Leadership in AMU [Re-release] (27 Sep 2023)

SPEAKER_00 0:00

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SPEAKER_01 0:23

Hello, everyone, and welcome to this podcast by the Training Members Committee of the Royal College of Physicians of Edinburgh. My name is Dr. Jonathan Bajett, and today I'm joined by Dr. Claire Gordon. She is an acute medical consultant working in Western General Hospital in Edinburgh and is the training programme director for acute internal medicine and ACCS. Welcome, Claire.

SPEAKER_02 0:44

Thank you. Thanks for having me along.

SPEAKER_01 0:47

So today we're going to be talking about leadership and management in the acute medical unit. And I think this is more important in these times during the COVID pandemic more than ever. So, Dr. Gordon, can you start by telling the listeners why we're talking about this and why it's so important?

SPEAKER_02 1:02

Okay, I'm going to my first proviso is that there's many better examples of leadership and management in acute medicine than myself. And there are some great examples within Scotland of acute medics who've gone on to be medical directors at a very young age and doing a great job doing that, and CDs. So there are people who are really good at this. And then I think that leads into my next answer, which is I think it I think all of us need to be good at leadership and management in acute medicine because actually, if you're an acute position and you're working at AMU, it is beholden to all of us to try and make our units run effectively and efficiently. And also surface development is written into our job. I mean, acute medicine is still quite a new speciality and it's it's quite old in Scotland compared to many other countries. So a lot of us are in AMUs that are still quite new or still developing or are being redesigned almost all the time. Our services are being redesigned all the time, and we are quite often looked to and have a real role to develop those and to say this is actually how we need these AMUs to work, this is how it's going to be best for our patients, this is how we're going to add the most value to our patients' journey and make their care better. So we have really valuable insights in how key medical units should run and a different way of seeing the hospital and the way patient flow works and patient safety and non-hospital-based ways of looking after patients that I think are pretty unique to our speciality. Not completely unique, but you know, we are pretty specialized there. And therefore, when we're in NAME, we are the ones who can really contribute to the conversations around how things should be managed and are quite often seen as the leaders of the team. So even if you're working with people who aren't medics, quite often we sort of naturally take on a bit of our leadership role in that and look after our trainees and structure training and arranged training. Definitely a lot of the AMUs where I have colleagues, it's the Q the acute medics who are looking after the educational side of things, the clinical governance side of things, the QI side. So, you know, I think that's probably because we spend so much time there and we are really woven into it, but also because I think acute medicine quite often seeks out trainees who are really passionate about the specialty and really keen to make things better and are quite, you know, we're we're quite keen to get things done. Most of us are quite type A, and that is in no way on belittling my acute medics who are type E. It's just that most of us like to just get on and do things, and that very much means you sort of take on a natural leadership and management role. I have been clinical director in the past, and again, quite early on in my career, because I was just wanted to make things better and wanted to change things. And I think, like I said, I think quite a lot of acute medics tend to go into that way where we progress into management because it's it's a great way to try and change your service and to make things better for patients.

SPEAKER_01 3:51

So that's a really good insight into that mindset of delivering better patient care. And I guess one of the things that you mentioned was it encompasses clinical education, clinical governance, quality improvement. So, what would your advice be to our internal medicine trainees or our foundation trainees or general internal medicine trainees about how we can develop our leadership skills in clinical education?

