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
Innovation

Simultaneous Safety: Purposeful Physiological Detection

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The Million Pound Challenge was a new event at the International Forum of Quality and Safety in Healthcare #Quality2013. Judges included Donald M. Berwick, Fiona Moss, Helen Bevan, ‘e-patient’ Dave deBronkart and JoInge Myhre.

The challenge: Junior health care staff to pitch an idea for what they would do with One Million Pounds to transform healthcare. Four finalists were shortlisted for presentation. The video of my presentation is here:

I was very humbled to be not only shortlisted but win the award with my idea for a multi-purpose saturation probe. In  summary the technology exists to not only calculate oxygen saturations and heart rate, but also temperature and respiratory rate from the same device. These four measurements together, adjusted by an internal microcomputer for a designated age range, could be used to simply display a green, amber or red light to given an impression of the patients health. This would NOT replace clinicians judgement but would support health care professionals and potentially those without significant medical training to make decisions on patient care. The probe would be powered by a small solar panel enabling its use in the developed and the developing world.

My presentation is attached. I am not a big fan of bullet points but the general sense is there.

A picture of my mock of what the device would look like is below (click on it to expand):

Annotated Picture of Monitor

So what turned out to be a ‘back of packet’ scribbling seems to have caught peoples attention. Could this really be taken forward?

To do this I need the help of the world-wide health community.

Do you work in medical technology industry?

Do you have a friend who is expert in solar panels?

Can you program algorithms into motherboards?

Would you like to just simply help!

Please get in touch by commenting on this blog. This is a real opportunity to change the world. Don’t just believe me. Donald Berwick said so….

General

I’m in the business of medicine, but do I really want medicine to be a business?

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Today is the beginning of a new era in the NHS. For supporters of the Health and Social Care Act it represents the implementation of a necessary shift to cope with rising demand and cost:

“[6] The main aims of the Act are to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and patient voice; to give NHS providers new freedoms to improve quality of care; and to establish a provider regulator to promote economic, efficient and effective provision.” [explanatory notes for Health and Social Care Act]

For its detractors, it is popularly described as the end of the NHS and an entire political party has arisen as a result. The debate has often been extremely heated but generally confined to those already in touch with medical “politics”. Anecdotally  (I have no supporting evidence for this) wondering around the corridors of a random english hospital may not find you many staff with a clear knowledge of the details of what has happened on 1st April 2013.  It is this lack of knowledge that may explain, despite some of the vitriol, why contributions by members voting on the Royal Colleges support for and against the bill last year were not that impressive.

College Total Voting Members Number of Respondents Votes against the Bill Response Rate
RCPL [1] 25,417 8,878 6,092 (69%) 35%
RCPCH [2] 10,289 1,492 1,184 (79.36%) 14.5%
RCGP [3] 33,837 in England nearly 2,600 completed responses 90% support withdrawal of Bill 7.7%

Independents have attempted to explain the detail (this summary from fullfact.org is good). There is also a visual timeline of events via the Kings Fund.

A great many commentators have put their hats into the ring about what will happen in the future. I am neither experienced or wise enough to do this. As a trainee, albeit a relatively senior one, I have been disappointed about the level of information given to the future workforce about the changes. It is is a complex area, the Health Act is a huge piece of legislation with arguments of recent terminology on the section 75 amendment making the area even more confusing.

What is without doubt is new ability to widen opportunity for any “provider” to deliver services for patients. I don’t think I am naive about healthcare as a business. The NHS has always run to accounts, tendered and has paid private companies to deliver operations it was falling behind on. But I am old enough to remember a day when there was one National Rail Service. I don’t know if it was true that ‘nationalisation’ was not providing effecient, cost effective services but rail is now clearly a competitive business, even though the trains are often not competing for the same track. However, as a regular train traveller, I know my experiences between the companies are often very different, that even if they do run on time it is at a cost or comfort detriment and I certainly don’t know who best embodies the rail service.

I ask myself is this really how I want to see the NHS?

References

1. Results of RCP Health and Social Care Bill Survey.

http://www.rcplondon.ac.uk/press-releases/results-rcp-health-and-social-care-bill-survey (last accessed 1st April 2013)

2. RCPCH votes for Government to withdraw the Health and Social Care Bill.

http://www.rcpch.ac.uk/news/rcpch-votes-government-withdraw-health-and-social-care-bill (last accessed 1st April 2013)

3. RCGP members support withdrawal of the Bill, says RCGP survey.

http://www.rcgp.org.uk/news/2012/january/rcgp-members-support-withdrawal-of-the-bill-says-rcgp-survey.aspx (last accessed 1st April 2013)

Innovation

A number counter that works within Powerpoint

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This great little customisable presentation was put together by Craig Sayers in response to a request I had put out via twitter

(it did help he also happened to be my best man)

The presentation is need for something I am doing to feedback on NHS Change Day  but I suspect a counter mechanism may be useful for other presenters. Just to note it won’t work in Powerpoint for Mac 2008 (I’m trying to find out if it works in 2011!)

