This is the 66th #WILTW and I am delighted to say the first guest posting! Many thanks to Edward Snelson (@sailordoctor) who runs a blog  called GPPaedsTips 

This year was the 200^th anniversary of the battle of Waterloo, famous for being the final conflict of Napoleon Bonaparte, one of history’s greatest generals. At this battle the resurgent grand Napoleonic army was defeated against the odds by Allied forces; the decisive weapon at the battle being the British foot soldier. As a bit of a military history geek I have always known that there was something special about the way that our troops were trained however I only realised this week that there was a lesson to be learned from this for medical training.

I have been practicing medicine for about 20 years now. During that time I have seen a transition from the “see one, do one, teach one” attitude to a complex system of portfolios, competencies and assessments.   Doctors are now trained in an environment which has a completely different set of rules. Training has improved in many ways and one of the major improvements has been the use of simulation as a learning tool.

Simulation is a teaching method allowing an individual, or a team, to role-play a scenario with a subsequent learning conversation about what has occured. One of the strengths of simulation is the ability to incorporate infrequently encountered events. For example, we could simulate an encounter with a  patient who may have Ebola. I’ve never seen this scenario myself and simulation would be a good way to get me to put into practice what I know only in theory. With the right facilitator I would get feedback that would prepare me well for the real thing.

Another of the strengths about simulation is that it is a relatively non-threatening learning environment.   If I make a mistake with my Ebola manikin, there is a lot less paperwork to fill out afterwards and, although I might feel embarrassed, I don’t need to feel guilty. Most importantly no-one has been harmed. However, I sometimes feel that we make simulation too nice and try to sanitise it.

This brings me back to the 1815 British Redcoat infantryman. These soldiers proved themselves in battle over and over against armies such as Napoleon’s. Napoleon’s army was larger in sheer size, as well as infantry and cavalry. Napoleon had far more cannons and his army was unified.

What swung the odds back in favour of the British soldiers was their training. While other armies were practicing the complex process of loading and firing a musket by role playing, the redcoats of Wellington’s army trained with actual ammunition in their guns. That meant that their training was as close to the real thing as possible. This was not pleasant. Firing a musket was deafening, it jarred your shoulder and filled your mouth with salty gunpowder (as each cartridge was opened by biting into it). Training with ammunition in your gun for a soldier of that era would have been gruelling and probably caused many injuries. But it made all the difference when battle came.

There is a possibility in simulation training that clinicians are be learning in comfort what they need to perform in a crisis. This may be a dangerous precedent.   As is frequently quoted (from an anonymous special forces navy seal):

“Under pressure, you don’t rise to the occasion, you sink to the level of your training,”

That was proved over and over when these two armies met, with the British Infantry consistently outperforming their enemies. Later, at the battle of Gettysburg, muskets were found which had been loaded 12 times and never fired. Was this due to being trained without ever learning to fire actual ammunition?

This year an article was published in the journal Pediatrics titled “Trainee Perspectives on Manikin Death During Mock Codes” exploring the issue of simulation that includes what I would call ‘mess‘. Medicine is messy and in high stress situations things go wrong. Sometimes despite all the best efforts children die.

There can be a reluctance to create stressful simulation with impossible tasks. What this means in practice is that we are failing to train our clinicians for the most important situation of all – the ‘no win” situation. I have had a significant part in the development of the Children’s Advanced Trauma (CAT) course and I am sometimes asked whether there is educational value in situations where there is too much to manage or where the situation is pre-determined to have a bad outcome. I believe that there is.

I would like trainers and learners to embrace the idea that failures are more valuable learning experiences than successes. As long as we are sensitive to the effect that these situations have on the learner I believe that the more mess you have in simulation the better. It is also important to have enough time set aside for the discussion afterwards.

There are other ways to look at this attitude towards medical training, which is to treat the most stressful experiences in day-to-day medical practice as learning opportunities. It takes a skilled person to do this well but when things do get messy, there is usually so much to learn that it is a shame to miss out on it. Medicine is messy. Perhaps as we train for the worst that acute clinical medicine has to throw at us we should include a few loud bangs in our learning?

