Saturday, April 28, 2012

Whose fault is it anyway?

I have calmed down nowadays..much calmer than when I was a trainee...honest, I have...the caustic comments are softer,the growls are less fierce-some... hey, nowadays I even grit my teeth just to stop myself opening my mouth. Not that I have anger management issues- where I would suddenly turn into the raging Hulk..but issues such as bullying, politics etc. does continue to anger me- especially when you know it's compromising patient care and it's about self protectionism, rather than anything else.But hey, much calmer now, much more chilled and does help when you have a team around you who shares your vision and ideology too! Perhaps one felt it was easier to put the bat-cowl on rather than simply go green..and touch wood, at least where I work, it seems to be doing the job. So it was after a long time that I chanced upon something that I genuinely seethed about, had a mixture of bemusement, anger and perhaps even, a bit of sadness for person concerned. Or maybe a realisation how lonely a place some now find themselves in.


One keeps hearing about we "all need to work together", how we need to keep on having group hugs from time to time just to see that everything is fine...but it does make one wonder whether that's just an inherent urge from most not to "rock the boat", a need to make sure we are all safe in what we do, and though most, if not all individuals concerned will have at their heart the need to improve patient care...when it comes down to the nub...a lot of times it does boil down to self protectionism, worry about one's own job, status, position..worry about "what do I do?".. Let's take the example of when any negative data comes out... what do you get? A lots of justifications, a lot of reasoning why either the data is faulty or why the data is true but there are reasons for it. 
A recent example was when the amputation rates in Portsmouth came out which made Portsmouth look like a red zit on the map of UK, as far as amputation rates were concerned. It wasn't good, more people were losing their legs than say Poole- and in my eyes, it was simply something that we had to get better. I spent a lot of time talking to all the key players...and I listened to all the views...our trust also looked after Hampshire patients, their data was better, so couldn't be the specialists fault, the podiatrists told me how the recognition wasn't there in primary care, primary care told me how they were overwhelmed, how they didn't know where to refer, and finally it was clear that it was also the patients fault... they didn't engage, they were poor...or as someone put it to me in a public meeting..."This is Portsmouth- and we are special". And maybe they are all right, maybe it was all of the faults put together, maybe the data analysis could be better...but the folks who stood up and said.."No we are part of the problem and we will solve it"...was in a tiny minority. It was always someone else's fault...Commissioners, specialists, primary care nurses, GPs, Public Health and finally patients..always someone else.


And then I met a patient who when I asked him what he thought about it said this.." Doc, I know how hard you,the nurses and the podiatrists all work...but have you ever lost a leg? Lost something on which you depend so much? I know I should have stopped smoking, but it's not all my fault, is it?". And I sat back and thought about that. I have been very blessed in my life, in fact downright lucky with most things and the only thing I have ever lost close to me has been a guinea pig..so no- I didn't know what it was to lose something close to me- but I did go to medical school to stop that happening to others. So what happened to all of us? Where did we all go wrong to this extent that we spend more time debating whose fault it could be rather than saying   that "I" am part of the problem- so will do my part to solve this? Thankfully, locally there now seems a zeal to get things better and in the Sharon Tuck, Matthew King, Darryl Meeking, Jim Hogans of the Portsmouth diaspora we have folks who want to do good. It's pointless debating what has happened or analysing data, its pointless thinking what went wrong...what's important is what we are doing about it. A negative data to me is a challenge to get better, where's the challenge in taking on something which is already "sorted"..and hopefully this passion does  infuse into others too.Don't get me wrong..patients and public health have a major part to play...but they form a fraction of the whole issue, part of which we all are.


On that theme, when one reads an article on why Community Diabetologists are a dying breed, one expected to see an article close to what I believe in, a view that the term Community Diabetologist has been divisive...or a reflection that hospital specialists had perhaps hadn't quite engaged enough with primary care "forcing" others to create this role within the community, do something that would shake hospital specialists out of their stupor. As a good friend of mine Niru Goenka said.."Isn't the hospital part of the community? So isn't a hospital specialist involved in the community?". Unfortunately, isolated away from the acute trust portals, community diabetologists have struggled but then again there have been shining examples of folks who have shown leadership, verve and panache to make it happen. It has involved negotiation skills to win over suspicious acute trust colleagues, primary care practitioners..but it has happened dependant on individuals. Locally the specialist team are as much a Community Diabetologist as an acute Trust one. Providers, acute or community, are just bastions where your jobs are housed, its your specialists skills, whether as a super-specialist or as an educator, which make you who you are...so who cares who your employers are- as long as you do what needs to be done for the patient, irrespective of your employer status.


But disappointingly some of the article was about why it didn't work out. It was, again, about someone else. It was about why it was a bad idea to leave an acute Trust, where all the barriers were and it was sad to read this from someone who did lead the charge, was bold enough to make the move away from an acute Trust and perhaps was a few years ahead of his time. Maybe the support wasn't there, maybe all the factors mentioned were hampering but when you are part of the process, the big thing is to step up and take responsibility, accept part of the fault may lie with oneself and take that step needed to make it better. Leadership is about standing up and accepting the bad times, while also glowing in the adulation of the good times. I have said this before and will do so again. If any model of care I have created doesn't improve patient care, I will be the first one to stand up and say "my fault" and walk back to the drawing board. 


So there we are. I have had my say- as usual, being open and honest about my views, not ducking behind political correctness or niceties. Take one step back- and we are here to do good for the patient. If in the process, you have to challenge your colleagues and say directly that they may not be good enough, then we must do so. We must not have another group hug to make us feel better about ourselves. The process could involve support, could involve coaxing, could involve showing data...but at the end of it all, at the end of all that you can provide, if the individual concerned is not up to the level patient care demands, then it needs to be said, doesn't it? 
Conforming to the norm of never challenging each other, mocking or shirking away from performance management seems to be what we healthcare professional do quite well..follow the motto of "lets take care of our own first" ; "close ranks" etc etc. Maybe its time to change that, maybe its time we learnt that as in any sphere of life, we don't have a god gifted right to continue in our jobs without being challenged.  
An alien concept for many especially for the ones sitting in the bastions of power, holding on desperately...but as one of the coolest dudes ever, Jimmy Hendrix said..."To be with the others, you have to wear your hair short and wear ties.So we are trying to make a third world happen. You know what I mean?"...yep, I think I do...I think I do. 

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