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John Wattis • Stephen Curran • Elizabeth Cotton

Practical
Management
and Leadership
for Doctors
SECOND EDITION
Practical Management and
Leadership for Doctors
Practical Management and
Leadership for Doctors
Second Edition

John Wattis
School of Human and Health Science
University of Huddersfield
Huddersfield, England
Stephen Curran
School of Human and Health Sciences
University of Huddersfield
Huddersfield, England
and
Consultant in Old Age Psychiatry
South West Yorkshire Partnership NHS Foundation Trust
Wakefield, England
Elizabeth Cotton
Middlesex University Business School
Hendon, England
and
Founding Director of Surviving Work
www.survivingwork.org
CRC Press
Taylor & Francis Group
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Contents

Foreword from first edition ix

Foreword for the second edition xi
Preface xiii
Authors xv

1 Introduction 1
Developing management and leadership skills 1
Core competences of managers and leaders 4
Starting in a new situation 7
Conclusions 16
References 16
2 Maintaining productive key relationships 17
Understanding our interactions with colleagues 17
Relationships in the multidisciplinary team 19
Relationships with doctors 21
Supervisory and educational relationships 22
Relationships with medical ‘peers’ 25
Relationships between doctors in management and other doctors 26
Appraisal and job planning 28
Managing performance 30
Relationships with managers 31
Relationships with people who use our services (and their
caregivers/families) 32
Relationships, relationships, relationships 34
References 34
Further reading and useful resources 35
3 Understanding your organisation 37
Understanding your organisation in context 37
Governance and management issues in the English NHS 39
Metaphors as a framework for understanding 40
Organisational culture 41
Organisation as flux and transformation 46
vi Contents

Practical applications 48
Culture is related to outcome 49
References 50
Further reading 50
4 Personal vision, values and goals: Alignment with the organisation 51
What’s important to you? Developing your ‘vision’ 51
What’s important to you? Checking your values 54
Making decisions 56
Difficult choices – when personal and organisational values clash 59
Influencing and persuading 60
Conclusions 63
References 63
Further reading 64
5 People skills 65
Communication 65
Communication is essentially two-way (or multilateral) 66
What is said must match what is done 66
Tackling toxic workplace dynamics 67
The form of communication must suit the situation 69
The special case of email (and other forms of e-communication,
including text messaging) 70
Negotiating 71
Cooperative working: Complexity demands co-operation 74
Iteration: Mutual understanding, interest and engagement 75
Developing others 76
Courses 77
Learning sets and management clubs 77
Coaching and mentoring 78
Reducing and managing stress 81
Time management 82
Balanced lifestyle 83
Appropriate emotional detachment 83
References 84
6 Organisation skills 85
Introduction 85
Managing and leading meetings 85
Raising concerns and duty of care 90
Managing conflict 93
Strategic thinking 95
Overall strategy 96
Product development strategy 99
Marketing strategy 100
Staffing strategy 103
Quality and effectiveness 103
Financial strategy 103
Risk-management strategy 103
 Contents vii

Business planning 104

Financial control 105
References 106
7 Maintaining and improving quality 107
Evidence-based practice and health outcomes 108
Relationships and quality 109
Service quality 109
Management quality 110
Timeliness and convenience 111
Evidence-based policy 111
Risk reduction and management 113
Governance 115
Competent and capable workforce 115
Safe environment 115
Clinical care 116
Using checklists to improve quality 116
Learning from experience 117
Healing wounds 118
References 118
8 Innovation 121
Introduction 121
Entrepreneurship 122
What motivates creativity? 123
Types of innovation 123
The process of innovation 124
Enabling creativity 131
Learning creativity 133
Not all innovation works 134
Managing innovation and change 134
Teamwork versus ‘command and control’ for innovation and quality 138
Conclusions 138
References 138
Further reading 139
9 When the going gets tough 141
The consequences of working in the current climate 141
Resilience and well-being 142
Relationality is key 146
Mental health first aid 147
Superheroes and super-egos 148
Protecting yourself at work 150
References 154
Further reading 154
10 Continuing development in leadership and management 155
Background 155
Changes in medical education 155
Identifying your training needs 156
viii Contents

Obstacles to accessing education and training 158

Types of education and training available 159
Leadership and development over time 162
Conclusions 163
References 164
11 Balance 165
Your most important asset is yourself 165
Understanding your needs 165
The work environment 171
Taking the longer view 173
Lessons from Toyota 173
Keeping fresh for the long term 174
Wisdom 175
References 176
Further reading 177

Index 179
Foreword from first edition

Medical leadership means different things to different people in different con-

texts. Leaders exist because they have people following them who are able to see
the vision and the courage that leaders bring with them. Sir John Tooke in his
admirable report following the Medical Training Application Service (MTAS)
debacle in England highlighted that one of the reasons for the crisis was a lack
of medical leadership. Lord Darzi, the then health minister, also saw this as an
important issue.
Are leaders born or made? How is leadership different from management?
Who leads and why? What is management? What is administration? In second-
ary care settings the role of medical managers is crucial in setting the agendas
for service planning, quality improvement and service delivery, ensuring that
services remain patient-focused and patients and their families are satisfied with
the services they receive. Leaders do the right thing in spite of challenges and
they have the vision, courage and passion along with a style of communication
that allows them to take people with them. Managers do things right, but the
agenda may not be set by them. Medical leadership brings with it responsibility of
improving clinical services, education, research and training. Medical leadership
has many facets and ski1ls.
This practical book is full of nuggets of wisdom of practical advice and theo-
retical underpinnings. I am sure medical professionals will find this of immense
value and use in their day-to-day activities.

Dinesh Bhugra
Royal College of Psychiatrists

ix
Foreword for the second
edition

As doctors we are increasingly asked to take on leadership roles. Leadership is a

skill most doctors possess – after all we lead in the hardest of all areas, the consult-
ing room. As a general practitioner, there is nothing I have done in any leadership
position that compares to my morning surgery. Working out which of the 30 or
so patient encounters every day require further investigation, specialist input or
active follow-up requires all the skills mentioned in Practical Management and
Leadership for Doctors. We have to be decisive, organised, skilled communicators
and deliver high-quality care – all in 10 minutes.
This is, of course, not to undermine the challenges of leading outside the con-
sulting room and today many doctors do take on extended roles in a number
of different settings. In fact, as the book points out, almost all senior doctors
should be involved in management and leadership in some guise or other, if only
to stop bad decisions being made and to influence the system to make it better for
patients (Chapter 4). For those who enjoy leadership, the sky is the limit. During
my career, I have held a number of national leadership positions, most notably
as Chair of the Royal College of General Practitioners (2010–2013). Leading,
whether in or out of the consulting room, is really about managing people, deal-
ing with their expectations and fundamentally understanding that you get the
most out of the teams or people you lead by modelling the behaviour you expect
from them. I have written in the past about the leadership styles that you see in
the current National Health Service (NHS) often exemplified by men – leading
as if to battle, playing the ‘heroic leader’. This contrasts with what I feel is most
required, and the style I hope I have used most in my career – that is the ‘Peloton
Style’, or dispersive leadership, whereby the workload of leadership is constantly
being shared.
Whatever style one uses (and in fact, the most likely style is a mix depend-
ing on the needs of the day or organisational issue), Practical Management and
Leadership for Doctors is a helpful guide. There must be thousands if not tens
of thousands of books on leadership, yet this little tome stands out amongst the
many aimed at doctors. Firstly, it is written for doctors, by those who understand

