AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Today, the subject is Dr Katherine Henderson, president of the Royal College of Emergency Medicine. Dr Henderson was awarded an MBE for her services to emergency medicine during the pandemic.
A podcast of this interview is available here:
How did you get to where you are today?
I am currently a consultant in emergency medicine. But when I was first training, emergency medicine didn't really exist fully as a specialty. When I trained, I knew that I wanted to work in hospitals, and that was a core decision - it was hospitals versus primary care, versus anything else that wasn't directly in a hospital.
I was interested in medicine, and so I went down the route of initially training as a general medical person. I was particularly interested in rheumatology. But I found that as soon as I'd become a medical registrar, the bit that I really enjoyed was the acute on call. I have to confess I found ward work difficult at times.
Everything seemed to take so long. What I liked about the acute take was the variety, the intensity, the burst of teamwork that you did, and then getting somebody sorted, and then moving on. It became rapidly apparent to me that emergency medicine was what I really wanted to do. I joined a training programme for emergency medicine. Having been a medical registrar stood me in good stead to do this.
I trained at a time when we did quite a lot of interesting secondments. I went to Canada to do my paediatrics secondment in Toronto. I also went to the ambulance service in Paris, which was great fun - and a completely different ambulance system, which was good. I did one of the helicopter jobs - I did the HEMS job at the Royal London, which gave me some pre-hospital training as well.
So I was able to fit together an emergency medicine training programme, sit the exams, and then ‘pop out’ at the end as an emergency medicine consultant. In reality, that's just the beginning of one's career, and I think that sometimes takes a bit of getting used to - the thought that you finish your training, you become a consultant or a GP, but you're really just at the beginning.
That's when you start having particular interests, or doing college work - in my case I had various roles within the Royal College of Emergency Medicine, then eventually became president. But I still do 70% clinical work at St Thomas', where I'm an A&E consultant, so I'm still doing frontline emergency medicine.
What makes an exceptional A&E doctor?
An A&E doctor has to be interested in the really interesting fifteen minutes of every specialty. The point of emergency medicine is that you've got this incredibly broad curriculum, so you've got to be somebody who enjoys knowing a bit about everything, as opposed to the sort of person who really wants to get detailed about one particular topic.
That means you've got to be prepared to know how to manage everything to begin with, but that you are also going to have people who know more about that particular patient's needs later on down the line - and you need to be happy with that.
It does mean that you've got to have the ability to retain a huge amount of information. You've got to be able to cope with a lot of other specialty teams who know a lot about something in particular. You've also got to do the job well.
You've got to understand how an emergency department works. That again is a bit different from many other jobs because you're running this extraordinary shift of a huge variety of patients, with very different needs, and with a very large number of staff.
It's a pretty flat hierarchy in an emergency medicine department, but you're going to have to know a lot of different people. You're going to have to understand how it all fits together, because you're trying to deliver a service for a population as well as the individual patient. So you could be a very good clinician for one or two patients, but that won't make you a great A&E physician.
You've got to be able to do great medicine for the individuals, but deliver a service that's going to be great for a large number of people who are with you at any one time.
You're the first female president of the Royal College of Emergency Medicine. What made you decide to run for this role?
I've always found that the best way of getting change was to get stuck in, to get involved, to put your hand up and have an opinion and express it. So I have ended up in leadership roles in my department. I was a consultant at the Homerton Hospital, a DGH in London, before going to St Thomas.
I was clinical lead there, so I've got the understanding of the need to get stuff changed. The best way to get stuff changed is to be in a position where you can influence. By being a leader within your specialty - and becoming president of the Royal College is the easiest way of getting influence - that's the way you get people's ear. You get doors opened, you've got access to people.
People respond to your emails, they listen to you, they value having somebody from the specialty in a particular position who is able to put stuff across. You have to know quite a lot about what's going on, and what the majority of your specialty thinks. You have to be able to hear what people are saying - it can't just be a dictatorship of one. But if you are wanting to get stuff changed, you need to get involved.
What are the most pressing issues facing emergency medicine?
