Monday, 26 March 2012

Hug a Medical Registrar.

Last week I played squash three times in four days, and when I walked in to work on Monday, I had the shuffle and hunch of a man twice my age. My excess physical exertion had left my calves tight, my shoulder was stiff, and there was the definite suggestion of impending tennis elbow.

One week later, I walked in for a morning ward round with exactly the same demeanour. The only difference was that this time, I had not done anything physical since last Wednesday.
I consider myself to be quite fit; if nothing else, I am fitter than I look, but my physical fatigue took me by surprise.  

What then can explain my broken state? Well, that is easy - it was the 39 hours in three days I worked as the Medical SpR, added to by the indignity of losing an hour’s sleep on Saturday night when the clocks went forward. The night registrar was chuffed about this. I wasn’t. I suggested that we split the difference and start the ward round at half past, but ultimately, we agreed that this would be an unnecessary faff.

The role of the Med Reg is a highly pressured one, and one that I know puts many people off being physicians at all. Forget the 30 years you spend as a consultant, it is the 5 that you do as a registrar that persuades many it is not worth the hassle. And sometimes, I can see their point. Today, I am exhausted, and I still have to get through this working week before I can put my feet up and recuperate.

My fatigue does not stem from the fact that I didn’t have any meaningful breaks on Friday or Saturday (I didn’t), but because over the course of the weekend, I played a bit-part in the major life events of a fair number of people. The absorbed stress of working with people who are going through a really bad experience inevitably begins to tell, but too often in medicine, we pretend that it doesn’t have any kind of personal impact. I would like to change this, and to say clearly that sharing space and time with people who are going through the kind of personal traumas that we deal with as physicians is a hard job.

Technical skill and knowledge base are important aspects to being a doctor, but that doesn’t change the fact that there is a real human element to it as well. I am not just a doctor, I am also a young-ish man who has seen lots of people suffer and die. And while there is always something I can do to help the situation, it is really hard not to take some of this home. Some of the events that you help with are moments that patients or their relatives will remember with emotion, sadness and clarity for the rest of their lives, and if that doesn’t affect you, then you have something that I don’t. In many ways, I don’t want it not to affect me. I want my patients’ experiences to be important to me, and that is impossible without empathising them.

I’m now in my fifth year as a medical registrar, and I always assumed that it would get easier as I progressed. To some extent this is true, but I have also observed that the things that I found challenging when I started are the things that I still find challenging now.  I am still staggered by the range of responsibility that one person has. From dealing with cardiac arrests, and really sick patients on the ward, the medical registrar also has to deal with admissions through A & E, referrals from other specialties, provide advice to GPs, supervise the more junior members of the team, try to ensure that they have good clinical exposure with enough support, manage the work flow, and make sure that the take is run the way that the consultant likes it to be run. And also deal with the strong emotional experiences that patients, their relatives and other doctors are going through. That is a lot.

So if you see a medical registrar looking flustered, being grumpy, or simply having a tough time, make them a cup of tea, and say something nice to them. Very few people did that for me this weekend, and it would have made a world of difference.

Sunday, 18 March 2012

Some thoughts on tolerance

Has your YouTube viewing ever led you somewhere unexpected? Mine has, and this week, I landed on Bronski Beat’s ‘Small Town Boy’. Before you judge, take a look:

If you don’t have time, the song is about Jimmy Somerville’s experiences growing up as a gay man in the 1980s, and forms a stark juxtaposition to contemporary attitudes to homosexuality. My memory of the 1980s is hazy, but it must have taken a degree of courage for Jimmy to have steel enough to play himself in this music video, when he knew full well that it would be played to a society that was still very uncomfortable with the idea of homosexuality.  

I first came to London in 1997 to go to University. I was thinking recently about how much the city has changed in that time. To walk down Tottenham Court Road today is to be oblivious to the fact that at the end of the 20th Century it was liberally littered with sex shops and kebab houses. Every July, there was a Gay Pride parade, and it had a real tension to it. It was about one group of people publicly celebrating the very thing that other members of society vilified them for.

