One of the unacknowledged ladders in medicine is the levels of effectiveness at which doctors may work.
As medical students and junior doctors, we are trying to establish our basic level of effectiveness, which is our ability to see, communicate with, diagnose, and treat an individual patient properly. Demonstrating this ability is the focus of medical finals and Royal College exams. So the first level at which a doctor must be effective is that of the individual doctor–patient consultation. Indeed if there are questions about our competence at this level then it is unlikely that we will gain respect at any of the higher levels from colleagues, patients, or managers.
But even at this basic level, to be effective the needs of the next level come into play. The next level is that of working effectively with local colleagues; for example, collaboration between GP partners, making appointment systems work for doctor and patients, referring patients at appropriate times, and getting information transfer and handovers right. It is at this level that many of the most intractable problems, both interpersonal and systemic, in medical practice emerge, and many of the stresses of medical practice happen.
Next is work at the area-wide level on overall patterns of activities and problems within the local healthcare system. It is at this level that public health doctors start their work. It is here where primary care trusts (PCTs) function, trying to make sense of what is happening at …