Junior Doctor Journal

ISSUE 1 | DECEMBER 2011

VICTORIA ISSUE

Australian Junior Doctor Journal

The Leadership Issue

Australian Junior Doctor JournalAustralian Junior Doctor Journal

Facebook Page: search for 'Junior Doctor Journal'Facebook Page: search for 'Junior Doctor Journal'

CONTENTSEditorialWelcome to this rst edition of the Australia Junior Doctor Journal. The broad aim of the publication is to involve, inform and inspire junior doctors about a wide range of issues affecting life as a doctor and healthcare in general. It is hoped that the Review will promote thoughtful discussion and debate within the junior doctor community.

This inaugural publication focuses on the topical and important theme of �‘leadership�’. A de nition of leadership is both elusive and contentious. Leadership is personal and should be continually challenged; therefore, de nitions of leadership will evolve. A particularly visionary de nition comes from Alan Keith, who states that leadership �“is ultimately about creating a way for people to contribute to making something extraordinary happen�”.

At a time of uncertainty and great challenge, the need for leadership in healthcare across all levels is unprecedented. It is increasingly recognised that junior doctors are well placed to make a valuable contribution to the future direction of the healthcare system in which they function.

We�’re excited to bring you a great selection of thoughtful, thought-provoking and inspirational articles from a diverse range of healthcare professionals.

The publication would not have been possible without the help of our sponsors and advertisers and we acknowledge their contributions.

What is truer than the truth? Answer: A Story.

We hope and trust that you will enjoy the stories shared in these articles and draw on them to create inspiring stories of your own.

Dr Karina McHardy - Editor in Chief

CONTACT US [email protected]

1 Calling all leaders: Your (health) world needs you!

3 Clinicians in Hospital Management: The need and their role

6 Medical Leaders

8 JMOs as leaders of change

10 Leadership with a small �“i�”

12 The Junior Doctor �– De ning our Future Leaders

16 JMOs as Functional Leaders

19 RACMA Leadership

Medical Indemnity Protection Society Ltd po box 25 carlton south vic 3053 | [email protected] | www.mips.com.aumember services | p. 1800 061 113 | f. 1800 061 116 | abn 64 007 067 281

You are almost there! Join MIPS as a new graduate member at no cost for the remainder of the membership year to 30 June 2012. MIPS membership benefits include insurance cover for medical indemnity matters involving the Medical Practitioners Board, Coroner’s Office, health complaint bodies, good samaritan acts, MIPS Protections for non medical indemnity matters, 24/7 medico-legal advice and MORE. Visit www.mips.com.au to download an application form.

Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is awholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general insurance business and is an Australian Financial Services Licensee (AFS Lic. 247301). Any financial product advice is of a general nature and not personal or specific.

To subscribe to receive email copies of the journal and to learn more about submitting articles contact us at [email protected]

1December 2011


Facebook Page: search for 'Junior Doctor Journal'Facebook Page: search for 'Junior Doctor Journal' 1December 2011

If we are to improve our healthcare systems and the health outcomes of our communities, and if this progress is to be sustained in the context of an ever-changing world, there must be a strong drive for effective global health leadership.

Whilst a lot of hands position themselves prominently up in the air when we discuss the various problems facing the health sector, there is often an eerie silence (coupled with some nervous side-gazing) when the next step �– i.e. possible solutions �– is considered. A recent news item1 covering the fall out from The Lancet Infectious Diseases�’ publication on the discovery of the new �‘superbug�’ (NDM-1) highlighted the shameful lack of genuine leadership on issues concerning global health. In such situations, a clear, rational, consistent, politically neutral and authoritative voice is essential. Yet this voice is virtually absent. So, to whom are we listening?

There is much power (and responsibility) up for grabs, but it seems that no one wants it. How can this possibly be, and what can be done to inspire the emergence and continuation of authentic leadership in the global health arena? How can we take away some of the chairs and instead force talent to its feet?

Brain power is not the issue: there are numerous frighteningly clever individuals working in this area. Resources will always be a concern �– it is highly unlikely that we will ever practice in an environment that oozes a surplus of, well, anything we really need. But, that said, this is an area that gets a lot of attention. To use the UK as an example, although there is an

1. http://www.channel4.com/news/drug-resistant-superbug-threatens-uk-hospitals

Dr Karina McHardy Global Health Tutor and DPhil CandidateUniversity of Oxford

involved in an adverse outcome, complaint or claim? “what should I do?”

1. don’t panic! Becoming involved in an adverse outcome complaint or claim is more common than you think and it will happen at some stage of your career. What is important is how well you manage the situation.

2. protect your interests If you receive or are served with a writ (formal litigation) or receive a letter of demand, immediately contact your Medical Defence Organisation (MDO) immediately.

3. be honest and open with your communications If your patient has an unexpected or adverse outcome, you have a responsibility

anticipated consequences

4. contact your MDO following an unexpected or adverse outcome to notify them of the incident. Failure to do so may prejudice your cover. Remember they are there to help you.

5. comply with any relevant policies, procedures or reporting requirements that your employer or practice might require and ensure patients have access to information about the process available to them to make a complaint e.g. relevant health care complaints commissions or the Medical Board.

6. complaints should always be taken seriously and addressed professionally however trivial they may seem. Be empathetic and don’t be defensive. Acknowledge concerns and agree on the next step.

7. apologise, but be careful not to admit liability. be sure to apologise, but beware not to admit liability before speaking with your MDO and your employer to protect yourself

8. ensure that medical care continues

9. act quickly never dwell on receipt of a writ, claim or complaint. Always get the advice of your employer, MDO or mentor who will guide you through this difficult period.

