All posts by Dr. Damian Roland

I am Paediatrician who works in an Emergency Department. I am currently undertaking a PhD and have formed the PEMLA (Paediatric Emergency Medicine Leicester Academic) Group with a colleague, Dr. Ffion Davies. I have interests in both medical education evaluation and policy

An ABC of an ACF (academic clinical fellow)

This was first writen in 2010 and never published – I was prompted by a recent article in Archives of Disease of Childhood Education and Practice to put it into a blog form.

“Ability is of little account without opportunity”.  ~Napoleon

Prior to the introduction of the Modernising Medical Careers Programme (MMC) it had been recognized that academic medicine was in decline in the UK and there were perceived deterrents to entry into this specialist field. Dr. Mark Walport, the director of the Welcome trust, brought together a number of stakeholders with an aim to use MMC to find solutions to the traditional barriers to an academic career. What emerged from these meetings was the Walport report and the development of an integrated academic training path (table one).

Table One – The Integrated Academic Training path as proposed by the Walport report [1]

integrated academic trainingpath

(please click on to expand – picture via Imperial College)

So although many doctors were unsettled by the experience of implementing the MMC programme, and even more disaffected by the initial failure of its recruitment method (MTAS), there was one group of trainees who potentially stood to benefit. Those interested in an academic career found themselves able to gain academic experience and competencies without having to go out of programme or at detriment to their careers. Introduced in 2006 the initial recruitment of the Academic Clinical Fellow (ACF) was slow. However as knowledge of these positions has increased they have become increasingly popular and for the 2009 year 260 posts were available.  The concept of the Post is novel and a summary of the role from the Walport report [1] quoted below:

Each trainee will have the opportunity to develop a flexible training programme to achieve his / her academic and clinical goals, through the provision of an ad personam training programme and mentoring. Delivery of these programmes should be trainee-centred as far as possible, with a single point of contact for the trainee.

Essentially an ACF is designed to give enthusiastic clinicians protected time (25% over three years) to develop a thesis proposal. When they embark on a PhD or MD their fellowship ends to return afterwards either to a clinical lectureship or back into clinical medicine. Their run through training pathway is protected and, subject to clinical competencies, they would be able to return with minimal disadvantage if their academic career was not successful or didn’t suit them.

So what’s it like to be an ACF and why would you want to be one? There are many popular misconceptions about academic medicine. You do not have to be the cleverest of your peers, have a photographic memory or be a social recluse. I know that because I was an ACF and received no distinctions or awards at medical school (you’ll just have to take my word for it that I have friends.)

Although originally designed for entry at ST1-3 I entered an ACF in paediatric emergency medicine in March 2008 at the level of a year three registrar (ST6). I already had some research experience from a fellowship I undertook in Australia so had a few imprecise academic competencies. Examples of some of these are listed in table two. They are much less specific than clinical ones and some may be interpreted in an open-ended manner. Therefore you need to go out and find the information required; it will certainly not present itself to you fortuitously while you are on call.

The aim was, given a protected day a week, to develop a research proposal which would enable funding to be obtained for a higher degree. I had an office, a desk in a blood taking room with painfully bright lights and a buzzing ultra-low temperature fridge, but away from a nurses’ station and a bleep.

Table Two – Selected Academic Competencies

Have developed critical and evaluatory skills such that they are able to engage with and review published research literature.
Demonstrate a comprehensive knowledge of reference sources and be able to use them in an appropriate manner.
Be able to summarise the hypothetico-deductive model of scientific work, illustrating how this may be applied to a particular clinical question.

There is always the potential for resentment from your colleagues when you are given time away from the shop floor. You sense they feel you will be sitting in front of a computer playing solitaire and looking up friends on face book. It is interesting that I am more tired at the end of an academic day than a clinical shift! When you start it is virtually impossible to sit there doing nothing as you have a range of meetings to organise, courses to book and journals to read. You feel guilty (not least because of your colleague’s unseen glares) if you don’t do anything. This is spur enough to wade through a soporific statistical book trying to explain the difference between sensitivity and specificity, something you thought you learnt in medical school but actually never understood.

