This is the 72nd #WILTW

This week’s #WILTW could have been on many things. The challenge of visualising academic data in a new age of presentation styles, understanding what makes sense to me might not make sense to my audience and finally remembering to do simple things like pick up plastic dinosaurs before leaving the house.

What I have settled on is something that has had quite a profound effect on me. I attended the Stanford University #MedX conference last weekend. There are certainly bigger conferences in terms of participants but its digital and social media prescence has always been substantial. I must admit to having a bit of skepticism about the aims:

Medicine X is a catalyst for new ideas about the future of medicine and health care. The initiative explores how emerging technologieswill advance the practice of medicine, improve health, and empower patients to be active participants in their own care. The “X” is meant to encourage thinking beyond numbers and trends—it represents the infinite possibilities for current and future information technologies to improve health.

However I am no longer skeptical and one of the most impressive things about the conference was the patient and public prescence. And not just in the audience, on the stage as well. I spent an afternoon at #MedX listening to how social media has been utilised by patients to engage and inform others.  I have another blog on the session but I want to highlight one particular lecture by Abby Norman (@notabbynormal). The story is best told by Abby herself so I would encourage you to read her talk. In summary Abby had a delayed diagnosis of endometriosis (an all too common occurence in healthcare). She spent a great deal of time researching her own symptoms, and in the process, creating a network of fellow sufferers via social media. At one stage she quotes her surgeon:

“You are either brilliant — or the most well-educated hypochondriac I’ve ever met,” he said. But he humored me. He scheduled another surgery.

It turns out she was brilliantly educated.

Abby’s story is painful to listen to. It raises many questions about the diagnostic abilities and listening skills of doctors which have been beautifully encapsulated here  (The article has bitter resonance for me as I brushed aside my wife’s abdominal pain for far too long – she also had kidney stones.)

There is a flip side to this challenge. It is difficult to explore, especially in a public setting, but it exists and influences the judgements of health care professionals throughout the world. Simply there are many patients who have chronic symptoms which do not have a physical cause. This is not saying they are any less ill or deserving of treatment just that an operation or a specific medication will not be curative. The reasons for this are multi-factorial and complex. Certainly dismissing somatisation in a patient is as bad a medical practice as failing to recognise an obvious  appendicitis. The medical management for somatisation and appendicitis are very different though. Furthermore through a quirk of human nature professionals are often too quick with their own pattern recognition of initial presenting complaints. It is easy to dismiss vague or nebulous symptoms as not being significant and quickly stereotype a patient as nervous or over anxious.

On the flip side, it is not possible to investigate all patients who present for all possible diagnoses. This would not be equitable or effective use of resources (2 of the core components of quality health care.)

So how do health care professionals avoid labels and perpetuating medical mistakes? Well we listen closely, we examine thoroughly and we remain open minded. We should be aware of the implications of our decisions:

This is going to be a cross-cutting theme through my talks at #RCEM15 pic.twitter.com/IrGJLcXXvS

— Damian Roland (@Damian_Roland) September 29, 2015

and if your decison gives the patient no safety net or no way out to review a diagnosis you must ask yourself: Is this a good decision?

What have you learnt this week? #WITLW

This is the 71st #WILTW

I am writing this at Heathrow airport. There are thousands of people here and in the last 10 minutes a sizeable percentage of them seem to have descended on one the few ‘Charging Poles”. There are some interesting stand-offs. How long is it acceptable for to plug in a device and is it safe to have your laptop lead running across the floor to the seats 3m away?  People are being generally British though and nothing has got too heated.

Rudeness in healthcare, however, is an all too common occurrence. From difficult referrals to inappropriate bed-side comments about another person’s clinical skills, most professionals will have felt someone has been rude to them. How many have knowingly been rude in return though? Would you confess to ever having delivered a  gruff back handed comment? Do you know what you consider as ‘rude’? How about being on your phone in the middle of a meeting as being disrespectful of the chair (I am guilty of this).

In a fascinating study published earlier this month in Paediatrics the impact of a individual being rude to a neonatal intensive care team during a simulation was observed. I have copied the results below

Rudeness in this study took the form of an apparent expert being dismissive of others performance

“..the visiting expert commented that while he liked some of what he observed during his visit, medical staff like those observed recently “wouldn’t last a week” in his department..”

And it appeared to be detrimental (although it possible to argue about the clinical impact of the differences between the groups in the study). This finding is pretty obvious in some respects. Rudeness is likely to be distracting, especially in high stake situations.

