August: A challenging time for doctors

doctor-feeling-stressAugust is here.  For the population at large attention is being directed towards holidays, enjoying longer hours of daylight and making the most of the great outdoors.  In sharp contrast to this season of relaxation, August presents a very different stage in the annual cycle for doctors working in hospital.

This week a fresh cohort of inexperienced, newly qualified doctors has arrived on hospital wards for the very first time.  Others will have changed discipline as part of their career progression.  Further along the experience scale, more senior doctors now have the challenge of supervising unknown subordinates.  Unfamiliar surroundings; new people; abilities being tested and stretched.  There is much to learn, relationships to be developed and endless questions to be answered – all of which takes dedicated effort and time.

Unfortunately, there is no change in the rate at which patients become ill, ongoing care must be maintained and the support expected for carers or families remains the same.  The inevitable result is that some degree of pressure is experienced by everyone involved.  Now a bit of pressure can be a positive driver, help us to get started, heighten our concentration levels and boost energy.  Too much however leads directly to stress which makes us lose focus and affects our approach to communication.  Confidence and tolerance decrease, mistakes and conflict increase.   The results……..more stress!

In 1968 Stephen Karpmann defined the Karpman Drama Triangle, where the people involved take on one of three roles:  Persecutor, Rescuer or Victim.  The result is that they all become locked into a no-win situation of blame, crisis and manipulation.  This can develop all too easily and at pace.  It can also be habit forming and even become addictive with the drama developing on a daily basis like a living soap opera.

Whether someone is a fresh face in a new environment or the long standing leader of the department, every member of a team has a role to play in ensuring that the balance is kept to the side of healthy pressure.  It is never too early to learn, or too late to refresh an understanding of how to avoid or to manage the drama.  It requires the development of self-awareness and to recognise why others may behave in different ways; an understanding of the differences between assertiveness and aggression and taking time to practice negotiation and conflict management techniques.

Unfamiliar surroundings; new people; abilities being tested and stretched.  What could be more exciting![/fusion_text]

Understanding the NHS: A moral and professional responsibility for doctors

The NHS is huge and complex.  The numerous organisations which form its constituent parts continually evolve, divide, grow, and merge.  Processes, authority and responsibilities forever shift with each change of the political winds.  How can any single doctor ever expect to exert a worthwhile degree of influence, even if they wanted to?

In the foreword of the recently published Understanding the New NHS booklet, Professor Sir Bruce Keogh, National Medical Director, eloquently communicates both the importance of and the key for doctors to play an active part in challenging and engaging to shape the future.  From an early position where he felt that “management” was someone else’s responsibility, Sir Bruce eventually realised, “If I really cared about how well patients were treated then I had a moral and professional responsibility to understand the system in which I practised.”  He emphasises that “Young, enthusiastic clinicians can add significant insight into our biggest healthcare challenges, but unless you know how to channel this enthusiasm and how the system works, nothing will happen.”  He ends by encouraging doctors “to empower yourself and your colleagues to get to know how the NHS works and really make it your own.”

Where all doctors share this “moral and professional responsibility” senior doctors should bear these words in mind when considering the development of their junior colleagues.  The need to see beyond the technical, clinical expertise and to support development in all aspects of practise is a regular topic of discussion in both our Teach the Teacher and our Medical Leadership and Management Courses.  Understanding who’s who, who does what, where, how, when and why takes both time and deliberate effort.  The booklet mentioned above is an excellent tool and will be of great benefit to many.  The encouraging support of a senior colleague who is skilled at passing on knowledge and enthusiasm is invaluable and has to be a key driver for doctors playing their essential part in shaping the future of the NHS.

Doctors are not immune to the effects of age

older doctor“Live long and prosper”.  “Be healthy, wealthy and wise.”  “Lang may yer lum reek!”  In every culture there is a desire for a long and happy life and the advances in healthcare are playing a major part in significantly extending our life expectancy.  It goes without saying that we want these additional years to be both worthwhile and enjoyable where we are active and contributing, rather than experiencing a sad twilight of dependency.  However these advances and the resulting ageing population are bringing numerous challenges which affect everything from the funding of healthcare to the ratio of carers to those requiring support.

In line with the rest of the population, the retirement age of doctors and other healthcare workers is planned to increase and being medically qualified does not qualify the body for immunity to the impact of the ageing process.  Potential age related medical conditions and cognitive decline has serious implications for doctors.

