Seek first to understand, not be understood.

An argument is an emergency of self definition

In my day to day life I have the pleasure to meet a large number of people from all walks of life, and play a part in helping them through sometimes very difficult times in their lives.  This is the privilege and responsibility of being a doctor.  Usually people are very willing to enter into discussions about how they are feeling, what their symptoms are, how treatment has been going, and then listen when I go on to explain what I think is going on, and make a plan for further investigations or treatment.

More recently I have had some conversations with people that did not follow the usual, fairly polite, and respectful pattern.  In one case, the patient did not appear to want to enter into any form of discussion at all about what symptoms or problems may have brought him to the clinic.

Thinking back to the consultation, it was clear that the usual power dynamic had changed significantly – and, although I was aware of it at the time, it seemed that I should try to get the consultation back to the usual footing – as that is how we operate in medicine.  This resulted in a fairly frank exchange, and both parties undoubtedly did not perform at their best.  However, the plan we arrived at was appropriate for the condition being considered and although the consultation was not terribly satisfactory – it ended up being effective.

Now, why did this small-scale conflict arise?  There were undoubtedly faults in the system that led to communication errors in written information.  But when I really look back at what was going on at that moment – I can see a couple of things.

#1 The patient was really upset at the medical profession as a whole owing to limitations placed on him by medical examinations, which he did not believe were justified.  He had most probably lost out on a significant amount of income, and was therefore not pre-disposed to cooperate with the medical establishment.

#2 I was unconsciously unhappy that the power dynamic had shifted away from me in the consultation – and I therefore tried to re-assert my authority when questioned again and again about each detail of my plan.

So, what will I learn from this experience?

First, that a saying I learned recently and have tried to practice will require more work – namely – “Seek first to understand, rather than to be understood”  By examining more closely the reasons why this patient was unhappy, I could actually identify the likely reasons for the conflict, and in accepting that these were of great importance for the patient, include them in my appraisal of the situation, and allow the patient time and space to express this frustration, and then move on to the other needs the patient had from that consultation

Secondly, to recall that ‘arguments are emergencies of self-definition’ and act accordingly.  I read this phrase recently in a short story (Aftermath – Rachel Cusk), and was struck by it as representing a simple truth.  In this consultation, the ‘argument’ arose because the patient wished to express their feelings or displeasure at previous experiences, irrespective of my lack of role in them, and I wished to assert my position as that of the doctor, and inherently therefore deserving of respect and deference in the consultation.

In the future I need to recognise that there are times when what a patient needs from a consultation may not be entirely relevant to what I think they are there for.  Trying to force the issue down another road is not likely to leave either party satisfied. It is far better to be alert to this possibility and deal with what is most important for the patient – and place my needs slightly lower down the scale until the patient will be in a better frame of mind to work together on the issue I am seeing them for.  Ultimately I would like to get to the position where every one of my clinic appointments is run along the principles of shared decision making – but that is a work in progress.

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Stairway to…

 

Medical education is an interesting topic – and almost everyone in the profession has an opinion on it.

If you believe one of the most recent papers looking at the subject – or, in fact, the media coverage (Telegraph and Daily Mail) of the paper, all junior doctors are unprepared ( and more to the point – feel unprepared) for their role on the frontline of medicine, looking after acutely unwell patients.

There are a number of responses from medical bodies which do well to illustrate their current gripes – with the RCS blaming the EWTD, and others raising the emphasis put on communication skills and not hard medical pracitce as a reason for this unpreparedness.

So, as a medical registrar, do I believe that juniors nowadays are somehow less well prepared to cope with acutely ill patients as when I emerged from the medical school?  Well, no, probably not.  I don’t think that I was miles ahead of the current cohort when I joined the ranks of junior doctors, but I do believe that I probably had to rely on myself a little more as I made my way through my early jobs.  These days juniors tend to be better supported, and have help nearer to hand than “when I was a lad”

And is this a bad thing?  I am not convinced that having the most junior members of a workforce, who are often the ones who first have to detect when patients are acutely unwell, being able to ask for help more readily is a bad thing – in fact, it is probably a good thing for patients.  The unintended consequence may be that the junior staff are less self reliant, and may cope less well at the next jump up the ladder of medical training.

Which brings me to my next thought – the step-wise progression in medical training.

Some people view te ideal medical training as a smooth progression through grades, with a constant acquisition of competencies as one progresses. There are even phrases like “the spiral curriculum” to highlight how this should be a slick process, rather than a bumpy ride.

The reality is very different.  It is more like a staircase, with huge steps up a learning curve at every transition.  The doctor in training who advances up this ladder is confronted with a sudden change in role – often stepping into the shoes of someone many years their senior, and being expected to fill the gap left behind.  This is a very stressful time for people going through the system, and can lead to huge anxiety at changeover time – leading to underperformance.