Emergency medicine is in quite a lot of trouble at the moment. It was also in quite a lot of trouble pre-pandemic. We were at a stage where we were unable to deliver the standard of care that we felt that we should be delivering. So we've had crowded departments, we haven't got enough staff, and we have difficulty moving patients out of the department.
The biggest problem that emergency departments have at the moment is flow - patients being admitted to the ward once they've been seen in an emergency department. That's a process problem that relates to a hospital.
Emergency medicine has the problem of trying to deliver a high standard of safe care in organisations that are maybe not making it easy for those clinicians to deliver the standard of care that they want to deliver.
That means you have a lot of people getting frustrated and worried about patient safety, and their own ability to sustain their career, because the operational pressures are such that it's actually not that much fun to work in that kind of environment.
We have a fabulous specialty from the point of view of the clinical work we do. We have a fabulous specialty from the point of view of the people who are in the specialty. But we have a real problem battling operational pressures, which can make it very hard to do the job as well as you want to do it.
People say: 'I love this job, but actually I just can't see how I can carry on doing it’. We've got a problem retaining people. We can recruit people easily, but keeping people in the specialty becomes quite hard.
One of my roles as president is to make that case and say: 'Unless we can reduce operational pressure on emergency medicine, we won't be able to have safe emergency departments, because we just won't have the staff to actually see patients’.
What can be done to make a career within emergency medicine sustainable and attractive?
This is really interesting, because there's a lot of talk about making people more resilient. I think emergency medicine is over the resilience thing. We all feel that we shouldn't need to be so resilient - we're a pretty resilient group of people anyway. You don't go into emergency medicine with low resilience.
It tends to attract an A-type personality - people who are decision-makers with not a lot of information. They're happy to get stuck in and to work very hard. We're reaching the point where to be sustainable we actually need to improve operational efficiency pressures.
There's this big division between ‘let's do a lot of wellbeing work’ - which is very important and as a College we've done a lot about wellbeing - how can you make it a pleasanter place to work around the edges? But fundamentally my job is to make things better by making the system that we work in better.
However, there are things that we can be aware of, like civility - making sure that people are polite to each other actually makes for much better team dynamics, both internally and to other teams. So making the same demands of teams coming down to the emergency department.
The campaign ‘Civility Saves Lives’ is something that we are passionate about, and we think is the right thing to do. We are very aware of bullying and undermining problems for trainees and other staff within emergency departments, and trying to minimise that, and as a College, having campaigns around that.
We are keen on making sure that people have decent rotas. So for trainees, having a ‘rota charter’ that talks about what's acceptable - because it's very different doing a job where a night shift is a full-on shift, and there are no gaps in what you're doing in an emergency department, and other sorts of night rotas where you will have a downtime within that time.
It’s about self-rostering - actually having control over your rota, because you can choose your work pattern. There are fundamental shifts that have to be covered, but self-rostering - which is something that we promote - gives back control to individuals making decisions about their working pattern.
That's on the medical side. But the other group of staff that I'm very concerned about is nursing staff. When you're working in an emergency department, you work very closely with your nursing staff. It's a very flat hierarchy generally, and it's a big team.
I think emergency nursing is having a really difficult time at the moment. They've had a very difficult pandemic. The moment there was any kind of slack in their system, they were redeployed somewhere else. So they were back on full working.
Doing a night shift as a sister in charge of an emergency department is incredibly hard work. So it's about how we support our other colleagues in the department, not just the doctor side of things. How do we think about the alternative workforce - so ACPs, EMPs, PAs, all the other people who can work with us. There is plenty of work! We're not short of work for anybody. So having the right skill mix, and making sure all those staff are valued, all helps towards making a happier department.
What is your opinion on the A&E four-hour wait target?
The four-hour standard is about what happens to a patient in terms of their arrival through to disposal. That means being admitted or going home. So it's never been a four-hour wait. That's been one of the battles that we've had with politicians at times, who talk about it as a four-hour wait.
But it's about being seen and sorted within four hours. It's been fabulously useful in its time, but we haven't made that target since 2015. It was an immense driver for improvement when it was first introduced - there was a huge amount of investment into emergency departments, and that was brilliant.
