David

Michael R. Gooseman 1 David J. O’Regan

1. Department of Cardiac Surgery
   Jubilee Wing
   Leeds General Infirmary
   Leeds Teaching Hospitals NHS Trust
   Leeds
   United Kingdom

Corresponding author: Mr David J. O’Regan Consultant Cardiac Surgeon
Leeds General Infirmary
David_o_regan@hotmail.com

Highlights
Diminishing role of percussion in clinical practice
Changing face of the clinical examination

Keywords
Clinical examination – percussion

Abstract
Objective: To establish how the practice of a basic clinical examination skill, percussion, is viewed and used in current medical practice.
Design: Interested individuals from the four main groups of the traditional UK medical firm were invited to take part – medical students, SHOs, registrars and consultants.
Setting: This study was conducted in two institutions – the University of Leeds School of Medicine and Leeds Teaching Hospitals NHS Trust, a regional teaching hospital – both in the United Kingdom.
Methods: Participants were invited to perform chest percussion on one of the authors. The level of sound produced was measured by a decibel meter. The quality of the percussion was rated and each participant was asked to rate the relevance of percussion in the current clinical environment.
Participants: We obtained percussion data from 56 different subjects – medical students (29), SHOs (14), registrars (8), Consultants (6).
Results: There was a clear increase in the level of sound produced as level of seniority increased. While all of the consultants and registrars felt percussion remains relevant only 26% of the SHO/medical students felt it is relevant.
Conclusion: The role of percussion in current medical practice may be diminishing. This is reflected by reduced quality of percussion and also attitudes from the more junior medical staff who feel it is of limited clinical relevance.

Introduction
Physical examination is undoubtedly an essential skill in clinical medicine. The structured approach of inspection, palpation, percussion and auscultation has been taught for many years. The ability to perform a thorough examination is important in both the diagnosis and management of a patient. We believe it should be viewed as a reflection of a clinicians’ underlying anatomical and basic science knowledge and should be taught with an understanding of the surface anatomy of the body.

In our specialty of cardiothoracic surgery the value of percussion has been clearly demonstrated in the assessment of pleural effusion – it can been likened to ‘clinical ultrasound.’ – the stony dull sound of an effusion can accurately determine the level of the effusion and appropriate site for drainage. Percussion is also recognised as an important tool in other systems examinations eg. Shifting dullness of ascites and percussion tenderness of peritonitis. The senior author, a recognised surgical trainer with two decades of consultant experience, has noticed a decline in the use of physical examination amongst students and surgical trainees. A review of the literature suggests this is not an isolated opinion (1,2).

We considered how we would be able to obtain quantitative data assessing ability to percuss – we do recognise there is no valid scoring system of percussion ability. However, it did seem sensible to consider its value in the clinical environment and acceptability to a patient. The first factor includes the ability to use it to produce clinically meaningful information and we felt the level of sound is important in this respect. We decided that this should be measured using a standard decibel meter. Maintenance of patient comfort is something that is now regularly assessed in medical examinations.

Finally, we asked for an opinion regarding the relevance of percussion in the clinical examination – not relevant, uncertain or relevant. We feel it is important but, regular comments from our students seem to suggest they see percussion as becoming redundant in an era with easy availability to many different forms of imaging.

Methods
We aimed to distinguish between different levels of medical staff in a manner that most likely reflects levels of training and experience. To this end we divided participants into four groups reflecting the traditional and widely recognised firm structure – medical student, senior house officer (SHO), registrar and consultant. Of note, all the medical students were in the ‘clinical years’ and had undergone system examination teaching.

One of the authors acted as the patient. A standard decibel meter (Figure 1) was placed on a table next to the seated author at a distance of 1 metre and the decibel level reached percussing over the clavicles was recorded. Of note, each participant was invited to percuss three times with the highest reading recorded. The author also made an assessment of the ‘quality’ of percussion; poor, satisfactory or good. Finally, the participant was asked to rate their impression of the relevance of percussion; relevant, uncertain or not relevant. The data was collected over a three-week period at the end of 2018.

Figure 1. Decibel meter used in study

Results
Data was obtained from 56 different participants – medical students (29), SHOs (14), registrars (8), Consultants (6).

The minimum volume detected by the sound meter is 30 decibels.this is less than the volume of a normal conversation which is 60 dB The number unable to percuss and achieve this level is illustrated in Figure 2.

