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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How did you not see that? #WILTW

This is the 159th #WILTW

You don’t need to have any medical expertise to spot the abnormality in this CT Scan

Drew et al. Psychol Sci. 2013 Sep; 24(9): 1848–1853.

If it took you a bit of time, don’t worry. Not an insignificant number of experienced radiologists missed the gorilla in the top right corner too.

While these cognitive games are good fun there application in real world medicine isn’t always clear i.e. if you’d swallowed a toy gorilla would it really be missed? It’s becoming clear there is a growing body of evidence that inattentional blindness does impact on the clinical decisions made by healthcare professionals.

Inattentional Blindess: The failure to see visible and otherwise salient events when one is paying attention to something else

In a talk to the International Paediatric Simulation Society this week Christopher Chabris presented his own research on the subject. It stems from a high profile incident in the United States when a police officer (Kenny Conley) was convicted of obstruction of justice and perjury because he failed to spot a fellow officer (Michael Cox, who was in plain clothes) being assaulted by other officers who had allegedly mistaken Michael as a felon. The prosecutors argued given Kenny Conley had run straight past Michael Cox it would have been impossible for him not to have seen the assault.

Professor Chabris ran an experiment where subjects (college students) were instructed to follow someone running in front of them and count the number of times the person they were chasing touched the top of their head. The volunteers were not told that they would run past a staged assault during the 400m run. Even during the day only 56% of the students noticed the fight that was happening right in front of them (video of the study here)

It does seem possible that once focused on an activity you may literally become blind to events around you. This misperception reveals itself in a number of ways. In the picture below (click here if it doesn’t work) can you see what is changing between the flicks of the screen?

It’s possible you may have spotted it instantly but certainly in the lecture theatre I was in at least half the audience of over 350 people took at least 30s, if not longer to find it.

Inattentional blindess may have a significant impact on medical practice. While it may seem astounding to an outsider that the falling oxygen levels or heart rate weren’t spotted, it may well be the staff simply couldn’t see the numbers changing on the monitor. And if they stop looking at the patient, to draw up drugs for example, you can see how sudden deterioration can be missed. It follows on the more stressed or distracted you are, the more likely that inattentional blindness may occur (although I am not aware of the specific evidence behind this). My colleague Gareth Lewis highlighted the reasons for poor performance in simulation may well be the anxiety of undertaking the exercise impacts on the ability to act on information provided in the scenario.

If nothing else the concept makes real the dangers of doing something as simple as glancing at your phone in the car. But I think it is also worth re-thinking your reaction the next time someone claims to have missed something that should have been in full view.

What have you learnt this week #WILTW

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Managing Risk: Don’t get burnt, a singe will do #WILTW

This is the 158th #WILTW

I recently published some thoughts on how Nassen Talebs’s book “The Black Swan” may influence clinical practice in Emergency Medicine. The books title is derived from the discovery of Black Swans in Western Australia. Despite being a very unexpected event that had a profound impact at the time, in retrospect the evidence was probably available  to have suggested such a thing was possible. A Black Swan event is, by definition, not predictable until it has occurred. Taleb argues understanding their existence is vital to understand economic theory (he was originally a market trader) but I think it is also an extremely useful concept in Medicine.

With Black Swan events are two states of mind that probably are relevant to patient safety. The first is that we think of written history as linear and easily described. Taleb argues this gives us unfounded confidence when we review events and how we think we responded to them. In serious case reviews the reasons why different systems failed are themselves interwoven with interdependencies, which fluctuated in real time i.e. the act of writing a sequence of events down can never truly describe why things happen. The second that we too often confirm ‘No evidence of disease’ rather than ‘Evidence of no disease’. This is a well known phenomenon in healthcare and describes a tendency to seek a particular test and use it as the sole process in which to make a diagnostic decision. This patient can’t have sepsis because their blood tests are normal or this patient can’t have appendicitis because they don’t have a temperature etc.

After the PERUKI annual meeting this week a group of us discussed how we can improve teaching about risk management to  doctors in the early stages of their careers. “Once you’ve made that mistake you won’t make it again” may well embed learning in a particular doctor but it is of absolutely no benefit to the patient who may have been harmed. However this is not an easy problem to solve as a result of Black Swans and related issues:

i) Some events aren’t predictable, or only possibly can be, in retrospect.

ii) It is very difficult to learn from the errors of others, as what might have been presented as the route cause of an issue may not actually have been the underlying problem in that case.

iii) We are still generally beholden to a model of practice that implicitly rewards a “Treat this patient with that presentation and this test as this…” pathway of care.

I pondered with Chris Gough about how being burnt by a particular case was an excellent re-inforcement of the above principles but not a adequate or acceptable education methodology. What Chris suggested was that trainees needed to be ‘singed’.

via #BigGreenEgg

This is still a practical challenge but there are things that educators can facilitate.