The number of consultants expanded hugely. It was all good. But we haven't made that target since 2015, so it's lost its bite as a way of getting improvement. What we were finding was that there was a lot of gaming going on, and a lot of initiatives were around what was called ‘low-hanging fruit’, or ‘quick wins’.
How you can treat your low-acuity patients really quickly, because there are many more of them, and that helps your denominator. Therefore you can make your performance better. What was actually happening was when we were getting 90% for all patients within four hours, admitted patients were actually at about 65%.
The highest-acuity patients were languishing on trolleys in emergency departments, and they did have a wait. They were increasingly having to wait - from being seen in an emergency department, sorted and a decision made, to being admitted and then going to the ward.
The other battle we were having is that one of the metrics used was ‘decision to admit’ plus 12 hours. In 2019, there were officially only about 3,000 patients who were like that, but the reality was there were 500,000 patients who'd been waiting 12 hours in a department for a bed.
These were patients who had arrived and 12 hours later were still waiting in an emergency department for a bed. So we were making the point around that.
While we're not against four hours, we think it's lost its bite to improve care, because it wasn't focussing on the sickest patients. We're keen to focus on metrics on the sickest patients, and the patients who end up staying the longest in the emergency department - often in corridors, and crowded - leading to departments being like a ward and an emergency department.
This is a nightmare for the nursing staff and not good for patients in general, and makes it very difficult to manage. That's why we engaged with the ‘clinical review of standards’. Consultation on that has been published, but the government needs to respond.
We're winning the battle on recording from arrival to a maximum of 12 hours. This should benefit many patients who have ended up maybe 20 hours on an A&E trolley in a corridor, with no privacy and dignity, and all the harm that comes from being on a trolley.
What are your priorities going forwards?
I've been president now for nearly two years. I had a whole raft of things that I was very keen on. I became president four months before the pandemic struck, and so the things I was going to work on, changed somewhat!
But still, the biggest priority is dealing with flow - it's dealing with getting patients through the departments so that we can actually deliver high-quality care. Then there’s getting crowding to be recognised as a patient safety issue - making it possible to make sure that the sickest patients get seen in a timely way, and so we don't have ambulance offload problems.
All of that stuff was my biggest priority, along with making the daily life of a clinical lead in an emergency department easier, by producing guidance or policy documents that they could then lift and use locally. There are also all the issues around patient safety in general.
How do we increase education around what we call ‘black swan presentation’ - so the really rare stuff - and making people good at spotting that. We were bringing in a new curriculum for trainees. And all the lovely work about recruitment and getting staff into emergency departments.
Then the pandemic came along, and my priority was immediately: how are we going to get through this pandemic as safely as possible? We didn't have time to sit around discussing it, because patients were arriving.
Back when people weren't talking about the pandemic, we were testing patients on our ambulance ramps, dressed in full PPE - the whole white suit, big mask thing - patients who'd come back from South Korea, or who'd been in China. We had patients like that arriving on the ambulance ramp. They were all completely fit and healthy, and we should've been testing people who were coming back from Northern Italy who'd been on skiing holidays.
But we had to just get on with dealing with who was coming to the emergency department, because the thing about emergency departments - and one of the reasons why it's so cool working in emergency medicine - is because in times of trouble, people know where the lights are on.
They will come to an emergency department, and that's true internationally. In some sort of natural disaster, where do you go? You go to the hospital. You expect the hospital to be a place of safety, so it needs to be able to function. It needs to get up and going.
You'll come to the emergency department because that's the front door. That's an enormous privilege and it's really exciting. At the beginning of a pandemic, that was also quite scary, because we were having to do an awful lot of change all the time.
My priority was to get information out to my members and fellows, so we set up national Zoom calls. Initially it was weekly. We've carried on doing it - we're now doing them fortnightly, but with some really practical stuff about how do you put up Perspex screens, and how do you have a red and a green area? How do you manage cases as they come in, and you see what the clinical presentation is like?
It was all about getting information out to the membership so that they could deal with the pandemic, and we could share learning as rapidly as possible. Technology was there to help us do that in a way that would have been really hard in previous times, but was possible because of doing things like Zoom calls very early on.
