Feel the fear #WILTW

This is the 169th #WILTW

Luke has just started a new job in the Emergency Department. As a foundation trainee he is at the beginning of his medical career. Enthusiastic and conscientious at medical school, he’d spent 5 years excitedly waiting for the moment he’d be able to call himself a doctor. His training in lectures, workshops, simulations and on the wards has prepared him to manage a variety of presentations and conditions. This morning he’d woken up with a spring in his step, inwardly chuffed that he’d be able to relate the same stories he’d seen on ‘24 hours in A&E‘. He picks up the notes for the next patient. It’s a screaming four-year-old, with an arm the triage nurse has described as ‘bendy’.

The colour drains from his face…. 

Alice is a four-year-old girl. She’d been playing in the local park and was very chuffed with herself that she’d scrambled up all the steps on the boat-shaped climbing frame. Mummy didn’t normally let her do this but she’d been talking with Sasha’s mummy and wasn’t watching. Alice thought it would be fun to try and swing around in a big circle on one of the metal poles (like she’d seen her older brother do). She slipped and fell onto the hard ground below.

Her arm hurt a lot. Mummy was very upset which worried Alice as she’d never see her like this before. Lots of people had come running over. She’d been carried into a car. Her arm still really hurt. They’d gone to a strange building where there were lots of other children. A person dressed in blue had looked at her arm and given her a funny look. Alice didn’t like that. She’d been taken into a little room with bright lights. Mummy was on the phone and still crying. Alice’s arm hurt a lot. She could hear lots of other children crying.

Alice started crying too. 

Who is the more scared? Alice or Luke? 

The first week of August is a scary time for our new doctors. Despite what the media might say it’s not a dangerous time for patients and shouldn’t be a frightening one. But there is often a sense of trepidation in those joining departments for the first time about what they might experience.

This fear is good. It keeps you alert and insightful. It will stop you making mistakes. But it must be acknowledged. For a child who is scared, experiencing your fear as well is not helpful!

Be cognisant of how you appear. Remember children have a different view of the world (click here if video doesn’t play).

Concentrate on the parents at first to begin with if that helps. As calm as they are is as calm as the child will be.

But above all remember the child or young person, adolescents get frightened too, will likely be more scared than you.

Take a deep breath – feel your fear – so you can deal with your patients’ fear.

What have you learnt this week? #WILTW

Related #WILTW: A parents view of the world is also knee high

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Close to certainty and far from agreement #WILTW

This is the 168th #WILTW

An entire generation’s knowledge of  chaos theory was based on a short clip in a Hollywood blockbuster (click here if video doesn’t play)

Some mathematicians have been relatively generous of this description although I suspect others view it in the same way marine biologists observe that clown fish are now called Nemo fish. What was being described was probably more akin to a complex adaptive system, a term which is being used increasingly frequently to describe healthcare environments. Thinking around complexity challenges the assumptions [1] that

  • Every observed effect has an observable
  • Even the most complicated things can be
    understood by breaking down the whole into
    pieces and analysing it
  • That if we analyse past events sufficiently, this
    will help to predict future events.

The final point merges into Black Swan theory but is also a cause of a great deal of tension between commissioners, policy-makers and providers of healthcare services. These challenges are encapsulated in the Stacey Matrix

Complexity Matrix (Stacey 2007)

The Stacey Matrix is a management tool designed to help guide the approach to a particular challenge. Just the insight that there are relationships between the certainty of outcomes following an intervention and agreement about what that intervention should be may be helpful. For example if the solution is obvious and all parties agree on it, the intervention is self-evident. Groups also may be agreed on what to do but no-one is certain on what the results may be. All too often there is little agreement on a path forward, even when the problem is very discrete and objective (close to certainty and far from agreement) .

These issues apply at micro (doctor-patient) and macro (health services-public) level. The former described by the treatment of a large inguinal hernia (likely to be agreement between doctor and patient that intervention is required) and the latter by the recent debate about the treatment of Charlie Gard.

There is nothing intrinsically clever about the way the matrix classifies complexity. However it is clear that it is often not recognised that systems are complex and so dis-agreements escalate. The below a list of interventions to improve flow in Emergency Departments.

Those who work in Emergency Care are likely to feel this is ‘close to certainty’ in terms of its impact and are often surprised at the ‘lack of agreement’ around its implementation. I offer no solution to this impasse other than an insightful response to this complex problem.

