Wi-fi

The technicians visited to survey the department for our wi-fi. Optimistically, it should be operational in 2-3 months!

Warfarin superior to aspirin for stroke prevention in AF: BAFTA published

Theheart.org

A Haiku

Say it, say it true.

The bell tolls, tolls, tolls for thee.

Yes. Every heartbeat.

Thriving After Life's Bum Rap

NY Times

A Haiku

Speak simply, clearly.

The bell tolls, tolls, tolls for thee.

Yes. Every heartbeat.

Speaking with patients

Patient satisfaction is entirely irrational and reasonably so: it is subject to a host of cognitive biases. Ultimately, satisfaction depends on whether the patient feels cared for, heard and understood. Patients are in no position to judge the technical or cognitive skills of the doctors who attend them and so they rely on their assessments of their clinicians’ social skills as proxy for everything else. I am reminded of Beckwith’s anecdote in which the lawyer stated that she had never had a client who said that she really, really liked her doctor, but that she felt, absolutely, that she had to sue him.

 

Speaking with patients needs time – time without distraction and time without a pressing deadline. And then there’s the real world. It also needs a history: people are subject to idiosyncratic shames, guilts and other prejudices that lead to omissions, ambiguities, diversions, misrepresentations and lies. No-one is immune: a colleague presented with a history of abdominal pain radiating to his groin when the truth was that he had an acutely painful and swollen testicle. Repeated interaction creates and improves trust which leads to more open and less ambiguous communication.

 

Communication is inherently and usefully ambiguous. In high pressure situations, the usefulness is inversely proportional to the ambiguity. We all need clarity when the stakes are high and ambiguity is most useful (ego-protective)in those circumstances.

 

Speaking with patients also needs simple language because stress slows down processing and big words and long sentences don’t make for easy repetition. Simple language is, unfortunately, very difficult and when I am tired almost entirely beyond me. It needs first that one know what is most important medically and to the patient. These may be two different things entirely. It needs also, an assessment of the patient’s receptiveness and the willingness and ability to recall the information given. To hear, to understand, to remember and to recall are all different things.

 

Information is provided with some end in mind, some action that must be taken or not or some burden that must be accepted. As always, one should begin with the end in mind.

The art of apology

The art of apology: when and how to seek forgiveness. Roberts RG. Fam Pract Manag. July/August 2007;14:44-49.  

LIFE BALANCE ANALYSIS MINDMAP

Generic Life Balance Analysis

Risk Management Mindmap

Risk Management

LAFB Mindmap

LAFB Mindmap

COPD and IV Magnesium

I disagree

 

Today I gave a COPD patient Magnesium sulphate IV. My consultant said, ”There’s no evidence of benefit…. Don’t do it.” I didn’t argue: Mondays are too busy for these kinds of arguments.

 

There is evidence that Magnesium:

 

• acts as a bronchodilator
• that it improves clinical outcomes in severe asthma not responding to inhaled beta-agonists
• is safe (LD50 in rats is 1200mg/kg)

 

We know that the following patients have reduced intracellular magnesium:

 

• those with severe chronic disease
• those who take long-term corticosteroids
• those who take inhaled beta-agonists
• those on diuretics
• those with abnormalities of potassium and/or calcium metabolism
• those with diabetes
• the very elderly
• those on chemotherapy
• those with eating disorders
• those with alcohol dependence disorders
• those with severe COPD

 

We know from the law of diminishing returns that those most severely affected by disease benefit most from its treatment and that harms and benefits have different curves that cross at different points for all patients.

 

We also know that “no evidence of benefit” is not evidence of no benefit. We lack data.

In COPD, we know that combination therapy acts synergistically and that steroids and antibiotics for acute exacerbations improve outcomes (even in patients without evidence of bacterial infection).

 

My patient had severe COPD: she had had multiple admissions this year, had suffered respiratory arrest more than once and was already on maximal therapy before her acute presentation. Did my patient benefit from the IV Magnesium sulphate? Probably. Can I prove it? No, but neither can it be proven that she did not benefit.

