EPISODE 21 Simon Fleming
===
Sharee Johnson: [00:00:00] Today's podcast with Dr. Simon Fleming is a long one, and I do encourage you to put it on in the car on a long drive or over several times and really dig into what Simon has to say. He has a lot to offer us when we're thinking about diversity, inclusion, bullying, lots of the cultural factors, uh, in medicine that are important, I think, to all of us.
Sharee Johnson: Simon has, uh, thought a lot about medical training and the culture of medicine, and he's been really vocal on these frontiers for over a decade, including while he was a doctor in training. It's fair to say that Simon wants us all to think a lot more about what goes on in healthcare and more importantly, what we can do about that, how we can become active bystanders.
Sharee Johnson: And he calls out this bad behavior, asking [00:01:00] really important questions, first of all, of himself. By doing this, by asking out loud, he's also inviting all of us to ask the same questions. And they're not easy questions. Questions like, if I don't speak up, am I complicit? Am I going along?
Sharee Johnson: And so what responsibility does that mean I hold? Um, if I permit some particular kind of behavior, am I actually promoting it? Now, these are not easy questions and, there's many of us who might be in survival mode who think it's easier to just avoid and go along, carry on. But ultimately, we all are part of the culture, and I think that that's what Simon is continuing to remind us.
Sharee Johnson: Simon's perspective is that everyone in medicine is a participant, and that if we notice something is wrong, the next question we should be asking ourself is, what can I do about it? What's my responsibility? And I think it's really salient to notice that Simon began this challenging, this questioning work when he was still very deep [00:02:00] in training himself.
Sharee Johnson: He didn't take the position that he was, you know, somehow low in the hierarchy and couldn't do anything about it. He decided, from a position of integrity really about who he wanted to be and then, uh, took those actions accordingly. And I think it's, um, pretty devastating to, to hear him talk about that his own life has been threatened as a result of these actions, and it really, uh, called out to me. Um, I used to, on social media, often say all voices are needed and many voices are needed for some of these issues, and I think Simon's really pointed me back to that again in this conversation. He balances, uh, the question about responsibility with a recognition that many things in healthcare are beyond our control, certainly as individuals.
Sharee Johnson: We talk about human-centered care rather than patient-centered care. We, talk about moral injury and burnout, bullying and harassment, uh, how to actively apologize and, we really acknowledge, , there are toxic [00:03:00] elements alive in medicine. And, these are, as Simon says, open secrets that the collective keeps that need really kind of active, combative kind of mindsets and approaches, and he's balancing that work with also doing a lot of work around growing diversity and belonging that requires a more collaborative approach.
Sharee Johnson: As I said, there's so much in this conversation. I look forward to your feedback about it, and I'm deeply grateful to Dr. Simon Fleming for what he has, invited us to really challenge ourselves and think about and respond to, in this conversation of Recalibrating with Sharee Johnson
[00:04:00]
Speaker: We're in for a real treat today. Dr. Simon Fleming is a hand and wrist surgeon, and he also has international acclaim for the work that he has done over many years looking at the medical culture and medical education. He is a fellow of the Royal Australian College of Surgeons, a fellow of the Australian Orthopedic Association, and a fellow of the Royal College of Surgeons of England. And holds additional qualifications in medical education that reflects a longstanding commitment to excellence in teaching and training of doctors. Simon has a clinical focus on complex trauma as well as the management of arthritis and Dupuytren's disease and other challenging conditions of the hand and wrist.
Speaker: He is a founding member of the International Orthopedic [00:05:00] Diversity Alliance and currently serves on the executive board of the Faculty of Surgical Trainees. He is a past associate editor for medical education and The Clinical Teacher, and is a current member of the editorial board of the British Journal of Surgery.
Speaker: His scholarly work, as well as his widely recognized and influential presence on social media, engages a global audience in evidence-informed discussion on surgical education, assessment, professionalism, workforce sustainability, and training culture. Dr. Fleming has delivered over two hundred and fifty invited keynote lectures internationally, presenting his landmark and award-winning work on diversity and inclusion, improving surgical training, and challenging toxic and exclusionary cultures in healthcare.
Speaker: He works with individuals, institutions, and healthcare organizations to support culture change, leadership development, and the capacity to engage in difficult but necessary [00:06:00] conversations about power, behavior, and accountability in medicine.
Speaker: Dr. Simon Fleming, welcome to Recalibrating with Sharee Johnson
Sharee Johnson: I know from your Instagram profile that you're a bit of a foodie. What's the latest recommendation? Let's get that out of the way straight away.
Dr Simon Fleming: So for me, food is, it's a, it's a weird thing. I come home from work and I wanna cook, and I have a day off work and I wanna cook, and if I'm not cooking I want to travel and, and eat. F- for me, I think, uh, you, you see people who talk about, you know, food is love and food is, food is medicine, and food is...
Dr Simon Fleming: I don't necessarily buy into all of that. But it is a way for me to, uh, de-stress. Mm-hmm. Uh, it's, it's a mindfulness exercise for me, cooking. Uh, again, in a, not in a cliched I, I do lots of breathing and I sense the ground beneath my feet sort of way. It is a way for me to, um- [00:07:00] process things by doing something that's both simultaneously a bit autopilot-y and gives off all those happy chemicals.
Dr Simon Fleming: But it is also a way that I demonstrate as clo- as much as I can the... For me, food is about n- nurturing and nourishment and community. So, um I will, when people ask me about holidays I've been on or travels I've been on or trips I've been on, I will normally associate it with a meal I had. Nearly all of my core memories are associated in some way with food or a meal.
Dr Simon Fleming: So during COVID, I, I really got into trying to make the perfect fried chicken I was in the United Kingdom for COVID, which was a whole other thing, when it wasn't awful, you had to fill the silence with something, 'cause otherwise all you did was cogitate and wallow on the fact that everything was on fire.
Dr Simon Fleming: Mm-hmm. Um, so I started trying to perfect my chicken recipe, and so I think I've nearly got it down pat. So I've, I brine it, but I use the brine that you get in the [00:08:00] pickled cucumbers you buy from a store. Hmm. 'Cause it's got a really nice kind of herby quality to it, and if you get the ones with a bit of chili in it.
Dr Simon Fleming: So I'll brine it in the brine you get from the pickled cucumber thing, which you then can serve as a garnish with your fried chicken. And then after an overnight brine, I will, uh, put it in a flavored buttermilk dredge, and then I tend to fry it in a 50/50, after double flouring, I will then fry it in a 50/50 mix of vegetable oil and duck fat.
Dr Simon Fleming: So it's super healthy. Um, but I think I've got it there. And again, it's one of those things where I've got a friend of mine, uh, who's a, a neurosurgeon in Sydney, and she will regularly come to visit, and she will put an order in. She'll be like, "I'm coming to visit. Fried chicken, please," which tells you that it's probably okay.
Dr Simon Fleming: Yeah. But the attention to detail is showing me that you are a proper foodie and it's not kind of let's just slap something together. Well, this is it. And, and so it's, it's funny. I, I've just started working in a new hospital [00:09:00] and, , it's weird the way my brain works. There are certain things I care about a lot. And there are certain things I fundamentally don't care about a great deal at all, and you'll work out which are which. So for example, I have two spaghetti bolognese recipes. I have my spag bol, which takes me 40 minutes, and I have my beef ragu, which takes me eight hours. Mm-hmm. And both have their place, right?
Dr Simon Fleming: There is, "I've just come home from work and everyone's hungry," and I knock up some spaghetti bolognese. And then I have a Sunday where I get chicken livers and I use milk and I use white wine and I slow cook and it's... And they're, they're very different meals and they serve very different purposes. So there's sometimes where attention to detail is good and healthy and right, and there's other times where, uh, what is it?
Dr Simon Fleming: Good is better than perfect. And you have to kind of pick your battles, 'cause otherwise perfectionism is a slippery slope to burnout.
Sharee Johnson: Yes, it is. I'm sure we're gonna talk a lot more about all of those things. Is the cooking a form of relaxation for you? Is [00:10:00] it part of switching off?
Dr Simon Fleming: Oh, 100%. Yeah. 1,000% it is, it is how I de-stress. And, you read my bio at the beginning, and my, my old bio when I was, was, was a bit more junior and it was a, a bit more humorous and a bit more human, I guess, was like, uh, "Simon enjoys food and travel, and works out in the gym to allow him to do the aforementioned activities."
Dr Simon Fleming: And, and it's funny, but it's true. I like to exercise and work out, and in equal measure, cooking and then eating said food, or at least feeding it to other people is, is a big part of that. I, I'm terrible for cooking for myself. Mm. If the family are away or if I'm away for work, I, uh, the food becomes fuel.
Dr Simon Fleming: Mm. But if I'm cooking for other people, then it becomes more of a ritual, of a, of an important thing I have to get right.
Sharee Johnson: And you're, you're living in Queensland these days. Yeah. But be- but before that you were in the UK. , How's the food informing you in, in terms of your understanding of the world and people? [00:11:00] 'Cause we will talk about diversity as we get going. How does food inform your view of the world?
Dr Simon Fleming: Well, again, if you wanna explore a place, food speaks volumes to it. If you think about Queensland as a perfect example, so my dad was an Aussie. But he was from Sydney. Um, and when I try to explain Queensland to people, because it's so big it's quite hard to explain it to people who've not been to Queensland. Mm. Uh, and the closest I can get is sort of Texas, in that sense of a proud tradition of, like, farming and being outdoorsy, and the weather, the weather and the geography dictating everything.
Dr Simon Fleming: Mm. And so you've got certain things that Queenslanders are very proud of. So there's a, there's, as with all towns, there's a multitude of Facebook groups around where to eat and what to do. And what I love, and you see it not just in regional Queensland, but even in some of the more metro and metro adjacent areas, is people will be like, "Oh, I'm coming up to," wherever it is, "for a couple of days.
Dr Simon Fleming: Where should I eat?" And everyone's like, "Well, this is the best butcher." [00:12:00] Mm-hmm. "And then you need to get a, go and buy a barbecue," or, "You need to go to the park and barbecue there." And, and so again, where I am in Central Queensland, because they're so proud of their beef and their produce- there's not much of a restaurant culture because they're like, "Why would I trust anyone to cook these ingredients better than I can?
Dr Simon Fleming: You know, th- social media isn't real life, and not all restaurants I go to are fine dining. I have no interest in fine dining. I have a- an interest in good, authentic, interesting, tasty food.
Dr Simon Fleming: And so much as I love fancy stuff with tiny flecks of caviar on it and whatever, equally If it's good food that speaks to the people it's been made by and the people who have put their love and, and attention into it, that's the stuff I love. And so around here, when you eat, most of the time you're ... it's at other people's houses.
Dr Simon Fleming: That's the culture here, is, is why would we go out when I can have you round and I can feed you? And again, that speaks to [00:13:00] that kind of sense of community that I think Queensland does really, really well.
Dr Simon Fleming: You know, bits of Tasmania feel like Wales or Scotland in the, in the, not just the geography, but the architecture and the food and the weather and, uh... And I grew up and trained in London. I mean, Sydney and Melbourne, there are bits of there where you could just as easily be in London in terms of every facet of it, and it's the same with the food,
Dr Simon Fleming: Again, the more of a melting pot you get in, in any one place, the more variable you're gonna get interesting food and interesting flavors.
