Management (week 7 of 8)

For this week's blog, I will focus on the area of management - of yourself, your career, your team and wider service. I have also thrown in some random images of key figures from the history of psychiatry, all of whom did groundbreaking work leaving lasting imprints within our profession. The range of work of these different individuals is interesting from a historical and scientific perspective while also serving to highlight the rich and varied nature of our profession, from the very 'biological' neuropsychiatric work of Alzheimer and Pick through to the psychotherapy and psychoanalysis of Yalom and Storr. Furthermore, scanning over the achievements of any one of them should be enough to fill you with stunned admiration and inspire you to make the most of your career. 

But back to the topic at hand. First and foremost, 'management' is not just for senior clinicians. You should be developing personal self-management and general management and leadership skills from your earliest days as a Trainee.

So always consider the ‘big picture’ in your everyday clinical work, e.g. ‘Why is this clinic so busy?’, ‘Why are there always people waiting to be seen here?’, ‘Are there ways in which we can improve the system to make things better for patients and clinicians?’, ‘What is the purpose of this clinic?’, etc. Asking and answering these questions will help motivate you to optimize your work performance and to make changes to ineffective and redundant practices, thus improving the service for your patients and improving the work experience for you and your colleagues.

Ugo Cerletti (1877-1963), the Italian neurologist 

who first developed electroconvulsive therapy (ECT) 
for use as a psychiatric treatment

Think also in terms of doing small quality improvement (QI) projects that are focused, feasible and with a clear end point and try and generalize the principles to other areas of a service. Think in terms of ‘bottom up’ and ‘top down’ perspectives, e.g. how does a small project relate to national strategy and, vice versa, how can we harness national strategy (e.g. clinical programmes) to develop local initiatives. For any management initiative, big or small, try and write it up, publish it and add it to your CV.

Think broadly in getting support and input from senior colleagues (e.g. Clinical Director) and from allied healthcare professionals; ‘early adaptors’ will jump in and help and their enthusiasm can be infectious and help mobilize others to get involved.

Also consider a formal management course at e.g. Diploma or Masters level, with a group of colleagues. Working with a group will help ensure that you complete the project, that you get the qualification and that the project is feasible and relevant to your particular service.

Alois Alzheimer (1864-1915), the German psychiatrist who first described, 
in a case of presenile dementia, the neurodegenerative 
process that would be named after him

As with teaching and research skills, management skills are developed constantly throughout one’s medical career and vary in terms of scope and complexity depending on your level on the medical career ladder and your personal levels of ambition and initiative.

Effective management skills begin and end with good self-management.  Unless you can safely and effectively manage your everyday clinical workload, you cannot move on to even consider leading a team, supervising junior doctor colleagues or developing and improving the service you provide for your patients.

Management of everyday clinical work should involve the development of one or two key review and new patient clinics during the week during which time maximum energy and resources are applied.  Other parts of the week should be assigned to inpatient work and don't forget to block off protected time for administrative work, teaching, clinical audit, research and service development.

An advertisement campaign in the US for Maytag washing machines used to present the Maytag repair man as someone who (because of the high quality of the product) was never busy or overwhelmed but always ready and alert to respond to crises. Likewise, you should plan your clinical working week as if you were ‘the Maytag man’, i.e. in control, alert and vigilant but never overwhelmed by the volume of problems. (I owe this analogy to Dr. Declan Murray and Dr. Pat Devitt and, I guess, to Maytag washing machines).

The Maytag Man - ready, equipped and waiting 
for the next problem (but never overwhelmed)

And now some for some more history:

Arnold Pick (1851-1924), Czech psychiatrist whose name 
is associated with a variant of frontotemporal dementia 
and some of the underlying pathology 

As outlined above, the weekly timetable should be designed to allow for prioritizing inpatient ward rounds, outpatient clinics (for new, review and emergency assessments) and also leaving time for administration (paperwork, telephone calls, etc.) and clinical and educational supervision time between the Consultant and Junior Doctor. A typical working week in a General Adult Psychiatry service is outlined below.

A diary - get one and use it every day 
(either electronic or an old fashioned paper version)

Monday

a.m. Multidisciplinary community team meeting

p.m. Inpatient ward round


Tuesday 

a.m. Outpatient clinic (reviews)

p.m. Outpatient clinic (new patients)


Wednesday

a.m. Outpatient clinic (new patients)

p.m. Administration work


Thursday

a.m. Emergency outpatient assessments

p.m. Inpatient ward round


Friday

a.m. Teaching and clinical/educational supervision - include time for audit, research, involvement in service development

p.m. Administration

Once you have established a stable bedrock of self-management you can then move on to managing and leading junior doctors and members of the multidisciplinary team, depending on your level of clinical seniority.  At a junior doctor level the key challenge is to work as a member of the team in an effective way, while also leading out on medical related issues.  At a Consultant level there is an expectation to act as the Clinical Team Leader and also in most cases as the manager and overall leader of the team.

Standard advice for those at Higher Specialist Trainee (HST)/Senior Registrar level is to attend management meetings that look at service wide issues and developments. Approach such meetings with a critical eye and a degree of caution and disentangle yourself early if the group is inefficient, poorly led or dysfunctional in other ways. Avoid the pitfall of attending dysfunctional management meetings just for the sake of attendance. An effective meeting/group should have clear terms of reference, useful and achievable goals, a strong chairperson and a membership that is active and takes responsibility. The meeting/group should also have a place in the overall context of service planning and delivery, with clear reporting and feedback lines to all management levels. 

And a few final points...

Remember that individual management styles vary depending on the personality of the individual doctor and I would advise that you become aware of your strengths and weaknesses as early as possible in your career. You may then need to e.g. increase your levels of assertiveness or, at the other end of the spectrum, tone down the intensity of your interactions with colleagues. Try and identify your core values and characteristics and remain as true as possible to these in your dealings with all colleagues, regardless of discipline or level of seniority.

Furthermore, some important basic principles include starting and finishing early, leading by setting a good example, being enthusiastic and open to new ideas and supporting team members in as much as possible. A simple rule to managing paperwork is that you should touch a document only once before it is either disposed of or filed; this simple strategy will help you avoid accumulating anxiogenic piles of paper on your desk (and that general principle applies to management of emails too).

Gerald Russell (1928-2018), British psychiatrist 

who first described Bulimia Nervosa

Once you are confident that your own self-management and team management is optimized you may then consider interactions with other services and outside agencies and you may start to see how your particular service fits in with regional and national strategy and developments.

And finally, some more historical figures, this time from the psychotherapy sphere:

Anthony Storr (1920-2001), British psychiatrist and psychoanalyst and author of 'The Art of Psychotherapy', my very first book on that particular topic

Irvin Yalom (born 1931), American psychiatrist, early pioneer of Group Psychotherapy and author who is still with us and is as productive as ever, his latest book being published in 2017.

Next week, for the last planned blog posting, I will focus on postgraduate qualifications. 

But after that, thanks to the contributions of two Trainees, I will have guest bloggers for the following two weeks, who have written their own personal reflections on how to make the most of your years as a Trainee in Psychiatry.