Don’t Multi-Task, Multi-Think #WILTW

This is the 134th #WILTW

There are very few completely original ideas.

Someone, somewhere is always likely to have thought of something before you have. Genius more in being credited for the idea rather than having it!

Andrew Tagg released a great blog post this week. He muses on there “never being enough hours in the day“. I am often challenged on how I find the time to do so much; especially considering that I am “always tweeting”.  My stock response to this is “well how do you know I am tweeting so much if you aren’t on twitter too?

Seriously though, like Andrew, I am relatively regimented about out-of-work routines and there are somethings I treat as a hobby rather than a chore. I do appreciate this is a fine line and it is important to take stock and be honest with yourself about why you are doing what you are doing (especially with social media). I share with Andrew a general aversion (or maybe more correctly an avoidance) of television and video games and also see so much kinship with this:

“I currently have ideas for about 20 blog posts in slow Brownian motion inside my head.” 

via https://www.discussingdissociation.com/

One of my greatest faults is to not always be present. My colleagues do very well to tolerate this in me. It is often because an idea or thought from 2 weeks ago  re-surfaces with a progression or solution. I am not knowingly mulling things over but somewhere in my brain synapses are firing away.

Having read the post I coined the term “multi-thinking”. I am not efficient because I am multi-tasking, it’s because my brain is simultaneously working on lots of projects in the background. Sadly after googling multi-thinking I realised I wasn’t the first person to coin this. There is actually science behind it; the more precise term probably being a variant of integrative thinking.

“..the predisposition and capacity to hold two diametrically opposing ideas in their heads. And then, without panicking or simply settling for one alternative or the other, they’re able to produce a synthesis that is superior to either opposing idea…”

The ability to multi-think is, I’m sure, impacted by state of mind or other external factors, but it’s a pretty reliable component of my productivity, especially what I learnt this week!

What have you learnt this week? #WILTW

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In googling for multi-thinking I found this post on procrastination which while not directly related is quite fun….

 

It’s easier to recognise wrong from right #WILTW

This is the 133rd #WILTW

While delivering a presentation at #MedX a member of the audience was taking notes in a different format than usual.

James is a healthcare designer and his visual note taking really appealed to me. He recently visited our children’s Emergency Department and had some amazing insights, both from a design point of view, but also because of his perspective from outside of the healthcare profession

One of his comments:

Kneeling down and reducing your physical size is so important. Witnessing situations where adults didn’t match the child’s eye level made it even more obvious of its importance.

Those working in paediatrics have an instinctive desire to kneel down. Jame’s statement stood out, not because it was new to me, but from his observation how obvious it is when you don’t do it.

While the message in this picture is self-evident

via http://amomwithalessonplan.com/mommy-fun-fact-17-look-kids-in-the-eye/
via http://amomwithalessonplan.com/mommy-fun-fact-17-look-kids-in-the-eye/

I think this is perhaps more powerful..

connecting-with-kids-3

The point is maybe obvious but I am struck that it is perhaps easier to recognise when something’s wrong rather than when it is right. We are observed constantly in healthcare; what might have you been remembered for on your last shift?

What have you learnt this week? #WILTW

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Unspoken stories: Going beyond the paediatric history

This post was inspired by a teaching session I run for our junior doctors during their induction (orientation) to our Children’s Emergency Department.  I shared some of the content with Liz Crowe and thanks to her amazing insight she has shaped this into a immersive #FOAMed experience. We really hope this will challenge all of those who work with Children to think that bit harder and look that bit closer. I’m hugely grateful to Liz for her patience and input. 

In paediatrics we cannot always rely on the patient to give the history, explain symptoms or give a complete story and may be dependant on the parents or caregivers to give us information, especially historical symptoms, about the children we see. It is not just the narrative we are told that is important though, it is the way we are told it. Family context is a major indicator as to the wellbeing, safety and potential compliance of the patient to treatment. Clues to that context can be as obvious, or as subtle, as the signs of respiratory distress.

Lets examine the same clinical scenario and see what we can learn from parental engagement.

You are working a long shift in ED.  An outbreak of gastroenteritis and a late bronchiolitis season means the waiting room is full of miserable children with a variety of complaints.  You are tired and hungry.  The next patient is an 8 week old accompanied by both parents.

They have been waiting around 90 minutes which is short compared to many in the waiting room. It is reported to you that the parents are ‘demanding’ and have come to the desk on a couple of occasions to enquire about the waiting time. Normally patients less than 3 months old are prioritised in your department but there were no concerns on initial triage and there has been a run of sick patients brought in by ambulance which have tied up staff. You brace yourself for a challenging consultation.

worried_mom
http://www.bestwayguides.com/

At triage the nurse has noted the baby to be afebrile and had had only one small posit typical for an infant that age. The baby has not been observed to be irritable but has been crying in the waiting room. Observations, both objective and subjective were normal.

In the following scenarios the infant is clinically well and there is no evidence of a serious bacterial illness, cardiac or metabolic problem. The mother has been concerned about the child’s feeding and some intermittent vomiting during the day.

