Caring and the EWTD

There’s been a lot of talk recently about the European Working Time Directive and the detrimental effect that it’s had on training; particularly in the “craft” specialities.  (EWTD limits the amount of time that junior doctors can work to an “average” 48 hour week, and places some other restrictions on working patterns.  You can still work 100 hours/week as long as the average is <48).  There seem to be increasing attempts to subvert the EWTD, either by trainees who stay late for “educational” purposes (I know, I’m one of them) or by official bodies.

Generally, the view seems to be:

  1. EWTD is a bad thing for medical care
  2. It’s bad for trainees as it prolongs training/reduces experience
  3. We should all complain about it

I trained in a fairly old-fashioned medical school, and I was shocked when I started working as an FY1 to see how much my hours had been cut.  I grew up watching “Cardiac Arrest”: I was going to be Dr Claire Maitland  (although possibly without the complicated social life).  And so I’ve been very anti-EWTD.

Gradually, I’ve come around to the idea that maybe it’s a good idea for patient safety if healthcare workers aren’t exhausted all the time.  I hadn’t really thought about the other aspects of being tired until this week.

I have just finished 5 night shifts so I may be feeling slightly jaded.

They weren’t easy nights in many ways (and I won’t go into details); but what always amazes me is how much the team cares about the families.  Sometimes, they’re people that we’ve known for a while; some are acute admissions with no previous contact with health services.  But I work with a great network of nurses and HCAs who listen & laugh & joke & cry with these families.  And doing that takes energy and commitment.

It’s exhausting, but it’s such a vital part of our job.  And it gets harder and harder to do well when we are tired & run-down & hungry & haven’t slept for 48 hours.  Every time I’ve seen a colleague breakdown at work, it’s been at the end of a run of long-shifts.  Every time I’ve had to slide into the treatment room for a minute to take some deep breaths, I’ve been working a long-day.

Being compassionate is tiring; caring is tiring; doing this job properly is tiring.

I know when I’m tired, I have to really think about what I’m saying; to take time & be patient feels harder.  It gets harder to do the “little things” that matter.  And they do matter, because if I can’t be bothered to get you a blanket or a cup of tea, then why would you think I was bothered enough to look after your child?

So maybe the EWTD is cutting training opportunities; maybe it is reducing patient contact time.  Does that really matter?

I don’t really care if my training gets extended.  I do care if I’m so exhausted that I’m not doing my job properly.

Being a doctor is about more than technical skills & being a diagnostician: this is supposed to be a caring profession.  Limiting the hours that I work doesn’t decrease my training opportunities, but maybe it does change them away from the purely technical and towards the human factors side of medicine.

Should we keep the EWTD? Yes. Not just because it’s safer for patients & staff, but because it allows us to do our job properly; it allows us time & energy to care. And really, that is the job

Advertisements

Academic Training: The Foundation Programme

It’s that time of year again: we’re all thinking about moving to new rotations; graduation ceremonies are happening; e-portfolios are being filled.  Inevitably, this means that my social media feeds are full of people panicking about ARCPs, e-portfolios, and trying to get things finished before the end…  In particular, I’ve had lots of comments about the Academic Foundation Programme (AFP) pop-up.

Maybe it’s because, unlike a lot of our training, the Foundation programme does feel like a separate entity with a definite end-point.  Most people move to different LETBs at this point, so it’s harder to keep connections going.  There’s extra pressure to get audits, projects, research  finished and completed.

And alongside this panic, there’s the retrospectoscope, and the “I wish somebody had told me” and the questions to yourself:

Could I have done it better? (Define better…)

Could I have done it differently? (Always)

And the most common questions coming through are these:

Why did I take this on? 

What was the point? 

 

I’ve seen a lot of the last two questions coming from Academic Foundation trainees over the past few weeks; and I understand why.  That’s exactly how I felt at various points during my FYA (and my ACF, and my PhD…) but I get the feeling that it’s for different reasons.

One of the things that makes me really sad is the feeling that the programme has somehow been a failure if FYAs haven’t completed a piece of research in that time; if they haven’t got a paper accepted for an international conference.

Publications are nice, but focusing on that is to ignore all the other things that the AFP gives you.  I started my academic training thinking that I would have a list of publications by now, and a collection of flight miles accumulated from numerous conferences in exotic locations.  The reality is that I have one published paper which came out of my FYA programme, and was published 3 years after I finished my FYA…

Publications are not what I got out of my FYA project.

 

So, what is the point of the Foundation Programme?

I think you should come out of the AFP knowing if you want to spend more time in academia or not.

It’s that simple.  Academia isn’t for everyone; it isn’t a failure if you decide it’s not for you.

