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Collusion, illusion, or delusion?

22 Nov, 16 | by Toby Hillman

fending_off_death_1_by_wiebkefesch-d3gy6ac
Fending Off Death 1 by wiebkefesch on DeviantArt

Doctors are – in the main – trained to prevent death.  Modern medicine has made huge advances, and life expectancies continue to rise.  However, there remains only one certainty in this life – that we are all going to die.

Patients in the last year of life are common in hospital.  Data from a 2014 study showed that nearly 30% of patients in hospital are actually in the last 12 months of their lives.  However, identifying these patients, and appropriately managing their last few months of life is notoriously difficult in those patients with chronic diseases like COPD, and in patients where multi-morbidity makes such predictions even more complex.

Patients receiving palliative chemotherapy for lung or colorectal carcinomas have been found to have an overly optimistic view of what their palliative treatments will achieve.  A 2012 study published in the NEJM showed that patients with stage IV disease overwhelmingly (93.6%) opted for chemotherapy treatments.  And of those that received chemotherapy, 69% of those with lung, and 81% of those with colorectal cancers wrongly felt that the treatment might offer a chance of a cure.

A study published recently in the PMJ from Dr Jeba and colleagues in Tamil Nadu looked at the prevalence of collusion during consultations with patients being seen in their palliative care clinic.  The authors defined collusion as consultations where information was withheld from the patient primarily at the request of family members.  There was surprising number of patients who made it to the palliative care clinic without knowing their diagnosis at all (18%), and collusion regarding diagnosis or prognosis was present in 40% of cases referred.  Of these, within a month 58% had had this collusion addressed.  The remaining cases were thought to be those where the family request for information to be withheld was very strong and persistent.

The study looked at factors which might be associated with collusion and found that collusion was more prevalent where female patients were affected, and was more prevalent amongst patients whose occupation involved manual labour.  It was felt that cultural norms will have led to a bias against women being fully involved in decision making.  Manual labour may have been a surrogate for educational attainment – and it is well described that less educated patients often have less information needs.

Fascinatingly, the study also revealed that if the family member attending the clinic was the spouse of the patient, collusion was very much less likely.  Perhaps the presence of one who knows the other so well simply means there are less opportunities to hide feelings and knowledge.  Other than trying to ensure that the spouse was present when a diagnosis was being discussed, no firm conclusions were made.

These three scenarios – doctors chasing an illusion of wellbeing – patients believing in a treatment will do what it emphatically cannot  – and finally collusion between treating doctors and relatives – are all important reminders that doctors hold a vital position of power, and how we wield this power has a significant impact on the patients we consult with, treat and comfort.

The delusions, illusions and collusions we all engage in as physicians are well-intentioned, but as the internet democratises information, and patients are no longer so willing to be advised directly on a course of action or of treatment – doctors must change.

We must truly reflect on our interactions with patients – and work out if we are peddling a myth, and if we are, why? Is it our own biases, experiences or fears?  And if we are acting in the best interests of the patients – have we actually given them an opportunity to express their opinion?

I suspect that if we do each of these things – we might find that the ones who have been a little deluded – chasing an illusion – are ourselves.

All in a day’s work

20 Oct, 16 | by Toby Hillman

24-hour-clock

Becoming a doctor is a long and arduous process.  It involves many years of study and more of practice.  It is inconceivable that this process leaves those who go through it untouched.  This process is called professional socialisation.  It confers values, and behaviours on the participants, and these help to mark our profession out from other groups in society.

The following reflection is from Dr Ciara Deall, a trainee plastic surgeon, recalling events which took place on a flight to North America, and in which her training allowed her to offer a stranger comfort, despite being off duty – a state that perhaps is never truly realised by those whose vocation is the practice of medicine.

We had cleared the west coast of Ireland and I was beginning to relax on flight AA365 heading for New York and a weeklong, intensive microsurgery course. Just time to let go of a non-stop week of on-call mayhem and enjoy some inflight entertainment to help wind down.

The intercom interrupted abruptly: “Hi, this is the chief steward, will any medically trained passengers please make themselves known to the crew; we have an emergency.” Almost without thinking I found myself standing up and telling a stewardess I was a doctor, before wondering what I might be letting myself in for – a stroke, anaphylaxis, heart attack, choking? Was I the only one?

