Professor Jeanette Dickson, President of the Royal College of Radiologists

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 Professor Jeanette Dickson, a consultant clinical oncologist and president of the Royal College of Radiologists. Professor Dickson’s main clinical interest is in the multimodal management of thoracic malignancies and she also maintains a strong interest in medical education. 

A podcast of this interview is available here 

 

How have you got where you are today?

I had a slightly unusual childhood. I was not the first person in the family to go to university but fairly close to it. I wanted a job that I could enjoy doing for the rest of my life, that would support me, and always be employed. It was so much a massive vocation but more a wanting to do medicine. But I found that I really enjoyed it. 

It was Glasgow, it was the 1980s, so the first medical ward I was on, the first clinical attachment, I had lots of people with signs. Now, in Scotland at that time it was often either heart failure or atrial fibrillation, so it was cardiovascular disease, or it was cancer. The SHOs at the time, now CMTs or IMT trainees, would take you and teach you about somebody with heart disease, and they'd tell you all about the management of heart disease, which was fine. 

But, if you went to see the cancer patient, you'd diagnose them as having cancer and then the SHO would say, 'Well, they're off to the cancer centre tomorrow and we don't quite know what happens there.' I was intrigued by the fact that an awful lot of folk went off to the cancer centre and nobody appeared to know what happened there. 

As I went through training, I really liked the cancer patients. I liked the variety; I liked the difference in the disease; I liked the different way of approaching it. I just thought that it was for me, so I went and did some house jobs in medicine with a medical oncology attachment. Then I did a surgical attachment in breast surgery and screening and neurology, so again, lots of cancer patients, then went off to get a membership, because you need a membership. 

At that time there weren't many rotations, it was usually stand-alone six-month jobs. So I did the first six-month job, but I failed my membership and I thought, right, I need to have job security because I don’t want to be continually trying to revise and apply for jobs. 

So I applied for any job that was a 1 in 5 or quieter, because at that time there were still 1 in 3s and 1 in 4s. I ended up in Eastbourne, 500 miles south. It was difficult to know who was more surprised, them or me, because it was quite culturally different, which was interesting. 

I did that for 18 months, got both parts of my membership quite quickly, knew I wanted to do oncology but then thought, well, will I go for medical oncology or clinical oncology? I took what was then a locum appointment for training (LAT) post in oncology back in Glasgow, and really found my tribe. Clinical oncology was it.

Radiotherapy, clinical oncology - I really just liked the people, liked the patients, liked the team, liked the vibe, so I thought, right, that's it. Got my FRCR after three years, and this was before there was a lot of money put into cancer services. It was very competitive, so I thought, right, I've been a bit gobby, I've not been the most overachieving registrar - I need to be competitive. 

So I managed to get an MD in Manchester at the Paterson Institute and did that for two years. I hadn't done an intercalated science degree, or a research degree, so I didn’t know what academic life would be like. Turned out it was just like being an SHO again - having to reapply for my job every few years which was not really my kind of thing. 

After that I thought I would like to see somewhere else rather than go back to Glasgow, so I wangled an inter-deanery transfer down to London, to Mount Vernon, which is where I finished my training. The rules were slightly more relaxed in those days! 

Then I decided that I'd moved about quite enough, so I stayed as a consultant at Mount Vernon, which was the true start of my career. It's quite a difficult thing because when you're in training you think the training is it and it's going to be forever, but actually you then get to a permanent job and you think, okay, I've got my permanent job and it's great. 

Then you think, well actually I'm going to be doing this for 20, 30, 40 years. And as much as I love the patients and enjoy the clinical medicine, I need something else to take me away from that intense thing with the patients. 

Around this time there was a lot about the European Working Time Directive, reducing hours, a lot of angst about rotas - things don't change - a lot of unhappiness about things. I took on that and then got interested in education and the experience of trainees, to try and make their training better, all for the benefit of the patient. It's all about the better you train trainees, the happier they are, the better they are for the patient. 

Then I became a head of school, then a clinical director of the department, because you could then make things better for your colleagues, which would make things better for patients, because happy colleagues mean better patient care. And through that I got involved with the heads of service at the Royal College of Radiologists (RCR), and national recruitment. 