Dr Simon Fleming: It's, it's, it's fascinating to explore any culture through w- how it feeds itself, how it feeds its community, what it's proud of when it's asked to put something up.
Sharee Johnson: You're noticing the, the contrasts i- in food and community what do you notice between, the UK and Australia in terms of medical training?
Sharee Johnson: 'Cause, uh, lots of people talk to me about, you know, the system does this, the system does that, but actually when we move across countries and ask [00:14:00] our doctors that come from all over the world now in Australia, what their systems were like, there are lots of similarities.
Sharee Johnson: What, what do you notice as, as differences?
Dr Simon Fleming: It's fascinating to unpack this because, by definition, I've chosen to leave the UK. Mm-hmm. Which in and of itself speaks volumes. Um, training-wise- The, the similarities are probably greater than the differences Mm. And that's not surprising because Australian training is, is
Dr Simon Fleming: And again, I'm speaking broadly orthopedic and surgical. But, but most Australian systems were historically at a DNA foundational level set up by Englishmen. Yes And I, I say the word men n- knowingly. Like it was set up by Poms who came across in the '40s, '50s, '60s, '70s. The, the rotations, the curriculum.
Dr Simon Fleming: Now, what's fascinating is if you look at Australian orthopedic training as a, as an exemplar, which of course I would have to say, but happen to [00:15:00] believe, um, they are pretty progressive, and they look to countries like Canada who are kind of market leaders, if you like, in the competency-based world. Mm. And they are always looking to improve their training, to make it as good as it can be and, and unpacking what good looks like is, again, interesting.
Dr Simon Fleming: So you have people who believe that time is training, whereas you've got other people that believe that time is a, is a resource, but actually training from a medical point of view should really be about competencies and behaviors and attitudes and, and developing you as a person. Because, and I, I say this, and it sometimes winds people up, but I'm not particularly fussed.
Dr Simon Fleming: The, the technical aspects of surgery are simultaneously foundational to who we are as a surgeon, as a, as a craft specialty. The fact that we do operations and, and the kind of taxonomy around the fact that we [00:16:00] do things and fix things and, you know, cut and hammer and stitch and whatever, is foundational to who we are, both in terms of identifying as a surgeon, but in terms of professional identity, all that stuff.
Dr Simon Fleming: I think it's also probably the least important bit of who we are in terms of the difference between, say, a surgeon and a technician. Because I, I, I remember interviewing some surgeons previously for some research, and they were like, "If we were just looking for the best surgeons, we would go to the local tradie school, and we would say, 'Who are your top five carpenters?'
Dr Simon Fleming: And you would bring them across. 'Who are your top five electricians?' And you'd make them vascular surgeons and plumbers, you'd make them urologists." It's not about the technical. The technical is foundational. It's so important to those foundations. But then in terms of what makes us surgeons, that's a much bigger piece.
Dr Simon Fleming: And so when you look at the training, the, the challenges faced by UK training and Australia training are the same and different. Training numbers in the UK are, are much different, in terms of job force and all the rest. But equally, for example, if you look [00:17:00] at the NHS, it's a, it's a monopoly employer.
Dr Simon Fleming: So when you finish your training, your only option is to go into the NHS. You're not going private and then seeing if a public job comes along. You, you have to get a job in the NHS. Or, or you're unemployed. Thanks for, thanks for playing. And so there's a whole market set up about that. Plus, m- a bit like here, to be fair, medical schools are a business, and so they're churning out more and more doctors with a hope that more and more of them will choose to become GPs and a hope that more and more of them will choose to work in certain areas.
Dr Simon Fleming: And just like in Australia, they're not. And so in the UK at the moment, there is a huge issue around junior doctors not being able to get onto training programs, junior doctors not having jobs to go to. Um, the competition ratios are climbing. There is a huge debate in the UK at the moment around IMGs, which as an immigrant is, is an interesting place to be and having been part of the establishment in the UK, and then moving here and being the [00:18:00] new kid on the, on the, you know, immigrant training pathway.
Dr Simon Fleming: Um, all of these sort of discourses, plus the UK is tiny. Uh, and the UK has a population of seventy million people. Uh, and Australia is very big geographically, but has a population of twenty-eight million people, of which 50% of nearly all healthcare is delivered in the private sector. The, the Australian healthcare model, the hybrid between the private and the public in Australia is, I think, the best I've seen of those models, of the hybrid model.
Dr Simon Fleming: They, they seem to play well together. It is an imperfect system. There is undeniably issues around m- money and means and two-tier systems and all that sort of stuff. And there is a huge divide between the metro and the regional and the regional and the rural. But in terms of accessibility, you know, in the UK, if you want to see a GP, the, the wait to see a GP is often two to three months,
Sharee Johnson: in the urban areas as well, in the city?
Dr Simon Fleming: Mm-hmm. Yeah. And so [00:19:00] if you are sick or if you need to see your GP for something, that's untenable, right? Mm-hmm. So then you go to ED, you go to the emergency department because you need a sick note or you need some antibiotics, or you've run out of inhalers or whatever that might be. Um, and so training is trying to reflect that.
Dr Simon Fleming: Um, again, the, the Australian system has a couple of things that are fascinating. So for example, in the UK, there is a, a debate at the moment raging around rotational training, having to move. Yes. In Australia, trainees are very prepared that that is just going to be the nature of the beast. You are gonna have to move, and you're gonna have to go all over the place.
Dr Simon Fleming: The, the, the Adelaide rotation at the moment supplies the orthopedic trainees to Darwin Okey-dokey.
Sharee Johnson: For, just for our listeners who aren't doctors, can you just explain that that means a full year in an, in another place?
Dr Simon Fleming: Yeah, it'll be, it'll be six or 12 months. Yeah. Um, in a area [00:20:00] remote to where you live, where your support networks are, where your family might be.
Dr Simon Fleming: Yeah. But the difference here is there are systems in place, there are means in place to financially support trainees in making that work. Yeah. So the, the, the, the costs around moving and setting up your home and all that sort of stuff. Uh, again, it's, it's all those little, all those things... I mean, if you wanna unpack some of the training aspects, one of the things Australia does well is it, does well relative to the UK-
Sharee Johnson: Mm-hmm
Dr Simon Fleming: is paying its doctors. Mm-hmm. Um, so for those who may or may not have been following in the news, there have been rolling doctor strikes in the United Kingdom for about the last 12 to 18 months. Mm-hmm. And at the moment that's been mostly junior doctors, but the consultants, the more senior doctors, are looking at that as well.
Dr Simon Fleming: And again, part of that is because no one expects being a doctor or a trainee doctor to be easy. No one expects it to be without its sacrifices. However, there's an argument that if you're not [00:21:00] paid for work done and paid your worth, it becomes really hard to ask people to do what junior doctors are expected to do if they're not remunerated in a fair way.
Dr Simon Fleming: So one of the things that Australia does, does fundamentally is it pays overtime. Mm-hmm. In a way that means that a doctor who's asked to stay late, or if there's a cool case to see or what have you, will be remunerated for that. And so what you find is, um- Working outside of those hours, those rostered hours, you're protected both from a fatigue point of view.
Dr Simon Fleming: In other words, if you, if you exhaust yourself, you can either have time off or money. And also, you are, you are remunerated for the work you do. And so one of the many reasons why people emigrate to Australia is because the salaries here are, are better.
Sharee Johnson: Yeah. Yeah. I think we should, I think we should just acknowledge the junior doctors, at least in New South Wales and Victoria, who have taken a legal fight both-
Dr Simon Fleming: I was about to...
Dr Simon Fleming: That's where I was about to go. That, you know, and then it's all re- but it's all relative, right? It is. So as you say, there have been [00:22:00] class action lawsuits in New South Wales and Victoria, and they have been multi-million dollar. And that comes down, and it's not necessarily a segue, but that comes down to culture, which is, um, if, if they're...
Dr Simon Fleming: Human beings are human beings the world over, regardless of their accent or the color of their skin, and there are certain things in culture that seem to persist no matter where you go, and one of them is hierarchy and power differentials. And so a lot of the junior doctors I speak to in Australia are like, "We're told not to put in overtime claims.
Dr Simon Fleming: We're told to keep our heads down and not rock the boat. We're..." Because human beings are human beings, and that, that's where those class action lawsuits have played out, is junior doctors have gone, "You've not paid us." They've gone to court, and They've won, and they've won big. The, I think recently, the latest headline last week was a junior doctor in Canberra who won $165,000 in back pay, in unpaid hours.
Dr Simon Fleming: However, in the UK, that would be unheard [00:23:00] of, someone being like, "You owe me 10 years of back pay for all these hours." I mean, people's heads would explode.
Sharee Johnson: Listening to you, I'm thinking about, the individuals, that they're, in these cases, there has to be an individual who's willing to stick their neck out, essentially, or, or a small number of individuals who are willing to- Yeah
Sharee Johnson: stick their neck out. Can you talk a little bit about what that's like? Not to say that you've done that, but what's that like for a junior doctor, given hierarchy and given the interest that you've had in medical training and how these things work? It seems to me that those individuals have to be incredibly brave or desperate or, you know- Yeah
Sharee Johnson: or belligerent, you know? Yeah. Something about them that's saying, "I can't stand for this anymore. This is not okay."
Dr Simon Fleming: Yeah. Um, so i- There's a, there's a dichotomy here, or there's a, a cognitive dissonance here. I am no longer a junior doctor. Mm. However, I was a junior doctor for a really bloody long time. So I was a junior doctor for 17 years.[00:24:00]
Dr Simon Fleming: Mm. Um, and uh, my advocacy work, I guess, started during that time period. So I can speak with relative ease about what it's like to be that person. The week that I knew that I'd finished my training was gonna get signed off, I wrote an article that got published called, The Consequences of Being a, a Junior Doctor Who Doesn't Know Their Place.
Dr Simon Fleming: And you're right, and, and part of it starts with moral injury. So again, for those who don't know, moral injury is where you, um, broadly speaking, are forced to or encouraged to or led to act in a way that goes against your core values. So a nice example of that is we saw a lot of that in COVID.
Dr Simon Fleming: People knew that people needed ICU, but there was no ICU. The ICU was full. Mm. And what you feel when you are experiencing moral injury is, is primarily kind of guilt, shame, and, and anger. And it's funny because when you speak to a lot of junior doctors, they conflate that with, with burnout. Mm. And often there's
Dr Simon Fleming: The, like, the Venn diagrams are [00:25:00] nearly perfect circle. Mm. But not, not quite there. And, and again, it's, it's hard because you get the overlap around burnout, moral injury, or moral, moral distress, And you get that kind of, um, oh, the kind of physician personality that sort of recognizes that you get the, what do they call it?
Dr Simon Fleming: The triad of, of compulsiveness. So it's, um, doubt, guilt, and an exaggerated sense of responsibility. So, uh, uh, is it me? Am I the problem? Um- Mm ... maybe, maybe I'm, I shouldn't rock the boat because maybe I'm, no one else is complaining. No one else seems to have a problem with this. Guilt, um, uh, maybe I'm not working hard enough.
