Are you as good as you possibly can be?

This is Roger Federer. Currently he is 3rd in the ATP World rankings. His record of 16 Grand Slam (GS) titles, including 10 consecutively, along with 23 finals appearances has him regarded by many as The Greatest Tennis Player ever. The other man is Paul Annacone. His highest ATP ranking was 12. In 7 years on the ATP Tour he never progressed further than a Grand Slam quarter final. Paul Annacone is Roger Federer’s coach. Previously he had coached a little known Californian by the name of Panayiotis Sampras. Most people called him “Pete”.

It is clear in tennis that leading players continue to excel not because of personal insight and innate talent but because of the input of coaches such as Annacone who can observe and guide their charges to even greater performance that they themselves may no longer or ever have been able to achieve. The suggestion that a player as good as Federer can improve or has a coach would surprise few. Many however would be uncomfortable with the knowledge that technical specialists such as Consultant Surgeons aren’t as good as they possibly can be and don’t have coaches to help them achieve optimal performance.  What is not suggested by either of these facts is that the performance currently achieved is unacceptable, merely that it is not not exemplary; Federer wants more Grand Slams and surgeons want to excel.

I raised this In my previous post . It may be uncomfortable to hear of shortcomings in performance, difficult to action and even harder to change consistently but if that improvement is possible for Federer or for a surgeon surely that achievement is of greater import than the disquiet, arrogance or ignorance resisting it. Personally, I’m interested to look at my practice both within the theatre and outwith to consider opportunities to improve. I’m sure the same could be applied to any clinician and even manager. Who wouldn’t want to be as good as they possibly can be?

Why I don’t like Atul Gawande.

There was a kid at school that reminds me of Atul Gawande; he was good at cricket, good at rugby, really, REALLY clever and worst of all, everyone really liked him. Atul Gawande is, according to his own website, “surgeon, writer, and public health researcher, practising general and endocrine surgery at ” blah blah blah. You can read it for yourself here because he is ALSO lots and lots of other things not the least a prolific and excellent writer. I’m sure he is also really nice and everyone loves him and he’s a delight to be with and an amazing lover and… and you know why i REALLY don’t like him? Because I think he’s right about most things he writes about and that just makes me uncomfortable. Harsh eh?

I’m not going to go through everything he has written, as there’s a lot and that would probably just wind me up even more. Suffice to say he was right about improving patient safety, right about adverse events and right about a lot of surgical education. I do have issues about some of the surgical training remarks but that is the American rather than UK standpoint which makes a big difference.

So the point of this little post is to highlight the wunderkid’s (he’s two years younger than me) latest piece “Coaching a Surgeon“. In this flowingly written and erudite piece he correctly points out that whilst the majority of highly skilled, technical professionals in sport and music have coaches, in surgery where, despite the teasing of our anaesthetic colleagues, we are actually pretty skilled technicians yet none of the senior staff have coaches to help us continue to progress and further excel. We may improve to a point but such self directed improvement is limited.  The reasoning behind this lack of coaching is probably less intricate than we’d like to think but has to do with ego, performance anxiety and the lack of invitation of critique.  Why do I not like Atul Gawande? Because he highlights my flaws.

Regular/ocassional readers of this blog may wonder at the value of a discussion on development of superior surgical skills within what used to be a blog on clinical leadership. Surgeons strive for perfection in what they do. The means to achieve this are complex and personal but require time, space, resource, reflection and encouragement. The potential results are clear. What is important however is to see beyond having our flaws exposed and see that as a positive thing, a source and opportunity for improvement rather than criticism; the difference between critique and criticism. Where does this fit within the current constructs of clinical leadership and medical management? It resonates with issues of engagement and reward but does not sit clearly in terms of resource planning and efficiency. Improved patient safety is not simply about checklists and mantras but about coaching the star performers and helping them to be the best.

Dang, if Dr. Gawande isn’t right again! I’d love to meet him. grrrr, I’ll probably really like him…

Context is essential

I just realised that I needed to advise any readers of a change in context from which I am writing. I left my previous job now 3 months ago. The unit I am now working in is essentially the complete opposite of where I previously worked, my colleagues are very different too. Sadly, my previous place of work is in increasing trouble, not the least I believe, due to failures in the structure and mechanism of the management. I’m not going to say, “I told you so,” as I neither believe I have that depth of insight to understand the reason nor that the situation is that simple. It is sad and I wish them well.

