All posts by Prof. Damian Roland

I am Paediatrician who works in an Emergency Department. I am currently undertaking a PhD and have formed the PEMLA (Paediatric Emergency Medicine Leicester Academic) Group with a colleague, Dr. Ffion Davies. I have interests in both medical education evaluation and policy

What I learnt this week: Are hearts and brains enough without courage? #WILTW

This is the 63rd #WITLW

“You have plenty of courage, I am sure,” answered Oz. “All you need is confidence in yourself. There is no living thing that is not afraid when it faces danger. The true courage is in facing danger when you are afraid, and that kind of courage you have in plenty.”

– L. Frank Baum, The Wonderful Wizard of Oz

If you are walking down the street and a person in front of you appears to accidentally drop an item of litter do you stop and tell them? Or do you just pick up the item and put it in the bin yourself.

What if someone has deliberately thrown the litter the floor? Do you challenge them?

On the DR-ED discussion group this week there was a discussion on courage. It was triggered by an article on from the Hasting’s Centre entitled “Must we be courageous“. A commentator suggested oppressive or bullying cultures in some ways promote resilient responses almost as if a negative environment is tolerated because it develops ‘courage’. This is a challenging theory which has an unnerving element of truth to it.

courage-wordle

Dwelling on my own ‘courage’ I do not think I had labelled it as such  but it is a quality I grapple with on a regular basis. Whether you are a consultant, manager, team leader, director or other position of responsibility you are required to set standards. Part of those standards you set visibly but non-verbally i.e.  you arrive to or start meetings on time, you are organised and you meet deadlines.

But some standards you need to set by intervention. You challenge behaviours, you correct bad practice, you constructively highlight inconsistencies and errors. This requires courage. It requires courage because the implication of your intervention is that you would not have done that. You are creating a moral distance between you and the perpetrator. The best leaders will minimise this perception with the style and approach they use because no one should feel like a criminal. However the divide between right and wrong will need to be made otherwise it wouldn’t have been necessary to do anything.

Emotional Masks

It should also take courage because you will be eliciting an emotional response in the person you are addressing. As you become more experienced your skill at this improves however the moment you are not aware you maybe causing distress, turmoil, or even anger, you risk demonstrating the very behaviors you are trying to address. Bullies do not care about how their victims are feeling and poor leaders are more than happy to publicly highlight deficiencies in individuals.

Being courageous is hard. I think I am clever enough to deliver what is expected of me and I have a love for my job in abundance. But am I truly demonstrating professionalism unless I can say lack of courage never stops me intervening?

If I really believe something is wrong I am always prepared to say so?

Are you?

What have you learnt this week? #WILTW

What I learnt this week: How to learn something you don’t understand #WILTW

This is the 62nd #WILTW

After a week abroad I have spent a week at home doing, well, not a lot.

A bit of time has been spent perfecting my daughter’s cycling skills.

I’d previously made the observation that learning to cycle depends on a skill-set that is actually difficult to describe. Discussing Tacit Knowledge, that which is usable but hard to express, isn’t really a great theoretical starting point with a 5 year old though. Ultimately given balance isn’t a easy thing to define it just needs to be practiced. Unlike scribbling (and subsequently writing) in which the effect of crayon on paper is obvious, the need for a certain amount of momentum to maintain stability when you are only on two wheels isn’t. This may be a peculiarity of the stubbornness of my daughter whose particular problem this week has been pushing off on her bike. After getting over a period of exasperation that Isla wouldn’t listen to what I was saying (and realising this was my unconsciousness competency) I reverted to an approach of just following her requests. This involved so much help at positioning and stabilising the bike that I thought she would never learn anything.

But she did get better and her competence and confidence increased at a pace she was comfortable with. It demonstrated that not only I am pretty useless doctor when it comes to my own children, I’m a cr*p educator as well.

Teaching Cartoon

The approach of letting the learner learn, especially with new skills, is a particular dilemma in medicine where obviously patient safety must remain a priority. A recently published article discussed the impact of the introduction of time targets (similar to the 4 hour model in the UK) on training in Emergency Departments in Australia. One of the conclusions was that it was reducing ‘trial and error’ learning to more senior role modelling.

