If you know what it’s not, is it ok to not know what it is? #WILTW

This is the 142nd #WILTW

A virus is an infective agent that typically consists of a nucleic acid molecule in a protein coat, is too small to be seen by light microscopy, and is able to multiply only within the living cells of a host.

Making a definitive diagnosis of having a viral infection is technically difficult. While there are rapid detection tests for specific viruses which aid in decision making about cohorting patients or prescribing treatments, those which cause colds and sore throats need long winded and expensive processes. However one of the most common diagnoses in paediatrics is that of a ‘viral’ illness. Special tests aren’t needed – just a good history and examination.  The child who presents with a fever, runny nose, a bit off their food and has a red throat or pink ears is likely to have a virus. Knowing the specific name of the virus is essentially redundant because the natural history of the disease is so predictable.

That is of course if it is a virus; the consequences of making an incorrect judgement on this are devastating.

Living with uncertainty is a fundamental part of a health care professional’s practice. But it isn’t easy. I can rarely be truly certain in my diagnosis of a virus. I can be very confident, I can give appropriate safety net advice and, most importantly, I can gain the understanding and trust of the family. If I can’t do these things and the risk of a more serious illness outweighs, in any way, my belief that this is a viral illness then more observations and investigations are likely to be required.

I was speaking at a patient safety conference this week on how scoring systems (sometimes known as Early Warning Systems or EWS) can be utilised as educational tools. Assisting, especially junior staff, in reducing diagnostic uncertainty regarding the level of a patients acuity is one method by which they are beneficial.

However it should never be a purpose of a scoring tool to make a diagnosis and they will never reduce uncertainty to zero. There was a powerful piece on this in the New England Journal of Medicine last year.

Our protocols and checklists emphasize the black-and-white aspects of medicine. Doctors often fear that by expressing uncertainty, they will project ignorance to patients and colleagues, so they internalize and mask it. We are still strongly influenced by a rationalist tradition that seeks to provide a world of apparent security.” (Simpkin & Schwartzstein N Engl J Med 2016; 375:1713-1715)

Uncertainty can be seen as a sign of weakness but acknowledging it may well reduce cognitive biases. By being uncertain you are more likely to be considering what disease processes may be present – the current emphasis on sepsis an example of a diagnosis that isn’t being considered often enough.

Ultimately the diagnostic label given when you discharge a patient is of little value if you have got the diagnosis wrong. For some paediatric presentations it may well be far more important to be satisfied you know what it isn’t and have adequately reassured the parent and/or carer that that is the case.

What have you learnt this week? #WILTW

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A Mental Health 5-a-day #WILTW

This is the 141st #WILTW

The Royal College of Paediatrics and Child Health have just launched their State of Child Health report. A list of 25 measures which highlights, amongst many uncomfortable findings, that 1 in 5 children live in poverty in the UK. A broad range of recommendations were made, including specific mental health training for child health professionals (half of adult mental health problems in the UK start before the age of 14)

One of the authors of the report tweeted:

The idea intrigued me, not only for my patients, but for myself. The concept has previously been encapsulated in the “Five Ways to Mental Wellbeing”  and a charity called mindapples are crowdsourcing suggestions.

I wondered what my 5-a-day would be? Having been knocked by some critical feedback this week, which was strong in tone but not completely undeserved, I was taken by how much of my time it occupied in comparison to other events. The following fell out of this.

Check-In: Let someone else know how you are feeling. This is a little awkward to write and I am sure certainly more awkward to do.

Check-Out: End your working day at a defined point.

Reflect: Or more precisely have some time to reflect on what you have done in the day and how that has affected your emotional resilience…

Keep Balance: …but be aware that spending all your time reflecting isn’t healthy either.

Maintain Perspective: The things that challenge you the most can become so much of  focus that it’s not possible to overcome anything. The perception of positivity in others, a virtual concept in our current generation, can exacerbate this feeling.

The official collection of 5 activities aren’t too dissimilar but the challenge with either is their implementation as a habit and not a hypothesis…

What have you learnt this week? #WILTW

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via Alex Tambourides https://hammersmithfulhamforum.com/2014/11/03/alex-tambourides-everybody-has-mental-health-lets-look-after-it/

 

 

With great (digital) power comes great responsibility #WILTW

This is the 140th #WILTW

While technically the world isn’t getting any smaller the ability to effectively communicate across large distances often makes it feel that way. Digital platforms have connected diverse networks in a fashion that wouldn’t have been possible a decade ago and there are a variety of social media in which to engage and entertain.