Figure 2 – Number of participants unable to percuss per group

The level of sound produced by the remaining participants is shown in the box and whisker plot figure 3.

Figure 3 – Box and whisker chart

Discussion

Perhaps the most striking result of this study is that despite the fact that all participants had been formally taught clinical examination, some were unable to produce clinically meaningful percussion. Additionally, those at the earliest stages of their medical career were more likely to feel that clinical percussion had no relevance in current clinical practice.

Our data suggests that clinical percussion may well become redundant. The reason for this could well be related to changes in medical education over the last few years. Medical student teaching has reduced drastically with a much greater focus on self-directed learning (3). Many medical schools have reduced the amount of time that is dedicated to teaching the basic sciences (4).

For the clinical examination to be successful, we believe the practitioner must have a sound understanding of the underlying anatomy. Within the surgical community there have been major concerns that anatomy knowledge may be falling – this has even been translated into concerns about patient safety (5). It may also be a case that the clinical need for percussion has drastically reduced.; the availability of imaging such as ultrasound and computed tomography may well mean that the ‘head to toe’ examination has been superseded. Ultrasound and Computer tomography may be a more ‘accurate’ method of determining pathology, but it is not without exposure of a patient to radiation, inconvenience of reattending for investigations and discomfort. Furthermore, CT scans and Ultrasounds with expert staffing and reporting is not without considerable cost. The senior author remembers being told as a trainee that ultrasound is just a more deliberate and informed palpation!

We would also like to propose an ideal technique of performing percussion. Having observed many different attempts and techniques there was one particular method that seemed to be consistently successful. The clinician places their middle finger flat over the area of interest and using the middle finger of the other hand it is struck crisply at ninety degrees in the centre allowing the extended wrist to fall in a relaxed manner. It is much the same as the pianist striking a key. We must point out that effective percussion is not possible with long finger nails.

From our personal experience we recognise the value of percussion in our clinical practice as cardiothoracic surgeons we are sure many colleagues share this opinion. However, it would appear that the next generation of doctors may not agree with us. We believe that more attention should be paid to proper examination skills – after all the syndromes described in the back of the Oxford handbook of clinical medicine are really just a result of astute physicians understanding the relevance of a collection of sometimes subtle clinical signs Inspection, Palpation, Percussion and Auscultation, in that order, applies as much today as yesteryear. We record an over 90% 5/5 patient satisfaction in our clinic – we believe that is because our full examination attends to these precepts

Limitations
We acknowledge that grouping students and doctors as we have does not always provide an accurate reflection of levels of experience – doctors at SHO and registrar level could quite easily have been practicing medicine before those in the consultant group. We also acknowledge that we may simply have highlighted the natural learning curve of clinical examination – consultants are more polished and practiced than those more junior to them. Finally, this is only a small study and the same results may not be borne out in bigger samples.

Conclusion
This study has shown that those earlier in their training are less proficient in clinical percussion and feel it is not relevant in current medical practice. These findings lend further support to the idea that basic clinical skills may be being eroded in an era with easy availability to advanced technology and imaging. We hope that it is able to highlight the need for re-emphasis on the fundamental aspects of clinical medicine.

Footnotes
Author contribution: Both authors contributed equally to the production of this article.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References

1. Faustinella F, Jacobs RJ. The decline of clinical skills: a challenge for medical schools. Int J Med Educ. 2018;9:195–197.
2. Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. J Hosp Med. 2009;4:304–307.
3. Howe A, Campion P, Searle J, Smith H. New perspectives–approaches to medical education at four new UK medical schools. BMJ. 2004;329(7461):327–331.
4.  Weatherall D. Science and medical education: is it time to revisit Flexner? Medical Education.2011;45:44-50.
5. Turney B. Anatomy in a modern medical curriculum. Ann R Coll Surg 89 (2).104

Katherine Hurst, David O’Regan

Have you been told during a weekend ward round or night shift.. ‘In our day we worked a one in two’, ‘In our day we lived in the hospital.’ These statements are impressively true, but along with this our now consultant body had meals provided, a bar in the Mess… an actual mess!, accommodation on site, a single ward of patients and most importantly a team. Ten years down the line; we have shift work, multiple handovers, are rarely able to work with the same junior doctors and consultants in a rotation, and daily piles of paperwork. To add to this, our on call rooms are slowly being removed or charged for, restaurants close at 7pm and inpatient numbers are significantly higher. All during the time of heightened awareness of a 24/7 NHS. Where has the fun in Surgical Training gone?
Socialisation is implicit in all the models of knowledge transfer. The original SECI model of Nonaka started and finished with socialization, and ‘tacit knowledge’ – knowledge which cannot easily be articulated, but is vital or organizational constructs, acts as one of the key pillars to this.