The impact was tangible though. It begs the question as to how other elements of rudeness, perhaps that of dis-engaging in meetings, have a long term effect? I’m not sure how well this has been studied but it will make me think twice about answering that “in-meeting” text message.

What have you learnt this week? #WILTW

This is the 70th #WILTW

This week saw the unfortunate fallout resulting from the breakdown of negotiations between the trade union for doctors in the UK (the BMA) and the government over a new Junior Doctor contract.

'I don't blame doctors for walking out of pay negotiations' – @CharlieCooper8 http://t.co/I3kZGuc0rY pic.twitter.com/liA3QYBdCP

— The Independent (@Independent) September 17, 2015

One of the documents circulating is from the Review body of Doctors’ and Dentist’s Renumeration. In it there is an interesting table which comes from an analysis by the Incomes Data Service.

Whether it is important or relevant to compare fast food restaurants with hospitals is not a question I wish to tackle here. However the last row did catch my eye as it appears airline pilots have a night shift window which starts at 1am. The DDRB document also has the following

Airline and Healthcare analogies come-and-go on a regular basis and probably have mixed utility. What I immediately thought of was the challenge pilots must have with their body clocks and the subsequent relief that I no longer have to do regular night shifts. However I fully expect that due to the current and future dynamics of the provision of health services in the UK that shifts going well into the early morning  will become a typical feature of rota’s for senior staff in Children’s Emergency Medicine (and I am sure this is happening in places already)

There is a great piece of work from the Royal College of Physicians on working the night shift (thanks @thefourthcraw for the heads up) and a Top 10 tips on surviving the night shift from the team at Life in the Fast lane.

Whatever eventually falls out for Junior Doctors and Consultants it is going to require reviews of shift patterns in order to maintain emergency services 24/7. I’m mindful of the impact this will have both on professionals (and therefore patients) and wonder if we have a common language about what a night shift is (and can do to you..)

What have you learnt this week? #WILTW

(for those receiving by e-mail there are clearer figures in the online version)

This is the 69th #WILTW

Health care professionals experience a lot of change. Either in the form of needing to follow updated guidance and clinical practice or by way of environmental change such as moving to a new ward or department. The latter can be quite daunting as you need to become accustomed to new names and faces and, probably most importantly of all, different ways of doing things. I had a good lesson this week in the importance of being empathetic to how unsettling this can be.

On Sunday I competed in my second ever triathlon. Given my first was over 20 years ago and took place at school I’d say I was a novice. I certainly don’t do any more swimming than splashing about in a pool with my daughters and my experience of cycling is a 10 minute relaxed ride to the train station and back. I do regularly run and used to be fairly competitive. I therefore approached this triathlon as someone with some fitness and knowledge of sporting events but basically zero understanding of this particular environment.

While these blogs receive (regular) jovial criticism for some of their speculative analogies I unashamedly would like to contrast the following:

• Having skills, but not knowing how to apply them, reduces your confidence

I remember looking around a the other competitors feeling very out of my depth. In fact, as it turned out, I wasn’t too bad at the running or swimming but I was spectacularly poor at the cycling. The context of putting a bike onto a metal bar and having to remember to put your helmet on before you touched your bike made me feel uncomfortable. It’s the same feeling joining a new department as an experienced health care professional – it’s not that your don’t know anything, it’s that you don’t know how to apply it in this new place. It’s ok for people to feel nervous and current staff should appreciate this.

• Not knowing what other people know is uncomfortable

Sitting in the cycle transition zone listening to other people and learning tips. Feel very out of my comfort zone! pic.twitter.com/lRNvYszM4m

— Damian Roland (@Damian_Roland) September 6, 2015

I remember feeling faintly amused as a group of people next to me  were talking about how they had spent the last evening practicing transitions between the swim, cycle and run. But I felt more nervous just before the swim as the others in my group (there were staggered start times with 3 minutes between groups) clearly knew each other. It’s a reminder that it can be lonely being in a new department with in-jokes and prior knowledge – everyone has a friend but you.

• There are some things you just need to experience to learn

We tried very hard at our new staff induction this year to give them as good a possible grounding to the working of our Emergency Department. Clearly though you can’t cover everything.

As I was awkwardly setting up my bike I over-heard someone talking about how its useful to set your bike up in the lowest possible gear so it’s easier to start after coming out of the swim. Really useful information – I wonder what gems we missed telling our new starters?

Whether it was nerves or just stupidity I nearly got all the way the swimming pool without my googles on before realising I didn’t have them. For someone who wears contact lens’ this is a pretty important omission; probably not dissimilar to forgetting your stethoscope. Something I suspect at least one new starter has done this year.

