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New People, Old Systems – Breaking Hierarchy: Leading from the bottom by Osman M. Ali

New People, Old Systems – Breaking Hierarchy: Leading from the bottom

by Osman M. Ali

Graduating from medical school was the happiest day of my life thus far. It sounds cliché, but I genuinely dreamed of becoming a doctor since I was a child. However, it was not excitement I felt on my first day. It was anxiety.

As a newly graduated doctor (FY1), I felt as though I was thrown into the deep end. By day, I was a glorified administrator, my role mostly involved following my seniors while they reviewed patients, documenting said reviews and actioning any jobs generated. There was minimal independent thinking. Night-time working was a complete contrast. I would regularly receive calls saying, “Doctor, I’m really worried about this patient. Can you come see them?” – No words strike greater fear in an FY1. Four months passed and I had begun to make strides. I felt confident. Gone were the days of apprehension at the thought of a concerned nurse asking for a patient to be reviewed.

On a cold, dreary November day, not dissimilar from any other day in England – I made my way to the hospital. I naturally prepared the list for the day’s patients and hoped for the best. Not all wards are hectic but few come close to a busy London Major Trauma Centre’s Trauma & Orthopaedics ward. This, coupled with the ongoing shortage of FY1s due to the ever-present flu season, led to an unbearable workload.

You would imagine that staff meetings would highlight, identify and provide solutions for the shortage. And you would be right. Problems and solutions were addressed and provided respectively, but implementation was lacklustre. My colleagues and I found ourselves at odds with increasing workloads and our direct seniors reticent to offload any semblance of our burden. Our cohort of FY1s felt obliged to attend work whilst ill for fear of further burdening each other. Clearly, this situation was not the individual fault of any single person but rather the amalgamation of multiple micro failures. Nevertheless, the question posed was, what can we do? Could we lead from the bottom? Would any attempt to solve this problem be viewed as dissent? Would colleagues be unwilling to support any proactive action? Was there a realistic threat of jeopardising our careers down the line?

I always viewed leadership as a top to bottom affair. The classic pyramid of hierarchy. Those who lead must be atop the pyramid. This, I later found, was neither the case conceptually or in reality. Leadership is not hierarchical; it is democratised. With retrospect, I identified that everyone had been participating in leadership all along – especially those of junior positions. We face conundrums every day that seniors and management were unaware of. We realised it was our role – in fact our obligation – to report these staffing issues and to suggest ways to move forward.

We – as FY1s, the most junior doctors on the team – convened and proposed temporary strategies to manage the shortfall on the wards. We discussed how seniors, as well as junior, could support us. We disseminated our conclusions, via email, to the whole department. We were proactive, pragmatic and diligent in our attempts to improve patient safety and staff morale, whilst avoiding a blame culture.

I can say with certainty that our intervention had a massive impact on myself, my colleagues and significantly improved patient safety as a whole. Our seniors at every level recognised our efforts and further encouraged us to participate in discussions of how to improve ward cover in future.

We all had our reservations on whether we should intervene and if it was appropriate to do so. A pyramid hierarchical view of leadership gives rise to these problematic notions of eligibility to intervene. What was more apparent in our case, was that when we did intervene, those who were perceived to be at the top had further encouraged the bottom to lead. Hence leading from the bottom feels more like taking ownership and responsibility of that which you are a part of. Be proactive, pragmatic and embody a no blame culture at work. Empower those around you to lead from the bottom.


Osman M. Ali recently completed foundation training in London. Currently he plans on taking an “F3” year aiming to gain further experience in surgery. You can follow him on instagram @ozzyalaby



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