When experience doesn’t help learning #WILTW

This is the 150th #WILTW

Grace Hopper apparently was behind the quote:

..the most dangerous phrase in the language is, “We’ve always done it this way”

It’s usually used to describe the persistence of organisational blindness to repeated but ineffecient processes. However there are individual practices, especially in medicine, that despite evidence to contrary persist throughout a clinicians whole career. Some of this is pure bloody mindedness, and some ignorance, but a small proportion is related to personal experience, often a result of being burnt.

I’m generally not an over-cautious doctor but children I see with a history of abdominal trauma definitely get over-observed. I can’t help it. I am completely aware of the cognitive bias my experience with a single patient has placed in my diagnostic armoury but its difficult to shake. While I have always tried to explain this to students and juniors I can’t be sure I always do so.

It is only now I understand some of the odd habits of senior doctors who have taught me in the past. These probably weren’t eccentric foibles but more likely the product of the one instance, in a very specific but probably un-reproducible case,  when a sign was missed or an investigation not ordered which unfortunately had a bad outcome. The learning for the individual obvious and profound. But perhaps this context may have been lost on all the doctors subsequently taught by them…

What have you learnt this week? #WILTW

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The Helicopter Hover: Counterfeit Cognition #WILTW

This is the 149th #WILTW

-“Stop being a helicopter consultant..


-“..just standing around and hovering

I’d been called out by a colleague for something I’d never heard of but which made perfect sense.

There is a perception that Emergency Medicine is a dynamic, all action job in which you are constantly on the go with no time to think or reflect. This can certainly be true but while there are periods of high intensity the reality is not always as shown in popular television series. There are also times when a particular patient or situation can take up a disproportionate amount of time. You might be heavily involved in delivering a treatment or intervention, you might be having difficult discussions with other specialties, or you might be closely supervising a junior member of staff.

But sometimes you’ll find yourself ‘hovering’. This can be an almost subconscious endeavour, perhaps noticed more by other staff than yourself. A sign perhaps of not quite wanting to leave at the end of a handover leaving you just standing at the end of the bed drumming your fingers against the bed rail. The cause of this ‘action in inaction’ is multifactorial (and inconsistent) but there are some common themes:

  • Active Thinking

This is typified by a difficult clinical case. You are creating space to weigh up available evidence so that you can make the most informed decision.

  • Passive Thinking

This is essentially procrastination. You are not sure what the best course of action is or perhaps feel there is not one best approach. If enough time passes it’s likely the correct management will become clear. While it might appear to others you are deep in thought you are actually just killing minutes.

  • Counterfeiting

This is the least easy hover to admit to. Although it may look like you are focused on one patient you are actually listening into a conversation about another. Or another method involves excessive tidying up, or record keeping, allowing you stay and see what happens to a patient you are keen to see the outcome of. Perhaps you feel like you’ve dropped a ball earlier in their care? You don’t need to stay but find a reason to.

The counterfeit hover is not always a bad thing and passive thinking may well be in the patient’s best interest. It is an interesting behaviour though. One I will be watching out for in others, and certainly in myself.

What have you learnt this week? #WILTW

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Five soft markers of organisational aptitude #WILTW

This is the 148th #WILTW

Some people appear to be inherently efficient. With no more hours in the day than anyone else they have extensive outputs, meet deadlines and never seem flustered. Pre-internet this was, in large part, due to hard work, dedication and perhaps cognitive skills suited to rapid processing of large amounts of information. Post-internet workloads are dominated by electronic communication and technology which has now become a blessing and a curse. The tools to deal with e-mails, documents and knowledge translation (whether that be from an academic or managerial perspective) are ubiquitous and you can spend hours organising information on how to organise information.

Key influencers in my personal learning networks are often asked to share how they stay so productive while simultaneously staying sane. Some examples below:

Getting sh*t done by @emcrit

How I work smarter from @ALiEMteam 

I come no where near achieving half of what is suggested in these blogs. However I have noticed in my role as a clinical supervisor a few indicators which demonstrate someone has considered how they manage their time. The absence or poor use of them is not a damning indictment of their organisational skills but helpful for framing conversations.

1) Folder Organisation

How quickly can you find a document you wrote 3 months ago? Is it pasted somewhere on the 112 items you have on your desktop or in a sub-folder labelled well enough to find via a search or side-bar?

