Category Archives: #WILTW

Blogs relating to What I learnt this week

What I learnt this week: The frustrating advantage of being difficult #WILTW

This is the 22nd #WILTW (and a little delayed due to my attendance at #EAPS2014)

This week I took our family car into be serviced and have an MOT. I dropped it at the garage just before work and was told it would be ready later in the afternoon. However  I had an answer-phone message at about 4pm to say that the service had been done but they hadn’t got around to doing the MOT so could I please leave the car with them overnight or come back the next morning.  I was a bit frustrated by this assumption as I either

i) I couldn’t get home or

ii) would be without an appropriate car for the school run.

I suspect, in fact know, I am a bit soft in these situations and although I was frustrated I tend not to let emotions get the better of me. So surprisingly, and probably because I missed the call and didn’t get put through to the person who had initially made it, I was able to be a little more ‘robust’ in my annoyance. I felt a little uncomfortable when I put the phone down having expressed my disappointment at the service I had received. However 5 minutes later I got a phone call back saying that manager had found someone to do the MOT…

There are often times when parents, carers or relatives of children become frustrated by hospital processes. Often they are scared and emotional and outbursts can be tolerated in the context of the situation they see their children in. But sometimes it does appear the smallest thing can be blown out of all proportion and you find yourself expending energy ameliorating the parents anger at the expense of care to other patients. Conversely in my experience parents are often very humble about things they could and should be annoyed about!.

My learning last week was reflecting on whether bad behaviour gains you rewards? My small outburst with the garage sorted a problem (which probably shouldn’t have occurred in the first place). What of the families or patients we see? When is strongly challenging the care they feel their child has received appropriate? and when is it simply a method of gamesmanship?

I hope I am never in a place where I assume the latter and will always do my utmost to facilitate the former.

What did you learn this week? #WILTW

What I learnt this week: Don’t discharge your discharge summary responsibility #WILTW

This is the twenty-first #WILTW

This tweet dropped into my timeline:

It was timely as I had only yesterday spoken to a local GP about a concern he had with a patient discharged from our Emergency Department. I had seen the patient on arrival and had been responsible for their care. Review of the notes by colleagues indicated that my decision making was entirely appropriate and my documentation was coherent. However, in retrospect, my discharge letter did not contain adequate information for the GP to not need to clarify some further details. The conversation was amicable, and useful for both of us I think (direct communication between health care professionals cuts through layers of bureaucracy that a written notification often piles high). Given the increasing attention paid to service pressures being placed on our primary care colleagues adequately explaining decisions we make at the urgent/secondary care interface is vital to maintain communication. This will both foster good relationships and maintain patient safety. I’m mindful that systems don’t always facilitate the production of timely and adequately detailed information between health care professionals. It’s therefore imperative we maximise all opportunities these improve systems regardless of dependance on human or technology factors.

Information Exchange

What did you learn this week? #WILTW

What I learnt this week: Balancing proper procedure with paediatric passion #WILTW

This is the tweentieth #WILTW

In my humble opinion the Royal College of Paediatrics and Child Health have been very lucky. On Tuesday an Extraordinary General Meeting took place in regard to the governance and trustee structure which would lead to an opening up an arm of the RCPCH to all child health professionals. Details on the proposals can be found here

The outcome of the EGM was that the Foundation of Child Health was rejected. This is a great shame but I say the college has been lucky as I had half expected to see a Daily Mail headline:

Paediatric doctors feel they are more important than other health care professionals“.

Fortunately this angle was not taken, in fact there was virtually no media coverage. Those opposed cited a potential conflict if the paediatric ‘medical’ lead for the college and a non medical lead for the Foundation disagreed with each other which would be bad for public relations. Given the lack of interest in the event I’d be more worried that we have any paediatric voice at all!

My position was clear (from a previous Running Horse Group blog)

“This junior paediatrician  feels the concept of not moving in a direction that makes us multi-professional is almost absurd. I work on a daily basis with nurses, nurse practitioners, health care assistants and play specialists. I have also been part of a college structure which is bureaucratic, hierarchical and slow to react.”

Having passionate views about something makes you very dangerous. The moment you are not willing to pause and reflect is the moment you no longer have sound judgement. I therefore always make a big effort to step into other peoples shoes and aim to see things from their stand point.

Boat Land

 

cartoon courtesy of Dr. Hilary Cass

So, to be fair to those against the motion, there were some issues with the approach the College had taken. Changes to the governance structure were/are independent of the need for a Foundation of Child Health. Placing them together did cause confusion and potentially gave the impression of rail-roading the policy. The hosting of a significant event on a lunchtime, on a weekday, in London, did not invite a high turnout (to be fair the rules governing the college’s charitable status dictated that the vote needed to be in person). Finally at the hustings stage it would have been preferable to have an ‘against’ speaker as well as those ‘for’.

