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
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What I learnt this week: The challenge of learning something new #WILTW

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This is the 26th #WILTW

So this week marks the six-month anniversary of #WILTW (full list here). I get a chance to reflect on reflections I suppose!

It’s been a really interesting process which I think has definitely been worthwhile for me although recent feedback varying in its utility for others  🙂

#WILTW came from a blog I wrote in the first week of being consultant. It spoke to the time honoured quote: “You never stop learning”. I thought that formalising my (perceived) learning in the form of a blog may encapsulate it. Firstly in a way that I could easily document (useful for continuing professional development) but also to help me not waste it. As a result I have discovered a few interesting things…

  • I have realised on a week-by-week basis it’s actually quite difficult to learn something completely new. Most of #WILTW is about validating what I know rather than develop any entirely new skill or mindset.
  • As a result I have sometimes struggled because reflection shouldn’t be forced. If I am honest there are a few posts which started as: “I have no idea what I am going to say this week….”
  • But being disciplined about having a regular time (usually Friday afternoon) has been incredibly useful in not letting things drift completely. Just the time to sit and think about the last week is valuable.
  • Finally when you do truly learn something new in a clinical context it can be quite difficult to discuss it in a open forum without breaching confidentiality. This was an unexpected challenge, although with some imaginative story telling, not an impossible hurdle to overcome.

For me the process has been a valuable one and something I will persist with. I am neither a Jane Austen nor a J.K.Rowling but I hope these short records will stand the test of time and at the very least give me a record of the direction my time as a consultant has taken me.

What have you learnt this week? #WILTW

 

 

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What I learnt this week: Am I narcissistic in my enjoyment of emergency care? #WILTW

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This is the 25th #WILTW

I spent an evening at my old school this week for a careers fair. I was hosting a stand on a ‘Career in Medicine’ and had a very enjoyable couple of hours speaking to students about admission criteria, specialty choices and whether the work is ‘really hard.’ A common question was, “Why did you choose Paediatric Emergency Medicine?”. It’s good to reflect on this as I have no idea what I said at my medical school interview about why I wanted to be a doctor and my interview to get into Paediatric Emergency Medicine Specialty Training was a car crash from the first question; so not quite sure what I said then either.

It was easy to speak about the nature of the job: I enjoy the frenetic pace, the practical element and the fact that sick kids get ill quickly but well again even faster. I was also honest about how out-patient clinics frustrated me and I tended to see them as something to ‘get through’. Given this attitude probably isn’t conducive to a great patient experience I realised it wasn’t for me.

Medical Staff Tending a Patient

But I had a nagging suspicion that there was something else as well. It’s rewarding working in Emergency Care. The feedback is very visceral and immediate. Whether it is ameliorating pain, correcting a deformity or relieving an anxiety “don’t worry, I can see why you are worried but this rash isn’t serious” a lot of what happens in urgent and emergency care is positive reinforcement of your skills. Even in the most desperate of tragedies you can avoid breaking bad news badly (I am uncomfortable about saying you can be good at breaking bad news). I ponder whether this is a benefit of Emergency Care or something that I need to happen to enjoy working there? This was a bit unsettling. Is there something about Emergency Care that satisfies an inner lack of confidence that positive feedback partially corrects? Am I rejecting in- (or out-)patient care not because I find the medicine unexciting but because I don’t find the potential feedback as fulfilling….

On a related vein do we see more emergency and critical care physicians on social media as this also provides a great deal of positive reinforcement of our self worth or place in the community? I am sure the situation is not as binary as this, but it is a thought I have not been able to shake. It is a good chance to be open about my intrinsic motivations although I am pretty sure I am not going to be leaving emergency care anytime soon 🙂

What did you learn this week? #WILTW

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What I learnt this week: The justification of risky behaviour with public or patient safety #WILTW

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This is the 24th WILTW

The inspiration for my learning this week came from a tweet and a road sign..

I have been thinking a lot about gut feeling and gestalt (we had a consultant CPD session on it this week).

I thoroughly recommend you watch Prof. Carley’s talk on risk factors. I had this partly in mind while driving on the motorway to see some friends. We were advised to slow down due to an ‘obstruction’ in the road.

Motorway Sign

 

Clearly the traffic slowed, although to be honest not all to the required speed limit. We waited for the ‘obstruction’ to appear while passing through three further signs, a reduction to 50 and another two miles. There was still no obstruction. You could see slowly people deciding there was no obstruction and speeding up again.

