5 hitmen and delegation by doctors

5 hit men

The winners of the 2020 Ig Noble Awards have been announced. If you are unfamiliar with this interesting alternative to the prestigious Noble prizes, the “Igs” are awarded annually for research and “achievements that first make people LAUGH, then make them THINK.” News media have followed the ceremony with a range of amusing reports. They include identifying what happens to an alligator’s “voice” when it inhales helium. Then there’s the Ig Noble Peace Prize. It’s goes to rival pair of governments for encouraging their diplomats to ring each other’s doorbells in the middle of the night, then run before the door is answered. And a collection of world leaders are now the bemused recipients of the Medical Education Prize. Their achievement? “…for using the Covid-19 viral pandemic to teach the world that politicians can have a more immediate effect on life and death than scientists and doctors can.”

As they say, research and achievements that make you laugh and then think!

Time to laugh

This year’s Management Prize is an interesting one. Ig Noble have awarded it to five professional hitmen who participated in a dark but comical conspiracy. Here’s a quick summary of the hit that never was.

  • A shady business man, Qin, paid a hitman, Xi, a total of 2,000,000 yuan to assassinate his business rival, Wei.
  • But Xi kept half the money and paid Mo 1,000,000 to do the deed.
  • Mo then sub-contracted Yang-KS for the job and kept a share of the fee.
  • And Yang-KS did the same by passing the job onto Yan-GS.
  • Next, Yang-GS paid Ling 100,000 to complete the hit. That’s just 5% of the original contractor’s payment.
  • Ling met Wei, the target, told him of the plot and they faked the assassination.
  • Wei went into hiding while Ling sent the “evidence” back up the chain of command.

Everyone’s a winner! It could be the skeleton for the mad-cap, feel-good movie of the year. But, as Ig Noble say, some things that make you laugh and then make you think.

Time to think

So, what does this remind you of?

Your first thoughts might well be toward the numerous healthcare related services and projects that are commissioned on a daily basis. A top-level person or body hands some big cash over to a multi-national who sub-contract work to another organisation. They, in turn, pass the work onto a franchise operation within their group which pays a local company of tradesmen to perform a specific task. Done well, with good governance, this can be an efficient and effective way to translate complex national or regional programmes into local actions. But there are risks. One is that cash can needlessly evaporate out of the system at every step. Another is when the person or body commissioning the activities assumes they are being completed to an appropriate standard. They’re blissfully unaware of the harsh reality of unfinished or substandard work.

Involving of chains of people, teams or organisations can end up with systems and ways of working that are costly, over-complex and fail to achieve their well-placed intentions. Take the appraisal-revalidation system for doctors as an example. Few would argue against the ideals. We must maintained standards and strive for improvement. Combining well-planned CPD with reflective learning makes perfect sense as the way to achieve this. Yet too many doctors find the current processes a waste of their time and effort.

Everyday delegation

You may, or you may not, have any influence in such commissioning or national systems. But, even if you don’t, the story of our five hitmen should still make you stop and think. At it’s heart, it is a tale of delegation gone wrong.

How often are tasks delegated to you? How often do you delegate tasks to other people? It happens all the time. It’s essential for continuity of patient care, for general efficiency and effectiveness. All doctors must learn to participate in delegation and learn to do this well. The best approach varies dependent on the abilities and confidence of person you are asking to undertake the work. It also varies dependent on the nature of the task and the reasons for not doing it yourself. Then there’s an additional layer of complexity if the person you are delegating to will in turn delegate onto someone else.

The need for good delegation occurs at the end of every shift, when one team must handover patient care to another. That second team will then handover to another at the end of their shift. When you factor in having a day off, there could easily be five acts of delegation before you are back in contact with your patient. Maybe more.

What lessons about delegation and continuity of care and can you learn from the story of the five hitmen?

Stephen McGuire – Managing Director

End of the specialist era?

The current system of medical education “places disproportionate value on specialism.” These words appear in the foreword to Health Education England’s latest paper on The Future Doctor Programme. And this thought is more than just a throw-away comment. Moving away from over-specialism is central to the proposals HEE have developed through collaboration with other bodies. The fact that our system is predominately staffed by doctors who have gained deep expertise in one area at the expense of breadth is identified as a key reason for its shortcomings. The need to see numerous different specialists, even when conditions are related, “costs patient time and risks fragmented care, duplication and waste.”

So, what’s the proposal?