xi
xii Foreword for the second edition

how doctors think and work. Secondly, it is a useful tool for the busy, jobbing
doctor to have to hand, with bite-size chapters, easily accessible help, case studies
and summaries at the end of each chapter. Finally, the book is relevant to so many
aspects of our working lives: It provides important and timely information on
areas which we face every day such as managing change, running meetings and
communicating effectively with staff; it talks to us about the pitfalls as well the
joys of leading and how leadership is about engaging others; if we want people to
listen to us, we must listen to them (Chapter 5, People skills).
The amount of jargon in the book is kept to a minimum and the references
at the end of each chapter call us, if we want, to explore particular areas in more
detail. The book draws on the work of the late Steven Covey and his 7 Habits of
Highly Effective People, and the two books should form part of most doctors’ per-
sonal library on leadership. Perhaps my personal favourite is the final chapter, on
Balance. For the last decade, I have been the doctor’s doctor, seeing and treating
doctors with mental health and/or addiction problems as part of the Practitioner
Health Programme. Initially for doctors in the London area only, the service has
since January 2017 been expanded across England to be available for all general
practitioners.
Over the years, I have seen thousands of doctors with burnout, depression,
anxiety – symptoms indistinguishable from post-traumatic stress disorder – as
well as small numbers suffering from bipolar disorder and alcohol or drug addic-
tion. Doctors go through the same difficulties as non-medical individuals (after
all, we are not immune to loss, sickness, marital issues or other such traumatic
life events). However, the biggest single cause of the mental illness amongst the
doctors I see is their work, and in particular the demands placed on them through
working in the modern, busy and demanding NHS. Doctors are trained to work
hard and when the going gets tough, their natural inclination is to blame them-
selves and work harder. Practical Management tells us that ‘your most important
asset is yourself’ and how it is all too common for people to succeed in their careers
at the expense of a wrecked personal life. The authors warn us from suffering
from ‘superman or superwoman’ syndrome and not to neglect our own humanity
and health needs. Whilst we might need to give to others, we also should receive
from them, maintaining ‘the emotional credit line with our partners and others’
described by Covey. The authors give us a simple exercise to perform, called the
‘Self Factor’. This helps us identify our own needs – be they physical, psychologi-
cal, creative or even spiritual – and how to use this information to prevent burnout
and remain healthy in the workplace. I use a similar exercise amongst the doctors
I see and it is helpful for this book on leadership to acknowledge the human limits
of all leaders and not, as many books on leadership appear to do, perpetuate this
myth of a super-person able to function always, anywhere and anyhow.
This book is light in weight, and heavy on common sense. It should form part
of the doctor’s armoury. Even those who do not see themselves as good leaders
are often humble enough to be unaware of their potential leadership qualities.
I learnt from reading the book, and I am sure the reader will as well.

Clare Gerada
Preface

In the years that have elapsed since the first edition of this book, we have seen
profound changes in healthcare and particularly in the National Health Service
(NHS). Our choice of Gareth Morgan’s metaphor of organisation as flux and
transformation as one of the key concepts in Chapter 3 on understanding your
organisation appears particularly prescient. At the core of the first edition was the
importance of relationships to effective leadership and management, and that has
not changed. However, there have been major changes in this edition throughout
with the introduction of three new chapters. One of these focuses on innova-
tion and change and examines how this can be led and managed using several
practical examples. Another, also particularly apposite to the state of healthcare
in many countries, and especially in the NHS, explores what to do as a leader
and manager when the going gets tough. Finally, we have added a whole chapter
on continuing professional development in management and leadership for doc-
tors. It seems strange to realise that the joint Faculty of Medical Leadership and
Management was only emerging as the first edition of this book was produced
but now (alongside many other providers) has such an excellent range of educa-
tional and support programmes available.
We have also added another author to our team, Dr Elizabeth Cotton, who
brings a particular interest in the stresses of working in healthcare settings as
well as greater familiarity with primary care than the two original authors. We
remain grateful to the panel of doctors – Professor Wendy Burn (now President
of the Royal College of Psychiatrists) and Drs Suresh Chari, Kate Kucharska-
Pietura, Ken McDonald and Jayanthi Devi Subramani – who read the drafts of
the first edition, for their helpful comments and suggestions. To their number
we now add Drs Aamer Sajjad and Gwenan Sykes, who have performed a similar
service for the second edition. Whilst we are grateful to them, the responsibility
for opinions expressed and any errors remains with the authors.

xiii
xiv Preface

As before, as a practical book this edition is grounded in the experience of the

authors in the English NHS, but we have designed the structure, examples, exer-
cises and approach of the text in a way that we believe will find wide applicability.
We have used illustrations from several different national contexts, particularly
in the chapter on innovation and change. We believe this second edition updates
and adds to the usefulness of the first.

John Wattis
Stephen Curran
Elizabeth Cotton
Authors

John Wattis is a Professor of Old Age Psychiatry, University of Huddersfield (UK).

John was full-time Medical Director for Leeds Community and Mental Health
NHS Trust from 1995 to 1999. He also held senior offices within the Faculty for
Old Age Psychiatry of the Royal College of Psychiatrists. He has been research and
development director for several National Health Service (NHS) trusts. Before his
retirement from his consultant post in the NHS, he trained as a business and life
coach. Since then he has continued in his visiting university post, lecturing various
student groups and supporting research. He has taught basic and advanced coach-
ing skills to psychiatrists through the Royal College of Psychiatrists Education and
Training Centre and coached several NHS, university and voluntary sector staff,
mostly in senior management positions. He has also acted for several years as part-
time medical director (mental health) to two primary care trusts and continues to
give medical management support on an ad hoc basis to these trusts.

Stephen Curran is a Professor of Old Age Psychiatry, University of Huddersfield

(UK) and Consultant in Old Age Psychiatry, South West Yorkshire Partnership
NHS Foundation Trust, Wakefield. Stephen trained in Leeds and worked as
Lecturer in Old Age Psychiatry at the University of Leeds until he took up his
current post as Consultant in Old Age Psychiatry in Wakefield in 1998. His pri-
mary clinical role is focused on acute in-patient service for older people, and
he is also Lead Clinician for the Wakefield Memory Service. Since his appoint-
ment, Stephen has had several medical management roles including Programme
Director, Head of Service and Clinical Lead. Since October 2017, he has been
the Associate Medical Director for Postgraduate Medical Education. Stephen has
contributed to significant changes in the organisation including service develop-
ment and changes to the medical management arrangements. He also has con-
siderable practical experience of dealing with the many management issues that
arise in a busy old age psychiatry service including job planning, appraisal, qual-
ity improvements, change management and dealing with complaints, conflicts
and the pressures caused by limited resources.

xv
xvi Authors

Elizabeth Cotton is a writer and educator working in the field of mental health at
work. Her background is in workers’ education and international development.
She has worked in over 35 countries on diverse issues such as HIV/AIDS, organis-
ing and building grassroots networks, negotiating and bargaining with employers
as head of education for Industrial, one of the largest trade unions in the world,
reflected in her 2011 book, Global Unions, Global Business (Libri Publishers). She
teaches and writes academically at Middlesex University about employment rela-
tions and precarious work. She is Editor-in-Chief of a UK Association of Business
Schools journal, Work, Employment and Society, looking at the sociology of work.
She blogs as www.survivingwork.org to a network of 30,000 people. In 2017, she
published the largest national survey about working conditions in mental health,
www.thefutureoftherapy.org. She set up www.survivingworkinhealth.org as a
free resource in partnership with the Tavistock and Portman NHS Foundation
Trust. Her current book, Surviving Work in Healthcare: Helpful stuff for people
on the frontline (Gower, 2017), was nominated for the Chartered Management
Institute’s practitioner book of the year.
 1
Introduction

DEVELOPING MANAGEMENT AND LEADERSHIP SKILLS

This book aims to be a practical introduction to the topic of medical manage-
ment. Our purpose in writing this is to provide an easy-to-use guide for doc-
tors in any kind of management role, including those preparing for their first
consultant or general practice principal post. We also want to help those moving
into more senior medical management posts to take stock and apply their knowl-
edge and skills in a new setting. Our approach is rooted in our experience in
various clinical, academic and management posts in the National Health Service
(NHS) and universities. However, in view of the constant change in this and
other health systems, we have sought to keep the text open to wide application.
We have also been selective in our reference to the ever-developing management
literature, aiming for approaches that we know from experience work in practice.
Because this is a practical guide, we have included examples and exercises to sup-
port readers in applying the knowledge and skills covered to their own situation.
Hopefully readers will not only increase their competence as managers, they will
also increase their enjoyment.

