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It’s all the little things.

13 Apr, 14 | by Toby Hillman

This week I have been privileged to be at “the Forum” or to give it it’s full title, the 19th International Forum on Quality and Safety in Healthcare.

The Forum is an impressive event – there were over 3000 delegates from 78 countries, and over the week the virtual presence of the event was significant. At one point delegates were asked to refrain from ‘pledging’ at the top of the Arc de Triomphe as the authorities were concerned that there was some sort of effort to start a revolution (which was sort of the intention, but not in the way they thought….)

The keynote speakers were impressive, global leaders in patient safety, healthcare improvement, and have led some of the revolutions in how we deliver healthcare, and how we think about healthcare in the last few decades. The delegates were impressive too – leaders of national, international and global efforts to improve care for patients.

The keynotes I attended often included a call for action – Maureen Bisognano  @maureenbis asked us to strive to reach escape velocity, not just 10% better but 10 times better than we are doing at the moment – to break the shackles that hold back improvement, and flip to a new way of “doing” healthcare. Indeed – she asked us to move beyond healthcare, and start to focus on health as the outcome we need to improve.

On Thursday was the turn of a giant in healthcare – Don Berwick [@donberwickforMA] to rally the troops. Don’s call to arms was a little different though, and, I felt, was a big risk. Instead of concentrating on the technical tasks of improvement, the challenge of balancing ever more demand with ever higher costs, and diminishing resource, he took us all to a different place.

Don spoke from the heart about his grandson, and the visceral joy it brings him to be with Caleb. And building on Maureen’s wish to see health as the goal, Don set out the case (medical and scientific) for flipping healthcare, and encouraged us to consider how we could wholeheartedly aim for health and wellbeing. He name checked gurus in what might be considered alternative thinking on healthcare, and used a word which was new to me, but got me excited – salutogenesis. (In later conversations with other delegates, it seems I am behind the curve on this one) the keythemes he wished to see included in the debate in the future are in there slide below:


But what about the hard thump of reality that is waiting for me when I get home? I don’t think I will be able to go to my medical director an say outright that we need to create a salutogenetic environment in our hospital and expect to be taken up on the scheme immediately. So for the non-superstar improvers, those who haven’t sparked revolutions yet? What did the conference hold for them?

Well, this was in fact the true message of this conference for me. The big, bold visions and calls to action were great, and my experience would have been less rich without them. BUT – taking a bit of time out to see the posters, and listening to the messages from many sessions on how to implement change, capture learning, use data effectively, I got a very different message.

It is all very well aiming for 10 times improvement in outcomes by flipping healthcare, and helping our patients achieving wellness, but the road to all of this is made up of tiny steps. Be that the simple, but massively influential #hellomynameis idea from Kate Granger @grangerkate or the rearrangement of clinical equipment stores to reduce time taken to get kit together from 2min41s to 26s) at St George’s Hospital, or learning how to tell your story to engage others – it is only through many thousands and millions of small changes, all anchored in the visions set out by the big players that we will achieve any of that vision.

The greatest moments for my own learning came through chatting about a problem I have to deal with at work with a few other delegates – very small, very personal, but it will start to introduce the changes my Hospital needs to make to reach a vision of enhancing health in the population it serves, not just delivering more and more health-care.

So – as one of the many quotes I noted at the conference says – we need to keep our feet on the ground, and our heads in the stars.

I hope that you will be able to make use of the conference resources or the ideas that delegates broadcast via the #quality2014 tag on twitter (even if you out don’t sign up its worth looking at twitter as a reference source for events like this) to start out on your own small change – however small that might seem.


Is it all in your head? – not quite…

31 Mar, 14 | by Toby Hillman


A paper in the current issue of the Postgraduate Medical Journal tackles a relatively modern concern: chronic postsurgical pain.

