Networking in Medicine – an essential clinical skill

Networking has some nasty connotations – and often conjures up the image of a smarmy second hand car salesman, or slippery politician ‘working a room.’

But is networking as a doctor so bad?

Junior doctors have a  number of roles.

They meet patients in their hour of greatest need, perform invasive procedures, make life and death decisions, analyse each others performance in audit, take part in research, prescribe medications, request investigations, discharge patients from hospital, explain procedures, explain illnesses progress to patients and relatives, and work in huge organisations – all whilst learning how to become more senior in their chosen profession and advance their careers.

In a typical day at work, junior doctors will be in touch with a number of different departments, and teams – predominantly to make requests – ask something of someone else and get that result yesterday.  This is hard work.

To keep a good working relationship with a wide range of fellow professionals, when all you seem to do is demand things of them takes not just communication skills, but a good understanding of how to network, foster mutually beneficial relationships, negotiate, comprimise, and understand power structures outside of the normal beauracratic hierarchies we work in.

The best juniors tend to know that Steve in ultrasound will be able to help out on a Friday afternoon with that urgent scan, that Marian, the Sister on ward X is great at putting in cannulas, and will probably know that Steve is a keen cyclist, and Marian loves to go line dancing at the weekend.

In fact, to get on in medicine it is almost essential that doctors can network.  Indeed, the power of networks is being recognised more and more – and this recent article from the Harvard Business Review highlights the power that Networks can bring over the more limited scope of smaller teams.

I guess what I want to point out is that networking is an essential clinical skill.

As I see it, networking in hospital is not about making the next sale (although this paper on Selling Patients might give lie to that sentiment) or brown-nosing your way to the top.  It is more about maintaining relationships which are beneficial to patients in times of need.

On a larger scale, networking is important for the dissemination of ideas, exchange of opinions and for widening ones horizons – so make use of the tools which are out there – Twitter is a personal favourite of mine – and so is The Network ( a particularly fine place to start if you are interested in improving the care of patients in the NHS before you are a fully-grown healthcare professional)

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Institutional Memory

Junior doctors are great at seeing problems, but often struggle with implementing solutions.

They move jobs every few months, and see new problems, inefficiencies, and defects in systems – and either quietly get on and reform things, or, if the problems are out of their power or scope to change, make suggestions, and then, before they can get up momentum – move on.

The peripatetic nature of our junior medical workforce is one of the major reasons why juniors sometimes seem to be seen as a problem to be dealt with, rather than valuable members of a highly qualified workforce.

Institutional memory is something which is built up over time, and is often held within the memories of the longer-standing members of the workforce, rather than written down and archived for future reference.  When key members of staff move on, or retire – that valuable resource is often lost.

In the case of junior doctors, it is more the handy hints which a shadowing period can help to transfer to the new crew which get lost in the transition – who to ask for for an urgent ultrasound, which secretary is best at passing messages to the boss when he is on study leave, which ward is most likely to look after certain types of patient better than others.

At a recent learning event, we had a discussion about how to combat this loss of ‘institutional memory’ within the junior doctor grades.

I’m not entirely convinced of the full answer – but for a start, wouldn’t it be great if those juniors who are due to move on after only a few weeks could write down their observations, maybe even with a little bit of data – and then next bunch could pick them up – analyse the problems, and implement the solutions.

A team file of ideas, trials of solutions and successful innovations could hold the history of improvement efforts of the team – and who knows – that part of the organisation may truly become a ‘learning team’

So – before I leave my current post – it seems I have just given myself a task – to record the handy hints and attempted improvements which were made throughout my year there, and I’ll pass it on to whoever comes next.  Hopefully they will see through some of my ideas and develop them to improve things further – and if they pass the baton on, who knows, in time things might just improve.

 

Life after death

There is life after death.

Now, I know that sounds like a very rash statement, and one which has kept philosophers, scholars, sceptics, clerics and a fair few others busy for some few millennia.

