Dr Tom Cromarty
Welsh Clinical Leadership Fellow, Paediatric ST5 Trainee

Having been a Leadership Fellow for at least three months now, I am beginning to appreciate some of the key traits which great leaders develop and demonstrate. The opportunity to attend leadership conferences enables me to be immersed with people enthusiastic about medical leadership. People who are passionate about improving the lives of medical staff and the patients they serve.
 
The “Leaders in Healthcare” conference was run by the Faculty of Medical Leadership and Management or “FMLM”. The FMLM aims to professionalise medical leadershipand improve patient care. Trainee membership is £84 per annum and you receive a whole lot of bang for your buck if you use all that is on offer. The conferenceconsisted of 3 days of masterclasses, keynotes and plenary sessions with a diverse set of speakers.
 

​To be honest the most reassuring reflection from the conference was that there are no ground breaking new short cuts, evidence or cheats to employing great leadership. 
https://hbr.org/2018/11/the-fundamentals-of-leadership-still-havent-changed.
 
Often with the best presentations, your practice is challenged, and usually more questions are generated than answered. Below I have put together a few small summaries of my favourite sessions over the week. I hope you enjoy them, there are also some exercises at the end to try.
 
Political Astuteness: aka “Influence in Organisations”
 
The world in which we work can seem vast, that’s if we are even given the chance to look up and have a glance for ourselves. Early on in a career, often the overwhelming thought is “I don’t do politics”. The usual pattern then follows with “Wowza, I need to know about politics” (to change things for the better) and finally “I need to tell everyone about how to master politics at work” (so we can all change things). This realisation is a like a loss of innocence. It’s easy to think you are just a sheep, but the world is complicated, and you NEED to develop political astuteness to be effective in the world.
 
Directing individuals through authority or using a badge/label to exert power is not leadership, it is management and poor management at that. Leadership on the other hand is the ability to influence individuals. Influence cannot be bought or attained through hierarchy. The internal values one holds, shape their external behaviours. Your behaviours are the markers on which you are judged by others. For this reason, influencing power can be developed by and exerted at anylevel.
 
“Does she/he do what they say?”
As an individual you decide…“Am I going to be influenced by him/her?”
 
Patterns not Problems: Working with Intractable Issues
 
Types of problems:

• Simple – seen before, solved before, can predict the outcome, minimum uncertainty.
• Complicated – break problem down to (many) simple problems, then can figure it out, e.g. hospital construction.
• Complex/wicked/intractable or “sticky” issues – e.g. people/social issues, bad culture, e.g. healthcare systems, Brexit
  • When old assumptions are challenged
  • Won’t stay solved for long
  • Too many factors/pieces – too big to think of all at once
  • Involve massive interdependencies, change effects so many areas, causes other problems to form. Any intervention in a complex system has effects that you didn’t expect
  • Non-linear effects- small change with big outcome, large change no impact.

 













Stephen Powis, National Medical Director of NHS England
 
“In uncertain times, the only known is that there will be change,
and it looks like it will be YOU doing the leading!”
 
Digital revolution: Not just AI, but intra-operability, health/medical data, wearables.
Link to the global health agenda.Genetic revolution: Need masses of space.
 
Currently leadership is seen as aposition for individualsrather than a behaviour for everyone. We must stop the unhelpful “I’m just a….” attitude and the notion of“Don’t get ahead of yourself there Dr. X, you don’t need to be doing that yet”. Leaders need to aim to regularly add value to the people around them, and everyone can do that, every day.
 
“It will never be someone like me” But think “Control your own destiny” it needs to be done by someone, why not make it you?
 
Read theBMJ Leaderfor leadership tips, research and evidence.
 
Matthew Hancock – Health Secretary England
 
The NHS needs a leadership culture change. We must stop apportioningblame but start really harnessing a culture of learning from mistakes. Anyone who says they have never made a mistake simply isn’t telling the truth. And the truth is at the heart of honest reflection, learning and moving forward. We want staff to challenge without fear and encourage complaints as these are opportunities to improve. Ideally, we want to give away the directive and hierarchical power and consequently empower all individual healthcare workers.
 
