Why even ask the question? As a consultant & trainee you’ve been leading teams for years and you know your stuff. You are great and we love you, you are awesome, amazing, superb, a pinnacle of resuscitation and an all round superstar. Or so you might think…, but how do you know? How do you know whether you are great? How do you know if you are keeping up to speed with how others are team leading? How do you know if you are falling behind? Do your colleagues really do it better than you and do your colleagues rejoice or quiver when you stride into resus.
In simple terms how do you know….. if you’re good?
It seems like a daft question but as you get older and perhaps wiser the checks on your performance that take place as a trainee disappear. As a trainee in the UK (and I suspect around the world) there is an almighty portfolio of work place based assessments (WPBAs) and supervised learning events (SLEs) that dictate how, when and what you will be observed doing. Observation, feedback and reflection is structured back into your portfolio, reviewed by your trainer as formative and in some cases summative assessments. Whilst these are somewhat clunky at times and certainly onerous (though that is getting better) it does mean that there are feedback mechanisms on your performance embedded into your working life.
Not so as a consultant.
As soon as the ink is dry on your job contract a degree of independence is granted and the automatic mechanisms of feedback and reflection largely disappear. In the UK consultants are in relatively short supply (for some reason they keep moving to Australia) so we tend to work fairly independently and without oversight from colleagues. In the past the first time a consultant might be observed in their practice within an assessment setting might be after referral to the GMC with that being both rather draconian and thankfully rare, but it does beg the question why.
So, let’s start with a question…. who is this man?
Some of you will know that this is the great Shane Sutton. A cycling legend and Head Coach at Sky Pro Cycling. He’s an ex-pro cyclist, is still quick but is no match for the youngsters on the track. However, he is coach to some big names in cycling. He co-ordinates, plans and feeds back to national, world, TdF and olympic champions. An amazing job, but stop and think. Why does someone like Chris Froome or Bradley Wiggins need a coach? They’ve got the awards, they’ve done the training and they are at the top of their game? Pretty much all top sportsmen and sportswomen have coaches to develop them to be as good as they can be, even though they are already ‘awesome’ in the eyes of the world. Is there something here that we can learn as emergency physicians. Is this where we as emergency physicians should be aiming?
I do like my Army quotes and one of my favourites comes from the UK Army manual on developing leadership. I like this book as I really think that military leadership and EM leadership have rather a lot in common and one of my talks on educational leadership at SMACC was structured around this document. There are 5 elements that are required to develop great leaders, but as a senior physician I was particularly struck by the 4th element – development.
We should be aiming to be as good as we can possibly be, but in many ways it is an unachievable goal. There will always be areas that we can develop and that’s going to require help.
Let’s take an (imperfect) comparison between sport and medicine. In sport the further you go up in terms of ability the more analysis, support and reflection you get help with. In medicine it is the opposite, in fact it is worse than that. As you progress in seniority it is less likely to be offered and will be perceived to be less welcome (probably because it is unexpected). Why is that? Why does medicine shun a method that develops trainees when they become consultants? Is it unnecessary or is it just cultural?
Anyway, back to the dilemma. How do you know if you are a great trauma team leader (TTL)? This particular role is quite difficult to measure, there are some vague process outcomes (such as time to CT) but that’s not the same as defining a great performance that encompasses so much about making things happen and the related human factors.
Obviously you will have done ATLS, but that will focus on knowledge and skills rather than leadership. Newer courses such as ETC and ETM appear to encompass more on human factors skills but they are still not real life. Perhaps you’ve done one of the many TTL simulation courses and that’s great, I’m a big fan, but it’s not the same. Dealing with an actor being difficult is different to managing the real thing and it is in the resus room with real patients that we perform (in situ performance), not just in the sim lab.
In situ performance can only be determined in the resus room and that means direct observation from someone who is in a position to make an informed judgement. Now you can try and get your trainee to do this for you, but even in the very flat, first name only, friendly ED at St.Emlyn’s the power distance that this creates means that the process is less than effective. It has to be a peer really, someone that you trust and who you can give you an honest assessment of TTL performance, in reality that’s going to be another consultant TTL.
The process is really straightforward.
- A trauma call goes off
- One consultant will already have been identified as TTL for the shift.
- If another consultant is present they attend resus as an observer
- They complete a TEAM sheet on the TTL performance.
- Post resus the two consultants discuss
- Consultant has the option of adding TEAM sheet to their portfolio for use in appraisal and revalidation
The TEAM sheet that we use is based on the original paper from Resuscitation back in 2010 and can be downloaded here – St.Emlyn’s Peer TTL feedback Alternatives do exist and I’m quite interested in the feedback forms created in London and published in the EMJ in 2013. I’ve not used the 2013 version in practice as they look a little more involved, but I suspect they may be more sensitive to different behaviours and they come with a useful descriptors guide for scoring. They are certainly worth a look, this link should take to the scoring sheets used in the 2013 paper.
Unknown:Unknowns. In Virchester we always worry that there might be something that we don’t know that we don’t know. As Donald Rumsfeld said the real concern in life is when we consider the unknown unknowns. Although riduculed at the time, this is really important for us as clinicians. How will we ever learn about things that we don’t know that we don’t know. This is worthy of a blog post in itself, as it’s a major reason why we love #FOAMed in Virchester, but additionally we can learn from others in the resus room and certainly I have picked up tips from colleagues and vice versa. For example, I saw a colleague struggling with the pump for the vacuum mattress the other week. No-one had ever shown them how to use the suction apparatus to accomplish the same task…., they just did not know what they didn’t know, but in a few minutes of peer observation and feedback learning took place.
Consistency. If you work in the ED then you inevitably have different team leaders as none of us can be there all the time. As a junior I found it really frustrating to work with different consultants who had wildly different approaches in resus. At the time I kjust divided them up into the good (those like me) and the not so good (those who were not like me). In other words there was little or no rationale behind the judgement, but the variability was difficult. Peer observation amongst a same-grade peer group allows participants to observe and adjust behaviours to a departmental norm. The hope being that more extreme practices will be challenged and thus regress to a departmental mean.
Calibration. Calibration is similar to consistency but focuses on ensuring that similar standards in measurement are developed. In the resus room this encompasses things like checklists, some behaviour acceptance and application of departmental policy. An important but often overlooked aspect of team leadership.
What about the followers?
You may ask (rightly) why we have focused on TTLs rather than team members and that’s a valid point. Team membership and followership are vital in the resus room and they can also be examined and improved. We have started with TTLs for the following reasons, and although we will return to members later it seems right to start at the top. If we are not prepared to reflect and listen to peer review then we should not expect our juniors to, so in terms of this process we feel it is important to lead by example.
Should I be worried that consultants still need training?
Not really, as a consultant it’s important to make sure that you constantly learn and reflect. The principles of peer observation and peer facilitated reflection are not confined to trauma either. All leadership tasks in the resus room can benefit from this approach, it’s just that trauma offers a particular focus and requires a true multispeciality and multiprofessional skill set. Nor should you worry that this implies that our team is not already up to a high standard, they are. This approach is not about reaching adequate, or even good. In Virchester we strive for excellent and in medicine that means you need a little help from your friends.
Is this new?
Not really, I’m sure others do the same or similar. Different medical cultures may accept this as daily practice or may recoil in horror at the idea of questioning the consultant. It will depend on where and who you work with. For us, this is a valuable tool and we invite you to give it a whirl.
So if you’re serious about being the best, and if you want to beat the rest get some peer review into your life, you might just learn something….. reminds me of a song…… (skip to 1:09)