All posts by Dr. Damian Roland

I am Paediatrician who works in an Emergency Department. I am currently undertaking a PhD and have formed the PEMLA (Paediatric Emergency Medicine Leicester Academic) Group with a colleague, Dr. Ffion Davies. I have interests in both medical education evaluation and policy

What I learnt this week: Shared values doesn’t always mean shared vision #WILTW

The fourth #WILTW post…

I’ve been mulling over the reasons why, even in groups of people who get on very well, there can sometimes be discord on direction or strategy. Since the Francis report there has been much written on culture, compassion, shared values and engagement. Less has been actioned to improve these things and less still proven to have made significant change. Why is this? Given the fact that the core essence of what staff do in healthcare is centered on a few key values why can’t we create environments where these shared beliefs are harnessed in ways that inspire improvement in the care of patients and each other.

I attended a session with the #NHSChangeday hubbies this week, and on the same day, a national strategy meeting about improving the management of the deteriorating child. At both groups it was clear the values of the individuals attending were very similar. Converting this into a shared vision of what was needed to achieve the objectives of the group may have been tricky. In very different ways both groups used the core values of those present to remain focused on creating a shared vision. Not always an easy process, but an important method to bring everyone together.  I’m not entirely clear there is one best way to do this but I’m certainly open to experiencing as many as possible.

However it happens given the challenges facing a post-Francis NHS translating values into vision will be an important process.

What did you learn this week? #WILTW

ED Attendances: Win, lose or draw – Does it matter if England can’t score?

This article was originally submitted to the Christmas BMJ and rejected as it wasn’t ‘interesting enough’. I’d forgotten I’d ever written it but reminded by the following tweet here is the original paper – please take it in the spirit in which it was originally intended!

The idea for the paper came from Ejiro Obakponovwe, who sadly passed away recently having developed ovarian cancer, I am sure she would have been delighted to see the paper released and if you do enjoy it please consider making a donation to a Joyful Joy – a charity she supported.

Presentations to Emergency Departments during a Major Football Championship:

Win, lose or draw – Does it matter if England can’t score?

Abstract:

Hypothesis: Anecdote suggests major sporting events reduce attendance at Emergency Departments. The poor performance of the English national side at this summer’s World Cup raised concerns that this was not occurring when England failed to win.

Objectives: To determine whether England match results during major football championships affect attendance at Emergency Departments

Design: A retrospective descriptive study

Setting: A busy city centre based Emergency Department

Data Sources: Attendances to the Resuscitation, Major, Minor and Paediatric areas were counted for the 8 hour period surrounding kick off time (4 hours either side) of World Cup and European Championship matches England played in events since 2004. These were matched against equivalent days in non-championship years.

Results: On average, the number of attendances to the Emergency Department around kick off on match days was 160 compared to 200 (Ratio 1.25, 95% CI 1.12 to 1.40). This reduction held true when the whole 24 hour period was considered (p=0.035). The trend was observed for categories of Minor (Ratio 1.51 (95% CI 1.28 to 1.77), p<0.0001) and Paediatric (Ratio 1.22 (95% CI 1.04 to 1.43), p=0.015) attendances but not Major (Ratio 0.96 (95% CI 0.82 to 1.12), p=0.578) or Resuscitation (Ratio 1.12 (95% CI 0.76 to 1.66), p=0.570). There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148).

Conclusions: The results indicate that staff in Emergency Departments should not have been concerned about England’s poor performance this summer as it did not increase their workload. Given an overall reduction in attendances the NHS should have an active interest in the England football squad and its management structure to ensure continued presence at World Cups and European Championships.

What is already known on this topic?

Although anecdote strongly supports the theory attendances to Emergency Departments decrease during major sporting events there is evidence to refute this.

Little research has examined the effect on the actual result of the English football team on attendances to Emergency Departments.

What this study adds?

A poor England performance does not appear to affect attendance although the public reduce their Minor or Paediatric attendances during championship matches in which England are playing. However they recognise that serious illness needs treating as demonstrated by the fact Major and Resuscitation area attendances are unaffected.

This may indicate the NHS should be interested in the future fortunes of the England team.

Introduction

Anecdote in Emergency Departments (EDs) often concerns a reduction of attendances when large sporting events are taking place. There is evidence to suggest this is not the case 1,2 and persons presenting with alleged physical assault to EDs may actually increase 3. The staff at the Leicester Royal Infirmary Emergency Department felt negative England performances were affecting attendances during this year’s disappointing World Cup campaign. Previous research in this area has only investigated presentations with alleged assaults when a national team played 4with increases following victories. We postulated that following an England loss attendances for minor injuries may increase in the hours following the game compared to matches in which England won (in the latter case the supporters’ physical pain is compensated by the enjoyment of celebrating).