“If you want to change any of the settings you need to go into Visual Basic from within Powerpoint.  Do this either by pressing F11 or double clicking on the Start Counter button on Slide 1 when editing it (not from within the slideshow).  You should then see a text editor-type box with the code in it.  I’ve added little comments (in green) to show which numbers need changing to do different things.  Just alter a number then close the Visual Basic window.  Next time you start the slideshow it should make the alterations.”

A huge thanks to Craig Sayers for putting this together (and providing the editing instructions)

Please send any feedback to @damian_roland or @tonythepianoguy

The presentation can be found here: Powerpoint Counter

Medical Education

Consent Cam: Want? Need?….Can?

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It all started with the following tweet:

and in no time at all the enthusiasm for all things #FOAMed found ourselves with a number of volunteers, a catchy 4’D’ mnemonic courtesy of Mike Cadogan and a working title “ConsentCam”

  • Dissemination: the power of global conversation through #FOAMed
  • Discussion: it marks the starting point for a conversation which can continue on twitter and through blogs, then onto #SMAC2013 so that a global perspective can be obtained
  • Development: the seedling inclination to pursue a random thought can be magnified with altruistic assistance
  • Deployment: this may well result in a collaboration which leads to the production of an essential element for medical education provision

An neat summary can be found here – please do contribute to the ongoing discussion and upload your consent forms to the dropbox!

Just wanted to answer a few questions which have sprung up during the process which I thought might be useful to clarify.

Do we want this?

The proof of the pudding for me is the fact that as soon as you mention consent, apps and patients on social media you are guaranteed to get a reply. Not always constructive I may add but the debate is there. Health care professionals want to be able to share key learning points with others and audio-visual media represents a great way of doing this. If you can find me a clinician who wouldn’t want a quick way of taking a picture and obtaining patient consent with regulatory approval then I will pledge to dance the funky chicken on a live you-tube feed on #nhschangeday

Do we need this?

Using audio-visual media to enhance medical education has been happening since even before we had VHS (thats a long time for those who have never actually seen a video cassette). Discussion fora, blogs and publications abound on the use of photos to highlight key clinical signs (although probably need to be clear that the evidence of clear benefit of video does still need demonstrating!). Is it an absolute necessity that a simpler way of simultaneously consenting and taking pictures is found – probably not. Would it transform resources such as gmep.org very much so.

Can we do this?

The appetite for #FOAMed extends to peoples own time and resources. The increasing use of hack days to create bespoke health care devices and an appetite for app development at a government level means the market is awash with individuals willing to give for free their skills to make ConsentCam a possibility

Are we allowed to do this?

This is probably the only significant issue so far. As long as patient confidentiality is not breached or impinged and the data is secure it should be possible to gain approval. There will be initial caution, and potentially some critics, but the very production of guidance on audiovisual records and social media by regulators such as the GMC means engagement is more likely to happen now than ever before.

So -please do comment on the life in the fastline blog and lets make the first #FOAMed inspired, designed, produced and utilised app a reality

Medical Education, Social Media

Was Clare Balding right? (and was it relevant I was slightly wrong)

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One of the great things about blogging is the permanency of your thoughts. Ideas and thoughts developed on a train journey are often lost forever but if you can encapsulate them in writing they are always available for ongoing reflection. Comments on your work are a functional way for this reflection to be forced upon you but I’d be interested to know how many other bloggers review their material, amend, maybe even comment their now changed views?

With this in mind a while back I posted on the Network site (@thenetwork001) a brief piece on an event that occurred during the Olympics “Was Clare Balding right? Adequacy versus Aspiration”. For those outside the UK Clare is a well respected BBC journalist and presenter. It’s short enough to share below:

“During the Olympics Clare Balding apologised to the nation, “I am sorry we can only offer you a bronze.” her words after Rebecca Adlington’s performance. There was an instant twitter and email response with a prompt, and sincere, apology. In a different event, but with a similar theme, a number of commentators during the games made reference to counterfactual thinking on how actually getting a bronze maybe better than a silver.