With the advent of modern anaesthetics, and advances in surgical technique, the potential for surgical intervention to tackle disease exploded.  Indeed, there is now a whole industry based on surgically changing the way people look, which in the early days of surgery would have been almost unthinkable. For example, Samuel Pepys put off an operation for his bladder stone (which caused great pain and many infections) for many years before submitting to be cut by Thomas Hollier. [The lithotomy is now a rare beast, having been superseded by less invasive means of removing stones from the urinary tract.]

So surgery is now a much more accessible, and much safer option for the management of disease than it once was.  However, it is not without its problems, and one which may have been under-represented for many years is that of ongoing pain.  The incidence of chronic pain is quite remarkable, with up to 35% of patients undergoing hernia repair reporting pain more than 3 months after their surgery, and higher percentages in patients  undergoing cardiac or thoracic surgery, and even in cholecystectomy rates of CPSP of up to 50% have been reported.

The paper discusses the pathophysiology of pain, and strategies to reduce the likelihood of developing chronic pain. The concepts of central sensitisation, secondary hyperalgesia, wind-up potentiation and pre-emptive and preventative analgesia are of great interest.

However, as one progresses through the article, a change takes place.  One is guided into the realm of the pain clinic.  Here, it is recognised that pain is not simple, it cannot be neatly captured in a line diagram of the spinothalamic tracts, but that pain is a multi-faceted experience for each patient, that can be influenced by a whole range of factors.  The physical risk factors identified for the development of chronic postsurgical pain are important to note, including surgical technique, repeat surgery, and radiation to the surgical site, but what struck me more was the number of risk factors which could be described as relating to mental wellbeing.  Six of the listed risk factors relate to mental state.

This key component of chronic postsurgical pain is borne out by the authors as they discuss the importance of the fear-avoidance model, and how anticipation, and fear have measurable influences on pain perception – confirmed through neuro-imaging studies.  These insights into the development of a chronic condition, and how patients respond to their pain is hugely important, and their application extends beyond chronic postsurgical pain.

One of the key interventions the authors highlight is the provision of information to patients who are undergoing surgery to enable them to understand what they were experiencing post-operatively.  The paper refernced was the report of an experiment conducted about 50 years ago   that examined the effect of an enthusiastic anaesthetist discussing the expected levels of post-operative pain, non-pharmacological methods of alleviating that pain, and a daily reinforcement of this message.  The results are quite impressive, with a reduction in narcotics required, improved comfort, and a 2.7 day reduction in length of stay.

It is on similar techniques that the enhanced recovery programmes employed by many NHS trusts are founded. Essentially, patients are encouraged to take an active role in understanding their condition, the surgery they are undergoing, and are briefed as to what is normal with regards to pain and limitation post-operatively.

The key intervention for me here is that patients are fore-warned about what they are likely to experience, they are given ‘permission’ to be in pain – and to know that this is not a harbinger of doom, or that they are doing irreparable damage to their newly fashioned wounds.  By being up-front about these experiences, fear is dissipated, patients are empowered, and outcomes tend to be better, even though the surgical technique, anaesthetic technique, post-operative pain regime and environment are all pretty much the same.  The major difference is that the patient has been offered some psychological protection, even if it is not labelled as such.

The lessons learned through the experiences of surgical patients over the years can be translated across many spheres of medicine – the marriage of body and mind is not always perfect, and yet, if we only pay attention to one side of the equation, our patients may well pay the price in the longer term. It is a shame that the lessons published in 1964 are not more widely employed, although the tide is changin.  I am convinced that psychological interventions can play a hugely important part in enabling patients to cope with their long-term conditions, of all sorts.

Despite being the calling card of politicians recently, it really is true that there is not such thing as health, without mental health.

Can do, or should do?

17 Mar, 14 | by Toby Hillman


Modern medicine is advancing at an eye-watering pace, and treatments are being utilised for ever-widening patient groups, who might not have been offered similar therapies even a few short years ago.  In this context, it is increasingly important to know that these remarkably effective, expensive, and life-changing treatments are aligned with the wishes of our patients.

Renal medicine is just such an area where a once relatively rare treatment, offered to relatively few patients (HD) is now being offered to an expanding pool of patients.  In a paper in last month’s PMJ, Davison and Sheerin describe some of the challenges around the provision of HD to patients with CKD.

