Moving the apostrophe

The patient’s best interests or the patients’ best interests?

I’m still in a reflective mood. I wrote recently about the memories I had from my first few weeks and months as a new doctor, and how those experiences had stayed with me through my career. It’s striking how the senior doctors I worked with at the time made an impression on me whose echoes persist. But an interesting part of getting older has been discovering how more ‘junior’ doctors influenced me once I’d transitioned into the senior group myself. Just as those early senior colleagues have stayed in my memory, so have some of my early ‘junior’ staff.

Growing up, changing perspectives

When I started out as a consultant in Paediatric Intensive Care in Cardiff, I found myself in that ‘senior’ position. I was ready for it in a clinical sense. I had been well prepared in my registrar posts at Great Ormond Street (GOS). I had been exposed to an enormous breadth and depth of situations and had benefitted from what I recognise as a ‘Goldilocks’ zone’ level of senior supervision – given enough autonomy and exposure but knowing where and when to get support. I had a feeling that must be similar to what a successful sports person experiences when they know they are at the top of their game. I’d worked with some world-renowned clinicians there, who had treated me with respect, and given me enough self-belief to work in a very pressured environment.  It wasn’t arrogance, but it was a firm confidence, with just enough appropriate anxiety to give me an edge and avoid complacency.

Nevertheless, there was a different feeling to becoming a consultant compared to an albeit senior registrar. In my early registrar days at GOS, I felt like I worked ‘in’ a unit: either Paediatric Intensive Care (PICU), Neonatal Intensive Care (NICU) or Cardiac Intensive Care (CICU). As I became a senior registrar, I started to realise I worked ‘for’ a service, not just a unit. I covered all three ICUs, and also in Critical Care Transport – all of these bracketed as a Paediatric Critical Care Service. But as a consultant in Cardiff, I realised that, in some sense, I ‘was’ the service along with my consultant and senior nursing colleagues. We were making decisions about how we configured our pathways of care, how we allocated staff and resource, and importantly, how we ensured we always had capacity for new patients, and contingencies for times we had limited capacity. I started to realise I shared responsibility for a population of patients I hadn’t yet met.

Those early registrars I supervised in Cardiff were all towards the end of their training. Most would become Consultants Paediatricians in the next year or two. I remember many of them well, and a few remain good colleagues locally. I identified with them, wanted to support them, and in moments of vanity wondered if I could be a role model for them. None of them were going to be Paediatric Intensivists, so although I might want to pass on all I knew about the care of critically ill children, their requirement was more general. In particular, they were focussed on become consultants themselves, and often asked me what the transition was like. They made me think about that a lot. The answer I settled on was ‘it’s all about the apostrophe’.

Moving the apostrophe

As a registrar or a ‘junior’ doctor, your decision making is based on the patient’s best interests. As a consultant your decision making must also be informed by the patients’ best interests. Your luxury as a junior is that you are generally concerned only with the patient in front of you. Ordering tests, referring for opinions, arranging admission to a bed are made solely on the basis of whether you think it is ‘best’ for the patient. In fact, often, it is just as much about what is ‘best’ for you, in terms of being cautious, avoiding complaints or being seen to ‘do everything possible’. Those are all completely understandable reasons, but notwithstanding, it’s a luxury not to have responsibility for knock-on effects – over-investigation, placing unachievable demands on other teams from whom opinions are sought, potential over-treatment or running out of capacity to manage the next patient in their ‘best’ interests.

As a consultant, those other issues very much came into play for me. I was managing a Critical Service for a population of patients in South and Mid-Wales. I wasn’t just managing a ward with a sign above the door saying PICU and concerned only with those patients who’d somehow managed to cross its threshold. My decisions had to reflect that broader population: the patients’ best interests. At its most obvious level, this meant that any temptation I had to admit a patient who didn’t actually require PICU ‘to be on the safe side’ or ‘because the referrer asked nicely’ or ‘because the referrer might not like me if I say no’ had to be balanced against the risk that I was then unable to admit the next patient who really did require PICU level care. That meant owning a level of risk at times, but that is an inherent part of running a service rather than managing a unit. It wasn’t always popular with referring colleagues. We were participants in a robust system for auditing outcomes at a population-service level and were happy to be held to account for our decisions on that basis.

Later in my career, as I took up clinical leadership roles, I began to see that not everyone in a senior position seemed to have moved the apostrophe. I was involved in many conversations about lack of capacity, when I could discern no coherent or at least consistently applied approach to managing admission and discharge criteria. There were conversations about ever-increasing demand on diagnostic services, secondary opinions and escalating waiting lists. As always, the reasons for these were multi-factorial, but there was a theme apparent that for many clinicians, they justified their practice by playing the patient’s interests card, with the patients’ interests seemingly someone else’s problem: often characterised as ‘management’, of which I was part.

If the apostrophe doesn't move

I began to understand the frustrations that many of my management colleagues. They were in an impossible position trying to manage increasing demands and waits, but any suggestions aimed at changing clinical behaviour would be regarded as anathema by some of my medical colleagues.

I remembered a fellow trainee in General Practice from much earlier in my career. The trainee was hard-working, knowledgeable and extremely conscientious. A model doctor for many. But when in their trainee year in practice, they continually over-ran surgery time. Not by a little, but instead of seeing 2 patients per 15 minutes, each appointment would more typically last up to 20 minutes. This resulted in the practice having to alter schedules, with the other partners seeing many more patients than usual, or else reduce the overall number of appointments. The patients who were seen by the trainee were appreciative and they were initially popular, but the impact on the whole practice was negative. The trainee’s defence was that ‘I have to act in the patient’s best interest, and that often means giving them more time’. Their future career lay in another speciality.

The defence ‘I will always act in the patient’s best interests’ must be challenged sometimes. We must, of course do our best for the individual, but it is not enough. We must also act in the patients’ best interests. We work in the context of a system, and we have a wider responsibility to make that system work as best we can for all. The two are not mutually incompatible, and it is not a question of rationing or compromising. It’s about doing what is appropriate and what is of value to each patient and to all patients. Agreeing a degree of standardisation for pathways of care can help provide clinicians with confidence and security in decision-making, but some of it will still need to be owned individually.

Role of Networks and Leaders

Whatever we call it – Value Based Healthcare, Realistic Medicine, Prudent Health Care – systemic change will not be possible without applying the principles at the level of everyday individual actions. The activity in the system as a whole is the sum total of all the individual interactions within it.

I benefited from a training environment that I characterised as in Goldilocks zone. I learned decision-making skills and how to manage and own risk as a result. Do we still give doctors that space to develop? I'm not sure we always do when I've spoken to colleagues, including those in training grades. I can't speak directly for other clinical professions, but as we require more of those collegues to take on decision-making roles previously the preserve of doctors, how will they treat the apostrophe. I worry they might feel more vulnerable to risk and so the apostrophe doesn't move so much.

A challenge for leaders, clinical or otherwise, is to create the conditions where colleagues have the time, environment and skills to apply those broader principles in clincial decision-making. One intention for National Clinical Networks in Wales is to play their part in setting that environment by describing and helping implement health and care pathways that provide support for that person-centred value based healthcare.

Otherwise, all those straplines we use for our system will remain posters on a wall and not much more. Systems won't change unless individual actions taken within it change too.