Understanding the differences between administration,

management and leadership
The distinction between administration, management and leadership is a vital
starting point (Box 1.1). Confusion between them leads to wasted time and even
to conflict.
Good administration is doing routine tasks well. A bureaucratic approach
works well here (see the section on management cultures and cultural appropri-
ateness in Chapter 3). Management involves making things happen even when

1
2 Introduction

BOX 1.1: The distinction between administration,

management and leadership

Administration: Doing routine tasks well

Management: Making things happen (often complex things in complex
environments)
Leadership: Developing shared vision and direction towards a common
goal or purpose and getting the best out of people in serving that
purpose

the environment is not simple and the tasks themselves may be complicated. It
requires attention to detail and often involves teamwork. Leadership means help-
ing a group or organisation to find its direction and drawing the best out of people
to serve a common purpose. Leadership motivates teams to work well.
Good administration is essential, but nobody should employ an expensive
doctor to do simple, straightforward administrative tasks. On occasion, we
still hear of doctors doing their own typing or filing for lack of adequate secre-
tarial support. There is no problem in this for those doctors who have excellent
keyboard skills and are supported by effective software and computer systems.
However, too often doctors who do not have these skills are expected to act
as typists when this is not a ‘core skill’. Lack of adequate computer systems,
software and support result in the wastage of many hours of expensive medical
time. This can mean doctors working unpaid overtime and/or employers wast-
ing medical competences and using doctors inefficiently. In addition, clinical
records are now predominantly electronic and system failures can create signifi-
cant clinical risks.
Modern medical practice is largely delivered by teamwork and so any con-
sultant or principal in general practice will need at least a basic level of compe-
tency in management and leadership skills. Many newly appointed consultants
and principals in general practice feel they have not acquired this basic level of
competency through their training, which has understandably been focused on
producing competent clinicians.
Those aspiring to more senior management roles as Clinical Directors,
Medical Directors, Associate Medical Directors and to managerial roles in medi-
cal education will require much more than basic competency. Until recently, the
development of higher levels of competency in these areas has been on an ad hoc
basis although, historically, the British Association of Medical Managers devel-
oped its own ‘Fit to Lead’ programme with associated standards and compe-
tences. These covered the following areas:
 Developing management and leadership skills 3

● Communication
● Developing people
● Developing the business
● Developing self
● The wider contexts
● Quality

The Faculty of Medical Leadership and Management (FMLM) courses and pro-
grammes cover similar topics (https://www.fmlm.ac.uk). These competences are
also covered in this book. The role of the FMLM in training and development is
discussed in Chapter 10.
Doctors in senior management positions (such as Medical Directors), most of
whom choose to continue in clinical practice, have the unenviable task of keep-
ing up to date in both management and in their chosen area of clinical practice.
Generally, continued involvement in clinical work by doctors in senior manage-
ment roles helps them to keep in touch and be seen to keep in touch with clinical
reality (see Chapter 5). There is enormous value in senior practising clinicians
being involved in management, medical education and professional leadership.
In senior medical management positions, the art is to design any involvement in
clinical work, with the help of colleagues, in such a way that it is circumscribed
so that interference in either direction between different roles is minimised.
‘Protected time’ for both clinical and management roles is vital and should be
recognised as such by employers.
Leadership and management can be distinguished, but the relationship
between them in successful organisations is close. Leadership defines direction,
enables, empowers and even inspires, but without management competency,
it does not deliver. The words we use to define management roles for doctors in
the NHS demonstrate the complex interactions between ‘direction’, leadership
and management:
● Medical Director (usually an executive director post)
● Associate Medical Director
● Clinical Director (often providing a lead and supported by a manager)
● Clinical Lead (not the same as clinical director or clinical leader)
● Team Leader (sometimes the team ‘manager’ rather than the leader)
Virtually all medical managers need also to be good leaders. But they have to
work within a context of direction set by their organisation, and that can some-
times cause conflict.
Clarity about roles and what titles mean is important. If a service has a
clinical lead and a non-medical manager, who defines the direction? (See
Box 1.2.)
4 Introduction

BOX 1.2: Conflict between management and leadership

due to lack of clarity
A new specialist service is set up. A service manager is appointed, but the job
description contains no reference to the relationship with the ‘Clinical Lead’.
The doctor appointed to Clinical Lead is unsure of his or her relationship
to the manager. Normally, leadership sets the direction and management
achieves the desired outcomes. Here it is different. The manager is heavily
‘performance managed’ (from earlier) according to national and locally
determined ‘targets’. So what is the role of the Clinical Lead? At one extreme,
it could simply be to ‘advise’ the manager about clinical issues (so why not
‘Clinical Advisor’?) or to ‘lead’ the clinical aspects of the service along a
direction determined by others; at the other, it could be to innovate and
inspire and give direction to the manager and the team. This can only be
resolved by careful negotiation and explicit agreement between the manager
and the Clinical Lead. This will need to involve more senior management and
take into account the views of other members of the team. Failure to resolve
this and to define the roles will lead to conflict and inefficiency.

EXERCISE 1.1
Different components of your job
Using three columns, make a list of the administrative, management and
leadership components of your (‘management’) job. Eliminate any tasks
in the administrative column (as far as possible) by delegation to others
(secretary, management assistant, personnel officer and so on) and/or by
using alternatives to traditional administrative support such as digital
dictation. If you have nobody appropriate to delegate to, ask how and
when such support can be developed and make it a priority. Now look at
the largely leadership and management tasks that remain and put them
into priority order. Decide how and when you will make time for the pri-
ority tasks. The rationale for this can be seen in Stephen Covey’s bestsell-
ing management book, The 7 Habits of Highly Effective People [1].

This task has elements of the first three habits: being proactive, beginning with
the end in mind and putting first things first.