Step forward The Extensivist and Generalist. I’ve replicated the diagram HEE have used to describe the T-shaped skill-set of this Future Doctor. The idea is that a system where more doctors have both breadth and depth in capability will be genuinely patient-centred rather than disease-centred. Doctors with T-shaped skill-sets are better equipped to manage multi-morbidity. They are more likely to see the big picture, recognise how and why one thing impacts on another and enable holistic management. So, their attention naturally shifts from treating a disease to patient care. Of course, there are still times when such doctors need help. When this is the case, their cross-discipline competence enables them to collaborate with others in a meaningful way.

And there’s more…

The Future Doctors described in the paper have more than breadth and depth in medical expertise. They are multi-faceted and multi-dimensional. They must be able to apply both the natural sciences and social sciences to clinical practice. Our Future Doctors are independent thinkers who are experts in managing uncertainty and ambiguity. They are confident in “resource stewardship… delivering quality care while balancing economic, environmental and social constraints.” The diversity of our population demands expertise in cultural awareness. They must understand the system they work in if they are to be able to optimise services. Leadership, followership and teamwork with the broad range of health and social care providers is essential. They must acquire knowledge about the general principles of scientific research. Then add expectations of excellent communication and teaching skills to the mix. The list goes on.

Many of these requirements are familiar. They are all present either explicitly or implicitly in Good Medical Practice. Yet, reading the lengthy list of “How Must Education and Training Adapt?” statements which appear in HEE’s document, the skill-set expectation of the Future Doctor sounds more like a multi-pointed star model than a simple T-shape.

Is the Future Doctor a realistic goal?

Going back to The Future Doctor Programme’s foreword, there’s recognition that, “For some, it will not go far enough or fast enough, and for others, it will feel like too much too soon.” The latter group may well include the doctors who have aspired to focus on specialism even before starting medical school. It doesn’t mean there will not be specialists. Just that their training and ways of working will be different than they are today. But there are questions over how to create this cohort of doctors who are Extensivists and Generalists.

Is it, for example, realistic for someone to develop the same depth of capability as the current specialist but also have this new desired breadth? How many doctors have the mental capacity to achieve both? Or is this breadth to be gained, to some extent, at the expense of depth? And, while we often think of steep learning curves, what of the “forgetting curve”? If you don’t regularly use what you’ve learned then you’re likely to lose it. After all, you can do anything, but you can’t do everything. So, there’s a risk that a longer time spent on broad-based training before specialism could be a waste of effort.

These are big questions with major implications.

What happens elsewhere?

Many employers in other sectors set out to recruit people with T-shaped skill-sets. But they struggled to find them. Such people can be few and far between, often found in the senior reaches of organisations. They have gained their combination of breadth and depth through many, many years in different roles, often across different organisations and industries. And their efforts at “creating” such people are typically doomed as their lengthy and costly development programmes lose direction. There’s always a high-risk point when the current leaders and sponsors of the programme move on.

But, if the idea of the Extensivist and Generalist approach is the key to efficient, effective, quality care, then these questions and challenges must be resolved. The Future Doctor must become reality. But how?

Sometimes it helps to look at things upside down.

Well, sort of. Rather than think about depth of expertise, let’s think about height. Let’s think about building a pyramid of skill rather than the point of the T drilling downwards. If you are building a pyramid, you will spend a lot of time on the foundations. Each time you begin to add height you will revisit the layers below right down to the foundations to ensure they are solid. You simply can’t imagine adding a new step if there’s nothing there to hold it in place. And you realise that a broad base with well-planned execution creates a more stable peak. Contrast that with trying to win the argument to widen the hole when drilling deeper and deeper downward as fast as possible seems to be bringing rewards.

Pyramid builders

Pyramid scene

Building a pyramid of skill is in itself a multi-faceted task. It requires excellent leadership, teamwork and communication. Planning, prioritisation and constant assessment is essential through robust management skills. It requires experts of many types who are capable teachers and mentors. Building multiple pyramids will require the commitment and co-ordination of everyone involved. So, the pyramid builders must optimise their own skills-set in terms of both breadth and height. The results will be spectacular!

What are you doing to develop yourself to play an active part in creating our Future Doctors?

Stephen McGuire – Managing Director

A new medical interview question

Doctor pondering a tough interview question

The pandemic has been a dramatic collective experience for our society. It’s the type of rare event where the lasting impacts are bound to be far and wide and deep. Healthcare is right at the centre of this, meeting unprecedented challenge with fundamental change. The NHS created field hospitals at surprising speed. Specialists took on unfamiliar roles. Many doctors and other healthcare professionals were trusted with greater responsibility. The need for genuine interdependence with the social care system became more obvious than ever before. Then there was the widespread transition toward digital consultations. I’m sure you can add many other points to this list and that’s before we even start to consider the impact that this has had on you as an individual.