However, as doctors, and healthcare professionals, we often seem to forget that there truly is life going on after death, or, perhaps more accurately, we get very easily distracted into concentrating on the life that has just come to occupy our attentions rather more than the one which has just ended within our sphere of influence.

Now, that may be entirely right and proper, modern medicine tends to have more to offer the living than the dead, but I there is an opportunity to practice medicine which all too often passes us by. It is not a cutting edge therapy, a new model of care or anything special, but it does take time, and effort.

On a couple of occasions recently I have encountered this life after death, and the outcomes of those meetings have changed the way I look at where our duty as physicians ends.

The two patients who have promoted this thinking passed away under the care of my team, and instead of the usual scurrying off of the house officer to fill in the death certificate +/- cremation form, we made appointments to meet with the relatives of the deceased as they came to collect the paperwork.

The discussions, questions and conversations which these meetings involved were, I hope useful for the relatives of the deceased, and certainly seemed to play a role in clearing up any misunderstandings, and allowed a chance to discuss events with less urgency than when their loved one remained alive but very ill.

I think the main thing these experiences bought home for me was the feeling that it is possible to continue to serve, care and help the healing process, even after death.

So when I say that there is life after death, I mean that we should remember those left behind by a death, and remember that we have some duty of care to them to.

I know that meeting with relatives after every death is unlikely to be practical, and that my colleagues in primary are probably better placed to help pick up the pieces than me, but I’ll do my utmost to be available, open and honest, and that way I hope to be able to assist a healing process, where clearly I wasn’t able to effect a cure for another.

March 2011 – Plus ca change…

This was something I originally posted on March 21 2011 on another blog which has since morphed into something else… but I think it still outlines what I think is important to salvage from the NHS Reforms (if they go ahead) or indeed whatever happens in their stead.

Recently the BMA representatives had a knees up in London where they debated long and hard about the NHS Proposed Reforms.  I was following on  Twitter

As I was following the (often predictable) passing of motions (no pun intended) on the live feeds, I was left with the feeling that perhaps this is too little too late – if the medical profession truly wanted to oppose these reforms outright, this should have been done well in advance of the first reading of the Bill in Parliament (see here for the Bill’s progress to date)  I honestly feel that the PCTs and SHAs have had so many of their staff leave that they are unlikely to be able to function as effectively as they had done up until the time that the reforms were  first publicized.

So what to do now?  I am not a politician, but passionately believe that politics matters to me and my patients – the current reforms show that more clearly than ever.  I don’t think that the BMA passing comment is going to radically alter the reforms, and if it does – how much real good can it do now – the horse seems to have bolted.

I feel that the way forwards now is to ensure that, whatever proportion of the reforms makes it through parliament, we as the medical profession sort out three things no matter what:

1.     Secondary care doctors must look to their local community.  It is naïve to think that a hospital only serves those patients that happen to be in the clinic, or on the wards.  Hospitals, if they wish to truly serve the public, which funds them, must look outside their walls, to the community.  We cannot sit on the inside of ivory towers complaining about the standard of care given in the community for patients with our particular illness, and do little or nothing to change that care.  This is “population medicine” – concern for the wider population, not just the referred population.  With limited resources, we need to be sure that specialists are seeing specialist cases, not just whoever happens to turn up.  Only through collaboration in networks or systems of care will we achieve this.

2.  Primary care physicians need to look to each other.  The unwarranted variation in the standard of care between primary care practices is no longer acceptable.  GPs, acting in networks across a community, and in collaboration with specialists should strive to bring up the standards of care across their patch.  Under-performance should not be tolerated, and clinical leadership, with solid clinical support, is essential to provide the credibility to enforce high clinical standards within a local health community. (This applies to the secondary care community too by the way)