That became my priority, and has still been my priority - sharing: how do we make sure that we manage what's going on safely? Now my priority is talking about: how do we get a vision for the NHS going forward? We've obviously got to get through this winter, which is going to be a massive challenge and really difficult. But actually COVID is not going away.
A lot of the underlying problems of the NHS have been more obvious during the pandemic. There has been a stark realisation about the health inequalities aspect of how the NHS delivers healthcare - it’s been put in the spotlight during the pandemic.
So we've got to work on all of that sort of stuff. Priorities have changed a bit but it's still fundamentally: how do we deliver a really good healthcare response to patients who have an emergency need?
What was it like when the pandemic first hit?
You realise the stress after the event in some ways, because actually at the time you've just got to get on with it. That's true in emergency medicine generally - very often people say: 'You're seeing terribly shocking, or very difficult things', but the reality is you've got a job to do.
So you get on with it, and that tends to be very much our characteristic. The same was true with the pandemic, because it was clear that we needed to provide a service very quickly that was going to be safe.
We needed to make sure that we were keeping staff safe at a time when we didn't know very much about the illness. The reality of treating patients at the beginning was unbelievably clinically fascinating.
It's an extraordinary privilege to see a new illness. It's horrible for the patients, but actually seeing an illness that you have not seen before was fascinating and you were learning stuff every day. So you were seeing presentations of patients who weren't the obvious: 'This is how they're going to present’.
For example, we saw very early on how badly affected diabetic patients were, and they could just present with their diabetes having gone off the rails, not with classic COVID symptoms as such.
Suddenly we had a body of clinical experience of something that was completely new - it was fascinating. We gained experience as to what was likely to happen to a patient who presented in a particular way, so that you could almost spot COVID patients from a distance.
A patient would arrive looking quite chirpy, not terribly hypoxic, on an ambulance trolley. You would get them to your A&E trolley, and they would drop their SATs dramatically. They might still look quite perky, but the fact that their saturations had dropped so quickly told you it was COVID. There's nothing else really that was doing that, so again, it was really interesting.
In the first wave we had this new illness, and what we then saw was the drop-off of other patients. Actually, during the first wave, for the first time in my career we had about the right number of patients for the right number of doctors, with the right number of beds to admit them to!
It was an extraordinary experience - it lasted about four weeks. Now, we realise in retrospect that there were a load of patients who should've been coming to hospital who weren't, but it was an extraordinary experience to actually have enough staff and capacity to manage the patient load.
That didn't last until the second wave at all, sadly, and the second wave was a lot more difficult. That became much more challenging, and people have been through some very difficult times. There have been people who found it incredibly stressful and scary.
There have been a lot of healthcare workers who have been directly affected, getting ill. There are people who have got symptoms that are ongoing. There are those who have known people who have come to significant harm and have died.
That's been absolutely ghastly, because there's no question that healthcare workers have been more affected than other people. That is something I think everybody should feel very uncomfortable about - that your frontline staff are at risk.
Fighting the corner for frontline staff is obviously something that we have done since the beginning of the pandemic, when people didn't have enough information to be able to make sweeping statements about what should, or shouldn't be happening.
Tell us about your advocacy for PPE.
I think part of the problem for us was that at the very beginning we were seeing patients who we had to dress up in what's called ‘high-consequence infection’ PPE outfits. That's a much higher level of PPE than we wear now even for COVID.
This was full kit to see patients who we were swabbing - who were asymptomatic patients. Then suddenly there was this change from saying that COVID was a high-consequence infection, to it not being a high-consequence infection, and us being dressed in much less significant PPE outfits - so surgical masks and plastic gowns, essentially.
That was a very difficult change for emergency departments to go through. One minute you're being told: ‘This is really high risk and you've got to be super protected’, and the next minute you're not. That's not a good way of managing people's expectations of risk.
Then there was the problem of people saying: 'Well, the people who are at highest risk are those in intensive care units, so they need to have FFP3 masks and full gowns with arms and aprons as well’.
And we were saying: 'Hang on a minute - by the time the patient is in intensive care, you know the diagnosis.
The people who are at the frontline when the diagnosis is unclear, should be wearing full PPE’. So we had to fight our corner to say: 'Actually it's just as scary in a resus room as it is on an intensive care unit. At this point we don't know what the patient has actually got. They could be agitated, they're not going to be wearing a mask themselves.
