Management miss the point (again)

Management miss the point (again)

I was saddened recently to hear of the death of Kate Grainger, a doctor in palliative care who was also a blogger and campaigner for improved communication in hospital. She left a wonderful legacy in the form of her “Hello my name is” campaign. This involves all medical, nursing and support staff trying harder to always introduce themselves to patients. Bighospital, like other hospitals have been quick to adopt this brilliant idea and have issued everyone with badges that instead of saying just “Mrs KBW” they say “Hello my name is Mrs KBW”.

Which is quite clearly NOT THE POINT!!!

I have by some miracle avoided this badge and continue to introduce myself and my boss and my team, no matter how fucked off they all get with me doing it 30 times on a ward round

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Training diary for trainers 

Training diary for trainers 

There is an interesting document I have come across recently, it is from those rather clever and switched on people in the West Midlands (wherever that is) who seem to come up with lots of good ideas. The link is here

They propose a really quite revolutionary idea that trainees should feedback to trainers what they think of them via a handover diary that they pass on the next fellow in a fellowship post, I think it was plastic surgeons but the lessons are transferrable to us in general surgery too.

The endless and one way process that goes on between trainer and trainee is good when it works well, obviously  I have to say it works well as I am a ticking clock heading towards independent practice. 

They tell us how to do things, they tell us what they like and don’t like. Some train like they were born to teach, these are the only ones who get feedback as they are rewarded by us telling them they are amazing, nominating them for silver scalpels (lots and lots of male winners, just the one female so far I think…), fighting amongst ourselves to go theatre with these golden gods of training. 

Everybody else (99%) is either ok or shit. They have highs and lows and good days and bad days but they receive no feedback on how they are as a trainer. Do they erroneously assume that they are good at it? How do they improve? How will I be the trainer I want to be?

West Midlands plastic surgeons possibly have the answer in the form of this diary.

All of us should keep a book of how to do operations and what individual bosses teach you. I know as many different set ups for how to do an anterior resection as I do things to do with my hair.

 Informally I have done the oral version of this trainer diary in the form of a chat with the incoming registrar to the job I was leaving. “He hates it when you use cutting diathermy, or the heel of the hook, he “doesn’t believe” in drains, he likes antibiotics to be iv for all things, he doesn’t like lateral sphincterotomies/ he loves lateral sphincterotomies, he hates Prof Bigshot/he is Prof Bigshots biggest fan”. The difference is we don’t tell them any of this. Only one person I have ever worked for has asked me what I think of him as a trainer and wanted feedback, it’s no coincidence that he is also the best trainer I have ever had. And I’ve been at this surgery malarkey for 15 years. 

How brave a trainer would you have to be to ask your trainers for honest and frank feedback about you as a trainer in written form to hand on to your next trainee? You would have to be thick skinned and able to cope with criticism, be willing to change your way of teaching to suit different individuals learning modes and needs (which almost none of them are able to do), willing to try new things and change and evolve. These are not easy tasks and are not very typical skills of consultant surgeons. 

Bighospital has been shaken recently by a lack of trainees and people talking about not everyone getting registrars if they don’t train. So far this is just chat and noise and there are no real plans to make it the case. It is conceivable though in the future that only those who can teach get the privilege of training the ever dwindling number of trainees, chances are we will have to be good at it. 

Will I be a brave enough brand new consultant to purchase a little notebook and ask my registrars for feedback? Yes. Will I cry under my desk when they write “KBW is a terrible trainer and has a short temper and a foul mouth”? Probably. 

Can you imagine how good they’d be at teaching if they thought we would write a report that was personal rather than the anonymous and vague GMC Survey? 

Taking charge of your training 

Taking charge of your training 

I think there should be a mirror in our registrar room, (this mirror would be handy anyway as a regular mirror for me to check my face in) but it should have a sign above it reading “The person responsible for your training”.

The apprentice/trainer model is dead in most hospitals and training is increasingly squeezed out of the operating theatre due to targets and time constraints. See this recent letter from the RCSEd president which makes this point well.  https://www.rcsed.ac.uk/media/414502/hunt.pdf

Many people, trainees and trainers, sit back and complain and compare today to the training in the good old days. As much fun as this is (I did a one in four, I did 90 hours a week, we operated 72 hours straight with no food…whatever!) it doesn’t help us in the current climate. I’m counting the days until I am done training, but will soon be a trainer. I think I am rather well placed to advise on training in general surgery as I have been training for so very long.

The people who have trained me, were trained in the old system by people who worked 100’s of hours more than I will. They learnt to teach me from how they were taught and most of them are bad at it.

