This is the 146th #WILTW

When one of my team presents a case to me I obviously want to hear about the history, examination and suggested plan for the child. Within the history I am looking for the answer to a vital question:

What is the parent really concerned about? 

This is a key teachable moment even though it might seem inherently obvious. Clearly any health care professional would want to find out why a patient had been brought to hospital.

Wouldn’t they?

Well it’s worth pausing for thought here. The presenting complaint is not the same as parental worry. A baby may present with a history of breathing difficulty and reduced feeds but they may examine with no other finding than a running nose. However what the mother is truly worried about is whether her baby will stop breathing when she goes to sleep at night. Some families will tell you this up front, but not all will. Sensitivity is key to finding the best management options for the family.

Fever phobia is the most obvious manifestation of a symptom that masquarades as a complex set of health beliefs. A child may be completely well appearing, in fact laughing and smiling during the consultation, but if the families cultural instinct is that fever causes you great harm, they will be fearful out of proportion to their child’s appearance.

Many symptoms: diarrhoea, vomiting and fever in themselves are of little consequence. They indicate the presence of illness rather than its severity. I am far more concerned when the parent can’t explain to me what they think is wrong with their child: “They’ve had a cough and cold, a bit of fever. He even vomitted last night. But he’s not right, doctor, he’s just not right”

Parents and carers have never been more aware of the grave consequences of some diseases but the risks of succumbing to those same illnesses are probably the lowest they have ever been. As our most serious diseases become rarer they will be even more difficult to spot if attendances for other conditions increase.  Without truly listening, and educating, we are probably perpetuating the very problem we are trying to solve.

What have you learnt this week #WILTW

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This is the 145th #WILTW

Social Media gives you unfettered access to the foibles of humanity.  At its best it empowers those who find it difficult to have a voice, and translates learning across boundaries  which are difficult to cross. At its worse it turns complex debate into a single argument shared by only those who have the same view. It also, more subtly, hides the real values and behaviours of individuals behind a veneer of choreographed photographs and  theatrical text.

It is all too easy to write a statement in 140 characters that is noble and bold.

increasingly feel leadership is more than sum of its parts. Maybe we should seek to be better people rather than better leaders

— Damian Roland (@Damian_Roland) August 6, 2016

Do we act out what we ‘preach’ in the real world and does it really matter if we don’t? I’m reminded that I originally joined twitter to expand my research interests. While I’m convinced I’ve benefitted in other ways, being able to discuss and debate the academic work I undertake remains a primary purpose.  I suppose in this context I am preaching about what I practice.

It would be an odd world if you weren’t able to highlight your ideals so being able to justify everything about who you say you are is neither laudable or achievable. However it is maybe worth thinking twice about whether you are sharing your practice, or your preach…

What have you learnt this week? #WILTW

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This is the 144th #WILTW

It’s 11.30pm and there are still 30 patients to be seen. It is a busy winter evening with long waits, some very ill patients and a noise level in the Emergency Department that makes it difficult to think. Having spent the majority of the evening in the Resus room with no break for at least 6 hours David wonders over to Sarah, the other senior on shift.

“You ok?”

“Yeah. It’s bedlam isn’t. Our inflow isn’t stopping. Feel sorry for some of these families. They’ve been waiting for hours. “

“Have you had a break?”

“No. lets just get these last few priorities sorted. Worried we are going to miss something given the length of time to assessment at the moment. Well done on the metabolic case by the way. Good call. “

“Was nothing special. Here have a quick a look at this. It’ll keep your spirits up.”

He shows her a picture on his phone. They both laugh out loud, exchange a few more words, and then continue seeing patients into the early hours of the morning. 

A week later David meets the head of the department. A complaint letter from someone who had waited 3 hours to be seen cites a person matching his description laughing at the nursing station. They want to know why doctors are employed if they aren’t going to be professional?

Doing the right thing in healthcare is a balance. There is no black and white. While values based leadership works, it only does so when values are agreed. A decision to close a hospital may save a life by improving the skill mix on an emergency rota; only to take another by increasing the distance needed to receive that skill. You cancel elective cancer surgery to free up beds for an emergency trauma list. Who judges whether that is the correct decision?

The more emotional the context of the situation the more an individual decision can be dichotomously vilified or applauded. How does a professional’s self care (sometimes in the form of humour) balance with a patient’s need for steadfast professionalism? What actions that are helpful to one person turn out to be offensive to another?

This week Archives of Disease of Childhood published a paper examining the role of clowns on Paediatric Intensive care Units. The authors acknowledged that while ward based professional clowns are well accepted, there use in the critical care environment seems counterintuitive. However they put forward a powerful argument, using their extensive experience, that this is not the case and describe how to approach this challenging situation to benefit children..