SPEAKER_02 4:14

So, I mean, I think leadership there's there's lots of different views on leadership, what have you? I am definitely more of a leader by example kind of person myself. So I think a lot of leadership is about seeing what you think works and then trying to do some of that where you can. So, say what did I most enjoy in my training, or what have I found very effective in my training, and how can I get involved with that? Is there scope within my units to get involved in training that I find useful and I am enthusiastic about? And be that being part of a clinical educator program, so you're getting some formal education and feedback about teaching experiences, learning about how to deliver tutorials and informal teaching and feedback, all that is useful. So I think the clinical educator program, for example, that we have in NHS Lothian is very helpful. And actually, although we may moan about it, the fact that we have to do modules as part of our appraisal to be trainers is helpful because it means you're constantly knowing that you have to keep up to date with your skills and education. I think nowadays as well, trainees and students have different ways of learning and different experiences of learning, and so they are then saying to me, Oh, this has been this form of learning has been really helpful for me, or I found this really useful, is great. Um, and so I think knowing just you know, cats in the net wide as to what different forms of teaching has worked for you and what you would be interested in delivering, and then saying to your service, like you know, is there opportunities for teaching students in this way, or how about other nursing groups or or other professionals? Definitely, you know, a lot of advanced nurse practitioners need supervision and really value from one-on-one teaching, and that multidisciplinary groups I think are also quite good fun to teach because we all have different aspects of uh of how we deliver patient care and how we see the patient. So there's lots of different modalities to educate, a lot of different groups to educate, perhaps, compared to how it was in the past, where you just thought about teaching medical students either the bedside or a group. So I think education is uh is much more diverse, and there's lots of ways into that. But I would definitely recommend a structured program into that because that's also something that you can put on your ePortfolio, you can put on your CV, and you know, it's uh it's it's a stepwise progression thing. And then when you if you become a consultant, then you've done it all and you have that behind you to move you on to be a clinical and education educational supervisor yourself. So I would try and do something formal with it as opposed to it all being a formal teaching that then is maybe the odd thing on your ePortfolio but doesn't really count towards something. But definitely units will be keen to have you teach. Like we love enthusiasm, and we particularly love enthusiasm in teaching. And education has been shown to be the one thing that impacts on nurse sickness levels, so I think you can extrapolate that to other things. I mean, medics as a rule, until perhaps this year, haven't really had much in the way of sickness absence. But if you want to improve morale, you want to improve workplace attendance, then you educate. Um, and therefore, I you know I can't be more positive about encouraging people to go into education.

SPEAKER_01 7:17

That's really insightful into how we can improve our morale but also our patient care. What I want to know is in terms of our ability to help our trainees learn these skills, how how can we help our trainees develop their managerial skills? And by that I mean maybe the non-clinical aspect of working within acute medical units.

