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The ideal patient-clinician relationship is one of concordance. A shared understanding is developed leading to the patient playing an active part in their care. They follow their agreed treatment plan to achieve the best outcome in the circumstances. If only we lived in an ideal world! Although there are many patients who diligently and effectively implement their plan there are many others who do not.

On our Advanced Patient Communication Skills Course for Doctors we explore the ‘non-compliant’ patient by considering them in three broad categories. Once defined, we then investigate the drivers of each group’s ‘non-compliance’. One such category is the group of patients who ‘know what they should do but choose not to’.

So why do patients choose to dismiss your well-informed, well-intended advice?

There are many answers to that question. Often, it will boil down to a gulf between your patient’s care-plan and their beliefs or desires. Thankfully, drawing upon the work of Groopman and Hartzband can offer clues to help resolve or, even better, avoid such situations. It can be helpful to think of patients in terms of minimalists, maximalists, naturalists and technologists.

At their extremes:

• Minimalists resist and want to avoid interventions, treatment or contact with healthcare professionals
• Maximalists want and even demand attention and action for every ailment – real or imagined
• Naturalists trust mother earth or spirituality to provide the best solution
• Technologists that the very latest man-made inventions, drugs and techniques must be the answer.

If the descriptions above are viewed as two clear dichotomies this leads us to the four mind-sets illustrated below.

It is likely that patients with each discrete mind-set will express themselves differently. The deeper the roots of the attitudes and the more familiar you become with them, the more obvious they become.

• How could you raise your awareness and identify these differences?
• Once you are aware, what will you change about your approach and the language that you use?

A review by Dr Shivaa Ramsewak

Teaching is, to varying extents, part of the day to day work of doctors, with memorable teachers often having significant influence over a doctor’s early career path. It is therefore unsurprising that most job applications ask about teaching experience, making it not only a desirable, but necessary skill for junior doctors to develop. Medical schools don’t always prepare graduates for a role as a teacher and so many junior doctors seek to learn from experienced seniors, embark on courses, or try to use feedback from their own teaching experience to develop their teaching skills.

As a junior doctor early on in my career, I have enjoyed my experiences in the role of a teacher, from impromptu bedside teaching for medical students to more formal didactic teaching. Preparing for such sessions has not only allowed me an opportunity to get feedback on my teaching skills, but also to help with my own learning as preparing for them helps me to understand more about the topic of interest and identify gaps in my knowledge. I am therefore always looking for ways to improve my teaching skills and hoped that Oxford Medical Training’s Teach the Teacher Online course would help me to do so.

The course is divided into several sections, which you are able to dip in and out of at your own pace. In all, it takes about three hours to complete, which includes the time taken for offline activities to help you develop your own training projects. I found it most logical to go through each section in order and then revisit the sections I wanted to focus more on. The course starts by describing the theory and psychological approaches behind different learning styles, then goes on to setting aims and objectives, tools for designing and delivering training activities and finally, assessing the success of a training activity and feedback. I liked that there was a variety of teaching styles used – from theory, to short clips, to MCQs. Examples are used throughout the course to highlight different points and bring everything together. There are also opportunities utilising videos with actors to critique goal setting and delivery of a teaching session, which was a good way to consolidate the theory provided.

In addition to providing ways to improve and reflect upon my own teaching sessions, I found that this course not only helped me to think about my own teaching style and ability, but also how I set aims and objectives for my own learning and my personal learning style – both things which I think will be useful in setting personal development plans and in studying for the many assessments and exams to come. If you’re a reflective learner like me, or indeed a theorist or pragmatist, you could use this online course as a great alternative to the usual 2-day face to face Teaching the Teachers courses, allowing you to explore different sections and work through them in your own time. Alternatively it can be used as an adjunct to a face to face Teaching the Teachers course to further consolidate your training as a teacher.

Since our launch in 2004 we have grown our list of regular course locations to include London, Oxford, Nottingham, Leeds/Wakefield, Manchester and Glasgow. We also offer a growing selection of online courses. To meet the continuing increase in demand we are now extending our locations to include Birmingham. Our new venue is Aston Business School, an excellent modern facility within easy reach of the city centre, train stations, motorway network and Birmingham Airport.

