Suzie: Hi, Kate. Thanks for having me. It's an absolute pleasure. Yes. I suppose the first thing I should say is, call me Suzie. Okay. I'm an Anaesthetist in Lanarkshire and also in Intensive Care, and I've been a consultant there for just over ten years. So I guess what's brought me to Realistic Medicine has been a kind of circuitous journey. But if we start off by saying that half of my working week is in high risk anesthetics and the other half is in intensive care, that gives me a kind of dichotomy in my job because I love talking, I'm a gab, I like patients, I love hearing their stories. And as you know, you do the same job. It's really difficult when half the time you're spending your work and caring for patients that are unconscious. So I have this desire to not just deliver high quality anaesthesia, but also to really engage with patients and as much as I can, I guess I started off doing a Monday vascular list. That was difficult because it meant I had to go and see my patients on a Sunday. I thought, that's not good. Like, you know, I don't want to go on Sunday and meet my patients at the last minute. But the kind of process evolved and I started bringing patients up the week before. Then I started involving the surgeon and said to the surgeon, listen, why don't we go and see the patient together? This is high risk stuff. Then I developed an interest in assessing high risk and what high risk actually means. I got funding. I managed to put in a business case and successfully got funding for cardiopulmonary exercise testing, which is one way of stratifying risk. So it kind of grew from there. And I think what I was trying to do was do the consent process better. But despite that, I just still had this sense that it wasn't enough. Although we were telling people what the risks were, it was almost when the decision was made for them. And I kind of got this. There was a few notable cases there's, a few patients that really stick in my mind over the years, but despite the risk assessment, having said, yeah, you know what? Probably good to go ahead, did badly or didn't do as well as I hoped they would. So I had this kind of growing idea that there might be a different way to do this. So literally, about seven years in, no part of a lie, I got this, itch. I had to go somewhere. Now my best friend says I've got itchy feet and my husband says that I've always got a project on the go. So despite having four children, I decided that the next project was going to be I was going to try and find another way of thinking and another way of looking at this particular group of patients who are very, very high risk for surgery. So I came across a job in New Zealand and I applied and I spoke to them and I said, listen, I want to come and work for you, because they were looking for a locum, really. But what I wanted to do was join a clinic that they had already established there and they had this clinic model that they called 'Complex Decision Path'. So I started trying to line up all the docs and negotiate with my workplace to go away for not just the three months sabbatical that you earn after seven years as a consultant, but really to go that far, I wanted to be away for a year. So I had a lot of persuading to do. And NHS Lanarkshire supported me, ultimately, and going away turned out to be on the brink of a pandemic. So in January 2020, I dragged my husband and four children to the other side of the world just for a breath of fresh air and to try and see if there was a different way to do what I was doing. And oh, my goodness, what a great decision. So I participated in the clinic there, which was really different, really labor intensive. Instead of it just being a patient coming to see Anaesthetist face the fase, to discuss risks, they have two consultants. And I think that that's an expensive idea for the NHS. But actually I think it is so valuable, you'll know yourself, Kate, that Anaesthetists, like surgeons, have got different attitudes to risk. And I think the problem with a lot of high risk patients coming to see one anesthetist is that although one anesthetist might have a risk discussion with a patient and think, yes, okay to go ahead, we've discussed it all, we've been through the consent process. The patient comes on the day for someone different. So definitely there's two things I'm really not sure about this. So that creates a problem. Patients then can get cancelled on the day. They're deeply disappointed, the Anaesthetist on the day, feels uncomfortable, but bad for having to cancel the patient. So it has to be a better way to do this. That's why my clinic idea requires actually two consultants. There's one anesthetist and there's one intensive care specialist. So I think that turns it more into a multidisciplinary team instead of it being one Anaesthetist dependent. And it also definitely puts the patient at the heart of the multidisciplinary team. And the patient's family who come along with that is absolutely true. So I've spent the last year setting this up and it's running and now it's been funded. I can't believe it. I mean, honestly, everybody returning at the moment. We're told there's no money for anything and I've managed to present this to our board in September and meet our goal, and it's rewarding and I'm loving it.

Kate: How did you do it when you were still kind of on a shoestring, like when you weren't funded?