Medical Indemnity Protection Societyp. 1800 061 113][email protected]]www.mips.com.au

CALLING ALL LEADERS: YOUR (HEALTH) WORLD NEEDS YOU!

Facebook Page: search for 'Junior Doctor Journal'

Australian Junior Doctor Journal Australian Junior Doctor Journal

almost unfathomable level of national debt and despite the announcement of unprecedented cuts in public spending, the current Coalition government has spared both healthcare and international development aid spending. It is not a stretch to realise that these are signi cant decisions that send an unambiguous message about where current priorities lie. Additionally, all things considered, the global health resource situation is not that dire. Those Gates�’, together with other individuals/philanthropists, associations, national and multi-lateral organisations have changed and continue to change our perception around what we have access to and what can be done in this eld. When we also consider that we�’ve actually got a decent amount of existing reliable information to work with �– in the form of good quality evidence that often stems from multiple international settings (therefore widening the research base) and that has been produced over time (kindly providing us with some valid longitudinal trends) - our access to broader resource looks ever more promising.

So, when we peer into our global health lunch box, we nd a hearty portion of piping hot �‘smarts�’ and a delicious side of freshly squeezed knowledge. There is even some moreish cash for dessert. So far, so good. But, though these are all satisfying, we need something else.

We need effective leadership.

We need people who will stand up, stand tall and communicate the issues to the world - preferably in an articulate, engaging fashion. We need people who are not afraid to outline direction, to establish priorities, to identify where responsibility lies and to demand and enforce both transparency and accountability. We need generous helpings of basic common sense coupled with enough bravado to think outside the proverbial square. Oh, and a distinct ability to detect and then waive all semblance of tolerance for crap would be good too.

The famous Vince Lombardi quote is true: �“Leaders are made, they are not born�”. As we invest in global health education and research, we must also keenly invest in leadership training. Here, active steps are necessary to secure the presence of prominent gures at the helm of this ship. Without this, all of the brains, good evidence, scal resource and energy currently seen in this area will be lost for want of direction �– a supremely wasteful and tragic outcome. We must identify and subsequently enthusiastically throw our weight behind those with passion, vision and real strategy. Note that this does not mean those who merely shout warnings, or even just shout. Let us now commit to giving individuals with the capacity to enact legitimate, meaningful change the platform from which they may do just that.

Our profession, indeed our world needs them.

CLINICIANS IN HOSPITAL MANAGEMENT: THE NEED AND THEIR ROLE

The need for clinical management in hospitals

Public sector organisations have become increasingly �‘managerialised�’ in recent times. This trend has led to the development of a relatively specialised public management workforce which has brought management behaviours, practices and techniques into the public sector. The health sector has not been immune to this trend.

There are multiple factors supporting the need for clinical involvement in hospital management. The 1983 Grif th Report called for the introduction of general management to drive value for money and accountability within the

United Kingdom�’s NHS. Moreover, this report explicitly called for the involvement of doctors in this management structure. Whilst public hospital management structures have primarily been concerned with the operational and nancial domains and accountability in these areas, medical professionals have traditionally remained encapsulated within the clinical domain.

There is evidence to support that a divide has developed between clinicians and management within hospital settings and that this has contributed to decreased performance and potentially also to decreased quality. The manner in which management and clinicians derive power and

By Dr Lloyd McCann Director of Clinical Strategy (EMEA)Carefx

December 20112 Facebook Page: search for 'Junior Doctor Journal' 3December 2011Facebook Page: search for 'Junior Doctor Journal'

5December 2011December 20114 Facebook Page: search for 'Junior Doctor Journal'Facebook Page: search for 'Junior Doctor Journal'

in uence within a hospital setting would support the creation and maintenance of this tension. Managers generally rely on positional power to exert in uence, whereas clinicians have relied on expert and personal power to exert in uence.

One major driver for clinical management therefore appears to be improving the relationship between management and clinicians to enhance overall hospital performance.

The concept of moving accountability closer to the patient is supported by involving clinicians in management. Clinicians are involved in making day to day decisions relating to patient care; therefore the same people should play a part in making wider management decisions. The rapidly expanding quality agenda within healthcare also acts as a driver for increased

clinician involvement in management. Ultimately clinicians are well placed to link quality and performance agendas within the hospital setting.

From a clinical point of view, two major drivers for increasing interest and involvement in management activities are: (1) a lack of understanding and subsequently a lack of regard for general management; and (2) the need to maintain autonomy as medical professionals by exerting some in uence in this sphere.

The nature of the role of clinician managersThe role of a general manager in the acute hospital setting is multi-factorial and spans across a variety of domains.

Factors in uencing the involvement of clinicians in management will be explored later, however it is appropriate to note at this point that clinicians do not generally receive formal management training prior to undertaking management roles. Therefore, this current model immediately implies that a clinician manager, without further specialised training, may not have the knowledge and skills to perform all the required roles of a general manager.

Within the hospital setting clinician managers do ful l some roles of a true manager or leader. There is however a wide range of evidence to suggest that clinician managers would ful l the role of a �‘ gurehead�’, rather than a true leadership role. On the international scene, multiple reviews have shown that many clinician managers can perceive their role as a leader in title rather than a �‘true�’ leader per se and that decision-making in these peer groups is largely guided by consensus.

Pick up $300 on your way home with ALMSA short shift comprises of one block of 3 patient calls all situated close to your home or workplace. So you could potentially earn $300* in around an hour.Shortshifts are now available in Melbourne and Perth for doctors currently working within the hospital system and/or general practice with minimum experience at HMO3 level or equivalence.*Estimated earnings may vary based on Medicare item billed.

