This is the 166th #WILTW
I am currently on a weeks social media blackout (and more importantly on annual leave!) 
A perfect opportunity for a break from What I learnt this Week. But if you are keen for a fix here are some of the most popular posts from 2017 🙂

Same Child, Different Room, More Risk

How did you not see that

Dogmalysis and Pragmatogenesis

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This is 165th #WILTW

The term ‘statistics’ strikes fear into many.

You may have 5 ‘A’ levels, have a distinction in finals, and be able to perform life saving cardiac surgery in a premature baby.  It’s also likely you’ll still start sweating if a junior colleague asks you:

…why was the power calculation insufficient to reject the null hypothesis in this paper?

An extremely well shared meme was released a couple of years ago aiming to explain the often mis-understood topic of type I and type II error.

The illustration doesn’t really do the underlying principle justice but the explanation is fair.

• A type 1 error is when you decide a test result is positive, or an intervention has worked, when in fact it isn’t/hasn’t.
• A type 2 error is when you decide a test result is negative, or an intervention has failed, when in fact it isn’t/hasn’t.

I was reminded this week by Professor Mayur Lakhani of a third type of error (in fact there is also a type 4 error but I’m not going to go there). A type 3 error is when you are correct that a test result or intervention is positive but you have decided this for completely the wrong reason.  Outside the realm of mathematics it is when you solve the wrong problem and don’t realise it. In an article written by Large Kiely, shared by Prof. Lakhani, this issue was explored though the lens of organisational culture:

“The type three error is a dangerous form of group-think and can happen very innocently and with all good intentions. The causes are a bit surprising, having to do with, believe it or not, too much expertise in the same field.” – Laree Kiely

In healthcare this probably occurs more frequently than we would care to admit. Take a group of highly trained consultants or managers, and set them on a problem. Very early in discussion, the cause of the problem will be decided, not via evidence, but through anecdote. Solutions will be presented to solve the perceived issues and any improvement attributed to the intervention(s). It will only be later, sometimes much much later, that other problems will materialise demonstrating the original assumptions to be flawed.

I’ve explored group-think previously but the type 3 error is a very tangible output of it.

The suggested advice by Laree Kiely is to always have 3 possible actions before deciding on one. This isn’t always easy to do but forces groups to avoid discounting relevant issues:

“Decision making studies have shown that if you think there is a right answer, then the first one that looks right becomes the final choice, and the thinking stops there. Problems today rarely have only one right answer.”– Laree Kiely 

Inevitably the time required to think of a third idea to avoid the third error will mean it rarely occurs. But at the very least we shouldn’t be scared of calling it out when we make this mistake.

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Videos below explain the concept of type 1 and type 2 errors further

This is the 164th #WILTW

I came close to starting this piece by making a fundamental error. I was going to discuss how the ‘case’ of Charlie Gard is a tragedy. A tragedy it is, but to describe it as a case does no justice to anyone involved in this heartbreaking situation.

It is events like this that demonstrate the fragility of social media as a communication mechanism. All sides involved, most importantly the  parents, but also the professionals (medical and legal), organisations and national bodies passionately believe in Charlie’s best interests. There are no monsters. There is sadly a lack of humanity, not from those who are involved, but from those who feel they have a right to judge, berate and decide what’s best for a situation in which few can comprehend the moral and ethical dilemmas at play.

In a completely unrelated, but actually quite relevant, BMJ blog this week Dr. Matt Morgan challenges the way we currently examine doctors in medicine:

Although undergraduate training has adapted to some of these changes, the postgraduate world needs to embrace the changing roles and skills needed by medical professionals of the next century.

Many of the current processes of testing competence rely on the doctor making the correct diagnostic decisions. But testing pure factual knowledge and clinical examination has been recognised as a poor surrogate for future clinician performance. To be fair, examinations necessary to become a Consultant or General Practitioner almost certainly also include complex cases involving ethics or challenging communication. But Dr. Morgan I think correctly highlights the difference between being able to answer difficult questions about a case, and being able to ask the right questions about a difficult case.

He identifies while it is almost certain the use of artificial intelligence in medicine will grow, it is difficult (currently) to see how a data led approach to diagnosis can deal with grey medicine.