What worries me is that 1) trainees feel that they aren’t suited to academia because they haven’t “achieved anything”, and 2) they have bad experiences because they aren’t properly supported.  You can get your name on a big research paper and not have had any sense of how research in the NHS works because you’ve been a lab monkey for 4 months.  You can spend your 4 months waiting for ethics /R&D approval to come through on a proposal that you drafted in your first week.  That’s not a great experience of research (it might reflect some of the reality, but it’s not all), and it certainly doesn’t feel like enough to make a decision about whether or not you want to pursue academic training.

We do things slightly differently for our trainees locally, largely because we think this is important. It’s not a perfect system by any means, but I think it’s got potential.  And it’s been running for about a decade – we’ve had time to learn what works and what doesn’t.

So, this is what I learnt from my time on the AFP:

1) Be realistic – 4 months is not a lot of time.  My first thought on having a research block was ” I actually get given time to do all this stuff??”  Let’s face it, most of us are used to the extra-curricular aspect of academic life; trying to squeeze it in between clinical commitments, and exams, and the rest of our lives. (Remember that? the rest of our lives??).  Those things don’t suddenly go away. Yes, you will have some dedicated time for reserach that you probably haven’t had before. Yes, this is exciting.  It’s still not a lot of time to get things done

2) Choose your project carefully: find something about it that interests you.  That might not be the topic, it might be the methodology.  Not everything about it will be interesting, and you still only have 4 months to get it done.

3) More important than choosing your project, choose your supervisor carefully.  You are a junior trainee coming into a research group for a short period of time.  The international professor might have a great reputation, but are they used to supporting junior researchers who only have limited time & experience?  Talk to your colleagues, talk to the potential supervisor, have plenty of meetings before you commit.

4) Learn some management skills and appreciate what you’ve learnt.  You’re learning to manage your own time, other people, organise projects… All that is important and relevant and much more useful in the future than a particular technique to count serum rhubarb concentration.

5) Boredom happens.  That’s OK.  Find other people who are in the same position as you (use social media – sometimes it’s easier).  Link up with the people who did the post before you, the people slightly senior to you, anybody who understands the frustration of a coding tree that will not make sense no matter how much you stare at it.

6) Get some training.  FYA trainees are trainees in research.  If nothing else, learn some critical appraisal skills.

Ultimately, see this as your chance to try something different, and make the most of it.

Good Luck!

 

Why #NHSChangeDay (almost) made me late for work…

Last Wednesday I was the woman doing the comedy half-walk, half-scurry into work.  I’d left on time (OK, early because I hate being late for work); I’d checked my bag (twice, because I hate not having stuff), and I was still clattering my way into work.

And it was all the fault of NHS Change Day.

It was all their fault because when I’d carefully packed my bag, I’d forgotten an essential piece of kit.  Stethoscope; dictaphone; 4 black pens; NHS ID badge; NHS SmartCard… All the things that I usually take.

And I’d forgotten the stickers.

I don’t normally take stickers to work.  Maybe that makes me a bad paediatrician, but it’s not something I got into the habit of doing. (I’ve never seen my seniors give out stickers either, so maybe it’s not just me)

And then I saw a pledge on the NHS Change Day pledge wall; pledging to have stickers at all times for the children we look after.

So I joined.  Because it’s such a small thing to do, isn’t it? To give a child a sticker for being brave in a situation when they are ill & terrified & in a strange environment.  (Actually, I sometimes think it’s worse if they don’t feel ill, because why are you going to see the doctor if you’re not poorly or having injections??)

And I’d already forgotten the stickers. So, back I went on Wednesday morning; dug out a pack of stickers; and scurried my way into work.*

And I offered each child I saw in clinic that morning a sticker, and said “thank you for coming to see me today”.

And that’s it; that’s one of my pledges for NHS Change Day done.  Box ticked; self-congratulatory mode engaged; happy patients, happy parents = happy me.  Except it wasn’t and isn’t that simple.  Because my patients weren’t just pleased to have a sticker: they all looked surprised that I was bothering to thank them for coming, for missing school, for being asked personal questions about how difficult things could be for them.  Having a Dr who recognised that coming to clinic isn’t a simple or easy thing was a surprise to them.

I like to think that I talk to my patients.  It really annoys me when colleagues ignore the patient, and talk to their parents instead.  It’s something that I think about quite a lot.

Giving out stickers and taking that extra moment to say “thank you” made me realise how long a way I have to go before I even come close to being good at that side of my job (sometimes, I really do not appreciate having insight.  It’s incredibly annoying).  So no, not a happy me.

 

Why bother pledging?

Some of the criticism levelled at NHS Change Day is that the pledges made are just things that we should be doing as part of our job; that if we need reminding to do this, then maybe we shouldn’t be doing this job at all.

I can see where the sceptics are coming from in some cases: maybe we should just be “doing the job”.  (Maybe if I need reminding to talk to my patients, then I shouldn’t be doing this at all)

And then I’ve read the pledges.