Scenario One

 

Scenario Two

 

Scenario Three

 

Have a think about how you would approach these cases? What further information would you like and what might be the cause of the observed behaviours? What realistically is your responsibility in a busy ED?

 

Potential background to Scenario One

 

Potential background to Scenario Two

 

Potential background to Scenario Three

 

Conclusion

Presenting the cases in this way makes it obvious that a huge amount of information is available to health care professionals from the attitudes and appearances of parents and family members. The source of these emotions will not always be clear and there might not be time in Emergency settings to obtain a full picture of events. But if we don’t take some sort of history and visual examination of parents and families we are missing vital clues that will help us mange children and young people more effectively and potentially put parents and children at risk.

 

The other part of the teaching session is on communication and illness recognition. I’ve recorded a short summary of this:

 

The look #WILTW

This is the 132nd #WILTW

It is late at night but the waiting room is full. There are parents and children everywhere. Prams provide an obstacle course for waddling toddlers, crying babies don’t quite succeed in drowning out the irritating background disney song and there is a palpable tension in the air.

You need to walk through the waiting room. Some have been there for hours; anxious for their children, tired and probably hungry. You know they will be looking at you with a mixture of expectation, despair and perhaps even anger.

In all walks of life eye contact is required as a fundamental part of communication. Accidentally or deliberately not maintaining it creates  unease and mistrust and can infer anything from undue deference to deliberate defiance. In a small glance you can recognise a huge variety of emotions; there don’t need to be words or body movements, the posture of a person’s body tells you much about them.

And that is why that walk is so difficult. Do you acknowledge each and every person who looks at you? See their frustration and sit with it. Even though, because you’ve been called to see a very unwell child, you know there wait is going to be that much longer?

via http://dailyplateofcrazy.com
via http://dailyplateofcrazy.com

Or do you put your head down and walk at pace. Ignore the stares piercing your back hoping they understand you are as conflicted as they are frustrated. Wanting to reassure all; but knowing there isn’t the capacity or time to do so.

The ‘look’ from waiting room is a huge cognitive distraction – it weighs on you even when you are not subject to its glare. It is not the fault of the parents or carers that this pressure exists nor is it callous of health care professionals to feel it. It is symptom of health care demand and a testament to the fact that health care professionals maintain that essence of respect and dignity in their practice. Do I wish I could keep my head down? Yes I do. But to not feel this discomfort would be a far greater cause for concern.

What did you learn this week? #WILTW

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Why a coffee replenishes more than just caffeine levels #WILTW

This is the 131st #WILTW

I remember being distinctly disappointed in my dad when he told me:

The day we stopped having lunch together as consultants was the day when healthcare got worse in the NHS

As a medical student I felt this comment seemed to belong to the era of Sir Lancelott Spratt where the rigid hierarchies of medicine encouraged Consultants to play golf on a Friday afternoon. To spend time in the company of colleagues not actively working was indulgent and would be better spent with patients.

Time has moved on, and although I am still of the opinion that a free lunch for a certain professional group in a separate area of the canteen is a distinctly backward step, I finally understand what my dad was saying. Commensality is essentially the act of eating and drinking at the same table. It is a widely studied phenomena and was discussed this week in a blog by Chris Ham of the King’s Fund.  His argument was that creating time for people to get together helps build relationships and therefore trust. This trust helps to heal some of the fractures that are dividing healthcare at present. Apparently (and this isn’t referenced unfortunately) the Mayo Clinic have undertaken a randomised clinical trial to demonstrate the benefits of staff sharing meals together.

There is inherent face validity in this. But commensality is probably more than a word that would not be out of place on a management bulls**t bingo game. As winter takes its toll on the health economy and individuals are pushed the limit a coping strategy used effectively by our team is to spend time having small coffee breaks together. Some organised, but most spontaneous, with no real agenda other than to offload, vent and chat. I wish I could do this with people outside of my team, with those colleagues of different specialities or areas I see less regularly. These are the people I will end up needing to work with when clinical situations are at their most challenging.

via https://www.etsy.com/listing/270746323/a-cup-of-coffee-shared-with-a-friend-is
via https://www.etsy.com/listing/270746323/a-cup-of-coffee-shared-with-a-friend-is

Chris suggests “Creating time for staff to meet, and to do so in a spirit of collegiality and fellowship, could be part of the solution“. This could easily be dismissed as another mundane attempt by a non-clinical professional to ‘improve’ things. However the discussions that have kept me sane and given me perspective have always been over a coffee rather than at a formal meeting though.

Dad, you may have been, in a small way, right.

What have you learnt this week? #WILTW

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Variation: Is it poor, or just different, practice that frustrates? #WILTW

This is the 130th #WILTW

Have you ever accidentally left something in a bag or pocket when you went through airport security that you meant to remove?

The alarm either pings as you walk through the frame or the security guard announces to everyone in the room; “whose is this bag…?