The challenge, increasingly, is to understand:

Not, what is the definitive cause of a symptom but what definitely isn’t the cause of it…?¹

Not, how do I treat this, but should I…?

Not what are the consequences of my decision now, but what might they be in the future…?

While ever cleverer computer algorithms, imaging devices and cutting edge diagnostic technologies will improve processes in medicine we must ensure that our underlying principles of practice remain true.

I am certain the doctors and nurses caring for Charlie Gard have used every tool at their disposal to investigate and treat him. I am also sure they have been equally diligent in exploring all the ethical and moral dilemmas exposed. To not do so would be leaving medicine in the hands of computer programmes which may well reduce patients to ‘cases’ to treat rather than people to care for.

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1. This topic was explored in “If you know what its not, is it ok to not know what it is?“

This is the 163rd #WILTW

Nearly a year ago I wrote on Sepsis and Self-Doubt

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

I highlighted the importance of doubt in decision making. It is not possible to admit all children who have features of infection. We must select those with high risk signs/symptoms for investigation & treatment and discharge low risk cases with adequate safety netting. This in itself is a conundrum and it is important that senior clinicians wrestle with this balance of risk. For not to do so results in either over-treatment, or in-appropriately conservative management. This is a significant cognitive and emotional drain, and in the context of spiralling presentations, it’s imperative we reduce the decision making load on acute and emergency clinicians.

It was for this reason I reacted strongly to a piece on the potential reasons behind the ever increasing access of emergency care by children and young people. In retrospect I was a little OTT in my concerns regarding an inference that there is a financial incentive to admit patients to hospital (see comment at the end of the article).  With all due respect to Quality Watch they responded and amended the text. We are both agreed the current financial model (where hospitals receive a set payment for each child admitted) sadly does mean there is little incentive to change the system.

The original version had hit a nerve because inappropriate admission to hospital makes diagnosing serious illness harder. A rising patient load of a potentially high risk group of children makes case selection on admission units and wards even harder. While there is much work to do in educating professionals and parents on the core features of common illnesses, neither group wishes children or young people to be in hospital unless they really have to be.

Over the last year it has become increasingly apparent to me that we are probably too focused on the identification of illness in the initial stages of a patient journey. Would it be easier to spot the needle if the haystack was smaller? Should the paradigm be spotting the well child early (and discharging) rather than the sick child late? We endeavour to create more specific scoring systems, biomarkers and analytics to identify the most unwell when  we probably need none of these things to identify the well.  It may be argued that discharging normality is a core function of medicine, I would challenge whether we truly operate out of that mindset. And if we wanted a different form of incentive, wouldn’t rewarding the rapid, but safe, recognition of the most well be in everyone’s best interest?

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A video exploring this theme:

This is the 162nd #WILTW

There are conflicting views on whether analogies between safety in the airline industry and medicine are reasonable. While aviation is applauded for its strong culture of training and disciplined team work, the fixed environment i.e. the same cockpit, with the same crew, in the same circumstances makes it difficult to compare with the unpredictable nature of clinical practice. The converse argument is that in healthcare we always find “an exception to the rule” so unified practice becomes impossible. It is likely this debate will continue to run, with no obvious winner, until medicine becomes a safe industry. Something it is currently, certainly not.

A safety initiative in road transport is a common feature of medical guidance: The Traffic Light.

The movement from green (clinical features which are not concerning and do not require intervention) to amber (may cause harm and require investigation) to red (must action immediately to avoid harm) is commonly used to highlight the key features of practice guidelines and risk in observation charts and scoring systems.

This approach implies there is a discrete and objective difference between the categories. While this may be true for vital signs (the movement from low to high heart rate for example) medicine rarely affords us anything which is black and white.

In a fantastic piece on the complexity of diagnosing paediatric sepsis Dr. Edward Snelson proposes the following:

Edward highlights that “Sepsis doesn’t appear, it develops“. There is a misconception that the point where sepsis began can always be identified. This is simply not the case and evidence supports this. A viral illness bringing you to hospital one day, may well still have been a viral illness regardless of whether you present to the hospital the next day with sepsis.

