In conversation with Bob Klaber

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Hello and welcome to this BMJLeader conversation. Today I’m talking to Bob Klaber.  Tell us about your current role and the career trajectory that took you.

Bob Klaber: I have a slightly crazy role that takes me in all sorts of interesting directions; I guess people might call it a portfolio role. A key part of it is I’m still a consultant general paediatrician; I do three bits of clinical work – on our on-call rota about every seven or so weeks, where I do Friday, Saturday, and Sunday as the consultant paediatrician responsible for the general paediatric inpatients at St Marys.  I have moved all my outpatient work into something called Connecting Care for Children. Rather than sitting in outpatients waiting for the next patient to turn up, it’s about working with primary care networks and, in modern language, integrated neighbourhood teams,  to support them as they think about improving the health and well-being of the population of children they serve. This means getting out on a bicycle into Hammersmith and Fulham, into the north of Kensington, or Westminster,  to go and do that work with primary care teams.  It is a totally wonderful experience. Anyone who ever experiences will feel much less inclined to set foot in outpatients ever again; patients and their families too.  Then, there’s a really interesting bit of work that a few of us Consultants at St Mary’s do around following up children and young people who were caught up in the tragedy that was the Grenfell fire.  I reckon these three areas of clinical work are probably about 20% of what I do.

The rest of my work is as a full-time executive at Imperial College Healthcare, one of the bigger Trusts in the country.  I have this wonderful role that is strategy, research, innovation, improvement, but there’s also a whole load of other interesting things that have grown off it. I’ve picked up things like being the board lead for sustainability, taken on a lot of our work around health equity, population health and how as a hospital we behave as an anchor institution. And there is lots of external facing work that is about partnerships. And then I have a few things that my medical students once described as ‘side hustles’ but thinking about it they are really the main hustle, and this is work on kindness and culture in healthcare that I try to run through everything else I do. I’m pretty convinced that the only way you get stuff done is through people and the kindness piece is very very central to that.

DMacA: You’re so positive about your clinical role and your executive role but one of the things that really scares most clinicians about leadership is the tension between trying to find the time to do both of those roles.  How do you manage that?

BK: No two ways about it, the clinical conversations, experiences, responsibilities I have make me considerably better at my executive job than I would be otherwise.  And yes I can always lean back on them historically but, as every week and month and year goes by without doing that clinical work I think it’s very hard, no matter how good willed you are, to keep really connected with what’s going on.  It is those weekend evening ward rounds on the children’s ward at St Mary’s that open one’s eyes to some of the issues that are going on out of hours, and the wonderful things as well.  So, also doing both is tiring, my clinical work and learning gives me a real energy and brings out lots of complementarity between the two roles.  There’s an awful lot, actually, where the skills are very similar.  Any job like this is about people, it’s about how you listen, about how you communicate.  That applies to a conversation with a family, that applies to trying to work my way through something that might be strategic, or working with government,  or call with the local council and the Public Health Team.  Those skills are very generic and very usable across things. I have definitely also got better at protecting that clinical time.  Maybe five, six, seven years ago I’d be trying to squeeze in a lot so, when I was on the wards, I’d still be thinking well, I’ll quickly try and squeeze in this meeting at 1:00. I’ve definitely got better at reflecting that all of us need to focus on one job at one moment. On ‘multi tasking’, you can have a lot of things on but I am pretty convinced that in any one moment you can only do something properly.  So, if I’m having a conversation with a family I can’t be sitting worrying about whether we’re going to be awarded the latest research grant. You’ve got to be able to separate those things out.  I think that’s key. I put a lot into my work, there’s no two ways about it, but there is a  richness around the breadth and depth of it.

And, the final thing I’d say, and I think it is really important, is that I get worried on a Thursday night before that Friday-Saturday-Sunday on-call, or as I’m cycling out to a clinic. I worry if I am as up to date as I could or should be on things. I worry that I might get things wrong.  But I think that worry is a good thing. It’s not a worry that paralyzes me and stops me from doing stuff but it keeps my feet on the ground.  It keeps a sense of humility and curiosity and a desire to keep learning.  And I say to myself that if ever that worry was to go, then I need to stop doing the clinical work. For the minute I’ve got bucket loads of energy for it and it feels really important.

DMacA: I have this image of you whizzing around on your bike from clinic to your executive roles, really fast paced but there’s a huge contrast between that fast paced life and one of the other area you’re really interested in, and that’s kindness in health care.  Talk to me about kindness and health care.

