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.

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It has to be… perfect

360 degree appraisals are often held up to be one of the most useful tools when seeking and obtaining feedback to inform personal development, and the appraisal process.

Their strength lies in them being a forum where peers, direct reports (juniors), members of the wider team, secretarial staff and other clinicians get to highlight not the clinical knowledge, but the day to day working of an individual.

These forms are usually anonymous, collated by a third party and then discussed with an educational supervisor who reveals some or all of the comments received.

As I understand it, 360s allow individuals to appreciate their impact on others, how they influence and work in a team, and provide a substrate to enhance reflection, and from there, personal development.

In true edu-babble speak, 360s help to “open your Johari window.”

Over the last few years I have heard several stories of people who have been pulled up in ARCP and RITA interviews for marginally negative comments in the free text of the 360s. Some have even been told that to have a less than perfect record on the 360 exercise is a threat to future employment.

I have a few difficulties accepting that this is the right approach to helping people develop.

Firstly, trainees are people, they are human and have human attributes. The people they work with are also humans and where there are lots of personalities, ambitions, emotions and stress, people will occasionally have differences of opinion and disagree with each other. To expect that trainees will go through life as perfect automatons with little in the way of character which will challenge those they work with is, I feel to be exceedingly naive. When I look at the people who I have worked with who are successful, are pushing boundaries, innovating and progressing medical science, I don’t see timid individuals who will simply get on with people for an easy life; I see ambitious, driven individuals who are not afraid of ruffling a few feathers to ensure that they get the resources they need, the access to services, or the time of others. Medical science would not be what it is today without the innovators and positive deviants. As Aristotle said: to avoid criticism,  say nothing, do nothing – be nothing.

Secondly, the idea that the 360 exercises should all be perfect is to deny the trainees the opportunity to explore how they affect those around them, their impact on other team members, and how they appear to the outside world. Instead of being a tool for revealing attributes which might require consideration, reflection and development, the tool becomes one which reinforces the status quo and fails to fulfil its intended role. Instead of being a tool for revealing aspects of ones personality and behaviour, it becomes a whitewash, masquerading as a genuine assessment, but in truth being only a paper exercise.  ( and to keep on with the greek quotes – Socrates pointed out that “The unexamined life is not worth living”)

In addition, the feedback given is often in a poor format. There are usually general statements, covering a broad sweep of behaviours and impresions, rather than being issue-specific.  Worse still, feedback can focus on who the person is, rather than the actions they have taken.  Feedback should try to concentrate on actual events, not inference and speculation.  The general comments often offered are not always helpful for a trainee to think about.  More helpful, and a better substrate for examining ones behaviour, are examples of specific situations where a behaviour has influenced others – either for better or for worse. Even better if the impact of the behaviour can be explained.  eg. when X said this after it happened, it made me feel Y, because of Z.  (This article and this pdf have some interesting ideas and principles for good feedback)

So – next time you are filling out a 360 form, be honest, but give real feedback that will help  the person receiving it – preferably with a specific example of when a behaviour resulted in a particular outcome.

If you are giving out the forms – be bold, discover something about yourself and don’t just ask your mates to be “nice” to you.

Finally, if you are reviewing the 360 appraisal of a trainee, please don’t tell them it must be perfect – it is unrealistic, unreasonable, and results in a charade which helps no-one.

It’s how you tell ’em

I recently heard two stories which made me think again about communication skills.

In each case, the information delivered to the patient (in both cases friends of mine) was entirely correct.  The problem was not in the decision making, the outcome, the skill, accuracy or dedication of the professional discussing their case, but in the way it was discussed.

In one, a friend who had been seeing a specialist for really very regular follow up saw a new doctor.  The new doctor had read the notes, seen the progress, and – it felt to my friend – made a decision on how the consultation was going to go, and ended up discharging him.  This was all despite having never met the patient, not heard the background, having no idea of the context of the illness – but the numbers looked good, the progress was clear and therefore the decision was an easy one.

The second was a friend who, on remarking how lucky they had been was told in no incertain terms that acutally they weren’t lucky that the illness had not had such severe effects on them, but really that they had been lucky this particular doctor had been around to help them – as it was really their intervention which turned a dire situation into one which has become far more stable and manageable.  Again, this may well be true, but the experience left the friend feeling somewhat bruised by the encounter – especially as all of the previous consultations had been painted in a positive light, and that the disease was always manageable.

So what am I to learn from these?

Well, firstly that context matters – whenever you are going to deliver information to someone – especially when that someone is vulnerable, then tact is still required to determine what level of knowledge is appropriate, and how explicit it is possible to be without overloading someone.  This may sound paternalistic, but part of communicating a message is making it understandable.  All at once is fine for some people, but with many, realisation and recognition of a serious illness or problem is a stepwise process.

