms with their own deimise can feel like the worst form of voyeurism, and the temptation is to pretend that it isn’t happening, that our medical magic will kick in and everything will get better.

It doesn’t work like that. Having conversations with patients and relatives about dying always feels hard, and it is very difficult to do it well. Sometimes I have to remind myself that it is not my bad news, that it isn’t happening to me, and if the most helpful thing that I can do is to allow someone the warning they need to plan how they would like to die, then it is my duty to bury my reticence and get on with it.

I have never regretted discussing end of life issues with patients and relatives,and I always wonder how well I managed it: it is impossible to really understand what it is like to know you are going to die, and therefore, whenever I talk to patients about it, I have to speculate a little on how best to help, what language to use and what to talk about.

Patients are often very generous, and acknowledge how hard these conversations must be - it can be embarrassing how lovely they are.

Diagnosing when someone is dying is also very difficult, because when one has been dealing closely with a patient, noticing that they are fading away can go unnoticed among all of the details of their treatment, blood test results and so on. It is also a big call to make, and in diagnosing the dying process, I often feel obliged to stop all active treatments.

There are two practices that I have learned to help me overcome these challenges: firstly I often ask for the opinion of another doctor or the palliative care team: a fresh perspective can be crucial in helping you believe what is in front of your eyes, and help you accept the need to change focus. Secondly, recognising that someone is dying does not mean that you have to stop all active treatment: there always remains scope for doubt, and often the treatments we have prescribed have a useful role in managing a patient’s symptoms. There is simply no need to stop everything. As the disease progresses, or the patient deteriorates then all of the different treatment choices can be reviewed: it does not all have to be done in one go.

This article by Atul Gawande ( ) also helped transform some of my attitudes to palliative care, and helped me understand that ‘active’ treatment is often a misnomer: modern palliative medicine is not about doing nothing, it is about recognising that the goal is not cure or preservation of life, but about patient experience: if a patient is breathless from their pleural effusion, then by all means drain it. Sometimes we need to admit that ‘active’ treatment is in fact ‘forlorn’ treatment, and the only thing really active about it is the degree to which we are engaging in the delusion of ourselves and our patients.

I am particularly struck by the evidence that patients can live longer when they abandon trying to cure their disease. I suspect that this is a function of the toxicity of treatments used to cure cancers and also something to do with the psychology of survival. There is good evidence that people, to some extent, choose when they die: how many patients do you know that live until the special birthday, event or anniversary and then die shortly afterwards, and how often have you heard of a couple who have been married for 50 or 60 years die within weeks or months of each other? A good way of reducing your autonomy over when you die it seems, is to try and cheat death, and hold out hope when there really isn’t any. Survival can be improved by accepting you aren’t going to survive. Odd but somehow apt.

Therefore, the patient who invited me to his funeral is someone that to some extent we should envy: he is someone who has been able to identify that no medicine could cure him and accept that; and in accepting this truth, we were able to help him spend his last days well cared for in a hospice with his wife by his side. And if that isn’t a success story after 87 years of life and 65 years of marriage then I no longer know what is

Tuesday, 17 January 2012

Sharing: be an open book.

When Claudia and I got married, my friend Simon read a fiercely difficult and wonderful poem for us, called ‘Having a coke with you.’ by Frank O’Hara. (this link gives both the poem and a video of Frank reading it - Simon bested Frank by a mile with his recitation ).

There’s a line in it, which if you don’t want to read the whole things runs thus:

‘and the portrait show seems to have no faces in it at all, just paint
you suddenly wonder why in the world anyone ever did them.’

We are partially driven by creativity, which manifests itself in many different ways, and is demonstrated by what we say, write, sing and paint; I liked it when Neil MacGregor, who on introducing ‘A History of the world in 100 objects’ remarked that ever since man has been making objects, he has been making beautiful objects.

That the creation of wealth is the modern obsession, confirms the primacy of performance and artistry in modern life: banking and capitalism are as much an exercise in showmanship and chutzpah as they are of science and maths. Our current economic woes make it plain that creativity can disguise itself as algorithm in even the most hard-hearted mathematician and that however hard we may try, and however, much we want to believe in it, empiricism and science still can’t trump the vagaries of the speculative mind.  