BK: If you’d met me 20 years ago, 25 years ago, I hope that we would still have had a conversation around kindness.  We might not have named it but I think it would have bubbled up.  It was definitely something that was important to me.  I’ve always been very optimistic and positive and I think that would have gently surfaced in our conversation. About five years ago, I was sitting listening to the wonderful Don Berwick and Maureen Bisognano up in Glasgow.  It was in March 2019 and I was in this great big conference hall at the SEC listening to this brilliant talk, which was a tour de force of all the things that were going on in healthcare. I remember sitting there listening when they put up this one slide on kindness, and that was some work that a guy called Len Berry’s done, amazing work.

And I sat there thinking, I’ve got this wrong, I’ve been framing this as ‘this is a bit soft and fluffy, but it’s really important’.  I’d definitely been proactive and brought it into teaching and leadership work but always framed with an apology and I just thought, what an idiot I’ve been. This is the most important thing.  It’s the starting point.  You can’t have a conversation about money, or about inclusion, or about safety, unless you get this stuff right.

I was sitting next to a great friend at the time and I said to him, “What about this” he said,  “Yes, you’re on to something here”.  We started to talk and found more and more people started to crowd in on the conversation and it’s got totally out of hand. We now have about 1500 people from 35 countries in a conversation about kindness; a conversation that’s all about action, that’s about testing, that’s about doing things, and it’s become the biggest thing and the most important thing. And it’s made me think hard about it all.  It’s made me think how do I become a better role model,  how am I am enabler for conversations in and around this.  How am I using it to change culture in my teams, in our organization,  in the health care system I work in,  in the NHS as a whole, and actually, more widely globally?  So the ambition is big.

DMacA: The concepts you tend to talk about, and forgive me if I’m wrong, about healthcare and kindness are external, about kindness to patients.  What strikes me very much is that we’re not very kind to ourselves as doctors, to our colleagues, or even to ourselves as individuals. Talk to me about kindness in the culture of our teams.

BK: Most of the literature and most of the work in the conversation, certainly post- pandemic, has actually focused in on staff and on teams.  I’m angry about how it took a once in a century global pandemic for healthcare leaders across the world to realize that looking after your staff is key to looking after patients.  This is a conversation about leadership, and that’s catastrophic leadership failure.  All of us who were in leadership roles pre-pandemic, what were we doing?  We were totally asleep to the idea that looking after your staff is critical. I think we have to look back on that and think why did we miss that? There’s plenty of signal around that it was an issue, and now we have finally started to wake up to it all and, right at the heart of that, as you say, is this focus around self.

Any good leadership textbook, and when I think back to the research work I did, the framing of thinking, starts with self. Think about self-awareness and how we look after ourselves.  And I agree with you that the culture, particularly among doctors, but actually other healthcare workers too, has not really been very good on that.

The bit about teams is so compelling. One of the great joys of this work has been connecting with all sorts of wonderful people including Amy Edmonson, working across at Harvard Business School.  She’s been the leading academic light looking at the concept of psychological safety in the context of the workplace. This work shows that if your team, your ward, your clinic, your organization, is not psychologically safe then performance goes down, outcomes go down. There’s a brilliant piece of work called Project Aristotle that Google wanted, for very commercial reasons, to simply ask the question what makes a high performing team?  And they did a whole load of ethnography, a lots of qualitative research, and spent a couple of years doing it, and found, surprise surprise, that absolutely top of the list for a high performing team in a very commercial organization is – do people feel psychologically safe? And , I’ve yet to find a better tool to create psychological safety than deliberate intentional acts of kindness.

DMacA: In addition to your interest in kindness and the culture of teams, you’re interested in medical students and educating the next generation of doctors.  There was something I read that suggests that you thought medical students might have lost their mission and purpose a little.

BK: I worry about this. I guess there are two angles where I worry about it. One is that our institutions, our medical schools, our nursing schools, our postgraduate training program across the globe, and this is not just an NHS thing, they’re a bit like oil tankers.  Anyone listening who’s involved in one of those things, whether you’re right up at the top of it as the Dean or you’re working hard within it, they are hard to move. They’re slow moving beasts, and the world is moving too fast for that.  We’re getting really behind the curve and I worry that our medical schools generally excel at producing students who are very good at passing their exams, but I worry that there’s a growing dissonance between this and the need for people to learn about the things that they’re going to be coming up against when they’re working in healthcare teams?  There’s lots of wonderful things going on so it’s not a broadside criticism but I do worry about the pace of change, and that the majority of medical schools and nursing schools are not keeping up.

Remember when you were aged 15, 16, or so, and thinking about – what you wanted to do with your career.  You had a great sense of mission and purpose.  There is a lovely exercise that you can do, and I’ve done this with halls of 200 to 300 people, where you ask people to hark back to when they were aged 15 or 16 and remember those moments.  And people smile.  They often describe this great sense of connection around what they wanted to try and do. And then the reality is that we have health care systems that basically beat this sense of mission and purpose out of people, whether it’s at medical schools or in the early years of working.