Dr Simon Fleming: Maybe I am bad at my job. Maybe I'm disorganized. If I do make a fuss, people are gonna have to back me, which means they're gonna end up in trouble as well. Or I'm gonna be on my own, in which case I'm just gonna ruin my life, the life of my family and my friends or whatever. And the exaggerated sense of responsibility.
Dr Simon Fleming: The world will fall down [00:26:00] unless I come to work every day, work myself to the bone, uh, set myself on fire to keep other people warm. . And that, that personality is prevalent in the junior doctor world. And so as a, as a junior doctor, I personally, 'cause I can't speak to other people's lived experiences, and I wouldn't pretend to.
Dr Simon Fleming: That way lies arrogance and white knight and speaking for people, which isn't any kind of advocacy or allyship as far as I'm concerned. But I can speak to my experiences, which is, um, I had all those feelings of moral distress. I had all those feelings of burnout, and I wondered if it was just me.
Dr Simon Fleming: Was it just me that didn't find the jokes funny? Was it just me that had a problem with the bosses who made comments about the pretty blonde doctors or the nurses? Was it just me who thought that these bullying behaviors were just, just bad, they were just a bad idea? Um, and it got to the point where I've realized that I either needed to completely accept them and be like, "This is just how it is."
Dr Simon Fleming: Mm. [00:27:00] "And this is just what it is, and I need to put up and shut up, or I need to do something about it." And when I started my advocacy journey, I spoke to my then girlfriend and I was like, "If I do this, I don't think you can half-ass it. I don't, I don't think I can just be like, 'By the way, um, maybe, uh, yeah.'" I was like, "You, you either have to do this properly and lean into it, or not at all."
Dr Simon Fleming: And then of course, those feelings of guilt and what have you come along because you realize that up until the point you speak up about pay, culture, whatever, fundamentally you've been complicit in it. Mm. You've been part of it. Because until you speak up, you've been going along. And so, um, one of my core memories around the first time I ever spoke out around workplace culture, uh, was the first time I ever presented the data we had on it.
Dr Simon Fleming: And I, I started my talk by walking to the very front of the stage, looking out to this [00:28:00] audience of the great and the good. And I said, um-
Dr Simon Fleming: I'm a bully I've probably made people feel small and worthless. I've probably broken the law at work. Statistically, most of us have, and we must do better. And I, I wrote that talk very consciously because previous attempts at culture change, and attempts since, I should add, and this is, you know, this is not a blame culture.
Dr Simon Fleming: I'm not pointing the finger, I'm just saying it's really easy to make it about other people. Couple of rotten eggs, couple of bad apples, insert your, again, insert your food metaphor. Uh, you know- ... it's not, it's not me, it's them. They're the problem. And so it then becomes really easy to externalize everything else about it.
Dr Simon Fleming: Whereas what you realize is, um, certainly in [00:29:00] healthcare, we're all sort of part of this. And, and the work from Stanford and the work from loads of other people highlights that you can't just put it all on individuals. You can't say, "Look, you, Simon Fleming, you, Sharee, need to sort this out." But there is some personal responsibility because, you know, again, all the cliches are cliches 'cause they're true, but what you permit, you promote, or the standard you walk past is the standard you accept.
Dr Simon Fleming: Whatever your, whatever your chosen bit is. I prefer the alliteration of permit and promote, but anyway. Um, there is a certain amount of personal responsibility because if you're not an active bystander, if you see someone being shouted at or being sexually assaulted and you walk past and do nothing, 'cause sometimes you can't do something in the moment, but if you do nothing full stop, on some level you are saying, "Yeah, okay."
Dr Simon Fleming: Mm. And, and so you're right. As a junior doctor who wants to speak up, whether it's about pay or about anything, and to be fair, as a human being, as a consultant, because those power systems are [00:30:00] everywhere. Like, I'm a consultant, and you better believe that there are people who tell me what to do and to shut up and whatever.
Dr Simon Fleming: You have to pick your battles. You have to decide how you're gonna approach it. But the first step is sort of accepting, A, that there's something wrong. There's something that is, is doing damage to you, to your mental health, to your, the world around you. And, and then you have to lean into what are you gonna do about it?
Dr Simon Fleming: And, and, and in healthcare that's a problem because we pride ourselves on being committed to patients and being thorough and, and being insightful. But then the flip side is we fail to relax. We have senses of responsibility beyond actually our locus of control, a sense that we're never doing enough, that we can't do enough.
Dr Simon Fleming: And so you get that overlap where, where you, you end up setting yourself up to fail because, because that kind of, it's not quite [00:31:00] hypocrisy, but it's not far off. You're like, "We should do loads of stuff on burnout," as I write my presentation at midnight. And you're like, "Oh, right." The, where somewhere there's a problem.
Dr Simon Fleming: There's, there's a disconnect. And, and it's hard because of this idea in healthcare of the patient-centered thing. So there's an academic called Lorelei Lingard. She works in the medical education field. She's somewhat of a hero of mine, but one of her phrases is the God term. And one of the God terms is the patient.
Dr Simon Fleming: "Oh, but Simon, what about the patient?" And I have come to believe that the patient are hugely important to everything we do. It's why we became doctors, nurses, occupational therapists, whatever. But I don't put them at the center of what I do. I don't think that's healthy, because that model, that model is the one where I have to accept harm come to me, because what about the patient?
Dr Simon Fleming: And so rather than patient-centered care, there's that sort of idea of person-centered care, which is for some people makes a lot of sense, and for other [00:32:00] people causes them moral injury because they're like, "But my patient has waited one week." And I'm like, "Do you accept- I don't know, substance abuse and depressive illness in your junior doctors in exchange for your patient being seen slightly sooner.
Dr Simon Fleming: And they're like, "Yes, that is the cost of the job." Mm. And, and that is one of the big ongoing debates around burnout and, and resilience in the, in the real sense, not the weaponized, toxic, awful, you need to be more resilient sense, of trying to find that happy medium. So I don't, for example, I don't use the term work-life balance.
Dr Simon Fleming: I don't think I can find balance. I, I don't work a job that allows for that. Mm. I have work-life integration. I have accepted that work, my work and my life are one in the same. And how do I make that work so that I can also be present and healthy and a partner and a dad and a friend? But yeah, sometimes my phone is gonna ring when I'm not at work.
Dr Simon Fleming: And for some of my [00:33:00] friends, the boundary there is, I don't answer it. And for some people, the boundary is, I answer it, but I'm not gonna go into work. Mm. And for some people the boundary is ... Like, and, and you, only you can decide what that looks like. But, but it's still not balance because when you speak to the people who are like, "I don't answer it," most of them then describe some sort of, "And I find it really hard and I stress about it and I worry about it, and then I have to go in early on Monday."
Dr Simon Fleming: And you're like, "Okay."
Sharee Johnson: Yeah. Yeah, I mean, the problem with not answering your phone and seeing that your phone did something is cognitive load, essentially, that you're still worrying about, you're still thinking about. But there's a few things I want to pick up. I, I think that one of the key questions that we ask in coaching is what's your role in this?
Sharee Johnson: And that's definitely what you're talking about with the culture understanding, you know? That, that we all play a role all of the time. So whatever the problem, the identified problem is, being able to understand, what's my role in it and do I want to pick it up, do I want to change it, do I want to ... I think that's a really valuable conversation for anybody [00:34:00] about any problem, really.
Sharee Johnson: What, what's the role that I'm playing in it? , We had Victoria Lister on, um, talking about the professions in an earlier episode on the podcast and how- Um, you know, the professional code is established a long time ago, and it's handed down and handed down and handed down. This sort of breaking the professional code is a, is a, a, you know, a big deal and, and probably one person can't do it.
Sharee Johnson: And, and she didn't say this, but my understanding of what she said is that maybe it even has to happen over generations because of its- Yeah ... deep history. So I guess I've got that kind of wide view here. I'm, I'm wondering about the senior doctors. When you were talking, so many of the people I work with are at least in their mid-career as my coaching clients or coaching counterparts, we like to say.
Sharee Johnson: Um, and, and they are, um, definitely having all the experiences that you're describing, where, um, power is always an issue. , Power is not just magically when you're Fellow and you become a consultant, now there's no more power issues. [00:35:00] I mean, they're, they're everywhere. They're all the time.
Sharee Johnson: I suppose I want to know what you would say to the young doctors and, and the more senior doctors up and down from where you are at, at the moment in your career. What's the invitation you'd want to extend up and down?
Dr Simon Fleming: It's funny.
Dr Simon Fleming: I- it's, it's weird 'cause, 'cause I'm now gonna revisit some of the stuff you just said. So the first thing is about that professional code, you're 100% right. So when I started my advocacy work, and still to this day, people will tell me that I've washed our dirty laundry in public. Mm-hmm. And, um, uh, when I started talking about, um, bullying and harassment, uh, when I published our, our kind of keynote paper around gender-based violence in surgery, um, I was told, "You're gonna make people afraid to come to hospital.
Dr Simon Fleming: You're gonna make people afraid to join the profession. You are harming, you are harming people by, by shining a light on these things that everyone knows about and everyone's o- everyone's okay with." And you're like, [00:36:00] I don't think everyone is okay with them, to be honest. I, I'm pretty sure they're pretty un-okay with them.
Dr Simon Fleming: And that kind of the first rule of Fight Club and that sort of, uh, hidden curriculum, don't tell tales out of school, I mean, it's how all toxic cultures survive. It ... Right? Mm-hmm. All forms of abuse come down to it's just our secret or we can't let people know. And it also creates a, uh, an illusion of powerlessness, as in, um, you
Dr Simon Fleming: Not only should you not tell anyone about it, but if you tell people about it, the only difference it'll make is it'll ruin your life. But it's not gonna change anything because it's been going since time immemorial, right? Mm-hmm. So you shining a light on gender-based violence or bullying, all that's gonna happen is your life's gonna suck.
Dr Simon Fleming: Um, and you're probably gonna do harm to people by telling people, but nothing's gonna change ... And again, you, you get this weird dichotomy of like everyone knows 'cause it's an open secret, and simultaneously no one can know because it's a secret. Yeah. And, and so yeah, the, the, the [00:37:00] unspoken rules of healthcare, uh, are, you know, never take all of your holiday, and the patient is always right, and,
Dr Simon Fleming: You know, you compete about who's the most burnt out. I didn't, I worked this many hours last week. Well, I worked this many hours last week. Well, I'm now under the care of a psychiatrist. Well, actually, I'm on, uh, the psychiatrist and antidepressants. And it's, it's, it, it was historically a real badge of honor just how burnt out you are.
Dr Simon Fleming: And some of that is historical. So again, if you wanna be a, a medical education nerd, the, the father of residency, if you like, is a guy called William Halsted who, was a US surgical trainee, and he created the idea of residency, of you being resident and of you running the ward and the patients and knowing everything that was going on.
Dr Simon Fleming: And if you read about him and his life he was very open that the way he made residency work for him was by being wealthy and doing a huge amount of cocaine. Mm. And then eventually all of his, all of his year of junior doctors became [00:38:00] so aggressively addicted to cocaine to, to be able to work the hours they were expected to work, that they were all started on morphine by their seniors to try and get them off the cocaine.
Dr Simon Fleming: That was the birth of residency.
Sharee Johnson: Yeah.
