Leadership – the immediacy of example

Leadership, I am sure, takes many forms, but explicit exposure to the theories and approaches that might have helped develop doctors of my generation was lacking. The leadership that I was conscious of, as a trainee, was the example set by my seniors. Thus, as a consultant myself, the most direct route to leadership that I have identified is the example I give. This may be one-dimensional, and I hope that over the years other ways will reveal themselves.

The trouble with leading by example is that we are, as fallible people, inconsistent. In medicine inconsistency is risky. After several years on the wards it is possible to recognise how the example one sets can translate, directly, into the care that is delivered. In this post I try to relate how that translation can occur with a short account. It is not a sophisticated scenario, but one that shows how healthcare, more than other profession perhaps, can excel or fail due to the behaviour and attitudes of those in charge.

oOo

A busy ward round – Monday. The consultant, Dr Blackburn, paces himself. He intends to see all the patients, but there are a handful whom he especially needs to ‘get my head round’. They are complex and potentially unstable. It will take an hour and a half to achieve that aim, and in the remaining two and half hours the spectrum of acuity and severity that he meets will be wide. Some of the patients will be medically fit, just waiting for a package of care. He tends, not unreasonably, to see them at the end of the round. But he will see them. They are his patients.

At twenty to one he looks down the list. There are still four patients to see. He has a regular meeting at one o’clock. He was late for it last time, and does not want to be late again. He asks for a précis of the patients’ problems, and they are pretty much stable. One was admitted overnight, but the word is that they failed an occupational therapy assessment at the front door, and if not for that they would have been discharged immediately. ‘Could you take a quick look?’ he asks his registrar, Emma. ‘Let me know if there are any real issues…medical issues.’ He leaves the team. In truth, he left them half an hour ago. His attention began to slip, he began to ask the same question twice. The intellectual meat of the morning had been chewed and digested hours ago. He was now using reserves of enthusiasm that only professionalism drove him to access. But the team has done well. The week should proceed safely enough, now that they have the measure of their charges.

Emma and the rest of the team need to eat. She will see the new patient later, as promised. Did she promise? Well, she was asked and did not say no. That’s the way it works. She has a clinic though, and it does not go as smoothly as she had hoped it would. At 4.50PM she bleeps the FY1, Luke, and asks him to make sure the new patient has been reviewed. He speaks his mind, does Luke, and he is just coming to terms with the requirements of the job – that is the ability to accommodate last minute requests and fit them into the sequence of the day. His job feels truly Sisyphean. Just as he is beginning to feel that he is getting on top of his list of tasks, another is added. ‘I thought you…’ he stops himself. ‘OK, but if there’s a problem, what should I hand over, the lumbar puncture or the new patient.’ Emma replies quickly, ‘Neither. But make sure the LP is done, please, that’s crucial.’

Luke circles the name of the new patient at the bottom of his list. But he concentrates on the LP. He’s done several, but cannot undertake them unsupervised. Emma would have looked on, but she remains tied up in clinic. His second option, Lucy, an experienced SHO on another firm, offered her time after lunch, but she is probably getting ready to go by now. He sees her, and sighs in relief when she makes the offer again. By 6.30PM they have done it. The samples are on their way. His day is almost over. Except for the new patient review.

A review. Just a review. But a new patient. That’s the catch. To do it properly requires a ‘from scratch’ assessment of the presenting complaint and past medical history, and a physical examination. It’s a 30 minute job, at least. He wants to do it. No, he wants to have done it. But now, at a quarter to seven, the task’s magnitude has become inflated. What if it’s complicated? What if the drug chart needs re-writing? It is unlikely. No-one has bleeped him about her during the afternoon. They must be truly stable – off legs at worst. Isn’t that what they said on the ward round? – failed OT assessment, no ‘medical’ issues. Dr Blackburn wasn’t interested. Luke recalled his far-away gaze, the evident lack of enthusiasm, ‘Let me know…’ he said, ‘if there are any real issues…’ Even consultants, with all their knowledge and experience, cannot achieve 100% of their work. Luke decides to take it on trust. The chances of that patient coming to mischief are minimal. Luke is not going to cut himself up about this one lapse. He’s done so much today.

At three in the morning the on-call FY1 is called to see the patient. She finds him confused and septic, with clear signs of pneumonia. She is surprised such basic diagnosis could have been missed, and puts the fact that his chest x-ray and his blood tests have not been scrutinised down to the circumstances – the decision to admit was made late in the evening, and they must have been arranged just before he went to the ward. But she would have thought the results of those investigations (which include grossly elevated inflammatory markers) would have been seen on the ward round that day. Strange, she was sure Dr Blackburn himself went round on Mondays.

 

oOo

 

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