I was originally interested in the way patients and their doctors make decisions about what sort of treatment is right for a particular patient, at a particular time - especially in an emergency setting. And as anesthetists, we often get called to these sorts of situations when the patient who might have a few comorbidities or might be frail in a particular way - for example, they have a serious condition requiring surgery. And there's the question of whether surgery – which might be life saving in some situations but might also have significant physiological impacts – is right for this patient, and trying to help the patient figure out what they want and what the doctors can offer to help them get their wishes. That was the original topic I wanted to investigate. But of course, it's a huge topic!The supervisors that the Elizabeth Blackwell Institute had me put in touch with, helped me refine it into understanding whether this sort of work could even be done! Whether we could feasibly even be there, in those moments, listening in to those conversations. Obviously, they’re very private and vital moments for these people.

At the moment, what we're trying to do is to just establish how these conversations are heard at the moment. And there's a huge variety! In my own clinical practice, I've seen these conversations done beautifully with an outcome exactly right, for this particular patient. But I've also seen them done in less than ideal ways where I thought, actually, I'm not sure this is really what the patient would have wanted in this situation. It depends, of course, on the clinicians and their communication style, but it also depends on the environment, on the workload, and on the patient's ability to even engage with those conversations at that time – because often, they're really unwell and in pain. They're scared, frightened. And nothing like this has likely ever happened to them before. So it's really, really hard to get these conversations right. And so for the moment, we're just trying to figure out what the conversations are like at the moment, and then hopefully, that will play a small part in making them better in the future. 

Well, I think this study is very much needed! I was lucky that so many of the clinicians at the BRI and my own hospital were happy to talk to me about it and all of them saw the significance of the work and found that this was an area they'd considered often. I was very lucky that all of the patients I approached about the study agreed to participate, which I think shows that, for patients, it is acceptable to be part of a study with a researcher being there; tape recorder lying on the table flashing its little light in those moments - that's really encouraging, I reached my goal of recruiting 20 patients, I think I got lots of interesting data from all of the consultations - often five or six consultations between the doctor and the patient for each encounter until they make their final decision about what to do. 

 

These conversations are never just in one moment, at one time with one person. They’re spread out over days with different people: nurses, junior doctors, consultants, family members – everyone having, slightly different ideas and ways of wording the wishes of the patient, or the implications of the surgery. But yes, I'm very encouraged to say that I think the study is feasible and acceptable. And certainly, my own communication style became better thanks to witnessing so many of these consultations, and borrowing all the bits that I want to replicate in my own clinical practice. There was an element in my study of looking at how much patients want to make these decisions for themselves, and how much they would like to be guided by the clinicians. And we talk a lot about shared decision making. A lot of patients when I asked them after the decision was made, said that they were actually just glad that the clinicians took responsibility for the decisions, guided them, gave them advice on what they would do if they were in that situation, which I thought was really interesting –  I had assumed that every patient would want to make this decisions 100% for themselves, but actually I don't think it's the case for everyone either.

 

I think that's very important to recognise that there are people who want to have a very clear say and feel like decisions were made by them. But there was a significant group of patients who I don't think were interested in that aspect. I read a really interesting paper where they talked about how patients use these consultations with doctors less as a sort of information exchange, but almost more as a means of gathering trust and making sure that in their minds, this doctor was an okay person. Certainly a lot of the patients confirmed to me that they were very happy once they felt comfortable with the doctor after these consultations to put the decision in their hands. It’s important to recognise that patients have different opinions on this – some will want to make the decisions and some don't. 

I think, as clinicians, we often feel that these decisions are very complex, and it's very hard to put them across without having seen what can happen. I think all of the clinicians were wanting to do the right thing for the patient. But perhaps some of them felt like they knew what the right thing would be. In some cases it was very clear, if you’re young and fit and you have appendicitis, or something that clearly needs an intervention, then that intervention needs to be done. And often then in those cases, there wouldn't be that much discussion about it. But then there are cases when the surgery becomes more high risk - perhaps the patient might be more frail or the issue is more complex – then often more time is spent trying to work out the right thing to do. 