Where was the justice, or the compassion, when the Admiral Duncan was bombed in 1999? I remember seeing the ambulances lining up around the corner on Gower Street, outside University College Hospital, and feeling a lit bit useless - as a second year medical student, the most helpful thing I could do was steer clear of the place.

But times change, and Gay Pride still takes place every summer, and the worst that any one can really say about it is that there are rather a lot of whistles being blown. It’s almost as if it’s all a bit passe, and that’s a good thing. It means that the tension has gone.

Of course, my view from London is not reflected every where, but it is gratifying to see how tolerances can alter and grow, and that from being something that people had to be afraid of, being gay has increasingly, albeit not universally, become something that people can celebrate.

But one has to wonder whether the society that we live in today is actually a more tolerant one than Jimmy’s world of 1984. In some ways it is, but in others I wonder if we might have gone backwards.

On the 7th of July 2005, I was sitting in A&E, trying to decide how to treat a patient, when the Big Red Phone went off, and told us that there had been a major incident at Kings Cross. What followed was the most emotionally turbulent day of my life. Initially there was the confusion about what had actually happened, then there was the panic of dealing with injuries, then there was the realisation of what had happened and why. And mixed in with all of this horror, were some essentially human displays that reminded me that however wicked people could be, there was at least an equal capacity for startling kindness. I remember people walking for miles to get into the hospital to help out, I remember the catering people bringing me sweet tea and cake every half an hour, and I remember the roads being filled with thousands of people quietly making the (often long) walk home.

That day, we experienced something of the worst of humanity, but also something of the best, and underlying all of it, was some deeply held tension, that still exists today, and I think corrodes us a little every day.

We all get scared by things we don’t understand, and we see the reaction to the fear it induces every day of our lives. What we see much less often, is people taking the time to understand the thing that scares them, before they decide what they think about it.

I’m pretty sure that each one of us has built in the ability to soar to great heights of empathy and kindness, which is matched by an equal ability to plumb the depths of obtuseness. And I think it is when we fail to understand the basis of our differences that we succeed in being the latter.

Wednesday, 14 March 2012

Lansley's fight back

Clare Gerada wrote to the PM last week, asking for a truce, and for the chance to re-engage with the process of discussing how the health bill might be implemented. We also found out today via Paul Corrigan’s blog (, that on the same day that she wrote this letter, she was asking some people to write to the PM to express their opposition to the same Bill.

The role of Clare in the organised opposition to the Bill is worth a quick look: as a partner at the Hurley Group GP practices, I know of some people who have questioned her motivation for opposing the Bill: she helps run an organisation that has fared very well out of current primary care arrangements. I suspect that her organisation will continue to thrive after the reforms, but there is still the whiff of something not quite right about it all.

Furthermore, if the same person is putting out conflicting messages on the same day, then many would assume that either the person is conflicted, or they are trying to manage competing interests. Writing to the PM to express her cooperation does not sound like the Clare Gerada we have seen in the media over the last few months, but asking people to email their opposition to him certainly does. Draw your own conclusions from that.

But this isn’t about Clare Gerada - the point I would like to make is much broader than that. The scenario I gave is just a good way of framing the discussion.

Much of the criticism about the Bill has centred around two general areas: firstly, there has been the contents and impact of the Bill itself, and secondly, there has been the communication and process management by Andrew Lansley. I’m not really expert enough to offer you guidance on either of those issues, but perhaps you will indulge some of my reflections on Andrew Lansley.

In the last couple of weeks, Lansley has been heard to utter that the miscommunication of the health reform has not been down to his misplaying of the situation, but due to opponents either misunderstanding what it contains or wilfully misrepresenting its likely effects.

The nature of this fight back from the Secretary of State was both unsurprising and surprising at the same time. We should not be shocked that a man under pressure gets bullish in response to widespread criticism, but it does smack of something like chicanery or self-delusion to blame public perception of the Bill on other people.

If the contents of the Bill have been misunderstood, then that says something about its complexity, which has created the need to speculate about its impact. Lansley is gutsy to swerve responsibility for that.