Sharee Johnson: It's such a ... I want to interrupt you, because it's such a sad tale. I just, you know- ... I remember when I read about this 10 years ago when I started learning about, more about doctors, and just it's just a quite an unbelievable tale.
Sharee Johnson: It's- Yeah ... it's a sad, sad story.
Dr Simon Fleming: Yeah. And, and the problem is it's not that unbelievable if you've worked in medicine. People are like, "Oh, yeah. Well, yeah." Yeah. Like, I don't sleep and then I do ... I drink coffee or then I abuse substances, and we see that. Again, burnout is linked so much to substance abuse and all the rest.
Dr Simon Fleming: And, and it's fascinating you talking about your, your, what did you call them? Your coaching partners.
Sharee Johnson: Mm. Um- Counterpart-
Dr Simon Fleming: So when you look at burnout, for example, uh, matriculating medical students have, have [00:39:00] better mental health than kind of university graduates in, in other fields, right?
Dr Simon Fleming: They've got lower burnout, lower depression, and better overall mental, emotional, and physical quality of life, right? So, so med students who come, who start medical school generally actually tend to be in a really good place. They've gotten where they want to be. Their life is starting. You know, there's, everything's great.
Dr Simon Fleming: And that pattern reverses by their second year in medical school. By their second year in medical school they learn all these toxic, behaviors, right?
Sharee Johnson: Their empathy declines at the same time.
Dr Simon Fleming: Well, you learn, you learn, you learn that empathy is bad.
Sharee Johnson: Mm-hmm.
Dr Simon Fleming: Empathy is not a survivable trait. Now- What, uh, bef- before I go off topic, which I will do, um, uh, what's fascinating is their burnout peaks during their, their junior doctor years, their residency, and then it starts to drop down again because you start to get some of your autonomy back. Mm-hmm. You start to feel like you have more control over your life.
Dr Simon Fleming: And then it peaks again, right? This is ... And I, I know I'm mansplaining. What is it? Um, correctile dysfunction. ... I find it fascinating that it then re-peaks [00:40:00] again 10, 10 to 15 years into your consultant life because then the autonomy starts to go again and you realize that nothing really changes and everything just sucks and you're just, you know, same, same shit different day.
Dr Simon Fleming: And so that burnout peaks again. Um, and the empathy piece is huge - I,
Sharee Johnson: i'm sorry to interrupt you again. Yeah. But I wa- I want to say that bit there is, is this all there is? Yeah. That peak there. You know, that's the mid-career, you mean this is all there is? I spent 15 years training and 15 years as a consultant, and still this is all there is.
Sharee Johnson: Yeah. Yeah. It's a devastating moment I think for people to arrive. Yeah. For me, when people arrive with me, that ... There, there's a lot of pain in that moment.
Dr Simon Fleming: Yeah. And it's, it's why I, again, a lot of the stuff I do upsets people. Um, it's why I encourage people to have portfolio careers. Mm-hmm.
Dr Simon Fleming: Now, you will get people who tell you that medicine is a calling and a vocation, and it has to be central to who you are.
Sharee Johnson: For some.
Dr Simon Fleming: And it, and it ... Right. Absolutely. And it, it becomes really core to not just their professional identity, but their [00:41:00] identity, right? And you get the other extreme where people are like, "It's just a job. It's a nine-to-five. I check in, I do my thing, I check out." And then you've got most people who are in the middle of the bell curve who are like, "No, it matters a lot, and I worked so hard for it, but-" Not having anything apart from work be your... If it's your whole being, if it's you, you work at work, you work at home, the problem is the moment cracks start to show in that, whether that's is that all there is or, or the, the job doesn't quite fulfill you or whatever it is, those cracks rapidly propagate because you've got nothing else.
Dr Simon Fleming: There is nothing else. There is only, there is only work. And the empathy piece is exactly that. So you learn ... There's the nature/nurture conversation of like, do people go into medicine because they're sociopaths and psychopaths, or do we teach people to be sociopaths and psychopaths? Or does everyone come with a certain amount of it?
Dr Simon Fleming: And of course, I'm using those terms in the sense of, um, not pathological, but trait. Mm-hmm. So, um, I have [00:42:00] been assessed by, uh, by someone, more out of academic curiosity 'cause it's the kinda thing I do. So there's an academic in the UK called Kevin Dutton who is like the, the, the godfather of psychopathy.
Dr Simon Fleming: And I ... And then one of the TV channels in the UK had psychopath night. It showed, like, American Psycho, and then it had a documentary about high-functioning psychopaths and criminal psychopaths and sociopaths. And I literally sent him an email after I watched these things saying, "Hey, Professor Dutton, I just watched all this stuff.
Dr Simon Fleming: A lot of the stuff you're talking about sounds like people I work with. Um, also I'm a little bit worried 'cause it sounds like me. Could we meet?" And God bless him, he came to the pub in East London. He works in Oxford, and he came to London to meet with me. Cool. And we had a chat, and we did some stuff. And I, as you might imagine, score very highly on certain traits.
Dr Simon Fleming: My empathy is turn on and turn off-able, because I, I cut people up for a living, and it doesn't [00:43:00] bother me. I don't have recurring dreams. I don't have intrusive thoughts about operations I do. Um, I'm fine with it. Uh, and what, when it gets really interesting is the people who score more highly than surgeons in, in psychopathic trait is, is pediatrics.
Dr Simon Fleming: Hmm. Pediatrics, because they have to be able ... How could you deal with children in pain and children dying of cancer every day and it not destroy you? Unless you had the facility, whether it's compartmentalization, whatever you wanna call it, the facility to turn that bit of your brain that goes, "This is a horror," and turn it off and be able to sympathize but not empathize.
Dr Simon Fleming: You don't put yourself in the place of the parents, because how, how can you do that every day, all day? And, and again, I'm not speaking for them, I'm speaking from my experience. There are moments when I am able to empathize less. But, but you know, when you're a ... You go to medical school, and it depends on the system whether it's post-grad or not.
Dr Simon Fleming: So you're either going to medical school when [00:44:00] you're 18, or you're going to medical school when you're 23. But either way- You know, within your first year or so, you are exposed to death and dissection and corpses. You see more dead bodies in one year than anyone should see in their whole life. You learn about all kinds of horrors.
Dr Simon Fleming: I remember, I remember my mum ... I'd been a, I'd been a doctor for maybe, maybe six weeks, and Mum called me up and, as mums do, she was telling me about her day. She was kind of talking at me, and I was like, "Okay, cool. Bye, Mum, gotta go." And she was like, "No, no, tell me about your day." And I was like, "You know what?
Dr Simon Fleming: Actually, I, I don't ... I, I'm fine. It's fine." And she was like, "No, I wanna know." And I was like, "You don't wanna know." And she's like, "Oh, but no, come on. Come on. I'm really sorry." I'm ... And this kind of went on in that way that conversations with mums do. And eventually I was like, "Well, fine. Today I told six different people they had cancer, of which at least three will be dead quite soon. And there was like this pregnant pause, and then she went to like, "Do you wanna talk about it?"
Dr Simon Fleming: "No." "That must be awful." [00:45:00] "Not f- n- not, not for me, but it is abstractly awful, and I've processed it, and I went ... I've done that processing piece, but I have to go to work tomorrow, and I still have to face people, and they're still on my wards. I still have to chat to them and be like, 'Hey, how are you doing?' And have conversations with them and make plans, and plus I've also got 40 other patients who don't have cancer that I need to be there for and present and not in my own thoughts about whatever."
Dr Simon Fleming: And she was like Oh. And then she got really upset, and then I had to kind of counsel her about it, 'cause she was upset about the kind of day I'd had. And you can see why very early in your career you learn not that empathy is bad, that's not true at all, but you learn that sometimes you either have to turn it off or it needs to be performative.
Dr Simon Fleming: And there's some fascinating work that shows that, um, performative empathy with patients is as effective as real empathy. They don't, they don't know. It's why this stuff coming out around AI is so fascinating. So I remember, [00:46:00] um, when we had medical school OSCEs, which are clinical exams, you got a mark for demonstrating empathy.
Dr Simon Fleming: And so when you learn how to do resuscitation for people having heart attacks, you learn about something called the head tilt chin lift, which is how you learn how to clear their airway, help them breathe. And for our OSCEs, for getting our empathy mark, we had the head tilt eyebrow lift, which was this.
Dr Simon Fleming: Mm. And then you would say something empathetic. "That must be really hard for you." And you would see the examiner tick a box. And you're like, "Jesus, really?" But the reality is, for the patient on the other end of that- They experience empathy. They experience you being, you listening to them and you hearing them and you acknowledging that something horrendous is happening in their life.
Dr Simon Fleming: And so it's fascinating that, that they, y- you kind of learn to save your empathy for the stuff that needs empathy. But, but, [00:47:00] uh, you know, if I see 20, 30, 40 people with fractures in a day, I can't feel their pain all day because I can't. I wouldn't be able to f- I wouldn't be able to function. So I don't.
Sharee Johnson: Well, we, we talk about that as empathic burden.
Sharee Johnson: Yeah, right. And, and, uh, you know, I actually think we ... I've got a, I've got a thing that people who work with me understand, that, um, you know, compassion fatigue is the wrong word. It's empathy fatigue that we have. Yeah. And the science is really pretty clear about that as far as I'm concerned as a psychologist.
Sharee Johnson: I, I'm, I'm not breaking and cutting people's bones, obviously. Um, but I think that this thing about empathy doesn't go far enough. We- empathy plus action, empathy b- plus being able to say, "I'm so sorry about this bad news," or, you know, um, you know, "How are we gonna work through this?" Or, "Who can support you?"
Sharee Johnson: Or you know, th- this active listening, these small, what feel like small things, but are actually significant to the other person, whe- whether it's a colleague- Yeah ... or a patient or a junior, senior, whoever, um, that this, this acknowledgement that this is painful, this is awful, this isn't [00:48:00] our plan A ob- obviously, and what can we do to support you?
Sharee Johnson: Yeah. That second piece is, is the important piece.
Dr Simon Fleming: And that's it. You don't, you don't have to be a sin eater. You don't have to take their pain and make it your own. But acknowledging it and being like, "I'm really sorry. That's awful. That must be awful." Mm. But pretending like I know what it's like to have a sarcoma, I have no idea.
Dr Simon Fleming: I don't. I've got no idea. So me being like that, I, "I know how you feel," no you don't. And, and, and the flip side is, and it's why so much of this work is so interesting, but equally why the link between, I guess, burnout and teaching people that empathy is maybe not bad but is something not always to, to have necessarily, or is beaten out of you because you can't be empathetic and revising for exams all the time.
Dr Simon Fleming: Like, again, they're sort of mutually exclusive. Um, you can't feel your feelings while you have to learn how kidneys work, is in a clinic where I see 40 patients as an orthopedic surgeon, or in a clinic where my oncology colleague sees 5 or 10 patients, whatever. Fundamentally, we, we do [00:49:00] that, and then we have to do our admin and our letter, and we do the thing, and maybe we go to the private and maybe we go to the public, and then...
Dr Simon Fleming: But for each one of those patients, it's the worst day of their life. Mm. Certainly the worst day of their year. Like, like you never know, 'cause they might be seeing you about high blood pressure or, or whatever. But for us, it's another patient on the Excel chart of people you're seeing that day. And so for them, it's something that's been keeping them awake at night.