Focus and purpose of a medical interview

Though it may seem like stating the obvious, the task for any interviewer is to find out about you. I’ll explain why this is worth mentioning shortly. They want to uncover your skill levels and development requirements, your attitudes and opinions, your interests and motivations. Rather than pose theoretical scenarios, (which they may well do), the most effective approach is that they probe your real experiences. The more recent, the better. So, with that in mind, a very good question for them to ask is…

What have you learned from the pandemic?

Can you answer that clearly and concisely? Then there are a whole host of underlying and related questions. Tell us about your experience. What challenges did you face? What did you do? Why? What was the impact? What do you now do differently as a result? Can you give us an example of that?

These aren’t really new questions as such. Together, they are simply a good example of an exploratory approach framed in current circumstances that every interviewee should be able to respond to.

Some doctors on our courses expect to be told what to say. But there are no stock answers for these questions. That’s because your individual experience within the global pandemic is unique. In fact, if the purpose of the interview is to find out about you, then there are very few questions where stock answers can be effective. That’s why our approach to medical interview preparation is to help you identify your most relevant experiences, then support you to communicate how they have influenced you to become the person that you are today. We believe that such awareness can open the door for you to become a better doctor. So, pausing to take stock and identify what you have learned from the pandemic is relevant for everyone – even if you’re not about to face an interview. It is likely to be a topic for discussion during your next appraisal or ARCP.

Lifelong learning

The best doctors are able to learn from their experiences. They grow as a result of their difficulties and failures every bit as much as they do from their successes. They identify areas for improvement and proactively take action, rather than simply collecting CPD points because they have to. Having the self-awareness to be able to provide evidence of learning and change will impress any interview panel, appraiser or supervisor and will be driving force for your ongoing development. Proactively revisiting reflective writing skills can open the door to achieving this.

So what have you learned from this pandemic and what are you doing differently as a result?

Stephen McGuire – Managing Director

Why don’t doctors ask each other for help?

A doctor not asking for help

What are the qualities which come to mind when you consider a good doctor? Your immediate thoughts might focus on medical knowledge, clinical expertise and patient communication. Spend a little longer on the question and you might add ability to teach, keep calm in a crisis and good time management to your list. Or, perhaps you came up with a different set of qualities. Now let’s consider a slightly different question.

What qualities do all good doctors have in common, regardless of experience or seniority? Think of doctors in their foundation years, in specialist training, SAS, locums and consultants. Think of the best examples and what they all have in common. Where does “asking for help when required” appear on your list. Does it matter?

Reluctance and the consequences.

In 2018, BMJ Leader published Team interaction for medical leadership, the output of our study into the behaviours of over 200 doctors. We found that 39% of doctors stated that they don’t discuss the support they required to fulfil their role either enough or at all. Participants ranged from FY1 to Medical Director. They included consultants, locums, physicians and surgeons. That’s effectively 2 out of 5 doctors not asking for help when they need it. Again, does that matter?

Failing to ask for help or discuss support required can have serious consequences. Patient safety is the most obvious. But there are consequences for doctors themselves. It can begin with the immediate stress of struggling with a situation. That can affect confidence. Unresolved, this can easily derail a doctor’s career away from an area of interest. Worse still, chronic exposure to stress and isolation are directly implicated in burnout. And there are consequences for teams, departments and organisations too. Failure to identify problems, shortfalls in performance and inefficiency to name a few.

So what’s the root cause?

If reluctance to seek help is the symptom, then diagnosing the reason can help to identify the solution. Unfortunately there are numerous potential causes. And the problem in any one case may be multi-factorial. Let’s consider the issue in three broad categories.

Doctors who don’t think they need help.

We regularly discuss unconscious-incompetence during our various Medical Teaching Skill courses. The inexperienced doctor who is out of their depth without realising it is the most obvious. Any doctor involved in supporting the development of others must be constantly vigilant to this possibility.

But it can easily affect the experts too. When we spend long periods of our time practising with unconscious-competence, our lack of attention and awareness allows bad habits and shortcuts to creep. That’s a step away from returning to unconscious incompetence. Revisiting and refreshing knowledge via Continued Professional Development across the entire scope of practice is therefore essential.

Those who are highly-skilled and knowledgeable with a long sequence of successes can also develop a sense of bravado and hubris. They may not see their errors or even be willing to discuss the possibility. So doctors need to be able to have the tough conversations required to prevent their colleagues joining the ranks of the problematic divas.