SPEAKER_02 7:44

Yeah, I just realized I was nodding away and you no one could see me nodding. Um so I think that's interesting. So I think the soft skills are much more difficult. Um and again, I think some of it is observing, some of it is observing and knowing what you're looking for. So I think um if you're if you're having a busy take and you see the consultant how they're managing that, um, and how the decision making is going, how the delegation is going, how the patient flow is going, the conversations they're having, the escalation they're having that they're doing. So watching someone in action, and it's difficult because you're really busy too, um, and seeing what they do and saying, Oh, I like what they did there, or they kept their cool and they were able to really manage lots of different things well, or they stopped what they were doing in terms of seeing the next person with heart failure and made calls to try and help the team. That experience counts for a lot. You learn a lot more from being in the in the cut thrust and seeing something like that, and then maybe having an opportunity to reflect on it. So on your way home that night, thinking, oh, that was a tough shift, thinking about what went well for you. So, you know, thinking about the three things that you think went well for you that day, trying to think about things something that you think maybe didn't go so well, and you know, metabolizing that, but also maybe reflecting on right, when I look at my boss, as I know we're not meant to think of them, what did they do that impressed me, or what did they do that I think, oh, that was that was that didn't really feel quite right, or I know that they didn't really like that, or that was a bit hard. Because I get quite a lot of feedback about different people and how they've responded in different situations, and definitely one of the most hurtful bits of feedback I had is about somebody I was working with was when the unit was going like a fair, they didn't listen, they didn't escalate it, they just sort of almost shrugged. Now that was years ago, and it's not someone who's working in the Western now, I hated that. But you know, that's that is where you should go for that thinking that's not leadership. Yes, we can all be in difficult situations, and yes, there may not be easy things we can do to make things better, but as the the leader of a unit, you it's your responsibility to listen to concerns, let people know that they're being heard and that you share the concerns, and let them know you're taking them seriously and you're going to escalate that. So I think seeing how people deal with difficult situations is important and being able to say, Oh, you know, I I I recognize good stuff in that. For me, when I'm really stressed, there'll be times where um I get a bit grumpy or a bit stressed, and uh and I snap at people, and people will have heard me talk before about my chimp, and and I will then have to go back and say, Look, I'm sorry I snapped, I was really stressed, or I'm sorry I looked like I was about to cry. Truth was, I was about to try to cry, and I know I have to try and manage that. And but I think also if trainees see that, then they realise that I'm human too, and it's not easy, and that you know, there are times where you know it's so busy and it's so stressful, and you've got no idea where you're going to put the patients or how you're gonna get them all seen, and you know, people are deteriorated all over the place. But it does it, it makes you uh want to cry or makes you want to run away from it all or makes you leave the department and never want to come back. We all have had takes like that, and learning how to deal with that, seeing how people deal with that, learning that that is human and it's part of our training, and it doesn't mean you're a failure or weak or will never progress, is just part of the way we part of where we're working just now. I think seeing how people manage that and how you come back the next day with a smile on your face and do it all again, I think is um is it's good to be able to see that. So I think I'm apologise for reading off topic, but I think role modelling is really important, and I think watching your role models, if you have some good role models around you, is really important. There are other things you can do that don't mean you have to cry at the end of your shift to learn. So um obviously the chief registrar movement is setting up in a lot of hospitals near you. I know quite a few key medics are have been or have applied for the chief registrar role. That's definitely a good taste into management. It gives you should give you some time to do it. Now, not all of these do, but I think they work better if you have some lots of timer for it. And that the interesting thing with the chief registrar program is that it's quite an interesting interface between management and your other trainees and the sort of you know, the people you work with, and as you progress to your career, you are that that is a difficult tension to hold. And definitely one of the things I find really difficult about being a clinical director is I'm someone who likes to be liked. And if you're in a management role, you have to be okay with people not liking you all the time, or people recognizing that you're having to make difficult decisions and you're not going to be miss popularity. And the chief registrar, you're trying to fight for your trainees and what your trainees want, what your colleagues want, and what you know, and all that, but also you're in a management role where the management is saying, but we we're not going to deliver that, or actually they have to be redeployed, or they're going to have to work more nights, or that's just not feasible. So, um, I think that the chief registrar program is interesting because I think it gives you a real insight into that, and actually it gives you an insight into the number of meetings you have to go to and what a lot of jargon is and paperwork is and emails you get if you're in a management role. So I would I would encourage people to think about the chief registrar role, but look closely at the small print about whether you'd be allowed time and what the job involves. Because if it's if you're if you're trying to do it on top of a full-time day job, it will be really tough. The other thing I think is a really good initiative, and I'm sorry this is Scotland-based, but there are initiatives like this elsewhere, is the Scottish Clinical Leadership Fellowship, and that goes on that's about a year out of program. Um, and it teaches you a lot of the fundamentals of leadership and actually goes beyond that too. There's a lot of um small group discussion, a lot of working through stuff. Um, I did an equivalent to it, so slightly different thing, which I found really helpful because you're working with small groups, you're exploring some of your problems. So there are people spread throughout Scotland who were too in my group, and we were based in Lanarkshire, they know all about the the AMU and how I wanted to redesign it and all this, and and you know, and the intricacies of take across Edinburgh. Like, you know, it was really good opportunity to explore things with people who aren't a key medicine and don't work in Lothian. Um, and I learned an awful lot from that. It really encouraged me to read more, learn more about myself and my management style, my leadership style, and how other people do it. So I've got a lot of insight into leaders around the world. And actually, when you start learning about leadership, you look at people like Trump, Obama, and Boris Johnson, and Nicola Sturgeon, and you you're able to sort of see styles of leadership and why that works for some people and why it doesn't work for others. So I'd really um advise people to do something like the Scottish Clinical Leadership Fellowship. And like I say, that's a year, so people may not want to do a year, but there are options that are smaller courses um or or smaller nuggets of that, and definitely, you know, if people are wanting my details, I've got a long reading list of things that I think have helped me practically or most as a as a consultant, and more than happy to share.

SPEAKER_01 14:46

That's really helpful, and I'm sure our listeners would be really interested in learning more about that. And I guess one of the themes that is really coming through, Claire, is that you talk about role models and learning by example and then leading by example and reflection on that, on their experiences throughout their training. And I guess one of the things that I would like to get your insight on is what it means to be a follower as part of the team rather than the leader, because you can't do both, or or can you?