Suzie: Yeah, so when I came back from New Zealand,I had 4 hours a week. A job within a job was being advertised to be the realistic medicine deputy. So I applied for that and I got it. So I have used that time, if you like, to set up my clinic to do all the legwork and stuff. However, the people I really have to thank here are my two principal enablers actually set up the clinic. They've given me their time. So I've got one colleague who's about the equivalent amount of experience to me and works in intensive care as well, and one who does just anesthetics. And they have both come a lot. I've basically come back full of enthusiasm with this idea and said, listen, can you come and join me? Can you join me in this? And they've given me their time, really impressive time, whetn they're meant to be non clinical or recovering, in order to deliver this kind of labor intensive consultation. So it's been great. So. Thanks, Graham. Thanks Vanessa. Thanks so much for letting this happen, really. And we've done that for a year unfunded, so I've kind of counted it sort of in with the other stuff that I'm doing. But they have given their time for free. Very grateful.

Kate: Yeah. And so how has it gone down with the, I suppose I've got two questions; how do the patients find it? And how did you show the benefit, when you're so limited on time, in a way to get funding to prove it's worth?

Suzie: Patients love it. So really, when I presented all my data to the board, the two principal threads were when patients come to speak to us in a clinic like this and you really put them at the heart of the decision and allow them to realise that actually sometimes having a big operation isn't the right choice for them. If you allow them to realise that and they effectively opt out of having high risk surgery and choose to spend whatever time they have left. Now, this is hard. These are hard, hard conversations. Like you're asking someone who's got bowel cancer, for example, to consider the option of not having a...

Norma: Well, first of all, you've already introduced what my name is, so the first is I grew up in the Highlands of Scotland, all over, but I ran away from home when I was 14 and pretended I was 16 and joined the QARANC, Queen Alexandra's Royal Army Nursing Corps in England. And from there I took ill when I was in the army and they had to do the very first operation on me that I'd ever had in my life, where they found I suffered from anaphylactic reactions to many anesthetic drugs. So under British law, you couldn't be in an armed forces with that because you'd be a danger. So I threw a dart into an atlas and it landed in a country called Rhodesia. So I packed up everything and just went to Africa. When I got there, I joined their military, which was combined forces, but carried on with nursing training and we would work with casualties, evacuating people out. I learned to fly an airplane and land it in case the pilots got shot, because this was a wartorn country. And this carried on to about the late 1970s. And then in 1979, I hit a landmine where everything changed because it was then found I became an incomplete quadriplegic. After everything settled down, I can move sometimes. I've got no sensation in a lot of parts of me. Every time I take an anaphylactic reaction, it causes swelling in the body and when that swells up, it also seems to cause problems in my spine as well. And it can take me ages to start getting movement back after each episode has gone, been cleared and I'm out of ICU. Can take months. I eventually got transferred back to Britain in 1986 and that was when local NHS and things got involved, because, yes, I was an incomplete quadriplegic and it's a CTC five. But I shouldn't be defined. That doesn't define me, who I am, it's what I can achieve. But then I was taking anaphylactic reactions to everything around me. I was in one hospital for 90 times in one year with anaphylactic reactions. So it was decided they were going to try and work out what was causing this. And they realized that I had what was called hereditary idiopathic and acquired angioedema, which all turned into anaphylactic reactions. The physical side of me, the disability, I can cope with. But that's the side that takes over everything, because you go to hospital, you'll take a reaction when you go through the door. Doesn't matter what you were going in for, they deal with the reaction get you out, realize, oh, we haven't done tests, we haven't done anything. I had a fantastic doctor later on who then took over and said, we've got to work a plan because I was falling through cracks.  And we then started with a different way of keeping me all together. And that's just roughly, in a nutshell, probably 40 years all come together.

Kate: Wow. What a fascinating journey you've had. And then what do you enjoy doing in life now back in the Highlands?

Norma: Anything that, as you can see, I like activities, I like action. Doesn't matter what it is. I like to be a dare devil. I've always been a dare devil. So even now, even in my wheelchair and everything else, as people in the Highland Senior Citizens Network know, one of their staff is traumatized. When a few years ago, with NHS, we had people from NHS and the government, but I decided I wanted to go to the skate park in my wheelchair and they did a film for NHS and I did it. And I finally got to the very top of the park, which nobody's ever done in the wheelchair, but they forgot to pull the camera through back, to stop me hitting the camera through. I pushed my wheelchair around to fly off the top and crash landed on the floor. And I was just so excited going yes, yes. But everybody was running, thinking, she's broke her neck proper this time. So, yes, I still like to, even if it's the tiniest thing in the house. And I can't move that day as long as I've done something that I can do, I've done something.

