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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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.

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)

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.