3. Primary care physicians need to look to their patients.  When patients come into the surgery looking for treatments that are of no benefit, or are not likely to lead to resolution of an illness or symptoms, GPs must be able to have rational discussions about the risks and benefits of treatment.  Shared decision making processes can help with this (Implementing shared decision making in the NHS — Elwyn et al. 341 …) and result in better-informed patients making better informed choices.  PROMS are an excellent way to make a start on this, and bring home the realities of life and illness to patients.  We have an NHS, we are very lucky – it can’t and won’t be able to provide everything, and you may not need a treatment, just because there was a report once saying it might help you.  Primary care physicians and teams really are the gatekeepers; we should not use a rationing mindset when discussing treatment with patients, but be highlighting the true intangible costs (physical and emotional) associated with some treatments where the benefits are marginal.

Something of the Spainish Inquisition came over me whilst writing – sorry…

4. We all need to look to what patients want.  When it comes to service re-design, we often look for examples of what works in one area, and think – this is what I must do for my clinics.  Involving patients in the work of service design can achieve surprising results.  I have mentioned examples in previous blogs where patient involvement blew apart assumptions of physicians, and service providers about what patients really wanted from a service.    Only by understanding what patients truly want to see in a system, and then making strides towards that, will we start to see “appropriate” use of services.

So, what should we do in light of the SRM outcomes.  Yes, we should push to amend the parts of the bill which threaten the ability of doctors to serve their patients well, but in accepting that we may not get our way (Mr Lansley is not known for giving in lightly) we must start to take a different, pro-active attitude to getting the NHS, our NHS, our patients NHS back on track.  I believe that if we can concentrate on some of the steps above, we have a chance to make the best of a bad job.

So that was what I thought then – and it seems that so much has changes, but also so little has that I can re-post this without any significant editing.

Inappropriate?

There is a phrase which goes around the wards and departments of many NHS hospitals:

Inappropriate attendance

This is most often used when talking about patients who pitch up to A+E with conditions which could usually be managed elsewhere.  These are the patients who are thought to cost the NHS a lot of money and are the target of various schemes to stream them to more appropriate settings.

So what are these ‘inappropriate attendances’?

I am very lucky to have benefited from a great education, am lucky enough to work in a pretty comprehensive health service, and because of my day job, have become pretty adept at navigating it, and getting help where and when I need it.

However, imagine if you haven’t had that benefit, and don’t know what a drop-in centre staffed by nurse practitioners can offer, or that you can get good advice over the phone from a GP out of hours, or that a pharmacist at the local chemists could deal with your ailment?  Well, what would you do then?

The decisions patients make about where to go for help are not simply random and unthinking, but they are made when patients are distressed, and searching for answers, and quickly at that.

The NHS is very good at taking a problem and designing a solution to it which works perfectly in a committee room, on paper and in a consultation document.  However, as Helmuth von Moltke the Elder once said, “no plan survives contact with the enemy”.  Similarly, no treatment pathway, referral criteria, single point of access or similar will survive in its original form, and the consequences are very often unintended rather than those set out by their architects.

Once we have set out a plan though, we often don’t recognise that patients (including ourselves) will follow the path of least resistance, and seek help where they will get it.  So if one sets up a system where the most efficient way to get a diagnosis for a funny rash “which isn’t a huge problem, but I don’t really want to take a day off work for it” is to go to A+E, then go to A+E the patients will.

We must recall also that “every system is designed perfectly to achieve the results it yields” (Paul Batalden)  In this case, we must recognise that we cannot force people to make choices which fit with our ideal, but instead that they will make choices which seem to them to make the most sense, and offer them the help the want as quickly as possible.

To change the way in which patients behave we must either match their behaviour (put urgent care centres staffed by GPs in A+E departments and hive off those we think are “inappropriate for A+E” to the GPs next door, or we must improve the alternative offer – and improve community services, awareness of community services such that they can compete with the A+E service to offer reassurance, diagnosis and therapy for those patients who seek it outwith office hours – however the promise of swift treatment and diagnosis at a hospital may prove too much – and the draw of A+E too strong 

There are positive points on both sides of the fence on this one, but one thing is clear – there really are very few cases where an attendance at A+E is “inappropriate”:

It may be that the patient didn’t want to wait and was playing the system – but then the system may be inappropriate, or it might just be that the patient was anxious, tired, scared and wanted some help. Equally, the patient might be lacking the skills and knowledge to manage and requires some additional information on how to navigate the complex health economies we have generated.