CORE COMPETENCES OF MANAGERS AND LEADERS

Table 1.1 gives a list of some of the skills or competences that medical managers
and leaders need (a couple of rows are blank for you to add your own ideas). This
is not to suggest that the two roles are completely separate or that leaders do not
need management skills and vice versa but to give a general idea of the different
priorities of the two roles.
 Core competences of managers and leaders 5

Table 1.1 Some competences of managers and leaders

Management Leadership
Negotiation Setting direction
Change management Enabling
Supervision Empowering
Conflict resolution Involving
Delegation Inspiring
Communicating information Listening
Giving feedback Influencing
Dealing with crises Avoiding crises
Performance management Leading by example

The trainee in medicine will have experience in a number of these skills. What
doctor, in a modern health service, has not had to negotiate with patients and carers
over treatment plans or with colleagues over on-call or leave arrangements? We have
all seen change managed (almost constantly in the modern NHS, and not always
well). All doctors in training should have had clinical and educational supervi-
sion. They will almost certainly have been involved in conflict resolution and crisis
management and will have been the object of much delegation! They may not have
had so much experience in setting direction; however, if they have been lucky in
their training experience, they will have been supervised by consultants who were
enabling, empowering, involving and even inspiring. Inevitably they will have been
influenced by the examples (though not always good) of those with whom they have
trained.
Many new consultants will feel that they have not had enough systematic
teaching or practical experience in these areas, though this, like the support for
those taking more senior management roles, is improving.

EXERCISE 1.2
Leadership and management competences
In two columns (one for management and one for leadership), make a list
of the competences you believe you require for management and leader-
ship in your current role. Rate yourself on a scale of 1 (poor) to 5 (excellent)
in each competency. If you have trusted colleagues, you may wish to ask
one or more of them to rate you too, to get different perspectives. Consider
how you can make the most of the areas you are rated highly on and deter-
mine how important it is to improve any other areas. If it is important,
make a time-limited plan to do something about these areas.

Achievement demands synergy between leadership and management. Staff work-

ing in the NHS often complain that ‘paperwork and form filling’ gets in the way
of delivering good patient care. The following documented example illustrates
6 Introduction

that this frustration is a longstanding issue and not only confined to the health-
care sector. The Duke of Wellington was a great military leader, but historians
attribute some of his success to attention to detail in managing the logistics of
his military operations. Inspired decisions on the battlefield were supported by
months of careful preparation, despite the administrative tasks imposed by the
central bureaucracy against which he sometimes rebelled (Box 1.3).

BOX 1.3: Duke of Wellington’s dispatch to Whitehall

(displayed at Mirehouse, the country home of one
of his descendants in Cumbria)

August 1812
Gentlemen,

Whilst marching from Portugal to a position that commands the

approach to Madrid and the French forces, my officers have been
diligently complying with your requests, which have been sent by
H. M. ship from London to Lisbon and thence by dispatch rider to our
headquarters.
We have enumerated our saddles, bridles, tents and tent poles, and
all manner of sundry items for which His Majesty’s Government, holds me
accountable. I have dispatched reports on the character, wit and spleen of
every officer. Each item and every farthing has been accounted for, with
two regrettable exceptions for which I beg your indulgence.
Unfortunately, the sum of one shilling and ninepence remains unac-
counted for in one infantry battalion’s petty cash and there has been
hideous confusion as to the number of jars of raspberry jam issued to one
cavalry regiment during a sandstorm in western Spain. This reprehensible
carelessness may be related to the pressure of circumstances, since we
are at war with France, a fact which may come as a bit of a surprise to you
gentlemen in Whitehall.
This brings me to my present purpose, which is to request elucidation
of my instructions from His Majesty’s Government so that I may better
understand why I am dragging an army over these barren plains. I con-
strue that perforce it must be one of two alternative duties, as given in the
following. I shall pursue either one with my best ability, but I cannot do
both.

1. To train an army of uniformed British clerks in Spain for the benefit of

the accountants and copy-boys in London, or, perchance.
2. To see to it that the forces of Napoleon are driven out of Spain.

Your most obedient servant,

Wellington.
 Starting in a new situation 7

STARTING IN A NEW SITUATION

In any new situation, whether on first appointment as a consultant, a principal
in general practice, or as a medical manager of whatever grade, it is essential
to start well. Handling the transition to a role with increased responsibilities is
never easy, and it is always useful to make time to reflect on developing roles
and responsibilities, preferably with the help of a mentor, coach or other level-
headed person. Even if you have been in your current situation for some time, it
makes sense to reappraise the situation and to make a fresh start from time to
time. Often this needs to be done after at least a few months spent exploring the
demands and limits of the role. The areas to be appraised to achieve this fresh
start can be summed up in the ‘three Rs’, as follows:

● Roles
● Relationships
● Responsibilities

Roles
One of the strengths of how medicine is organised is that management jobs often
involve continuing clinical practice (and sometimes academic and/or training
roles as well). It is useful to make an inventory of key roles. See Table 1.2 for an
example of key roles for a newly appointed Medical Director. Clarity about the
key roles as they develop helps to ensure that no one area is neglected or sacrificed
accidentally. It also enables a continuing review of both the roles and the prior-
ity to be given to them. One of the authors has even, from time to time, colour-
shaded his weekly programme according to the different roles over a period of a
week to get a clearer idea of which roles were taking the time! Be aware, if you do
this, that one of the things you may find is that roles (especially administrative
roles) that are not properly your own can be stealing time and that delegation is
called for.
Organisations that are run by ‘Boards’, like NHS Trusts, have a mixture of
Executive Directors in roles such as Chief Executive, Medical Director, Finance
Director, Human Resources Director and Director of Quality supported by Non-
Executive Directors chosen for their expertise in areas like accountancy, business
management, local politics and so on. One of the Non-Executives acts as Chair of
the Board and, collectively, they are responsible for providing a degree of outside
scrutiny, support and common sense to guide the Executive Directors in their
work and the Board in its decision-making. Once decisions are made, the Board
is expected to stand behind them.
Figure 1.1 gives an example of how a ‘balance wheel’ can be used to look at
the different roles, for example, of a newly appointed Medical Director and how
well they are being fulfilled. In this kind of a plot, the subject makes a judgement
about how well she or he is fulfilling each role on a scale of 0 (centre of circle) to
10 (periphery). Some people join the dots and make the point that if you end up
with an odd shaped figure you are in for a ‘bumpy ride’!
8 Introduction

Table 1.2 Key roles for a newly appointed Medical Director

Role Remarks
Medical advice and This will involve good communication with relevant
leadership to Board medical colleagues and fair evaluation of
sometimes competing priorities. It will also
involve good relationships with other Directors
and a recognition of what they contribute.
Medical standards Here the relationship with the Director of Human
(including role as Resources, other human resources staff, the
Responsible Officer local representatives of the BMA and the
[RO] for GMC doctor’s own defence union as well as the GMC
revalidation), for issues of revalidation are likely to be helpful.
employment and
disciplinary matters
Leader of team of Mutual respect between members of the medical
doctors management team and senior colleagues is
vital.
Continuing clinical work For more junior management posts, clinical
workload may only require minor adjustment;
for the most-senior posts, it may have to be
severely limited. In either case, smooth
organisation and the co-operation of colleagues
are essential.
Wider responsibilities Some medical managers will also have roles within
professional organisations of clinicians or of
managers or be involved in wider health service
or related work.
Other roles At this stage, it does no harm to remind oneself of
the wider roles within work (eg teacher,
researcher) and outside of work (eg parent,
partner, participator in recreational activities).

In this example there are eight radii, but there can be as many or as few
as the situation demands. The labels applied to each radius here are roughly
the same as in Table 1.2, but note that the issues of medical employment and
standards (including Responsible Officer [RO] role) have been separated out
in the table.
This tool can lead to a reappraisal of priorities. For example, the balance
wheel above leads to an understanding that the issue of medical advice to the
Board needs urgent action. Recruitment and retention of senior medical staff and
leading the team of medical managers also appear to be priorities. Review of all
the information in the balance wheel might lead to an action plan such as that
outlined in Table 1.3.
 Starting in a new situation 9

Medical advice to board

Maintaining standards of
medical practice,
Partner
including RO function

Recruiting/retaining
Parent senior medical staff

Educational Leading team of medical managers

supervisor
Clinical work

Figure 1.1 ‘Balance wheel’ for the role of Medical Director.