Given the evolving nature of many diseases is “tri-chotomisation”  a valid approach? In practice some clinical features may sit in one category, while some may sit in others.  Rather than green or amber, should we have brown? Trajectory of illness means it is far more meaningful, but infinitely less practical, to have a spectrum of colours rather than a traffic light.

Does the ease of use and face validity of the “Traffic light” trump the practical difficulty its implementation may produce?

With that particular challenge I leave you with Edward’s extremely relevant summary:

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This is the 161st #WILTW

What would you do if the picture you posted on social media went viral? Be pleased that you had shared the love or be embarrassed that you had forgotten to check your privacy settings. Were you even aware that your posts could be seen by people you’d not ‘friended’

For those who are frequent users of social media understanding the public nature of your communication is obvious. But is everyone aware of this?

In a comprehensive blog by the @Mental_Elf and the South West Peninsula Collaboration for Leadership and Applied Health Research and Care (PenCLAHRC) a recent systematic review on “any qualitative methods to collect data on attitudes on the ethical implications of research using social media” is discussed.

Essentially the paper was looking to examine perceptions of ethical considerations when performing research using social media.

Ethics of social media research: from Big Brother to rainbow unicorns

There were a variety of findings (please do read the blog and the review itself) but the one that caught my eye was the potential necessity for obtaining informed consent for using material on social media.

Don’t get fact wouldn’t be allowed to examine tweet in academic paper without consent but I'm allowed to RT/Comment on it to my followers?

— Damian Roland (@Damian_Roland) June 15, 2017

If someone posts something in a public forum should you have to ask them if you want to comment on that post in an academic journal? This is more than a mere ethical conundrum. Our news feeds are now full of leaders and commentators using social media to inform and debate. It would be difficult to argue that they don’t want the information to be consumed and digested.

The FAKE MSM is working so hard trying to get me not to use Social Media. They hate that I can get the honest and unfiltered message out.

— Donald J. Trump (@realDonaldTrump) June 6, 2017

But what of the general public? Whose responsibility is it to let them know that what they are saying may be available to everyone? The terms and conditions as you register? A regular reminder as you log-on? Or just common sense?

Colleagues and I will shortly be publishing a paper that (in a small appendix) uses tweets as part of the research exercise. It hadn’t even occurred to me to obtain individual consent to use those (public) micro-blogs in our work?

Would you mind if your tweet or facebook posting was used by a researcher?

..and why?

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This is the 160th #WILTW

In medical school you are swept away by the prospect of doing good. While you appreciate you are naive you don’t realise there are many unknown unknowns. At the time, therefore, it seems illogical working out what is wrong with someone can cause more harm than benefit.

As you grow in experience, both good and bad, facilitated and self-learnt, it becomes clearer that the “Gregory House” school of investigative medicine really is a recipe for disaster. There are very few ‘tests (blood or otherwise) that make a diagnosis for you. From white cell counts to spot sepsis and x-rays to find pneumonias, these investigations  just alter the patients’ prior risk of illness. Positive or negative they don’t definitively tell you whether someone has a disease.

In paediatrics there is the additional challenge of the test itself doing harm. Blood tests are not an enjoyable exercise, for child or family, and the benefits must outweigh the risks. Even with the most effective distraction and analgesia if a child’s first memory of a hospital is an unpleasant one, subsequent visits become more challenging. And for the child who already has had multiple blood tests and cannulas, that solitary precious vein for use in an emergency does not need unnecessary damage.

And what happens if you are not successful? Even the most experienced practitioner has a bad day. Do you really need that test? Will you have 3-4 further attempts and then decide it is not required? What does that tell the parents, and what does it say about your decision making?

In an era of over-diagnosis we must consider the consequences of investigation as a similar challenge of our time.

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This is the 159th #WILTW

You don’t need to have any medical expertise to spot the abnormality in this CT Scan

If it took you a bit of time, don’t worry. Not an insignificant number of experienced radiologists missed the gorilla in the top right corner too.

While these cognitive games are good fun there application in real world medicine isn’t always clear i.e. if you’d swallowed a toy gorilla would it really be missed? It’s becoming clear there is a growing body of evidence that inattentional blindness does impact on the clinical decisions made by healthcare professionals.

