Mr Edward Morris, President of Royal College of Obstetricians and Gynaecologists

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.

Here the subject is Mr Edward Morris, a consultant gynaecologist and president of the Royal College of Obstetricians and Gynaecologists. Mr Morris has a strong interest in both menopause and endometriosis.

A podcast of this interview is available here:

 

How did you get to where you are today?

I started as a medical student at St Thomas' Hospital in 1983. I qualified in 1989, and did most of my training in the south- east of the UK, and then became a registrar at Guy's and St Thomas' Hospital. I spent some time doing some research at Guy's as it merged with King's, and then was offered a consultant post in Norfolk.

What particularly excited me about moving to Norfolk from south-east London was the quality of life, which is always something to consider,  but also there was a brand new medical school. As I'd been part of the medical school training at King's, the opportunity to be involved with the building and development of a new medical school was pretty irresistible. So I came to Norfolk, worked as a consultant gynaecologist, and was part of the team devising the curriculum for the O&G part of Norwich Medical School.

I've been involved ever since, and then developed an interest in medical leadership. After about 15 years of being a consultant, I found myself working at the Royal College of Obstetricians and Gynaecologists (RCOG) quite a bit, and here I am as president. It's very exciting.

 

What’s your fondest memory of King's?

It's difficult to pick one specific thing. When St Thomas’s merged with Guy's there was a bit of rivalry to begin with, which was quite good fun, but when we merged with King's I think the common purpose that links medical schools became a strength for good, and King's place in medical training in the UK has been strengthened. I've greatly enjoyed being part of it.

Another fond memory is doing research with Professor Janice Rymer, who is the dean of students at King's at the moment, and a very good friend.  We worked as vice presidents together at the college. 

 

What attracted you to obstetrics and gynaecology?

Choosing your medical career path is like being in the perfect sweet shop: what do you choose? What actually pointed me towards obs and gynae was when I chose to do an intercalated BSc in reproductive physiology as a second-year medical student. As part of that I met the most amazingly inspirational professor, a gentleman called Morton Jones, who, sadly, is no longer with us.

He really taught me about reproduction and how hormones are at the centre of so many parts of the female body. That really motivated me to want to learn more, and I found myself working with gynaecologists and obstetricians. 

Someone told me once that I fell amongst thieves. I don't think I fell amongst thieves; I fell amongst a really motivated team of people who really wanted to do their best for women's health. So when I qualified as a medic, I pointed my career very much in the direction of obstetrics and gynaecology. 

 

What are your clinical and research interests?

The two are very intertwined. Sure, I work as a general gynaecologist. For about 15 years of my career I worked as a general obstetrician and gynaecologist offering clinical services in both. But throughout my career I've had this interest in hormones, and that has driven both my clinical practice and my research.

So if we look at my clinical practice, I'm very interested in endometriosis and also hormones, and largely the menopause. I've not really got into fertility so much, because I think that's almost a business part of the speciality in itself.

Whereas, menopause, the cessation of ovarian function, is a time that every women goes through, and every woman has a different experience of menopause, and that really drove me to get really interested in that area.

When I worked with Janice Rymer I worked as part of her team, as her menopause research fellow, and we did a lot of studies on various forms of hormone replacement therapy, but also studies looking at quality of life, irregular bleeding in the menopause, and that really cemented my desire to do more in that area. Certainly, I carried on when I came to Norwich doing research in that area. 

The other area that particularly interested me, and which has impacted both my clinical and my research work, is the effects of withdrawing or modifying hormones in the treatment of reproductive diseases such as fibroids and endometriosis. When I came to Norfolk, where the incidence of fibroids isn't quite so high, I started to focus on endometriosis.

So I set up the first endometriosis units in Norfolk, and we now cover most of East Anglia in partnership with Addenbrooke's. So it's amazing how things have changed. Who'd have thought that endometriosis and the advanced surgery that I do would be started by that early interest in hormones? 

