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 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 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. 

Saturday, April 21, 2012

The time

6 months into a new way of working in diabetes care and into my heaving inbox drops an email from our local Commissioners bearing words of praise, bearing encouraging news that patient and primary care praise has been present, “feedback had been excellent”…and you know what? It felt…nice. I thought back to those days when it started, the planning, the financial modelling, the negotiations, the concerns…and in between all, trying to keep up the bravado in front of senior colleagues, nurses who had placed faith in me..that it was all was all would work. “Trust me guys…I will deliver” has been a constant façade to maintain- and even though one prides oneself in one’s unshakeable hasn’t been easy. And although one shows the external features of “I don’t care for anyone…”at the end of the day, as any normal human being, appreciation does sit well.

But it has been possible due to the faith put in me by senior colleagues, folks who have been my Consultants and guided me, nurse colleagues who have seen me as a trainee, Community nurses who have shared my vision,GP colleagues who have helped and stood by me, Trust executives who have trusted and of course Commissioners who have believed. So you know what? Something which I don’t do enough…thank you guys and with the deepest humility, it wouldn’t have happened without you all- so do appreciate the whole hearted support.

However, a blog by my wouldn’t have been a blog by “me” if I didn’t aim some guns at some others. My friends and supporters who have stood by me will always and always get my unflinching loyalty…but those who steeped themselves in negativity, tried to undermine what we have tried, spent time more interested in politics and had a façade of patient care….I say again…you are NOT the future of this country. I will send you the feedback not to prove myself/ourselves but to point out squarely to you how something which is built on getting to work with primary care colleagues, treat them with respect..actually works. Step aside and let the ones with belief, passion and fire in their belly do what’s needed for patient care. You have tried, you have argued, you have spent time debating how to entrench yourselves, defend your position and in turn have left the patient wondering who does actually care for them.

I make no apologies for visibly flinching when specialists shout out loud about the "preventable Type 1 deaths" when the naked truth is that in the vast majority of  areas,Type 1 patients ARE under specialist care. Folks..a bit of reality shows WE are not doing well either! As specialists, do we do a fantastic job in all adolescent diabetes is the stark why haven't we devolved our resources to tackle this high risk group while being educators for primary care as regards the vast majority of Type 2 patients? Reason is a fear of letting go, a fear what would happen to us, an arrogant belief that "we know best".

Anyhow, enough of folks who wonder about “what if” rather than daring to try something new. Lots of challenges ahead, so who has the time to spend on organisations or individuals who don’t dare to dream? Lots of things in the innovative educational portfolio working in a business like manner with pharmaceutical industry (who themselves deserve a blog in their own right…so forthcoming!); a revamped foot pathway; possibly expansion of Consultant colleague; definite expansion of nurse workforce- and a major area of passion –whereby I will focus my energy and passion in type 1 diabetes care. An area which has been deprived, sucked into the abyss of Type 2 diabetes, an area where we have done a huge disservice to our young patients…so its time to stop that- and as ever, one can only advice nationally, if one has done so locally.
Some colleagues and friends have asked me to slow down, take things easy…and maybe there is a need for that…but you know what? You never know whats around the corner- and I have never done regret. Why come to a point where you regret what one could have done? And the energy and drive is there now…so now is the time to do it or at least give it one heck of a try.

"I can accept failure, everyone fails at something. But I can't accept not trying" said one of the greatest sportsman ever to have been born, Michael Jordan. And to that I say only one word…Amen.

Friday, April 13, 2012

Does the patient actually care?

Provocative, isn't it? The title that is? And I know readers first instinct will be .."ooh, fella's now taking on the holy grail..the patients!!"....but hold fire, it isn't anything like that. The question I have always asked myself is whether as a patient one really cares which organisation you work for. I know I didn't when I was on the other end of the table, so to speak...remember feeling distinctly unwell after having come back from a trip to Goa. No one had the foggiest what was going on- all I had was high temperature and rigors before after a few days of investigations revealed it to be case of paratyphoid. What however struck me was the care shown to me by my GP, Consultant on MAU, the nurses, junior docs...and very few knew my title...and I was sitting there thinking...I actually don't care who you are, who you work for, what your skills are...but hey, thank you so much for making me feel better!