This has been noticed by our regulator – but solutions are not exactly pouring out of the sky. (The First 5 scheme from the RCGP recognises this issue in the GP world)

And my solution? – it is about self awareness, and awareness of the needs of the team.  At present, it feels like I am a very good SHO (ST1-2 in new money) when I was an SHO I felt like I was being a very good House Officer (FY1) – I have always felt like I am achieving comfortably the standards required of the grade I have most recently been through.

As I get nearer and nearer to a consultant role, I hope that those training me – my clinical and educational supervisors, will be able to recognise that I need to start making the transition to a consultant role not on the day I move to a new job, but starting now – a couple of years out.  Often the culture of the workplace keeps you in a grade – and unable to act beyond it (the variety of standard of members of a particular grade make the judging of this very difficult for clinical supervisors I know)

However – it is too easy to blame the culture of the places where I work, the people supervising me, and ‘the system’ for keeping me down, or holding me back – I think that I, and all the trainees taking this staircase to a career in medicine, need to get slightly more real about how we are going to progress.

We need to shake ourselves out of the habit of fulfilling the minimum required to get to the next step, and start to act up where safe and possible, and learn from those above us, or more experienced than us, to enable us to start practising the skills they need every day – be that interacting with other colleagues, managing certain medical decisions, or unerstanding how to manage patients through juniors rather than doing it ourselves.

It is only when doctors in training notice at half way through their current grade that in the near future they are going to be taking more responsibility soon, and proactively start to behave in a manner appropriate for that step up, that we will start to smoothe out the jumps in the training ladder, and reduce this perceived unpreparedness.

That said, one can never fully prepare for the unknown – but forewarned is forearmed – I fully intend to enter the consultant grade with my eyes open, and not sleepwalk into another learning curve which feels more like Everest than the smooth or spiral transition that some educators believe it should be.

Failure – it is the only option

At a recent conference, a poster was published in abstract form showing a negative result.

This was not a ground-breaking moment which will be held up in years to come as an example of how to advance scientific progress, or, indeed as a shining example of a service re-organisation which led to widescale sustainable change across the UK.

As it turned out, when it came to the time for the authors to describe and expand on their work, they didn’t turn up.  There was no representative of the team to explain what they had tried to achieve with the scheme, what factors had made it less successful than they had hoped, and how they might approach it again, if they really did feel it was still a good idea.

I think it is a real shame that, having submitted an abstract, the authors were unable to attend, or send a representative.

What was a greater shame was the way in which the paper was described by the chair of the meeting.  I can’t remember the exact words, but they went along the lines of:

“Well here is another one of those pie in the sky schemes, which someone spends a whole load of money on and then it folds within a year – like so many of us have been involved in”

This was greeted by a ripple of knowing chuckles in the room.

Fair enough – the idea fell flat, it cost money, and didn’t really produce any improvments.

BUT

And that is a big but; there is in that statement, an subsequent laughter a failure more significant than that highlighted in the study.

It is the failure of the medical profession to tolerate less than perfect resuts, it is the reinforcing of a professional culture where teams are not allowed to help the world out by sharing lessons of a plan gone wrong, it is the failure of our wider culture to understand that one cannot propose the perfect answer first time, and it is the collective failure of the people in that room – me included – to say “hang on – lets look at this another way”

Instead of the statement above – why not:

“Well here is a record of an innovative scheme which sadly wasn’t successful, and highlights how even a well-resourced, committed group can discover that some ideas won’t make a huge difference – it would be great if the team could let us all know what they came up against so that we don’t all have to go through the same challenges and problems that they did.

Failure is the only option.  This talk by Tim Harford highlights the importance of failing as a route to ultimate success.

or view it here

Moreover, this editorial highlights that iterative change is what is required to advance the frontiers of the practice of medicine – and advocates the use of the SQUIRE guidelines to really explore what went right and wrong in studies – particularly those looking at changes in practice, or service innovations.  There are simpler versions of tools to write projects up too – like the one on The Network

So – I would encourage you when next looking at an attempt to improve a service or change practice which ‘failed’ not to dismiss it as another one to chalk up to experience, but instead as a rich opportunity to learn why the people involved came up against problems.  If as a profession we will only accept the finished article, and learn nothing of how the changes occur, we are doomed to repeat the failures of the past.

I applaud the authors of the poster for having the guts to publish the news that not all ideas work, but would have been bowled over if that committment went as far as explaining it to others working in the same field.

Uncertainty – and the NHS reforms

This is a blog I originally posted in June on The Network, but I thought that it was still relevant, so I would post it here too…

What are the three most significant words a doctor can use? When it comes to three word phrases, there are a few which stand out. Classics include “I love you” “I am Spartacus!” and “Run, Forrest, Run!”

