D is for Directing Your Dream Team

The unauthorised guide to project managing your way out of trouble…

If I was famous and I was being interviewed about seminal influences on my life, then I would have to talk about Steven Moffat. Steven Moffat is basically responsible for my career. Long before Benedict’s Sherlock and David’s Doctor Who, Steven Moffat was writing the best children’s programme on TV about a bunch of teenagers who ran their own newspaper, led by the brilliant, bullish, and frankly slightly nightmarish Lynda Day. This was ‘Press Gang’ , and Lynda Day was my #1 hero. Not because I had any interest in journalism, or a lifetime ambition to edit a newspaper, but because she was awesome, and she was in charge. Being ‘in charge’ appealed to me a lot. I didn’t have any particular preference what I was in charge of, just as long as I was the one calling the shots. It’s no surprise then that rather than aspiring to be an astronaut or an actress, I decided at an early age that I wanted to live in London, wear a suit and high heels, and tell (‘advise’) people what to do. I got my wish, and just as I was settling nicely into those super smart stilettos, cancer came along and put me on a compulsory career break.

Managing stuff is what I do. It’s my specialist skill. So when cancer hijacked my life I felt like David Beckham waking up one day to find both his legs in traction and his pretty face covered in pimples. Here was a shock development that I didn’t plan for, didn’t really understand, and was basically powerless to do anything about. For someone who has spent a lifetime wanting to be ‘in charge’ this did not sit particularly well. But I rapidly concluded that if this process was anything then it was ‘Project Emma’. Everything, and everyone, was working in pursuit of my good health. And every successful project needs a superstar manager; every F1 team needs a Frank Williams. There is only one woman for this job and she’s spent her whole life in training for this kind of challenge – someone pass me a pair of my finest, fiercest power shoes, because here is a Project with a capital ‘P’, and it’s got my name written ALL over it.

We’ve got something to do. Probably the biggest thing we’ll ever do. And your co-operation is more than appreciated, it’s compulsory – Lynda Day, Press Gang

A successful project is all about the 3 ‘P’s – People, Plan and Process:

1) People
Rubbish managers think they are brilliant at everything. Brilliant managers know they are rubbish at most things, so surround themselves with people who better than them, and equip them with everything they need to be brilliant. The first and most critical task of the Patient Project Manager is to define your dream team:

• Board of Directors – the Consultants
  Surgeons and oncologists – these experts are at the top of the chain of command. Without these people you don’t have a project. You trust them with your life and treat them with something akin to hero worship. You never really tell them what to do; rather they present you with the options, you ask some intelligent questions just to ‘kick the tyres’ and sustain the impression that you are ultimately in charge, and then they provide their recommendations, which you duly accept and approve unless you have a) a PhD in medicine, or b) a deathwish.

• Team Leads – Family and Friends
  No matter how independent and capable you are when you start this project, you will swiftly conclude that you need a lot of help to keep it on track – from simple logistics like ensuring you have bread and milk on the days you can’t actually get out of bed, to morale boosting team events – i.e. necking martinis with you while you adjust to your new ‘role’, and then joining you for kale stew with a side of kale because the Sunday supplements told you it had more cancer fighting properties than martini. People will naturally settle into roles on your core leadership team according to their position (in your life), proximity (to your house) and core interests/skillset (if they can’t prepare a cheese toastie don’t put them on Nutrition). These people have ‘skin in the game’ – they are just as passionate about this project as you and are your steady stars through stormy weather. Together with your wider team they are the reason to get up and go to work every day; they put the fun into project activities, bear a share of a load you can’t possibly carry alone, and will even (probably) forgive you the occasional foot-stamping managerial outburst.
• Out of Hours Support – Anyone who lives abroad/suffers from insomnia
  This is a 24 hour a day undertaking. It follows that you require a ‘follow the sun’ support network – i.e. someone available to pick up the phone or answer your whatsapp at 2am. If you don’t know anyone who lives abroad then consider sending someone. Failing this target someone with nocturnal Netflix habits, or a new mother.

• Executive Coach – Psychologist/Counsellor/Confidante
  No one ever won a boxing match without some bloke shouting in their ear to get them up off the ropes. It stands to reason you need a coach to keep you in line, so you can in turn keep this train on the tracks. Ideally this should be a professional, well versed in the specific challenges of this type of project, who can act as sounding board, trusted advisor, and generally keep your head in the game.