Table 1.3 Illustrative action plan that might arise from considering the issues
highlighted by the ‘balance wheel’ of Figure 1.1

Role Action Timing

Medical advice to Board Discuss with Chief Today
Executive.
Recruiting/retaining Discuss with Associate Next week
senior medical staff Medical Directors.
Maintaining standards Discuss (and if Before ‘away day’ below
of medical practice necessary, develop)
(including RO role) policies with other
relevant Directors.
Find out more about
the RO role in
revalidation.
Leading team of Plan for ‘away day’ to Plan now for next
medical managers develop shared month
vision and values.
Clinical work No action.
Educational supervisor Explore support to This week
trainee from another
appropriate
consultant.
Parent Get home on time. Tonight
Partner Don’t neglect. Always
10 Introduction

EXERCISE 1.3
List your key roles
Make your own list of key roles. Reflect on how important each is to
you personally and to the organisation you work for. On a scale of 1 to
10, make a judgement on how well you fulfil each of these roles (you
can make a table (see Table 1.2) and/or use a balance wheel (Figure 1.1).
Consider how you could improve your scores where necessary. This might
mean reallocating time, delegating some less important tasks to others,
working to get more support in a particular role or any other action for
which you can take responsibility. Plan definite actions and give them
timescales. Resolve to make at least one change in the week ahead and
others incrementally, ideally allocating dates to start and complete each.

Relationships
Each of the earlier roles involves key relationships. Modern medicine is a team
effort and good relationships are the foundation for effective clinical and man-
agerial teams. Many failures in health and social services are blamed on poor
communication; however, as the management writer Stephen Covey points out
[1], good communication depends on trust and trust, in turn, is based on our
assessment of the other person’s ‘character and competence’. This can be briefly
expressed as a management ‘equation’:

Communication ∼ trust = character × competence

Starting in a new job, one needs to make a list (or ‘mind map’) of key relation-
ships. These relationships will generally relate to the roles considered earlier. For
example, in making sure adequate attention is paid to medical opinion on the
board in the previous example, the Chief Executive is a key relationship. Other
Directors with clinical responsibilities are also likely to be important in this con-
text. In issues of medical staffing and discipline, the Personnel Director and any
medical personnel specialist are likely to figure and so on.
What makes effective relationships at work? Here is a list that you may wish to
expand:

● Mutual respect
● Shared vision (and mission)
● Shared values
 Starting in a new situation 11

● Clear definitions of roles and responsibilities

● Flexibility (within limits)
● Integrity

Mutual respect is a vital starting point, but how often do we hear doctors ‘slag-
ging off ’ managers or vice versa? Barack Obama, in his autobiographical trea-
tise on reshaping American politics, The Audacity of Hope [2], stressed the
importance of respecting the views of others even when we don’t agree with
them. This is especially important in the current UK context. People have very
different views about a wide range of topics including Brexit, religion, immi-
gration, privatisation of public services and political parties, and these diverse
and often split political and ethical positions will also be reflected in the peo-
ple we work with. As a foundation for effective team working, it’s essential to
acknowledge, accept and respect this diversity. This requires a degree of empa-
thy, of willingness to see and acknowledge the other person’s point of view. It
requires spending time finding out about their values, their understanding of
what motivates people and their vision for how services should run and be
developed. It emphatically does not involve the lazy prejudice of always imput-
ing the worst motives to others. We all need to understand and respect each
other’s positions. That is the starting point of good relationships.
Within the work context, shared vision is also crucial. This does not come
naturally and requires hard work. It applies at all levels. The clinical team needs
shared vision. The different elements of a service require shared vision. The dif-
ferent parts of an organisation need shared vision. At Board level this vision
needs to be a guiding principle that is genuinely shared not only by board mem-
bers but by all managers, clinicians and other employees. Everyone in the organ-
isation should be able to articulate what the organisation is there for (mission),
where it is heading (vision) and how it intends to get there (values). Lack of such
shared understanding leads to inefficiency and disruption within any organisa-
tion as different factions pull in different directions. When an organisation is
new, shared vision can be developed by a process that involves all staff and also
takes fully into account the ideas of service users.
In practice, a strong vision for future direction often comes from a Chief
Executive or senior manager. But, however charismatic the manager, it is essen-
tial to listen to other people’s points of view and to ensure, as far as possible,
that all staff feel genuine ‘ownership’ of the vision. A doctor newly appointed to
a management position needs to find out what senior managers think about the
purpose and direction of the organisation. He or she may even need to help oth-
ers to become clear about this.
If mission is what we as an organisation are there for and vision is about the
direction we are heading in, values are about how we get there. What standards
of behaviour are expected of us? Values can be expressed in an ethical code. The
General Medical Council’s (GMC’s) statement on ‘Duties of a Doctor’ [3] (Box 1.4)
is at once an expression of standards and of their underpinning values.
12 Introduction

BOX 1.4: Duties of a doctor

Patients must be able to trust doctors with their lives and health. To justify
that trust, you must show respect for human life and you must do the
following:
● Make the care of your patient your first concern.
● Protect and promote the health of patients and the public.
● Provide a good standard of practice and care.
● Keep your professional knowledge and skills up to date.
● Recognise and work within the limits of your competence.
● Work with colleagues in the ways that best serve patients’ interests.
● Treat patients as individuals and respect their dignity.
● Treat patients politely and considerately.
● Respect patients’ right to confidentiality.
● Work in partnership with patients.
● Listen to patients and respond to their concerns and preferences.
● Give patients the information they want or need in a way they can
understand.
● Respect patients’ right to reach decisions with you about their
treatment and care.
● Support patients in caring for themselves to improve and maintain their
health.
● Be honest and open and act with integrity.
● Act without delay if you have good reason to believe that you or a
colleague may be putting patients at risk.
● Never discriminate unfairly against patients or colleagues.
● Never abuse your patients’ trust in you or the public’s trust in the
profession.
You are personally accountable for your professional practice and must
always be prepared to justify your decisions and actions.
Source: General Medical Council, Good medical practice, https://www.gmc-uk.org/
ethical-guidance/ethical-guidance-for-doctors/good-medical-practice, 2013.

Though the GMC publishes more detailed guidance on management and lead-
ership for doctors [4], this general ethical statement, with minor additions, serves
as a statement of values for doctors involved in management. Some of the key duties
of a doctor in the workplace are summarised in Box 1.5. It is worth emphasising
that the delivery of good quality patient care can only be done if we respect each
other as clinicians and work to build teams that can communicate effectively, even
when there are disagreements.
Another random document with
no related content on Scribd:
 V

Le 29 août [1841, à Paris]. [46] — Vous voulez que j’écrive mes

impressions, que je revienne à l’habitude de retracer mes journées :
pensée tardive, mon ami, et néanmoins écoutée. Le voilà ce
mémorandum désiré, ce de moi à vous dans le monde, comme vous
l’avez eu au Cayla : charmante ligne d’intimité, sentier des bois,
mené jusque dans Paris. Mais je n’irai pas loin dans le peu de jours
qui me restent ; rien que huit jours et le départ au bout. Ce point de
vue final m’attriste immensément, et je ne sais voir autre chose.
Comme le navigateur au terme de la mer Vermeille, je ne puis m’ôter
de là. O ma traversée de six mois, si étrange, si diverse, si belle et
triste, si dans l’inconnu, qui m’a tant accrue d’idées, de vues, de
choses nouvelles qui ont laissé tant à dire et à décrire ! Mais je n’ai
pas tenu de journal. Qui devait le lire ? Que penser à faire si
quelqu’un ne se plaît à ce que l’on fait ? Sans cet intérêt ma pensée
n’est qu’une glace sans tain. Du temps de Maurice, je réfléchissais
toutes choses ; c’était par lui, associé à mon intelligence, frère et ami
de toutes mes pensées. Un signe de désir, un mot de dilection,
suffisaient pour me faire écrire à torrents. Qu’il était influent sur moi
et que l’influence était belle ! Je ne sais à quoi la comparer : au vin
de Xérès, qui vivifie, exalte, sans enivrer.
[46] Cahier déjà imprimé dans les Reliquiæ, 1855.

