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
This tweet came out of a meeting of the Q community.
The pre-mortem is a psychological approach popularised by Gary Klein and embraced by the business community as a methodology to avoid project management failures. Essentially it demands you imagine why your improvement or business plan has utterly failed and consider the events that might have led to its demise, such as overlooking critical factors like indonesia eor implementation or underestimating local regulations. You can then aim to ensure these don’t occur. There is nothing clever about this technique and it’s a wonder so many people end up learning through hindsight rather than this approach.
I’d not heard of it before but it was a welcome validation of a process I use on a regular basis.
It is indeed morbid. It is important to remember that Emergency Medicine is not black and white. Illnesses fluctuate and children I discharge may become more unwell and develop disease processes which were only in the early stages of evolution when I saw them. The key role I must perform is to ensure I’m making decisions based on the best available information & evidence and justify them. The “Brought Back Dead Test” forces me to re-read my notes to ensure my decisions makes sense.
On reflection there is another pre-mortem technique I use. It is at the early stages of managing a critically unwell child. Fortunately most practice in the resuscitation room is relatively perfunctory i.e. there is a standard way of doing things and your intervention as a consultant is to deliver these as efficiently and effectively as possible. In fact the major issues with delivering consistently high quality care tend to be with team work and interactions between staff rather than the severity of illness of the patients.
With experience you build an increasing “curve ball” library. This is a repository of situations in which there are difficult to predict system failures, human factor errors or an unexpected cause to an illness. It allows you to have a quick run though of a number of “ok, what if this happens?” scenarios and refresh your memory of the particular solution. It’s about thinking – in children I’ve seen like this before who have had a bad outcome, why was that and how can I try and prevent it?
A pre-mortem to prevent a post-mortem. An uncomfortable but important process…
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This does not last long.
Time management is a skill and an art. Some are better at it than others. However anyone who claims not to have some time management problems aren’t busy enough.
I have a sinusoidal pattern of time pressure. This fluctuates from being on top of e-mails, ahead of deadlines and having spare capacity to being in a nadir of behind on just about everything and needing to persistently sprint to keep up. Things reach a head when every meeting becomes a heart sink moment as you know you have a thousand other things to be done. And then just at the point I tend to get on top of things, and claim I’ll never let this happen again, the pattern seems to repeat with a metronomic frequency.
I was prompted to question my very involvement in a meeting this week as I realised despite being physically present; I mentally wasn’t. In writing this blog I thought I’d been unique in coining the term ‘meeting mindset.’ It appears this is not a new phenomena.
Via Time Management Ninja https://timemanagementninja.com/2011/02/can-i-work-during-your-meeting/
Vacationer (using the meeting to get out of what they should be doing)
Hostage (doesn’t want to be there)
Expert (feels they will learn nothing new)
and Explorer (keen to solve a new challenge)
I relate to the first three on a far too frequent a basis. But whose fault is that? Your mindset before entering a meeting must have a huge impact on your participation in it. I suspect just checking your own state of mind in the preceding couple of minutes may be beneficial. It is not going to make you any less busy but it might stop the meeting being an utter waste of time.
What did you learn this week? #WILTW
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“Paediatricians often think of themselves as clinicians who are always willing to go that extra mile for their patients and that no child will receive less than the best care on offer. Unfortunately, looking at the wider healthcare system, evidence does not bear this out, in terms of overall mortality rates, variance in care and patient experience….[1]”
Prof. Mary Dixon-Woods and Prof. Graham Martin published an article this week entitled “Does Quality Improvement improve Quality“. It is a sobering read and explores the mis-conceptions and mistakes made with the deployment of ‘Quality Improvement‘ techniques in clinical environments. It certainly puts into perspective a passionate, but well meaning piece, I wrote with a colleague Bob Klaber 3 years ago “Quality Improvement: The need to believe it is necessary”
“….It may well be that the term ‘quality improvement’ is misunderstood or mistrusted. The concept of evidence-based medicine (EBM) took years to be accepted by the medical profession and it seems likely QI may suffer from similar resistance.”