This is what we are! This is where were going! This is how were going to get there!
Ends with a challenge:
What are you going to do?
 
 
Tim Swanwick - Leadership in the Undergraduate Years
 
“Leadership is a contact sport which brings about change. This cannot be done from the comfort of a desk or department headquarters. The key to developing leadership skills is to get outside of your comfort zone, that’s when you learn the most. Seek out opportunities and go for it. Lead the way to your own future.”
 
“Management makes sure the ship is stable, Leadership sails it in the right direction.”
 
It seems like it wasn’t too long ago where communication skills were thought of as innate. If you had them, you’d be a GP, if you didn’t then you’d be a surgeon or a pathologist (I jest of course but you get the point). Thankfully, at least for the past 15 years, medical schools have recognised that everyone needs to be taught these key skills and consequentially there have been significant improvements. Communication workshops with breaking bad news and explaining diagnosis and management plans have upskilled all doctors and made a massive impact on the care delivered to patients and their families.
 
The tide is changing, leadership & management is being asked about in medical school interviews. Specific leadership skills curriculums are being introduced into universities across the country next year.
“What if every newly qualified healthcare professional graduated thinking as a leader.”
 
GMC document 2018 – “Outcomes for graduates”. 1stdomain in the curricula.

https://www.ted.com/talks/angela_lee_duckworth_grit_the_power_of_passion_and_perseverance?language=en
 
The science of Leadership & Management is not new. There are 15,000 members of the American Academy of Business who have been researching L&M for many years. The BMJ Leader could bring business school world evidence to medicine.
 
His best advice: Go and get some honest feedback, it will be perhaps the most useful gift you will receive from a colleague?!? Try asking this… “Tell me one thing that I do which is negative?” It takes a degree of bravery for you to ask and reciprocal bravery for them to answer honestly as well. He also insists that we should all have mentors. One can have multiple mentors, e.g. a leadership and speciality mentor. They offer a sounding board for example, difficult interactions with a colleague. They can guide you and order your thinking.
 
Consider the following as some of the more “formal” leadership opportunities:

​Other Resources:
NHS Improvement: Developing People Improving Care
Great project in Scotland: Project Lift: NHS Scotland https://www.projectlift.scot/
 
Diversity And Inclusion in Healthcare
 
Do you know what the 9 protected characteristics of the Equality Act 2010 are?
Do you know what “BAME” stands for?
 
This was a really interesting session recognising that even if there is diversity in the workforce or patients, these groups may still lack full inclusion or equality. Leaders need to learn how to o address these issues and respond to unconscious bias. How to hear some difficult messages, and how to respond positively. All too often issues are not confronted as “Oh this is making me feel uncomfortable” or “Of course we’re not, that can’t happen here”. We all need to be “Power aware, Identity aware and Self-aware”. The mindset we embrace in the workplace that liberates other people.
 

​Often organisations only take a stand when it gets to “Discrimination” stage, as the lower levels are largely invisible to those not affected by it. We need to upskill leaders so that everyone is aware of what is happening, the behaviour is addressed sooner, everyone has the courage and permission to call out bad behaviour. Courage is the most important of all the virtues, without courage you can’t do any of the other virtues consistently.
 
“The behaviour we walk past is the behaviour we accept”
 
Barriers to successful inclusion:

• Complex problems with discomfort talking about them.
• Denial re-enforcing the status quo easy for people to deny that it is the case in their institution – embeds the behaviour people complain about).
• The burden of calling out issues is not equally distributed across the organisation. Need to raise awareness across the whole team so that it is not the same people have to be courageous and highlight bad behaviour time and time again.
• Unsure about what to do/where to start. Be curious enough to understand.
• “It’s the silent violence that goes on”. Don’t want to say the wrong thing.
• Lack of understanding about how structural and systemic forms of inequality manifest themselves. Modern day discrimination manifests itself. Silenced, dissuaded from being themselves in the workplace, NOT name calling, etc.
• People misunderstanding how to use themselves in a leadership role to make a difference. We need to recognise that we can allbe instruments of change, and it is “how you show up” every day that can influence other people and transform the lives of those people you work with. In fact…

 
“The only person I can change is myself, how I show up might encourage others to shift their focus, their attention and their behaviour”
 
If you are reading this, you are part of the generation that can make the change!
 
