This week I returned, energised and enthused, from the Faculty of Medical Leadership and Management (FMLM) conference in Edinburgh. One of the reasons I so enjoy attending conferences is that sense of renewal you gain; in our hectic day jobs we rarely have the opportunity to pause and reflect on everything we do and conferences give us that chance to look at the bigger picture and discuss our practice with fascinating people from our own day-to-day sphere of practice.
I attended a particularly good discussion, chaired by Clare Marx of the RCS council, where our table discussed how we should prepare trainees for leadership. We had a fairly wide-ranging and heated debate but one key problem we discussed was why so many junior doctors are not interested in the management and leadership of the hospitals and trusts for which they work.
At this point the conversation turned decidedly dark. Most of our table were trainees at varying stages from FY1 to senior registrar, and we all had stories of how trusts we had worked for had generally failed to engage with us and make us feel part of the team. Now, I do not want to write a list of the calamities and irritations that I and so many of my colleagues have had to put up with when we move to a new trust, I think the NHS has quite enough vocal critics on the net, but instead I want to collate examples of good practice I have seen and heard about and put it into a description of a fictitious doctor starting at a hospital somewhere next August and show what good might come of it. Please excuse my use of a work of fiction (and references to a popular Radio 4 soap) to explore this topic, but it is more entertaining to write!
Jane was excited about her FY2 year job at Felpersham General Hospital, Borsetshire. She had always wanted to do paediatrics and this was her chance; after a year of general medicine and surgery at the other hospital in the county she was moving to do paediatrics, adolescent and child psychiatry and ENT. It was her first choice rotation which, she hoped, would give her some great experience to apply for her training post in paeds in a few months’ time.
She was nervous though. She hadn’t done any paediatrics since she was a medical student and the thought of being on the SHO rota covering sick children in A&E and on the wards was rather daunting. Not only that, but she worried about her applications due in a few months. She had not published a paper and knew she should get involved in a quality improvement project, but just did not know how to go about doing it. And that was just her professional life; her fiancé was working over 2 hours away and it was hard enough to see each other to catch up let alone plan their wedding next April.
She was a bit surprised when an email appeared in her inbox at the beginning of June, two months before her job was due to start. It was from the HR department of Felpersham General so she opened up the email and read it with interest.
“Dear Dr Austin,
It gives me great pleasure to welcome to our trust, we are looking forward to meeting you at the induction on the 4th of August. I wanted to introduce myself and to give you the information you will need before you join us in a couple of months. I am the HR manager for junior doctors in paediatrics, psychiatry and surgery and am the key contact for you for all things administrative! Please, if you have any problems or questions just drop me an email or give me a call, we are here to help.
First, we want to make the paperwork as smooth as possible for you. I have attached a list of documents that we require; please scan and email them to me and we will get all your forms processed as soon as possible. Please also send us a copy of your current payslip so we can ensure you get correctly paid from the first month, we want to avoid any problems. You won’t have to come in before induction to do anything, email copies of everything will be fine.
Occupational Health require you to fill in a form and email them; they can then contact your current trust with your permission and get all the information from them to save you time and hassle. If there are any problems and they need to see you in person we will schedule you a time to see them on the day of induction.
I am sure you are keen to know what the rota will be; it is drafted now and we will send it out in two weeks’ time, six weeks before you start the job. We like to be as flexible as possible to make things easier for you, so if you have a couple of important dates that you would really like off we will try to accommodate this for you. Please email me 2-3 days or weekends you would prefer off and once we have everyone’s preferences in we will do our best to make this possible.
I have attached a timetable for induction for your information. If you are on night shifts at another hospital the night before you are allowed to be absent and we will share links to the videos of the presentations for you to watch.
We have tried to minimise mandatory training as much as possible. We have therefore contacted your old trust to show us your certificates for data protection, child protection, fire training, manual handling, blood transfusion, documentation, communication skills and incident reporting and if these are valid you will not have to retake these.
Finally, I just want to say welcome to the trust. We are a friendly place and hope that your year with us is a really positive one. Please do not hesitate to contact me with any questions or queries you may have.