With ALMS Short Shift, earning extra income can be as easy as picking up some groceries.

www.shortshift.com.au

In terms of the decisional category, the evidence tells us that clinician managers have a limited function within this area. Anecdotally, clinician managers have the ability to resolve disputes and performance manage within their professional area, but have been reluctant to involve themselves in inter-professional con icts and issues. Furthermore, despite an apparent situation of nancial control, many clinician managers still feel that they do not truly control budgets and have an in uence on �‘bottom-line�’ decisions. A contributing factor may be that, ultimately, budgets are largely centrally retained in the provider setting, despite the fact that accountability for nances does appear to be devolved to a local level. Finally, clinician managers�’ ability to contribute to entrepreneurial strategy appears limited due to a perceived lack of education, skills and understanding within this area.

On a more positive note, the role of clinician managers can be viewed as a boundary or bridging position between medical

professionals and management. By virtue of their position, clinician managers are able to participate in both management and clinical activities. The clinician manager role therefore spans across the entire spectrum of activities within the hospital. These activities can broadly be broken down into the provision of healthcare (clinical activities) and the management of the organisation (hospital management activities).

Clinician managers may not take part in the full spectrum of management roles within the hospital, however they still have greater access to information, meetings and input into decision-making. Clinician managers are able to bring the clinical perspective to the management table and are in a position to take management practices and thinking back to the clinical environment. This places clinician managers in a commanding position, given that they can use expert, personal and positional power to exert in uence within an organisation.

7December 2011December 20116



patient care still have a duty of care to the patients within their health service, and that they must ensure the effective and competent delivery of health services by clinical staff for whom they are responsible or associated.

In Australian and New Zealand it is the Royal Australasian College of Medical Administrators (RACMA) which is the recognised body that de nes competence in medical leadership, providing training and offering ongoing professional development to medical practitioners who have moved into clinical leadership as their chosen medical specialty.

There are a plethora of didactic learning opportunities that are available to assist the clinician gain knowledge in the science of leadership, however the attainment of competencies in clinical leadership requires practical workplace based problem focused learning accompanied by a structured mentoring programme. It is this practical supervised experiential programme that RACMA provides.

The College expects the competent medical leader to be able to:

Articulate a clear vision

Lead teams to drive improvement in service quality and safety

Engage constructively and effectively with management and planning functions

Maintain a contemporary knowledge of health and management issues

Manage a high quality clinical service in an environment of limited resources

Maintain strong professional and ethical standards

Encourage and assist with the education and research activities in health

Fellowship with RACMA offers specialist registration in medical administration with the Medical Board of Australia and the Medical Council of New Zealand.

Medical leaders are an integral and vital part of an effective health service. While mainly engaged within health service delivery organisations, they are also critical to the formulation of effective health policy, governance of clinical practice, health service purchasing and the monitoring and reporting of health outcomes.

While not directly involved in the diagnosis and treatment of patients, it is the clinical skills and knowledge inherent in medical training that separate medical administrators from health service executives. In making day to day decisions in health service management, the medical leader is applying their clinical knowledge to assess the impact, risk and clinical outcome of decisions. It is the role of the medical leader to apply clinical medicine to the development of policy, strategy, service design, behaviour change and determining effective clinical outcomes.

The focus, orientation and language of the clinician are very divergent from that of the health service manager or executive. Yet for a health service to function effectively and ef ciently, these two groups must work collaboratively. It is the role of the medical leader to bridge this gap in orientation and interpret the impact of change across the divide.

To be an effective clinical leader a doctor must possess a range of skills and competencies that are not taught at medical school. This body of knowledge should include an understanding of health law, health economics, health care nancing, health care organisation, human resource management and the management of change in a complex organisation.

Unless a clinician is uent in the language of executive management they face a very real risk of frustration and marginalisation from strategic decision making.

The Bristol Royal In rmary enquiry reinforced the principal that practitioners working outside direct

MEDICAL LEADERS

CLINICIAN

MED

ICA

L LE

AD

ER

HEALTH EXECUTIVE

Patient Focus Service Orientation

Clinical Outcomes Fiscal Outcomes

Patient SafetyOrganisational Risk

and Assurance

Clinician Performance

Organisational Performance

Risk of Harm to patient

Media and Reputational Risk

Patient Need Ministerial Priorities

Evidence Based Practice

High performing, peer organisations

New Technology Facility maintenance

Patient SatisfactionData collection and

reporting

To be an e! ective clinical leader a doctor must possess a range of skills and competencies that are not taught at medical school. This body of knowledge should include an understanding of health law, health economics, health care " nancing, health care organisation, human resource management and the management of change in a complex organisation.

Dr David RankinSenior AdvisorChild, Youth and Family




I have since re ected on the process and thought about what I could have done better:

Managers and IT people work to budgets and numbers. I could have calculated the potential cost saving from an effective list. Six House Of cers arriving 15 minutes early every day to create lists, at a per hour cost of $60 = $32,850 per year. I�’m sure this simple gure would have caught the attention of managers and provided a compelling argument to invest a little money required for the lists. It is shocking to think about the nancial cost of such a silly and simple process of creating a patient list. Imagine what could be done with that money.

There is a well-entrenched hierarchy in surgical specialties. On re ection, I should have held strong and should not have allowed the surgeons to impose what were impractical and ill-considered views. This is dif cult, particularly as they are the gatekeepers to training programs and write our appraisals.

The purpose of the list should have been communicated more effectively.

Once the list was implemented, I could have performed a follow up survey to elicit feedback on how they could be improved. As I had moved department, I should have offered this opportunity to a colleague.

