Maimonides and Bruce Lee

What links the 12th Century mystic/philosopher/physician with the 20th Century martial artist/philosopher/actor?

They are joined through their philosophical interpretation of improvement, learning and growth.

This all started with me writing about a recent incident at work and was followed by a discussion on quality improvement and learning.

If you step sideways, you can connect the ideas behind ‘Teach thy tongue to say I do not know,’ and Bruce Lee’s philosophical tale.

As to who originated the story I don’t know, this is the essence:

Enthusiastic student, after travelling for many years finally reaches the Master’s house hidden in the depths of a forest.

‘Master… at last I have found you – how wonderful!’ He proclaims, ‘I have been searching for you for such a long time… Please teach me your ways.’

And so, Master starts to explain his philosophy.

Before he is able to complete even the first sentence the student interrupts, ‘But, Master, I have been taught like this,’ or, ‘Isn’t it easier if we…’

After some time, the Master becomes exasperated. He thinks to himself – this guy is so smart, it seems he want to teach me!

The Master then calls for tea.

The student, still full of energy and eagerness, happily accepts; he holds-out the cup and the Master pours the fresh brew.

He pours and fills the cup and continues pouring. The tea overflows. Yet, he keeps pouring.

‘Master – the cup is full! Stop!’

The Master responds, ‘The value of the cup is its emptiness, you cannot learn unless you also become empty.’

And so, the connection.

It is not enough to ask the question. We must also be responsive to the answer.

Don’t just arrive at the class – listen.

The noise and mess of our pasts can drown any sound of tomorrow.

I do not know.

My cup is empty.

Let us break bread tonight.

mountains and water

What makes networks work?

I think it is now established that the only way to meaningfully achieve anything new or novel, at scale, is through networks.

One person going it alone, battling away at whatever is not enough to change the world or create a movement; equally, although there are some very bright, creative people out there, the only way to move beyond the current moment is through the power of our connectedness.

One and one equals three or four;

The existence of Mallard Ward is a case in point – is it the result of incredible team working, a scintillating culture of care and support and a network of passionate individuals who have come together to create something special.

Yet, not all networks work.

Just having the people or the shared goal or sense of meaning is not enough; there needs to be a glue which holds things together. A website or homepage is inadequate, nor is money or fame, innovation or enthusiasm;

It is ineffable; it cannot be grasped.

You can’t hold-on to the magic that allows certain stars to align – to fit together in the best of best possible Goldilocks worlds to generate something special. There is no recipe book or field-guide that point the way.

We potentially stumble into these things.

Networks simmer with energy as they take the talent of one and combine with another and joining two to three to create eight, then 64 connections; exponential fizzing.

Some folk seek to destabilise the networks.

There are nutters out there who see something good, yet, because it doesn’t align with their interpretation of the world, seek to tear the bonds apart, to demolish. Yet, the network, when it works, is always greater than one or even two or three feral extremists.

Look at Al Gore.

I read an article about him in today’s Observer – he describes the way that democracy has been hacked by the likes of Trump and Johnson – egotistical bigwigs who bully their way to power and stay afloat by keeping people down.

Yet, Gore is fighting back.

He has established The Climate Reality Project, a global organisation to take-on the oil and fat-cat syndicates who are screwing our world; he is teaching lessons in un-doing the double-speak.

This is network generation to save our planet.

And, this is just as vital as the network of health and care which supports my patients, which keeps going despite the thinness of the air.

Good begets good, which lets us survive.

There is hope, there is tomorrow, there is coming together, holding hands or social media accounts; I am convinced that Facebook despite its malevolence in relation to the US elections was beneficial in the recent UK vote.

We just need to understand the power.

For social media and the networks they support are tools of fearsome influence;

Come together, right now.

come together

Teach thy tongue to say I do not know.

Those of you who read my last blog through to the end will have seen a painting of the 12th Century Jewish philosopher, astronomer and physician, Maimonides – sometimes known as Rambam*. The painting contains one of Maimonides’ quotes –

‘Teach thy tongue to say I do not know and thou shalt progress’

I love this as it so very well sums-up who I am and my approach to life – it encapsulates the ideas behind Quality Improvement that I am so committed to pursuing.