And I’ve started to wonder what exactly “doing the job” means, because when you’re working in the NHS, then it is so easy to feel that “doing the job” is completing tasks.  Fill in blood forms, take bloods, examine patient, explain management plan, supervise juniors, call the wards to make sure they’re happy, try and scurry around a quick 6am ward round to pick up any problems… For a long time, I thought that was doing my job.

Gradually, I’m realising that isn’t all.  And seeing the pledges from NHS Change Day have helped me think about my practice, and what I can improve.

These aren’t pledges from people with massive resources in the most part; they’re individuals who want to make things better for the people we work for & with.

What’s amazed me about reading the pledges is how practical they are, and how wide-ranging.  Bringing in treats for the night shift just makes things tick along a little easier (it’s also sanity-saving if you haven’t had a “break” all night) – that’s not in anyone’s “job description”***

Reviewing documentation & forms to make them more user-friendly: potentially time-savingfor clinicians, and safer for patients.  Not one of the tasks that comes into the “job description”.  (Someone is going to quibble that we should be doing audits and QI – trying to negotiate a quality improvement project past your supervisors without also having to do an audit that the department needs completing is an interesting task)

 

So, what is the point of NHS Change Day?

For me, it’s been a great opportunity to think about my practice and the kind of Dr that I want to be.

It’s given me so much additional support because I’ve been able to use the pledge wall as a practical tips section for improving how I work.

Most importantly, it’s been a massive catalyst for communicating ideas and enthusiasm from everyone else who’s involved.  We’ve discussed ideas (I’ve lurked on some fantastic discussions).  I’ve heard real experiences from people like me, who can change things in their daily lives, that make a difference.

I’ve realised that it isn’t a failure if I don’t change the entire NHS.

It isn’t a failure of NHS Change Day if we don’t solve the budget deficit; cut waiting times; keep local hospitals open…

What I can do is make things better in my way.   After all, change begins with me 🙂

 

* I wasn’t late, by the way.  I just wasn’t as early as I like to be.**
**No patients were delayed in the making of this pledge
***Job descriptions are a bit like contracts sometimes – mythical beings that are rumoured of, but rarely seen

My Pledges

“I will remember to say “Thank you” to the colleagues I work with for doing an exceptional job everyday (not just when they’ve done a superhuman one)”  If this sounds like just part of my job, then you should know that I feel spectacularly uncomfortable when somebody thanks me for doing my job.  I didn’t realise that other people don’t feel like this until I did a Myers-Brigg session with an amazing facilitator.  Ooops

“To treat the children I work for with respect; explaining what I’m doing & why; and sharing decisions as much as is possible”  No patient should feel that they need a contract like this. This blog breaks my heart.  And again, I’m a paediatrics registrar, and I should be doing this anyway because that’s how paediatrics works, right? Wrong: this paper is a brilliant observation of just how children are treated, and how we all seem to accept this as normal.  This is the speciality that still publishes phrases like “the terms patient, parent, and patient-parent set are used interchangeably”

“I pledge to ask my paediatric patients what I can do next time to make their visit to hospital better; and to listen to, and respect their ideas”  Children are still marginalised in paediatrics – sounds silly, but it’s true. We ask parents to fill in satisfaction surveys, talk to parents about management plans, and ask parents about their worries. Parents are important, but they’re not the patient. It’s far too easy to forget that there’s a “real” child lying in that bed, with worries & fears of their own. Inspired by http://www.justbringthechocolate.com

Why medicine isn’t like the driving test…

I failed my driving test the first time around.  It was 13 years ago, but I remember that day vividly.  Getting stuck in a traffic jam on a hill (repeated hill starts); being taken on the country road that absolutely petrified me (and insisting on driving at a comfortable 40m.p.h rather than the 60 that everyone else was doing); and the overwhelming sense throughout the whole thing that I was going to fail, that I couldn’t do it, that I couldn’t change anything about it.  I remember coming home, and the following morning, still wanting to through something through the window.  (A pyrex pepper pot, by the way.  My mother removed it from my hand, and made me a bowl of pasta…)

And I remember the second attempt a few months afterwards, where I passed.  It wasn’t a perfect run by any means: my 3-point turn became a 9-point turn; I abandoned my reverse park the first time, and had to pull out and start again; the emergency stop was a genuine stop because I hadn’t realised that the examiner would do that on the approach to a junction….  But I passed, and I was elated.

On neither of these attempts was I allowed to drive home.

Apparently, the emotional upheaval of sitting the driving test is so enormous that my instructor didn’t allow her students to drive afterwards, whether they’d passed or failed.  (This wasn’t just me being 18 and emotionally crumbly: a quick look on internet fora suggests this is quite common).  It makes sense: passing your driving test is a fairly major life event.  I wouldn’t have been safe on the roads after that!  Having to go back and do something that you know you’ve just failed to do is difficult because your confidence in your abilities has taken a massive hit; passing makes you confident, over-confident maybe.  Either way, mistakes happen. So, having a break to reflect and re-group before getting behind the wheel again makes sense.