In a couple of weeks time a new group of junior doctors will start in our Emergency Department many who have minimal experience of interacting with ill and injured children. Increasing patients numbers but the need to maintain high quality care and deliver a good patient experience means we too will be striking a balance to allow development at a learner’s pace without claustrophobic supervision. This is something no one can afford to be bad at…

What did you learn this week? #WILTW

 

 

 

What I (am learning) this week: Why you need a digital holiday #WILTW

This is the 61st #WILTW

… although it is a bit of cheat. Currently I am on holiday and this is a pre-programmed blog I wrote before I left.

I am having a so called ‘digital holiday‘. This is an interesting term which probably didn’t exist a decade ago. Its origins aren’t clear; a quick google revealing travel companies selling digital ‘detoxifications’ rather than a list of psychological references.

digital-detox-holiday-computer-beach

The question I am asking myself is why do I need an electronic spring clean? All things being equal there shouldn’t be a reason to switch off twitter, let my phone battery run dry or revert solely to paper-based reading mediums. But I have a strong feeling I need to do this. Whatever the extent of my dependancy is on being up-to-date in a social network sense (as opposed to an evidence-based medicine one) it is still a dependancy. Then as you continue to work in advanced technical roles, legal advice specific to the industry can save you from unintended pitfalls. A reliable resource like https://www.newjerseycriminallawattorney.com/white-collar-crime/computer-crimes-attorney/ can guide you in navigating complex legal challenges related to computer crimes.

I do check my phone too much, I do care who retweets me and yes, I admit, I do watch the numbers of hits on this blog. None of these things make me a better doctor or father though.

Therefore for now: “cheers!” Hopefully I am on a beach or in a pool a but more clear on why a digital holiday is so important.

What have you learnt this week? #WILTW

(I did find this article on 5 steps on how to digitally cleanse on holiday though)

What I learnt this week: I am not negotiating the way you think I am #WILTW

This is the 60th #WILTW

This week I participated in a day’s workshop on “Working effectively with others”. Hosted by the Royal College of Paediatrics and Child Health it was an eye-opening day facilitated by Liz Saunders (of Alternative Guide to the NHS fame)

The day was themed on negotiation and conflict and involved some challenging discussions with a group of actors. We were given the chance to complete the Thomas-Kilmann Conflict Mode Instrument (Figure below via Ben Ziegler). I must confess previously I had not been the greatest fan of these type of personality assessments. My general feeling is, while fun to fill in, they tend to tell you what you already know and don’t meaningfully affect change (for you or others).

cross-cultural-conflict-management-4-638

In a nutshell the instrument matches your level of assertiveness with tendency to be cooperative. It’s pretty simple and has that face validity that makes you jealous of Thomas and Kilmann for coming up with the idea first!

Essentially:

Competing is ensuring the outcome is focused on the best needs of you rather than anyone else

Avoiding is simply not engaging by postponing or withdrawing from the issue (slightly different from Accommodating which is ensuring the needs of others are met before your own)

Comprimising involves always seeking a middle-ground which is different from Collaborating which is an active mind-set to find a solution which will meet both parties needs.

I had an inkling that I might be in the middle or towards the lower half of the graph and I was right (the numbers a score out of 12 demonstrating which domains you generally acting out of).

My Conflict Style

What surprised me was a few colleagues mentioning they thought I was at the higher end of the assertiveness line. This gave me food for thought. It might be the feedback sample was unrepresentative, others having a similar opinion as the instrument. It also might be that conflict-handling style is not something that you can judge in someone else…?

The dissonance is relevant though. Regardless of the how you might use the chart to improve your own negotiating skills could you leave a room thinking you had been accommodating when others left frustrated at how competitive you are? I am sure there is a lot of literature on this and it is an area in which I am keen to improve my knowledge and skills. One thing I definitely can do is seek feedback following difficult team discussions (I am thinking one-to-one encounters might not be a good place to start!). Even thought this might be an uncomfortable process it will ultimately be important in improving the productivity of meetings.

What have you learnt this week? (and what do you think the style you act out of most is?) #WILTW

What I learnt this week: The poison of passion #WILTW

This is the 59th #WILTW

https://twitter.com/WhoseShoes/status/616600360669548545

This tweet hugely resonated with me. I am generally a ‘can-do’ person. I like to be able to complete tasks on time. I don’t like letting people down. This applies to patients & colleagues and I take great pride in what I do.

