We need more variation!

Part of the trouble we face as clinicians is the call to standardisation. There are undoubtedly multiple clinical areas where all clinicians are expected, if not exhorted to do the same things in the same way. Management of AF for example.
Sadly this does not always happen and I would like to suggest a theory why not.
In every given population there is a distribution, the classic bell shaped curve, or asymmetric curve will undoubtedly be present.
By definition 50% will be above the mean, 50% will be below, and two standard deviations will see 95% of the population covered.
When it comes to adopting the standardised behaviour we're all given the same map, guideline, instructions and expected to follow them.
Now we can all see that the instructions I need to get to New York, will be different from the instructions required by a resident of the Broncs.
So why is it that we are helped to achieve best practice by instructions written by those engaged in best practice and no understanding of how far away some of us live?
Would we not achieve greater success in reaching our destination by recognising the various places from which we start?
I would suggest that NICE and other guideline generating organisations would do well to produce various guidelines all designed to work from various starting places, approximating to success and useable by those who live in different clinical lands.

What is Creativity?

Part of the issue surrounding creativity is that many people are not sure what it is- they think its something to do with art, or only for gifted and talented people.

The reality is that we all have a creative side, we all have imaginations, we can all ask ourselves "what if...".

So in truth, we can all be creative.

The next issue is that people sometimes think they need to be taught how to be creative, that years at art school or university are required.

The reality is that no education is required to be creative at all. Children possess innate creativity which our education system has previously tried to beat out of them. Current education methods are focussed on development of creativity, encouraging the questioning environment and association of ideas which is the hallmark of creativity.

So- now you know what it is- why not try it?

Just look around you now and select two objects, any two. Now mentally link the two objects, what have you "created"? I'm sitting at a desk in a shared office environment. It has loads of objects cluttering the surface.

The cleaner has left a bottle of cleaning solution, on my right hand side and there is a stapler on my left.

Ok- so cleaning spray, stapler- what have we got?

A spray for cleaning your desk equipment? Staples that smell? A stapler that releases a scent onto the paper?

Three ideas in less than a second.

Now next time you are in a clinical area and have the luxury of a minute spare, just relax and try the same game. Granted its unlikely you will come up with the bagless vacuum cleaner, but you never know.  

Why do we do what we do, when we can be so much more?

I know it sounds like a lyric from Gerry and the Pacemakers but I was thinking about motivation this week.

Daniel Pink in his excellent book "Drive" outlines some of the science behind motivation and draws some lessons for how we manage and motivate. I must admit his work did resonate with some facets of how medicine is currently configured.

No medic starts out with the ambition of being mediocre, avaricious or dangerous, yet some of us become exactly that. Extrapolating the theories outlined in Drive in to the current NHS it would seem that many doctors, regardless of area of practice, are being subjected to rewards based on action which saps their intrinsic drive, their willingness to just be the best they can be, and replaces it with a financial focus on activity.

I would argue that this applies equally to GPs in carrying out QOF and hospital doctors in warning of "destabilisation" if activity levels change in outpatients.

How then can we take the lessons of "Drive" and apply them to the NHS?
Developing a payment mechanism that remunerates fairly without some form of performance measurement is pure fantasy in our current structures.
If however we were able to reward systems that perform well, with all parties in each health economy receiving some benefit for their innovation, economies and creativity, then we might find ourselves in a virtuous circle.

This circle would see patients, primary and secondary care all looking out for each other, offering challenge to unhelpful behaviour and being part of a system that strives for excellence, driven by the intrinsic motivation in each of us.

Simply put-the reward is being the right thing, not doing the right thing.

Transforming the Horse and Cart

Part of the problem in healthcare is that we don’t actively seek transformational change. We focus on being better, being safer and just working darn harder to get results. Unfortunately building a better horse and cart has inherent limitations.

Sport illustrates this quite nicely, the high jump in the early days of the Olympics was a standing jump, which became a scissor jump after a run up. Of course performance increased, and thanks to occasional falls a mat was introduced to prevent injury.

Things went on for a while with slightly better results every four years but then, the straddle jump evolved and results improved dramatically. Now everybody did the straddle jump and things were slightly improving every four years, it seemed that the straddle jump was the best way of doing it, period-until Dick Fosbury came along that is.

Once again a transformation occurred which changed the game with a quantum leap.

Of course now the NHS faces a major pressure to survive, and surprise surprise we’re squeezing efficiency out of the current systems, getting that better horse and cart. Even the potentially transformative shift to Clinical Commissioning Groups looks like it will be focussed on better pathways, again that horse and cart.

So what should the transformation be? Who is the Dick Fosbury of our NHS. I don’t know, it could be you or me. The solution is not going to come to those of us who are equine focussed in mentality. The solution will come from people who are not afraid to question the status quo, and ask the question “why not?”

What kind of bike do you ride?

Do you ride a bike? What kind of cyclist are you? If you ride a bike you know what I mean, generally there are two tribes, the roadies and the MTBers. Although the are different demographic features of the two groups, certainly different appearances and features in the various bits of mechanics they employ in their leisure pursuits, I would like to suggest that there is a more fundamental difference in the way you think in the two pursuits. As a Roadie the Tarmac is endless, your body settles in to the rhythm, the pace line, the drafting and, odd pot hole aside, the Zen. The mental quiet, conversation and interaction in the group is the reward and in many cases reason to be a roadie.

MTBers on the other hand are always physically interacting with the bike, the terrain, the changing challenge, conversation is impossible especially on the "gnarly bits". The impact is that MTBers focus on the here and now, no chance to think beyond the next rock, dip or bend.

Neither group is superior to the other, no one is wrong or right. They are just very different in how the same activity is performed and the thought processes which the activity requires and generates in it's performance.

Medicine is like that, we have at the moment two tribes, the generalists and the specialists, each performing and to a certain extent thinking in different ways. 

Neither is "better" than the other and both are required to deliver a functional healthcare system. 

My issue at point is that there are a group of cyclists who are happy to wear Lycra, ride the road, accept the zen of the racing bike on a Sunday morning. Those same cyclists will have been out on the Saturday morning attacking the trails, making the jumps and wearing the baggy shorts of the MTBers. 

Where are those who straddle both primary and secondary care? The GPWSI is one breed, but the Consultant with interest in primary care is not yet on the map.

Should it be? Isn't there a piece missing from the landscape? Perhaps consultants in intermediate care are the closest we have at present but their value needs to be recognised and we all need to recognise the beauty inherent in each others craft.