  • Highlight minor cases in which a correct diagnosis doesn’t determine outcome but where errors have been made (e.g. non-specific rashes)
  • Seek out ‘what if’ scenarios (what would you have done if the white cell count had been normal)
  • Actively discuss cases in forums conducive to open learning

All of us need the experience of being singed to avoid patients being burnt.

What have you learnt this week #WILTW

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Statistically, the thing most likely to kill me, is me #WILTW

This is the 157th #WILTW

During, and since leaving school, three of my fellow pupils have died by suicide. I can not claim to have been best friends with them but sudden loss of life puts into perspective even the most briefest contact or interaction.

Suicide remains one of the last taboos. While public awareness of mental health issues has hugely improved it remains a difficult topic of conversation to have with others. What are you more likely to bring up over a coffee: your fleeting dyspepsia or the fact for the last week you’ve just not been able to see the positive in anything? Neither of these things mean you definitely have serious illness, and both may well be transient conditions, but the latter is often perceived to carry an implication about you.

Mental Health Organisations and individuals dedicated to improving outcomes have had a huge part to play in reducing the stigma of mental health. But the sharing of honest stories, sometimes from unexpected sources, probably has had a sizeable impact on cultural perceptions.

Recently the wife of a doctor in Brisbane who had died by suicide wrote a short, and extremely powerful letter, to the medical community. She didn’t want it to be a secret that her husband, Andrew, had died and wanted people to know how proud she was of him. In response an ENT surgeon, Eric Levi, had some insightful perspectives on the impact that work can have on your mental health, in his words, “..through the dark seasons“.

The blog has been shared over 150000 times.

“I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital” Eric Levi – The Dark Side of Doctoring

I found Dr. Levi‘s piece quite challenging on first reading as his theme of loss of control grated with me. I entirely get the bureaucratic inertia that plagues healthcare professionals. The weight of targets, heavy handed communication and silo mentality at times a maelstrom. One that I have ranted and raved about as much as anyone else. But these are joint problems to sort. I am sure I am as much a part of the problem as I perceive others to be. But if the administration of the hospital will not let me off a clinic the day after the birth of my new born child the system is so rotten as in my mind to not be tenable.

But that attitude makes me as guilty as the system itself.

Andrew Tabner writing powerfully on physician suicide reminds us:

We need to abandon the macho persona that is often evident amongst doctors, especially those in acute specialties, and embrace well-being initiatives, wellness drives, career sustainability interventions, psychological tool-kits and anything else designed to help us cope with the inevitable stresses and strains that come when your job involves seeing birth, death and every facet of human existence in between, within a single shift

I am not immune from being in dark places but am lucky, through no action on my part, not to have ever been so low as to consider harming myself.  If we are to impact on the rate of suicide it is going to take continued dialogue within, and between, employees and employers to ensure that early signs of distress are recognised and can be acted on in the most appropriate and facilitative fashion.

What have you learnt this week? #WILTW

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I have taken a slight liberty with the title of this blog. The actual statistics relate to the 20-34 year old group. The title itself inspired by Christoper Young’s comments in Soul Music: A review of Waterloo Sunset 

Post Release Note:

I was contacted by Alys Cole-King (who I had linked to as an individual with a passion for improving outcomes in Mental Health ) post the blog to correct some of my language regarding suicide. Died by suicide has replaced committed suicide.

The following provides information and support on the issues raised above:

Resources for people in distress and those supporting them Staying safe if you’re not sure life’s worth living on line resource for anyone struggling to offer hope, compassion and practical ideas and suggestions on how to find a way forward connectingwithpeople.org/StayingSafe

U Can Cope film and resources The U Can Cope 22min film shares the three inspirational stories of Matt, Anthony and Cathy for whom life had become unbearable but who, after seeking help, are now leading fulfilling lives connectingwithpeople.org/ucancope

U Can Cope was designed to help young people develop resilience and cope with any current/future difficulties in their life but is just as helpful for adults. If Feeling overwhelmed and staying safe and for anybody struggling to cope when bad things happen in their life and includes advice on how to make a ‘Safety Plan’

Feeling on the edge helping you get through it:  for people in distress attending the Emergency Department following self harm or with suicidal thoughts connectingwithpeople.org/ucancope

Dear Distressed: Poignant and compelling letters of hope and recovery written by people with lived experience to reach and help others who are struggling with some much needed hope connectingwithpeople.org/wspd16

Tips on self-care connectingwithpeople.org/content/mhaw17

The Ghost Guideline #WILTW

This is the 156th #WILTW

Improved digital accessibility via smartphones has transformed access to information for health care professionals. A variety of apps exist, some accredited by national organisations such as the National Institute for Health and Care Excellence  (e.g. NICE National Formulary for Children: iOS or Android) and some approved by extremely stringent regulators such as the Medicine and Healthcare products regulatory authority (MHRA). Mersey Burns (iOS or Android), an award winning programme for calculating burn area percentages,  was the first app approved by the MHRA and such is its ease of use it’s downloaded much further afield than the North-West.

