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Archive for January, 2015

It’s good to talk…

28 Jan, 15 | by Toby Hillman

Image by Uberprutser via wikimedia commons

When I think about my work on the acute medical unit, or my clinics, it is almost mind boggling, the number of interactions I have with other humans – trainees, consultant colleagues, radiographers, radiologists, professionals from other hospitals, biochemists, nurses, physios, therapists, and of course – patients.  As Atul Gawande points out in this splendid article, medicine is now more about pit crews than cowboys, and this level of teamworking brings an inherent babble of communication.

The central point of all of this communication is to provide a service to patients – alleviating symptoms, diagnosing and curing disease, or helping patients to manage long term conditions. It would be incredibly difficult to do any of these core activities in healthcare without communicating effectively with patients.

A paper in the current issue of the PMJ reviews the literature relating to the assessment of communication skills within more senior postgraduate trainees (within two years of completion of training) and those who have already become established in practice.

The paper synthesises the evidence on assessment of communication skills, and draws the rather disappointing conclusion that currently there is little in the evidence to demonstrate benefit from educational initiatives, that there is no definitive, validated tool to evaluate communication skills, and that there is no defined standard of what constitutes good communication in the senior postgraduate, or consultant workforce.

The conclusion is disappointing from my point of view, as I consider communication to be such an important part of my day job; but when I think back to my own training, is really not all that surprising.

In my higher training I cannot think of one training session that used any of the methods reported in this paper to evaluate my communication skills.  However, if the evidence is so heterogenous, and there is no clear basis on which to build educational efforts to improve communication skills in senior clinicians, is there any indication that such training is even required?

If we stick to the published evidence on this front, a mixed picture emerges again, with two of the referenced papers indicating that communication skills increase with increasing experience, whilst two others showed that communication skills worsen with increasing time in postgraduate training.

But if we go outside the published evidence on communication assessments, and look more at the outcomes of healthcare, we see that deficiencies of communication play a major role in almost all categories of incident that resulted in death of permanent loss of function investigated by the Joint Commission (an accreditation body in the US.) The Joint Commission estimates that breakdowns or errors in communication contributed to over 50% of post-operative complications, around 2/3 of wrong-patient/wrong-site/wrong procedure events, and  70% of medication error events.

These events are not the well controlled OSCE style scenarios that are traditionally used to evaluate one-on-one communication skills, but are real-life incidents that will have involved all of the complexity of current healthcare provision. Communication in these areas include so much more than those areas traditionally concentrated on in training programmes.

Email, pager, telephone, written notes, electronic health records – post-it notes, all of these forms of communication are used in real life, and perhaps the reason for the heterogeneity of evidence about what makes good communication, and the lack of clear path to improved communication skills is that we aren’t really looking at all the right areas of communication.  Whilst using appropriate non-lexical utterances, empathetic questioning and establishing rapport with patients is very important, we perhaps also need to pay attention to the wider aspects of communication and start to improve outcomes and reduce the number of events where poor communication underpins the error.

There are some recommendations out there about closed loop communication techniques, standardised communication systems (eg SBAR) and other techniques to improve understanding within and across teams, many of which have their roots in the military and aviation industries. These are often resisted by medical practitioners, but as I sit here, watching 24 hours in A&E it is clear that in the critical pinchpoints of communication in medical emergencies, we have started to use more structured, team approaches to communication where the feedback from poor understanding can have an immediate and disastrous impact.

Whilst, as this systematic review shows, the evidence for improving communication skills in senior postgraduate trainees and consultants may be lacking in standardisation, and validation – the outcomes of poor communication are often plain to see.

There is undoubtedly a paucity of training around communication skills in the higher grades of training, and, just because there is an absence of evidence, we should not take this as evidence of an absence of benefit of paying attention to what is one of the core activities we all engage in every day.



I am curious… are you worth your salt?

7 Jan, 15 | by Toby Hillman

Photo by SoraZG on Flickr via Wikimedia Commons

Clinical curiosity is a key trait amongst learners, and in clinical practice, curiosity is necessary to reach a diagnosis of even the most simple nature, but particularly so to diagnose cases that do not readily fit the heuristics that one brings to bear in everyday clinical work.

However, clinical curiosity can be supressed by the requirements to learn a huge volume of ‘facts’, the time pressures of work, a culture where certainty is admired and rewarded, and uncertainty often frowned upon.  Indeed, being able to see a case from many different perspectives, rather than picking a line and sticking to it can be very inefficient, but curiosity is vital to ensure that the first diagnosis for any given presentation isn’t adhered to just because it was the first one made, but is constantly re-evaluated, and tested against new information as it is acquired.

These ruminations on the subject of curiosity were prompted by a chat with a colleague about her often random questions to me about a diverse range of medical subjects.  Her contention to a colleague was that curiosity should be the driving force in clinical medicine, to avoid clinicians becoming protocol-driven drones.

A recent paper in the PMJ also got me wondering a little bit about curiosity, and wondering if in fact we have lost a bit of this wonderful character trait in medicine, and left ourselves satisfied all to easily by diagnoses and treatments that seem right, but don’t quite cut the mustard?

The paper reports a retrospective observational study across three Trusts in London, examining the investigation and management of hyponatraemia in all patients in whom the condition was identified.  Laboratory data were monitoried to identify cases, and once 100 cases were identified, the study stopped. The seriousness of the condition of hyponatraemia was highlighted with an inpatient mortality rate of 16% ( I hasten to point our that there is no claim of causation) and 9% of the patients required ITU admission.

However, what was the response of medical teams at the three centres? Well, it could be described as a little disappointing – with a diagnosis recorded in the notes of only 42% of patients.  And these weren’t just low sodiums one might explain away; to be included in the study, the serum sodium had to be ≤128 mmol/L.

What was actually done for the patients?  To fully evaluate a patient with hyponatraemia and reach a rational diagnosis, and hence management plan, the authors considered that a full set of: volume status, paired serum and urine osmolalities, urinary sodium, thyroid function tests, and cortisol.  A complete work-up was performed in just 18% of patients across the three centres,

And the management – even if a diagnosis wasn’t achieved, what was acutally done?

37% of patients did not have any specific therapy at all, and predominantly patients received isotonic saline.  Cessation of potentially causative drugs was next most utilised therapy, and this was followed by fluid restrictions to various degress,

Treatment failure was recorded in 15% of those treated with isotonic saline, and 80% of patients undergoing fluid restriction, and 63% of patients were discharged with persisting hyponatraemia – and as the authors indicate, this is perhaps not surprising given the lack of diagnosis, and treatment in many cases.

So what is going on?  The most common electrolyte disturbance seen in hospitalised patients is easily diagnosed (try being admitted to hospital without having a U&E sent…) and yet is poorly investigated, diagnosed, and treated.  Is this a reflection of a lack of guidelines, education and therapeutic options as the authors suggest?

I would point out that a simple internet search on any smartphone or computer for ‘hyponatraemia algorithm’ will generate a few options of how to assess and manage patients with hyponatraemia – so availability of guidance wouldn’t necessarily be a major barrier.  However, I agree that there is perhaps not quite enough education on clinical chemistry in the medical curriculum.

But perhaps it is due to a diminution of the curiosity of clinicians – be that a result of the way we educate, train, or the efficiency we expect of our doctors that curbs the desire to seek the truth in complex cases, and leads to a satisfaction with first pass diagnoses rather than cradling diagnostic uncertainty, and going through the full work up that our patients need to manage their conditions.




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