Adesthepoet

 

During the hustings the chair of the parent and carer’s group gave a emotional talk about her experiences of being a parent. She showed pictures of the twitter celebrity that is Adam Bojelian and the multiple interactions with doctors, nurses and therapists he has:

no child has ever died of too much communication between health and social care professionals

Her talk, followed by a focused argument from Dan Lumsden, the chair of the Trainees Committee, set out I think an unintentional confrontation between ‘procedure’ and ‘passion’. On one side, yes, there were some governance and policy issues at stake. Things could have been done differently in a very systematic fashion with extreme attention to detail. One the other we were deciding on a tone for the future. If the college of Paediatrics and Child Health are unable to embrace their fellow professionals and create a unified organisation to improve outcomes who else will?

I therefore found it very unnerving when the following was quoted as an argument AGAINST the changes…

“Management is doing things right; leadership is doing the right things.”

― Peter F. DruckerEssential Drucker: Management, the Individual and Society

A further speaker then worried that the potential non-elected nature of some of the trustees would risk a situation that is currently occurring in Hong Kong.

I spoke up in support of the motion but emotions are a strange thing. I have been more confident in a crowd of 1500+ than I was in front of the 100 or so in the audience. This was due to the fact, and I said this at the time, I was speaking against people who have mentored and supported me in the past. But it was also because I felt an overwhelming surge of righteousness about the motion; inflamed by an argument that the previous consultation was invalid due to its low turnout. This seems ridiculous given the equally poor responses rates for the Health and Social Care Act debate (context of table):

Voting in Health and Social Care Act

But also on reflection I was perhaps not as charitable as I should have been in regards to the comment comparing the college to the Chinese government.

Only time will tell as to the long term impact of this EGM. Many of the those voting no said they were voting against the lack of information  or “devil in the detail” provided. They weren’t against the Foundation in principle. Was this simply a case of the right thing to do but at the wrong time? I remain to be convinced. I worry that if the chance is to come again some equally obscure bye-law will be raised. If we are to be a multi-professional organisation then there will come a point that hierarchy and power is shared. That is unavoidable and no amount of procedure can bypass it.

Or maybe I just can’t see past my passion….

What did you learn this week? #WILTW

Additional Entry 11th October 2014

Please see the comments section. There has been some confusion I think about the Foundation being more important than the RCPCH. This is not the intention or the proposal. This diagram clarifies I hope:

Integrated College of Child Health

What I learnt this week: What you see is maybe not what I see? #WILTW

This is the nineteenth #WILTW

A significant proportion of patients in health care services are seen by multiple health care professionals (excepting primary care and out-patients). Acknowledging some patients do deteriorate rapidly, generally there are the same clinical signs and symptoms to be observed regardless of the different staff seeing them. It is well recognised however that patients can have many clinical encounters before someone finally recognises they are seriously ill [1].  The fact that some clinicians see different ‘things’ in patients is not unsuprising. There are some clinical signs which are very subtle, such as work of breathing and fine movements, which require training and repeated exposure to be able to put into a context which makes pattern recognition obvious.

However others are more clear; physiological features such as heart rate and breathing rate being fixed signs which should not differ when examined by different individuals. To be clear I am not pondering over gut feeling here. The literature on the use of ‘gestalt‘ by experienced clinicians to recognise serious illness is substantial but this is not about subtle signs or intuition. How is it that in the same time span a patient who has clear features of illness may be recognised by one person but not by another? Experience and knowledge play a role but continued failure to recognise significant illness even by experienced  professionals represents a significant challenge for the health care community.

I have a research interest in the educational use of clinical video cases. This hat often collides with my clinical practice hat when system errors occur in the recoginition of illness in children. This dilemma of why a particular patient isn’t recognised as being ill (or the converse – when someone is overtreated as being very unwell when in fact they weren’t) is an important issue as is often the root cause of communication problems between departments in hospitals.

The video below was consented for general viewing by the patients’ mother (appropriate hospital and national guidance was followed). I use it (hopefully!) as a potential grey case to highlight how the same clinical features can be interpreted differently . I’m hypothesising there maybe differences in determining which are the salient clinical signs in this case. Please feel free to leave your thoughts in the comments section (appreciating previous comments may bias you so try not to look!). Regardless of whether I’m right or wrong I hopefully will learn something I can feed back on in the future!

[Oxygen Saturations 96% – Heart Rate 170 – Temperature 36.4]

What have you learnt this week? #WILTW

[1] RCP NEWS standardising assessment of acute illness severity 

What I learnt this week: Am I really learning..? #WILTW

This is the eighteenth #WILTW (and a little delayed due to working the weekend!)