Furthermore, if Lansley is accusing others of wilfully misrepresenting the Bill, then he is doing exactly what many people who oppose the Bill have done to him. Last week, I decided that the most productive viewpoint to take was to assume that Lansley’s vision encapsulated in the Health Bill is his earnest opinion of what needs to be done to help the Health Service meet the challenges of the next generation. Along the way, he has been accused of many things, most repeatedly of privatising the NHS, but maintaining this opinion of him made any kind of decent dialogue of travel from either side impossible.

A different response to the one Lansley has taken would have been to acknowledge the concerns that have been raised, and instead of just saying that they are the product of confused or lying minds, address them directly. The same issues and concerns have been stated and restated by a great many people, and accusing this plethora of educated, engaged parties of either incompetence or deceit is not the move of an enlightened man. Imagine how impressive it would have been if Lansley had humbly, honestly and patiently talked us through the problems as we see them, and explained how his interpretation differed. In all honesty, I’m not sure many people would have given him the chance to do that, but it would have been nice to see him try.

But he didn’t do that - having been accused of incompetence and poor communication himself, he decided to do the same to his critics. This I fear was a missed opportunity: Lansley is going to win this particular fight, but I suspect that he has exhausted most of his political surplus in doing so - political influence that he is still going to need in abundance to make a success of the reforms, and to stop them becoming the glaring failure that does for this government at the next election.

Sunday, 11 March 2012

Working with colleagues - lessons from football

Do any of you know who the Secret Footballer is? Neither do I. Not many people do. If you’ve never heard of him, he is a top flight footballer who writes anonymously for The Guardian, about the world of professional football.

Sometimes, he is so good that I wonder whether he is a footballer at all. That may sound unfair, but you get so used to hearing footballers talk uninsightfully in the dramatic present (‘He’s taken the ball, and he’s put it in the back of the net.) that it can question your credibility when you are faced with someone who bucks this trend, but won’t tell you who he is. His column this Saturday was one of those times. (

He was talking about how assistant managers rarely go on to make good managers, because being a good assistant requires a different skill set to being a decent gaffer, and the one does not translate into the other. In fact his argument goes even further - he argues that being a good assistant precludes the ability to be a good manager.

I particularly like the point he makes when he says that the indifferent form of a team can often be put down to the players becoming too comfortable with the man in charge, and no longer trying as hard. He argues that when a manager says that they have taken a team as far as it can go, what he is actually saying is that ‘this group of players is no longer motivated by me.’

Knowing when to let go as a leader is really hard. Few people get the timing right: there are loads of sporting examples, such as Mohammad Ali, Ricky Ponting and Michael Schumacher. In politics, Margaret Thatcher and Winston Churchill are excellent examples of leaders who overstayed their welcome, and their usefulness. Picking people who have timed it well is more difficult, and the best example I can come up with is Bill Gates.

Which is interesting, because he hardly has a stellar reputation. I suspect that some of the negativity with which he is viewed comes from the fact that Microsoft has failed to thrive since he stepped down, and also from the fact that he was never as cool as Steve Jobs was. I guess this underlines how hard the challenge is: it is not just a question of recognising that you as an individual are not the one to take things forward, it is also about recognising who or what is. Bill, I guess, fell down on this standard.

A couple of weeks ago, I spoke about what it means to lose the trust and confidence of patients and their relatives, and this week I have been thinking about how one goes about winning the trust and confidence of new colleagues.

Working with lots of different people, I sense that it is important to try to establish an effective way of working that fits best for all of you: no one person has the right approach, and finding a balance is crucial.. This may seem like a lot of effort, and it is, particularly given that you often only work together for a very short space of time, but there are two things that make it worthwhile. Firstly, medicine is a small world, and many of the people that you come across now will reappear at some later date, so getting a good working relationship sorted at the start would seem to be a good idea. Secondly, it is hugely rewarding to learn how to adapt to new styles of working, and to see what they teach you about your own preferences.

Of course, it is difficult to get it right all the time: I was in one handover meeting with some people I hadn’t met before. I thought it would break the ice and make everyone more relaxed if I made some light-hearted gags. It didn’t, and they weren’’t. And they were right: I had not earned enough of their professional trust to convince them that I had taken on board the relevant clinical information and that the patients would be safe in my hands. The humour could have waited until I demonstrated the required level of clinical competence to put their minds at rest.

