Workings hours – experiences untarnished?

The issue of whether it is possible to adequately train doctors in a 48 hour average week has long been the subject of discussion  (some background here). A recent piece in the Guardian raised a number of eyebrows from those on either sides of the argument. The article, written by a healthcare software provider, was essentially saying longer individual shifts would be better for all involved. This point didn’t really resonate with those doing the shifts.

https://twitter.com/tweediatrics/status/373269863885991936

However whenever the EWTD (or technically EWTR) gets mentioned the debate re-opens.

As a member of the Temple report on working hours I was given the opportunity to hear from those of all those involved in training and being trained. As a result I was asked by the BMA (point of note I have never been a member of the Junior Doctors Committee) to write a short article on my personal perspectives. I was surprised to find, despite having  written this in early 2010, I still stand by what I said then:

Reflections on the European Working Time Regulations

“In August 2002 I returned to the UK having spent a year in Perth (Western Australia) after my PRHO year (Foundation year one). I had spent it at a children’s hospital and had thoroughly enjoyed my clinical experiences there ; the 80 hour fortnights also helping take advantage of the sun, sea and surf. I retuned to a tertiary neonatal unit in the East Midlands with a degree of disappointment, worsened by the fact I knew I had to start getting my paediatric membership. The fact that the job was “Band 3” didn’t really mean much to me at the time except I knew it would help clear my substantial travelling debts. In practice “Band 3” meant a 4 and a half week run of shifts with only four days off.  I look back at that period now with mixed feelings. Without a doubt I went from a neonatal novice to being able to make middle grade decisions within six months. The confidence felt by the end of the job certainly outweighted the utter panic of a first night shift spent peering through Perspex glass wondering how I would get a cannula into the minute bag of skin and bones in front of me. To say I enjoyed the experience would be looking back with rose tinted spectacles. During the runs of long days and evenings you resented every little bleep or request for fluids. The maternity theatre bleep was a clever device never going off when you were being grilled on a ward round but waiting until your hurried lunch break. They would be exhausting shifts whether you did them for 10, 40 or 60 hours a week. However having to do them for 50+ meant you were never truly on top of your game. Fortunately the camaraderie of the team of SHOs (specialist trainees) provided an outlet for times when you became utterly frustrated. I count myself lucky though I have experienced both sides of the EWTR coin and am convinced on which side I prefer it fall.

It is clear one size does not fit all but in paediatrics because of the high demands of out of hours working a suitably staffed rota does provide sufficient learning opportunities within the 48 hour framework. It is unfortunate however that many paediatric rotas are not suitably staffed! My experiences with EWTR have been favourable as I have always been rostered to allow exposure to elements in my training that are not just simply deciding whether a feverish child is ill or not.  Others have not been so lucky and Out patient clinics, case conferences or governance meetings which all count as training are easily sacrificed if there is no-one available to clerk the next patient on the assessment unit. Without these opportunities the disadvantages of longer shifts, increased fatigue and less ability to unwind are irrelevant. As a trainee I want to be given the opportunity to train and want the system to flexible enough to allow me to take these opportunities. Ultimately though when frustrated that the systems fails I remember my neonatal job and am glad I don’t have to do it again. However as time progresses my memories will fade and the need to be effectively trained will remain. For paediatrics it is not the 48 hours that is the problem it is the delivery of training within it.”

I have always been clear that training is not one size fits all with the needs of the craft specialties different from the acute ones, and different again from community based services. I wonder as education and training changes over the next decade whether this problem will still persist, and whether I will still feel like this….

Tweets, Text and Trolling

The recent dreadful events surrounding Caroline Criado-Perez @ccridoperez and abusive tweets has now reached the UK Parliament (see here). It’s a sad story and represents a dark undercurrent to the way some humans choose to communicate and act. Although clearly not in anyway the same league as the dreadful comments made to @ccriadoperez a number of recent twitter conversations have given me reason to reflect on what people say, and the context in which they do it.

