3: Healthy minds, healthy professions

20 April 2023

Winds of cultural change are blowing through many sectors, and the legal and medical professions are no exceptions. In part two of their discussion, lawyer Chris Georgiou calls out the culture of learning that the legal profession must embrace, while surgeon James Kinross explains the “patient safety culture that has been the biggest healthcare revolution in my professional lifetime”.

Kinross describes a “no-blame learning environment” where morbidity and mortality data is meticulously recorded and appraised to discuss “what went wrong, and why, and how do we make sure this never happens again”. There are lessons here for many professions, legal among them.

The two men also discuss the mental pressure that is heaped upon professionals, and the prevalence of anxiety, depression and burnout. And they reflect on the increased need for professionals to have technology expertise to perform at the top of their game, while understanding the limits of tech and how humans still add value.


Hello, and welcome to Ashurst Business Agenda. This episode is the second part of a two part conversation between James Kinross, who is the Senior Lecturer in colorectal surgery and a Consultant Surgeon at the Imperial College London, and our very own Chris Georgiou, Partner and Head of Ashurst Advance. The conversation picks up on the similarities between surgeons and lawyers in a data rich world then goes on to discuss the apprenticeship model and the innovations adopted by the two professions out of the COVID pandemic. You are listening to Ashurst Business Agenda. From an outside perspective, your two professions could be perceived as having an aversion to failure. I'd be interested to hear both your thoughts on this issue of failure and what happens in regards to failure in this data rich world, in which we live in Chris, did you have some thoughts on this?

Chris Georgiou:
I think where we're getting to in the legal profession is more of a focus on learning and continuous improvement, but I think we've got a huge road to travel there. I don't think it's yet embedded within our DNA, that you look at the process, you fix and rewire it. You maintain rate or risk logs to surgically identify and pinpoint exactly where something went wrong and remediate it and learn the lessons for later. I think we've got a lot to learn there from other professions.

James Kinross:
I would say that the change in patient safety culture has been the biggest revolution in health care that's occurred in my professional lifetime, and it's probably been the most impactful. Patient safety has transformed the way that we think about risk and the consequences and implications of failure in medicine. Before really the patient safety culture came in, surgeons operated very independently with no transparency whatsoever in their practice. And there was a culture that went with that that was not conducive to high performance or to being transparent about your outcomes. And that has fundamentally changed.

Now, in healthcare we've borrowed the kind of fundamentals of our approach to patient safety from the aviation industry, which broadly there were simple things like crew resource management and how you communicate and how you share findings from failure. In healthcare we tend to... Well, there is a historical practice of really hiding from failure and just not being honest about it. And again, outside of surgical, look at pharma when a drug trial fails, we bury that data and it never comes out because it's bad for business. And actually if a plane crashes, you really, really want to know why, you want to learn absolutely everything you possibly can from that episode of failure and make sure that it never, never happens again.

In surgery, so just to come back more specific, this is what I do. In surgery, of course, we borrow a lot of the practices from the broader safety culture around transparency, communication, data reporting, clinical governance and those sorts of practices, but we have some more specific practices. So we have something called a morbidity and mortality meeting, which back in the old days used to be very hostile and quite challenging, but they've got better over time and more data-driven, right. So now we have a kind of more honest appraisal of that data, but in morbidity mortality boards.

We openly discuss our failures in a learning environment, in a no-blame learning environments. It's can we have an honest conversation about what went wrong and why, and how do we make sure this never happens again? And also, how do we constantly audit and report on that data so that we have a continuous learning culture and that continuous learning culture again, happens across the NHS, happens across the board, we have national reporting systems.

And one of the major drivers for that actually came through the introduction initially of targets and open data reporting at hospital level and national level. And then we also report on that locally. And in fact, actually one of the biggest learnings of COVID has been that some of those data sharing processes were not as robust and as good as we wanted and I think that will be a major innovation for us going forward. So safety for us it's a major theme. Every operation that I do, at the beginning of every operation, we have a World Health Organization checklist, and I will, like a pilot we'll tick things off, have we checked if we've got enough fuel in the jet? Yes, we have.

We will do that for every single case. Every single case that I finish, I will check out. These are the things that we said we were going to do. This is what happened. This is where we deviated. These are the problems that we've addressed. And this is what this means for this patient going forward postoperatively. And we constantly audit. I'm not saying it's perfect. It's not perfect. We still don't ask you these things as well as we should. And we're constantly trying to improve that process, but at least we now have that process.

