Category Archives: #WILTW

Blogs relating to What I learnt this week

What I learnt this week: Whose ‘change’ is it anyway? #WILTW

This is the 42nd WILTW

The main dangers in this life are the people who want to change everything… or nothing.

 

In late summer 2012 a small group of junior doctors, nurses and graduate management trainees met to discuss a methodology of engaging other health care professionals in innovation and improvement. Follows is a quote from my call to action:

But like others in the NHS I have a sense of belonging, anyone who has been on a department night out will note the sense of commoradie amongst us. Despite this sense of belonging the NHS, much like a steam roller, is a machine that does not move quickly. It eventually gets to its destination and achieves its goals but the journey is slow and often painful for those at the bottom.

I was a junior doctor at the time and was really excited to be part of a project which I believed may help others make changes, however small, to their practice. Our aim, born out of a few hours discussion, was to model the Earth Hour social movement and create a day in which any health care professional would be asked to pledge a health care action. It wouldn’t be defined or mandated but could be shared and copied. In the room at the time were no government representatives, regional strategic directors, presidents of Royal Colleges or BMA representatives. There was a group of (relatively) young people connected by various leadership and improvement networks and brought toghether by Helen Bevan, then of the NHS Institute for innovation and improvement. At that meeting we set the day for early March 2013. I make this point because on the 6 February 2013 the Francis report was released. The date of release had fluxuated for some time but even given my health service naivety I was unprepared for how this would affect our project. Let me be clear first. The Francis report was a defining point in the history of the NHS. The underlying issues affecting not only Mid Staffs but other hospitals are clearly fundamental problems that need to change.

change1

However NHS Change Day was not a response to the Francis report. It has been, and still is, very difficult to convince people of this. The timing too ‘co-incidental‘, the concept clearly ‘from government‘, the ethos ‘reactionary rather than visionary‘. I will accept much criticism of change day (I am not an evangelist and continue to ponder whether we got the name right) but I do get upset, and I’ll be honest angry, when this particular charge is laid at my door.

From then on I have become very aware of the differences in the way people value what is important and right to do. Motivations to change (either yourself, organisation or system) are in part dependant on the values that you hold. I would have thought that many people would have had a shared vision of what change day was trying to achieve. But that in itself is a false and arrogant premise. It is not for me to decide what other peoples values are. So while thousands of people join a pledge on smiling at work, others lambast this as weak and something that should already occur. While we aim to bring discussions together on various social media channels, others see this as talk rather than action.

And no one is ‘right’. The Change Day team have aimed to move from pledge to actions, remove the emphasis on ‘totals and targets’, increasingly get involved at a local level, facilitate discussion with more patients and create more space to engage with all those interested. But we are always going to rub someone up the wrong way. We are also not homogenous in our own values. I personally can not promise that enthusiasm and passion haven’t over-run. I apologise to those who believe they are excluded and am honestly very upset to hear stories of where people have felt affronted during conversations.

But in return when I have been contacted with concerns about these events I find it increasingly difficult to arbitrate. The rapid nature of conversations that take place on social media does no-one any favours (believe me I know the Daily Mail have taken hold of an ill-phrased tweet of mine). When you combine limited characters with a topic such as ‘change’, in an organisation as emotional as the NHS, friction is likely. A simple question is perceived as antoginism resulting in an overly defensive response and there begins a spiral in which both sides feel aggrieved.

And there we have it: ‘sides’. An outcome that was never intended or desired but the ‘change’ those of us at the outset wished to take place is not the change others wish to see. It’s a shame it’s developed into ‘sides’ especially as I am sure my ‘change’, and I use this term of any methodology I might use to improve myself or others,  is no better than anyone else’s ‘change’. In fact I agree there are some fundamental issues in the NHS that are going to need a lot more than NHS Change Day to alter. And these changes are certainly not going to happen through change processes I use…

It’s my change though and I am passionate about it. My action, is neither evidence based or groundbreaking. But it’s something different, outside of my comfort zone and it creates a conversation which previously didn’t exist.

If you have something you would like to act on or join, please do and if not, I certainly think no less of you. And if I am not offering the change that you would like to see, I’m sorry, but I’m sure or hope someone else is!

