Month: November 2014

Glide

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A now traditional Christmas Carol-esque cautionary tale for busy doctors, which also owes something to another, less esteemed cultural influence…

oOo

Jim, a thirty-something medical registrar, stared out of an eighth floor window into the lifting darkness. With dawn came the prospect of home, and the end of his fourth night on call. He thought about going to the pub on his way back, but decided against it. Beer, at 9.30AM! What a mess.

A patient called out to him. Jim averted his gaze, the time-worn method of avoiding engagement with those who might distract him from more urgent tasks. But he was doing nothing, just staring at the city’s transition below, so he answered.

“Can I help you Sir?”

“Here, here.” growled the old man. Jim liked the look of him; there was humour in his eyes, a spark of cynicism.

“Yes?”

“Come here lad. I’ve got something to tell you.”

“Go ahead. I might get bleeped away though.”

“No, you won’t.” The tone was oddly prophetic. With a thin arm he directed Jim to make himself comfortable on the bed. Then he began…

I was a doctor you know? I was. I don’t tell people when I come into hospital… at 85 I know very little that would help, medically. But I know how people should be treated. I’ve been studying you… Jim, isn’t it. You’re at the top of your game aren’t you. Slick. I’ve seen you field questions, referrals, crises. You know a hell of a lot, and you think clearly. You’re fast too. I was fast. I could get round a huge ward of patients in a couple of hours, I could see twenty-five in a clinic. At your age. Then… I changed. I slowed down. I annoyed those in charge of the hospital, I caused a backlog, but I had to, you see. Want to hear why?”

“Yes.”

“I was doing a ward round. A man grabbed my hand, a bony hand it was – just as I grabbed your attention a moment ago. He pulled me down so that his mouth was at my ear, and he said – young man, you’re gliding, you’re gliding. Like you Jim. You glide. You’re fast and you’re smooth but you never touch down. What did he mean? He meant… I wasn’t connecting, wasn’t engaging. I wasn’t leaving anything behind. I was fast yes, I made the right decisions, mainly, but after I had left the patients they could barely recall the interaction. Do you remember seeing me yesterday Jim? Vaguely? You were in and out in a flash, focussed entirely on the medical facts. I was impressed, you made the right diagnosis and changed my treatment for the better, but I wanted to talk to you… about something else. I started, but you were already turning away. Teflon. Smooth. You didn’t realise I had something to say, because you were not open to the possibility of anything obstructing your serene progress through the ward. Leaving nothing behind…”

“How can you leave something behind with every patient? You’d be eaten away.”

“Nice image! Like piranhas eh? No, no. It’s exhausting, it has to be. If it’s not exhausting you’re not doing it right. It’s called empathy, and it costs, in the short term. And to do it you have slow to down, and touch the ground.”

Jim nodded, not exactly in agreement, but too stunned to object.

“Anyway, just a little bit of feedback! Off you go Jim. Get home.”

Jim stood up, ashen faced. He murmured his thanks and walked away. When he arrived at the nurses’ station he turned to look at the old man, the gnarled old physician with bright eyes. The bed was empty.

“Talking to yourself were you? Bit tired?” asked a nurse.

“Possibly. Possibly.”

And he walked home, slowly.

oOo

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The place of blame

The importance of a ‘no blame’ culture in the NHS has become axiomatic. It is accepted that the chain of learning that connects adverse healthcare events to improvements in safety is fatally interrupted when incidents are not reported. If people fear blame and censure, they will not report. Berwick focussed on this in his 2013 post-Francis report, ‘A promise to learn – a commitment to act Improving the Safety of Patients in England’. It says,

Patient safety problems exist throughout the NHS as with every other health care system in the world.

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

Fear is toxic to both safety and improvement.

 and recommends,

To address these issues the system must: 

– Recognise with clarity and courage the need for wide systemic change.

– Abandon blame as a tool and trust the goodwill and good intentions of the staff.

 blameberwreportfront

 

As a doctor who is involved in mortality and morbidity meetings, I often think about the role of blame in learning lessons. At my level medicine consists of numerous interactions between just two or three kinds of people; patients and doctors/nurses. If a mistake is reported an assessment is undertaken as to whether that mistake was due to a fault in the system (eg. poor process, unclear guidelines, bad IT, poor labelling) or a restricted error on behalf of the health care worker. The latter might include mistakes due to a lack of knowledge, or due to a lack of concentration.  But what if the lack of concentration is the result of unintelligent rota design, or distraction due to an over-burdened system? The spectrum of potential accountability is wide, but whenever an error is identified it is necessary to see at what point on that spectrum the underlying cause lies. Or the blame.

blametz

Example: a junior doctor gives a patient an antibiotic that she is allergic to, the doctor having failed to recognise that the trade name (let’s say Tazocin) disguises the fact that it contains penicillin. The patient has an anaphylactic reaction and spends a week on intensive care.