A good reminder to me to be aware of what it is like to be in a new starters shoes…

What did you learn this week? #WILTW

This is the 68th #WILTW

An ambulance has arrived at the Emergency Department with a mother and her child.

The mother looks anxious but her 3-year-old is happily playing with a glove ballon given to her by the paramedic. They have both been hit by a car at an unknown speed. The car left the scene but eye-witnesses are sure the car was going at least 20 miles per hour. Mother recalls hitting the bonnet of the car and the road. She doesn’t think she was knocked out but can’t be sure. She remembers being so shocked that she just lay on the floor amazed she was still alive. 

You do a thorough examination but apart from minor abrasions there appear to be no serious injuries.

Their physiological parameters are normal.

Clearly a period of observation is needed. Is anything else? The mechanism of injuries sounds very dangerous. Should you do a head scan? Do they need x-rays?

What happens if you are then are shown this video of the event:

https://www.youtube.com/watch?v=efNhIaZl2rE

Does, and should this, change what you do?

CCTV has been around for a while but increasing use of mobile devices has enabled recordings of clinical events to be frequently available to health care professionals. In the field of neurology this has been incredibly useful and while there are concerns about quality (and disagreement between neurologists themselves about what the videos show!) some medical institutions have embraced this technological revolution.

In the field of trauma this has added complexity however. Whether they realise it or not, doctors are commonly using Bayesian methods. (Very) basically patients they see have a certain risk of illness,  tests are then performed which increase or decrease that risk allowing doctors to make a decision on whether to treat or not.

You may see a patient who from appearance and the history has a low risk of having a particular injury or illness. The test results you are looking for would have to be striking for you to act on them and you might not even consider doing tests at all. But what if you had new information which changed your perception of risk, Would you be comfortable doing nothing on the child and her mother having seen the video? Technically nothing has really changed as before seeing the video you had already mapped out in your head the likely outcomes. In the era prior to CCTV and mobile phones you would have had none of this dramatic footage to guide your decsision making so how should this effect your judgement?

This week I was given a similar diagnostic connudrum. The patient suffered no harm but it is ever more likely we will have our normal practice challenged by information we would never previously had access to. It is important we do not start becoming defensive practitioners but at the same time patient safety is paramount.  What has become most obvious to me is the communication challenge this will present. As a parent, carer or family member you may have difficulty understanding how you can not do any tests if you have seen footage as dramatic as that above. In this new age communicating risks and benefits based, not just on reported history and examination, but visual recordings of actual events will become part of a health care professionals skill set.

What did you learn this week? #WILTW

(For those receiving this blog via e-mail please note there is an embeded video which you will need to click onto the website to see)

This is the 67th #WILTW

Ed appears to be the cause of many problems. He missed the sepsis, the hairline fracture and the pneumonia. All on one shift. To make it worse no-one ever pronounces his name right either. It’s the “E” “D” people say. And then roll their eyes.

My colleagues and I spend a lot of time debugging problems caused by Ed. The last clinical conversation I had before going on leave last week was about Ed and why other specialities seem to dislike him so much. It was with this in mind that I spent a bit of time mulling over what I could do to help him. A few weeks ago I wrote a blog entitled “5 referral tips what won’t annoy a paediatrician.” While it proved popular with paediatricians I realise it was potentially an example of further implicit tribalism against Ed.

So for #WILTW an Ed fact-finder!

1. Ed is not one person – he didn’t miss the fracture; an individual did. Everyone makes mistakes but Ed seems to be charged as an entity that tarnishes all those working in Emergency Medicine with the same brush. Ed’s mistakes have obvious implications for specialities managing that patient. The mistakes are probably not substantially different than in-patient team mistakes but these remain confined to that team, not dissected at morning hand-over. While orthopaedic surgeons are often sterotyped it is still the case of the “that particular orthopod on-call last night”. Poor old Ed seems to single-handley run the Emergency Department 24/7.

2.Ed must be a jack of all trades and is a servant to all. He works in a high intensity environment but is also held to account for a number of quality indicators and (increasingly) national ‘pressures’. While admittedly the ‘time target’ appears to dominate all others he is also subject to scrutiny in the treatment of sepsis, the management of fractures in the elderly and public opinion of whether they would recommend his service. While these are relevant throughout many medical specialities no-one other than primary and intensive care will be managing such a range of conditions and be held to account across all of them. Ed does not like to whinge and whine – he choose his job for exactly this pressure. But feeling smug when you have met your one target against Ed’s potential seven should not be something to be proud of.