“Everyone who’s ever taken a shower has an idea.  It’s the person who gets out of the shower, dries off and does something about it who makes a difference”.  ~Nolan Bushnell

The purpose of the ACF programme is to steer you towards obtaining funding for a thesis (MD or PhD). Although the academic department you are based in will have its own research themes this application will not have been written yet. Ownership and development of an idea by the ACF is considered good practice. It is both enjoyable and frustrating to develop a project. The learning process involves being able to formulate a question (very different from an ‘idea’) which is practical, achievable but most importantly fundable. Many of the suggestions you have will be placed on a back burner as, although good, they are just not achievable in time scale available. In order to develop your ideas experienced advice is needed and developing that advice is a useful first lesson. In my first year as an ACF I had 42 distinct meetings with various individuals and groups and many more ad hoc encounters with my research supervisor. While trying to formulate a research question I first approached those who had any potential connection with my planned topic. Those initial discussions spawn many ideas and lead to a cascade of meetings both within and without the university, hospital and even region. You quickly learn it is vital to have a plan or strategy prior to any meeting. All health care professionals whether doctors, academics, research nurses or representatives of funding organisations are busy people. An initial question of “what can you do to help me?” can be easily be perceived as wasting their time. Explaining your background, interests and aims focuses your direction of travel and it is a lot easier for appropriate advice to be given.  Directly associated with this is need to record information effectively. It was three months before one senior lecturer asked me why I was writing everything she said on a small scrap of paper; “how on earth was that going to be useful in the future?” The next day I brought an A4 ring binder and now have an organised log of all meetings and most importantly outcomes. This is not only necessary for project development it was also a vital piece of evidence for my academic ARCP.

“Librarian is a service occupation.  Gas station attendant of the mind”. ~Richard Powers

In conjunction with developing your question it is important to understand the background research which already exists in your area of interest. Libraries are familiar places to doctors from the late nights spent trying to cram, now long forgotten, knowledge into your brain prior to finals. Librarians at this stage were of little practical use especially as they never seemed to find riotous laughter as much of an adjunct to revision with friends as you did. However the clinical librarian is a mine field of information and is extremely useful in being able to locate a recent article of the “Journal of Amytrophic Lateral Sclerosis” or a 1974 response to an editorial in “Augmentative and Alternative Communication” (both real journals). They are also extremely skilled in designing literature searches and an hour spent with one reaps many hours saved in the future.

Having reviewed the relevant journals and spoken to various authorities on the subject I began putting together an initial research proposal. This document was subsequently revised 13 times before an acceptable version was submitted for a NIHR Research Doctoral Fellowship. Although the theme, questions and method of the final version was very different from the initial draft it was not unrecognisable. With each draft came an increased focus to the question, a better idea of the projects limits and perhaps most importantly an increased understanding of the style of language needed to write applications. Aside from the draft of the proposal the final application took nearly three months to complete. In applying for grants all monies have to be accounted for, which includes your salary, pension and national insurance contributions. The costs of expenses as simple as paper and pens need to be included and statistical help is unfortunately not free. In hindsight trying to bring a whole application together on a day a week (and I certainly did a lot of work in the evening and weekends) added to the stress of the process. With advance agreement and co-ordination the time taken for research over the three years can be taken in any form up to 25 % of the total clinical time. Some centres provide a six month academic block which is especially useful for laboratory studies and allows the ACF to gain experience to inform the thesis application. Others allow a mix of time dependant on the clinical demands (some attachments require a greater clinical commitment to achieve competencies – neonatology during paediatric training is a good example). It is expected the ACF will progress at a faster rate than their peers enabling the academic time to be taken without prolonging the training programme.

Effective forward thinking is important as decisions on major grant applications may take up to six months. Following submission it may take a month to decide whether to send the proposal for peer review and even then a final decision, based on interview, may not be made for another 4-5 months. In that time there will be other grant applications to write and additional research to be performed. It may be during these periods that a return to full time clinical medicine occurs to obtain competencies and exams.