Friends?

NY Times

A Blueprint For 'Smart' Health Care

 

Where should people die?

Should people die at home or in hospices or in acute care hospitals? Who should decide? When should the decision be made? What should inform it? And when should it be reviewed?

Discovery

"Discovery consists of seeing what everybody has seen and thinking what nobody has thought."
--Albert Szent-Gyorgyi, 1937 Nobel Laureate in Medicine

 

Ovarian transplant

Woman has successful ovarian transplant from her sister - News-Medical.net

from Google News - Health

 

 

Reflections on retirement

Morale in the NHS

Reflections on retirement

Philip D Welsby

 

 

Do I need to say that I enjoyed this?

Glan Clwyd

Hospital may need rebuilding

Resuscitation

A dead patient arrived late on Saturday and I initiated resuscitation. It was the wrong call.

 

The history: the patient, in her 80s, had been found collapsed. She had been leaning to one side and she had facial asymmetry. She had been collapsed for an indeterminate period of time and it was ten minutes between being found and the paramedic crew arriving on scene.

 

On arrival on scene, the patient’s GCS was 3. She was breathing but stopped soon after and was then ventilated by bag-valve-mask. IV access failed and the patient was transported with bag-valve-mask ventilation. She arrived at the ED 35 minutes after being found. GCS remained 3.

 

Initial examination: apnoea, pupils 5mm bilaterally and unreactive with no brainstem reflexes. Pulse (radial) present, bradycardic, MAP = 54.

 

The patient was dead. Dead people do not have beating hearts. That was my reasoning. However brain dead people do have beating hearts. The probability of CPCR was zero. The incongruity of a beating heart led to a futile attempt at resuscitation that was continued for an additional 15 minutes.

 

The next dead patient who arrives with a beating heart will not have resuscitation attempted. Information that does not make sense cannot be processed under extreme stress. I know that I should disengage, but knowing and remembering under the circumstances are two different things.

Suturing

I did a rotation in plastic surgery as a junior doctor: I wanted to have practice suturing.

 

During my first on-call I spent 6 hours suturing one patient: he had been assaulted with a panga. At the end of that and with more than 12 hours to go to the end of my call I felt that I had had as much practice as I could conceivably want. I still had six months of my rotation to complete.

 

Our commitments are made in ignorance. And hindsight is no good: given the answer all problems look solvable.

 

Last night I sutured a complex facial laceration on an elderly patient – it was slow, difficult suturing and took some time. It reminded me of two things: practice makes perfect (cf. practice makes permanent) and time is the ultimate value (cf. Wal-Mart vs. Google).

 

Spannungsbogen

Where do you draw the line between maturity and pathology?

Brain Scans Reveal Why Meditation Works

Live Science

Dr. Robert Schuller

What would you attempt to do if you knew you could not fail?

    Dr. Robert Schuller

Personal Development

Personal Development

Metacognition

Metacognition

LPFB Mindmap

LPFB mindmap

Personal development goals

• Think better
• Speak better
• Read faster
• Type faster
• Move better
• Imagine!

 

 

 

Life and Death

All stress, including fatigue, narrows one’s focus. A narrow focus means failing to attend to relevant information and weighting some information too heavily. A narrow focus, then, misdirects sometimes disastrously.

 

Reflection improves performance and reflection in action improves it sooner. In clinical care many events are singular so that reflection after action helps only with process rather than specific actions whereas reflection in action helps with what one is dealing with specifically. Highly dynamic, time critical events do not lend themselves to reflection in action particularly because they are stressful. What is needed is the facility to step back in critical moments, to disengage.

 

The patient is dying; disengage. That, friend, is easier said than done.

 

My belief that I have no control over life and death and that death is destined allows me to disengage. I cannot save those who will die: nothing I do will make a difference. My task then is to see that those who survive do so with the best possible outcomes. There is a central inconsistency here, but inconsistency is human. And I have no wish to debate whether death is destined or not. My conviction is pragmatic: I do not decide life and death so I am free to be as heroic as I choose: I have control of the process, not the outcome.