Only by admitting your ignorance can you learn; contextualised within this is the idea that you must first feel safe to admit your lack of knowledge or understanding, to express this to others.

We move from ignorance to knowledge; pretence does not facilitate growth.

Safety is of great importance – people must feel secure, appreciated and valued – this perhaps why, in keeping with some of my recent experiences, my world sometimes feels stifling.

A culture of openness and honesty – one which allows people to challenge accepted wisdom, to question beliefs and norms, is the one which will survive.

This is another form of expressing, that good will triumph over evil, for, evil, whether in the form of bullying, oppression, state-sanctioned coercion or right-wing censure, this approach always stifles creativity; the innovation required to win the war, to topple the dictator, comes from freedom of thought.

I was talking with colleagues last week and expressing the difficulty some doctors have when they don’t know what is wrong with a patient. There is a pressure to think of something, anything, to provide a diagnosis, and with this, an action, test or treatment which is potentially wrong.

Candour – ‘I am sorry, I don’t know why you are in pain/confused/tired/breathless’ is perceived by those who are less experienced as a demonstration of ignorance, rather than of openness or confidence;

Yet, ‘I do not know,’ allows the doctor to engage in a more open discussion with their patient and others, to determine the cause. (We move from the folly of one to the wisdom of the collective), This allows one to learn.

I am fortunate – I have been around long enough to be confident in announcing my ignorance;

This should perhaps become integrated into the training of doctors and nurses, physios and pharmacists – the conviction of ‘I don’t know’ aligned with, ‘I will find-out’ as a basis to the clinical interaction with a patient.

To revert to the personal – Dad, did you get the job? Why did I not get the job?

I still don’t know.

I haven’t been provided with an adequate explanation.

And this, is another form of ignorance when we are left in doubt, when we are left looking for answers and all we have is hypothesis and soul-searching; perhaps I was too slow, too limited, not right, perhaps, the stars were not aligned or, the politics out of synch.

Whatever;

In these situations, it is our natural instinct to look for answers; and finding none, we go on until we have forgotten what it was we wanted. This is growth.

Ignorance is not bliss.

Don’t just leave your patient with, ‘I don’t know,’ provide them a framework, a timescale for your investigation; safety-net, action-plan.

No one enjoys limbo.

rambam.jpg

*For those of you who are super-observant, this is the guy on the back of my phone.

 

Length of Stay

There is an obsession within healthcare about Length of Stay – usually shortened to LoS.

In general terms, the shorter the LoS the better, although in some situations, if the LoS is too short, that can be a problem too.

For every disease, condition, treatment or ailment that requires a person to spend a period of time in hospital there is an associated LoS. Elective hip operation 48 hours, fractured hip, 7 days, pneumonia three days, stroke seven, and so on.

You name it and there is a corresponding LoS.

There are complicated calculations that sit alongside these numbers – for example, the LoS for a one-legged man who breaks their hip is likely to be longer than an otherwise able-bodied person (for obvious reasons). These sums tend to translate to complex payment system calculated both in the NHS and around the world.

If we keep things simple, imagine two people, both similar ages, with not too many other health conditions, both of whom contract pneumonia.

If person A, let’s call him Marcus is admitted to hospital F, let’s call it Farflung, and stays four days before returning home with whatever additional support might be needed in the community then the LoS if four days. Everyone goes home happy.

If however, person B, let’s call her Gloria is admitted to hospital O, let’s call this one Outskirts, and stays eight days before she is released home, the LoS at eight days, double Marcus’, suggests that either Gloria was more unwell than Marcus or the systems and processes at Outskirts are not as good as at Farflung, which has managed to address delays and obstacles to care potentially encountered at the other hospital.

At Farflung, they may have consultants working seven-days a week, they may have rapid access to diagnostics, their safety profile might be better, there are endless possibilities.