Many thanks and kind regards,
Jane stared at the missive with her jaw hanging open. She had never received such a lovely email from HR at her current hospital. Already she could feel the stress lifting from her shoulders. She wrote a quick email back thanking A.J. and asking if she could have the weekend of her wedding off and if she could have the weekend of her father’s 60th birthday off too. She had a reply from A.J. the next morning congratulating her on her engagement and asking whether she was planning on having a honeymoon straight away as he could pencil in her annual leave for the two weeks after the wedding as well if she wanted. She had no idea how worried she had been about the wedding until now; it felt like an invisible weight had been lifted from her and she walked to work that day with a smile on her face that not even the rain could dampen.
Sure enough a week later the rota came through; she could go to her father’s birthday after all and, joy of joys, she had her wedding weekend and honeymoon off! She phoned her fiancé straight away to tell him the good news (and to make a few more veiled references to Tahiti; she hoped he would get the hint!)
More surprising still was the email she received from her future educational supervisor a few weeks before starting. He wanted to know what her career plans were, what she wanted to get out of her rotations in the next year and what quality improvement and management experience she had so far. She told him her hopes of becoming a paediatrician and her worries that she did not have much experience in QI or in management. He emailed her back and suggested that she contact one of the registrars who was working on a project to improve prescribing and reduce drug errors on the paediatric ward. He also asked if she wanted to join one of the hospital committees as the trainee representative as a way to improve her knowledge of management. One of the two trainee posts on the Medicines Management Board would be vacant from August and he would help make sure she had time out of her day to attend their meetings once every 2 months.
She contacted the registrar who was just about to start the project and glad to have her help. He was going to be away for most of August but because they had made contact so early they were able to discuss the project and she even went into the hospital a week before she started to meet him and the ward pharmacist so she could start the project as soon as she got there. She also talked to the registrar about some of her worries about working in paeds and he reassured her that there was always someone to ask for help and gave her some useful tips for her first on-calls.
The last few weeks of FY1 passed in a blur. In a way it was sad to leave the friends she had met during that first eventful year, but she could not hide her excitement at joining Felpersham General and starting paeds. The induction was nothing like she had expected; rather than a barrage of short talks about the different colours of fire extinguisher and how to lift a cardboard box without hurting your back, they had a brilliant talk from the Chief Executive and the Medical Director. They talked to her about the transparent and honest ethos of the hospital and their overall aim to improve quality and safety for patients. They stressed how much it was down to junior doctors like her to look out for areas needing improvement. They explained how in every department there was a manager who would do a patient safety walk around the department each month and they should make sure any problems be discussed then. They also told her about their programme to introduce junior doctors to management; they were keen that every committee in the hospital had 2 trainee members and that members of the senior management team would be coming to special teaching sessions once a month with the trainees to talk about their role in the organisation and to run a question and answer session.
With so little mandatory training on the induction day the afternoon was spent in departmental induction. They met the consultant in charge of the department as well as the manager of the paediatric division. They were then shown how the team worked by one of the registrars and given the paediatric department handbook which gave all the hints, tips and phone numbers that she would need for the job.
When Jane walked back to the accommodation that night with some of other new doctors, all they could talk about was how crazily nice this hospital was! They were all so enthused by the positive talks they had had that morning and were already planning projects to work on whilst they were working together in paeds. It all felt so much less daunting than she had expected and she was so grateful to her new trust that the induction process had been so painless and that her wedding and Dad’s birthday were sorted. She really did feel part of the team, even after just a day.
Now I am well aware that this story will not be winning the Pulitzer Prize, but I wanted to explore what might be achieved if trusts took a slightly different view to the junior doctors that join them each year. You might, quite reasonably, say that the above story describes good, old-fashioned, employee management, and you would be right. But that just does not happen most trusts I have been in or heard about.