Dixon-Woods and Martin aren’t belittling Quality Improvement’s ability to reverse some of the endemic problems in health systems but pointing out the poor use of methodologies and inadequate reporting of outcomes. The quote that particularly stands out:
“The NHS continually loses learning, and this is an urgent problem [2]”
They suggest four ways to improve Quality in Quality Improvement
My interpretation of these suggestions:
i) It is too easy to act in isolation and “allow a thousand flowers of QI interventions to bloom [2]” rather than deliver improvements across ‘sectors’ in a standardised and methodologically robust fashion.
ii) Too often an initiative with some appealing face validity will be picked up and rolled out without any understanding of the environment it was originally developed in. An intervention may work because of the ethos of the institution it is practiced in not necessarily because of the intervention itself.
iii) Too little time, and resource, is spent understanding the (ii). Monies are directed towards providing quick fixes rather than detailed evaluations involving different specialties and disciplines.
iv) A model has evolved, particularly in education, that rewards involvement in ‘micro’-QI projects delivered over short time periods. Larger programmes, which by their very nature are more likely to fail but provide better learning, are not seen as beneficial for or by trainees.
The challenge is that significant senior leadership will be needed to make these changes happen. What of the healthcare professional wanting to make a difference now? How do we maintain enthusiasm and passion in an increasingly disillusioned workforce when a more organised, and therefore potentially more bureaucratic, improvement strategy may be needed. Healthcare training, particular in medicine, is increasingly dependant on the micro-QI project to develop creativity and provide team work and leadership skills. We may still need a thousand flowers of QI interventions to provide these insights even if they don’t provide improvement.
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[1] Klaber R and Roland D. Delivering quality improvement: the need to believe it is necessary. Arch Dis Child 2014;99:175-179
[2] Dixon-Woods M and Martin G. Does quality improvement improve quality? Future Hospital Journal 2016 doi: 10.7861/futurehosp.3-3-191
The person in front of you pulls, instead of pushes, the door they are trying to get though. How long do you leave them trying to heave open something that just needs a gentle nudge forward? Probably not long and it wouldn’t bother many people (even if they are British) to intervene and witness their awkward embarrassment.
But what if you are at the resuscitation of a seriously unwell child? The mechanistics of hospital staffing with many different specialties mean you may not know all the people around the bed.
This can raise problems if someone does something out of keeping with normal practice or hasn’t noticed that the child’s condition has changed. This may mean what they are currently doing might be making things worse. Although it may be assumed any health care professional would intervene, sadly, time an again, hierachies in medicine conspire against this (please click here if video doesn’t play)
A mechanism I was reviewing this week is the ‘CUSS’ method. CUSS stands for Concern, Uncomfortable, unSafe, Stop (there are slightly different versions out there). The aim of CUSS is to give any individual an approach to becoming more assertive. The standardisation of this approach has two benefits.
i) It is empowering to the individual using it
ii) It might prompt the recipient to become an aware that the tool is being used on them. Ideally this may trigger them to reflect on their own practice.
So if you are ever in a high stakes situation and someone is going in the wrong direction maybe a chance for a good CUSS.
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Details on CUSS and other situational awareness tools are available from the RCPCH Safe Programme.
In the last 100m of the final race of the World Triathlon series Alastair Brownlee gave up his own position to help his brother Jonny complete the race
Alastair acted on instinct. He doesn’t look around to see if anyone is catching him, he doesn’t pause and think, he just supports his brother and walks him across the line. The reaction of some was to declare Alastair’s actions outwith the spirit of sport, ‘competitors shouldn’t help each other‘, but what would the reaction have been if Alastair had carried on to leave his brother to collapse to the floor?
Alastair said it was a natural human reaction to help his brother (although he did add he “… wished the flipping’ idiot had paced it right and crossed the finish line first..” )
Even with a number of different options available to you, acting on instinct is relatively easy if the outcomes of your actions can be easily ranked. Alastair’s love for his brother outweighing his desire to win the race.
What if your instinct to do something is challenged because undertaking it may have adverse consequences. This may seem like a ridiculous scenario but it is not uncommon in busy Emergency Departments, or other areas, managing unwell and sometimes critically unwell patients. As we approach winter in the United Kingdom we will be faced with increasing volumes of children, generally with respiratory disease, who become ill extremely quickly. At any given time you could be managing a baby, a toddler and a teenager all with signs and symptoms requiring experienced input and intensive treatments.
…and then another patient can arrive looking blue, fatigued and close to collapse. The instinct to run to them and help impossible to ignore. And receive care this patient must – primum non nocere. But doctors and nurses in charge of clinical areas have additional responsibilities. Not all resources can be directed at one patient. The most appropriate staff, with the most appropriate skills, must be re-directed to the most appropriate patients. Continually robbing Peter to pay Paul as more and more patients arrive over the course of an evening steadily increases cognitive load and stress on those running the department.
