Networking in Medicine – an essential clinical skill

Networking has some nasty connotations – and often conjures up the image of a smarmy second hand car salesman, or slippery politician ‘working a room.’

But is networking as a doctor so bad?

Junior doctors have a  number of roles.

They meet patients in their hour of greatest need, perform invasive procedures, make life and death decisions, analyse each others performance in audit, take part in research, prescribe medications, request investigations, discharge patients from hospital, explain procedures, explain illnesses progress to patients and relatives, and work in huge organisations – all whilst learning how to become more senior in their chosen profession and advance their careers.

In a typical day at work, junior doctors will be in touch with a number of different departments, and teams – predominantly to make requests – ask something of someone else and get that result yesterday.  This is hard work.

To keep a good working relationship with a wide range of fellow professionals, when all you seem to do is demand things of them takes not just communication skills, but a good understanding of how to network, foster mutually beneficial relationships, negotiate, comprimise, and understand power structures outside of the normal beauracratic hierarchies we work in.

The best juniors tend to know that Steve in ultrasound will be able to help out on a Friday afternoon with that urgent scan, that Marian, the Sister on ward X is great at putting in cannulas, and will probably know that Steve is a keen cyclist, and Marian loves to go line dancing at the weekend.

In fact, to get on in medicine it is almost essential that doctors can network.  Indeed, the power of networks is being recognised more and more – and this recent article from the Harvard Business Review highlights the power that Networks can bring over the more limited scope of smaller teams.

I guess what I want to point out is that networking is an essential clinical skill.

As I see it, networking in hospital is not about making the next sale (although this paper on Selling Patients might give lie to that sentiment) or brown-nosing your way to the top.  It is more about maintaining relationships which are beneficial to patients in times of need.

On a larger scale, networking is important for the dissemination of ideas, exchange of opinions and for widening ones horizons – so make use of the tools which are out there – Twitter is a personal favourite of mine – and so is The Network ( a particularly fine place to start if you are interested in improving the care of patients in the NHS before you are a fully-grown healthcare professional)

Institutional Memory

Junior doctors are great at seeing problems, but often struggle with implementing solutions.

They move jobs every few months, and see new problems, inefficiencies, and defects in systems – and either quietly get on and reform things, or, if the problems are out of their power or scope to change, make suggestions, and then, before they can get up momentum – move on.

The peripatetic nature of our junior medical workforce is one of the major reasons why juniors sometimes seem to be seen as a problem to be dealt with, rather than valuable members of a highly qualified workforce.

Institutional memory is something which is built up over time, and is often held within the memories of the longer-standing members of the workforce, rather than written down and archived for future reference.  When key members of staff move on, or retire – that valuable resource is often lost.

In the case of junior doctors, it is more the handy hints which a shadowing period can help to transfer to the new crew which get lost in the transition – who to ask for for an urgent ultrasound, which secretary is best at passing messages to the boss when he is on study leave, which ward is most likely to look after certain types of patient better than others.

At a recent learning event, we had a discussion about how to combat this loss of ‘institutional memory’ within the junior doctor grades.

I’m not entirely convinced of the full answer – but for a start, wouldn’t it be great if those juniors who are due to move on after only a few weeks could write down their observations, maybe even with a little bit of data – and then next bunch could pick them up – analyse the problems, and implement the solutions.

A team file of ideas, trials of solutions and successful innovations could hold the history of improvement efforts of the team – and who knows – that part of the organisation may truly become a ‘learning team’

So – before I leave my current post – it seems I have just given myself a task – to record the handy hints and attempted improvements which were made throughout my year there, and I’ll pass it on to whoever comes next.  Hopefully they will see through some of my ideas and develop them to improve things further – and if they pass the baton on, who knows, in time things might just improve.

 

Life after death

There is life after death.

Now, I know that sounds like a very rash statement, and one which has kept philosophers, scholars, sceptics, clerics and a fair few others busy for some few millennia.

However, as doctors, and healthcare professionals, we often seem to forget that there truly is life going on after death, or, perhaps more accurately, we get very easily distracted into concentrating on the life that has just come to occupy our attentions rather more than the one which has just ended within our sphere of influence.

Now, that may be entirely right and proper, modern medicine tends to have more to offer the living than the dead, but I there is an opportunity to practice medicine which all too often passes us by. It is not a cutting edge therapy, a new model of care or anything special, but it does take time, and effort.

On a couple of occasions recently I have encountered this life after death, and the outcomes of those meetings have changed the way I look at where our duty as physicians ends.

