Category Archives: #WILTW

Blogs relating to What I learnt this week

Digital Detox

This is the 166th #WILTW
I am currently on a weeks social media blackout (and more importantly on annual leave!) 
A perfect opportunity for a break from What I learnt this Week. But if you are keen for a fix here are some of the most popular posts from 2017 🙂

Same Child, Different Room, More Risk

How did you not see that

Dogmalysis and Pragmatogenesis

What have you learnt this week? #WILTW

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A third idea to counter a third ‘type’ of error #WILTW

This is 165th #WILTW

The term ‘statistics’ strikes fear into many.

You may have 5 ‘A’ levels, have a distinction in finals, and be able to perform life saving cardiac surgery in a premature baby.  It’s also likely you’ll still start sweating if a junior colleague asks you:

…why was the power calculation insufficient to reject the null hypothesis in this paper?

An extremely well shared meme was released a couple of years ago aiming to explain the often mis-understood topic of type I and type II error.

The illustration doesn’t really do the underlying principle justice but the explanation is fair.

  • A type 1 error is when you decide a test result is positive, or an intervention has worked, when in fact it isn’t/hasn’t.
  • A type 2 error is when you decide a test result is negative, or an intervention has failed, when in fact it isn’t/hasn’t.

I was reminded this week by Professor Mayur Lakhani of a third type of error (in fact there is also a type 4 error but I’m not going to go there). A type 3 error is when you are correct that a test result or intervention is positive but you have decided this for completely the wrong reason.  Outside the realm of mathematics it is when you solve the wrong problem and don’t realise it. In an article written by Large Kiely, shared by Prof. Lakhani, this issue was explored though the lens of organisational culture:

“The type three error is a dangerous form of group-think and can happen very innocently and with all good intentions. The causes are a bit surprising, having to do with, believe it or not, too much expertise in the same field.” – Laree Kiely

In healthcare this probably occurs more frequently than we would care to admit. Take a group of highly trained consultants or managers, and set them on a problem. Very early in discussion, the cause of the problem will be decided, not via evidence, but through anecdote. Solutions will be presented to solve the perceived issues and any improvement attributed to the intervention(s). It will only be later, sometimes much much later, that other problems will materialise demonstrating the original assumptions to be flawed.

I’ve explored group-think previously but the type 3 error is a very tangible output of it.

The suggested advice by Laree Kiely is to always have 3 possible actions before deciding on one. This isn’t always easy to do but forces groups to avoid discounting relevant issues:

Decision making studies have shown that if you think there is a right answer, then the first one that looks right becomes the final choice, and the thinking stops there. Problems today rarely have only one right answer.”– Laree Kiely 

Inevitably the time required to think of a third idea to avoid the third error will mean it rarely occurs. But at the very least we shouldn’t be scared of calling it out when we make this mistake.

What have you learnt this week? #WILTW

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Videos below explain the concept of type 1 and type 2 errors further

 

Good questions are as important as good answers #WILTW

This is the 164th #WILTW

I came close to starting this piece by making a fundamental error. I was going to discuss how the ‘case’ of Charlie Gard is a tragedy. A tragedy it is, but to describe it as a case does no justice to anyone involved in this heartbreaking situation.

It is events like this that demonstrate the fragility of social media as a communication mechanism. All sides involved, most importantly the  parents, but also the professionals (medical and legal), organisations and national bodies passionately believe in Charlie’s best interests. There are no monsters. There is sadly a lack of humanity, not from those who are involved, but from those who feel they have a right to judge, berate and decide what’s best for a situation in which few can comprehend the moral and ethical dilemmas at play.

In a completely unrelated, but actually quite relevant, BMJ blog this week Dr. Matt Morgan challenges the way we currently examine doctors in medicine:

Although undergraduate training has adapted to some of these changes, the postgraduate world needs to embrace the changing roles and skills needed by medical professionals of the next century.

Many of the current processes of testing competence rely on the doctor making the correct diagnostic decisions. But testing pure factual knowledge and clinical examination has been recognised as a poor surrogate for future clinician performance. To be fair, examinations necessary to become a Consultant or General Practitioner almost certainly also include complex cases involving ethics or challenging communication. But Dr. Morgan I think correctly highlights the difference between being able to answer difficult questions about a case, and being able to ask the right questions about a difficult case.