And that's what is the biggest bug bear of the NHS...multiple organisations, the essence of competition which has pit colleagues against each other, making enemies out of old friends, raising ambitions amongst clinical professionals to "expand their territories", develop grandeurs of Alexander the Great...which does make one wonder why such individuals can't concentrate on getting top quality care sorted where they are, rather than expansionist ideas...but I digress. We in the NHS want to learn from the private sector, we are told competition raises standards and surely there have been examples to support it too...but there comes a time when competition can also be counter-productive, when the essence of competing means someone has to lose, thus putting hard working professionals out of jobs, changing existing systems...while in the meanwhile if you ask the person who matters, the patient..the answer is likely to be.."Can't you just all get along together?"...

And there is the nub of the issue. We are quick to slate the private sector, damning them with faint praise when it suits us all...but there are also abundant examples where different organisations work together to make sure no one "loses out". Working together to make sure systems which work are not why can't we in the glorious NHS? I go back why we all went to do this job...and I know it does sound corny, but it was to help others. And I am going to say something controversial...I have yet to meet a single individual within the managerial it a Commissioner, or your General Manager...who at the end of the day hasn't been trying to do exactly that. It sounds nearly blasphemous, doesn't it? But in my multiple roles, I have spent a lot of time with managers in different organisations who have been trying to help..their frustrations have been in clinicians not engaging with them appropriately...sounds familiar doesn't it? Same complaint from clinicians all the time....

So we all now work in silos...doctors, nurses, managers, organisations...while patients look on with amazement or bewilderment.But maybe, just maybe there is a chance organisations will become less relevant- and I for one, am quite excited that GPs will be taking over the reigns of the NHS. Good on them for taking up this challenge- and its our job to try and support them- not damn them at this stage with the negativity that they can't.Organisations don't provide integrated care, clinicians maybe this may just be the chance...listen to the patient...he/she doesn't care who you work for...they just want to be seen, be made a bit better, be listened to.To those who read this..all I would encourage is to be true to what attracted you to this profession and use the present change to support those who are leading the NHS ...the rest will fall in place.

Your name tag which proudly demonstrates your organisations name means little...what the name of the kind soul who is trying their best to be there when needed. That's what the person opposite you will take away along with the thought of being cared for when the need was there. Trust me...I know it...and I speak as a patient, not a doctor.

Saturday, April 7, 2012

Looking back...and saying....thank you

20 years walked through the gates of a college called NRS Medical College...full of bravado, full of swagger...but inwardly, a bit nervous...not sure whether being a medical student was the right thing or not. But hey, the dye was cast! One was here...and then in a blur, the years passed. One finished as a medical student, qualified as a doctor...and made friends and foes along the way. Egos stopped people talking to each other, political affiliations made enemies...but at the end, it was a time worth looking back at.
There was the inevitable "divide" based on one's background...the guys who came from the rural side of this rich country bonded quickly together, while those of us who came from missionary schools failed to understand their beliefs..having never been exposed to folks with such beliefs.

But you know what? Time passed and one got closer, became friends..political divides based on socialist or capitalist beliefs faded and one grew to know the Sumit Chatterjees, the Joydeep Mondals...with as much fun and a sense of humour as the evergreen Suparno Ganguly. And then there was us..a group of boys who took a lot of pride in the friendship we had..Rajiv Singh, Partha Kar, Rakesh Roy, Suparno Ganguly, Kaushik Banerjee...the list was big- and the bond was tight...nicknames flew about..Kochi, Jodu, Bando.....and the camaraderie was infectious!

Then of course, there were the girls..beyond all the teasing etc, there were some good friends..Mandeep, Debashree, Sriparna....romances blossomed, broke down, re-built themselves..wasn't it such a wonderful time...ahh those years of youth!!Amongst them all were some others whose tag line called them seniors...but they were anything but...they were friends...the Saswatas, the Rajarshis....those times spent in the canteen playing cards, chomping on hot 10 am, while the girls diligently attended some crap lecture on something.

And happened...contacts broke down, work took over, family life took over...and suddenly no one had time any more...where would we have been without social media?? Thank god for Facebook...some old contacts came back to the fore...some relations were rebuilt, some egos were too big to cross the divide.

