Perspective is all

25 05 2011

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?

A Love Supreme

20 10 2010

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?

The fine ART of management

27 10 2009

I am blessed that currently I work in an institution that gives me many opportunities to reflect on different management styles. A further blessing is some insightful and gorgeous friends who stimulate and support my thinking and development.

Take a look at this piece of art. I love it.

sinister rainbow

Sinister Rainbow, Emma d'Souza (medium- acrylic, silk thread & felt)

Is it just paint splashed around? Is the artist authentic ? Does it encourage other people to come and look at other pieces of work? Will it influence others? Will you look at your own work and want to do better or differently next time? Could the artist explain why? Would you be proud to display or own this piece of art? Is it art?

I believe the same questions can be raised of management style.

I’m sure, with the right materials and time I could attempt to produce something like that. But is that art? Is it just the finished article we are looking for? Is a poor copy worth the same? Surely what is more important is the journey to that end point.

We all have to accept that targets are met, roles fulfilled, projects planned and appraisals achieved but surely (please?) what is actually more important is not the end point but the nature of the  journey in getting there. There has to be more art to management than simply administration.


17 08 2009

Few people can have missed the American Republicans’ disastrous approach to the healthcare discussion straying beyond normal political posturing into farce, exaggeration, lies and the plain ridiculous when it comes to using the NHS as an example of how bad healthcare can be. One of the expressions of annoyance at this criticism of the NHS has been a spontaneous twitter campaign #welovethenhs, even supported by the Prime Minister himself.

But I believe there is something we can learn from American healthcare.  Am I aligning myself with Conservative “maverick” Daniel Hannan? Not in the slightest. My point is to echo a line from a paper by Reinertsen (2007) at The Institute for Healhcare Improvement. They have tried to address some of the difficulties in engaging clinicians in a quality agenda and ways to improve it. I have to confess to having a physical reaction on reading this paper, which for me and management science must count as a first:

 “Administrators need to stop regarding clinicians as customers and start treating them as partners in the delivery of healthcare.”

There is a lot clinicians have to learn about management and the whole topic of engagement I suspect will never be fully analysed. I accept there are dramatic differences in funding and organisation (sic) of American healthcare but this I believe is something they have correct.  I believe it sums up a fundamental difference that both offers solution and defines some of the difficulties. Clinicans are not overspending budgets, failing to make cutbacks, having shortfalls in clinic returns rates. Clinicians are dealing with patients. With the patient at the centre of this debate and the ONLY reason for the service being there each side may stop regarding the other with suspicion and regard each other as partners in the delivery of healthcare.

The reasons why we are currently at this juncture may contribute to our learning and progress from here. That I suspect will be my thesis.

Reinertsen, J., Gosfield, A., Rupp, W., & Whittington, J. (2007) Engaging physicians in a shared quality agenda. Institute for Healthcare Improvement, Cambridge, MA.

All is not as it appears.

12 08 2009

The recent gap in posting has been partly due to the large amount of work I have been putting into our degree assignment. This morning I (hope I) put the finishing touches to the wee beastie and popped it in a zip file. My paper is on “Engagement of clinicians and management in the NHS” and after considering the issue in terms of organisational structure, strategic planning and clinical leadership I do think I have some useful thoughts.

One of the principal causes of poor engagement is that, contrary to the Mintzberg classification of organisational structures, hospitals (or ours at least) are not being run as the professional bureaucracy that the clinicians expect but as a machine bureaucracy.

I appreciate that for some of my readers I might as well be speaking Polish but I am also encouraged that many people read this who are not approaching the topic from an in depth study of organisational taxonomy and yet show an interest and insight. I think it helps me to try and explain this (to myself) in different terms so I will try and do the same for you.

In a managed professional bureaucracy the “operating core” (clinicans) are the source of production and because of the specialised nature of what is produced (clinical care) the core have a large degree of autonomy, control over performance and are supported in this by the “strategic apex” (management).

A good example of a machine bureaucracy would be a factory with highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

Unfortunately, in the modern NHS the latter rings more bells than the former. Drives for performance, merged and centrally managed waiting lists, cross covering, out-sourcing, the lack of core professionals  influence or even be involvement in strategic planning, imposition of “guidelines” and “protocols” may be viewed as a move away from the autonomy and professionalism expected of a managed professional bureaucracy.

Bate proposes changing the culture of a hospital as the “experiment” of clinical directorates has failed. He may be right. What is sure is that the current structure is not as the operating core would like, nor as Mintzberg suggests it should be. Perhaps this partly explains the lack of engagement between clinicians and management.


