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At work the pressures to get people seen, assessed and home as quickly (and safely) as possible continues.  All week there were reminders of just how busy we were.  Emails, crisis meetings, phone calls from managers.  Even the TV offered no chance of respite – The NHS ‘crisis’ was making headline news almost every day.

Yes, the war of rhetoric versus reality seemed never ending.

It would be exhausting if it weren’t for the glimmers of light that insisted on shining through.  It’s been a really weird week in that respect.  Without particularly looking for them they appeared.  This is what I want to get into this week – inspirational people.

Throughout my life I have looked to others to inspire me with confidence, a sense of belonging and a sense of possibility.  Watching Barack Obama’s farewell speech this week however, got me thinking about not just how some are able to inspire, but why is it that we seem to need these people?  Why can’t we inspire ourselves?  Bear with me as I realise that may sound a bit conceited or even arrogant.

When Joe Biden was awarded the Presidential Medal of Freedom with distinction, he spoke about ‘getting credit he didn’t deserve’.  In fact his whole speech was incredibly humble and yet to many he is an inspiration.

I think we want to mirror aspects of our own character in other people whilst recognising that we are all a bit flawed.

So coming back to reality how do we do this?  Moreover, how do we do this at this particular time in the NHS’s history?

We are all trained to put the needs of our patients above anything else.  We need to remind ourselves though that we are as important as our patients. The system continues to limp on but if we as a workforce become sick who is going to take care of us?

How we do this is a matter of style (or taste). To quote Leslie Knope from Parks and Recreation ‘one person’s annoying is another person’s heroic and inspirational’

I am a fairly social creature so will look to bring people together with coffee, cake or a simple ‘how’s it going?’

That said, I do think we need to come back to the idea that we can and should inspire ourselves.  We need to tell ourselves ‘You’ve got this! You are amazing, cut yourself some slack.’ Easier said than done when all hell is breaking loose but if I may, can I suggest that you write down some inspirational phrases or quotes.  Put them on your desk so when you’re in the midst of chaos and cannot see, they will make you smile, they will reassure, they will offer hope.

Who knows they may even creep into your subconscious so that…

‘….every time it rains

You’re here in my head

Like the sun coming out

…..I just know that something good is going to happen

… I don’t know when

But just saying it could even make it happen’

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Say something…


Day one. New Years Day.  I volunteered to work the early shift as we were short. My most favourite day of the year is New Years day. It is literally the quietest day of the year.  The silence of the morning is amazing!  Not even the sheep or the cows are making much noise.  Its like having the whole world to yourself.

The noise was of course shattered by the hullabaloo of the acute receiving unit.  It’s about this time that beds become scarce.  Xmas isn’t too bad.  Not that illness is any less prevalent.  I think many people have this idea that they should ‘hang on’ over Xmas so by the time New Year comes they are usually pretty sick.

The only new year resolution you hear about is trying to get through the day without writing last year’s date in the notes.

Another thing you’ll hear people say is “When can we get back to normal?”.  Normal in the NHS is usually defined as a fully functioning multi-disciplinary team and various other departments working ‘normal’ hours e.g. social work, pharmacy etc.

To be honest I’m not sure there is a normal anymore.  When you have the head of the Red Cross talking about ‘responding to the humanitarian crisis in our hospital and ambulance services across the country’  it is not surprising that people may feel like they are working in a war zone.

Add in the changing language that some in management use (we don’t board, we transition care…) and it also has the feel of that scene in Titanic when the string quartet played as the ship sank.

So when I came across this book the other day I thought ‘You know what, yes! This is a book I need to read and apply in my working life’


I even showed it to colleagues and suggested we use it as a template for future job planning sessions.  Much hilarity!

However predictably I started to find it less funny.  In fact I was a little worried.  Not that I had any time to mull on it – work, work, work…….

Periodically that sense of unease would work itself to the surface.  I’d try to latch on for a closer look but some other issue would divert my attention.  It was only when a comment about the ‘prickliness’ of work colleagues came back in my mind did I really stop and think.

We were desensitising.

Now most of us are already desensitised to the minus X bed emails and phone calls (people are usually referred to as beds before ‘transitioning’ to patients).  No, my worry is we are desensitising to each other and that we’re too busy to notice or care.

So with this in mind one of my aims for the coming months is to try to bring people together again.  I’ll be honest, I’m not sure how successful I’ll be but I think its worth the effort.  If history tells us anything then we owe it to our NHS and the people it cares for.  That it includes the people working within it…..

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It’s the most wonderful time of the year….


