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Sir Lancelot Spratt RIP?

Lancelot Spratt and Shewli Rahman, The Doctor, October, issue 14

Do powerful, unaccountable ‘diva doctors’ really still command the wards, as a report for the GMC suggests? We find a profound shift in leadership style since the days of Sir Lancelot. Keith Cooper reports

What type of doctor are you? When you’re in charge, under pressure, up against it.

You might not feel you’re a ‘type’ at all.

You might just feel that you’re doing your best under very difficult circumstances.

‘There were some absolutely superb surgeons and physicians. Really superb but fundamentally flawed’

But according to a report commissioned by the GMC, there are ‘notable subcultures’.

They sound a little like the outline for a new medical drama on daytime TV. The subcultures might be: ‘factional’, riven by endemic disagreement; ‘embattled’, where they feel perennially unequal to demand; ‘insular’, isolated from the wider organisation; or based on patronage, where there is a leader who may inspire loyalty but be difficult to question.

It’s the fifth, though, which has attracted the most attention. The ‘diva’ subculture, ‘when powerful and successful professionals are not called to account for inappropriate behaviour, and colleagues modify their working practices to accommodate them’.

Inevitably this became ‘diva doctors’ (why not also diva managers or diva nurses?) in opinion pieces thundering that they were the ‘symptoms of a rotten culture’ – which seemed a bit harsh, as the report was talking about perceptions and working practices more than real individuals.


Not my type

The report, by the medical ethics consultant Suzanne Shale, is not aiming to stereotype doctors and still less aiming to rubbish the profession. Instead, its title claims it sets out to establish ‘How doctors in senior leadership roles establish and maintain a positive patient-centred culture’.

But, it inevitably raises some interesting questions about whether there are types of doctors, whether it’s helpful to think in this way, and, of course, to go in search of a diva or two. Here, Hugh Montgomery (pictured below) can assist us.

‘These people were relatively prevalent in the 1980s,’ says the professor of intensive care medicine at University College London.

hugh montgomery

‘I worked with quite a lot of them.’

Still, he feels ambivalent towards them.

‘There were some absolutely superb surgeons and physicians. Really superb but fundamentally flawed. They would put their own social life and personal agendas ahead of their clinical practices. It was an odd thing to watch.’


'Worst traits'

As a junior doctor, Professor Montgomery aspired to match their ‘extraordinary clinical acumen and skill set’, tolerating the eccentricities in their behaviour.

Now, instead of populating his ambitions, they populate his published fiction. His thriller, Control, features a ‘super brilliant but vain and arrogant’ surgeon. ‘He’s an amalgamation of some of the worst traits in people I’ve known, all mashed into one.’

Were you to amalgamate the behaviours described in Dr Shale’s study, it would make a pretty ghastly fictional character, too.

It describes medical leaders who deny bad news – instead of questioning every patient death, shrugging it off (‘a recognised complication’) – or choose to embrace only the positive aspects of patient feedback. These characteristics have been observed in reports into massive NHS failings.

This doesn’t mean there is a tribe of doctors with diva-ish traits stalking the wards.

‘As a surgeon, I am used to being labelled as single-minded and not suffering fools gladly’

London medical oncology specialty trainee 6 Adam Januszewski says: ‘It is rare to see these “caricatures”, but you do see some traits in individuals.’

Dr Januszewski, who holds a position with the FMLM (Faculty of Medical Leadership and Management), also believes this is not just an issue for very senior doctors, the main focus of the GMC-commissioned report.

‘Doctors are naturally in leadership positions,’ he says. ‘We can evaluate complex situations and manage uncertainty, but people assume we are good leaders because we are doctors, which is a problematic assumption. Good leadership skills are not automatic, doctors need the right development and nurturing of these skills.’

In the hierarchy of the hospital, trainees also find themselves setting the tone in the workplace, he says.

‘I have underestimated how much of a role model I’ve been for medical students and more junior doctors,’ Dr Januszewski adds.

‘When you are on call, overworked and it’s the end of a shift, it can be stressful. People can be curt or discourteous. It’s probably because we have many competing priorities. I’ve now learned to sense when I’m feeling anxious, to look after myself a bit more. And when I’m gruff, I reflect on it.’