Sir Bruce Keogh was recently quoted in the Daily Mail that the NHS should emulate the retail model of high street chains Dixons and PC World. This comment didn’t go down particularly well to some on twitter leading to a very interesting tweet from one of his clinical fellows

To some, the content of the Daily Mail needs to be taken with a pinch of salt. I suspect many were willing to the give the NHS Medical Director the benefit of the doubt.

But what about this example? Emergency Medicine in the UK has recently been described as being in crisis with a serious shortfall of trainees completing trainees leaving many rota unfilled.  I was amazed to find a headline in a scottish newspaper “Doctors avoiding hard work in A&E” [and it’s not because the papers still haven’t worked out it’s Emergency Medicine not A&E!]. The second paragraph reads,

The claim from David Caesar, clinical director for emergency medicine at NHS Lothian, that young life-savers are lazy has thrown the harsh working conditions they face again under the microscope.”

The bold is my emphasis, but the term rankled with many, see the comments, and lead me to say this.

A reasonable response was:

But my concern was how much was spin, versus some underlying truth.

Often the problem with twitter is the originator of a discussion isn’t on the discussion to defend themselves. The doctrine of  “be careful what you say” has been blogged, commented on, and researched numerous times over the last century. I am not covering new ground here but twitter has opened the ability to respond, in a public manner, in a striking way.

So I have paused to reflect to my response to this tweet. First I have no idea why I used “Alan” in my tweet. I don’t really know Alan, we have certainly never met him. Did calling him by his first name somehow balance the antagonistic nature of my response? And was my response antagonistic – I was not alone in my opinion…

To his credit Prof. Alan Maynard responded but I came back with:

In the cold light of day this is a harsher response than perhaps I had originally intended. I still posted it though, in the wake of a ‘storm’ about communication and trolling on the internet my reflex was to go straight for the jugular. I am fairly certain my actions do not constitute aggression or violate any law (and I note did immediately post a tweet saying this wasn’t directly aimed at Alan). This does not let me off the hook though. Could I have approached things in a different way – I am fairly sure I could. Could I have done so in 140 characters  though? (waiting for the research that the character limits encourages a more direct, and potentially more aggressive approach)

The abuse received by  @ccriadoperez was unacceptable but from a small minority of twitter uses. However maybe everyone should remember the words of Laurence J. Peter:

“Speak when you are angry – and you’ll make the best speech you’ll ever regret.”

7 breaths is launched

Respiratory rate needs to be measured over one minute

A fundamental part of medical practice is the measurement of primary physiology. For centuries heart and respiratory rates have been calculated to help identify disease and demonstrate response to treatment. However Confidential Enquiries, internal reviews and other studies frequently show that observations are poorly taken. This in part has lead to an inexorable rise in early warning scores and system to identify acute illness. A potential barrier to the recording of observations, whether by doctor, nurse or other health professional is the time taken to measure them. Traditionally a minute has been the gold standard in order to ensure reliability. Studies have supported the 60s approach (Simoes 1999) but with increasing pressures on health services and rapid advances in easy to access technologies the time has come for a review. Can you help?

Take part in a large scale observational trial using your smartphone

This idea was first outlined here, tweeted and published on the NHS Hackday googlegroup. This idea was very quickly picked up by Neville Dastur, a consultant vascular surgeon, software developer and owner of Clinical Software Solutions and 7breaths was born.

What are we going to do with the data?

The data will be openly available to data analysts and mathematicians to attempt to generate an algorithm that can be used in future version of 7breaths that will automatically report the respiratory rate once the software is ‘confident’ that it is able to predict within set level of confidence what the respiratory would be at 1 min.

 We envision that this will take into consideration

  • Inter-breath duration

  • Variability and pattern of the Inter-breath duration

Why bother with this?

Ultimately this is a demonstration of the power of open source, collaborative healthcare innovation. While it is a bit of fun there is a real possibility that new methods to improve the accuracy of RR measurement and that can also save time could transpire. It’s also a demonstration that a simple piece of software may enable an economical way of gathering data at the point of care that does not require any form of duplication of efforts.

