A man in his sixties comes to my clinic because his wife made the appointment. He sits down a little heavily.
“Doc, I’m not too bad.”
He gets breathless, yes.
“But it has always been like this.”
That last bit makes me pause. He’s telling me how it feels from the inside, which is a different thing from how it is.
So I ask something else.
“What did you use to do that you don’t do now?”
For a while, nothing comes. Then he starts remembering.
He parks nearer the shops. Takes the stairs one landing at a time, with a pause he hardly notices anymore. He gave up the allotment two summers ago. The grandchildren come to him now because the hill to theirs is too much. His wife does the shopping.
When you put it all together, quite a lot has changed. But he hasn’t been putting it all together. He has been getting on with his life.
Each adjustment made sense at the time. Why struggle up the hill when they can come to you? Why keep an allotment you can’t manage?
His aortic valve was severely narrowed. It had happened gradually, over the years. During those years, he had gradually been doing less.
He was comparing his breathing with last week’s, not with the man who walked up the hill to his grandchildren. And last week looked much like this one.
You get used to it
We are quite good at adapting. Often we have to be.
Someone leaves and isn’t replaced. The rota has another gap. A reorganisation arrives while everyone is still trying to make the previous one work. People work around it because there are patients waiting and colleagues who need help.
I don’t want to dismiss that. A lot of care depends on people finding a way through a difficult day.
But after a while, we can lose track of what we are working around.
“We always run short on nights.”
“Clinic always overruns.”
“That’s just how this department is.”
I can imagine saying any of those things without thinking much about them. Explaining the place to someone. Perhaps even trying to reassure them.
Diane Vaughan used the term normalisation of deviance in her study of the Challenger launch decision. Engineers had seen O-ring damage on earlier flights. Those flights returned safely, and over time the damage came to be treated as an acceptable risk.
It is uncomfortable to think about how reassuring “nothing happened last time” can become.
On a ward, it might sound like, “We managed.”
And we did. People stayed late. Something less urgent waited. Someone went home worrying about something they hadn’t had time to finish.
But when we look back, do we remember those bits? Or just that we managed?
A newly appointed ward manager once told me she lasted three weeks before she stopped writing down what shocked her. The notebook had been her idea. She just stopped using it. Nobody decided. The things she’d written down had become familiar. None of them had improved.
This is what I mean by Cognitive Oxygen® (COx). When there’s too little room to think, you keep working, but you consider fewer possibilities. You’re shorter with people. Something you’d normally be curious about becomes one more thing you can’t face. I call it cognitive hypoxia.
You may notice some of that. You may also think you’re just having a difficult week.
And when somebody asks how you are, “fine” is the quickest answer. Sometimes you haven’t got the energy for the longer one.
Ask someone who has just arrived
A new colleague can help us see things we’ve stopped noticing.
They won’t understand everything yet. There will be reasons for some of what surprises them, and history they haven’t heard. But I wonder how often we explain all of that before we have properly listened.
A staff nurse in her first month, say, or a manager who has come from another trust and still looks a little puzzled when nobody takes lunch.
Ask what surprised them during their first fortnight.
Perhaps it was the late handover. Or the consultant’s email at 23:40 that nobody thought unusual. Or the way another rota gap was announced and everyone simply nodded.
They may be apologetic about mentioning it. They are new. They want to get on with people. Being the person who keeps asking why is not always comfortable.
And hearing it isn’t always comfortable either, especially when you’ve spent years trying to hold the place together.
An Assumptions Challenge™ in Red Team Thinking® offers a way into this: what are we taking for granted?
“That’s just how it is here” would be somewhere to start.
There may be a real constraint behind it. There may also be an old workaround that nobody has revisited. We won’t know if the sentence ends the conversation.
Of course, medicine will always involve pressure. There will be hard nights and days when lunch goes wrong despite everyone’s best efforts. I don’t think we help anyone by pretending otherwise.
Still, I want to know when an occasional difficult day became the arrangement.
And whether anyone actually agreed to it.
What have you stopped doing?
The question about what my patient used to do helped me understand how much his life had changed. “How is your breathing?” hadn’t brought that out.
His answer was honest. My question was the wrong one.
Teams can ask the same question, and so can those of us leading them.
What did we use to have time for?
What have we stopped doing without ever deciding to stop?
Perhaps it was talking through a difficult case together. Perhaps it was leaving work with enough left to listen properly at home.
Some things we used to do probably needed to go. Others we might miss more than we have allowed ourselves to say.
I’d like to think I would notice this happening. I’m less sure I would notice it in myself, especially during a week when getting everything done felt like enough.
This week, ask one new colleague what surprised them when they arrived.
Write it down.
Give yourself a moment before explaining why it has to be that way.