Medicine doesn’t work like that: regardless of what happens, we still have to keep going.  I’m not 18 anymore, I’m (probably) not as volatile: but I don’t just sit a driving test anymore.  Work just isn’t like that: you can genuinely see life & death within moments of each other.  And at each point, you just have to keep going and do the best that you can.  I don’t mean the technical skills: although doing that is hard enough.  I mean the bits that count: explaining to families what’s going on; talking about stopping; knowing that we’ve done what we can, and it hasn’t been enough.  And then turning around and giving another family good news.

And being a brilliant health care professional is about doing it honestly.  The most amazing thing I’ve seen in the past few weeks is watching my absolutely fantastic team share the pain of losing a patient, and supporting their family; and then coming back and sharing the joy of the baby steps of progress for another family.  And they’ve been absolutely genuine whilst doing it.  Seeing the looks on their faces when they come into the coffee room; when they’re on their way home.  It’s exhausting, and draining.

Doing that is hard: it takes a huge chunk of emotional resilience.  Doing it whilst also leading a team, and allowing them to see that you’re vulnerable is astonishing, and I’m very lucky to work with seniors that I can look at and think “if I can be that for my families in the future, then I’ll be doing my job”.

But in order to do that, then we/I need to also care for myself.  It’s why I’ve missed being part of a team so much the past few months: we look out for each other.  That’s not selfish: it’s making sure that our families get the care that they deserve, and that we can give it to them for the duration of our careers.  Maybe that’s a sensible New Year’s resolution?

I know this is a rambling post, but I’m not sure this is something I can think of in a more detached way.  I don’t know what I’m doing with my career path really.  I hate the “where do you see yourself in 5 years time?” scenario.  One thing I know: if I can be that doctor for the families that I care for; if in 10 or 15 years time I can be that leader for my team, then everything else is just extra.

Leadership 2: Talking about mistakes

Speak no evil…

I’m going to keep talking about this conference that the King’s Fund hosted last month, because it was a genuine light-bulb moment.  Usually, I go to conferences about women in leadership and I hear about successes; the smooth path and straight career trajectory.  They almost never talk about the stumbles and falls; the days when they thought about giving up.  I’ve never found these talks inspirational – I’ve always found them depressing.  I’m not on this straight path through management; I don’t know what I’m doing in 1 year/5 years/10 years… I usually come away thinking that there is such an enormous gap between me and them that I might as well not bother.

So the King’s Fund was a revelation.  A group of powerful, successful women talking about their careers… and what had gone wrong.  I can relate to this: I’m usually quite aware of what I’m getting wrong.  Often, I’m told to build on the positives and learn from my mistakes.  That sounds encouraging; as though there’s hope and potential for development and growth (and all those other buzz words I come across)

We all make mistakes…

It sounds good: that’s often not what’s replicated in the talks and speeches that “successful” people give.  It makes it harder to learn from mistakes, and to grow, and to develop, if the people held up as leaders don’t talk about their mistakes.  I’m sure that they’ve made mistakes, and learnt from them, but for some reason it isn’t seen as acceptable to talk about them.  Taking an outside perspective, it’s a really interesting dichotomy: where the internal must accept mistakes and learn from them to be a leader, but the external persona isn’t supposed to reveal this.  From the inside, it’s profoundly confusing and limiting.  Yes, I’m beginning to realise this, but reflecting on my experiences and how they relate to my professional development is time-consuming and draining.  I don’t always have time for this: why does it have to be so covert??

Which is why the King’s Fund was so refreshing: it was an open and frank discussion of differences between individuals who happened to be women, and who were prepared to share what they’d learnt.  And inevitably, that meant learning from the mistakes.

It’s what happens next that really matters

I almost saw this as an isolated event.  Maybe, even, as a “women’s” way of doing leadership (the supportive, nurturing model.  Apparently).

Except, that last week, we had a teaching session from a male, surgical consultant I like working with; I also respect him hugely as a clinician (that does not mean it’s always easy to work together; it’s not, but it’s satisfying, and it’s good patient care).  He talked about the situations where he could have done things differently; points at which he wished he could have taken a step back.  He wanted us to learn from his mistakes; and more importantly, we could see that he was learning them too.  That’s more important because that’s a skill that we need to have throughout our careers to continue to learn.  I think that’s more relevant than learning a single point in a unique case that may never come up again.  It’s also a lot harder, in so many ways.

Balance

There has to be some sense of balance in all this.  Nobody wants to be paralysed by the thoughts of past mistakes to the extent that they can’t do their job.  I’ve been that person: it’s not good for you, and it’s certainly no good for your patients.  Sharing your mistakes with your team is a way of getting some proportion back.  It’s also potential for solutions.  It’s what we do within our peer group: why is it so rarely visible between levels of hierarchy?