There can be no doubt that HD makes a huge difference to patients with CKD who require it – both positive and negative.  However, it was surprising to read that some studies have found up to 60% of patients on HD regretted the decision.  Sadly it was less surprising to see that a number of these patients felt that either their families or their physicians played a role in ‘pressuring’ patients to embark on this treatment.

Doctors train for many years to be able to manage diseases, put off the inevitable, and maintain the functioning of vital organs through acute and chronic illness.  As such it is entirely understandable that they would wish to offer treatments they have at their disposal to their patients, especially where these treatments can confer a survival advantage. However, the doctors involved in these decisions may not be best placed to ensure that these treatments are initiated for the correct reasons… and it is a feature of many consultations I have had with patients over the years that they often take actions to please their relatives – even if their own preference might be something else entirely.

As we enter the sunset of the baby boom generation, and we develop ever more effective treatments to treat once terminal illnesses, the medical profession must start to take the idea of patient preference more seriously.  This is especially so where resources are scarce, and making the wrong diagnosis of patient preference can lead to (potentially) years of treatments which the patient may well regret starting in the first place, or to missed opportunities to intervene when assumptions have been made in the opposite direction.

There are two key steps that we must make to move towards true patient choice.

One is by enhancing our skills at sharing decision making with our patients and for specialist services to start developing relationships with patients that allow a better understanding of their hopes, concerns and expectations for the future. As Iona Heath pointed out in her fantastic Harveian Oration in 2011 - GPs tend to deal with one set of patients, but their illnesses change over time, but specialists tend to deal with fewer diseases, but it is the patients that come and go.  As such, specialists will be on the back foot when it comes to developing a deep understanding of the true wishes of their patients, but with time, care and with the right tools  it is possible to get nearer to the ideal scenario for our patients.

The other is to realise that just because we can do something, doesn’t mean that we should.  This last issue may take a little longer to resolve.  Diane Plamping highlighted this ‘can do, should do, and that doing means treatment’ thinking as a central tenet of working in the NHS  in an article for the 50th anniversary of the organisation.  She offered no quick fix, but does encourage us to talk about ‘can do, should do’ with our colleagues.  I would suggest that we should discuss this with our patients.  For those we have known for a long time, we will be halfway towards knowing their true preferences, for those who we have met more recently, we need to afford a little more time to ensure that we make perhaps the most important diagnosis when it comes to long-term conditions – the patient’s preference.

Proper preparation and planning… part 2

2 Mar, 14 | by Toby Hillman

I have blogged previously about the readiness of medical students to take on the role of a doctor when they exit medical school.

The previous paper I looked at highlighted that a significant proportion of medical students felt unprepared for the jobs they were ostensibly trained for, and that this proportion was variable across the different medical schools in the UK.

In this month’s PMJ a new paper continues this theme of preparedness.

The authors designed a questionnaire for all medical students at one UK medical school who had recently completed their elective attachment.  The students had gone to a variety of locations around the globe on their electives, and their experiences of death whilst abroad were compared with their experiences in the UK on other placements.

As one might expect, students who travelled to less developed countries were exposed to a greater number of young patients dying, and less elderly patients. Those students who travelled to less developed countries were also exposed to resuscitation attempts in greater numbers, and a high percentage (26%) were involved in solo resuscitation attempts – which would be incredibly unusual in a healthcare setting in the UK.

The impact of this direct exposure to death amongst medical students was explored with supplementary questions about the availability of time to reflect on the experience of being close to death, and if talking to others (and whom) was useful.

The free text responses to the questionnaire are revealing about how the hidden curriculum of the medical profession is at play in this sphere of clinical practice – with one medical student commenting that, having witnessed a resuscitation attempt, ‘I had partaken in what I thought to be a very important part of practical medical training’

This ‘rite of passage’ is undoubtedly an important part of becoming a medical practitioner – and I would consider a vital experience to have at medical school, rather than finding oneself at a cardiac arrest call for the first time when expected to play a vital role within the arrest team.