Dr Simon Fleming: It's been the topic of conversation on the family WhatsApp group. They've got a plan for good news and a plan for bad news. They- they're planning a holiday, but maybe they have to cancel the holi- all those things. I've gotta speak to the boss about work. Oh, my God, how am I gonna pay my bills? I hope... But that's 40 or 50 people I might see in a day going through that journey.
Dr Simon Fleming: Mm. So simultaneously, you have to remember that. 'Cause you can't just be like, "Next, next." Patients pick up on that. Mm. And when you deal with complaints, when you enter those roles, some of the most common complaints are, "I didn't feel heard. I didn't feel listened to. I didn't feel seen [00:50:00] or acknowledged."
Dr Simon Fleming: And they're not looking for you to necessarily hold their hands and weep with them for an hour, but they're looking for you to be like, "That must be awful." Mm. Uh, like, it's, uh, you know... So my, my, my standard opening question is, "Hi, my name's Simon. I'm an orthopedic surgeon." I, so my, my standard schtick is, "Hi, my name's Simon Fleming.
Dr Simon Fleming: I'm an orthopedic surgeon, which means I fix bones and the squishy things around bones. How can I help?" And then you sit back, and you let them talk, and normally within about 45 seconds, you get to what they're worried about, what they're concerned about, what their expectations are for that, that day, that thing.
Dr Simon Fleming: And yeah, sure, sometimes you have to be like, "Well, I can't really help you arrange a plumber," or, "I, I know that that's, your biggest worry is that your car needs this, but you're in a hospital." But you tend to get to the nitty-gritty of it. Whereas again, in, certainly in medical school, um, even though you're taught to be holistic, and you are, you are undeniably, you have an agenda, which is, you know, [00:51:00] getting to the answer.
Dr Simon Fleming: Mm. You know, and so there are certain medical schools that are- are award-winning, and it's because part of the stuff they examine is maybe there is no answer. Maybe it's all just about having a conversation for five or 10 minutes, and the point is not find, find the right answer, which is very philosophical.
Dr Simon Fleming: Like, the answer is not the answer. Maybe it's just about learning how to listen effectively, which is really hard for us as doctors. Like, I'm on a podcast, right? My job for this thing is to talk, right? But statistically-
Sharee Johnson: Which you're doing an excellent job of.
Dr Simon Fleming: Yeah, it's, it's, it's a problem I've had my whole life.
Dr Simon Fleming: And what's fascinating is, throughout my life, like literally since I was in kindergarten, the feedback's always been, "Simon talks too much." But I have no frame of reference for what talking less looks like. So whenever I used to get that as a junior doctor, I'd have my three-month review or whatever, and they'd be like, "You talk too much."
Dr Simon Fleming: I'm like, "Okay." And so I'd go quiet [00:52:00] And then normally within six weeks I'd have a wellbeing check. "Simon, what's wrong? People are really worried." And I'd be like, "Well, you told me to shut up." They're like, "No, we said you need to talk less." I'm like, "Well, what does that look like?" There's me talking, like verbal diarrhea-
Dr Simon Fleming: and then there's n- not talking. I don't, I don't... Everything else to me either seems rude, disinteresting, or... again, in medical school we, you learn, and you, again, there's great papers. Medical students and doctors as well interrupt their patient within 45 seconds of a consultation starting-
Sharee Johnson: Actually-
Sharee Johnson: 'cause we're like- It's worse than that. Yeah. So some research that says 11 seconds, some that says- Yeah ... up to 18 se-
Dr Simon Fleming: I can believe that. Right. I can believe that.
Sharee Johnson: So very, very rapid. Because I think of what you're speaking to, that, you know, people, doctors want to get to the answer. I taught for 10 years as a casual, tutor at Monash Medical School and, you know, the, the things that were to be examined were the things that the students focus on, focused on.
Sharee Johnson: Of course, they're trying to manage their energy and where they should put their focus. Um, [00:53:00] and they worried that if they let the patient talk, that it would go on for too long. And as you rightly said, the research says within about two minutes, most patients will, will come to the point. Um, and, uh, there's this, this tension, isn't there, between our own expectations, like I wanna have a high standard, I wanna do excellent work, I want to tick all the boxes, um, I wanna have a good reputation.
Sharee Johnson: A- and that story somehow has us do things that might actually be undermining us. That if I would slow down and pause and take a breath occasionally, and let the other person talk for a minute or two, maybe I'd learn something.
Dr Simon Fleming: Yeah. Undeniably.
Dr Simon Fleming: So my, my research background is mostly qualitative, and most doctors like to think they're quantitative, right? So again, um, positivist or neo-positivist people fundamentally think there is a truth. There is an answer. Two plus two is four, the end. That's not [00:54:00] up for negotiation. There's no debate. Uh, the color blue is the color blue.
Dr Simon Fleming: That is what it is. I don't necessarily hold that to be true, right? Which of course is the whole point. So when you be- do qualitative research, you have to unpack your own philosophy around the nature of truth, which is, again, for me, fascinating, and for other people, very airy-fairy. But, but this is it, is, is what I hold to be true, a fracture feels like this and you do this, cancer, you do this, whatever, may not be true to other people.
Dr Simon Fleming: And so i- it's really interesting when you've got some people who are like, "But I need to get to the answer." And there are other people where you're like, well, there's, there's bits to it. So there's a truth, which is they have carpal tunnel syndrome, and then there's other stuff, which is how it affects them and what it means for them, and therefore why they do or do not want an operation, or do or don't want to see you, or have waited this long.
Dr Simon Fleming: All those other bits, if you unpack those a little bit, [00:55:00] your patient gets a better outcome, you feel more fulfilled. The kicker of course being that that takes time. So then you get into the, the, you alluded to it at the beginning, the system stuff, which is, you know, in a, in the UK, GPs are told they must see each patient in seven minutes or less.
Dr Simon Fleming: Mm-hmm. That is, that is the guidance. So if you have seven minutes, and someone's waited three months to see their general practitioner, you have choices to make, and your choice is miss some stuff but get them to at least some progress, some answers, some resolution, or run late, run over, be late, stay work late, get home late, have patients upset 'cause they've been waiting an hour to see you.
Dr Simon Fleming: Like, those choices, there, there's no win there. It's which, which of those losses is more palatable.
Sharee Johnson: Mm-hmm. ... There's lots of recalibrating in these stories. There's the I'm talking too much, I'm not talking enough.
Sharee Johnson: You know, the, the, the learning that goes on. The, the, you know, how long can I let this patient talk? Can I let any of the, any patients talk or I'm [00:56:00] already this far behind, the rest of the patients today don't get to talk much. Like, a- and there's the moving countries. Like, there's lots of recalibrating.
Sharee Johnson: There's the research that you do where you're learning about what happens in education and, and what happens when bullying is rife and, and how do we teach people to think, think differently about this? How do we invite people to be allies? Lots of recalibrations. What, what have you learnt about change or insight ? How do you do that? How do you pull up stumps and go, "Ooh, there's something here new that I need to, uh, reassess or adapt around"?
Dr Simon Fleming: Um, w- without turning this into a full-on therapy session, 'cause then you'd probably be able to invoice me, um, uh, I sit very comfortably in being uncomfortable.
Sharee Johnson: Mm-hmm.
Dr Simon Fleming: Uh, and that is probably based partly on my upbringing and partly on inherently who I am. It was a talk I attended by a guy called Eric Holmboe, who is an education guy from the United States. And he said something that [00:57:00] changed my worldview, 'cause at the time I was, I was an angry young man.
Dr Simon Fleming: Like, why don't people get it? Why can't they just get it? It's obvious bullying is bad, being a sexual predator is bad. Like, how, how is this a conversation? Why am I wasting my time with this? How can people not... And again, part of it's probably, you know, narcissism. Like, why can't people see I'm right? But, but to be fair, the stuff I was talking about really isn't leaps of logic.
Dr Simon Fleming: And he gave a talk, and he talked about change as loss. And he talked about the grief cycle, and he was like, "When you ask someone to change, whether it's how they run their clinic, how they run their life, who they are at work, how they behave with people, the jokes they can tell, how they create relationships at work, especially with members of the opposite sex or people in underrepresented minority groups, how they, how they talk," and in all those things, [00:58:00] Asking them to change is asking them to consciously choose to, to give up certain things they take to be true and certain.
Dr Simon Fleming: This is how the world is. These are, these jokes are allowed. These comments are okay. These behaviors are fine. This hierarchy is how it should be because I went through it and it didn't do me any harm, and, and, and, and, and. And so you see people go through the grief cycle. You see people go through anger and denial and sadness and negotiation and all those steps.
Dr Simon Fleming: And, and once you recognize that for what it is- Um, and if you have a growth mindset, if you actually see change and getting stuff wrong, failure, for want of a better word, as opportunities to grow and be better and come out the other side maybe a little bit m- more, whatever that means, um, suddenly these [00:59:00] things that to others seem really daunting, I'm like, "Let's do that. Let's do that."
Dr Simon Fleming: And, and, and a- again, there is a human nature piece. I've always been the guy who did the road less traveled. It's just inherently who I am. When I was a child, I was seen as, like you say, belligerent. But like, I'd just be like, "But why? Give me a reason. Give me a reason why I should do this thing.
Dr Simon Fleming: Give me a reason why this is true and right because you, you haven't given me any evidence other than because it's what we've always done." And I don't ... Either there's an obvious better alternative, or I can't think of a better alternative, but this, again, this can't be it. This can't be as good as it gets.
Dr Simon Fleming: There must be better than the, you know, the beatings will continue until morale improves. Like, there, there has to be a better business model than that. And, and it's funny you say insight, because one of the things in qualitative research that I love is you don't pretend that there is no bias in my science.
Dr Simon Fleming: There's no bias in my science because I have identified all [01:00:00] my biases and they are gone. In qualitative research, you're like, "Well, of course, because it's a human being doing this research." And so they're not biases, it's just authentic. It's just who I am, and I will list them and name them and shine a light on them.
Dr Simon Fleming: And so I did a whole bit of research around what makes someone operatively competent, and I did that by interviewing a bunch of orthopedic surgeons and orthopedic trainees. And one of the things that came out of my research kind of left field, and I've, I've had external people look at my research to make sure it wasn't just me being like, "Say the following words," is insight As the defining characteristic of the operatively competent surgeon.
Dr Simon Fleming: Mm-hmm. This idea that it's like a, nearly a force field around, around the other competencies, and that if you have it, and you demonstrate it, and you continue to have it and deliver it, it allows you to continuously be good at what you do and get better at what you do. Whereas if you lose it, you run the risk of becoming a [01:01:00] technically competent surgeon.
Dr Simon Fleming: You stop paying attention to all the other things. And for me, insight was always defined as, uh, self-awareness, self-critique- Mm ... and self-assessment. Uh, and this idea that all of us beat ourselves up. Most, most doctors self-critique. We're, we're hugely self-critical. I always used to joke that the reason I'm a reflective practitioner is because there is no criticism anyone can levy at me that I haven't already levied at myself far harsher than they could ever levy at me.