Doctors who want help but can’t ask.

Sometimes, a doctor may believe that they can’t get help. This may genuinely be the case. A time-pressured emergency situation arising when the department is over-stretched is one example. But sometimes the lack of available help is only a perception, rather than reality. In our “Team interaction challenges…” study a quarter of the doctors involved reported that they believed their colleagues were unwilling to take on additional tasks to support them. Yet almost every participant said they were willing to help their colleagues.

Practical leadership and management is essential to ensure that the team learns from it’s difficulties, establishes robust support processes and that everyone knows how to get the assistance they require.

Doctors who choose not to ask for help.

Good doctors are appropriately knowledgeable, competent, confident, consistent and reliable. Unfortunately, some interpret the expectations that others have of them, or that they have of themselves, to mean that asking for help is a sign of weakness. In fact, there’s evidence that the opposite is true. People who seek advice in the right circumstances are generally perceived as more competent than those who do not.

Another barrier to seeking help is the expectation of a poor response. A doctor may feel intimidated in approaching a more experienced colleague. “My door is always open if you have a question,” is easy to say. But attitudes and actions speak far louder than these well worn words. Why would anyone approach someone for help if they expect to be dismissed, ridiculed or greeted with irritation?

The way forward.

The days of the infallible, heroic, solitary doctor are long past. In contrast, the demands of modern healthcare mean leaders must strive to develop real teams with a strong sense of interdependence. This is where everyone is willing and actively engaged in supporting each other. This requires an understanding of team dynamics with awareness of each members attitudes, strengths and insecurities – and even the most experienced doctor is willing to ask the most junior for input and ideas.

What are you doing to ensure that you and your colleagues around you are able and willing to ask for help?

Stephen McGuire – Managing Director

Herd immunity to groupthink?

Cartoon image of a herd of animals

When we are debating an issue, loyalty means giving me your honest opinion, whether you think I’ll like it or not. Disagreement, at this state, stimulates me. But once a decision is made, the debate ends. From that point on, loyalty means executing the decision as if it were your own.” So said Colin Powell. He was the four-star U.S. General who became a popular figure to quote for leadership training in the first decade of the 21st century. It makes sense, right? But now sit his words beside those of astronaut Chris Hadfield. “There is no problem so bad that you can’t make it worse!

Hadfield ventured into space three times in his career with NASA. He used this phrase to great effect during a talk he delivered on TED. It’s basically an update on the old adage that, “If you’re in a hole, stop digging!” Unfortunately, “no problem so bad that you can’t make it worse,” is a sentiment which those involved in space exploration have learned at great cost. They have learned from tragedies which have, rightly or wrongly, been blamed on problematic groupthink.

What is groupthink?

People connecting with each other, creating consensus of beliefs, what is right and wrong with positive peer pressure can provide a solid foundation for the development of a community or team. It can create a virtuous circle of improvement, achievement and wellbeing.

However, ‘groupthink’, as defined by Irving Janis, is a problematic mindset where tribal instincts where desire for belonging and expectations of conformity spiral out of control. The ‘echo-chambers’ which can develop in social media are a good example. Participants can become close-minded, hearing what they want to hear, rationalising all information and events as evidence which reinforce their beliefs. They may even reject conflicting facts as ‘fake news’ or a hoax. Members of the group then typically fall into line and avoid rocking the boat rather than question the obvious. A bad problem can get worse and worse as participants become more and more deeply entrenched.

There may well be a broad range of contributing factors. However, groupthink can develop quickly and easily. Our tribal instincts of needing to belong can drive us toward thinking in terms of “them and us” faster than we often realise. Last year, the GMC identified a set of problematic subcultures which exist within the medical profession. Subcultures can grow around divas and/or patronage of certain individuals. Factions develop. Groups of people who feel embattled can collect together, reinforcing each other’s feelings of pressure and hopelessness. Some groups can become insular and detatched, their practices increasingly deviating from accepted standards but are convinced that they are doing the right thing.

Risk points

The problems of groupthink can become greatest when the stakes are highest. It may become acute when time pressures are intense, when there are conflicting demands or when there is a lot to lose. This loss could be physical, emotional, reputation or about resources. Concerns over loss of resources can include time having been wasted, need for unexpected additional time commitment or finances.

We may become closed to new information or fail to speak up when there is a state of urgency. We may not want to hear what we need to hear when the message means having to admit we got it wrong. And we may argue against any idea if it means undoing a great deal of work where we have already invested time and energy – even when tat idea makes perfect sense.

