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Hello, I’m Domhnall MacAuley and welcome to this “BMJ Leader Conversation’. Today we’re in the UK and I’m talking to Clare Lemer.
Let’s bring it back to the very beginning. What started you in medicine?
Claire Lemer: So that’s a really good question because, if you’d known me when I was a child, I was the most quiet, shy, watchful child. Doing something like medicine would not have seemed a natural choice for people watching me grow up. I think it comes down to two things. One, I come from a family of Jewish origin, some who escaped and some who didn’t manage to escape the effects of Nazism. And I was very aware of the privilege of living in a country like the UK and feeling that I really had to honour the luck of being born in the moment that I was.
As well as that, being really drawn to (and its such a classic phrase) to helping people. If I look back at my teenage years, I see that coming through in a couple of ways. One, really watching the evolution of organizations like Médecins sans Frontières and Médecins du Monde. And two, I was a teenager as the Aids epidemic was really swelling and painful to watch, and there was an extraordinary column in the Guardian every week by a young man who was suffering the ravages of Aids and who was documenting that beautifully. I can distinctly remember rushing down every Saturday morning to read that column and being completely overwhelmed by intrigue at the science of what was happening, but also feeling forcefully that I wanted to do something to make a difference to people like that young man.
So it was that combination of feeling a responsibility to do something, and also a sense that doing something would give me satisfaction and joy, which I’ve been lucky enough to find to be absolutely true.
DMacA: You went to Cambridge and then you began your postgraduate career.
CL: I did go to Cambridge and I did my clinical training at UCL, but I think it’s really important for me to say out loud, that I didn’t quite get the grades that I was asked to go to Cambridge. I spent 36 hours in tears, thinking that the world had ended. Because at that age, when you set your sights on something, you find it hard to adjust. And then, because I’d done various other exams, did get my place. And the reason I say that is because I don’t want it to sound like my journey has been a gilded one with no hiccups along the way.
Because, actually, I think I’m definitely a better doctor, and hopefully a better person, for the fact that for every up there was a down and that there were challenges as well as easy steps forward. I don’t think we talk about that enough. We talk about the successes but we need to talk about the hurdles as well.
DMacA: Let stay with the success note because after that 36 hours of tears, you finished with a distinction in both medicine and surgery, so that was pretty good!
CL: But you know, what’s really interesting is that it came from something that I hope I’m able to learn from and actually pay forward – unbelievable mentorship from many people.
But, in particular, I’m going to call out Bob Souhami, who was the Dean of UCL Medical School at that time and who really helped me to understand that practice, when it comes to clinical medicine, that really makes perfect. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761186/. I have to thank my childhood teddy bears for being willing patients during the run up to clinical finals.
And, learning that the key to success was spending huge amounts of time with wonderful patients who would let me continue to practise on them. For me, I think there’s a valuable lesson as well, as I find my way through the various aspects of my career, in learning from people who were willing to give up their time, great mentors, inspirational patients, and family friends, but also putting the effort into the foundations. All that hard work in the clinical basics meant that, when I was tested in a Viva, it didn’t make me wobble. That’s something that I learned then and hopefully continue to employ.
DMacA: Those teddy bears then led to paediatrics and, as a paediatric trainee, you did a Harkness Fellowship. Tell us about that.
CL: I was very lucky to spend time at Guys and St Thomas’s as a paediatric trainee. And, I can distinctly remember being on a neonatal unit one night and trying to calculate how much Potassium to give a baby, and thinking, this cannot be a safe way to do this. I’m doing this with a pencil and a calculator. I’m interrupted every five minutes by bleeps or by questions. Slowly realizing that we could put people on the moon but we were still using the same ways doing that complex, pharmacological calculations the way we’d done it 20, 30, 40 years earlier, if not more. And that led to me start reading articles in the BMJ around the evolving world of what I came to understand was patient quality and safety.
It was just around the time that I guess, that “To err is to be human” (https://nap.nationalacademies.org/read/9728/chapter/1#iii) was being published in the States and Liam Donaldson was starting to follow through that thinking with clinical governance changes in the UK. I then had the opportunity to think about looking for something to do in the States and, I came across the Harkness Fellowship and, luckily for me, I didn’t quite understand what it was otherwise I would have been too intimidated to apply as a very junior doctor. Even more luckily for me, the year that I applied, the Health Foundation wanted to encourage more clinicians. I based my project around patient safety, particularly prescribing practice and the world of electronic health records, which was rapidly happening in the States but was barely being talked about in the UK.
