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Patient Safety

In the land of the blind…

13 Jun, 16 | by Toby Hillman

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Leadership is one of those areas of medical training that is increasing in prevalence, and the number of schemes to ensure that medical leaders are available within the workforce is ever expanding.

Some in our profession feel that the ‘leaders’ who are ‘trained’ seem to have few leadership qualities, and even less legitimacy to lead their colleagues than those who possess ‘natural’ flare for leadership. (COI: I have been a leadership fellow in the past)

There is one very well defined team, though, in which very clear leadership is absolutely required, and in which even the most junior member of the team can display leadership, clarity of thought, and situational awareness – the cardiac arrest.

With the adoption of international algorithms, regular training days, a huge manual, rigorous testing of candidates, and mandatory updates – advanced life support has to be one of the most directive environments in which we find ourselves at work.  So leadership is required within the cardiac arrest team, to ensure that the team is working to time, maintaining compressions, and giving drugs when required – and most importantly, to review progress, determine measures of success of failure, and sadly – most often – to ‘call it’ when an attempt has failed.  Leadership skills then, would appear to be a necessary attribute of anyone on the cardiac arrest team.

A couple of recent papers published online in the PMJ raise separate but linked questions about leadership in this most stressful of situations.

A paper on leadership at cardiac arrests helpfully documents data that is a bit of a wake up call for those who ‘lead’ them.

Dr Robinson and colleagues studied the perceptions of leadership and team working among members of a cardiac arrest team.  They surveyed a range of members of the crash team at a n NHS Trust in London that covered two acute hospital sites.  Admirably the survey included wider members of the crash team too – healthcare assistants and nurses, as well as those who carry the crash bleep (pager).

The message I took from the data was that the leaders (SpRs / senior residents usually lead cardiac arrests in UK hospitals) thought that leadership at the cardiac arrest was good in 90% of cases, whereas the ‘followers’ (nurses) only thought that there was good leadership 28% of the time.  And perhaps best of all, 100% of the SpRs strongly agreed that they were confident in leading cardiac arrest response.

In this cohort, around 40% of all groups of respondents said they had experienced a debrief at any arrest they had attended.

The second paper, which looks to provide an answer to the questions posed by the first paper, through the use of a debriefing tool, considering the cardiac arrest response to be a missed learning opportunity  The authors again surveyed their cardiac arrest responders – and found that only about 30% had ever experienced a debrief following a cardiac arrest at their centre.  However, there was a great appetite for the opportunity to debrief in a structured way – using a tool which singles out leadership in particular as a domain of interest (93%).

I think that these two papers demonstrate that, although leadership remains one of those areas which induces feelings of revulsion amongst those who have experienced terrible role models, it is one of those skills which, instead of being inherent amongst the medical profession, requires practice.

What is worse is that those who occupy leadership positions by virtue of their grade of training appear to be mistaken as to their effectiveness, and demonstrate misplaced confidence in their abilities.

Whilst I have been fortunate enough to have had the opportunity to participate in a leadership programme, I don’t think I would anoint myself as the next great thing in the medical profession. However, the training I went through did teach me a lot about the capacity people have for self-deception, and the importance of truthful feedback from colleagues (see this blog from a while back)

I have doubts about the enthusiasm of crash to use a debriefing tool in the immediate aftermath of a cardiac arrest response, but these two studies have gone some way to reassuring me that there has been a shift in the culture of the medical profession to even be studying such subjects.  Long may it continue.

 

 

 

Look not for the fleck in your brother’s eye, but the gorilla in your own…

25 Jan, 16 | by Toby Hillman


Gorilla

Teaching for medical graduates approaching clinical exams such as the MRCP PACES exam is an anxious time.  One is expected to ‘perform’ under pressure, wary of the need to elicit signs leading to potentially outlandish diagnoses.  The breadth of knowledge and skills required to confidently identify CMV retinitis at one station, followed by a complicated communication scenario, with a subtle fasciculation to pick up on at the next is quite a task.  It is also a task that is asked of graduate trainees in almost all specialties – the clinical portion of any membership exam is a vital stepping stone on the route to full qualification and independent practice.