So here’s the flaw in taking Colin Powell’s words at the top of this page out of context. “When we are debating an issue, loyalty means giving me your honest opinion, whether you think I’ll like it or not. Disagreement, at this state, stimulates me.” Such an approach is an excellent groupthink preventer. However, “From that point on, loyalty means executing the decision as if it were your own,” must come with some caveats. Commitment is commendable, but these words can easily be interpreted as, “we will now be resistant to new information.” That would be a dangerous groupthink catalyst.

Developing herd immunity

There is no problem so bad that you can’t make it worse!” Time and the inevitable inquiries will tell if the “herd immunity” approach to dealing with the COVID-19 pandemic was ever the government’s original policy. Was it this approach that made the bad problem worse? Did it have it’s roots in groupthink? Or could it turn out to be the only solution after all? Let’s park that debate and think of herd immunity in a different context.

Herd immunity – where enough members of a community are resistant to something – is an interesting concept to think of in relation to problematic groupthink. If enough members of a team are willing and able to challenge beliefs, point out the issues, listen to inconvenient truths and at the same time stay true to their values then that team will collectively develop an immunity to groupthink. Achieving this requires all members of the team, from most senior to most junior, to develop excellent team communication skills. It is dependent on every member being able to engage in difficult conversations in a constructive manner. People have to be able to speak up if they can see a problem – even after the decision has been made.

What are you doing to help develop herd immunity to groupthink?

Stephen McGuire – Managing Director

Getting the most from video conferencing

Someone falling asleep on a video conference

The pandemic has impacted our lives in dramatic fashion. Some of these many changes will be transient. Others are likely to be fundamental with our perceptions, values and behaviours permanently altered from the previous norms. One notable phenomena is the acceleration of video conferencing across the globe. Families, friends and businesses are keeping in touch via Skype, Zoom, Webex, or any of the other digital platforms which facilitate people getting together. These programmes have been around for a while but have constantly developed and become increasingly effective in recent times through improved internet and WiFi connections.

A change in healthcare

When it comes to healthcare, the most obvious and lasting change may be the shift toward online patient consultations. In the right circumstances, they provide clear benefits to both doctor and patient. They work well for discussion based consultations and for triage. And there can be clear time benefits too. For the patient, a 10 minute visit to a doctor in hospital might represent around three hours away from work. A 10 minute online session on the other hand will take them just over 10 minutes. And for the doctor? If it normally takes an average of one minute for your patient to gather their things, walk to your room then get seated and you’re working on 10-minute appointments. well that represents 10% of the allotted time.

The rise of the video conference

Video conferencing is also now being used for a growing percentage of the other meetings that doctors are involved in. There are progress meetings between trainees and educational supervisors. There are team meetings to maintain and develop everyday working standards. Then there are inter-team project and programme meetings to create new systems and services. Many of these are now taking place online, just as they are in every other sector.

A quick search of the internet reveals all sorts of hilarious video conferencing disasters. You’ll find the toddler marching into the room followed by baby sister then the panicking mother while Dad is being interview on BBC News. There’s the guy who is presentably dressed in jacket and tie – not realising that everyone can see that from the waste down he’s only wearing boxer shorts. And then (oh, dear), there’s the woman who actually goes to the bathroom and everyone can see what she’s doing. Such embarrassing escapades are easily avoidable by engaging even the smallest bit of thinking.

But how do you really get the best out of video conference meetings? It’s useful to consider this from two points:

  • How does this differ from the traditional meeting?
  • How is it the same as the traditional meeting?

So what’s different?

The obvious point is that you’re not in the same room together. So the focus of your attention and the distractions are different. Background noise can be significantly reduced if everyone turns their microphone off unless speaking or directly involved in a discussion. Engagement is always best when everyone has their camera turned on. At very least, it discourages “doing other things” as others can see you.

Most digital conference platforms give you a choice in what you see on your screen. For example, in Zoom, selecting “Speaker view” fills your screen with the person who is speaking. This is a good choice when there is one person talking as you can give them your full attention – just as you would in a normal meeting. “Gallery view”, on the other hand, shows everyone present on screen at the same time. It’s a good choice for dynamic conversation or for the times when you are the key speaker as it helps you’re awareness of the whole group. Controlling and altering the type of view at different times is a good way to keep your focus.