For direction on your own institutions’s preferred approach to managing certain conditions you need to look things up on local servers. Sadly, and I have never been given an adequate legal explanation for this, hospitals rarely allow their guidance to be made public. This means if staff don’t have quick access to a computer they need to find an old guidelines folder hidden away in the recess of a desk. The Royal Children’s Hospital Melbourne have taken a far more pragmatic approach and allow anyone access to their clinical practice guidelines. It’s no surprise then to see the format (content!) of their guidelines emulated around the UK.

Huge amounts of resource are used in trying to get doctors and nurses to deliver evidence based treatments and care. Easier access to guidelines should result in more patients receiving the most clinically appropriate and effective treatment (which may often be no treatment in paediatrics). However clearly laid down ‘best practice’ is often ignored and poor practice can persist simply because it has been heard on the ‘grapevine’. This ghost guidance, which can’t be found on any website, manuscript or protocol can be pervasive throughout an organisation. The speed at which it becomes known to new-starters is incredible given it can take up to 17 years for some practices to be adopted.

House rules are not just about treatments but often relate to cultures and behaviours and can be incredibly stifling. This latter type of ghost guidance is often applied inequitably and inconsistently making it divisive but also difficult to remove. Conversely some ghost guidance is behind the emergence of positive deviance and may well be an informal method of spreading learning from excellence. It’s certainly not a new phenomena and forms of house rules were first defined by Stephen Bergman, writing as Samuel Shem, in “The House of God“.

Some of the house rules from Samuel Shem’s “The House of God”

In researching for this blog I discovered that Stephen had added to the original house rules first published in the 1978.

Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you’re not connected, you can’t talk about anything, or deal with anything. Isolation is deadly, connection heals.

Law 15 : Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.

These seem like the types of ghost guidance that should be written down and shared…

What have you learnt this week? #WILTW

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Why are so many children ill? #WILTW

This is the 155th #WILTW

Co-inciding with the opening of our new Emergency Department was the release of “Emergency hospital care for children and young people“. Produced by the Health Foundation and Nuffield Trust the report analysed Hospital Episode Statistics (basic data relating to a patients’ admission to hospital) over a 10 year period. It is a sobering read with a headline figure that, although attendances in the under 25s increased by 14% (compared to 20% in all ages), in the under 1s the figure was 30%. These increases over time are no surprise to us with the figure below our own local data from the last 4 years (thanks to Dr. Gareth Lewis for this)

The reasons for this persistent upward spiral are not clear. It is important to note that a large amount of the total change is actually due to population growth and an increasing birth rate. However the birth rate has slowed in the last few years whereas admissions haven’t. Increasing parental anxiety, poor or inequitable access to local health care services and a risk averse medical culture have all been suggested as causes, but whatever the underlying problem is, it’s definitely going to need more than one solution.

http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QualityWatch%20CYP%20report.pdf
via Health Foundation/Nuffield Trust 2017

The data presented gives an indication of where research and improvement work needs to focus as long as we are aware of some of the challenges in interpreting the figures. Large scale data analysis projects like this are very dependant on the quality of data entered. Healthcare has not had a brilliant track record in recording, or more precisely ‘coding’,  information about patients effectively. This is generally because doctors aren’t trained in how important this is and are therefore quite ambiguous in their clinical records. Hospitals employ teams of clinical coders to read notes (and decipher handwriting) so they can record the key outcomes related to a patient’s stay. To make the coders job either they collate conditions into particular predefined and agreed categories. The most common of these are shown in figure 3.6 from the report.

Source: Quality Watch report 2017 (Emergency care for children and young people). Data via HES

Notwithstanding the complexity of being able to extract information about the underlying condition there are some interesting trends here. I am most taken by the huge increase in numbers of children diagnosed with a viral infection. The authors note:

“– in particular, the large increase in emergency admissions for viral infection and acute bronchitis, as well as the increase in admissions for other perinatal conditions (feeding and respiratory problems) and haemolytic and perinatal jaundice in infants. These may be related to more children surviving with complex disabilities and requiring more intensive healthcare support”

Children with chronic illness are more susceptible to the adverse effects of even the most simple viral illnesses so it is very plausible that an increase in children with complex needs will result in greater presentations with viral infections. The increase in number of viral illness cases seems so large though, especially given that other upper respiratory infections and acute bronchitis* are also predominantly caused by viruses, that either we are in the middle of some unrecognised ‘viral’ epidemic or there are some cultural issues at play. There is no evidence that viruses are being more virulent (length of stay is actually decreasing) and we have been using vaccines for flu and rotavirus (the bug that causes gastroenteritis) for a while.

So we have a challenge. A challenge that is not for any one individual organisation, committee, institute or group to solve. It is not sustainable to have a continued 4% rise in presentations to emergency care year on year so systems need to start talking to each other and the public. They need to discuss not only how to continue to provide quality care given the increasing pressures but to really start to look at the underlying reasons behind these trends so we can continue to give children and young people the most effective care when they most need it.

*note acute bronchitis is not a term I use or really recognise. It is used here to describe a number of different types of short lived chest infections

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