Tuesday, August 21, 2012

Allegiance: With whom do you lie?

Kevin Pietersen…what can you say? On the face of it, an uber talented cricketer, a rebel character, a bigger match winner than Freddy Flintoff as per statistics, has been cast adrift from the establishment- as he did not “conform”…the main allegation being that his allegiance was compromised. And the pundits have been out in force weighing up on both sides. For the traditionalists, he has no place in the team, for the non-conformists, such a talent needs to be handled with care. Didn’t all the “greats” have their foibles? Warne, Botham, Richards..all quintessential rebels…all great masters of their craft…and uniformly feted as the darling of the masses.

The rebel within finds that endearing….till one reads that the root cause or at least the alleged one…whereby one hears that he gave tips to the opposition how to get his own team mate dismissed. Perhaps thereby lies the crux, perhaps it’s not about the rebellious nature, its not about the talent or the arrogance, it’s about what has been compromised. It’s about the loyalty to your team mates, compromising on something sacred, something dear, and compromising on your allegiance. And for that Kevin, I am afraid...you are done.

“Allegiance”. It’s interesting to discuss this particular word in the context of what we do nowadays- and as doctors, we face this question pretty much every day…such is the nature of the “business” we are involved in, I suppose. The basic question being…as a doctor who does your allegiance sit with? Is it with the patients, the institution that is the NHS, the Trust that employs you, your line manager, your colleagues or is it your specialty? 
Or are they all the same thing but in different garbs? I must admit to not knowing the answer to that conundrum…instinctively, you would think your primary “allegiance” is to your patients...the reason you went to medical school etc etc…but if that’s the case, how come you see only handful of examples where doctors have come out in raging protest against the system they seem to think have dealt the patient an unfair hand?

Here’s an example…the diabetes world continues to be divided as regards where best care sits…and although a broader debate, excluding the individuals who resist as they are self-protective about their jobs, the majority genuinely believe that moving patients out to primary care will result in poor care. A perfect example where the system is being resisted as clinicians believe that patients will be compromised, thus any move to switch patients out without adequate cover or resources cannot be a good clinical decision- whatever the pressures maybe. So far, so good. Let’s drill into that a bit further. There are some areas who have let that happen…without so much as a murmur, because their Trust wanted to reduce activity, or the present policy of the NHS said so. Most of those areas now have poor care in diabetes. So where does the allegiance lie in that case? Is it because the doctors concerned don’t care- or has the cynicism taken such a hard bite that they are past the point of caring? Who is the vanguard of the speciality if the specialists stand aside? Who fights for the patients in an arena such as a PCT board or Trust Board meeting... where they have no voice? Answers on a postcard please.

So how does one go about trying to marry all those- and more importantly can they be married? In these times of flux, it will be a struggle. Many a decision are bound to be taken which to the clinician, will challenge the ethos they believe in, firmly strike against, in their opinions, good clinical care…for example, if a Trust feels that a department doesn’t need a diabetes nurse anymore, how far would the diabetes team go to fight it? Take on their employer? Take on the NHS policies…or consider picking their fights which are winnable? As the film clichĂ© goes “A storm is coming”…and the need to make less money work for more will inevitably lead to services being rationed, cut…and all of these allegiances are set to be challenged hugely. Each one of us will need to make a decision, need to make a call –as the time to sit it out is probably past. This storm will pass…and if we choose to be on the sidelines, we may come back to tattered services.

Individually, its easy to simply say patients matter and nothing else. Reality suggests it’s difficult to do so for many, simply because of the multiplicity of vested interests involved. And I suppose this is where we have moved away from the ethos of healthcare or for that matter the NHS. What was supposed to be a system based on taxation to improve the health of the population has now become a battleground of multiple providers, people looking at the their bottom lines in the financial charts, profits, losses, closures…it suddenly is no longer, simply, about getting someone’s health better. So far, touchwood, I have been able to stay close to that- and maybe that’s because of my relative inexperience. So far, my allegiance has lay with the patients, my specialty, my department and my colleagues- with the ones named after patients- intrinsically linked with patient care. I have had no compunction about snapping or snarling when any of the above has been compromised or threatened. The question is..how long does one continue doing so? A colleague recently worried whether my “pugnacious” nature would hold me back in my career….to which my rakish answer was “I wasn’t aware this was an audition for the X factor”. But it got me thinking…has it finally come to this? I looked back at all the instances where I had picked up a fight- and either it were because of a personal insult or mostly it was down to not compromising patient care. Do I care that much about my career progression that I abandon the customary growl?

Such questions and dilemmas are sure to grow- and challenge each one of us…where does our loyalty or allegiance lie…where do we draw the line..and make no mistake, with all the flux upon us, the questions will become louder. I cannot “advise” anyone senior to me but for anyone who is starting off, my suggestion would be to hold the line, and when questioned..always work to one basic rule..the allegiance has to lie with the patient. If that involves fighting battles, one needs to have the broad shoulders to fight that. Or as in KP’s case..if you compromise on the quintessential issue of loyalty…I am afraid, it doesn’t matter how amazing you are..its unlikely you will be back in the fold.

In the words of J K Rowling…”It is our choices that show what we truly are, far more than our abilities.” The time to keep avoiding or ducking the allegiance question is fast approaching….are we all ready for it? The Pietersen saga makes us think what compromising trust can do...are we ready to repose the faith and trust placed in us by our patients? Or are we ready to test our allegiances? Tick tock...

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