Eye contact is another simple change that can have a significant impact. When we are with people, we spend most time looking at their eyes and mouth. It let’s them know you are interested in them. When you are on a video call you are looking at a screen and the position of your camera will often mean it looks like your gaze is elsewhere. So, make sure you know where your camera is – and look directly into it when you are speaking. It will look like you are looking straight at your listeners.

And what’s the same?

Perhaps the biggest improvements come from recognising there are more similarities to meeting together in one room than there are differences. Acting the way that you would – or at least should – if you were there in person provides good guidance. But that brings up a whole new set of issues because too many “real” meetings are ineffective because the people participating get it wrong too often.

So any meeting, wherever it takes place, will have a better chance of success if:

  • everyone is clear on it’s aim – why is it happening and what should be different as a result
  • everyone has prepared properly – arriving on time with the information they need to hand and with all actions required completed
  • everyone participates in a constructive manner and gives the meeting their full attention
  • everyone is clear and in agreement about what should happen next – who should do what and by when
  • for repeating meetings, the participants regulalry discuss how they are being conducted – what’s going well, what’s not and how they can make things more effective.

If you’re taking part in a video conference meeting from home just do the same things. All you need to add to that list is letting your family members know what you’re doing, go to the toilet before you start and, of course, remember to put on your pants!

Find out about courses running in our Virtual Training Room.

Stephen McGuire – Managing Director

Adapting to the new reality

Sunrise over water

Change is a journey. And, just like any physical journey, it doesn’t happen in an instant. Such a feat transportation is for the realms of science fiction. We don’t just teleport from A to B in a flash – and we don’t expect that to be possible anytime in the near future. A lot can happen on the way from A to B. And the longer the distance, the more unpredictable our journeys become – especially if we are heading somewhere we’ve never been before. So, we shouldn’t expect to be able to instantly change the way that we think, feel and act to be able to function in this new unpredicted reality any more that we would expect to teleport from A to B. Likewise, we shouldn’t expect our teams and colleagues to perform feats of instant change that belong to the world of science fiction either.

Enabling change

Achieving and sustaining real change depends on alignment of numerous behaviours and factors. It demands collaborative and compassionate leadership: envisioning the future; getting others on board; harnessing energy and channeling it in a constructive direction. It requires considered practical management to clarify plans, define processes, allocate actions and ensure everything is on track. Effective team communication where everyone takes responsibility, encourages or challenges colleagues as required and speaks up when something isn’t right is also essential. And it typically requires teaching new systems and skills. Or it may require coaching and mentoring individuals to help them find their own solutions, enabling them to think for themselves.

This doesn’t all just happen by chance. Any collective of individuals will only function in this way if they have developed relevant leadership, management, communication and teaching skills. And this takes deliberate, dedicated effort. But how can you spend time on personal development when there is so much going on? How can you access quality learning activities when there’s restriction on people getting together?

The skills development challenge

At Oxford Medical, we’ve been considering these questions too. We support the development of around 3,500 doctors each year, with the largest percentage of this taking place via courses at locations across the UK.

We’re pleased to be able to say we’ve created a range of CPD accredited interactive online courses over the past few years which have been very well received. Are they better or worse than attending courses? Well it’s better to think in terms of each modality being different. Each has it’s advantages and limitations. So, they’re different entities which each provide opportunity.

Well designed modular online courses mean you can dip in and out as you choose. You can do a 10 minute module any time you have a break. You can chew over the various reflective exercises for as long as you want – 5 minutes or 5 days. Alternatively, you can sit down and work through the entire course in one sitting in the comfort of your own home during an evening when there’s nothing worth watching on TV. It’s all under your own control.

What about courses to attend?

Our courses where you attend in person are available to book for dates where we believe we will be able to safely resume such activities. We’re keeping up to date with latest guidance and making adjustments accordingly. When we had to cancel courses across March and April we were able to successfully support delegates via virtual events.

On virtual events, we explore the same subject matter as the courses where everyone is in the same room. We just do it in a different way. It’s still interactive and everyone still gets the same CPD certificate for attending a 1 day or 2 day course as appropriate. In fact, with a great deal activity moving on to Skype, Zoom and other virtual meeting software, virtual versions of our Consultant Interview or Advanced Teach the Teacher: Mentoring Skills for Doctors provided experience in the perfect format.

So there are always options. They’re all just different. What is important is that skills development continues. In fact, you could argue it’s more important now than ever.

How are you developing and enhancing your skills to play an active part in adapting to the new reality?

Stephen McGuire – Managing Director

In denial of wilful blindness?