Chris Georgiou:
It sounds like what you've done is systematize the processes really, really effectively. And I think at the moment in the legal world, we haven't yet systematized. I think we have collections of teams and units and individuals and departments that operate on their own. I don't think we are sharing institutional knowledge in the same way. One thing we have done, which I think is making a huge, positive difference to the profession is we've started to introduce new types of professionals into the profession that are not lawyers. And sometimes they're awfully labeled non-lawyers by the professionals. And nobody quite likes that label as if the universe centers around lawyers.

But so we've introduced these new types of professionals and amongst them are people like process engineers and legal project management professionals, and what they do is they have come in and they've brought skills and processes that we didn't really have before. And they are starting to do that kind of systematizing, if you like.

So they will start to plan how matters are, and projects are conducted, for example, and they will maintain rate logs around things and share the learnings from that and try and instill a process of continuous improvement. But you've got to have one of those professionals in your world in order to be able to be doing that. It's not yet embedded in the DNA of the profession. I think in a way that it sounds like it is increasing also in healthcare and in aviation.

James Kinross:
When you were talking, I was just thinking about one other thing, which is that failure is so painful, and there is an emotional cost to it. Like when your case goes up in flames and you lose a client, or someone goes to prison, or either, you know, my imagination is slightly running away with me. Actually there's burnout associated with that. There is a mental health consequence and in surgery it is the same, right? If the worst happens and I lose a patient, it's awful, my life falls apart, I don't go home and switch off and not worry about it. There's a consequence to my ongoing practice, right. A real practical application.

And I think one of the things that we're slowly learning is that actually you have to acknowledge that and you have to support people, right. And particularly like through COVID, for example, we've just done a piece of work. We've done a big international study, 67% of the workforce is efficiently burnt out. They are exhausted. You cannot have an effective, high-performance team that is emotionally distraught, burnt out, anxious, depressed.

So actually safety it's about not acknowledging the human aspect of what we do for the professionals delivering that process, right. And it's stressful. And you can't flop that horse. And the other thing that I wanted to say was the word trust. So what happened, if you go back to the nineties and when we started reporting morbidity and mortality data, one of the things that surgeons were really worried about was that we were going to be judged unfairly on the quality of that, on the quality of that data.

So the truth of the matter is that you can go into the website and you can see my mortality data. You can see how many patients that under my care died from their surgery. And that leaves you feeling very exposed. And I think it eroded trust, professionals felt they couldn't trust that data and they couldn't trust that process. And so if you're going to start using information and data, and you're going to start developing deep learning tools and to start developing algorithms that are going to try and improve performance, the professionals using that software, using that data have to have real trust in it. And that means that they have to understand how it works and the detail of the consequences of it not working effectively. And that means in my profession that actually, if you've got an algorithm that's going to have an impact on patient care. Actually, it's a therapy, right? It's a medical device. It is an intervention.

And I wouldn't give a drug to someone if I didn't know how that drug works and what the side effects of that drugs were, or the consequences of an adverse drug reaction and then what to do if it fails, I mean, I have to know about it. And it's the same for digital interventions. There is a generational divide, right? And young people coming into the medical profession definitely have more insight than perhaps my generation do, or those who were born pre-digital in the dark bronze ages, right. But I think still they have to understand the language of code. They have to understand bioinformatics in the way that we did. And actually we are also bringing in people.

So, we also have experts on our team who are not doctors who are medical doctors, at least. And I think we're going to have a really diverse team of players in the future that have some of those skillsets. And dare I say it, probably more legal representation because there is a huge amount of unknown in what we're doing here, this is genuinely right at the frontier and a really exciting one by the way, which I think is going to be generally for the good, but there's no doubt that whenever you have a really radical innovation, which you try and innovate, you're going to cause harm along the way. And you have to kind of mitigate for that and protect yourselves and protect your patients as much as you can, but also protect the professional needs to be kind of wrapped in common a little bit.

Chris Georgiou:
Well, one of the points you made there is whether or not the professionals themselves need to... you were talking about kind of needing to really understand the algorithm and have trust in it. And that raises the question of whether or not what we're saying is that our professionals need to have real expertise in the tech itself. And that's the question I think we've been laboring with a lot in the legal profession as well about whether or not is what we're saying, that all legal professionals or healthcare professionals need to become experts in tech themselves. And I think probably that you don't necessarily need to be an expert in that yourself, but you definitely now need to be literate in it. And that literacy needs to extend to being aware of what all the available tools are, and also their benefits, but equally their limitations and the risks attached to it.