Related to the above point, I should not have given up when I did. Hospitals can be bureaucratic beasts and change takes time and patience.

JMOs are faced with opportunities for improvement every day. It is easy to accept the status quo, but this is not good for our healthcare system. It requires leadership to take the initiative to improve systems. We are ideally positioned to do this as we work at the coalface and hence experience the pain of inef ciency rst-hand.

We should not wait for hospital management to ask us about how improvements can be made. We need to stand up and voice our opinions for change, and help push them through.

In the short term this will be a painful process as hospitals simply don�’t know how to deal with JMO-lead initiatives. But, with persistence and time, managers will learn about the important role JMOs can play in leading improvements in our healthcare systems.

At the end of the day all parties need to work together towards a common goal. It often seems as if managers don�’t want to work with us. It is up to us as JMOs to take the rst step as leaders of change.

Why do some locums get paid top dollar to ‘sleep’ on a quiet night rotation? Why does every ward have a different set up? Why do I need seemingly hundreds of passwords to access computer systems? Hospitals are peculiar beasts where many things don’t make sense to the mind of an JMO.

One such question troubled me during my 1st year as a House Of cer. The various departments in the hospital I was working seemed to have no channels of communication between each other. I completed a General Medicine rotation where my team�’s patient list would magically appear at a printer every morning �– it was great. My next rotation was General Surgery where I had to arrive 15 minutes every morning to create a list by taking screen shots off a nursing list, pasting into Word, cropping and then repeating if the list ran over one computer screen. Everyone agreed that this was ludicrous, but �– predictably �– nothing was ever done about it.

So, I set out to nd why Gen Surg couldn�’t simply copy the Gen Med process.

Mistake #1: assuming that this would be a simple process!

I had moved onto my next rotation by the time this ordeal came to its bitter end. Understandably, I was left bemused and disheartened by this attempt to improve the system.

JMOS AS LEADERS OF CHANGE Dr Manoj PatelMBCHB, MBA (Harvard Business School)Management Associate �– Elsevier

1. F ind the IT department responsible for developing the Gen Med patient lists. Incidentally, this department was not based in the main hospital.

2. Learn that the creation of such a patient list required a �‘work order�’.

3. This �‘work order�’ required approval from the departmental head.

4. Develop and conduct a survey of what the �‘ideal�’ Gen Surg patient list might look like

5. Arrange a meeting with the department head to present the survey ndings and request the aforementioned �‘work order�’.

6. Co-ordinate a meeting between the IT department and department head.

7. Re-present proposal.8. Be informed by IT that my proposed

patient list was different from the Gen Med patient list and hence would cost a few thousand dollars to implement

9. The department head thought he knew best and said we would simply copy the Gen Med list.

10. Despite this, the consultant surgeons then insisted that their names should appear in full on the list, together with their respective titles (e.g. Associate Professor of Lower GI Surgery). This column alone took up one third of the page, therefore leaving no room for writing notes!

1 1. The new patient lists eventually appeared on the wards, but no one used them because of their poor layout.

12. All surgical RMOs continued to use the original copy, past, crop method!

Over a 3-month period this was the sequence of events that unfolded:




exercised at the level of a ward, clinic, or practice. Its goal is to create and oversee the local operating system in which each doctor�’s patients receive their care. A consultant and a senior nurse on a ward have such a leadership role. So does a registrar training a house of cer, trainee intern, and a medical student; or a nurse leading a multidisciplinary chronic care team.

Optimising the performance of a small scale operating system requires both leadership (articulating a vision and setting direction) and management (assigning accountabilities and monitoring performance). An essential leadership task is to frame the clinical team�’s work: elevating the staff�’s perspective from the immediate activities that consume their day, such as tests, referrals, and paperwork, to the goals that these activities are intended to achieve. Clinical care can be framed as �“production�” (execution of highly speci ed protocols), �“problem solving�” (the search for a unique solution to the patient�’s problem), or learning (creating new knowledge from current experience).

Not only is each frame appropriate to a different setting but each also requires a different operating system. An emergency doctor who frames the department�’s work as �“stabilise and ship�” will create a very different operating system from one who frames the work as �“diagnose and initiate de nitive treatment.�” They will select different policies, technologies, clinical protocols, and performance measures and will establish different relations with the inpatient wards and even different physical layouts. Hence a clinical leader�’s second important task is to help design the operating system in which their patients are treated, including the mechanisms by which performance is managed: measurement, monitoring, and accountability systems. A third task is to shape the culture that surrounds these structures and processes. For example, quality and safety improvement require an environment in which people feel comfortable sharing unpopular information, expressing dissent, and admitting mistakes.

Small �“l�” leaders perform these tasks by being and doing. Although much is made of leadership as �“being,�” a leader�’s actions are also important: something as simple as a doctor�’s tone of voice has an important effect on how others will evaluate him or her. Simple deliberate actions�—for instance, inviting the input of lower status staff and publicly admitting your own mistakes�—can help create a culture that promotes patient safety.

LEADERSHIP WITH A SMALL �“I�”

What exactly do we mean by leadership in health care? Does it mean to take formal positions in senior leadership teams in hospitals, trusts, health boards, ministries of health, and professional societies—what might be termed leadership with a big “L?” Or does it mean something fi ne grained and local –leadership with a small “l”?