What have you learnt this week? #WILTW

(Thanks to Dr. Ben Teasdale for sharing the Stacey Matrix this week)

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Further Reading:

Complex Consultations and the edge of chaos

Lessons from Jurassic Park: Patients as complex adaptive systems

[1] Taken from Complex Adaptive Systems by the Health Foundation

Experience of care: Parent vs Child #WILTW

This is the 167th #WILTW

Experiences are very personal. Go to trip advisor and you’ll find, for the same time period, families rating hotels and holidays in completely different ways. The appearance of “colourful’ surroundings to one person may well be perceived as “tacky” by another. This phenomena is not restricted to the leisure industry. It is not uncommon to receive a glowing compliment and devastating complaint within the same 30 minute during busy periods in Emergency Departments.

This happens in part because clinical conditions and the reasons for presentation are obviously different, but also because values and expectations vary widely. Quality in healthcare runs across a number of domains and while healthcare may be delivered well in one area, this may impact detrimentally on a patient’s perception of another.

There is a further intriguing imbalance when you consider intra-family perception of care. In an interesting paper published this month children and young people’s experience of care was compared with those of their parents. A validated questionnaire was used on 257 children (aged 8 to 18) and 257 parents to determine their experience of care in a Children’s Emergency Department. Overall the experience of both children and parents was positive but areas rated poorly included entertainment activities (43.2% of respondents) , waiting time (23.7%) and treatment of pain (10.5%).

Children were more likely to poorly rate their experience of waiting times, explanations, privacy and pain than their parents (further detail of explanation and pain below)

The differences are not huge, but in the case of pain, difficult to ignore. There are many cues that clinicians take from parents to judge the impact of their treatments. In relation to injuries especially, parental acknowledgment that pain has been treated is likely to be taken as a sign no further analgesia is needed. These results emphasise the importance of child centred care. This is not a tokenistic buzz word, if you value your ability to ‘do no harm‘ the child’s perceptions of their illness must be addressed. There are many reasons why there might be dissonance between the pain reported by a child and the amount of pain they are perceived to be in. None of these diminish the need to try and (appropriately) reduce reported distress.

It’s important to remember that experiences are very personal, even between close friends and family.

What have you learnt this week? #WILTW

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Digital Detox

This is the 166th #WILTW
I am currently on a weeks social media blackout (and more importantly on annual leave!) 
A perfect opportunity for a break from What I learnt this Week. But if you are keen for a fix here are some of the most popular posts from 2017 🙂

Same Child, Different Room, More Risk

How did you not see that

Dogmalysis and Pragmatogenesis

What have you learnt this week? #WILTW

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A third idea to counter a third ‘type’ of error #WILTW

This is 165th #WILTW

The term ‘statistics’ strikes fear into many.

You may have 5 ‘A’ levels, have a distinction in finals, and be able to perform life saving cardiac surgery in a premature baby.  It’s also likely you’ll still start sweating if a junior colleague asks you:

…why was the power calculation insufficient to reject the null hypothesis in this paper?

An extremely well shared meme was released a couple of years ago aiming to explain the often mis-understood topic of type I and type II error.

The illustration doesn’t really do the underlying principle justice but the explanation is fair.

  • A type 1 error is when you decide a test result is positive, or an intervention has worked, when in fact it isn’t/hasn’t.
  • A type 2 error is when you decide a test result is negative, or an intervention has failed, when in fact it isn’t/hasn’t.

I was reminded this week by Professor Mayur Lakhani of a third type of error (in fact there is also a type 4 error but I’m not going to go there). A type 3 error is when you are correct that a test result or intervention is positive but you have decided this for completely the wrong reason.  Outside the realm of mathematics it is when you solve the wrong problem and don’t realise it. In an article written by Large Kiely, shared by Prof. Lakhani, this issue was explored though the lens of organisational culture:

“The type three error is a dangerous form of group-think and can happen very innocently and with all good intentions. The causes are a bit surprising, having to do with, believe it or not, too much expertise in the same field.” – Laree Kiely

In healthcare this probably occurs more frequently than we would care to admit. Take a group of highly trained consultants or managers, and set them on a problem. Very early in discussion, the cause of the problem will be decided, not via evidence, but through anecdote. Solutions will be presented to solve the perceived issues and any improvement attributed to the intervention(s). It will only be later, sometimes much much later, that other problems will materialise demonstrating the original assumptions to be flawed.

I’ve explored group-think previously but the type 3 error is a very tangible output of it.

The suggested advice by Laree Kiely is to always have 3 possible actions before deciding on one. This isn’t always easy to do but forces groups to avoid discounting relevant issues:

Decision making studies have shown that if you think there is a right answer, then the first one that looks right becomes the final choice, and the thinking stops there. Problems today rarely have only one right answer.”– Laree Kiely 

Inevitably the time required to think of a third idea to avoid the third error will mean it rarely occurs. But at the very least we shouldn’t be scared of calling it out when we make this mistake.