Inside of a ring or out, ain’t nothing wrong with going down. It’s staying down that’s wrong – Muhammad Ali

2) Plan
First you have to define the scope of the project (i.e. extent of the issue and treatment plan to fix it), and then the key tasks and timeframes. However, the first rule of this plan is that there is no plan. At least not one you can stick to with any level of rigidity; this is more of an aspirational ‘guide’ subject to a high degree of uncertainty and risk of unforeseen eventualities. Like Arnold Rimmer’s revision timetable, you will likely spend so long replanning the plan, that you may find it difficult to squeeze in the tasks required to actually execute the plan.

The Battleplan Timetable – inspired by Arnold Rimmer, Red Dwarf

3) Process (i.e. doing stuff)
Successful project management is as much about appearing like you know what you’re doing as much as actually knowing what you’re doing. Hence you nod sagely and say with absolute authority “Absolutely. What we need here is a replan, and we need it yesterday”, when really you have absolutely no bloody clue what just happened, what needs to happen next, or where you left your house keys. Once you’ve got your people and plan in place then it should just be a question of making stuff happen. Simples. Except this is a relatively specialist subject, so you need a crash course in cancer jargon to protect your reputation and ensure you at least look like you know what you’re talking about.

“I’m not responsible for everything. I just make it look that way.” – Lynda Day, Press Gang

Breast Cancer Management Jargon – 15 key terms every Patient Project Manager needs to know (the unauthorised & selective guide*):

• Anaesthesia – upside of painful surgery; the equivalent of a project party. 1) LOADS of (at least 3) people fuss around you, which makes you feel very important; 2) 7 seconds of the most delicious drunken feeling ever, with none of the queasiness or copious drinking that was required beforehand; 3) the most charming men in the hospital are hiding in the depths of the surgical unit ready to put you to sleep – and they’re the first person you see when you wake like Sleeping Beauty emerging from a hundred year slumber of delightful drug induced dreams…for the split second until you have to assume your leadership persona and inform them in no uncertain terms that yes you are in some discomfort, and YES you require additional pain relief.
• Biopsy – tissue sample to exclude (or confirm) cell malignancy; essentially a ‘hole punch’ of the part of the body under investigation. For breast irregularities this is generally performed under ultrasound – the same as a prenatal scan: excessive amounts of cold jelly, a little image on the big screen (except this definitely isn’t a baby), and loads of anti-absorbent blue paper towelling to wipe yourself down.
• ‘Breastoration’ – unofficial term to describe the process of restoring breasts to something vaguely resembling their former glory. Encompasses (but is not limited to) lumpectomy/mastectomy, implant and/or tissue reconstruction, and nipple salvage/substitution (more on which anon). Forms a lengthy portion of the project plan, with reasonable risk of Complication. Like building restoration it “demands special skills, expensive materials, and can involve hidden costs” (OED)
• Clinic – Regular meeting with members of the Board and their supporting teams for status reviews, decision making, and occasional crisis talks. Like any executive meeting it pays to be well prepared for the topic under discussion and any potential ‘curve-balls’ that may arise. These people are generally quite busy saving people’s lives, so I believe it’s best to keep things succinct and to the point – even if you have waited 2 hours for a 2 minute consultation.
• Complication – polite term for anything that can go wrong, ranging from mild infection to accidental death. Also known as ‘exception scenarios’ – these should be considered and planned for according to the relative risk and likelihood of the eventuality.
• Grade – measure of ‘aggressive potential’, i.e. how much your cancer cells resemble normal cells on a scale of 1 to 3 – Grade 1 are mildly non-conformist; Grade 3 are in full scale rebellion (consider this payback for your teenage years as an insufferable nerd and goody two-shoes). One of several key inputs to Board level decision-making on the overall treatment plan.
• Hormone Receptor Status – the level to which breast cancer cells feed on the hormones oestrogen and progesterone. Measured on a scale of 0-8; 0 being that they don’t, +8 being that they are big fat lardybums feasting on the chemical source of your youth and feminine vitality. Another key input to the project plan; positive hormone receptor status means you can cut off their supply and starve them out through hormonal therapies which are a bonus weapon in the treatment arsenal. However, no pain, no gain – hormone treatment generally comes at some personal cost and inconvenience, especially for younger women. Generally measured in combination with Protein Receptor Status – the extent to which cancer cells respond to human epidermal growth factor (HER2). These can be treated with targeted biological therapies, notably wonder-drug Herceptin. Breast cancer with negative receptor status is classified ‘triple negative’, and is the subject of trials to identify effective targeted therapies.
• Lymph Network and Nodes – part of the immune system, the lymphatic network transports fluid around the body and the nodes filter out harmful substances. Important because cancer cells can be transported within the lymphatic network from the original tumour to other distant sites. If the lymph vessels are the motorway network of the body, the nodes are the service stations. Lymph node biopsies reveal if the cancer is contained within inner London, or has ventured outside the city walls to Watford Gap and beyond. Lymph node removal may be carried out to contain the cancerous cells. In breast cancer this is like closing the M1 between your breast and your wrist and can result in severe congestion – a Complication, technically known as ‘lymphodema’.
• Mammogram – breast X-ray. Requires you to place your breast in a vice and let someone compress it until your eyes are watering and it can be compressed no further. Naturally it was invented by a man and – to my knowledge – there is no equivalent procedure for male sensitive parts.
• Medical Student – people who were generally born after 1995, and therefore do not appear old enough to know anything about medicine. The equivalent of the office intern, however inept and clueless they may appear they are the Consultants of the Future, so it’s important to support their education by showing them your breasts (they may blush), sharing things they don’t know about cancer (basically everything), and letting them have a go. Except at anything which requires them to place a needle anywhere near your actual body – politely suggest that they pick another poor pin cushion for target practice.
• Morphine – narcotic analgesic. Impairs judgement so critical decisions should be avoided at this time (ditto cold-texting old flames to tell them what you really think of them). Makes you sick as a dog, until you receive the maximum strength anti-sickness medication, at which point it can be quite effective at minimising pain and providing a general sense of well-being despite the relatively stressful nature of directing proceedings from your hospital bed (no wifi; the Ward Sister officially outranks you). Apparently people take this for pleasure, though I cannot imagine why.
• MRI – magnetic resonance imaging. Another critical diagnostic tool for initial project planning, and regular status reviews. An MRI of the breasts requires you to mount a long narrow table, assume the plank position, and then lower yourself slowly with your naked boobs dangling until you have positioned them perfectly within the Perspex ‘breast-box’, before finally settling yourself into a rigid ‘Superman’ flying pose which you have to maintain for 45 minutes WITHOUT MOVING lest you ruin the imaging process and have to start again. During this time you will be transported into a magnetic tube, subjected to a cacophony of deafening electronica, and have ice cold contrast injected in your outstretched hand. Requires bodily strength, mental fortitude, and a plan to distract yourself. Personally I find it helpful to run through the full unabridged lyrics to American Pie (8 minutes) and then move onto Tennyson’s Lady of Shallot (19 verses) which we had to recite at Primary School, during which I rapidly zone out and imagine I am in an episode of Spooks, subject to stress-position interrogation by a foreign enemy, and will shortly be rescued by Adam Carter providing I DO NOT MOVE. This tends to sustain me for the remainder of the scan.
• (NB the instructions on what to wear under your hospital gown may be unclear at best. In medical procedures, as in life, I find it is generally advisable not to remove your knickers unless explicitly requested.)