If the newly arrived patient is unwell, but not critically so, this creates the greatest instinct versus ‘other action’ challenge. There are no correct answers to maintaining the right balance between being appropriately involved a few patients care and ensuring situational awareness for all patients. Time spent evaluating extent of illness and redeploying resources appropriately takes senior staff away from managing and treating patients directly. Healthcare systems appreciate and plan for this; overall leadership of a department one of the core skills of an Emergency Department Consultant.
I wish though, like Alastair Brownlee, acting on instinct had no real consequence, but I am also very glad that this instinct exists and I hope it always will.
What did you learn this week? #WILTW
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“I am pretty sure it is impossible to change the world alone. You may be innovative, provocative, and inspirational. But even our greatest leaders will cite key influencers to their success”
Hello – My name is Damian. I am a paediatrician. I am also a father and when my second daughter was 8 weeks old she was admitted to hospital with suspected meningitis. I saw the best that healthcare has to offer patients and their families during that worrying time. Compassion, dedication and great skill. To the colleague who expertly performed procedures on Bella’s delicate veins I will always be grateful.
But I also saw the worst of healthcare. A failure of senior staff to introduce themselves, the neglect of staff not washing their hands and the public display of hierarchy for the benefit of an individual needing to assert their authority.
There are many things I wish I could change about Bella’s stay in hospital. What would you change in healthcare? If you are a patient what frustrates you most? As a health care professional, how would you like your service to be run? Sadly change can become somewhat of a dirty word.
Max Davie, a paediatrician, once said to me, “we are fed up of change, but not of improvement”
There are many things we can improve with robust research and the scientific method. The dose of chemotherapy, the type of surgery or the treatment of infections with new generation of antibiotics. But what of personal change, system change, cultural change? For these we need movements.
Social Movements are collective actions by large, but sometimes informal, groups of individuals or organisations to carry out, resist, or undo a social change. When we think about resources for change we tend to think about economic resources (budgets, technology, individuals etc). These resources are limited and finite whereas social movements can release resources in the form of social capital which is vital in environments where monetary intervention is not possible.
Within healthcare there are many shared values, both for patients and professionals, so achieving common goals through a movement has an obvious appeal. For example, the Institute for Health Care Improvement’s (IHI) “5 million lives” campaign aimed to reduce medical harm in American hospitals. The movement generated considerable publicity and the IHI claimed they surpassed their target.
Social Movements are not a new idea. They have been occurring for centuries. However in the last decade there has been a seismic change though the accessibility and reach of social media.
Social media is increasingly seen as credible and accepted medium by which to disseminate information, decrease the knowledge translation gap and allow professional and patient engagement in a meaningful way. It has hugely increased the momentum and motivation behind social movements. I’d like to discuss some social media derived movements I have been involved in, or aware of, and share some learning.
NHS Change Day was about harnessing the power of collective action. It was a grass roots frontline movement for improvement in health and care and 98% of the activity was undertaken by volunteers. It asked for a simple action. To pledge to perform a healthcare intervention on a single day (March 13th 2013). It became single biggest day of collective action for improvement in the history of the NHS with 189000 pledges made. Change Day has been replicated across the world and is now in its 4th year.
Change day started with a tweet that enable a first conversation between junior doctors and an improvement leader. From that first conversation a timeline can be drawn that resulted in a national event that impacted on the lives of patients.
Change day taught me about the power of stories. My pledge in the first year to try some of the medications that I prescribe to children. One, an antibiotic, was absolutely vile. It was truly disgusting. It made me realise that this wasn’t something you could give to parents and expect them to religiously give to their child. I realised you need to provide clear guidance on how to hide the taste and encourage adherence.
Importantly the process created a story of my experiences. The staff in my department know about my pledge. They have seen the video of the odd contortions my face made when I tried to swallow it. The narrative a powerful back drop in promoting change in others.
This year Kate Granger, a doctor, passed away having been diagnosed with a rare form of cancer. She was responsible for #hellomynameis. A social movement that clearly begins with her encapsulation of how frustrating it is when health care staff don’t introduce themselves. Her campaign started on twitter and with now 1300 million impressions continues to spread throughout the world. A powerful personal narrative with meaning for others.