Back in the real world

Having these experiences so close to each other has led me to think about the other leaders I admire in my everyday life.

Here’s what I realised: they all do this.  In different ways, they are all honest and open about the mistakes that they make, and how they change (or try to) as a result.  The really amazing ones are open with everyone. (I think this is important too: I’ve seen before consultants talk through decisions that didn’t go well with families, and how they could have done things differently.  I’ve seen the same consultants then not accept that with themselves or their team.  I think that’s a much harder thing to do, because it’s both personal and professional.  But that’s another whole post.)

What makes these people so powerful is their recognition of mistakes.

Power isn’t about pretending everything is OK, that you are perfect.

It’s what happens when you own yourself enough to realise that mistakes happen, but that learning & changing is how to improve.

Note:

I can do the theory – that’s the easy bit.  Actually applying this in practic …*shrugs shoulders*.

Note 2:

Especially the section on “balance” and “not getting paralysed by fear of mistakes”.

Note 3:

And no, I still haven’t completed my multi-source feedback self-assessment on how amazing I am supposed to think I am at my job.

Leadership 1: Making a cup of tea…

Leadership & Management….

Another one of those things that was high on the list of things I was never going to do, and that I seem to find myself increasingly drawn towards.  So, I’m starting from the beginning really: going to conferences & meetings; having chats with some really inspirational leaders; bouncing ideas around via Twitter and my amazing Action Learning Set (honestly, I am so impressed with Health Education East Midlands for funding these; and for being around to chat with a trainee on Twitter… @EastMidsLETB)

Last week, I went to the King’s Fund Women in Leadership Conference.  Considering a lot of the discussion was about how women are perceived in the workplace, maybe I shouldn’t be starting a blog on leadership with “making a cup of tea”…. But after a lot of discussion and thought, I’ve started to think that making a cup of tea is a key part of a being a leader.

Bear with me on this: I’ve given it a lot of thought, and the more I think about it, the more important it seems.

For somebody else…

Taking a moment to make a cup of tea for someone else is a way of showing someone that you care about them as a human being.  It’s a demonstration that you’ve noticed that they’re tired, or stressed, or worried.  (Lets face it, we’re always at least one of those in the NHS; usually a combination of all three).  It’s a sign of respect; of recognition that they’re there because they care.  And everyone can show that to the people on their team.  It’s the bosses who always bring in snacks for #teamweekend (especially those who remember to bring extras for #teamnightshift).  It’s the fantastic HCA who once stood at the door and force-fed me tea when I’d had a particularly bad shift.  It’s the play specialist who noticed I was getting ratty, and rather than react to that, decided to bring me a coffee.  It’s every time I’ve been sent on a break by my nurses.  Individuals caring about each other, and all it takes is a cup of tea (and a biscuit if you really, really care)

For your team…

But it’s more than just individuals: it’s about bringing your team together.  When I was a student, and we still had “firms”, the post-take round always finished with the night team going for breakfast together.  It was a moment to spend time together, and recognise that actually, everyone had come together.  Cups of tea do the same thing.  I remember being a very new SHO, and coming out of a resuscitation that hadn’t worked.  My SpR and I were both stunned, but we thought we had to get on with it in the last hour of the shift: handover sheets, blood gases, re-writing drug charts.  Our consultant sat us down in the staff room, made us both cups of tea, and insisted on us drinking them while he disappeared.  He knew there was nothing he could say.  Instead, he went around the ward, doing all the little jobs, and giving us time to recover.  It’s just one of the ways that we knew our team would support us and look after us.

For yourself…

And sometimes, making a cup of tea is a moment for ourselves.  It’s a strange thing: you can’t rely on muscle memory and it does take a bit of thought (does x take sugar? is that milk off?); but it leaves you enough space to think.  Space to step back and realise what can you change about the shift so far.  Sometimes, it’s a clinical niggle that just doesn’t fit the pattern.  Usually, for me, it’s the realisation that I’ve missed the connection in my team; that there’s a point that I need to address.  It’s not deliberate – they’re just things that float into my head as I’m sorting milk, sugar, tea bag whipped out, tea bags left in… But most often, it’s a mental intake of breath and a moment to regroup before heading out to start all over again.

 

Fear and loathing in patient safety?


894814

I have a confession: I’ve never seen the film, and never read the book.

From what I gather it’s a surreal and strange world: that’s how I’ve felt about my place in patient safety recently.

