Oxford Open Grand Rounds

0:00 Olivia: Welcome everyone. Thank you for joining us. We’ll give it just a minute or two to allow people to join and then we’ll get started. We had registrants from all around the world, so hopefully this is an opportune time and not in the middle of the night for you all. Otherwise, we’ll record and this will be available in the future. Welcome everyone.

0:37 Olivia: All right, I’m going to go ahead and get started just because we have a packed agenda today. My name is Olivia. Thank you for joining us for our Oxford Open Grand Rounds, 'You’ve mastered the clinical skill set: what’s next?' I’ll introduce myself really quickly before passing it over to our guest speaker.

0:51 Olivia: My name is Olivia. I am the Associate Course Director for our MSc in Surgical Science and Practice and our PGCert in Patient Safety and Quality Improvement here at the University of Oxford, and I work very closely with Tom. I’ll let him introduce himself in just a moment.

1:06 Olivia: A few housekeeping items. If you have any questions or comments, please pop them in the Q&A function and we’ll keep an eye on them throughout this 30-minute discussion. Otherwise, some of you had submitted questions in the registration and we will do our best to touch on them throughout the session.

1:22 Olivia: This event is being recorded and you will be receiving a link to the recording via email after this event. It will also be available on our website, where you can see all of the recordings of past sessions of our Oxford Open Grand Rounds. So, without further ado, Tom, welcome.

1:42 Tom: Thanks very much, Olivia, and thanks to everyone for joining. As Olivia said, I’m Course Director and look after two master’s-level courses for practising doctors, surgeons and other health care professionals. It’s part of a family of courses at Oxford University covering non-clinical skills for clinicians.

1:58 Tom: Although I’m not clinically trained, I’ve worked in healthcare and education for 20-plus years and look to translate ideas from non-clinical areas in ways that make sense for clinicians, while also having some sensitivity to clinicians’ perspectives on what it’s like to be working in healthcare.

2:29 Tom: Today’s session is called 'What next?' All of you will face that question at multiple times in your careers. Many of you will have already faced that question a number of times. I’d like to offer some ways of thinking about three aspects of that question: what are the choices, how to choose, and choosing well.

2:57 Tom: Before I get going, a disclaimer. This is not my academic domain. I’m not a careers researcher, so what follows is based on my conversations with health care professionals and my observations of career paths. Many of the students who come on the courses Olivia and I are involved in running are using the courses as a way of asking, and maybe answering, that question: what next?

3:29 Tom: That means I have had many opportunities to talk with doctors and other health care professionals grappling with career choices. With limited time, I’ll focus mainly on medical careers, but I think most or all of what I say will translate to other healthcare professions.

3:55 Tom: Here’s the basic sequence of a career as a doctor, and I’ll use that term to cover both physicians and surgeons: beginning with medical school and foundational training in clinical knowledge and skills, moving into a specialty, and then qualifying as an independent specialist. Even with that fairly straightforward progression, there are some choices which all of you will face.

 4:33 Tom: These are not going to be the principal focus, but it’s important to acknowledge them. Firstly, there’s a choice about geography. Many choose to practise close to home, but for others, your medical qualification is your passport to the world. Doctors are in demand everywhere, and it gives you the ability to change geography.

4:57 Tom: Secondly, if you look at the literature on careers for medicine, the big focus is choosing your specialty. That seems to be the thing that predominates in the literature on career planning for doctors, and it is certainly an important choice. According to the UK medical authorities, there are 64 medical specialties, with subspecialties within them.

5:28 Tom: Finally, all of us have 168 hours in a week and we need to make choices about where we allocate that time. The head of an organisation I once joined suggested at induction that a way to think about it was: a third of the week for sleeping, a third was what the organisation was buying from me, and a third was for me to do with as I pleased.

6:00 Tom: That’s not compliant with the European Working Time Directive, and the UK still has that on the statute books, but nonetheless I found it a useful rough rule of thumb. There are going to be times when we are far off those proportions. Some of us will take time out for parenting or other caring commitments. There were also times when I took a part-time role because there were other things I wanted to spend more time on.

6:50 Tom: Maybe that applies across the piece to these three choices. None of them are once-and-for-ever choices. Over our careers, we’ll put more or less time into our professional commitments, and we may make big or small geographical moves. Even specialty is not fixed in stone forever. It’s possible to change specialty and to work across more than one specialty.

