• epistle
• december

A while ago, when I was in a role which meant I worked very closely with the management team, we messed up. The precise details elude me but suffice it to say that a group of the consultants we were responsible for were going to have a really bad couple of days dealing with some very upset families. Characteristically this information came to light late one afternoon, and having run things through with me, one of the service managers started to compose an email to the lead consultant, telling them about the situation and how we intended to help them with what was going to be a difficult response. “What are you doing?”, asked the senior manager. After a short explanation, the senior manager said: “No. That’s not email information. That’s face to face. You go and find them, and talk with them. Do you want me to come with you?” It was at this point that I understood that I was working with the right people. The key distinction, which the senior manager had grasped, was—to borrow from some managerial jargon—the difference between transaction and transformation.

In these pages we often focus on transactions. This is the nature of much of the basis of medicine. It means: Given situation X, you must consider antecedents A to E, be concerned about complications F to J, and then take actions K onwards. For example, given the symptoms that a child who has a urinary tract infection may present with, then you must think about how to confirm this diagnosis, how to treat it, and then consider why they might caught it in the first place, and whether it will cause them any lasting harm, and so on. The transactions can get quite complex, but they can be written down—and are often written formally in guidelines or pathways.

Sometimes, however, we look at transformational situations, and in this issue we’ve quite a few. Perhaps the best way to understand the distinction here is to look at these papers. For example, Emily Harrop, Katherine Boyce, Tania Beale and Karen Brombley share some of their experience in discussing Advanced Care Pathways ( see page 282 ). It’s very important—and quite humbling—to realise that two of these authors have been on the other side of that conversation; they’ve had to discuss the pathway about their own children. What for me is transformational about this paper is that at no point do they suggest you go into the conversation with a formula. To state the obvious, for example, you don’t request some imaging at a fixed point. Instead, you have conversations, backed up with knowledge of a framework and understanding of some of the items you need to cover, which take you to a mutually acceptable point. This is this month’s Editor’s Choice.

I should add that in this same issue Ella Aidoo and Dilini Rajapakse do an excellent job of reviewing the NICE guidance on End of Life Care ( see page 296 ). Some aspects of this can be —and should be—transactional, and it is not to subtract from the very good guidance and this helpful review of it to describe it as such. My point is only that you can be perfectly adequate in managing transactions, but some situations require transformative interventions.

Take, also, Martin Ward Platt’s piece on supporting colleagues through an incident ( see page 288 ), and Sanjay Suri and Eleanor Nash’s paper on resilience ( see page 291 ). Both have ‘do’ and ‘don’t’ in them, but they provide a framework not a strict pathway to follow. They simply wouldn’t work if they said ‘You must do this’—there is no equivalent to the ultrasound scan for the child who has had a urinary tract infection here.

One final point. There has been a bit of a backlash against resilience recently, which I find a bit of a shame. The negative view is that we if we do lip service to caring for ourselves given intolerable stresses, it removes the need to examine the causes of those stresses—where they are overwork, underfunding and so on. There may be pockets of this, but I find this a misuse. I find resilience as my way of maintaining my sense of who I am in the context of, sometimes, needing to give quite a lot of that self into distressing circumstances. I am utterly drained after Advanced Care Plan conversations, and I label the ability to replenish myself ‘resilience’. If you are going to do more that transact; if you are going to transform, then you need to be kind to yourself as well.

As ever I’d love to hear what you’d like to see in the journal, or write for us.