Perspective is all

Our department is being faced with some significant changes and we have, for the last few weeks, been struggling to find any opportunity that we might meet to enable appropriate feedback to the senior management in the organisation. It has proven almost impossible for the six of us to find any time within our already busy calendars, including early mornings and late after work, to meet.

Last week when I returned to my car in the hospital car park I found my car blocked in by two cars. There is never enough space and this is actually fairly accepted local practice. Our permits display contact details so we can be contacted, nip out and release trapped colleagues. I telephoned both owners who both agreed to come straight away and let me out so I could to the peripheral clinic that afternoon. As luck would have it the owners of before I had the chance to leave my office and car 1, in her haste, allowed car 2 out and quickly re-parked (keeping me blocked in) and ran off. I arrived literally 10 secs after her departure. With a heavy heart I telephoned her again explaining that my car remained blocked by her and I would need her to return so that I could go to my clinic. “I’m afraid I can’t come; I’m in a very important management meeting.”

It struck me then the differing perspectives on “management meetings”. As clinicians, we have no time whatsoever set aside within our schedule for something that is actually essential to the functioning of our unit. It is not considered a priority in the job planning meeting that such meetings should be timetabled and yet a management colleague believes that her time at a management meeting is so important that she cannot spare literally five minutes to release a colleague trapped in the car park.

Surely we could learn something from each other? Effective clinical engagement can only occur if management discussions are given some priority within the clinical job plan but realistically, just how important can a meeting be that you would leave a colleague trapped in the car park?

“Thank you…yes, it’s lovely…but not really what I wanted.”

At this time of the year children all around the world are advising their parents (via Santa Claus, elves, the chimney, heavy hints, Argos catalogues and letters sent to the north Pole) of their desires for Christmas. What they receive on the Day is not always what they asked for.  The returns desk at major department stores bears further witness to this. The difference comes about for many reasons not least unrealistic expectations, limitations of the family purse and different understandings of what we actually mean by something scrawled on a list. So it is with Clinical Leadership.

The unitarist view is that management requires clinicians in posts of leadership to lead clinicians along the path prescribed by the strategic apex. Clinicians however adopt a pluralist approach and desire their leaders to express these multiple views and directions to management such that compromise can be mediated. The difficulty is that these two views are disparate and as such agreement is difficult to reach with those in the posts frequently failing to satisy either camp, the philosophy and goals being so different. This stress is highlighted in many reviews and the rejection of clinical leadership as a viable career option by many clinicians, including, sadly, those who also undertook such positions with high hopes of making a difference.

Does this sound familiar, “Thank you…yes, it’s lovely…but not really what I wanted.” So it is with clinical leadership.

A Love Supreme

In case anyone was wondering- I passed!  My thesis was accepted and now I am a Master! And yet I recognise I’m not, I shall always be insei, rather than sensei.

I shall blog more of my thesis over the next few weeks but perhaps my most insightful moment I had was one day from the deadline when I stumbled into an analogy that helped me (at least) have an understanding of clinicians and their work and the interaction with this by management: clinicians are in love with their work.

The intensity, depth and true nature of that love is variable as is the love of ice cream, a football team or for a child. It is a relationship that has potentially spanned over 30 years since beginning as medical students and may have been desired for years ahead of commencement. This is no one night stand. The love relationship is completely individual and deeply personal.  Clinical practice, a reflection of the individual clinician in their beliefs, character and skills is the outward expression of that love. Clinicians will go many, many extra miles for their love, put up with many disappointments and hurts simply to maintain their love seeking their reward principally from their love. Whilst it would be naive to suggest clinicians would work for free, the majority would report that their reward comes principally from their practice not their employer.

This is the reason for the poor engagement between clinicians and managers.

Clinicians are in love with their job and view external influences upon this relationship the same way any one of us would view external interference upon a personal relationship. Similarly suggestions by external agencies of measurement or efficiency of this relationship are met with disdain. The validity of the conceptual position may be questionable but the analogy allows understanding of the difficulties encountered. The different realities and understandings of clinical leadership may be understood by use of  the analogy. Clinicians regard effective clinical leadership as that which facilitates the development of their individual love relationships in stark contrast to the managerial directive and restrictive expression of leadership.