Another response quoted in the paper exposed the raw emotions which affect students who witness death : ‘shock—never seen anyone die before’  It is this reaction which should perhaps prompt us to examine how we train medical students and how involved we allow them to become in our clinical teams.

The proportion of deaths which take place in hospital varies widely throughout the UK – as low as 45% of deaths in some areas, and as high as 70% in others(see this interactive atlas for more information) However it is likely that medical students will be working on wards where there are patients who are approaching the end of their life, or are living with incurable or progressive long-term conditions.

Very often – and I know I do this myself, these patients are protected from the parade of medical students looking for ‘signs’ and examination practice.  As such, I wonder if we somehow sterilise the clinical experiences of our students, and create the conditions which pre-dispose our students to unpreparedness for facing death in practice.  If we are to train the next generation of physicians and surgeons who will be skilled enough to discuss end of life care issues, help facilitate advanced care planning and ultimately enable patients to die as they wish to, then we must consider how we can allow medical students to become more familiar with death and dying.

I am certainly not suggesting that we thrust medical students into the mix at the end of a patients life just so that they can ‘experience’ this aspect of care, but we certainly should be bringing death and dying into our conversations with medical students more, and looking to develop learning around death and dying when medical students are attached to firms whose patients may be approaching the end of their lives.

Charities like Dying Matters, the Natural Death Centre, and The National Council for Palliative Care work hard to develop resources for patients, families and professionals who are dealing with end of life issues.  We need to ensure that we bring some of this knowledge into training for our medical students.

It is a shame that  87% of medical students on one course felt that they were unprepared to deal with the death of a patient, and I suspect that this would be a similar finding on other courses.  It is beholden on all who train the next generation of doctors to ensure that our most junior colleagues are equipped with the tools to do the job they are being trained to do – not just up to, but including tending to the needs of patients who are approaching the end of their lives.

How to mend a broken heart…

13 Feb, 14 | by Toby Hillman


photo credit: Mrs Magic via photopin cc

“Doctoring her seemed to her as absurd as putting together the pieces of a broken vase. Her heart was broken. Why would they try to cure her with pills and powders?”


So, it is Valentine’s day – and what better than a bit of medical education about broken hearts.  As it happens, Leo Tolstoy may have been onto something when he wrote Anna Karenina.  Why would one try to cure a patient with a broken heart?

Well, helpfully, this paper examines the question of what non-pharmacological treatments are available for end stage heart failure.

The paper explores the major recent advances in devices for heart failure, and is a great primer for the general physician, or generally interested on the recent advances in medical technology available for those with end stage heart failure.

The devices which grab my attention are those which have the potential to inform patients, and their treating physicians even before symptoms of an exacerbation of their condition occur.

This paper describes three existing systems which can allow patients to monitor their own condition.  The devices use surrogates for fluid overload, or impaired LV function (intrathoracic impedance, left atrial pressure, or right ventricular pressure) and can be used to provide feedback to decision makers to allow adjustment of therapy, pre-emptively arrange admission, or intervene in other ways to avoid an exacerbation.

These advances may represent something of a watershed in the management of this particular long term condition, and in the involvement of patients in management of their own diseases.

For years patients have sought help, relief, and advice from their physicians. The traditional model is that patients attend clinic with their physician, have an assessment which lasts a few minutes, and then a plan is made to last for the next few weeks / months or years.  This doesn’t, however, reflect the lived experience of long-term conditions when seen from the patient perspective.

Patients with LTCs actually live with the condition impacting on their every day life.  Indeed, the condition ultimately can become part of their personal identity.

Recognising that patients live with a particular condition, and yet, are often subject to the decisions made by physicians, and live with the consequences of these decisions until their next visit is vital if we are to understand how to assist patients in taking back control of their disease, developing greater health literacy.

