Clinical experience is paid for by patients

Misdiagnosis has been described as “the greatest threat to patient safety in the UK” and at a recent acute medicine conference was highlighted again as one of the major threats to patient safety which hasn’t yet been the central target of a big safety campaign.

Missing a diagnosis is relatively easy; the information we gain from patients of often through the lens of an individual who is frightened, delerious, or on occasion completely unconscious. The story very often changes overnight- a classic trap for a junior doctor (this song (lyrics) (iTunes) (YouTube) by The Amateur Transplants helps explain what a frustration that can be.)  The problem with the crime of procrustes is that we frame the information available to us in such a way that it supports our position, rather than using it to test our hypotheses and whittle down our differential to a definitive (or at least confident) diagnosis.

So how do we combat this, and in a system which is trying hard to make attendance at hospital ever more efficient and less time consuming?

In the ‘good old days’ there was three-layer clerking where the houseman would take the history, the senior houseman repeat it, and finally the registrar review it before the final, glorious history (now practised, refined and distilled into a thing of wonder) was presented to the consultant.

Nowadays there is less of this time consuming repetition taking place, and decisions are made more swiftly, on incomplete, less accurate information, and management plans enacted accordingly.

This has advantages and disadvantages.

The patient often has a, quicker path through the system, gets treated quicker, and one would hope, gets better sooner.  The turnover of patients in a department can be greater, and so the system is happy.

But what about the patient, and the doctors? If patients can avoid repeating their story a thousand times, and still get the right treatment, great. But, the reason stories change, and management changes so often in the first few hours is because new information changes the differential diagnosis, a different slant in thinking produces a new hunch and eventually, the voice of experience can declare on what the final, or at least working diagnosis should be.

Unfortunately this uncertainty over diagnosis when patients are admitted can lead to a “nebulised co-amilomoxifruse” approach where all differentials are treated with equal importance, and therapy is rather scatter-gun like rather than perhaps the pinpoint accuracy that the popular media present as the pinnacle of medical endeavour.

So how can one get that vital experience (a posteriori knowledge)?

Few junior doctors these days get to regularly present their patients to a specialist in the field of the patients problem, and then have a useful conversation about management and further investigation of the problem. Acute medicine is more often a game where one hopes to get on the fairway in the first 24 hours, on the green on the next ward round, and finally sink the ball into the diagnosis hole on the second day – without the continuity of a single firm then it is difficult to follow a patient through this seive of investigations and opinions before arriving at a final definitive diagnosis.

In general practice this can be amplified in the case of patients with acute illnesses – who may go on to have a prolonged and complicated hospital stay – and that initial diagnosis may never be confirmed or modified by the information sent back by the hospital.

To combat this, better feedback loops are required.  The learning cycle proposed by Kolb demands a period of reflection, gained from concrete experience to allow effective learning.  But reflection – without accurate outside information to ensure that the concrete experience is valid – will lead to a self-propelling myth that the trainee is always right. There is value in understanding our failings, and planning to rectify them in the future. (Tim Harford on this)

As Kierkegaard puts it:  life can only be understood backward, but it must be lived foward.

One way that used to be employed in a hospital where I worked was that the discharge summary of each patient seen by medical trainees was sent to them in the internal post so that they could reflect on what the ultimate outcome of the admission was, and what the final diagnosis was.

In these days of electronic patient records, demands that doctors keep a record of the numbers of patients they see (word document explaining how to calculate how many you might have seen) it should be relatively simple to provide such feedback and allow trainees to develop true experience in diagnosis and management of medical problems, rather than using a medicine by numbers approach which may see a patient through the first 24 hours, but may not influence their progress over the longer term.

As members of a profession which relies so much on the experience of our elders to filter and clarify the importance of information when making decisions on how to treat patients, we have a duty to develop better ways to make every encounter count for our junior colleagues – experience is hard won, and on the cost of every missed diagnosis is borne by a patient who may suffer as a consequence.

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2 thoughts on “Clinical experience is paid for by patients

  1. Very nice perspective Toby; you have captured one of the perennial issues of life on the front line.

    Interesting point on framing information, in addition I feel that there is a tension between acting on the available evidence verses one own hunch based on experience.
    Hunches often (by definition) cannot be derived from available evidence and puts the clinician in a weak position legally. Increasing fear from litigation in the profession can sometimes delay quite appropriate treatment and clinical progress. Perhaps remembering the messages illustrated by the Bolam v. Friern Hospital Management Committee case are key here http://medical-dictionary.thefreedictionary.com/Bolam+Test ?

    Regarding reflection too often (and I am guilty too) doctors rarely follow up or get to hear the outcomes of their clinical encounter. Moving to a shift pattern of working will likely increase this problem and I am sure you have seen this happening over the last few years as I have.

    I almost feel that it is our duty to follow up our interactions with patients and I frequently learn a great deal about myself when doing so. I try to follow up as many patients as possible but time and justice (your time is precious to your other patients) are limiting factors.

    I have suggested to my hospital exactly what you have suggested i.e. sending doctors the discharge summaries of their patients. However context is illuminating and sometimes it is difficult to extract meaning from a discharge summary without the notes. Which doctors involved in the case should get sent the summaries? It is desirable to avoid information overload. Perhaps it would be better to place the onus on the individual to follow up their own patients. Do you think this should be a measure of a good clinician? Could this be a new metric of evaluating performance as a doctor?

    I have seen some ingenious ways of doctors keeping track of their patients. I hope that new ways of collaborative working in conjunction with new information systems will help but until then my spreadsheet will have to do.

    • Thanks Steve,

      I think you are right – there is often a lack of personal drive to follow up on patients seen on the acute take. One difficulty being the busy-ness of doctors when on site at work. With NHS email, it would be easily possible for an automated summary to go to the admitting doctor, and I am fairly certain trainees would find it useful – sometimes it needs an outside push (or nudge if you like) to engender certain behvaiours.

      I hope that I can get myself together enough to build a spreadsheet like you – but other concerns often crowd out what appear to be low-value activities, although these are often where the real learning is to be found.

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