What can and should be done to ensure that the increased later years of practice are both productive and are safe for patients?

Doctors would do well to consider this question, along with potential situations which could arise, in depth.  This is related, but distinct to the professional dilemmas and scenarios which are often explored in medical interview questions.  It is a topic which all experienced doctors should be able to discuss.

In response, the Academy of Medical Royal Colleges has organised a national conference to take place in October this year which aims to explore the problems associated with increasing the retirement age for healthcare professionals; explore possible solutions and develop an action plan to present to National Governments.

Of course we should not just view this from a negative viewpoint.  With age can come great experience and wisdom.  At the same time as considering how to avoid issues with performance and safety, effort should be also given to planning how to utilise such a valuable resource.

The ultimate team vs the ultimate doctor

2014-champions-germany-trophyAt the end of what has been an excellent World Cup, an editorial in the Lancet has echoed the alarm which many will have felt at the spectacle being sullied by the poor management of players who were apparently concussed.  Uruguay’s Alvero Pereira lay motionless for some time during a game with England.  Argentina’s Javier Mascherano stumbled and collapsed midway through a match against Netherlands.  Germany’s Christoph Kramer wandered in state of confusion during the final.  It’s not the fact that the injuries occurred in the first place that has raised the concern – there are other sports which bring much higher risks.  It is the fact that in each case, the dazed and confused were returned to the physical exertion of competitive contact sport.  Only Christoph Kramer was substituted when it was clear he could not continue.

In another incident, even viewers with basic first aid training must have felt uneasy about the method used to scrape Brazil’s Neymar Jr off the park with an obvious back injury.  The news that world’s most famous young star has a fractured vertebrae should be making those involved in the sport question his removal from the field on something which more closely resembled a bakers bread tray than a spinal board.

Yes, football has a lot to learn from doctors.  Can doctors learn anything from the World Cup?

The final was billed as Germany vs Lionel Messi: “The Ultimate Team vs the Ultimate Player”.  No one was saying that Argentina did not have a great set of players, just that Germany as a team were outstanding.  Lionel Messi was never destined to win.

Germany demonstrated advanced team communication skills.  They had great awareness of each other.  They observed, listened, supported and challenged each other.   They showed great resilience in the face of adversity, avoided complacency even when thrashing Brazil and celebrated their success, recognising everyone’s contribution.

How many healthcare departments strive to be the Ultimate Team?  How many doctors prefer the appeal of being the Ultimate Player? 

Top surgeon becomes a viral hit


There appears to be no shortage of opinion at the moment about the financial predicaments facing the NHS, with concerns being raised about its realistic life expectancy.  Lead stories are grabbing the headlines on an almost daily basis.  Take for example the BBC Health report prompted by a Nuffield Trust survey which concludes that there will be “a funding crisis this year or next”.  Labour’s Shadow Health Secretary Andy Burnham describes “an NHS now heading rapidly in the wrong direction.  It’s not just standards of patient care that are getting worse but NHS finances are in a dire state.”  Health Minister Lord Howe’s response is that “These predictions are pessimistic and paint an unrealistic picture of how the NHS is working.”  The political to and fro would appear to be never ending.

But where is the voice of the doctor in all of this political debate?

In late May of this year, a consultant surgeon, Dr Philippa Whitford who is originally from Ireland took the bold step of speaking out publicly, describing two possible futures for the NHS in Scotland and comparing this with likely developments in England. The youtube video of her speech has now received almost 40,000 views.

You may, or may not agree with Dr Whitford’s interpretation of the situation and the very act of speaking at a political event may be a bone of contention for some.  What is beyond doubt however is that Dr Whitford has a good grasp on the increasingly divergent NHS systems in each of the four nations which make up the UK.  She has taken this knowledge and used it to form a clear opinion.

The more we understand the systems which we work in, the more we understand what is changing and why.  This also enables us to participate more constructively in any discussions with colleagues, to implement changes more effectively and to increase individual influence.  For that reason, we have made changes to our Leadership and Management Courses to outline and discuss the differences of NHS in England, Scotland, N.Ireland and Wales.  Many doctors are surprised by what they discover!

