Reflections of an orthopaedic surgeon as Medical Director for planned care

Andrea H Sott

Andrea H Sott is a Consultant Foot & Ankle Orthopaedic Surgeon and Divisional Medical Director for Planned Care at Epsom & St Helier NHS Trust/ London. After graduating from medical school in Germany, she completed 10 years of basic and Higher Surgical Orthopaedic Training on the SW Thames Training Programme, London. She entered the GMC Specialist Register as a fully specialty qualified Orthopaedic and Trauma Surgeon in 2004, when she joined Epsom & St Helier University Hospitals. She is a Senior Examiner for JCIE and previously Surgical Tutor for the Royal College of Surgeons of England, sits on Consultant Appointment Committees as Royal College Rep and attends standard setting meetings for the JCIE, Edinburgh.

Tao Te Ching:

• A leader is best when people barely know she exists

• Not so good when people obey her

• Worse when they despise her

• Fail to honour people they fail to honour you

• But of a good leader who talks little

• When her work is done...aims fulfilled

• They will say: “We did it ourselves!”

A few years ago, when I was a recently appointed Clinical Director for Trauma & Orthopaedics, I was facing our executive panel across the board room table during my first high level performance meeting. With a welcoming smile our paediatrician Medical Director greeted me and exclaimed her delight and surprise to see an ‘orthopod’ at a very senior leadership meeting with the words: “We usually don’t expect orthopaedic surgeons here – aren’t you guys always busy down at the private hospital?” In that moment, reflecting on the implication of her remarks I promised myself and our executive team that things were going to change...and for the better! High time to demonstrate our skills, dedication, passion and determination as Orthopaedic Surgeons to step up to the top table and have our valuable clinical voice heard.

How I got here

I joined the NHS 28 years ago as a Senior House Officer in A&E working day and night to earn a living, give my best as a doctor and learn the language to pass the FRCS and gain a training number in T&O in the South West Thames rotation. I remember my SpR interview in 1997 only too well. My first child was still recovering in neonatal ICU after an eight week premature delivery. This was then followed by 6.5 years of full-time training as a single parent without any immediate family in this country. Hail to my au-pairs and friends who were the backbone at home and allowed my career to take off including passing the FRCS Orth and a trauma fellowship at Hannover Trauma Unit.

Now a Consultant Surgeon with a subspecialty interest in foot and ankle surgery and trauma at Epsom & St Helier since 2004, the ethos of hard work and absolute focus never left me and permeates my clinical and managerial work at all levels.

In my early years, I mainly focused on building our Foot and Ankle Unit where there was none before as well as helping to establish one of the best performing Hip Fracture Units according to the NHFD. We now run a well-recognised foot and ankle service with three Consultants, a BOA fellow, two SpRs and a surgical scrub practitioner who manages our PROMS Amplitude database as well.

Fast forward to 2015 when my CEO rang me during a summer holiday run at Saunton Sands beach to see how I would enjoy interviewing for the new role of T&O CD? By then happily settled in life with my lovely supportive firefighter husband and two more children, I embraced the challenge which over time led to the role of Divisional Medical Director in planned care – one of five divisions at our Trust.

DMD role - What’s in a day?

As Medical Director for planned care I am now part of a TRI structure leadership team (Director of Operations, Director of Nursing and Medical Director) responsible for the day to day running of our large division which includes all surgical specialties, A&E, anaesthetics, theatres and critical care as well as endoscopy and outpatient services overseeing over 110 consultants, several hundred junior doctors and even more nursing staff. Little did I know back in 2019 when I accepted the job how this role would magnify a thousand times during the pandemic.

I manage daily operational processes of patient care, chair clinical governance meetings, undertake disciplinary procedures, oversee job planning, AAC work and represent our division at Trust executive committees and regional meetings. I am responsible for managing a £60 million budget and I lead a large team with purpose, compassion, clinical insight and accountability. My management days (five per annum) are filled with a variety of leadership demands and requires decisions to be made in a continually changing playing field.

These changes and challenges have been hugely amplified by the pandemic. We transformed our elective centre into a large critical care unit with a few days’ notice. Just when elective processes had restarted in June 2020 with completely new networks emerging. We had to respond to the directive to supercharge planned care processes NOW to manage thousands of long waiting patients, alongside tasks involving surgical redeployment, shielding staff and providing proning teams.

During my clinical sessions (six per annum) I completely enjoy surgical work including a 1:12 on call and undertaking regular trauma, elective clinics and operating lists which preserves my clinical credibility and sanity.

Leadership programme

In 2018, I completed a six month senior clinical leadership programme (SCL) at the Kings Fund London which I would recommend highly.

I cannot emphasise enough how much this has shaped and helped me in overcoming the daily challenges of my role. Concepts such as instilling passion and leading your team with purpose, embracing a culture of kindness, holding difficult conversations amongst the frequent daily chaos of limited resources, fast paced imposed changes, managing deadlines and too many meetings. Our facilitators Matthew and Belinda frequently reminded us that leadership is indeed a contact sport! Undoubtedly, the best and most powerful conversations are often those which happen by chance in the corridor, carpark or lunch queue. Your conversations and your learnt skill to LISTEN WITH FASCINATION will help you get on with people and have them stand by your side as their leader. My natural curiosity (some might simply call it being ‘nosy’), the ability to chat and relate to just about everyone in the organisation and beyond helps me to develop great working relationships conducive to kind and understanding leadership.