• Pathology Report – official ‘as-is assessment’ on the state of your cancer. Defines how big, how advanced, and how it behaves. A more comprehensive view than the biopsy report, this forms a crucial input to defining what treatment you need, and in what order.
• Prognosis – the likelihood that your project will result in success. Strictly prohibited for use unless you are a member of the medical profession. Do not even think about speculating on this with the boss unless you are a professional, and even then you’d really better know what you’re talking about.
• Stage – a category used to define how advanced your cancer is, based on the characteristics identified in the diagnostic tests. Put simplistically the combination of Size + Grade + Lymph Node Status = Stage (1-4) which advises your personal treatment plan. Also linked to ‘Prognosis’ on the basis of historical survival data, though – like any statistical calculation – it is beset with shortcomings, not least that the data is necessarily 5+ years old, so should be treated with caution. Like age, Stage is but a number, and makes no allowance for the individual. And, like the Grand National, a horse can look like an old nag on paper, but with the right alchemy of team, training and tenacity and a little bit of Lady Luck can still win the toughest race in the calendar at 100-1.

^{*Partial selection focusing on diagnosis; other key terms will be explored in future posts.}

Lynda : I’ve had my day off now. Can I come in?
Kenny: It’s still the morning.
Lynda : I got up early.
Kenny: Look, Lynda, make the effort. Relax.
Lynda : Have Spike wrapped and delivered. I’m bored

– Steven Moffat, Press Gang

Links & References

The authorised and comprehensive guides:

Initial Tests: http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/diagnosis/breast-cancer-tests

Further Tests: http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/diagnosis/further-tests-for-breast-cancer

Treatment: http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/treatment

^{[1]Press Gang written by Steven Moffat, produced by Richmond Film & Television. Lynda Day – further tributes: https://www.youtube.com/watch?v=2Z-a11MjdDY}

^{Background image credit: David Ring for the Europeana Fashion project (www.europeanafashion.eu) https://commons.wikimedia.org/wiki/File:Stilettos.jpg?uselang=en-gb}