CHURCHILL FELLOWSHIP 2002

My Route Latest Update (so you know whether you've already read this one): December 18, 2004

Contents

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Project Title & Aims

The role of the Healthcare Computer Analyst/Programmer

Aims: Visit centres within the three main non-UK software-producing countries, spending 3-4 days at each selected centre (dependant on size and travelling required between centres). I will interview (using a proforma to ensure comparability) and observe (to gain additional unstructured information) analyst/programmers at work: their influences, pressures, sources of projects, project methodology, software and hardware tools used. The intention is to do this within a culture that is more task-oriented and more goal-oriented than the UK in order to link outcome to input. In addition, I intend to promote, via a series of presentations, experience and skills present within the NHS to an audience outside of the UK, which will also give something to the hosting centres.


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Preparation

In choosing the three countries to visit, I had in mind not just those that were major players in software authoring, but also those that I felt I could gain contacts in (I found a contact route for India about three weeks before departure but it was too late to add it in).

My original plan was to spend 2-4 days at each centre and then move on. The Churchill Trust dissuaded me of this idea, recommending that a week was the minimum to spend in each place. So I began looking for seven appropriate centres to visit.

My German contact was an ex-pat Medical Physicist I had been in touch with when I had considered emigrating to Heidelberg (beautiful city - didn't get the job). I figured that he would know the Medical Physics field in Germany and be able to put me in touch with the appropriate departments. I wrote to him just as he was preparing to return to the U.K. - dead end number one.

My American contacts were a colleague who has done a lot of work in the U.S.A. and some friends who currently work in a University there. One without a medical school. Dead End number two.

My Japanese contact was another colleague who I knew had undertaken a Churchill Fellowship himself, in Japan. He put me in touch with two of his contacts both of whom replied. Prof. Furukawa went the extra mile, however, organising almost my entire two weeks there.

Undaunted, I decided to make professional contacts and wrote to the chairmen of two professional organisations for Medical Physics in each of the three countries twinned with our own (the Institute of Physics and Engineering in Medicine). Two of these wrote back: an American requesting further details (which I duly sent and never heard from again) and a German, Prof. Wucherer, who suggested three of his colleagues. Two of these were happy to host me for a week each - one put me in touch with a colleague on the same campus who would also be happy so see me.

With Germany and Japan "sorted", I turned my attention to the Americans. And drew blank after blank. Of all the contacts my colleague supplied, only one responded favourably (most didn't respond at all). So I (or rather, Rachel, my wife) turned to the Internet for help. She found many likely and promising places: most of whom didn't write back. Those that did generally were either out of the country themselves during my planned visit time or weren't involved in appropriate work any longer. Finally I drew a friendly e-mail: from Dr. Tonellato, who was visiting Japan at that time and promised to get in touch again once he returned to the U.S.A.

One week left to plan... I had become very interested in Small World Theory by this time and was toying with the idea of visiting a university in New York State and then writing to Prof. Strogatz (one of the founders of the theory) to ask if I could drop in and see him, as I was in the neighbourhood, as it were. In the end, I decided to see if I could spend the whole week there instead: bulls eye (I should have thought of this sooner).

Now to flights and hotels... Flights were easy (thanks to David Scott): a round-the-world ticket, meaning that my journey would be one-way (causing a few jokes) and easier to plan. I decided to fly on Saturdays. Although this meant I'd be leaving places without a day to see any sights I'd been recommended, it did mean I had a day to recover from the longer flights. This all went wrong when it came to Seattle to Osaka as I was crossing the date line the wrong way. Consequently, I would be leaving on Saturday and arriving on Sunday, with no time to recover. I felt this was a bad idea so cut short my visit and flew on Friday (arriving Saturday).

Hotels were mostly done by recommendations from the hosting organisations and booked either by them or over the Internet. The only really difficult one was Ithaca, who had a parents' weekend beginning on the last night of my stay. Once I'd realised why everywhere was booked for the nights I wanted, I changed my search and moved hotel for the last night.

