Tuesday, 20 September 2016

Stoicism and hard graft.

Who was not charmed by the sight of Alistair Brownlee giving up his own chance of victory in the World Series Triathlon in Mexico to help his brother Jonny cross the finish line? Jonny hit the kind of athletic wall that would have put you or me into some form of terminal cataplexy. These are tough men - they wonderfully understated, stoical and talented Yorkshire men. They chose to daily inflict on themselves the kind of physical pain that would render me couch-bound for a week, all in the name of sporting excellence.

Jonny Brownlee chose the physical state he found himself in by continuing to push himself when his body was screaming at him to stop. Alistair put it rather more prosaically when he called him a 'flippin idiot' for not pacing it correctly.  Yet, this was an afterthought- his first reaction, instinct, if you prefer, was to help him finish; but it was not instinct that made Alistair gruffly shove his brother over the line ahead of him, in second place. He'd had at least 500m to think about it. That was a choice, and it was borne out of love, and sporting respect. He was rewarding his brother for the race he had run, and the effort he had given.

That brotherly shove encapsulated a great deal: it was a practical solution to the problem of negotiating a limp body over a finish line; it ensured his brother finished by himself (kind of) and ahead of him. It was also a payback for a finishing 500m that Alistair hadn't counted out: presumably he had held enough to get himself over the line but hadn't counted on having to do it for two. He was also making sure they weren't overtaken by the man behind them. It was practical, unfussy and unceremonious. I found it all rather tender. And inspiring. When Alistair Brownlee says that he would have done it for anyone, I believe him.


I have something of a soft spot for understated excellence. I am inspired by success through endeavour, and it often makes me rather emotional to see someone succeed on the back of hours of graft, pain and commitment. I outrageously interpolate unjustifiable conclusions about the type of person a sportsman or woman is from their performance. It's why the outing of Lance Armstrong was so bitter for me. Today, when the provenance of sporting performance is so murky, it is the Brownlees who help me keep my faith.


I want to think that they must have been terrible at school, such was the challenge of persuading them to sit still for long enough to learn something, but that might be my desperation to find a chink in these otherwise amazing athletes. These are not lime-lighters. Every interview with them seems to have the forebearance of someone under obligation. They were recently in an episode of Top Gear, but they seemed to use the challenge as a training exercise.

I suppose we find inspiration in different places. I find mine in sport, and in particular, I find it in sportsmen and women who practice, and train for the chance to win, but without the fear of failure.

I need that inspiration at the moment to counter-balance the clagging tribulations of being a doctor in the NHS right now. Today, it has been announced that the Consultants are to be expected to publish their private earnings (£0 for me - job done) which is one thing. Quite another is the manner of portrayal, as Nick Triggle on the BBC website reports that it is 'certainly not uncommon' for consultants to earn 'in excess of £500,000': this 'fact' can only be explained in 3 ways: it is either a loose representation of reality, a lie, or it is true -in which case my wife will probably tell me to pull my thumb out. Yet it taps into something important: many non-medical acquaintances of mine assume I work short hours for lots of money, with loads of lovely leisure opportunities at a golf course, which I drive to in an expensive car.

In itself, this is a small moment, but death by 1000 paper cuts appears to be looming, as the drip-drip of undermining reporting about doctors eventually makes you ask yourself whether you really are the earnest, hard-working person you try to be. I was bowled so far over by Theresa May suggesting that junior doctors were 'playing politics' that I did wonder whether I'd Rip van Winkled it and woken up in another world. The endless repetition of £10billion of extra investment in the NHS, with the highest number of doctors and nurses in the health services history, and the need for the NHS to be more efficient has been a prevalent, endlessly repeated riposte from the DoH at every marker of NHS crisis, syncophantically repeated by every news outlet that reports on it.

Yet every day, we doctors, nurses, therapists, managers and social workers go to work and know the realities of those pressures. We know that we are not so inefficient that savings will make up the shortfall. We know that we work flat out so much of the time that there is never any time to think about how to do things differently. And we know that no one is really listening, or think we are exaggerating.

Frustrating, isn't it.

So ask yourself this: what would the Brownlees do? Tapping into my habit of detailed character profiling from minimal robust psychological information, I have decided they would:


  1. Keep working as hard as ever, to do the best with what they have. 
  2. Not complain, but plough on
  3. Wait until someone asks them for help sorting the mess out
  4. When they do get asked, they would have a list of practical, sensible measures ready to implement.
So, from watching a brother help his hobbling brother finish a race, I have decided that I can finish this race by continuing to work on the things I do best (being a doctor) and spending time with my teams working on how we can continue to provide good care for our patients with what we have. We will be honest about what we can't do, and then just get on with it. Right now, no one wants to hear anything different, so we'll have to wait for someone that does.

If, in the meantime, you need cheering up, then perhaps you can watch the clip of Alistair and Jonny. Or perhaps you could watch this one, or this one, or even this one. 