The 19-year old girl was doubled up in agony, clutching her stomach, clearly very frightened and panicky. “Hi, I’m a doctor.” She was French and couldn’t understand much English. However, her GCS was 15, pulse and respiratory rate were raised but in range, she was not breathless and on eyeballing her from the aisle, she was in pain, but not acutely deteriorating.

The stewardess asked if there was anything I needed. “An interpreter please.” Not quite what she had been expecting, but after another intercom request, the perfect match was found and I made rapid progress in establishing my patient wasn’t pregnant, had no fevers, no urinary symptoms or diarrhoea, but had been out the night before eating too many different foods and drinking too much alcohol with subsequent vomiting episodes. Her pain was 4-5/10, crampy in nature and relieved by lying down. On abdominal examination she had very mild generalised tenderness, but a completely soft abdomen with no guarding or rigidity; bowel sounds present.

Her panic was subsiding fast with my apparent calmness as I completed the full history and examination. I was offered an astonishing state-of- the-art medical kit and pointing to an endless array of emergency drugs, including adrenaline, atropine and morphine, the stewardess invited me to help myself to whatever I wanted! I almost felt guilty in only using the sphygmomanometer and some mild pain relief, explaining the other drugs could severely harm or even kill her!

My patient settled to rest lying down, with water to hand for her dehydration. I promised to be back in 15 minutes. The crew were effusive in their gratitude and what it meant to them to have an ‘expert’ on hand. They recounted some past horror stories where no one had volunteered. Unwittingly I had calmed their nerves as well.

Back in my seat I reflected for a while on my encounter and realised the potential vulnerability of tens of thousands of long haul travellers daily and their attending cabin crew. Crossing immense oceans a truly sick person could be many hours away from trained medical staff and properly equipped facilities, unless there happened to be a willing, qualified passenger on board; clearly a gamble that is a daily occurrence. I was glad of my ATLS training, recognising it could be called on at anytime, anywhere, even at altitude.

Furthermore, it was a reminder of the unique (and privileged) position that doctors have, where particularly in emergency situations, complete strangers are willing to put their absolute trust in us. Even when we least expect it, the way we conduct ourselves and the skills we deploy can have a profound effect on those around us, for both patient and onlookers. No one cared whether I was a junior doctor or not. At 38000 feet I was valued for my willingness to offer and use my expertise. It was a sobering, almost humbling thought and without overstating it, I reminded myself that we are never completely ‘off duty’.

My patient slept. On waking she smiled feeling much improved and couldn’t thank me enough. Approaching New York, the stewardess asked if I had space in my carry-on for a bottle of their best champagne. I did!

At the end of the flight I accompanied my French charge off the plane. Another fascinating day in the life of a junior doctor.

Turning over a new leaf

5 May, 16 | by Toby Hillman

Decayed Aspen Leaf in B&W

Via Shaun Fisher on Flick CC by 2.0

 

The PMJ blog has been running for 2 and a half years, and in that time I have looked at many aspects of medical practice and education that have been thrown up by papers published in the PMJ.

As time has gone on, we have had several submissions to the journal which seem to fit better within the blog format than as ‘fillers’ within the published journal, but do not necessarily link directly to manuscripts that are due for publication.  However, they stand in their own right as pieces of interest to the PMJ readership, and cover experiences wider than my own.

As such, you will see different ‘voices’ within the blog, and I hope that these voices will also challenge and inform about subjects that have struck them as important in their clinical lives.  In contrast to the ever increasing enforcement of reflection in clinical practice, here are vignettes and observations that demonstrate reflection, but are submitted for wider circulation, and not hidden away on the servers of an eportfolio, or appraisal folder.

So over to Dr Welsby who has submitted the following ‘jaundiced view of jaundice’:

A confused young man and had been admitted with “?Hepatitis.” He was febrile and deeply jaundiced (patients with Hepatitis A or B, once jaundice is obvious, are usually afebrile and, barring complications, often feel better).