 Want to take part?

Download the App

App Store  

Google Play

Register

When you first download the app, you have the option of registering the software. We would encourage this as it would allow us to acknowledge your contribution and also provides a degree of provenance for the data collected.

Start collecting data

When you are next counting a patient’s respiratory rate, use our app instead. At the end of one minute it will report the respiratory rate and it will give you an option of sending the data to us. That’s it!

Please spread the word….

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Who’s behind 7 breaths?

Wai Keong Keong – Haematology Registrar (@wai2k)

Neville Dastur – Vascular Surgeon (Clinical Software Solutions)  (He built the app > Sourcecode on GitHub)

Damian Roland – Paediatrican (@damian_roland)

Don’t just leave the NHS to the next generation…

As a disproportionate amount of my blogs do, it all starts with a tweet.

https://twitter.com/Modernleader/status/354984152942129152

I unfortunately have a few issues with this concept of “generational” fixing

I think it is ‘our’ problem to fix, but by our I mean everyone in the NHS. The quality, safety and financial issues facing the NHS are not paradigms to be tinkered with, appreciated to be difficult to redress and then passed on like a parcel (not sure anyone would want the music to stop on them). Virtually all journals and health organisations have had a commentary on the reasons why you should listen and engage with junior doctors – the latest from the HSJ “Why junior doctors are innnovation leaders” , but there are many others on [1,2,3]. I’m afraid that will have to suffice as ‘evidence’ the engagement with a future workforce (and not just medical) is a valuable exercise – if you disagree it might be a blog for another time.

The thing that really gets my back up though is the presumption that junior/trainee/developing health care professionals are always given opportunities in change or quality improvement exercises. Need to be clear here: I am not talking about leadership development on a grand scale – not all junior doctors need or desire to have the skills to become operational managers or involved in national projects. I am talking about taking things beyond simple audit (which trainees have experience of in abundance) on to process change, at however small a level, with the purpose of improving quality of care. If you haven’t already done so please do read the blogs from Dr. Partha Kar which cover a wide range of issues. At the centre of many, though, is the notion that nothing will change unless individuals stand up and be counted. You can blame others for current predicaments but no-one will be able make a difference unless YOU do. This philosophy was also espouced at the recent Agents for Change “Speak.Act.Lead” conference. The challenge is how juniors doctors (or any health care professional in training..) can most effectively do this.

For me any health service has a duty to help support its next generation. However, I am not sure how in environments which lack leadership or role models this can really happen. Gilbert and colleagues, in an admittedly regional survey, determined 91.2% of respondents have had ideas for improvement in their workplace; however, only 10.7% have had their ideas for change implemented. Many possibilities for this – ideas actually weren’t any good, junior doctors weren’t persistent or had a poor implementation strategy. I am willing to bet though, having both experienced and heard reports of this, that in a number of cases the barriers were beyond the means of the junior doctor to breakthrough. And more that than there may have been negative influences preventing even initial initiation. I am not naive, anyone at any level may have difficulties with leadership or quality improvement. Junior doctors certainly do not have an monopoly on change challenges but their experiences during training will have profound implications for the future. So I am more than willing to challenge negativity from trainees who feel they can’t get anything done but I must equally fight the lack of opportunity that comes from their seniors and management structures.

This is not universal, many organisations/individuals are clearly supportive, but others aren’t and these outliers won’t be changed by junior doctors alone. I hope I am not a lone voice in this regard [4] as it is not just the next generation that need to Speak, Act and Lead

[1] Coltart C, Cheung R, Ardollino A, et al. Leadership development for early career doctors. Lancet 2012; 379: 1847-1849

[2] Warren O, Carnall R. Medical leadership: why it’s important, what is required, and how we develop it. Postgrad Med J 2011

[3] Involving doctors in Quality Improvement. The Health Foundation

[4] Roland D, Warren O and Klaber R. Engaging with leadership learning in the workplace. The Lancet 2012;380(9841) 563

Practice makes perfect…or does it?

