Complaints, contrition and constructive criticism

Put yourself out there.


I wrote a letter to my MP last week. It’s fair to say that I was unimpressed with the response. There were some good points to be fair – it was sent the day after my email and it was polite. But that’s pretty much where it ends.

In essence my letter to my MP was a letter of complaint about the actions of a senior minister. I tried to keep to the basic rules of complaints – courteous, specific and some clarity over my expectations. The reply – in my view – avoided answering the issues raised, ignored one aspect completely and didn’t contain a hint of apology. I was left feeling cross and that my issues were not being taken seriously.

I’m not writing this to have a go at my MP. My MP is widely respected and rightly so. I suspect any MP of the governing party…

View original post 889 more words


Absorbing the Hurt

It was a long time ago. I was a scarily young Houseman, barely 22, the last generation of preregistration doctors to work unsupervised in, what were then called, Casualty departments. With surgical ambitions, I was straight from central casting: brash; callow; untroubled by self doubt. There was a moustache, very much of its time, which stated: I want to look older and be taken seriously.

I was quite clear why I was there: I was there to fix stuff. To make broken things better. I dealt with what came my way; infarcts, stabbings, the fallout from weddings where the father of the bride developed chest pain and her brother gave the best man the kicking which had been in genesis since school.

Occasionally I was puzzled. The father of the teenager who brought his son up to A&E having found him smoking a joint. He wanted…… I am not sure what he wanted. Advice, I guess, for himself, guidance and a talking to for his wayward son. He left disappointed: – without either.

One of these nights the staff approached me. They wondered whether I would talk to someone; it was a bit awkward; he wasn’t really a patient; he wasn’t ill…

He told me his story. His young daughter was in the children’s ward. She was dying. This was a time when hospices barely existed, let alone Children’s hospices. I could only listen, he was completely dignified, matter of fact. There was no trace of the self pity, anger or resentment to which he had every right.

He spoke of chemotherapy, disfiguring surgery, hope and despair. He told of where they had taken her, what they had gone through. Above all he spoke of the dawning awareness of how this was going to end; of how it was about to end.

He was kind to me. He knew I was un-equipped to deal with this. He made it plain that I was not expected to fix this, that all I had to do was listen, not to share in his pain, nor help him understand it, but simply to absorb a small part of it.

We talked well into the night. At least, mainly he talked. I mainly sat listening, absorbing, taking the whole story in. I offered no advice, no guidance. I had none.

He finished, stood up, shook my hand, thanked me for listening, returned to his daughter.

Over thirty years later much has changed: the moustache is long gone as is the requirement for props to make me look older: I am an experienced senior clinician.

Much is the same: I remain largely expected, by myself as well as others, to fix things. The majority come with clear expectations that symptoms will be resolved, or at least explained. I have a mainly oncological practice: enormously rewarding, challenging. Lots of people benefit from the treatment our team deliver. That treatment, however, can be distressing, harrowing. Success is, of course, not assured. Treatment related morbidity, long and short term, is considerable: dental, aesthetic: swallowing problems are common: some never swallow again.

So, mostly I try to fix things: I endeavour to diagnose, treat, manage, explain, mitigate. That is my default setting. It is what is expected of me, not least by myself.
We are largely consulted for our knowledge, our expertise, our technical skills.

There are times whenever, when knowledge, techniques and skills are not enough.

Times when knowledge, skills and techniques will not deal with the problems, answer the concerns.

In those times we can only listen; let them talk, let them speak with words or with silence;
absorb the hurt and pain, the disappointment, the regrets. It is only left to us to own our vulnerability, to allow our essential humanity: to remember the lesson taught me by that father.

Polishing Narcissus’s Mirror

this was originally posted on @Ayrshirehealth on 18 September 2013

One does not have to go far to find concerns being raised about our Health Service. Over the last 2 decades there has been a procession of headlines: Bristol Children’s, Alder Hey, Shipman, Mid Staffs, Vale of Leven, Morecambe Bay.

Each of these represents a myriad of disappointments, of betrayals of trust. Over this time the professionals, the professions and the institutions have been called to account. The climate has changed. The unquestioning acceptance of decisions has gone. It is clear that arrogant and overbearing professionals are not acceptable.

At the root of the change in professional culture is the expectation of reflection. Individual professionals are expected to be open and above all to reflect on the quality of their interactions and outcomes. The expectation of the appraisal and re-validation process is that it will deliver this open reflective practice.

As it is for the individual clinicians and their teams, so for the systems in which they work.
Health systems function at the macro, meso and micro levels. The micro level is that level of individual clinicians and their teams. This is where the rubber meets the road, where all the important clinical interactions occur, where the effectiveness or otherwise of the system becomes apparent. It is the level at which Quality Improvement is demonstrated.
No one would, or should accept clinicians being anything other than frank, open and candid about their processes or outcomes. The importance of this professional integrity cannot be overstated. That breaches of probity cannot be tolerated is self evident: at least as important is that the assessment of Quality and Effectiveness and attempts at its improvement are rendered unreliable without complete candour.

The Meso level is the level of the Institutions and groups of Institutions. These are the august institutions in which we all work. They engender a potent collective identity and the practices and standards which pertain define the culture of that institution. That culture is apparent to everyone, be they patient, carer, staff or visitor, who crosses the doorway. All staff are concerned about reputation of the institution. It perhaps bears consideration how best to bolster that reputation, enhance that culture. Many of the institutions named in the opening paragraph fell for the idea that accentuating the positive, minimising the negative was a short cut to an enhanced corporate image, that declaring excellence would make it so. The truth is that the institutions that have truly attained excellence, that have built a culture of, and a reputation for excellence, have done exactly the opposite of that. Institutions, such as Cincinnati Children’s, declaimed perfection, took responsibility for, and ownership of their shortcomings and mistakes. They took their weaknesses and crafted them into their strengths. They did not waste effort in trying to redefine success, to mistake mediocrity for excellence. To claim that one’s results are no worse than anyone else’s is not a mission statement of which anyone can be proud. Even if one does feel that criticism is unjustified, is it not better to put effort into trying to improve rather than into defending what may be an untenable position? Quite rightly that would not be acceptable in a clinician or clinical team; corporate reputation does not render it any more so.

The Macro level represents the state or country. Political or leadership ambition may similarly be attracted to that temptation to minimise bad news or over-egg achievements.
My plea is simple: Irrespective of the level at which one works, be it Micro, Meso, or Macro there is nothing equivocal about who we all serve. There is no place for serving the corporate master. The patient is the only proprietor. Ergo: the same imperative applies for open, transparent reflection irrespective of whether working at Micro, Meso, or Macro level.

It is to the great credit of your Board that concerns with data have been dealt with head on. It is the standard expected of us all. Organisational Hubris is not a driver of Quality. None of us should be wasting effort polishing Narcissus’s mirror.