7:15 Tom: As mentioned, that’s not going to be my focus. I’m coming in now to look beyond clinical knowledge and skills. What else do people choose to focus on in a career based around medicine? There are a range of other competencies and capacities which support your role as a doctor.

7:46 Tom: Over the last 10 or 20 years, some of the medical associations have had a go at formalising what those supporting roles are. On the left, you’ll see the CanMEDS model, developed in a broad, consultative way by asking what society expects of a doctor. On the right, there’s the UK General Medical Council generic professional competency framework, asking what the public can expect from doctors beyond their clinical knowledge and skills.

8:27 Tom: Looking further at the CanMEDS model, there are seven different roles. One is your core role as a medical expert, with six supporting roles. Within each of these, the model describes in some detail what the expectations are, and does so by level of seniority. As you move to the right in the table, the expectations grow as your level of experience grows.

9:09 Tom: Looking at these detailed descriptions, I would make three observations. Firstly, you could spend a lifetime working your way through these different areas and developing your competency and proficiency as communicator, collaborator, health advocate and so on. In other words, just working on the supporting competencies for being a doctor could legitimately take up a full medical career, particularly if you have other things outside your professional life that you are putting significant time and effort into, such as parenting.

10:02 Tom: My second observation is that buried in these frameworks are whole separate career paths beyond medicine. I’ll come back to that because I want to pull out some of those alternative or additional complementary career paths. My third observation is that no one is going to make it all the way to the right on all seven domains, at least from my personal perspective.

10:36 Tom: I’ve not gone far enough into the CanMEDS model to see whether formally their expectation is that this is what you do, but if you look at the level on the far right described as advanced expertise, I don’t believe that any one person will be able to be over on the right-hand side on all seven domains, which also comprise around 27 specific subdomains.

11:09 Tom: Rather, I think it’s reasonable to expect that you are going to get to a baseline level, what you could call good enough, in each of the seven areas, and then choose to put more energy and effort into one or two other areas.

11:27 Tom: As a brief digression on that idea, I want to share something that got me thinking, which was the partnership election process at an organisation I worked in for a period. It was structured as a partnership, so once a year the committee of existing partners would decide which of the upcoming cohort to elect as a new partner, the equivalent in medicine of becoming a consultant in the UK or an attending physician in the US.

12:15 Tom: The approach included what you can see illustrated here. If we’ve got two candidates for partnership, blue and yellow, one of the aspects looked at was whether they met the bar across the five domains considered necessary for the attributes of a partner. Just as CanMEDS had seven domains, this partnership had five domains that were looked at.

12:39 Tom: If you looked at these two candidates and asked who the committee would elect as a partner, you might think it would be the yellow candidate. In fact, neither candidate would be successful. While the yellow candidate meets the bar across the board, the committee was also looking for what they referred to as a spike: an area in which you really stood out and were distinctive.

13:17 Tom: You can see that the blue candidate has that spike, but they are below the bar in one area. If we were giving feedback to those candidates, we would say to the blue candidate that they need to meet the bar on competence three, and to the yellow candidate that we need to see some greater level of distinctiveness.

13:41 Tom: If we then saw the blue candidate again in a year’s time and they had successfully met the bar in that third area, we would be happy to admit that person into the partnership because of their area of distinctiveness. That might be distinctive knowledge or how they are in developing people. The requirement was that you need to meet the bar and have an area of distinctiveness.

14:16 Tom: Returning to the competency frameworks, I’ll pull out some career paths and complementary roles that you can take on alongside being a doctor. There would be different ways of classifying this, but I’m going to suggest five: researcher, leader, educator, innovator and improver.

14:46 Tom: For the top three, there are relatively well-defined career paths. For the researcher, the academic medical path is well-defined: academic clinical fellow, or equivalents in other countries, moving on to a PhD and then a postdoctoral research position, ending up with the consultant equivalent of being a principal investigator.

15:20 Tom: You might want to stop at that point, because if you go further along that career path, you start to move away from the work of research and into leadership and management positions. Some will want to do that; others will want to stay with the hands-on work as a researcher.