Kate: Yeah. That's amazing. You're braver than me, that's for sure. You don't catch me in skate park.

Norma: I don't do that now. But that was about four years ago, was the last time we were out.

Kate:  So tell me a wee bit about what's most important to you, particularly from the delivery of your health and your care. What's important for you?

Norma: Well, the main part, I think the whole lot would come under one heading of this is my reality and keeping it real in my care. To me, it's got to feel you've got sufficient time with the carers or the doctor, whoever's dealing with you, that they see you not as the problem, but they see you as the person. And we then are able to work forward individually to try and work on what needs to be done. And that is the most important thing of all, is that we're seen because often you're not you're just you're a number.

Kate: Yeah. And you're obviously very experienced and eloquent in the way you get yourself across and confident, what advice would you give people who maybe are new coming into healthcare? I meet a lot of patients and people coming into the system, and they've maybe been previously healthy and they've had a bad diagnosis and they feel so worried about asking questions and about asking to be seen as an individual. So I'm on a bit of a crusade with my colleagues and there is a kind of global movement trying to make sure that health care people are asking, like, what's important to you? What's important for you, your goals for life and for us, you've had any kind of treatment, but how do you think we get our patients and the people using our services to feel like, empowered, to be as active as you are?

Norma: Well, to start with, what you see now is what has taken years to finally get to this. When I first became physically disabled and everything, probably for the first 20 years, I wasn't seen, I wouldn't speak out, I would be very quiet and fell through many, many cracks. And you felt you couldn't speak to the doctors, they had to make the decisions, they had to do this and you just had to go along with it. What made the big difference for me was when I finally got to talk to a doctor. Where they actually didn't have their back to you while they were talking to you. Because normally they're on a computer or they're writing in a book where they're actually facing you and make you feel. I can actually talk to this person because they're facing you. They're looking at you and you think. Oh. Maybe I can talk about this problem. Because when you go to the doctors, you go in and the doctors are often very busy because they've had another patient, so they're finishing up the notes on that, or they're busy trying to sort your notes and then they ask you with their back to you, what's the problem? And you think, Well, I've got this, but I don't know, should I talk to you about that? I should have talked about this. Like now when somebody's looking at you, you can open up and say something and then the conversation can start. Until then, you just sit there and say, oh, well, it's this, and get out as quick as you can because you're so uncomfortable. And yet you think, oh, I should have said this, I should have said that.

Kate: You almost need to go in with a script. I'm a doctor, but I've also been a patient, and I totally feel that feeling of almost like panic and pressure to get the right words out in time. And obviously, we're like, GP appointments are so short and I ...

Amanda: Thanks, Lyndsay. So, yeah, as Lyndsay said, I'm Amanda. Amanda Gotch. I am the realistic medicine programme manager for NHS Grampian and NHS Orkney. We actually have a collaboration with Orkney. We started that just around early this year, early 2022. And I will go into a bit more detail about that as Lyndsay and I chat. I am a midwife by clinical background. I've been a midwife for a very long time, but I really kind of came around to doing this work as a programme manager for Realistic Medicine after undertaking the Scottish Quality and Safety Fellowship. I Heard about Realistic Medicine whilst on the fellowship and thought, well, that makes sense to me as a midwife. So really, from there, when the opportunity came up to be the programme manager at the time for Grampian, I absolutely jumped on the opportunity and here I am.

Lyndsay: Absolutely, yeah, it's a bit like myself. So when I saw the post for the program manager for Realistic Medicine come up with my background, I look on a daily basis at the evergrowing waiting list within every hospital in Scotland, not just ourselves or with yourself in Grampian. And, you'll know, and the amount of times that I've seen patients who sat on a waiting list for weeks and weeks, then when we had capacity, we would call for the patient. And I can't stress the amount of times we had patients on the phone to us saying, oh, I don't know why I'm on the waiting list for that procedure. Or we'll phone them and say, yep, we're going to call you and you're going to come in for your colonoscopy. And when we say to them, you know, you'll have four litres of bowel prep what the procedure actually is straight away, they're going, oh, I can't do that, I don't want to do that. And if they used realistic medicine at either a clinic appointment or at the GP appointment and said, this is what might happen, you can have that conversation there, and then to the patient to say, you know, this is what to expect, there might be an alternative that they can do, but also, if there is no alternative, you're giving the patient the right information to prepare themselves. I know myself, I'm terrified of the dentist and I had to go for my first filling and I had a nightmare for a week until I actually asked the question and it put my mind at ease. So I think it makes sense. It absolutely makes sense.