Ce soir, je me retrouve un peu sous ces impressions que je

croyais perdues ; mais, je vous l’ai dit, je ne saurais parler que du
malade, pauvre jeune homme qui ne se doute pas de l’intérêt qu’il
m’inspire et du mal qu’il me fait en toussant. O vision si triste et si
chère ! D’où vient cela, d’où vient qu’il est des souffrances qu’on
aime ? dites, Jules, vous qui expliquez tant de choses à mon gré. Le
grand M. de vis-à-vis vous a trouvé bien aimable ; vous étiez en
verve ce soir, mais, plus ou moins, votre conversation abonde
d’esprit, d’éclat, de mouvement. Elle monte, s’étend, se joue dans
mille formes, sous une forme inattendue, magnifique feu d’artifice.
« Le beau parleur ! » a dit ce grand monsieur, en saluant la Baronne
qui a confirmé d’un sourire, ajoutant : « Ne croyez pas qu’il pense
tout ce qu’il dit. » C’était sans doute au sujet de saint Paul, et pour
écarter le soupçon d’hérésie que vous avez encouru en discourant
mondainement sur cet apôtre. Que je voudrais aussi ne pas vous
croire ! Bonne nuit ; je vais dormir, je vais chercher mes songes gris
de perle. Et à propos, pourquoi a-t-on ri lorsque j’ai comparé les
vôtres au son de la trompette ? Il y a donc là-dessous quelque
signification singulière, de ces sous-entendus de langage que je
n’entends pas ? Ce qui m’arrive souvent. On donne dans le monde
de doubles sens aux choses les plus simples, et qui n’est pas averti
s’y trompe. Quand je vois rire, allons, je suis au piége ; cela me
donne à penser, mais rien qu’un moment par surprise. A quoi bon
s’arrêter sur des complications ?
La charmante m’a dit : Nous causerons demain. Ce qui promet
d’intimes confidences. Quand les sources d’émotions ont coulé,
quand le cœur est plein, c’est sa façon d’en annoncer l’ouverture.
Nous causerons demain. Nous nous embrassons là-dessus.
Chacune va à son sommeil et je ne sais si on attend le jour pour
causer. Une tête agitée fait bien des révélations à son oreiller.

1er septembre ou dernier août, je ne sais ni ne m’informe du jour.

— Ce vague de date me plaît comme tout ce qui n’est pas précisé
par le temps. Je n’aime l’arrêté qu’en matière de foi, le positif qu’en
fait de sentiments : deux choses rares dans le monde. Mais il n’a
rien de ce que je voudrais. Je le quitte aussi sans en avoir reçu
d’influence, ne l’ayant pas aimé, et je m’en glorifie. Je crois que j’y
perdrais, que ma nature est de meilleur ordre restant ce qu’elle est,
sans mélange. Seulement j’acquerrais quelques agréments qui ne
viennent peut-être qu’aux dépens du fond. Tant d’habileté, de
finesse, de chatterie, de souplesse, ne s’obtiennent pas sans
préjudice. Sans leur sacrifier, point de grâces. Et néanmoins je les
aime, j’aime tout ce qui est élégance, bon goût, belles et nobles
manières. Je m’enchante aux conversations distinguées et sérieuses
des hommes, comme aux causeries, perles fines des femmes, à ce
jeu si joli, si délicat de leurs lèvres dont je n’avais pas idée. C’est
charmant, oui, c’est charmant, en vérité (chanson), pour qui se
prend aux apparences ; mais je ne m’en contente pas. Le moyen de
s’en contenter quand on tient à la valeur morale des choses ? Ceci
dit dans le sens de faire vie dans le monde, d’en tirer du bonheur, d’y
fonder des espérances sérieuses, d’y croire à quelque chose. Mmes
de *** sont venues ; je les ai crues longtemps amies, à entendre
leurs paroles expansives, leur mutuel témoignage d’intérêt, et ce
délicieux ma chère de Paris ; oui, c’est à les croire amies, et c’est
vrai tant qu’elles sont en présence, mais au départ, on dirait que
chacune a laissé sa caricature à l’autre. Plaisantes liaisons ! mais il
en existe d’autres, heureusement pour moi.
… Ce que je ne comprends pas dans cette femme, c’est qu’elle
ait pu s’attacher à ce Mirabeau que vous nous avez dépeint. Mais
l’a-t-elle cru ce qu’il est ou est-il bien ce qu’on en dit ? Le monde est
si méchant, on s’y plaît tant à faire des monstruosités ! Il y a aussi de
véritables monstres d’hommes. Quoi qu’il en soit du docteur
irlandais, il ne voit pas un malade en danger qu’il ne lui parle d’un
prêtre, et il est lui-même exact observateur des lois de l’Église.
Accordez cela avec sa réputation. Pourquoi encore, avec tant
d’audace, paraît-il timide et embarrassé devant nous trois, comme
M. William ? Il rougit autant et son regard rentre encore plus vite.
Est-ce là ce fougueux Jupiter [47] ? Je n’y connais rien peut-être :
oui, l’énigme du monde est obscure pour moi. Que d’insolubles
choses, que de complications ! Quand mon esprit a passé par là,
quand j’ai longé ces forêts de conversations sans trouée, sans issue,
je me retire avec tristesse, et j’appelle à moi les pensées religieuses
sans lesquelles je ne vois pas où reposer la tête.
[47] Un peu plus tard, il m’est venu des idées plus
étendues sur cet homme très peu connu, profond et
fermé.
 (Note du Ms.)

Qu’alliez-vous faire dimanche à Saint-Roch ? Était-ce aussi pour

vous y reposer ? On a fait bien des investigations là-dessus. Peine
perdue. Que découvrir sur l’incompréhensible ? Dieu seul vous
connaît. Oui, vous êtes un palais labyrinthe, un dérouteur, et, sans
ce côté qui vous liait à Maurice, et où luit pour moi la lumière dans
les ténèbres, je ne vous connaîtrais pas non plus ; vous me feriez
peur. Et cependant vous avez l’âme belle et bonne, honnête,
dévouée, fidèle jusqu’à la mort, une vraie trempe de chevalier, et ce
n’est pas seulement au dedans.

Le 3. — J’ai commencé Delphine, ce roman si intéressant, dit-on.

