A pioneer in her field, she broke boundaries never broken before. But beyond that, she was a leading orthopaedic surgeon in her field. This week we speak to Miss Clare Marx, former President of the Royal College of Surgeons and now with the FMLM. We discuss her journey to the top and how she sees her legacy panning out.

Firstly, thank you for speaking to us! I understand you’ve now moved on from the role of president in the Royal College.  But could you just tell me a little bit about your journey getting there and a little bit about that?

Okay, so I was an orthopaedic surgeon.  I started my training in London and worked around the Midlands, and came back to London to do my Orthopaedic training.  I went over to the States to do a bit of my specialist training over there.  When I came back, I got my first consultant job in London at St Mary’s, and then got involved with undergraduate medical students at that stage. After 3 and a half years, I got married and moved out to Suffolk, so I’ve been out in Ipswich for 25 years but I always was interested in education; when I came to Ipswich, first of all after a year, I became clinical director of the departments here, which at that stage was A&E and Rheumatology as well.  That’s challenging.  That’s 4 years, but I also was involved in continued medical education for the British Orthopaedic Association (BOA) and distance learning for the BOA.

So I after I’d done the job as the clinical director for 4 years, I moved to becoming the chairman of the LMC of the BMA at my hospital for a couple of years.  I was also still doing work on educational type things for the orthopedic association and then I was told to be chairman of the Medical Staff Committee in this hospital for another few years. By that stage, I started to do some work on the specialist training board for British Orthopedic Association, so then I went to chair that and wrote the new curriculum for Orthopaedic with the help of some colleagues. I then went on to become president for British Orthopedic Association for a year and went onto the college council for the Royal College of Surgeons.

Were you recommended for that role?

I mean, I’ve stood for election. I was elected after the Council of the BOA,  I was elected to be president and elected onto Council of the Orthopedic Surgeons and finally, elected to be president in 2014.

When you became president, I think it inspired a lot of women in healthcare, it challenges a lot of sort of traditionalist views. How do you think you ensure that the changes that you’ve brought in are sort of followed by a continued push to encourage woman to take up surgery?

You’re asking me about the legacy issue!  I think there are whole raft of ways you do that.  The first is to actually get people to understand how is it important to recognize the problem and the way you do it is by actually just advertising the difference. We know that not many people are going into surgery, but absolutely not many people are going into surgical leadership. I’ll give you an example: the examiners of the RCS, there are 560 examiners with about 23 women. You have to know what the size of the problem is before you start thinking of ways to address that. That’s less than 5%.

The first thing you do is look at the figures, then you look at the people who are responsible for recruiting examiners and you say to them, what are you doing about it? The normal response is, okay, well, you know, we advertise, but women don’t come. You just say okay, but what are you doing about it. What are you doing about the fact that women don’t apply? it’s getting people to understand that why women don’t apply, actually they need to go out and say to the women who they know are good women, “how about applying?”. Or they need to go to the men that they know and say we really are looking for women who are good and we want them to apply because if they don’t apply, then they can’t even be considered.  Once they’ve applied we make sure there is a proper application process and if they’re good enough, then they will tell you a chance of being elected. This is not about positive discrimination, this is about a positive encouragement to apply, so that they can actually ever be considered.

You know I have a great maxim in that if you don’t apply for a job, or you don’t apply for award or you don’t apply for scholarship or research cost, you’re not going to get it. We know from some of the research has been done by psychologists, that if women don’t apply, they don’t think that they have got all the boxes ticked. By contrast, you know, men do apply and women don’t. To get these things embedded, you get men to understand they have a responsibility to try and encourage the women just as much as women encourage the women. Actually, once they started doing that, they realized it’s actually quite rewarding because not many people set up to the mark.  People apply, they get accepted into roles and they can see the benefits of having women in teams. There is a lot of research now on how important it is to have diversity in teams, women engage all sorts of other protective characteristics.  But that’s the population group we treat, so we actually need to see that sort of diversity in our teams as well.

That’s really interesting. Moving back to as when you were president what do you think has been your most successful moment?  Obviously becoming president would have been one, but other than that?

If you really want to know what I’m most proud of in my career, is actually having been a good orthopedic surgeon and provided really first-class care to patients for a long and sustained period of time.  For most clinicians, the most potent driver is the care they provide to the patient.  It’s more, but what is interesting is when you’ve done that, you realised that by engaging in education, in standards, in leadership, in management, you can actually create an atmosphere and create changes that are going to be of benefit for those patients in a different sort of way. Understanding what motivates you, which for most clinicians is about providing improvement in care and excellence for patients.  Once you’ve understood that’s actually underlying everything you do, then all the other stuff like education and management and leadership, can follow on from that. At the end of the day, having patients say to you “Miss Marx, you’ve changed my life” is very powerful.

On the flip side of that, what do you think is the most challenging moment you can think of?