I’m always in a reflective mood at this time of year.  For me Xmas brings a sense of renewed hope and possibility.  So it’s in this frame of mind that I am casting a backwards look over my shoulder to the year that has been.

I started in Forth Valley just over a year ago and it has gone by crazy fast!

The challenge of starting somewhere new can be quite daunting.  A friend of mine cautioned me ahead of the move that I would no longer have a ‘support network’ to lean on.  At least not to begin with. Grateful for the advice I set about putting on a metaphorical life jacket prior to getting on the boat.

My first year in Forth Valley has been more like trying to navigate a boat in choppy seas.  Sure there have been periods of calm and work is plain sailing.  However all too often though the sea has been littered with icebergs.  I think it would also be fair to say that on occasion, I have sailed directly towards the icebergs in order to force hidden issues to come to the surface.

Sometimes this approach has worked very well.  What could be described as ‘confrontations’ have produced some of my best working relationships.  There are some collisions that have not ended as well.

I am trying to go with the ebb and flow of this new working life. Those who have worked with me in the past will testify this is not a change that has come easily to me.  That said there is still work to be done and my focus will always be on what is best for patient care.  How I personally go about working with others will not always be a perfect.  As I was reminded recently I am only human.  I will make mistakes.

So my thoughts turned once more to our Chief Medical Officers report on ‘Realistic Medicine’ in particular these points:

  • How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients?
  • How can people (as patients) and professionals combine their expertise to share clinical decisions that focus on outcomes that matter to individuals?

How can you standardise the machine of human nature when the two most commonly heard phrases I have come across this year are; ‘that’s not how we do things here’ and ‘that’s a job planning issue’. It is like being up against a proverbial brick wall.  I should stress as well that this is something that you will hear across many NHS organisations.

Now I am not suggesting we become totally altruistic in our pursuit of person centred healthcare. We do need though to somehow strike a balance between what matters to us as healthcare professionals and what is best for the service and ultimately the patients.

Do I have a solution that will see this brick wall come tumbling down?  No I don’t.  To be honest I worry more about the other side of the wall these days.  The sledgehammer approach takes a lot of energy.  Energy that is needed to guide people through a new landscape when the wall eventually cracks.

So back in my boat it is less full steam ahead and more of a steady flow. I will continue to look out for ice bergs and carefully navigate round them.  Keep my eyes on the horizon.  Looking behind will only serve to give me a crick in the neck….

Merry Xmas everyone!merry-christmas-wallpapers-1080p-hd-images

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Everybody’s Talking (at me…)


I’m stuck. How to I get people to assess and document mental capacity?

This is something I have been struggling with for a few years now.  I know I’m not alone either.

In last weeks blog I alluded to the fact that part of the Older People in Acute Care inspection focused on mental capacity documentation.  I also spoke about how nursing staff were being held to account for it when it is medical staff who are responsible.

I also came across this tweet by the British Geriatrics Society (@GeriSoc):

‘Some pts in hospital for ages, have multiple procedures, before capacity finally questioned only because they want to go home! #bgsconf‘ 

This is a situation I have been witness to repeatedly.

How can we be striving for person centred care and yet the most fundamental aspect of this is not addressed?

It was therefore fortuitous that I was asked to present to our Clinical Governance Board on this topic.  So with the question twirling in my brain of how to improve it I started with some basic education.

Does this person have capacity?  What about the others….?

Now the first thing I had to do was make an assumption that the people sat in the room had capacity.  That’s how we should approach the assessment of anyone we see in hospital, clinic or at home.  They should have a broad understanding of what is wrong with them, the treatment offered and what would happen if they refused treatment.  They also have to be able to communicate this decision and we should help facilitate this if they are unable.

I quickly ascertained that my audience was full of mentally competent people who were keen to hear what I had to say.

I moved onto what is meant by mental capacity.

Just because you can make bad choices it does not mean you lack mental capacity.  You just have to explore the reasoning behind why they believe what they do.

Mental capacity can also be fluid.  This is true in the case of the person with delirium. As the condition fluctuates there can be times when the person is lucid but at other times they can be confused and/or hallucinating.

Finally mental capacity is task specific.  This is of particular importance in the person with dementia.  They may be able to understand the need for treatment for a chest infection but lack insight regards their own safety at home.

So how can we maximise the decision making ability of the person?  Well first you have to have enough time to go through things, including time to re-assess where necessary.  You need peace and quiet.  The person should have every possible chance to use what capacity they do have. That means put their glasses on, check that hearing aids work, have written information available and allow family members or carers to be present.

Lastly I have spoken about mental capacity in relation to medical treatment.  There is a whole other aspect to it that encompasses decisions pertaining to financial and welfare matters.