 

What are the biggest changes you've seen in the management of endometriosis and also menopause?

Well, that's quite a question, because a lot has changed. With the menopause the big change came in 2001 when a large, randomised, study was published in the US that sowed a seed of doubt in many women's minds as to whether HRT was safe.

Everyone accepted it was effective, but was it safe? That had a huge effect on the uptake of hormone replacement for a lot of women who actually needed it and, since then, that big study has been criticised, methodologically, in many different ways.

Many experts in menopause feel that there's a ten-year cohort of women who could have benefited from HRT but no longer can. So we've done a lot of learning from that, and I think the system nowadays works very well, and NICE, our institute of clinical excellence and guidance, has put together a very helpful guideline. And that shows the value of bringing studies together and producing guidance that is very practical and applicable. 

For me, the NICE guideline published in 2015 was instrumental in the road to recovery for the management of menopause. More recently, it's the acceptance of how a woman can be impacted at work by menopause symptoms.

For endometriosis, the biggest advance is recognising that it is a condition. I'm very sad to say that in 1996 it took, on average, seven-and-a-half years for a woman to get a diagnosis. It's about the same today. That's something that we should be ashamed of and my PhD student is just about to be examined for his PhD on that very subject.

Here we have all these diagnostic tools, but we are still behind the curve on diagnosis. Setting up endometriosis centres in the UK has made access to treatment better, so I'm really optimistic now that, with raised awareness, we will see further advances and, hopefully, prevent women from suffering the more severe end of the consequences of endometriosis.

 

You spent seven years as a clinical director.  What did you learn about the challenges of delivering care?

The biggest challenge that any leader has, and specifically a clinical director, is resource. That's financial resource and human resource. When I was a clinical director, which was in the 2000s, there was a financial crash. That really impacted the NHS quite significantly.

What I found myself doing was being a persistent advocate, not just for the women that I looked after, but also for the staff, to make sure that they were recognised, rewarded and supported. One of the best ways of supporting people is to listen.

As a leader you have to listen and you have to demonstrate understanding - compassion, actually - but no one goes to work to do a bad day's work, do they? They go to work because they're doing a job that they want to do, especially in a healthcare setting, and they want to look after people, because we're driven to care.

As a leader, it's about giving people the opportunities to do their job properly, making sure that you have set-up the systems to support the people to do a job safely and to the best of their abilities. 

 

What advice would you give doctors and students considering an obs and gynae career?

Well, I'm going to say obs and gynae is the best career in medicine. It would be remiss if I didn't. It really is fantastic in so many ways, and it's not just the old cliché about having ‘a bit of medicine and a bit of surgery', although that applies to a point.

Fundamentally, if you're really interested in physiology, then just think how that applies to the pregnant woman and the production, conception, and incubation of a baby, because that's physiology at its finest. Yes, we're always studying what can go wrong, but actually what you're doing is supporting a natural process, and that degree of motivation is what drove me towards O&G.

It's that lovely interplay between physiology and pathophysiology. So the advice that I would give is just look for the opportunities in obs and gynae. Every medical school will have links with an obs and gynae department. If I get approached by a student, and they say, 'I'm interested in obs and gynae. I know I'm only a year-one or a year-two medical student.

What can I do?' I will say, 'Well, what are you interested in?' I try to visit the medical school and give lectures to the various societies to try and encourage people into the specialty, as do my colleagues, and I think it's a two-way thing.

I feel that if I want more people to go into obs and gynae, which of course I do as president of the RCOG, I need to go out there and tell people what a great specialty it is, but I also need people to listen. It's great; wherever we go, we get people listening because they want to be having a career in O&G, or at least to think about it. 

 

What made you decide to run for president?

It's one of those things that crept up on me, and it very much isn't an end game for me, but I've always had an interest in patient safety. Patient safety has really, really motivated me, because it's an area of the NHS where we can always do better.