How many times do you need to experience something for you to learn from that experience? In medicine health care professionals will often refer to ‘sentinel’ events. A clinical incident which has forever changed their practice:

I will never forget the patient who…. ”

These events often have a patient safety element to them, with harm or near harm, unfortunately occuring. It is the seriousness of the outcome making the event the more memorable. A catalogue of these stories by senior health care professionals can be found in the handbook  “Medical Error“. It is shame that these sometimes tragic events need to occur to ingrain key actions and principles in people. But how do you make sure you don’t repeat mistakes when there isn’t a significant outcome to an error you have made? Take this example; males presenting with abdominal pain could actually have a problem with their testes. Failure to examine the scrotum may miss a testicular torsion (twisting of the testicle) resulting in the patient having to have it removed. However it would be possible to examine hundreds of patients with abdominal pain – never examining the testes – and no one ever coming to any harm because none of them had testicular torsion as the cause of their pain. If no-one ever audited your notes and fed back to you may never realise you were missing out this important part of the examination.

Medical Error

I am reminded of this as my second ever post on #WILTW was about the importance of clinical guidelines and how sometimes guidelines may trump gestalt. Last week I was involved in a similar case demonstrating following  a tried and tested pathway was probably better that thinking ‘I know best”. Although ultimately it wasn’t a black and white issue, and there was no harm to the patient, I was left with a real sense I hadn’t learnt my lesson. In some respects cognitive errors that involve the interplay between guidelines and gut instinct are not great examples of sentinel events.  I am though left with the feeling that despite blogging publicly about “what I had learnt this week” a couple of months ago maybe I had not learnt anything at all? Or maybe the event opened my mind to note when I am making similar errors. Maybe this post was only possible because of that previous experience? Learning might not be so concrete as to ensure when this event happens you will always do this. It’s probably a little more subtle than that. At the end of the day I hope this catalogue of reflections will always inspire me to think that little bit harder about the consequences of my actions.

What have you learnt this week? #WILTW

What I learnt this week: The importance of #connectingwith #WILTW

This is the seventeenth #WILTW

This week Alys Cole-King went on a 24 hour tweetathon in aid of world suicide prevention day. She used the hashtag #connectedwith aiming to “raise awareness that strong relationships, connectedness and a sense of belonging are powerful protective factors against suicide.

She also wrote a great blog on the importance of friends and family and how easy it is to sacrifice this in trying to be supportive to the patients and colleagues you work with. It is a theme that has run since her NHS Change Day pledge. It is very well timed as on the other side of the planet Mike Cadogan has written on very similar themes as part of a personal reflection on the challenges he has faced in delivering the #FOAMed movement. “Family comes first” his first of 5 lesson learnt.

Connect

 

Being connected with people is a very easy thing to think you are doing when in fact you are not. It has been a painful process but I am now all too aware of times when I haven’t actually been truly engaged with people close to me.  At times this may have led to active antagonism with no insight at all on my behalf that this was happening. I do my best to always be utterly honest with the problems or issues I may be bringing to a discussion. Unfortunately too often there is little time to sit down with people, catch up and actually listen to the issues at stake. We work in health care environments in which time spent in the cafeteria may be seen as being work shy as opposed to being engaged. Its clearly not an easy think to balance but true connection is something I really hope to work on.

What did you learn this week? #WILTW

What I learnt this week: Everything is awesome #WILTW

This is the sixteenth #WILTW

The following tweet raises a number of interesting questions:

Are we really that miserable? My immediate response was surely not! I think, by and large, my day-to-day interactions and social media output concurs with that. I admit a tendency to look a little more stressed than I actually am (although this has advantages in not being given a deluge of additional tasks…) but think/hope my outlook is generally positive.

But if I look a little deeper then there is something to reflect on. Going back through blog posts I can honestly say that my view of the world is not “wow – isn’t everything great!”. There is a slight negative aspect to a number of them and an underlying theme that change is a very long and laboured process. I look at my recent timeline and, although there are a fair sprinkling of supportive #nhschangeday and #FOAMed tweets, there are also not an inconsiderable number on difficult situations and challenging world events. On further reflection I must be honest that actually my interaction with social media (twitter in particular) is not always a “smiley-happy” experience. All too often I can be rankled by editorials or upset by the black-and-white nature of peoples thinking. I must also admit, and this is slightly painful, occasionally it is a little frustrating to see others comments and material go quasi-viral when you have had the same idea (or even previously released the same content).

Am I more miserable than I actually think…! It is a sobering thought.

I think this is good wake up call to the importance of mindset. Earlier this week, my wife and I, without our kids(!) watched the Lego Movie. I personally highly recommend this film. It runs out of ideas towards the end but basically nearly 90% of the jokes are adult orientated (or I am just a big kid perhaps). The signature tune is “Everything is awesome”

Once you have heard this tune you are destined to hum it for the rest of the week; so beware!

It’s likely there will remain times that content flowing in-and-out of social media is frustrating and incites a feeling of dejection and depression. But there are many other times when collaboration and support are clearly demonstrated to be intrinsic to the motivations of many FOAMites and Medical tweeps. And while Mike Cadogan’s frank review of his learning over the last 5 years is not a litany of joy  – the nature of the comments on this post and the learning from it leads me to believe we will all be the better, and more positive, as a result.

Everything is awesome.

What have you learnt this week #WILTW