What have you learnt this week? #WILTW

Edward Snelson

Consultant Paediatrician specialising in Paediatric Emergency Medicine (Sheffield Children’s Hospital)

This is the 65th #WILTW

This week was the first complete Monday to Friday for many new doctors (either to the profession or to a new hospital) in the NHS. Fortunately this year there hasn’t been quite the diatribe in the media about reported increased death rates in August, and I hope this signals the start of (some) news corporations starting to understand the differences between forms of statistics. The original research demonstrated a difference of only 45 patients out of almost 300,000 records over nine years between July and August. Statistical analysis would indicate this increase is significant but it’s just impossible to say whether this is due to the new-starters themselves. There is no reason to say it is not also explained by the fact that relatively more staff are likely to be on holiday during that month or that there aren’t differences between April and May for instance (which wasn’t examined).

Regardless all hospitals recognise that their new staff need support and we have worked particular hard to ensure our most junior doctors starting in the Paediatric Emergency Department are as prepared as possible. One of the things we’ve done is produce a short video demonstrating a toddler’s view of their experience.

This is more than a simple social media gimmick. You rarely see those who are used to working with children standing in a cubicle  while examining patients. Also although guidance has recently changed which will hopefully reduce the amount of children being brought in with neck collars and on spinal boards the below is not a friendly view for a five year old:

What became apparent to me this week was how important it is to appreciate the parents’, as well as the child’s, view. The Emergency Department may also be a scary place to them. One in which they are entrusting the care of their loved ones to people they have never met. However friendly you may came across as a health care professional there is an implicit hierarchy or authority gradient which may need to be addressed. Your body language is just as important to an adult as to a child. When their child is at their most vulnerable a parent or carer will see the world through their eyes. How will you look to them?

What have you learnt this week? #WILTW

[for those receiving this blog via e-mail it has come to my attention you tube links are not shown. Please click on the website version to see all the links!]

This is the 64th #WILTW

Today I gave an induction lecture to our new doctors entitled:

“Risk Assessment and Communication: An audio-visual journey”

I’d spent the week mulling over the arc of my story  and was struggling to piece together the individual pieces of knowledge I wanted to share into a coherent narrative.

I have a long standing interest in the use of patient video cases for education. My belief (beginning to be backed up by research) is that video is not only useful for the learner to conceptualise signs they have read in text books but vital for educators to assess how learners are processing information. I am hoping to demonstrate that we can use patient video cases to aid our understanding of gut feeling or gestalt but for the moment it remains a powerful under- and post-graduate educational tool. Apart from the novelty of the medium what would inspire the audience to understand the value of video?

The breakthrough came when I concentrated on the audio-visual nature of my presentation. What am I demonstrating that another presentation couldn’t do? What will the learner see and hear that is unique?

It made me think about what I see and hear that my juniors may not. When I walk into a consultation room I do an observation check on both the child and the parent/carer. When I start listening to the history I am not just noting the key words but the way they are being said. When I spot an abnormal sign I check whether it is in isolation or in keeping with other features of illness. In this way I am using my senses in a parallel not in series.

My plan then to show the audience what they had been taught previously wasn’t wrong but history taking & examination can be so much more than hearing and seeing – it is truly listening and observing.

What have you learnt this week? #WILTW

Observation is a common theme in these blogs! Some related postings

It’s not what you say it is how you say it

What you see is maybe not what I see?

The importance of listening and language

This is the 63rd #WITLW

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

– L. Frank Baum, The Wonderful Wizard of Oz

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

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

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

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

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

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

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

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

Are you?

What have you learnt this week? #WILTW

This is the 62nd #WILTW

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

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

You can't really describe balance but it can be learnt thro' experience https://t.co/NMg8srxVmO
c.f Gestalt #meded#smaccUS @EMManchester

— Damian Roland (@Damian_Roland) June 28, 2015

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

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

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

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

What did you learn this week? #WILTW

This is the 61st #WILTW

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

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

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

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

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

What have you learnt this week? #WILTW

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

This is the 60^th #WILTW

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

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

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

Essentially:

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

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

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

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

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

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

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

This is the 59th #WILTW

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

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

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

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

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

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

What have you learnt this week? #WILTW

This is the 58th #WILTW

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

We train paramedic, nurse, med students in silos and then expect them to work in teams when qualified. We shld train them in teams #smaccUS

— Cliff Reid (@cliffreid) June 25, 2015

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

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

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

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

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

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

What did you learn this week? #WILTW

This is the 57th #WILTW

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

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

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

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

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

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

What have you learnt this week? #WILTW