2) Out of office notification

Not sure this counts as being a method of improving productivity but it is a common courtesy to highlight you won’t be responding to e-mails for a set period. Responding to e-mails when you have the notification active is a different issue…

3) Number of e-mails waiting to be triaged

This is controversial I know.  However I’m not convinced it is possible to say you are on top of things if you have 1324 e-mails in your inbox. Smarts phone often show the total number waiting to be read so a glance at someone’s front screen (aside from potentially being an invasion of privacy) can tell you a lot.

via http://lifehacker.com/5977441/how-i-cleaned-1328-emails-out-of-my-inbox-in-an-hour

4) How you record your jobs and/or to-do list 

I’m not convinced there is a right or wrong way of doing it but you should have some way. Watching someone trying to find a scrap of paper to start scribbling a list of jobs on doesn’t inspire confidence (which is why I’m gutted when I end up doing it!)

5) Ability to share documents 

This is the least discriminatory of the indicators but I’ve seen a definite increase in the last couple of years of using Google Docs/Dropbox etc as a means of avoiding file version hell. At least three colloborations I am part of will say this is a bit rich as I am not a paragon of virtue in this regard. However suggesting, “How shall I share this?” says a lot about underlying mindset and experience in my humble opinion.

Be interested in thoughts and very happy to take criticisms!

What have you learnt this week? #WILTW

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Dogmalysis and Pragmatogenesis #WILTW

This is the 147th #WILTW

I was first introduced to the idea of dogmalysis by Cliff Reid. It’s the break down (-lysis) of a widely held belief (dogma-). As Cliff points out numerous cognitive biases “prevent us from conducting an impartial analysis of objective clinical data“.  Essentially some of the things we do in clinical practice have no real foundation and persist despite evidence to the contrary. When I started in paediatrics all children with wheeze received a dose of steroid and a nebuliser regardless of age or severity of illness. This practice has altered significantly in my career but dogmaphiles still do exist.  Whether Cliff truly invented the term might need to  be subject to some dogmalysis itself but it’s a wonderful concept to consider in medicine.

I reviewed a recent publication with two registrars this week.

Wilson et al. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Ann Emerg Med 2017 doi: 10.1016/j.annemergmed.2016.12.010.

This concise paper takes on a very common issue which has been surprisingly under explored. The last decade has seen a huge increase in the value placed on observations as markers of severity of disease. This is in part driven by the increase in Early Warning Systems but also repeated demonstration that physiological changes which may predict death often occur in patients hours before they deteriorate.

It’s a relatively well designed study in which, although the disposition and treatments of patients in North America may be different from the UK and Europe, the number of patients and granularity of the reported data make the study findings externally valid.  While there was a slight increase in return rates for children discharged with high heart rates; overall outcomes were not different i.e. in isolation a high heart rate at discharge was not predictive of patient harm.

Admittedly it’s retrospective study (A non concurrent cohort study sounds a little more sexy), we don’t know the interplay of a high heart rate with other physiological features and the overall incidence of serious negative outcomes was low. This for me means that the dogma you should never discharge a child with a tachycardia can not be ‘lysed’ just yet. But even before reading this paper I’d not had a high heart rate and do not pass go attitude myself. There are rarely absolutes and contextualising each case you see is vital.

Pragmatism is really important. When you realise that admission is not always the safe option basing your judgements on one clinical finding doesn’t seem to be in the patients’ best interest. This study supports a balanced approach to the care of the acutely unwell child and should help aid decision making around the discharge process. Why am I sending this child home with these observations?  In the absence of other identified risks, and appropriate experienced review, then it’s probably safe to send the child home.

I’m looking forward to reading some more pragmatogenic papers in the future.

What have you learnt this week? #WILTW

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Related Reading:

A Pre-mortem to prevent a post-mortem 

Sepsis and Self-Doubt

Have we forgotten to teach doctors how to think? 

Do you know why the parents are concerned? Why not? #WILTW

This is the 146th #WILTW

When one of my team presents a case to me I obviously want to hear about the history, examination and suggested plan for the child. Within the history I am looking for the answer to a vital question:

What is the parent really concerned about? 

This is a key teachable moment even though it might seem inherently obvious. Clearly any health care professional would want to find out why a patient had been brought to hospital.

Wouldn’t they?

Well it’s worth pausing for thought here. The presenting complaint is not the same as parental worry. A baby may present with a history breathing difficulty and reduced feeds, they may examine with no other finding than a running nose. But what the mother is truly worried about is whether her baby will stop breathing when she goes to sleep at night. Some families will tell you this up front, but not all will. Sensitivity is key to finding the best management options for the family.