And I seem to remember that that falls fairly squarely into the lap of the caring profession of which I am proud to be a member.  It does not become us to castigate our patients for their lack of understanding or anxiety.

Procrustes

I am guilty, guilty as sin.

I think I commit this particular crime on a fairly regular basis, but I am trying to get better.

No, not speeding, not gluttony (although some might disagree), certainly not anything as serious as murder, but still, this crime has the potential to cause harm, and long-lasting harm at that.

So what crime is it, some sort of fraud?  I guess so… it is:

The Crime of Procrustes.

Procrustes was a robber (and wayward son of Posiedon) who lived in Attica and had a particularly nasty way of ‘helping’ his victims.  He would invite travellers on the road to Athens (or Eleusis) to come in and stay the night in his fort, promising them a comfy bed which had amazin properties – namely that it was a perfect fit for everyone.

The slight issue was how this bed managed such a seemingly impossible task.

Well, if you happened to be too long for Procrustes bed, you would be cut down to size, and if you happened to be a bit short, then there were handy winches at each end of the bed to ensure that you would fit just right (after a bit of stretching.) To catch out those lucky ones who fitted the bed without adjustment – he had two beds!

So, a nasty chap – and not an invitation you would want to accept – and thankfully, Theseus put an end to this practice by getting Procrustes to ‘fit’ his own bed when he stayed the night on his way to Athens.

So – what manner of torture chamber do you imagine I keep at home? Thankfully not – only a toddler bed which feels like torture if you are ever unfortunate enough to have to kip on it.

And what does this have to do with me?

The crime I am guilty of is of fitting information to the case I wish to make, rather than using it without prejudice to form an accurate picture of what is going on.

This is an easy trap to fall into, and causes real problems. The trap is often set unwittingly by those who are taking the initial details from the patient – be that the GP, the ambulance crew, or the A+E staff.  The initial phase of a patients admission is often a confused/confusing time, and the diagnosis is often attempted on incomplete information, or without the benefit of the increasing volume of data we generate about patients from the time they arrive in the hospital.

There is a desire amongst the medical profession to be right (it is, after all what we are drilled to do for 5 years or more at medical school) and there is a particular satisfaction in being able to tell a patient what is wrong with them.

Once enough information is gathered to have a reasonably firm diagnosis, it is usually written at the top of a differential – and becomes the working diagnosis.

The difficulty is that this suggestion, when a new pair of eyes comes to pick up the thread of the story, influences their thinking and sets them in the ways of Procrustes.  Further information as it is gained seems to reinforce the original diagnosis, and thereafter it is incredibly difficult to challenge it.

Now, there are a few caveats – the initial diagnosis has to hold some weight for this process to play out.  The medical tribes and hierarchies which exist mean that if the working diagnosis was made by someone that you consider to be less good than you, you will have little difficulty overturning it.  However, if someone of stature makes the initial diagnosis and plan – then it is increasingly difficult to turn the thinking around – and it somehow seems easier to fit the information to what we want to believe.

The key to avoiding this is being aware of the influences on you when you approach a case – especially if you are junior.

The data will be what it is, no matter what spin one tries to put on it. If things are not adding up, or there are inconsistencies in what is going on – go back to the beginning, and re-examine.  It has never ceased to amaze me how many diagnoses are challenged by the juniors on ward cover at night – and I am certain that it is because there is less distraction, more time to focus, and less fear of looking stupid if one questions the status quo.

So please, next time you are faced by a slightly ropey diagnosis, or are trying to explain away anomalies in what you are seeing – think again and try to avoid being guilty.

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.