The importance of enabling people to meet and chat was an underlying principle in the design of the modern science institute behind the British library. Architects, sociologists and psychologists understood the need to enable people to ‘bump’ into each other on a regular basis and designed buildings like ‘large hadron people colliders’. Many an innovative thought has originated from a chance encounter.

The anthropometric value of our very being is underlined in the fact that work is a social construct. We need formal and more importantly informal social contact to realise our ‘relatedness’ needs (as described by Aldefers modification of Maslow hierarchy of needs). We need other people to communicate with, build relationships and thereby foster trust. We cannot work in isolation as individuals. The world of health care is very complex and complex systems depend on good relationships.

Sadly, this opportunity is being removed from medical staff. The doctors mess, dining room and residents have been consigned to stories of a bygone era. In less than a quarter of a decade we have gone from starched white table cloths and sit down lunches breaking a full theatre day, to grabbing an anonymous sandwich on the run. Of course this has had to change for many reasons; as we have moved to a more egalitarian and multi disciplinary way of working, but why can’t we recognise the fun and camaraderie that it engendered and build it into today working environment.

This is certainly not to say our consultant staff did not have a hard time; they were largely unsupported, learned from mistakes, and worked 100+ hour weeks… but there was an obvious emphasis on teamwork and fun in training. At present increasing number of trainees are taking time out of training, moving abroad or leaving the profession. Causes for this are wide, but certainly include burnout, lack of support and/ or value, and increasing work demands due to lack of staff.

Senior perspective
Due to unforeseen circumstances, the senior author was left resident without a foundation doctor or registrar one Sunday. Although a pleasant day, as night closed in, it became more apparent that he was seeing fewer and fewer colleagues. There was no ‘chit chat’. The hospital divested itself of all visitors and the number of people seen in the corridors dribbled away. The place became desolate and void of any human interaction. The lack of relatedness needs was troubling and further exacerbated by the fact that basic needs of food, hydration and a place to put you feet up were not met in any form or fashion. The experience was soul destroying and appropriately described by the encounters of Harry Potter with the dementors. The scattering of poorly maintained vending machines could not provide enough chocolate to mitigate the effect. This led to a reflection that the conditions under which we expect junior staff to work are appalling.

In contrast, on a trip to the USA, Mr O’Regan visited John Hopkins hospital that colloquilised the term ‘rounding’ due to the fact that wards were arranged around each other. The day started early at 0600 having breakfast in a food / dining emporium not to dissimilar to those found in shopping malls. Staff and whole teams were noted to be taking breakfast together at round tables. The meet and greet was generous and genuine. The work of the day was shared and discussed. The SECI model of knowledge transfer was alive in a purpose built and dedicated food court that was clearly bringing out the best in everyone. Excuse the pun but this offered food for thought!

One or the senior cardiac surgeons provided a coffee machine in their department at his own expense of six thousand dollars a year. The offices were organised around a central administration hub and the coffee machine was in the middle. He noted and valued the fact that the cardiac team met in this informal hub at the beginning of the day to share experiences, exchange knowledge and conduct the business of the day. This simple and generous act paid for itself many times over as the team reached and aspired to do better. It is well recognised that happy staff make for happy patients.

It was not surprising to learn that a well known coffee outlet in the foyer of the hospital was doing a roaring trade and has now elected to be open 24/7 including Christmas Day. Could this not be a lesson for all leaders and managers in the NHS. Look after your staff and the staff will look after you and the patient. It is all there in the theories of anthropology, sociology and psychology- after all doctors are human too.