“Failure is only the opportunity to begin again more intelligently”. ~Henry Ford

My initial NIHR Doctoral Research Fellowship application was unsuccessful. The detailed feedback indicated that although I was a suitable candidate the thesis project and support was not of sufficient quality. It is important for grants that you show that you are a committed potential candidate with a robust project detailing measurable outcomes in the planned time frame. You must also demonstrate your supervisors have sufficient experience to supervise you and a training programme is in place for you to obtain the skills necessary to complete the work. It is easy to forget the latter two points in applications. I had presented a couple of abstracts at national meetings based on reviews and audits performed while an ACF. This improved my academic curriculum vitae however we had not thought carefully enough about some of the research techniques needed for the qualitative components of the project. During the next year we refined the question and developed a project group consisting of my research supervisor but also containing academics with specialists interests which were not present in my academic department. I have subsequently obtained funding for a revised project via a fellowship opportunity which has become available at my trust. This certainly would not have been a possibility without the time available from an ACF position.

I have thoroughly enjoyed my time as an ACF despite the pressures of applications deadlines, hours in front of a keyboard and a buzzing fridge.

Regardless of how my academic career develops the experience has been extremely stimulating and rewarding and will be of benefit to me whatever the future holds.

References

1. Medically- and dentally-qualified academic staff: recommendations for training the researchers and educators of the future (the ‘Walport report’). The Academy of Medical Sciences. 2005.

Harry Potter may have been a leader but Neville Longbottom was the radical one

(apols for advert at start)

I watched the Harry Potter and Deathly Hallows during the christmas holiday period. It first reminded me that I really need to go back and read the books as I am sure they are lots of subplots that I missed. But secondly that Neville gets a pretty raw deal compared to Harry Potter. If I was going to be a hero, Neville Longbottom is the hero I would like to be. Little point in believing I am not a geek. But at least a geek who achieves things, a quiet leader.

Neville Longbottom: So how are we going to get to London?

Harry Potter: Look, it’s not that I don’t appreciate everything you’ve done, all of you, but – but I’ve got you into enough trouble as it is.

[walks past everyone]

Neville Longbottom: Dumbledore’s Army’s supposed to be about doing something real.

[Harry stops turns around to face them]

Neville Longbottom: Or was all that just words to you?

[extract from Harry Potter and the Order of the Phoenix]

The concept of leadership in medicine is pejoratively and passionately pontificated. The impossibility of everyone being a stereotypical ‘leader’ balanced with the importance of all professionals needing to demonstrate ‘leadership’. Harry Potter commonly seen as the former archetype but not everyone can be a ‘Harry’. This is either because they don’t have the subtle instinct to act the right time, are not willing to embrace the negatives or simply weren’t in the right place at the right time. Conversely not everyone sees Neville as a traditional leader but from a hesitant ackward beginning he quietly goes about his business supporting those who need help. He actually has much in common with Harry. Their values and motivations are no different and he ultimately co-ordinates a resistance movement in Harry’s absence. Neville demonstrates true leadership by followership.

Perhaps it is time for us to acknowledge the Neville Longbottom’s of the healthcare system. Those that deliver, sometimes in the absence of guidance, even when everything is stacked against them. The Neville’s appreciate the desire to be involved in creating an effective, high quality healthcare  (it’s not just the Harrys) but acknowledge the system doesn’t give everyone the chance to help deliver it.

If you feel more like a Neville than a Harry then there are things you can do. The School for Healthcare Radicals has opened – an opportunity to learn how to develop yourself, and others, to create change in health and care environments. This school itself has percolated out of NHS Change Day, the 2014 event being now less than two months away. Both are open to all regardless of your profession, grade or place of work. The ideas and pledges you submit are yours and the manner in which you carry them out is up to YOU. But like Neville its likely that you are the type of person who will be delivering more than words…..

“Text, Slides and Videotape”: #SMACCGold Workshop Pre-reading

The pre-conference workshops for #SMACCGOLD represent an opportunity for delegates to gain additional skills direct from some of the conference speakers

The Education Workshop contains a short session on “Text, Slides and Videotape” hosted by yours truly. The aim of this session is to aid delegates use of audio-visual tools to maximise the impact of their teaching. There will be lean towards the use of video as resources on other medium are easily found elsewhere (and its the area in which the greatest gains for least effort can be made IMHO)

I will also be offering an individual feedback session on videos/pictures used in teaching/assessment for attendees. Please send me your cases in advance (secure if needs be) and I’ll touch base at #SMACC. There might be a prize for the best use of audiovisual material for teaching….

