Only good for a cool box?

Are you a clinical academic feeling you’ve not quite managed to make the clinical academic equation work? Feeling a bit sad, guilty, inadequate? For sure it must be you not getting, since so many others seem to have cracked it?

Let me tell you now. It is not you. It’s not that you haven’t tried hard enough, or done the right things. It is. Not. Your. Fault.

I may have finally found a way to articulate some of my own feelings about the challenge that so many of us seems to experience. The challenge of making both the clinical and the academic systems to accept us, even to embrace us.

I don’t have the numbers, but my sense is there are an awful lot of us, exceptionally capable NMAHP clinical academics, that the (healthcare) system has rejected. We’ve tried, often for years, to take different forms in order to fit a mould (any mould, we are not fussy!). We’ve tried to push on all the possible doors. We’ve pushed gently and politely. We’ve pushed hard and forcefully. But even when the doors have opened they’ve only led to infinite rabbit holes with no other person and no meaningful activities in sight.

This is how I now think of it (apologies for the slightly reductionist analogy): think of organ transplantation. It requires strong organs. But it also requires a system that has been prepared to accept the organ, and begin to function with it. It’s no use just harvesting a lot of strong organs. The system needs to be prepared too.

Many systems, like the human body and healthcare, seek to sustain their existing structures and functions. They do that, in part, by ejecting things that are too foreign – different from what the system recognises based on its own make up. The systems kill off things that challenge the structures because they are perceived as threats to the system.

The academic training is about culturing the person to a new way of being (as much as it’s about growing knowledge and skills). As a result, we change. Our academic training, in a way, makes us seem like foreign cells to the system in which we are meant to operate. We become other than the norm. Good different. But different. Insufficiently similar. Seemingly incompatible. Increasingly appearing to be from outside the system.

This is present in everything. The way we always ask questions – it comes across as too challenging. The knowledge and evidence we are excited about, it’s too many steps on the side or ahead of practice. The analytical approach we have worked hard to master – too alien for practice. The academic networks, with the people from all sorts of strange sounding disciplines – unrecognisable when compared to the disciplines and job titles of the home system.

I think that, collectively, over the past 10 years, in England, we’ve become really good at spotting and growing strong NMAHP clinical academics. I think we now do this at scale (if you don’t believe me, check out the NIHR application numbers!!). However, I think that, too often, we grow clinical academics to, essentially, put them in the figurative organ cool box. For we have very few systems capable of working with these clinical academics.

Instead accepting us, and using us for the good of the system, the system rejects us. It might not be individual people. But the system. Nothing specific to point to. Yet, as a system, we just don’t seem to fit. There always seems to be something a miss. Always a barrier. Never quite the right fit.

What am saying is, I now believe the thing that can feel like our failure to make it work is, in my view, a tacit, system-generated effort to sustain the system as it is. It is, in fact, a side effect of… a histocompatibility of sorts! A side effect from usual functions of a self-preserving system.

So does this mean it’s all inevitable? Clinical academics are only ever good for the cool box?

No. For here’s the thing. A system isn’t born knowing what’s foreign and what’s not. This is learnt. It’s behaviour modelled from (selected) others. Norms adopted. And it can change.

I believe it needs opinion leaders within the system who are not clinical academics to play their part. To change organisations. Leaders who are valued within the system and who are not us. These leaders need to role model support for research. To promote open discussions about research, and show how working together can contribute to the wider efforts. Facilitate change in the system so that it doesn’t reject new organs but learns to benefit from them.

With hindsight, I now believe that we have, collectively, put way too much weight on an idea that if we place enough new, strong (and incompatible) organs in the system then ultimately the system will change. But this strategy is way too costly and wasteful of talent and humans. A sole organ cannot change a whole system but ends up destroyed. Work needs done with the system too, to help it adapt and accept the organ as a valuable part of its function and performance.

I wish I had realised, much much earlier, that continued survival of clinical academics within the system requires not just an excellent person but compatibility between them and the wider system. It requires local leaders’ everday commitment to, and demonstration of, action for system adaptation and collective growth.

So what’s one to do if the local, everyday support is not forth coming?

One of the best pieces of advice a national funder ever gave me was: not to continue to beg for crumbs but take my talent elsewhere. Invest your assets (time, intellect, effort) in organisations that progress goals aligned with yours. This is better for the individual, but it’s also better for the system – as it rewards the parts of the system that are willing to adapt and grow.