Junior perspective

Only 6 years ago as a foundation doctor, I thought life could not get any better. As part of a medical/surgical team we would see and treat patients, learn skills as an apprentice, and at the end of the list (or week) regroup in a local public house with time to reflect, relax and even laugh. Although shifts were busy and we often finished several hours late, there were still opportunities for a team coffee or evening dinner when rotas allowed. These events not only provided opportunities for guilt free ‘down time’, but also encouraged the development of bonds within teams, scientifically proven to improve patient outcomes. I cannot believe the difference in only six years. At present we are fighting a demoralised NHS system, where paperwork and overwhelming numbers of patients are leaving doctors tired and stressed at the end of the day.

The last thing colleagues wish to do is stay around the hospital for longer periods of time. Even if possible – who do they stay with; the foundation doctor they have met once before or the boss who is only their boss for a week. There is no will or time for social and team bonding events, which has knock on effects including; colleagues being less willing to swap shifts or stay late to help a ‘friend’, fewer ‘corridor conversations’ which would benefit patients, and juniors struggling to sign off even the commonest of daily tasks. Rotas have inflicted ‘shifts’ rather than vocational jobs, and time spent in the hospital is becoming a chore, not a commitment to patient care. I remember a time when the whole department attended our National Conference. This was the perfect setting for tacit knowledge. Socialisation, building of trust and rapport, and discussing future projects outside a busy NHS working day. This year one consultant and one trainee attended.

How can we change this – it is difficult to say. Trusts simply do not have the money to improve staff facilities, or provide the amenities which had been available to our predecessors; but these factors are vital for staff morale and retention and more importantly patient care.

We need to stop the rot around surgical training which is demoralising current trainees, inhibiting the uptake to surgical training numbers, increasing our drop out rates and most importantly affecting trainees mental health. Lets put the fun back into working for the NHS!

David O’Regan
Consultant Cardiac Surgeon
Director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh

Arthur Ignatius Conan Doyle was born in Edinburgh in 1859 and decided to study medicine at Edinburgh University. It was one of his teachers, Dr Joseph Bell, a Fellow of the College of Surgeons, who most impressed him and influenced his career. Dr Bell was a master of observation, logic deductive reasoning and diagnosis. These attributes were to stimulate him to create that character
of Sherlock Holmes. The back pages of the Oxford handbook of medicine are filled with syndromes eponymous to the clinicians who demonstrated similar skills. Almost all the syndromes described are a collection of observations using the all the senses during inspection, palpation, percussion, and auscultation. Perceived lack of time in clinical practice and the advent of tick box clerking forms are eroding clinical skills, costing money and removing the joys and nuances of history and examination. Inspection of the patient in bed and the surroundings will tell you of the patient is well or unwell – lipstick, glasses and a cup of tea are usually signing well-being. Observation of the patient getting out of a chair and walking into the outpatient room offers indication of frailty and mobility. The handshake is good measure of grip strength and nutritional status 1 . A welcoming smile and a proper address reflect respect.

Few people can talk without hesitation or deviation for more than a minute, but it is recognised that doctors have a bad habit of interrupting 2 . ‘In your own words. please tell me what is bothering you today…’ and listen while observing the ninety five percent communication that is non-verbal. It is what matters to the patient that counts. Verbal and visual cues are important. It was sad to hear a seventy six year old lady presenting for coronary artery bypass surgery telling us that her husband has dementia and falls and that she does not want surgery but wants help with her husband who is asking for a divorce after fifty five years of marriage because she believes he needs to be in care’; it is what matters to the patient that counts. We should not encourage disease conveyor belts – not operating with reassurance is all that is required. Finding a fungating penile cancer inserting a urinary catheter in a patient requiring acute revascularisation is indicative of silo thinking and failure to enquire or look; systems enquiry is a diagnostic sieve predicated with open questions and followed through with direct deductive questioning.

Examination is a privilege. Inspection takes in every detail – a faeculent burp of patient four days post cardiac surgery was the clue to a strangulated umbilical hernia on a late Friday afternoon ward round; this did not need CT confirmation. Palpation is done with the lightest of touches with the extended fingers of steady hand at the level of the elbow whilst cognisant of a knowledge of surface anatomy. The patient is often too polite to tell you if it is uncomfortable, but their facial expression will tell you all. Percussion and tactile vocal fremitus are akin clinical ultrasound. Auscultation should be able to detect the whisper of a murmur and the tinkle of obstruction – what happened to Korotkoff sounds? All patients all the time deserve a full examination no matter how or where they present. A proper examination in our clinic has removed the need for follow up chest X rays and realised a saving of £24 000.00 a year, improved the flow and reduced the waiting times. Investigations should supplement and not replace clinical acumen – ‘routine’ preop tests 3 and post op ‘bloodletting’ 4 costs and caused distress.