Serendipity allowed me to be appointed a Harkness Fellow and to go to Boston and to do a number of things that were fundamental to what came next. One was to work with an amazing set of people and particularly my mentor there. And two, he encouraged me to get involved in two areas beyond the policy work. The first was the School of Public Health, so I ended up doing the clinical effectiveness program in Harvard which then evolved into a Master’s in Public Health which gave me a really broad understanding of the wider determinants of health and public health as a whole, and the second was to immerse myself in the Institute for Health Care Improvement, which was at the time very much led by paediatricians so that felt very comfortable for me, but it also made me really start to get to grips with the concepts of quality improvement. That was eye opening. And I think the most profound thing I took away from that time in the United States was, actually, being so proud that we have an NHS, and that it is valued and realizing that for all its flaws, there are other health systems which have far bigger flaws, not least the fact that when you see a patient you have to think about what they can contribute rather than what they need.
DMacA: You’re balancing these two areas, clinical practice and the academic side, because you did a Master’s in International Health Policy and then you did an MD as well. How did you manage to juggle all these balls in the air?
CL: Yes, you might say I got a bit greedy because I then went on and did an MBA as well. Actually, I don’t know how I found the brainpower or time alongside doing clinical medicine. I think where there’s a will, there’s a way. I was very lucky that I found that if you step up and take on a bit more responsibility, you get more flexibility. I organised the rotas in my registrar years which then meant that I had a bit more flexibility to work out when I wanted to take leave, which let me do some of the stuff in Harvard. The MD was really hard because I’d have to set aside days at the weekend to rewrite and rewrite and rewrite. You have to make choices about that being a priority at that moment in time but I absolutely would encourage people to do both a Master’s in Public Health and also an MBA, because they both changed my way of thinking, and that has been incredibly useful to me going forward. I’ve also talked earlier about that need to have a foundational platform. Both of those gave me the confidence not to be scared to have conversations about balance sheets or about markets or strategy and also taught me some other skills. On my MBA, there were 10% women and less than 5% of us from the public sector, so I had to learn to defend my values and to appreciate other’s perspectives, and that’s a really invaluable skill.
DMacA: Then we move on. You’re a consultant paediatrician and you’re trying to balance all these things. Tell me how you balance your life.
CL: Before that I just want to add one more bit of the story, which others might say odd but I would say joyous in that I did the final part of my medical training working part time and, for the other part of my working week I worked in an adjacent hospital as a service manager. So I got to live the reality of working both on the operational side and the clinical side. I have so much respect for service managers and general managers because that is, without a shadow of a doubt, the hardest job I’ve ever done, and that started to teach me really good time management. When I moved to being a consultant, I talked to various people about how they divided up their week because my consultant role wasn’t pure clinical medicine, it was half transformational, helping to set up an integrated care system and health services research unit and half clinical. Wise people had said to me to put things strictly into days of the week. I’m afraid I failed miserably. That’s just not my way of doing things. And instead, I’ve let myself be much more flexible about things merging across time barriers, possibly too flexible. I wouldn’t say I keep classic 9 to 5 working week hours but I suppose
I have a couple of principles which maybe I didn’t have at the beginning of my consultant career. Maybe I took on too much at the beginning and then had to have a stabilization phase and then a re-energizing phase. They are that- good enough is absolutely good enough and the extraordinary amount of time that you sometimes spend making something perfect may not be the best investment. I keep meticulous lists mostly on my phone because I have truly terrible handwriting and would otherwise have to spend too much time deciphering the lists of things to do. The third is about not micromanaging but giving people the opportunity to do things, letting them do it their way even if it’s not my way, and therefore not taking on things that other people have done but aren’t quite the way I want them. Just letting it roll because there are very few things where doing it one way, the way I have in my head, is the only way.
DMacA: Tell me about these jobs and tell me about your career path to date.