And we've got some parallels there. So when for example, if we've got a very large document review exercise to do, we need to know that there's a whole bunch of tech tools out there that can help perform those tasks and do it very effectively. But one of the things we also need to know is what are the limitations there and why do you still need the human angle? How much volume do you need for that tech to actually be effective and to be worthwhile at all, and actually increase efficiency rather than reduce it.

And I think that then also feeds through to that point you've raised about training. How do you train the professional of the future if actually you're taking away from them all of the things that we used to cut our teeth on? By doing the same boring task a hundred times a day late into the night, and then slowly, slowly, over years, you get on the job experience and you become an expert in a particular field, but if you've taken all of that away, because you deployed nice tech to do those things, how do you recreate that for people? Do you create artificial scenarios that they would get in real life? Give them data-driven insights, is that less effective or is that more effective?

James Kinross:
Well, yeah, I mean, I'll come right back to the beginning of this conversation, whether we train kind of in a similar way, which is effectively, we both have an apprenticeship model, which is that you do your time. And the whole goal was that you came into that system, you sweated hard, you didn't sleep for about five to six years. And if you were lucky, you progressed. And the problem was is that that apprenticeship model was completely heterogeneous, right? So your experience of training in one center was very different to another, and very difficult to quantify and very difficult to measure. And most of the time it worked, but sometimes it failed and when it failed, it failed disastrously and you had lots of bad actors.

And actually the apprenticeship model is not a safe system. It's really unsafe, right? Because first of all, you have that hierarchy. So communicating failure and acknowledging that things aren't going well. And I've been in the operating room where things are not going well. And actually we were just too junior and too frightened to say, have you considered doing X or Y that conversation just was never going to happen, mercifully that would not occur today, but also I think it's not an efficient way of training. It's not an efficient way of learning. Yes, I take your point that at some point you've got to do the graft, right? So particularly for a technical skill like mine, I've just got to do a certain number of operations or I'm not going to be able to do it safely, but actually we can use technology very effectively to change that process, to give you a really good example and this is totally true when I was a junior doctor, again, I'm very, very old.

So this is long time ago in a galaxy far, far away. I was 20 something middle of the night, child with appendicitis. My registrar said to me, I'm going to bed. You're doing this operation. Don't come and get me. Don't wake me up under any circumstance, crack on. Right. And we had a music stand. This is true. We had a music stand in the operating room. This is like every operation room how a set of music stands. And you would put the operating text manual on the music stand, right. And you'd start. And the assistant would turn the page for you as you sort of poured sweat, right. And that was my education. That was my training. That's awful. It's awful. It's unsafe, it's dangerous. It's stressful. There's nothing good about that training and education.

And that's what I mean, mercifully again, that doesn't happen anymore. And that's part of what I was saying about safety culture. So actually I think the apprentice model needs disrupting. It needs changing. It needs updating. And actually, again, like COVID, I think for us is going to be a really important tool for doing that. So COVID has taught us again, that medicine has really radically transformed in the last 20, 30 years in its approach and attitudes to training. And actually now I'm really pleased to say, we have a very, very structured program where our trainees are constantly measured and appraised and they get kind of constructive feedback, but it still takes 15 years to go from med school to surgical consultant, which is just too long. We actually have massive workforce requirements that demand that we produce more doctors than we currently are.

We were 50,000 nurses short before COVID struck, right? Now, post-Brexit, post-COVID. We definitely don't have enough nurses. So the training cycle has got to get faster. It's got to get more efficient. It's got to constantly get safer. And technology has a lot of value there because actually you can simulate. And we are investing a lot of time in simulation technology. So you can stress, you can stress positions in really high-fidelity environments and test their processes out. And you can test failure modes and you can assess team responses, not just the surgeon, it's the team, right? The team is what makes clinical care safe, and you can feed back and you can learn in those environments, but we can also deploy learning technologies into real world clinical environments.

Those learning systems are deployed in real time at the patient bedside. So as that surgeon is performing a task, he or she, it's constantly being assessed, measured, and their performance has been recorded and then fed back to them, so they get real time data on their technical progression and their cognitive and learning progression, knowledge based progression, sorry, as they progress. So I think digital is probably going to have one of its biggest impacts in training and learning for our profession, as we go forward.