Tuesday, 6 September 2016

Timeline melancholy

My Twitter time line is a forlorn place right now. The dominant theme is the Junior Doctor's strike, and there are three prevalent themes:


  1. Junior doctors are striking because of their concerns about patient safety
  2. Junior doctors are striking and are threatening patient safety.
  3. This person says Junior Doctors shouldn't strike, and this is why they are wrong. 
In the last couple of weeks, David Oliver (@mancunianmedic) has been asking doctors close to CCT how they will behave when they are consultants (#whenimaconsultant), and he sparked my current train of thought. 

I struggled emotionally through registrar training, and my overall synopsis of those 5 years could be presented in the motif  'I was a happy geriatrics registrar and miserable med reg.' Too much of my time was spent worrying about why I was finding the role difficult. I spent way too little time articulating to myself and others what made the role unnecessarily hard, and what could be done to improve it. I spent a lot of time feeling bad about feeling bad. I felt guilty that it mattered to me that I felt unsupported, over-worked and stressed. 

I would go to talks about leadership and hear platitudes about embracing the leadership potential of junior doctors, and about improving training. In the end, there were two things that made all the difference to me. The first was taking a year out to do a leadership programme that taught me all about reflective practice, and the habits of personal sustainability. The second was working for a consultant who offered all of his registrars the opportunity to help him develop his service and develop beyond the delivery of clinical services. He was fun, energetic, kind and restored my faith. 

A great many consultants I worked with over my junior doctor career were guided by the ethos of 'telling not asking', and 'bollocking not understanding,' and for them it was easy pickings: the entire focus of my junior doctor training, until I wrestled some control back, was entirely focused on clinical skills. None of the other essential skills of stress management, team working, team building, reflection, or understanding behaviours featured on my curriculum. 


Junior doctors now, as then, find out their rotas the day they start a job. Contracts never appear, pay not confirmed until you are actually paid. I once presented myself at induction, only to be told to go home as I was starting nights that evening. One hospital tried to be organised, and demanded that I take a day off work before I started there to visit their HR department. I refused. The consultant I was working for told me not to make trouble and to go along. 

There is something very akin to bad schooling about how we treat junior doctors. Publicly, we encourage them to question, to enquire, to be open about mistakes and feedback, but in private, our behaviours scream the exact opposite: we expect them to do as instructed, to mask their independence and intelligence until they are consultants, because until then, they are someone else's responsibility, and cannot be trusted to use all of their clinical skills, common sense and social skills effectively. I found it infuriating then - it still is now. 

Too little trust and autonomy is placed in these capable, effective men and women who staff our wards and clinics. Too little time is spent on helping them develop the habits and skills that will help them navigate stressful and demanding jobs with happiness and satisfaction. 

Twitter is currently reminding me of how toxic this kind of culture can be. The GMC has escalated the rhetoric about the risks junior doctors run by striking; the Association of Medical Royal Colleges has decided to discount the value judgement behind the decision to strike. Everyone seems to have an opinion about the justification of strike action, or the risk to patients, but with each comment we mark ourselves as dissociated and out of touch with the very doctors we are supposed to be mentoring. The debate around the strikes has turned into conversations with them, advice given to them, instruction given to them. No one would know we are all part of the same professional family. 

Imagine you are part of a rugby team, and you are planning a foreign tour somewhere, but your forwards don't want to go because of the poor human rights record of the country you are planning to visit. Do you tell them not to be silly, that they are putting in jeopardy the whole tour, upsetting the sponsors, and anyway, all the tickets have been booked? Would you go without them and try to beat a 15 man team with your 7 man team? Or would you listen to them?

In Bowling for Columbine, Marilyn Manson was asked what he would say to the children from the school, and marking himself out as something of a sage for our times, he replied 'I wouldn't say a word to them. I would listen to them.' Who knew that occasionally you need to consult a Shock Rocker to get any sense of a situation? What he realised about Columbine is that rock music wasn't the problem, it was a symptom, and that when kids feel like they're shouting and no one is listening, the shout louder, and more violently. 

Our junior doctors are shouting loudly, and instead of listening to them, we keep bollocking them. They are shouting loudly because no one seems to be listening properly, and those that do come up with childish put-downs which clearly misunderstand the point being made. Junior doctors are people who articulate complex problems for a living. They interpret a raft of symptoms into neat, precise sentences. They have analytical skills, deductive and inductive insights, and they have the verbal fluency. They are telling us there is a problem. That means there is a problem. 

Remember, junior doctors all learn when to ask for help. Good ones take the problem they are dealing with as far as they can, then call their consultant. These juniors have called their consultants, and now it our job to help them find a solution. It is our duty because they are part of our professional family, because they are crying out for support, and because they clearly recognise that they cannot fix this current impasse by themselves. They are doing all the things we have taught them to do. 

Perhaps with this round of industrial action we can do more than either support them or criticise them. Perhaps we can engage with the discussion both at our own trusts and more broadly about how we move forwards. Perhaps we can demonstrate to our junior colleagues that times have changed, and not only do we trust them, but we also believe them, and we value them. 

That was what I promised to do when I became a consultant.