There's always something to learn from an adverse event. So I think the position within the NHS to improve patient safety, it's been there as a defined term probably since the start of this century, and I think I got a job just volunteering, really, at the National Patient Safety Agency, which was an arm's length body.

I did some work on that, and some of the work that I did ended up being quite high profile, just by the very nature of it at the time. The current president of the RCOG asked me if I would like to set up a committee that particularly looks at patient safety and quality of care at the RCOG and, of course, I leapt at the chance. I was not expecting that to ever come, and that president, Professor Arulkumaran, has supported my career ever since then. 

Really, I have just done more and more work with the RCOG in my own time, and that's one of those things; it's always been in my own time, and then within the region, the eastern East of England, my colleagues then voted me to be their representative on the RCOG council.

I did more work for the RCOG on that council, and ended up being elected as a VP in 2016, and then it seemed the right thing to do, to stand to be president. I had a lot of people who were very supportive of me standing, and I had a very clear set of things that I really felt needed addressing in the UK, and here I am, and I'm really, really flattered, very proud, but also hugely motivated to effect change.

 

What are some of the most pressing issues facing obs and gynae as a specialty?

The pressures facing obs and gynae are numerous, but I think that the bigger pressures are with regard to our workforce and also the effects of the pandemic. Before the pandemic started, it was very clear that the numbers of doctors in O&G and the number of midwives supporting maternity were below what they should be, and the pandemic has thrown into very sharp relief those problems.

That's a large part of the advocacy that I'm doing. As a clinical director I'm advocating for my staff, as president I'm advocating for fellows and members and those practising obstetrics and gynaecology, but I’m also supporting the Royal College of Midwives and its calls for more midwives. Post-pandemic, waiting lists are growing and growing and growing. Those are the two most pressing issues. 

On the workforce we have made progress, very definitely. The Government really is listening to our words, and has agreed to fund an additional 2,000 to 3,000 midwives, and most likely another 100 or so obstetricians. We believe we need more, and we're doing the numbers to support the government's calculations.

 

What are your key priorities as president going forward?

The workforce is a huge priority. That needs a very strategic approach and the Government needs to understand where the problems are. Unpicking that and presenting it in a way that really shows not just that we need more consultants now; but also how we can train more consultants and home-grow our own.

I'm vehemently against going to other countries and taking their doctors from them. We need to train our own. That means more trainees, more vacancies in obs and gynae, and, for people training in obs and gynae, hopefully, less pressure and fewer gaps in rotas. It's a complex web, but once we start on it, I'm very optimistic that when I end my term there will be a clear plan as to where we should be going. 

But the other key priority is one of the things that I think as a country we have to be actually pretty embarrassed about, and that is the fact that if you are black and a woman and pregnant, you are four to five times more likely to die during pregnancy than you are if you are white in this country.

For me, that is something that as a country we cannot support, so one of my main tasks was setting up our race-equality taskforce, and that taskforce has brought lots of elements of the health system together, and we're addressing things in three ways.

One is looking at women's health outcomes, bringing together all the evidence to try and devise a plan. The second is to change the way the college provides guidance and patient information so that they are produced through the lens of inequalities, both racial and social?

Finally, one of the things that upset me hugely when I launched the taskforce was that I got letters from trainees and consultants from around the country who were experiencing racism in their workplace. That, to me, demonstrates there is structural racism within the NHS, and I don't believe that you can address differential outcomes in women without addressing the racism experienced by staff. 

 

What are the most exciting things on the horizon?

Some of the most exciting work, actually, is demonstrating that if a good team learns how to work together well, outcomes are safer. Now that sounds really simple and straightforward, but actually it's quite a hard thing to demonstrate.

When I trained, we worked as firms on pretty punitive 1:3 rotas, but we knew how each other ticked and that helped. Was it safer? I don't know, but it made the job a lot more enjoyable than some of the shifts that I've seen recently. Nowadays it's very rare that you work with exactly the same people, so every time you come on you're setting up a new team and that opens up gaps through which patients can fall.