More worryingly, it’s a phrase that’s resonated through my head a lot more over recent weeks (If you’ve read this blog before, that’s what happens: phrases circulate in my head, and I over-think them…)
It’s taken me a while to work out what’s so strange, and why “fear and loathing” resonated with me so much.

fmlm

I went to a conference: that’s not strange, I do that quite a bit.
But this wasn’t just any conference:  this was the FMLM annual conference in Edinburgh.
Great line-up;
fantastic participants;
and really important themes of changing culture in the NHS, and managing risk.
Things I’m interested in; that I care about. Or so I thought.
Now, I accept, I usually get a bit cross at conferences, but I also get enthusiastic.  FMLM had me feeling just dispirited.  I thought I was tired, and generally fed-up, so I’ve taken a while to think about it.

1376770_765024355678_1826643598_n

 I’ve had…
sleep…
 chocolate….
burgers….
chips….
wine….
and watched two episodes of GBBO
(not all at the same time; although there was chocolate with the GBBO), and things are no better.
???
The conference followed a Twitter conversation I had with the inspirational Dr Umesh Prabhu (@DrUmeshPrabhu).  He pointed out that BME doctors won’t speak out on patient safety because they’re too scared.  He’s one of the few people who acknowledges just how important fear is in preventing doctors from speaking out.
screenshot
What really made me think about this exchange was this: I believed that the problem was junior doctors standing up in the NHS hierarchy.  (To be honest, I’d always assumed that I was being a bit cowardly about the whole thing, and it’s always been easier to use the “but I’m just a junior” excuse…)  Dr Prabhu highlights the issues that BME doctors face in the NHS: fear is a huge part of that.   That’s an issue for thousands of professionals in the NHS; it’s also a massive issue for patient safety.
Then I had another look through my Twitter feed: it’s full of professionals and patients in the NHS who are scared for other reasons.  People with mental health diagnoses facing stigma, and talking about the bravery needed to be honest about a clinical diagnosis (@LisaSaysThis is a brilliant example of sharing experiences).  There are female doctors facing discrimination and sexual harassment who don’t want to report it in case it affects their careers and references; doctors on career breaks; working LTFT; who’ve failed exams or had complaints (and if neither of these applies to you, then you are incredibly lucky)…
FMLM was great;12018921-emoticon-with-adhesive-bandages-over-his-lips
it was full of inspiring speakers and champions for patient safety;
we talked about culture change;
we agreed we had to make patient safety a priority…
We didn’t talk about the fear that stops us speaking out.

Is there a link between patient safety and fear?  The tabloid press would see it as easy: patients terrified of entering the NHS, disasters on every corner.

Then there’s the other side: the fear that whistleblowers overcome; the bravery that is every small daily challenge that makes patients safer.  We know about the “big” cases of whistle blowing, the dramatic ones.  We don’t talk about professionals overcoming their fears every day to make patient care a little better.  We don’t acknowledge how much courage it takes to go against the convention of a group, and to question.

If you think I’m being over-dramatic about this, then just think about the terminology we use about people who do raise their concerns:

“raising their head above the parapet”
“courageous”
“whistleblowers”
(“Whistleblowers” – I have no idea where the term comes from, but it makes me think of referees, calling time on people that aren’t playing the game.  Except that this isn’t a game.  This is the NHS, and people’s lives and wellbeing.)
Incident forms are completed “against” someone; their completion apologised for.
Rather than seeing this reports as a chance to work together to find good solutions, we function defensively.   It’s hard to see critical incidents as learning experiences and opportunities to make things better, when the fear of standing out limits us.
And that’s what made me so dispirited.  I came out from the FMLM conference thinking that I have to speak up; I have to keep sticking my head above the parapet; I have to be brave, and be awkward.
And what makes me so furious is that I shouldn’t have to be brave.
Making changes; raising concerns; shouldn’t be an issue for anyone in healthcare.  This shouldn’t be something that we’re struggling to do, that we’re seen as different for doing.  This should be a basic part of our job as professionals, as carers.
And this is where the self-loathing comes in.  Staying scared goes against everything that I believe in as a healthcare professional.  It goes against what my colleagues feel as doctors, nurses, cleaners, porters; as parents, children, partners; as human beings.  Protecting others; caring for others; trying to make things better is a basic component of our motivations and inspirations to work.  It’s part of being human.  And yet we work in an atmosphere where we are too scared to undertake such an essential part of that work.
No wonder we’re burnt-out, disillusioned, and habituated to the environments we work in.
We’re constantly working against our preferences in this situation; against our inclination and need to make things better; And fear is what underpins that.
Solutions are complex, but in the meantime, I can’t keep working against my inclination.
And that means that in order to do my job, I have to continue to be awkward…
And to be awkward I have to overcome my fears.
But if I can get help from anywhere, I’m taking it.  Hopefully, to use my courage wisely…
Fear-is-the-path-to-the-dark-side.-Fear-leads-to-anger.-Anger-leads-to-hate.-Hate-leads-to-suffering-Yoda

Although, I may need a little of the anger…

Just to see me through…

Just a little, teeny, tiny bit of fury….

