Who do you belong to?

Communities of practice are an interesting concept which have helped people to understand professional groups and other collections of people.

They often have common goals, highly specialised terminology, a high level of general expertise, specific methods of information exchange, and participatory mechanisms – all of which help to define them.

These characteristics all go to help create a sense of belonging – and even loyalty to a particular community or identity.  We can see these communities at work within medicine all over the place – there are the orthopods, the anaesthetists, intensivists, surgeons, medics – and within each of these there are further groups.

As we move up the traditional hierarchy of medicine, it is possible to see that at some point consultants and GPs start to join the communities that exist within their workplaces.  They become ever more involved in the work of their trust or practice, and ultimately become a full member of that community.  Indeed, they would probably not be able to do their jobs effectively if they were not part of these groups.

As trainees, we move between organisations, and sites and specialties, even between regions.  This prevents us putting down roots and becoming accepted members of a community.

I think this can have negative effects – some trainees never truly feel like they belong in one place or another – and this is often a circular argument with organisations often seeming to treat juniors as peripatetic units of work rather than integrated members of their workforce, with meaningful contributions to make.

To reverse this, it is possible to take a few steps to start to reach out into the commuities we come into contact with.  Let’s look at two parts of the concept of communities of practice.

If we wish to join the community of practice that is our workplace, as well as the one which is our chosen specialty, then we could look to access some of their “participatory mechanisms” – that is, look at, analyse and probably get involved with the ways of working which exist within the organisation.  I would argue that one way to get involved is to identify areas where the quality of care being given is somehow sub-optimal and then in a non-threatening way, exlore this with the existing members of the community.

From the other direction, I think that there is a great deal more that organisations could do to improve their relationship with their juniors.  Information exchange is one way…

For example… at a hospital I worked for, I needed to contact the new registrars before they actually started work there.  The HR department were able to help me with a full list of personal email addresses, to which they would send information.  Two weeks later, once the registrars had arrived and started working, the HR department could only offer me internal mail addresses (which are almost never checked by junior doctors).  Quite how the hospital hoped to get important information about clinical issues to this group was beyond me, having discarded the most efficient way of getting in touch with them, and adopting one of the least efficient.

So – which communities do you identify with, and which would you like to join?  If you wish to be a doctors doctor, and always fight the system – beware – you may find that you have to let your guard down as you start to want to settle in one place, and establish yourself in that organisation, or face the consequences of always being a belligerent outsider.

On the other hand – if you are an employer of junior doctors – think about how you can engage your juniors in the work of the organisation, develop some loyalty and allegience by communicating effectively with them, and offering chances to participate.

As we move dangerously towards the fragmentation of the health service, it will become more and more important to be aware of how communities work – to keep them together where this is required, and nurture them when the quality of care depends on it.


Doctors, patients, contracts

I recently posted about a patient who wished to exist outside the system set up at my workplace.

I finished with a question – should we value individual choice above and beyond the systematic delivery of safe care?  Well, I suppose I have come to a form of answer.

I still firmly believe that for patients in general to receive high quality healthcare, which is therefore clinically effective, personal, safe (and fair – this bit was dropped from later definitions)   it should ideally be delivered in a systematic way which seeks to reduce unwarranted variation, and inherently follows the best evidence where it is available.

However, care should be personal – each patient we meet is unique and therefore we must consider each time how the evidence fits this particular situation, and, in discussion with the patient, establish a management plan which is acceptable to both parties.

So what can we do when this ideal of personalised care seems to be completely at odds with the system in which we work?

Quill (Annals Internal Medicine 1983 98:228-234 – subscription only I’m afraid) looked at doctor patient relationships as a form of contract.  Usually the contracts entered into by patients and doctors are explicit, and built on trust – with an exchange of information for a return of advice / remedy / referral / guidance etc.  Occasionally it is sensible to define more exactly what is available in the contract being agreed on by each party.

In the case of my patient who would not engage in the system – that is fine – it is their choice.  However, it would be wrong – and potentially detrimental to other patients to expend excessive amounts of time pandering to every demand that they might make.

It is surely the doctors role in such a situation to ensure that the patient is making a truly informed choice – ensuring that adequate information is available about what treatments are possible, what services can be provided, but also what consequences there might be if a patient wishes to operate outside the normal bounds of what a service can offer.  (please note the choice involved here – I don’t think those that are forced to exist outside the system fall into a similar category)

This is a fine line to tread, but it is important to be aware that one strong patient who defines the terms of their engagement with a service ought not deprive others of that service owing to the efforts made to accomodate the first.