SPEAKER_02 15:17

So I think I think that's a really good question. And the answer is that um all leaders also have to follow because there's a hierarchy and none of us are at the top. And I think also, as you described, there's a there's a time and a place for being both. And as some of you will have seen the the YouTube about followership. I don't even know what you would type into YouTube, but I think if you put in first follower or followership, you'd probably find it. It's at a music festival, it's about dancing. And as someone who is always the first to dance for, um then I'm a big fan of followership. And followership is about knowing when to when someone needs a bit of backup and you should be the person standing behind them saying you're doing the right thing, and I think this is a good idea, and I'm going to do what you tell me to do. I'm going to give you some feedback and help along the way. I'm not going to just necessarily completely say yes, but I'm behind you and I will follow you to do this. Now I'm quite a rule follower, like I'm that kind of girl, so it's probably quite easy for me to be a follower. I, you know, I do med rec on all my admissions, I follow the antibiotic prescribing policy on almost all my admissions. I'm kind of like that. Um, but it's interesting because COVID, which I know we may we'll come on to in more detail, COVID, I was definitely there were some periods at the start where I really struggled with that that balance between leadership and followership, where my place in the organization is not really a leadership role. I don't have a formal leadership role, but because I do a lot of the rotas, I do a lot of induction, a lot, and I do quite a lot of the clinical governance and the policy of safety and stuff, quite a lot of people would would come to me as uh, you know, what's happening with this? What are we doing about FFP3 masks? You know, I'd be I'd be getting a lot of questions that actually needed me to be in a leadership role to be able to make decisions on an answer, and yet was also feeling like these decisions are not being taken by me, and that's fine, but I need to find some way of communicating or being part of that leadership team without really having a formal role. And I found that tension at times quite challenging because it's really hard when people are looking to you for answers and you don't have answers, and definitely quite at the start of COVID, there were not many answers, or the answers weren't very helpful, which were, oh, we don't have any FFPP masks. Never mind, go yourself. So I think it's a good question, and I think I think different people are differently inclined towards leadership and followership. I do think it's important to be able to do both and to recognise, like like I say, about two weeks into COVID, I realized I had to stop being gobby in meetings and actually just shut up and let people make decisions because I was only getting causing frustration for many people, including myself, and that was helpful. Um, but I needed, I probably needed, I needed some time to think about that, and I needed probably a little bit of coaching on the recognizing where my place was. So if you are feeling in a situation where you are about to explode, then being able to analyse that with someone is really helpful because they'll be able to say perhaps more objectively, the reason you're feeling like this is because. Um, and that really helped me to take a step back and say, actually, my role here isn't to try and say that we should be you know stopping this and pulling doctors from there and making this word. That's not my role, that's other people's role. My role is to try and manage my team, make sure my team are healthy, are well looked after, are well informed, have a rota that may be redesigned but is looking after the well-being. These are the things that are within my gift or my role to sort out, and I will focus on these and do these the best I can because I am a cog in a wheel that is moving this machine forward, and I am not going to solve COVID single-handedly. I'm not going to solve COVID of the Western single-handedly, but I can do my bit of that machine as well as I possibly can and actually let other people do theirs and accept that they're they have different insights and different ideas, but they're doing their cog a bit, you know, as well as they possibly can be. And I will trust the machine to move.

SPEAKER_01 18:58

So that leads nicely into the question I was going to ask and how COVID has changed how we run the Cute Medical Unit and how we adapt to the pandemic and how that's changed our leadership style. What are your thoughts on that?

