Category Archives: #WILTW

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When aiming to do good does harm #WILTW

This is the 187th #WILTW

The nature of working in paediatric medicine means the joy of ‘high-fiving’ a four year old after fixing their broken arm comes with the utter despair of telling parents their child is dead.

Death is not a regular event for many who work in child health but your actions may have a huge impact on families or carers. You can’t make grief better but you can certainly make it worse.

The impact of an unexpected death in a child is also profound for those involved in the final moments of their care. Many will have never seen an adult, let alone a child, die before. There may be completely unwarranted feelings of guilt from the ambulance crew (“did I do CPR effectively?“), to the nursing staff (“did I give the right dose of drugs“), to the doctors (“did I make the right decisions?“) and there is often a visceral urge for senior staff to hold others grief and suffering. This commonly occurs in the form of a debrief, an open forum to discuss the tragedy that has just occurred. This may be ‘hot’, taking place immediately, or ‘cold’ arranged in the days or weeks afterwards.

The role of debrief has always been debated and contested. Is reliving the detail of a traumatic event, traumatic in itself? A recent study (in print this week) of over 300 paediatric trainees experience of child death adds to evidence in this area. The survey’s response rate was only 50% and it wasn’t possible to control for responses i.e. those completing the survey having stronger feelings in this emotive area than those not. Or conversely those not responding having potentially been more adversely affected by the events. Non-withstanding this limitation there was much food for thought:

  • About 15% of respondents had only experienced 1-2 deaths in their training. Less than 30% had a been a team leader during the resuscitation of a child who died.
  • An acute stress response occurred in up to 9% of trainees and Post Traumatic Stress Disorder (PTSD), as measured by a questionnaire, developed in 5%.
  • These reactions were not associated with age, gender or working patterns but there did seem to be a relationship with debrief – with those attending debrief more likely to develop PTSD than those who didn’t.

Association is not causation. This work in itself does not mean that debrief is always harmful and there may be many other factors which haven’t been measured which may be significant. But this study adds to others that have hinted at the same thing. So why should it be that debrief, a powerful educational technique, may cause suffering rather than take it away?

These are not frequent events and are unpredictable in their nature. By definition they are highly emotive events where staff are acting at the height of physiological stress. Importantly many will never have experienced this pressure before, and critically, those leading the debrief may never have had to facilitate a discussion like this. In fact training in this area is almost non-existent. Learning through watching others is how many will develop skills they may deploy for the first time as a consultant.

The public deserve the best and most appropriate care, especially in the most tragic of circumstances. But so do staff who need the research to guide the best way to deal with these catastrophic events and training in how to help others recover from what may well be their most significant life event to date.

What have you learning this week? #WILTW

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The frame of error #WILTW

This is the 186th #WILTW

This is an extension of a post I wrote over 2 years ago describing my experience of airport security.

The delay, even with an express security pass, was considerable and I must admit I was getting increasingly nervous even before my bag was picked out as having a problem. The delays were not due to volume of people but the absence of any haste from the staff. There was absolutely no urgency at all. It was painstaking to watch. You could see people becoming increasingly frustrated as the pre-scan person would carefully manoeuvre items around the boxes before pushing them through the machine. The person reading the x-rays would move backwards and forwards on each and every item. The man handling those flagged as ‘at risk’ would ponderously remove each and every item from the bags he was reviewing. It was painful to experience with the frustration clearly exacerbated by being in a rush.

Emergency departments also have to process lots of people but equally need to make sure each person has a thorough, and timely, assessment as they may suffer harm if they aren’t ‘processed’ quickly enough. Gavin Lavery who was giving me from the airport to the conference venue raised an interesting point about how in healthcare, in order to meet an ever increasing demand, the staff just ‘find a way’. Either going beyond capacity to find beds, or being able to review more patients in less time, during peak periods. The benefits of this are obvious but it creates a paradigm where you don’t follow the ‘manual’ at all times. Arguments regarding the use of checklists persist because staff want flexibility in the way they work. Sometimes because they are stubborn and don’t wish to change, but sometimes because they know they do need to change they way work in certain circumstances. A challenge in healthcare is maintaining safety during these flexible periods of working.