It would be worthwhile for all participants to have a look at the following: (more will follow in the new year)

Resources

Education by Video 

P (cubed) A blog on Presentation Skills by Ross Fisher 

A literature review of Patient Video Cases (only for the seriously interested!)

ABC of learning and teaching in medicine

Tasks (these are not obligatory but will help inform the workshop)

1) Please register on www.spottingthesickchild.com (you’d don’t need to have any paediatric experience. This is to demonstrate videos in education. Orientate yourself to the site and then please go to

My waiting room > Patient Stories > Difficulty Breathing > Case 1

I’d like to start a discussion about this google + site.

2) I have added a test video to my vimeo site. It is password protected as the consent for this film means is only available to health care professionals. If you need a password please find it on the SMACC Education Google Discussion group or e-mail me on damianroland@me.com

Look forward to seeing you in 2014!

On Change, Challenging and Christmas Carols….

Last week I went to see my daughter’s school carol service. A small church in our town hosted pupils singing carols in-between reading the nativity. I was particularly inspired by a nine-year old girl commencing the proceedings with a solo version of “Once in Royal David’s City” but also by the general quality of the readings.  My daughter, barely 4 when she started this year I suspect was not as interested, but over the next few years I hope she will take on board this sign of a very positive culture at the school.

This has been a year of emphasising culture and compassion in healthcare. Francis and Berwick laying down a gauntlet that the status quo is simply an unacceptable path to follow. The mechanisms by which this can occur are still not clear though. This has been clearly illuminated to me as I spend my last few months in medical training. Having recently been appointed as a consultant, to start in spring 2014, I reflect on the current thinking about the need for cultural shifts in the future. My practical skills, clinical reasoning and communication with other health care professionals have been developed during my training to avoid the need to ‘step up’ once in post. However developing and enhancing a culture of quality and compassion in my department will require me to speak up about others practices and be exemplary in my own. As a junior medical professional it is easy, although not necessarily right, to turn a blind eye to others’ terse tones with patients, unnecessary delays providing treatments or passive aggressive overtones in communicating with colleagues. I am not talking about clear breaches of professionalism or causing patient harm but those things which unchecked can lead to the development of ‘acceptability’ of poor practice.

This will be a hard for me.  I am also very aware it really easy to talk about these things on a podium at a conference (or in a blog) but a completely different thing to act on in the clinical work place. I have much to learn from other colleagues but I hope I can be a credible and consistent champion for excellent practice in my trust. On a national level much time has been spent developing medical ‘leaders and managers’. I am still not clear of the definition of these words but I am increasingly aware that management skills and techniques can be learnt and developed but ‘leaders’ are not so easily bred. “Leadership” though is something that any health care professional can display. Demonstrating compassion, empathy and quality of practice, consistently, even if not challenging others sets a tone for a strong culture. Anyone can do this, you just need to remember that you are always potentially being watched. The cynics who challenged the Change Day 2013 “Smile” pledge missed the point:

Yes, it seems like such an obvious thing to do, but do you always do it?

This is a time of year of reflection. For some reason a particular christmas song will remind you of past events and states of mind. The constant repetition of these songs forces an often frank summation of where you have been and where you are going. New Years Resolutions one mechanism of acting these subtle challenges.

I hope in 2014 I can set a similar example to colleagues and patients the pupils of Farndon Fields school showed to their fellow pupils.

Have a great holiday period and New Year…….

Post Blog note:

If you want an mechanism for acting on any healthcare related resolution please do pledge at changeday.nhs.uk and join a social movement of individuals, teams and organisations delivering on what is important to them. Look out for the #100daysofchange listing some of the achievements so far..!

We must never forget what we have failed to do.