 

How do you deal with stress? How do you free your stuck cognitive gears when life is on the line?

To my networks

What are you particularly good at?

 

What are you becoming particularly good at?

 

What would you want to be particularly good at?

 

 

Social Networks

If memory is part structure, part process and part cue and knowing is largely network both internal and external, how is social-network knowing if it is unmapped and almost all tacit? We don’t know what others know and can never know.

 

Needing to know, we can ask. Broadcast is most efficient, but how responsive are our networks to broadcast requests? Until such time as networks are ubiquitous and intelligent and people are responsive, broadcast will not be workable for important things.

 

ICT literacy is generally, lamentably, poor.

 

 

NHS SAS Contract

BMA response to delays.

 

Meetings

 

• Start and finish as planned
• Have an agenda; stick to it
• Attendees as needed only
• Document decisions and make someone accountable
• Be transparent

 

 

Symptoms Found for Early Check on Ovary Cancer

NYTimes

Petitions

I received an email from the BMA to sign an online petition to the government for movement on the SAS contract. I signed the petition – despite Cialdini’s observation that petitions act only on the petitioner creating an activist, defining self, rather than the petitioned.

 

I wonder: does knowing this mitigate the effect? I expect it does to some small extent. Such adjustments are never complete (cf. anchoring bias).

DO LESS

I have long had a problem doing less. There are so many important things to learn and do that choosing is difficult. I am reminded though that there are an infinite number of things to do and very limited time in which to do them, so ultimately, we all have to choose our “Yes!” carefully.

 

This then is everyone’s essential task: to decide or discover what is important.

 

I searched Google for “what is important” and got 896,000,000 results.

 

“Why?” That is the beginning.

 

I value life. I value life because we have only one life to live. I know nothing of what came before or what comes after. I know that something came before and that something comes after, but I am not convinced that my identity has been continuous. An amnesiac is not the same person as his premorbid self.

 

I value life because the living have agency. I know that I can effect. Control is an illusion; agency is not.

 

My problem is what to effect.

 

 

PAIN

The language of pain

 

 

There is a language of pain. We are taught it at medical school: throbbing, stabbing, lancinating, crushing, bursting, cramping, burning, stinging, aching, boring, gouging, …. In the learning of it we experience it too, convinced always that we have some fatal and incurable malady.

 

 

Pain has a timbre and a cadence; it has body and soul; it is alive and separate and malevolent.

 

 

It is unfortunate that patients come to us not knowing the language of pain. All they seem capable of saying is that it hurts; a lot. They can’t even always say where – somewhere. And when we treat the pain they are relieved but not satisfied: they want to know why: cause and motive.

 

 

Longevity Quotient

Proposed:

 

 

LONGEVITY QUOTIENT: RATIO OF PHYSIOLOGICAL AGE TO CHRONOLOGICAL AGE MULTIPLIED BY HUNDRED.

 

 

LQ = PA/CA x 100

 

 

knowledge Ends

Advancing technology makes it easier for individuals to plan, create and develop new products and then to market them. Knowledge is the most important and most valuable product, but knowledge has to serve some other external end.

 

Ends:

 

• Community
• Longevity
• Health
• Education and Training
• Creativity
• Engineering
• Posterity
• Repair
• R&D
• Negotiation
• Transaction fulfilment
• Inventory management
• Recruitment and retention
• Architecting capability
• Enforcement
• Persuasion

 

 

The above list is in no particular other than the order in which they came to mind (How revealing!). Nor is it meant to be exhaustive.

"Top 10" Medications Involved in Adverse Events

1.     Insulin (8%);

2.     Anticoagulants (6.2%);

3.     Amoxicillin (s) (4.3%);

4.     Aspirin (2.5%);

5.     Trimethoprim-sulfamethoxazole (2.2%);

6.     Hydrocodone/acetaminophen (2.2%);

7.     Ibuprofen (2.1%);

8.     Acetaminophen (1.8%);

9.     Cephalexin (1.6%); and

10.  Penicillin (1.3%).

http://www.medscape.com/viewarticle/556487?src=mp

 

Productive Effort

Productive effort is directed towards improving our tools and improving our tool use. This is captured as improved productivity.

