This is the 176th #WILTW
Assume = to make an ‘ass’ out of ‘u’ and ‘me’.
Assumption is my enemy.
I can’t assume in a hectic resuscitation that an instruction has been heard unless it is confirmed back to me. I can’t assume relevant clinical signs have been identified when a patient is discussed with me and I can’t assume I always make the right diagnosis.
A further challenge when you become an autonomous practitioner is that it’s much more difficult to determine how your colleagues practice. The assumption is you do things in a similar way but you never really know this. It’s part of the reason why I enjoy immersing myself in Social Media. It’s a great way of determining and sense-checking what other people do.
Safety-netting, the provision of information to help patients or carers identify the need to consult a healthcare professional if a health concern arises or changes, is an important intervention where there are probably many different ways of saying the same thing.
The assumption is that there is a common approach but recent conversations lead me to believe this may not be the case. If only to start a debate, I’ve determined the 5 principles I use to structure my safety netting advice.
Avoid enacted criticism – Your advice is about the future trajectory of illness not implying what the parents or carers could have done to have avoided seeing you in the first place.
Establish the process of making a diagnosis is a partnership – This is what you have told me and this is how I have interpreted it, so this is the suggestion for what we are going to do. I often quote a comment a parent/carer has made about their child’s illness. This demonstrates I have been listening and am interested in addressing concerns. This phase is important as this sets the scene for the key component of safety net advice..
Explain the natural history of the disease process if your diagnosis is correct – one of the worst things to do is suggest that typical symptoms of the illness you have diagnosed could be worrying. A child with gastroenteritis will vomit and have diarrhoea.
“If he vomits bring him back” is NOT safety net advice.
“…your little guy is likely to continue to have vomitting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated” is more useful.
Explain what the features of illness will be if your diagnosis is incorrect or the disease process worsens – I am very clear to parents that 24 hours is a long time in a small child’s life, the decision to discharge is based on the features of illness now. These may change.
I always say, “my opinion is based on the child I am seeing now- if that child changes- bring them back”.
— Nikki Abela (@NikkiAbela) September 24, 2017
Openly ensure shared understanding. I directly ask if the parents or carers are happy with the decision that is being made. It is rare to be caught out at this stage, but I still find some clinicians seem unable to read parental body language, so I always suggest my juniors do this.
I don’t assume that this is a perfect approach, and certainly there will be individual nuances at a patient level. Would love to hear from others about their approaches.
What have you learn this week? #WILTW