To uphold quality and standards of care whilst remaining authentic as a clinician (as opposed to authoritarian) and most importantly, to develop personal resilience are amongst the pearls of wisdom forever in the back of my mind.

My Trust was extremely generous to offer funding for this programme as well as participation in a national QSIR (Quality and Service improvement course) and two personal coaching programmes. Currently, as a TRI, we are benefitting from a targeted SCL coaching programme giving me space to reflect, take stock and develop my skills as a leader. Believe me, no one is born a leader. It is largely a learned skill and where some people truly excel, I just keep ploughing away… grateful for the mentorship and opportunity to be mindful amidst the current unprecedented crisis of society and the NHS.

Challenges as a Medical Director

These, on occasion, continue to play in my mind. I tend to discuss this with my triumvirate and will not hesitate to lean on experienced senior leaders from other divisions as a sounding board to help me. Having worked for many years as a surgeon alongside my wider team including surgeons, anaesthetists, nurses and managers definitely helps calm the waves and bring it all back to why we are here in the first place: to provide the best care we can for our patients despite often very difficult circumstances.

Continuous email streams (I get copied into just about everything at the Trust) and a permanent phone presence juggling several WhatsApp groups of general surgery, urology, head neck, critical care plus TRI can be wearing and requires discipline to switch off at times to recharge my batteries when off duty.

It goes without saying that leading a large division has its challenges. Difficult conversations occasionally need to be held, struggles around job planning principles resolved and being the arbitrator between feuding colleagues which is often a result of clinically stressful situations can be hard.

The female perspective - Girls most definitely can!

It is impossible to write this piece as a female surgeon without reflecting on my special position as a role model for women in surgery.

For some reason, during medical school in Germany and throughout my UK training I have never really encountered boundaries because of my gender. The glass ceiling was not truly visible to me, rather a strong belief in my knowledge, skills and ability as well as absolute dedication to be a good surgeon dominated my outlook. I fully believe in meritocracy independent of gender.

However, we need to acknowledge the fact that currently 6% of UK Orthopaedic Consultants* are female and there remains a lack of female representation in subspecialist societies and councils. This clearly needs addressing and changing.

As mother of three (the youngest seven years of age) and a full-time working surgeon, I have complete empathy with female trainees and mothers who might feel the choice of being a senior leader and having a family might appear daunting. In my opinion, the UK has one of the best health care systems to allow female doctors to flourish: reasonable working hours, flexible working options, provision of childcare at the workplace and a salary to allow for at home childcare really makes a difference.

By comparison in Germany, the ‘Nanny’ is a virtually unknown concept and combined with surgical starting times of 7am or earlier this is a significant barrier to many female surgeons. My salary and my working pattern plus a supportive husband allows me to flourish in my career and I am endlessly grateful for it. Less than full time training (LTFT) can be good choice for others and I would always support this. We currently have two LTFT trainees who are a real asset to the team as they have organised themselves in an effective way.

The fact that my oldest has chosen a career in medicine seems to reinforce my strong belief that girls need good role models. I believe the sky is their limit should they wish to take on a career in surgery as well as professional senior leadership roles.

All of this does not hide the fact that amongst 42 orthopaedic surgeons at our renowned Elective Orthopaedic Centre, mine remains the only female face on that large wall of impressive photographs in the entrance hall... time for change!

Work life balance matters. A lot. My husband and I had the unique opportunity to build a (German) eco house directly by the River Thames after three years of project management (me after hours) and hard work (my husband and various contractors). I am extremely grateful for an oasis of calm and refuge. Running, fitness and boating alongside family and friends are my remedies to restore strength and staying power when it gets tough.

Rewards

As a senior clinical leader, I feel extremely privileged in my role. I feel I can add true value to senior decision making in our organisation. Just this year our Trust has been granted permission to plan a new major acute hospital to translocate our somewhat fragmented emergency services into one modern contemporary and well planned facility. From a planned care perspective, over many hours of analysing, planning and teamwork, my vision and clinical view have shaped this new facility and I felt very valued throughout this process.

Show casing our newly developed T&O, urology and ophthalmology hub all developed at pace in the summer of 2020 to NHS London and GIRFT leaders, I felt so proud of what our Planned Care Division have achieved under the most challenging of circumstances. It was a perfect opportunity to demonstrate effective senior clinical leadership and great patient care during elective recovery after COVID-19. I believe that my work as Divisional Medical Director has definitively added value to these achievements and pulled our large team together in the midst of a healthcare crisis.

As orthopaedic surgeons, we are very accomplished and skilled to fix what is broken. Our unique knowledge and skillset, our resilience and calm in the operating theatre and our ability to restore are invaluable to senior leadership. Add to that passion, communication and listening skills and good time management and you have the perfect scaffold to develop into an effective and valued senior clinical leader.

* Editor’s note: 30% of female consultants are ‘early years’ consultants within 5yrs of CCT (the other 70% qualified 5-30 years ago).