Last week I attended the latest King’s Fund Medical Leadership Network/Development event. These bring together a number of clinicians and managers of varying degrees of experience. There is a focus on outcome, rather than just being talking shops, and there is a clear aim to increase the number of those attending who are early in their careers.

One of the talks was from Prof. Rory Shaw, the Medical Director of Health Care UK. This organisation aims to bring NHS healthcare expertise to the world and establish partnerships that will be beneficial for the UK economy. Prof Shaw was quite open about the questions this raises and some of the challenges to be faced. My interest peaked however in respect of NHS expertise in digital healthcare. It is an interesting paradox that many worldwide healthcare services don’t have access to, or any clear plan to develop, some of the initiatives and expertise which exist here. The concept of a universal number, for example,  is something that is taken for granted in the UK but is not present at all in many other healthcare systems. However from my point of view, a young (but potentially naive and impatient) junior doctor, there is nothing particularly brilliant about our digital systems. Very recently I was involved in a case where the failure to have access to the healthcare information of a patient presenting to a paediatric emergency department may well have resulted in harm to the patient. This was not an individuals fault, it was the fault of the absence of an electronic system that can share information about patients throughout the country.

I was pretty vitriolic about this at the conference, and despite furtive glances and frowns from some members of the audience, will remain so about this. It is not an excuse to say we tried that and it didn’t work. The simple fact remains that most members of the public remain extremely surprised that we are unable to access electronic records in one vicinity but not another. Even worse it remains a cause for concern patients can frequent numerous different health care providers  without any of them knowing anything about these visits. This isn’t about being a ‘big brother’; it’s about managing risk for vulnerable patients and ensuring patient safety in a system which harm if often to easy to come by.

What then are we to make of the failure of the National Programme for IT in the NHS? One argument is that we have moved on, the initiative for local solutions and then joined up working more pragmatic and ultimately more achievable. There are still large costs involved though as the governments recent announcement of a £1Billion fund for Emergency Departments emphasises. Appreciating it’s sometimes easier to judge rather than action, I have been working hard locally towards an electronic integrated illness identification system for children (POPS)  which is now used in other centres and could ultimately be used to compare acuity rates between emergency centres. This solution had to bypass NHS IT and is not the safeguarding safety net that is desperately needed.

It is vital that we remember where we have been in the past and what we haven’t achieved. There are many people and organisations passionate about improving the digital infrastructure of the NHS, and Tim Kelsey is clearly keen on making progress. It is likely solutions will eventually been found but we must honest about our past failures. It would be equally disastrous, probably more so,  should further Berwick and Francis reports be needed, but unfortunately history demonstrates we often fail to learn.

Extolling our strengths is fine, acknowledging our failings much the braver thing to do.

Beyond the ‘why’ of twitter: Remember there are lots of ‘hows’

A recent tweet got me thinking

There are many reasons for health care professionals to use twitter (all described well elsewhere). One of the things that puts people off is the feeling that they have to constantly, and actively, participate. When introducing someone to twitter it is worth demonstrating that you can simply just watch timelines of hashtags. Examples of this are in the NHS Employers app which contains the @nhsemployers twitter feed. Anyone downloading the app can get a sense of what happens on twitter without having to create a username or password. A more bespoke way of doing this is using a hashtag website such as http://twubs.com. You can simply type in a hashtag and follow all the conversations related to it (also useful for twitter journal clubs).

Those who are not typical ‘social media’ types (trying not to be discriminatory here :-/ ) usually come across twitter at conferences. The ability to see ongoing debate without actually having to sign up for something can be appealing; and so the above methods provide a ‘way in’. Technically your ‘interaction’ with twitter could stop there. For those whose interest is peaked they then probably do need to create an account. I try to explain to novices that twitter users fall into one of three categories [There is absolutely no science behind this but if you want an equally anedoctal breakdown but from someone with more credibility see here.]

i) Observers      [the Outpatients]

ii) Engagers        [the Wards]

iii) Captivators  [the Emergency Department]

Basically some people (observers) just watch others, learn from conversations and favourite the occasional interesting link. You then may engage in some conversations, tweet some stuff that appeals to you or join in in the odd tweet chat or journal club. Engagers may only be on twitter at certain times, or leave it alone for days/weeks on end. There is probably a spectrum of engagers however some will end up  captivated by the whole experience. Providing the material for observers and engagers, the captivators provide the material for the twitter to work. Taking in, and then throwing out ideas, at an outstanding rate.