Engagement can be seen as the evidence of the love relationship. Importantly this engagement is with either patient groups or a clinical practice and not with the greater organisation as is desired by the unitarist view of management. It should be clear that this love relationship is monogamous. As such, blundering attempts at “engagement” by another suitor in the form of forced appraisal, insincere “conversations”, imposition of “core values” and attempts at corporate branding are seen as cheap as garage forecourt flowers.

The astute amongst you will recognise the photo in my avatar and the connection with the title of this piece. Regarded by many as one of the greatest jazz albums ever, “A Love Supreme” by John Coltrane is an expression of love and thankfulness. It is at times impenetrable, at others openly joyous but all the while a deeply personal reflection and expression of love. Can you imagine the engineer stopping Coltrane half way thru’ and telling him how it could be played more efficiently, with less notes?

I had a dream

What is it about dreams? They are weird places where exciting, gorgeous, impossible, frightening and some would say telling things happen. I have a few recurring dreams: my stress dream of not being able to run away properly due to a muscle injury and  my happy dream that I can fly.

So what, you are rightly asking, does this have to do with “a learning journey into Clinical Leadership”? Well, I am currently writing my thesis for the Masters and I suspect this is why my head is full of thoughts struggling to escape or find order depending on one’s view of the universe. This morning I was having the weirdest of dreams but, just as I awoke, I had the most amazing moment of clarity: the reason I don’t want to be a manager is that I can’t make it work, it is a wicked problem.

Let me explain that this is a reasoned argument, based on current leadership theory and not just casual street speak either. innit!

Grint, in an oft quoted but exceptionally difficult to source monograph, “Wicked Problems and Clumsy Solutions” explores the reasons why most change initiatives fail and suggests that “this failure might be more to do with our framing of the problem and the consequent approach to resolving it.” He goes on to look at the nature of problems and the leadership approach most suited to dealing with these.

Essentially there are three situations for which we seek guidance from authority. (I am trying to avoid using phrases like management and leadership until the concept is clear.)

The first are those extreme and urgent situations, such as a fire or fight, where, what is needed principally is simply a decision. Ultimately that decision may not be perfect, it may not be the best thought out but what is required is immediacy and action. From that movement further action may be taken in a more structured manner. Grint classifies this as a “Critical” problem for which we look for Command and Control style direction.

A problem for which there is clear solution, however complex that solution may be, is classified as “Tame”. Essentially a puzzle, there is a proven and effective approach that the use of management strategies can offer resolution.

Lastly there are conditions for which there are no solutions, a “Wicked” problem. Importantly, this is not due to the urgency or complexity of the issue but essentially, because it cannot be removed from its milieu to be analysed and solved, it is unsolvable the use of either Command and Control or Management approaches. What is required is, as termed by Grint, a “Clumsy” solution, recognising that the problem cannot be solved but must be addressed by a less than perfect solution cobbled together by the collective minds. He uses the analogy of the “bricoleur” a do-it-yourself craftworker who makes do with what is available rather than seeking the answer of perfection and design. Grint proposes that the searching for the perfect solution (viewing the problem as tame/solvable) is part of the problem and the leader’s role is ” to ask the right questions (of the collective) rather than provide the right answers.”

So, back to my moment of clarity, my waking dream. My life and training is about fixing things, small children in particular and cobbling together a clumsy solution for wicked problems just doesn’t fit with that. I can see people who would revel in such activity and they should be the ones to facilitate the rest of us in our collaboration.

Now, of all the dreams we can have, including those ones, to wake up de-constructing leadership theory is not what I live for. My Prof may or may not be impressed but there you go, it’s part of my journey.

“plus ça change, plus c’est la même chose”

When I was a child our dentist was really, really poor. One day, during a general anaesthetic I woke up. He left broken teeth in my mouth that took months to fall out. I had baby teeth filled without any anaesthetic. He promised to stop if I felt pain; he never did. Even now I can still see the broken plate of glass in the bottom right hand corner of his lamp any time I visit my new dentist 300 miles and many years away. I struggle to forget.

When I was a surgical trainee I was abused so badly by one senior that in a moment of deep depression I’m ashamed to say I considered suicide. Any time I see a Volkswagen Scirocco like she owned I feel the shame.

Large numbers of clinicians have had and continue to have very negative interactions with managers. I suspect the converse is true too.