 

Productive effort is also directed towards solving significant problems that could not be solved before due to lack of resources or lack of knowledge.

 

Improving our tool use involves using our tools more skilfully and applying our tools more appropriately in addition to finding creative, uncommon uses for existing tools.

 

As always we have to remember to do the right things before doing things right.

On teaching patients to begin with the end in mind

Patients consult with symptoms = problems. They are often in search of solutions that remove the causes without due regard for what is possible.

 

 

Patients fail to consider that a determination of cause is not always possible and that knowing cause does not necessarily mean effective correction and that even effective treatments are not guaranteed effective in their specific circumstances. And there are always trade-offs, side-effects, costs. These have to be balanced against the anticipated benefits.

 

 

Ironically, in an age when healthcare providers are more effective than ever, patients trust their caregivers less than ever. Expectations are to a large extent misinformed. The essential question given this mismatch is who is responsible for educating patients?

 

 

I do not consider it my responsibility to teach the general public how to think. I have enough difficulty persuading my colleagues that their thinking is a skill that can be improved.

Information Design

Clinical documentation serves several purposes:

 

To note facts and perceptions that are relevant to diagnosis, investigation or treatment that are too numerous to remember or too complicated

To note relevant positive and negative findings on examination or investigation

To note a rationale for acting or not acting

To plan a course of action

To note the specifics of patient interventions

To signify results

To coordinate multi-specialty care

 

Documentation serves to make memory unnecessary and helps to make thinking as explicit as possible. Intent, process and outcome need to be as transparent as possible. Clinicians do not, as a rule, explicitly consider the purpose of documentation on a case by case basis.

 

(Wikipedia)

 

News: NHS Direct 'Health of the Nation' snapshot survey, Jan-Mar 2007

http://www.networks.nhs.uk/news.php?nid=1431

 

NHS Direct website ‘Top Twenty’ encyclopaedia topic searches. Jan-March 2007

• Pregnancy - 115,008
• Chicken pox - 82,201
• Contraception - 51,886
• Immunisation - 47,777
• Diabetes - 46,850
• High blood pressure - 45,966
• Accidents first aid - 42,153
• Irritable Bowel Syndrome - 37,757
• Back pain - 37,296
• Cystitis - 34,853
• Under-active thyroid - 34,528
• STIs - 33,621
• Depression - 33,149
• GP - 32,721
• Healthy eating - 32,588
• Flu - 29,234
• Chest infection - 27,059
• Thrush - 25,081
• Ovarian cyst - 25,064
• Glandular fever - 23,632

 

HBS Response 070507

Diagnosis is complex and inductive rather than deductive. The list of all possible diagnoses is long, much longer than one person can know. In seeking diagnoses, clinicians are looking for an action path: to prevent, treat, mitigate, palliate and/or prognosticate. Treating and healing are different things and sometimes simply naming a problem is enough for a patient.

 

What can managers learn? Not all things are knowable; not all things are fixable; humans are finite. Logic does not serve and experience always counts. All acts involve trade-offs, costs and benefits. And judgement is very fragile.

 

None of the above is actionable.

 

So, the essential lesson is this: life is uncertain, still you must act – in humility – because you are likelier to be wrong than right. Act and reflect. Outcomes direct actions, but intent is paramount. As Musashi observed, action is distilled intent.

 

How do you teach a child to begin with the end in mind?

How do you teach a child to begin with the end in mind? Keeping in mind that adults teach what they do, not what they say, and that learning needs feedback and doesn’t happen without it.

For children, beginning with the end in mind means beginning with an unmet desire; needs and drives are the responsibilities of their carers. And those desires are likelier to be impulsive than planned. Frustration is likelier to promote learning than easy and early success. All this suggests that teaching an awareness of ends will be very challenging.