Two of our most popular courses will run regularly from April 2017 with online booking available now. Top level descriptions of these two courses are listed below. Just click the course title for more detail and dates. Remember, we keep our course sizes small, ensuring optimal support with an interactive experience. Spaces are therefore limited. So book now to secure your place.

Teach the Teacher Course for Doctors

• 2 day interactive course
• Key theories of adult education
• Constructing effective teaching sessions
• 1-2-1 teaching skills
• Small group tutorial skills
• Large group teaching skills
• Accredited for 12 CPD points
• Click here for more detail, dates and bookings

Essentials of Medical Leadership & Management

• 1 day interactive course
• What makes a high performing team?
• Leadership Style and how to adapt
• Motivation and influence
• Leading both creativity and consistency
• Dealing with under-performance
• Accredited for 6 CPD points
• Click here for more detail, dates and bookings

Are you nearing the end of your specialist training programme? Then it is time to start considering your consultant interview. What do you think it will be like? Will it be anything like the candidates’ experiences on BBC One’s The Apprentice?

Watch this first clip where the interviewer has some first-hand experience of the interviewee’s work.

 

Ouch! How would you respond? How would your reaction affect your chances of gaining the position you seek?

To keep things in perspective we have to bear in mind that The Apprentice is created primarily for our entertainment. We all laugh and/or squirm as the outrageous claims on the CV’s are forensically examined. Thankfully, it should be rare to come up against the attitude taken by Lord Sugar’s henchman. However an interviewer does have a duty to dig deep to uncover the reality of who you are.

Take a look at the next clip. Unfortunately, even though the interviewer is far more reasonable, things go wrong once again.

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In this case the candidate in the hot seat digs herself deeper and deeper into a hole. Eventually she has dug so deep that it is impossible to recover.

What could have been different had this interviewee been able to anticipate the type of questions that would be asked?

Moving on from The Apprentice, amusing as these clips are, your consultant interview is a serious matter. Securing the position you desire after all the years of training can be a pivotal point in your career. It is no joke when we find ourselves in a position when we realise we could have either avoided or managed a situation more effectively with a bit of preparation. There is a lot at stake.

In the year, months, weeks and days ahead of this transition stage you will benefit from reflecting on your past personal successes and challenges. Its essential to choose the best examples, clarify your opinions and practice how to communicate them to deliver your best performance at interview.

We wish you well for the big event!

Any preventable death is a tragedy. The impacts are wide and varied. Families, carers, doctors, nurses and wider healthcare teams can all be affected. Though it is impossible to turn the clock back it is essential that one response to any such event is a thorough and robust review. Since the failings at Southern Health Foundation Trust he CQC has been exploring the processes of review and investigation of patient deaths in the NHS. The output is the publication of a report titled Learning, candour and accountability.

Learning, candour and accountability are three very well-chosen words. They are an excellent summary of the purpose, appropriate attitude and desired outcome for any investigation. Sadly, though not surprisingly, the CQC found great inconsistencies in the triggers, approach and quality of investigations across the NHS. Improvements have to be made.

Preventable deaths are at the high end of holding a review. As such, it is appropriate that such cases are led by senior personnel. In general they will be supported with the investigations and input of potentially numerous healthcare professionals of all levels. We should be expect that the leaders of the investigation will have undertaken dedicated training to be able to facilitate a quality review. What, however, of the skills of more the more junior doctors involved?

How appropriate is it to expect the skills required to conduct a thorough review,  to simply grow through experience? It’s more than just the process of reviewing itself. Investigations must also reach appropriate conclusions and ensure learning points are applied to future practice. There can be many pitfalls: confirmation bias; failure to gather information from appropriate sources; blame-focus; protection-focus and failure to effectively share learning to name just a few. Bad habits are as just as likely to embed as good practice when we leave development solely to experience.

With proper input and guidance, however, the principles of learning, candour and accountability can be grown from the earliest stages and throughout a career. Practicing their application to lower scale, more routine, even everyday matters today can pave the way to being able to deal with the tragic, controversial and high-profile investigations when the time comes.

How are you responding to the CQC’s latest report?

The skills associated with conducting an effective review are explored in our Practical Leadership & Management Course for Doctors.

A key point in Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry from 2012 was a call for ‘the recognition that healthcare management and leadership is, or should be treated as a profession‘.