I was teaching some PACES candidates this week, and played my usual game with them – what can I tell by observation of a patient and just watching their examination – that they miss.  This isn’t just a mean trick – I find it helps me to concentrate on what they are doing, and in turn, helps to identify additional signs that might have been missed completely, be unknown, or simply passed off as unimportant.   The gems this week included the white plaster over the bridge of the nose of a gentleman with COPD – which led to a further inspection of the surroundings  – and the tell-tale NIV mask and tubing just poking out behind a bedside cabinet.  The second was the white sheet of A4 stuck at eye level behind another patient’s head with the very large letters NBM written in green marker pen.

In both cases these clues to the wider diagnosis were staring the candidates in the face.  However, it was only when brought to the fore that their implications for the clinical context was appreciated.  So I finished the teaching session having had my fun, and the pupils might have learned a bit more about the value of careful observation, and how this can influence clinical reasoning.  It was only when I got home and read this recently published paper by Dr Welsby on the neurophysiology of failed visual perceptions that I started to consider this interaction a little more objectively and how the lessons from it could be applied in other spheres.

The paper is one of those analyses of physiology and its application to everyday life that makes medical education and medical practice so enjoyable.  Dr Welsby has taken 3 eye problems, and 7 brain problems, and presented them in such a way as to highlight why clinical experience – the act of examining patients, and the slow acquisition of the lived experience of using and applying knowledge over time – is so important in medical education – and suggests several reasons why he feels trainees today aren’t afforded the same opportunities to develop this experience as he was.

The paper can also give lessons for the more experienced clinicians, and perhaps could be used to highlight errors of clinical understanding on a much wider scale.

Essentially, the data our brains work with is flawed – and to compensate – our brains make it up, or completely miss the obvious because we were concentrating on something else.  The paper has links to two videos which are well worth looking up – this one is my favourite.  The video is a perfect demonstration of how easy it is to miss vital information, and when we apply this to the situations we work in daily – it is more impressive that we ever reach diagnoses, rather than that we sometimes get them wrong.

As one climbs the slippery pole of the medical hierarchy, it would be as well to reflect on Dr Welsby’s observations further.  Clinical experience can make what seems impossible to a first year graduate,  second nature to the fourth year registrar.  The development of this experience allows senior clinicians to spend time thinking and working on other problems – but still with the same eyes and the same brains.  Indeed – it is often successful clinicians who are chosen to lead on projects far from the clinical environment, and demand a somewhat different form of observation and synthesis of information.

As more and more clinicians are becoming involved in leadership positions, and managerial roles – those lessons learned at the bedside should not be forgotten.  If the data from our health systems is flawed – the decisions we take to modify, ‘improve’ and reform them will be as flawed as those conclusions reached by a brain compensating for the incomplete information fed to it by the eyes.

Leaders from the medical profession have a duty to both remain patient with their students who miss the ‘glaringly obvious’ but must also remain vigilant for the gorillas hiding in plain sight no matter where they find themselves.

 

 

Aiming for ‘normal’

14 Nov, 15 | by Toby Hillman

Don Quixote via scriptingnews on flickr.com

Normal ranges are papered to the door of almost every clinical medical student’s lavatory door or fridge, inside the cover of every notebook in the wards – accompanying every result on the EHR – everywhere we are told confidently what normal is. But as this paper studying the laboratory findings of several thousand inpatients at a hospital in North London highlights – ‘normal’ is not as clear cut as it may initially seem.

A paper from the hospitals looked at in this study was the subject of a previous blog  which highlighted the variation in practice and often poor implementation of ivestigations into the cause of low sodium values in patients acutely admitted to the three hospitals involved.

This paper has taken a signal from a previous one and has now produced data that questions the validity of the 135-145 range for serum sodium.