It’s a simple mistake, a bottle of water at the bottom of a rucksack, a metallic belt buckle you forgot you were even wearing. Frustrating, but at least it shows the system works. But what if you ‘smuggle’ something through that isn’t picked up?

Toolkit

In a side pocket of my rucksack I have a portable tool kit. I can’t remember when I put it there but it has a spanner attachment for my foldable bike.  I don’t think it could be used as a dangerous weapon (although one of the screw-driver attachments is quite sharp). I must have been through at least 3 airport security checks without realising it was there.

That’s why when the security guard pulled my bag out of the x-ray machine and did the ‘show of shame‘ I had a panicked moment someone may have placed some illicit substances in it. What would make them want to check?

Having pulled all the objects out and hung the bag upside down I eventually saw the pocket at the side. I was relieved when the guard looked at the tool kit and appeared to indicate this was the offending item.

I’m not sure you can take this with you sir.”

[Brief conversation in my head – it’s been through 3 airports and no one else seemed to care – it would actually be really useful should I need it, it’s probably not inexpensive and it was a present – basically I don’t really want to give it up. Can I say I didn’t know it was there? Did I say at check-in that I declared I knew all contents of my bag?]

Errr. Can you check that?”

The guard wonders off to chat to another officer. I have that sense that people are watching me and judging. Similar to when I take my children to the supermarket.

It’s ok, sir. My captain has said you can keep it

Relief was quickly followed by a sense of annoyance. Is there not an international object recognition standard? Were the other airports lax or was this one over the top? What is the point of variability of approach when lives at are risk?

It is easy to get frustrated. But this is probably the frustration experienced everyday by patients, or their carers, when they receive, or perceive they receive, different advice or management about their conditions. Medicine obviously does not operate by algorithm. There are reasons why conditions are treated differently and why patients are not all managed in the same way. But you can see why it might be confusing to take your hot, unwell toddler to one doctor and be given antibiotics and then later, with what is apparently the same problem, to a different doctor to be given nothing at all.

variation of care

Variation is practice is huge but I’d never been on the receiving end of it before.  In the future, if you see your patients or parents face fall when suggesting a management plan, don’t assume it’s because they don’t like your suggestion.  This is maybe the first time they have had an ‘alarm’ and are victims of the system rather than their own health care beliefs.

What have you learnt this week? #WILTW

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Perspective #WILTW

This is the 129th #WILTW

“The declining level of performance in A&E is a marker of stress across the whole system of health and social care. But performance standards or targets for A&E should not only be viewed as the ‘canary in the mine’ for system-wide pressures. They matter primarily because long waits in A&E affect patient safety and patients’ experience of care.”

The Health Committee report into Emergency Department performance is a no nonsense pragmatic review highlighting safety concerns due to unmet demand, underfunding in social care and too much variation between systems. It highlights the persistent and worsening decline in the four hour target

via Nuffield Trust
via Nuffield Trust

While some will bemoan the creation of the standard, with the resulting gamesmanship and tension between clinicians & managers it produced, it did serve to drive forward changes in staffing and process in Emergency Care. Either way a fall to 85% is uncomfortable and knowing that patients are waiting for prolonged periods is an additional stress for staff in an already demanding environment. There is a feeling that things are getting progressively worse with an associated despair that improvements are not around the corner.

But what if 85% was something to aspire to? I was in Canada this week and delegates at the conference I was speaking at were kind enough to give me a tour around the Toronto Hospital for Sick Children (Sickkids) Emergency Department. I noticed some of the waiting times and found this monthly update from the Ontario Health Ministry.

Note the average time spent in the department. There weren’t any recent comparative target figures available but in 2010-11, 45% patients were admitted from the Sickkids ED with a wait time of less than eight hours, a significant improvement from the 36% recorded the year before (there have not be significant changes in last five years). A consultant recollected they have come onto night shifts with 85 patients still waiting to be seen. For those used to working to a 4 hour target, which Canada does not have, these figures are astounding.

It must be noted Toronto Sickkids is a very busy metropolitan children’s ED. It sees over 75000 patients a year and unlike many UK departments there is no assessment unit to send patients prior to formal admission to the wards; so it is not completely fair to directly compare admission waiting times.

However the perspective this has given me can’t be understated. I must be clear, it is not a case of, “well we’re ok because there is someone much worse..” From what I observed I have no reason to believe the quality of care provided, as measured by other metrics, is no worse than  the UK. In fact the huge numbers of consultants providing on site 24 care with exceptional levels of supervision to junior staff is something to aspire to. They undertake world class research, have a number of extremely impressive training programmes (including  point of care ultrasound) and there is a clear sense of camaraderie between staff.

The dissonance between the waiting times is accentuated by the fact if just children and young persons data is used the average 4 hour target is often 95% or above in the UK. So whatever we may feel about the challenges currently being faced in relation to time based measures these pale into insignificance compared to our North American colleagues. We should continue to strive to improve patient experience by investing appropriately and continually re-examine our approaches to providing emergency care. But we should also be proud of the services we offer. A perspective it is all too easy to lose sight of.

What did you learn this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts. 

 

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