What do you believe? with Iain Beardsell

In order to provide the best emergency care, we need a rest on unsustainable changes and focus on attainable vision and goals.

A change is as good as a rest, or so the saying goes. Working in Emergency Departments we are constantly changing. Many of these changes are directed at the processes within the ED, continually striving to find the “golden bullet” solution to the “four hour question”.

Over the first six years of my consultant career the department I work in, like many others across the UK I’m sure, has been subject to constant change . These have come in different guises: “Lean”; Service Improvement; Perfect Week; the list goes on. Many of these are run by external agencies, at huge cost, all hoping to solve the dominant question in Emergency Medicine – How do we achieve the four hour target

Like, I suspect, many Emergency Physicians I have a very short attention span. This was part of the reason I chose the specialty that I love. Not unlike Martin Sheen’s President Bartlett of West Wing fame, the question on my lips most often is “What’s next?”. This serves me well when seeing patients, but not when I require the sustained interest required for successful change. We throw ourselves into projects, but over time this quickly wanes and the much vaunted developments are cast aside for the next new thing. The last few years in our ED are strewn with unsustained changes and I’d estimate that no more than one in ten ideas, no matter how promising or useful, have continued beyond six months after their inception.

Why is this? It can’t simply be that we lose interest. I recently watched a “TED” presentation that struck a chord.

In his talk Simon Sinek, an author best known for popularizing the concept of “the golden circle” describes a simple but powerful model for inspirational leadership all starting with the simple question “Why?”. As I watched, I realised that many of these changes over the years I had been happy to participate in, but I just didn’t believe in them. Apart from the temporal reasons with which we are obsessed I didn’t know why we were changing. We have keep doing new things, yet our “performance” hasn’t improved, in fact it has got worse.

As doctors and nurses in Emergency Departments we chose our career paths, I hope, because we believed in the best care for all, especially those with life threatening illness, at any time of day or night. This is our fundamental belief. Why is it, then, that we struggle to to adopt and maintain these changes that may help us towards that goal?

As Sinek discusses in his talk, it isn’t necessarily that the ideas we try to implement are bad, but because the premises on which they are based do not address our beliefs. There is a fundamental disconnect between the four hour target and what we think is best for our patients. Of course this is untrue – a faster, more efficient process for seeing people must be better for many, but with years of government scrutiny and management interference we have simply refuse to believe this anymore. We are, in general, a stubborn bunch and will not have others force their beliefs on us without the appropriate analysis

Change goes on apace in my department, as I am sure it does in yours, but it is my belief that it is time for us to pause and rethink what and why we are changing. Constant, rushed implementation of quick fixes that the clinical team do not believe in, but merely participate in, simply will not work. It is time for us to reappraise what we, as doctors and nurses, believe and then to proclaim these beliefs to others.

So I ask you all – what do you believe in? What does your department stand for? What is your vision? I asked this question of colleagues recently and was met with blank, rather guilty stares. We simply did not know. I’m sure you could come up with a few without any thought: to provide evidence based compassionate care to all, whenever they need it; to educate and encourage all staff so that work is not just a job, but a vocation; that no patient should be in pain; that we should aggressively resuscitate all those who require and desire it and tenderly and gently care for those who life is at its end. Articulating these visions and beliefs is easy – the real challenge is making them a part of your ED’s philosophy and daily life.

Of course, the irony is that none of these beliefs in anyway contradict the aims of the four hour standard. In fact they compliment it – evidence based care is efficient and limits unnecesssary testing and giving appropriate pain relief early facilitates discharge. And a happy clinical team, who work together will always, always be more effective and efficient.

We need a rest from the change. We need to look within ourselves and find what it is we believe in and then work towards these visions with passion and enduring commitment. We need to ask others, managerial and political, to trust us, to help us work towards achieving what we believe in and to join us on the journey. Given this opportunity we will provide the best emergency care we possibly can (including achieving government set targets). And that is my fundamental, unshakable belief.