15:42 Tom: We had one question that came in, which was how to move from medicine into being a pure researcher. I would say that this still holds: it would be a good idea to see if there is some version of an academic clinical fellow role, where you are developing as a doctor but also have a formal research component. You are going to need to do a PhD, and once you have that, you can look for positions that are purely research and drop the medical role.

16:16 Tom: Clinical leadership also has a clear path: clinical lead, looking after a specialty, clinical director and then medical director. There is a dotted line to CEO because very few doctors in the US and the UK go on to become chief executive of a hospital. Some data suggested it is something like 5% of hospitals that are run by somebody with medical training. There is an interesting question about why that might be the case, but for many that pathway will stop at a medical director role.

17:08 Tom: Before moving on from leadership, there are many other ways in which you will use leadership skills and capacities besides the formal clinical leader role. That comes into the more senior levels of the research path, and also into the next pathway: educator.

17:34 Tom: There is a reasonably well-structured medical educator path. Fellowships can offer the opportunity to focus on teaching alongside clinical training while you are a doctor in training. At a more senior level, this includes supervising the development of other doctors, then moving into training programme director, head of school, and postgraduate dean or director of medical education roles.

18:13 Tom: Again, there are dotted lines to those senior roles because, for many people with a love of learning and teaching, the joy is in teaching and supervising. There is a comparison here with teaching in the school system, where people can advance through their whole careers as classroom teachers and get better and better at doing that. Likewise in medicine, it is often in the individual consultation with your patient that you are able to directly touch lives.

19:00 Tom: For many of us who work as educators, the meaning and joy lies in teaching and one-to-one educational supervision within the medical educator path.

19:23 Tom: The last two roles, innovator and improver, have less structured career paths. There are fellowships, such as clinical innovation fellowships, that allow you to combine some focus on innovation or improvement alongside a training role. Beyond that, it tends to be more fragmented and varies a lot by country.

19:52 Tom: In some organisations there are innovation leads, and there are programmes such as the NHS Clinical Entrepreneur Programme. In many cases, you will be looking for what contextually, in your environment, organisation or area, gives you a vantage point to do the innovating or improving that you want to do.

20:08 Tom: It could be that a clinical lead role allows you to take on a significant change in the service you work in. For innovators, in many cases those who find success will end up with roles on the boards of companies that they have helped to set up.

20:35 Tom: So, those are five complementary roles that, for those who decide they are looking for something beyond medicine, draw on everything you have learned and the position you have as a doctor, but provide a complement to it.

20:56 Tom: It is messier in reality. It is often not the case that you pick one of those and follow a path along it. Some of you will recognise Florence Nightingale, not a doctor but a nurse, and her career combined elements of all those areas.

 21:11 Tom: She innovated, not least in developing the visualisation of data. In the illustration, the core represented soldiers who died from combat wounds in the Crimean War in the 1850s, and the blue around the outside represented those who died not from battle wounds but from infections or disease. She used that in a leading way to get changes made in the sanitation provided in hospitals treating soldiers. She also taught other nurses and set up a school for nurses.

22:08 Tom: A more up-to-date example is Ryan Kerstein, one of our tutors on the course Olivia and I are involved with. He developed something called Tournistrip, either as a medical student or an early trainee, and set up a company to commercialise that product. He is not only an innovator; he is also an educator, teaches on our innovation module, and has a leadership role as Associate Medical Director for Research and Innovation.

22:53 Tom: So I have called it messier mix. Actually, part of the magic is that these are reinforcing roles. They build on one another and complement one another.

23:09 Tom: That is all I have time to say about what the choices are, so now I’ll move on to how to choose. I’m going to use the illustration of a frog in front of a pond covered in lily pads to illustrate two approaches I’ve seen when talking with people about developing their careers and making career choices. It probably also applies to me if I look back.

23:47 Tom: Each lily pad represents a point in your career: the particular role you are playing or combination of roles, since you might have a portfolio of several roles, as we saw with Ryan. Frogs are quite short-sighted, so one way of progressing in a career, which I’ll call the tactical mode or discovery mode, is that from the vantage point of whichever lily pad you are on, you can see the immediately adjacent lily pads.

24:24 Tom: You can decide whether you are happy where you are, or whether another nearby lily pad is more appealing. That might represent a mix with more research in it, or a group of people you would really love to spend more time working with. It could be about the activity, the people, or whatever aspect you are looking to optimise for, or whatever is dissatisfying you at the moment.