I wouldn’t be able to work a security officer in an airport. I am not sure I would be able to maintain the air of someone whose desire for safety completely overrides any patient experience, day in-day out, regardless of queues and the relentless stares of the public. But perhaps on a busy shift I’ll remember that just working that bit harder, or cutting that small corner, isn’t really what a ‘safe’ system should do.

I had completely the opposite experience this weekend. A surprisingly deserted security area for an international airport with staff looking around for something to do. It was a pleasure to be able to pack my hand luggage and coat into the grey boxes without the stress of losing anything or feeling you have a 1000 eyes bearing down on you because it’s taking more than a millisecond to unpack your pockets.

It was only when I went though the metal detector I realised I’d packed a couple of items above the 100ml limit in my bags. I felt frustrated to likely to be losing some aftershave that had been brought for me as a present.

But it wasn’t noticed. My bags came through the machine without being pulled aside and I was allowed on my way. I am not entirely sure of why there is a 100ml cut off but I am sure that what I’d brought was more than 100mls. What is the point of advertising a security standard that you aren’t going to uphold? Especially when you are rigid about the reproducibility of your approach regardless of how busy you are.

Conversely mistakes happen in all walks of life. Our tolerance of them dependant on the impact they directly have on us. Why should I be frustrated at a minor slip up at an airport but able to explain away minor deviation at my own place of work? The frame of the impact of error an important determinant of your reaction and response to it.

What have you learnt this week? #WILTW

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Educational Professionalism: A 21st century competency #WILTW

This is 185th #WILTW

The landscape of information exchange is radically different now than it was 20 years ago. There has been a huge shift in access to knowledge, and how that knowledge can be transferred to you. Technology has been at the core of this, namely the ability to make vast amounts of data portable. While the fundamental educational principles of active learning and feedback are no different now than there were before the digital revolution; the scope of opportunity is immense.

The advent of Social Media has been a disruptive influence in education, although it is possible that this has more to do with the underpinning technology than the platforms themselves. Would Twitter be as popular if it wasn’t possible to carry a micro-computer in your pocket? Networks, propagated through social media environments, have transformed (or re-invigorated) educational opportunities for the adult learner (and from what I see of how my children are taught at school not just adults either).

This changing nature of interaction is not without risk. While the negatives of social media are obvious from political and cultural perspectives there are potential pitfalls and perils to the way we learn, or perhaps more precisely, think we are learning. Information is now at your fingertips, you can choose content that is relevant to you, presented in a format you determine. Whether it be blog posts heavily infused with infographics, or a podcast on the way to work, educational consumers have more choice than they have ever had.

The echo-chamber effect may have consequence here. I am firmly opposed to the notion that individuals can’t make appropriate decisions about the quality of information presented to them. Concerns about ‘celebrity status‘ in the network of emergency and critical care clinicians who utilise #FOAMed (Free Open Access Medical Education) have little tangible evidence behind them. However it is possible that unintentional selective browsing may take place as learners are drawn to a particular style or type of resource. While there was this risk at other times in history the huge breadth of information may lead to greater imbalances, potentially leading to a presumption that you are more informed than you actually are. Protecting against this are the communities of practice, and more specifically personal learning networks, which should highlight the range of opinions, evidence and developments around a particular topic. This return to a participatory nature of education [1] should balance the potential biases in selective consumption of resources.

Ultimately we are now in an era where self-directed learning requires you to not just not know how to learn but to understand the landscape of your educational environment. A set of skills in how to interact, develop networks, understand the importance of reciprocity in engagement and respect the multitude of ways of learning are needed to navigate this new world.

The guiding principles behind this need development but may include being able to recognise the soft and hard signs of quality in digital educational materials, knowing how to development personal learning networks and using work flow strategies to manage knowledge volume (i.e. whether you are drinking from or playing with the fire hydrant [2])

via http://informationcuration.wikispaces.com/The+Current+Status+of+Information+on+the+Web

It is likely educational professionalism may be required of us all.

What have you learnt this week? #WILTW

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[1] Thanks to Chris Walsh for highlighting this paper

[2] Credit to Chris Connolly for this twist on the meme

 

 

 

Single Minute Exchange of…. Simulation #WILTW

This is the 184th #WILTW

I am wary of citing business examples as a means of improving healthcare processes, however it’s always useful to look at something with a different frame.