I think that working in a constantly changing environment and the leadership of that constant change, some of which I have initiated and some of which has been driven changing technologies and changing systems and changing curricula.  I think working in a constant time of changes, I think is most difficult thing for any individual, certainly for me. I think understanding how you react to those changes, understanding and managing oneself during that constantly changing period, is probably the most difficult thing and yet probably the most important.

How much, say did you have in the policy-making process when these changes were happening?

It varies. At a local level and actually a national level.  When clinicians come together with standards of care that positively affect patients, it is extremely difficult to resist it.  And I’ll give you some examples.  If you think about the stroke pathway in London, when the clinicians laid out the standards of care they wanted to bring to patients, then the reorganization of where that care was provided in London follows on from that.

If you think about the major trauma networks, where the clinicians came up with the standards of care for improving trauma care for patients, then the advent of the trauma centers came after that.  When you think about fracture neck of femur management, when the clinicians said that these are the standards we want, then the service had to come in behind that. It’s getting people to understand that where you have clear-cut standards of care that are going to be of benefit to patients, but are universally reproducible, then people are going to get by it.  I think one of the most difficult things is normally what we do is we try as clinicians, is to have a workaround, so we’ve seen workarounds for an issue at a local level. By working around at a local level, we tend to actually impact negatively on some other services, and then we object to it when people say you can’t do that.  I think it’s understanding the broader picture of how do you get a system to work with you to deliver and improve standards of care and that’s when clinicians can be particularly powerful.

At the end of the day, having patients say to you “Miss Marx, you’ve changed my life” is very powerful.

I understand you have a lot of focus in patient’s safety now?

I used to chair the patient safety group at the college but I don’t do that now. I also used to chair the professional standards group at the college and again don’t do that now.  But I try and use the learning from all those things that I’ve done in the past. At the moment, I’m chairing the Faculty of Medical Leadership and Management.  What we’re trying to do there is to encourage people to understand how the medical leadership can actually improve patient’s care and safety simply by, you know, having medical leaders at the forefront.

From your point of view, how do you balance sort of increasing resourcing change with maintaining patient’s safety?

One has to understand that nothing stays the same and that clinicians are very good at trying to carry on doing more of the same. But that doesn’t work.  When one is faced with resource shortage against an increasing demand and changing technologies, that’s when the clinicians who have trained to be good problem solvers really come to their forefront. I think that understanding that things are going to have to change and leading that change and harnessing the ideas of people around is really important.  That doesn’t necessarily mean that what we want to happen, which would be good for us as a service, is going to be the best thing overall and sometimes it means actually understanding that services are going to have to be rationalised and changed, which may be as a disadvantage to the individual doctor.

With the example of Stroke Services in London, can you imagine what it was like if you’ve been busy delivering Stroke Services in one of the 40 hospitals that now don’t take acute stroke? It’s quite a change for them.  There is something about those people who want to head up the services, are going to have to accept that going to be a lot of push back from a lot of people who have a lot of vested interests in things staying the same because it’s actually much more comfortable for these to stay the same, and just try and do a bit more of it rather than actually changing the way of work.

I’ll just give another example, in America, because of the huge distances and issues in providing intensive care across vast swathes of the country, they now have got the virtual technology so that you can talk to somebody as if they were the other side of your hospital except they’re in St. Louis, Missouri, rather than in Florida. Those are the sort of things that we need to be thinking about to change. If you’ve got 10 good intensivists in one place, what’s difference in phoning somebody in your own hospital and phoning somebody who has access to all that data who is just in a centre 200 miles away.

That’s how new technology is going to challenge the way we work at the moment and that’s how we ought to be thinking. A lot of resource issues are to do with the personnel never mind the money.

What do you think is the most important trait that a junior doctor should have when it comes to working in surgical training in your perspective?

I think you actually have got to want to do it! You actually have to want to treat surgical patients and you need tenacity because I think it is quite a demanding discipline intellectually and physically.  Even with the new working hours, nothing that is worth doing is easy.

I think you need to be flexible and have to be able to think broadly and you need to have a very positive personality because that way people want to work with you and you will be opened to new ideas.  You’ll be able to incorporate those new ideas to move through your career.

You’ve got to be willing to think about something new every 4 or 5 years because at the moment that’s the cycle of change, probably in a few years time, it’ll get to be something new every 2 or 3 years.  The way things are changing so quickly.

Women might be a bit unsure about it having to strike a balance between family and their careers…

Women and men actually!

Would you have anything to say on that respect about how you strike the balance between sort of training and the rest of the things that life brings?

I just don’t know how you strike a balance because I’m not if I’ve ever got the balance right! I think the important thing is to do what seems right at that moment and if you want to have a career in surgery then just go full out for it and just see how things come along.  Usually things fit in one way or another. Like me, moving out of London, you know, things fit in and you’ve just got to be open to things changing.

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