The post-Darzi drive for Quality remains a powerful influence in commissioning, service delivery and outcome metrics. Appreciating quality has rarely been defined in terms of Gold, Silver, Bronze and ‘placed’ an exploration of delivery of healthcare find being ‘placed’ a common place event. Take, for example, Medical Education; those despairing at the acquisition of a host of work-place based assessments find the target to achieve a fixed number at a minimum standard. Achieving a gold standard performance is not really an option. How about a service delivery standard? The four hour wait is one part of the Emergency Medicine clinical quality indicators along with unplanned re-attendance and left without being seen amongst others. Trusts stagger towards achieving each of the minimum required standards but it would be more than possible to cluster performance across indicators to enable ‘medals’ to be awarded for going the extra mile. 

How do you rate your own performance? – are you happy that the patient was treated efficiently or effectively? Perhaps just treated? Do you check that your contribution to their care was as evidence based as possible? Do you hope that a percentage of patients thank you specifically for your role in their care. 

Ultimately, as unsustainable as it may feel, are you happy with your bronze performance…”

Reading back now, not sure I would change much, but I did get an e-mail from my educational supervisor (a line manager in a medical training sense) saying it was important I got my facts right. My immediate reaction was concern that I had mis-quoted Clare Balding! However, this was not the case – I had used the term “wait” instead of ‘target”. This may not appear to be a significant error to the casual reader but it is an important principle. The NHS four hour target is well known throughout the world. It is not a ‘wait’ though, the “target” is that the patient spends no more than 4 hours in the department from the moment they register (which includes the consultation, investigations and decision to either discharge or move to a ward). For some in the Emergency Department world the distinction is really important both for public perception and the fact the target is dependant on a number of factors outside of the control of the Emergency Department.

Ultimately this is a really minor point. However lets say I had said something very  incorrect – does this really matter? I have never had a comment on a blog from a member of my own institution, and one involved in my training. What questions does this raise about blogging (and wider social media) as a means of assessment or professionalism. Obviously stripping naked on a night out isn’t an ideal thing for a line manager to see, but what degree of error is needed in a quasi-professional social media to attract the attention of an educational supervisor? As Social Media closes the boundaries between work and home-life these questions are likely to continue to be asked.

Innovation, Medical Education

Presentation to TASME (Leicester) 19th January 2013

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I was due to given a talk to the Trainee section of ASME (TASME) on the 19th January 2013. Unfortunately the event was cancelled due to the weather  conditions. I therefore recorded a practice run through (or at least a portion of it).

It is a bit rough and ready and maybe missing an introduction about the aims (which were to talk about my experience of research, leadership and entrepreneurship).  I will probably update it at a later date and the presentation at this stage is just about the research element.

Hope it gives you at least food for thought and I have certainly learnt a great deal about narrating over powerpoint presentations! The lack of interactivity or audio-visual cues from the audience was quite disconcerting! Also on play back its amazing to hear how many unnecessary words I use so a learning experience all round….

A related resource is a storify of a question I had asked on Twitter prior to the event – click here

Medical Education, Social Media

Peer Review – Pointless, Perfunctionary or Practical?

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The twitter heaven gates opened today, although they have been building for some time, with postings around the following blog noted in the tweet below

There has been mixed response to this – some quite clear

Some more contemplative

and some amazingly not related in any way shape or form to the #FOAMed discussion but yet highly relevant!

The term scholarship has been used a lot. How do educators prove to institutions that they have been undertaking ‘scholarly’ activity by producing FOAM materials? What is scholarship? Well there are a few key papers

1. Fincher and Work (2006) Perspectives on the scholarship of teaching

2. Boyer (1990) Scholarship Reconsidered

3. McGaghie (2010) Scholarship, Publications and Career Advancement in Health Professions Education (AMEE Guide 43)

(1 and 2 don’t have a pay wall!) But I am struggling to find a definition I really like. Adrian Stanley at the University of Leicester has talked about

“Scholarship is the body of principles and practices used by scholars to make their claims about the world as valid and trustworthy as possible”

The key issue is the quoted need  (paper 1 above) to have peer review as a fail safe to ensure that standards are up held and maintained. Three issues arise for #FOAMed

i. Time

The beauty of anything #FOAMed is that it exists in the realtime of its creator. When it is ready it goes online. There is no delay. Peer review by the very nature of its objectivity requires a period of reflection which delays the product getting to the people who want to see it.

ii. Standards

Peer review is typically based on ‘peers’ judging your work against some implicit or explicit standards and then having those cross-referenced against a third party editor. These standards may vary between journals, grant reviewers or regulators but there is some criteria none-the-less. #FOAMed is  by definition what the user makes of it. If they like it they go back or spread the word and if they don’t, they don’t (and if they really don’t like it then they may tell people they don’t!). But the burden of ‘peer judgement’  is spread across many peers in what some might describe as crowd sourcing. However the open access nature of FOAMed allows anyone to have there say in a fashion that is easily counted via hits, tweets and likes.

