Wednesday, 22 May 2013

Horizontals & Vertical - healthcare has to get it right

Medical/technical knowledge is vertical. Leadership knowledge is horizontal. Healthcare, especially doctors, need to understand this.

Clinical and medical knowledge i.e. technical knowledge – is vertical. It always starts with wide basic foundations and over time doctors knowledge becomes deeper and narrower. As a first year medical student you need to know about everything about a human body. But, say someone like a anal sphincter repair specialist or a paediatric neuro oncologist, who are very highly defined sub-specialists deliberately move away from their broad knowledge to knowing everything about their narrow scope of work. Such knowledge can mainly be learned from senior, mostly older more experienced persons, who have a higher technical knowledge. The process is pyramidal. Quite rightly so.

Leadership (and many aspects especially non-technical aspects of management) i.e. non-technical knowledge is horizontal. Leadership starts small and expands widely around us mostly in a flat transverse plane with amorphous blobby edges not necessarily circular. Leadership is where anyone and everyone has something to offer/teach/show anyone and everyone else irrespective of age, sex, colour, nationality, hierarchy, wealth, etc. The process is similar to an amoeboid motion expanding and ending up with varying end dimensions, yet no well defined end points for learning and development (though leaders themselves do have goals and aims).

Pilots learn flying (technical) mainly from other older, more experienced pilots – vertical; but crew resource management techniques (non-technical) is learned together with all staff who will be in an aircraft - horizontal.

What may be happening is that we are learning clinical, medical and technical stuff in multi-disciplinary, multi-professional combined learning atmosphere (some of the learning using this approach especially for procedural skills may be valid)


Leadership learning is being offered in situations and by organisations mainly or solely consisting of, designed for and responsible for doctors (such as deaneries, FMLM and many others).

I do not think there should be doctor leaders or nurse leaders which is what we find now; at least within organisations such as the NHS there should be leaders who happen to be doctors and leaders who happen to be nurses. Courses, teaching systems, learning atmospheres, pathways, about leadership in healthcare that are exclusive to any profession does a disservice to the whole cause by pre-defining a narrow mental perspective. The hierarchy in the professions are based on narrowing similarity (vertical) whereas leadership is based on broadening equality (horizontal).

It is possible that healthcare is now confused between horizontals and verticals. The quicker we resolve it the more successful we will be.

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Tuesday, 7 May 2013



A rethink of training is happening. We debate that here.

In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.

Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.

In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more. 

At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.

There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly. 

Of course my favourite argument is costly care is generally not beneficial at a system level.

The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.

There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).

However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.

I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.

What do you think will work for UK/NHS? Are generalists a good idea?

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Shape of Training:

I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.