SPEAKER_02 19:12

So I think most people who've been working in hospitals in COVID will realize that actually change, and actually not just in hospitals, change, we were suddenly able to do things at a pace we've never done before. So the NHS and many healthcare organizations are quite known for their lack of ability to change quickly. And suddenly we were, you know, the things were changing at a at a rate of pace that none of us have seen before. You know, wards were changing overnight, pathways were changing overnight, admission criteria or criteria of how you manage patients were changing very quickly. So that was really helpful, but it's hard to keep up with that, and it's hard to keep up with you know emails every day and things changing every day. But definitely the pace of change has been a breath of fresh air in many ways, but obviously it brings about a lot of challenges too. So we have to so infection control has always clearly been an issue, and bed management has always been an issue, and patient flow has always been an issue. Suddenly, the three of those align to make it really difficult, where you have one group of doctors and nurses working in one front door, and suddenly you have to make two front doors, and you have to try and not cross-contaminate. You try and have to keep a COVID and a non-COVID dish as much as possible front doors, and that's difficult if you don't have staffing. Now, initially, the redeployed staff made a massive difference, but that's not really being continued, which is good for training, but it does mean that we're essentially having to, you know, most sites are having to run two parallel pathways and staff that and bed management is you know, we have people with COVID separate from other people, and they have to be inside rooms as much as possible, and we have to protect people who are vulnerable and who are shielding. So, bed management, like I say, has always been another challenge, is now just so much more complicated, and some of that is adversely affected patient care. So the rules we had before about multiple patient moves have kind of gone out the window because it's all gone down to well, is it red or green or a lamber that they're they're going into? So, so yeah, it's definitely made um patient management, patient flow more challenging, and you know, testing patients, the rules on who we test and how we test, patients and staff change, and we've got to keep up to date with that. I have to say, I think quite early on we realized that communication was really important. So anxiety levels are high, anxiety levels in the hospital were high. You're you know, at the mid-March or early March, we're seeing photos from Italy of patients rammed into ICUs in corridors getting CPAP, we're hearing about medical staff and nursing staff dying. There was an awful lot of anxiety at the start of all this, and the best way to really engage with that was to try and keep communication happening, you know, so making sure people knew what was happening on a daily basis. And definitely locally at the Western General, we had really good huddles, we had really good clinical communication from the management team, and within our own group, we had daily huddles for the junior staff. Try and disseminate some of that and try to address some of their fears, which were very, very uh you know understandable and allowed us to also sort problems in real time. So, you know, if there is a shortage of PPE or if there's confusion about patient pathways or patient testing, then we were able to address them pretty much immediately, as opposed to waiting for three people to be asked and then not really be sure, and then maybe email someone. So I think the alacrity of change has been helped by that real, you know, a real focus on communication and a real recognition that communication was pivotal to all this. Communication's been uh been a really important part too. And I think managing you know redeployment, managing trainees whose training has been affected by this, you know, my heart goes out to trainees whose training has been affected, be that exams being cancelled, be that rotations not rotating, be that having to stop their research and come back to general medicine, be that the neurology registrars who suddenly had to learn how to be a respiratory registrar, you know, it's affected loads of people and will continue to affect people. And that's it's about trying to balance up the real personal aspects of that, along with trying to keep a service going, trying to keep patients safe, trying to, you know, run them the medical side too, but recognize, like I say, the human cost and the and uh and what it's like to be a human working in this in the specialities we are working in, just uh I think the key thing that's coming through, Claire, is that whilst being a leader is really can be very, very tough, um it also uh you know there's a there's a pattern behind those decisions.

SPEAKER_01 23:38

What would be your best advice on how to manage that stress or deal with those tough decisions and focusing really on how you can maintain your well-being when you you finish your shift and reflect on your day and then switch off and try and gather yourself for the next time you come into work?