Methods

The Leicester Royal Infirmary Emergency Department Information System (EDIS) was interrogated for attendance figures from 2004-2010. We extracted attendance data for each England match day (Table One) of the European Championships (Portugal 2004) and the World Cup (Germany 2006, South Africa 2010). Unfortunately England did not qualify for the 2008 European Championships. Attendances were categorised into Resuscitation, Major, Minor and Paediatric Group with the age and time of presentation also noted. Non-match days were identified for comparatives on the same day of the week in the following year (or a year earlier for 2010). Attendances, for the purpose of this study, were counted for the 8 hour period surrounding kick off time (4 hours either side).

Slide1

Poisson regression models, correcting for over dispersion, in SAS version 9.1.3 were used to compare the number of attendances between the 13 match days and the equivalent non-match days, both overall and by categories of Major, Minor, Child and Resuscitation. Poisson regression models also compared the number of attendances in ED on match days between matches where England won to matches where England drew or lost. No identifiable data was requested from the database.

Slide2

Results

Attendance data is demonstrated in Figures One and Two. There were a lower number of attendances in the 8 hour period surrounding match days compared to non-match days (p<0.0001). On average, this was 160 on match days compared to 200 on non-match days (Ratio 1.25, 95% CI 1.12 to 1.40). This trend was observed for categories of Minor and Paediatric attendances but not Major or Resuscitation (Table two). Using a matched pairs t test, there was also a lower average number of attendees in the 24 hours period of a match days compared to non-match days (p=0.035).

Slide3

There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148). This trend was observed for all categories (Table Three).

Slide4

Conclusion

Although there were only 13 available matches (England’s failure to qualify for the 2008 European championship reducing our dataset) it appears actual results impact little on attendance figures. Therefore staff not on shifts during match days should not feel too guilty about watching the match as the result is unlikely to be relevant to the department’s workload. In fact, as our results support the anecdote that attendances decrease, they may feel even less guilty. The general public appear to be able to tolerate the discomfort of a minor illness or injury on match days but perhaps do not feel strongly enough about England’s chances when faced with a more major complaint. The overall reduction in attendances indicates EDs, and perhaps the NHS, should strongly support the English Football Association’s attempts to secure England a strong manager into the next decade as this may well affect attendances and subsequently costs. This would be especially true if England do win the rights to host the 2018 event.

 

Many thanks to Suzanne Rafelt (Medical Statistician) and Patrick Walsh (Medical Student) at the University of Leicester for their initial help with the article.

Please consider making a donation to a Joyful Joy – a charity Ejiro supported.

 

 

What I learnt this week: The power of personal stories #WILTW

This is the third in the series of #WILTW 

I seem to have discovered this viral video extremely late:

It tells an uncomfortable story of Social Media use which is a little cheesy in places and clearly ironic in its success. It is however a powerful film. I have been a convert to the importance of story telling through my involvement in NHS Change Day. Previously dismissiveness of those who celebrated individual case studies as a means of getting their message across I am now a firm believer in the importance of personal narrative. I highly recommend this short Petcha Kutcha style presentation if you are unsure.

This week I attended the second day of the Children and Young Peoples Outcomes Forum annual summit where we spent some time discussing the difficulties of data sharing. My views on this are very strong (see this blog for the background) and I am wary of letting my frustrations stop productive conversation. It struck me though that my most useful contribution to the debate was not any technical argument or counter assertion about risks/benefits but the simple personal story of why data sharing is important to me. Essentially a child may have come to harm because simple information was not able to be flagged up to me through a universal database (as intended by contact point). It was a story that others could relate to and provided a common ground for all.

I may well be preaching to the converted but my learning this week is to not be afraid to use personal narrative as a means of engagement. It may well be the best argument you have.

 

What did you learn this week? #WILTW

(thanks to my wife, Katie, for pointing out the Looking up video!)

#WILTW – the importance of ‘shared’ gut feeling

This is the second in the series of “What I Learned This Week #WILTW

It was an unnerving experience to be completely let down by my own gut feeling this week. A particular case caught me by suprise and it was only through following protocol that the right decsions were made. Essentially my gut feeling told me it was unlikely extra tests would be needed for a patient, but I did them because our guidelines said so, and lo-and-behold the guidelines were right! Although initially I was a little taken a back, on reflection I’ve decided that in fact gut feeling did win the day on this occassion. Not my gut feeling – but everybody else’s…

Flock of sheep, New Zealand, Pacific

In hospital Clinical Practice Guidelines, or Standard Operating Protocols, are used to condense knowledge and experience to help healthcare professionals make decisions about patients. Ideally guidelines are based on the best evidence but often clear research is not available to determine what to do in any given situation. In these cases Guidelines are often based on the consensus of experts. This happens at a local level (consultants coming together to determine department policy) or a national level (the National Institute of Health and  Care  Excellence [NICE] bringing together expert Guideline Development Groups).