My ability with foreign languages is poor. At school I took the minimum allowed: three (it was a Grammar school): German, Latin & French. In my only year of German, I achieved 27% in the exam and was congratulated by the teacher for doing far better than heíd predicted. I soon dropped German & Latin and concentrated on science. Oh - and I got a grade 9 in my French ĎOí level (I think thatís about an ĎFí at GCSE). Iíve normally tried to get by with a few nouns, a lot of gesticulating and a "pardon, monsieur, je suis anglais" - which really confuses the Germans.

I promised myself faithfully that I wouldnít be packing for seven weeks away at midnight on the night before I left. I kept that promise - it was 1am... Iíd had two suitcases on the landing for a week (one for cabin baggage, one for hold) and it took me at least an hour to cut my stuff down to something approaching the weight limits.


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The Tour

home

At 6:20 (am!) I locked my house and leapt into a taxi taking me to the railway station. It still didn't seem real that I was not going to be unlocking that door again for 51 days. I arrived at Hull station to discover that my train (the 7am to London) had been cancelled. We were advised to catch the 6:40 to Sheffield and change at Doncaster. My plan had been to book a taxi for 6:30, thus allowing it to be 15 minutes late. It arrived at 6:20, thus meaning I was 30 minutes early for the train I meant to catch - but only 5 (once I'd bought a paper and heard the announcement) for the train I now had to catch. Praise the Lord (as we evangelicals tend to say at such times) for taxi drivers who can't sleep.


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I've moved the separate visits off to separate pages, as there's a lot of pictures...

Prelude - Prague

Erlangen

Marburg

Ithaca

Milwaukee

Seattle

Osaka

Tokyo

Back in the U.K.

Itís a long long way to Copenhagen (a stop-off to change Ďplanes) (films: Signs, Hollywood Ending, Stuart Little 2. I also saw the Frighteners, although I can't recall whether this was flying into or out of Japan). Anyway, Copenhagen welcomed me back to Europe by being very very wet. It was early evening but my brain said 2am. Sadly my body seemed to be agreeing with it. Thatís my excuse for leaving my duty-free behind, anyway. I flew back to Manchester (I was boarding the Ďplane as I realised...) with visions of a bottle of Saki and some rice cakes being exploded by security ("We were right, Olaf, it was a very sticky bomb").

Back at Manchester, I located the SAS desk (Scandinavia Airlines - I didnít think I posed that much of a security risk) and the nice woman there (whose name I have completely forgotten) said sheíd see what she could do (she found it & it turned up in Hull a couple of days later). I returned to the lobby and started Ďphoning Nigel Mills (whoíd heard of Rachelís hospitalisation and had offered to collect me instead - heís been round the world (twice) so he must appreciate what itís like to be met at airports. Either that or heís a very nice man. Or both). Iíd just found his name in my mobile when his voice said "Hello Mr. Ganney". I had just enough presence of mind to realise that I hadnít dialled his number yet and turned round to see the man himself striding across the foyer. I was back in England.

back home - spot the difference!

They think it's all over...

It didn't end there, though. I've presented the stories of my exploits locally (at work in Hull), in Yorkshire (at the East Pennine Churchill Fellows' Association), nationally (the IPEM conference, twice!) and internationally (the European Federation of Medical Physics) - see my publications page for slightly more detail.

But then they presented to me. A silver medallion, by the Duke of Kent, no less. Sadly, apart from a lifetime of wonderful memories, it is all over now.

Can you spot me in the audience?


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Thanks and Acknowledgements

David Scott at John Good Travel in Hull, for flights and sensible advice.

My referees: Syd Howey and Judith Whitehead, for telling others I could do it.

The Hull & East Yorkshire Hospitals NHS Trust, for letting me have the time to do it.

The Churchill Trust, especially Judith Barber, for helping me do things at short notice (and reminding me of things that had even shorter notice).

Ian Hutty at H&EY Hospitalsí IT for e-mail assistance.

