A couple of weeks ago I invited Sarah, another GP in our practice to observe one of my surgeries. All the patients were warned before-hand that another doctor would be there. She watched and listened intensely and took notes as I consulted. Before calling in some of my patients, I explained about their background:
I’ve known Brian for about 7 years, he was diagnosed with Parkinson’s disease when he was just 45, and has had several falls, fracturing his hip and shoulder in the last couple of years. He had to take early retirement and sell his building firm and has been severely depressed. His wife does everything she can to look after him, but she’s at a loss, and to be honest so am I. He’s lost a lot of weight because he stopped eating. I asked the psychiatrists to see him but he hasn’t had an appointment yet. I’ve really been worrying about him.
Being able to describe to another clinician, an experienced, trusted peer, how much I knew about my patients along with my concerns and fears, was really powerful. Like every doctor who values continuity of care I know the majority of my patients, but being given the opportunity to describe them to Sarah, really made me think about how important this is.
So much of what we do in clinical practice is done in silence. While I listened calmly and intently to Mehmet my mind was silently whirling, trying to identify clues that might help me make sense of his constellation of symptoms and the investigations he’d been through and medications he had tried. So much of general practice is spent in the ‘swampy lowlands’ between suffering and disease, where symptoms are far easier to describe than to explain. The tools of our trade: protocols, pathways, guidelines and diagnostic categories can be applied to a minority of the problems our patients present with. Multimorbidity is the price we’re paying for longevity, so we can now survive with an array of diseased organs, but they’re intricately connected; a drug for one is poison for another, and if one fails the others struggle to take the strain, in often unpredictable ways.
But working in isolation, we rarely articulate the uncertainty that characterises so much of our work. The limits to how much we can tolerate move in and out with the tide of our resilience. Confidence and strength, far from being sure of the answer, is being able to live with the anxiety of not yet, or perhaps never knowing. My friends and colleagues are more stressed than ever before, and an inevitable consequence appears to be more referrals to hospital where the burden of uncertainty can be shared, a phenomenon already understood. Sarah and I shared the uncertainty, and discussed how to help Mehmet.
I had watched Sarah in a surgery the week before. One of the things she asked me to look for was the way she concluded consultations, she wanted to know how to conclude a difficult discussion with one patient and not keep the others waiting – we have only 12 minutes for each appointment. I had written recently about how we give reassurance, whether we do so for our benefit or our patients, and how giving confidence might differ. I took notes and we discussed how she worked, how patients responded, where she thought it went well, and how it might go better.
Opening your practice up to close scrutiny and learning from the experience, means being able to say, ‘I’m struggling with this’, it’s not about showing off, so much as exposing yourself. The majority of doctors never do this. To do this requires trust; that the person you’ve invited in, understands what you’re trying to do and that they are there to help. John Launer’s wonderful work on clinical supervision, teaches us that a very powerful way to help one-another learn is by curious questioning – helping the person you’re supervising to think deeply about the way they’re consulting. He concludes,
Collectively, good conversations can be transform a working culture from one that is technocratic, impersonal and potentially dangerous, to one that is both kinder and safer.
The Berwick and Francis reports into poor patient care at Mid Staffordshire hospital recommended above all, that patient safety depends on lifelong learning, aware perhaps, that the features that unite under-performing doctors are isolation and lack of insight. Sadly all of the emphasis has been on more regulation and inspection and the experience of many clinicians is that they have less time for education and are less supported than ever before.
US surgeon and writer, Atul Gawande argues convincingly that the most experienced doctors can benefit from coaching in the same way as professional sportsmen and women do. Gawande, an experienced surgeon, was used to operating independently, without supervision, but invited a respected colleague to watch him perform a routine operation. His colleague made several critical observations that made Gawande realise that unless supervision is required or actively solicited, opportunities to improve the quality and safety of patient care will be missed.
We owe it to our patients and each other to open ourselves and our practice up to our peers who can provide education and support in equal measure. Clinical supervision should be for life, we cannot afford not to make time for this.
Several people have asked how we found time.
We both came in on our half-day to observe, in our free time. This isn’t sustainable, but it was far more valuable than many (most) conferences or ‘educational’ meetings I have been to, and I would happily use some of my study leave to do this in future.