We need to be completely protected’. So we got agreement after a certain amount of argument that when we were dealing with a patient like that, we should be wearing FFP3 masks. We won that argument.
Now, we're still wearing FFP3 in our resusc rooms and we're wearing some PPE - so we're wearing the basic PPE - with asymptomatic patients. We have to remember that at the beginning, one of the problems was that people didn't realise that there was asymptomatic transmission.
This is going back a long way. I'm sure when it all comes to enquiries in the end, there'll be lots of discussion about that. The original SARS wasn't transmitted in asymptomatic patients, and so there was an initial assumption that this was going to be the same. That turned out to be wrong.
I think a lot of healthcare workers - and if you look at London, which is where it first really bubbled up in significant numbers - did get infected in those early weeks when you weren't wearing the proper PPE around asymptomatic patients. It took a bit of time for us to win the battle to say: 'Actually, you should err on the side of caution in the undifferentiated patient’.
A&E departments have always been at risk from infection. I've gone through my career with people getting measles outbreaks or chicken pox outbreaks or flu outbreaks in emergency departments. So we've always been a place where we haven't necessarily had available to us enough infection prevention and control.
Departments are just not designed for it. Increasingly, when we're looking at emergency department design, we’re looking at having side rooms so you don't have to do lots of contact tracing, wearing a mask whenever you see any respiratory patient.
All those sorts of things are becoming really important. I am really hopeful that going forward after this pandemic, nosocomial infection, staff-to-staff spread, staff facilities - because a lot of the outbreaks that happen in hospital are actually coffee rooms and changing rooms - and IPC measures, which are considered fundamental on the wards - will be applied to staff facilities and how hospitals are designed.
What did you learn about leadership during the pandemic?
You need to be visible, and so making oneself obviously advocate for the specialty to the members was really important so that they felt that there was somewhere to go for advice in very uncertain times, and that there was someone who had their back - so being visible to my own specialty members.
The other thing was then explaining stuff to other people - so explaining the speciality became more and more important to politicians, to the public, to other specialties. And then working collaboratively with the other specialties, because when we were talking to leaders in healthcare management, or talking to politicians, a group of professionals talking together collaboratively was incredibly powerful.
If you had the physicians, the surgeons, the GPs, the emergency medicine people all saying the same thing, it was very hard to ignore. Being a leader of a specialty is actually as much about making sure that you look for the overlaps with other specialties so that you can amplify your message.
So looking for other leaders that will work with you to get your point across. If you turn into a big silo, you just get treated in a silo and you don't get the change that you're trying for. So getting support.
Getting somebody from the surgeons to say: 'The resuscitation room really is a frontline part of hospitals and they need to be wearing appropriate PPE', was incredibly useful. That actually adds power to the message that you're trying to get across.
How do you deal with pushback?
Repetition, particularly when you're dealing with organisations where that timeframe comes quite slowly. You just have to be consistent and keep saying the same thing over and over again, without rolling your eyes. You don't jump about, you stick to your message, and you keep saying it.
Now, if the pushback is actually legitimate, you acknowledge that it's legitimate. You adapt what it is that you're wanting to do because there are times when you say: 'I'm pushing for this. We think this is the right thing to be going for', and somebody says: 'Well, hang on a minute, actually maybe it's not.
Maybe this is better’. So acknowledging that someone may have a better idea that you want to think about. But if it's pushback that is just the inertia pushback - which I'm afraid you tend to see in big organisations quite a lot - you just have to keep saying the same stuff over and over again.
Show that you really mean it, that you're not going to go away. That you're going to keep on saying it until somebody listens. Then you hope that they become curious about why you're being so persistent.
It's not just petulance - you've actually got a sincere belief that this is what needs to happen. Then you hope you get a change. Some things, like getting us to say that measuring time in an emergency department from arrival, have taken me two years to get to the point we're at, and it's just by saying it over and over again.
What advice would you offer to medical students and junior doctors interested in emergency medicine?
The first thing in thinking about this career is: this is not what it's like when you're training. You have to look to the long term, which is sometimes actually quite difficult to do as a medical student. You look at what the F2s in an emergency department or the registrars are doing and think: ‘Is this what I would want to do?’