The other thing is that communication skills matter.  Paying attention to the participants in a consultation – appreciating where they are coming from, and what experiences they have been having are hugely important.  As we move more and more to efficient models of care, we have to ensure that we, as doctors, and other heatlhcare professionals do not allow ourselves to be caught up entirely in the “production line” and that we retain the important one-on-one relationships that are so important in medicine.

Both of my friends were really quite happy with their care – and the decisions about them and the information they received were absolutely correct.  The problem lay in how they were told – without real care or compassion.

Your decision might be the correct one, the outcome may have been perfect, but patients are humans, not statistics – and humans have feelings – we sometimes need to remember to tread lightly, no matter how bad a day we are having.

 

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)

Clinical experience is paid for by patients

Misdiagnosis has been described as “the greatest threat to patient safety in the UK” and at a recent acute medicine conference was highlighted again as one of the major threats to patient safety which hasn’t yet been the central target of a big safety campaign.

Missing a diagnosis is relatively easy; the information we gain from patients of often through the lens of an individual who is frightened, delerious, or on occasion completely unconscious. The story very often changes overnight- a classic trap for a junior doctor (this song (lyrics) (iTunes) (YouTube) by The Amateur Transplants helps explain what a frustration that can be.)  The problem with the crime of procrustes is that we frame the information available to us in such a way that it supports our position, rather than using it to test our hypotheses and whittle down our differential to a definitive (or at least confident) diagnosis.

So how do we combat this, and in a system which is trying hard to make attendance at hospital ever more efficient and less time consuming?

In the ‘good old days’ there was three-layer clerking where the houseman would take the history, the senior houseman repeat it, and finally the registrar review it before the final, glorious history (now practised, refined and distilled into a thing of wonder) was presented to the consultant.

Nowadays there is less of this time consuming repetition taking place, and decisions are made more swiftly, on incomplete, less accurate information, and management plans enacted accordingly.

This has advantages and disadvantages.

The patient often has a, quicker path through the system, gets treated quicker, and one would hope, gets better sooner.  The turnover of patients in a department can be greater, and so the system is happy.

But what about the patient, and the doctors? If patients can avoid repeating their story a thousand times, and still get the right treatment, great. But, the reason stories change, and management changes so often in the first few hours is because new information changes the differential diagnosis, a different slant in thinking produces a new hunch and eventually, the voice of experience can declare on what the final, or at least working diagnosis should be.

Unfortunately this uncertainty over diagnosis when patients are admitted can lead to a “nebulised co-amilomoxifruse” approach where all differentials are treated with equal importance, and therapy is rather scatter-gun like rather than perhaps the pinpoint accuracy that the popular media present as the pinnacle of medical endeavour.

So how can one get that vital experience (a posteriori knowledge)?

Few junior doctors these days get to regularly present their patients to a specialist in the field of the patients problem, and then have a useful conversation about management and further investigation of the problem. Acute medicine is more often a game where one hopes to get on the fairway in the first 24 hours, on the green on the next ward round, and finally sink the ball into the diagnosis hole on the second day – without the continuity of a single firm then it is difficult to follow a patient through this seive of investigations and opinions before arriving at a final definitive diagnosis.

In general practice this can be amplified in the case of patients with acute illnesses – who may go on to have a prolonged and complicated hospital stay – and that initial diagnosis may never be confirmed or modified by the information sent back by the hospital.

To combat this, better feedback loops are required.  The learning cycle proposed by Kolb demands a period of reflection, gained from concrete experience to allow effective learning.  But reflection – without accurate outside information to ensure that the concrete experience is valid – will lead to a self-propelling myth that the trainee is always right. There is value in understanding our failings, and planning to rectify them in the future. (Tim Harford on this)

As Kierkegaard puts it:  life can only be understood backward, but it must be lived foward.

One way that used to be employed in a hospital where I worked was that the discharge summary of each patient seen by medical trainees was sent to them in the internal post so that they could reflect on what the ultimate outcome of the admission was, and what the final diagnosis was.

In these days of electronic patient records, demands that doctors keep a record of the numbers of patients they see (word document explaining how to calculate how many you might have seen) it should be relatively simple to provide such feedback and allow trainees to develop true experience in diagnosis and management of medical problems, rather than using a medicine by numbers approach which may see a patient through the first 24 hours, but may not influence their progress over the longer term.

As members of a profession which relies so much on the experience of our elders to filter and clarify the importance of information when making decisions on how to treat patients, we have a duty to develop better ways to make every encounter count for our junior colleagues – experience is hard won, and on the cost of every missed diagnosis is borne by a patient who may suffer as a consequence.

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.