Inattentional Blindess: The failure to see visible and otherwise salient events when one is paying attention to something else

In a talk to the International Paediatric Simulation Society this week Christopher Chabris presented his own research on the subject. It stems from a high profile incident in the United States when a police officer (Kenny Conley) was convicted of obstruction of justice and perjury because he failed to spot a fellow officer (Michael Cox, who was in plain clothes) being assaulted by other officers who had allegedly mistaken Michael as a felon. The prosecutors argued given Kenny Conley had run straight past Michael Cox it would have been impossible for him not to have seen the assault.

Professor Chabris ran an experiment where subjects (college students) were instructed to follow someone running in front of them and count the number of times the person they were chasing touched the top of their head. The volunteers were not told that they would run past a staged assault during the 400m run. Even during the day only 56% of the students noticed the fight that was happening right in front of them (video of the study here)

It does seem possible that once focused on an activity you may literally become blind to events around you. This misperception reveals itself in a number of ways. In the picture below (click here if it doesn’t work) can you see what is changing between the flicks of the screen?

It’s possible you may have spotted it instantly but certainly in the lecture theatre I was in at least half the audience of over 350 people took at least 30s, if not longer to find it.

Inattentional blindess may have a significant impact on medical practice. While it may seem astounding to an outsider that the falling oxygen levels or heart rate weren’t spotted, it may well be the staff simply couldn’t see the numbers changing on the monitor. And if they stop looking at the patient, to draw up drugs for example, you can see how sudden deterioration can be missed. It follows on the more stressed or distracted you are, the more likely that inattentional blindness may occur (although I am not aware of the specific evidence behind this). My colleague Gareth Lewis highlighted the reasons for poor performance in simulation may well be the anxiety of undertaking the exercise impacts on the ability to act on information provided in the scenario.

If nothing else the concept makes real the dangers of doing something as simple as glancing at your phone in the car. But I think it is also worth re-thinking your reaction the next time someone claims to have missed something that should have been in full view.

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This is the 158th #WILTW

I recently published some thoughts on how Nassim Talebs’s book “The Black Swan” may influence clinical practice in Emergency Medicine. The books title is derived from the discovery of Black Swans in Western Australia. Despite being a very unexpected event that had a profound impact at the time, in retrospect the evidence was probably available  to have suggested such a thing was possible. A Black Swan event is, by definition, not predictable until it has occurred. Taleb argues understanding their existence is vital to understand economic theory (he was originally a market trader) but I think it is also an extremely useful concept in Medicine.

With Black Swan events are two states of mind that probably are relevant to patient safety. The first is that we think of written history as linear and easily described. Taleb argues this gives us unfounded confidence when we review events and how we think we responded to them. In serious case reviews the reasons why different systems failed are themselves interwoven with interdependencies, which fluctuated in real time i.e. the act of writing a sequence of events down can never truly describe why things happen. The second that we too often confirm ‘No evidence of disease’ rather than ‘Evidence of no disease’. This is a well known phenomenon in healthcare and describes a tendency to seek a particular test and use it as the sole process in which to make a diagnostic decision. This patient can’t have sepsis because their blood tests are normal or this patient can’t have appendicitis because they don’t have a temperature etc.

After the PERUKI annual meeting this week a group of us discussed how we can improve teaching about risk management to  doctors in the early stages of their careers. “Once you’ve made that mistake you won’t make it again” may well embed learning in a particular doctor but it is of absolutely no benefit to the patient who may have been harmed. However this is not an easy problem to solve as a result of Black Swans and related issues:

i) Some events aren’t predictable, or only possibly can be, in retrospect.

ii) It is very difficult to learn from the errors of others, as what might have been presented as the route cause of an issue may not actually have been the underlying problem in that case.

iii) We are still generally beholden to a model of practice that implicitly rewards a “Treat this patient with that presentation and this test as this…” pathway of care.

I pondered with Chris Gough about how being burnt by a particular case was an excellent re-inforcement of the above principles but not a adequate or acceptable education methodology. What Chris suggested was that trainees needed to be ‘singed’.

This is still a practical challenge but there are things that educators can facilitate.