Free Open Access Medical Education (FOAM) is an international movement that has brought together people from many backgrounds and specialties. It describes the production of educational materials in a variety of forms that are openly accessible. The concept of FOAM started in a pub (much like all great innovations!). Mike Cadogan coining the term during an international emergency medicine conference. It has come to represent a focus point for critical care and emergency medicine communities in particular. The term encompassing not just the materials produced but the bringing together of enthusiasts who design and digest them. It has developed into a true digital community of practice as demonstrated by examination of the hashtag #FOAMed. FOAM, along with patient derived digital communities such as #chroniclife, are social movements almost entirely derived within social media yet have all the attributes of a community of practice with the potential benefits they confer on professional and patient outcomes.
We are now at the beginning of a new approach to social movements. One in which anyone: pubic, patient or professional can contribute to the challenge that is change.
A very public social movement can inspire others to feel passionate about what they are doing. To do this we must:
Learn to tell and share stories, always keeping in mind the event(s) that prompted the initial story
Let these stories build communities
I am sure it is impossible to change the world alone. But with others we can achieve great things. The 21st century social media enhanced social movement will continue to teach us about connectivity and community. I for one am very glad to be part of it.
Huge thanks to Helen Bevan, Jackie Lynton, Daniel Cabrera, Jesse Spur, Chris Nickson, Mike Cadogan and many others who have impacted on my thinking in some way.
This is a shortened version of my presentation at #MedX 2016
I am currently in San Francisco at #MedX. The conference looks at new technologies and innovations, keeping the concepts grounded in good design and patient applicability. The team have developed a process called Everyone Included™ which aims to ensure ‘expertise’ is defined by what people can contribute rather than a strict notional concept of what they know. It aims to ensure that all potential participants have been considered. Below is some of the criteria that are required for the highest level of integration.
Medical conferences in the United Kingdom don’t have a strong track record of patient involvement. To be blunt there remains a strong paternalistic attitude that there is little patients would contribute to medical debate. Some of this is based on the correct notion that an academic conference is not a suitable venue for individuals to be seeking resolution of a complaint. Sadly there have been occasions where the boundary between patients telling stories to aid learning and to vent their grief have become blurred. This is neither fair on the delegates or the patient. However these are rare, and are over played as a reason to not allow patients to contribute.
At the first day of the conference Michael Seres spoke eloquently on patients and their role in research (click on this link to play)
and Lucy Kalanithi spoke movingly on the concept of suffering (click here for the video)
There will be some who will say the ‘expert’ patient is not representative of the general population. There will be those who feel that certain conversations would be restrained. And there will be those who cite tokenism. But we don’t really know what the outcomes will be because we have yet to start trying. #MedX has proved it is possible to integrate what should be a unified population of patients and providers. It is up to other conferences to start following suit.
What have you learnt this week? #WILTW
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The concept of collective competence came under my radar this week (click here if the video by Dr. Lorelei Lingard doesn’t play)
While the slide below probably dumbs down the theory it is a very good introduction to the concept (and is used by Dr. Lorelie Lingard herself):
Picture via Lorelei Lingard (collective competence)Competence is an education buzzword which goes in and out of vogue. It is almost always used in respect of the individual, a mindset that Dr. Lingard is trying to change. Consider the child with a severe head injury, non-withstanding the need to have recognised they are seriously unwell, a number of individuals need skill sets (competencies) to ensure the child gets the best possible care. Observations need to be recorded reliably, medications need to be given precisely, intubation needs to occur safety and leadership of the team needs to occur robustly. Not all of these things are performed by an individual; so the outcome of the child is dependant on the collective competence of the professionals in attendance.
Being a big fan of the conscious competency model (or more precisely 2×2 matrices generally) I couldn’t help thinking there are insights needed to ensure the group as a whole doesn’t go off track.
Groupthink, the plague of many teams, committees and organisations perhaps a consequence of collective incompetency? Are you as an individual aware of the mistakes your group might be making?
What have you learnt this week? #WILTW
For some further thoughts by Dr. Lingard please click here
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I did a double take on an e-mail I received this week. It was from a sales agent who had been chasing up confirmation of a booking I’d cancelled due to a change of plans.
“Ok shame but thanks for letting know.
Noticing your email signature….keep up the valuable good work!”
The cynical might suggest this was good business practice. Saying something positive to the customer in the hope of future sales. If this was the case – fair play – but I’ve never had this happen before and I’m hoping it was genuinely felt.
Doctors often rank as the most trusted of the professions.
