Wednesday, August 26, 2009

Friend of Simplicity - Dr Phil Shute

I am delighted and indeed honoured to have as my 'Friend of Simplicity' Dr Phil Shute. Phil is a General Practitioner (Family Doctor) in Torbay, Devon, here in England.

I've known Phil for about 20 years, initially as my own Family Doctor and then as a professional colleague in the National Health Service (NHS). When I was a healthcare manager in the NHS Phil and I worked together as a team on ground breaking community health development in a very deprived part of Devon. I have to say (because Phil is far too modest to say this) that Phil was the leader, the inspiration and the driver for the project.

As a professional colleague Phil is simply a pleasure to work with and speaking as a patient I can truly say my life is richer and better thanks to his skills, support and understanding.

Good men are few - Phil is a VERY good man.

I know Simplicity readers will enjoy Phil's straightforward no-nonsense views and I look forward to receiving many comments. It is brilliant to get a medical perspective on some of the issues we regularly debate on this Blog from such a highly regarded doctor.

Trevor - Phil – thanks so much for agreeing to take part in my series of ‘Friend of Simplicity’ interviews. Can you briefly outline your career to date?

Phil - Hi, Trevor - My career to date: State Primary, State Grammar, both in Plymouth. Academically diligent and not brilliant. Older than my years, was always seen as the responsible one who could be relied upon to do an honest job, equitably and without disadvantaging anyone else. Captain of sports teams, glittering schoolboy rugby career......... got me into St Mary's Hospital. London (my academic record would not have stood out).
Career at medical school above average, never considered anything other than a career in General Practice, though was offered many more "glittering open doors" when in hospital posts.

Did "Publish" whilst still a student (only one in the year so to do..... BMJ - British Medical Journal too!)
Always felt that in whatever speciality I spent time as a student or qualified doctor that I was restricted by specialities; I was always holistic in my outlook, still am, probably more-so. Both house jobs at my teaching hospital..... Sounds prestigious but the first post I landed through rugby connections, the second by my reputation as an honest workhorse. Proud of that, still am.

GP training scheme in Barnstaple (back in Glorious Devon) wonderful place to have worked. Teaching Hospital jobs can be a bit self-serving, chasing small print and not enough substance... look great on CV's but less learning experience.
Absolutely adored my time in Barnstaple and as a trainee in Bideford. Won the GP research prize locally and then awarded the Royal College of General Practitioner National Trainee research prize for 1985, Published again, JRSM - Journal of the Royal Society of Medicine this time.

Settled in General Practice in Torquay; still there; avidly "into" research in the early days, gave highly regarded paper but realized that chasing publications really wasn't the path for me; just a work horse. I now teach students at the Peninsula Medical School, not because I'm an academic but I'm in a great practice for teaching with a wonderful body of honest patients whom students ought to see.

Have been involved in many schemes and initiatives, proud of many of them. Not least the Gym we have within the practice.... first in the UK and "state of the art". The way we funded it was seminal and inspiring..... Just shows that when you have a body of good ideas someone, sometimes, listens and really splendid things can happen. Our area - Torbay (population 110, 000) is a fitter place as a result.

Similar things happened a few years back when we kick-started a local "Health Gain Initiative" looking right outside "Health" for a change into the broader field of "Welfare" (not the benefits system, but what patients really needed)

Very proud of my work in sport to this day. I'm a medical advisor to the Amateur Swimming Association, and as a medic and technical official and club manager. I facilitate sport from grass roots level up to World and European Cup levels and World Championships; from the youngest kids up to veterans.

I have a regular column or two in local papers where I exercise my skills as a sports journalist.

Trevor - I’m very interested in how Doctors view management. As a Doctor what do you look for in a manager in healthcare?

Phil - I look to management in health care to free up my time to work the coal face, to facilitate patient care and to make up for my own inadequacies in management, I frankly don't expect to manage in any other way than "Policy".

My 360 degree appraisal flagged that management was not my forte, a view with which I'd concur.

My own approach to management is the same as it was when I was captaining sports teams.... I led and hopefully still lead by example, not dictat. I have always gone the extra mile for colleagues and patients; will always put my body on the line. I expect managers with whom I work to do the same.

The managers within our Practice do just that, and I'm very proud of how we all get by in the face of a quite dizzying workload. If I've been influential by my example it would, I hope, be honesty, integrity, compassion and hard work. I'd love that to be said about our practice; all aspects, management, reception, patient experience, clinical expertise. I don't manage, but in a quiet way I'd like to think I lead in some ways.

Trevor - As you know Phil I am very interested in the study of leadership. Can you identify someone you would describe as a leader that has inspired you in your career and what qualities did that person have that made them stand out from the crowd?

Phil - Leadership is a true gift, and believe it or not, it's seldom evident in day to day medicine. It's probably far more in evidence in day to day management, where leaders can set an agenda. In clinical practice our patients set agendas.