The authors noted during their previous studies that many of the patients acutely admitted to the hospital had low sodium results, whilst a cohort of patients from care homes had higher values, and seemed to be dehydrated.  The mortality for patients being admitted rose with increaing sodium concentrations – but the break-point in the graph was within the normal range. So we have a population whose results don’t fit the ‘normal’ range, and a ‘normal’ range that seems associated with increasing mortality:

 

Locally estimated regression (locally weighted scatter plot smoother, LOWESS) plot of serum sodium against mortality for inpatients aged under 65 and 65 and older.

 

Clearly these retrospective observational studies shouldn’t have lab managers running around redefining normality and encourage us all to drive our patients’ sodium to the lower half of normal in an attempt to save lives…

BUT and it is a big but that deserves capital letters – we do need to work out who defined normality.  Thankfully Prof McKee and his colleagues have done a bit of digging for us and give a potted history of the normal range for sodium measurement. And it turns out that this range – embedded in millions of memories the world over is actually based on comparatively few data points – the first papers used about a hundred healthy volunteers using flame photometry – a technology that is largely superceded by more accurate methods.  The subsequent studies they refer to us up to a 1000 measurements (often in multiple sub-groups) from which they drew their conclusions.

How can this be? Surely we don’t just take decades old evidence and allow it to heavily influence our treatment plans, delay discharges and so on?

In this case the answer seems to be… yes.  However, this is not the only sphere of medicine where old data continues to heavily influence current practice.

Oxygen is one of the most commonly administered, but not prescribed, drugs in the formulary. In COPD it is one of the few drugs that has evidence for influencing mortality, rather than simply altering a trajectory of decline…

And the evidence for this? It is predominantly based on an MRC funded study from the late 1970s that included 87 patients.  That evidence was enough to change practice, and alter lives I am sure, but it probably would not stand up to scrutiny for the basis of a major shift in practice nowadays.  The linked paper on sodium measurements, for example looks at more than 100000 samples and trials of therapy in COPD looking to demonstrate a mortality benefit now need to have thousands of patients (the TORCH trial enrolled 6200)

So what is truly normal, are any of our favourite ‘common sense’ treatments justified in modern medicince, do we do anything right in our every day practice?

Clearly yes, there have been huge improvements in survival from many diseases over the decades, and common medical practices are clearly successful at identifying pathology, seeking out the underlying disease, and then targeting that.  However, when confidently stating that something is the correct strategy to pursue, we should also be mindful that our convictions might just be based on less than solid ground.  And this uncertainty is at the heart of a healtyh academic examination of our medical practice on a daily basis.

We should not be paralysed by doubt, but we should have a healthy degree of scepticism when appraising both existing practices (the PANTHER IPF trial is perhaps one of the most significant turnarounds of recommended practice triggered by high quality trial evidence) and when new technology comes along (see this blog on troponins in acute medicine.)

So next time you are on a ward round, and find yourself struggling to guide a patient towards ‘normal’ for a biochemical test, or some other finding that we all ‘know’ to be true – you should perhaps make a mental note and work out from the evidence if all we are doing is tilting at windmills, because that is what we have always done, or if there is a genuine reason to strive for that particular outcome.

Service, safety and training – a tricky trio.

16 May, 15 | by Toby Hillman

The National Health Service is more than a health service, is is perhaps one of the biggest postgraduate universities in the world.  Within the corridors, operating theatres, and wards of the hospitals in the UK, healthcare professionals are learning.

They are taught by example every day, and increasingly are allocated time out of the service to learn at dedicated teaching days / seminars and courses.

This key role of the state-funded health service in the UK can sometimes be forgotten, or hidden away under the demands to provide a service to the sick and needy that are entering hospitals in ever-increasing numbers.  But ask patients who are in any of the teaching hospitals in the UK, and I am sure that they will be familiar with the request for a student to practice taking a history, or performing a clinical examination.   Alongside students, there are many more trainees of different levels of seniority who also ask permission to learn from patients: patients consent to procedures where a trainee will be carrying out the procedure, under the supervision of a colleague who is fully qualified.

This type of learning is essential to ensure that the next generation of doctors is suitably skilled and qualified to deal with the problems they are to encounter during their careers.  These procedures might be simple – like inserting a cannula, or a urinary catheter, or far more complex.