It is tempting to frame the discussion in terms of the rst, if only because the big issues dealt with at higher levels in delivery organisations and government�—such as licensure, reimbursement, malpractice, technology licensing, and working hours�—profoundly affect the working lives of so many doctors. But mounting evidence of the impact of organisations on clinical outcomes is making the second model of physician leadership increasingly important. As the growing complexity

of clinical problems is paralleled by increasing organisational and technical complexity of health care, medical outcomes have become as much a function of organisational performance as of individual doctors�’ skill. Quality and safety failures are driven by system failures as well as failures of individual physicians�’ skill and decision making; and higher performing hospitals are differentiated by their greater use of organisational interventions, cultures that support innovation, structures such as multidisciplinary teams and computerisation, and highly speci ed care processes.

Thus for doctors to assure optimal health outcomes for their patients they now need to concern themselves with the performance of the organisation in which these patients receive their care. From the perspective of an individual doctor it is the small scale operating system that is most important in determining health outcomes. This microsystem is the small group whose members collaborate to create a clinical outcome�—their information, technology, and physical environments and the management policies and clinical processes they follow. Small �“l�” leadership is

But perhaps the biggest impediment is that practising doctors simply do not think of themselves as leaders, nor do they see leadership as vital for the care of patients.

Richard BohmerSenior Lecturer, Harvard Business SchoolBMJ 2010;340:c483 (Reproduced with permission)

A number of barriers prevent doctors from taking a greater leadership role: the �“siloed�” structure of delivery organisations, the demands of clinical practice, and the challenge of managing autonomous professionals. Moreover, small �“l�” leaders often lack formal authority and control over resources in their working environments and must lead by creating consensus, modelling behaviour, articulating vision, and asking questions. And they are usually not paid for this work.

But perhaps the biggest impediment is that practising doctors simply do not think of themselves as leaders, nor do they see leadership as vital for the care of patients.

Medical training, in fact, emphasises exactly the opposite: individual action and accountability. For most doctors the small �“l�” leadership skills needed to improve the performance of individual practices, clinics, and wards must be learnt. Doctors�’ daily work is de ned by a collection of individual activities and transactions; little in medical and postgraduate training emphasises the interdependencies between these often fragmented events, nor the way in which they are part of a larger system designed to realise a speci c patient outcome. Although some schools offer joint medical and management training, most doctors learn little about how complex organisations work and how they can be made to work better.

As we call for medical leadership in healthcare reform, we should not focus solely on big �“L�” leadership and overlook the importance of leading the micro-systems that have such an effect on care outcomes. We need for medical and postgraduate training to prepare doctors to lead at this level. Any call for leadership should include a call to doctors to think of their daily work as not only treating individual patients but also helping create and manage the small scale operating systems that support their medical work.




Do you see yourself as a leader? As an intern attending your fi rst Code Blue, did you have a clear understanding of your role and who was in charge? When faced with an angry patient attempting to leave against medical advice, did you improvise and form fl exible strategies, or wait for the guidance of others? Leadership is certainly not easy, but we have chosen to enter into a profession that necessitates leadership at various levels of hospital, team and patient care.

When you think of a leader that embodies greatness and inspiration, who comes to mind? Muhammad Ali, Mother Teresa and Mahatma Gandhi all have a unique place in this world, but also embody critical attributes. They have all persevered in the face of adversity and display tremendous moral courage.

Life isn�’t always easy for a junior doctor. Whilst our work can be immensely rewarding and meaningful, we can also encounter anxious and emotional patients, angry family members and con icts within the treating team. Medical practice continues to evolve to become increasingly complex and team-based in nature. This requires high levels

of coordination and leadership skills. At medical school we learn many useful skills, but are we truly prepared for a successful life in the medical workforce?

Clinical skills are a necessary foundation for a medical doctor. We cannot hope to be con dent or progress in the workplace without excellent theoretical knowledge and sound clinical assessment. However, clinical skills are not enough. Non-clinical skills such as resource management, communication, con ict resolution and decision-making are seldom formally taught, yet are equally important in error management and improving patient safety. Our role in driving patient care requires the doctor to act as a leader. This belief is re ected in a recent Australian Medical Association position statement which supports the emerging view that doctors�’ value is in their clinical judgement, diagnostic reasoning and leadership skills1.

A great medical leader displays a number of key attributes. These include: high emotional intelligence; situational awareness; self awareness; and the courage to make dif cult decisions in the face of limited information and under high levels of stress.

Interns are not encouraged to make dif cult decisions without appropriate guidance or senior support. However, as junior doctors transcend into senior responsibilities throughout their careers, real-time decision-making and contingency planning become critical qualities separating outstanding from acceptable doctors. It is often dif cult to take a step back in stressful clinical

DEFINING OUR FUTURE LEADERS: THE CHALLENGE FOR JUNIOR DOCTORS

By Dr Verna Aykanat HMO II ResidentPMCV JMO Forum Co-Chair

Non-clinical skills such as resource management, communication, con# ict resolution and decision-making are seldom formally taught, yet are equally important in error management and improving patient safety.




situations and take the opinions of others into consideration. However, this approach allows valuable opinions to be heard before they are obscured or overshadowed by the most senior voice. Sometimes, the most comforting thing to do in a tricky situation is to sit on the fence, but leaders are required to make tough calls. As baseballer Yogi Berra famously proclaimed, �“when you come to a fork in the road, take it.�”

CanMeds is an innovative, competency-based framework adopted by the Royal College of Physicians and Surgeons of Canada in 1996 articulating the competencies required for optimal patient care and health outcomes. The seven roles identi ed are: medical expert; communicator; collaborator; manager; health care advocate; scholar; and professional2. These roles are now recognised nationally and internationally as a benchmark in the art of medicine and have been adopted by the Australian and New Zealand College of Anaesthetists for their revised accredited training program in 2013.