But there is a flip side, a danger with taking this mindset too far, a poison of this passion as it were. It’s a result of feeling that you need to close all loops even when the result may be detrimental  to you personally. A paediatric colleague described this as ‘hero’ syndrome to me. It is diagnosed in the junior doctor who never leaves on time; the one who is always going that extra mile for their patients. While intuitively this seems an admirable, perhaps even essential quality, perversely this approach isn’t always as beneficial as it seems. Sometimes a ward doctor concentrating on the one child they think is in most need of care misses little things in other patients. The doctor at a weekend going back to repetitively check on a baby they have admitted may result in emergently presenting patients not being seen as promptly as they should be. “Heroes” are diligent, hard working, compassionate doctors but need managing all the same.

Superhero

As an Emergency Medicine consultant I must be extremely careful not to get caught up with just one patient. My responsibility is to all in the department. This sometimes means I can’t spend time chatting with parents in a way I might have done as a junior. It may be rewarding to be involved in the care of our most sick patients in resus from start to finish but once they have been stabilised and are awaiting admission into hospital I need to ensure other patients in the department are receiving timely treatment. This conundrum of focus is not related to patient care, it impacts on administrative and academic responsibilities as well.

And this is my Achilles heel. The desire to get tasks done and always complete on time can be unhealthy. It is true that poor time management can result in difficulty in balancing your priorities. But even with effective use of Eisenhowers window it can still be difficult to say ‘no’. What might be of great importance to you in terms of another project or research idea is not good for you if you come home distracted and distant to your family.

time_management

What is the antidote to this? I think I am still working on it. I know it is easy to shrug off the comments of friends and family who often recognise the symptoms before you do. It is also true the poison acts like a virus and can lie dormant for long periods returning insidiously. A start maybe to frame the decision to do that extra ‘thing’ or to stay that bit later with the question: Is this is important to me or for me?

What have you learnt this week? #WILTW

What I learnt this week: Are you calling for help for you or your patient? #WILTW

This is the 58th #WILTW

The second of our paediatric ED simulation days took place this week. The need for simulation is well summed up by Cliff Reid (I couldn’t let #WILTW go this week without a #smaccUS reference!)

There is always as much for the faculty to learn as the candidates and this was no exception. Simulation immerses health care professionals into familiar and unfamiliar situations. As technology has improved it has becoming increasingly possible to create high fidelity scenarios where participants often forget they are dealing with a plastic dummy. Even though team based simulation should not be a formal assessment of individual skills participants know they are being observed. There is no getting away from the fact if you make mistakes you feel you are judged in front of your peers. This creates anxieties and uncertainties and not everyone relishes the opportunity to get involved.

While the simulation maybe stressful for the candidates, it is the  debrief afterwards which causes me angst. I have a great deal to learn in the art of ‘debriefing’. It is a vital skill for simulation participants to experience if they are to gain the most out of this learning experience. Knowing that you need to tease out mindsets, challenge behaviours and support those sometimes are visibly emotionally struggling is a daunting prospect. The debrief aims to highlight communication and behaviour, by individuals and groups, which may or may not have been in the patients best interest.

Simulation

What stood out at for me at this weeks event was a reminder of a particular communication conundrum teased out by a fellow faculty member at a previous session. At times of stress individuals don’t always state the obvious in their concerns for another person’s decision. For example, a doctor choosing to to give a particular medication when the nurse feels another treatment may be better. Simple queries such as, “can you explain that decision to me?” become lost in either submission to hierarchy or a perception that their confusion represents a knowledge deficit. What compounds the problem is that the original decision-maker often fails to pick up on this (even when body language and tone make it blindingly obvious to everyone else there is uncertainty!). A route of this impasse is a suggestion to call for more help i.e “if you are not getting me the answer or information I need I will ask someone else.

I don’t think this is a dynamic solely confined to doctor and nurses as it happens in grades within professions and between specialities. It is also not just a process observed in education during a medical simulation. Looking to a third party to bypass an obstructive individual or someone not understanding your concerns happens in all team settings.