I quite liked the college and I thought, actually, I can influence more colleagues, so I could make it better for more patients. I applied to become the medical director of professional practice, which is the officer who looks after professional standards post-training. 

Then I went on to be the vice president for oncology, and I'm now the president. It's all about improving - essentially, it's all about patient care, but it's improving patient care not necessarily directly but indirectly by improving the staff and colleagues.

 

What are your clinical interests?

I'm still a practising clinical oncologist. I work in the NHS about three or four days a week, mostly out of hours or at the weekend, and I'm at the college for about two and a half days. 

At work I do predominantly thoracic malignancies - so lung cancer, mesothelioma, thymoma - and I treat patients with chemotherapies, systemic anti-cancer medicines, so the new immunotherapies, the targeted agents, and radiotherapy. To me radiotherapy is the interesting bit; the unique selling point of clinical oncology. 

I do a bit of radiotherapy for lymphoma but not very much else. I'm still an educational supervisor and a clinical supervisor. I do supervision of F1s because it's always nice to meet folk who are coming into medicine because they're always really happy and really keen, and it's nice to see young, enthusiastic people. Also, it means you can sometimes influence them to join the specialty later, which is what it's all about.

 

The royal college is both for clinical radiology and clinical oncology. What's the history behind that?

I don't know if you've ever seen that X-ray picture of the hand with the wedding ring, Mrs Röntgen's

hand, but that was cutting-edge technology. At first there were only what we call low-energy X-rays, kilovoltage X-rays, those that take X-ray pictures. Around the same time that Mrs Röntgen's hand was being X-rayed, there was an understanding that you could use them to treat superficial cancers, mainly skin cancers, because they are not very penetrative. 

Also, at the time, they were used to treat some dodgy stuff like lice and scabies of the head. And the pioneers were both takers of pictures - radiologists -  and treaters with radiation - clinical oncologists. 

The college started off with two groups who were the same, who were cutting-edge technology specialists, and we've diverged because radiology has taken on ultrasound, MRI, interventional radiology, treating things, functional imaging, radioisotopes and so on. 

Oncology has adopted drugs, systemic anti-cancer therapies and also treatment with radionuclides. As technology has advanced, what brought the specialties together has diverged, but we still have radiation in common, which is why the motto of the college is, 'From Rays, Health' in Latin. The college is a moderate-size college. 

I'm hoping we'll get to 12,000 members before I leave. At the beginning of 2022 we're at about 11,500 across the UK and beyond. We have a huge global presence; a quarter of our members and fellows reside overseas, a significant proportion in Hong Kong, Singapore, India, Egypt, but as far flung as Papua New Guinea. 

The college is there to promote the art and the science of clinical oncology and clinical radiology, to raise the profile of the specialties, to raise the importance of the specialties to the public and to politicians in the UK, but also to help put in standards around delivery of the services, and also to train people.

 

What made you run for president?

I really enjoyed being vice president and, before that, medical director of professional practice. I really liked going to college. It was really good and, as a tip for your junior doctors, it's really good to get away from the clinical job to see another type of workplace, another type of thing happening. 

It refreshes you and it also gives you distance from the clinical things so you can step back and say, 'Oh, this is a system - I can change the system'. It was one of the things that allowed me to step back, but also still influence patient care. I really enjoy my time at the college. It's hard work, but it's fun, and you meet people from all round the country. 

You meet people from all round the world. You get to talk to people you would never get to talk to, so you get to meet the chief medical officers of the country. You get to meet politicians. You get to meet the folk who influence and who run NHS England and the other NHS bodies, so it's a really interesting thing to do, and you get to influence, and you get to shape things. 

I'd enjoyed doing that as vice president, and the question was, could I do it as president for a specialty that wasn't my own? If you look at most of the royal colleges, they're usually one specialty, so it's paediatrics and child health, obstetrics and gynaecology. 

The physician specialties are different in that there's 30-odd of them in the college of physicians, but they are linked by being physicians, having inpatients, doing the take, and the surgeons are linked by surgery. But with these two different specialties, it was a personal challenge, ‘Could I do it?’

But I thought I'd done quite well as the vice president for one specialty, so I thought I could take that and make the organisation better. The college represents me, and it will represent me when I am no longer the president, so should I take the college into that stronger position?