3.Ed manages unwell patients. Let me repeat that. Ed manages unwell patients. The very environment Ed works in means patients are sick. Yes – patients should always receive the optimum initial care and treatment the moment they are recognised as being critically unwell. Ed feels very guilty when he makes mistakes. But he cannot make all patients 100% better in the time available to him. Hospitals are there to manage unwell patients. Phoning Ed to tell him the patient he sent you was sick when he had told you this in the referral is not helpful to you or Ed, and certainly not the patient. Which leads nicely to…

4. Ed likes to learn. He likes feedback on how to improve. Overhearing how dreadful his referral was second hand in the queue for the canteen is not useful feedback. Useful feedback occurs in a fashion that does not intimidate, threaten or subvert. It may involve talking to Ed’s boss or may, hold your breath, involve actually talking to Ed himself.

5.Ed manages increasingly, and more often than not, appropriately expectant patients, parents and carers. Specialities know how it feels when an out-patient clinic is over-running and you have a room full of eyes on you everytime you call the next patient in. Ed works like this hour-in and hour-out. Ed see’s first hand the anxiety, the tears, the stress and the anger in people. Ed often turns this into relief, happiness and gratitude. But sometimes he doesn’t and every so often time is needed or another professionals’ advice. Ed doesn’t phone you up to tell you about all the patients he has discharged only the ones he feels you need to see. Sometimes all that is being asked is a simple opinion. But that simple opinion may be of huge relief and be a powerful intervention in itself.

This is the 66th #WILTW and I am delighted to say the first guest posting! Many thanks to Edward Snelson (@sailordoctor) who runs a blog  called GPPaedsTips 

This year was the 200^th anniversary of the battle of Waterloo, famous for being the final conflict of Napoleon Bonaparte, one of history’s greatest generals. At this battle the resurgent grand Napoleonic army was defeated against the odds by Allied forces; the decisive weapon at the battle being the British foot soldier. As a bit of a military history geek I have always known that there was something special about the way that our troops were trained however I only realised this week that there was a lesson to be learned from this for medical training.

I have been practicing medicine for about 20 years now. During that time I have seen a transition from the “see one, do one, teach one” attitude to a complex system of portfolios, competencies and assessments.   Doctors are now trained in an environment which has a completely different set of rules. Training has improved in many ways and one of the major improvements has been the use of simulation as a learning tool.

Simulation is a teaching method allowing an individual, or a team, to role-play a scenario with a subsequent learning conversation about what has occured. One of the strengths of simulation is the ability to incorporate infrequently encountered events. For example, we could simulate an encounter with a  patient who may have Ebola. I’ve never seen this scenario myself and simulation would be a good way to get me to put into practice what I know only in theory. With the right facilitator I would get feedback that would prepare me well for the real thing.

Another of the strengths about simulation is that it is a relatively non-threatening learning environment.   If I make a mistake with my Ebola manikin, there is a lot less paperwork to fill out afterwards and, although I might feel embarrassed, I don’t need to feel guilty. Most importantly no-one has been harmed. However, I sometimes feel that we make simulation too nice and try to sanitise it.

This brings me back to the 1815 British Redcoat infantryman. These soldiers proved themselves in battle over and over against armies such as Napoleon’s. Napoleon’s army was larger in sheer size, as well as infantry and cavalry. Napoleon had far more cannons and his army was unified.

What swung the odds back in favour of the British soldiers was their training. While other armies were practicing the complex process of loading and firing a musket by role playing, the redcoats of Wellington’s army trained with actual ammunition in their guns. That meant that their training was as close to the real thing as possible. This was not pleasant. Firing a musket was deafening, it jarred your shoulder and filled your mouth with salty gunpowder (as each cartridge was opened by biting into it). Training with ammunition in your gun for a soldier of that era would have been gruelling and probably caused many injuries. But it made all the difference when battle came.

There is a possibility in simulation training that clinicians are be learning in comfort what they need to perform in a crisis. This may be a dangerous precedent.   As is frequently quoted (from an anonymous special forces navy seal):

“Under pressure, you don’t rise to the occasion, you sink to the level of your training,”

That was proved over and over when these two armies met, with the British Infantry consistently outperforming their enemies. Later, at the battle of Gettysburg, muskets were found which had been loaded 12 times and never fired. Was this due to being trained without ever learning to fire actual ammunition?