iii. Relevance to a new age

When scholarship began the internet didn’t exist. Who would have thought 100 years ago that a musician may have more followers than an entire country (Lady Ga-Ga), who would have predicted that entire university courses may be taught without you physically being in a lecture (Distance Education at Harvard) and who would have believed that a academic conference in Australia may be accessible to anyone in the world (#SMACC2013)

So if I am an institutional director and I want to promote scholarship in my staff. Do I proceed with a system which takes time, may not be accessible to anyone outside my institution, the published beneficial outcomes only read by a small minority and in which there is no social media presence at all?  If educational resources are of poor quality – how do I know?

Or do I promote my staff producing resources which are instantly available to all, may have hits of 1000s and, if popular, are discussed across a spectrum of discussion sites. If they are of poor quality they will not get used.

Academics will continue to discuss peer-review into the next decade

IF #FOAMed is good enough it simply won’t matter

General

Why do you do what you do?

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This blog actually appeared in its first form on the The-Network Blog site (well worth joining this free initiative if you are interested in quality improvement and health system leadership and management – there are 2000+ other members!). Its posting here was prompted by the following tweet

So writing back in July 2012…..

At the end of last week I attended the International Conference on Emergency Medicine (#icem2012) in Dublin. Like many conferences the benefits of attending (meeting friends and networking) outweighed the costs (exorbitant registration and travel) but resulted in very little practical knowledge gain.

One lecture particularly stuck in my mind and has re-shaped my enthusiasm for medicine. The speaker, from America, was introduced as a giant in the field of Emergency Medicine and an expert in paediatric emergency care. He was speaking on the topic of “Neonatal Emergencies”. About half way he started talking about a 5 day old presenting to the Emergency Department with Jaundice. His slide set finished with the comment – “stopping breast feeding can be used to confirm the diagnosis of Breast Milk Jaundice”. I have rarely been so angry in my entire life. This is not far off saying “to confirm that people get dehydrated don’t let them drink”. Breast milk jaundice is a physiological process which does not need confirming (other causes of jaundice need excluding if you are unable to do this clinically).

In the middle of the lecture I started waving my hand frantically in the air and stopped when I realised people were looking at me strangely (although this is not the first and last time that will happen). I was the first to put my hand up for questions at the end of the talk and politely asked if I had misheard the speaker in their assertion that stopping a normal process to confirm a diagnosis of no practical relevance was a useful medical intervention. The reply included a denial of being in the pay of a formula manufacturer (something I hadn’t been concerned about but now was) and the fact practices varied so discussion with the family should always take place. I remain perplexed that even in America this could be deemed a suitable practice and was relatively reassured by the number of delegates who came up to my afterwards to agree with my concern. I was also equally horrified that a number of non-paediatric emergency physicians were dutifully scribbling down every word.

Recently I have taken on a little too much and my enthusiasm for the clinical side of my work has waned. I have been reflecting on what matters most to me and which direction I should be taking. Clinical credibility has now firmly been planted back into my life plans and I never wish to become so distant from actual clinical practice that I lose sight of fundamental principles.

I am sure I said at some point in my Medical School interview I came into medicine to help people but this also includes helping my colleagues understand bad practice. On reflection this is what I do with my research, representative and leadership roles and is actually what really drives me forward.

Why do you do what you do?

Social Media

Hijacking Hierarchies: A potential and a peril of social media

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Do you remember a time before facebook? There must have been an internet, and there were probably even blogs, but being popular meant a lot people would turn up for drinks at your birthday party. Since social media has taken off there has been an insidious introduction of more formal popularity measures. You have friends on facebook, hits on wordpress, followers on twitter – all potentially irrelevant information but a constant objective ‘measure’ non-the-less. I have mulled over this as on christmas eve a twitter posting (which frustratingly I forgot to favourite) stated the best leaders would concentrate on their families, not new followers, over the holiday period. I am not sure how many people actually look for followers on twitter (apart from the really annoying spam you receive) but the most popular tweeters (in terms of followers) are often clearly not concerned about ensuring wide appeal from their tweeting. However their does seem to be an increasing obsession with measuring popularity on social media. A number of social media ‘personality’ awards now exist. What purpose do these serve? Do those on twitter or facebook actually need reminding who they are all following? They certainly don’t affect those outside social media as they aren’t even on it. A ‘mercury music prize’ equivalent might be more reasonable with up and coming tweeters celebrated . Ultimately though however popular the Mercury might be if you don’t listen to music it probably doesn’t mean much to you! More formal measures of popularity exist (klout and others),  there is some science (seeking influence) and I have always liked [log(number of tweets)*(followers/following)]. So far major healthcare organisations have resisted this ceremony but might we one day see a British Medical Journal #SoMe award…