 

What were your key priorities and what have you achieved?

I started off in September 2019 and I was asked by the chief exec to give a presentation to staff about what I wanted to achieve and my vision for my presidency. I did gently point out that visions are what you have when you have too much alcohol, and I struggle with having big visions because you can be derailed by circumstances. 

There is a fateful slide in that presentation that says, 'I want to do some things, but I am aware I may be derailed by circumstances,' which shows that I could probably make money as a mystic! Anyway, on day two of my presidency, the chief executive announced he intended to leave the job; he wanted to not work full-time. 

So I was tasked with replacing him, and it was really important for the college, and for me as the president, to be supported by a really strong staff team. 

You don't achieve anything without a team and so replacing the chief exec was the major thing that I had to do and again, it's one of those things.I have done a lot of interviewing and a lot of recruitment in my time, but never for somebody in the chief exec role, so that was the first challenge. 

The next challenge was our charter, which is the way we run the college. It was given 48 years ago and it's creaking because times change. It's good, it's lasted really well, but it creaks a bit; for example, it has no female pronouns in it. 

So there was a need to overhaul the governance structure, which involves agreeing what we need to do, taking it to the membership and getting it to the Privy Council. We are two-thirds of the way through that. We're at the point where we're going to talk to the membership about what we think we should do, so I've done those two things despite Covid. 

The other thing I really wanted to do was land the importance of diagnostics. Politicians get the importance of cancer treatment, but diagnostics they don't. Covid really helped because it has allowed us to move diagnostics, imaging especially, front and centre. 

That has meant that this year, as well as achieving a ten per cent uplift in oncology training posts, we've achieved a ten per cent uplift in radiology training posts. That’s not enough by any manner of means, but 110 new training posts in radiology is more than any of my predecessors has ever managed. 

The other thing was to try and improve what's called 'membership benefits'. Colleges are membership organisations. You join them because you want to join them. As a trainee generally you join them because you have to, to get the curriculum, but after you've become a consultant, you don't have to be a member of the college, so it's really important that we provide value. It was trying to work out what provided value for my colleagues. 

Things like producing standards and guidance that actually helped people. Trying to help produce useful documents around job planning. Trying to, for example, promote equality and diversity within the college.

I don't come from the most privileged background, so it's quite important for me to talk about widening participation so that the specialty and medicine better reflect society. Your doctors and your healthcare professionals should reflect all of society, not just one bit of it. 

And if you have those members and fellows within your college, it's really important to hear all of the disparate voices, because all of the voices are really important. The diversity of the voices is what really drives change. I've not done as well on that as I had hoped, but we're getting there.

The other thing is supporting colleagues. I am a trained Schwartz Rounds facilitator, which is the only evidence-based way of supporting the whole team and improving the morale of the whole team. We have done some work on stress, well-being, and promoting that within the workplace, and we've also worked across faculties. 

We've brought the two halves of the college together, which I also think is really important. For many years the college has done stuff for oncology and stuff for radiology, but it's not mixed the two, and we do have a lot in common and a lot to learn from each other, and I wanted to do that as well.

 

What are the challenges facing the college and the specialty?

As a college we have struggled, as everybody has, through Covid, but actually we've come out the other side quite well. We've had some issues with our exams, which we've now moved online, and we're working through those, but the college itself is financially sound. The major issue for radiology and oncology is workforce - there isn't enough. There just isn't enough. 

Demand is rising and how do we expand the workforce? How do we protect the workforce we have from burnout, from stress, and keep it working? How do we retain that workforce within the NHS? How do we promote the value of our specialties to the public because, essentially, it’s the public who influence the politicians. 

If you want to influence politicians, you can influence them directly or you can influence the public, and we've done a lot of work around expanding our communications team to promote the value of the specialties. 

 

Can you tell us about the RCR’s Care Is Not Just For The Patient report?

Yes, this comes back to 'health and well-being'. It usually gets called 'stress and burnout', but I much prefer to talk about the health and well-being of the workforce because the NHS is a difficult place to work at any time. It's much more difficult at the moment because of COVID and it's also going to be more difficult as we come out of COVID with long backlogs and austerity because we've not, as a country, got a lot of money at the moment. 

