There are many reasons for recommending this book although, sadly, not all of them will please the author.
By chance (a file mangled by email) I didn’t start with Chapter One and if you do the same I think you will find the early chapters charming. They introduce us to a bright boy in a working class family and take us through his early life, the 11 plus, medical school, early house jobs and on to several years spent overseas working with voluntary organisations in what we then called the third world.
Drew describes himself as a good storyteller and these certainly held my attention and interest. He comes over as passionate, forthright, bold, and creative in his determination to do the best for his patients. We see him choose paediatrics at ‘an astonishing time to be setting out as a young paediatrician’ and through his eyes we see it develop as a specialty with the introduction of new insights, new technologies and a new College.
Throughout these early years we watch him revelling in developing relationships with his patients and their parents, and enjoying their confidence in him as a result. We also see him putting his patients before other concern: rules, for instance, funding limitations, or the long term ability of an organisation to succeed in its humanitarian aims. We watch him fall out of favour with a charity whose rules he has broken while saving a life, and perhaps begin to wonder whether, with a different demeanour, this showdown could have been avoided.
We enjoy seeing him ‘cultivat[ing] the habit of getting to know everyone, drivers, messengers, secretaries, cleaners, any old no-body. That was where you found out what was really going on’, and at this point barely notice his negative attitude to people who aren’t wholly adulatory.
Back in the UK we watch him confirm his commitment to paediatrics, turn down an opportunity to become a partner in General Practice and take on locum roles in various paediatric departments, learning and giving along the way. We see him supporting a consultant colleague with alcohol problems by ‘ducking the issue’, and tipping his colleague off, when questioned by the ‘Three Wise Men’ trying to assess the situation. He seems to take pride in doing so, despite then living with the anxiety of knowing that something can go wrong clinically as a result. ‘Knowing how to deal with fellow consultants was never easy’ he says.
He is then appointed as a consultant at Walsall hospital, and his descriptions of all of this period are vivid reminders of the behaviours and organisational dynamics of the times – and for those not familiar with them this is an important part of the history that has brought us to the current unproductive relationships between doctors and government, doctors and management, and well worth reading. Seen through Drew’s eyes we can enjoy viewing administrators and managers as bureaucrats who have to be outwitted. They make silly decisions that have to be dealt with by shows of force – many of which are successful.
We see his energetic development of innovative approaches that save lives (and how good to be reminded of just how much innovation has always characterised clinical practice). And eventually, appropriately, we see him take on the role of Clinical Director for the paediatric unit. Again descriptions of this role and the attitudes towards it will be familiar to those who lived through this period, again they are worth reading by those who didn’t.
All of this first half of the book is rich in the kind of detail that brings history to life and enables us to feel how it influences the present, but perhaps none more so than in Drew’s descriptions of how the paediatric consultants (and the wider organisation) deal with the perceived underperformance of one of their colleagues. Even though we are by now wondering slightly about the reliability of the narrator, the descriptions of actions and reactions by managers and clinicians ring horribly true, and should raise important questions.
Questions about the role, responsibilities, training and support for medical directors. Surely the most important role for any healthcare organisation, though rarely treated as such.
Questions about what expectations we should have of consultants to behave as a team, to make strenuous efforts to make the team work, and to insist on having their performance judged as a team , as a wider service.
Questions about the relationships between (the then) Deaneries and Trusts. The description of the assessment visits by the Deanery, concerned that particular consultants are not properly supporting their trainees but refusing to tell the Trust which consultants these are, left me wondering if we would accept this in any other industry.
We then come to chapters describing the death of a young patient at the hands of a relative, and the blame Drew ascribes to one of his consultant colleagues. He makes a strong case, both to us, the readers, and to senior members of his Trust. The latter, caught up in the financial pressures of the time, and also in Gordian knot of dealing with clinical underperformance, respond in ways which give us the opportunity to enjoyably shake our heads or give way to scandalised exclamation. Several enjoyable chapters describe many skirmishes between Drew, the passionate clinician, and management.
And then, in the way that a scene in a thriller suddenly takes on a very different feel with one look, or move, or flicker of an eyelid, the first few lines of a new chapter cast a very different slant on what I had been thinking and feeling.
At the end of the previous chapter our hero, Drew, had successfully averted danger with the not entirely enthusiastic aid of the medical director. The situation (dangerously low temperatures when an elderly heating system fails overnight) is saved, and I am rather looking forward to hearing in the next chapter of new adventures in the ongoing battle between clinician and management. Instead, Drew uses his time the next day to search for evidence of wrongdoing, not to prevent this happening again but as a means of pinning blame onto his adversary, and I suddenly see his relations with managers in a different light.
