This is the 173rd #WILTW
I suspect the following rings true for many in medicine.
I wish "because I have a bad feeling about this patient" was an acceptable admission diagnosis 😕
— Jessica Willett, MD (@jkwillettmd) September 4, 2017
It inspired this movie related response…
— Damian Roland (@Damian_Roland) September 5, 2017
… which then spawned an inevitable flurry of similar Star Wars inspired decision making analogies:
“It’s a trap!” – Admiral Ackbar
Learning it is very easy to make mistakes is a lifelong endeavour. The frantic pace of acute and emergency care makes it all too simple to follow a line of thinking that may directly result in patient harm. In fact St. Emyln’s, and in particular Richard Carden, are well ahead of me with this quote. A great summary of failures of thinking and cognitive biases can be found here, including anchoring and availability biases. While it might appear being aware that you may be ‘trapped‘ by your own cognition, will stop you being trapped, there is some evidence to suggest this isn’t the case!
“Never tell me the odds!” — Han Solo
There is a slight dichotomy for those experienced in emergency care who practice using some form of Bayesian Probability. When a patient presents they have a certain risk of disease. For example, over the course of a year, of all the children who present with a head injury, 5% perhaps may have a problem that needs an intervention. When I see children I will take a history, do an examination and sometimes perform some investigations. All these things will change the probability that the child in front of me does have a serious injury. Sometimes it will increase the risk (positive test result) and sometimes it will decrease it (child looks very well and is running around the waiting room). However this very process creates an immediate bias as there is a real danger you won’t properly adjust the odds. If the incidence of a disease is really low then you can develop a mindset that it’s unlikely you will see that particular disease; so even if your history and examination reveal positive features you may ignore them.
Han Solo is telling us: Be aware of how to use odds but don’t necessarily depend on them.
“Your eyes can deceive you. Don’t trust them.” – Obi-Wan Kenobi
Increasingly there is evidence to suggest that external distractions can cause such a loss of focus, you literally become blind to things you are looking for. The impact of this in medicine is unknown, but needless to say, its important you sense check what you are seeing is actually what you were expecting to see.
“In my experience there is no such thing as luck.” – Obi-Wan Kenobi
..this quote is also told to junior staff by wise old consultants. At the heart of this is understanding how intuition is not a form of magic but a collection of heuristics accumulated over time by experienced clinicians. Some conscious, some not, but all invaluable to collating the vast amount of information that can be derived from patients and putting them together to create one picture. Understanding the use of gut feeling and gestalt, much like the demonstration of the Force itself by Jedi knights to their padawans, is impossible by didactic teaching alone. But it is a fundamental part of the path to mastery.
“Great, kid. Don’t get cocky.” – Han Solo
Han Solo may have come across as arrogant, but his own awareness of his arrogance, is what kept him alive.
“In all fields of medicine, but especially emergency and intensive care, the junior doctor does not need close supervision because of what they do not know, but because of what they do not know they do not know” [Spotting the Black Swan].
‘Do. Or do not. There is no try.” — Yoda
Is it possible to make a half a decision? It is definitely very easy not to make a decision at all and hedge-your bets to avoid being burnt. This may appear to be in a patient’s best interests but the burden of over-diagnosis and unnecessary admission are not insignificant. The facilitation of junior staff’s decision making by their seniors is vital but it is often simply not possible due to capacity issues in healthcare. We owe it to the next generation of clinicians to invest in delivering services which also deliver reliable education.
Similar to my posting on the Star Wars guide to Quality Improvement please do send me further suggestions which I will happily post here and credit!
What have you learnt this week? #WILTW