This is the 76th #WILTW

Trip-advisor and related review websites have revolutionised realtime feedback to organisations. This is not just limited to hotels and restaurants as both Patient Opinion and NHS Choices allow ‘consumers’ to rate the care they have been given in health care settings. However individual feedback is a different matter. Doctors tend to receive anonymised 360 degree feedback. This consists of colleagues (of varying professions) rating a doctors’ performance across a number of domains and being able to provide short comments about them (but not needing to identify themselves). There are mixed views on this approach but it is useful for those who lack insights into certain behaviours to receive feedback in a way that doesn’t promote individual conflict.

This week I put my mouth in gear before engaging my brain at a meeting and said something I hadn’t intended to. It wasn’t something I thought was actually true just a very poorly thought out quip.  This wasn’t the first, and won’t be the last time, I do this I am sure. The reaction of my colleagues surprised me though – a number felt it was very out of character for me to make sweeping generalisations and seemed quite taken aback. This is not something I’ve been told before (but at the same time not sure it is something you would actively feed back to someone!) It made me think whether the traditional anonymised feedback process makes it difficult to ascertain what you are normally like, not just what you are specifically good or bad at. You can certainly suggest to people you’d like this feedback but in the context of the way an online 360 appraisal form works this is often not easy to do. Also feedback you feel is important for you maybe different from what is perceived to be relevant by those feeding back. I have often thought health care professionals should undertake the JoHari window exercise more often

Even just thinking about undertaking a JoHari window makes you wonder about how you will be described. Seeking out open feedback can be quite a challenge so it was interesting to see the success that Anne Cooper had this week in asking for comments on her own digital behaviours. It’s clear the process interested people, as not only was there a great deal of social media discussion about this, the blog has over 45 comments already. I wonder how this process would work for someone who doesn’t have such a large profile as Anne does but it demonstrates such as undertaking is a possibility (although I’m not sure it always needs to be done via social media!)

Anonymised feedback will always serve a purpose but I wonder whether direct “give me what you’ve got” feedback has an important place as well.

What did you learn this week? #WILTW

This is the 75th #WILTW

At some point in the future…

It is late at night. A doctor in an Emergency Department has just reviewed a nine month old infant. He clicks “discharge” as a final instruction into the hospital’s electronic medical record (EMR) system. An algorithm kicks into life and compares the initial observations of the child with its most recent set. It highlights a persistence of a slight tachycardia for age (calculated against a perpetually updated data set of all the children presenting to the hospital over the last 5 years) despite a lowering of the child’s temperature. A voice analysis device, installed into all cubicles, detects hesitancy and doubt in the mother. Finally it notes a cousin of the child (the EMR matches against all possible genetic records) died secondary to pneumonia when only 6 months old.

This combination of findings prompts an alert. A video of the child (all patients are monitored in real time) is sent directly to the audio-visual doctor arbitrator (ADA) who cancels the discharge and alerts a senior clinician to review the child. 

While this may seem Orwellian it is not an inconceivable possibility. Hospitals already have the ability to constantly record patient observation data and some have explored the use of constant video recording. It is possible to undertake sentiment analysis on people’s speech and there is no current reason why third parties (especially if not human) would not be able to match patient records looking for risk factors for immunodeficiency or genetic disease if it would be in a patient’s best interest.

So if we accept the technology is possible when should an ADA be called?  In the dying seconds of the Australia vs Scotland Rugby World Cup Quarter Finals Australia were awarded a controversial penalty. The conversion of the penalty resulted in Australia stealing victory from Scotland. Had it been reviewed by the Television Match Official (TMO) it probably would not have been given. However rugby laws did not give the referee the option of seeking TMO assistance in this case. But should all decision be reviewed by a third party? The sporting community would wince at such an infringement of the rapid, spontaneous nature of contact games.

What of medicine when patient safety is stake? Clearly capacity is a obvious obstruction – not all patients can be directly reviewed by someone more senior (although currently certain high risk groups are afforded this in emergency medicine.) So who chooses?

The Doctor – well useful if they are not sure but most mistakes will be unconscious error i.e. you can’t predict when you are going to make a mistake or otherwise you wouldn’t make the mistake….

The Patient – Could lead to a paradigm shift. We know parents may be as good, if not better, than health care professionals at detecting serious deterioration. In Australia there is a system called Ryan’s rule enabling the public to ring a hotline if they think a bad decision has been made about a family member.

A Computer – As in the example there is no reason why algorithm based technology could not be used to identify those patients who have management plans that might go against standard practice (which could be to discharge or admit).

A Watcher – Could there be a permanent virtual referee as an ADA? Observing from a distance and picking patients at random, or perhaps by gestalt and experience, for closer inspection.

So will ADA’s transform medicine or as in the Rugby World Cup just create another mechanism for potential system failure. And do we know what the conditions are for when they should be used? Given that almost anyone would agree a third party opinion is useful when a difficult medical decision has to be made is it now a question of when rather than if?

What have you learnt this week? #WILTW

…entirely randomly during the writing of this piece @natalieblencowe drew my attention to this:

Can video recording medical procedures revolutionise medical quality? https://t.co/BQgRoRIhr8 pic.twitter.com/xO7AJCDADC

— The BMJ (@bmj_latest) October 22, 2015

This is the 74th #WILTW

“Do you remember that patient you saw last night…?”

Is quite possibly the most terrifying thing anyone can say to a doctor.

The fear is that it’s followed with, “…they have’t done so well” and an implication you have missed something in your investigations or management. It is testament to the generally humble nature of health care professionals that the initial reaction is one of negativity. No one expects, or remembers being told,  “Good job!” as the following reprise. Instead there is an expectation of failure or inadequacy.