Models of training

1. Apprentice and trainer. This model is the ideal and results in steady progress and a joyful and rewarding relationship over time. This model is dead in most hospitals and is what we all constantly lament the loss of. 

2. We don’t know any other models. 
I don’t really know how to get better at teaching people, I keep trying it and I’ve been reading lots of books on the subject but I cannot quite bring myself to do a certificate or diploma in education because it will cost me some of my hard earned money and probably be boring. 

I know I vehemently dislike most undergraduate teaching; nothing fills me with ennui more than 4 dull faced slack jawed millenials who can’t tell me what a hernia is, what the contents of the inguinal canal are, what bugs cause wound infections and how local anaesthetic works. 

Why should I show these eejits what I am doing and explain what is vas and what is sac when they are patently clueless? Somewhere there are lots of parents going without summer holidays and sirloin steak to put these children through medical school, they are most undeserving of the sacrifice. 
I do like post graduate teaching though, these are motivated learners, panicking about career progression and paying out their own money for exams. 

What I’ve realised over the years of good and bad trainers is that the person responsible for it all is me. Most of the years have been good but I have behaved appallingly at times in the past and let someone not train me, because I was being petulant and it suited me to say that this person doesn’t teach. I stood about huffing and moaning that they don’t let me do anything whilst never asking to do anything. 

ISCP, our internet based reflective continuous assessment website is really good when used regularly and appropriately and sadly it is not used to its full advantage by most trainers and trainees. I have had the benefit of working for one or two amazing trainers, one person in particular who I want to be like and so far I am managing to do what he did when I operate with the juniors. I am desperately trying to use ISCP the way we did but am failing to get my trainers to engage with what my needs are. 

In a relationship if you aren’t having your needs met you have “a talk” with your other half and sit down together and tell them you need more hugs/sex/help with the hoovering. In a training relationship you should do the same but I am struggling to find anyone who wants to listen.

How can we all engage more in training, how do you motivate the people who teach you to train better, how do you get them to change what they are doing without moaning and complaining and offending?  

(Don’t feel sorry for me, this situation is very much all my own fault) 

Surgery and Sports Psychology 

Surgery and Sports Psychology 

The hopes of a nation rest on one man as he prepares to take a kick with 30 seconds left in a game, the pressure is immense. The player does not disappoint and the try is converted. Millions roar with delight and admiration. The pressure on that person in that moment is unimaginable, even watching it you feel the tension. 

What you don’t see is that they have prepared for this eventuality. They have rehearsed this moment and developed coping mechanisms. They have prepared and rehearsed and are ready for the pressure. 

Have you ever watched a bobsleigher mentally prepare for a race? Or a formula one driver? Or any sportsperson at a high level prepare for a big event. They are “in the zone”.  They perform at the highest levels with high stakes and millions of eyes on them and they excel and exceed those expectations. 

Arguably, the pressure on a surgeon or trainee in the operating room are similar. The nurses are talking, the anaesthetist is laughing loudly and the rectum is not coming out easily; a piece of retractor digs painfully into your side when you suddenly get torrential bleeding that wells up obscuring your view just as the medical student on the StMark’s says she’s going to faint.  At that moment we batten down the mental hatches and cope, we do not launch the StMark’s across the room or start swearing, or indeed swearing more than you are already. 

The stakes are high, not just life and death although that is often a consideration; but continence, sexual function, bowel continuity (absence of a stoma) and other equally important outcomes depend on our ability to perform under pressure.

Unlike for example, premier league footballers these coping skills are not formally taught to us, we do not have a team around us helping us mentally prepare for operations but perhaps we should adopt some of the lessons learnt in professional sport to help us become better surgeons and crucially, better trainers and trainees. 

Even in amateur sports many people are obsessed with improving their performance. The proliferation of books on this subject are evidence that even the humblest of sportsmen and women wish to achieve their maximum potential, or at least remove any psychological obstacles. 

Traditionally and stereotypically surgeons are portrayed as being confident and composed in every situation. In theatre we act the part as expected of us and do not hesitate or crack under pressure. 

Squashing Ants is the term used by sports psychologists (ANT’s being automatic negative thoughts) to overcome our doubts and negative thoughts. “I can’t do that operation on my own” or “I can’t get this tumour out” are dismissed with positive rebukes for each negative thought. 

It takes practice, especially if, like me, you are prone to catastrophising and worrying that you can’t do something. For each “ant” you squash it with a good thought; for me this would be  “I know I can do this operation and if I need help I will call for it”. 

Visualisation is another sports technique that should be applied more in surgical training. Running through the operation verbally with a trainer and mentally alone prior to a case is very useful. Imagining intraoperative challenges and how you would respond to these helps build confidence and maximise learning, I think. 

I’m off to squash some ants!