Mighty Oaks from Little Acorns grow…


Normal or deviant? – culture in the caring professions

I have just been to the Lilly Lecture at the RCP in London, and owing to the fantastic opportunities to discuss the evening with colleagues after the lecture, I failed to ask Don Berwick a question that has been plaguing me.

In a guardian article Prof Berwick is quoted as saying that one of the problems at Mid Staffs was the normalisation of deviance.

My simple question is ‘have you got this the wrong way round?’

I personally feel that the medical tradition I have grown up in has not been one where the norm used to be total concern for the patient at the centre of every activity, but instead the legacy of 500 years of medical tradition where the doctor usually holds all if the cards and deals them to the patient.

I don’t mean to say that doctors are universally uncaring or dissociated from the suffering of their patients – far from it. But I feel our heritage points more to a culture where patients have not always been the centre; but -an increased transparency, patient involvement and empowerment have redressed some of the balance, and instead of a normalisation of deviance, we (society) have developed a new set of expectations against which the old normality fail to satisfy and it’s vestiges continue to fall short – and it us this which now appears as deviance rather than the expected or desired norm.

A moot point perhaps – but if we are to truly address the culture of the caring professions – we must understand where normal sits, and not put the cart before the horse.

Changeover / turn turn turn

Every six months, or less, there occurs a seismic shift in the medical workforce.

Thus usually goes unnoticed by the public (except for the usual scare stories in August) but for those involved – junior doctors, nurses, physios, consultants, medical secretaries, human resources departments, education centres, deaneries, and of course patients it is quite an upheaval.

The thing is that doctors in the UK ‘rotate’ during their training.

The rotational nature of training dates back to xxxx when it was noted that experience of a wide range of specialties (which are increasingly diverse) can be beneficial to the broad medical education of doctors in training.

When I first qualified I used to do an info graphic a bit like this one (flight path tracker around UK) in my mind on the day that nearly every junior in the country would pack their car – maybe do their last night shift – and arrive at their next hospital at 8am to start their next post.

Overlaps are hard to ensure, rota nightmares common, and continuity blown out of the water.

Changing jobs requires some mental gymnastics, political savvy and flexibility. Resourcefulness is also important.

I tweeted the other day that changing jobs is like wearing a new pair of shoes (I mean proper shoes, not trainers)

They usually chafe – cause a few blisters, and take a week or two to wear in. Sometimes it takes longer, sometimes they fit like a glove from day one.

I was challenged – what one thing would you say is most important to smooth the process? What would be the compeed to stop the chafing?

The challenge was not identifying what is awkward, inconvenient, and stressful about changing jobs, but narrowing down to one main thing.

There are a few big contenders…


Induction is supposed to help – but in reality is a sorry parade of speakers who don’t wish to be speaking, preaching to an audience that doesn’t really want to be there – not the best environment for education and inspiration.

The reason for this – I believe, is that, induction is useful if you are new to the game, haven’t heard the principles of horizontal evacuation a dozen times, or need to learn about moving and handling policies. They are also useful if changing organisation for the first time in many years.

But if you have worked in the same sort of job, and in basically the same sort of organisation, and the lectures don’t contain any new or highly relevant information – they are simply a way of NHS trusts ensuring a minimum of legal duties have been covered with respect to new staff.

occupational health screening

Again, if you are new to the country, or new to healthcare, or have illnesses / problems which require adaptation at work, then seeing occupational health is sensible.

If you have worked within the same rotation, doing the same job, and have nothing new to report, it is a charade, fulfilling an important legal obligation in a fairly mechanical manner.

Other stuff

This is really where changeover impacts – not the big ticket, set-piece things which take hours and need lecture theatres, but the little stuff, which should be sortable – but rarely happens smoothly.

Human Resources – just a struggle always – and that lingering doubt that you won’t get paid, won’t get the right pay, or the discovery that you were never expected.

IT – almost always a delay in getting access to one of the myriad systems in place in every hospital

Clinics – for those senior enough, you will probably be in a full clinic on day 1 or 2 – still green behind the ears, with no idea how to work the system. These will be overbooked.

