Lessons I eventually learned
Professor Sir Graeme Catto
It was all going so well. Having returned from a spell in the USA, I was a clinical academic working with a bunch of enthusiastic and talented colleagues. Not only was our research going surprisingly well but it was all good fun. Then I was asked by the newly appointed chief executive of the local health board if I would become the first medical director of our university hospital. Persuaded by the offer of additional staff and declining a pay increase, I agreed and was sent away for a month-long residential management course.
Returning to the fray, I became aware that the way I had created a reasonably successful research team was not a model for helping to lead a major hospital. Colleagues chose to join the team because they found the work interesting and the environment stimulating. They stayed only if their personal interactions with me and existing team members worked well. Otherwise they left. That type of close personal interaction was neither possible nor desirable when helping to lead an organisation with more than 5000 employees. Fortunately I simply could not remove those (often the majority) with whom I disagreed. Negotiating skills, poorly developed in my case, became important. I rapidly realised that not all my fellow doctors were supportive. The most tricky were sometimes not the less competent or lazy but rather those who ran a good service but which by consuming additional resources functioned to the detriment of the rest of the hospital. Sharing resources fairly and ensuring that patients were not disadvantaged by poorly performing specialties were integral parts of the job about which I had never really given much thought before.
My own specialty involved treating seriously ill patients across the hospital. That clinical interaction with colleagues helped maintain communication channels in the face of different approaches to controversial issues. It is hard to sustain hostility when working together on a clinical problem at 3 am. Of course, a degree of competence and a sense of humour help too…
Since those days I have often reflected on our medical education. While the importance of working effectively in teams is emphasised throughout undergraduate education and postgraduate training, it is undermined by the practical realities of clinical practice particularly in our hospitals. The need to ensure clinical cover for large numbers of in-patients while ensuring an acceptable work / life balance for staff make it difficult or impossible to bring the same team together every day. Not only has continuity of care suffered but job satisfaction for staff has also declined, and not just for doctors. No-one regrets the passing of the old paternalistic system when your future was determined by the whim, contacts and reference of the “chief”. The current system is more equitable and transparent but encourages individuals to take full responsibility for their future at a time when many already have family commitments. We now have a fair if fairly inflexible form of Darwinian selection, not always compatible with the need to foster a caring and compassionate workforce. A radical revision of medical education and training is long overdue.