So it's very important we learn the good bits about teamwork and what makes one unit safer than another, and that really excites me. When I started my career 30 per cent of women had hysterectomies, and it's now down into the teens. Many patients would have long inpatient stays after a hysterectomy,  now they're largely done as day cases.

Might they be in the future done as outpatient procedures? Unlikely, but a lot of things we do in gynaecology have converted from inpatient to day case, and now to outpatient procedures. When you look at the effect that robotics and robotic surgery is having on outcomes, on safety and on recovery from procedures, I think we're going to see a lot of changes in the years to come.

There's one other exciting bit that is coming, and that's artificial intelligence. When people go through a care pathway they leave behind them what the boffins call digital touchpoints, and a digital touchpoint could be a blood test result, it could be a scan result, but equally, it could be a blood pressure, or it could be a length of stay.

Collecting those bits of data, allowing machines to do the analysis in the background, but applying it to clinical diagnoses, we're going to learn an awful lot. Microsoft have started work on this, and the RCOG is doing a project with Tommy's, the charity that actually started at St Thomas' Hospital when I was a trainee there.

That project is all about looking at the digital touchpoints a woman makes during her pregnancy, to see if that affects prediction of a pre-term birth, pre-eclampsia and other pregnancy diagnoses. 

 

How can doctors learn more about effective teams and developing teamwork skills?

The RCOG has done a lot of work over the years about teamwork, and I think when we started a project in 2014 called Each Baby Counts, that was looking at the factors that influenced an adverse event of a seemingly-normal-progressing pregnancy at term. The RCOG got every unit in the country to inform it of any at-term pregnancy that resulted in stillbirth or brain damage. Then we would investigate the causes in-depth.

Human factors were really important in a lot of these cases, including new teams that don't really know how to work together, or don't work together as efficiently as they might, but also things like situational awareness; how situations can arise where you just don't realise time is passing as quickly as it is, and how, at certain points of a labour, time can mean everything.

So we quickly established that getting human factors right and producing tools that could support good teamwork on every shift was one of the directions that we wanted to travel in. We also found large variations in the way teams responded to changing risk in labour.

This is probably one of the big things that contributes to the rate of stillbirth and perinatal loss in the UK. So we know what the main problems are; we now need to produce solutions that will help units improve the care they give mums in labour.

So we're embarking on a project called the Avoiding Brain Injury in Childbirth collaboration with The Health Improvement Studies (THIS) Institute in Cambridge, where we're co-designing solutions with obstetricians, midwives, and patients to support them better in labour and respond to changing risk more quickly.

Some modelling we've done shows that using the tools that we're designing at the moment, we may actually not change the mode of delivery, but just do it an hour, or even two hours earlier. That will very materially affect outcomes. It's very early days, but the aim is improving care. 

 

Are there any particular reports about improving maternity care that you would recommend?

The reports looking at the maternity system make very sobering reading. The first high-profile one was the Morecambe Bay Report in 2015. That really showed how teams that don't work well and aren't led well, run into problems. Now we're in the middle of the Ockenden Report, between report number one and report two.

The similarities between Ockenden and Morecambe Bay worry me, but if you're interested in O&G it is important to read them because they can help you understand why learning how teams work, learning how to lead a team, and making leadership part of your training can only be a force for good.

These reports are not all bad news. The Ockenden Report demonstrates how an under-pressure workforce that's under-staffed and under-supported actually runs a less-safe service. So the chief executive of the Royal College of Midwives and I have used the information to go to the Department of Health and lobby for an expanded workforce.

That has been fantastically useful and I know that parents who have suffered loss find it helpful that the investigation is leading to improvement in the system. The other reports that I would suggest are the Marmot Reports. Professor Sir Michael Marmot has written two reports on inequalities and how they affect care, and I really do recommend them as a read.

They're a general read. They're not specific to obs and gynae, but they really show that the UK is not sorted when it comes to health and inequalities. He very kindly came and gave a lecture at one of our congresses recently, and an O&G audience were completely transfixed by his words. 