I was first inspired by a teacher in my primary school, year 6, a fine man, towards the end of his career in teaching who always put his pupils first, was authoritative, firm and directive and unflinchingly fair.

I was next impressed by my captain when I first played rugby for Devon aged 17, the captain was 18, full of testosterone and adrenaline, a bit feckless, but who was so totally superior to everyone else on the field. You couldn't help but follow him, he was "everywhere". He went on to captain England and even the British Lions. Clearly others were similarly impressed.

The professor of medicine at St Mary's Hospital, London was the best and most gifted physician I've ever seen to this day. He weekly conducted his "Open Round" in the biggest lecture theatre at St Mary's and it was always packed. One or two of the registrars or senior registrars would select a patient unknown to the Prof and the consented patient would be wheeled into the theatre. Without taking a history, and without access to any "imaging" and investigations, solely by examining the patient meticulously (and talking us students through the process) he would seek a diagnosis and teach us all his clinical method in the process. It's the most impressive thing I've ever seen. Skills like this are not so valued these days as imaging and diagnostics has largely taken over; good, as that means diagnosis is available to everyone irrespective of which doctor is looking after you, BUT there is no substitute for genius.

Trevor - There has been a lot of publicity recently about radical reform of the US healthcare system. I would love to hear your views about that and in particular the publicity that has come from some parts of the US media and US politicians who openly and heavily criticise the UK National Health Service.

Phil - I don't know a lot about the Health Service in America other than they pay more than twice as much as we do and as result there is much more provision than we have.

Much of the NHS bashing coming out of USA is ill-informed. Much of the NHS bashing is engendered by lobbyists in the pay of astronomic profit-takers in the USA. They should re-examine their service if it has the inequality of access that I'm led to believe.

We have a service that has evolved around our patients and has probably had more thought put into it.
We undoubtedly provide better value for money, our productivity is astonishingly high, we are ethically driven and our system, whilst far from perfect, is worth looking at if not worth adopting (well.... no-one else has adopted our system)

Trevor - What are your views about the development of electronic health records and patients having greater access to their own electronic records?

Phil - Patient-held electronic records would be splendid but I suspect would be as accessible when needed as their NHS card or NHS number (i.e. almost universally mislaid or filed under "lost") forget it.

Universally available health records would be splendid but the truth would upset a lot of information holders. Bureaucratically it would be a nightmare.......... I'd spend all day and every day talking people down from their anxieties and clinical work would be totally paralysed.
Political correctness gone insane.

People only want to know what's in their notes when something goes wrong, OK they can have them if that's the case when it becomes appropriate for the patient.

We've already got that system.
I think it would be an even bigger waste of money than ID cards (I'm not anti-ID cards). Just because we can do it, even if it's a good idea, doesn't mean we should. I'd rather spend the money on clinical care.

I'm reminded of a report on our local in-patient psychiatric unit where the quality of care for detained psychiatric patients was not even mentioned; but of course there had to be universal access to legal representation for all detained patients. It was, of course, written by lawyers.

Whose idea was the electronic record with universal access to data? What a security nightmare? I know the intentions are noble but if this isn't "1984" what is?

Trevor - I know that you and I agree we must look way beyond healthcare professionals such as doctors and nurses to improve the health of the population. It is everyone’s business. What would your vision of a healthcare system that promoted health look like?

Phil - This is like "Life, The Universe and Everything"
There is no doubt that health equates to wealth in many societies. So much research relates poverty to ill-health and in this respect it's the poverty and life-style link that results in increasing morbidity. We can't rule out poverty but we can start to address equity of access to health care, at least we can in the NHS (Not in the American system).

If we're talking life-style then education/example and opportunity/provision is the way forward.
There are more 50metre swimming pools in Paris than in the whole of Great Britain. We're better at swimming than the French, that's because they're French; but more Frenchmen swim than Britons and their rates of heart disease are way better than ours.

It's no good the government telling people to take more exercise if they've grown up not doing it, don't know how to do it and there's no where to do it.
If there was a single measure we should consider, it's what the Scots are doing with alcohol, and which I've been advocating ever since it was proven beyond doubt 50 years ago that the only 2 factors which reduce alcohol related problems and morbidity is price and availability. We should charge according to alcoholic content and not discount, and reduce the number of licensed premises or restrict access to them.

Trevor - Are there major differences in the patients expectation in 2009 than when you started work as a Family Doctor and if so what are they?

Phil - There's far less demand for home visits than when I started.... more people have cars (though not that many more), education is working, patients are actually more realistic in their demands.

But the main reason is we make ourselves far more available in many different ways. 30% of my consultations are now over the 'phone. In many instances this is far more appropriate. A whole new set of consultation dynamics has become apparent. We used to be looking for body language as a diagnostic tool, but patients are inhibited in our consulting rooms and have had to drag all the way to get to you and then get coughed-over in the waiting room; how valid is their body language going to be? Patients often give far more relaxed and less inhibited consultations in the comforts of their own homes and favourite arm chairs over the phone.