Earlier this week I enjoyed two excellent days at the Leaders in Healthcare Conference. Over 800 delegates packed the halls and conference rooms listening to speakers from across the world and sharing their thoughts on the topic. There was a recurring theme of the principle that leadership is a behaviour rather than a job role. All  doctors have a responsibility to develop and utilise their skills to meet the challenges of the healthcare system, to support colleagues and to deliver excellent patient care. The event was a real demonstration of the drive to promote,enhance and professionalise leadership.

Half way through the second day I made an observation that I shared with some of my fellow delegates. Of the 35 sessions on the schedule more than 20 contained the words ‘leader‘, ‘leading‘ or ‘leadership‘ in the title. Only one contained any reference to ‘manager‘ and one sub-session the word ‘management‘. None mentioned ‘manage’ or ‘managing’.

Some delegates I discussed this with expressed the idea that when talking about leadership they really mean management too. It begs the question:

Is there a difference between leadership and management and does this really matter?

Countless writers and high profile speakers have expressed their opinions and given their personal definitions. Though some say they are one in the same, the majority would generally fall in line with the words of Rear Admiral Grace Murray Hopper who, at the end of her many years of service, as the oldest serving officer in the United States Navy: “You manage things, you lead people.”

The conference was an excellent example of the real focus that is being placed upon the development of leadership. Leadership is being discussed in terms which are ethical, noble and even heroic. Can the same be said of management? That is management with a small ‘m’, as a behaviour and not a role. Many doctors happily attended the Leaders in Healthcare Conference and will be putting next year’s event into their diary. How many of the same delegates would attend a Managers in Healthcare Conference. Again, does it matter?

Developmental focus

On our Teach the Teacher courses we often discuss the issue of people concentrating their development upon the things that they want, rather than what they need. The immature student without a study plan will often tend to read what they already know and what they find interesting. They do so at the expense of dedicating effort to the topics which they need to improve performance – the things which are less popular, less attractive, seen as difficult or even dull. Could this be happening to the medical profession with its focus on leadership at the expense of management skills?

Putting a clearer definition to the different terms may help:

• Leadership – getting things done through interactions with other people.
  • understanding of how teams develop and function; understanding your leadership style and the alternatives; engagement, motivation and influence; encouraging both innovation and consistency and dealing with under-performance.
• Management – getting things done through organisation and utilisation of people, projects and resources
  • establishing proficiency in the tools and process which enable everything from decision making, effective participation in short meetings through to complex projects; conducting effective reviews and research; clearing defining what is required and how even ‘soft’ targets can be measured; robust planning techniques; effective time management and delegation.

A doctor with strong management skills will increase their personal effectiveness and efficiency. A healthcare team with strong management skills will be more effective and efficient. A healthcare system with strong management skills will be more efficient and effective.

The development of medical leadership is gaining real momentum. How do we  make the change where developing the skills of practical management for doctors also receives the attention it deserves? That, ironically, is a challenge for medical leadership!

Let’s step away from your medical practise for a few moments.

Ask yourself: When do I learn the most?

How did you develop your ability to play that musical instrument/play that sport/bake that cake/do that card trick or whatever else you are capable of?

Do you believe in natural, god-given talent with instant brilliance or that we learn through making mistakes?

In the words of Oscar Wilde, “Experience is simply the name we give our mistakes“.  The sentiment here is simple, clear and difficult to argue with. However, does this pose a dilemma in relation to supporting the development of other doctors? Are the  consequences of mistakes in healthcare such that they are unacceptable?

How then to support the progress from novice to expert?

A great mentor and teacher will recognise that mistakes are an essential, integral element to develop knowledge,  skills and attitude. This concept is referred to across history, culture and literature. Through his characters in Journey to the Centre of the Earth, Jules Verne imparts the wisdom that, “Science, my lad, is made up of mistakes, but they are mistakes which it is useful to make, because they lead little by little to the truth.”

Of course, there is a fundamental difference between the acceptance that mistakes are essential to progress and that they should be allowed to go unchecked. A starting point must be a recognition that something has indeed gone wrong. In the words of martial arts master Bruce Lee, “Mistakes are always forgiveable if one has the courage to admit them.” How forgiving is the environment that you work within? Truly forgiving cultures, with openness and honesty, are highly dependent upon the attitude of the leaders, teachers and mentors involved.