The focus of accountability could reasonably fall on one of several points. It could be the doctor not being aware that the antibiotic contained penicillin, or for not checking that the patient was allergic. For not bloody thinking, his exasperated supervising consultant might say to herself, immediately succumbing to the emotional retort that is ‘blame’.  Or, could it be the doctor’s educators who have not emphasised that fact in his training? Or the drug firm for releasing a medication which does not make its crucial ingredient plain? Or the Trust for not being responsive to the fact that this doctor is routinely over-pressurised at night, and making decisions in a hurried way. Or the Department of Health for capping central funding, or David Cameron for supporting a policy of austerity…  or mortgage lenders in America for contributing to the 2007 financial crisis.

This begins to sound sounds absurd, but the point I’m trying to make is that the chain of blame could be a long one. And when you make a mistake, it is natural to look up and around for mitigating circumstances.

Now imagine that the junior doctor is brought into his educational supervisor’s office. It is explained that the patient came to harm because the doctor prescribed the drug to which the patient was known to be allergic. It’s my fault, is how the doctor will feel. But the educational supervisor will be quick to soften the criticism by explaining that there will be a review of systems, more nurse education so that injections are not actually  given if it says penicillin allergy on a drug chart, and the Trust will arrange some extra pharmacology teaching for House Officers. Use of the misleading trade name will be banned. The system has learned. It’s not your fault.

Immediately the sense of blame rises from the shoulders of the junior doctor and it becomes clear to him that it is not just his problem. Should that doctor walk out of the room with no sense to blame? Well, I can recall most of the mistakes that I have made in my career, and the intense sense of blame and guilt that accompanied them. Whether it was mismanaging Gentamicin and causing renal failure, missing a cord compression or making a late diagnosis on data that I should have interpreted correctly. It is blame, the sense of personal responsibility, that nagged at my mind and made sure I never made the same mistake again. For this reason I think individual blame does have a role. And I am not alone. A National Patient Safety Agency presentation from 2004 includes these slides:

blamejustculture

blamegraph1

 

At least 90% of error can be attributed to system problems or ‘honest’ errors, while only a small percentage are deemed ‘culpable’. This data is largely derived from the aviation industry, where many parallels with healthcare have been identified. But even this presents problems. The ‘honest error’ is still an error. Just because it is honest (ie. not intentional or negligent, an error that quite would probably have been committed by a peer in the same combination of circumstances) there is still something to be learned by the individual.

The psychologist James Reason describes person and system approaches. The former attributes unsafe acts to,

aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.

 Whereas a system approach accepts that,

 humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors.

 

For those of us dealing with error on a day to day basis, an approach that tackles individual blame while paying heed to system-wide lessons must be taken. For reporting to be encouraged, blame must not apportioned in public… for that is where shame develops, and its lethal consequence – inhibition. But in private, as we look at near misses and significant errors, we will sometimes accept that it really was a silly thing to do. And we will not hide our concern, nor conceal our disappointment if the error appears to indicate a worrying gap in knowledge, method or attitude. If this is the case a way must be found to lighten the sense of personal blame by looking up at systemic factors (if present), but without allaying personal discomfort entirely. In this way we (for it will happen to all of us at some point) will remain alert, and perhaps even a little paranoid, when we enter a similar clinical scenario in the future.

 

oOo

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Consultant outcome data – GP skit

Terence needs a bowel resection for cancer. This was found at colonoscopy as part of his company’s health insurance policy . His GP has referred him to Miss Emma Thomas, a colorectal surgeon at the local Trust. Terence has looked her up on the new NHS England ‘Consultant outcome data’ website. He has some concerns.

 

In the GP surgery 

Terence: “I looked her up. I’ve got some questions.”

GP: “Go ahead.”

“Right. I looked her up by name, and it said that her mortality rate was ‘OK’ – which I assume means acceptable, safe…”

transpidity base

“Good.”

“But when I clicked on the ‘source data’ it showed all the surgeons in the hospital, and Miss Thomas’s adjusted 90 day mortality rate (I think I understand that) was 8 or something… whereas some of the others were much lower, between 1 and 3. It made me think, I want to have my operation done by one of those.”

transpidity colleagues

“Right. Right. Well…”

“So can you re-refer me? I haven’t actually seen her yet.”