Whose change is it anyway? #WILTW

What I learnt this week: Patience can be the cruelest of virtues

This is the 41st #WILTW

There is some irony to the fact this #WILTW is a little late. It’s been a long term ambition of mine to use a video of a patient, with consent to be shown to anyone, as a #FOAMed resource. The project has finally come to fruition but obtaining the footage, editing, formatting, reconfiguring this website etc. has meant it has been a lengthy process. Given it’s needed to happen with other projects with clear timelines has meant it was never going to be a priority. I was hoping it would be a novel and unique contribution to the FOAM concept. Last year however the reeldx team started doing something very similar, with greater quality and much greater scale. It’s not a race or a competition but I’ll be honest in admitting I thought, “wish I had prioritised that.”

This week also sees the launch of my REMIT project, the educational ‘outcome’ of my PhD. This has also been a long term endeavour, fitted around finishing training, starting a new consultant job and trying to create a research strategy. When first imagined, I had hoped it would be cutting edge. Having spent years breaking down barriers of resistant video technologies and obtaining endorsements the rest of the online educational community has definitely caught up.

Patience

I feel perhaps patience hasn’t really paid off. Waiting for things to fall into place and thinking, “it’ll get there in the end” has allowed so much time to pass that more iterations of work are needed. Have I just demonstrated poor time management? Although I am not sure what else I could have substituted so perhaps it is just bad prioritisation!  I suppose it is more the frustrating as patience is something I have been trying to develop. Rather than a shot-gun approach to tasks and overwhelming frustration that nothing gets done taking the long view has been a personal development aim of mine.

I then reflect on the only person who is really frustrated is me. No system or process has been affected. It is only my personal ambition that has been bruised. And it’s not really a big bruise at that. While researching this blog I found the following anonymous quote:

Patience is both the love of action and inaction

Not quite sure this quite fits for me yet but maybe something to aspire to.

What have you learnt this week? #WILTW

 

 

What I learnt this week: What estate agents can learn from healthcare #WILTW

This is the 40th #WILTW

This week we were guzumped on a house. It was pretty frustrating as we’d already started planning what our new home might look like and made provisional financial and legal arrangements.

The estate agents started with, “..we have bad news..” rather than “..we are sorry.” This may seem incredibly petty to dwell on but the ramifications of the phraseology have become more obvious as time has gone on. The estate agents said they had technically done nothing wrong and were under a legal obligation to the sellers to inform them of all offers. They seemed affronted when we didn’t appear very charitable about this.

Monopoly Board

I suspect others have been in similar situations. I feel Estate Agents are failing to recognise that it is not the legal aspect people get frustrated about, it is the principle. Its about doing something which is, and this may be overstating it, morally right. Yes you can gazump, yes your estate agent has technically done no wrong, yes they will get a slightly bigger commission, but no they have demonstrated little in the way of a shared value of respect.

In health care patients want to hear you are sorry, not that the mistake was a long term system issue which has yet to be resolved. While it is virtually impossible to compare a public funded health care system with a financially motivated real estate trading model, honest apologies and a value-based operational system are important in both. The increasing privatisation of  health care in the UK comes with the danger of the health system doing things ‘by the book’ rather than for the best. I hate to think patients would ever be ‘guzumped’ for a more financially profitable one.

What did you learn this week? #WILTW

 

What I learnt this week: The importance of capacity in system AND self #WILTW

This is the 39th #WILTW

The health system in the UK remains in a perpetually fine balance. In acute care the constant inflow of ill patients requiring care is only just met by the availability of hospital beds for them. The winter crisis of 2015 demonstrates what happens when the system becomes utterly overloaded and capacity is breached resulting in patients spending prolonged times in Emergency Departments.

It is often argued that hospitals need to run at 85% capacity in order to function efficiently (although trying to find the facts behind this is hard). This means that there must always be a good excess of empty beds at any given time (with available staff to care for patients  who may be placed in them). Without this whenever the system is faced by increasing inflow i.e. lots of patients requiring admission in a short space of time it just grinds to a halt because there is no where for patients to go. Often hospitals in the UK run at 95% capacity or more meaning there is absolutely no flexibility in the system. The challenge of keeping beds empty is a difficult one and one which NHS England have been trying to plan for. For managers or clinicians wanting to utilise spaces for surgical procedures or other non-urgent tasks it can be frustrating but failure to maintain adequate capacity can cause problems with the quality of care.