If you’re such a good doctor, how come you want to be a manager?

2 03 2009

I remember being in Mr Gordon’s class aged 12 and telling both him and my peers that I wanted to be a doctor. I don’t know if I actually knew what that meant more than “helping people” but over the next 24 years I have struggled through Med School and the rigours of surgical training to reach my current position as a Consultant Surgeon. Within that role I have been steadily progressing for eight years. In all humility, I am actually quite good at what I do.

Why would I want to stop doing that and take on a role in management?confusion3

The dichotomy of clinician management is significant. Many clinicians feel that “management” are completely out of touch with the reality of medical practice and that this role is best filled by someone with knowledge of the discipline. The discipline of management, whether an art, a science or even a black art, is clearly not covered in any detail in the training and practice of medicine. It is similarly clear that clinicians cannot simply step from, say, an operating theatre, into a committee room and hope to practice with the same élan. If we require our management colleagues to be trained, then shouldn’t we as clinician managers match similar criteria?

Assuming this is resolved, there are many other significant issues to be dealt with. If management is so important, then it is also important to devote  appropriate quantities of time to the role. Relinquishing hard earned and valuable clinical skills seems iniquitous on both a personal and organisation level and yet neither tasks will be effectively carried out on a part-time basis.  Is it possible to be both clinician and manager?

Authority of this management role is neither implicit nor uniform. Often clinicians of lesser experience take on positions that are imbued with an authority that itself may not be respected or accorded by more senior colleagues. The history of  the clinician/management interface is one of many pitched battles, multiple casualties and much propaganda often the fault of the system rather than the protagonists. Students of management are clear that futile application of inappropriate strategies over the past decades has resulted in a deep mistrust that underpins many subsequent interactions. It is often held that the two sides actually have completely divergent aims and thus achieving a common purpose takes even more skill than would be required in a profit seeking organisation. Is it possible to undertake a role where the ultimate goals of the protagonists are so disparate?

It is clear that clinicians are required to be involved in clinical management and that to do so requires a commitment of training, time and loss of clinical skills. The task is rife with historical prejudice and the rewards are not clear. Why exactly would someone take on such a role?

“Lies, damned lies, and statistics.” Benjamin Disraeli

20 01 2009

This variously attributed quote was most probably made originally by Benjamin Disraeli. His point was to highlight the use of numbers in an argument, the further use of statistics to bolster weak arguments and then the ultimate disparagement of statistics themselves, particularly if those statistics don’t fit the correct side of the argument.

The debate over the MMR vaccine sprung from one single scientific paper that spawned a million column inches, months of debating hours and possibly even the death of some children. Everyone has an opinion. Yet eight years later the study has been totally discreditied and Dr Wakefield, the first author has been struck off for research “issues”.

Have you actually read the paper? Did you know there were only 12 apparently random children in the study? And that only 8 had the histological change that allegedly was the “cause” of autism itself becoming clinically apparent within 6 days of the vaccination. Now, what was your opinion on MMR vaccination again?

Currently, the hot topic on the lips and legal pads of medical managers everywhere is “The Surgical Checklist.” Everyone has heard about it particularly how a simple list is hugely reducing surgical complication and even death rates across the world.

Have you actually read the paper?

What do you think about the potential for bias in the data collection (see results, not method)?

How many patients actually had the checklist applied?

What does the “checklist” actually comprise of?

Save for the list, are there any other particular changes to care that may have affected the outcome?

How do you think a simple surgical checklist on its own actually reduces the rate of complications such as myocardial infarction, pulmonary embolus and ventilator requirement? Or is it perhaps something else affecting results?

Importantly for hospitals trying to prevent “wrong side surgery”, what evidence does the paper provide for reduction in this problem?

Is the reduction in death rate statistically significant?

What is the Hawthorne effect?

(I’m not sure it’s clear but what economic area does it suggest UK, Canada and New Zealand are in?)

The newspapers are particularly hot for this topic not the least because of the highlighted resistance of surgeons to this change. The fire of this debate is fuelled additionally by the age old antagonisms and prejudices particularly of managers and patient groups.

A small sample of that debate can be found in the comment section here. It is not supportive of the medical profession. Perhaps we could hand out some ladders of inference to help calm things?

Now read just about any news article or pronouncement from management on the issue. Are the changes to be instituted  justified by the vigour and results of the study? Can you understand why there may be some antagonism between the two groups? If you were (are) a manager, how would you approach the situation?

Now I’m not against improvements in clinical care or checklists or debate, I’d just like it a bit better informed.

Lies, damned lies or statistics, you decide.

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