No type of person is any better or any worse. They are just participants to varying degrees. So there is not just one way of engaging with twitter and by not being clear about this, to those dismissive or curious about it, is doing it a disservice. There are lots of reasons to be on twitter, there are even more ways of being on it.

 

COI: I was involved in the design of the NHS Employers app via www.quackapps.com

Workings hours – experiences untarnished?

The issue of whether it is possible to adequately train doctors in a 48 hour average week has long been the subject of discussion  (some background here). A recent piece in the Guardian raised a number of eyebrows from those on either sides of the argument. The article, written by a healthcare software provider, was essentially saying longer individual shifts would be better for all involved. This point didn’t really resonate with those doing the shifts.

https://twitter.com/tweediatrics/status/373269863885991936

However whenever the EWTD (or technically EWTR) gets mentioned the debate re-opens.

As a member of the Temple report on working hours I was given the opportunity to hear from those of all those involved in training and being trained. As a result I was asked by the BMA (point of note I have never been a member of the Junior Doctors Committee) to write a short article on my personal perspectives. I was surprised to find, despite having  written this in early 2010, I still stand by what I said then:

Reflections on the European Working Time Regulations

“In August 2002 I returned to the UK having spent a year in Perth (Western Australia) after my PRHO year (Foundation year one). I had spent it at a children’s hospital and had thoroughly enjoyed my clinical experiences there ; the 80 hour fortnights also helping take advantage of the sun, sea and surf. I retuned to a tertiary neonatal unit in the East Midlands with a degree of disappointment, worsened by the fact I knew I had to start getting my paediatric membership. The fact that the job was “Band 3” didn’t really mean much to me at the time except I knew it would help clear my substantial travelling debts. In practice “Band 3” meant a 4 and a half week run of shifts with only four days off.  I look back at that period now with mixed feelings. Without a doubt I went from a neonatal novice to being able to make middle grade decisions within six months. The confidence felt by the end of the job certainly outweighted the utter panic of a first night shift spent peering through Perspex glass wondering how I would get a cannula into the minute bag of skin and bones in front of me. To say I enjoyed the experience would be looking back with rose tinted spectacles. During the runs of long days and evenings you resented every little bleep or request for fluids. The maternity theatre bleep was a clever device never going off when you were being grilled on a ward round but waiting until your hurried lunch break. They would be exhausting shifts whether you did them for 10, 40 or 60 hours a week. However having to do them for 50+ meant you were never truly on top of your game. Fortunately the camaraderie of the team of SHOs (specialist trainees) provided an outlet for times when you became utterly frustrated. I count myself lucky though I have experienced both sides of the EWTR coin and am convinced on which side I prefer it fall.

It is clear one size does not fit all but in paediatrics because of the high demands of out of hours working a suitably staffed rota does provide sufficient learning opportunities within the 48 hour framework. It is unfortunate however that many paediatric rotas are not suitably staffed! My experiences with EWTR have been favourable as I have always been rostered to allow exposure to elements in my training that are not just simply deciding whether a feverish child is ill or not.  Others have not been so lucky and Out patient clinics, case conferences or governance meetings which all count as training are easily sacrificed if there is no-one available to clerk the next patient on the assessment unit. Without these opportunities the disadvantages of longer shifts, increased fatigue and less ability to unwind are irrelevant. As a trainee I want to be given the opportunity to train and want the system to flexible enough to allow me to take these opportunities. Ultimately though when frustrated that the systems fails I remember my neonatal job and am glad I don’t have to do it again. However as time progresses my memories will fade and the need to be effectively trained will remain. For paediatrics it is not the 48 hours that is the problem it is the delivery of training within it.”

I have always been clear that training is not one size fits all with the needs of the craft specialties different from the acute ones, and different again from community based services. I wonder as education and training changes over the next decade whether this problem will still persist, and whether I will still feel like this….