When cultures clash

This week has been difficult for doctors in the UK. More than that it has been difficult for all healthcare workers in the UK. The feelings engendered by the imposition of a contract to make Saturday a normal working day are complex and for many deeply unsettling. I think it feels hugely aggressive and plain wrong from the point of the compassionate humanistic ethos that most of us in healthcare base our working lives on. In trying to make sense of the almost physical pain that I saw in colleagues at work I started to think about this conflict. 

Conflict, an inherent incompatibility between the objectives of two or more characters or forces, is what we are involved in. As a healthcare worker I want to understand it more, so that I can make it better, that is what we do.  Our training, our community, our professionalism sets us up to heal not fight, to do that right thing no matter how difficult, to continue with quiet resolve and a firm hand on a true course, these are the paradigms healthcare workers exist by. So when in doubt I choose to fall back to the familar, what is the diagnosis?

I think that the work of Edgar Schein is helpful here. Schein, a former professor at the MIT Sloan School of Management, is a hugely influential organisation psychologist having proposed a widely accepted model of orgaisational culture. The model describes three distinct levels in organizational cultures:

  1. Artifacts and behaviours – these are openly visible things such as offices, dress codes, official structures
  2. Espoused values – these are the stated values and rules of behaviour
  3. Shared basic assumptions -these are deeply embedded, taken-for-granted behaviours which are usually unconscious, but constitute the essence of culture. 

The model also describes sub-cultures within a multifaceted organisation like the healthcare. Trouble arise if espoused values by leaders or leaders basic assumptions are not in line with the deeper tacit assumptions of the subcultures. I think this captures the current situation. In healthcare, you can describe some basic assumptions, these are things that are givens and many of us would consider incontrovertible. That everyone deserve to be treatment and reduced suffering. That all people deserve fair consideration. That we respect the individuals right to decision making. But deeper than that, that we do good, that we are kind, that we look after society. 
When our basic asdumptions as a group are challenged, it creates a schism and conflict. This is a clash of cultures. Culture clashes are known to be profoundly unsettling as they threaten the world perceptions of a group. I think this is the centre of the disquiet we feel over the events of the last few days. The culture of healthcare as we have grown-up in feels threatened, the basic assumptions we all work by seem ignored. We work daily as teams, we negotiate treatments, we care, we believe compassion is a cornerstone to our working lives. The enforced encrochment on the British cultural assumption of the weekend is deeply counter to our world view. 

Unfortunately culture clashes do not disappear because of any edict or because someone says they are not so, they are a real thing and need careful managing, otherwise they continue in one form or another whether that is visible resistance as in stikes or avoidance as in seeking alternative career paths. For all our sakes we must recognise the diagnosis, and act on the root causes. 

Lets Celebrate the New Ones

We all remember how tough it was starting our first day as a doctor. All the work through medical school in preparation still left you wondering, could you really cut it?  It is natural to doubt our abilities when they are untested, confidence would seem misplaced when one has no experience so you’d hope we all share this common beginning. We all had to trust in the training many had given us, the friendly guidance on the job of many a nurse and the support of our more senior colleagues. We made it through as do thousands of doctors each year. 

Daunting as starting is, it is portrayed in an oddly negative light by the profession with terms like Black Wednesday in common parlance. Does this really help the group of novice doctors coming up to their first day, let alone any patients coming in to hospital. We need to celebrate the new beginnings for the profession starting as a doctor represents, not denigrate it. To show our new colleagues the greatness of the profession they are entering and how much that profession values them, not ramp up the pressure with a vision of failure. 

This is all the more acute in current times. Austerity is a challenge to all healthcare, one can not deny that. Open political debate is vital and a profession must stand up for its values, but  young doctors are particularly social media savy and starting your career when the dominant twitter sentiment is #weneedtotalkaboutjeremy or the cry of anger that is #iaminworkjeremy must seem incredibly daunting. We need to temper our passions in this, to focus on these new medics and engage them in the vision of our profession that gives rise to such strong feelings. So we would like to start a postive wave around our new starting doctors. We would like to let them know it is a great profession they are entering, a job that is challenging emotionally, mentally and physically but one which the majority of us would follow again given the choice, and one that will welcome them, nuture them and support them to grow into the doctors they want to be and the future needs. We are going to be tweeting on #newdocsday to celebrate the new starters from 1st August, join us.

Beware the politician doing his job

I had to steady myself to stop. I had been swept up in the wave of professional outrage, at the speech of a politician, Jeremy Hunt, Health Minister. I was righteous in my indignation, this was an afront to my core beliefs, I would unite with my fellow doctors we would stand unified against this injustice. We worked hard for our patients, we were on emergency duty at weekends, how could our professionalism be questioned by this man? Then a single post to Twitter pulled me up, the comment was “This is odd.” It was simple and short in comparison to some of the other postings, blogs and media reporting, but it stopped me in its truth, this was odd. What was actually going on?

I really like a quote from Edward Demming, the renowned american professor of management “Noboby goes to work to do a bad job.” I have found it is a useful starting point in many challenging situations at work, how did this apply here? Jeremy Hunt, the politician in question, is not inexperienced, he has a history of canny political strategy that has seen him persist at high levels in government for a number of years. It might therefore be reasonable to assume that he is effective at the job of modern politics. What if I assumed he had come to work to do a good job as a politician? This is not simple, as the next question becomes what was the job he was wanting to do well? 