Having ‘capacity’ is not just a concept that can be applied to health systems. This week I completely ran out of capacity. This wasn’t an inability to do things – I’d hadn’t lost enthusiasm or suffered from acute writers block – I had simply not allowed any extra space to deal with a couple of unexpected tasks. I think for a couple of months I have been trading an ever dwindling capacity to accommodate what appeared to be an ever increasing work load. In hindsight I am now not actually so sure my workload was actually increasing; I was just failing to protect anytime to deal with ‘acute inflow’ as it were. This gradually weaned down the capacity I did have until suddenly everything ground to a halt.

Over burdened

So along with being research resilient, insightful, avoiding narcissism, and not being as busy as a Backson I now have a new #WILTW behaviour to add to weekly reflections. Will it be possible though to create space, which might not be used, within any given week? This I think will be a personal challenge that may take many winters to solve….

What have you learnt this week? #WILTW

 

What I learnt this week: Bringing two worlds together #WILTW

This, the 38th #WILTW, comes in response to call out from Andy Bradley. Andy is a pretty inspirational guy and if you are ever dis-enfranchised with some of the efforts the NHS makes to motivate/engage staff I would recommend you watch his TED talk.

Andy has recently been promoting #wisdomofkindess and asks the question

“In your minds eye what does our future health and happiness look like, sound like, feel like?

How would you love it to be?”

In my initial response to the blog Andy replied with:

I sometimes feel I live between worlds. There is a the clinical world I inhabit; being physically present on the “shop-floor’ of a busy Children’s Emergency Department or as part of a clinical leadership team improving the quality of care we provide. I try to be constantly aware of the effect my emotions and biases have on other staff, parents and especially the children and young people I meet. Simply put: it’s not easy. While #hellomynameis is a reflex, other aspects of compassionate care sometimes aren’t. It’s not simple to challenge others behaviours when you have witnessed a professional interaction that is not acceptable. Maintaining persistent empathetic engagement with families can be one of the most draining aspects of my job. Do I sometimes resent it. Yes, I’ll be honest I do. I don’t think that makes my unprofessional, callous or dispassionate. I hope it makes me aware of when I do need to take a break, re-group and re-energise.

The other world is the network of individuals and groups I belong to who are championing change, within and outside of the health service. Generally via social media, but also through conferences, projects and campaigns. There is a steady flow of what some might call ‘positive energy’ but others see as mis-informed and ill-placed conjecture and eulogising. My efforts with #nhschangeday are on the public record. As it reaches its 3rd year I am proud to have been part of a movement which I do feel has engaged people in understanding how and why change can occur in any health or social care setting. The networks I have developed from this and other initiatives are supportive, inspiring and positive. I have developed insights and skills which clearly have benefited me and hopefully the patients I treat.

And yet despite this latter point it feels sometimes as if these worlds are in contradiction with each other. If you watch Andy’s videos you think – why isn’t every clinical encounter like this? Why is it that the energy I can have from one phone call on developing a new social movement can be utterly deflated during a clinical meeting a mere hour later. Idealism often crushed by the reality of some of the things that need to be overcome. So how would I like our future health and happiness to look like? For me it would be to live in just one world. One in which there doesn’t need to be a jump from what we think we should be doing to what we are doing. But I appreciate that mostly starts with me. It’s my mindset and my beliefs that predilict the energy and compassion reserves I possess. I encapsulated this a while back without realising it:

Creativity and Compassion Matrix

And while I realise the very thought of this matrix will turn off many, I hope one day to create in both worlds the possibility that: “Today can always be a good day”

What have you learnt this week? #WILTW

What I learn this week: Paracetamol – a simple drug with not so simple dosing? #WILTW

This is the 37th WILTW

A while ago I was surprised to find an unusual dose of paracetamol written on an anaesthetic° friend’s kitchen wipeboard (1.2ml). On closer questioning it transpired that his son had developed a viral illness while on holiday in Spain.  The anaesthetist was frustrated as he could only buy a small volume of paracetamol and spent a long time negotiating for a 90ml bottle. On returning to his holiday residence he realised the reason for the pharmacist’s reluctance – in Spain a 100mg/ml concentration is used.  Although this is a standard European dose, in the UK it is more common to have 250mg/5ml which is half the amount per mililitre.