What you actually really need to do is talk to the consultants, and the senior SAS doctors to see what it's like as a long-term career, because training is so many years. I've actually been a consultant for over 21 years.
So it’s the bulk of the time that you'll be doing something, which is what you need to think about. If you are applying and you're wanting to put over a strong case, make sure you understand what the specialty is.
Understand what it does and doesn’t entail. It's not all about helicopters and going around in jumpsuits. People sometimes get seduced by thinking that's what it's going to be, and that may be part of it, and that may become your specialist interest, but there are many other fascinating areas within emergency medicine that you would be able to be interested in.
Understand what the training does entail. People who say: 'I don't really know what the training is' - that never looks good. You do need to understand what the training is like, and you need to have shown a particular interest in it.
Whether that is talking to people, doing a taster week, having chosen your FY1 job to include emergency medicine, or having spent a bit of time there. Show that you are genuinely interested. Go to a webinar about emergency medicine. Go to a careers day about emergency medicine.
Understand a bit more about it so that people can see that you're clear-sighted about what you're taking on. It's a great career to be able to have as a portfolio career. It's really easy to be a teacher, it's really easy to have a special interest.
You can do training in intensive care medicine, paediatrics, or pre-hospital care as a special interest as part of your main job. You can become a guru on ultrasound. You can become somebody who loves frailty, and actually doing emergency medicine for the elderly - very cool. Silver trauma for the elderly.
There are lots of things that you can do, so having an understanding of the breadth of the specialty is really important, to sell it. Then when you're being interviewed, smile - don't look like you're terrified.
Actually show humour, engagement, and try and get some personality over so that you don't look like you're a ‘rabbit in the headlights’. It's really scary interviewing people who look like this - you always worry they're about to fall over and faint on you! You get distracted. You want somebody you can have a conversation with.
Have your diverse experiences and background have helped you as a consultant?
Absolutely. Practically nothing you do is ever wasted in emergency medicine, because we find that we'll get somebody who's done an ENT job or an obs and gynae job or a bit of dermatology - it always comes in useful. There's nothing ever wasted about what you do.
At the same time, there are also the opportunities these days to have out-of-programme experience. So you get into a training programme, and then you apply for an out-of-programme experience, and you can go and do all sorts of interesting things. I would advocate for doing that.
I think diversity of experience is incredibly useful. It also means that it's a good specialty to come into, when maybe you started off in something else. Even if you have to do some years of training, what's the rush?
There's plenty of time - as I've demonstrated - to be a consultant. So even if you then go back in terms of seniority of your position, the chances are what you did will be useful. You'll find that clinically it's a helpful thing to have done.
It's a good specialty to go in directly and to do diverse things once you're in it. It's also a good specialty to go into when you've done a bit of something else beforehand. The bit I like is the acute stuff, the bit I don't like is sitting in an outpatient clinic. I couldn't stand them.
Now, the world has changed a bit, and a lot of these things are much better organised. But actually what interests me is the daily variety. I've got the attention span of a flea! I like to keep moving.
I'm interested in follow-up of acute outcomes so I will follow up with my patients, but I'm not necessarily wanting to have that long-term relationship with them that people in specialty jobs do. It’s just about different personalities. Somebody who is taking on long-term care is fantastic, but it doesn't suit me.
How did you first become interested in emergency department culture?
The patient safety aspect - the realisation that if you want your staff to do the right thing, they will do the right thing because they care - and they care if they're happy. If somebody is really unhappy in their role, the risk is that they take shortcuts, and shortcuts lead to trouble.
You find people will just not go that extra mile to check that what they're doing is the right thing. What you want is people who are really invested in patient care, and that definitely comes from having contented staff who think that this really matters. So I was really interested in that. I did an MSc.
When I first became a consultant I did a master's in healthcare risk management. It's so much about having staff who are willing to speak up, who are not scared of saying: 'I think there's a bit of a problem going on here', or, 'Are you sure you're doing the right thing?' or, 'Actually this is about to go horribly wrong, we all need to stop’.
