Two jobs

Two (& a half) jobs: doing too much?

If you don’t already know, I’m a consultant surgeon and Medical Director of my trust. These are both important and potentially stressful roles but I love them both. One could make a case that both of these roles could and should be near full-time.
As part of the revalidation for doctors, Responsible Officers can’t be appraised internally. I have appraised six other Medical Directors/ROs. For each of them, having enough time to fulfil all their various duties was a very important and pressing issue, so I am not alone in finding time-management a problem.
I was a member of council of the Royal College of Surgeons for 10 years, which inevitably meant time away (at least 2-4 days a month) from work, often in London, for various meetings. This term of office has now come to an end but I have recently been appointed as chair of the East of England Clinical Senate so I am unlikely to find myself with spare time on my hands.
I don’t only work. I got married almost two years ago and my wife, Liz, not unreasonably would like to see me occasionally. She has even taken up cycling, which is something I really enjoy, to allow us to spend more time together; true devotion.

My priorities as a surgeon

In essence there is a balance and tension between clinical and managerial commitments. Clearly as a doctor, care of patients has to come first. Indeed that is rightly my prime responsibility under the GMC’s “Duties of a Doctor”. In addition, I have a responsibility to keep myself clinically up-to-date. My being a surgeon, which is a technical specialty, compounds this. If you don’t do enough, your skills will inevitably get rusty.
My clinical practice undoubtedly helps me as a manager and as Medical Director. I still do my full share of on-call commitments as a consultant general surgeon and this is more than many MD colleagues.
I am also a member of a small and friendly general surgical department and a team of six consultants who share the on-call. Whilst I might have one and a half feet in the management camp, I do think on balance they like having the Medical Director inside their tent. I do know though, that the moment I cut back or stop doing my full share of on-call they will quite rightly see me as at-best a semi-detached member of the team. I would also run the risk of rapidly becoming clinically de-skilled.
Whilst I don’t look forward to my on call weeks, when I’m actually doing them it’s quite fun. We have a nice setup whereby we are on-call with the same junior doctors for the week and it’s a pleasure getting to know, work with and listen to them. Being visibly present in the hospital in the evenings and at weekends is good for my credibility amongst my colleagues. In addition the significant clinical exposure, both in and out of hours, helps me understand how the hospital does (and unfortunately at times doesn’t) work and I am able to bring this experience with me to my role as MD.
Finally I don’t intend to be MD forever and I need to keep my options open. I'll be 50 next year and if I were to stop clinical practice or on-call it would be near impossible, even with a “retraining package” to resume either.

My priorities as medical director

As Medical Director I still have a priority to put patients first, with the difference being that this applies to all our current and future patients, not just the individual patient in front of me.
The NHS is facing huge challenges, and my organisation will need to adapt to face these challenges and to survive. We are under ever-greater scrutiny to ensure that we provide high quality, safe, effective patient-centred efficient care. There are major change clinical projects that we need to implement. My Chief Executive wants and needs more of my time to help deliver this change.

Why am I writing this now?

I am fortunate to work in a generally supportive environment with great surgical colleagues who are also prepared to challenge me when necessary. Clearly my appointment as Senate chair meant I needed to adjust my timetable. To discuss this, my clinical director and general surgical colleague arranged to meet me with my Deputy Medical Director. They wanted to articulate concerns that I was trying to do too much and, from a clinical perspective, was at risk of taking my eye off the ball.
I am so glad that they felt able to say this to me as it had been starting to concern me too. As one of my pledges for NHS Change Day I had said that I would publish "an error diary". I had identified a few episodes where I felt I could have done better and it had already become apparent to me that there was a unifying theme: trying to fit in important clinical work such as on-take ward rounds on days when I had major MD commitments such as Trust Board day.

What do I do now?

I have already openly discussed these issues with my collective general surgical colleagues. In addition I have talked this through with my specialist registrar (and also apologised if I haven't been supportive enough of him, though he did say this hadn't been a problem from his point of view).
There are some simple things that I can do to improve matters. For example we have a fixed on-call rota but swaps are feasible. It is clear to me that I simply can't be on call on a trust board week and I've arranged, thanks to my colleagues, the necessary swaps.
I will also ensure that I reduce to the barest minimum my non-clinical commitments during my on-call weeks, though stopping them completely isn't possible.
I also need to ensure that I delegate appropriate tasks to ensure that I can concentrate on the things that really need my attention.
The fact that these issues have come to a head will also force me to consider, in more concrete terms, how I see my career progressing. The steps above will help but I will, I am sure, continue to face considerable time pressures. It may well be the case that something will have to give and that I will need to stop doing something.
I have wondered if I am kidding myself that I can simultaneously be both a functioning Medical Director and a safe/effective consultant surgeon participating in the on-call rota, whilst also have a fulfilling family life. Chairing the Clinical Senate is likely only to compound these issues.

Wider issues

Just as I have to address these issues at a personal level, it has prompted me to think about how this impacts upon the professed need and desire for the wider NHS to have greater clinical leadership to help meet the quality and financial challenges that the service faces.
The role of the Medical Director has changed enormously. It is no longer the preserve of a senior doctor who plays a patrician role in the run-up to their retirement. The role is much more hands-on than it used to be and this potentially conflicts with clinical practice.
Interestingly there are currently five medical directors posts, in acute trusts, advertised in the Health Service Journal and on NHS Jobs. Clearly a number of trusts are considering recruiting external candidates and the inference is that the clinical commitment is likely to be small.
All parts of the service want as much clinician involvement and leadership as they can get. There is a cohort of doctors who relish the challenges of the role and the opportunities offered to make a difference. I do fear that for many of these doctors a de facto requirement for Medical Directors to be almost full time might be too high a price to pay. The NHS might find itself recruiting from a small a pool of potential talent, particularly as there is no obvious “exit strategy” for ex-Medical Directors.
This is also an issue for doctors. There is a tendency for us to regard only clinicians who still see patients as being “proper doctors” and this is becoming more untenable. It can however be argued that being part of an “exec on-call rota” when beds are tight on a Sunday night does give one a pretty good idea how a hospital works (or doesn’t work) when under pressure.
I have started to wonder whether it is possible to combine being medical director with a significant clinical practice (particularly for those of us in front-line specialties with a “caseload” of patients under our care). I do wonder if a shift towards near (or actual) full-time Medical Directors risks losing some of the undoubted advantages that having clinical exposure offers to medical directors.
I am soon going to face a crunch point when I need to make a difficult career decision. Similarly the Trusts and the medical profession need to be clear as to what they expect of their most senior clinical leaders.
As a post-script, I regard this blog a fulfilment of my NHS Change Day commitment to publish an “error diary”.
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© 2013 Dermot O'Riordan
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