25:02 Tom: In this mode, you can only see the immediately adjacent lily pad. It is an incremental approach to discovering the right mix for you.

25:21 Tom: The alternative, which some people have but I do not think is the majority, is imagining that we can send the frog up into the sky, give it a good pair of spectacles, and allow it to see that at the end of this sequence of lily pads there is a particular career goal it is looking to achieve.

25:50 Tom: I have used the terms we talked about earlier, but there could be other ways to describe your longer-term career aspiration. The advantage, if you are able to articulate what you are looking to accomplish over 10, 15 or 20 years, is that you can plot the shortest number of hops that are going to get you there and avoid hopping in the wrong direction.

26:18 Tom: So, you are either discovering by looking at the change right here and now that will give you a better mix than you currently have, or you are plotting out what you need to do to move as directly as possible towards your career aspiration.

26:42 Tom: A few pointers on what helps with either approach. The first is knowing thyself. That is the Greek philosophical idea that fundamental to flourishing in life is understanding what it is that you want.

27:06 Tom: The model on the left is the Ikigai model, a Japanese model which says that the career you want is at the intersection of four things: what you love, what you are good at, what you can get paid for, and what matters to you or gives you a satisfying purpose. You can use this to ask yourself questions, or to have a dialogue with someone you trust to explore those questions.

27:41 Tom: Other models are out there. I hear good things about the book 'Designing Your Life' by Bill Burnett and Dave Evans. Another exercise I like is the lifeline exercise, where you draw a horizontal line to represent time, with good above and bad below, and plot the career trajectory you have been on.

28:05 Tom: The ups and downs will be particular moments in your career or a particular role you might have had. Ask yourself what made the highs high and the lows low. Was it what you were doing? Did you love the particular type of work? Was it about the people or some other aspect of the context? The trick is to look for patterns in the highs and lows.

28:42 Tom: In our last couple of minutes, I’ll talk about choosing well. As I have already said, a central part of that is knowing thyself. On the right-hand side, I have put another model that can be helpful: the Johari window.

29:00 Tom: The idea is that there are four quadrants based on what is known to you or not known to you, and what is known to others or not known to others. I’ll focus on the top two. The open area, or arena, includes the things that both you and others know. But there are some things that others know about us that we do not know ourselves: our blind spots.

29:27 Tom: How you uncover your blind spot is partly through conversation and asking for feedback from people you trust. That will be part of the second activity: reserving two to five per cent of your professional capacity for your career development.

29:41 Tom: Thinking of the third, a third and a third split, or whatever you dedicate to your professional work, reserve two to five per cent of that for career development. This might vary over time. When you have just started a new role, it may be low. If you are midway through or starting to think you need to look for something else, it may be at the higher end. It probably comes out as something like five to 10 hours per month.

30:12 Tom: The reason for doing that is that, at the time you are looking to make a move, it is too late if you have not been investing in relationships and developing knowledge of what else is out there. You are going to delay the move if you have not been making that investment on an ongoing basis.

30:27 Tom: How do you use that time? Mainly through conversations. Reach out to people. People are flattered, and people you do not know but can explain why you are interested in hearing from or meeting them will generally be very glad to have that conversation.

30:43 Tom: Finally, learn from other people’s stories. What career choices have others made? How have people you admire ended up where they are? To close today’s short session, I will link that to the theme we intend to have for the upcoming series of our Grand Rounds.

31:10 Tom: The upcoming series will explore the trajectories of a range of doctors who have developed complementary roles. We will talk with them to understand what led them to make the journey they have had, to be honest about mistakes and wrong turns, which are often how we learn and figure out what the right turn is, and to understand what that has meant for their work as doctors.

31:41 Tom: That is all we have time to cover. As I mentioned, Olivia and I run a couple of courses for clinicians at Oxford: one particularly aimed at surgeons, and one more broadly for health care professionals with any professional background on patient safety and quality improvement. If you are interested in finding out more, there is the QR code.

32:04 Tom: If I did not answer a question you have, please feel free to drop a line to the email address you see there and we will do our best to answer. I will stay on to see if there were any questions. Otherwise, thank you very much for spending the time with us today, and I hope that gave you some useful pointers.