The report looked at the lived experience of our specialties in terms of burnout and mental health issues. Oncology is generally higher anyway, but both specialties have had significant experience of that through COVID but also pre-COVID. It looked at what were the specific triggers in their specialties. It looked at what could be done to identify colleagues with potential stress-related things and what interventions could be put in by departments to help colleagues. 

It also brought up some stuff we could do. For example, our job-planning guidance is being re-written to try and promote a healthy work-life balance. It also signposted people to all of the national resources available, so the title says it all. Everyone goes, 'Oh, we need to care for patients, and caring for ourselves is not good - it's taking away from patient care.' 

Actually, if you don't care for the workforce, you get bad patient care, so caring for the workforce, supporting people, supporting all of the team, actually improves patient care. You need to care for yourself as a person but the NHS needs to care for its workforce. The document was about how you could do that within the services that we have.

 

What are the biggest changes you have witnessed within the field of oncology during your career?

I came into oncology because I liked the variety of patients, and when I trained, you saw lots of different patients, but you didn't have many treatments for lots of them. As treatment has become more complicated and better - and we are doing better in cancer, I think that's really important to say - we have narrowed how many cancers we see. 

I now do lung cancer and occasional radiotherapy for lymphomas, so that's two tumour sites. When I started, everybody did everything or four or five tumour sites, and now we're moving towards one or two. 

Some places which are really struggling are still doing three or four, but generally there's specialisation, so you lose the variety, but you gain something in that you're seeing the same type of patients all the time. You can choose what sort of patients, what sort of patient population, suits your personality best and suits your skill set best. 

Multi-disciplinary team working is a way of discussing all the patients and getting the best care. One of the things I think oncology has been a real trailblazer about is about multi-professional team working. You cannot achieve anything in medicine without working as a team - you just can't.

No person is an island. You don't do anything on your own, but oncology, when we had a lot of expansion of oncology services in the early noughties, there were not enough doctors to do the work. 

There was more demand from the patients than we had doctors available to fill the jobs, so we started extending the roles of the nurses we worked with. We started extending the roles of the radiographers we worked with, the radiographers who work the radiotherapy machines, and the pharmacists we worked with. 

We began evolving multi-professional teams where, if you are a patient, you would be seen by the team member who needed to see you, rather than just the doctor.  That means patients are often seen more rapidly and more efficiently by another member of the team, and the more complex patients are being seen purely by people like myself, so you're working at the top of your skill set. 

Unfortunately, there isn't enough of everybody, so I'm still doing a spectrum of things, which is quite nice because it means I don't constantly deal with incredibly complicated patients, but also I lead a team that isn't just doctors. So you've got people with different skill sets and different views. 

That interests me a lot. It's really nice to work with people from a pharmacy or a radiography background, because they come at it from a different angle and they see different things. That's probably the biggest change that we've seen over the past ten years.

 

Where do you see oncology heading in the next five to ten years?

Am I ever going to be out of a job? No. Demand is increasing significantly. The population is ageing. Despite what you see in the media, cancer is predominantly a disease of the elderly. Younger people get it, but the vast bulk are older, they're multiply comorbid, they're more complex, so there's going to be more cancer coming. 

The treatments have got more complex, and that's going to continue, and we're going to have much more individualised treatments. At the moment, my biopsies of lung cancer patients get sent for five tests and, depending on what comes back, I treat them in very different ways because we have drugs specifically for each type. 

That personalised medicine is really good. The technology in radiotherapy has come on massively, so that we not only cure a lot of people, but we don't leave them with as many long-term side effects as we did, and I see that continuing. 

I see us expanding the skill mix more and having wider, bigger teams. I see change in technology and changes in drugs and we’ll be challenged to do new things like learning new radiotherapy techniques. As well as us clinical oncologists, there are also medical oncologists who don’t use radiotherapy and just treat cancer patients with drugs. 

They started off as academic pharmacologists, drug developers in big, tertiary centres, university hospitals, and there were only a few of them. But as the number of drugs for cancer patients has increased, they've expanded as well. 

We usually work in a mixed team of not just nurses and radiographers and pharmacists, but also medical and clinical oncologists together, but we're two different specialties. We're two specialties in two different colleges - they are in the college of physicians - and it seems daft to me that we don't work more closely together. 