The future of the NHS as a topic for medical interview questions

Several recent and current healthcare news stories from different viewpoints are colliding to create increasing alarm over the future pressures upon the NHS. The Health Select Committee has highlight the fact that dealing long term health conditions, such as diabetes, accounts for 70% of all health spending to be focused upon just 30% of patients.  By 2025, they estimate the number of such patients could rise from the current level of 15 million in England to 18 million.  The MP’s state that cutting back on hospital services “is a recipe for disaster”.  Side by side with this on the BBC News Health webpage coming regular reports of major investments in research and drug developments – investments which the manufacturers will want to recoup once their products are approved and released.

On the 7th of July, a letter was sent to The Times, signed by numerous high profile healthcare opinion leaders, including heads of Royal Colleges, provider representative groups and charities.  Their message was hard hitting and clear.  “Unless action is taken, by 2020 maintaining the current level of service provision will require an extra £30 billion just for the NHS.”  To put this in context, £30 billion is equivalent to the amount that we spend each year on defence.  They add the fact that similar financial crises face both social care and housing.  Simply making the NHS more efficient will not be enough and “the status quo is not an option.”  Stretching resources further can only add to the shortfalls in care which make the headlines.  The signatories point out the options: “higher taxes, payments for some elements of healthcare or a review of what is available on the NHS.” And they call for a “national conversation” to start now between politicians and citizens to be completed by the end of 2015.

Any doctor currently preparing for a medical interview, whether for a new consultant post, or at this autumn’s round of ST interviews, can reasonably expect NHS funding and structure to be on the agenda.  A firm grasp on the facts, including the range of opinions and an understanding of how future changes may impact upon patient care, colleagues and personal practice will demonstrate that you are in touch with reality.  This requires time to be set aside to proper research the topic and to crystallise you own point of view.   When doing so, it is always worth looking outside of our own system to see what others are doing.

One article in the Health Service Journal argues that Japan’s healthcare model, with a radical 2025 vision to address its own ageing population sets an example to the UK. Appealing though the ideals of integrated health and social care delivered via micro-multifunctional facilities may be, could an approach with such extensive private sector, corporate involvement ever gain commitment on these shores – especially as there is minimal evidence to support the model’s foundations?

More naming and shaming in healthcare

Hot on the heels of last week’s headline grabbing story regarding the new website which, as part of its brief, will name and shame NHS Trusts which have been rated poor for honesty and openness, Health Secretary Jeremy Hunt has gone on record to state that he wants to expose doctors whose failure to spot cancer may delay sending patients for potentially life-saving scans.

Naming and shaming is undoubtedly an NHS Hot Topic at present and therefore likely to be the subject of medical interview questions.  When asked a question on any topic, an effective answer conveys the correct factual information that is then used to convey a reasonable opinion.

But is naming and shaming only an issue for the top line of NHS leadership and management?

In his powerful lecture “Doctors make mistakes. Can we talk about that?” Dr Brian Goldman makes a very persuasive argument that the approach to errors is a piece of medical culture that has to change at all levels.  He discusses the messages which are ingrained from the earliest stages of being a medical student: “Be perfect; never, ever make a mistake”.  He describes his feelings of being alone, isolated and of shame when a mistake has been made.  He highlights that there are two kinds of physicians: those who make mistakes and those who don’t, those who can handle sleep deprivation and those who can’t.  He then goes on to describe what he calls the “redefined physician” who “is human, knows she’s human, accepts it … and she works in a culture of medicine that acknowledges that human beings run the system.”

Such an understanding, supportive, learning culture is quite different from both the naming and shaming world and the other unpalatable alternative where mistakes are hidden, denied and ignored.

Culture is something which has to be grown, nurtured and cultivated which depends upon deliberate acts of leadership and management.  The Healthcare Leadership Model states very clearly that these acts are not only for those who have the title of leader or manager.  Going back to Dr Brian Goldman, “it starts with one physician – and that’s me”.

Where do you stand on the naming and shaming approach to managing the NHS?

Naming and shaming in the NHS

A dominant story in the news this week has been the output and reaction to a government review which suggested that a fifth of hospital trusts in England may be covering up mistakes.  As part of their actions to stop 6000 preventable deaths over the next three years, a new website has been launched allowing patients to see the performance criteria of individual hospitals.  On this site, there will be an indication where a trust has been rated poor for honest and open reporting.

In their lead story on the topic, BBC news included the comments and opinions from a number of leading NHS stakeholders.  Amongst the contributors was Martin Bromiley, founder of the Clinical Human Factors Group, who campaigns for a safer NHS.  He made a number of key points:  simply naming and shaming would not bring the best results; understanding why organisations were not reporting incidents is key to progress; the best organisations were the ones that encouraged learning; he made a call for safety experts in hospitals.  In his view, there is a need for the NHS Leadership and doctors to learn from experts in other sectors and industries.