A paper written with colleagues in America, Canada was published last week. We postulated about the existence and development of new types of digital scholar to promote and enhance knowledge translation. Translating knowledge from academic literature and expert consensus into clinal practice has been a constant challenge in healthcare.

In order to provide quality care to patients, health care professionals need to remain up-to-date on best practice. It is well recognised that evidence can be poorly applied, and even ignored. While undoubtedly our three types of scholar are not new we hope that defining their characteristics will help others understand the role they, and others can have, in improving knowledge translation.

There is a subtle flip side to our construct however. What are our responsibilities to adopt these roles? The influence of those with large numbers of followers or those who connect at important network intersections can be quite substantial. While you must abide with your regulator’s guidance on social media this is no compunction to be a proponent of good medical practice. Indeed actively avoiding medical discussion is the sole purpose of some professionals use of social media.

But the world will continue to be an increasingly smaller place. Whether we like it our not our digital footprint could be as substantial as our physical one. Whether a fellow or first year, professor or practitioner we probably do have responsibilities to aid diffusion of knowledge should the opportunity arise. And while not everyone needs to be a critical clinician or translational teacher those that adopt this role should be mindful of the responsibility they have.

What have you learnt this week? #WILTW

Thanks @Brent_Thoma @MDaware @TChanMD (and @CJEMonline)

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Failure – likely and visible #WILTW

This is the 139th #WILTW

I chanced upon an old article on the relationship of learning and performance and how it appears to improve the former you often see transient decreases in the latter. The authors describe:

  1. The visibility problem: Collecting the data to demonstrate improvement before-and-after an intervention often shows you are currently performing far worse than you thought or reveals problems you hadn’t previously looked for.
  2. The worse-before-better problem: Learning to do new things results in performance deficits. The example given was that of touch-typing: there is a period where you are actually slower in creating a manuscript as you transition between single and multiple finger keyboard use.
Singer and Edmondson 2006 When Learning & Performance are at Odds: Confronting the Tension

A logical consequence of this relationship is that failure becomes a not uncommon event when something is initially implemented (or at least if the evaluation takes place at the nadir of the learning curve).

What really struck me is their observation that failure is not only more common than success, it is also more visible.

This visibility becomes increasingly more overt the bigger the scale of the intervention. This in some ways is inherently obvious but it really isn’t acknowledged enough. Failure is often taken as a set back, or even worse, covered up with an over-glamorisation of positive results at the expense of any real learning.

At times when system pressures are critical the ability to develop new ways of working is vital. However it becomes potentially even more likely that the innovation or improvement will come only after there have been multiple public failures. Given the challenges the organisation is facing this may be even less well received.

At times like this it is important boards, directors, clinical leads and individuals are brave and pragmatic with their interpretation of new strategies and projects.

What have you learnt this week? #WILTW

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The three curses of organisational culture #WILTW

This is the 138th #WILTW

At the start of every new year comes my annual appraisal. Despite it requiring a bit too much form filling and box-ticking I have always welcomed the chance to discuss problems and review strategies with a peer who is outside of my direct area of practice.

The day before this year’s appraisal I chanced upon a re-share of an old post by Bernadette Keefe on tribes and silos in healthcare. This is a recurring theme in many healthcare blogs and something that I’ve repeatedly returned to.

The sad irony is that perhaps I silo’d myself even making these comments.

Bernadette links to a very powerful story by the exceptional educator Victoria Brazil on how tribalism in medicine impacts on patient care and clinician moral (please click here if video doesn’t play)

Understanding the context of why people speak and act in the way they do is vital. Bernadette links to  another blog in which we are reminded of Plato’s insight:

Be kind, for everyone you meet is fighting a harder battle”.

I left my appraisal cognisant of three things, curses almost, which afflict the mindset of healthcare professional.

  1. Our point of view is shaped by the environment we work in

There is a need to recognise that all the most complex and difficult issues don’t just happen to you.

But even when you externalise yourself to see a wider picture:

2. We often only communicate in a narrative or style that we are comfortable with.

..so sometimes we tell stories that others can’t relate to. Either because we are telling the wrong stories or the format (e-mail/corridor conversation/meeting) isn’t an effective method for the listener.  I often note always bringing it back to the patient perspective isn’t as an effective strategy as we think.

And when communication efforts have been exhausted, or are waning:

3. We implicitly acknowledge the status quo as an acceptable place to be.

This is a difficult admission but when challenges become really difficult it is easy to let things drift. Sometimes it is necessary to have  time to let ideas settles and embed. But often  what needs to be done is perceived to be too great an effort, despite the fact that the efforts needed to maintain what you are currently doing are just as great. Sadly this further embeds curse one….