Simulation may have a key role in the education of leadership skills. Previously, simulation has been demonstrated to be effective in the training of procedural skills and in crisis management. It also has a current role in accredited colleges and clinical workshops. There is emerging research into the use of simulation for teaching higher order clinical reasoning and clinical judgement skills. However, the simulation of crisis leadership skills including contingency planning, controlling one�’s environment and delegation of roles is a critical component of training that requires further development and research validation.

We have discussed the utility of non-clinical skills in providing optimum patient care, but have

Therefore, as junior doctors we continue to urge healthcare providers and key stakeholders to collaborate on solutions to ensure that all junior doctors have access to protected teaching time for both clinical and non-clinical domains.

We continue to support the existence and further revision of professional development programs such as the Postgraduate Medical Council of Victoria�’s �‘Teaching on the Run�’ program, as well as the development of new leadership programs, for which the author would like to welcome input from you, the reader.

Finally, we need to ensure that this information is disseminated in a context-appropriate way, such as via simulation or live workshop to enable the subtleties and artistry of this information to be conveyed in its entirety. So whether you hope to one day be the president of the AMA, director of surgery at a metropolitan hospital or a rural GP, we

all need to hone the skills of honest self re ection and develop the courage for self improvement to enable us to achieve our greatest potential in our professional and personal lives. Only then can we genuinely be present for those who are struggling, help lead our colleagues to develop sound moral and professional codes. Ultimately, we aim to provide reassurance to our colleagues and the public that we are deserving and quali ed for our special role in patient care . So ask yourself: What kind of leader do you want to be?

References

1. Australian Medical Association Doctors in Training. AMA Position Statement: Role of the Doctor 2011. Apr 2011. [Available Online: http://ama.com.au/node/6569]

2. Rank JR. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. 2005. Ottawa: The Royal College of Physicians and Surgeons of Canada

we considered moral leadership and excellent bedside manner? What is the best medium to convey this information? After years of books and lecture notes at university, junior doctors value the role of �‘leading by example�’ by mentors. This unique insight is perhaps of most bene t to a junior doctor and emphasises the importance of ongoing support and protected teaching time for senior staff in promoting these educational opportunities. There is a further need to train junior doctors in the skills of teaching, assessment

and feedback as they embark on their own journey of mentorship.

Sometimes the best leaders aren�’t the hero of the day. They do not have to perform the show-stopping intravenous line when everyone else struggles for access at a code, or resolve seemingly impossible logistics in imaging, discharge planning and theatre schedules. Often, the best leaders take a step back so that they can critically observe what is going on around them. Only then will they be able to offer a hand to a colleague after observing they are overwhelmed with jobs, or dedicate twenty minutes of their time to reassure a colleague who has experienced a traumatic night shift. They recognise the resident who is starting to display slight changes in behavior and take the initiative to ask if they are coping. Sometimes the best leaders aren�’t obviously apparent, but their unique insight is testament to why they are invaluable to the team.

As graduating medical student numbers continue to increase and the training program bottleneck escalates, it is imperative that we don�’t ignore the education gap that lies between medical students and training registrars: the prevocational years.




Group Dynamics

JMOs are usually thrust into a leadership position. This may be as the day-to-day leader of a small medical team, or the chair of an MDT group. Group dynamics are an important factor in the functional leadership model.

Every group has speci c requirements �– examples of these are: cohesion, leadership, principles, education, a de ned role and success. The role of the leader is to recognise these needs and ensure that they are met. This is where the rst issue arises �– often group needs may be in direct con ict with task needs. Ultimately it falls to the JMO leader to attempt to balance these needs.

Individual Dynamics

Individuals form the basis of any group or team - without individuals the achievement of any task becomes impossible. Individual needs vary from basic to more specialised (e.g. basic needs such as food/water/rest versus the need for development and education). In many group situations, individual needs are often pushed aside for the bene t of the group and task achievement.

Within the medical setting, basic and more advanced needs are important. For example, House Of cer teaching is something that is mandated and clearly necessary for personal and professional development, but this is often in direct tension with team and task requirements. Again, it falls to the JMO leader to ensure that balance is maintained, but also that, where necessary, needs continue to be prioritised.

When a leader is able to balance task, group and individual requirements, they can consider themselves to be �‘in the zone!�’

A Practical Tool

Now that we are aware of the potential competing needs JMO leaders must balance, we can focus on applying a practical tool to lead in our environment. The tool is based on a New Zealand Army model �– PICSIE:

These are general steps and provide a process to follow when approaching a workday/set of tasks etc. Naturally, we already do plenty of these things (perhaps subconsciously), but what this does provide is something to refer back to, in terms of practical steps that can be applied in a number of situations.

Planning

This rst step is often overlooked or rushed and many pay the price later on. Involving your team in planning and taking time to plan is a great investment. When your team is involved in planning there is a higher level of engagement and ownership �– the task becomes shared and is therefore more likely to be achieved. It is imperative during this step that the leader is clear about the tasks and that these are expressed with great clarity to ensure group understanding.

Initiating

Frequently, this involves delegating or assigning people to perform tasks or components of a larger task. Never forget that you are part of the team and can complete tasks yourself!

P lanningInitiatingControllingSupportingInformingEvaluating

There is ample available literature on leadership frameworks, leadership styles and leadership theories. In recent years, the concept of clinical leadership has come to the forefront within healthcare systems and healthcare delivery.

Whilst the notion and concept of clinical leadership remains relatively vague, it is heartening to see that there has been a return to increasing managerial responsibility for clinicians. There is also increasing recognition that clinicians bene t from leadership and managerial training and cannot simply ful l leadership roles and management positions based on clinical credibility alone.