Indeed, we need to start being more honest with patients about the limitations as well as the benefits of what we can offer.  I hope that the recent surge in shared decision making will lead to a more open discourse with patients, and this can include logistical factors, as well as medical ones…

Living outside the system – a dangerous place to be?

At the moment, I am helping with the care of an interesting patient at work.

It is not really her condition which is fascinating me (although it is an interesting pathology) but more how the system is coping with her, as an individual.  Her choices regarding her healthcare provision donot fit with ‘the system’ – that is, they do not fit with the way that care is delivered at present where I work.  

Normally, a joint clinic would deal with her problems, and this clinic is held in an area of the hospital which this patient is unwilling to enter – for very valid reasons – which are not relevant to this blog.

What is interesting is that the system which has been set up to help patients does not suit this woman’s personal choices.  The system, however imperfect it might seem, provides a framework within which doctors operate, and know how to operate.  It is also how the institution providing this patient withcare ‘knows’ how to operate.

So now we have a patient who has come to the right place, which is set up to deal with her problems, but because she has chosen to exist outside ‘the system’ certain aspects of her care have been delayed, and may not have been optimal, and equally may not be optimal in the future.

Not a huge problem – I can chase around, re-arrange and re-book tests, phone the patient to ensure she can make it to alternative clinics (which are really for other patient groups, but can accomodate him) But what would happen if every patient made similar choices – decided that the system could bend to their will, and their convenience?

Now, I am not advocating a return to the bad old days of paternalism, and patients being grateful just to be seen, within a year of being referred to a hospital – but this experience has highlighted a tension between how we set up healthcare ‘the system’ which allows us to manage risk, reduce errors, standardise care pathways and diagnostic workups… and that of patient choice, and trying to accomodate those who do not choose to follow or engage with the standard way of working.

Already colleagues have expressed concern that operating outside ‘the system’ means that the usual safety nets don’t really exist for this patient – and that her case will be difficult to manage optimally (something which is really quite important with this particular illness)

I suppose what I am wondering is; which is top trump?

#standardised care to enhance patient safety?


#personalised, flexible care which enhances patient experience?

The privilege of our profession

It is a rare pleasure to be able to take any individual and guide them into environments and to experiences that are entirely new to them.

I was fortunate enough this week to be given an opportunity to do just that. The opportunity did not show itself in a good light when I first got to hear of it. The new clinical medical students were coming to the ward, and needed volunteers to take a history from. My colleague was due to run this particular session, but his child had taken ill so he was unable to sort everything out.

Queue a couple of hours of running around the ward like a debutante looking to fill a dance card, and finally things seemed sorted. The students arrived in a nervous gaggle, and were duly corralled into the MDT room. They were split up into threes and I went round introducing them to their first ever patients. They had been talking histories all morning and had a plan, and a pro-forma. They knew how this was meant to go…

And of course, it was nothing like they had imagined.

Each of the groups had experiences as unique as the patients they spoke to. One group struggled to encourage a patient to start their story any more recently than the mid 1960’s, one group encountered a patient who was so straight to the point, that they felt they had nothing more to ask after about 15 minutes, and needed gentle coaxing into delving slightly deeper into the “I woke up and it was there” of the presenting complaint.

It was fascinating to observe a group of four medical students collude as one to avoid asking the most obvious questions in a social history when confronted with one particular case.

However, what struck me most was the absolute privilege these students were getting – within five minutes of meeting of these people (for that is what patients are) the students were being trusted with the most intimate information, trusted with the opportunity to ask probing, personal questions about their fears, concerns and expectations, and were repaid with an experience I hope they will carry with them through their working lives.

Taking histories from patients can be seen as a chore when on take, slogging through an outpatients clinic or clarifying details on a ward round, but really it is an immense privilege, and I hope that the students who met my patients the other day remember that as they move from the lecture theatre to the wards, and onwards in their chosen profession.

Patient choice – where does that leave doctors?

Doctors got a lot of bad press in the past for being paternalistic, not involving patients in decisions about their treatment – as exemplified by Sir Lancelot Spratt in this clip (see 1:30)

The King’s Fund recently published a report on shared decision making, and highlight some of the challenges, and benefits of a ‘shared decision making’ approach to the medical consultation. All of the recommendations are pertinent to most consultations and the general advice is excellent.