• Highlight minor cases in which a correct diagnosis doesn’t determine outcome but where errors have been made (e.g. non-specific rashes)
• Seek out ‘what if’ scenarios (what would you have done if the white cell count had been normal)
• Actively discuss cases in forums conducive to open learning

All of us need the experience of being singed to avoid patients being burnt.

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This is the 157th #WILTW

During, and since leaving school, three of my fellow pupils have died by suicide. I can not claim to have been best friends with them but sudden loss of life puts into perspective even the most briefest contact or interaction.

Suicide remains one of the last taboos. While public awareness of mental health issues has hugely improved it remains a difficult topic of conversation to have with others. What are you more likely to bring up over a coffee: your fleeting dyspepsia or the fact for the last week you’ve just not been able to see the positive in anything? Neither of these things mean you definitely have serious illness, and both may well be transient conditions, but the latter is often perceived to carry an implication about you.

Mental Health Organisations and individuals dedicated to improving outcomes have had a huge part to play in reducing the stigma of mental health. But the sharing of honest stories, sometimes from unexpected sources, probably has had a sizeable impact on cultural perceptions.

Recently the wife of a doctor in Brisbane who had died by suicide wrote a short, and extremely powerful letter, to the medical community. She didn’t want it to be a secret that her husband, Andrew, had died and wanted people to know how proud she was of him. In response an ENT surgeon, Eric Levi, had some insightful perspectives on the impact that work can have on your mental health, in his words, “..through the dark seasons“.

The blog has been shared over 150000 times.

“I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital” Eric Levi – The Dark Side of Doctoring

I found Dr. Levi‘s piece quite challenging on first reading as his theme of loss of control grated with me. I entirely get the bureaucratic inertia that plagues healthcare professionals. The weight of targets, heavy handed communication and silo mentality at times a maelstrom. One that I have ranted and raved about as much as anyone else. But these are joint problems to sort. I am sure I am as much a part of the problem as I perceive others to be. But if the administration of the hospital will not let me off a clinic the day after the birth of my new born child the system is so rotten as in my mind to not be tenable.

But that attitude makes me as guilty as the system itself.

Andrew Tabner writing powerfully on physician suicide reminds us:

“We need to abandon the macho persona that is often evident amongst doctors, especially those in acute specialties, and embrace well-being initiatives, wellness drives, career sustainability interventions, psychological tool-kits and anything else designed to help us cope with the inevitable stresses and strains that come when your job involves seeing birth, death and every facet of human existence in between, within a single shift”

I am not immune from being in dark places but am lucky, through no action on my part, not to have ever been so low as to consider harming myself.  If we are to impact on the rate of suicide it is going to take continued dialogue within, and between, employees and employers to ensure that early signs of distress are recognised and can be acted on in the most appropriate and facilitative fashion.

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I have taken a slight liberty with the title of this blog. The actual statistics relate to the 20-34 year old group. The title itself inspired by Christoper Young’s comments in Soul Music: A review of Waterloo Sunset 

Post Release Note:

I was contacted by Alys Cole-King (who I had linked to as an individual with a passion for improving outcomes in Mental Health ) post the blog to correct some of my language regarding suicide. Died by suicide has replaced committed suicide.

The following provides information and support on the issues raised above:

Resources for people in distress and those supporting them Staying safe if you’re not sure life’s worth living on line resource for anyone struggling to offer hope, compassion and practical ideas and suggestions on how to find a way forward connectingwithpeople.org/StayingSafe

U Can Cope film and resources The U Can Cope 22min film shares the three inspirational stories of Matt, Anthony and Cathy for whom life had become unbearable but who, after seeking help, are now leading fulfilling lives connectingwithpeople.org/ucancope. 

U Can Cope was designed to help young people develop resilience and cope with any current/future difficulties in their life but is just as helpful for adults. If Feeling overwhelmed and staying safe and for anybody struggling to cope when bad things happen in their life and includes advice on how to make a ‘Safety Plan’

Feeling on the edge helping you get through it:  for people in distress attending the Emergency Department following self harm or with suicidal thoughts connectingwithpeople.org/ucancope

Dear Distressed: Poignant and compelling letters of hope and recovery written by people with lived experience to reach and help others who are struggling with some much needed hope connectingwithpeople.org/wspd16

Tips on self-care connectingwithpeople.org/content/mhaw17