This holds true in many other countries, although it is of note a similar survey in Australia ranked nurses top (92% – unchanged from 2015 and the 22nd year in a row they have come first)
Does this support matter? It is topical as the recent announcement of further strikes by Junior Doctors in the UK is likely to push public support to the limit. It is a challenging debate – one in which truths are hard to come by. Ultimately the junior doctors are taking on a wider challenge – what can, and should be, delivered by the NHS? This is as much a question of political ideology as it is one of economics. The Junior Doctors the first victims of a desire to provide a greater spread of services in the same cost envelope. Others will follow and in some case already have (although to much less fanfare). Sadly for the junior doctors their services are in between the government and the patient. They will be seen as arbiter of the disruption that is caused. They are in a trap. It will be Junior Doctors that the media will see as the problem. However eloquent their arguments the narrative can always be brought back to their withdrawal of work.
It may well be remembered the medical profession let the juniors down. Long term flat growth in the NHS is not sustainable and the system will fail. This is the unified argument that needs to be moved forward by professionals to the politicians. The doctor’s strike perhaps a welcome distraction for the government.
But what of the public and the patients who need the NHS? What argument should they make? This open letter from a group of patients to both Jeremy Hunt and British Medical Association may provide the answer:
“If this dispute is strictly about pay, then fine. The two of you should be able to sort it. But if it is about pay AND conditions, then it is about patient safety. And if this is about patient safety (and both sides say it is), then enough is enough—patients need to have a say.”
The medical profession has been blessed with strong public support for a considerable period of time. If we think it matters what the public think of us then perhaps considering how they can be practically involved in aiding this dispute would be a good way of repaying the respect.
What have you learnt this week? #WILTW
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“Hospital Doctors miss signs of illness because of chronic staff shortages”
This headline played across news outlets and social media this week. Based on the results from a doctors survey it encapsulated the pressure currently felt by many health care professionals. Politics aside there remains increasing demand for services with a relative fixed amount of staff to deal with it. Additional challenges were revealed by the extent of General Medical Council training concerns at over 70 hospitals in the United Kingdom.
Regardless of the underlying reasons; patients expect not to have signs of illness missed which in retrospect should have been detected. This is not saying all diagnoses should be be correct or timely. Some conditions are difficult to detect in their early stages and some require extensive work up to define the extent of illness. However even with an increasingly litigious society a large amount of NHS funding is expending settling complaints which could have been avoided had appropriate initial interventions occurred. Why does this happen? Why do healthcare professionals miss seemingly obvious signs and symptoms? Obviously the reasons are multi-factorial. External pressures as noted in the doctor’s survey will play a part. However there are some intrinsic factors in the way that doctors make decisions that often cause problems.
Some of these Diagnostic Reasoning errors were reviewed in a blog published this week summarising a lecture delivered by Jonathan Sherbino. Jonathan works in an Emergency Medicine Department in Canada and has a research interest in decision making processes. System 1 (fast) versus System 2 (slow) thinking was reviewed along with some myth busting of how diagnostic errors occur.
One of these was speed of diagnosis. Evidence suggests that going slower makes you slow, not better. This isn’t saying going faster makes your more accurate but that you often gain little in the way of accuracy by spending more time thinking about a problem. Even more interesting was the fact in some studies interruptions, which would seem an inherently bad thing when you are busy cogitating a problem, didn’t seem to make diagnostic accuracy any worse. The final take home message was that reflection, in this case a cognitive forcing strategy of structuring a second review of your decision, only really benefited those with prior experience. Experience coming up again and again as the best way of avoiding diagnostic error.
This then asks some difficult questions of how we should best structure our healthcare service. Having more senior staff is something many Royal Colleges have been calling for for some time. But those senior staff need to gain their experience from somewhere which resonates with the blog’s author Jesse Leontowicz closing point to ensure that learners get experience in the Emergency Department and not just hope it happens. I’d add something else as well. Health care professionals, especially doctors, need to understand why they make mistakes rather than hope they don’t happen and be chastised when they do.
Learning the processes that facilitate making mistakes makes it much easier to avoid getting caught up in them.
This blog co-incides with the release of the summary of my induction lecture to our Emergency Department new starters (click here if video doesn’t play).
One of these was speed of diagnosis. Evidence suggests that going slower makes you slow, not better. This isn’t saying going faster makes your more accurate but that you often gain little in the way of accuracy by spending more time thinking about a problem. Even more interesting was the fact in some studies interruptions, which would seem an inherently bad thing when you are busy cogitating a problem, didn’t seem to make diagnostic accuracy any worse. The final take home message was that reflection, in this case a cognitive forcing strategy of structuring a second review of your decision, only really benefited those with prior experience. Experience coming up again and again as the best way of avoiding diagnostic error.