However, a recent paper shows that patients, when it comes to some decisions, would prefer their doctor to take a leading role.

So where does that leave us doctors as we consult with patients with different health beliefs, different attitudes to their entitlements and different agendas when it comes to their own healthcare? Trish Greenhalgh has written an excellent paper looking at this

I would like to say it puts us in the driving seat – with access to the data, both official and anecdotal. With that comes responsibility. As we move to seeing more and more ‘provider organisations’ entering the health economy, patient choice is likely to expand – and with it, the number of decisions to be made regarding treatment and investigations.

Shared decision making relies on the fact that patients are informed enough to be able to make a choice about where or when to be investigated for a possible condition. This is a ‘good thing’. I love the idea that patients in the future will be able to discuss with their GP about which hospital offers the best service for a particular condition, how far away they are, what the waiting time is like, what the outcomes have been for previous patients with similar problems… BUT

And it is a big BUT – this relies on accurate, up to date and relevant information. Open data projects which are being geared up and are providing health-related data to the public domain like the London Datastore are a step in the right direction, and the recent interest in health apps as publicised yesterday by the Department of Health here will go some way to democratising the information about health services, and empowering patients.

There is however, some more basic, down-to-earth common sense which is required in all of this – and a couple of patients I have seen recently illustrate this perfectly.

One was a lady with a history of cough – which resolved after a period of a few weeks. She had attended one hospital, had an x-ray and the report indicated that TB could not be ruled out. Choose and book being what it is, she was offered a choice – and chose to come to my hospital for further specialist attention.

The second was similar in that three chest x-rays had been taken at one hospital, and as the appointments on choose and book indicated a quicker consultation at my hospital, the patient chose it rather than the one where the x-rays had been performed.

In both cases the patients had gone through what must have been some sort of decision making process with their referring doctor. Now, they may have had an excellent discussion about the relative merits of each of the institutions available to them, but something fundamental was missing – the fact that the NHS is not, has never been , and if competition between providers increases, probably never will be an organisation which is excellent at sharing information at the drop of a hat, or transferring things like x-ray films and images between institutions.

However, that is not the image of the NHS that patients have, and their expectation – in the world of instant messaging, flickr and facebook – is that images and information should be flowing freely like water.

So – yes, let’s get more shared decision making into the consultation room, but let’s not forget that:

1. Doctors have a duty to advocate for their patients, and we should take into account the additional guidance some patients need in complex situations.

2. There are still some very mundane limits to the efficiency of the NHS and the strife that this causes patients when they realise that their questions cannot be answered, and never could be by the doctor they ultimately consult with.

Patient ‘choice’ as it becomes more and more fashionable will mean many things to many people – but patients should not suffer as a result of doctors being poor advocates, and not highlighting all of the important information – even if it is simply the logistics.


Trust underpins the way doctors and patients interact, and trainees are always encouraged to build a rapport with patients, put patients at their ease and effectively gain their trust to enable a fruitful doctor-patient relationship to flourish.

In the background though are often competing demands on the emotions of doctor and patient alike.  A couple of vignettes might explain a bit better;

A patient I met recently found herself without a vital lifelong treatment because she was ‘treated like a child’ and then ‘dismissed’ when she attended a clinic and was refused a prescription because she wasn’t following the rigid protocol, and no flexibility was allowed.  She said this was because some ‘idiots don’t know how to look after themselves’ and she was refused despite being a long-term patient who usually managed her own medication very well.

The other patient was a man who had lost all faith in his surgical management after complications, which were inadequately explained to him.  This man has a very high level of formal education in biomedical sciences and simply did not believe he was being told the truth about his problems, or what the solutions should be. (all this complicated by his care originally being under a private provider, all causing him suspicion about their motivation to care for him once his original procedure was completed.)

On the other side of the desk, trust in the face of cultural norms and heuristics like “trust no one, assume nothing, and give oxygen” and in the face of a common view that doctors have superior understanding and knowledge about most things (our “say it with confidence and you will probably be right” approach) is difficult.  If you add in the conflicts of interests generated by fee for service private providers, there are increasing numbers of reasons why trust is so hard to build.