I suspect that the need to create is hard-wired in us, and encapsulates our need to understand the world we live in by reflecting on the events that have happened to us, and sharing our perceptions with each other. These perceptions of the world come in the form of pictures, stories and songs, and sometimes, a picture, story or song will resonate so clearly with us that it will change the way we think about the world. We all have our own examples, and this is one of mine (again borrowed from ‘A history of the world in a hundred objects.’:

The Ain Sahkri Lovers is an 11000 year old pebble, which shows that the person who carved it knew something about love and tenderness - this is not a portrayal of two people merely mating - this is two people making love, and that is an important distinction. What is perhaps most telling is that someone, a very long time ago, perhaps on the edges of insight, self-awareness and abstract thought, felt it important to make this depiction of this act, and perhaps share it with others. And we have been doing it ever since.

I had reason to reflect on this recently, and I had to question what purpose it served to share with you my thoughts through my blog, and whether the potential risk to my own reputation was worth it. I would be very surprised indeed if my blog made it into any future list of important works, but the process of writing has for me been transformative: spending time thinking about the issues that I have dealt with in life and at work, thrashing out what I feel and believe about them, and then wrestling with choosing the right words to share it all with you is time well-spent: I emerge with a much clearer idea of how to deal with problems that I have often been struggling with. And hopefully, you find it interesting too, and have the chance to gain an insight into someone else’s world - engaging, if not life-changing.

Of course, the opportunity of the open-access world of the internet is also the risk: words that you publish with sincerity and earnestness are there to be consumed and used at the whim of whomever may choose to, and there is no means of gate-keeping what people may do with your work. Meaning is defined by context, and taken out of context, it is possible to make someone’s writing an easy portrayal of what a turnip they are, and this risk will exist however careful one is with content and phrasing.

The option exists to reflect in private, and not air one’s thoughts, and this is what a great many no doubt choose to do - often, I imagine, with a huge amount of personal benefit. But I am minded to stick my elbows out a bit in a world that seeks to silence the individual: it is not so much that the world needs to hear what each person has to say, but that each person stands to gain considerably from having managed the challenge of grappling with complex issues and emotions, and found a way to express those feelings with consideration and empathy.

Duchamp is my ally in making this point: he argued that artistic creation is not only carried out by the artist, but also involves the process of being viewed (or read or listened to) by the audience - the interpretation of the work by the person consuming the art is a central component of the creative process, as the impact and meaning differs from person to person.

Thus in sharing my blog with you, I have always hoped that each time I click the ‘publish’ button, I am starting something, fuelled onwards by the feedback and comments I get, and the conversations I have. I can make sense of the experiences I have had using the framework and insights that I have, but sometimes that sense has greater resonance when understood through someone else’s lens or perspective.

In revealing the way you think and feel, it can feel like you have created an asymmetry of information that is inviting exploitation from the unscrupulous: surely if they know something about the way you think, they have all the ammo they need to undermine you? Possibly. Much more likely is that one’s ability to be open allows others to understand you, work with you and respect you much more than they ever could if you played your cards close to your chest.

I once met a senior executive in a health care organisation who’s working style was every day to take a risk and reveal his deep ambitions and fears to those he worked with, and effectively invite them to work with him, or work against him. What would you do if the person you worked for was prepared to let you know exactly what he was trying to achieve, and how he would like to go about doing it? Seems easy doesn’t it?

Perhaps more of us should try it.

Sunday, 8 January 2012

A rational debate about rationing?

The debate about the responsibilities of the NHS towards women who paid for poor quality breast implants privately has been fascinating to watch.

On Saturday, I just happened to catch an exchange on BBC news, when Bruce Keogh (Medical Director of the NHS) was interviewed straight after a lady who had had to have her breast implants revised after one them had ruptured. Bruce was subjected to what I thought was an unnecessary amount of ire, not just from the lady, but also from the interviewer, when he outlined that the NHS will replace any substandard implants that they put in and they will remove any ruptured implants, but they will not replace implants that were put in by private clinics.