Also set on an intensive care unit and published this week, a different study demonstrated a letter of condolence sent by staff to bereaved families had no effect on grief reactions and may in fact have worsened depressive symptoms.

Interpreting how we are perceived by others is an almost impossible task.  As the ‘spirit’ of some communication is so spontaneous simply being aware our actions maybe mis-construed is the most pragmatic path forward.

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.” – How the NHS Spirit pulls through 

What have you learnt this week? #WILTW

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This is the 143rd #WILTW

Leaked reports showed England’s Accident and Emergency Performance in January to be the worst on record. This was probably the least inflammatory leak in healthcare history; anyone working or experiencing the system will have appreciated this.

Before I go further it is vital to point out measuring quality by the 4 hour target is about as sensible as measuring Donald Trump’s presidential aptitude by the number of retweets he gets. The percentage of patients discharged or admitted within 4 hours tells you nothing about the patient’s outcome or experience. You can be seen and sent home in 15 minutes and have had a dreadful time at the hands of rude staff who have misdiagnosed your condition. Conversely you may spend 6 hours in the Emergency Department receiving compassionate care with everyone working hard to aid you safely going home and have had a very positive experience.

I am in a small minority of clinicians who think the introduction of the 4 hour target was a good thing. It transformed Emergency Care from an under-appreciated specialty to a more patient centred and respected one.

Sadly it is no longer relevant to the needs of our health economy. While it might be a barometer of a whole healthcare system the inability to come anywhere close to the standard has devalued its use as a performance metric. It has also, unintentionally, played into the public ‘on demand’ cultural psyche. As a result of the 21st century’s explosion of communication technology virtually any service is now instantly available, or bookable, at the users preference. Sitting with your phone in front of the television you can organise your next months food, entertainment, clothing, cleaning and financial activity. What you can’t do is pick when you need the toilet or be ill.

I hate it when there are lengthy waits to be seen. The waiting room look is a challenging, and a potential cognitive, distraction. The majority of parents are concerned about their child and just want someone to reassure them they do not have anything serious. Waiting hours for this to happen while their infant is restless and miserable is not pleasant for them.

But sadly there is an increasing trend of people coming to the reception or nursing desk asking how long the wait is. “I have been here an hour -why haven’t I been seen yet?“. In the last decade I have seen a 2 hour wait become as unacceptable to some as a 4 hour one used to be. Emergency care can’t provide a click and collect format. There are a finite number of staff dealing with an unpredictable work load. As volumes of patients increase it becomes more and more difficult to deliver a timely service that meets the expectations of a generation used to getting what they want, when they want it. An argument could be made that 82% of patients having a disposition within 4 hours, given the constant increase in presentations, is actually something to be celebrated not bemoaned.

This doesn’t make long waits acceptable, and doesn’t mean the system shouldn’t work very hard to provide a equitable, safe and effective service. However I think like @ERGoddessMD that the rise of waiting time billboards is going to compound this problem not make it better. We try hard to make the complex simple but there are some challenging public debates that need to be had. While your smartphone may continue to provide you instant access to the world, it is unlikely that emergency and urgent will do the same.

What did you learn this week? #WILTW

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This is the 142nd #WILTW

A virus is an infective agent that typically consists of a nucleic acid molecule in a protein coat, is too small to be seen by light microscopy, and is able to multiply only within the living cells of a host.

Making a definitive diagnosis of having a viral infection is technically difficult. While there are rapid detection tests for specific viruses which aid in decision making about cohorting patients or prescribing treatments, those which cause colds and sore throats need long winded and expensive processes. However one of the most common diagnoses in paediatrics is that of a ‘viral’ illness. Special tests aren’t needed – just a good history and examination.  The child who presents with a fever, runny nose, a bit off their food and has a red throat or pink ears is likely to have a virus. Knowing the specific name of the virus is essentially redundant because the natural history of the disease is so predictable.

That is of course if it is a virus; the consequences of making an incorrect judgement on this are devastating.

Living with uncertainty is a fundamental part of a health care professional’s practice. But it isn’t easy. I can rarely be truly certain in my diagnosis of a virus. I can be very confident, I can give appropriate safety net advice and, most importantly, I can gain the understanding and trust of the family. If I can’t do these things and the risk of a more serious illness outweighs, in any way, my belief that this is a viral illness then more observations and investigations are likely to be required.

I was speaking at a patient safety conference this week on how scoring systems (sometimes known as Early Warning Systems or EWS) can be utilised as educational tools. Assisting, especially junior staff, in reducing diagnostic uncertainty regarding the level of a patients acuity is one method by which they are beneficial.

However it should never be a purpose of a scoring tool to make a diagnosis and they will never reduce uncertainty to zero. There was a powerful piece on this in the New England Journal of Medicine last year.