I don’t think there are any easy solutions, or and rules of thumb which necessarily help to resolve these difficulties in establishing a trusting relationship between doctor and patient, and sometimes it is absolutely appropriate to mistrust the information one is given, or an individual’s reliability but I think we should try to overcome mistrust as a default position.

Far better to give our patients and colleagues some credit, and enter into a more equal relationship wherever possible, than to alienate patients, and create divides where usually we all have the same aim of achieving a diagnosis and instituting a management plan with ultimate aim of improved health.

Competition 2.0, high tech and low tech

Cohort Review

Technology is a great thing, and has advanced the human race at an almost unimaginable pace over the last few years.  I love being almost a native when it comes to IT and technology.  I am not overly confused when a new technology comes out, can sort of understand the way the web works, and don’t completely lose it when it comes to cloud computing ( something my parents don’t really feel comfortable with)

But, I am also a bit of a Luddite, and find pleasures in timeless pursuits, like walking up hills, camping, sitting by a fire, reading from paper (although the majority of my reading is now on a screen of one sort or another)

When it comes to healthcare, I have pretty similar views, and appreciate all of the advances that can be made with our new technologies, but also find fascination in the seemingly simpler, but often more complex interactions between individuals, especially patients and doctors.

This week I got to see all of the things I find interesting rolled into one.  The meeting I went to was the North Central London cohort review.  Cohort review is a method of rolling audit if you like, in which a service reviews it’s most recent cases, checks on performance and outcome, and tries to lear lessons along the way.  Each case seen by a service is presented by the case manager to a panel of experts, with an audience of their peers from their own, and other services.  Various essential pieces of data are presented, including detailed information on outcomes of treatment, adverse events, and the results of contact tracing. the presentation is made to a panel consisting of an independent chair, senior case managers, an epidemiologist, a microbiologist with access to a vast array of lab data, and public health representatives.  In future editions, local primary care physicians will be invited.

The Cohort Review process was used in New York in the 1990’s to reverse a trend of increasing TB incidence, and is credited, along with other changes in management as one of the main reasons incidence of TB in NYC is falling, rather than rising as it is in most major capitals. (see here for more information)

So, what is so special and why did I get so excited.

#1. Cohort review is not an audit in the sense of a junior doctor clinical audit, but falls more in the category of continuous quality improvement, with lessons learned on the hoof, solutions thought of and shared by those on the ground ( the TB case managers) and a process of rolling review to see how improvements have impacted on the outcomes achieved.

#2. Cohort review is a public test of how well you are performing as a service, with your peers scrutinising your practice, and competition between services being very much on outcomes and reputation (see Muir Gray’s blog for more on this). It is slightly unusual in the health service to hold people to account in a robust way, but this meeting made that possible, and clearly drove people onwards to achieve higher standards.  The fact that this meeting covered a number of neighbouring services, but remained local enhanced this sense of being held to account, but by those who understand and sympathise with the local context.  An independent, respected, and expert chair helped to keep this a robust, but fair process.

#3. Cohort review combined the latest in technology with something very basic, and this brought out amazing opportunities to fight a disease.  TB is caused by a mycobacterium, and each of these can be strained by analysing it’s ‘fingerprint’. When this fingerprint data is added to the clinical, and demographic data, it is possible to see clusters forming, and data from the ground can highlight areas of social interaction, which in turn allow targeted efforts at controlling the spread of the disease.

So the strain typing is the high tech bit, but the simply all getting together in a room, not with just the directors if each service, but the foot soldiers, allowed the tacit knowledge from the front line to inform those with a high level overview ( an epidemiologist and public health doctor attend the cohort review) and create strategies for investigation in real time. (an example was a cluster of 17 cases presenting to a large number of services, but with common geographical and epidemiological data, highlighting a very specific area of high transmission – a charity mission as it happened)

#4. This is scaleable.  Solutions to problems are often very situation specific, and transplanting one solution into another context can rob it of any chance of working, but the principles which make the CR process so effective, in my mind, can be applied to many different fields, especially where we are moving to distributed networks of practice.

So, competition between services, but experienced in a meaningful forum (not just a league table produced every few years), a continuous process of improvement, with accountability for performance being felt at the front line, along with a blending of high tech, and simple communication between those looking at a problem from different perspectives.

All these ingredients made me more excited about this process, and brightened up my Thursday morning more than I could have hoped for.  Now I need to look at where else this could be applied, and see if I can sow the seeds. Get in touch if you would like more info.