Simon Judkins is an Emergency Doctor from Australia. This week he published an extract from his book in an newspaper. The short piece was entitled “What did I miss?”. It is powerful narrative in which he is candid about sending home a child at night who returned the next morning with meningococcal septicaemia and needed intensive care treatment. The pain he experienced is obvious from the way he tells the story.

Those who work in acute specialities, especially those in which patients are discharged at all hours of the day, must learn stratagem for dealing with risk. You can not admit and treat all patients who present with a fever. The system would crash and furthermore those most in need of care would no longer receive it. You must make judgement calls. Those who are clearly well or unwell are, generally, easy. But many snotty, slightly miserable children, are brought to Emergency Departments by parents who are concerned about them. Following thorough examination, observation, and investigation (when required), with the important addition of ensuring parental concern has been addressed, many of these children will go home. They are no different to the 11month old Simon Judkins saw.

But you can’t end your shift and worry about all the patients you have sent home. It would not be possible to have a reasonable work-life balance if you did. In fact, I have learnt over time, when I come home uncomfortable about having discharged a child that is a sure sign I shouldn’t have done so. Gut Feeling is a funny thing.

But there is a deeper issue at stake here. I read Simon Judkin’s article and thought – poor guy.

I didn’t think – poor kid.

At least not immediately. It was quite an uncomfortable train of thought. I have written previously about a small aspect of emergency practice that is narcissistic. Not always in a “Look at me!” type way, but a pride in performance, a belief that in some patients you can make a difference. This balances the risks of the job, the possibility that at some stage you will bare the brunt of a poor decision. This I think is an aspect of self preservation. As I become more experienced the total number of patients I see with whom I could make a mistake becomes bigger. I hope the rate of my learning matches the ever increasing level of risk. But I wonder if I have adopted a strategy of risk management that is not primarily aimed at protecting patients but more aimed at protecting me from the ordeal that Simon went through…

What have you learnt this week? #WILTW

This is the 73rd #WILTW

The story of thalidomide is a tragic one. A drug which was deemed to  be safe, but not adequately tested, resulted in over 10000 children being born was thalidomide related disabilities. The impact of thalidomide would have been even more tragic were it not for Frances Kelsey an American scientist, who despite a considerable amount of pressure, refused to licence the drug in America without more evidence of its safety.

Sometimes even with thorough testing complications can be missed. A compound containing aspirin was probably used by Hippocrates in around 430 BC and it has been used close to its current form since the First World War. However children with viral infections can become severely unwell, or even die, if given aspirin (due to the development of Reye’s Syndrome) and hence it should be avoided until adulthood. It wasn’t until the late 1980’s that this was realised and national recommendations to avoid aspirin in children were released. Since that time the incidence of Reye’s syndrome has dropped.

Clearly all drugs have an element of risk to them but it is  surprising when something you think you understand turns out to have unexpected consequences. A recent publication in the Lancet examined what happened to infants admitted to hospital with bronchiolitis (a very common winter virus). The researchers cleverly developed an oxygen monitor that showed a higher oxygen level (or saturation) than was actually the case. Essentially when a child had saturations of 90% the monitor would tell the doctor it was 94%. Over 300 children were managed using these modified monitors compared to another 300 with normal ones. The result of this was that one group received more oxygen therapy than the other (doctors will tend to prescribe oxygen at levels below 94%.)

A very good analysis of the study can be found here but essentially the authors found that not only did the infants who had the lower oxygen levels do no worse; they might have actually done better than those with the normally functioning monitors.

As with all research nothing is completely black and white. The trial was designed with a  very patient (?parent) centered outcome of time to resolution of cough. The ‘bronchiolitic’ cough can be very persistent and the time until it resolved was the same in both groups. However the study design meant some of the other improved outcomes, such as time to return to normal feeding or representation following discharge, in the lower oxygen levels group could have occurred by chance alone. But even with some of these potential statistical quirks there is an enough in this study to seriously question whether supplementary oxygen could cause harm in some babies with bronchiolitis. In fact we already know too much in pre-term babies can cause eye complications but this study has really struck at the heart of a perceived wisdom in medical practice.

This study should make all health care professionals wary of dogma and the status quo. While clearly is not the time for knee jerk reactions or mass panic it is a timely reminder of the importance of re-evaluation and research in all that we do. It has certainly fuelled the fire of my own academic interests and I hope it does in others.

What have you learnt this week? #WILTW

This is the 72nd #WILTW

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

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

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

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

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

It turns out she was brilliantly educated.

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

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

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

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

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

— Damian Roland (@Damian_Roland) September 29, 2015

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

What have you learnt this week? #WITLW

This is the 71st #WILTW

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

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

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

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

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

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

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

What have you learnt this week? #WILTW

This is the 70th #WILTW

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

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

— The Independent (@Independent) September 17, 2015

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

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

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

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

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

What have you learnt this week? #WILTW

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

This is the 69th #WILTW

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

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

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

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

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

• Not knowing what other people know is uncomfortable

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

— Damian Roland (@Damian_Roland) September 6, 2015

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

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

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

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

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

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

What did you learn this week? #WILTW

This is the 68th #WILTW

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

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

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

Their physiological parameters are normal.

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

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

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

Does, and should this, change what you do?

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

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

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

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

What did you learn this week? #WILTW

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

This is the 67th #WILTW

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

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

So for #WILTW an Ed fact-finder!

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

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

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

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

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