Recently there have been pressures on this style of training.  Opinions differ on the relative impact of each development, but the European Working Time Directive, competency based curricula, formalised workplace-based assessments and streamlining of the training career ladder have all affected how we train teh next generation of Consultants.

The increasing concern for patient safety, and the increasing awareness of patients about potential complications have resulted in less invasive procedures being carried out by general teams, but instead by specialists in more controlled environments – conferring undoubted benefits to the individual patient receiving the treatment.

This situation leaves us with a tension – trainees need to train, patients require a service, and patients need to be safe.  To train safely, trainees require willing patients, supervision, and opportunities to learn techniques in a safe, supervised environment. Increasing pressures on services have led to a situation where taking time off the ward to attend such opportunities seems beyond reach, and negatively impacts on the care of other patients within the same service.

BUT – emergencies happen, our trainees are usually the first on the scene, and will need skills usually developed in elective procedures to deal with the emergency confronting them.

So, in the modern world, are we balancing this tension – are we giving trainees the chances to develop the skills we expect of them, whilst ensuring the patients who kindly offer the opportunity to trainees to learn are safe – both electively and in the emergency setting?

A paper published recently online in the PMJ takes a look at this question in one area that sits right in the middle of this conundrum – the insertion of intercostal chest drains.

This core skill for general physicians is increasingly becoming the preserve of respiratory specialists, and even then, is becoming the preserve of sub-specialists.

The paper looked at attitudes, experience, and training in chest drain insertion.  The results are interesting, and pose very important questions for those who train general physicians, or any trainees where procedures are considered a core skill.

Overall, there was consensus that general medical registrars (general physicians) should be able to place chest drains, and that the procedure should not become a specialist only activity.

So – general medical trainees should be trained… but how much did they think was required?

Overall, trainees and consultants agreed that to be considered competent, an individual must place at least 5-10 chest drains, and to maintain this competency, must place 5-10 per year thereafter.

And… how did they do compared with their own standards?

Higher trainees (senior residents) who are most likely to be the ones called on to perform these procedures urgently had, in the main acquired the suggested number of drains to be called competent.

But only 5% of those who weren’t Respiratory trainees had been able to maintain their competency – as defined by their own standards.

So – as the authors conclude, chest drain insertion is a vital procedure for a service to be able to provide, but those we rely to provide this service – by their own admission, cannot maintain the necessary competence.

This is a worrying admission to make, and should ring alarm bells for those managing acute medical services, and those charged with the education of doctors within the university that is the NHS.

The solution will not be a quick fix, but it seems that the relationship between training, service and safety has changed in recent years.

This tripod is a tricky one to balance, but if one leg grows out of proportion to the others, something is bound to fall over…

Picture by RetSamys

Still only human

13 Feb, 15 | by Toby Hillman

A perfect specimen?

There is something different about medics.  We stand out at university – often forming into a clique that others find difficult to fathom, break into, or tolerate.  We strive to be different in many ways; we learn a huge range of facts and figures, along with new languages ( we are taught about everything from the arachnoid mater to xanthelasma, via dysdiadochokinesia) and new ways of behaving – “Hello, my name is…. I’d like to examine your chest if I may?”

This difference has been reinforced over centuries, helped along by the formation of royal colleges, and more recently, by real successes in actually curing some diseases, and managing others so that hospitals are no longer feared as places of death, but instead as places of relative safety for those needing their services.

I think that this paper in the January edition of the PMJ may help to take us back to our roots a little.  The paper is a quality improvement report looking at the impact of a mnemonic device on the completeness of information recorded in the notes in a paediatric department.  The problem was that documentation was of a poor standard, impairing the investigation of complaints and incidents.  The solution used an acrostic to help junior doctors record the important aspects of care that are encompassed within the post-take round.

Results were impressive, showing an increase in completeness of the notes in areas that were previously neglected, including parental concerns, fluid prescriptions, nursing concerns, and investigations.  Understandably there was less increase in areas that had been previously well documented – the final plan, vital signs, presenting problems, and examination findings.