In healthcare crisis situations this additional call for help does have consequences. While often beneficial, a senior intervening effectively, it can have negative consequences. The skill set of the individual(s) arriving or their insight into understanding why they have been called may mean the original concern is not addressed. Obviously in a patient in cardiac arrest the reason is clear but this is only a small proportion of the total number of medical emergencies in hospital. Failure to clarify concerns also disempowers the original decision maker who may well have been grateful for the question to solidify their own thinking.

It fascinates me that the simplest phrase, “can you explain why you are doing that?” is something that health care professionals (and patients) often struggle with.

What did you learn this week? #WILTW

What I learnt this week: Quality is not one box to tick #WILTW

This is the 57th #WILTW

I showed the following video at our Paediatric Emergency Department Senior Team meeting this week (you may need to watch directly on youtube as embedding has been disabled: link)

https://www.youtube.com/watch?v=M3bIs_Sk30k&feature=player_embedded

I was talking on the theme of quality as I’m developing a research programme to look at Quality Indicators in Children’s Emergency Care. The video is clearly of comedic, rather than clinical value, but like many health-care parodies there is always that nugget of truth which makes you feel uncomfortable. There are many ways of describing quality (a short presentation I use is here) but an often cited approach is that used by the United States Institute of Medicine: Safe, Effective, Person Centered, Timely, Effecient and Equitable care. A spin on this approach by the US institute for Healthcare improvement is:

Quality Matrix

I think most people would agree with the general domains. What is challenging is the interpretation of the some of the specifics. Kate Granger kicked off her Hello my name is tour in Leicester this week. While some may argue an introduction isn’t a sign of quality (it’s a fundamental part of basic communication!) it is a vital process. Or is it?

I was made aware this week of a situation where a health care professional hadn’t introduced themsleves clearly. However this wasn’t noticed by the patient but by their friend who happened to be a health care professional themselves. In the midst of a busy healthcare environment what was perceived to have been the biggest arbiter of quality was a definition of the problem and its solution. How often does a failed #hellomynameis get overlooked because the patient is concerned about a different aspect of care? The variation in perception of quality may explain why it is possible for a department at exactly the same time to receive both a compliment and a complaint about the care provided.

The challenge is which aspects of quality to look at? It is currently not possible, or desirable, to look at everything simultaneously. For example is the Friends & Family test alone an adequate measure of patient experience? What is for sure is that a suite of measures is needed; acknowledging quality is not a thing but a culture. Quality should never be one box to tick.

What have you learnt this week? #WILTW

What I learnt this week: Confirmation bias – the cousin of over-confidence #WILTW

This is the 56th #WILTW

During my medical training I sat in many outpatient clinics. The vast majority I don’t remember specific details about but there is one that has always stood out for me. I was in a clinic with a Professor of Paediatric Cardiology. The Professor was nearing retirement, in fact, this may have been his last ever clinic. I has been asked to listen to a child’s heart and describe what I found. I remember not really being able to either describe the heart murmur or diagnose the problem. The Professor kindly explained to the family what the sound he was hearing was and that he would send the child for a scan to confirm his diagnosis. As the parent left the room he confidently explained the key features of this heart condition and what the plan would be to treat the patient.

You see, Damian, it is not always possible to hear the fixed splitting characteristic of an Atrial Septal Defect but this child has all the other obvious presenting features

The patient returned from the echo-cardiography suite with scan findings completely different heart problem than that suspected by the Professor. He was surprised and a little perplexed. You could see a range of emotions briefly come over his face before he professionally explained to the family the next steps.

After the clinic the Professor was clearly still mulling over the patient. What was troubling him seemed to be the unexpected nature of this error. As a clinician on the edge of retirement I got the sense that his confidence had been rocked. I think the reason I remember this case so clearly amongst the hundreds of other clinic cases I have seen was his disbelief and palpable disappointment.

decision-making-processes1

16 years later I was asked to review a child with breathing difficulty. His parents were concerned about him and the junior wasn’t sure what was causing the problem. The child looked moderately unwell but on listening to his chest and reviewing the history it seemed they needed treatment with inhalers.