Malala Youssef – Nobel Peace Prize award speech– “Let this end with us”
 
 
Richard Watson – Futurist: 
Mega Trends and Technologies2017-2050
 
It seems that Richard and many others who look to the future can only be sure on one thing, “it is UNCERTAIN and there will be many ways of doing things”.Now for someone who is highly paid for their predictions this seems like a great way of hedging your bets. He also highlighted the worrying change in society with the dominance of screen delivered information and a sedentary lifestyle. Previously children would have been told “behave or you will have to go inside!”, now it is the opposite! He described a world where devices know more about you than you do about yourself.
 
Anybody who says they know exactly what the future holds is lying. However, we spend too much time worrying about it. We NEED to spend time as communities figuring out what we want to happen, using a proactive and positive mindset. It doesn’t matter if we are wrong. We must all have a collective vision of where we want to go, build narratives around the vision and step towards it. I agree with Richards aim of…
 
“Every day waking up and trying to get better,
making things better for ourselves and others”
 
Another interesting person is Yuval Noah Harari: 21 Lessons for 21stcentury - interview
 
Professor Megan Reitz: Professor of Leadership and Dialogue
Speaking Truth to Power – Have a look for yourself here– it was an excellent 60 mins.
 
Megan delivered a fantastic session about “That moment!” The one a person decides, shall I say something or not, and educated us on the act of “Speaking up”. All the scandals in healthcare organisations of recent times have something in common. People knew bad stuff was going on, but they didn’t speak up, and this resulted in patients coming to harm.
 
One reason is the belief that it is always someone else’s responsibility and absolving oneself from responsibility. “They” aren’t speaking up, “they” need to show courage. Another issue is that often those very people who say the one time they did build up the courage and spoke out, they weren’t listened to and it made no difference. What if you experimented, what difference would it make at a collective level? Think about an occasion where you decided to say something, or not. Megan uses T.R.U.T.H to discuss the issues about these decisions.
 
TRUTH: Trust, Risk, Understanding, Titles, How-to
 
Trust: The value of your own opinion
Risk: Realizing the risks of speaking up to powerful people and the ensuing struggle
Understanding: Will I be perceived negatively, will I upset someone,“Will I belong”?
Titles: We label inherently. Depending on the context, convey levels of authority
How-to: Knowing what to say, when, how and to whom
 
Megan then describes a number of traps and behaviours we all fall into which stop us from having the conversations we know we should have!
 
Speak-Up Traps: We doubt ourselves – Imposter syndrome. Check the voice, notice when it comes in. Engage with it, am I going to listen to it this time.
 
The Blind Spot: You will not listen unless you trust the value of their opinions. Can I empathise with how risky it might feel for this person to be speaking up? What titles do I have on me to affect what kind of information this person is telling me? Individuals ALWAYS think they are better at listening than other people.
 
Listen-up traps: It’s easy to forget that no matter how lovely and approachable we seem as juniors, decades later, given some labels and titles, we are all quite scary. Make sure you don’t send“Shut up” signals and not “speak up” signals by knowing your face (and the rest of your body language signals, and environment you create).
 
Today and every day, we make choices about what to say and when to stay silent. When we really help someone else to speak up or silence them. Choices feel mundane but if you add them up together it is what defines you. How you speak up and listen up represents the values you hold and the culture in which you work. If you think about it and act accordingly, you will change habits and change cultures.
 
Some exercises and information to peruse at home in your own time!
 