The topic had been one that I'd found interesting and important for some time. I've worked on Intensive Care for quite a while in the past and was witnessing a lot of conversations about whether people should be admitted to the intensive care unit; whether that would be the right thing for them. And actually, when I was asked in my anaesthetic job interview about the moment that made me want to become an anaesthetist, I instantly remembered this one occasion where I had gone with one of the consultants to see an older lady who needed surgery. She was really afraid and clearly wasn't going to do very well from surgery. And the anaesthetist was amazing - she pulled up chairs for all of the family and for us, and everyone sat in this really calm way and discussed all the different things that were important to the patient; pottering around her garden and being at home with her family. I just remember being so impressed by how the anaesthetist managed to tease out all these things and then put the choices to the patient in those terms, and what the different choices might mean for her and the things that were important to her. 

 

So that's why these questions are so important to me. I'd heard from a few colleagues who’d done similar things about the Elizabeth Blackwell Institute, and the Primer Scheme. It just allows you to dip your toes in to research, as I wasn't that sure whether it was going to be right for me, so it seemed like the perfect way to do it. 

Having witnessed all of these consultations; the 20 patients I recruited and all the different other ones that weren't part of the study, that I interacted with have definitely made my own communication skills better and made me realise how I want to speak to my patients in the future, when I am in those moments. 

 

And doing a research project has given me a lot of perseverance. It was really tough doing a feasibility study where, almost the point of it is knocking your head against the wall in all kinds of different ways until you find the one thing that finally works. It was tough, every time one of my ideas didn't work out, or something didn't quite go the way I expected. Or when I would spend all day following a particular surgeon without finding a single patient. All of those things were important to do but were really tough at the time. And it’s great to be able to look at these problems and try to find a way of making them work. 

I had to take a year out of my anaesthetics training programme. And when I applied to the Deanery, who oversee us, they kindly allowed me to take the whole year off, so I had a little bit of time off completely before and after starting the research. I had a few months of seeing my family in Germany, and going travelling, which was lovely.

 

It's a very different thing. research to clinical medicine, and I found that quite a hard transition. The pace is very different. Because I was doing it full time, and I was working with people who had so much else to do, often I found myself waiting for email replies or for panels to meet and approve my proposals. I found that quite challenging and so I was impatient to get to the actual data collection. And that took longer than I wanted it to, which I also found tough. But it’s lovely being able to spend whole days just studying one topic - doing literature searches or learning about qualitative research, doing courses and so on, and having time to do all of these things properly without being distracted all the time by clinical commitments. That was a great opportunity. 

I think I would like to continue research but not full time. One or two days a week would be prefect for me, I think. Right now I'm really looking forward to going back to clinical work. I was able to do one day a week of clinical work and during my research, and I always looked forward to that day. A couple of days a week of research, and the rest in the clinic would give that sort of instant satisfaction of having achieved something clinically and with the clinical team, along with the longer-term goals of research and the ability to delve into one topic really deeply and think about it, which I really loved.

 

I loved having the time and the mind space to really think about and develop the questions that I wanted to ask. And I love the freedom that the Elizabeth Blackwell Institute gave me to do that, that I could develop my own question and pick how to answer it. And whenever there was a problem that I was stuck on for ages, when I finally solved it, that was a really nice feeling! 

My supervisors were really helpful. We met almost every week, mainly for a pep talk where they would tell me that everything was going the way it was meant to, and not to worry! Apart from that, it was a bit tricky knowing how to get all the processes started - that was something that I've never done before, applying to the ethics panels and submitting all of my proposals to the hospital and the university and so on. So it took a lot of scratching my head to figure it out! 

Asking advice became much easier once I was working at the BRI because I could pop my head into people's offices or linger in the hallway hoping for them to pass me! Everyone was really helpful in answering my questions, but often, I didn't even know which questions I needed to ask.

There’s a colleague of mine who's applying for an NIH-funded PhD to look into this topic – we've chatted quite a few times. He will be taking a lot of my findings on board when he does his own research. And he's been able to mention my work to the funding panel and demonstrate that his proposal is feasible. And I'm also going to publish what I found in academic journals. And I hope that that will make it possible for people to use my insights, wherever they are, whether I've met them before or not.

 

It's been a really, really great opportunity; I feel grateful that I was allowed to participate in it. I would recommend it to anyone who was interested – whether I choose to continue research or not, I think this experience will make me a better doctor in whatever the future holds.