Technology can provide the answers in some cases, but only if we trust patients by giving them back some control.  In the case of heart failure, it seems that providing patients with the ability to monitor various indices can lead to improvement in symptoms, and even lead to an overall reduction in drug treatments.  People with diabetes have been entrusted to control their own blood sugars through self-administration of insulins for many years now, and the provision of action plans for patients with respiratory conditions like asthma, bronchiectasis and COPD have resulted in improvements in overall symptom and disease management.  The blending of technology and self-management is gathering pace, and the opening up of clinical information to patients through systems like Renal PatientView are transforming the way some clinicians and patients approach long-term condition management.

So, on this feast of St Valentine, why not take a look at the options for patients of yours who may have broken hearts, but also think about how utilising advances in technology can help to transform not only disease management, but also change the relationships we have with our patients, and they have with their diseases.






Help! – I need somebody…

1 Feb, 14 | by Toby Hillman

One of the best school mottos I have encountered is that which introduces the General Knowledge Quiz of King William’s College on the Isle of Man.  The motto is:  Scire ubi aliquid invenire possis, ea demum maxima pars eruditionis est.  It  essentially translates as, ‘ to know where you can find anything is, after all, the greatest part of erudition’

I sometimes feel that this should be a touchstone for healthcare professionals nowadays.  Often we encounter situations where we don’t know the answer, and yet, that doesn’t really have such an impact now that we can access focused, accurate and useful information readily – if we know how to use the tools available.

But what is it that makes us recognise our knowledge deficit and press the HELP button?

A paper published in the PMJ has studied what makes emergency physicians consult an emergency poisons advice service. This study found that rates is consultation to the poisons service were significantly lower than in previous studies (only 11.4% of cases were referred), and there were some important differences between those whose cases were discussed with the poison centre, and those whose cases weren’t.

However, female sex, multiple substances, and suicidal intent did result in a higher rate of consultation with the poison service. The day of the week that the case presented to hospital had an influence on referral (more often consulted on Mondays and Tuesdays) and the severity of the incident had a fascinating influence in that if the poisoning severity score was zero (low) or three (severe) then consultation was more likely, but mild and moderate cases prompted consultation less often.

The authors of the paper offer some reasons why they feel the results were returned, but can’t offer explanations for all of the observed associations.

So, for the emergency physicians studied – does a case of poisoning with no symptoms offer few clues as to the required management, or what to suspect – hence the call for help, and is it that odd poisons are ingested on Mondays and Tuesdays, whereas on Fridays and Saturdays it is just the familiar alcohol / heroin which is sadly routine in many EDs in this country too?

The low rate of referrals reported in this paper made me consider my own decision making. What is it that makes me reach for the phone to check on my decision making, and in which situations am I more confident?

Cognitive bias can be defined as a pattern of deviation in judgement, which can lead to illogical decision making.  This paper in the NEJM highlights the importance of being aware of cognitive bias, and advises physicians to undertake regular surveillance of one’s intuitive behaviour.

Many biases can come to bear on the diagnostic thinking of physicians within the ED, and other wards:

Triage cueing – the difficulty of leaving the initial judgements of the triage assessment behind, even when new evidence comes to light.

Anchoring – the attribution of greater importance to a key feature that is heard early in the history.

Ascertainment bias – when stereotyping and prior expectations exert undue influence on a supposedly rational process.

There is also the cultural context to be considered.  This paper on the culture of medicine offers some additional food for thought about why and when we ask for help…

It may not be that cognitive bias and cultural context can fully explain why physicians don’t consult dedicated poison centres when confronted with cases of poisoning, but this paper does provide an opportunity for us to reflect on our own practice – how often do we stop to question our own intuitive behaviour, and consider when and why we ask for help?

Next time you find yourself holding back from asking for help to solve a bit of a diagnostic conundrum, or feeling that you ‘really should know the answer to this one’ just consider if it is your cognitive biases trying to persuade you down a particular route, or that your intuitive behaviour is taking over your analytical thinking – and if in doubt, really do ask for help… especially if it involves poisons.