Hear no evil, see no evil, speak no evil

“There are none so blind as those who will not see. The most deluded people are those who choose to ignore what they already know.” These words of wisdom still resonate today – some 500 years after they were written by John Heywood. And there’s plenty of evidence that “those who will not see and choose to ignore what they already know” exist within the medical profession.

Take, for example, the report from the independent inquiry into the case of Dr Ian Paterson. He’s the breast surgeon whose unnecessary, inappropriate and ineffective operations on hundreds of women led to a criminal conviction. His 20 year prison sentence makes clear that he holds the ultimate responsibility for his unacceptable actions.

What’s that got to do with anyone else?

Bishop Graham James, who chaired the inquiry, doesn’t hold back in his report. He makes it perfectly clear that the scandal was far more than the reckless actions of a rogue surgeon. “The suffering described; the callousness; the wickedness; the failures on the part of individuals and institutions as well as Paterson himself – these are vividly described in what patients told us.”

The normal reaction to a scandal is to look at the organisational and legislative steps which should be set in place to avoid repetition of similar events. That should sort it, shouldn’t it? After all, Paterson was suspended in 2011. Surely things have tightened up a good bit since then? Well, Bishop James also states, “It is wishful thinking that this could not happen again… Our healthcare system does not lack regulation or regulators. This report is primarily about poor behaviour and a culture of avoidance and denial.”

An “offloading of responsibility at every level” enabled his actions. “This capacity for wilful blindness is illustrated by the way in which Paterson’s behaviour and aberrant clinical practice was excused… Many simply avoided or worked round him. Some could have known, while others should have know, and a few must have known.”

What’s this got to do with “normal” practice?

Paterson is an extreme case. No amount of legislation or policing will ever eliminate the chances of the occasional maverick slipping through the net. But as suggested earlier, there are numerous examples of “those who will not see and choose to ignore what they already know” in everyday medical practice.

Our previous blog posts have referred to the common problematic sub-cultures which have been identified by the General Medical Council. There are sub-cultures centred around divas and factions. There are groups of people where deference to specific individuals creates sub-cultures with patronage at their heart. Groups of embattled doctors are not uncommon. And then there are others who have separated from the mainstream and become isolated.

Just like the doctors who were working with Paterson, who was “hiding in plain sight,” it’s all too easy to develop wilful blindness to the existence of these sub-cultures or to their consequences. Their presence is disruptive to patient care and detrimental to staff well-being alike. Let’s add bullying, rudeness and carelessness to the mix.

Someone else’s problem?

If problematic behaviours are being noticed, rather than denied, then surely someone should say something? Definitely. But who? Could there be an element of wilful blindness to the fact that no-one is taking any effective action? That such lack of action actually sends the message to the perpetrators that says, “It’s ok, carry on with what you are doing.“? To think anything else would, in itself, be an act of denial.

Speaking up and saying, “That’s unacceptable,” can be an uncomfortable experience. It’s bad enough when dealing with a more junior colleague. Maybe worse when it’s a peer. And what about if it is a more senior doctor who is behaving inappropriately? There’s no doubt that these are tough conversations. But change won’t happen without them.

Doctors already dedicate themselves to learning how to have tough conversations with patients. This includes dealing with sensitive subjects, breaking bad news and saying no. How much time is spent developing ability to have tough conversations with colleagues? If improvements to patient care and staff well-being are the obvious outcomes then there has to be a professional duty for this.

How ready are you to have the tough conversations that will make a difference?

Stephen McGuire – Managing Director

Like deja-vu all over again!

Punxsutawney Phil

February 2nd is Groundhog Day. Have you watched the classic comedy from 1993? If so, you’ll remember the cynical, sarcastic news reporter Phil Connors being dispatched to Punxsutawney, Pennsylvania. Once there, he scoffs at the pointlessness of the smalltown annual festival where the happy locals use a groundhog to predict the weather for the next six weeks. Phil hates everything about it. Unfortunately, his day gets worse when he is trapped in the town by an unexpected blizzard. He then wakes next morning to discover he is now (inexplicably) locked in a time loop. Every day, from this day forward, is exactly the same for Phil Connors.

Groundhog day in the NHS

The film was a big hit. So much so, that we now say, “It’s Groundhog Day again!” when the same situation repeats itself over and over again.

I regularly hear doctors on our courses using the phrase in relation to numerous aspects of their working life. Take your pick from the following: disorganisation; wasted resources; bad behaviour of colleagues; the struggle with difficult patient behaviour; the need to prepare for another appraisal. Or how about finding yourself teaching the same thing in the same way to another group of uninspired doctors for the countless time. You may well want to add your personal gripe to that list.