Exercise 1: Personal Values
Think about your own values! What matters to you? How do you display your values at work? Much of the conflict at work results from a mis-alignment of core values.
Spend some time writing down your beliefs. What behaviours demonstrate your values? None of these have anything to do with medicine or your background/grade.
 
Exercise: Search for 50 personal values on the internet. 
Step 1: Make 3 groups of importance to you (High, Medium, Low)
Step 2: Place each of the 50 values in a group
Step 3: Take the “High” group and again split these into high, medium and low.
Step 4: Group similar values together until you have 3-5 left.
Step 5: Welcome to your values, enjoy them, be true to them, live them!
 
Check out…Harry Kramer, Values in Leadership.
 

​One moves around the grid, depending on what is being demanded of us. Who else is there? Personal circumstances? Ideally there is a sweet spot (in Green) of moving around all areas, aiming to avoid the inept/donkey.
 
How do you bring people and landscape together in your head and put it onto paper?
Stakeholder mapping, mind mapping, network mapping. 

​Another tool: Understanding people landscape map(Like Nike said… just do it)
 
Length of the line: how far they are away from you
Arrow direction: if you want them to be closer or further from you
Dotted lines: are relationships you want to develop
Small circles: /10 effort to build relationship (realistically)
Stops: how far you want to bring them closer
Wordsadd a narrative: Rich picture without words doesn’t show much
 
Update it regularly, do it for different work groups. Use it for work networks, family situations, family events. For example, see diagram below:
 

Do you know the 9 protected characteristics in the UK workplace?
Age, Disability, Gender Reassignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion or Belief, Sex, Sexual Orientation.
 
 
A reflective exercise to do at the end of any teaching session, activity or experience.
Take for example this blog (which I’ll admit has a lot crammed into it). Try and think of at least one behaviour in each of the following headings...
 
Start doing: something you don’t do but think you should actively work to do more of.
Stop doing: something you currently do but will actively try to do less of or stop doing.
Continue doing:Something you are doing already but will do more of it because it works.
 

An OOPE in Sydney, Australia.

Dr Thomas Cromarty

I have just returned from an OOPE and wanted to share my experience of living and working in Australia. After embarking on the best training scheme of them all (Paediatrics) in 2012, I worked around South Wales from ST1-5. The Welsh Paediatric Training Programme Director is keen to produce well rounded paediatricians and encouraged me take the opportunity in Westmead Children’s Emergency Department, Sydney.​

I could tell you about all the trips we went on: Visiting my dad in Canberra, Campervanning around Tasmania, watching the tennis in Melbourne, taking selfies with the quokkas on Rottnest island (Perth), surfing in Margaret River, watching the Commonwealth Games in the Gold Coast, swimming with turtles on the Great Barrier Reef and night treks in the Daintree rainforest. But that will just make you jealous and me sad, so I’ll try and give you unbiased view of my reflections on a year working there instead.

​​It would make a mockery of a blog if I didn’t start by mentioning the Work:Life balance situation! My partner and I lived 500m the beach in a place called Queenscliff near Manly. Our end of the beach was quiet, had waves most of the time and was pretty much perfect. We lived on the top floor of an apartment block which included a roof top terrace aka skin cancer zone. As an “outdoorsy type” I was in heaven. There were running, cycling and triathlon clubs, surfing beaches, SUP, yoga studios, open water swimming and even Dragon Boat racing! You name it, it was expensive, but it was available.
 
Unfortunately, I worked 40km away in the west of the city which meant that I had my old friend, traffic, to contend with on a regular basis. I worked 4 x 10 hour shifts per week in the Paeds ED, with most shifts mirroring the peak attendance times of 14:00-00:00. Despite the commute, there was no chance of me moving to other side of the world and not living by the Ocean!

• Remuneration was fantastic, I received about double my UK salary, and although cost of living was more expensive, there was still plenty to go around.
  