Obviously ”liver function tests” were in order. The first liver function test was to observe that his underwear was bile stained. The usual liver function tests were mandatory but predictable. His bilirubin was obviously high, too high to be caused by haemolysis alone (because haemolytic jaundice is lemon coloured and mild whereas obstructive or hepatitic jaundice tends to be deep and greenish). His ALT was moderately raised – unsurprising because his liver was tender on palpation and his alkaline phosphatase was raised in keeping with anatomical or physiological obstructive jaundice.

Obviously a clotting screen should be undertaken but what two tests that are rarely considered to be liver function tests should be performed. Firstly, the blood urea was high. This is unusual in hepatitis because the inflamed liver tends not to make urea (in formal hepatic failure the urea is characteristically low) and his raised urea suggested a degree of renal failure. Secondly, the glucose level (it is mostly liver glycogen that keeps up the blood glucose. In formal liver failure the glucose is characteristically low and intravenous glucose is often required. Hypoglycaemia is the only liver function test that can be immediately normalised.

One investigation that should not be omitted was the most important. A phone call to get a full history. He had recently been in Africa and his blood was full of falciparum malaria that would not have shown up on a routine blood count.

His parasitaemia demanded an exchange transfusion because parasitized red blood corpuscles cannot transport oxygen. Accordingly his blood was venesected and replaced by donated blood. Now, here is a question to which I have never received a sensible answer “How long does it take for stored blood, once administered, to start to transport oxygen?” Answers range between “a few hours” to “about 24 hours.” For stored blood duration of storage would obviously be relevant (someone should do an MD to investigate this). If he were given non-oxygen transporting blood there is a prospect of doing him a disservice by making him more hypoxic. This is why fresh blood is often used for such exchange transfusions.

 

Hidden in plain sight.

5 Apr, 16 | by Toby Hillman

 

Hooded Grasshopper by J.M.Garg – Own work, CC BY 3.0,

Patients do not come with diagnoses attached to their foreheads.  If only they did,  huge numbers of hospital visits and admissions could be avoided.

To overcome the ever increasing number of potential diagnoses, and the rising tide of illness encountered by our ageing populations, we rely ever more heavily on investigations to guide us to the likely diagnosis, and thereafter, management.

But what if the tests don’t tell you what you wanted to hear? what if the clinical picture says one thing, but the tests say another?  Usually this scenario starts a ‘merry’-go-round for the patient concerned.  Oligo-organists (specialists in normal terminology) become increasingly irate with each other, sending a patient on a wild goose chase from clinic to clinic, trying as hard as they can to reassure the poor patient that there is nothing wrong with their X, and it must be the Y-ologists who will hold the key to unlocking their symptoms and making that breakthrough in management.

Heart failure is one of those areas where patients can go for some time before a diagnosis is firmly settled on.  Patients don’t go to their physician complaining of heart failure.  Instead they complain of breathlessness.  It is telling that there are two distinct rating scales for dyspnoea in common usage -(MRC scale if COPD and NHYA class if Heart Failure) – it is a symptom that has become divided by a common language.

Patients with heart failure are not helped by the way in which we as a profession have been guilty of listening to ourselves, and our tests, rather than our patients.  The seemingly contradictory Heart Failure with Preserved Ejection Fraction (HFpEF) is an entity that has been hotly contested, but looks to become the predominant mode of heart failure.  A review recently published online in the PMJ into the pathophysiology and treatment of HFpEF  shows just how far we have come over the last 20-30 years in understanding that such a disease even exists, that it can be characterised using an imaging modality that was once used to cast doubt on a clinical diagnosis of heart failure.  However, despite this increased understanding, we are only just getting to know which treatments might be beneficial, or harmful for a growing cohort of patients.

As I read the review, along with bewilderment at the detail that can be obtained from a non-invasive bedside test, I was struck by the journey that HFpEF has come on in the time that I have been training and practising medicine.

I clearly recall times when I was told that I was plainly wrong when a patient with the clinical syndrome of heart failure was given a clear bill of health by an echocardiogram – causing me to doubt my skills and insight.  And yet now, we discover that by examining the heart with a different mindset, very detailed pictures of the diastolic function of a heart can be estimated, allowing patients to be treated in a more refined manner.

