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.

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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)

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.