Firm Timetable – often a vague, nuanced affair with idiosyncratic variations which take a few weeks to ‘get’

Requests – a different system in almost every hospital, takes time to explore and work out what is available / banned / impossible…

And finally, and perhaps most importantly – the goalposts and rules

If I were to boil everything down to just one thing – please can we know where the goalposts are, and the rules of engagement early on.

A big day of lectures is tedious, occupational health tolerable, IT systems infuriating to the point of apoplexy, but the best experiences I have had slotting into new posts has been on the back of a friendly, welcoming chat with the rules of engagement at a local level spelled out clearly. Usually this is best done by an existing junior – and I owe a lot to juniors and seniors who have coached me in the local foibles and pitfalls in the past.

So – my one ‘changeover compeed’?

A reduced clinic – before which there is a clear explanation of the basic procedures / policies which cover 80% of the pathways one is likely to encounter.

I think that the thought processes behind such a move will shine through and speak volumes about a department that values it’s trainees and the quality of care they provide from the off.

Lets set out some house rules.

In days gone by, FY1 doctors were called housemen, house officers, house physicians, house surgeons or similar.

Their training was mostly through a school of hard knocks. They spent unholy numbers of hours tramping the corridors of hospitals up and down the country, lived on site and essentially existed to serve their team and their patients. The deal was quite clear – live in, know everything about your patients and pick a career at some point during that year – or at least divide it into knives, potions, or GP. Further detail would come later during an SHO rotation.

The choice of jobs when leaving medical school was more about geography than subject matter. It was clear that you would spend 6 months doing surgical house jobs, and 6 months doing medical house jobs.

Over the past few years, particularly with recent changes to working hours regulations, career structures and overall philosophy in medical education, this deal is not quite so clear. Indeed, FY docs now have to spend a portion of time in the community (in the first year when not fully registered with the GMC I have always wondered what service commitments are like for these docs) and the choice of job combinations available through FPAS is bewildering.

It is quite possible to go through the majority of the first year out of medical school without being anything except supernumerary.

And therein lies a problem.

The first weeks and months in a house job are a formative experience. This was when, in the words of a brilliant registrar of mine, you learned to ‘love your patients’. You learned that attention to detail, accurate recall of clinical histories, obsessive organisational skills, and a dogged determination to acquire key investigations, opinions, or procedures where what made a difference to the outcomes of the patients, and therefore your team. In those first few weeks, late nights, self doubt, early morning wakening, and late night calls to wards to check on results and requests were the norm.

Today there can be a very different experience for some of our junior colleagues. Some are placed in jobs where they are little more than observers, an appendage to the team, rather than the tightly coiled spring turning the inner cogs of the medical machine.

What does this do for their formation into the medical workforce of the future? What impact does it have on their feelings of self-reliance, of knowing they have made vital contributions to the care of patients?

I’m not sure what the long term outcomes are, but recent experiences make me feel that there has been at least one detrimental effect.

Previously the rules of engagement were clear – you were the houseman, you fetched notes, maintained lists, knew or had to hand the bloods etc. it didn’t really matter which firm you were on, those were the rules.

With FY1 jobs in critical care, GP, and other ‘non-traditional’ house officer specialties, the role of the junior is less clear, and boundaries of knowledge and competence are more blurred.

Given that in the medical world knowledge about fancy subjects like critical care can afford a veneer of competence – this sometimes offers false confidence to trainees ( see here for some theory) and their position in other more traditional firms is less clear.

So – with the senior doctors of today ( I can’t claim to be senior, but was one of the last cohort to go through traditional house jobs) all having trained in the old model, it is understandable why they might assume the old house rules apply.

On the flip side, with new trainees not going through the same formative experiences as their seniors, it is entirely understandable why the unwritten rules are not immediately apparent to them.

This corrupted hidden compact between seniors and juniors is one reason why there is sometimes a disconnect between expectation and delivery of duties on the wards.

To point fingers, blame, shout and generally be exasperated is not the answer.

I would suggest that departmental inductions firstly need to happen, and secondly need to include a bit of explicit contracting – setting out of the house rules of engagement. And in the deal should be something of benefit to both sides – including a bit of mentoring / coaching, honest mutual feedback and real training.

A meandering wander, or a hard climb?

Bad news is never welcome.

Bad news about one’s family is even less welcome.

When patients come to hospital, there is usually a very good reason. That might be a short, acute illness which requires a short stay, it may be a prolonged series of unfortunate events, which render a loved one devoid of that vitality that once defined them.