“It’s not that easy actually.”

“It is my choice isn’t it.”

“It is. Certainly. But let me explain… this data is helpful, but I think it’s the outliers you really have to look out for. And Miss Thomas is certainly not an outlier. She’s very good. And very nice to her patients.”

“But she’s had 4 deaths, based on 70 operations… while the best one in that group has had only 2, out of 90! I don’t want to be number 5. It’s obvious.”

“It may be that her colleagues have operated on less sick patients.”

“It’s adjusted isn’t it?”

“It is, you’re right. But those deaths, they are within the expected, or acceptable range.”

“Not to the ones who died, surely.”

“No. Sadly though, some deaths must be expected in patients with serious bowel problems. Sometimes they come to hospital as emergencies in a terrible state, with infections or obstruction, and they can be very frail…”

“So you think Miss Thomas has had more than her fair share of those?”

“I can’t say…”

“Or just a bad run of luck?”

“Well… who knows?”

“If you don’t mind I’d rather not be operated on by her until that run of luck has run its course.”

“Terence, this data.. I’m not sure if it’s really designed for such detailed scrutiny. The basic fact is, all the colorectal surgeons in that hospital are good…”

“Some are better than others though…”

“The more experienced ones, possibly…”

“Is Miss Thomas new then?”

“She is the newest, but she’s been there for 18 months.”

“Still on her learning curve? So you are asking me to agree to being put on that learning curve?”

“No. She’s fully qualified.”

“The older ones must be better. It makes sense.”

“They are a team, they collaborate, advise each other. You will be cared for by the whole department. The hospital as a whole does very well when you look at the graph of all the Trusts in the area. You saw that?”

transpidity trust

“I did. It takes you to a secondary website, coloproc- something.”

“Exactly. Your ‘outcome’ will depend more on how the unit is run as a whole than your individual surgeon’s skill…”

“Really? You mean that?”

“I do. This isn’t eyewash.”

“But doctor… who would you want to do your operation? Or one of your parents?”

“I understand completely what you are saying Terence. I would instinctively go for the one with the lowest number, of course, but as a doctor, as someone who worked in surgical units as a trainee, I know that it’s often more about the general quality of care you receive. There are surgeons who are technically questionable, but there are lots of systems in place to identify those… and as I said, if one was an outlier on this website I would steer clear. But the mortality limit has been set for a reason here, and if your surgeon is below that limit then you should be confident that your treatment will be acceptable.”

“If not the best?”

“We can’t all have the best all the time.”

“Just average then?”

“Average is good, sometimes. Acceptable is… acceptable.”

“Average is average, surely. And below average is… ‘OK’”

“It’s…”

“It’s what I must settle for.”

“I really…”

“I know. I’ve taken up enough of your time. Thank you.”

 

 

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Sick enough? Doctors, illness and the scaffold

Some time ago, during a weekend on call, a young doctor called me to say that she was ill and probably needed to go home. When I went up to see her she was leaving the sluice, having just vomited. She had felt awful since waking up in the middle of the night. There was of course no question – “Go!” I said. She left, but reluctantly. There were tears in her eyes. She was embarrassed and ashamed. For being ill!

“But what about the jobs?” she asked. The list of tasks and patient reviews that she had picked up in the morning was enormous.

“Don’t worry, we’ll deal with it.” I said. But I knew we wouldn’t deal with it very well. There is rarely enough slack in a hospital, especially at the weekend, to easily accommodate the transfer of one person’s entire workload. As I watched her leave, encouraging her when she hesitated at the door, I thought oh dear, this is going to be a bad day. And it was, for everybody. There is no doubt that patients on the ward waited longer for the medical care that they needed that day, although I am equally sure that no-one came to harm.

I wondered what went through her mind when she woke up that morning? Perhaps…

‘I’ll manage…’

‘However bad I feel, the only thing that will really stop me is if I’m actually vomiting…’

‘Because I can’t not go in… I saw the handover list last night, there are 30 patients to see…’

‘… and they are worse off than me…’

‘You don’t call in, nobody does’

‘But what if I’m contagious – only if I’m vomiting… and I’ll be careful…’

‘They say we shouldn’t go in if we’re unwell, but they want us to, really…’

‘…because the work has to be done…the policy doesn’t account for that!’

‘I know how annoyed I feel when a colleague calls in sick… some just do it…’

‘I’m going in… I’ll see how it goes…’

 

In this post I am going to explore the decision to call in sick. Much has been written about the rather profound insights that doctors’ behaviour when ill provides, and I would strongly recommend Jonathon Tomlinson’s January 2014 blog post ‘When doctors become patients’ on the subject (of which a little more later). Here though, I wish to examine the milder end of the sickness spectrum, and specifically the apparent rise in short term junior doctor sickness.