How reputations are formed

All doctors must wrestle with the occasional brusqueness of colleagues. In a service where work pressures are high, rising and unpredictable, it’s inevitable. But there’s a skill and an art to maintaining good relations with colleagues of all levels and creating a ‘positive working culture’ under pressure, says East Sussex consultant orthopaedic surgeon Scarlett McNally.

‘As a surgeon, I am used to being labelled as single-minded and not suffering fools gladly,’ says Mrs McNally.

‘We’re all getting labelled because of something we said or did without realising it. You get a reputation from what people think you’re like; not from what you meant.’

She found one misunderstanding, early on in her career, on a list of her operating requirements. It had: ‘Mrs McNally prefers to operate in complete silence,’ penned in.

‘I thought it was odd that people were being really quiet. It must have been something I said in one of my early operating lists there. I had a chat with the sister, we had a laugh, and we went back to normal.’

Mrs McNally now alerts colleagues to potentially stressful parts of operations in ‘pre-op team briefings’.

‘I say, I’m a bit worried about this bit, please don’t go on break and I might swear. We talk about it. We have a laugh.’

As a council member of the Royal College of Surgeons of England, she has helped compile qualities of ‘good’ and ‘disruptive’ medical leaders for its report, Surgical Leadership: A Guide to Best Practice.

Dominance, arrogance, aggressiveness, and egocentricity are out. In are: integrity, honesty, and the ability to recognise stress in yourself and your effect on others.

Many doctors will know what negative leadership looks like in a service where targets must be met, whatever the weather.


Close to tears

West Midlands emergency medicine consultant Shewli Rahman (pictured below) witnessed a group of consultants brought near to tears by a medical director’s berating about their inability to achieve the NHS four-hour target.

West Midlands emergency medicine shewli rahman

‘He told us what an unimpressive team we were,’ she says. ‘I raised my concerns to the chief executive through the trust’s whistleblowing process and ended up in a meeting with the MD, listening for an hour and a half about the huge pressure he was under. It was eye-opening.’

‘I raised concerns and ended up in a meeting with him, listening for an hour and a half about the pressure he was under’

Emergency medicine specialty trainee 3 Hannah Baird, who also occupies a position at the FMLM, recalls similar experiences after night shifts when senior managers question why patients are still in the department.

‘There is often quite a lot of negativity about waiting times. This is often to sleep-deprived teams after 10-hour shifts who are expected to come back that night. It makes me feel quite disappointed – where is the compassion?’

These experiences led these doctors into studying the qualities they need to lead, those that it can’t be assumed are imbued in medical school. Good leaders take the time to listen and know their team, says Dr Rahman.

‘I’ve known medical directors who nobody would recognise in a line up and others who knew everyone’s name. To show that you know and care for the people you work with seems an obvious thing to do in a system that is caring for people.’

Dr Baird gives an example of a ‘listening’ leader, who acted with compassion and what she calls the ‘no heroes’ approach.

‘This senior manager came down during one of the worst shifts I’ve ever worked. He asked, what do you need me to do? You look incredibly stretched. They made tea for patients and dipped wees. We didn’t need someone else telling us where to move beds.’


Moulded in their image

Coventry emergency medicine consultant Chris Turner (pictured below) has also experienced the effect of poor medical leadership on workplace culture. He was a witness at the public inquiry into failings at Mid Staffordshire NHS Foundation Trust.

Now a well-known campaigner and speaker against rudeness for Civility Saves Lives, a growing movement, he believes, like the GMC, that a debate about ‘leadership’ and its link to workplace culture is needed.

‘Cultural tides are very strong,’ he says. ‘You are far more likely to become like the people you work with, than make them the sort of person you are.’

‘The starting point is caring for people in a team, calmness in the face of adversity and getting the most out of people’

If doctors are to make good leaders in an increasingly complex service, the profession must decide what good ones look like, Dr Turner says.

‘The starting point is caring for people in a team, calmness in the face of adversity and getting the most out of people. If we are all going to behave in a certain way then we all need to know what that looks like.’

If such a ‘model’ of the good medical leader exists, Dr Montgomery hopes there will be room left for those with ‘rough edges’.

‘There are some things that cannot or should not be tolerated, of course but people’s personalities do differ,’ he adds.

Villainous and fictional caricatures aside, of course.

Read the GMC report



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