So we can see that, in a time-pressured, complex situation, the junior members of a team find that they are better able to record relevant information when following a set pattern of information recall / record for each case.  This is not perhaps a Nobel-worthy discovery, but it is an important contribution to the ongoing realisation in our profession that there are tools and techniques we can use to enhance our practice, and improve safety and outcomes of the processes we use in our daily work.

Many of the ‘new’ ideas in healthcare like LEAN, six sigma, crisis resource management, human factors training, pitstop handovers, checklists and so on have origins outside of medicine, and in other high-risk, high-reliability, or high value organisations.  The impact of these ideas though can be significant, and in some cases hospitals have been impressed enough to adopt philosophies from industry wholesale – notably the Royal Bolton Hospital.  The medical profession itself though is usually somewhat more reluctant to adopt these concepts, and apply them in practice.

The resistance to checklists, communication methods like SBAR, and other tools that seem to constrain clinical autonomy provides an interesting point to consider.  Is there something inherently wrong in encouraging medics to communicate or work in standardised ways?

Well, no. The ALS algorithm – much maligned by those who have to repeatedly take assessments and refresher courses using the same stock phrases, and act out scenarios that have an uncanny knack of ending in a cardiac arrest – has had great success.  Indeed, when you think of the teams that work in any hospital, the arrest team is one of the most efficient in terms of understanding  common purpose, using a common language, and following a set pattern of actions.  This process even works across language barriers as Dr Davies showed in this article.

And yet, there is always something uncomfortable about being asked to write / think / talk / communicate in a particular way as a medic.  Is this because we are somehow different from those other human beings working in complex, challenging environments?

My feeling is that perhaps we aren’t entirely to blame for our reluctance to adopt these ‘new’ ideas of working.  The hubris required to enter chaotic, painful, emotional situations, take control, decide on a decisive course of action, and do this within a very short space of time is bred into us from the point at which we decided to become doctors.  As I said at the start – we medics are different – and have been since we started on our journey to the positions we now hold.

And therein lies the rub. When it comes down to it, we aren’t really different from those we try to guide through the challenges of illnesses both acute, long-term and terminal. We have the same brains, same cognitive biases and same susceptibility to distraction, and therefore next time you are asked if you can follow an acrostic, use a checklist, or submit to a protocol – before rejecting the concepts out of hand, consider if you are doing so because the tool really isn’t fit for the job, or if you need to follow the advice of Naomi Campbell – don’t believe your own hype.

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.

 

 

Are you safely socialised?

26 Aug, 14 | by Toby Hillman

Social Animals

Social Animals

Changes in role within the medical profession are times of great upheaval.  One of the most challenging is the change from being a medical student to a fully qualified doctor.  A cohort of medical students qualifies every year around June/July time, and members of this cohort take their first steps on the wards and in clinics as junior doctors each August.  Recent guidance has enforced a period of shadowing and induction for all newly qualified junior doctors in the UK before they start their first jobs – in recognition of the fact that schemes with targeted teaching and shadowing can reduce safety incidents by a significant margin.

At other points in the medical hierarchy, there tends to be less focus on the doctors changing from one grade to another.  However, at Consultant level, the stakes rise, and organisations often spend a little more time considering how to smooth the transition from trainee to fully independent practitioner.  Mentoring – a two way learning process between a senior and junior member of a team, organisation, or even healthcare system – is a concept that many organisations have identified as being beneficial to new consultants, and mentoring programmes exist in a fair number of hospitals.  Like many relationship-based exercises, there is a deal of trial and error involved, and mentoring relationships don’t always work out perfectly.  A paper in the PMJ recently examined what makes mentoring work for new consultants.

The authors interviewed new consultants and senior leaders within acute hospitals in the Yorkshire and Humber region of England and through thematic analysis, six major themes were identified.  These included the protective nature of mentoring – both protective of patients under the care of new consultants, and of the consultants themselves; the mechanics of the process of mentoring (variability in expectations, informal and multiple mentors, the importance of personality in the mentoring relationship) and the prominence of mentoring as part of professional identity.

