This is eighth #WILTW
An interesting week which demonstrated that my learning, in many aspects of medicine, really has only just begun. This tweet resonated:
Although the context of the tweet was about #FOAMed and information transfer I read into this a more generic point:
The importance of not dropping a level to that of a potential antagonist but developing an ability to move up one level instead.
Engagement, Quality, Delivering shared values will always be a problem given the challenges of human nature. I am reminded of the need to reflect not on what others have done, but on what I can do to improve.
What have you learnt this week? #WILTW
The seventh #WILTW post
Over the last couple of years the concept of “compassion” has increasingly been discussed in healthcare. This may seem odd – hasn’t healthcare always been compassionate? Unfortunately high profile events at numerous health care institutions have highlighted this may not have always been the case. The drive to remind health care professionals about compassion has been delivered with zest but also some incredulity. The uncertainty surrounding the reasons for obvious failings in human kindness probably the cause of different responses. Regardless of your views it is certainly always useful to reflect on your practice.
I hope I provide compassionate care. I am not sure how I ‘know‘ I do? I suppose feedback on my interactions with patients is rarely, if ever, negative and families tend to thank me when the consultation or treatment has finished. I don’t have definitive evidence of my ‘compassion’ though. This became a relevant point when during a particularly demanding shift, I realised I was having to concentrate on delivering compassionate care. I am not sure how to completely encapsulate what I mean by this but in order to engage children and their families I believe that credibility comes with enthusiasm. You must be keen to interact with children and young people. This interaction is age appropriate of course; but there is a demeanour and body language that is important to gain trust. For some this probably comes very naturally (everyone knows a Patch Adams) but I know I need to adopt almost a paediatric power pose prior to seeing patients. Completely irrespective of your clinical skills it is this compassionate approach to dealing with children and young people which families will remember.
(consent obtained for publication of this photograph)
This became increasingly difficult during the shift. I realised that I was almost resenting the effort it was taking. This is an uncomfortable state of mind to be in, challenging my own internal motivations. I hope none of the patients I saw that evening were affected by this inner tension but it has certainly given me pause for thought.
Today is the 6Cs for Everyone Event (#6CsR4E) a movement highlighting the essentials of quality care for all healthcare professionals. It is also #nhschangeday celebration day. A 12 hour long webex highlighting the powerful pledges made in healthcare communities throughout the world. I discussed my pledge this year, lying on a spinal board for an hour, something which has clearly influenced my practice in dealing with young children with trauma. What was obvious from the webex was the enthusiasm to deliver the best possible care, all of the time, from all of the speakers and participants. I am reminded this is a necessary but sometimes demanding challenge. I will certainly be mindful of my colleagues in the closing hours of a shift and encourage them (through a variety of ways, humour included!) to continue to provide the care that you would want to receive yourself.
What did you learn this week? #WILTW
[The #nhschangeday webex can be joined until 2000 GMT 4/7/14 via this link ]
“Assessment drives learning” raises wry smiles (and occasional heckles) whenever it is mentioned. However it’s unfortunately the case that ‘encouragement’ to understand and learn comes from the need to demonstrate that new knowledge in some form of test. In Post Graduate Medical Education these tests are specialist exams which are required in order to progress to more senior stages of training. The scope of information needed is huge (and often the exams split into various sections to make them manageable!). The curriculum describing the knowledge similarly large and there is great heart ache as you scroll through 50+ pages of bullet points each starting, “the trainee will be required to know…”.
By necessity curriculum are bland but what has become increasingly apparent to me is the large blocks of ‘grey’ knowledge that appear to be missing from them. I say ‘them’, I can only really speak for Paediatrics, but I am given confidence in this assertion by the ever increasing momentum of the #FOAMed movement. Chris Nickson has previously eloquently explained why #FOAMed itself doesn’t need a curriculum. However while assessment drives learning, so does experience. It’s quite clear from the huge amount of materials posted daily on a variety of clinical topics there is a thirst for information that is not readily available by common reference sources. I’ll use the #SMACCGold conference to demonstrate this point.
