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.