SPEAKER_02 23:56

I think, yeah, that's tough, and I guess um we're all still learning that. Um and I think people will find something that's right for them. I have to say, and I know I've I've got into a few discussions about this in the past about the whole idea of resilience training. I think I think what you describe is actually resilience. I know resilience is a bit of a dirty word, and it's and it's not about making yourself stronger or saying that you know you're a failure if you you go home in tears, because that's absolutely not what resilience is. Resilience is being able to come back into work the next day or recognizing when you can't come back into work the next day and working out what you need to allow yourself to come back as an okay person. So, like I say, I think there's lots of different things that tell people. Um, and I think one of the things that medics are, I think, bad at, and this may be a stupid generalization, but I recognise it myself, is rumination and self-flagulation. So I use my act of community home to have a think about the day, but I think I am getting better at recognizing when I'm turning it into just a barrage of how bad I am, I need to stop and stop thinking about things that make me feel bad because it doesn't really help. You can think about things, you can reflect about things, you can think I would do that differently, and then you have to let it go and put it behind you because I think spending too much time reflecting on the things that went badly, or the things you'd like to done differently, or why did I not spot that in patient X, or why did someone so come along and get that blood gas immediately, you know, that doesn't really help anyone. It doesn't make it doesn't help you coming into work the next day. So if things have if there's been an instant where things have gone wrong, reflect on it, try and do something useful with it, and then put it behind you. Also focus on things that went quite well because I think we all we all have days where we go home with a little spring on our step because it's been quite a good day and you've done good stuff and it's been good. So it's good to recognise that. Um many of you will know I'm quite a fan of the physical exercise. So for me, my well-being is really important to be able to do, go for a run, go for a cycle. When I'm not locked down, getting into the mountains is really helpful me to get a sense of perspective because when you're in the mountains, you realise how small you are, and that the mountains have been there for years and they will continue to be there for years, and therefore the fact that I'm worried about the four-hour emergency care standard in AMU is actually quite a small thing. Yes, it's got big implications, and yes, I don't want patients to die needlessly, but actually, standing in the middle of the mountains is really good for my mental health because I realise how small and insignificant I am in the general scheme of things. So get out into the outdoors, um, exercise if you can. Later on this evening, I'm going to do some yoga. Now, yoga isn't a great, you know, it's not going to make you a healthy person or a well-being person, but it does help for me to just focus on different things and to look after my body in a different way. And like I say, I think there's a time and a place for reflection, but don't let it take you over, don't let it become something that's just constantly playing on your mind. One of the books that's on my reading list that I've not read yet because I don't think it's published yet, which is my excuse, is about listening to your own chatter, listening to your own internal chatter. And like I say, I think it's important when you start realizing that you're overdoing the introspection and the self-flagellation and the I wish I was a better person and I'm so bad because I did this. I've only recently become, I guess, a bit more aware of that, and now I'm still at a stage where I think it feels a bit weird to talk about it publicly, but I'm kind of hoping other people know what I'm talking about. That every so often you kind of just tell yourself you're rubbish and um think now that that's not very healthy or helpful, and therefore, if I recognize myself doing that, then I try and stop it. Sorry, Johnny, that may have gone a little bit too far.

SPEAKER_01 27:28

It's it's really useful to um to share your experiences. And I guess just before we finish up, I just wonder if you could just give the listeners some some take-home points and just some key messages about leadership in the general medical take, acute medicine, especially uh during these times, and just leaving our listeners with some key thoughts to take home.

SPEAKER_02 27:51

So I guess, like I say, role modeling I think is really important, and you can be a role model no matter where you are, no matter who you are, no matter what you're doing. The way you present yourself at work, the way you handle yourself at work, and the way you approach your work is is key, and people will see that and they will and they will take something from it. So I think role modeling is really important. I think learning more about yourself and how you handle yourself under pressure and and how other people see you is really important too. So I think 360 degree of feedback has been one of the most useful things I've ever had as a consultant, and that's been from trainees giving me that feedback. So when people ask you for feedback, be honest, be kind, but you know, and read feedback too, because quite often feedback is just uh, oh, you're great at everything. Be aware that sometimes actually really helpful feedback doesn't feel very great, and but it's it's really useful. So um seek feedback and helpful feedback and also recognizing yourself when you know, you know, how you are acting as a human in uh in certain situations and how you might be able to learn from that and and and respond to that and do differently. The other thing I would recommend, which is a practical thing, is a pause. And again, many trainees will have heard me talk about this before, and many of you will have heard about it before, but when you are wanting to react to something or when you're feeling stressed, and the chimp, as I call it, or many people ahead of me have called it, is about to get out, then taking 10 seconds to count to 10 or think about something calm or use the calm app and look at a nice picture, or just think stop, and allow your brain to the dual loops of your brain to sort of catch up with each other and allow yourself to approach it in a more rational, less passionate and emotive way. I think is really helpful. So if you're in the thick of it and you want to shout or cry, or you're going red and the sweat is prickling, then just think about trying to take 10 seconds to calm down because there's very few medical emergencies where 10 seconds will make a massive difference, but it might actually make a big difference to you how you are as a leader.

SPEAKER_01 29:49

Dr. Gordon, thank you very much. And once again, thank you for agreeing to come on the podcast and share your experiences. It's been a very uh insightful um opportunity. And once again, thank you very much.