With all this to consider is it any wonder that mental capacity is a complex and time consuming process?

So back to my question – how to engage people with it?  I personally think we need a much broader range of people trained in the assessment of mental capacity.  I think our nursing staff have much to offer in this area and I would welcome any thoughts or comments around this.

I also think we need to ensure that medical staff are properly educated.  It is a daunting topic but one that is relatively straight forward to understand if taught well.

Meantime I draw parallels with DNACPR discussions and documentation in terms of importance and the legal aspect.  We would not dream of having a conversation around treatment escalation/resuscitation and not document it.  Why do we not apply the same level of importance to a person’s mental capacity?

It makes no sense….!

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Doing the best you can…

I’ve been reading Brene Browns book ‘Rising Strong’ in which she explores this idea.  I’m not entirely sure why but for the first time it actually hit home.  I’ve heard it said a hundred times but generally dismissed it.complaints_328x212_ThinkstockPhotos-515056570

Sure I know they’re trying but are they…?  Really?’


I even found myself saying it at work to be told it wasn’t good enough.  That can be hard especially when you’re being held to account for things that are out with your control.  I know I’m not the only one who has experienced this from what I see discussed on social media (Professor David Oliver’s tweets from the weekend are a good starting point @mancunianmedic)


Medicine sometimes feels like a giant mechanical beast to be dissected and analysed.  We’re very good at coming up with diagnoses, tests and management plans.  We’re great at refining ‘process’ when things don’t go well.  We also have a complaints department whose job it is to write letters with our findings.  It’s all very…. clinical.

Where is the feeling?



I’ve been a supporter of Patient Opinion (@patientopinion) for years.  I love its simple concept of real time feedback.  I have become increasingly frustrated and disillusioned with the clunky, time consuming/wasting complaints process on offer to patients and families.  Patient Opinion allows people to share stories – good and bad.  It allows us not only to be transparent and honest but also lets us share with the whole team.  It opens up the possibility of real time change in a way that the current system doesn’t.


This ability to effect change in real time I think is crucial in maintaining the trust of patients and their families.  I also think however it has a role in protecting the emotional well being of the team.

A colleague on twitter Dr James Fisher (@JimboFish) introduced me to Schwartz rounds (@PointofCareFdn).  The idea is again a simple one.  While we can do a significant event analysis we rarely focus on its impact on the team from an emotional perspective.  We don’t talk about the frustration of dealing with an agitated delirious person who we wish would just sit down in case they fall and break a bone.  Or how we felt being shouted at by angry relatives in the middle of the ward.  I understand their stress and worry but does that mean they can call me all the names under the sun and twist my words….?

I tried to introduce this to the post take ward round debrief when I was on call this weekend.  After going through the job list I asked Tania, my FY1, was there anything else we should or wanted to talk about.  It turned into a discussion about the non pharmacological management of delirium.  We spoke about trying to change perspectives to see through the eyes of the person we are trying to help. What was amazing was the realisation that actually the most helpful things are often the most simple and easy. Feeling empowered she went off to put into practice what we had spoken about. All with a renewed sense of confidence.

Having tried a modified version of it on call I’m thinking of making it part of our weekly multi disciplinary team meetings.  I think emotional vulnerability is hard especially in an organisation such as the NHS.  However if we are entrusted with the care of the most physically and mentally vulnerable – sharing our own emotional vulnerability can only be a good thing.





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Come fly with me….

Changeover week is always a bit of a funny week.  It starts off much the same as any other. There’s the ward round to be done, results to be chased and plans to be made.  The whole thing has a certain ease to it.  The familiarity of the team makes for a relatively relaxed atmosphere.  Everything is sorted. Everything is in hand.  Ahhhhh…!

IMG_4624Then Wednesday arrives and it’s a bit of a jolt to the system.  Suddenly the team is brand new and not only do they not know the patients they don’t know how things are done.  Its kind of like when a plane hits turbulence.  Its all a bit unpleasant but no one is in any kind of real danger.  That’s how I feel manning the ward on changeover day.  I’m the pilot of the plane trying to get us through the worst as quickly and safely as possible.  I consider our senior charge nurse to be my co pilot. We make for a pretty awesome team having been through it many many times!

So what makes it that bit easier? Talking.  Plain and simple.  It offers reassurance that the unpleasantness of the new will pass quickly. It creates a safe place so that no ‘stupid question’ goes unanswered.  And because I’m fundamentally nosey I get to know my new team better too.