What on earth are we doing in the way that we train people, the way that we employ people, the way that we think about them? These are our most precious and wonderful commodity. The starting point is that we have way more applicants per place, people with great hope and aspiration, and yet, we’ve designed systems that beat that out of them.

Back to leadership failure.  We’ve got to get ourselves focused on what this work is all about, and we have to do something really dramatically different.  It’s no good, old people with grey hair like me sitting there going,  ‘oh well in my day I had to…’ Absolutely, what can I learn from in my day, but it isn’t my day now, this is 2024,  we’ve got to get real to what the issues and the problems are.  And there is a real difficulty there.

One of the things is that we have to get young people involved in shaping the future.  That requires people like me in senior leadership positions to cede some power, to go and listen, to go and engage, to co-produce things, and largely we don’t have the skills for that.  We don’t really have the courage, the leadership courage, to think like that, and that’s the stuff we’ve got to change.

DMacA: So, you’re one message to the medical student of the future ?

BK: Stay hopeful,  is definitely my message. As hard as things can feel at times for us all there’s so much to be hopeful for. I’ve got teenagers at home and maybe one or two of them are heading towards medicine. People ask me, aren’t you trying to put them off? I’m not trying to put them on or put them off. Healthcare is a massive privilege to work in. It’s not going away and it’s right at the core of what humanity is, in my view, and society is about.

Being a doctor is an extraordinary privilege.  It’s a great pressure and stress as well but, you know, it’s a wonderful choice to make. The bit that upsets me, and I’m going to spend the rest of my career doing absolutely everything I can to do, is to make sure the conditions and the environment are more suited for people to come and thrive, to not get burnt out, to not get fed up, to not think I’ve got to go and move to the other side of the world. We need wonderful people leading and driving great care and one of the things to be hopeful about is that we’ve got a wonderful substrate in our young people wanting to come into health and care.

To change this we have to look very hard at ourselves, about the brutalization of the systems that we that we run, and that’s about leadership.  I recognize that people like me have definitely got influence around it.  If you’re listening, thinking or reading “I could do more”, we could all do more, and so let’s do more together.  We absolutely can and must change the culture around the way our healthcare systems are delivered, the way we train people.  It’s absolutely essential to the future.

DMacA: I’m really struck by your enthusiasm and commitment, and the energy required to develop that type of leadership and to encourage people.  But, there’s a risk to that, there’s a flip side, and that is, when you commit so much of your time, there’s a risk of burnout.  So as a leader, and in your message to other aspiring leaders, how do you look after yourself?

BK: I think the single biggest thing is for people to recognize they’re not on their own. I’m struck by that. I have been doing some thinking about this clinically.  The best example clinically with a young person is when they come with issues around enuresis or bed wetting and, during the conversation, you see this extraordinary look of “What,  I thought I was the only one”. Because , you know,  funnily enough this is not talked about at the school gate. One of the things that I spot in leaders, particularly when things are feeling hard and they are struggling,  is that they get more and more isolated.  I definitely get great energy, learning, compassion, support, and hopefully give some of it too, from the networks of people around me and I think it’s this really critical idea that we mustn’t get ourselves isolated.  We’ve got to connect.  So, spending time building trust, building relationships, listening to each other, are incredibly valuable activities.

Getting on with a whole load of processes and actions that have no meaningful link into things that matter is a waste of time and we need to stop doing that.  I know processes and systems are important for many aspects of our work, but we’re drowning in them.  You were asking me, when we started, about my wallpaper. This bit here is Julia Unwin’s work about the rational and the relational. It’s really important stuff.  Her thesis is that we’ve focused on this rational response to everything, introducing lots of systems and process, but we’ve forgotten about, and largely lost, the relational side.  We need to have both.  We need to have good systems and processes and governance but, if you don’t have a relational side to it as well, you get this dry, arid, detached health care system.  Health is about people, it’s about trust, it’s about relationships.  Let’s get our focus back on that.

DMacA: What a beautiful note on which to end, on the relationships, on the trust, and the importance of people.  Bob it’s been an absolute pleasure talking to you.  Thank you very much for sharing your enthusiasm and commitment, and those wonderful leadership attributes.

Photo on Bob Klaber

Bob Klaber

Bob Klaber is a consultant general paediatrician and director of strategy, research and innovation at Imperial College Healthcare NHS Trust.  Along with an incredible group of friends from across the globe he leads the conversation for kindness. You can find more information here: . He also serves as an Associate Editor on the Editorial Board for BMJ Leader.

Professor Domhnall MacAuley

Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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