Guidelines often get a bad name as being part of the ‘tick box’ culture that often pervades health care. Perhaps it is worth thinking of them as a shared gut feeling. One that will sometimes get you out of a sticky hole.

 

What did you learn this week? #WILTW

 

What I learnt this week #WILTW

The full list of #WILTW 

A few weeks ago I posted a blog with some thoughts on becoming a new consultant. I’d postulated that having insight into learning being a  life-long journey was an essential element to being a good healthcare professional. I’ve now been in post a couple of weeks: finding my feet, performing induction rituals and thinking about the goals I would like to achieve in my next year.

online-learning

What has hit me like a bomb has been my first clinical experiences on the shop floor. It’s been an amazing learning curve, far greater than I expected actually. The pure clinical component is not really an issue. I have been acting, in some respects, in a consultant capacity for the last three years as I performed locum shifts as part of my PhD. Making clinical decisions, practical skills and running a busy emergency department are almost second nature. What struck me was how little thought I’d previously put not into ‘what‘ I was doing but ‘how‘. I am now a consultant. Clearly I don’t want to create false hierarchies, I recognise I am part of a senior team of doctors and nurses and that the title does not make me lord of the manor. However I also recognise that I have  a responsibility to role model the best possible professional and clinical behaviours. In all situations the demeanor with which I speak to colleagues, the way I approach children, young people and their families and how I interact with staff sets a tone. It’s not until now that the importance of this has become crystal clear.

I thought I knew a bit about leadership. It transpires I have a great deal to learn. Reflecting on my approach to particular challenges (mainly difficult conversations about referrals or picking up staff on sub-optimal behaviours) has demonstrated how difficult being a consistent and strong ‘leader’ is. It is very easy to take a second-best option; that in order to avoid confrontation a compromise is reached which may not be your preferred choice. But when do you draw the line? Obviously always ensuring your way is the best way is no better than always accepting the other person’s point of view. However it’s all too easy to avoid the conversation about the tone that a junior has taken (potentially accidentally) with a parent or other member of staff, for example; but it’s these conversations I need to start having.

Tough Decisions Ahead Road Sign

(via http://www.advisoranalyst.com)

So what I have I learnt this week? Well, I’ve learnt that potentially I’m not as strong as I thought I was. That some of the things I thought I would be able to do in role will take a little more embedding. I am also sure that with the guidance of colleagues and passing of time I will get better. As I said previously – the learning has only just begun again….

So what have you learnt this week? #WILTW

13 years of training and tomorrow it all begins again…

The art of medicine was to be properly learned only from its practice and its exercise.
Thomas Sydenham 

So after managing to prolong my training to its maximal extent, with two separate years in Perth, Australia and a PhD, tomorrow my medical ‘training’ in one sense comes to its end as I start work as a consultant. I’ve had a chance to reflect on what I have actually learnt since starting on the wards as a wet-behind-the-ears junior doctor back in 2001. Its funny, I don’t feel I am in any way, shape or form an expert now, even though I have probably done my obligatory 10000 hours. I certainly don’t feel as wise as the paediatric consultants I remember when I was a house officer. This might reflect an element of an impostor syndrome – or perhaps I have actually become unconsciously competent.

I’m not really sure how this all happened. I struggle to remember more than a handful of occasions when I specifically learnt anything from anyone, although there are some notable exceptions.

Don’t listen for the murmur, listen for the absence of noise

This brilliant advice has always stuck with me, especially as someone who has always struggled with the complexity of paediatric cardiology.

I remember being shown during my first neonatal attachment that babies often open their eyes when put over their mother’s shoulder (which makes identifying the red reflex much quicker).

One of my most powerful experiences occurred in Australia as I watched an Emergency Department Consultant at the resuscitation of an infant from an out-of-hospital cardiac arrest. After several of rounds of CPR it was clear the outcome was going to be devastating. I saw the mother realise this; she was inconsolable. And then the consultant handed leadership of the resuscitation to someone else and went over to her, putting his arm around her and bringing her to her child’s side. He spoke to her about loss and how no more could be done. I don’t remember exact words but I vividly emember him crying with her as we all took a step back. It was one of the most incredible things I have seen a consultant do.

Clearly I was taught things – lectures, seminars, ward rounds must have had an impact – but nothing tangible remains and many of the times I know I learnt the most were situations when I was on my own, sometimes inappropriately so.