In addition, the review brought home the absurdity of relying solely on a single test to determine the diagnosis of a clinical syndrome.  The review outlines the risk factors for HFpEF – it is a familiar roll call of the diseases of age and lifestyle.  So the test we used to think of as the gold standard to rule out a diagnosis, has been fine-tuned, and gives a more nuanced picture, but despite advancing technology, we return to the need to treat the patient before us, and not the test result.  And in treating the person, we must treat the whole person. This includes their co-morbidities and risk factors, and not just the ones we happen to find interesting.

Perhaps the journey that the diagnosis and management of HFpEF has taken from seemingly outlandish diagnosis to the dominant mode of heart failure also reflects the journey that physicians must go on as they progress through training – from relative ignorance and lack of experience – to specialist knowledge and a narrowing of focus – and back again to a more generalist role, encompassing multi-morbidity and diagnostic uncertainty.

As we face an increasing burden of multi-morbidity, escalating healthcare costs, and increasing patient expectation, I don’t think it will be appropriate in the future to say – no, your lungs are OK, off  you go to see the heart docs. Instead, a more generalist model of care, helping patients to navigate their multiple long term conditions, to reach a balanced solution will be the standard we will aspire to.

Fashionable inequality?

13 Sep, 15 | by Toby Hillman

Gluten free- fashion or fundamental?

Modern life in developed societies is a world away from the lives our recent ancestors lived. Better sanitation, advances in farming and food supply, the cumulative effects of public health interventions over the years, and huge advances in medical knowledge and technology have also shifted the landscape of disease.

As a society, our preoccupation is now with controlling potential illness, improving wellbeing, managing risk factors, and trying to improve our health through individual actions.  Pick up any newspaper on a weekend, and you will find sections discussing the latest discovery of a link between a foodstuff and cancer, another reason to do this, or that.  The open availability of medical information is a great advance, that allows patients a greater degree of control over their illnesses, and a greater degree of autonomy in the management of long term conditions.  Shared decision making must be the future model of the medical consultation.

However, alongside the valid, sensible information, there are many health concerns that achieve wide publicity that can generate anxiety amongst the worried well, and can lead to profound changes in the way people live their lives.  Often the roots of these fears are in the translation of medical advice about well described pathologies into lifestyle choices to address concerns that are less well established, but popularised through mainstream media.

The impact of these choices is mainly on the individual, but a recent paper in the PMJ about the availability and cost of gluten free (GF) food in supermarkets, and shops in Sheffield provoked the thought that these choices may have a wider impact in our modern, marketised society.

The paper from explores the availability and pricing of gluten free products in the city of Sheffield.  The authors examined  a number of variables, and examined deprivation as part of their analyses.

On the price and availability of gluten free food – there were striking findings.  The price difference between ‘normal’ and GF foods were large – with GF foods costing, on average 4.1 times more. In the case of bread, the cost was ~7.6 times higher per 100g for GF than a non-GF alternative.  Combined with cost was the issue of availability – where budget supermarkets and corner shops did not stock any GF foods at all – the greatest choice being within regular, large supermarkets.

As a slight aside, I found it interesting that shops in Sheffield do not seem to follow the ‘rules’ of deprivation – in that ‘quality’ shops had no significant difference in deprivation score when compared with ‘budget’ shops.  This point may be a quirk of the analysis used (postcodes rather than wards), or that in Sheffield as in many other cities, areas of deprivation and affluence co-exist in close proximity, rather than in geographically discrete ghettoes.

The authors have noted a number of factors that could contribute to their findings regarding the maintenance of hight prices for gluten free foodstuffs, and how this might negatively impact on patients with coeliac disease who are from lower socioeconomic groups.  However,  their paper made me think about the additional impact of consumer choice, and market forces within the system they examined.  Wheat free, and gluten free diets are often advocated to improve general wellbeing, and food intolerances in general are commonly held to be responsible for a number of non-specific symptoms.