On the whole my reading tends towards Terry Pratchett rather than Aeschylys, but here I found myself watching, as a rather horrified audience, a Greek tragedy unfolding. The downfall of a noble hero, in pursuit of a noble goal, because of a flaw in his own character.
From here on we witness a witch hunt. Not of Drew (as he contends), but by him. There are chapters and chapters of hearings of different kinds, all peopled by villains who are either incompetent or unprincipled or have conflicts of interest. I found myself grieving for Drew himself and for everyone else involved, sharing their despair and frustration.
it was good to be reminded from time to time of just how good a doctor and teacher Drew could be, because it was possible to forget that when watching the unhelpful upset he was causing. As readers we see others too grappling with this disconnect.
What these chapters show us in detail is a lot of people trying to deal with difficult situations and often not handling them very expertly. We might wish for people in senior positions to be better able to do this, but often they aren’t – and that’s just life. (We could stop paying them as though they are, and while we were at it stop pretending that leadership is the answer to all the problems of the NHS , but that is a different matter).
Drew is clearly astute and committed, but he is not the only astute and committed person around, as he seems to believe. If he could have credited others with competence and concern, and heard what they were trying, in his own interests, to tell him, how much better for everyone that would have been – including and especially for patients. Drew’s riposte is always that he is fighting for his patients (babies), that management is threatening their welfare – but management is also fighting for an effective clinical team, and for the long term sustainability of the department and Drew seems cavalier (wilfully oblivious) in his preparedness to sacrifice that.
By the time it comes, his eventual dismissal (the internal disciplinary hearing is the substance of the Chapter One I suggested you leave until the end) feels both sad, inevitable, and a relief for everyone involved.
Should you read it? Well, there is plenty of behaviour here, on all sides, for you to enjoy being scandalised by.
There is a level of detail only normally seen in Inquiry papers and this also makes it excellent material for teaching and learning purposes, provoking useful thinking and discussion for clinicians and managers alike, and allowing individuals to reflect on how they themselves would react, So I would certainly put it on the reading list for many pre-registration programmes on professionalism, and I’d recommend it strongly for development programmes for healthcare leaders of all kinds.
Talking of which: at one point Drew is amused to find that he is lambasted for disregarding organisational hierarchies, and for not paying appropriate regard to the views of ‘the most senior person in the organisation’. I think here I am with Drew: can we get away from the idea that anyone is the most senior person in a hospital? What does that mean? No, really, what does it mean? And while we’re thinking about that we could also ask what it means to say that a Board runs a hospital?
Wouldn’t it be helpful to drop this stupid idea that anyone is ‘the most senior person’ or runs a hospital? and the even more stupid one that anyone runs (or could run) the NHS? Or, if we must use that language, lets agree that we run them in the way that governments (or families) are run. Not by hierarchy and diktats (at least not in a democracy) but by frameworks, encouragement, some sanctions, and then by allowing everyone in the country, or family, or hospital, to pursue ends they see as valuable, so that the system has a life of its own –so much richer and more dynamic than anyone ‘running’ it could devise.
But there’s another reason to read this book. The medical education system still fails to challenge problem behaviours sufficiently, supervisors at every stage preferring to leave it to those that follow them to tackle. So there is a real chance that a drama of this sort, a dysfunctional team of consultants (Drew consistently fails to recognise the charge of being a dysfunctional team of consultants and rebuts a different one: of being a team of dysfunctional consultants), and an ineffectual management response, is endangering care in a service near you. We see here, if we did not know it already, how difficult this can be to address, and how managerialist responses can inflame rather than resolve, but we must find ways of doing so.
Indeed we should forget everything else. The money. Restructuring . Everything. And focus on one thing. Really managing doctors. No I don’t mean boxing them in with contracts and tick-box lists, I mean people (often other clinicians) actively supporting them wholeheartedly when they are being creative, dedicated, passionate, thoughtful, inclusive and curious. Challenging them determinedly and effectively when they are being self righteous, complacent, judgemental, profligate, and careless. And in doing so enabling them to be the kinds of doctors they want to be –leading the creatively designed, patient centred services we need. Thoughtful discussions of the tragedy we watch in this book may help us see how important this is and to think about how best to do it.