Medicine – a team sport

13 Jan, 14 | by Toby Hillman


Different uniforms, but we’re all on the same team…

Medicine could once be practised in isolation – indeed, young doctors often found themselves working alone – a situation evocatively described by Bulgakov in his ‘Country Doctor’s Notebook.’  Nowadays, it is almost impossible to work in isolation, and team working is the norm.  Atul Gawande wrote about the different approaches of Cowboys and Pit Crews in the New Yorker a few years ago, and these are a couple of the texts I regularly refer medical students to as we walk along to consult radiology colleagues, or when I ask physiotherapists for their input into a case.

So, we all tend to work in teams.  Some, especially those which form in emergencies – like the crash team, for example, tend to function very well.  Some, particularly those which are distributed across organisational boundaries, and throughout the health economy tend to function less well (in the main.)

In an excellent article (online ahead of print) the importance of effective teamwork for the protection of patients is reviewed, and strategies for improving teamworking are drawn out of the literature.  I have been thinking about teamworking – especially across the traditional divides of the healthcare economy a lot recently, and this piece really brought home a couple of things I had been thinking about.

The paper covers a lot of ground, and mentions several features of effective teams.  Possessing a shared mental model is one of these.  In teams where I have experienced very good team-working, I can see now that this has been at play.  The acute take team sometimes displays this, the arrest team almost always does.  The unifying, common theme, and common training at play when the medical take team tackle a long shift, or the diverse members of an arrest team all work to the same ‘rules’ and ingrained protocols gives an almost physical feeling of common purpose when one is in the thick of it.

In contrast – I have also experienced a very tangible feeling of frustration, disbelief and pure exasperation when I have had conversations with members of the wider healthcare team, when it is clear that those I am working with are coming at a problem from a very different perspective, with entirely different priorities and beliefs about what the outcome should be.

As we see the medical profession move towards an era of ever closer working across the healthcare economy, and as patients start to play an ever more prominent part in the decision making about their disease management, we as healthcare professionals will need to be open to others mental models.  One way to increase such awareness is through training together with members of other disciplines.

To realise this ambition, we need to change undergraduate and postgraduate training:

We still train the doctors of tomorrow to work in the hospitals of yesterday.

If teams working across the traditional boundaries of acute / specialist / general / primary / secondary are to be effective – we need to take this evidence to heart and start developing programmes where professionals work together to build respect, understanding and empathy for each other.  The resulting communities of practice will enhance not only the lives of those working in the teams, but will very likely enhance the safety of those they serve.

Exercise in older adults – time for a New Year’s Resolution?

30 Dec, 13 | by Toby Hillman

Via wikimedia commons

Exercise is good for you – but then we sort of know that already – The Earl of Derby had it right back in 1873 pointing out that

‘Those who think they have not time for bodily exercise will sooner or later have to find time for illness.’  

Take a look at this brilliant animation if you are in any doubt:

But, what about when you get a bit older – (over 65 to be precise)?  A paper in the January issue of the PMJ (Editor’s Choice so it is free!) has examined the current recommendations for physical activity in older adults (over 65), looks at the measurement of physical activity (in trials self-reported activity doesn’t seem to have the same benefits as objectively measured physical activity) and how to increase participation in exercise.

The conclusion is that yes, there are clear health benefits associated with physical activity in the over 65s, but also that there is a rapid drop-off in participation – 20% of men and 17% of women aged  65-74 managed the recommended amount and in the over 75s this dropped to 9% and 6% respectively .  The key barriers to participation in physical activity were ill-health, pain and injury.

The section of this review which caught my eye was the section on the importance of the physician when considering physical activity.

How important is it that physicians give these messages?  The review highlights some evidence that GPs can have a positive impact on participation in physical activity – simply giving advice can have an impact.  If that advice is tailored to the individual, and backed up with follow up from exercise professionals, then there is a positive benefit on uptake of physical activity – and perhaps more importantly, on hospitalisations in the subsequent 12 months.