Amanda: Yeah, absolutely. And I think that shared decision making and personalized care with the kind of two of the six principles that spoke to me most, lindsay as well, and I think, again, not just as well, yes, as a midwife, but also as a human being. And you're right. It is that we always imagine the worst case scenario. Don't we. When we've got to go through something and it might be bad. It might be bad. But being able to have the opportunity to prepare for it and at least start to maybe understand a bit more about the things that could happen and the things that definitely won't happen. It goes a long way. I think. To helping make people make decisions. And we do know there is evidence out there that when people are given all the information to help them to make a decision. They usually choose the most conservative option as well. Which I think is especially in today's healthcare kind of landscape that we're looking at. I think that's something we need to be aware of. That. You know. Like you say. Those people you phone up that say.

Lyndsay: Oh. No.

Amanda: I don't know why I'm on that waiting list. That's some work we're going to be doing in Grampion. We've just been awarded funding in Grampian and in Orkney to look at why people are unnecessarily put on waiting lists. Why are people added to these? What is that? Is that just in case? Is that just we need to feel like we're doing something. I'm just kind of plucking things out here, but we've got an external company who's going to come. They did the it's okay to ask a campaign for the National Campaign for NHS 24, so we're going to employ them to do the research in the first year around. What that's about, these unnecessary or inappropriate referrals, and to work out how we can give colleagues the skills, the confidence, the permission to be able to say no sometimes. That actually that procedure is not going to add value to you. And that speaks to all six principles, I think, of RM.

Lyndsay: You definitely think as well. When we put a survey round to health care workers in Highland and just said, what do they feel the roadblocks were? And a few people did come back with saying, well, you know, we don't want it to look like we're saying, no, you can't have a treatment, and then a bad guy, I come back. And I think that's where it's so important that as program managers, that we have almost like a book of communication. Yeah, absolutely. And that's something we're working on. Just to say no. The point of realistic medicine is not just to say no. That's it.

Amanda: No.

Lyndsay: It is to offer and have a conversation and explore all the options. Yes, it might take a little bit longer at an initial appointment, but I think in the bigger picture, when you look at a patient's pathway, it will give patients a better experience. They'll be more streamlined. There won't be, you know, being put on one waiting list, have a long, long wait to then say no and get put on another waiting list. It's not great for anybody, for the initial clinician putting it on or for the patient's experience as a whole. So I think that's one of the really important aspects of realistic medicine, to look at those.

Amanda: Absolutely. And, you know, just to go back on what you said there and about the first appointment might be longer, I've had that conversation with clinicians because that could be one of the potential barriers, perceived barriers as well, is that it will mean it will take longer. And yeah, I mean, it could, but like you just said, the experience will be different. And also there's the chance that future appointments either will be shorter or will be required because they have such a good discussion at that first appointment that a decision can be made or the option to do nothing, which is one of the brand options, is what's chosen. And it's okay. I think we need to get better. Speaking as a clinician, I've been comfortable with the option of nothing, because you're right, there is the whole thing. I need to be seen to be doing something or making this person better. But again, this might be coming from because I work in maternity services, which is different. I appreciate that, but that the option of doing nothing should be a valid option and should be spoken about the same way as any other option.

Lyndsay: Yeah, definitel...

Graham: Yeah. Thanks, Kate. And thanks for inviting me to take part in this. I'm a recently retired GP. I retired August last year, having spent most of my career as a GP in Montrose on the East Coast in Tayside. And I suppose I spent a lot of time in general practice with a big interest in people living with long term conditions. And for a few years in the latter half of my career, I was seconded to Scottish government as a clinical lead for self management and health literacy, kind of terms that are slightly confusing and people struggle to think what those might mean. But at the heart of it, it's really enabling and supporting people to be the sort of lead partner in their care, because we know that when people are the lead partners, when they're the active agent in their encounters with healthcare professionals, often health care outcomes are better, people make better decisions relevant to themselves when these sort of things happen. So there's a big political economy around supporting people to self manage, and a key ingredient to that is people being able to understand and engage in their own health and health care. And that's where some of health literacy comes in. And this is very important.