I have no idea how I learnt to cannulate the septic ex-prem with tiny hands already scarred, little knowledge of when I gained the confidence to lead a group of people I have never met to deliver emergency care to an injured child, and certainly not a clue when I began to appreciate the subtle difference in the reaction of a parent who has not deliberately injured their child compared to one who has when asked how that bruise happened.

But what is more incredible is what I still have to learn. I am a mere ’13 years old’ – health permitting, I may be practicing medicine for double that time yet. It is inconceivable that I will not learn exponentially in that time. And it will be an exciting time, I think. I hope I continue to reflect on those learning experiences, painful or not, in this next phase of my life.

My training begins again  – it’s just that now I have a different title.

Networking: Twitter doesn’t build communities, stories do…

This blog posting is based on my talk to the #HSJRisingStars. It’s good to have the opportunity to expand on my thoughts as it’s clear from feedback that this didn’t quite touch the nerve I was expecting. Raising concerns about twitter, within twitter, is an interesting experience…

In the run up to NHS Change Day 2014 a number of constructive criticisms had been voiced on the type of pledges made. How can it be that health care professionals are pledging to “deliver safe care”, “create caring cultures”? Aren’t these pledges just paying lip service to the broader purpose? Are people just jumping on a bandwagon?

I wrote a blog in response to these concerns. It centred around my acknowledgement that on a busy shift I had forgotten to introduce myself to the parents/child I had just seen. I had essentially failed Kate Granger

I am not a prolific blog writer, I’m probably not even a good one, but Kate tweeted the blog post and in the space of 3 hours it had received 1300 views. This was dissemination on a pretty impressive scale and in fact far more powerful than any previous networking opportunity I had been engaged in. It made me really think about reach and how I had communicated in and out of networks.

Change Day has taught us a lot about the NHS. There seems to be a unmet need to publicly discuss and celebrate core values; reports by Francis and Berwick have removed the taboo of some of these issues. It has taught me personally a great deal about my role in change and the roles of other networks. The story of Change Day began with a discussion about junior doctors and at the very first Change Day meeting I told a story inspired by Helen Bevan, describing how it is the new generation who are most likely to bring about radical change. Interestingly, though, one of the groups least involved in Change Day (in terms of raw numbers) were junior doctors (probably second only to GPs).

How did that happen? Did my networks fail to understand to the message? Was I wrong in my belief that Change Day can – and will – be a powerful instrument for cultural change? I think the reasons are subtle but well worth exploring.

Change Day was in essence about individual people. The real narrative was the reasons behind the individual pledges; the event itself was more like a big scrap book recording and highlighting more than half a million stories. My biggest transformation of thought in the last couple of years has been about the power of narrative. It’s personal narrative which drives us. The networks you are part of, represent, lead or create, contain people who share parts of that narrative. But I wonder how often your (or your network’s) narrative is shared by others. Just because I know ‘x’ doesn’t necessarily mean that an e-mail to their “network” will spread to a wider “network” and will be effective at spreading the message.

I’m sure I am as guilty as anyone at pushing the ‘send all’ button. Similarly asking friends  “can you send to your networks?” is something I have realised may not really add value. In fact the use of networks in this way may, in fact, create silos due to the lack of proper dialogue between them. “Nobody talks anymore” is oft quoted but there is some danger that it really is a little too easy not talk. By all means use technology – Hangout, FaceTime and Skype have enabled conversations to take place that weren’t possible previously. They are conversations with animation of expression and vocal nuance. But the real essence of good narrative goes beyond the physical conversation to the nature of what is being spoken. My story of failing at #hellomynameis is much more powerful than telling people how important Change Day is. Similarly describing my personal pledge is a much better vehicle to create interest than a newsletter about the day itself.

None of us wish to create silos as I’m sure we share the same the values. The translation of those values into a vision is probably different between our networks though. So in this time of social media and electronic interfaces, maybe we all need to be a bit more personal. We need to reconnect with each other with personal stories and communications that unite networks – not just transfer information between them.

“In this age of omniconnectedness, words like ‘network,’ ‘community’ and even ‘friends’ no longer mean what they used to. Networks don’t exist on LinkedIn. A community is not something that happens on a blog or on Twitter. And a friend is more than someone whose online status you check.” – Simon Sinek

This (admittedly controversial) quote was really brought home to me when I attended #SMACCGold, a social media and critical care conference. I thoroughly recommend watching the talks when realeased as they are all very much personal stories. Undoubtedly it was twitter, google and blogs that brought people in the #FOAMed community together but the real benefit for me was meeting the people there and engaging directly with them. As I said after the #HSJRisingStars event:

 

(Thanks to Natalie May for pre-publication proof-reading and editing)