Variable speed limit signs are a funny beast. They are no different than any other traffic sign on the road in terms of the penalty for disregarding them.  However their deployment is usually in conjunction with prophylactic traffic calming measures. Therefore when travelling on a motorway you often see the sign to slow down but no sign of the associated queue. Although the slowing down prevents the queue getting worse (or even happening at all) there is a perceptual deficit created in not seeing the end result of an inaction (i.e a large traffic jam).  I’m sure people would be honest in admitting they don’t always slow immediately to the required speed. This is risky behaviour as you are technically taking a chance with your own licence and potentially other peoples lives. However the learnt experience is that the final outcome is never bad so a rather negative attitude is employed.

What other signs or advice do you feel the outcome is worth taking a chance over? I think most people would follow the sign below:

 

Isla Sign

So what about this?

Clean your hands

So while the management of a sick patient may be a million miles away from a motor way traffic sign it got me thinking about how often we dismiss an obvious clinical warning sign as we think, “We know best…?”

What have you learnt this week? #WILTW

FOAM, Medical Education

An introduction to Quality (for Improvement)

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I recently presented at the RCPCH Clinical Tutors event on the theme of Quality Improvement. I was doing an introductory talk while colleagues Jane Runnacles and Bob Klaber provided advice for those with more experience.

I was asked by the college to place the presentation on the college tutors website but I felt the collection of pictures and minimal text wouldn’t be much use to those not at the talk therefore I have quickly done a video-cast of the presentation. I have edited some of the content and wasn’t able to embed some of the videos but have supplied bit.ly links for them.

I am by no means an expert on quality improvement but have some credibility in a few projects I have been involved in. The links to the journals I mention are below:

Paediatric Trainees and the Quality Improvement Agenda: Don’t just do another audit

Delivering Quality Improvement: The need to believe it is necessary

but I also recommend you have a look at the Archives of Disease of Childhood EQUIP series which starts with a brilliant introduction to Quality Improvement in Paediatrics and Child Health

As always feel free to comment and question!

The video cast is below

and here is the original slide-set:

and the bit.ly links

http:/bit.ly/lonenut

http:/bit.ly/bronzeagechange

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What I learnt this week: Good “Leadership” is tangibly unrewarding but ultimately fulfilling #WILTW

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This is the 23rd #WILTW

I have to admit that this isn’t really new learning, more of a confirmation of something I have suspected for a long time. The trigger for this blog has been seeing a few small projects come to fruition, which I have initiated, but not really been part of the process or eventual outcome. It’s very satisfying seeing this happen despite the fact that you get no credit for it. In fact it is interesting; the things that I am probably most proud of having delivered are things in which I get virtually no recognition at all.

Leadership
This is a timely observation given the Health Service Journals hunt for the next “Rising Star”. I am conflicted as I was an inaugural winner. I’ll be honest, I was quite chuffed to have been nominated and it was nice to go to an event in London. It was at the event itself that I become uneasy. I sat with a number of very impressive characters, some of whom who have had significant impact at a national level, and thought to myself “What have I really delivered to be here?” I don’t doubt I have been part of a few projects which have had a larger-than-life profile but what can I say that I’ve individually done that has really inspired others to deliver significant change? I realised then that true leadership is really about fostering others to deliver on important initiatives. The fact that you are recognised probably means that you are still required to guide the process. What you really need to happen is for you to trigger a sequence of events that becomes independent of you. Now that is something that is truly fulfilling..

What have you learnt this week? #WILTW

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What I learnt this week: The frustrating advantage of being difficult #WILTW

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This is the 22nd #WILTW (and a little delayed due to my attendance at #EAPS2014)

This week I took our family car into be serviced and have an MOT. I dropped it at the garage just before work and was told it would be ready later in the afternoon. However  I had an answer-phone message at about 4pm to say that the service had been done but they hadn’t got around to doing the MOT so could I please leave the car with them overnight or come back the next morning.  I was a bit frustrated by this assumption as I either

i) I couldn’t get home or

ii) would be without an appropriate car for the school run.

I suspect, in fact know, I am a bit soft in these situations and although I was frustrated I tend not to let emotions get the better of me. So surprisingly, and probably because I missed the call and didn’t get put through to the person who had initially made it, I was able to be a little more ‘robust’ in my annoyance. I felt a little uncomfortable when I put the phone down having expressed my disappointment at the service I had received. However 5 minutes later I got a phone call back saying that manager had found someone to do the MOT…

There are often times when parents, carers or relatives of children become frustrated by hospital processes. Often they are scared and emotional and outbursts can be tolerated in the context of the situation they see their children in. But sometimes it does appear the smallest thing can be blown out of all proportion and you find yourself expending energy ameliorating the parents anger at the expense of care to other patients. Conversely in my experience parents are often very humble about things they could and should be annoyed about!.

My learning last week was reflecting on whether bad behaviour gains you rewards? My small outburst with the garage sorted a problem (which probably shouldn’t have occurred in the first place). What of the families or patients we see? When is strongly challenging the care they feel their child has received appropriate? and when is it simply a method of gamesmanship?