The ever thought provoking Javier Benitez (@jvrbntz) had this to say recently

The study in question explores relationships between implicit memory [wikipedia saying Implicit memory is a type of memory in which previous experiences aid in the performance of a task without conscious awareness of these previous experiences] and explicit memory [wiki: Explicit memory is the conscious, intentional recollection of previous experiences and information. People use explicit memory throughout the day, such as remembering the time of an appointment or recollecting an event from years ago]. Essentially in the study the participants where asked to perform a task of pressing one of 4 keys in response to different cues falling down a screen. There were two groups all completing a main task but one group given time to memorise the sequence of the falling cues while the other group just had practice time without realising (or more correctly being told) there was a sequence. In this study sequence learning wasn’t improved by  pre-training memorization of the sequence. The authors hypothesised that explicit and implicit memory may be independent of each other.

In response to an initial question Javier clarified by saying in the context of deliberate practice it may well be worth re-practicing rather than re-reading which was summated as:

At this point yours truly, having not really read the initial paper properly, but enough to notice that the task used in the study was similar to sequencing required in a popular game, waded in with:

Javier pointed out that the tasks needed to be predictable but the overall philosophy was that implicit and explicity are different points of memory.

Now fully acknowledging I had waded into an area in which I am not familiar (and it’s not great practice to pick up “tweetends” without knowing context!) it still got me thinking about how this piece of research was really applicable to post graduate medical practice, and in particular the busy world of emergency medicine. If we take, for example, putting in a interosseus needle the espouced theory may have some merit. Yes an understanding of the theory is needed but actually it’s not really until you have done it in a real patient (or even a dummy) that you can really understand the practicality of it i.e memorise the sequence all you want but you really need to ‘play’ the game to get the hang of it.

However much of what we practice in emergency medicine at a senior level is a complex array of operations of which are not predictable or follow algorithms. So I responded with

At that point I confused poor old Javier a bit and this blog serves as a way of clarifying my thought trail (and conveniently may help me frame an argument in one of the chapters of my Phd on junior doctors perceptions of competence and confidence). Does this implicit/explicit memory split really hold for complex tasks? And how would we test if it does. So an open question to the (#FOAMed) world:

It’s 6pm. The Emergency Department is heaving. Red phone goes off. Nine year old, hit by car at 40mph, thrown off bonnet. Initially agitated now quiet, clear open right femur and obvious trauma to chest.

You are team leader: what memory is going to get you through the next 20 minutes….

The #FOAMed universe – normal laws of evaluation don’t work here

I try and write blogs which can be accessed by anyone, at anytime, with minimal prior knowledge. However in this case you probably do need a understanding of what #FOAM and it would be useful to also read @boringEM‘s thought provoking commentary on methods to evaluate #FOAMed sites. Essentially he proposes a number of metrics to evaluate, and potentially, rank #FOAMed resources. A number of tweets about this got me thinking of a potential conceptual challenge that may inhibit the debate:

I have spent the last three years looking at the evaluation of practice changing interventions, in particular educational ones, as part of my PhD (see summary here). Part of this involved an analysis of the term evaluation, which is different from assessment and effectiveness. One of the things that happens when medics start evaluating things is that they often apply the same measures to a variety of different environments. As soon as discussions started on judging #FOAMed content inevitable comparisons with the process of evaluating academic literature arose (some of my previous comments on this here). The problem with that is:

i) Not only are #FOAM sites, by definition, designed to share learning in an OPEN access fashion but

ii) The methodology of engagement with #FOAMed was always going to be different from that of an academic paper.