This last point struck me, and led me to wonder about how different specialties socialise trainees, both in their approach to interpersonal relationships at consultant level, and potentially to much wider aspects of care.

Professional socialisation is a fascinating concept – it has been studied in a diverse range of professions – from the clergy to the military – and within the medical world, plays a huge role in setting the culture of different departments, and probably specialties.  One teaching hospital training scheme I know of had a throwaway line at the back of the trainee handbook that spoke volumes about the culture of the specialty: ‘remember, you are an xxxxx-ist : keep it cocky!”  This encapsulated perfectly the culture of the trainees in that particular specialty within the region, and I now recognise this as one part of what is commonly held to be the ‘Hidden Curriculum’ of medical education.

The paper examining mentoring schemes mentions that three specialties in particular may lend themselves to more natural mentoring relationships – surgical specialties in general, gastroenterolgy, and anaesthetics.  I wonder if the craft nature of these specialties demands a closer supervision during training – where consultants are less willing to let trainees gain experience on their patients unsupervised and therefore engage in more hands-on training, engendering close working relationships? Or perhaps it is less high-brow than this, and the downtime between cases in these procedure and list-based specialties offer the opportunity for trainees and seniors to develop more meaningful relationships than in other specialties where the clinic room, or set-piece ward round is the main arena of interaction – affording less opportunity for relationship building chats and debates.

So, if certain specialties prepare new consultants better for mentoring relationships, and mentoring is thought to be a positive influence on patient and employee safety, do some specialties socialise their workforce to be unsafe, to reject a collegiate approach to work, and impair the personal development of their practitioners?  The hidden curriculum is at play in all spheres of medical life, and it pays to look around from time to time to ensure that you aren’t sleepwalking into a culture that is detrimental to the safe conduct of healthcare, but are an active participant in a culture that promotes sharing of lessons, and fosters and develops individuals as they climb the greasy pole of their medical careers.

 

 

What do all those numbers really mean doc?

15 Jun, 14 | by Toby Hillman

 

What is ‘normal’

Go into hospital nowadays, and you will do well to escape without having a blood test of some sort.  Very often these are routine tests, which give doctors an overview of the state of play. There might be a few wayward figures here or there – but the doctors will ignore them, or explain them away as part of the normal variation of homeostasis.

In the PMJ this month the spotlight turns to one biomarker that is commonly requested when patients are admitted to hospital.  Indeed, the troponin is one test which I see regularly used completely out of context, and providing information which is often difficult to assimilate into the clinical picture.  The paper – an analysis of >11000 admissions to a large medical facility in Dublin, Ireland has examined troponin results for all admissions under the medical (but not cardiology) service from January 2011 to October 2012.

Now, the troponin is a test that has undergone a change over the time that it has been available to clinicians in everyday practice.  I can remember taking serial CKs in patients with suspected myocardial ischaemia, and my joy at the troponin becoming available for use in my potential CCU patients.  I can also remember the many patients who have been admitted to hospital for 12 hours just to see what their troponin will be – a clear case of a biomarker dictating practise, rather than been a tool for me to use.  And I have many memories of strained conversations with colleagues about the meaning of a mildly raised troponin which had been requested as part of a bundle of tests at the point of admission – without any real thought being given to how one might interpret the results.

These strained conversations have altered in tpne over the years as the blind faith in the value of troponin to indicate ischaemic heart disease which accompanied the hype of the test when it was first released, has been eroded by realisation that troponin is no way near as specific as we were once led to believe – and interpretation now requires quite a lot of Bayesian reasoning to clear the waters.

The article looking at troponin tests on the acute medical take makes a fascinating read, and helps provide some data to the consideration of the not uncommon problem – “well what do I do with this result now?”

The answer in the case of an unexpected elevated troponin is to consider the overall clinical context, and attempt to understand where the physiological stress has proceeded from, as this study shows a significant association between elevated troponin and mortality:

Exponential relationship between high-sensitivity troponin assay (hsTnT) results and in-hospital mortality.

So – a helpful paper looking at a common clinical scenario, and providing a fairly robust argument for how to approach the problem.

