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Archive for November, 2014

I took the road less traveled by…

23 Nov, 14 | by Toby Hillman

I took the road less traveled by And that has made all the difference. aia.fernandez111 / CC BY-SA 2.0

Picture the scene – it’s the wee small hours, say around 0330, when the energy really ebbs on a night shift – it is still pitch black and the gentle lightening in the east is still at least a couple of hours away. You’ve been on the go since you started your shift at 2030 the night before. The last patient with chest pain has settled nicely with the gaviscon you prescribed, and you are heading back to the team office for a well deserved sit-down.

The vending machine starts calling at you from down the corridor – a bright light – like a guiding star, constant, ever present – a reassuring island in the maelstrom of a night shift. The bright colours seem to warm you as you approach, and the chocolate offers the prospect of an immediate relief from the doldrums of the night shift, a swift rush of dopamine, with just the right amount of caffeine to get the shift back on track. And anyway, calories on call don’t count, right?

A recent editorial in the PMJ sets out the argument for a greater degree of control over the context in which NHS employees make choices about the food that they eat when they are at work – and how this could have wider benefits to society as NHS workers become advocates for improved diet in their communities.

This proposal is a public health intervention on a bold scale. As Malhotra indicates in the article, effective public health measures, particularly related to perceived choices in lifestyle, are often directed not only at educating the individual to empower them to make better choices, but by altering the context in which those choices are made. That is, move from an obesogenic food environment to a salutogenic environment that positively encourages healthy choices.  This proposal is audacious in view of the powerful compaines that have so much to lose should healthy choices start to become the norm.

Prominent libertarians often protest against public health interventions that seem to curb the choices of individuals – indeed this central to libertarian philosophy… so how much choice does the individual above really have when it comes to what they are going to eat to get through the shift and carry on delivering care over the next few hours? And how much has this choice already been made for them? – the canteen is shut, the crash bleep chains the subject to the hospital grounds, and Abel and Cole don’t do late night take out. The choices really are limited.

But is the consumption of a high sugar, high salt diet the only arena where an illusion of choice exists in medicine?

It may have been an unlucky stretch recently, but of late, I have noticed a few other arenas where the medical profession might be pedalling a ‘choice’ but really are presenting more of a Hobson’s choice.  I have met, and heard of patients who, having looked at the options, weighed up their beliefs, and opinions on the value of a course of treatment, and opted for supportive, rather than disease specific care – both early on in the course of a disease, and in the latter, more desperate stages.

As a result, some of these patients have appeared to be cut off from their treating teams, and left to generalists, to deliver appropriate, but not expert care.  And what have these patients done, except exercise their choice – more insistently and bravely than we do daily when faced with some of the more mundane choices of life in the 21st Century Western Society we inhabit? And so, for swimming against the current, and declining to go along with the conventional rounds of treatments, and escalations to ever more invasive therapies, these patients seem to somehow be treated as if they have personally rejected the physicians offering them, and are therefore offered a cold shoulder.

But as a profession we recognise that the evidence is there that outcomes can be better with less treatment, and that the well informed often take a more conservative approach to management at the end of life.

So whilst I agree that we should support efforts to improve the ability of individuals to make sensible healthy choices about their diets – and any change in the food landscape that makes these choices less one-sided would be welcome…  We must also hold these arguments up to our profession and the ways in which we both propose courses of treatment, and how we react to the choices patients make.

We should not be found guilty of skewing these decisions through a sense of altruism that tends towards paternalism, but instead should ensure that patients have the opportunity to make truly informed choices, and after they have made them, make certain that such pastoral and medical support is available to them as would be had they chosen another option.

Uncomfortable truths.

2 Nov, 14 | by Toby Hillman

Simulation is an educational tool that is almost ubiquitous in postgraduate medical training – with diverse examples of implementation – ranging from video recording of consultations with actors, to full immersion scenarios allowing trainees to test their skills and mettle in managing medical emergencies.  Indeed, it is so established in some fields that there are contests to show off medical skills being practised under pressure to draw out lessons. SIMwars plays out at the SMACC conference each year to great fanfare.

But what if you aren’t planning to demonstrate the perfect RSI on stage or in a video for dissemination around the world? What if you are just doing your day job – how would you feel, and would it be any use to suddenly find Resusci Annie in the side room you really need for a patient with c-diff, and be expected to resuscitate her from a life-threatening condition?

A paper in the current issue of the PMJ looks at just this – the perception and impact of unannounced simulation events on a labour ward in Denmark.

The research team had planned to carry out 10 in situ simulations (ISS), but only managed 5 owing to workload issues in the target department.  The response rate to questionnaires before and after the ISS events was strong.  Within the questionnaire were items concerning the experience of participating in an unannounced ISS – namely the perceived unpleasantness of taking part in an unannounced ISS, and anxiety about participation in the same.

One third of the respondents reported that, even after participating in an unannounced ISS, they found the experience stressful and unpleasant, however, 75% of them reported that participating in an ISS would prepare them better for future real-life emergencies.  The corresponding numbers for non-participants were a third thinking the experience would be stressful and unpleasant, but interestingly – only a third thought participating would be beneficial to them.

These results made me think about the experience of learning, and if the experience is ever relaxing and pleasant if it is truly effective?

I can’t think of many learning environments where I have felt completely at ease providing me with really deep learning, food for thought, or opportunities for development.  Indeed – a great number of my most profound learning experiences, that have taught me lessons I carry with me today – have been truly unpleasant.  These rich educational experiences tend to have involved challenge – requiring justification for a course of action, or the challenge of making a decision that is later to be judged through clinical outcomes, or a challenge to my strongly held beliefs – requiring an exploration of opinions, morals or prejudices.

Now, not all of these experiences have been publicly unpleasant – observed by others, but all have been relatively uncomfortable in different ways.  And perhaps this is key to deep learning – that it requires examination, challenge and reflection, not just sitting passively in a lecture theatre being told facts, or actions to take in a particular scenario.

So when we look at educational interventions employed in postgraduate medical education nowadays, have we lost a little of the challenge that used to be such a prominent part of the ‘learning by humiliation’ approach? We perhaps don’t need to return to the days of Sir Lancelott Spratt.

 

But equally we shouldn’t shy too far away from the idea that learners require a degree of challenge, discomfort, and even unpleasantness to gain insights into how their knowledge is being put into action, and it is far better to receive that challenge within the simulated environment than to have to face those challenges in real life, without the chance to re-run if things don’t go so well.

Magic

 

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