Figure One

The wipeboard contained relevant values for the son’s age but had such diligence not be applied to reviewing the actual dosage it is possible that an un-intentional overdose may have been given. I had thought of submitting this as a case report to alert Paediatricians, GPs, Pharmacists and Parents to the potential problems that buying medications in countries outside of their country of origin may bring (and also a weight rather than volume based syringe may be helpful as parents sometimes find dosing difficult [1]).

Figure 2This case sprang to mind as I have recently reviewed some literature on liver injury secondary to paracetamol overdose [2]. The study based on data from Australia and New Zealand revealed the majority were in small children (< 5) as a result of parental medication errors. An (unrelated) discussion on twitter this week therefore caught me eye. It related to the use of 30mg/kg of paracetamol as a loading dose to aid discharge of chidren from Emergency Departments

I’m going to try to steer clear of the ‘fever’ treatment debate in this blog but I think this is a salient reminder of the dangers of variable medication volumes in children. While I can see the pharcomological rational behind the loading dose, the potential for confusion does exist, especially if parents mis-interpret its use. While I have previously highlighted the medical profession are a little paternalistic about parental decision making (thoughts here) there is evidence children have come to harm as a result medical errors. The work mentioned in the tweet only suggested an improved reduction in temperature, rather than other clinical outcomes, so for me currently there is no a clear reason to use the larger dose. If this was proven to reduce distress in children to the extent disposition decisions could be more safely and effeciently made then I suspect the whole fever debate will be re-ignited!

Until then we know medication errors occur as a result of health care professional and parental/carer mistakes. We should continue to do all we can to ensure we work towards them being never events.

What did you learn this week? #WILTW

°Many thanks to Richard Eve for being so thorough with his dosing calculations!

  1. Marlow R, Lo D, Walton L. Accurate paediatric weight estimation by age: mission impossible? Arch Dis Child 2011;96:A1-A2
  2. Rajanayagam JBishop JRLewindon PJEvans HM. Paracetamol-associated acute liver failure in Australian and New Zealand children: high rate of medication errors. Arch Dis Child. 2015 Jan;100(1):77-80

What I learnt this week: Research resilience #WILTW

This is the 36th #WILTW

This week I formally received my PhD. A chance to dress up, wear a funny hat and sit with a sense of dread that you will be the person who trips up the stairs en route to shake hands with the vice-chancellor. My PhD was completed well over 6 months ago – my first graduation ceremony postponed as it ironically clashed with the presentation of my findings at an academic conference. Since then enough time has passed that I have ‘graduated’ in other ways; most notably a new consultant job with increased levels of responsibility and accountability.

Completing a PhD is a big task – the write up was painstaking and the viva a more challenging process than I had expected. The latter perhaps a sign a naivety on my part, the former an inevitably. It was uncomfortable though, in a week in which I have faced a number of challenging clinical situations, to be forced to ponder what I had gained from this academic qualification? Other than some letters after my name and a life time of, “so can we call you Dr Dr now?” of course..

Snakes and Ladders

Earlier in the week I spoke to a group of academic trainees in Emergency Medicine. I was in hindsight maybe too stark in my views of the challenges of academia. The pressure of ‘output’ doesn’t relent. You can leave what might be the most horrible shift behind but even when you press submit on your grant or paper submission you can’t relax until you find the words ‘accept’ on the email in response. This maybe months later. You have repeated tough decisions about which paths to follow, which projects to chase and which fantastic ideas to drop to ensure you have a balanced work load with adequate capacity to not impinge on your clinical duties.

I wasn’t initially sure my PhD really prepared me for any of these challenges, it certainly hasn’t had the dramatic effect on my writing style I hoped it might! What it has given me though is resilience. Despite all the negative things I could think of, some in honesty clearly over-emphasised for effect (follow @academicsay for examples), I still feel enthused and passionate about my work. For every rejection letter there is (eventually) a publication. For every day wasted on a grant application there is chance to work with some truly inspirational people and feel that you are contributing to work that makes a difference. Whether the PhD gave me resilience or just confirmed I had it I am not sure. What I learnt this week that tenacity is always eventually rewarded.

Graduating Isla 2(My daughter on her graduation from nursery…)

What did you learn this week #WILTW