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.

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.

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)

The privilege of our profession

It is a rare pleasure to be able to take any individual and guide them into environments and to experiences that are entirely new to them.

I was fortunate enough this week to be given an opportunity to do just that. The opportunity did not show itself in a good light when I first got to hear of it. The new clinical medical students were coming to the ward, and needed volunteers to take a history from. My colleague was due to run this particular session, but his child had taken ill so he was unable to sort everything out.

Queue a couple of hours of running around the ward like a debutante looking to fill a dance card, and finally things seemed sorted. The students arrived in a nervous gaggle, and were duly corralled into the MDT room. They were split up into threes and I went round introducing them to their first ever patients. They had been talking histories all morning and had a plan, and a pro-forma. They knew how this was meant to go…

And of course, it was nothing like they had imagined.

Each of the groups had experiences as unique as the patients they spoke to. One group struggled to encourage a patient to start their story any more recently than the mid 1960’s, one group encountered a patient who was so straight to the point, that they felt they had nothing more to ask after about 15 minutes, and needed gentle coaxing into delving slightly deeper into the “I woke up and it was there” of the presenting complaint.

It was fascinating to observe a group of four medical students collude as one to avoid asking the most obvious questions in a social history when confronted with one particular case.

However, what struck me most was the absolute privilege these students were getting – within five minutes of meeting of these people (for that is what patients are) the students were being trusted with the most intimate information, trusted with the opportunity to ask probing, personal questions about their fears, concerns and expectations, and were repaid with an experience I hope they will carry with them through their working lives.

Taking histories from patients can be seen as a chore when on take, slogging through an outpatients clinic or clarifying details on a ward round, but really it is an immense privilege, and I hope that the students who met my patients the other day remember that as they move from the lecture theatre to the wards, and onwards in their chosen profession.