Is this a ‘disgusting’ abandonment of responsibility by the NHS, or a reasoned decision based on the Utilitarian ideals that underpin the health service? I know where I stand on this issue, but I am not in the business of trying to get you to agree with me - what I would like to see is a world in which we can debate issues like this without accusing the individuals charged with making difficult choices of being evil when they outline their decisions and reasoning.

A consistent theme that I have  particularly seen on the TV has been the revealed assumptions by journalists and lay people interviewed that the NHS has a duty of care to all ladies who have these faulty implants, regardless of the circumstances in which the implants were fitted.

Furthermore, it has also been interesting to register the reaction among these same journalists and lay people, when someone from the health service challenges these assumptions and argues that all clinics that used sub-standard implants have a duty of care to correct their mistakes, and not just the NHS. Has anyone else noticed that the standards and expectations we have of the NHS differ from those we have of private health providers?

The beauty and the curse of the NHS is that it wholly separates the business of paying for the service from the business of using it. This affects the way we consume healthcare, and encourages us to use it like an all-you-can-eat buffet, and have more than we actually need.  This curse has also been politically compounded by the promise of better and more effective healthcare, and the frequent language of failure that is used when talking about the NHS.

Standards of care do vary, and not everyone receives the service they deserve, but as I have said before, overall, we get the health service that we deserve, and there is no use pretending it is something that it is not. Resources are finite, demand is potentially limitless, and we as a community have to be honest about what we can afford. Someone has to decide what we do and do not fund, or we all have to agree to pay a lot more - those are the simple choices we face.

Of course, it is all a lot more complicated than that, but the breast implant fiasco has revealed a couple of things that are likely to have increasing relevance in the future. Firstly, under the changes heralded by the health bill, we are likely to become a lot more familiar with having different treatments supplied by different providers in a range of different facilities. How good will the after-care for late-developing complications provided by private providers be, and who will be held responsible for correcting mistakes of the kind that we are currently dealing with? Given the financial imperatives, you can guarantee that providers will do their best to avoid responsibility, and the only people that will lose out will be the patients, while they wait for the different organisations to thrash out their arguments in the courts.

Secondly, the reality of health care is that it is a hungry beast, with an insatiable appetite. Remember the episode of The Simpsons when Homer gets sued for over-eating at an all-you-can-eat seafood restaurant? Marge is asked by the lawyer in the court what they did after they were thrown out of the restaurant, and the conversation goes something like this;

Marge: ‘We drove round Springfield for a couple of hours.’
Lawyer: ‘Why did you drive around Springfield for a couple of hours?’
Marge: ‘We were looking for another all-you-can-eat seafood restaurant.’‘
Lawyer: ‘You drove to another all-you-can-eat seafood restaurant?’, and turning to the court, ‘Are those the actions of a man who has had all he can eat?’

I use this rather self-indulgent reminiscence to make the simple point that it is unlikely that we would ever be prepared to spend so much on health care that everything that anyone needs or wants could be afforded. The obvious conclusion, therefore, is that the reach of our health service will be limited to what we decide should be paid for. Naturally, this means that there will be treatments and services that we withold.

The nature of any such rationing discussion is necessarily difficult, emotive, and potentially explosive, but we all need to start at the same point, which is the understanding that over time, and depending on the financial pressures the health service faces at any one time, we will have to exclude some levels of provision. The discussion, therefore, needs to be open, frank and responsible about what are the values that underpin such rationing.

And the breast implant debate is perhaps a good place to start: can we justify the £150 million it would cost to remove and replace all the faulty implants that have been used? If we do use the money in this way, what else are we foregoing?
Tax payers have no choice about whether or not they contribute to the health service - it is their obligation. Would it be fair to also say that we have an obligation to understand that the NHS will provide the best service it can, but that this will never cover everything? Is it fair to make the promise that the health service will be open, transparent and consistent about what it won’t do for you and be prepared to debate with you? Or would such a move merely represent an inevitable erosion of the level of provision offered similar to what we have experienced in dentistry?

I’m going to mull this over, but feel free to let me know what you think.