So is there any reason to continue supporting such narcissism? Can we see a day when gongs may be won on the basis of influence via social media. Well there might be one. If there is one great advantage to the explosion of SoME is the complete breakdown of hierarchy and flattening of communication channels. Who could have thought 5 years ago you could contact directly the chairs of the Royal College of General Practitioners (@clarercgp) , the president of the royal college of paediatrics and child health (@rcpch_president) or the chief executive of NHS Employers (@NHSE_dean) . Just follow their twitter lines to see examples of trainees and colleagues posing questions directly and getting responses. In the short term the promotion of individuals who use twitter (and other tools effectively) may draw attention to this brilliant engagement opportunity. In fact if objective measures of influence, rather than popularity, can be found it may promote greater involvement of organisations who have up to this point resisted dipping their toes in the water.

Ultimately popularity, whether relevant or not, will always be measured. It is now up to those on social media to decided on what the most constructive use of this is.

Innovation

Am I productive? A triad of system barriers

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A recent twitter posting prompted a discussion which took on a number of directions

The resulting discussion can be found here. The concept of productivity caused me reflection during and after the twitter chat; in particular on the theme of individual performance.

Obviously in the big scheme of things the number of patients I see on any given shift has absolutely no bearing on the overall productivity of the NHS. But is my own work rate or output in any way correlated? And more importantly are the metrics themselves even comparable?

What is productivity? Wikipedia describes it as thus:

Productivity is a measure of the efficiency of production. Productivity is a ratio of production output to what is required to produce it (inputs). The measure of productivity is defined as a total output per one unit of a total input.

Is this in anyway meaningful for the health sector? The Kings Fund (@thekingsfund) give a range of possibilities but I am still left asking: Am I productive?

I think back to my last weekend shift. I work in a busy Paediatric Emergency Department which links to a tertiary children’s hospital. I think of myself as having been productive if I see x number of patients (for me x is 20 but I am not sure the number is transferrable as a comparison measure). Although the actual case-mix is very variable virtually every weekend contains a number of specific events/presentations which has a large bearing on my self-productive rating (and sense of achievement by the end of the shift).

  • The state of the department prior to my arrival. A weekend shift runs from 12pm-10pm and there is a back log of reviews to clear (I am a relatively senior registrar) even before I can see new patients. Any productivity I bring in respect of patient decisions or interventions is not additional benefit it is based on prior inputs (or patient presentations in a health care sense) to my arrival. Is it efficient to potentially reduce my de novo productivity at the outset of my shift? 
  • The number of emergency cases (defined as patients requiring immediate, potentially life saving, intervention). A prolonged resuscitation requires multiple resources and, regardless of the efficiency of the team, drains time from seeing other patients.
  • The number of complex non-emergency dischargeable (CoNED) cases (bear with me on this…). Appreciating the subjective nature of ‘complex’ these are cases which do not immediately  fit a pattern which an experienced health care professional would recognise.  I suppose it is self evident that lots of complex cases will require more time and therefore less patient turnover per clinician. However in an emergency department once it is clear a patient needs to be admitted you become less productive if you spend effort utilising resources that could be done by the inpatient team. Conversely from a patient perspective there are some investigations or managements if commenced early save time later in the patient journey. So there is a balance between ‘fast tracking’ and the overall length of stay. Additionally you must also have insight that this is a complex case; often reviews on patients on behalf of juniors reveal patients who were thought not be complex but in fact are (and vice-versa!). Ultimately the ability to manage a complex case requiring admission is a skill which improves with experience and I am not sure affects my overall productivity . However if a complex patient does not need to be in hospital this may be particular time leeching. From a 4 hour target perspective (see @drmarknewbold‘s brilliant blog on this) it may well be easier to admit but this is not always in the patients best interest. The number of CoNEDs is in part a function of the success of modern medicine and the ability of health services to provide effective and prompt follow-up.

I am very happy to concede that the number of patients seen is not a brilliant metric for productivity and that emergency medicine is only a small part of the NHS workload. I believe, the triad of, the current capacity of system, the number of serious cases and the number of complex cases not requiring referral to another provider is an important factor in determining productivity. The solution therefore may not depend on the individual. That will certainly not stop me working very hard to get x as high as it safely can be.