We are all offering "advanced access" and it's MUCH easier to offer "same day appointments" negating the need for home visits.

People are a little more pro-active and advice-seeking, but still not as much as we'd like (the 'phone is particularly good for this).

The government is much more demanding than our patients.

Trevor - Finally and based on your experience what are three key pieces of advice you would give to a young Doctor now starting their career in medicine?

Phil – Yep – here we go

1. If you don't like hard work get out now

2. Work is what you are. It's no good having your ego first and the work as an unfortunate if necessary poor second place. Medicine isn't a job, it's not a vocation, it's a way of life. You eat and sleep and breathe and drink it; you can't deny this. It defines you, regulates you, establishes your value-bases, controls you. This is not scary at all. You have a valuable knowledge base, a good income (but it's not easy money), respect and respect for others. It is a privilege to practice medicine and to be invited and welcomed into other people's lives; value their lives and hence your own.

3. Take yourself seriously.......... but not too seriously; surely you are an important person in the lives of many patients........ But you're not family and you're not God.

Trevor - Many thanks Phil – I appreciate your words it is always a pleasure and an education to listen to you.


Simon D said...

Phil - I enjoyed reading the blog – I had a London Teaching Hospital training and I remember the expert clinicians well. Sadly many of those skills have been lost – some replaced by better methods, others lost to the detriment of patient and doctor.

Simon Dodds

Anonymous said...

Loved the emphasis on promoting health and activity. It would be great if all practices understood these links and were able to find some energy to work more proactively to promote health in this way. I worry that the current incentive regime does very little to encourage this approach - and even discourages it since higher prevalence rates can be good for the bottom line.

I would just challenge Phil's views on electronic health care records, however. It does not have to work in the way promoted by connecting for health. Records can be stored in a way that can be accessed over the internet, with suitable security as with my internet banking. Not everyone will want that but I feel that it is important for patients to have access to their records if that is their wish (and not have to go through the practice every time)

Graham Box

Phil S said...

Thanks Simon - Like minds :-)

Phil S

Trevor Gay said...

Graham - good to hear from you - hope you are keeping well.

Phil was always way ahead of the crowd on promoting health.

He and I worked together on a major project in 1985 in Torquay that was all about using non-NHS led interventions to improve health and lifestyle issues around housing, employment, exercise, diet and poverty etc.

Phil S said...

I'm worried that with Graham's good intentions, based on a good idea, that billions will be taken out of patient care for political correctness and administrative reasons. Is he happy to have his hip replacement postponed indefinitely? Health resources are finite, use them on health. That was exactly the point I made about the report on our psychiatric unit being written by lawyers who felt the entire psychiatry budget should be spent on providing lawyers for patients.


Simon Abrams said...

Thanks for the link. Phil sounds a very interesting man. I enjoyed reading the interview.

Dr Simon Abrams

Anonymous said...

I am with you Phil that it is absurd to spend billions on allowing patients access to their electronic records. My point was that the systems are already in place to deliver this at very little cost. There is emerging evidence that the health benefits justify these smaller levels of expenditure. But I do agree that we seem to be finding many ways to spend money that do not directly improve health,


Dave Wheeler said...

Trevor/Dr. Phil...

I most emphatically disagree with Dr. Phil one one point!

"My own approach to management is the same as it was when I was captaining sports teams.... I led and hopefully still lead by example, not dictat. I have always gone the extra mile for colleagues and patients; will always put my body on the line. I expect managers with whom I work to do the same."

Management is not his forte? His approach may not be one that flagged him as a manager on his 360. But it is one the truest and simplest prescriptions for being a terrific leader that I've read in some time!

Great interview!

Trevor Gay said...

Graham - I wonder what our younger generation will expect in say 20 years time. Kids are being brought up and educated in a world of electronic everything' and I think customer(patient) demand will drive this subject.

Trevor Gay said...

Dave - You are spot on about Phil - he under-estimates his management ability and as a leader he has few equals i my experience and I worked closely with Phil for a number of years.

Phil S said...

well........... that's very kind

Thanks Dave!

Dave Wheeler said...

Dr. Phil,

One's position gives one the title of manager. One's actions makes one a leader. I too spent many playing sports and spent 20 plus years in the military. All the folks I considered to be my "benchmarks" as leaders have the same attributes you describe!

If it sounds like a leader, and acts like a leader...thanks for sharing your knowledge and experience sir!

Phil S said...

Dave - too kind!!!!!!!!!


Marilyn Jess said...


As a wellness coach and dietitian, I am right with you with regard to health promotion. Thank you for sharing your story. It is stories like yours we in the USA NEED in our quest to reform our broken system.

I respectfully disagree about the electronic record. While it cannot replace the clinician-patient interaction, it has made my practice much better. I wouldn't even consider working anywhere that isn't 'wired,' as they say.