Dr Simon Fleming: So they would say, "You talk too much," and I'm like, "Yeah, I know. Here's my..." I would then word salad at them about what a terrible person I was 'cause I talk too much and whatever. Um, it's, it's a bit like people... And so I used to be very overweight. I'm now just marginally overweight, but it's like the fat guy always makes the fat joke first so that you can't make any comments.
Dr Simon Fleming: So a lot of doctors will be hugely self-critical, A, because they're told to be from the day dot. You must be perfect. You can't make mistakes. You make mistakes, people die. [01:02:00] Harm happens if you make mistakes. And so they internalize that. If I make a mistake, someone dies. Fundamentally, I'm a murderer.
Dr Simon Fleming: Fundamentally, I killed someone. I shortened their life. I ruined their family because I decided to have a 10-minute nap, whatever that might be. But also, you, you learn very quickly that one of the ways of demonstrating reflexive, being a reflective practitioner, which is held ... Again, it's one of these God words.
Dr Simon Fleming: You must show that you are reflective, is by being like, "Well, I've already thought about this, and here's my answer. I've already s- I've already ... All the things you're critiquing me about, I've already critiqued myself about, so I must have insight." Which is different to having a healthy level of self-critique.
Dr Simon Fleming: How can I be better tomorrow than I was today? How can I grow from this? How can I learn from this mistake that I've made? Not, I mustn't make mistakes, but how can I be a better person from that?
Sharee Johnson: How did you measure your insight? Was it self-report? How were you, how were you-
Dr Simon Fleming: Well, you can't. Uh, well, I know that's not true. You can, I just don't [01:03:00] like any of the measures.
Sharee Johnson: In your piece of work, though, when you were concluding that the operatively competent surgeons had insight, is, is that what you ... You were looking for their self-awareness, their self-critique, and their self-assessment.
Sharee Johnson: Yeah. But were you doing-
Dr Simon Fleming: I didn't have, I didn't have a tool. Yeah. And I even said, there's nothing really out there. Most of the tools-
Sharee Johnson: The interview, the interview you were doing with them was your tool?
Dr Simon Fleming: Yeah. Yeah. And, and you will know more about it than me, undeniably, because there are tools out there for measuring insight.
Dr Simon Fleming: I, I just don't necessarily buy any of them as being ... because of the nature of medical training, the moment you make insight a thing- Mm. Dr. Fleming, can you please
They'll start making the face.
Dr Simon Fleming: They'll start making the face,
Dr Simon Fleming: 100%. I have demonstrated insight in the following ways. You know, there was a conversation when we started doing work around racism that it should be part of assessments, and diversity should be part of assessment.
Dr Simon Fleming: All this stuff should be part of assessments. And, and people were like, "Maybe we can score it. Maybe you have to keep a logbook." And people were literally [01:04:00] joking, but I don't think they were fully joking and being like, people will turn up and be like, "This week, I have not been racist four times." Right?
Dr Simon Fleming: This week I didn't hurl a racial slur at someone. This week I did advocate for this. I found someone who looked like they needed advocating for, and I advocated at them. Because people will game the system because assessment drives achievement and all this sort of stuff, and assessment drives learning.
Dr Simon Fleming: And if you make something a thing, right, if you make something a measure that has to be counted and weighed, it kind of loses all meaning. And, and so we didn't measure their, their insight. We ... I interviewed all of these surgeons from the UK and Canada, and I interviewed all of these trainee surgeons, and I asked them all these questions.
Dr Simon Fleming: But one of my favorite questions to ask them was, "Close your eyes and think about the most operatively competent surgeon you've ever worked with or trained. Not abstract, put a name to a face. Describe them to me. Tell me about them." [01:05:00] And I did the same in the negative, "Tell me about the worst. Tell me about the reddest flags, operative, competent."
Dr Simon Fleming: And then we would unpack that. And, and what's funny is it rarely came down to their hands or the X-rays or the whatever. It was, it was those things. It was, were they self-aware? Did they know who they were? Did they know the bits of their personality that were Vegemite, Marmite, whatever, the bits that, that rub people up the wrong way?
Dr Simon Fleming: Did they know ... Were they aware enough to know what they were like when they were tired, when they were grumpy, when home, like, did they have that sense of themselves, of who and what they are in this world? Did they hold themselves to account? Did they look at cases, patients, interactions, mistakes, complaints, compliments and go, "What can I take from this? How can I be better?"
Dr Simon Fleming: Was that the best I could do? And is that okay? Is that acceptable? All those little things, um, and it, and actually the, the next step, 'cause we're writing it up, [01:06:00] then the next step is, is that something we can train for? Is that something we can select for?
Dr Simon Fleming: One of my favorite stories is in the UK, neurosurgery, years and years and years ago, one identified that psychopathic, there were certain traits, personality traits that allegedly are present in successful surgeons. Mm-hmm. And again, it was all kind of quasi-pseudoscience, whatever. But they wanted to see if they could select for it, and so of course they needed a baseline. And so they ran all these tests on the neurosurgery selection panels.
Dr Simon Fleming: And, um, what they found was that they were all just dripping in pathology. You know, psychopathic traits, sociopathic trait, narcissism, borderline personality disorder, obsessive compulsive. Obviously there was ... Not obviously, but there was a certain amount of neurodivergence, and they were like, "Are we allowed to publicly say we're looking for this?"
Dr Simon Fleming: number one. And number two, "Should we be looking for this? Is this w- is this what we want the profession to look like?" And the whole thing just fell by the wayside [01:07:00] because-
Sharee Johnson: Because it's compli-
Dr Simon Fleming: Because it's complicated, right? And, and this idea that, again, you could have a tick box of like, "This is what a surgeon looks like," is also how you build a very monochromatic workforce.
Dr Simon Fleming: Yeah. Right? It's-
Sharee Johnson: I'm very in- I'm very interested in this question of insight, and I don't want to get stuck here 'cause I think there's a couple more things for us to do before we, we finish. But I, I do want to, um, I- just to offer, I guess, a reflection that the work that I do with doctors across all crafts, and so we're not only talking about surgeons, we're talking about general practitioners, pediatricians, all kinds of doctors, is this ability to change, a willingness to change, you know, a willingness to be able to see the shadow, if you like, to see something that's not appealing, that we don't like, or that might be, you know, this repeated pattern.
Sharee Johnson: Well if 10 people are having the same problem with me, perhaps the common denominator is me kind of thing. You know, this a- ability to, A, notice that this might be something that I'm doing or something that's coming from me, and I might be repeating it, and I might be [01:08:00] the only person who can change it.
Sharee Johnson: I think for me, that's part of insight. Just I'm, I'm just cooking that up as I'm listening to you. I'm just kind of bouncing off what you were noticing and thinking, "Well, what is it about insight? What is it as a psychologist when we say, 'Ah, the person's demonstrating insight'? What are they doing?" And I think the key thing is that they are, uh, notice- noticing something out loud with a witness for a start.
Sharee Johnson: That's a very powerful thing, not just to yourself. And then entertaining, it doesn't mean you know what the answer is yet, but entertaining a willingness to change seems to me-
Dr Simon Fleming: Yeah. Again, full disclosure, I'm not receiving any money for this or whatever, but it's why coaching and therapy and those sorts of things are so powerful.
Dr Simon Fleming: Because actually sometimes it's just useful to have someone maybe not hold a mirror up, but just be in the room while you go through the process. Because there's something very powerful about kinda, like you say, saying it out loud. And, and insight is one of those things, a bit like resilience, where it gets thrown around.
Dr Simon Fleming: "Oh, Simon lacks insight." What do [01:09:00] you mean by that? Yeah. 'Cause he gets weaponized a lot. "The reason he made this mistake is 'cause he's, he's got no insight." Well, no, he does have insight. He knows he, it, he lacks this or he lacks that, but it's not, it's not insight. And you're absolutely right. And, you know, it's that running joke of like, "What's the common denominator in all the relationship breakups you've had?"
Dr Simon Fleming: Well, by definition it's you. Mm-hmm. And, and, and it's a, it's a bitter pill to swallow to go, there are certain things I can change. What is it, the, the, the, St. Francis of Assisi? Like, there are certain things you can change about yourself. There are. Mm. And there are certain things that are so core, so, uh, embedded to who you are that actually you can't, and you have to kinda lean into that and then find ways to mitigate for those if those things are still problematic.
Dr Simon Fleming: Yeah, yeah.
Dr Simon Fleming: I, I talk a lot. Uh, I therefore warn people that I talk a lot. I warn people that if I go silent during an operation, that's a red flag and they should be paying attention to why I've gone quiet.
Sharee Johnson: That's the important thing here, Simon, which is context, [01:10:00] isn't it? You know? Yeah. You know, having, having context and, and team.
Sharee Johnson: Gosh, we could just talk all day. Let's, let's pause here. I really want to talk with you some more about diversity. I think that- Yeah, for sure ... you know, you, you have, um, made a commitment, I think, a very public commitment. You're a founder of the International Orthopedic Diversity Alliance. Yeah. You know, there's something very important about this to you. I don't wanna say you're gonna die on a hill over it.
Dr Simon Fleming: Oh, no, I will.
Sharee Johnson: But I, I get the feeling that-
Dr Simon Fleming: I've received, I've received- you know ... death threats about it and all sorts. Like, like, a- a- again, it's not something you can do lightly. I've been called many things, and kind of ally and advocate are titles people can give you. I- it always makes me cringe when people call themselves one.
Dr Simon Fleming: Um, uh, but fundamentally, whatever your worldview is, we, we know, we can show and demonstrate that diversity of thought as well as characteristics is good for things. Mm-hmm. It's good for outcomes. It's good [01:11:00] for health and wellbeing. If you're cold and dead inside and you don't care about anything, it's good for making money, right?
Dr Simon Fleming: Uh, and, and one of the things that became very apparent is that there were systems in place across healthcare that were- So in- indentured in, in who and what we are. The, the, the, the phrase I use a lot is, you know, healthcare wa- isn't broken, it was built this way. All the previous conversations were about, like, fixing the NHS, fixing this.
Dr Simon Fleming: Well, fixing suggests going back to before it got broken, but it was built this way. You know, the, the health systems were built by mostly older white men, mostly to benefit the patients that they were treating and the people who they hoped would take over their practices, which were younger white men.
Dr Simon Fleming: And, and so there is this whole body of work that shows that, that [01:12:00] fundamentally, in particular in healthcare, but in any walk of life, that that model doesn't really work. And, and so it became really important to not only make orthopedics, but healthcare in general, somewhere where everyone can kind of thrive, uh, not just survive and, and do well for themselves and their patients physically, mentally, emotionally, all those sorts of things.
Dr Simon Fleming: And a big part of that was unpacking and unpicking the systems that are in place that stop that from happening. Whether that's patriarchy, whether that's bullying, whether that's assessment models, whether that's, uh, selection models, all those little things, because it is in the DNA of what we are and who we do.
Dr Simon Fleming: And so again, a bit like with the bullying work, it felt like a hill worth dying on. It felt like a place where, where I could make a difference and make things better, and the, the challenge you have when you step into one of these roles is, uh, it goes against all the [01:13:00] stuff we've been talking about.