None of this means that all dentists are poor, all Scirocco drivers are abusive, all managers useless and all consultants bitter but you can understand why many hold negative opinions at least some of the time. This (sadly) is source of the permanent mutual resentment I mentioned earlier between managers and clinicians. It was even was twittered about!

18 months ago our Trust undertook to try and communicate with all employees by staging “The Big Conversation”. This was an event to which everyone was invited to come and share their thoughts on the organisation; a brave and very positive move. Virtually none of my consultant colleagues went. I asked many why they wouldn’t go the simple answer from virtually everyone was, “Why bother, nothing will change.”

The more I look into this, the more sad I feel; this situation isn’t going to change suddenly, it is crippling development and progress. I mentioned it at the meeting itself and was met with disbelief and even a degree of disdain from one of the Executive Board members. I mentioned it within our directorate to similar effect. To resolve such denial and bitterness and then develop engagement will take a lot of talking, understanding and forgiveness on both sides otherwise the permanent mutual resentment will remain (and grow) and no-one should be surprised.

The Trust encouraged us at the meeting to “write a postcard to your future self” saying one thing we’d like see happen. I wrote, “I will remain positive and look for the change.” I wrote this blog post immediately after “The Big Conversation” but, as a commitment to change I resolved not to publish it; one has to remain positive.  The postcard arrived 6 month ago and I have to confess I feel even less positive than I did way back when I originally wrote this piece. I still resolved to remain positive. Six more months have passed. Sadly, nothing has changed, both sides were right.

Clinicians do not trust or believe the signalling of management. Management do not trust the intentions of clinicians. There is a significant, almost total lack of effective engagement. Is it any wonder that little changes? I wonder what Sartre would have said?

When we means us and us means them

Managerially, things are a little “difficult” around here. Recently we were invited to our first ever “Strategy Meeting” to which I went, trying to be positive and viewing this as a sign of progress and engagement. Sadly itwas actually just an opportunity for senior management to tell us how bad things were and how “we have to make big changes that had already been decided otherwise we will not achieve Foundation Trust status and this will be a bad thing for us.”

I have commented previously on the nature of engagement between clinicians and management and particularly around the nature of organisational structures, as described by Mintzberg. The present feeling is that hospitals are managed professional bureaucracies (mpb) in which the “operating core” (clinicans) are the source of production and, because of the specialised nature of what is produced (clinical care), have a large degree of autonomy and control over performance. They are supported and to some extent directed in this by the “strategic apex” (management).

In light of our recent interactions I am beginning to question this classification. Previously I have suggested that rather than a mpb, hospitals are becoming more akin to a machine bureaucracy (mb) such as a factory characterised by highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

What struck me in our “meeting” was the frequent use of inclusive words such as “we” and “us”. Now, regarding this as more than simply management speak, of which I am heartily sick, and sadly also the insincerity with which we are frequently faced, it is clear that the management approach is based upon the concept of a team working in a united manner towards a common goal. This is to be praised and valued. Sadly this is patently wrong on many levels.

The operating core does not share the stated strategic goals of the bureaucratic apex. In the worsening financial climate with calls for “efficiency savings” in the face of four years already attempting such, the fact is that these new strategic aims are diametrically opposed to those of the core and possibly their fundamental belief systems. Even the most liberal minded strategist would see that rather than the example used previously of  an emergent strategy as being the joyful union of intended and deliberate strategies what is about to occur is discordant, divergent strategy.  This would be almost impossible in a managed professional bureaucracy and untenable in a machine bureaucracy.

Moreover, the operative core has recognised that “management failure,” in whatsoever guise this occurs, will not bring about apocalyptic destruction or failure of the bureaucracy (hospital),  merely a change albeit dramatic and possibly total, in and of the strategic apex. Complexity theorists should watch this space, we have serious disequilibrium.

Consequently, the nightmare scenario painted by the apex of “failure” for us is actually for them and holds few concerns for the core. It may even bring dramatic improvements. This failure is almost inevitable, not simply because of the financial crisis, but due to an instrinsic failure in the understanding of machine structure.

Clearly I’m missing something

Following on from the last post, yesterday I was briefly interviewed by a junior doctor who is “on a leadership course”.

He was running a survey to find out “why theatres don’t run efficiently and who is to blame and whether this maters (sic) to anyone”. I tried to help by answering the questions but they were so vague as to be impossible to give a valuable response to. I asked what all this had to do with leadership and he responded, “To make people work better.”

I knew I was missing something.