The social history not only gives the clinician the sense of value and utility of the decision making for the patient, but it also enhances the clinical contact. How many people have met the designers of the Spitfire or soldiers that have paraded the colour for our Queen? People bring stories – attention to the ‘name of the dog’ 5 and the last holiday recorded in the notes adds to the 5/5 patient experience. It is a simple trick understood by many in the service industry but rarely in the NHS were the operative word should be SERVICE. Ignatius, the editor of Harvard Business Review stated that health care is complex. The CEO of Starbucks said that his business is simple – one customer, one barista and one cup of coffee at a time. Health care is the same – one patient one need and one clinician at a time. The best hospitals in the world have learnt that to fail in that interaction just once is more than enough. A good history and examination is fulfilling for the clinician and ‘transformational’ for the patient 6 . It delivers what matters to the patient, improves flow, reduces costs / litigation 7 and is an enjoyable experience for the clinician and patient.

References
1) https://www.ncbi.nlm.nih.gov/pubmed/31501128
2) https://www.ncbi.nlm.nih.gov/pubmed/31388903
3) https://www.ncbi.nlm.nih.gov/pubmed/26721128
4) https://www.ncbi.nlm.nih.gov/pubmed/25383435
5) https://www.ncbi.nlm.nih.gov/pubmed/30281983
6) https://youtu.be/uoWp52mfUjg
7) https://www.ncbi.nlm.nih.gov/pubmed/30525963

Culture and Needs

Many companies finding themselves in a predicament start calling for a change in culture. It is also claimed in the business literature that culture eats strategy for breakfast. Modern human resource management (HRM) is no longer a transactional (i.e. pay and conditions) but more translational (ie investing in your employees). I really do believe the inimitable value of the NHS can be found in our staff. Yet, sadly, national and local leaders do not appear to be investing their employees.

Culture is defined by how things are done around here and ascertained by listening to the conversations in the corridors. But, how do we change culture? What levers do we pull? This is a question that has vexed me for some time until I discovered the guru on organisational culture; Edgar Schein is a Professor at Massachusetts Institute of Technology in Boston. I ascertained this when I attended an Institute of Health Improvement Executive Patient Safety Officer Conference in Boston in 2008. I was talking to two Harvard professors and they referred to Professor Schein in the present tense. So important is his name in the field of organisational behaviour, I wrongly assumed him to be deceased and got his attention by recounting my surprise and delight to find him alive and well.

Professor Schein agreed with me the term culture is bounded about by many with little concept of what it means and with no instruction on how to change it or what levers to pull. He did make a profound observation however, that attitudes and behaviours culminate in culture. I summarise it as

It is that simple. The HRM established paradigm that you hire attitude is upheld. The organisation code of conduct then needs to make explicit and coach desired behaviours. These can all be derived from the espoused values of the said organisation, but, I believe it all stems from the operative word ‘SERVICE’ as in National Health Service. It not surprising that many of the values that are published by health care organisations say the same thing. It is a variation on the trite phrase ‘we aim to please!’ We are all ‘aiming’ but are we achieving it? Do the values actually carry the same meaning to all? Is it just empty rhetoric?

It all very well to talk the talk but can you walk the walk? Modern leadership has moved from the heroic to servant. The role of the modern leader is to attend to the needs of the staff and provide an umbrella to protect the employee from the organisational rain.

This is where I would like to introduce the counter point to culture. It is commendable to call for a change to the culture but if we do not attend to the needs of the staff, I do not believe this will ever happen. Culture of the organisation and the needs of the individual are interdependent.

I would like to draw on the concept of the needs hierarchy as described by Maslow and others.