“Our protocols and checklists emphasize the black-and-white aspects of medicine. Doctors often fear that by expressing uncertainty, they will project ignorance to patients and colleagues, so they internalize and mask it. We are still strongly influenced by a rationalist tradition that seeks to provide a world of apparent security.” (Simpkin & Schwartzstein N Engl J Med 2016; 375:1713-1715)

Uncertainty can be seen as a sign of weakness but acknowledging it may well reduce cognitive biases. By being uncertain you are more likely to be considering what disease processes may be present – the current emphasis on sepsis an example of a diagnosis that isn’t being considered often enough.

Ultimately the diagnostic label given when you discharge a patient is of little value if you have got the diagnosis wrong. For some paediatric presentations it may well be far more important to be satisfied you know what it isn’t and have adequately reassured the parent and/or carer that that is the case.

What have you learnt this week? #WILTW

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This is the 141st #WILTW

The Royal College of Paediatrics and Child Health have just launched their State of Child Health report. A list of 25 measures which highlights, amongst many uncomfortable findings, that 1 in 5 children live in poverty in the UK. A broad range of recommendations were made, including specific mental health training for child health professionals (half of adult mental health problems in the UK start before the age of 14)

One of the authors of the report tweeted:

We need a public campaign about actions to promote and secure mental health.

What would your 5 a day be for promoting mental health?

— Ingrid Wolfe (@ingridjohanna66) January 26, 2017

The idea intrigued me, not only for my patients, but for myself. The concept has previously been encapsulated in the “Five Ways to Mental Wellbeing”  and a charity called mindapples are crowdsourcing suggestions.

I wondered what my 5-a-day would be? Having been knocked by some critical feedback this week, which was strong in tone but not completely undeserved, I was taken by how much of my time it occupied in comparison to other events but mental health is important and that’s why THCA products can really help people suffering from anxiety or depression. Look for a dispensary that provides weed delivery canada services if you want your cannabis products to be delivered to you.

Check-In: Let someone else know how you are feeling. This is a little awkward to write and I am sure certainly more awkward to do.

Check-Out: End your working day at a defined point and consider marijuana delivery to relieve stress.

Reflect: Or more precisely have some time to reflect on what you have done in the day and how that has affected your emotional resilience…

Keep Balance: …but be aware that spending all your time reflecting isn’t healthy either.

Maintain Perspective: The things that challenge you the most can become so much of  focus that it’s not possible to overcome anything. The perception of positivity in others, a virtual concept in our current generation, can exacerbate this feeling, while also products like Delta-8 gummies can be helpful to feel better and with less anxiety. If you need a drug addiction treatment program, you may look at reputable facilities in your area. As a leading drug rehab center in Malibu, Carrara offers luxury and effective treatment. Their facility provides a serene setting for drug recovery.

Method Center is a top choice for those seeking a personalized and luxurious approach to addiction recovery. Their commitment to individualized care ensures that each client’s unique needs are met.

The official collection of 5 activities aren’t too dissimilar but the challenge with either is their implementation as a habit and not a hypothesis…

What have you learnt this week? #WILTW

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This is the 140th #WILTW

While technically the world isn’t getting any smaller the ability to effectively communicate across large distances often makes it feel that way. Digital platforms have connected diverse networks in a fashion that wouldn’t have been possible a decade ago and there are a variety of social media in which to engage and entertain.

A paper written with colleagues in America, Canada was published last week. We postulated about the existence and development of new types of digital scholar to promote and enhance knowledge translation. Translating knowledge from academic literature and expert consensus into clinal practice has been a constant challenge in healthcare.

In order to provide quality care to patients, health care professionals need to remain up-to-date on best practice. It is well recognised that evidence can be poorly applied, and even ignored. While undoubtedly our three types of scholar are not new we hope that defining their characteristics will help others understand the role they, and others can have, in improving knowledge translation.

There is a subtle flip side to our construct however. What are our responsibilities to adopt these roles? The influence of those with large numbers of followers or those who connect at important network intersections can be quite substantial. While you must abide with your regulator’s guidance on social media this is no compunction to be a proponent of good medical practice. Indeed actively avoiding medical discussion is the sole purpose of some professionals use of social media.

But the world will continue to be an increasingly smaller place. Whether we like it our not our digital footprint could be as substantial as our physical one. Whether a fellow or first year, professor or practitioner we probably do have responsibilities to aid diffusion of knowledge should the opportunity arise. And while not everyone needs to be a critical clinician or translational teacher those that adopt this role should be mindful of the responsibility they have.