All my contacts and hosting bodies - my overriding impression has been one of being on the receiving end of enormous generosity and friendship, all given to someone they only knew through a few e-mails.

Geoff Howlett and Nigel Mills, for sending me the football results and match reports.

My wife, Rachel, for encouraging me to do it, even when she didn't want me to.


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Results

The Cultural Experience

Being surrounded by people who constantly apologise for their poor English is very humbling, especially given my ability with foreign languages. Itís very tempting to go and eat in places that advertise 'we speak English' or in familiar ones such as McDonaldís (someone told me recently of a friend who went to China & ate in McDonaldís all the time, which seemed a major crime at the time but is now very understandable). The only awkwardness would be: is it Ďdie BigMací or Ďder BigMací? I decided that if I was to get the most out of this tour, then Iíd have to eat local as much as possible. I also decided to start each visit in German (in Germany - that would have confused the Americans too much) and see how far I could get before I was 'rumbled'. Hopefully, Iíd get further each time. I still think that the time I spent with a menu and phrasebook trying to decide what to eat probably gave me away, though.

In Germany, it's odd to see so many people smoking and to see dogs in restaurants. It's also odd to see women attendants in the gents lavatories, not to say a little offputting the first time you see one.

Germany is also a lot less "animal rights" than Britain. Medics are open about animal experiments (although all I ever really saw were radiographs of dead mice) and markets have lovely soft scarves which are labelled "Echter Pelz" this isnít a brand name - it translates as "real fur".

Germany also seems to have a larger expectation that the population are honest and trustworthy: bus passengers with travelcards just board the bus, without showing their cards: there are several doors and only one gives you the opportunity to pay for your journey (the one by the driver). A busy shopping centre I went through had piles of new chart CDs in the centre of an aisle. You browse and then try to find the stallholder in order to pay. However, it is unfair to extend this trust everywhere: the Hospital at Marburg has more locked areas than any other Iíve been in. If youíre with a member of staff who has a key, then you can get anywhere. If youíre not, you may have trouble retrieving your coat from the office you left it in.

America, though, is different. The Rough Guide describes America as "the thrill of the familiar". So much of American culture is well-known through music, film & TV that you wouldnít expect a culture shock. There are a few things, though that make it apparent that this place is real and not just part of a set design, such as live lobsters in the supermarkets crawling around their tanks and "Hunting is permitted" signs in the woods.

America is also a very "car" society. It took me ages to find a postbox (sorry, mailbox) because I was looking for a large box with an opening on the pavement side, instead of the road side. Mind you, the cars normally yield to pedestrians. After Hull, this took some getting used to.

Perhaps the biggest shock is the one you should be expecting: the language. I was asked if I wanted some sprouts in my salami wrap. Once Iíd ascertained that we werenít talking Brussel Sprouts but something akin to cress, I was fine. Donít expect your colloquialisms to be understood, either.

On the subject of food, don't expect high cuisine nor anything more indigenous than a burger. Quantity, not quality, is the American diet. Everything is fried, too. Even the salad. (Alright, I made that last bit up - but it certainly seems that way at times).

America is, as has often been noted, very service-oriented. I came across no surly shop assistants (loud ones, weird ones, but no surly ones). When browsing in a record shop (some habits die hard) and someone walks between you and the CDs youíre viewing, they always say "excuse me". Even the teenagers. The thing is, you don't realise it immediately: after all, there are nice people everywhere. It just takes a while before you realise that you could buy a Bay City Rollers CD in Tower Records and not be sneered at. Not that I tried it.

Japan is very westernised, which makes it tempting to think that you understand it - assuming you could understand the writing, that is. It's similar to Germany in that a lot of people smoke (about half the population, according to the Rough Guide) and animal experiments are even more openly discussed (I was even taken to see some goats that had artificial hearts implanted). It's similar to Holland (and, increasingly, the UK) in that cycles share the same paths as pedestrians. It's similar to Gameboy games in that eveything plays pretty tunes at you: pelican crossings and subway trains (it sure beats "beep beep beep", although I've never found myself humming "Mind the gap" for an hour after hearing it).