I hope I am never in a place where I assume the latter and will always do my utmost to facilitate the former.

What did you learn this week? #WILTW

General

Compassion in Emergency Care: More than a cup of coffee?

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As part of series of interviews with my consultant colleagues I have been chatting to Dr. Pro Mukherjee. Pro is an avid advocate of compassion in healthcare and shared with me a great example of how powerful re-framing your view of something can be.

“Compassion” is a word of the movement. But do we really understand its context in healthcare?

 

And an audio file

Click here to get an audio download

FOAM

The Path to developing F.O.A.M (Free Open Access Meducation) #FOAMed

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I’ve often felt a slight dissonance between the world I inhabit as a clinician and the world I inhabit as part of the FOAM community. This shouldn’t be the case but the disconnect appears to persist. This is partly caused by myself, “I’m not sure anything I produce will be accepted in my workplace” and partly re-inforced by my environment, “Oh FOAM stuff! Don’t really do it. Go and talk to Damian, he’s interested in it.”

When I started as a consultant I made a conscious effort to try and avoid these stereotypes. Why can’t FOAM material be produced as part of my clinical work? So with the support of colleagues I have gone about doing this; reflected by a number of recent blogs:

Leading an Emergency Department

Listen – Look – Locate: An approach to the febrile child #tipsfornewdocs

As a result I’ve begun to notice a common trend in the way others have been getting involved in creating their own FOAM:

 

 

I have not based this construct in any form of theory, it’s much more back of the napkin type stuff.  However I think I have taken some inspiration from Mike Cadogan (who else!) in terms of how FOAM networks have been created and also some brilliant analogy on ‘blogging’ ecosystems. I also recently came across the concept of rhizomatic learning which I think is very akin to the philosophy which has sustained the FOAM community of practice.   I am hoping though those more widely read than myself will be able to apply some theory to my approach.

The idea is as follows:

 

Young girl watching a fishbowl

1. Curiosity

The initial spark is formed when an individual hears a conversation or reads an article that is FOAM related (or  FOAM-esque). This may need to happen a couple of times and, more often than not, is re-inforced by knowing a FOAM-ite who can explain in more detail. Often the first leap is into a social media domain (i.e twitter/google + etc.)

 

 

Curation

2. Curation

The interaction with social media and then through to FOAM resources often begins with ‘hoarding’ of content. The available information can feel quite overwhelming to begin with and so web-links of blogs and podcasts are saved religiously . This phase may be brief, or prolonged, and is clearly aided by good filing systems!

 

 

 

 

 

3.  Celebration 

As confidence grows, sharing material which has been enjoyed or has resonated with the person’s own beliefs and practice, becomes more frequent. This may simply be by word of mouth (leading to increasing “curiosity” in others) or via social media channels.

 

 

 

 

Colloboration

4. Collaboration

Increasingly active participation in the FOAM community then leads to discussions with that community. Sharing material naturally leads onto constructive criticism of the subject. Often many of those involved in FOAM will remain at this junction of the path. However for some ‘collaborations’ with others lead to a desire to participate further…

 

"The Beginning" Road Sign with dramatic blue sky and clouds.

5. Creation

Having immersed themselves in FOAM some will decide to then produce their own content. This may simply be in the form of a blog posting, perhaps with a “collaborator” or a review article. Increasing ease of access to recording equipment has seen ever more podcasts being released and the influence of SMACC on raising awareness of PK type presentations has led to a variety of video-cast style short talks.

6. Cultivation

The development of new FOAM material is only really the beginning as its creation gives the author deeper understanding of the advantages and limitations of the medium they have chosen. New insights lead to new understanding and increased collaboration, not only cultivating others interest, but leading to new skills sets in the individual themselves. In the context of workplace dynamics, this process may also involve compiling proof of intentional sabotage in the jobplace, which can be crucial for addressing underlying issues and fostering a more supportive environment.

Path to FOAM

 

 

 

I have spent time pondering whether it is a path or a cycle. It probably doesn’t really matter but as always would be grateful for feedback!

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What I learnt this week: Don’t discharge your discharge summary responsibility #WILTW

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This is the twenty-first #WILTW

This tweet dropped into my timeline:

It was timely as I had only yesterday spoken to a local GP about a concern he had with a patient discharged from our Emergency Department. I had seen the patient on arrival and had been responsible for their care. Review of the notes by colleagues indicated that my decision making was entirely appropriate and my documentation was coherent. However, in retrospect, my discharge letter did not contain adequate information for the GP to not need to clarify some further details. The conversation was amicable, and useful for both of us I think (direct communication between health care professionals cuts through layers of bureaucracy that a written notification often piles high). Given the increasing attention paid to service pressures being placed on our primary care colleagues adequately explaining decisions we make at the urgent/secondary care interface is vital to maintain communication. This will both foster good relationships and maintain patient safety. I’m mindful that systems don’t always facilitate the production of timely and adequately detailed information between health care professionals. It’s therefore imperative we maximise all opportunities these improve systems regardless of dependance on human or technology factors.