CL: I became a consultant with this dual set up, where half my week was clinical and half my week is setting up the integrated care system. And that was completely joyous because most of what that involved was spending a lot of time listening to families, patients, the public, and hearing what didn’t work, what did work, and spending a lot of time with GP’s, which was actually wonderful because I really got to understand a bit more about how the health care system functions in the UK. I did that for nearly five years and then had opportunity to follow a more classic medical management route. I evolved from being Head of Service of general paediatrics into being Clinical Director for medicine and neonatology at Evelina Children’s Hospital. I did that for three years when I took on another role, which was Director of Transformation focused mostly on capital projects, but spreading beyond that as well. I’m not very good at giving up roles. I’m much better at squeezing more in which is maybe not a trait that one should follow if one wants to keep a sane mind.
DMacA: Let’s move on to talk about your current role.
CL: I spent 11 extraordinary wonderful years at the Evelina, and every few years I evolved into different roles during that time. But every few years, I get what I call itchy feet syndrome, which is where I’m starting to think about being challenged again and doing something different. And this time that itchy feet syndrome has allowed me an extraordinary opportunity, which I am incredibly grateful for, which is to go and be Chief of Strategy and Innovation at Birmingham Women’s and Children’s. I am absolutely loving learning about a new system, understanding the expectations of a different role, hopefully fulfilling some of them and just getting to have interesting, challenging, exciting conversations with people to help to try and shape the infrastructure that allows clinicians and others to provide really great care to patients and their families.
DMacA: As you mentioned earlier, life hasn’t been always that kind to you, and you suffered a very severe accident. So, as my final question, tell us how that affected you and how it affected your perspective as a doctor.
CL: I’m very lucky that I don’t remember the accident. I can just about remember the morning before the accident but I can’t remember very much until about 4 or 5 days later. The benefit is that I don’t have, and I never had, a negative reaction to that experience.
And I came to terms with where I was at physically, almost imperceptibly, because I was clearly thinking and processing, although I don’t remember anything during that time. I spent ten days in hospital. I left hospital with metal work in my legs and in a wheelchair because I’d fractured my pelvis in so many places. I spent three months in a wheelchair, with the fear of God put into me by the orthopaedic surgeons that if I put weight on my right side, that would end in further surgery, so I was a relatively well behaved patient. I then went on to do huge amounts of physiotherapy, hydrotherapy and rehabilitation, and I am incredibly fortunate as it got me back to, not just being where I was before physically, but got me into all sorts of forms of exercise, including running, which I still do, and probably drove me into doing my first and possibly only marathon, because running was a little bit more exciting than the physio exercises that I was doing at home. It was a very unexpected physical journey. I like to talk about it as an unexpected sabbatical, but with more physio than most people have on sabbatical.
What it changed for me as a doctor was that it made me understand the sense as a patient, particularly in hospital, of the need for explanation of goals. When you’re lying in a hospital bed, and a ward round comes around and says, we’re going to do X, Y, and Z and then disappears, that isn’t very helpful. What you actually want to hear is we’re going to do an x ray today so that it can give us the information so that we can work out when you’re going to be able to do x, y, z. And then you can go home. And that really changed for me the way that I interact with families on ward rounds. I try to start with what they want to understand and then, how I can help them on the journey and particularly to plan things for discharge. I really try to talk with families on that first ward round. Are you going to be here for a day, for a week, for a month? And the other thing I try to set up early on in that doctor patient relationship is that we’re on a journey together and I don’t have a crystal ball, but I’m going to help try and guide that journey using my experience. But this is a journey that we go on together. It’s a really simple change in framing when I say it out loud, but it is very different. And what it has given me, for example, is the opportunity to sit with families who are really angry and fed up, and sometimes shouting at staff, and listening to why they’re like that and, all too often it’s not because they’re bad people or angry people but, it’s because the healthcare system is so confusing and frustrating. And actually, if you can do that, it makes that relationship better. And it helps to improve the care that we give to our patients, as well as the journey for that particular family.
DMacA: Thank you very much for sharing your personal journey, your academic journey, and what you learned as a patient. It’s been wonderful talking to you today. Thank you very much indeed.
Claire Lemer
Claire is an experienced General Paediatrician, with a special interest in organisation and system transformation. She has significant experience in medical leadership, combined with operational management skills and strategic leadership, at an organisational, regional, national and international level.
Claire is currently Chief of Strategy and Innovation at Birmingham Women’s and Children’s. She combines working for the NHS with her love of theatre, hiking, travelling, baking and supporting her faith community.
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.