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.

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.

 

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.

Play nicely – or you’ll drop the ball

 

When working in a complex organisation, especially one which is split up into different teams dealing with an overlapping number of projects, it is important to understand the rules of engagement.  This is even more so in healthcare, where conflicts over responsibility and disagreements about the roles of others can lead to significant harm for patients.

I have been on call quite a lot recently, and it has been both a wonder to behold teams coming together to solve massively complex cases in the best possible way, but also a huge disappointment to see squabbling, ping-pong, and downright obstructive behaviour have a negative impact on the experience, care and potentially (although I cannot claim to have seen this) outcomes.

The complexities of modern medicine mean that no one team or person can really be able to treat each and every patient that comes to the hospital to the highest standard, and where specialist skills are required 24/7 (to provide acute diagnostic and interventional procedures for example) it is seemingly obvious that specialist teams will be on call to provide such a service.

Recently there have been times when it has not been clear where a patient would be best cared for, or who should be providing that care.  It is at times like these that stretched teams all over the hospital can become more stretched, and tempers can flare.  I have been guilty of venting frustration at the system on occasion, and this week I have been able to look back and realize one of the key elements to the frustration:

Teams not seeming to play by the same rules…

If a football team gets on the pitch with a rugby team, and each team tries to play by their own rules – chaos would ensue.  That much is obvious, and the division of work within the medical take is not quite so obviously different as rugby and football.  It is slightly more like when two strangers play each other at squash, and may not have agreed beforehand what would constitute a let, or fully understood what each others house rules are.

For the majority of the time, they will play nicely, but, when the stakes are high, and they have invested considerable effort in winning a point and their opponent calls a let – then conflict can arise, and the game can descend into farce.

Caring for patients is not a competitive sport, but for those who care about their patients, care that they get what is required, and care that they get the best standard of care for their particular problem – the emotion invested can be of a similar order.

So what, I hear you cry – why should I be bothered if you get upset by the way some teams seem to be Teflon when it comes to admitting patients, but you have to take them all?  Well, it is not me that I am particularly worried about – I can always go home at the end of the shift, and ultimately I will be ok when the dust settles.

But in these days of increasing specialisation, and centralisation of services, we need to be sure that we do not construct a system that works perfectly for those patients that fit into diagnostic boxes nicely, but resolutely fails to address the needs of those who fall between the specialty lines.

We must remember that the focus of care should be the patient – not just the diagnosis, not just the disease, and especially not just the procedure required to sort them out.