One of our non-executive directors, who has a background in industry, highlighted “Single Minute Exchange of Die (SMED)” to me after a talk I delivered this week on simulation. SMED is designed for manufacturing processes and aims to reduce time taken for transitions in assembly lines. The name comes from the ‘dies’ on the large stamping machines that produced car vehicle parts. These are heavy blocks which precisely set the stamp for the next ‘press’; to create a new door for example.

via https://www.lean.org/lexicon/single-minute-exchange-of-die

The idea is that the process is reduced to a single minute (although in practice it is recognised not all things can be done in less than 60 seconds). The relevance for medicine comes from the processes that are used to deliver SMED. One of the techniques is to video a changeover, or simulated changeover, and extract behavioural data from the video in conjunction with the team involved in order to improve the process. The frame for discussion is to differentiate Internal and External processes, essentially those that can be prepared for, and those that can’t.

While I am not convinced the SMED objective is an implementation strategy to be pursued in medicine, the concept of internal and external processes is useful for simulation debrief. For example in Emergency Medicine, what could the team have prepared for, given the limited information they have before a patient arrives, and what do they have no control over? If they ran the simulation again – could they have altered preparations of drugs, deployed staff differently or changed communication cascades? This is a useful feedback approach to highlight to participants how processes are linked together and which can be co-ordinated.

What have you learnt this week? #WILTW

Many thanks to Andrew Johnson, University Hospitals of Leicester non-executive director and Chair of the People, Process and Performance committee for his contribution this week’s #WILTW!

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Remember the cause as well as the cure #WILTW

This is the 183th #WILTW

Medical research is about doing things better for patients. It’s exciting to see new treatments and interventions develop (even when the evidence eventually suggests doing nothing at all is the best thing to do!)

Although I’m biased, in paediatric research simple changes can have quite profound effects on children and their families. Take a common condition such as asthma; treatment of acute exacerbations has traditionally taken the form of inhalers and a course of steroids (prednisolone) given over three days. The need for multiple daily doses, with the resulting challenges for families and children, has recently been challenged.  It is proposed a single dose of strong steroid (dexamethasone) may be adequate. A brilliant review of a paper on this topic by the Skeptics guide to Emergency Medicine (SGEM) prompted debate this week about why practice hasn’t changed.

In the UK a bottle of dexamethasone is far more expensive than a packet of prednisolone tablets (which can be crushed to give to children) so the argument on the equity and equivalence of treatments will continue for some time yet I suspect. However in the comments section one of the blog’s authors highlighted a potentially far more challenging debate.

Here is great graph looking at asthma rates and area in NY city. As you can see it is quite serioulsy overrepresented in the areas with the highest endemic poverty rates (or I can see it knowing the city, sorry)

The relationship between deprivation and asthma (and many other medical conditions) is well described. Clearly the causes are multi-factorial but regardless, the variability in attendances and outcomes must be of concern.

The same unexplained variation equally applies in the UK

via Atlas of Variation (click to link to document)

Clearly we need to continue to deliver the best treatments to children and young people most in need of care. But if there are underlying reasons behind why they need that treatment, we must not forgot to concentrate on ameliorating these as well.

What have you learnt this week? #WILTW

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Can you measure the science in the art of presenting? #WILTW

This is the 182nd #WILTW

It’s been a busy morning, you’ve got e-mails to catch up on and a report due in imminently. But you don’t want to let down the presenter at the lunchtime teaching session so you grab a sandwich and find a seat at the back of the seminar room.

Regardless of content what’s likely to grab your attention for the next hour and what isn’t?

It’s with this in mind a paper I read this week on quantitative analysis of slide presentations caught my eye (found via this article). It’s a review of talks from an ophthalmology conference where various potential metrics of presentation quality were compared to overall audience feedback. There were only 17 presentations and the evaluation ‘rubric’ was an amalgamation of perceptions of value and quality measured via a 4 point scale (1 – low to 4 – high). While there are some inherent issues with using this scale as a gold standard the metrics reviewed covered a wide range of potential influences on presentation quality.

Ing et al 2017 Quantitative analysis of the text and graphic content in ophthalmic slide presentations Can J Ophthalmology 52;2 171-174

Only the number of slides per minute, with higher scoring lectures showing a greater average (3.07) than lower scoring ones (2.17), were associated with a difference. Given the number of metrics evaluated, this difference may have occurred by chance so I don’t think anyone should rush away and add in extra slides to their already crowded presentations!