There are seldom reasonable times or places in medicine to utilise these particular phrases, but there is another which is possibly under-utlised at all levels of the medical profession. “I don’t know”

When we enter medical school, we enter a new world and a new way of thinking. Over time we are moulded to a greater or lesser extent into a recognisable form of doctor. In the first few years this is the classical junior doctor – pale chinos, blue shirt, looking tired, bleep going off constantly, always slightly harassed. We move on, and acquire the trappings of authority – suit, real leather shoes, Mont-Blanc pen, more letters after the name. But one thing remains constant. We are expected to hold the answers. When seeing a patient for the first time as an FY1, we are often asked on the post-take round – “…and what’s the diagnosis?” As a registrar in clinic – “so what is it Doc?” As the consultant in the Grand Round / M+M meeting – “So, Dr/Mr …. What would you have done?” The whole of medical science it sometimes seems is about obtaining that final, all encompassing diagnosis of which Occam himself would have been proud.

However, as we know for ourselves, and have seen on the larger scale recently – we do not always know the answer. What then, are we supposed to do?

I would argue that we should not collude with the questioner, we should not give false reassurances, or misleading hope, but instead admit our uncertainty, and then set out a vision of how we are going to go about tackling the problem at hand, keeping to a guiding set of principles.
This is what we are facing at the moment in the NHS – a period of unequalled change, and challenge at a time when the economy is fragile, and there are perceived threats to the very fabric of the NHS.

In this context, it is only right to admit that we don’t hold all of the answers, but we are going to work very hard to understand where we are, and adhering to some fundamental principles, work our way towards a solution. Thinking about this, I am reminded of Shackleton, and his words after he lost ‘Endurance’:

“But although we have been compelled to abandon the ship,… we are alive and well and we have stores and equipment for the task ahead of us. The task is to reach land with all the members of the Expedition.”

As we navigate the health reforms, and continue to provide services to patients, we need to be aware that sometimes the most useful answer is “I don’t know… but” and that ‘but’ must include the principles of patient-centred, fair, effective and safe care. For if we keep those principles in mind, at every level of this fantastic organisation, we are more likely to succeed than if shaky answers are given, and false hopes raised.

Ask – and you will receive

Doctors work in a fairly hierarchical profession.  There are grades, lots of letters before and after names – all of which mean things to those in the know (even Mr means something special to those in healthcare in the UK)

Your rank in the NHS means a lot – and means that you get treated differenty from your colleagues, especially when asking a favour, or making a request or referral.

A couple of instances recently have made me think about how I use my seniority in the medical hierarchy, and how this can lead to adverse unintended consequences.

The first thing which made me stop and think was a conversation I caught a snippet of in the mess.  It was between two new house officers (most junior grade of doctors – just out of  Med School)

“I didn’t know why I needed the scan, so he said no, I couldn’t have it urgently, and I had to go back – and my registrar shouted at me, and told me just to go and get the scan – today!  Next time I think I’ll just make something up to get it done.”

I have also noticed that in meetings about discharge dates and plans, if the chair of the meeting is really keen for answers, and won’t move on until a discharge date is set – the junior staff start to offer anything as an answer – just to get the focus off them.

These examples show how the pressure felt by junior staff to be seen to be up to the job – able to get the scan, or able to predict discharge dates – can lead to misinformation, and where the care or safety of a patient depends on the answers given, can lead to harm.

The basic problem, as far as I can see, is twofold.  On the one hand – the questioner wishes to have a quick, accurate answer.  The other is that it is assumed that the most junior and least experienced members of a team are going to be aware of, and hold all of the information which more senior, experienced colleagues think is important, and be able to convey that in high-intensity interactions, which hold great significance for them – for if they fail to come up with the goods, they perceive that their reputation will be tarnished.

Sadly, and predictably the way out of this is to make stuff up – ask someone something enough times, or place such importance on simply having any answer – then you will ultimately get an answer, even if it is nonesense.

There are some good things about hierarchies in the training of doctors, and I am sure that no-one would disagree with the idea of a progression of responsibility as one climbs the slippery ladder of medical training, but if they are so steep sided as to make it easier to blag one’s way through day to day life, rather than do the job properly – something has gone wrong.

As I continue to move along the path to a consultant job (if such a thing exists when I get there) I hope that I will be able to achieve a balance between maintaining high standards in my own, and my teams practice, without stepping into the territory where my team will simply mislead me to ensure a smooth ride.

If I ever get to hear that people have simply lied to me to avoid saying ‘I don’t know” then I will have failed.

If that has already happened – please get in touch (ideally privately) – I need to know when and how I let that happen – only through hearing about our failings will we ever be able to address them. ( see The Johari Window for more on this)