Not being scared of speaking to that scary consultant because they'll get shouted at. It’s really important for patient safety to do that, and it's important in all sorts of high-risk industries. There is plenty of evidence that you need to have contented, confident staff to be safe, whether it's the nuclear industry, or an oil rig in the middle of the North Sea.
All of those things depend on people who are prepared to say: 'Actually, I think there's a problem here’. It might be a very junior member of staff doing that. It's often easier said than done, and I can get as grumpy as the next person.
But I can get away with being grumpy because people know my heart is in the right place - that's not my general mode. If you're developing a department that is just an unhappy department, the chances are it will start becoming a high-risk department. That's unhelpful.
It's not that you just are ‘lucky’ because you've got a lot of very happy people who happen to be working. You can make it happier. You can do this by listening to people, listening to their concerns, and having the opportunity to get feedback on how something is working.
When things get reported, thank people for making the effort to report something, and actually demonstrate to them that you've taken on board whatever the thing is that needs to be sorted. You can make it happier by having opportunities to socialise, to actually appreciate people out of uniform.
Very often people look so different in their own clothes versus their work clothes. You suddenly realise a whole side of their personality that you didn't know and appreciate. You can actually work at making a team happier. It's not just something that happens.
Once teams are unhappy, though, it's quite hard to pull it back. That takes a lot of very deliberate effort and quite honest conversations, saying: 'We need to look at this, and how are we going to make things better?' Sometimes it involves bringing in people from the outside to say: 'Why is the culture not right?'
But if you end up in a whole organisation - and I'm sure CQC would say this - where people will not tell the highest in command the truth about what is going on, you end up with deeply unsafe practice. You've got to be sure that the medical director or the chief executive will know the reality of problems. If they don't know, they've got a significant problem.
What can you do as a junior member of staff?
I think that is very difficult, particularly if you're the most junior person -just calling it out is not an easy thing to do, and I don't think it necessarily will help. You will occasionally - something will happen and you will say:
'Actually this isn't right' and everyone will say:, 'It's not right - we need to do something about it’. But it's more that low-level general rudeness or unpleasantness that I think is incredibly divisive. The risk is that you disengage. And so as an individual it's about finding an ally.
That might be, if you're an FY1 joining a team, finding another FY1 that covers the same team and ganging up together - behaving yourselves in a particular way, so that the way you talk to each other, the way you talk to the nursing staff, the way you talk to your registrar, is exemplary.
So that it's really obvious to everybody that you're making an effort, and then chipping away at a little bit of challenge. You need an ally - you can't do it on your own. That might be an ally from the nursing staff. It might be an ally from the PA or the ACP that works with that team. Finding somebody who's also quite junior but who also sees the problem, so that you can start getting some traction.
But if you just go nuclear from the beginning, you will find it very difficult. You will probably end up in a more difficult position. I think it's very hard. So work on finding an ally early on.
What advice would you give to your younger self?
In terms of my initial training, I made some quite interesting decisions. I don't regret them but they possibly made it slightly more difficult for me doing medicine. I did a short medical course and then I did a part two at university in sociology and politics.
I don't regret it at all, because it was incredibly interesting. It meant that I had quite a hard time when I started my clinical time and felt that I was doing an awful lot of catching up. In some ways I slightly regret the hit to my confidence during my clinical training.
I really enjoyed doing the year of sociology and politics. It was incredibly interesting. In terms of other advice to myself: taking opportunities. I've always been quite good at taking opportunities and I think I've done reasonably well. I feel I've been very lucky in my career. So I would say: 'You did all right, actually! You will do all right in the end’.
What lessons have you learned during your career?
The issue of taking opportunities is a really big one. Sometimes people spend too long weighing up pros and cons. Sometimes it's just making a decision. Emergency medicine - that's our characteristic - will make decisions.
I think that is really important when you're making career decisions. It's never perfect to do X or do Y. Just make a decision and get on with it and enjoy it, and don't spend too much time beating yourself up about it.
So taking opportunities - if people make offers, if that sounds like a really good thing to do, go for it. Don't turn things down because you think it's all going to be too difficult. If you think you've made the wrong decision, make a fairly quick decision to get out.