You see, John, it’s not always possible to hear wheeze, but if you notice he is having difficuly breathing out and the history of persistent cough despite regular antibiotics is consistent with viral wheeze

I was subsequently called into the resuscitation room but on returning found that the child had had an X-ray taken. While I had been away the child had detriorated and had started grunting. The X-ray is below:

Empyema

This took me somewhat by suprise as it isn’t the typical X-ray of a child with viral wheeze and is consistent with a severe chest infection.

Every clinical shift brings a new opportunity to learn and develop skills in medicine. Sometimes you need a reminder of biases inherent in decision making. I had fallen victim to confirmation bias 

Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive.

Constantly re-evaluating decision making is not something that should dissipate with experience. I hope I am open to the possibility of making mistakes right up to retirement.

What have you learnt this week? #WILTW

 

For medical readers the Echo-cardiogram revealed a VSD

Many thanks to the family of the child in question who were happy for me to discuss this story but I have also made some subtle alterations to the clinical events. 

What I learnt this week: Noise from stress or stress from noise? #WILTW

This is the 55th #WILTW

Most mornings I have a cycle-train-cycle journey to work. The train is generally busy, as it’s on a commuter line to London. I am constantly bemused, and sometimes irritated, by the desire of my fellow commuters to get off the train as soon as possible. It is actually quite frustrating if you are sitting by the train door to have a whole line of people ready to disembark 10 minutes before you arrive. There is some unconscious sense that you should be getting ready to get off as well. Even with my fold-up bike it takes me less than 15s to stand up and put my bag on. Why would I chose to stand up far in advance of needing to?

The ‘hurry’ of life is an ever present force and I am often victim to it sweeping me away. I suppose my train stance is one way of avoiding this. I am not so great in others. I admit to being dreadful at turning off e-mail alerts – an instant fix to unnecessary stress and interruption. I am also bad at working ‘to‘ deadlines rather than ‘for‘ them i.e if it doesn’t have to be done until that date, I won’t do it until that date. This works well unless you have mis-categorised your Eisenhower box or the task takes much longer than you think it should.

eisenhower_box(The Eisenhower box via JulienRio.com)

But the ‘hurry’ of life can also be outside your control. A nice little abstract in this months Emergency Medicine Journal describes the affect of  noise on performance. In this study from South Africa it was found that loud ambient noise didn’t affect performance but it did impact on reported stress. Your environment affects your senses and your perceptions. Generally a busy Emergency Department is a noisy one but a noisy Emergency Department isn’t necessarily a busy one. On some shifts I’ve found myself thinking: Why do I feel so stressed there are hardly an patients? It’s because noise levels increase your stress directly or remind you of previous associations between noise and stress.

Conversely a silent Emergency Department, or any place of work, feels like a controlled one. Unfortunately silence isn’t always in our control.

What have you learnt this week? #WILTW

 

 

What I learnt this week: Not everyone knows how to hold a child #WILTW

This is the 54th #WILTW

A little chap who presented with a rash this week allowed me to capture some video footage I’ve wanted to obtain for some time. In lots of paediatric consultations it’s important to look in the throat of the child. This, as most junior doctors and parents will attest to, can be challenging. The secret is more in the technique of the parents than the doctors though and for some reason this isn’t well shared. This is a shame as Paediatricians can be quite judgemental of the poor quality throat exam performed by other specialties but never explain how they managed to visualise the tonsils.

A good opportunity arose when we had a little guy who wasn’t too fussed about opening his mouth but was still realisticially fidgety! Mum also had natural experience and huge thanks to her for consenting to demonstrate this video.

The key point is that the child’s back should be parallel to the chest of the parent (to be fair in this video this hasn’t quite happened). The parent then puts one arm around the child’s chest AND both the child’s arms and the other arm around their forhead. This should be quite a comfortable position at rest but as you can imagine you do need a decent grip for the squirming toddler.

This position is basically dependant on the confidence of the parent and the knowledge of the doctor to set them up in this position. I therefore share this as it constantly suprises me how often not knowing this results in a failure to visualise the throat properly.

 

For the child who won’t open their mouth levering the tongue depressor between the almost universal cross-bite that exists between the molars towards the back of the mouth often does the job.

A few viewings and a comment “oh – that’s how you hold…” proved it’s not all common knowledge but apologies to those for whom this is bread-and-butter clinical practice.

Many thanks to David for volunteering to examine and to the family for consenting to share the film in this way.

What did you learn this week?