But one of the most fascinating parts of this analysis is the determination of what is ‘normal’ and why do we love to have such binary answers to complex questions?

The manufacturers of the assay employed recommend a cut-off of 14ng/L for the normal range. But, given that the test isn’t as specific for myocardial injury as they would like – a figure of ≥53ng/L should be used to indicate myocardial ischaemia. For the purposes of the published study a figure of <25ng/L is used as the cut-of for normal, and ≥25 as ‘positive.’

The persistence of a desire to classify a test result that the outcome of this large observational study indicate is a sliding scale, indicating physiological stress, rather than any specific disease process (in this study that effectively excluded cardiac disorders as the presenting complaint) into normal and abnormal categories belies a huge cognitive bias that we all carry around with us. Essentially we like to make judgements based on prior experience, heuristics, and easily interpreted chunks of information – what David Khaneman would call a ‘System 1″ or ‘fast” process. We do this regularly with a high degree of accuracy when on the acute take.

What this paper could be seen to do is boil down a clinical problem into another readily available answer, that can be applied in everyday practice – to me, it is a reminder of the blind faith I used to have in a test that I and it’s manufacturers understood poorly, and drove clinical protocols and pathways, rather than me applying some critical thinking to my actions, and their results – and using the test to its best effect.  I wonder how many more biomarkers we will see undergoing this sort of evolution.

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.

Scribes and scribbles

3 Nov, 13 | by Toby Hillman

Poor communication is often at the root of complaints about clinical care (see here and here)

Poor communication with patients is concentrated on in a number of spheres of medical education – the CSA exam from the Royal College of General Practitioners is an example where consultation style and communication is assessed as a key outcome for career progression.  Medical schools deliver communication skills training, and postgraduate training (especially for General Practitioners) sets a premium on communication between healthcare professionals and their patients.

In the background is communication between healthcare professionals within a team, or on different teams.  Acute situations are often covered well, and the ALS training system is a good example of creating a common language which enables swift understanding and communication in a time critical situation. Work within simulation labs in particular is bringing communication tools from other industries to bear on emergencies, and ‘crisis resource management‘ – with an emphasis on team communication is very much part of the current vogue in anaesthetic training (among other specialties)

But what about that staple of the medical world – the notes? Are we all trained as well in communicating in the written form?
As electronic notes loom on the horizon, perhaps it is understandable that note writing is becoming a lost art, and flourishes with a fountain pen becoming a rarity.

However, until we reach the nirvana (?) of a fully electronic patient record, we still have the task of communicating the complexities of a clinical examination in the notes.

An organ close to my (and your) hearts – is the lungs.  Examination of the lungs with a stethoscope has fallen out of favour in some quarters  but remains a key procedure in investigating the acutely unwell, or recuperating patient.

In the PMJ this month is a great paper on the use of different symbols used in medical notes to ‘describe’ findings in the chest examination – and the conclusions make a lot of sense. I was surprised to see foreign symbols which would make no sense to me at all, but reassured by the simple advice to make these hieroglyphics more understandable.  Below is one of my standard examination pictograms. I seem to have a different dialect from the studied population for wheeze, but agree with them in general for crackles…

 

My depiction of the study clinical description

A set of lungs with wheeze in the lower zones, and crepitations at the right base.

 

A common language would be the ideal, and this paper shows how we can improve this small but vital part of our communication in the notes.

When thinking about how to tackle this on a wider scale, it is tempting to think that to improve the accuracy, relevance and quality of note-making, the most senior member of the team during that consultation makes the note.  This is not the usual experience on ward rounds – where the most junior member of the team often scribbles down their interpretation of a consultation and then defines the actions taken by the team thereafter.

To enhance educational opportunities on the ward round, improve team understanding of the case, and the patient’s understanding of what is happening to them, Dr Caldwell in Worthing uses a technique which is discussed on this thread

The PMJ paper sets out the variation possible in understanding a ‘set-piece’ of clinical examination when written in the notes; we need to take the lessons from this and apply them more widely – to improve communication – which will in turn enhance patient safety, and potentially experience and engagement too.

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