When I was training in medicine, I was having a fairly miserable time, and I actually thought about stopping doing medicine and becoming a lawyer. I got as far as being offered articles at a very big law firm.
I would be considerably richer if I had carried on doing that. I got a place at the College of Law in London. I had to send them £80 to hold my place. I had a fortnight to send it in, and the experience of getting the articles was great.
I had to write a CV that showed what skills I'd learned as a junior doctor, and you realise that you've actually got a lot of skills. They gave me a cup of tea in a china cup, which as a junior doctor was unheard of!
They gave me biscuits that were wrapped in gold paper, which as a junior doctor was pretty unheard of as well! Generally they were nice to me, which at that point wasn't happening a lot. They treated me with respect, and understood that I did have skills that might be valuable.
Then I had to send in the money to hold the place at the College of Law. I suddenly realised that I was enjoying flirting with the idea of being a lawyer, rather than actually wanting to do it. What I really wanted to do was to have a nice time being a doctor.
Being a lawyer and being a doctor actually have enormous similarities, such as case histories - there's a lot of crossover. I never sent the cheque - I decided not to do it. I turned down the article clerk job and I went back to doing medicine, and I never regretted it.
I made a decision I was going to apply, and it gave me an opportunity to have a really good think. I was able to back out of it and move on and, ultimately, it didn't cost anything.
Who have been key role models during your career?
I've worked for a lot of leaders in emergency medicine in my time. My very first consultant - who was actually at the hospital that I have now come back to - was Dr David Williams, who hadn't trained in emergency medicine because emergency medicine training didn't exist.
He was somebody who could see round corners. He knew what was going on in the department without necessarily being visible to people. He was a single-handed consultant in the emergency department, but he had such a good overview, and such a good relationship with his staff, he would be told if there was trouble.
That was something I realised was incredibly important. In a big emergency department, you can't know about every patient when you're running a shift, but you do need to have the confidence of your staff that they will tell you what is going on.
He would just wander through and say: 'Have you checked the glucose?' Everyone would say: 'Damn it! We've done everything except check the glucose’. We'd go off and check the glucose. He's still around, and was one of the first people I wanted to tell when I became president.
He was at the faculty of emergency medicine, so before we were a Royal College he was the first president of the faculty. So I was really pleased to be able to say to him: 'Look how far I've come!'
How do you successfully maintain a healthy work-life balance?
I think emergency medicine has a reputation which is not necessarily real, because actually you've got an incredible amount of flexibility. It's a really easy job to do flexibly, part time. Sure, there's a lot of training to get through, and there will be a lot of nights along the way, but with rota charters and self-rostering you can make that better.
You don't have the problems of continuity of care as, say, someone who has to think about their clinic in six months' time, when they're wanting to take some leave. We don't have that issue. So if you plan, you can actually have quite a good portfolio career.
You can do a bit of emergency medicine, a bit of postgraduate education, a bit of pre-hospital care - you can do an awful lot of different things. So in many ways, work-life balance is actually easier to organise than it is in some specialties.
You don't have the rigidity of having to do an operating list every Monday except when you’re on annual leave. You don't have to have those fixed arrangements that you do in many specialties. So emergency medicine gets a bit of a bad rap. I think this is because the training is quite intense. There's a lot of training, but you need to look at the end result, and the end result can be very flexible.
What is your favourite book?
A favourite book is Into Thin Air, which is about the 1996 disaster on Everest. I've been a bit obsessed with climbing. I've always been interested in books about mountaineering and going up big mountains. Into Thin Air is written by a journalist and so has a very racy style. It's a very good narrative of an unfolding disaster, which is incredibly interesting, very human, and really makes you feel in the place.
It's incredibly well written, and there are a lot of climbing books that I admire a lot. It's got a lot of decisions in it. I'm quite interested in decision-making - how people make decisions and how you make a decision early - before it's too late - so that you make the decision to turn back rather than go to the top of Everest and then die.
Yes, you made it to the top, but you die on the way down. So that's not that great really, because the only way to have actually summited a mountain is to have gone to the top and come down the other side, and be alive at the end of it. It's a really interesting book about good decision-making, and not-so-good decision making that can end in disaster or success.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.