My time in clinical leadership

By Arthur Stephen
Consultant Orthopaedic Surgeon, University Hospitals of Derby and Burton

Published 11th May, 2023

I like fixing things; how successful I have been is for others to judge, but it’s one of the reasons why I chose orthopaedics as a career.  Bone has that unique quality of healing ‘like for like’, but only if provided with certain conditions.  The degree of stability, the soft tissue envelope and the integrity of the blood supply will determine the chances of success.  These are simple rules that yield consistent results if adhered to. After a couple of decades as a consultant and 10 years in clinical leadership roles, I am now beginning to realise that leadership skills also follow rudimentary principles.  ‘Managerial discord’ can often be unpicked and with the benefit of hindsight, one can see where these principles have been abandoned.  Here are a few to ponder.

Training

There wasn’t much in the way of training or guidance a decade ago, but that is changing.  For those interested in such roles, there are courses that are available (such as the Future Leaders Programme run by the BOA) where one can:

• Learn from the successes and failures of those who have gone before
• Establish collegiate networks
• Appreciate that most centres experience the same problems
• Find a safe place provided to vent!

Apples and oranges

I have witnessed countless examples of different groups of clinicians comparing their practices to other groups, either in the same units or elsewhere.  There is an inevitability in this situation to feel either superior or inferior, depending on which side of the fence one finds oneself on.  Such comparisons are common and can be used for constructive improvement or destructive criticism.  Where there are unit deficiencies, it is rarely the consequence of one individual and more often than not, the system/pathway that needs addressing.  Always be sure, however, to make sure direct comparisons are just that, equitable, comparable and with robust data.  Ask both sides to produce the same metrics and if there are wide differences, establish if there are administrative/data collection reasons before attributing clinical incompetence.  Where possible, use regional or national comparators as benchmarks.

In the round, comparisons can be healthy.  Would Messi be the player he is without the comparisons to Ronaldo?  If we are in the pursuit of excellence and strive to level up, then they will only serve patients well.

Meetings

‘Far too many and with no purpose’ is a frequent summation of the usefulness of meetings.  Why?  Time is precious and time spent away from patients is a waste of an expensive resource (our medical workforce), if one doesn’t see purpose or output. So:

• Never start a meeting without a clear and realistic agenda, preferably one that has been shared with the participants in advance.  Give time for a meaningful discussion and avoid having to ‘bring it back’.
• Make sure the people in the room have a mandate to make the appropriate decisions.
• Ensure the correct expertise is available if it is outside your area of specialism.  However, it is sometimes beneficial to have an external perspective on a problem that has proven difficult to solve for some time.

Circles of influence

Possibly the most valuable lesson I have learned.  Know where to invest your time and energy:

• The circle of concern. These are external influences that are completely out of our control (government policy, the economy, the weather and whole system reorganisation, etc).  We cannot change these things and there is little benefit or purpose in trying to do so.  However, reflecting on their potential impact is of course useful and to ignore them may be hugely detrimental.
• The circle of influence encompasses our relationships, our working environment our territory.  Here we can exert some control by example or influence. This is probably the most nuanced area where there is most scope to change, but perhaps the hardest area to do so!
• The circle of control.  These are those things that are absolutely within our gift to control (what we say, our tone, our actions, etc).  It is often these actions that others look at which consequently determines how one is perceived.  As a result of these perceptions, people will decide whether to listen, engage, contribute… or not.

Therefore, be responsible for those things that are directly within your control.  If I can’t control something, what ability have I to exert influence?  If I can’t influence or control, can I learn to accept?  A hospital merger is probably out of our control.  How we set up a joint department is up for discussion, debate and influence. How we act within that new structure is absolutely within our control.

Solutions

Solutions can come from anywhere.  Put the right stakeholders in a room and one will find solutions to most issues.  Try not to isolate the issues down to the smallest degree; patient care is all about pathways and the unintended consequences of one element of that pathway can change things right along it.  Think about how change requires total pathway consideration.  Being more productive in a theatre either means you do the same amount of operating in less time or you do more operating in the same time.  If the latter is the case, you need more patients, more beds, more pre-op, more physio, more rehab, etc.

Shouldering responsibility

As a clinical leader, you do have to make difficult decisions.  No different to making difficult decisions in a clinical setting with patients, but as clinicians we are trained to do this and often seek counsel when those decisions are difficult (MDTs for example).  Managerial decisions should be no different.  Try and establish a culture of collective responsibility; it should all be for the benefit of patients.  Seek guidance from those who have done it before, peers in other centres or networks.  Don’t be afraid of challenge. Encourage it, as long as it is constructive and be prepared to change if it is for the greater good.  Decisions can be iterative and develop.  Entrenched positions, however, are rarely helpful, there may not always be a best solution, but there will always be a ‘least bad’ one.

In summary, as sung by Sinatra: “Regrets, I’ve had a few,” but by and large I have found my time in clinical leadership more rewarding than not.  I would encourage everyone to think about it if you think there is scope for improvement wherever you work. Remember, you can’t stop a juggernaut by standing in front of it.  Get in the cabin.