Dr Simon Fleming: So I do loads of training, uh, for organizations, where I go in and I talk about how to be an ally and how to be an advocate. So generally you're speaking to a room full of very important people, um, not all of whom, but many of whom will be of certain characteristics. And the first line I tell them is that the first job of an, of an ally is to shut up
Dr Simon Fleming: Because silence is so uncomfortable and we have to talk and we have to fill the silence and I have to tell you my thoughts and my opinions and my worldview and, and especially if you're a capital L leader, you're expected to have the answers again, the answers to the questions, to the truth that everyone is looking for, right?
Dr Simon Fleming: What's the answer? Well, you speak to the CEO or the consultant or the clinical director or the, or whoever.
Dr Simon Fleming: But the challenge when you're doing diversity work, and, and I think it's important to clarify here that I [01:14:00] have my own diversity characteristics, some of which are visible, some of which are not. But 99.9% of the time it is hard to explain to a room full of people who want to know how to m- make things better that it's not about them.
Dr Simon Fleming: Mm. And it is really hard when you're used to being the doctor, the consultant, to de-center yourself from those conversations. "Well, this is how I am going to get more women into orthopedics, and this is how I am going to get more people of color and members of the LGBTQ, and this is how I am going to create a psychological safe space, and this is how I..."
Dr Simon Fleming: Uh-huh. Uh-huh. Uh-huh. Have you spoken to anyone in those spaces and listened, actually listened? And, and again, it's, it's, it's n- m- often well-meaning. There's, there's rarely malice there. It's more just about being in this diversity space, which is the flip side of the kind of culture [01:15:00] change space. So on one side I'm in this sort of nearly combative space where you challenge toxic cultures, and you teach people how to be an active bystander and how to challenge bullying and harassment and, and sexual assault and rape in the workplace, all these things that are prevalent and awful, and you need to be quite active.
Dr Simon Fleming: From my point of view, if you're not actively anti those things, you're sort of for them. And then you've got the other side of the coin, which is the diversity work, which is about building stuff, not breaking it down. It's about bringing people in. It's about inclusivity and belonging, and it it, it balances out the combative work of being like how do you call out these behaviors? How do you, how do you walk that fine line between cancel culture, which can be extremely toxic, and challenging behaviors that are known to be toxic? Um, and the flip side of, of the diversity work is recognizing that it is multi-generational, it is gonna take [01:16:00] years, and that we won't have true equity and true inclusivity until, until fundamentally everyone gets the same opportunities and access and,
Dr Simon Fleming: They're not even glass ceilings. Like, they're reinforced concrete, right? And, and there was a piece of work in the UK recently that showed that there were more surgeons called Dave than there were women in certain departments. And you're like, you're like, "Yeah, that sounds, that sounds about right." And again, it's, it's such a fascinating bit, 'cause you've touched on it before around change.
Dr Simon Fleming: So one of the pieces of work I do around diversity is a classic example. And, and the, the DEI (Diversity, Equity and Inclusion) umbrella covers all kinds of stuff. So for example, I do work around explaining to people how to authentically apologize, 'cause we're shit at it. Mm. Um, now technically, as far as I'm concerned, an authentic apology is "I'm sorry".
Dr Simon Fleming: And then you walk away. Unless they want to [01:17:00] talk at you some more and you need to do some more listening, but fundamentally, your apology should be, "I'm sorry." And then you demonstrate through your actions and your behaviors how you have learnt from it and how you won't do it again. If you feel the need to have an I'm sorry semicolon, I would allow, "I'm really sorry, and, um, I, I'm gonna do better."
Dr Simon Fleming: I give you that, fair enough. But the de-centering part is th- they, they don't have to accept your apology. Not only do they not have to accept it, they don't owe you anything. They don't have to re-follow you on Instagram. They don't have to write you a letter. They don't have to give you a hug. They can still be like, "Yeah, whatever, man."
Dr Simon Fleming: Because it's not about you. Your job is then to go, and go and be better. Which again, sits really uncomfortably for a lot of my colleagues who are like, "Well, I apologized, and they were still rude." And it's like, as is their right because you got stuff wrong, and now you have to do [01:18:00] better. And it's h- it's hard.
Dr Simon Fleming: And th- th- that, that diversity piece, of course, covers a whole um- umbrella of pieces. So then you get into the realms of, of, you know, challenging behaviors, and you get into the realms of does it count as diversity work to challenge gender-based violence in the workplace? Well, I think it does. If work isn't a psychological safe space for women and the members of the LGBTQ community and people of color, because we know there's an intersectional component to it, then you cannot have a sense of inclusivity and belonging.
Dr Simon Fleming: If fundamentally, as a woman, you have to accept the bum squeezes and the comments and the jokes and the ... There's much worse that happens. So, so that whole umbrella of work, again, you, you simultaneously can pick your battles. So I have colleagues who work just in one space or another space. They work in the neurodivergent space or what have you.
Dr Simon Fleming: Or you can say, broadly speaking, these are things we need to improve, and this is [01:19:00] why. And so a big part of it is explaining the why to people. So I remember having conversations with people, and they'll say things like, "Well, I'm, I'm an easygoing guy. I'm a good boss. I've got an open door policy, and in my 25 years, no one has ever complained to me about any of this stuff."
Dr Simon Fleming: And people would tell me. And of course, part of it is you go, "Well, how many women are there in your whole hospital, your whole department, your whole whatever?" And part of it is, well, what would happen if they told you? Number one, like, be honest. Come on. Do the insight piece. What does it look like when people do it?
Dr Simon Fleming: Do people shout whistleblower, and do they end up for the high rung, and do they suddenly not get into theaters, and does it mess with their assessments? And number two, how would it feel if you were part of this conversation? What would you do if they said, "You are bullying me, making me feel unsafe"? And for some people, that's a horrible experience, and, and it should be.
Dr Simon Fleming: And I've been on the receiving end of, of feedback that I've not particularly enjoyed, and you have to kinda suck that up and, and internalize that and learn from it and [01:20:00] grow. But the, but the diversity work is, is some of the most important work I, I feel I've ever done because- It's ... Podcasts like this are really hard because it's, it's hard for it not to sound like a humble brag.
Dr Simon Fleming: And, and it's very hard to de-center yourself when you're asked to speak in the first person. And so it- I'm used to talking about we, and it's hard when to be like I. But when this work started, the culture change work, n- no one else was really doing it. No one else was really talking about it. And so I had to make the choice to throw myself on the, on the bonfire of, like, we'll see where this lands.
Dr Simon Fleming: And undeniably, it has been a part of work that now is global, and that was always my dream. And I I have, I have bits of writings from 2015 where I was like, "The goal is that I get hit by a bus and nothing, and the work keeps going." It can't be a force of personality work, right? It can't just be the Simon Fleming show.
Dr Simon Fleming: That doesn't work. And [01:21:00] now there are some people who know what happened 2015, '16, '17, but now it's on everyone's agenda. Now it's on ... It's, it, you know, now I'm not saying that I have anything to do with the US government, but now DEI is on people's hit list. If you look back 10 years ago, no one was talking about it.
Dr Simon Fleming: Well, and of course that's not true. Uh, lots of people were talking about it, but it wasn't safe to talk about it publicly. It was whispered. It was little, little rooms where people talked about how do we hire another female professor? How do we bring in another person of color into this department? And it has its, it's resulted in threats to my career, threats to my life, threats to my family, from healthcare providers.
Dr Simon Fleming: And it, and it is hard, but I have to force myself that they are fundamentally terrified. Mm-hmm. Because the world ... I'm suggesting that the world underneath their feet might not be as stable and as steady and as certain. And, and again, it's fascinating because some of it, again, comes back to guilt and shame.
Dr Simon Fleming: So I've had, [01:22:00] I've had people reach out, and the, one of the most common questions I get, for example, is, um, "Well, so I can't date in the workplace. Everyone I know married a doctor or a nurse they met at work. Well, we can't do that now, right? 'Cause, 'cause it's sexual harassment." Well, no, I think you can. I think there's ways of doing it.
Dr Simon Fleming: You can do it like a respectful adult. You can say, uh, "Hi, I, I, I wonder if I, if you'd might- like to go for a drink?" And if they say no, the response is, "Well, thanks," not to send them a picture of your penis. And they, and they kind of go, "Well, I, blah, blah, blah." And, and again, it's the insight piece. Yeah. So, so the insight piece is fascinating.
Sharee Johnson: It's not just insight. But- It's not ... Sorry, sorry. It's not just insight, it's respect.
Dr Simon Fleming: Yeah, 100%.
Sharee Johnson: And, and, and trust.
Dr Simon Fleming: Yeah. And- and you, you can't pretend ... People pretend they don't have any power. The number of consultants I get who go, "Oh, all these, all these junior doctors who think I have power. I don't have power."
Dr Simon Fleming: No, that's your insecurities. Of course you have power. And so here's the thing If you are a consultant surgeon [01:23:00] in your mid-40s and you are single, should you date your 23-year-old intern? Hmm. Now, that's ... When I do workshops and stuff, I love to throw that out there, because then you have to unpack it, and there's no easy answer.
Dr Simon Fleming: Because if they're a consenting adult, and if they're only gonna be with you for a couple of months, and, and what if ... A- are you signing off any of their assessments, or actually are your s- the assessments done by different consultants and whatever? And all these conversations. Well, does it make a difference if they're 33?
Dr Simon Fleming: What if the age gap is less? What if they're 43? What if they're a graduate entry late starter? What if they're, you're the same age, but you're still their consultant and they're still your intern? What, what if, um, can you date someone in your hospital who now doesn't work for you? All these little conversations where we don't have systems in place, and I remember previously to the regulator in the UK, we were having a big ..
Dr Simon Fleming: I was like, "Well, we actually, what we need, [01:24:00] one thing, is probably some sort of confidential registry where people can register consensual relationships." It's what private industry have. You say, because then you say, "Look, my name's Simon Fleming. I'm a consultant orthopedic surgeon." I should add I'm, I'm happily married and my wife is just in the living room, but for the purpose of this example, and I am single or divorced or widowed, and I have a junior doctor who I would like to be in a relationship with. And they have said yes to that, that relationship consensually.
Dr Simon Fleming: Which is again, hard to unpack because can they say no, right? Can they say no in a world where your consultant says, "I'll see you in the pub"? And that's a whole other conversation which takes hours and hours to unpack because I don't think they necessarily can. But it does mean that if you're gonna declare this as a consensual relationship, and you both have to sign off on it, You can't sign assessments for them, be an examiner for them, be in any part of [01:25:00] the many systems that give you other hidden power behind them, right?
Dr Simon Fleming: You can't be their reference. You can't be any of those things that they might, you might hold over them if you were a horrible, nasty piece of work trying to force a junior doctor into a relationship with you. And so this is a per-
Sharee Johnson: It's the transparency that makes it really, uh, critical.
Sharee Johnson: But I, I think the other thing that's really important about this, and people listening will agree to registers or no registers or whatever, but I think the thing that's important here is the conversations, that these conversations- Yep ... need to happen and that you are giving people a vehicle by saying, "This is some of the work I do," to, to say, "Let's have the conversation with somebody who's thought about this stuff."
Sharee Johnson: And, and in the tr- Yeah ... in the training bodies and so on that you're working in.
Dr Simon Fleming: And I don't pretend to have the answers. Like, the register thing generally tends to be put out there because it then gets people talking about whether that's gonna work, whether that's not gonna work. Who holds that data?