Over the next ten years I think we will come together. The new curriculum launched in 2021 has a common year. The first year is common for both clinical and medical oncology.

The outcomes at the end of that year are common, and I think as time goes by over the next ten years, that will increase, and we will work more closely with our medical oncology colleagues and maybe come together in one big specialty. 

That would be nice, I think, and I think it would be beneficial for us all. We need to work together for the patients. Politicians often try to drive a wedge between us, and I think it would be good not to have that happen.

 

What makes a great oncologist?

The thing that makes a great oncologist is this thing that makes a great doctor, actually. One of the joys of being a president is you get to meet all the other presidents, and you begin to realise that stereotypes exist for a reason but, also, the skill sets you have are much the same. You can't really exist in medicine without working in a team and you have to be patient centred. 

When I'm having a conversation with a patient it's, “What do you want from your treatment?” and  “What can we achieve for you?” It’s not, “What I think you should have” or “What your family or neighbour thinks you should have” it’s, “What can we achieve for you?” 

That communication, finding out what the patient wants and trying to match those expectations with what you can achieve, and the ability to let people choose things that you wouldn't, that's quite difficult. 

You also need to be open to change because technologies and drugs change quite quickly. Sometimes you go to a conference one year and you learn something, and you say, 'Oh, yes, great.'

Then the next year it's something new, something different, so it's quite a rapid pace of change. What else? You need to like people, but I don't think any of these things are particularly oncology-centric. You also need to be pragmatic. 

The stuff we do to people is quite expensive and complex and you need to be able to talk to patients about what they want and what you want and what you can achieve. It is about marrying those expectations.

 

How does the UK compare globally in terms of cancer outcomes?

Generally speaking, we compare quite badly. There's a lot of argument about whether we are as bad as we appear to be. We are blessed in one way with very accurate cancer reporting because we report on every patient, and we have universal healthcare. 

If you look at the US, they often will only report on that proportion that can access healthcare, which is not everybody. However, when you look at us compared to countries with similar universal healthcare systems, we don't do as well. 

We are improving. We improve year on year, or we did up until Covid. We were improving, but we hadn't closed the gap between ourselves and other countries, and I think one of the major reasons for that is because of the lack of capacity we have, especially in diagnostics, but also in primary care. 

In the UK, patients are less willing to bother their GPs than they are in other countries, so we need to educate people to access general practice more, but we need to have enough GPs for that to happen. 

We find that we do a lot fewer imaging tests - CT scans, diagnostic scans - than other countries do. We have a very small workforce and it's too small for the demand we have already, so we need to increase capacity more than we're already increasing it. 

I think we also need to make sure that the oncology workforce, the delivery workforce, is supported to deliver the best care available, be that by technology or by drug availability. I think it's a multifactorial issue across the pathway, but I think we don't do as well as we should.

 

With new treatments, more demand, and the spiralling costs of healthcare, is it sustainable?

I hope so, because I think universal healthcare is the only truly ethical, equitable health care but what you're talking about is rationing, and we do ration anyway. What we should be doing is looking at using the resources we have in a more efficient way. 

For example, expanding that diagnostic capacity so that we can do more imaging and screening of asymptomatic people, diagnose cancers earlier, and improve survival. We do need more investment, but we need to target the investment. If you diagnose cancer earlier, you don't spend as much and you cure more people. So where do you get the best bang for your buck?

 

What have you learnt about leadership during your presidency?

Oh, lots! It's one of those things where you may start off thinking it's going to be one thing, and you may find that you have no control over what it actually becomes.

You do need to be aware that you might not get the path you want, and you need to be resilient about that, and you need to be able to re-prioritise and reassess and move forward. You need to communicate - you can't communicate too much - and you need to do it in a way that's accessible. 

It's been quite nice because people email me every now and again about my monthly blog.  What they say is, 'I've read your blog and it just sounds like you've just got a normal experience. You are obviously on the front line like us.' Communication needs to be relevant to people and their experiences. 

What else have I learnt? When you talk to people about chemotherapy and the risks and the benefits of chemotherapy, you get to know that people have variable risk appetites. But Covid has really thrown into quite stark relief how variable people's risks appetites are and how people view risk. 