Gloria might fall on her first day in hospital, she might receive the wrong medicines, her x-ray might be misinterpreted. She might be infected with an unusual bacterium that doesn’t respond to the initial antibiotics and requires two courses; the possibilities are endless.

Yet, in the eyes of the system four is good, eight, less so.

Four is even better as that means you can treat Marcus twice for the time you treat Gloria.

In terms of system efficiency, Farflung is 2x as efficient as Outskirts. The treatment cost half as much, or double, depending on who you are looking at.

The systems used by hospitals are however far from adequately sophisticated to analyse at this level of detail.

One might assume that on average, all things being equal, if Farflung and Outskirts are both equivalent in quality, effectiveness and care, the average LoS for 100 people like Marcus and Gloria would balance at four days – with Gloria being an outlier, or, perhaps six days, as Marcus was actually a miraculous super-healer.

Equally, Farflung might be in a prosperous area where there are many affluent patients who present early, don’t smoke, look after themselves, and, have good support networks to facilitate early discharge, whereas Outskirts is less so, with folk less aware of health issues, smoking more, presenting later, and so on.

You could probably write an entire Tale of Two Hospitals about Farflung and Outskirts, demonstrating the similarities and differences of the two.

When it comes down to it however, these subtleties I have described are often lost in the system and regardless whether one is better than another, more efficient or effective, the staff more dedicated and caring, whether a week after going home Marcus is back again because he had the same infection as Gloria but did not receive the same appropriate mixture of medicines, we don’t know (this, we call, readmission – again, something for another day.)

Humans tend to be as unsophisticated in their analyses of systems as the systems themselves are complex.

We see a number, fixate on that, generalise and imagine, ‘Four good, eight bad,’ or, the inverse, again, it depends on your point of view, or, it could be that when Marcus returns to hospital, in a worse state than he originally presented, he stays for two weeks; yet, the Four sticks; the 14 of the second admission become lost in the arithmetic of the accountant’s ledger.

And what is my point?

Is there a point?

My point is essentially, that the sledgehammer used within the NHS to measure good vs bad, with LoS sitting at the head of the tree is inadequate. It is blunt, amenable to manipulation and confabulation. It can be embedded within a myriad of other factors which are either unavailable or unknowable.

LoS, LoS, discharge, discharge…

Like a crazy mantra that takes you to the same place as Nam Myoho Renge Kyo – in other words, in circles.

The repetition creates tension that does no one any good.

My message – consider LoS to be important although no more or less than the other measures, the other means by which we determine effectiveness. Just because something can be translated into a number ‘21’ doesn’t mean good or bad; it is quantity and quality; one without the other is a weakened structure that does no one any good.

When in doubt, go to the people, listen, hear, feel.

Why I’ve been so upset (& dumplings)

It all began this winter.

The pressure was extreme, despite the mild weather.

More and more patients arriving, more people waiting to both be seen and admitted, and hanging-around even longer to get home.

‘When can I go home?’ Has become a mantra of my patients – matched by my platitudes… ‘As soon as we can organise care,’ ‘When the social worker comes,’ ‘Maybe tomorrow,’ ‘I’ll ask sister.’

The winter made me a liar.

And worse than that; it placed such unimaginable pressure on co-workers that behaviours were changed; interactions distorted.

There is a story by Shaul Tchernichovsky called ‘Boiled Dumplings’ (Levivot Mevushalot) – it is an idyll describing the process of cooking dumplings as an analogy for the experiences of students at the time (1920’s, Germany) whose lives were so constrained and pressurised, compressed within the confines of strict gymnasium life, that when exposed to the outside world, they explode with the sudden drop in pressure – become radicals, revolutionaries, (just as the dumplings burst if over-filled when dropped into boiling water).

I see my colleagues, challenged through a sort of systematic bullying that is emotionally and physically draining, who drink and smoke too much in an attempt to relieve the stress, who I see growing old before me, their faces lined by poor sleep and early waking.