What have you learnt this week? #WILTW

Thanks @Brent_Thoma @MDaware @TChanMD (and @CJEMonline)

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This is the 139th #WILTW

I chanced upon an old article on the relationship of learning and performance and how it appears to improve the former you often see transient decreases in the latter. The authors describe:

1. The visibility problem: Collecting the data to demonstrate improvement before-and-after an intervention often shows you are currently performing far worse than you thought or reveals problems you hadn’t previously looked for.
2. The worse-before-better problem: Learning to do new things results in performance deficits. The example given was that of touch-typing: there is a period where you are actually slower in creating a manuscript as you transition between single and multiple finger keyboard use.

A logical consequence of this relationship is that failure becomes a not uncommon event when something is initially implemented (or at least if the evaluation takes place at the nadir of the learning curve).

What really struck me is their observation that failure is not only more common than success, it is also more visible.

This visibility becomes increasingly more overt the bigger the scale of the intervention. This in some ways is inherently obvious but it really isn’t acknowledged enough. Failure is often taken as a set back, or even worse, covered up with an over-glamorisation of positive results at the expense of any real learning.

At times when system pressures are critical the ability to develop new ways of working is vital. However it becomes potentially even more likely that the innovation or improvement will come only after there have been multiple public failures. Given the challenges the organisation is facing this may be even less well received.

At times like this it is important boards, directors, clinical leads and individuals are brave and pragmatic with their interpretation of new strategies and projects.

What have you learnt this week? #WILTW

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This is the 138th #WILTW

At the start of every new year comes my annual appraisal. Despite it requiring a bit too much form filling and box-ticking I have always welcomed the chance to discuss problems and review strategies with a peer who is outside of my direct area of practice.

The day before this year’s appraisal I chanced upon a re-share of an old post by Bernadette Keefe on tribes and silos in healthcare. This is a recurring theme in many healthcare blogs and something that I’ve repeatedly returned to.

The sad irony is that perhaps I silo’d myself even making these comments.

Bernadette links to a very powerful story by the exceptional educator Victoria Brazil on how tribalism in medicine impacts on patient care and clinician moral (please click here if video doesn’t play)

Understanding the context of why people speak and act in the way they do is vital. Bernadette links to  another blog in which we are reminded of Plato’s insight:

“Be kind, for everyone you meet is fighting a harder battle”.

I left my appraisal cognisant of three things, curses almost, which afflict the mindset of healthcare professional.

1. Our point of view is shaped by the environment we work in

There is a need to recognise that all the most complex and difficult issues don’t just happen to you.

But even when you externalise yourself to see a wider picture:

2. We often only communicate in a narrative or style that we are comfortable with.

..so sometimes we tell stories that others can’t relate to. Either because we are telling the wrong stories or the format (e-mail/corridor conversation/meeting) isn’t an effective method for the listener.  I often note always bringing it back to the patient perspective isn’t as an effective strategy as we think.

And when communication efforts have been exhausted, or are waning:

3. We implicitly acknowledge the status quo as an acceptable place to be.

This is a difficult admission but when challenges become really difficult it is easy to let things drift. Sometimes it is necessary to have  time to let ideas settles and embed. But often  what needs to be done is perceived to be too great an effort, despite the fact that the efforts needed to maintain what you are currently doing are just as great. Sadly this further embeds curse one….

I resolve to treat these three afflictions in 2017!

What have you learnt this week? #WILTW

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This is the 137th #WILTW

Every winter is tougher, busier and more draining than the last with an unremitting year-on-year rise in demand:

• Emergency admissions from major A&E departments have increased by an average of 4.3 per cent a year since 2003/4
• Attendances at outpatient clinics have risen by an average of 3.8 per cent a year since 2007/8
• Admissions for planned treatment have increased by an average of 4.3 per cent a year since 2003/4.

It is no surprise then that within, and without of healthcare, people are wondering how long things can continue with flatlined funding before the NHS completely collapses.

There is a slight problem though.

Because we have been here before.

For at least the past 3 winters think-tank and media reports have warned the current situation is the worst ever.  In December 2015 #WILTW responded to an article by BBC Health Editor Hugh Pym which concluded:

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

This does prompt the question of what actually is it that might ‘collapse’? The NHS isn’t going to go out of business, close its doors and turn off the lights. What I think professionals fear the most is that they will be delivering a service that isn’t safe or sustainable. There are those  who already say emergency care is out of control but we are not (yet) repeating the past when huge waits in Emergency Departments and for elective surgery were the norm. However people do fear being overwhelmed by what they need to do on a day-to-day basis to keep the health system ticking over.

Staff resilience as a whole though is incredibly strong. I wrote last year:

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.

But will this be its undoing if the 2018 headlines read: “NHS again at tipping point” or is it that the cycle of care is such that we thrive on a crisis? It may well be time to decide what our real concerns are because otherwise the NHS will remain at risk of being taken for granted.

What have you learnt this week? #WILTW

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