However, a gap remains between clinician managers, management and leadership training and the everyday �‘shop- oor�’ leadership required by clinicians and particularly JMOs.

JMOs will all be thrust into a position of leadership or coordination at early stages in their careers. Registrars are expected to competently lead ward rounds, organise radiology conferences, run tutorials, chair MDT meetings and lead small teams. Most learning in these aspects of the JMO role is learned through �‘osmosis�’ �– JMOs observe more senior doctors and other colleagues, including JMOs, in these roles.

Some medical students and JMOs have the distinct bene t of being involved in student and committee leadership positions as well as wider positions of leadership or management through external activities.

This brief article aims to outline some practical frameworks that JMOs can use in their everyday work to manage and lead their teams. The concepts outlined here are all related and based on Functional Leadership theory.

JMOS AS FUNCTIONAL LEADERS Functional Dynamics

There are 3 basic components that make-up the functional leadership framework. Whilst this is a framework, it provides a realistic view of the factors anyone in leadership position must attempt to balance in order to lead successfully (see functional dynamics diagram).

Adapted from: http://en.wikipedia.org/wiki/Functional_leadership_model

This framework focuses on how leadership occurs rather than who is leading. Translated, this speaks to anyone being able to focus on and exhibit these behaviours when necessary.

Task Dynamics

Medical work is largely task orientated. The functional leader must never lose sight of the task/s to be achieved �– this has a direct impact on patient outcomes. This is why many teams will sit down after a ward-round to con rm the list of jobs for completion.

In many instances, task needs must be placed rst in the medical setting as the health outcomes of our patients rely on investigations being organised, treatments and procedures being performed and administrative tasks being completed. As functional leaders, JMOs must always have task needs in hand.

By Dr Lloyd McCann Director of Clinical Strategy (EMEA)Carefx

FUNCTIONAL DYNAMICS

Task

Team Individual

The ‘Zone’


Facebook Page: search for 'Junior Doctor Journal' 19December 2011Facebook Page: search for 'Junior Doctor Journal' 19December 2011December 201118

Controlling

This sounds counter-intuitive - especially in circles where we tend to operate as independent practitioners. However, the leader must maintain control of the task or situation and ultimately ensure that the group is moving towards achieving their task. This relies on communication, seeking feedback on understanding and progress, and monitoring. This step is closely linked to �‘supporting�’.

Supporting

Whilst maintaining control, the leader must make certain that team members feel supported and are comfortable with what they must achieve.

Informing

This involves ensuring that the team is aware of any potential changes in the situation or actual changes in the task. It is imperative that the leader provides information and feedback to their team in a timely manner.

Evaluating

This step is critical and is often overlooked. The leader must evaluate individual and team performance to allow for improvement and the identi cation of strengths and weaknesses. This step allows for individual and team development and ultimately contributes to a team�’s overall effectiveness. Here, both �‘real-time�’ and retrospective evaluations have a place within this cycle.

So, in a nutshell, there you have it. The more you think about the functional dynamics and apply the steps to situations, there more natural it becomes. Remember that this approach focuses on how to lead and does not rely on integral qualities or styles of a leader. Yes, it is important that we are authentic and apply appropriate styles and behaviours, but this outline provides a good basis whereby JMOs can function as leaders in everyday situations.

RACMA LEADERSHIP

Effective medical leadership is recognised as essential for improving the performance of health services and enhancing the wellbeing of patients and the quality of outcomes. A growing body of literature has also argued that medical leadership plays an integral part in the success and effectiveness of organisational change in the health sector (Ham, 2003).

This is largely because medical practitioners in the health sector are often viewed as having greater control over decisions than workers in other areas. Medical practitioners are more likely to be in uenced and persuaded by medical leaders to bring about positive change because they believe they have �‘walked a mile in their colleagues�’ shoes�’ and view them as more reliant, trustworthy, and credible.

It has been suggested that medical leaders �‘run�’ organisations; they �‘de ne what the future should look like, align people with that vision and inspire them to make it happen despite the obstacles�’. In other words, medical leaders engage people who are dif cult to engage, serve as role models for their peers, and create an environment in which quality improvements can thrive. For individuals who are trained to manage individual cases and guard their professional autonomy above all else, the effect of being asked to take on these leadership roles in the consumer interest is considerable, and not often acknowledged.

Being an e! ective medical leader clearly requires a di! erent set of skills from being a good clinician (Reinersten, 1998).

It is therefore important that medical leaders are supported and equipped with the high-level skills required for their role (e.g. leading and developing multidisciplinary teams,

understanding organisational systems, processes and interdependencies, redesigning services and working collaboratively with a wide range of stakeholders). Indeed, reviews of medical programs have found that individuals who participate in leadership training are more likely to feel empowered to in uence the provision of patient-centred care, develop a greater sense of self-awareness and con dence to initiate positive change, and promote better team alignment (Stoller, 2008).

In the UK, the National Health Service established the Enhancing Engagement in Medical Leadership Project in response to the publication of Lord Darzi�’s NHS Next Stage Review nal report in 2008. This UK-wide project aims to �‘stimulate creation of a culture where doctors seek to be more engaged in management and leadership of health services and non-medical leaders genuinely seek their involvement to improve services for patients�’.

The Royal Australasian College of Medical Administrators (RACMA) was formed in September 1963 to train medical practitioners to use both their clinical training and experience and their specialist medical management expertise to lead and in uence health service delivery.