 

Paradox

Why was it that the thought of going home made that doctor distressed? It is not usual for people in other walks of life to feel so upset when they have to take time off. Was it the thought of letting her patients down? I don’t think so. More likely it was a lack of confidence that the hospital would easily adjust to her absence, and a concern that chaos would ensue. Patients were at the centre of her thoughts, not as people, but as incomplete tasks that would create stress for her colleagues. Whatever the reasons, sickness was something that this doctor had clearly tried to stave off, until the inevitable viral emesis overtook her. Typical doctor!

Or perhaps I have got this all wrong – this doctor was actually atypical, because there is evidence to show that doctors are now taking more time off. According to a study performed in a single NHS Trust before and after the introduction of a 48 hour working week,

 

Taking into account the increase in trainee numbers, the proportion of junior doctors taking sick leave increased by 90% (p = 0.001), and the total episodes taken by 170% in the year following the implementation of EWTD-compliant rotas

During the study period, episodes of sick leave among junior doctors more than doubled with just over 1 in 3 taking leave in the year to August 2007 and nearly 3 in 4 the following year. The number of days taken and the number of repeated episodes of leave increased.

 

There appears to be a paradox here. On the one hand we know that doctors find it hard ‘be ill’ – Jonathon Tomlinson’s illuminating post (regarding chronic or more serious illness, including mental illness) describes internal blocks to accepting illness such as dissolution of the medical identity as healer, stigmatisation and shame. In the case of life changing illness there are even more subtle psychological factors at play, including loneliness and the insiders fear of modern medicine’s fallibility. Some of these probably apply to minor illness, albeit disruptive ailments that impair young doctors for 1 -3 days, but there is no denying that the threshold has dropped. Trainees are, in general, more comfortable picking up the phone to call in sick. What is the answer?

 

Presenteeism and indispensability

An Audit Commission report into medical staff sickness (2010) stated,

Another cost, closely associated with sickness absence but much harder to quantify, is ‘presenteeism’.

Presenteeism is the loss in productivity that occurs when employees come to work but function at less than full capacity because of ill-health. The cost of presenteeism could be as high as one and a half times that of sickness absence. This cost increases when the cost of staff turnover due to ill-health is considered.

The Boorman review interim report found that ’presenteeism is greater in those who work long hours and experience managerial pressure to return to work’. There is little available data on presenteeism but Boorman found that 71 per cent of qualified nurses and midwives in the 21-30 age group report presenteeism compared with 45 per cent of staff in the same age group in corporate services.

 

In my experience presenteeism (which I have interpreted as the tendency to come to work when ill, rather than the ‘cost’ of such behaviour) is driven not by external pressure, but by an internal sense of indispensability. Because healthcare workers are always busy and pressurised, this perception seems unavoidable. How can we not regard our presence as absolutely vital to the service?

Another illustration: although I minimised the concern for the experience of individual patients earlier, there are times when this does play on one’s mind. These are when the clinical commitment is a ‘one man/woman show’ with no prospect of internal cover. I remember arriving back from holiday a couple of years ago with a resolving, though still rather scary looking dose of conjunctivitis (picked up from a dodgy hotel swimming pool I think). The chance of getting a replacement at such short notice was zero, but the impact, of sending 16 or 17 patients away, was going to be huge. I visualised their expressions, and the difficulties they would face in rebooking within an over-pressed system. I decided, on their behalf, that they would rather have a hands-free consultation than be cancelled on the day. This was a classic case of perceived indispensability, in the context of a contagious illness for which occupational health would have had me quarantined!

If indispensability does feed presenteeism, could it be that trainees feel less indispensible now than before? I’m not convinced. Although shifts are shorter, they are probably busier. There is more to do on the ward, there are more frail and deteriorating patients, and the expectations of both patients and relatives are higher. Each team member is just a vital as before. This argument does not scan very well… but it does bring us to the idea of the ‘team’?

 

Team cohesiveness

The pre/post European Working Time Directive study comments,

Both shift work and reduced working hours may contribute to a loss of the ‘group cohesiveness’ provided by the traditional medical team.