When you're leading people, if you want consensus to move forward or support for your leadership you need to understand where people are in their risk appetite. You also need a Plan B; my life is full of Plan B, Plan C, Plan D, and you really need that when you're a leader.

 

What are some of your proudest achievements?

Oh, that's a really tricky one. I'm proud that we've got the college and the specialties through Covid, so far, reasonably well. We've not managed everything and we've not done everything perfectly, but we have been a positive force. 

If you'd said to me as a teenager, 'You could be the president of a medical royal college,' I would have used an Anglo-Saxon phrase that I will not repeat at the moment. But you look back and you think, ‘I looked after 30 per cent of the trainees in the UK. I was a head of school.

I was the clinical director for a department with a £20 million turnover’. I wouldn't say I've achieved everything I wanted to achieve, but I would say that most of the things I've taken on, I've made better and when I've left, I've left them better. 

One of the other things that I'm quite proud of is that I can leave gracefully. If you leave a job, you really need to leave it for the next person coming in. I'm quite proud of the ability to step back and let somebody else do what they would with the job.

 

What has shaped you as a physician?

Simple things like ‘please’ and ‘thank you’ take you an awful long way. Kindness, courteousness, civility cost nothing and have a massive, massive impact. In fact they have a disproportionate impact. There is nothing as good as saying ‘please’ and ‘thank you’ and recognising people's contributions. 

The other thing is that mistakes happen, no matter how good you are, and no matter how much you try to mitigate against them. Mistakes happen, and you need to accept that, and you need to be able to reflect on it.

It's okay to say, 'I've reflected on this and I made a mistake and next time I won't make the mistake, and things will be fine.' But it’s also about realising that not every bad outcome is because of a mistake. Actually, there was no mistake. Things have just gone really badly. 

I have a number of patients who've died fairly shortly after I've treated them with chemotherapy. And, when I reflect, I would still have the same conversation with them, I would still give them chemotherapy, and they would still die. You need to learn how to deal with that.

Yes, you have to reflect, and learn from your mistakes, but sometimes, when you reflect, you can't actually change things, and how do you cope with that?  

I've also learnt that teamwork is better. It's much more fun doing it as a team. I've also learnt that you don't need to do everything. You can delegate and you can let other people do things, and that's great. A bit of a hotchpotch of things learnt there.

 

What would say to young doctors about how to excel and have a fulfilling career?

I'd say, one, it is a great career. It really is a great career. There are frustrations, there are irritations, there are things that do need to change, but I still wouldn't have chosen to do anything differently. 

Clinically, I've had a great time. The important thing is to do something that you enjoy. I knew very early on what I thought I enjoyed, but actually you need to accept that sometimes it takes a wee while to dawn on you what you enjoy. 

Make sure you have a work-life balance and, also, remember that you are part of a team. You don't have to do it alone. You are allowed to reach out for help. It is not about soldiering on. I think that one of the joys, one of the things I've learnt about enjoying my career is engaging with the members of my team and having that team discussion and that fulfilment in the team.

 

Have there been any role models who have shaped you as either a clinician or a leader?

That's really tricky. I started in medicine a long time ago and there weren't very many female role models about. I didn't actually work for, or be trained by, a female consultant until 18 months into my career. 

But there have been lots of role models, and what has attracted me to those role models is that they think the same way I do. They have the same values that I do. They have humanity. They have a desire to serve the patient. They are there for the patient. They've a desire to do the best for the patient, and sometimes that best for the patient is not the best for the patient in front of you. It's the best for a group of patients. 

Those are the people who I have learnt from and used as role models. They have been all shapes and sizes and all persuasions and ethnicities and genders and whatnot, but they have come at different times. I've never met anybody who reminds me of me but I've met people who I would want to aspire to be bits of, but not be that person.

 

What's your favourite book?

I'm not a great one for favourite books. I tend to have favourite authors. I don't read a lot of high-class literature. I tend to read less challenging things, like a nice crime novel. I like a bit of science fiction. I like a bit of comedy. 

There's a science fiction writer called Anne McCaffrey; I very much enjoy her writing. Terry Pratchett, I really enjoy some of his stuff. Probably if you were to twist my arm, some of the Discworld series would be my favourites, but I do like a good crime novel as well.
 

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 researcher.