To set some context the naysayers and skeptics for #FOAMed have always stated there is no quality control of resources. How do you know if the content holds up to current evidence? What if the authors are not credible or has a conflict of interest? Well – think of the last journal you read? Did you go away and practice immediately what it told you? I am fairly sure you didn’t, probably for a variety of reasons, but ultimately because critical evaluation has been ingrained in most clinicians from early in their training. This criticism  is a particular bug-bear of mine and puts people off receiving information via Social Media (see here for previous thoughts). The lack of peer-review of #FOAM material makes it more vital that the reader is aware of potential error (if I was to change one think it would be a universal alert statement is placed on site highlighting this – this would also act as a very useful #FOAM brand) but the reader can still make their judgement. As an example this paper on Early Warning Scores in Emergency Departments has been a cited on a number of occasions but is neither peer reviewed or commissioned, ultimately it should have no more value than anything else lifeinthefastlane.com or St.Emlyn’s have produced. Why does being in a journal make it have more value?

But I suppose I digress slightly, what is different about the evaluation? Well academic literature is spread by publication in journals, promoted by citations and only recently  encouraged by social media. #FOAM has always been essentially reliant on word-of-mouth. The route to #FOAM is rarely discussed. Think of the last #FOAMed site you went to – why did you go there? Did you just find it? I suspect (and please comment and say I have got this wrong) it’s because it is from a source you already follow or someone has directed you there. And who was that person? My guess it is someone  you trust,  follow or is a leader in #FOAM. Not really sure how you define a leader in #FOAM but I stake trust in the sites that key #FOAM supporters recommend. So if @sandnsurf@emmanchester, @_nmay, @predordialthump, @boringem, @jvrbntz or @tessardavis mention a site I take a look. Others may have a completely different list – but it probably doesn’t matter who they are. There is a different form of peer review in process here – that of trusted followership.

Could there be mistakes in the process – well yes there could. But the process of academia and publication has not been risk free . So when it comes to evaluation the metric is at stake is the spread of information. The more recommendations leading to website hits being a proxy measure of word of mouth assessment of the perceived quality of site. Problems still exist if you want to be pedantic- hits to sites can be manipulated (but this can be controlled for) and the “quality”, in terms of readability and evidence, if you are determined to measure this as well has still not formally been assessed. But if you are evaluating  the primary purpose of FOAM then it is metrics like hits which have value. How this reflects the sharing ability of some of the FOAM leaders is open to question? This also prompts the question about what is the ultimate aim of #FOAM and whether it wishes to be constrained by old paradigms of evaluation or maybe create new ones.

Friday Follow #ff: Functional or Frivolous?

I have previously written about the notion of followership on twitter (distinct from the leadership concept which is equally as important!) and would like to ‘follow’ it up with a muse on #ff. A quick guide to what #ff actually means can be found here.

Those on Twitter will know as Friday morning comes around some people go to great lengths to include as many of their twitter colleagues in #ff lists. I always feel a little awkward about watching people list either:

i) the same people each and every week or

ii) fill as many people as possible behind or in front of the #ff as they can.

I feel awkward not because it really bothers me what they are doing but because I actually secretly enjoy getting a #ff but never really have the inclination to do #ff spamming myself. There is also something unsettling about what to do when you have received an #ff – do you have to #ff back? do you even have to acknowledge it at all?

I have #ff a number of people but I do try to choose people that I think others really should follow i.e not selecting close friends who have only tweeted 3 times in their entire life. But I often ponder if I am just being a miserly kill joy. There is something quite warming about a collection of people simply being nice to each other in a very public way. In fact there are few things, other than a ‘like’ on Facebook, which are as easy to publicly demonstrate your support, friendship or commoradie with others.

Currently healthcare is taking a bit of beating in the media, is under constant reform and moral is particularly low. Those who use social media to unwind or refresh from the constant pressure of clinical activity could easily be forgiven for celebrating a bit of shared good feeling. So maybe a random #ff , which actually may not be hugely beneficial for your followers, may actually be very beneficial for the recipient. Furthermore given the fact the art of simply smiling at work is clearly something health care professionals would like to see more of (NHS Change Day Interim report) a simple #ff is maybe what everyone needs.

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