Lets take the section on statistics in Royal College of Paediatrics and Child Health (RCPCH) emergency medicine curriculum.
To be fair this is clear, practical knowledge that is needed by clinicians. How does this translate into actual practice though? How will we use this to provide better patient care? What will convert these concepts into something clinicians can practically deliver? I think the answer comes from Prof. Simon Carley’s two excellent lectures at #SMACCgold. One on what to believe and when to change and one on risk factors in ED
As another example Paediatricians are involved in extremely challenging situations in resuscitating seriously ill children and sometimes need to make decisions about when that resuscitation should end. Is there a curriculum that defines and aids this process? It appears not but certainly Cliff Reid’s talk at SMACC is a great example of how this topic could be approached.
Finally I scanned through the College of Emergency Medicine curriculum for “chronic pain” and struggled to find anything. However with over 1000 views so far this probably fits the bill:
It would be harsh to say that those writing curricula have been lax in their tasks, it’s more that some topics are not easily encapsulated. They are often hidden, or camouflaged, in between more clear cut points.
This is where #FOAMed has come to the rescue. A variety of brilliant minds around the world have been able to recognise knowledge they needed to know but just wasn’t currently available ( a recent talk is entitled #paedstips you won’t find in books!). Ultimately #SMACCgold stands as a testament to revealing this camouflaged curriculum content (and I am sure more will be revealed at #SMACC2015). It may well be the case that assessment drives learning, but perhaps those in charge of medical education may want to use #FOAMed to drive curricula…
The sixth #WILTW post
I was fortunate enough to attend Agents for Change (#A4C2014) this week. An annual event since 2008 it was where I first learnt the value I could provide to the entire health system, not just individual patients. I delivered a short workshop with Jeremy Tong about the challenge junior doctors face in delivering change. We spoke about narrative and the importance of personal stories in engaging with others, something we learnt a great deal about during #nhschangeday. Jeremy has an extremely powerful story about his personal experiences of sepsis which clearly have focused his efforts on developing the paediatric sepsis six tool.
Anyway I digress from the point in hand! The conference started with an introduction from Fiona Godlee, editor of the BMJ. She revealed the following:
and described how doctors typically have a huge range of talents, not just academic ability, which makes competition for medical school very intense. I have always thought that doctors are actually spineless. Generally at school they have one thing they are really good at but don’t have the guts to pursue that as a career/vocation and medicine becomes the safe choice. It made me reflect on my visit to the Foxton Locks Festival last weekend. There was a circus skills area and I got a chance to play around with toys I haven’t had fun with since being at school. I’ll be honest there is no way I could have made a career as a juggler but it was certainly something I’d forgotten I could do.
I’m sure others have other ‘outside of medicine’ skills. Just looking through the range of #FOAMed material delivered by singing, artistry or technological wizardry proves this. If you’ve let something you enjoyed doing slip in the last few years this is a reminder to pick up it again. You might just enjoy it.
What have you learnt this week? #WILTW
The fifth #WILTW post
So I could have written about 5 different blogs such was the intensity of learning this week! A few of them probably need more reflection so I leave you with this; a little more medical than usual but I hope understandable to all.
One of my consultant colleagues sent around this interesting website: xrayrisk.com
This was timely as I have only just been reviewing the latest evidence on when you need to do a Head CT (brain scan) in children who have a head injury and their only symptom is vomiting. This recent paper makes interesting reading.
Essentially if your child has a head injury and they only have vomiting afterwards it’s likely they don’t have anything seriously wrong with them. Paediatrician’s have always felt uncomfortable about CT scanning children uncessarily as their chance of developing a brain tumour may increase. This assumption has recently been challenged but I think remains a valid concern. The interesting thing about this x-ray risk website and similar resources is how is this publicly available information going to be used? Is it possible a parent may come to the Emergency Department and know more about the risks/benefits of scanning children with a head injury than I do? Although this may seem uncomfortable I think clinicians are increasingly becoming curators and examiners of knowledge rather than gatekeepers of it (the #FOAMed world is a great example of this). What is important is that we are aware of the common sources of information that patients and their families may use and know the values and evidence base behind them. This acceptance comes with the responsibility of trying to be familiar with the sources of information available. So if anyone does use x-rayrisk.com and spots something interesting please let me know!