It was also in this changeover week that a good friend of mine was admitted to hospital. She doesn’t work in the NHS so it was through her eyes I got another perspective on how we communicate as doctors.  I should say she’s happy for me to share this.  When I first visited she’d been in for 3 days.  In that time she’d seen several different doctors but was uncertain which of them was her Consultant. She also had been kept in the admissions area of the hospital rather than being moved to a ward elsewhere. Now my friend is not exactly the shrinking violet type so I was  surprised to hear her comment that she didn’t want to cause any bother by asking why.

Another doctor appeared when I was there. My friend was told very succinctly that ‘Your CRP is coming down but I’ve spoken to micro so we have a plan for the weekend.’

The doctor was about to walk away when my friend asked ‘and the plan is what?’

Biting my tongue is something I’m really bad at.  However it wasn’t my place to start interjecting with questions.  Suffice to say I asked my friend if she knew what a CRP was?  ‘Not a clue’ was her response.

I tried to think about what had particularly irritated me about it.  Technically the doctor had done nothing wrong.  I understood it all perfectly.  As a doctor….

So putting it to one side I visited my friend again  – day 5 of feeling sore and fed up.  I visited just before tea at which time I was asked to leave for protected meal time.  There were 3 other people in the ward.  None were old or obviously confused.  We both asked why I would have to leave.  ‘Its so we can help people with their tea’  Looking around it wasn’t exactly clear how they needed to be assisted so we asked again.  The reply was the same ‘its protected mealtime’.

So I had to wait outside for an hour while my friend ate her tea by herself. As she had been all day.  After eventually catching up I hug my friend goodbye, wish her a speedy recovery and start to reflect….

Back at work the turbulence had eased and everyone was feeling that little bit calmer.  Everything was in hand, everything was sorted.  As we became more mindful of looking out for one another I asked them to think about the people in the beds or sat out in chairs.  We thought about a time when we knew no medic chat.  We started to think about talking to our patients as people going through a turbulent time.  They are looking to us for reassurance that everything will be ok.  The best way to do that is just to talk like a normal human being – jargon free, calm and reassuring.  Like any good Captain would do….


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‘What’s the one thing you know now that you wished you’d known at the start?’

I asked the team this at the start of this weekend’s on call.  It was met with groans and comments of ‘don’t do it!’

Yes its changeover on Wednesday! Its like a second Halloween to the media.  There are stories designed to terrify the public of how you’ll meet a grizzly end if you are unfortunate enough to be admitted to hospital on the first Wednesday of August.maxresdefault

There are also emails reminding the senior clinicians that we run a service and targets are key during this time.

Somewhere in amongst all that are people.  While we focus on ‘people not patients’ could we perhaps extend that to ‘people not the FY1’?

There have been great improvements over the years to move away from the traditional baptism of fire on your first day.  There are now preparation for practice or shadowing courses.  On social media there is a great hashtag #tipsfornewdocs (my top tip was ‘when on call eat at every opportunity/like you’ll never eat again).

We are much more supportive of our new doctors than ever before.  There is growing recognition that to run a safe, efficient service you have to do the proper training and education.  I say growing recognition as at times it seems we still can’t see the blindingly obvious inefficiencies.

I listened to http://www.bbc.co.uk/programmes/p041svjg this week by Dr Kevin Fong. It was all about ‘Lean’ in healthcare.  This has been about for years in management circles – standardise the process to make it more efficient.  Which is fine if we are making cars but we are caring for people.  A point acknowledged in the program.  I then thought about our Chief Medical Officer’s report on ‘Realistic Medicine’ which also talks about standardising process http://www.gov.scot/Resource/0049/00492520.pdf



Just at the point my head was about to explode from the buzzword bingo of management language it all became clear.  Strip away the language and what you have is blindly obvious.


Time to spend with patients. Time to gain experience. Time to spend with families. Time to talk to your colleagues. Time to finish on time.



I would therefore argue that we are missing a huge opportunity during changeover to uncover the blindingly obvious.  As our doctors move hospitals, departments and wards we should be asking them ‘what do you know now that would save you time when you started?’.

You then get a different response:

‘A map of the hospital so I know where to run when the cardiac arrest page goes off’

‘What time the phelbotomist is in and where they leave forms for those that they couldn’t get. It means you don’t discover mid afternoon some bloods haven’t been done’

‘The Treatment Room: Prepared ‘Procedure specific’ trays‘ This was beautifully presented by Dr Yesmin Karapinar an FY1 at the Women’s Medical Federation Conference in May 2016 .


‘Where’s the nearest place for coffee?’  Ok that was mine.  Where’s the nearest toilet is my second question.

Starting a new job is an exciting time for most doctors – lets ensure we uncover the time to make changeover process enjoyable as well as efficient.