Dr Simon Fleming: Who can see that data? Do you have to tell them if you break up? What if you're, what if you're polyamorous and you're in a relationship with four people and it's all consensual? Do... How does [01:26:00] that work? And it, it's not the answer. The point is, at the moment, because of the hierarchy, and mostly patriarchy we still exist in, most of those relationships are kept on the down low.
Dr Simon Fleming: Mm-hmm. It's everyone knows that Dr. So-and-So is dating Dr. So-and-So, and the healthy relationships are kept just as secret as the unhealthy relationships until they're official, right? Until you've been going out for, like, eight months and then you kind of do a soft launch and everyone, and everyone's like, "Yeah, we knew."
Dr Simon Fleming: Right? "You went to that conference together, and also Paris for some reason. Like, we're not idiots." Yeah. Like, but equally, it a- it, it allows all of these, all of these dark spaces allow the dark stuff to exist there, too. Whereas if you shine a light on the good stuff and you say, "Well, actually, this is how we...
Dr Simon Fleming: These are..." You know. So the classic example is, is people who, who... The flip side, junior doctors who cry bullying when they've just been given negative feedback. Yeah. Well, if, if we don't have good systems for recording and documenting feedback, and if [01:27:00] we don't train people to give constructive feedback, then it allows people to be like, "Well, you're a bully."
Dr Simon Fleming: No, I'm not a bully. I, I, I gave you constructive feedback using the Pendleton Model, and here's my documentation of where I explained to you the things you could do differently or better. And I'm sorry that, that you feel this way, but at no point was there an abuse of power and at no point did I make any disparaging comments.
Dr Simon Fleming: I just told you that you had done something wrong and how you might do better next time. Uh, a- and again, and like you say, until those conversations are out there and transparent- It, it still creates, like you said, the secret rules, the secret hidden stuff, and that's where all of these barriers to diverse, all of these barriers live.
Dr Simon Fleming: They live in the place where you, you can create secret rules and secret things, but because they're not out there, there's no way to challenge them. There's no way to be like, "It is weird that we've never managed to hire anyone who doesn't look like me." And you go, "Well, you must be... I, I don't know. It's just one of those [01:28:00] things."
Dr Simon Fleming: Have we ever shown the job description to someone who isn't a consultant in this department? No. Why would we do that? Well, is it possible that it reads like we're looking for more of the same? No, it can't do. Well, why don't we show it to some people and see... Why don't we show it to some people of color and some members of the Aboriginal community and some members of the LGBT, and get them to red pen it?
Dr Simon Fleming: Mm. Oh, well this... And, and I've done that before. I've done that exercise with departments, and it's fascinating the stuff that comes back. This reads like you don't support parenting of any kind. This reads like all of your meetings are basically exactly when the school pick up and drop off are.
Dr Simon Fleming: This reads like I will have to work school holidays for the first three years, 'cause I'm the new consultant. This read- oh, well, I guess, hmm, uh, hmm, yeah, fine. Right. Fine. But it's hard if no one's ever challenged you on that.
Sharee Johnson: Uh, totally. But it, it's also true that women and minority groups and, pick whichever minority group really you want to talk to, um, feel like they have to... this [01:29:00] very subtle thing of I have to work twice as hard or three times as hard. It's not that anybody's actually, um, naming anything that's wrong. Yeah. It's just that I've got to prove myself so many more times, or have... And this is again feeding into the excellence and the perfectionism and the so on that, that- Yeah are all problematic.
Dr Simon Fleming: And they're not wrong. So we saw that in the US. Loads of data came out of the US that showed that women surgeons were given less autonomy in the operating theater. So if you're gonna be given fewer opportunities and simultaneously held to a higher standard- Mm ... the only way you can come out of that not looking not good is to work harder, to be, to give more, to sacrifice.
Dr Simon Fleming: You know, what is it? What's that thing? Like, we won't have equity until a woman can be as successful as a mediocre man. Those systems still exist, and because of that, until we challenge them and deconstruct them and, and name them, we can't then go, "Now, how do we unpack that?" You know?
Dr Simon Fleming: The conversations around neurodivergence in assessment. Oh, you need extra time? Man, I'm a great doctor, but it takes me twice as long to read stuff. But, but how is that a [01:30:00] prob- Well, in an emergency. In an emergency, I don't have an MCQ. Like, what are you talking about? In an emergency, I'm surrounded by people, and I don't have to write an exam answer.
Dr Simon Fleming: In an emergency, I also have my phone in my pocket and all kinds of stuff. Like-
Sharee Johnson: i want to just ask you one more thing before we get to the end, , I want to ask you what you think about leadership development because, , we spend an inordinate amount of money across industry on leadership training. Some of the reports say something like $300 billion a year in the world spent on leadership development. It's a huge amount of money, uh, for... I, I guess I'm questioning the ROI, and I'm wondering specifically in medicine, if you could wave your magic wand and have a couple of things happen around leadership development in medicine, what do you think we need to do?
Sharee Johnson: What, what brings the return for these issues? Because it's the leaders that can shift the needle the fastest in these matters.
Dr Simon Fleming: We do too little, too late. And I guess, I guess the challenge we have is that there is no perfect system, and so my answer [01:31:00] is already flawed out the gate. But most people don't go on leadership development until they've already been identified as a leader, which by definition means they've either- Already self-identified or, or have just find themselves in that position, or one of the previous systems that we've just discussed, they went to the right school, they're friends with the right people, then they, you know, they're whatever Because there is no leadership development really when you're a medical student or when you're a junior doctor, unless you join the trade union, join the whatever, and go on the special course.
Dr Simon Fleming: It's just assumed you'll pick this stuff up, right? So I'm not making overt comparisons to the military, because they have their own problems. Mm-hmm. But you join the Army, and immediately it is recognized that as a day-one soldier, you will have certain leadership responsibilities, and you are taught how to do those things, how to lead, like small L lead.
Dr Simon Fleming: Yeah. And then you get promoted either as a non-commissioned officer, as an officer, and it's recognized that [01:32:00] you are going to lead larger teams in different contexts, probably with, um, bigger decisions and smaller decisions, with bigger budgets and smaller budgets, maybe in more emergent situations, maybe more conflict.
Dr Simon Fleming: And so you are trained to another level, so that by the time you get to a certain level of seniority, the courses you're going on, if you like, are about finessing those skills. Whereas if you look at, uh, and it's not just Australia, I should add. If you look at Australia, if you look at the, the UK, if you look at America, a lot of their, um, emerging leader leadership type courses are generally aimed at early years consultants, in other words, people who've been at this for, like, what?
Dr Simon Fleming: 20 years? Mm. And, and by definition are either invited or applying because they're already in those roles. They're already a clinical director. They're already on ... And, and if I was given a magic wand, it, I would probably, A, change selection out of the get-go, and then B, I would, I would have that leadership development stuff be more integral to the [01:33:00] training at every level.
Dr Simon Fleming: Mm. And, and I'm not talking about the performative stuff, and some of it is performative. But it is about recognizing that if you don't give people these skills, you can't expect them to have these skills. It's unfair to expect a PGY3 to suddenly lead a team of junior doctors when the only training they've had is what they're role modeling.
Dr Simon Fleming: The only training they've had is what they're role modeling, and so if they've worked with a bunch of bullies and a bunch of hierarchical old school whatever, that's all they know. Right? And, and-
Sharee Johnson: It's not only all they know, it's what they have been indoctrinated with. It's like this is- Yeah ... this is how we do it. So it's not only, all I know, and also I feel a bit uncomfortable about it, but I don't wanna step out too far because, you know, I need these referees. I need these people to help me progress.
Dr Simon Fleming: 100%, absolutely.
Sharee Johnson: Okay. We could go on, like, all day I'm sure, Simon. It's fascinating. I've got 10 more things to talk to you about that we'll skip over today.
Dr Simon Fleming: To be continued.
Sharee Johnson: [01:34:00] What are you, what's your mantra? When you were talking about the concrete ceiling, the reinforced concrete ceiling, I was gonna ask you were you optimistic, but when you said that phrase, I feel like, well, that's, that's maybe a stupid question. I wonder if you can invite, how, how would you invite other people to join you in this- Oh quest of, of culture change?
Dr Simon Fleming: My mantra is a quote that I've stolen from Maya Angelou, which is, "Do the best you can until you know better, and once you know better, do better." Unashamedly, I have cocked up in the past and will continue to make mistakes forever.
Dr Simon Fleming: I continue to do the best I can, and every now and then something opens my eyes, something changes, the world moves on, and I adapt, and I change, and I do better. And so when I try to get people to come along with this, I'm not expecting everyone to suddenly become flag-waving, soapbox-ranting advocates for change.
Dr Simon Fleming: I'm not expecting people to put their lives or [01:35:00] careers on the line in the way that perhaps I have. I'm asking people to be open to the idea that there might be better ways of doing things, quantitatively or qualitatively better ways of doing things, and to give that idea a chance, and to, by the definition of that quote, allow for the possibility that you will probably cock it up.
Dr Simon Fleming: You'll probably get it wrong. Mm. And that's okay too, so long as you get it wrong, you learn from it, and then you have another punt with the new knowledge you have. So if you do the best you can ... So I, I give talks to people who've been consultants for 30, 40 years, and they're like, "Well, I've clearly been a racist for the last 40 years."
Dr Simon Fleming: And you're like, "Well, yeah, but no one told you that ... You've, you've not been, like, a go to jail racist. These are the, these are the behaviors you've demonstrated. Um, but this is news to you. The stuff I'm telling you today is news to you." Mm. "So from tomorrow, do a bit better. Try a bit more. Put a bit more effort in."
Dr Simon Fleming: Try and change a little bit, accepting [01:36:00] that it will be hard and that you will make mistakes and that you will go through this grief cycle. So my mantra is do the best you can until you know better, and once you know better, do better. It allows for learning, growth, and change, but it allows for accountability.
Dr Simon Fleming: Because if I tell you these things are not okay, these things are harmful, these things demonstrably harm patients and harm your colleagues, and you then persist, you can't go, "I didn't know." And so that, that opportunity to be a better person tomorrow than you were today, but also be held to account if you choose, actively choose, willfully choose to not change, well, that's a different conversation.
Dr Simon Fleming: And again, that allows for culture change because then the conversations you have going forward, um, you don't have to start with, "Well, did you know that that joke was unacceptable?" It's like, "Well, you did. You'd been told." You know? And, and that is [01:37:00] how you bring people along, I think, it- by recognizing you don't have to be perfect.
Dr Simon Fleming: You don't have to get it right. You don't have to be an evangelist. You just have to listen, recognize that most of these things actually aren't about you, and try to be slightly better tomorrow than you were today. And honestly, all the evidence points that those small changes create massive, massive tidal changes in the world around you.
Sharee Johnson: Mm. It's been an absolute joy. I think you talked about curiosity early in our conversation, and that's the thing that I think you're leaving us with too, is just stay curious about the impact we're having on each other in the world, and how we might shift that to have better impact collectively and individually.
Sharee Johnson: Thank you so much for your time today, Dr. Simon Fleming. I'll see you down the track somewhere.
Dr Simon Fleming: It's been an absolute pleasure.
[01:38:00]