I remember being amused when one doctor introduced a bit of variation to the “Groundhog Day” phrase by saying, “It’s like deja-vu all over again.” (I’m not convinced that he said it as a joke!)

Sadly, many who find themselves trapped in the seemingly hopeless loop struggle to see any humour in their situation. When this is the case, they risk becoming cold, hard, cynical and/or sarcastic. Just like Phil Collins at the start of the movie.

Breaking the loop

However, the original Groundhog Day celebrations have absolutely nothing to do with hopeless repetition. It’s roots are in ancient European traditions which are celebrations of awakening. The appearance of the Punxsutawney Phil means the end of hibernation. It’s the earliest indication that spring is approaching. And spring is nature’s time for new beginnings and fresh starts.

In the movie, Phil Connors initially indulges in some of the very worst aspects of human behaviour. If anything, he becomes even more bitter than before. Then he slowly begins to do some little things that make a difference. As he starts to look at his world differently he dedicates time and effort to improving his abilities. His new skills enable him to bring about some dramatic changes to the world around him. He finds himself contributing more than he ever thought possible – and he’s much happier for it. So are those who are around him.

What efforts are you making to develop the skills that will enable you to break out of your own version of Groundhog Day?

Stephen McGuire – Managing Director

Rumination, automation or facilitation?

How do you really feel about reflective writing? It’s frequently demanded and is an expectation of being a good doctor. You know: “You have now completed this course. Please complete your Reflective Learning Statement.” And you have to keep your e-portfolio up to date for your appraisal or ARCP meeting. Many doctors report feelings of irritation. “Here we go again.” “What’s the point?” “I could be doing something useful instead.” Such thoughts often lead to procrastination. But you know that you still have to do it eventually.


There are a lot of things in life that we do on auto-pilot. It happens when we’ve completed a task over and over again without negative consequence. So, we default to ingrained, habitual behaviour. We do it quickly and efficiently without really thinking about it.

This is a common approach to reflective writing. It’s the chore that has to be done. Going through the motions. Ticking the box. If this is the case, then it genuinely has become a time-wasting activity. If there’s no benefit then what really is the point? You would definitely be better off doing something else. But what’s the alternative?


Things can and do go wrong. Sometimes we say the wrong thing in the wrong way at the wrong time. Sometimes, no-one has done anything wrong – yet we are still exposed to events and circumstances which are upsetting or confusing.

It’s easy to fall into rumination, where repetitive thoughts go round and round in circles. We can become victims of our own thinking. Problematic ideas undergo fermentation. This can lead to pre-occupation and to poisonous fixation. Anxiety, depression and burnout are all-too-familiar results of un-managed rumination. So, we need an alternative to that too.


“Keep a lid on it.” “Dissociate yourself from the situation. Concentrate on the task.” “Move on, there’s another patient here to be cared for.” “Keep your work at work and your private life private.”

On a personal level, tucking our toughest experiences away in our darkest corners can seem like a logical, attractive solution. But what to do when thoughts start to resurface? Drown them out with some form of distraction? This can lead to problematic ‘coping’ mechanisms and even fragmentation of character.

And what about the impact on others? Does ablation of our memories and experiences go hand in hand with abdication of responsibility over our behaviour and actions? If so, then does this lead to constriction of self-awareness? Does it close the door on learning, meaning there is stagnation rather than progress? This is one clear reason for empathy to measurably decrease over the course of a doctor’s training. So this doesn’t seem like the right way forward either.


What’s really required is a method which enables facilitation of strong foundations for stability and growth. Different people prefer to do this in different ways. Silent introspection, discussion with a mentor or reflective writing are good examples of this. When done well, they utilise awareness of the past to inform a better future. But none of these methods should be taken for granted.

Silent introspection can work well for those who have learned and practised a disciplined approach. Otherwise rumination and lack of conclusion may be just a small step away.

Discussions with an experienced coach, mentor or colleagues offer the benefits of externalising thoughts. When we do this, we are more likely to channel our mental processes into something constructive.

The same can be said of reflective writing when it is conducted for the right reasons and using effective methods.

Unfortunately, many doctors have never been taught how to do this well. The ability has been taken for granted. Or if they have learned in the past, they have fallen out of love with the practice through over-familiarity. That’s why we’ve now launched our new course Reflective Writing Skills for Appraisal & CPD.

So, rumination, automation, dislocation or facilitation. What’s your current approach to reflective practice?

Stephen McGuire – Managing Director