He identifies while it is almost certain the use of artificial intelligence in medicine will grow, it is difficult (currently) to see how a data led approach to diagnosis can deal with grey medicine.

The challenge, increasingly, is to understand:

Not, what is the definitive cause of a symptom but what definitely isn’t the cause of it…?¹

Not, how do I treat this, but should I…?

Not what are the consequences of my decision now, but what might they be in the future…?

While ever cleverer computer algorithms, imaging devices and cutting edge diagnostic technologies will improve processes in medicine we must ensure that our underlying principles of practice remain true.

I am certain the doctors and nurses caring for Charlie Gard have used every tool at their disposal to investigate and treat him. I am also sure they have been equally diligent in exploring all the ethical and moral dilemmas exposed. To not do so would be leaving medicine in the hands of computer programmes which may well reduce patients to ‘cases’ to treat rather than people to care for.

What have you learning this week? #WILTW

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  1. This topic was explored in “If you know what its not, is it ok to not know what it is?

Spot the well child, not the ill one #WILTW

This is the 163rd #WILTW

Nearly a year ago I wrote on Sepsis and Self-Doubt

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

I highlighted the importance of doubt in decision making. It is not possible to admit all children who have features of infection. We must select those with high risk signs/symptoms for investigation & treatment and discharge low risk cases with adequate safety netting. This in itself is a conundrum and it is important that senior clinicians wrestle with this balance of risk. For not to do so results in either over-treatment, or in-appropriately conservative management. This is a significant cognitive and emotional drain, and in the context of spiralling presentations, it’s imperative we reduce the decision making load on acute and emergency clinicians.

It was for this reason I reacted strongly to a piece on the potential reasons behind the ever increasing access of emergency care by children and young people. In retrospect I was a little OTT in my concerns regarding an inference that there is a financial incentive to admit patients to hospital (see comment at the end of the article).  With all due respect to Quality Watch they responded and amended the text. We are both agreed the current financial model (where hospitals receive a set payment for each child admitted) sadly does mean there is little incentive to change the system.

The original version had hit a nerve because inappropriate admission to hospital makes diagnosing serious illness harder. A rising patient load of a potentially high risk group of children makes case selection on admission units and wards even harder. While there is much work to do in educating professionals and parents on the core features of common illnesses, neither group wishes children or young people to be in hospital unless they really have to be.

Over the last year it has become increasingly apparent to me that we are probably too focused on the identification of illness in the initial stages of a patient journey. Would it be easier to spot the needle if the haystack was smaller? Should the paradigm be spotting the well child early (and discharging) rather than the sick child late? We endeavour to create more specific scoring systems, biomarkers and analytics to identify the most unwell when  we probably need none of these things to identify the well.  It may be argued that discharging normality is a core function of medicine, I would challenge whether we truly operate out of that mindset. And if we wanted a different form of incentive, wouldn’t rewarding the rapid, but safe, recognition of the most well be in everyone’s best interest?

What have you learnt this week? #WILTW

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A video exploring this theme:

The Traffic Light Analogy: Patients aren’t cars #WILTW

This is the 162nd #WILTW

There are conflicting views on whether analogies between safety in the airline industry and medicine are reasonable. While aviation is applauded for its strong culture of training and disciplined team work, the fixed environment i.e. the same cockpit, with the same crew, in the same circumstances makes it difficult to compare with the unpredictable nature of clinical practice. The converse argument is that in healthcare we always find “an exception to the rule” so unified practice becomes impossible. It is likely this debate will continue to run, with no obvious winner, until medicine becomes a safe industry. Something it is currently, certainly not.

A safety initiative in road transport is a common feature of medical guidance: The Traffic Light.

The movement from green (clinical features which are not concerning and do not require intervention) to amber (may cause harm and require investigation) to red (must action immediately to avoid harm) is commonly used to highlight the key features of practice guidelines and risk in observation charts and scoring systems.