Kate: Grand yeah, because it's a term that we talk about a lot. And it became clear to me recently that not everyone fully understands what health literacy means and how they can improve health literacy. Can you kind of explain to us what it is from a clinician point of view and maybe from a patient's point of view?

Graham: Okay, that's interesting. I think there are sort of a few definitions of health literacy, and I just recently reading a paper, which was a whole paper discussed to sort of teasing out the various definitions of health literacy. It's really complex and I thought it would be disingenuous, but I think some of these are very good definitions. But I would argue that they suck. And I mean suck as a Mnemonic with S standing for skills, u standing for understanding, c for confidence, and K for knowledge. I think fundamentally, health literacy is about people having the skills, the understanding, the confidence and the knowledge to do what? To access and navigate the healthcare system, to be able to collaborate with their health care professionals, and I suppose, finally, to be able to self manage their own health and their health conditions in the way that they would want to necessarily force our treatment, some people. So that's sort of I think a light way of understanding that it's just remember the mnemonic suck skills, understanding, confidence and knowledge. There is a problem with these definitions because they often locate the problem with the person. So we might argue that people have insufficient skills and understanding, confidence and knowledge. And I suppose there's this great temptation to sort of really try and improve that, improve their skills and understanding and give them knowledge and things like that. And that's very important. But it's also a challenge for us to make healthcare much more easier to understand and more accessible and easier to engage with. I guess sort of in the evolution of the development of health prevention, health promotion, particularly in the old days where perhaps the biggest health problems were infectious diseases, communicable diseases, and health education was really important. So health literacy sort of was conflated a bit with health education. Now I think we're moving where people living with long term conditions. It's not really just the responsibility of public health teams. It really impacts us clinicians on how we engage with people and the onus for us to make healthcare much more understandable and engageable. The analogy, just a brief analogy that I've always used often tell this story, is 40 years ago, none of us had any computer literacy. We didn't really understand how computers work. And of course, IBM produced the first computer, which was this massive clunky thing which would have filled half your living room. And you would have had to have been an uber scientist or a geek to really want to be able to engage with one of these. And of course, what the computer industry could have done is they could have educated us all. They could have given us books and pamphlets to read about how to use these computers and how to code. They could have sent us off to evening classes. But in fact, what they did is they made computers a lot more engaging and simpler to use. And now, whether you're five or 85, using an iPad is so instinctive. I guess that analogy is how can we shift health and healthcare and the services we provide to be less like an old IBM computer and a bit more like an iPad, which people can engage with? So that's a useful analogy and hopefully that's sort of helpful overview of what health issues about.

Kate: Yeah, and when you say that, that resonates with me because the mnemonic that you talk about often as healthcare professionals, it's so easy to slip into Jargon and having the confidence and the knowledge on how to explain things in a way that people understand and within the confines of the time that we have to explain them can be incredibly challenging. I wrote all my letters to patients now, and it definitely takes practice and I'm sure I make mistakes in it.

Graham: I think that's a really good point. The thing about Jargon is these are terms that us healthcare professionals are so familiar with. We don't even know their jargon. We don't even know that the other person doesn't understand them. We do have to be very careful and it works some ways because sometimes if you try and oversimplify things for people and avoid jargon completely, some people feel at risk of being patronized. So I think perhaps the safest thing to do is it's okay to use jargon, but as long as you clarify that jargon, I'm just going to go and get my Glucometer. That's the little machine that I use to test your blood sugar and things like that. So use the words and then people pick these things up. And I guess in your case of point, if you are writing a letter, you can use the technical work but then put a bracket in as to explain that or have a little glossary at the end of something like that that explains these things.

Kate: Even translating terms between specialties can often be difficult because having an awareness that acronym in your world of anesthetics can mean something completely different in obstetrics. Yes, there can be a lot of confusion there, too.

Graham: I remember one little story, this is quite a case in point, actually, where people, when they go into hospital, acutely ill, and then they come out of hospital and they used to come and see me and I used to ask them, do you understand what happened to you in hospital? And it was surprising how many people didn't have a clue what happened, particularly of the sort of elderly. And I remember going to visit a nursing home and a little lady and the nursing home got a copy of the discharge letter and the diagnosis on it was non STEMI, which is a non St elevation myocardial infarction a heart attack. I went to see her with the carers and the nursing home and I said, how are you getting on after your heart attack? And none of them knew she had a heart attack. The patient didn't know that she'd been in with a heart attack and the care...