Mais les romans ne m’intéressent guère, jamais ils ne m’ont moins
touchée. Est-ce par vue du monde et du fond qui les produit, ou par
étrangeté de cœur ou par goût de meilleures choses ? Je ne sais,
mais je ne puis me plaire au train désordonné des passions. Il y a
dans cet emportement quelque chose qui m’épouvante comme les
transports du délire. J’ai peur, horriblement peur de la folie, et ce
dérangement moral qui fait le roman en détruit le charme pour moi.
Je ne puis toucher ces livres que comme à des insensés, même
l’Amour impossible. De tous les romanciers, je ne goûte que Scott. Il
se met, par sa façon, à l’écart des autres et bien au-dessus. C’est un
homme de génie et peut-être le plus complet, et toujours pur. On
peut l’ouvrir au hasard, sans qu’un mot corrupteur étonne le regard
(Lamartine). L’amour, chez lui, c’est un fil de soie blanche dont il lie
ses drames. Delphine ne me paraît pas de ce genre. Le peu que j’ai
vu présage mal, et j’y trouve un genre perfide : c’est de parler vertu,
c’est de la mener sur le champ de bataille en épaulettes de capitaine
pour lui tirer, sous les yeux de Dieu, toutes les flèches de Cupidon.
Mme de Staël ne cesse de faire mal et de prêcher bien. Que je
déteste ces femmes en chaire et avec des passions béantes ! Cela
se voit dans les romans, et on dit aussi dans le monde : le grand
roman ! On m’en ouvre chaque jour quelques pages. Étranges
connaissances ! Est-ce bon ? Peut-être pour l’étendue des idées,
pour l’intelligence des choses. J’observe sans attrait, sans me lier à
rien, et cette indépendance d’esprit préserve de mauvaise atteinte.
Journée variée comme la température, ciel de salon, gris et bleu,
traversé de vapeurs brillantes. Ces teintes de la vie, qui les pourrait
peindre ? Ce serait un joli tableau et que je donnerais à faire à M.
William, l’artiste idéal. Je lui crois beaucoup de rêverie dans l’âme, et
l’amour passionné du beau, une nature tendre, ardente, élevée, qui
présage l’homme de marque. J’apprécie fort M. William sur ce que je
vois et sur ce que vous dites, vous, le jugeur. Mais surtout j’aime
cette candeur de cœur que vous dites encore d’un charme si rare
dans le monde. Vous l’aviez trouvée aussi à Maurice. Tout me
ramène à lui, je lui fais application de toute belle chose. Combien je
regrette que M. William ne l’ait pas connu et qu’il n’ait pas fait son
portrait ! Nous y perdons trop. Quelle ressemblance ! comme ce
beau talent eût saisi cette belle tête !
Je reviens de la rue Cherche-Midi, mon chemin d’angoisses.
Hélas ! que cette maison indienne m’est triste, et cependant il y a
quelque chose qui fait que j’y vais : il y a sa femme, toute couverte à
mes yeux de ce nom. Plus rien à dire.
Soirée musicale, artiste italien, grands chants et chansonnettes,
le tout d’heureux effet sur ma chère malade, qui est, au demeurant,
facilement contente. Aussi je me méfie un peu de ses jugements, qui
ne sont que des sensations bienveillantes. Elle perçoit par le cœur,
et cette transposition de facultés…

Le 8. — Il est mort, le jeune malade, hier soir à onze heures. Il

est mort ! Je savais qu’il allait mourir ; j’avais toujours cette pensée
devant moi comme un fantôme, et me voilà interdite. Oh ! toujours la
mort nous étonne, et celle-ci soulève en moi tant de souvenirs
accablants ! Le genre de maladie, cette belle tête, les détails que j’ai
recueillis sur sa bonté, sa douceur, son attrayant, ce je ne sais quoi
de certaines natures à magnétiser tout le monde, l’affection de son
valet de chambre, sa fin chrétienne et pieuse : tout cela est d’une
ressemblance touchante. Je voudrais être la sœur de Charité qui a
reçu son dernier soupir. Que de fois j’ai rêvé d’être sœur de Charité,
pour me trouver auprès des mourants qui n’ont ni sœur ni famille !
Leur tenir lieu de ce qui leur manque d’aimant, soigner leurs
souffrances et tourner leur âme à Dieu, oh ! la belle vocation de
femme ! J’ai souvent envié celle-là. Mais ni celle-là ni une autre :
toutes seront manquées. Il manque beaucoup de ne se vouer à rien.
Il semble que le bonheur soit dans l’indépendance, et c’est le
contraire.

Le 10. — On a renvoyé Delphine, avant que je l’aie achevé de

lire. Je n’en suis pas fâchée. Les livres, c’est cependant ma passion
intellectuelle ; mais qu’il en est peu de mon goût, ou que j’en connais
peu ! Ainsi des personnes. On n’en rencontre que bien rarement qui
vous plaisent. Vous et Maurice êtes toujours mes préférés. Je vous
vois au-dessus de tout ce que je vois. Vous êtes les deux hommes
qui me contentez le plus pleinement l’esprit. Oh ! s’il ne vous
manquait une chose ! et qu’en cela je souffre et souvent ! Chaque
fois qu’il en est question, on fait après votre départ le relevé de vos
principes et de vos paroles avec un blâme d’autant plus pénible que
je ne puis pas l’écarter. Bien loin de là, je le donne dans ma
conscience. La conscience agit souvent à contre-cœur. Non, je ne
puis entendre des choses qui lui font mal et qui vous font tort. J’ai
entendu quelqu’un vous traiter de fou à ce sujet. Vous vous
aventurez, dit-on, étrangement dans les questions religieuses. Je ne
vous les vois pas aborder que je n’éprouve les transes de cette mère
d’un fils aveugle, lancé sur l’Océan. Pardon de la comparaison, mon
cher Jules, je la reprends. Certes, vous ne manquez pas de vue,
hormis de celle de la foi.

Le 16. — Rien que la date. J’écrirai demain. Cœur triste ce soir

et tête lasse.
 Le 17. — Ce que j’aurais dit hier, je ne le dis pas aujourd’hui. Je
vous ai vu, nous avons causé, cela suffit au dégagement du cœur, à
la délivrance de la tête, ce poids fatigant de sentiments et de
pensées que nul autre que vous ne pouvait recevoir. Me voilà
soulagée, mais je souffre de ce que j’ai mis au jour.
… O fin de tout ! fin de toutes choses et toujours des plus chères,
et sans cause connue souvent pour les sentiments du cœur, que par
je ne sais quel dissolvant qui s’y mêle. En s’unissant, il entre le grain
de séparation. Cruelle déception pour qui croyait aux affections
éternelles ! Oh ! que j’apprends ! mais la science est amère.
… Qui me restera ? Vous, ami de bronze. J’ai toujours cherché
une amitié forte et telle que la mort seule la pût renverser, bonheur
et malheur que j’ai eu, hélas ! dans Maurice. Nulle femme n’a pu ni
ne le pourra remplacer ; nulle, même la plus distinguée, n’a pu
m’offrir cette liaison d’intelligence et de goûts, cette relation large,
unie et de tenue. Rien de fixe, de durée, de vital dans les sentiments
des femmes ; leurs attachements entre elles ne sont que de jolis
nœuds de rubans. Je les remarque, ces légères tendresses, dans
toutes les amies. Ne pouvons-nous donc pas nous aimer
autrement ? Je ne sais ni n’en connais d’exemple au présent, pas
même dans l’histoire. Oreste et Pylade n’ont pas de sœurs. Cela
m’impatiente quand j’y pense, et que vous autres ayez au cœur une
chose qui nous y manque. En revanche, nous avons le dévouement.
Une belle voix, la seule agréable que j’aie entendue de ces voix
des rues de Paris, si misérables et boueuses. L’abjection de l’âme
s’exprime en tout.
… En général, nous sommes bien mal élevées, ce me semble, et
tout contrairement à notre destinée. Nous qui devons tant souffrir, on
nous laisse sans force ; on ne cultive que nos nerfs et notre
sensibilité, et en sus la vanité ; la religion, la morale pour la forme,
sans la faire passer comme direction dans l’esprit. Cela fait mal à
voir, pauvres petites filles !
 Le 22. — Rien ne me choque plus rudement que l’injustice, que
j’en sois ou non l’objet. Je souffre d’une manière incroyable rien qu’à
voir donner raison à un enfant qui a tort et vice versâ. Le moindre
renversement de la vérité me déplaît. Cette susceptibilité est-elle un
défaut ? Je ne sais. Personne ne m’a jamais avertie de rien. Mon
père m’aime trop pour me juger, pour me trouver aucune
imperfection. Il faut un œil ni trop loin ni trop près pour bien
distinguer une âme et voir ses défauts. Vous, Jules, êtes à parfaite
distance pour me voir et ce qui me manque. Il doit me manquer
beaucoup. Je veux vous demander cela avant de nous quitter ; je
veux avoir vos observations que je tiendrai comme une preuve de
votre affection. On se doit de perfectionner ce qu’on aime. On le
veut, on en parle même mal ou mal à propos…