Where this lack of understanding for junior doctors comes from is complicated. Part of it stems from the abnormal employer/employee relationship between junior doctors and their employing trusts. Doctors in a training programme are allotted to hospital trusts for a fixed period by the deanery (now the LETB). The trust does not have a say in who they get and they know they are only there for a few months, perhaps a year. After a while it must seem like a continual flow of itinerant workers, like fruit pickers coming for a season and then heading off into the wider world, never to be seen again. Maybe it feels like it is not worth the trust’s while to make the effort to make us welcome, to inspire us with the trust’s values and aims, but instead tell us the minimum possible and get us out onto the shop floor.
Rotas, induction, mandatory training and occupational health are normally the first thing that creates a rift between the doctors in training and the trust. Inflexible rotas with no opportunity to request dates off in advance are often only given out a few days before starting a job. This means that weddings, birthdays and holidays in August and September are virtually impossible to plan or attend. Junior doctors’ lives are put on hold because someone has not yet got round to writing a rota. It feels to us like no one cares about us, our stresses, our worries, our lives. (I have a friend who asked her future trust 5 months before her wedding day for the weekend off, well before they wrote the rota. They put her on night shifts on her wedding night. She had a really hard time finding a swap due to how tight the rota was. She went to HR and politely said that she was happy to work any time but would not work that weekend because of her wedding, swap or no swap. The person told her if she did not turn up she would be reported to the GMC. But I did say I would stay positive, so I won’t dwell on any more dark stories!)
Induction is normally uninspiring and functional – there is rarely a proper welcome to the trust from anyone senior. Occupational health departments ask people to attend appointments before starting the job, even though they are in full time employment at another trust so cannot attend and even though another occupational health department in their current trust has all the information that they need. Mandatory training has to be replicated at every trust and is simply soul-destroyingly boring. Generally it is now online, which means you have to do it in your own time, late in the evening, with a glass of wine just to get you through the pain of going through another powerpoint presentation about data protection or Caldicott guardians.
What is the end result of all of this? By the end of the induction day the trust has succeeded in uniting all the junior doctors in one respect: their universal dislike and frustration with the trust that they have just joined. They head to the pub to discuss how patronising the induction was, how late the rota was released, how long the mandatory training lasted, how frustrating the occupational health and HR paperwork was. The result is a culture of ‘them and us’. Junior doctors unite in their antipathy to management.
This is no way to train doctors in leadership. Those same frustrated, deflated, un-empowered trainees will be GPs, CCG members, consultants and management board members in a decade. And how have we trained them? We haven’t. Nor have we inspired them. All we have done is perpetuate the harmful divide between management and clinical staff, an artificial and unhelpful outcome of poor employee management.
My conclusion is that the first step to training doctors for management and leadership is to make them feel a part of the organisations for which they work. Make them feel proud to work at your hospital. Make them indebted to you for all the help you have provided them. Make them keen to work to improve the hospital and to get involved in quality improvement and management.
Now maybe my story about Jane starting at Felpersham Hospital is a bit trite. Well, very trite. But I hope it serves a purpose. Jane’s view of the hospital was shaped by simple but thoughtful interventions. We junior doctors are a relatively easy bunch to please! We don’t need bags of cash or a swanky office, just our rota, minimal paperwork, a sense that we are welcome and valued and a bit of forethought into how we can make the most of our time at the hospital. I don’t think any of this is complicated. I don’t think it will cost very much, if anything at all. All it requires is a bit of joined-up thinking and a change in priorities.
But the benefits that a legion of motivated, empowered junior doctors could bring could be enormous. This is just a first step in training doctors in management and leadership, but I believe it is the foundation onto which leadership training and management experience can be built. Without this foundation any intervention to improve the leadership skills of doctors in training will crumble into a rubble of disaffection and negativity.
PS: This is very much my opinion, not that of the FMLM or of the conference. What I would really like is your comments and thoughts about this. As a junior have you felt inspired and motivated by your trust? Have you felt ignored and disillusioned by rotas or induction? What else could employers do to improve things? Is there anything you think juniors should be doing to be more involved – do we expect too much from our employers? Do you work as a manager or executive and see this from a different perspective? I’d really appreciate any views about this. Thanks! Fitz