Along with dietary modification, medication adherence, and smoking cessation, physical activity is another domain to be added to the growing list of behavioural changes which doctors of all types are now expected to facilitate.  But are we any good at it?  The evidence presented shows that actually mentioning the subject of concern is important ( for 38% of older adults in one study had no mention of exercise in consultations) but are we equipped to truly impact on the health behaviours of the patients we meet?

Often messages about health are from the perspective of the doctor, and we encourage patients to adopt behaviours which will deliver outcomes we are interested in (this paper examines diabetes care in this light) Perhaps unsurprisingly, patients often don’t appreciate their problems from the point of view of a national audit or a QoF point counter.  Patients tend to be more interested in outcomes which directly affect them. Even framing problems correctly may not be enough.

So what to do – simply repeating ourselves doesn’t seem to be that logical, so a different approach is required.

At a recent conference one of my colleagues asked a brief but powerful series of questions:

How many of you advise your patients to stop smoking?
How many of you prescribe smoking cessation medications?
How many of you have had training in motivational interviewing or behavioural change?

The answers were telling – the first two questions revealed a forest of hands – the third could barely summon up a shrubbery of positive responses…

As doctors, we are trained to understand pathological processes, to diagnose diseases, and prescribe drugs. Communication skills have come to the fore in training of late, but tend to be based on how to deliver a traditional message in a more palatable form.

To be truly effective agents of behavioural change, we need to acquire new skills. Our current skills tend to achieve adherence to medication regimes in the order of 50% (see a paper here on this)  The precise way forward is still debatable (this review looks at motivational interviewing for physical health) but will undoubtedly draw those of us who care for physical health problems closer and closer to psychological interventions – perhaps it is us physicians who really need to engage in a bit of behaviour change… perhaps a good resolution for the new year?





Is that a smartphone in your pocket?

15 Dec, 13 | by Toby Hillman

Smartphones are almost ubiquitous on the wards nowadays.  In a departmental meeting the other day a question popped up about the commonest reason for admission to hospital acute medical services.

Out came my smartphone, and after a search, and a tweet – almost instantly (and quickly enough to furnish an answer by the end of the session) answers came flying at me through the ether. (It depends on how you cut the numbers, but chest pain is the winner.)

Indeed, twitter is not the only useful educational tool I keep on my smartphone.  I have a number of apps (26 in fact) which can only be used for work purposes.

This paper ( epub ahead of print) looks at the proportion of Interns using smartphones in the Republic of Ireland.  Unsuprisingly the vast majority of interns use smartphones on a daily basis, and the most popular app was the BNF (which is free to NHS employees)

The questionnaire formalises what is common sense in terms of the utility of smartphones for communication within teams – with 87.3% reporting receipt or broadcast of a work related SMS message and 83.3% having made or received a call about work.

More important issues raised in the paper include the use of other smartphone functions – for example cameras, with 52% of those surveyed having taken a picture at work, and 22.% reporting taking a picture for work related reasons once a week.  This use and storage of sensitive information on a personal device is of concern, and that such proportion of doctors use these functions shows just how useful they can be.

What is not examined in this paper is the impact of increasing use of technology – and smartphones in particular on the clinical relationship between doctor and patient.

Many medical students now take notes on their mobile device – often sitting in a clinic room tap tapping away at a screen.  I am sure that most are being diligent and using technology to enhance their learning, but I have no guarantee.  I wonder how I would feel as a patient if a student in my consultation seemed to be organising a night out, or looking up the latest football results?

Indeed – I use a smartphone in consultations with my patients on a regular basis – I have predicted spirometry calculators, risk scores, and the very useful BNF app to turn to when required.  I always tell the patient what I am doing, but I am concerned that this intrusion of technology might put some patients off, or somehow leave them with questions about my bedside manner.

There has been some research into the use of electronic health records in primary care consultations – here looking at the new triumvirate in consultations, and here  how software design can influence how the computer develops a ‘face’ in the consultation.

Some advice on the use of computers in consultations – and how to use them to enhance rather than detract from a consultation has been offered here.