Things I said I’d never do…

This morning I woke up and realised, I should just draw up a list  of all the things I said I would never do, and just do them.

Firstly, there was the research

Then there was the hill-walking…

And the camping…

And now…

I have a terrible confession to make: I think I’m becoming a management person.

I’m not entirely sure how this happened.  I think my inability to keep quiet in front of seniors probably has something to do with it, along with sticking my nose into things, and having an impatient streak that doesn’t see why we can’t just find a solution to things. (One of my A&E friends used to say “see a problem, fix a problem”, except that half the solution is being able to “see” the problem in the first place).

And I’ve ended up doing things I told myself I would never do.  I’m talking to seniors about getting more junior doctor representation; I’m taking part in the BMA; I feed juniors cake and try and sort out their rotations (not very successfully so far, but it’s a start).  There are things that no-one else is doing, and I’m not sure why I’ve taken them on.  I just have because they needed doing.

What happened to the girl who was going to be a “pure” clinician? Who was just going to put 120% into her firm, and patients, and team? Who wasn’t going to “waste her time” on all the paperwork, and re-organising things?

When I was younger, I wanted to change the world.  I thought the only way of doing that was to be a big chief somewhere (I thought I was going to run the WHO, because that’s what paediatricians do!  I do not have delusions of grandeur. I just get a bit carried away sometimes…)

Then I met my first patient, and I realised I didn’t need to stand on some podium to change the world. (*sentimentality alert*)  I could make a difference by talking to them; listening to them; remembering what their job was.  If I was the best doctor I could be, then I would be making that difference.

But more and more, I’m realising that I can’t be the best doctor I can be, because it isn’t about how much work I put in, or how many hours I spend staying late after work (not that I would ever do that, and I faithfully promise that I have completed a breach form for every single minute I am delayed leaving work…).  Eventually, something in the system stops my patients getting the best.

Sometimes it’s me: because I’m looking after three new admissions at once, and I can’t explain to families the way I want to; because I have bad times when I’m tired and grumpy and I need rescuing by amazing people; because I make mistakes when I’m dealing with those three things at once; because I don’t make contemporaneous notes (for the simple reason that I’m doing the things I’m supposed to be recording); because I’m human. (*should probably tell myself that more often*).

Human beings don’t set out to make mistakes, snap at parents and nurses, & forget to write things in the notes.  We don’t aim to go out and generate incident forms about ourselves. We don’t wake up in the mornings and think “today, I’m going to give someone sub-optimal care.  I’m going to put them at risk because I can’t be bothered to do it better”.  This is not the kind of job that you can survive in unless you care.

But we don’t work in isolation.  We’re part of a system.  And when things go wrong; when there are repeated and consistent mistakes and omissions; when patients and families and your colleagues don’t get the best from you that you can deliver, that’s not about individuals.  That’s about the systems that we work in.

So, if I want to be the best doctor I can be; if my patients are to get the best care they can get; if my amazing, fantastic team are going to get the best team member they can get, then something has to get better.  Things have to change.

I can’t just change myself.  I have to change the systems I work with.  It’s never going to be perfect.  It can’t ever be perfect.  But we have to keep trying to make it better.

Just being a “pure” clinician isn’t going to do that for me.  Getting involved in systems change and joining the dark side of management might be the way forward.  Dealing with teams and structures means being trained to do that, so I’m going to a conference.  I’m getting some training from my LETB (because I’m a trainee.  I’m entitled to be trained to do this, just as much as my clinical work.  Plus, they’ve already top-sliced the study budget to provide the course, so I’d be crazy not to take it up.  But then I still think I’m crazy to be doing it…).

I have friends who are so disheartened by the systems we work in that they tell me it’s a waste of time & energy; that we’ll never change anything.  And maybe they’re right.  Maybe there’s one little tweak that won’t make any difference to the NHS.  Maybe I won’t run the WHO.

But trying to get enough otoscopes on the wards would be a start…

 

Being marmite…

Most of my thoughts about academia seem to come out of random phrases that float into my brain at odd phases.  “Being marmite” is one of those phrases that I’ve heard several times at leadership & management conferences.  I have to say, it didn’t mean a lot to me, because I’d never tried marmite (I know, I’m 31 years old, and I’d never tried marmite.  This is on the list of other things that I’d never done, like camping, but that I might have to catch up with during my 30s!)

During the discussions, it turned out that what they meant was marmite is a love/hate relationship.  Everyone (apart from me, clearly) knows whether or not they love or hate marmite.  Everyone remembers marmite; they recognise the brand; they recognise the taste instantly. Nobody is going to forget about marmite.