I resolve to treat these three afflictions in 2017!

What have you learnt this week? #WILTW

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Is the #NHS crying wolf? #WILTW

This is the 137th #WILTW

Every winter is tougher, busier and more draining than the last with an unremitting year-on-year rise in demand:

  • Emergency admissions from major A&E departments have increased by an average of 4.3 per cent a year since 2003/4
  • Attendances at outpatient clinics have risen by an average of 3.8 per cent a year since 2007/8
  • Admissions for planned treatment have increased by an average of 4.3 per cent a year since 2003/4.

It is no surprise then that within, and without of healthcare, people are wondering how long things can continue with flatlined funding before the NHS completely collapses.

There is a slight problem though.

Because we have been here before.

For at least the past 3 winters think-tank and media reports have warned the current situation is the worst ever.  In December 2015 #WILTW responded to an article by BBC Health Editor Hugh Pym which concluded:

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

This does prompt the question of what actually is it that might ‘collapse’? The NHS isn’t going to go out of business, close its doors and turn off the lights. What I think professionals fear the most is that they will be delivering a service that isn’t safe or sustainable. There are those  who already say emergency care is out of control but we are not (yet) repeating the past when huge waits in Emergency Departments and for elective surgery were the norm. However people do fear being overwhelmed by what they need to do on a day-to-day basis to keep the health system ticking over.

Staff resilience as a whole though is incredibly strong. I wrote last year:

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.

But will this be its undoing if the 2018 headlines read: “NHS again at tipping point” or is it that the cycle of care is such that we thrive on a crisis? It may well be time to decide what our real concerns are because otherwise the NHS will remain at risk of being taken for granted.

What have you learnt this week? #WILTW

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If the NHS ran Disney #WILTW

This is the 136th #WILTW

Please read this with the Christmas spirit it was intended 🙂

In 2004 Fred Lee published “If Disney ran your hospital: 9½ Things you would do differently“.  His observations, as an American hospital executive who went on to work for Disney, are technically more pertinent to “pay-as-you-go” systems but remain relevant to all healthcare providers. His key idea is that customer experience is paramount and being obsessive about it will improve quality across an organisation. The famous example from the book highlights that healthcare professionals never say why they are drawing curtains around patients. He argues just explaining it is for the patient’s own privacy would be a small but tangible approach that would improve experience.

Having taken my daughters to Disneyland Paris this week I can vouch that the ‘Disney’ experience is certainly something special. The attention to detail in the Sleeping Beauty castle, the brilliance of the Buzz Lighter Laser Blast and the charm of the Dumbo flying ride all definitely have a ‘wow’ factor. However having completely  immersed ourselves over a couple of days I do think there are areas where the NHS might just have an edge over the corporate machine that is Disney.

  1. Waiting Experience – In both the NHS and Disneyland you need to be patient and wait in line. However while waiting in an Emergency Department to have your broken arm mended is not the same as waiting to fly through the sky with Peter Pan you can pretty much guarantee in the NHS there will be toys in the waiting room. The interaction during queues was surprisingly sparse in Disney, perhaps they need to employ some Play Specialists..
  2. Waiting Times – While a matter of great political and clinical debate the NHS does have standards it aspires to. Are there waiting time for rides that Disney wouldn’t publically be prepared to publish? What percentage of visitors get to ride Big Thunder Mountain having had to use a significant proportion of their total visit time for the privilege? The 4 hour target is a cause of great controversy but at least it’s a matter of public record.
  3. Prioritising Services – In order to maintain flow for emergencies the NHS may chose to delay elective surgical procedures. While this is clearly frustrating for some it maintains the service within a finite resource envelope. Disney doesn’t have the ability to sacrifice Mad Hatter’s Tea Cups to improve access to Pirates of the Caribbean.
  4. Managing demand – The services the NHS can provide do not match the need for care it wishes to provide. Therefore prioritisation decisions need to be made. These are difficult, and sometimes very unpopular, but aim to ensure treatments are given to those most in need of help or most likely to benefit from it. In Disney however it is possible for a group of adults to decide they’d like to have their pictures taken with Mickey over breakfast denying a couple of toddlers the chance.
  5. Knowing your environment – while many hospitals are like mazes at least NHS staff will be honest if they don’t know where ‘Clinic 23’ is. To the Disney staff member who looked like they weren’t sure where we wanted to go, but still cheerfully sent us completely in the wrong direction, we forgive you.

Have a good holiday period – whatever you maybe doing.

What have you learnt this week? #WILTW

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