When it comes to chronic conditions – in particular those where there are few treatment options which affect mortality – be that COPD, dementia, certain cancers, heart failure (to name but a few) there is a variation in the trajectory which each patient takes, but the general direction of travel is often quite obvious to those looking in from the outside – and indeed, has been mapped out for a number of them – this is an example from NHS Lothian:

Illness trajectories – from NHS Lothian Website

One problem which I experience all too often is that the view from the ‘inside’ of some cases is very different indeed.

It is not unusual for me to meet patients who are struggling with their daily care needs, and have recruited family and friends to help with daily tasks which most healthy people don’t give a second thought to; walking to the toilet, having a shower, getting into or out if bed.

The human race is great at adaptation – it’s one of the reasons we have taken over our globe so completely. Individuals are great at adaptation too.

Adaptation and compensation for deteriorating health is great, but can become a charade, a way of covering up a slow decline into dependence.

And here is the problem, people often cope so well with their failing health, that to point out the trajectory can come as a shock, and as with all major revelations, patients can experience the full range of the Kubler-Ross grief reaction: (put in picture)

Kubler Ross Grief Cycle from

However, if, as doctors, we go along with the impression that all is ok, we can end up colluding with patients in a fantasy that all is well, and there is no need to worry.

In chronic conditions that lead to death, is this collusion actually good medicine? To expose a patient to the full, often stark, reality, of their condition in an explicit way could do significant harm, and precipitate worsening meta-problems such as anxiety or depression, and their coping could worsen, but equally, I hate the way that many end of life conversations seem to fly in the face of years of ‘its alright, we’ll keep you safe’ type conversations, and rather than a slow unveiling of the terminal phase of an illness, feel more like a push off a cliff into the void.

I don’t want all of my patients with chronic conditions to buckle under the weight of their diagnosis, and equally don’t want them all labouring under a false impression of invincibility – or an unrealistic expectation of durability (the futile encouragement from relatives that an elderly relative will ‘fight’ a metastatic disease, or multi-organ failure is tragic to witness).

I would, however like to be free to have more honest conversations at the right time, in the right way for each patient.

The problem seems to be multifactorial, but a culture of giving hope where perhaps there should be gentle revealing of reality is one if the key barriers. Death and illness seem to be failures in our clean, tidy, forever young western world. However, brutal honesty is not always helpful, and patronising collusion seldom is.

The right balance is different for each patient, but societally I think we need to start to reconnect with the frailty of the human frame, and not believe the hype about living forever in perfect health.

Lest we forget: life is a sexually transmitted disease with a 100% mortality rate…

Every day is a school day

Doctors have a strange sort of a career path.

There are few other industries where professionals who have passed long degrees, taken postgraduate exams, been working in their chosen field for up to 10 years, developed expertise, possibly gained PhDs and are still routinely referred to as ‘junior’

We work long hours (albeit reduced over the past few years by European legislation) and see hundreds, if not, thousands of patients in the time it takes to become a senior doctor.

These long hours have long been held up as an essential part of the training of a doctor – and hark back to the apprentice model of medical education which is where medical training has its roots.  In this model, by working alongside a master, one gains experience, tries out new techniques under supervision, and slowly becomes skilled enough to be considered an independent practitioner.

This model has been eroded somewhat in recent times by the move towards a competency based approach to curricula whereby one progresses, not through a slow acquisition of skills, but seemingly by hopping through the right hoops at the right time and getting the right box ticked on a bewildering number of forms  – all of which purport to confer – confirm – or convey competence in the procedure or process onto the trainee being appraised or assessed.

This competency based approach is lamented by those who feel that it has reduced medical education to a simple process of tick-boxes and has missed the essence of the apprenticeship model of learning.

But what is it that has changed?

I don’t think that juniors spend significantly less time being supervised any more – indeed the more senior members of the medical team are far more visible nowadays than they ever were in the past.  As I have progressed up the grades, it has become the norm to have registrars on-site, clerking patients, and twice daily Consultant ward rounds, even on the weekends.  So supervision has not necessarily gone – so why is the apprentice model no longer working?