Le 27. — Écrire des lettres de deuil, en lire et concerter avec ce

pauvre M. de M…, qui n’en peut plus à lui seul sous tant d’affaires et
de peines, c’est mon emploi de temps et de cœur depuis quelques
jours, aux dépens de mon Mémorandum. La mort de M. de Sainte-
M… accroît tellement le poids des peines de notre affligé, que je
demeure tant que je puis auprès de lui comme aide ou diversion.
Bien souvent je surprends des larmes dans ses yeux, qu’il détourne
de sa femme pour ne pas se trahir. Le terrible secret, qu’une mort
dans le cœur vis-à-vis du cœur que cette mort doit frapper ! Marie
est incapable en ce moment de supporter un tel coup. Je ne sais
tout ce qu’on peut craindre pour elle à cette annonce, même en
meilleur état de santé. Que deviendra-t-elle en apprenant qu’elle a
perdu son père, si bon, si aimable, si digne d’être aimé ? Tout ce
qu’il y avait en lui d’attachant va la saisir éperdument comme les
étreintes d’un fantôme. Elle en aura des épouvantes de tendresse,
ne verra que de quoi se désoler et se trouver, par cette mort, la plus
malheureuse des filles. Au fond, elle tenait à son père, et ce fond est
si excellemment tendre ! Elle n’a jamais méconnu les qualités
distinguées de son père, son élévation d’âme, de cœur,
d’intelligence. L’homme rare par tous ces endroits ! Par sa droiture
de principes, sa raison forte, son amabilité, sa religion éclairée.
J’aimais cette piété franche, gaie, vive, toute militaire, l’homme des
camps dans le service de Dieu, et que la foi avait entièrement
dompté. Maurice me l’avait dit, et je l’ai vu de près. Il avait dû y avoir
là un Othello, un caractère fort et terrible. Certains traits de violence
l’attestent et le trahissaient encore quelquefois ; mais en général cet
homme était si contenu, que, pour qui le connaissait, c’était un bel
exemple de la puissance morale. Et puis, qu’il était bon, doux, facile
à vivre ! C’est là, dans son intérieur, dans ce coin sans draperie, qu’il
se faisait bien voir, et de façon à se faire aimer beaucoup. Il
m’appelait sa fille, et je lui donnais aussi bien tendrement le nom de
père. Hélas ! que sert de multiplier ses affections ? C’est se préparer
des deuils. Je regrette bien profondément M. de Sainte-M… Sa
mémoire me sera toujours en vénération et pieuse tendresse,
comme un saint aimé.

Le 2 octobre. — Au retour de notre pose au Palais-Royal, je me

repose dans ma chambre et dans le souvenir de notre entretien. Une
femme a dit que l’amitié, c’était pour elle un canapé de velours dans
un boudoir. C’est bien cela, mais hors du boudoir, pour moi, et haut
placé sur un cap, par-dessus le monde. Cette situation à part de tout
me plaît ainsi.

Le 3. — Détournée hier sur mon cap. Je ne reprends mon journal

que pour le clore, n’ayant plus liberté d’écrire en repos. C’est
dimanche aujourd’hui ; heureusement j’ai puisé du calme et de la
force à l’église, pour soutenir un assaut accablant.
 VI

[1842, à Rivières.] — Je n’écris plus depuis quelque temps, mais

il est des jours qu’on ne veut pas perdre, et je veux retrouver celui-ci
si rempli d’émotions et de larmes. O puissance des lieux et des
souvenirs ! C’est ici, c’est à R… qu’il était venu souvent dans les
vacances, joyeux étudiant, bondissant dans les prés, franchissant
les cascades avec les enfants du château. Nous avons rappelé ce
temps et parlé de lui, intimement et sans fin, avec cette bonne,
tendre et parfaite Mme de R… qui pleurait. Qu’il m’avait tardé de la
voir pour ce que nous venons de faire, parler de Maurice ! Il y a pour
moi là dedans une jouissance de douleur, un bonheur dans les
larmes inexprimable. Mon Dieu, que j’ai peu vécu parmi les vivants
aujourd’hui ! Et ce qui m’a fort touchée encore, c’est de voir une
caisse où il y a son nom, une caisse de collége où il mettait des
livres de moitié avec le petit G…, précieusement conservée en ce
souvenir à R…, on m’en a demandé le don. Il y a de ces simples
choses qui pénètrent l’âme.
Ouvert par hasard un album où j’ai trouvé la mort de Maurice,
mort répandue partout. J’ai été bien touchée de la trouver là, sur ces
pages secrètes, dans un journal de jeune fille, dans un fond de
cœur : hommage inconnu et le plus délicat qui soit offert à Maurice.
Que cette parole est vraie : il était leur vie ! Tous ceux qui nous ont
compris la diront. Il est de ces existences, de ces natures de cœur
qui fournissent tant à d’autres qu’il semble que ces autres en
viennent. Maurice était ma source ; de lui me coulait amitié,
sympathie, conseil, douceur de vivre par son commerce intellectuel
si doux, par ce de lui en moi qui était comme le ferment de mes
pensées, enfin l’alimentation de mon âme. Ce grand ami perdu, il ne
me faut rien moins que Dieu pour le remplacer.
 Espérer ou craindre pour un autre est la seule chose qui donne à
l’homme le sentiment complet de sa propre existence.

[31 décembre, au Cayla.] — C’était ma coutume autrefois de finir

l’année mentalement avec quelqu’un, avec Maurice. A présent qu’il
est mort, ma pensée reste solitaire. Je garde en moi ce qui s’élève
par cette chute du temps dans l’éternité. Un dernier jour, que c’est
solennellement triste !
 TABLE

Pages.
Avertissement I
Journal d’Eugénie de Guérin 1
I (15 novembre 1834-13 avril 1835) 3
II (14 avril-5 décembre 1835) 59
III (mars-mai 1836) 105
IV (mai-juin 1837) 119
V (26 janvier-19 février 1838) 143
VI (19 février-3 mai 1838) 161
VII (3 mai-29 septembre 1838) 199
VIII (10 avril-25 mai 1839) 247
IX (21 juillet 1839-9 janvier 1840) 275
X (9 janvier-19 juillet 1840) 327
XI (26 juillet-29 août 1840) 391
XII (1er novembre-31 décembre 1840) 409
Fragments 419

PARIS. — IMPRIMERIE DE J. CLAYE, RUE SAINT-BENOIT, 7.

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