What did you learn this week? #WITLW
The revolution of technology and social media has transformed the way information and knowledge are transferred. There is no greater demonstration of this than in the medical education community, and in particular for the ‘lecture’. Standards in pedagogy will be forced to rise as excellent demonstrations of presentation content, technique and style are shared in an instant around the world. Currently the #SMACC conferences are assembling a fantastic group of individuals who are leading the way in how audiences can be engaged and enlightened.
At #SMACCGold this year there was on particular lecture that really caught my attention. Cliff Reid talking on “When should resuscitation stop”.
It is brilliant talk with a well pitched narrative, evidence based insights and a constant return to the human side of clinical practice that is all too often forgotten. It was also conceptually clever as the real theme was when resuscitation shouldn’t stop. As a Paediatrician with a special interest in Emergency Medicine the child presenting in asystole (no movement or electrical activity of the heart) is one of the hardest aspects of my job and the decision on when to stop CPR often a challenging one. It is vital that anyone who works in Emergency Medicine listens to Cliff’s talk and takes home some of his key points:
Never make decisions in isolation of each other and a blood gas should never make your decision for you
(my interpretation and not Cliff’s actual words)
The talk uses two examples, both of children, to demonstrate the huge human factors element to decision making in halting CPR. In one of the cases the child made a full recovery despite nearly being in situation where attempts to resuscitate were stopped (Cliff was clear these were examples and all cases are unique). The cases certainly were unique – one involving cold water immersion and the other a complex congenital heart defect. What of a potentially more common scenario – sudden infant death syndrome. These are still unique events, there is no other child in the parents’ eyes, like the child you are trying to restore a circulation to. What evidence or anecdote will you use in these situations? Does the knowledge that one child, in one place, at one time, survived after a heroic resuscitative effort lead you to do the same? What if the parents knew that there are reported cases of children surviving after hours of down time. Could you convince them why you are stopping after 20 minutes if you think the child has never shown any signs of life? Only the clinicians in these unique situations will know the real circumstances of what made them go that extra minute or seek that extra intervention. Encapsulating their gestalt will be nearly impossible – so we are left trying to do the best we can with the information we have available. As Cliff says:
“The important thing about human life is that its about other people – it’s about connection and it’s about love. It’s about our love for other people that motivates us to do everything we can.”
For these most complex and emotional decisions the chance to reflect before these tragic events can only be of benefit in my opinion. Cliff Reid’s talk is certainly an excellent chance to do that.
The fourth #WILTW post…
I’ve been mulling over the reasons why, even in groups of people who get on very well, there can sometimes be discord on direction or strategy. Since the Francis report there has been much written on culture, compassion, shared values and engagement. Less has been actioned to improve these things and less still proven to have made significant change. Why is this? Given the fact that the core essence of what staff do in healthcare is centered on a few key values why can’t we create environments where these shared beliefs are harnessed in ways that inspire improvement in the care of patients and each other.
I attended a session with the #NHSChangeday hubbies this week, and on the same day, a national strategy meeting about improving the management of the deteriorating child. At both groups it was clear the values of the individuals attending were very similar. Converting this into a shared vision of what was needed to achieve the objectives of the group may have been tricky. In very different ways both groups used the core values of those present to remain focused on creating a shared vision. Not always an easy process, but an important method to bring everyone together. I’m not entirely clear there is one best way to do this but I’m certainly open to experiencing as many as possible.
However it happens given the challenges facing a post-Francis NHS translating values into vision will be an important process.
What did you learn this week? #WILTW