Who have slipped from, Jean in the corner, retired postmistress from Fife, to bed 12;

TTO (To Take Out) & prescription ordered and form signed, tests completed and heaven-forbid you should consider changing/stopping any of the medicines at last minute; the spectre of ‘the Nomad’ (pre-packed dosette boxes), is relentless; the phone, ‘How many beds today,’ and on and on.

Fortunately, we have arrived at such a level of refinement of care, in my department at least, that the pressures have not caused a deterioration in quality – we have still managed to process the patients and avoid any significant harms (indeed, we seem to be improving all the time) – as if, ‘I work better under pressure,’ is the new normal.

And back to the rationale.

I came to the conclusion that this winter was likely to be the same as the next, and, probably everyone after, more and more compression, the workforce squeezed from coal into diamonds. The structure of our teams realigning, reforming, harder and harder.

And with this realisation, which was augmented by the announcement of the retirement age moving further away (really, does anyone of my generation believe that retirement will exist in 20 years?) – and the knowledge that my experience, my sense of wellbeing and those around me is likely to continue, accelerating towards the unsustainable reckoning of the winter months, and my need to do something about it.

Something about it.

That was my sense.

That, all is not lost; that, despite the changes, the ever-increasing complexity of systems and processes, the diminishing resources and growing need, there was a way out, a way to unravel the madness and, return compassion, caring and sympathy to the system, to embolden colleagues, bolster their emotions and create a workplace that will support decades more work.

It is all about meaning.

A few months ago, I wrote about Victor Frankl and his great book, ‘Man’s Search for Meaning,’ in which he describes the experiences which led to the creation of logo-therapy, Frankl’s meaning-based Psychoanalytic theory.

If you have a why to live, you can bear with any how.

The why is easy – helping people, easing suffering, being kind, caring, sensitive, listening, treating, empathising, supporting, leading, nurturing.

It is the how that dissembles.

How can you do all of this within a system which is under constant threat of collapse?

When people become process and individual’s numbers?

The how, was quite straightforward – developing a person-centred quality improvement programme in the organisation, to industrialise doing-better, to take the imaginings, hopes, ideas and aspirations of the thousands of our staff and provide a voice to support their solutions, to cohort their creativity and provide a translation.

Being the means to improvement, to doing better, to securing the future, was what I felt could be my how.

And that, was taken away.

That was when the system said, ‘You may have your how, but it is not our how, your how is not consistent with our principles, our values, or direction; we respect your difference, but please, take your difference someplace else.’

And that was shattering.

Without the how to see me through, without the answer to the turbulence there can be no continuing.

And this is my call.

First find meaning, and, if the meaning is diminished, is missing or fake, look elsewhere.

We become trapped in routines, imagining that our way is the only way, when in reality there are an infinity of options, of opportunities before and around us.

Meaning first, and the rest can follow.

So said Viktor and so wrote Shaul.

 

*This winter saw unprecedented numbers of early Painted Ladies in the UK – a reflection of our mild winter. What might a big-freeze have looked like?

 

 

Values

Thank you, Wendy for the comment to yesterday’s blog. You mentioned the close-shave in my awakening to the values.

And, you are one hundred per cent correct.

If the values are at odds, you can’t go anywhere.

It is ironic, for within the NHS, values are so pivotal to everything that happens – the good and the bad. The establishment in 1948 of universal, free at the point of receipt healthcare reflected a societal value that has survived; just.

Three years ago, following the initial interview, I was advised that I didn’t have a future in the organisation, that, if I wanted to do anything meaningful, I should look elsewhere. The perception was that my values were not aligned with those of the higher-ups.

I didn’t heed the call. I know it’s not the organisation, for the place is made-up of amazing people who hold it together, who walk through the snow, juggle childcare and home-life to arrive for shift, who sacrifice, smile, care, feel the pain of others, and yet, when we consider ‘organisation’ we often end-up talking about those who are in positions of authority – the leaders, directors, managers. This seems unfair.

Yet, it is these folk who through dint of ambition and sometimes talent find themselves as the decision makers, the wayfarers who attempt to unravel the noise that carries disproportionate sway. And if, within this cohort there is a bad-egg or two, well, what can you do?