When 60’s rock icon Jimi Hendrix pointed out, “I’ve been imitated so well I’ve heard people copy my mistakes.” he was expressing awareness that he, a virtuoso, could have performed more effectively. When a teaching doctor is unaware or unwilling to recognise their own shortcomings, the risk is that these are repeated by the learners.

No-one benefits from a Dr Britney Spears regularly declaring, “Oops, I did it again!” or a witty Dr Peter Cook version who dryly quips, “I’ve learned from all my mistakes, and I’m sure I can repeat them all exactly.” The point of being open and honest about errors is that they are explored in a manner which leads to changes – changes which are the stepping stones to expertise.

So how, where and when is it acceptable to allow doctors to make mistakes for learning?

We regularly discuss these challenges in our Teach the Teacher and Mentoring Skills Courses for Doctors. There are many options. This is where development activity overlaps with risk management, planning and supervision in all its forms.

Talent takes us so far. Expertise takes conscious practice, pushing forward, recognition of mistakes and taking action to change.

How are you supporting your learners in making their own mistakes?

Stephen McGuire – Managing Director

A review by Dr Shivaa Ramsewak

Having taken a year off after F2 to do a masters in public health, the idea of joining an entirely new healthcare team, at an unfamiliar hospital, in a previously unknown area was incredibly daunting. During medical school and foundation training, there was a lot of emphasis on team working and leadership, and junior doctors are required to complete 360 degree assessments which require feedback from each part of the healthcare team (consultants, other junior doctors, nurses, ward clerks, pharmacists, and so on, depending on the rotation) in order to pass their F1 and F2 years. My hope for Oxford Medical Training’s online ‘Healthy Teams in Healthcare‘ course was that it would serve as another tool to help me reflect on my own behaviours that could hinder my ability to perform effectively and become accepted into the healthcare team, and to understand how to change these behaviours so that I would be able to assimilate into my new job more easily.

The course described two frameworks for understanding what makes a successful team: the Healthy Teams model, which outlines the key requirements of a team, and the Five Dysfunctions of a Team, which illustrates elements which may cause problems within a team and thereby result in ineffective teamwork and poor results. I found that these frameworks were useful ways to think about working in a team, and although a lot of the material covered was information I had either been told previously or had thought about in abstract, I found it much more practical and memorable to aggregate the various concepts into more formal structures. The components of the Healthy Teams model and the Five Dysfunctions of a Team were each described in detail, as well as ways in which each requirement of a healthy team could be affected by the relevant dysfunction. While working through the course, I was able to put the concepts described into the context of my own experiences when teams had worked well (and not so well), and the questionnaire at the end helped me to reflect on how my individual performance might have contributed to these outcomes. I found the sections on common goals and effective feedback particularly relevant, as forming goals and giving and receiving feedback are areas that I have had difficulty with in the past.

Overall, I found this to be an enjoyable and practical course, which provided me with the knowledge needed to reflect on my own previous experience of working in teams, as well as ways I can improve to become a more valuable and effective team member. I would recommend it to anyone who’s interested in understanding more about the dynamics of team working. It took just under an hour to complete, and so would also be ideal for anyone with a spare hour who is looking to build up their non-clinical skills. I am looking forward to repeating the questionnaire once I have had a chance to put these concepts into action at my new job and seeing if and how my responses change.

Oxford Medical Training specialise in developing teaching, interview, communication, leadership and management skills for doctors.

An open letter to the BMJ.

Our NHS struggles to identify cost savings without impairing quality and efficiency. Sometimes its sheer scale can make it difficult to see how any one person or team can make a significant difference.

In a recent edition of BMJ, David Oliver correctly points out: ‘To become an effective consultant, learning through clinical practice isn’t sufficient: it increasingly requires grounding in leadership, management, research, appraisal, and quality improvement. These skills are taught by existing consultants, taking time away from direct patient care.’

Developing any quality training event takes considerable time and effort. One-hour sessions require several hours of preparation. Creating a one-day course implies significant time away from direct patient care – unless this work is undertaken voluntarily ‘out-of-hours’.

How many doctors are at any one time developing teaching sessions on the exactly same subject? What are the associated costs and time away from patients? With each of these doctors inventing their ‘own version of the wheel’, how variable are the standards?