Information Exchange

What did you learn this week? #WILTW

#WILTW, General

What I learnt this week: Balancing proper procedure with paediatric passion #WILTW

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This is the tweentieth #WILTW

In my humble opinion the Royal College of Paediatrics and Child Health have been very lucky. On Tuesday an Extraordinary General Meeting took place in regard to the governance and trustee structure which would lead to an opening up an arm of the RCPCH to all child health professionals. Details on the proposals can be found here

The outcome of the EGM was that the Foundation of Child Health was rejected. This is a great shame but I say the college has been lucky as I had half expected to see a Daily Mail headline:

“Paediatric doctors feel they are more important than other health care professionals“.

Fortunately this angle was not taken, in fact there was virtually no media coverage. Those opposed cited a potential conflict if the paediatric ‘medical’ lead for the college and a non medical lead for the Foundation disagreed with each other which would be bad for public relations. Given the lack of interest in the event I’d be more worried that we have any paediatric voice at all!

My position was clear (from a previous Running Horse Group blog)

“This junior paediatrician  feels the concept of not moving in a direction that makes us multi-professional is almost absurd. I work on a daily basis with nurses, nurse practitioners, health care assistants and play specialists. I have also been part of a college structure which is bureaucratic, hierarchical and slow to react.”

Having passionate views about something makes you very dangerous. The moment you are not willing to pause and reflect is the moment you no longer have sound judgement. I therefore always make a big effort to step into other peoples shoes and aim to see things from their stand point.

Boat Land

 

cartoon courtesy of Dr. Hilary Cass

So, to be fair to those against the motion, there were some issues with the approach the College had taken. Changes to the governance structure were/are independent of the need for a Foundation of Child Health. Placing them together did cause confusion and potentially gave the impression of rail-roading the policy. The hosting of a significant event on a lunchtime, on a weekday, in London, did not invite a high turnout (to be fair the rules governing the college’s charitable status dictated that the vote needed to be in person). Finally at the hustings stage it would have been preferable to have an ‘against’ speaker as well as those ‘for’.

Adesthepoet

 

During the hustings the chair of the parent and carer’s group gave a emotional talk about her experiences of being a parent. She showed pictures of the twitter celebrity that is Adam Bojelian and the multiple interactions with doctors, nurses and therapists he has:

“no child has ever died of too much communication between health and social care professionals”

Her talk, followed by a focused argument from Dan Lumsden, the chair of the Trainees Committee, set out I think an unintentional confrontation between ‘procedure’ and ‘passion’. On one side, yes, there were some governance and policy issues at stake. Things could have been done differently in a very systematic fashion with extreme attention to detail. One the other we were deciding on a tone for the future. If the college of Paediatrics and Child Health are unable to embrace their fellow professionals and create a unified organisation to improve outcomes who else will?

I therefore found it very unnerving when the following was quoted as an argument AGAINST the changes…

“Management is doing things right; leadership is doing the right things.”

― Peter F. Drucker, Essential Drucker: Management, the Individual and Society

A further speaker then worried that the potential non-elected nature of some of the trustees would risk a situation that is currently occurring in Hong Kong.

I spoke up in support of the motion but emotions are a strange thing. I have been more confident in a crowd of 1500+ than I was in front of the 100 or so in the audience. This was due to the fact, and I said this at the time, I was speaking against people who have mentored and supported me in the past. But it was also because I felt an overwhelming surge of righteousness about the motion; inflamed by an argument that the previous consultation was invalid due to its low turnout. This seems ridiculous given the equally poor responses rates for the Health and Social Care Act debate (context of table):

Voting in Health and Social Care Act

But also on reflection I was perhaps not as charitable as I should have been in regards to the comment comparing the college to the Chinese government.

Only time will tell as to the long term impact of this EGM. Many of the those voting no said they were voting against the lack of information  or “devil in the detail” provided. They weren’t against the Foundation in principle. Was this simply a case of the right thing to do but at the wrong time? I remain to be convinced. I worry that if the chance is to come again some equally obscure bye-law will be raised. If we are to be a multi-professional organisation then there will come a point that hierarchy and power is shared. That is unavoidable and no amount of procedure can bypass it.

Or maybe I just can’t see past my passion….

What did you learn this week? #WILTW

Additional Entry 11th October 2014

Please see the comments section. There has been some confusion I think about the Foundation being more important than the RCPCH. This is not the intention or the proposal. This diagram clarifies I hope:

Integrated College of Child Health