Japan thrives on service - and expects it. Consequently tipping is very rare, as is acknowledging waitresses, secretaries etc. It didnít stop me saying ďthank youĒ - some habits are too ingrained.


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The role of the Analyst/Programmer in Healthcare

As the tour progressed, so the scope of my study widened. I tried to keep it under reasonable control and eventually allowed myself only one other avenue of consistent investigation: software project management for small development teams. By small I mean a maximum of three people (per project, not per department). In most cases, the project team had a size of one. It seems to me that there has not been much work done or guidance produced for such situations, even though it is very common globally and is certainly appears to be the norm for the NHS. I hope to present some work on this later.

The Analyst/Programmer in Healthcare is involved in a variety of activities, from design and specification, through coding and on into implementation and maintenance. In all cases, however, one overriding principle has become clear: specialisation.

A successful Analyst/Programmer is specialised, be it in software technology (e.g. web databases), in medical specialty (e.g. Radiotherapy) or in hardware technology (e.g. CT imaging). New knowledge is normally acquired incrementally, by gradually expanding the bounds of the skill set. (However, a well-funded research project may short-cut this approach, mostly because it also provides funds and time for training).

The analyst/programmer has a responsibility to innovate.

The senior programmer should be a senior member of staff, normally a member of the board/management team.


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The way forward for the U.K.

Dedicated software engineers and especially analyst/programmers are rare in healthcare. In the three countries I visited they were treated with more respect than in the UK (a fact that seems to be true for all branches of engineering: in the UK we equate "engineer" with someone who changes spark plugs; the rest of the world equates "engineer" with someone who designs & builds bridges).

Software engineering in healthcare will never be as financially rewarding as software engineering in industry or finance. The profession must seek to attract graduates by extolling the positives: principally, that the software you write will enhance (maybe even save) lives.

Due to the rarity of analyst/programmers in the NHS, the temptation to do everything and to learn every technique must be resisted. Knowledge that is broad but shallow will quickly find limitations: knowledge that is narrow but deep will survive better, if only by knowing when a project cannot be started because it is out of scope. An acquaintanceship with many medical and scientific disciplines is good, but only if it is in addition to expertise in one or two areas. Most people join the NHS because they wish to be of service (see the previous paragraph) and the temptation to say "Yes" to every project is high, especially if they sound very interesting. However, unless the project is backed up by the time and money to learn the new skills prior to attempting to employ them, incremental expansion of knowledge is to be preferred.

One of the most powerful things that the Department of Health could do, though, is to require registration of all those who write software within Heathcare for the use of others (there is naturally a great difference between the small program that someone writes to assist them in their practice (and consequently is subject to their experienced and critical usage) and software written to implement expertise away from the experts). The registration of professions is seen as a measure that protects patients against poor practice: software is so all-pervasive and can be so powerful, that the effects of poor practice can be far-reaching.


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Things I learned about myself


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Some observations that may be of use to Churchill Fellows prior to embarking

Leave yourself some thinking time! If you rush from one presentation/display/observation/event to the next then youíll never take it all in.


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What I did that I wish I hadn't


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What I didn't do that I wish I had


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What I did do that I'm glad I did


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What I didn't do that I'm glad I didn't


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Useful things to buy/borrow to take with you - not all of which I did


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Germany

I've been to Germany so many times I thought I could "get by" in German. That was until I went off the tourist trail and needed to find my contact's department. The receptionist spoke no English. I found out how poor my German really is. I bought an English/Deutsche dictionary before I even thought about lunch.

Food is good, plentiful & relatively inexpensive. Eat local if you can, even if youíre not completely sure what it is that youíre ordering. In general, there is enough English spoken to get by (but see caveat in previous paragraph), but itís far more polite to start a conversation in German and have them answer you in English (and they will, because you really are that obvious). It's far more satisfying, too.

Cash is easy to get hold of (provided youíve a Visa or Mastercard, of course), but be warned that the majority of eating-houses donít take plastic. Or if they do, they keep it very quiet. I planned to pay for most evening meals with a card - I soon drew out some extra cash instead.