Fever phobia is the most obvious manifestation of a symptom that masquarades as a complex set of health beliefs. A child may be completely well appearing, in fact laughing and smiling during the consultation, but if the families cultural instinct is that fever causes you great harm, they will be fearful out of proportion to their child’s appearance.

Many symptoms: diarrhoea, vomiting and fever in themselves are of little consequence. They indicate the presence of illness rather than its severity. I am far more concerned when the parent can’t explain to me what they think is wrong with their child: “They’ve had a cough and cold, a bit of fever. He even vomitted last night. But he’s not right, doctor, he’s just not right

Parents and carers have never been more aware of the grave consequences of some diseases but the risks of succumbing to those same illnesses are probably the lowest they have ever been. As our most serious diseases become rarer they will be even more difficult to spot if attendances for other conditions increase.  Without truly listening, and educating, we are probably perpetuating the very problem we are trying to solve.

What have you learnt this week #WILTW

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Practice what you preach or Preach what you practice? #WILTW

This is the 145th #WILTW

Social Media gives you unfettered access to the foibles of humanity.  At its best it empowers those who find it difficult to have a voice, and translates learning across boundaries  which are difficult to cross. At its worse it turns complex debate into a single argument shared by only those who have the same view. It also, more subtly, hides the real values and behaviours of individuals behind a veneer of choreographed photographs and  theatrical text.

It is all too easy to write a statement in 140 characters that is noble and bold.

Do we act out what we ‘preach’ in the real world and does it really matter if we don’t? I’m reminded that I originally joined twitter to expand my research interests. While I’m convinced I’ve benefitted in other ways, being able to discuss and debate the academic work I undertake remains a primary purpose.  I suppose in this context I am preaching about what I practice.

It would be an odd world if you weren’t able to highlight your ideals so being able to justify everything about who you say you are is neither laudable or achievable. However it is maybe worth thinking twice about whether you are sharing your practice, or your preach…

What have you learnt this week? #WILTW

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When laughter causes pain #WILTW

This is the 144th #WILTW

It’s 11.30pm and there are still 30 patients to be seen. It is a busy winter evening with long waits, some very ill patients and a noise level in the Emergency Department that makes it difficult to think. Having spent the majority of the evening in the Resus room with no break for at least 6 hours David wonders over to Sarah, the other senior on shift.

“You ok?”

“Yeah. It’s bedlam isn’t. Our inflow isn’t stopping. Feel sorry for some of these families. They’ve been waiting for hours. “

“Have you had a break?”

“No. lets just get these last few priorities sorted. Worried we are going to miss something given the length of time to assessment at the moment. Well done on the metabolic case by the way. Good call. “

“Was nothing special. Here have a quick a look at this. It’ll keep your spirits up.”

He shows her a picture on his phone. They both laugh out loud, exchange a few more words, and then continue seeing patients into the early hours of the morning. 

A week later David meets the head of the department. A complaint letter from someone who had waited 3 hours to be seen cites a person matching his description laughing at the nursing station. They want to know why doctors are employed if they aren’t going to be professional?

Doing the right thing in healthcare is a balance. There is no black and white. While values based leadership works, it only does so when values are agreed. A decision to close a hospital may save a life by improving the skill mix on an emergency rota; only to take another by increasing the distance needed to receive that skill. You cancel elective cancer surgery to free up beds for an emergency trauma list. Who judges whether that is the correct decision?

The more emotional the context of the situation the more an individual decision can be dichotomously vilified or applauded. How does a professional’s self care (sometimes in the form of humour) balance with a patient’s need for steadfast professionalism? What actions that are helpful to one person turn out to be offensive to another?

This week Archives of Disease of Childhood published a paper examining the role of clowns on Paediatric Intensive care Units. The authors acknowledged that while ward based professional clowns are well accepted, there use in the critical care environment seems counterintuitive. However they put forward a powerful argument, using their extensive experience, that this is not the case and describe how to approach this challenging situation to benefit children..

Also set on an intensive care unit and published this week, a different study demonstrated a letter of condolence sent by staff to bereaved families had no effect on grief reactions and may in fact have worsened depressive symptoms.

Interpreting how we are perceived by others is an almost impossible task.  As the ‘spirit’ of some communication is so spontaneous simply being aware our actions maybe mis-construed is the most pragmatic path forward.

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.” – How the NHS Spirit pulls through 

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts. 

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