Gluten free diets are both fashionable, and medically necessary.  My feeling is that the increasing availability of gluten free foods in supermarkets is testament to the wider popularity of gluten free food rather than the exploitation of an increasingly prevalent medical condition to create a market.  The reported incidence of coeliac disease is around 1% – although it is predicted that only a quarter of patients with the disease have been formally diagnosed.  Such a small segment of the population is unlikely to be able to sustain a £0.5 billion market in the UK alone.

The popularity of a (costly) gluten free diet amongst people who have not been diagnosed with coeliac disease is therefore likely to be both expanding the selection of available GF foodstuffs, but also keeping prices high. When GF foods are also restricted by market forces to shops where patients with coeliac disease and a lower disposable income are unlikely to frequent – we see that the popularisation of health concerns, and a widespread adoption of a dietary choice by those privileged to afford it may have negative consequences for patients with a pathology which demands the very same diet.

This is, of course, all speculation, and further examination of the provision, availability and consumption of GF foods would be welcome.  In particular, my knowledge of what prescribed gluten free foods are available is minimal – so I’m not sure how this plays into my argument.

However, as our society seems to be ever more obsessed with avoiding risks to health (although strangely resistant to simple, effective measures like increased physical activity) I wonder how many more areas it may be possible to observe where a lifestyle choice appears to exacerbate a health inequality for those with a formally diagnosed condition.

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 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.

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.

 

Yes to one thing… no to the others.

13 May, 14 | by Toby Hillman

 

 

Wellcome Library, London

One of the perennial problems that faces doctors who are in direct contact with patients is time management.  It is the one resource we all have to allocate, and with the multitude of different roles we all have to play – parent / sibling / doctor / teacher / friend / spouse / club captain / society president / charity trustee / or anything else for that matter – it can be difficult.

As a junior house officer (FY1 in modern parlance in the UK) I can remember literally running between patients on my first on call shift – simply to try to get everything done that was required.  It was only when I became more experienced and could prioritise, work smarter and effectively allocate my time that my shifts became significantly less sweaty, and I felt more confident in my work.

As we progress up the career structure of medicine, doctors tend to acquire new roles and responsibilities which take up more time, and can stretch ones resources significantly.  The most consistent advice I had when I was appointed to a consultant job was – say NO to everything for at least the first six months (and in some cases the first year.)  It is a little worrying that the main bit of advice for new consultants is to say NO – but highlights the fact that as a new face in an organisation, with seemingly a lot of time on their hands (whilst clinics are set up, and services start to gear up) most new appointees are keen to show willing, and take on projects which rapidly snowball and can overwhelm.

This month’s PMJ has a great article which should almost be on the key texts list of all postgraduate training schemes.

The paper is all about time management, and how to recapture time for what YOU want to do, not what your colleagues or boss want you to do.

The advice is all very useful – and perhaps the most important bit is beyond the tools and tricks for managing time – prioritising tasks and the like, but it is actually around the importance of goal setting.  It is easy to be very busy, but not necessarily make forward progress towards a defined end point.  If we can make time (ironic I know) to reflect on our priorities, and our desires for the future – both for work and for home, we are in a far stronger place to assess options and opportunities and how they fit into this scheme.  This process of goal setting can be difficult, and working on it alone can lead to skewed ideas about what will be profitable, and what is even possible.

This is where I have found mentoring and coaching input to be invaluable in the past.  The process of active reflection with a mentor or coach can help to crystallise ones thinking into genuine priorities and goals, and formulate a framework for assessing new opportunities as to how well they help one achieve what you have decided on as a goal.  Mentoring and coaching is often seen as a slightly left-field activity within medicine, but if you discuss personal development with any board level doctor or manager in the NHS and you will find that almost all of them will have regular coaching or mentoring sessions to assist them in their roles.  Oliver Warren and Ruth Carnall wrote a useful piece in the PMJ in 2011 which covers mentoring and coaching – and its relevance for medical trainees.

And now for my advice… the one thing which tends to keep me on the straight and narrow when considering my time management (or lack of) and my work-life balance, is that:  saying yes to one activity or project intrinsically implies saying no to something else. The decision about what you say yes to, or no to  is up to you, but we shouldn’t fool ourselves that we can do everything all of the time…

 

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:

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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.

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