In general, the Germans seem very happy with the Euro - although there is a feeling that prices rose at its introduction (I recall a similar feeling when Britain went decimal) especially in restaurants - some of whom were accused of just changing the DM sign to a Euro.

Pelican crossings are a little unusual - a green (walking) light doesnít mean that there is no traffic coming your way, just that you have right of way. A flashing orange light indicates this. This is especially important to know if youíre driving.


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the U.S.A.

The biggest confusion in the USA is when driving. There are numerous "Stop" signs at junctions at which everyone stops, with no indication as to who has right of way (maybe they just never got the hang of the roundabout). At some traffic lights, you can turn right on a red light if the road is clear. At others (normally marked with "no turn on red") you canít. Being on the other side of the road is a doddle. (Incidentally, youíre supposed to give way to traffic from the left, as though you were on a roundabout).

Like Germany, a "Walk" sign (for a pedestrian) doesnít necessarily mean you have the road to yourself.

Watch out for sales tax - itís not included in the displayed prices and varies from State to State (it can be as low as 0%, apparently). But before you wince at the thought of 12% tax, remember that VAT is 17.5%. But at least itís included in the displayed price.

Light switches work the other way: up is on.


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Japan

Japan is very status-sensitive. Don't therefore ask trivial questions of important people, especially before meeting them.

Shoes: wear slip-ons or tie your laces loosely (not whilst shopping, unless you go to an upmarket restaurant).

Japan is very expensive for some things, incredibly cheap for other. Get used to the exchange rate before you spend £160 on a pair of ornate chopsticks (I kid you not - I had to do the calculation twice to make sure).

Make sure you know who David Beckham is and be prepared to speak appreciatively of him - even if you're a Liverpool fan. It was not unusual for conversations to go:

Them: Where are you from?

Me: England

Them: Ah - David Beckham.

I'm sure my stock rose when I explained that I'd actually seen him play three times.

Japan is very compact. They like to build up (8-floor shopping arcades are not unusual and little shop fronts often extend up, down & back for a fair distance) and down (there are several large shopping arcades underground). It is therefore unwise to estimate how long a window-shopping trip will take, based on land area. Like America, the first floor is on the ground. Also like America, there's a 5% sales tax to add on to most purchases.

Practice using chopsticks before you go - I was often complimented on how well I could use them, even though I donít think Iím particularly good. I got the impression most westerners call immediately for a knife & fork.

I was often asked what I ate - after realising that this was a "do you have any religious taboos?/are you a vegetarian?" question, I found that a reply of "anything" was the most useful. There was also surprise expressed that Iíd eaten rice before.

Sushi is not just raw fish - itís actually the name of the rice cake that itís embedded in or on, so sushi can also be vegetable. On the subject of food, itís worth remembering that most foods in Japan come from one of three basic ingredients: rice, seafood and fresh fruit. So the caramel-looking sauce tastes slightly fishy, the slab of icing is sugared rice cake and the pineapple really is pineapple.

The people really are smaller, as evidenced by the size of tables and chairs (and shoes). Theyíre also able to sit cross-legged for a lot longer than I could.

Beware the green stuff that looks like Avocado - itís horse radish!


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Touring/Travelling

Donít expect all your arrangements to be in place before you go. Although this is more comforting, concentrate on the necessities: your flights, your luggage and your first hotel. Donít forget that although for you the Fellowship has begun, for those you will meet later you donít arrive for several weeks yet. Therefore make sure you can contact them! (The Internet is ideal for this purpose).

Practice carrying your luggage up and down stairs (especially up). Airports generally (but not always) have escalators. Railway stations don't (but again, not always).

Have enough stuff in your hand luggage for one nightís stay (remember that your hotel will have certain stuff available so you donít need it all), as your hold luggage will go AWOL at least once.

Remember customs allowances: you can carry £145 worth of stuff back into England, but you can only post £36 worth to one person.


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