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Archive for September, 2014

Professionalism – a team game

29 Sep, 14 | by Toby Hillman

Frm LibAmanda on Flickr. CC by 2.0

Professionalism is one of those peristent themes that run through medical education, and through the comments that are passed whenever there are concerns about clinical performance – be that the perceived clock watching engendered by the EWTD, or the failings at Mid Staffs.

Very often the term is used to highlight either a failing, or an upstanding quality in an individual and when I think of examples of high levels of professionalism, I tend to think of individuals and their reactions to particular situations, how they conduct themselves, or their dedication or discipline within the workplace – be that on the international sporting arena, at work, or in the headlines for other reasons.

What I hadn’t really considered (and perhaps this is a failing unique to me) is that professionalism is a team game.  However, I am having my eyes opened to the concept of professionalism as more of an active team game.  A paper published in the current PMJ discusses the results of an experimental series of 90 minute group discussions about professional matters in a safe environment or ‘legitimate space’ where talk of professionalism was deemed to be valid.

The paper is an exploration of the themes that the discussion groups generated over the course of 6 months, and their impact on the participants.  Key findings the authors draw out of the data are that the ‘storying’ of experiences related to professionalism within a legitimate space may help to foster professionalism within organisations, that the act of discussing the nature of professionalism can encourage the development a form of professionalism that considers not just the individual, but the team, work, and culture of an organisation, and that simply having a group to focus on professionalism enables discussion and learning about the subject that simply isn’t possible the the normal routine of daily work.

The ideas that caught my imagination within this paper though, were those of professionalism being a collective practice.  This may seem to be so obvious as to not warrant comment, but I think a little further consideration is due.  There is an interesting tension within the common definition of professionalism as listed in dictionaries eg:  “The competence or skill expected of a professional.”   that is – the expectation of a standard of behaviour defined, or set by a group, but expected of the individual.

This paper highlights the success of the intervention to foster a feeling that professionalism can be more than just individual actions/conduct, but is a collective venture. Professionalism is one of those ideas that when a group comes together, and discusses it intently, can glow brightly like coals in a fire, but when the individuals are taken out of that context, it falls to the background as the slightly nebulous concept that characterises a certain approach to situations, and the glow fades a little.  By bringing the implicit presence of professionalism into the legitimate space created by these groups, the concept of professionalism becomes more valid, and the trials and tribulations that everyone faces on a day to day basis can be used to learn lessons, share experiences and plan for the future.

The connections between individuals that are generated by this recognition of a professional basis to practice are could well hold the key to starting to change the cultures of organisations – the professionalism of one individual is a stimulant to professional behaviours and attitudes in others, and so the ripples continue ( I have blogged elsewhere on positive conversations in organisations.)

So what next – what will this do for me and my practice?  I don’t necessarily have the resource and time to start up a series of group events to foster professionalism within my teams, but I have been reminded of my potential impact as a role model for junior members of my team, the positive and negative ripples that I can generate, the interconnectedness of modern medical practice, and the need to sometimes bring slightly hidden concepts of professionalism to the fore – as the main subject for discussion.  With this, I hope I will be more effective in developing and fostering professionalism within my sphere of influence.

Too much medicine…

10 Sep, 14 | by Toby Hillman

Pills

 

A famous quote from the eminnet paediatrician Sir Cyril Chantler was published in the BMJ in 1998:

“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”

As medicine progresses, it is worth keeping this in mind.  The complexity of modern medicine is one of the challenges that has led to a deal of dissolusionment with with Evidence Based Medicine movement – and the recent calls for renewal of the principles behind EBM from Trish Greenhalgh and colleagues highlights the importance of relating evidence to the individual being cared for, rather than just the guidelines that relate to the ‘perfect’ patient.

A paper recently published in the PMJ on the risk factors and features of non-variceal upper GI bleeding in inpatients, and its relation to antithrombotic drugs made me think again about my own practice, and probably the practice of a great many colleagues of mine up and down the country.

The paper examined cases of NVGIB at the University Hospital Crosshouse in South West Scotland.  The investigators looked at all cases of NVGIB in their hospital over a period of 12 months, to understand the risk factors associated with this condition, and in particular the role that antithrombotic drugs play.  The investigators split the patients into two groups – those developing NVGIB as inpatients, and those presenting to hospital with bleeding symptoms and signs.  The data were collected as part of an ongoing prospective examination of the epidemiology and management of upper GI bleeding.

The two groups showed some interesting differences – those developing bleeds as inpatients tended to be older, more likely to be female, were on more antithrombotic medication (particularly non-aspirin drugs), had more cardiovascular disease, and have higher Rockall scores than those presenting to hospital with bleeding.

The authors conclude that secondary care physicians looking after the older female population that suffers with cardiovascular disease should consider more strongly the need for prophylactic anti-ulcer therapy.

This advice would seem to be borne out by the evidence, and is a practical solution.  The paper did not examine the appropriateness of the use of anti-thrombotics in the first place – it would probably be beyond the scope of an observational study such as this.

However, as I read the paper and the conclusion – that more medicine is probably where the answer to this conundrum lies, I wondered how many of these elderly ladies derived significant benefit from the additional anti-thrombotic medicines they were prescribed.  This is pure supposition, but I wonder how many were given their new drugs in response to an admitting complaint that perhaps didn’t completely justify the use of powerful, complex, dangerous medicines?

I can easily imagine a patient presenting with some atypical sounding chest pain, some breathlessness accompanying it, who is written up for “ACS protocol” medications on admission, and spends a little time awaiting investigations to rule in or out significant cardiac disease.  After a couple of days the patient may develop their bleeding complication, and on the story goes.  The patient has probably had great protocolised medicine, and has had their risk factors assessed, and their symtpoms noted and reacted to, but perhaps their whole situation hasn’t been weighed up.  For example, the application of the “ACS protocol” to patients who don’t fit the evidence base (eg those with a history, but without ECG changes or enzyme elevation were excluded from the CURE trial after the first 3000 patients) may not be great evidence based medicine – but it is often a protocol applied to patients presenting with cardiac sounding chest pain to the acute medical unit, prior to the full information, and therefore full estimation of benefits and harms can be considered.

When we then consider the solution to this conundrum seems to be to add in further medications to offset the harms of those potentially initiated on a less than optimal basis, I wonder if we aren’t just ending up chasing our tails.

Maybe we need to come back to Sir Cyril again, and finish off his quote:

“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous. The mystical authority of the doctor used to be essential for practice. Now we need to be open and work in partnership with our colleagues in health care and with our patients.”

It is the being open, and working in partnership with our patients that will deliver the better results.  Lets be honest – if a story doesn’t sound quite like a high-risk ACS then perhaps we could wait a bit for the evidence to back up our proposed management plan, and avoid overtreating, over medicating, and harming those at highest risk of both ‘natural’ and ‘iatrogenic’ disease.

 

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