The two patients who have promoted this thinking passed away under the care of my team, and instead of the usual scurrying off of the house officer to fill in the death certificate +/- cremation form, we made appointments to meet with the relatives of the deceased as they came to collect the paperwork.

The discussions, questions and conversations which these meetings involved were, I hope useful for the relatives of the deceased, and certainly seemed to play a role in clearing up any misunderstandings, and allowed a chance to discuss events with less urgency than when their loved one remained alive but very ill.

I think the main thing these experiences bought home for me was the feeling that it is possible to continue to serve, care and help the healing process, even after death.

So when I say that there is life after death, I mean that we should remember those left behind by a death, and remember that we have some duty of care to them to.

I know that meeting with relatives after every death is unlikely to be practical, and that my colleagues in primary are probably better placed to help pick up the pieces than me, but I’ll do my utmost to be available, open and honest, and that way I hope to be able to assist a healing process, where clearly I wasn’t able to effect a cure for another.

Value and Carbon

 

Value is a concept which is making waves in the management / leadership / policy world of medicine at the moment.  It is not an entirely new concept, but has been worked on and promoted as an approach to the management of healthcare which will unite providers, commissioners, and payers in healthcare economies across the globe.

Michael E Porter has been looking at this area for some time, and has defined value as:

outcomes / $ spent

This deceptively simple equation helpfully focuses the mind on the numerator of outcomes – specifically those important to the patient – and cannot only be improved only by cutting at the denominator.

A recent seminar at City Hall in London (see here for slides from the talks) explored this idea further, highlighting to a number of prominent leaders from the world of medicine how this concept of value unites different actors in the system around the thing which matters – outcomes for patients.

Porter gave six steps in a strategy to realign objectives along the value agenda:

1.  Organise into Integrated Practice Units around patient medical conditions

2. Measure outcomes and cost for every patient

3. Reimburse through bundled prices for care cycles

4. Integrate care across separate facilities

5. Expand areas of excellence across geography

6. Build an enabling Information Technology platform

Of these 6 steps – one of the most complex is probably the costing of care.  This is not simply the tariff, or the invoiced cost,  but the true costs of each care cycle (this may be a short emergency admission, or a year of chronic condition care – depending on how the care is bundled up)

One cost of healthcare which at present is often hidden away, and not really counted in business cases, service proposals etc is the carbon cost of care.  Carbon useage has been estimated for the whole of the NHS (with updates regularly – here is the 2012 update– one of the first healthcare systems in the world to take this important step to understanging the impact of care on the environment.   It is not so simple to find out what the carbon costs of individual episodes or cycles of care – or what the solutions might be.

Understanding this aspect of care cycles is going to be increasingly important with the introduction of league tables of carbon useage (find your organisation on the current table here)  and with the UK having legally binding targets for reducing carbon consumption ( we  have a target to reduce CO2 emissions by 80% from 1990 levels by 2050 – and in the meantime need to get down to 34% of 1990 levels by 2020 – not that far away)

Simple efficiencies are not likely to make huge differences to the overall footprint – but re-examining the way we ‘do’ medicine could – building use makes up 19% of the current footprint, whilst procurement still makes up 65% – and pharmaceuticals making up the lions shar of this.  Frances Mortimer explored this in an opinion piece published in 2010 – and there remains considerable doubt about what could be done.

Respiratory disease is a major burden to the NHS (pdf), and the UK economy – £6.6 billion pounds spent on it in 2006, and around 1 in 5 people dying of respiratory disease (more than ischaemic heart disease for example)  The chronic nature of many respiratory diseases, characterised by periods of stability, punctuated by dramatic episodes of illness make it a complex care model to decipher.  However, the fact that respiratory disease – and in particular COPD can be both prevented, and ameliorated by non-pharmacological means, improved self-managment and better organised care make this area one of huge importance if we are to understand and control the carbon costs of the NHS.

I am pleased to be working with the Centre for Sustainable Healthcare on a project to determine what the carbon costs of different care models are for COPD, and use this to help focus the minds of commissioners when it comes to defining high value treatments and strategies for addressing respiratory disease.

It would be great to have your opinions and ideas about how respiratory care could be made more efficient, or if you think that counting carbon could help to discriminate between care models, and help us to improve not only the quality of respiratory care in the UK, but also enhance the value we can offer patients through smart commissioning.

Please visit the Centre for Sustainable Healthcare and sign up to the networks they have there to get the latest news and resources to inform your practice, and see how you can help to improve the services we offer – in terms of value, quality and carbon.