I think that part of it is the acceptance by trainees that training can never be mixed with service, and that one cannot learn when doing a ‘menial task’ such as re-siting a cannula, or re-writing a drug chart on an on-call shift.

Indeed, this idea that learning can only take place in the lecture theatre, or when time has been set aside, or one is told “now here is an opportunity to learn” is, in my view, one of the most disabling attitudes, which prevents the aqcuisition of experience, dumbs down the privilege of providing a service to patients in need, and encourages trainees to resent time spent learning the trade which they are likely to follow for the rest of their lives.

In a discussion the other day I highlighted that I take the view that every day is a school day.  One should never go home without learning something.

This view has been backed up by the observations of a cohort of NHS graduate scheme participants who recently shadowed junior doctors.  Almost universally they were struck by the fact that junior doctors are being actively trained the whole time.  And when one takes a moment to think about it – every chance conversation about a clinical problem, every x-ray meeting, every checking of an idea with a senior is a moment of training.  That conversation may take place in the course of everyday service, but the information is gold-dust.

We have access to the experience, mistakes, triumphs, and disasters of our seniors, and if we only open our ears, we can take advantage of all of that.

Today was an example – a patient in clinic is proving to be a diagnostic challenge – are we to do this, do that, do nothing, or something else?  A brief conversation with my consultant, and I am now researching the cost to the NHS of medically unexplained breathlessness, and how this can be addressed, using a combination of medical reasoning, judicious use of ‘tests’, coaching techniques, and communication skills.

So – if you feel that you are stuck in a dead-end service job, that you learn nothing on a daily basis, and are longing for a conference where  you can return to the comfort of a didactic lecture – I think you might be missing out on a world of learning and knowledge every day.

Keep your eyes and ears open, and I am convinced that you will find that every day is a school day.

The Devil is in the detail

Recently I have had the unfortunate experience of having to take a member of my family to hospital – have them admitted, and stay there for about a week.

Luckily the system worked brilliantly at the front door and the treatment required was started promptly and appropriately, quite possibly preventing serious harm.

What followed after was a a mixed bag.  Some staff were excellent – going out of their way to explain what was going on, how things were progressing from their point of view, and allowing me to present my own ideas (along with those of friends with a specialist interest in the field) as to how things should be managed.  Others were less impressive – but probably for understandable reasons.  It was of interest to note that the more senior the doctors became – the harder it seemed for them to meet us at our level and have an equal conversation – resulting in some dissonance (Eric Berne has some answers for why this might have happened)

Doctors are a terrible bunch to have as patients – especially doctors with friends who can give advice with partial information, and thereby stick a spanner in the works for those in the team actually responsible for their care.

On reflection though – the difficulties did not come as a result of gross deficiencies in care, but in the details – single words here and there which made all the difference.  As you can imagine, parents of sick children pay attention to what doctors say.  If they have any kind of inkling as to what the doctors are saying implies then their hearing will be all that more acute.

Some of the disappointments during our stay came as a result of minor details – and I am sure that it was because we, as parents of the patient, were paying more attention to each and every word that was being said than perhaps the doctors were.

Other problems came later when we discovered that some things which had been told to us were simply untrue or inaccurate. This was especially hurtful – again, they did not amount to any negligence or deficiency in care – but they did waste time, effort and tears.

Having transferred to a different centre (for geographical practicality more than anything else) we were met by a team which seemed to work that little bit better.  Was this because hierarchies were obviously flatter – and communication between the senior staff and junior workers was more free? or simply that the confusion which exists at handover periods in the acute phase of an admission wasn’t present?

However, the details which made the difference continued – one team member very deftly avoided explaining the brutal truth of a possible course of treatment (one that was not necessary in the end) – and we are especially grateful for not having to confront that possiblility which ultimately never came to pass.

Well, whatever the reasons – we will continue to have mixed feelings about the first hospital, and have a better impression of the second – but for my own practice, I have now some experience on which to draw when dealing with my own patients – be they medics, nurses, plumbers or forestry workers (anyone really.)

And the lesson I have taken is that truly effective communication is a huge factor in the experience any patient has when receiving care – particularly as an inpatient.

And that communication must be consistent, accurate, and honest.

If not, you will lose the trust your patients have in you, and that can really damage the teamwork that is required between doctor and patient to tackle the mutual challenge of dealing with an illness and treating it effectively.