The College�’s education and training programs are based on the achievement of a range of competencies adapted from the CanMEDs framework, developed in 1996 by the Royal College of Physicians and Surgeons of Canada. The Medical Leadership and Management Curriculum focuses on the speci c competencies needed for medical management and leadership practice. These competencies are organised around the seven CanMEDS roles. For the College the central role is that of Medical Leader based on the foundation of medical expertise and supported by competencies embedded in the CanMEDS roles of Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional.

Dr Karen OwenChief Executive RACMA


December 201120 Facebook Page: search for 'Junior Doctor Journal'

Webb (2009) looked at the performance of medically quali ed health service executives working as chief executives, directors of medical services or department heads. These specialist medical managers were involved in a broad range of activities crucial to sustainable health care delivery and had a direct and immediate effect on the quality and safety of patient care in Australian and New Zealand hospitals. Gruner and Boyd (2006) refer to the in uence that specialist medical managers have on medical staff based on their medical expertise. This in uence was acknowledged by non-medical managers and was lauded as being instrumental in implementing successful and cost-effective change.

RACMA is one of a few medical colleges in the world accredited to offer Medical Administration as a specialty. While many undergraduate and postgraduate medical curricula contain elements of medical leadership these do not equip graduates with adequate skills, knowledge and experience to be safe and effective medical managers.

References

Gruner, L and Boyd, R (2006), Factors affecting recruitment and retention of medical managers in Australian Hospitals, RACMA Report

Ham, C (2003), Improving the performance of health services: The role of clinical leadership, Lancet 361:1978- 1980

Mountford, J and Webb, C (February 2009), When Clinicians Lead, McKinsey Quarterly

National Health Service (NHS) UK, Department of Health (2008), High Quality Care for All. Also known as the Darzi report, see www.nhshistory.com/darzi nal.pdf.

National Health Service (NHS) UK, Institute for Innovation and Improvement (2010), Enhancing Engagement in Medical Leadership Project. See: www.institute.nhs.uk/building_capability/enhancing_engagement/enhancing_engagement_in_medical_leadership.html

Reinersten, L J (1998), Physicians as leaders in the improvement of health care systems. Annals of Internal Medicine, 128:833-838

Stoller, K J (2008), Developing physician-leaders: Key competencies and available programs. The Journal of Health Administration Education 25(4):307-328

The Royal College of Physicians and Surgeons of Canada, (2005), The CanMEDS 2005 Physician Competency Framework, Better Standards. Better Physicians. Better Care, (J.R. Frank, ed.) This replaces the previous version Skills for the New Millennium (1996)

Using their skill and leadership role the specialist medical manager draws on a combination of clinical and management competencies, to form a bridge between the needs of doctors, other clinicians, government and business to achieve the operational needs of health services and deliver safe patient care outcomes. The integration of medical and management knowledge enables the medical administrator to work through others to accomplish complex outcomes while simultaneously being accountable and accepting responsibility for medical services outcomes. While medical management is not directly involved in the diagnosis and treatment of patients, the medical manager brings to decisions a medical �‘lens�’ through which they are able to view decisions and emerging issues. It is the application of this medical lens that distinguishes medical management as a specialty.

Professional medical managers take a global view of health service delivery and the pathway to improvement. What they need to know in a particular specialty, they can absorb quickly from their medical specialist colleagues to gain an understanding of what is important in moving health care forward. This often involves understanding, absorbing and analysing information from a variety of specialties simultaneously to make a decision to bene t the health service or health service delivery as a whole. Doctors are the most important health service staff in evaluating new health care interventions and use of resources.

The empirical evidence supporting the contribution of the professional medical manager to improved medical care is primarily qualitative. An analysis of qualitative case studies by Mountford and


Who else... has finance specialists for junior doctors on call?

Equipment, Fitout & Motor Vehicle Finance Commercial Property Finance Protection & Life Insurance Call & Term Deposits Home Loans Professional Overdraft Income Goodwill & Practice Purchase Loans

www.investec.com.au/medicalfinance

Investec Professional Finance Pty Limited ABN 94 110 704 464 (Investec Professional Finance) is a subsidiary of Investec Bank (Australia) Limited ABN 55 071 292 594 AFSL/ACL 234975. Income Protection/Life Insurance is distributed by Experien Insurance Services Pty Ltd (Experien Insurance Services) which is an authorised representative of Financial Wisdom Limited AFSL 231138 (AR No.320626). Experien Insurance Services is a preferred supplier of Investec Professional Finance Pty Ltd.

Med ica l and Denta l F inance

James Thomas0418 863 [email protected]

Krissy Hamilton0488 226 [email protected]


MDA National is the Perfect Fit for your Medical Indemnity Insurance.

Insurance products are underwritten by MDA National Insurance Pty Ltd (MDA National Insurance) ABN 56 058 271 417 AFS Licence No. 238073, a wholly owned subsidiary of The Medical Defence Association of Western Australia (Incorporated) ARBN 055 801 771, trading as MDA National. The liability of Members is limited. With limited exceptions they are available only to MDA National Members. Before making a decision to buy or hold any products issued by MDA National Insurance, please consider your own circumstances, read the Product Disclosure Statement and Policy wording available at www.mdanational.com.au. DIT113

We Listen to Our Members.

Call us today on 1800 011 255

At MDA National we o!er the indemnity cover that Doctors in Training really need, including unlimited billings within your accredited training program and increased billings for private work.Wholly aligned with the medical culture, we understand the professional risks you may face in your career and have a team of reputable medico-legal experts to support you 24 hours a day.

With MDA National you’ll !nd the perfect !t.

We know that you expect policy features tailored to your career needs.

Junior Doctor Journal

Documents

Transcript of Junior Doctor Journal