This year an article was published in the journal Pediatrics titled “Trainee Perspectives on Manikin Death During Mock Codes” exploring the issue of simulation that includes what I would call ‘mess‘. Medicine is messy and in high stress situations things go wrong. Sometimes despite all the best efforts children die.

There can be a reluctance to create stressful simulation with impossible tasks. What this means in practice is that we are failing to train our clinicians for the most important situation of all – the ‘no win” situation. I have had a significant part in the development of the Children’s Advanced Trauma (CAT) course and I am sometimes asked whether there is educational value in situations where there is too much to manage or where the situation is pre-determined to have a bad outcome. I believe that there is.

I would like trainers and learners to embrace the idea that failures are more valuable learning experiences than successes. As long as we are sensitive to the effect that these situations have on the learner I believe that the more mess you have in simulation the better. It is also important to have enough time set aside for the discussion afterwards.

There are other ways to look at this attitude towards medical training, which is to treat the most stressful experiences in day-to-day medical practice as learning opportunities. It takes a skilled person to do this well but when things do get messy, there is usually so much to learn that it is a shame to miss out on it. Medicine is messy. Perhaps as we train for the worst that acute clinical medicine has to throw at us we should include a few loud bangs in our learning?

What have you learnt this week? #WILTW

Edward Snelson

Consultant Paediatrician specialising in Paediatric Emergency Medicine (Sheffield Children’s Hospital)

This is the 65th #WILTW

This week was the first complete Monday to Friday for many new doctors (either to the profession or to a new hospital) in the NHS. Fortunately this year there hasn’t been quite the diatribe in the media about reported increased death rates in August, and I hope this signals the start of (some) news corporations starting to understand the differences between forms of statistics. The original research demonstrated a difference of only 45 patients out of almost 300,000 records over nine years between July and August. Statistical analysis would indicate this increase is significant but it’s just impossible to say whether this is due to the new-starters themselves. There is no reason to say it is not also explained by the fact that relatively more staff are likely to be on holiday during that month or that there aren’t differences between April and May for instance (which wasn’t examined).

Regardless all hospitals recognise that their new staff need support and we have worked particular hard to ensure our most junior doctors starting in the Paediatric Emergency Department are as prepared as possible. One of the things we’ve done is produce a short video demonstrating a toddler’s view of their experience.

This is more than a simple social media gimmick. You rarely see those who are used to working with children standing in a cubicle  while examining patients. Also although guidance has recently changed which will hopefully reduce the amount of children being brought in with neck collars and on spinal boards the below is not a friendly view for a five year old:

What became apparent to me this week was how important it is to appreciate the parents’, as well as the child’s, view. The Emergency Department may also be a scary place to them. One in which they are entrusting the care of their loved ones to people they have never met. However friendly you may came across as a health care professional there is an implicit hierarchy or authority gradient which may need to be addressed. Your body language is just as important to an adult as to a child. When their child is at their most vulnerable a parent or carer will see the world through their eyes. How will you look to them?

What have you learnt this week? #WILTW

[for those receiving this blog via e-mail it has come to my attention you tube links are not shown. Please click on the website version to see all the links!]

This is the 64th #WILTW

Today I gave an induction lecture to our new doctors entitled:

“Risk Assessment and Communication: An audio-visual journey”

I’d spent the week mulling over the arc of my story  and was struggling to piece together the individual pieces of knowledge I wanted to share into a coherent narrative.

I have a long standing interest in the use of patient video cases for education. My belief (beginning to be backed up by research) is that video is not only useful for the learner to conceptualise signs they have read in text books but vital for educators to assess how learners are processing information. I am hoping to demonstrate that we can use patient video cases to aid our understanding of gut feeling or gestalt but for the moment it remains a powerful under- and post-graduate educational tool. Apart from the novelty of the medium what would inspire the audience to understand the value of video?

The breakthrough came when I concentrated on the audio-visual nature of my presentation. What am I demonstrating that another presentation couldn’t do? What will the learner see and hear that is unique?

It made me think about what I see and hear that my juniors may not. When I walk into a consultation room I do an observation check on both the child and the parent/carer. When I start listening to the history I am not just noting the key words but the way they are being said. When I spot an abnormal sign I check whether it is in isolation or in keeping with other features of illness. In this way I am using my senses in a parallel not in series.

My plan then to show the audience what they had been taught previously wasn’t wrong but history taking & examination can be so much more than hearing and seeing – it is truly listening and observing.

What have you learnt this week? #WILTW

Observation is a common theme in these blogs! Some related postings

It’s not what you say it is how you say it

What you see is maybe not what I see?

The importance of listening and language