Wendy, referring to values was something I considered three years ago – I reflected on the irony of the trust’s expressed values – putting patients and staff first and, the lived values where around me colleagues were taken-out, prematurely retired, shifted to places not of their choice, manipulated into finding other jobs.

A sort of professional refinement; distillation; like the making of flour. The chaff is discarded and only the essence remains, the wisps of spirit that are adequately valued, carry-on. The remainder is land-fill.

And where does this leave you?

Essence of Groupthink.

Eau d’ blinkers.

And perhaps if you are special you go on fighting regardless; Robben Island here I come!

Yet, likely, the best approach is to accept the inevitable.

That you can’t divert the flow of the river without adequate resources. Yes, you have friends, colleagues, patrons and patients, but their leverage in this system is tiny in comparison to the machinations of the few.

It is frustrating but true.

I go back to Grenfell.

It was likely a tiny cabal who sat in a room and calculated the potential saving from dodgy cladding versus a more meaningful renovation. That is just the way it is.

We are all victims, one way or another.

By accepting victimhood however, this is not giving-up, this is saying, the strategies we have employed to date have not worked. We’ll find another way.

Ars longa, vita brevis, as Hippocrates said.

This is not a notice of giving-up; sure, it is a statement of change of direction, but, no more.

The challenges still exist, they are out there in ever increasing number, their complexity growing by the day.

Come now, let’s be having you; square go!

 

Working 9 to 5

I just popped downstairs – my phone was ringing (Acker Bilk, 1030, Saturday evening).

It was the ward.

One of my patients had unexpectedly become unwell.

I felt touched and relieved that the on-call doctor felt comfortable ringing me, out of hours.

This is one of the hardest things to square-away when working as a doctor – when do your duties begin and end. Perhaps I would have felt differently if it had been three in the morning; I doubt-it.

Over the past decade, partially through compliance with European Working Time Directives (‘EWTD’) and more recently because of the mismanagement of medicine by the government, doctors in training experience a very different world to the one I occupied when younger; even that, however, was different to the work patterns that first introduced me to the life of a physician; Doctor in the House – on-site living, on-call every second day, meals in quarters, deference, cap-doffing and all that.

Yes – relieved that the 120 hour weeks are in the past, but the model of medicine, the image of doctor holding hand, expressing empathy and understanding has also shifted – moved so much that we not only have to teach the science of medicine, but also focus on the caring – the person-centredness.

When William Carlos Williams trundled in his Model-T across the New Jersey night to deliver a baby, it was unlikely that he needed a guide on holistic practice.

And today; where does it end?

Today, doctors, like others are constrained by shift patterns; their relationship with individuals fragmented and disjoined.

‘Mary fell last night,’ you are informed, and, first thought, ‘Who is Mary?’

We have invented strategies to get to know our patients better – This is Me – the form that translates who a person is into a section of the medical notes;

‘Shift-work’ – does it work for doctors?

Yes – to a greater or lesser extent it is the only way to provide care within the complexities of the 21st Century.

Patients are no longer OK with receiving the wrong drug and the wrong dose from a bleary-eyed medic who hasn’t slept in 48 hours; just like our cars, computers and washing machines – we seek reliability and consistency, not something that is at risk of breaking-down on the hard-shoulder.

And the phone call.

I talked with the doctor, who despite his youth, I know will evolve into a fantastic guy – a clinician to reckon with, regardless of where he heads in his career.

And, as I sit here, my patients sleep – well, at least some; others not. They are getting by, through a complicated on-call, rota, shift-based, system of multidisciplinary working.

And my job ends with the end of the working day, and I move on, and perhaps prepare dinner, watch TV or feed the fish, and life becomes fragmented and this, I suspect is a loss, a diminution of the meaning of doctor.

It is in part this fragmentation which allows us to keep going, to work for longer than those guys 50 or 100 years ago.

And with this exchange, is clearly a loss.

A loss that I have yet to understand.

A loss that leaves me thinking, what it is to be a doctor.

Or maybe, I am just tired.

william-carlos-williams