This is conjecture, but it does chime with people’s general feelings. A vivid memory, for me, is the sense of team working that pertained during the early years of my training. At the end of attachments I pledged to stay in touch with various colleagues, strong bonds having been formed over several months in the forge of long hours, silly levels of fatigue and vital inter-dependency. Life has moved too fast to maintain all those relationships, of course, but the sense of fellowship at the time was real. Indeed, when I was a junior house officer my registrar said one day, ‘Take tomorrow off – we’re on top of things here. Take a Mental Health Day’. And how I enjoyed it! I would love to offer the same to my present day juniors now and again, but the idea of being ‘on top of things’ is laughable. Back then the team was fast… however, I’m not sure if this made me more or less likely to call in sick. If you know colleagues well, and they trust you in return, you may be more comfortable picking up the phone and excusing yourself. If you are part of a larger but more ephemeral team – brought together just for the weekend for instance – there may be less of an expectation that colleagues with whom you have an easy relationship will cross-cover without question or reproach. The ‘team’ in this case indicates a collection of individuals whom a rota has thrown together, not a group of mutually supportive colleagues. The leader of that team, the consultant, may not know who is on the team, so dispersed are modern shifts and responsibilities. Yes, there is less cohesion, but the link between that and a greater willingness to call in sick is not clear in my mind.

 

The scaffold

So far I have presented the internal debate that precedes the decision to call in sick as a battle of pro’s and con’s, but this neglects the person’s general state of mind. No enquiry into the subject of medical staff sickness can ignore mental wellbeing, and it is this (largely unspoken) issue that may provide the link. The rising problem of anxiety and depression among junior doctors has been described recently (in the BMJ)-

 

Head of the Practitioner Health Programme in London Clare Gerada has found that since the service began, an increasing number of doctors have presented with mental health problems — 195 in 2008/09, compared to 242 in 2012/13.

Significantly, Dr Gerada found that more than half — 55 per cent — of the patients presenting to the service in 2012 and 2013 were 25- to 35-years-old, while only 22 per cent were 46 or over.

‘It may be that job stress, rather than personality, pre-existing mental health problems or factors at medical school, are behind the mental health problems seen in newly qualified doctors.’

 

These small numbers represent a tiny proportion of the workforce, and do not explain sickness behaviour overall. But if it can be safely assumed that beneath those with manifest, admitted mental health symptoms there are hundreds and thousands more with sub-clinical or contained anxiety or depression, we can begin to understand how an individual’s threshold for calling in sick might fall.

A survey by the BMA (the 7th report of the ongoing cohort study) in 2013 found that 44% of 368 doctors thought that stress levels were ‘worse or much worse’ than they had been a year before, and one in five reported ‘unacceptable’ levels. 40% said that morale had worsened. The BMA said in response that working patterns had resulted in a ‘trial of endurance’. The stress that surveys like this elicit is hard to define. It is not necessarily a pathological thing, more an overtone, an absence of well-being, a reaction to never-met demand, or bewilderment at the Sisyphean nature of the task.

When you are sick, physically, the inclination to work depends on a more general sense of positivity towards the workplace, and a feeling that one’s efforts will be appreciated. If the individual feels unsupported, rarely acknowledged, an isolated cog in a huge automated machine, the likelihood of fighting what might be quite trivial or transient physical symptoms, and pushing them to one side, is likely to be smaller. If the supporting mental and emotional scaffold is weakened, the fortitude required to ‘push on through’ cannot be mustered. Perhaps this is the link between ‘team cohesiveness’ and the observed increase in sickness absence. There is mental disquiet, but it is rarely described in words – only absence.

 

Empowerment

Or, there is a more prosaic explanation… younger doctors have got over the traditional, undesirable trait of ‘illness-martyrdom’, of equating the acceptance of illness to moral weakness, and have instead been empowered to develop a more mature and assertive approach – I am ill, therefore I do not work. This suggestion is not backed up with evidence, but may be part and parcel of the generally welcome changes in medical culture that have flattened the hierarchy (a little), and made it easier for trainees to speak up and challenge their seniors. Training needs are vocalised. There is less awe and fear on the wards. Perhaps the thoughts of that (atypical?) young doctor should have been…

‘Face it, I’m ill… we all get ill.’

‘And if I don’t go in today, what will happen? Will anybody die? No.’

‘I’ve covered others, they will have to cover me – that’s life.’

‘I will feel guilty… perhaps that is just another part of being ill. It will pass.’

‘They know me. They know I wouldn’t do this if I didn’t feel absolutely awful…’

‘And if something happens, if the work is not done, and someone complains, then I’m sorry…perhaps it’s needed to demonstrate that we need more people, rather than working at maximum intensity all the time…’

‘You know I’m over-thinking this… where’s my mobile…’

‘Hello, Sam, sorry, it’s me Esther…I can’t come in today, I’m ill…’