This approach implies there is a discrete and objective difference between the categories. While this may be true for vital signs (the movement from low to high heart rate for example) medicine rarely affords us anything which is black and white.

In a fantastic piece on the complexity of diagnosing paediatric sepsis Dr. Edward Snelson proposes the following:

Edward highlights that “Sepsis doesn’t appear, it develops“. There is a misconception that the point where sepsis began can always be identified. This is simply not the case and evidence supports this. A viral illness bringing you to hospital one day, may well still have been a viral illness regardless of whether you present to the hospital the next day with sepsis.

Given the evolving nature of many diseases is “tri-chotomisation”  a valid approach? In practice some clinical features may sit in one category, while some may sit in others.  Rather than green or amber, should we have brown? Trajectory of illness means it is far more meaningful, but infinitely less practical, to have a spectrum of colours rather than a traffic light.

Does the ease of use and face validity of the “Traffic light” trump the practical difficulty its implementation may produce?

With that particular challenge I leave you with Edward’s extremely relevant summary:

What have you learnt this week? #WILTW

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You can’t repeat that, I said it in public! #WILTW

This is the 161st #WILTW

What would you do if the picture you posted on social media went viral? Be pleased that you had shared the love or be embarrassed that you had forgotten to check your privacy settings. Were you even aware that your posts could be seen by people you’d not ‘friended’

For those who are frequent users of social media understanding the public nature of your communication is obvious. But is everyone aware of this?

In a comprehensive blog by the @Mental_Elf and the South West Peninsula Collaboration for Leadership and Applied Health Research and Care (PenCLAHRC) a recent systematic review on “any qualitative methods to collect data on attitudes on the ethical implications of research using social media” is discussed.

Essentially the paper was looking to examine perceptions of ethical considerations when performing research using social media.

Ethics of social media research: from Big Brother to rainbow unicorns

There were a variety of findings (please do read the blog and the review itself) but the one that caught my eye was the potential necessity for obtaining informed consent for using material on social media.

If someone posts something in a public forum should you have to ask them if you want to comment on that post in an academic journal? This is more than a mere ethical conundrum. Our news feeds are now full of leaders and commentators using social media to inform and debate. It would be difficult to argue that they don’t want the information to be consumed and digested.

But what of the general public? Whose responsibility is it to let them know that what they are saying may be available to everyone? The terms and conditions as you register? A regular reminder as you log-on? Or just common sense?

Colleagues and I will shortly be publishing a paper that (in a small appendix) uses tweets as part of the research exercise. It hadn’t even occurred to me to obtain individual consent to use those (public) micro-blogs in our work?

Would you mind if your tweet or facebook posting was used by a researcher?

..and why?

What have you learnt this week? #WILTW

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The blood test that causes harm #WILTW

This is the 160th #WILTW

In medical school you are swept away by the prospect of doing good. While you appreciate you are naive you don’t realise there are many unknown unknowns. At the time, therefore, it seems illogical working out what is wrong with someone can cause more harm than benefit.

As you grow in experience, both good and bad, facilitated and self-learnt, it becomes clearer that the “Gregory House” school of investigative medicine really is a recipe for disaster. There are very few ‘tests (blood or otherwise) that make a diagnosis for you. From white cell counts to spot sepsis and x-rays to find pneumonias, these investigations  just alter the patients’ prior risk of illness. Positive or negative they don’t definitively tell you whether someone has a disease.

In paediatrics there is the additional challenge of the test itself doing harm. Blood tests are not an enjoyable exercise, for child or family, and the benefits must outweigh the risks. Even with the most effective distraction and analgesia if a child’s first memory of a hospital is an unpleasant one, subsequent visits become more challenging. And for the child who already has had multiple blood tests and cannulas, that solitary precious vein for use in an emergency does not need unnecessary damage.

U.S. Air Force photo/Staff Sgt. Desiree N. Palacios

And what happens if you are not successful? Even the most experienced practitioner has a bad day. Do you really need that test? Will you have 3-4 further attempts and then decide it is not required? What does that tell the parents, and what does it say about your decision making?

In an era of over-diagnosis we must consider the consequences of investigation as a similar challenge of our time.

What have you learnt this week? #WILTW

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