Finally, have a look at some of the CQC reports of hospitals that aren't doing so well but also of those rated as outstanding. There are not many hospitals rated outstanding across all five domains in the UK, but there you can learn what makes a good service. 

 

What can individuals do to help improve services and make a difference?

I'm a firm believer that if you are an individual and you want to improve services, firstly, you have to be part of a team. You can't do it on your own, but whatever you do, think of the patient.

Put the patient at the centre of your plans. Help that patient go through the system in a more efficient way, because systems that have been designed around the patient are more efficient in the use of resources and patients feel that they've been better managed.

It's this co-design thing; involving the patient, understanding what their issues are with the system, and trying to design out the obstacles. We know that the health service is full of obstacles to care. As a trainee, as a student, you see those obstacles, so tell someone.

Reflect on what you've seen, put it all together in a way that a leader can properly absorb and, if they're a good leader and they listen, they will go away and reflect and effect change. 

One of the best places to really get to the beating heart of a department is to go to a clinical governance meeting. A clinical governance meeting is where incidents, research and audits happening in a department are discussed.

And that's how you really get to learn just how well the department is working, and how well it is being led. That will help you contextualise the blocks you're seeing on the shopfloor so that you can start to make change in the unit where you're working.

That's quicker than just listening to what’s going on on your day-to-day shifts. Governance meetings tend to bring things together really well.

 

What have you learnt about leadership as president?

It's making teams. It's helping people work to the very best that they can, without just making them work. It's making their workday enjoyable, efficient and safe. It's making systems to support them. As a leader you have to demonstrate integrity and outward listening.

When I teach communication skills at the University of East Anglia, I teach attentive listening; demonstrating to someone that you really are listening and that you really are taking it in, and following up with actions that have meaning. If you can get those things all together, then people really feel that you are leading them and part of their journey as part of the team.

 

What are your proudest achievements?

In my professional life, it's the fact that, a few decades into my career, I still love it. That's something to be really proud of. I've not reached a point where the system has ground me down, and that may be the opportunities that have come my way, or the opportunities that I've made something of as I've gone through my career.

I'm also incredibly proud to have been elected as president and I hope that when I finish people will look back at my tenure and see that is has benefited obstetrics and gynaecology. The clinical side, any healthcare professional will be able to reflect on times when they have saved someone's life.

Whenever that’s happened, I have a great feeling of satisfaction. Sure, that comes with the losses, but if you are supported in your workplace, then people help you understand what happened, why you lost that patient, or why there was an adverse outcome, and whether there was anything that could have been done differently, so that you learn from it.

The other thing is achieving the right balance with my family. Medicine puts a lot of stress in many areas of your life, and certainly it's very hard not to take some home. I'm married to a paediatrician, who I love to bits, and I've been with her for a long time now, and we've both experienced those stresses. I think that helps. 

 

What have you learned that shaped you as a surgeon?

The biggest lesson was one I learned when I was a houseman at St Thomas' Hospital. One of my bosses  told me that when you're a surgeon it's an absolute privilege that the patient allows you to, effectively, modify their body when they are at their most vulnerable, ie deeply anaesthetised.

That is something that really should be in the back of our minds. That is the highest level of trust that anyone can give. You have literally the power of life and death in your hands, and I think medicine teaches you a measured approach to that trust; the sort of matter-of-factness of being a doctor, experiencing loss and also saving lives can be part of a day's work, and we must never lose sight of the privilege that we have there.

The other element of being a surgeon is that over the years, as your career develops, you are able to do more and more complex stuff. Does that mean you get better at the surgery? You probably do. That’s not necessarily because you become technically brilliant, it's because you work as part of a well-functioning team.

So as a surgeon, there are individual factors but actually the team has each others’ backs. The WHO checklist system and the way that we work in theatre helps team members to recognise that we're there to support each other. As a surgeon don't forget the trust the patient gives you and the whole team, and don't forget that if you respect your team they will respect you and support you to deliver safe care. 