Chris Georgiou:
I quite like your terrifying story, actually about how you learnt, because I certainly had several years at the early stage of my profession being thrown into absolutely situations that I was completely unqualified to handle and being completely rigid with fear through it, but actually learning so quickly as a result, because you just wanted to survive that situation, come out with your dignity intact, not make an utter fool of yourself. And next time do it better. And actually I found that probably in the space of two years, I've probably learned more than many people did in four or five. So I've often reflected on whether or not to introduce a terror style apprenticeship for genius. But I somehow fear that actually that wouldn't go down very well and we should be focusing on something a bit more data driven as you're suggesting.

James Kinross:
But I also think like if we come back to the hierarchy thing, right? And the apprenticeship model is that I sit in a lot of interview panels, right. I interview a lot of kids coming to med school and I have a lot of trainees and a lot PhD students. And these... I call them kids because they're in the twenties, right. But they are so good. They are so capable.

These people are amazing. Their CVS are embarrassing, I'm embarrassed because when I was 25, I mean, I certainly didn't have their level of focus, their level of competence, right? So these are really good people and they are capable of so much. And actually we under utilize this amazingly valuable resource.

We put these people in a position where we ask them to match menial processes, which is a waste of their talent. And you're kind of right, there's a balance because actually, when you were going through those highly stressful situations in the early part of your legal career, actually you got through them and you got through them for a good reason, which is because you were completely capable of dealing with it. You just weren't properly supported and helped and managed through that process, right?

So it's not about removing young trainees from those experiences. It's about enhancing them and helping them to get through that experience more safely in a more controlled way, with more support and more learning. And actually, I think for that reason, we should be able to dramatically shorten our training times. I think to be really frank about it. I think we patronized quite a lot of our trainees. We say to them that you've got to go through this process because I went through it. That's not the way. And I think that's going to be an important change for us.

Chris Georgiou:
I totally agree with that. Actually. I really liked your point about how much talent actually is coming through the profession because we're seeing exactly the same thing people are coming through with ridiculous levels of skills and qualifications and all kinds of skills that actually, I don't think we had when we were starting out and how you harness that and deploy it for the benefit of the firm or the industry that you're in is probably one of the biggest challenges actually.

Because again, I feel like you that to some extent you stifle that because we put people in boxes too much just because it's easier to run life that way, rather than looking at this wealth of skills and talent and ideas and embedded innovation that is living inside the newer waves entering the profession and seeing how we can actually release the palette, that sick that's contained in there and use it for all of our benefits. And I think that's something we need to focus on quite hard.

James Kinross:
So basically what we're saying is the future is really exciting. And having a future where I was on a different panel yesterday, and we were talking about the impact of COVID and we've been talking about how we were going to get our way out of it. And of course, those organizations, which are able to embrace change and have enough resilience in organization that they can adopt innovative practices to adapt are going to survive.

And I think the thing about digital is that it's not optional for us. We have to do this. It's not like we've been given a drug and we can choose not to take it. We've got to do it because we know that our processes are inefficient. We know that it could be safer. We know that outcomes could be better. If you look at outcomes from cancer care, survival has improved by about 50% in 50 years, it's still not a hundred percent, but it needs to be, so we've got to get better, we've got to improve. And we have to use every tool at our disposal.

And I think that's a mindset. That's a culture. You either work within an organization that says, yep, we are an innovative organization and we're going to enable our leaders and our managers, and also we're going to train, so they've got the skill set to adopt and apply those innovations, or we're not. And if you don't, you won't survive anything.

Chris Georgiou:
And actually we took some incredible lessons actually from one of our biggest clients recently through the COVID pandemic, which was McLaren. And people have seen this as well, where their business was massively impacted, the production of formula one cars and the world needed more mechanical ventilators at the time. And there was a massive shortage in the NHS. And so they effectively got their best minds together, collaborated across the industry, took all their engineering prowess, all their innovation expertise. And in record time, they got together and they started producing ventilators as opposed to formula one cars, which is when you think about it, just truly remarkable. And actually I think nobody would ever have that that was possible. And I think just looking at lessons like that show you the art of the possible, don't they?

I think COVID does provide that wonderful opportunity. The light in the sand to really transform not only the health profession, the legal profession, but many others, Chris and James. I want to thank you very much for your time today, for your insights, for your great storytelling and thank you for being part of Business Agenda.

James Kinross:
Thank you very much indeed.

Chris Georgiou:
My pleasure. Thanks for having us.

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