The attempts of numerous Trusts to save costs through staying in-house collectively cost the NHS dearly, both in time and money, with variable quality results. Other options are available.

Letter sent to the BMJ by Stephen McGuire, Training Manager, Oxford Medical Training, on 13th September 2016 in response to Don’t undervalue non-clinical work; David Oliver; BMJ 2016;354:i4656

Oxford Medical Training specialise in developing teaching, interview, communication, leadership and management skills for doctors.

In recent years, some high profile writers, including Atul Gawande, (The Checkpoint Manifesto) and Matthew Syed, (Black Box Thinking) have drawn sharp contrast in the approach to learning from errors within healthcare when compared to aviation.

Aviation is, in relative terms, a young and technologically advanced industry.  It is one where basic errors can result in catastrophe.  The culture which has developed is one where there is belief that errors and malfunctions are inevitable in the face of complexity.  Errors and malfunctions, from the minor to the disastrous, are opportunities to learn – not just for the individual, or the organisation, but for the industry as a whole.

Similar dramatic advancements can be witnessed in other arenas, including Formula 1 motor racing.  The detailed, critical analysis in response to every incident means that we now regularly witness racing drivers walk uninjured from the most spectacular high-speed incidents.

The writers mentioned have presented the practise of medicine to be considerably different – with a culture which is problematic to learning and progress.  They describe a culture where there is a lack of investigation, in awareness regarding the cause of errors, of avoidance and even concealment.  Rather than suggesting any willful malpractice, one driver of this culture is identified as the historical, unhealthy, hierarchical reverence which results in a reluctance to challenge.  Another driver is the well-meaning concern for the feelings of patients and relatives, to soften the blow when things have gone wrong.  Doctors have learned to talk in euphemisms where ‘malfunctions’ and ‘mistakes’ morph into “complications”, or “unexpected outcomes” in a world where “I’m afraid these things happen”.

Aviation and Formula 1 have many advantages over medical practise.  Financial investment of commercial organisations versus public services would seem like an obvious difference.  Yet there is plenty of evidence to support the approach of reducing medical errors to reduce costs from further patient care and litigation.  Aviation and Formula 1 do benefit from a variety of technical tools, including black-box recorders, a mind-boggling array of sensors and simulators.

While the tools themselves are difficult, if not impossible, for many medical disciplines to replicate, the underlying principles can be utilised:

• Reviewing the collated information enables the identification of any deviation from normality.
• Review is applied to minor as well as major incidents.
• Small errors are the early warning signs of future major incidents.
• The identification of patterns of errors should lead to change.

Thankfully, there are plenty of healthcare examples where significant progress has been achieved.  One high-profile example is the Virginia Mason Health System in Washington which pioneered the Patient Safety Alert System.  This review system, where healthcare workers report their own errors or safety concerns, is credited with transforming the hospital into a genuine learning organisation.  As a result the Virginia Mason is now recognised as one of the safest hospitals in the world.  However the change did not happen overnight.  Doctors and other healthcare workers were initially reluctant to file reports and raise alerts as their attitudes were rooted in the previous culture.  Eventually, they found that, other than in situations where they had obviously been reckless, they would be appreciated and not punished for presenting a problem.  This in itself required a significant and sustained change in the leadership approach throughout the hospital: the acceptance that errors and malfunctions are inevitable in the face of complexity and are an opportunity to learn.

Of course, there are other high profile examples of similar progress.  There are many examples where systems have been implemented in response to patterns of errors being identified.  Where ideas have been shared, others have been able to build upon the successes – just as in aviation and Formula 1.

Problems, however, definitely still persist.

In 2015 the UK Government published a report into clinical incidents in the NHS.  It concluded that processes for investigating incidents were in place but that the prevailing culture was preventing them from being effective.  It found that the focus of reviews was ‘preoccupied with blame or avoiding financial accountability.’

To quote Matthew Syed: ‘This is the paradox of success: it is built upon failure.’ and from Dr Gary Kaplan of Virginia Mason: ‘We learn from our mistakes.  It is as simple and as difficult as that.’

What are you doing to make the changes required in healthcare to make this learning a reality?

The challenges raised in the text and the solutions are explored in our new CPD accredited one-day course Practical Management for Doctors.