 

What advice would you offer to young doctors about how to build a diverse portfolio of interests in their career?

There are two things here. Don't close your eyes to anything, that's the biggest. Be open to opportunities. The second is to deliver on what you promise. We all have busy lives, so you need to plan your life so that if you find an opportunity, for example, to do a piece of research with the team in the department, and you volunteer to be part of that team, you must deliver on what you promise, because not only will you benefit from the end product, be it a publication or an abstract and presentation at a congress, but actually you will earn the respect of that team.

When you earn the respect of that team, you develop a reputation, and that's a good thing to have, because then people go, 'Oh, yes, you know that guy; he was really good. He did this work, and we got a publication out of it, and he worked so hard.' I can think of many trainees who have done that with me, and they've gone on to some really great things, and indeed, a couple of them are working with me as consultants in my department at the moment.

It really does help. So don't close your door to anything, but when you take something on, be honest with yourself: can you do it? If you can, get on and do it, and enjoy it.

 

Is there anything that you'd wish that you'd been told when you were starting out your career?

I wasn't formally taught the art of attentive listening as a medical student. That wasn't part of the communication skills curriculum, because we didn't have one, but now it's great because they teach you the toolkit of communication with patients.

I'm lucky in that I'm blessed with an open style of communication, and that's how I have always been and so, when I came to Norwich, one of the things I did was work in a small faculty of senior medics teaching the art of teaching communication skills to other consultants and senior doctors.

That, for me, was the one thing that I didn't have at medical school that I wish I'd had, but I'm glad to have been part of that process at the University of East Anglia. I'm also really glad that it's there in other medical schools around the country, because I think communication and understanding how best to communicate is really important, not only because it makes people feel listened to; it also makes communication more efficient.

So you can get an awful lot more done in the time that we have available, and as we know in today's NHS, time is absolutely precious.

 

Have you had any key role models?

I don't think there is one single person, and I say this because I think your role models can be anybody. Sure, they can be that consultant or that professor who's doing today what you want to do tomorrow, and you want to do that in his or her way.

Yes, that exists, but another role model could be a colleague. It could be someone very junior to you who counsels someone beautifully, compassionately in front of you, and you learn from that, and I think this brings in the fact that actually, yes, role models are really good in that they show you where you want to be in the future, but I would say aim to be better.

Pick up the tips and tricks from everybody around you. You may see a midwife do one of the best counsellings ever in front of you, and that may well give you some hints about how you might address that in the future.

So it's the concept of lifelong learning that we're all encouraged to do, and we actually have to do in our medical careers as a part of appraisal, but I would say keep your mind open. Role models are there every day. There are people doing amazing stuff around us all the time. 

 

What's your favourite book?

This is such a hard question, because I absolutely love reading, but my absolute favourite book was a book I bought in my first year as a medical student, and it was called the Curry Club Handbook, written by Pat Chapman, and it was a recipe of curries.

As a student I worked through every single curry and knew how to cook them. The issue here is that I think food helps build friendships and relationships. It's core to a good family, and core to being a good social being.

From that, I have developed a passion for the country of India. I went there on elective as a medical student, and since then I've been there both on holiday, but also with the work that I do for the college, and some of the research I've done, people in India have wanted to hear about.

So I've gone out there and learnt not only my own interpretation of that Indian food, but also how enormous food is culturally in India, and how much more you can make of food as a cultural experience back in the UK. 

So yes, it was a curry book, of all things. It was a recipe book, but I'm not ashamed to say that. I have one tip of a book, though, and it's a very current book. It's written by Professor Michael West, and it's called Compassionate Leadership. It's quite a big book, and it's written like a textbook, but with illustrative cases.

It talks about how, if you want to lead effectively, you need to lead with compassion, understanding people and the situations that they are in, valuing their place in the organisation, and helping them shine. So I really recommend that book at the moment because it's an excellent read.

 

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