So – I think we have to accept that smartphones are here to stay – and that their utility in clinical practice means that they are going to be more and more prominent on our wards and in our consulting rooms as time goes on.  The rules of engagement when introducing smartphones into routine clinical practice are yet to be defined, but you can be certain that basic manners will be a good place to start.

However, two key points for clinicians will remain:

Listen to your patient – he is telling you the diagnosis.


The art of medicine consists in amusing the patient while nature cures the disease.


Proper preparation and planning…

2 Dec, 13 | by Toby Hillman

There is a basic assumption that medical schools prepare medical students to become doctors.

One might expect that medical schools prepare medical students to broadly similar standards, and that by extension, their students would be broadly prepared for practice when they emerge blinking onto the wards each August.

In a fascinating paper, Goldacre, Lambert and Svirko have analysed the latest responses to a questionnaire sent to each and every newly qualified doctor (from UK medical schools) registered with the GMC in 2008 and 2009.

The responses show an overall improving perception of preparedness amongst our most junior colleagues.  In 1999/2000 only 36.3% of medical graduates agreed or strongly agreed that their training had prepared them for practice, and in 2008 and 2009 this was 53% and 49.4% respectively.

So, things are getting better . Why they seem to be getting better is not clear.  Is training really improving the preparedness of graduates, or is the increasing level of supervision in the workplace protecting today’s FY1s from the worst ravages that previous generations were exposed to?

However, in spite of the improvements, can it really be true that we are barely able to equip half of our medical graduates to feel prepared for work when we unleash them after 5, 6 or even more years of training and education?

And what are the responders unprepared for?  The questionnaire offered some domains for further comment.  In 2008/2009 responders felt unprepared in terms of:

  • clinical knowledge 17.5%
  • clinical procedures 21.3%
  • administrative tasks 31.8%
  • physical/emotional/mental demands 26.4%
  • interpersonal skills 2.7%

Reassuringly the proportion of responders who felt their unpreparedness was a ‘serious’ problem was low at 2.7%, and was a ‘medium-sized’ problem for a further 22.6% (again, a reduction on similar cohorts in previous years)

In addition to the analysis offered in the main paper, the online supplementary data reveals even more stories -for example, one medical school increased preparedness in their students from 33% in 1999-2005 to 62 and 61% in 2008 and 2009, and yet one school continues to have graduates that feel unprepared – with only 24% feeling prepared in 2009, and similarly only 30% in the 1999-2005 period.

So – what is the message here?  There are almost too many conclusions one could leap to, but for me there are some urgent points which need addressing:

1:  There is unwarranted variation across medical schools.

It may be hubris on the part of the full list of graduates from medical school 12, but more than 80% of the graduates of 2008 and 2009 felt well prepared, and yet in comparison, from school 16, 38% strongly felt that they were under prepared.

This kind of variation is not unexpected given the variety of courses, curricula and training opportunities available to the different medical schools in the UK, but for over a third of graduates to feel strongly that they were underprepared for practice demands further attention.  This attention is vital, as the data shows that over time schools can improve, and the domains for which FY1 doctors felt least prepared for are all vital to maintain a safe, efficient and effective workforce (administrative tasks and physical / emotional resilience)

2.  We are not preparing our students for they key aspects of the jobs they are taking on.

The finer details of the survey show that of the domains graduates feel least prepared for, administrative tasks, and the physical/emotional/mental demands of the job rank highly (figure here).

The authors argue that preparedness for administrative tasks could be seen as ‘trivial’ and do not comment further on the physical, emotional or mental impact of working as a junior doctor. Clearly medical schools are not responsible for all of the factors which affect preparedness for practice, but it is vital that as a profession we start to value our most junior colleagues – even before they start to work with us, and ensure that they are developing the tools to help them cope with the demands of what can be a very stressful career.

With proposals to move the date of full registration with the GMC to that of graduation from medical school, the concept of preparedness amongst medical graduates has never been more topical, and if some of our institutions are falling as short as they seem to be in preparing the next generation of doctors, some action is required.


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