If this were to happen, would the NHS actually listen?  If so, what would be “heard”?

During our Teach the Teacher courses for doctors, we discuss the fact that listening is an active process by both the educator and the learner which requires willingness and effort from both parties.  There are numerous barriers to listening which can get in the way, in addition, when messages are heard they will then be interpreted through numerous filters by the listener.  Expectations and assumptions; feelings of authority or vulnerability; timing and previous experience.  These are just a few of the elements which come into play and colour what is understood.  This has to be considered for any teaching/learning environment, whether it be individual coaching, small group tutorials, large group presentation or indeed for expert consultations with large organisations.

So is the NHS ready to listen and learn?  Will the “teachers” be able to effectively listen to and understand the NHS?

Appraisal for doctors in the spotlight

The topic of appraisal, particularly in relation to revalidation, has been a focus of discussion at the British Medical Association’s Annual Representative Meeting this week.

Although doctors were keen to stress that they had welcomed and embraced what they believed would be a valuable process, which would make better doctors and benefit patients, the report on BMA news relays numerous negative comments.  Appraisal has become “burdensome”, “too time consuming”, “hijacked and made part of revalidation”, and is “no longer meaningful”.  There are “hoops to jump through and boxes to tick”, plus the process takes “both appraisee and appraiser away from spending time with patients”.  One delegate even told of his personal experience where his recent appraisal “found he had not reflected enough, nor reflected enough on his reflection.”  His summary stated “It’s not what we signed up for and it’s not what we developed.”

This final quote in particular begs the question:  Is it the principle or the implementation which is at fault?

There are responsibilities all round here, from the Responsible Officer developing and maintaining the appropriate culture, supported by effective processes, through to the appraisee adopting a positive approach to the process.  The initial and ongoing training of appraisers has to be a critical factor here.

The GMC’s revalidation requirements for doctors are dependent upon sufficient numbers of medical appraisers to be trained to a high and consistent standard in order to ensure a robust, effective process.  Before being absorbed into NHS England, the NHS Revalidation Support Team emphasised  in their document Quality Assurance of Medical Appraisers (Version 5: January 2014, that all medical appraisers “should demonstrate the same level of core competencies, so training programmes should be based on a strong core of material”.  In addition, doctors who work as medical appraisers are required to undertake continued professional development in this area, keeping up to date, enhancing skills and calibrating practice with other appraisers.

These are positive statements, which the RST has backed up by making outline training materials available.  However, to avoid appraisal and revalidation descending into the reported hoop jumping, box ticking, pointless exercise, it is essential that Responsible Officers ensure that quality appraiser training be delivered by expert facilitators.  This applies to both the initial training and to the ongoing improvement.

Can the current appraisal/revalidation system be implemented in a way which will achieve the intended goal of making better doctors and benefitting patients?  Or do we need a major rethink?

Satisfaction with the NHS

trends-in-satisfaction-with-the-nhs-since-1983Satisfaction with the NHS in Scotland has increased significantly in the last decade, research suggests.

According to an official survey of almost 1,500 members of the public (rather than patients), satisfaction with the NHS in Scotland has increased significantly in the last decade.  61% of those polled were either very or quite satisfied with the health service, compared with 40% in 2005.

Scottish Health Secretary, Alex Neil, attributed the findings to increased NHS staffing and a reduction in waiting times.

The statistics, the latest to be released from the Scottish Social Attitudes Survey 2013, were collected between June and October last year. The findings in Scotland outperform the latest findings in the rest of the UK. The British Social Attitudes survey collected results from June to September 2013 and found satisfaction to be the same as 2012 at 60% compared to a high of 70% in 2011. Attitudes towards the NHS are on a high with the last decade showing an improving trend for the whole of the UK, from a low of 38% in 2001 to 60% today. In only two of the past 30 years (2009 and 2010) have satisfaction levels been greater than those recorded in 2012 and 2013. Read a full report here.

At Oxford Medical, satisfaction with our own services is just as important. We regularly monitor, and act upon, feedback from doctors who attend our courses. If you’ve been to one of our courses, or purchased distance learning or guides online you can now contribute by posting a review about your experience on the independent review site Trustpilot.

If you’re thinking about attending a course why not see what others are saying about Oxford Medical and our services first?