And it would have been an entirely predictable response, if I had taken the time to think ahead. But I’m not going to beat myself up about that - much more important to reflect and learn, than to make the usual sporting platitudes to ‘get organised’ and give it ‘110%’.

And what does the Secret Footballer teach us? Lots really, but this weekend, he taught me that you need to understand the people you work with. Even if they don’t spend any time thinking about the way you do things, it will be effort well spent, even if all it saves you from is some poorly-timed jokes.

Sunday, 4 March 2012

The risk of polarised views

The debate about the Bill rages. Boy oh boy does it rage. Am I the only one who feels a little like we are on a fast track to mutually assured destruction, or at best, the deep entrenchment of views, and the widespread attitude that one side will win, and one side will lose? The option of compromise, it would appear, has been removed from the table.

And I can see why we have got here. The White Paper and the Bill have been part of the collective consciousness now for 18 months, and in that time, I have seen a couple of things happen. I have seen lots of people take a long time to get a feel for what they think the Bill represents, and what its impact on the health service will look like. This is understandable, it is a complicated beast. Secondly, there has been the show of movement from the government, which has resulted in a staggering number of amendments, to a staggeringly large bill (but apparently about 700 amendments involved changing ‘GP consortia’ to ‘Clinical Commissioning Groups’) but little actual compromise; for many people, these amendments have been shadow dancing, and have only added to the sense of fragmentation that override the whole process.

These are real and heartfelt concerns, and whether the actual risks are real or perceived, the reworking of the Bill has served only to cement the view, that a Bill as remodeled as this one will result in a patchy implementation of a debatable model of progress. The whole sense of control, cohesion and accord has disappeared.

Add to this the added anxiety that we are being hoodwinked, and there is ample reason to get very intransigent about the whole affair. It reminds me of the story about the Cyclops I was told as a child (although I am not sure that the story is correct) that the Cyclops gave up an eye in a bargain they struck with some God - they thought the swap would give them the ability to see the future, but inevitably they were tricked, and the only future they were able to divine was the manner and time of their own death. ‘What would we really be signing up for?’ is a question that has lingered for many people when thinking about the health reforms

But it is important to remember that however poorly one thinks the government has handled this process, it would be odd indeed if they were motivated by a desire to do something harmful to the health service. It is in fact, highly likely, that Andrew Lansley thinks he is doing the right thing, and has come up with a very clever way of making the NHS more responsive to patient needs, while improving its efficiency. There are certainly a lot of people that he has failed to convince, but this does not mean that he does not think he is right.

And here we face a choice. We can either dig in, slog it out, and ensure that one side loses, or we can take a broader approach to the issue.

The scale of the debate is larger than any I have ever taken part in, but the principles are exactly the same as every disagreement we face at work. Remember how people behave when you tell them that you disagree. The first, and natural reaction, is to become defensive. If you tell people that their idea is bad, they will start by justifying their plans. No one will move, no will agree, and no one will end up happy. This is what happens when polarised views collide.

There is no point having an argument or debate if no one is prepared to modify their opinions. If you find yourself in this position, go and do something pointless but energetic, like squat thrusts, or star jumps. At least then you might gain some cardiovascular benefit.

What happens instead if you take a much more positive approach to disagreement? Instead of simply saying that the thing that is being done or proposed is wrong, or dangerous, propose what you would like to see happen instead. By doing so, one demonstrates where you actually stand, and measuring the distance between you becomes easier. It also allows you to establish what is really important to both sides, and what can be sacrificed. But most of all, it shows the person that you are debating with that you are not just being obstructive, but that you are prepared to be constructive, and engaged.

So, although I think it’s OK to ask the government to drop the Bill, we should also be offering our vision of what we should be doing instead. If we have no concept of how we are going to deal with rising expectations, rising technological costs, an ageing population and a flat budget, then we really shouldn’t be obstructing the passage of some legislation that Andrew Lansley has designed to deal with all of those things.

He may not be successful, but at least he has laid out a vision. And that’s important. So oppose the Bill, do so with gusto, but please, please have a think about what you would like to see happen instead. If we can all do that, then we can become people with whom the people in power are prepared to debate with.