One may start wondering at this point...why this sudden twist of nostalgia? Cue the recent article in the Guardian..mentioning the top 5 things a dying patient said to a palliative care which one of them was.."I wish I had stayed in touch with my friends"...and it got me thinking. I learnt so much in those days in Kolkata- forget the medical side of things, I learnt about politics, learnt about negotiation, learnt how to use charm when needed, aggression when desired...hey wasn't NRS the place where I sharpened my skills? All of what I have done in this country...I owe so much to that place...and more so to all those around me...who helped me, allowed me to be me.

So this blog is dedicated to all those folks in NRS Medical College I spent time with...even to those who are no longer with us...thank you for everything. Time flies- and the arrogance or cockiness of Partha Kar hasn't changed much...the inherent desire and belief that "I will come out a winner" hasn't shifted but that hasn't changed also the personality who would do anything for his friends. To those who have been out of contact, I wish we meet someday, to those who still feel aggrieved, the hand stays extended. It's one life...may as well not leave anything behind which one would regret. It's so difficult to say thank you- and in a token way, hope this blog will serve as one to all those friends who are here and the ones I left behind.

As one batters ones way through the maelstrom of politics, egos of personalities and organisations in this country in an effort to do good for patients, one also realises the benefit of having such close friends from college days...folks with whom one can drop one's guard and bounce ideas of.
That, my dear simply....priceless- and for that...I do thank you from the bottom of my heart.

Sunday, April 1, 2012

Capetown....lessons of equality....

Cape town...a city of magic...such a pleasure watching the clouds roll over Table top mountain, but more amazingly, to be in a place where the hurts of the past seem to have given way to joy and happiness, a country where one was segregated on the basis of the colour of your, vibrant place.
And to here I came..attending a meeting of experts, a meeting where I sat revisiting the treatment of atrial fibrillation, learning why targeting glucose control without a thought for the patient may not be the brightest idea ever...and after a long time? I took notes! I learnt, I enjoyed...being a student again. Away from the local politics, away from the incessant battle with other specialists who do not respect what you do in your profession, away from the bravura performance of being the one who is always in control...This was bliss. it may just be over the weekend...but at least I could let the guard down...just for a little bit.
One takes a deep breath sometimes, the continuous battles...hey...even Batman needs a break,eh?

But then....meetings are a funny bump into people, you meet new people, you meet folks who appreciate what you do, they aren't the naysayers, they don't exude say "well done", they say " we are with you, mate" and you stand up one more time..the battle goes on. Paddy English, Stephen Lawrence, Saravanan...guys who
belong to the new generation, folks who want to make the change..and in the midst of it all?
Some from the old guard, but as much a part of the awareness of making things better, the legendary "firebrands" such as Jiten who do not want to stop you, but see reflection of their younger selves, but advice a degree of temperance, but have that knowing smile, when you say "I can take on anyone".

Politics kills us all, doesn't it? The burning desire to hold on to old ground, the burning desire to protect ones own turf...and we seem to have forgotten why we went to do this job in the first help the person who has come to us asking to be made...better. How much have we moved away from what is our core that we are now entrenched to organisations? Let me say this boldly and clearly...Organisations do NOT change things...individuals do. And you know what? That's what the powers that be are saying too.
I met Bruce Keogh, I met Malcolm Grant...all here in Cape town..talking of the future of the NHS,..wise men who are willing to listen, willing to change, passionate about making the change..understanding the need for specialists go come close to primary care, and organisations who don't get that will be left behind, left in their own little mire...still thinking of what has to be done, what could be one.

Diabetes care has had too many divisions, too many organisations...why do we need a specialist organisation, a primary care organisation, a patient organisation when we all believe in helping patients? Get together fellas, sort your differences apart...or only 1 group falls through the cracks....or while you contemplate how to do it, watch Generation Now show you the way. The powers that be are ready to listen...come out of your trenches or be left behind.
Cape town, South Africa..a country which used to treat some of it's own like second class everyone's equal. Can we in the English healthcare system develop the concept of mutual respect? Not the phoney chat, not the "let's get together to show we are together" belief that we are equal as professionals trying to do the right thing. Away from the UK, when you meet folks who want to do exactly that, you know it's do-able. You know what? Rest time is over....battle armour back on...and my fellow Gastroenterologist? No, my job is not to look after patients you "don't want", my duty is to those patients who will benefit from my expertise. And can I take you on for that?
Hell Yes. Lock and load....