Fair play to the authors for looking for concrete reproducible techniques with which to improve lecture quality. However I suspect even they would have been surprised if they’d found the magic bullet with this approach. The challenge is the components of a good lecture can often be described but less easily defined. Ross Fisher has been championing an approach to the delivery of the better presentation called P3 (story x supportive media x delivery)

Seems as if fretting over font size, graphics and your text density probably isn’t where the good presentation is going to come from!

What have you learnt this week? #WILTW

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Related post: Is your powerpoint slide teaching or are you?

Be brave, acknowledge our failings #WILTW

This is the 181st #WILTW

If you are frequent blogger it’s easy to experience deja-vu.

I got that sense having been invited to an “innovation leadership” event. It was better than it sounds [a note to organisers that sadly cynicism has made the juxtaposition of these words an oxymoron in many peoples’ minds] but I started the event badly as I couldn’t let a  bug bear of mine go unchecked.

“I’ve rallied against this topic before” I thought. And I have, back in December 2013 before I was even regularly using #WILTW.

The below is the blog “We must never forget what we have failed to do“. I am re-sharing as although there has been some progress (our trust has moved forward to newer digital solutions and my bespoke work-a-round is no longer needed) so much still stands. Have we really learnt the lessons of the past of what went wrong or are we just developing different ways of not being able to provide solutions?

Last week I attended the latest King’s Fund Medical Leadership Network/Development event. These bring together a number of clinicians and managers of varying degrees of experience. There is a focus on outcome, rather than just being talking shops, and there is a clear aim to increase the number of those attending who are early in their careers.

One of the talks was from Prof. Rory Shaw, the Medical Director of Health Care UK. This organisation aims to bring NHS healthcare expertise to the world and establish partnerships that will be beneficial for the UK economy. Prof Shaw was quite open about the questions this raises and some of the challenges to be faced. My interest peaked however in respect of NHS expertise in digital healthcare. It is an interesting paradox that many worldwide healthcare services don’t have access to, or any clear plan to develop, some of the initiatives and expertise which exist here. The concept of a universal number, for example,  is something that is taken for granted in the UK but is not present at all in many other healthcare systems. However from my point of view, a young (but potentially naive and impatient) junior doctor, there is nothing particularly brilliant about our digital systems. Very recently I was involved in a case where the failure to have access to the healthcare information of a patient presenting to a paediatric emergency department may well have resulted in harm to the patient. This was not an individuals fault, it was the fault of the absence of an electronic system that can share information about patients throughout the country.

I was pretty vitriolic about this at the conference, and despite furtive glances and frowns from some members of the audience, will remain so about this. It is not an excuse to say we tried that and it didn’t work. The simple fact remains that most members of the public remain extremely surprised that we are unable to access electronic records in one vicinity but not another. Even worse it remains a cause for concern patients can frequent numerous different health care providers  without any of them knowing anything about these visits. This isn’t about being a ‘big brother’; it’s about managing risk for vulnerable patients and ensuring patient safety in a system which harm if often to easy to come by.

What then are we to make of the failure of the National Programme for IT in the NHS? One argument is that we have moved on, a new initiative for developing local solutions and then joining up, being more pragmatic and ultimately more achievable. There are still large costs involved though as the government’s recent announcement of a £1 Billion fund for Emergency Departments emphasises.

Appreciating it’s sometimes easier to judge rather than action, I have been working hard locally towards an electronic integrated illness identification system for children (POPS)  which is now used in other centres and could ultimately be used to compare acuity rates between emergency centres. This solution had to bypass NHS IT and is not the safeguarding safety net that is desperately needed.

It is vital that we remember where we have been in the past and what we haven’t achieved. There are many people and organisations passionate about improving the digital infrastructure of the NHS, and Tim Kelsey is clearly keen on making progress. It is likely solutions will eventually be found but we must honest about our past failures. It would be equally disastrous, probably more so, should further Berwick and Francis reports be needed, but unfortunately history demonstrates we often fail to learn.

Extolling our strengths is fine, acknowledging our failings much the braver thing to do.

So to those at #innovationleadership I apologise for stating that we don’t really care about patients, because I know we do. But we must persist in being honest. The right things to do are often the most difficult and we definitely haven’t got everything right yet.

What have you learnt this week? #WILTW

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