• Westmead Kids is a single point of entry system, meaning that the ED and CAU are combined and all referrals from the whole region come through the same door and are triaged the same way.
• The ED is the Major Trauma Centre (MTC) for the whole of New South Wales and that was one of the main reasons I initially chose this placement. Paediatric major trauma is thankfully not a common event in many places in the world, however when it occurs it needs to be managed well. There were slick procedures in place, excellent staffing of the acute areas with capable nurses and consultants on the shop floor for most hours of the day. It was a perfect environment to learn in.
• Online systems for the whole hospital; ordering imaging, bloods, “consults” and other investigations was easy. Prescribing medications appeared to be safer as the process was all electronic (as long as the weight was checked correctly). Notes are easier to read and backgrounds easier to copy and paste. It does highlight the importance of touch-type skills in the future.
• Observations recorded online allowed easy recognition of abnormal and normal vital signs (“Between the Flags”). The objective numbers empowered nurses to call for help early, and if there was no improvement to the numbers, a “Rapid” assessment was required and the on-call team to review. This system picked up acutely unwell children and alerted them to senior staff quickly before they deteriorated further. Senior clinicians were able to alter alarm criteria if appropriate, for example regular salbutamol and sinus tachycardia.
• Procedure nurses on shift from 15:00 till 23:00 enabled doctors to continue to see and make plans for patients. Of course, this came with the caveat that it was only the difficult cannulas/bloods that doctors were then asked to perform, with fewer potential veins and less practice.
• An Emergency Medical Unit (EMU), allows extra time for patients that need more observation but don’t need to be admitted, using vital ward beds. Ideal for stretching wheezers, small babies with feeding issues or minor head injuries for neurobs etc.
• Paediatric trainees rotated through the department for 3 or 6 months at a time, with many completing multiple placements at Westmead or as part of the “relief rota”. This built trusting relationships between individuals and enabled much better inter-team working. These relationships are key to providing superb multidisciplinary healthcare.
• Specific work mobile phones (1 for the acute and 1 for the non-acute sides of the department) allowed messages and pictures (with consent) to be sent to fellows and consultants both day and night. Sharing of information was therefore easy, which reduced waiting times for families and enabled faster and more accurate communication between teams.
• Regular education sessions: “PET” / Acute Care Round / Simulation / Fast Sims
  
  • Ward rounds from 08:00 were followed by some form of teaching every weekday at 08:30 – 09:00 allowing the nights team to attend if they could manage.
    
  • Daily 14:00 – 15:00 teaching - afternoon starters could also attend some sessions.
    
  • Anaesthetic days where trainees could practise managing airways and intubations.
    
• There was a 2 strike rule for cannulas for everyone at every level, with Anaesthetics generally happy to come down to assist with their USS guided skills if required.
• Clowns – Dr Smarty Pants and Dr Quack. Loved them! They visited the ED relatively frequently, keeping patients, relatives and medical staff entertained.

 

I produced a PDP of goals to achieve throughout the year, these included upgrading my USS skills as well as confidence managing paediatric trauma and minor injuries. I found this particularly useful and would encourage everyone to take some time to establish some short, medium, and long term goals for life both in and outside of work.
 
I think it is essential for all medical staff to experience working in a number of different settings. This enables them to be exposed to a number of working environments and behaviours, choosing which to adopt into their personal style, facilitating their journey to becoming a more effective clinician and leader. My year working abroad will undoubtedly be different to yours and you need to decide if it is right for you (and your significant others!) What I would say though is if you don’t try it, you’ll never know… What’s the worst that could happen?!

The start of “Hells Bells” 24 hour adventure race in Noosa, Queensland

Helicopter trip over Sydney CBD

Fair Dinkum, I had a ripper of a year out and am looking to continue that growth of skills this year as a Clinical Leadership Fellow in Cardiff and Vale, engaging junior doctors in leadership and QI development. If you want to get involved with this project, have any questions about taking a year out or just want to see some more photos please don’t hesitate to contact me at Thomas.cromarty@wales.nhs.uk.