Wikipaedia defines politics as the practice and theory of influencing other people. If you have read any recent political memoirs, it is clear that speeches by a politician, particularly to important audiences like the Kings Fund are meticulously planned events to do just this. A backroom prescence of speech writers, public relations and policy experts pore over every detail. They consider the aims they wish to be achieved, no content is not analysed, from different phrases down to timbre of voice and body language in delivery, it is anything but unconsidered. If a response to a speech seems obvious in any way, it is highly likely that that response was intended or even the aim of the entire speech. At this point you start to wonder, why would a politician want to set an entire profession of able, morally driven individuals against them? It is well recognised that threats of unilateral application of power in a relationship  together with actions that question the core identity of a group is an effective way to start a conflict. Was starting a conflict with doctors therefore the aim, and why? The primary beneficiaries of such a conflict tend to be the threatened group.  Identifying a common threat allows individuals to not only realize a common interest but also to reaffirm a shared identity that may have a longer history, medecine has rich territory here. This is clear in the #ImInWorkJeremy response with over 50000 contacts in a day. What other group cohesion is fostered by the conflict for the benefit of the politcian? 

I wonder if the intention was to address the institutional representation of doctors; the BMA and the Royal Colleges, did he feel they were somehow out of step with the workplace doctors? Social media networks people without the need of representative bodies, the collective response is now rapid and based outside the institutions. The speech will have revealed this new cohesion of the medical profession, can the political strategy behind it really have not expected this? Was the intention to somehow couch this in terms of the profession now revealed against a larger grouping? Is the danger in afirming cohesion against the threat, that we ignore our core purpose, the patients? In defending ourselves against the politician’s rhetoric we start to alienate them, our staunchest allies? I do not have the answers, but I worry this is a smokescreen, a calculated act. As a profession we must proceed with care, kneejerk resposes are rarely correct, particularly if they are to the beat of someone else’s drum. Is Jeremy Hunt sitting at home smiling at how we took the bait? We We must maintain the focus on the genuine concern, which is the 16% increase in 30 day mortality in the group of patients admitted on a Sunday in comparison to a Wednesday, to explain the reasons and provide a effective solution for our patients, this is the problem, we remain are the only ones who can effectively provide this. I do not have the answers,but all I can say is, take care this is odd. 

Hello I am a professional

Sometimes you see a opportunity that appears to be an open goal, and easy chance for improving something at work that seems obvious. You take your best shot, but somehow the ball doesn’t sink into the back of the net it rebounds off the goalposts and ends up hitting you in the face, painful and embarassing. This happend to me recently, I suggested introducing #Hellomynameis at work. This campaign, for those that don’t know, encourages people working in heathcare to properly introduce themselves and their role to patients each time they meet them. I carefully composed my message, part informative, part personal experience, only sending it after several rewrites. With it I posted a picture of my badge from the campaign, that only included my first name, which has been how I introduce myself professionally for years. Can you spot my error, how I entered a controversy? I certainly didn’t, but the response rapidly made it clear to me I had made a false assumption. Not over #hellomynameis, a simple idea, all staff should introduce themselves and their role to patients they are interacting with, little controversy there. My badge, on the other hand, suggested that all heathcare professionals should be using their first names. You can almost hear that ball thumping back into my face, as that is not a given by any means. 

Our names are extremely personal but public at the same time. We do not choose our true names, but as we grow-up they are integral to our identity. We develop nicknames and family names that identify us in our families, often not used in the outside world. At school other names may be used, the same in teams, clubs and social circles, again often not chosen they all confer social meaning and we associate particular social roles with them. Once we enter the workplace we have the opportunity to choose the professional name we are addressed with in a given interaction. The name that we practice day-to-day under. A professional name may be influenced by the local, national and international professional and social culture, but in the end is a personal choice. We have to inhabit our professional name in all aspects of our professional life. While much interaction with patients and staff is relatively amicable, healthcare professionals must undertake some extremely challenging interactions at times. Tragedy, disability, conversations on mortality, death and abuse to list only a few, our names must allow us to perform these roles too. We must therefore be comfortable  in the professional name we choose to do all this under, we must be comfortable to express all aspects of our professionalism through the professional name we choose to use. Our names do not define us as doctors, our actions towards patients do that, but they do permit us to feel confident in that role. All this before we start considering the expectations that patients have for addressing doctors, which have similar social narrative constructs behind them. 

So what am I saying? The term of address you chose must allow you to perform as a doctor, this is personal and nuanced by the patient and the particular interaction. For myself, I introduce myself with “I am Jason Neil-Dwyer, I am your doctor” I am comfortable with my first name in most circumstances, but will choose a more formal address in particular difficult circumstances or if the patient wishes. Others will be different, but I do not believe it matters. I think it is not the particular name that matters, more the quality and nature of the actions and communications with  patients and staff it is part of, after all that is the core of doctoring. Is that the sound of a ball hitting the back of the net?