Culture is the expression of a collective feelings of the staff reflected in the corridor conversations. More often or not the themes express dissatisfaction around pay and conditions of work and how they are implemented by the immediate managers. It is part of the organisational gossip. These are the ‘Deficiency’ needs that are attended to by the transactional activities of HRM. These have to be satisfied before anything else. Six years ago a newly appointed colleague came to me as Lead and sheepishly told me that he had not been paid and since the hospital was running essential services over Christmas, it would be January before this could be addressed. He had bills to pay at the beginning of January. I reached for a cheque book and the phone and was fortunate to find a very helpful person in Finance who sorted it before he left the office. I caught this one but there are plenty of examples. I am disappointed by the ‘banding’ process and the fact that the individual has been reduced to a ‘cell’ on an excel spreadsheet. We are in a people business and not a spreadsheet trade. It is not personal and individual needs are not being met. I believe many of our organisations are failing in their basic ‘hygiene’.

In the West we consider the individual as being one self in contrast to the East where the concept of many selves is recognised. The individual staff, to use a colloquialism, have many hats to wear. Each person has at least a work, social and domestic self.

I have taken the liberty of populating these scales and the ‘deficiency’ needs become apparent – safe, secure, pay and conditions.

The ‘relatedness’ needs are summarised in the word TRUST. I often think it is an oxymoron that we refer to many of our health care organisations in the UK as Trusts. I return to a quote by Edgar Schein.

Integrity, honesty and transparency of local leadership are requisites for cohesion and fostering commitment at work. The most important leaders in a hospital are he Matrons, Ward Sisters and Clinical leads. Before anyone can realise the shared and expressed worth of the staff, which I believe be a mark of a successful organisation, we not only need to attend to deficiency or hygiene needs but also to practice our relatedness skills. The advice to managers holds true. Be seen and communicate, communicate and communicate. Salience is essential in any organisation and will dispel the many conspiracy theories that often echo though our corridors.

How do we get the best out of staff and realise WORTH? Monetary reward is recognised as a motivator in some sectors especially manual labour but for health care staff, once the basic or hygiene need is met and relatedness needs are optimised then further development can only be achieved by creating opportunities for self- improvement and development. Of course, this takes TIME and requires SPACE. These dimensions are, in fact, two of the five basic assumptions described by Edgar Schein as essential ingredients for establishing a culture. It is disappointing that our health care organisations look to remove seminar rooms for clinical space and many rotas are so hectic that time is not given to training the individual yet alone the team. The paucity of learning space is reflected in the fact that we have to book seminar rooms furnished with audio-visual equipment a year in advance.

Lastly, Simon Sinek describes Autonomy, Mastery and Purpose as powerful motivating factors. I believe this applies not only to the individual but also to the team. I would add to this triad the word identity. All the staff that I have worked with over the years have taken pride in their identities as teams that deal with specific patient conditions e.g. Vascular team. Urology team and Respiratory team etc. Almost all these functional teams are organised around a specific patient pathway. They are the Masters of patient care. They should be afforded Autonomy. Deming told us that the professional ‘doing the work’ be allowed to ‘design the work’ and ‘inspect the work’. Is that not what trust means?

It is folly to interfere with these established yet sometimes informal identities that reaffirm Mastery and Purpose. I believe it is unreasonable expect people to cross cover other disciplines. I would go even further to suggest that this may not be safe as staff may not be familiar with ‘the way things are done’ in each area of the hospital.

Empowering is somewhat condescending but emancipation is more pertinent and relevant to motivational theories and individual needs. The question is ‘Do our leaders have the courage to let go and give staff the latitude and discretion to do what they think is best for their patients?’ The opportunity to self-organise and be supported by visible servant leadership is summarised in a simple question, HOW? Wouldn’t it be wonderful to work in an organisation where the leaders ask you ‘How can we help?’

The NHS is the people. It is possible to outsource every other function of a hospital but you cannot find the skills and compassion of the people who care for patients. This is the inimitable and what we should value. An organisation should take responsibility of ensuring staff excel and surpass their skills and those of others. I call this TRANSCENDENTAL HRM. NHS management should assume the responsibility for GROWING people and realising their worth. This applies to any organisation.

Complex systems require that we trust our staff. Our leaders should be visible and be asking HOW can they help. In other words they must be seen and heard serving the needs of the employees.

In summary, I believe a happy productive culture can be achieved through meaningful service values and attending to the needs of the individual and teams. I would call it a HOW campaign. I suggest HOW as it stands for a Happy On-board Workforce. I offer my strap line that we are in the business of

Educating People and Creating Value

David J. O’Regan

MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd

Thesis –‘Why can’t Dinosaurs Boogie?’