I’ve needed some time to think about this.  I don’t really want to be hated, but nor do I want to be forgettable.  Would I rather be liked and not taken seriously? Or not liked and remembered?
That’s a really difficult thing to think about, and I can’t see it working in a clinical setting: we’re a team, and that’s what makes things work. Why would deliberately creating a love/hate impression just so that you’re easily remembered work in academia? or management?
Things like this are why I never wanted to get involved in management; why I just want to sit in my little box, and let the world of work trundle past… until I get so annoyed about something that I have to get involved!
Two things happened in the past few weeks to make me change my mind.  Firstly, I had a talk on leadership and management from one of the best (OK, probably the best) consultants  I have ever had the privilege to work with.  And yes, that is a deliberate work with and not work for.  (Anyone who’s worked with Andy Currie will know that’s true).  It made me think about why he’s such a brilliant leader: it’s not that he deliberately sets out to make himself memorable by generating this love/hate scenario I keep hearing about (the marmite effect).  It’s because compared to getting the job done, and done well, personal things become irrelevant.  The team works better when we all get along; because it delivers good care.  That’s what we feel is important.  It’s not that we need to be memorable to be good leaders; it’s that leading the team to get the best possible outcome over-rides all those personal considerations.
The second thing that happened, is that last week, I had my first taste of marmite.  And, it was OK.  It was nice. It would work really well with cheese on toast; I can see me putting a bit into a tomato sauce or a chilli; it would probably give a really nice dimension to some bread (of course it would, it’s yeast!).  But it isn’t this yes/no, love/hate phenomenon I was told it would be.  Actually, it’s a really nice flavour enhancer that helps everything else sing a little bit more; work a little bit better…
Maybe being a good leader is about being marmite after all: but it’s my kind of marmite

Does everyone need research training?

For reasons that still make me too cross to mention (sorry if you’ve been on the receiving end of one of my rants over the past week…), I’ve been thinking a lot about the academic training programme for the foundation years.

And then I read Daniel Lumsden’s piece in the RCPCH bulletin this month

http://www.rcpch.ac.uk/system/files/protected/news/RCPCH_Newsletter%20Summer%202013_for%20web.pdf

As I’ve read it, his point is that all trainees should have an understanding of research in order to be able to deliver the best care to their patients, and ensure the successful delivery of research projects.

I’m really not going to argue with that.

What bothers me most is what this concept of “understanding research” actually means.

A few months ago, I was asked by a colleague for some help in critiquing a paper for journal club.  Her problem? She didn’t understand the statistical tests that were being used, and thought I might be able to help.  Of course I couldn’t: I’ve never understood statistics before (I’m one of these people that has a notebook with the definitions of sensitivity and specificity written down…); I certainly wasn’t going to understand some convoluted test involving curves and words I’d never heard of before.

What’s more, I didn’t need to know.  It didn’t take long to work out that this paper (no naming and shaming I’m afraid!) was reporting a study that was badly designed, and that had chosen an inappropriate methodology to answer their research question.  None of that required an in-depth knowledge of statistics.  But it did require a basic understanding of research methods and purpose.

Now, I don’t think that most “grown-up” researchers can argue about Popper or post-modernism in research.  But maybe that’s part of the problem.  Our research training is organised and structured by scientists who structure their research in a particular way.  We understand about randomised controlled trials, but less about good epidemiology.  We understand chasing a single “truth” more than we appreciate what that truth means.  We’re more au fait with numbers than people.

Health services research, in all its unwieldy complexity, is a closed book to most.  Restructuring a service, a clinic, an outreach group is going to have more immediate impact on our patient care than the outcomes of a phase 1 trial.  But how many of us appreciate how to appraise this, or can critique a paper on this kind of topic?

Understanding the research methodology is essential to understanding research.

I’d go further.  I think that we all need an understanding of the history of research, and to understand why our standards have developed in the way they have.  We need to accept that there are different schools of thought; that not all research is hunting for a single truth; that generalisability isn’t the goal of all studies; that population statistics are applicable only to that population; that opinions & beliefs have an impact on which research questions are asked (and which are funded).

Only if we appreciate these things (and I think it would take a lifetime to understand them properly) can we spend time thinking about the fine detail of statistical tests.  Without understanding why a study has been designed in a certain way, how can we possibly hope to critique the fine detail?  There is simply no point looking at the p-value of a study where the question is irrelevant.  Using the wrong statistics might get you the wrong answer from the data you have available. Asking the wrong question renders that data meaningless, regardless of the tests you apply to it.

If the Keogh report is right, and junior doctors are “the clinical leaders of today”, then we need to understand the systems that we work with.  Research training needs to move on from the days of RCTs, and embrace the complexity of structural change.  It’s a big ask: this is complex, involves people and systems.  There aren’t simple designs or answers.

But the principles are the same regardless of the research approach: what you’re asking is important; how you answer it is important.  Realising that the answer you get at the end depends on the question you ask is something that applies to all forms of research.

Ultimately, understanding this makes us better doctors. I think it goes a long way to making us better researchers too.