What have you learnt this week? #WILTW

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Videos below explain the concept of type 1 and type 2 errors further


Good questions are as important as good answers #WILTW

This is the 164th #WILTW

I came close to starting this piece by making a fundamental error. I was going to discuss how the ‘case’ of Charlie Gard is a tragedy. A tragedy it is, but to describe it as a case does no justice to anyone involved in this heartbreaking situation.

It is events like this that demonstrate the fragility of social media as a communication mechanism. All sides involved, most importantly the  parents, but also the professionals (medical and legal), organisations and national bodies passionately believe in Charlie’s best interests. There are no monsters. There is sadly a lack of humanity, not from those who are involved, but from those who feel they have a right to judge, berate and decide what’s best for a situation in which few can comprehend the moral and ethical dilemmas at play.

In a completely unrelated, but actually quite relevant, BMJ blog this week Dr. Matt Morgan challenges the way we currently examine doctors in medicine:

Although undergraduate training has adapted to some of these changes, the postgraduate world needs to embrace the changing roles and skills needed by medical professionals of the next century.

Many of the current processes of testing competence rely on the doctor making the correct diagnostic decisions. But testing pure factual knowledge and clinical examination has been recognised as a poor surrogate for future clinician performance. To be fair, examinations necessary to become a Consultant or General Practitioner almost certainly also include complex cases involving ethics or challenging communication. But Dr. Morgan I think correctly highlights the difference between being able to answer difficult questions about a case, and being able to ask the right questions about a difficult case.

He identifies while it is almost certain the use of artificial intelligence in medicine will grow, it is difficult (currently) to see how a data led approach to diagnosis can deal with grey medicine.

The challenge, increasingly, is to understand:

Not, what is the definitive cause of a symptom but what definitely isn’t the cause of it…?¹

Not, how do I treat this, but should I…?

Not what are the consequences of my decision now, but what might they be in the future…?

While ever cleverer computer algorithms, imaging devices and cutting edge diagnostic technologies will improve processes in medicine we must ensure that our underlying principles of practice remain true.

I am certain the doctors and nurses caring for Charlie Gard have used every tool at their disposal to investigate and treat him. I am also sure they have been equally diligent in exploring all the ethical and moral dilemmas exposed. To not do so would be leaving medicine in the hands of computer programmes which may well reduce patients to ‘cases’ to treat rather than people to care for.

What have you learning this week? #WILTW

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  1. This topic was explored in “If you know what its not, is it ok to not know what it is?

Spot the well child, not the ill one #WILTW

This is the 163rd #WILTW

Nearly a year ago I wrote on Sepsis and Self-Doubt

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

I highlighted the importance of doubt in decision making. It is not possible to admit all children who have features of infection. We must select those with high risk signs/symptoms for investigation & treatment and discharge low risk cases with adequate safety netting. This in itself is a conundrum and it is important that senior clinicians wrestle with this balance of risk. For not to do so results in either over-treatment, or in-appropriately conservative management. This is a significant cognitive and emotional drain, and in the context of spiralling presentations, it’s imperative we reduce the decision making load on acute and emergency clinicians.

It was for this reason I reacted strongly to a piece on the potential reasons behind the ever increasing access of emergency care by children and young people. In retrospect I was a little OTT in my concerns regarding an inference that there is a financial incentive to admit patients to hospital (see comment at the end of the article).  With all due respect to Quality Watch they responded and amended the text. We are both agreed the current financial model (where hospitals receive a set payment for each child admitted) sadly does mean there is little incentive to change the system.

The original version had hit a nerve because inappropriate admission to hospital makes diagnosing serious illness harder. A rising patient load of a potentially high risk group of children makes case selection on admission units and wards even harder. While there is much work to do in educating professionals and parents on the core features of common illnesses, neither group wishes children or young people to be in hospital unless they really have to be.

Over the last year it has become increasingly apparent to me that we are probably too focused on the identification of illness in the initial stages of a patient journey. Would it be easier to spot the needle if the haystack was smaller? Should the paradigm be spotting the well child early (and discharging) rather than the sick child late? We endeavour to create more specific scoring systems, biomarkers and analytics to identify the most unwell when  we probably need none of these things to identify the well.  It may be argued that discharging normality is a core function of medicine, I would challenge whether we truly operate out of that mindset. And if we wanted a different form of incentive, wouldn’t rewarding the rapid, but safe, recognition of the most well be in everyone’s best interest?

What have you learnt this week? #WILTW

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A video exploring this theme:

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