Sometimes it is better to act before you think; most times it is better to think before you act.

So, these are the necessary conditions: an unmet desire that has been frustrated; a proximate non-malevolent desire that can be satisfied given some help and thought and the willingness and patience to teach something that can be taught.

An awareness of ends implies an awareness of ecology: how things fit together, how they relate, what the facilitators and obstructors are or are likely to be.

Friction and inertia are practically ubiquitous. They are easily taught and often forgotten. The motivations of others are difficult to ascertain and confirm and are always changeable. And it is natural and common to ascribe to others degrees of latitude that are greater than we are aware of having ourselves.

Knowing how to teach children would make teaching adults easy.

Problem Based Learning

A letter to my consultants:

I am committed to being better. This is not an occasional goal or aspiration: it is me. Kaizen. I am not in competition with my future self but I am driven by an ideal self that may not be realised.

I have a great deal to learn and my learning progresses day by day. Learning is what I do.

I understand that protocols exist to standardise safe practice. Both standardisation and safety are important severally and together for many reasons. Standardisation should not mean petrification.

Auditing my own practice more intensively over the past 6-9 months, one of my goals has been to reduce my admission rates and to do so safely. So, I have paid more attention to the numbers and been more aggressive with treatments: keeping in mind that more aggressive action needs finer feedback, more acute monitoring – time is a resource that acts.

I have said many times that I am not invested in specific acts; I am invested in process.

We agree that practice should be informed by evidence and that evidence is sparse; however, we do generate evidence and don’t use it to inform our practices. When evidence exists to change practice and you don’t, it would be helpful if you could say what (achievable) evidence would be necessary to change practice. As consultants, ultimately responsible for safe practice in the unit, it would be considerate if in changing the management of my patients you did so because you believed it necessary rather than preferable. Art is always arguable: your interventions should benefit me as well as the patient. If you don’t change my mind about my course you won’t change my practice – and so you do me and my future patients a disservice if a change in practice is necessary.

Medicine is experiential; no book learning can substitute for treating patients. And guided, moderated experience always beats trial-and-error learning.

Thanks!

Decision Technologies and Evaluation

http://www.york.ac.uk/res/iht/events/HTAiRome2005/romepresent/Dowie.pdf

NHS Knowledge Management Briefing

NHS Knowledge Management Briefing

Junior Doctors' Recommended Reading List

Medical Heuristics: The Silent Adjudicators of Clinical Practice

Clement J. McDonald, MD

The theory and practice of clinical decision-making

Pat Croskerry, MD PhD

peter senge and the learning organization

Peter Senge’s vision of a learning organization as a group of people who are continually enhancing their capabilities to create what they want to create has been deeply influential. We discuss the five disciplines he sees as central to learning organizations and some issues and questions concerning the theory and practice of learning organizations.

Information bias

List of cognitive biases

Lean Learning

This is borrowed from Lean Manufacturing or just-in-time manufacturing: no inventory. It is just-in-time learning as opposed to just-in-case learning, the premise being that know-why (judgement) is most important and that know-how is next and that know-what can always be looked up.

Many years ago, I was surprised to learn that Einstein did not know the mass of the earth. It wasn’t necessary to know it because it was referenced. It took more time and effort then to look up something like that than it does today. Knowing it remains unnecessary.

In medicine practice is supposed to be informed by the evidence, but for most of medicine there is no evidence. Where cause and effect are proximate, common-sense serves; where they are not it does not. We have already picked all the low hanging fruit of proximate effects. We are in uncharted territory with huge numbers of patients and small effects and a severely constrained cognitive biology.

What is the solution? More data and more sophisticated data mining and a more pervasively statistical perspective. Never, of course, forgetting human and humane engagement.

Presenting a case on the floor

Begin with your assessment: define the problem – the patient's problem

State your decision point: you need to act: what are your action options and what determines which one you choose

e.g.

The patient has an elbow injury

Do I x-ray or not?

Do I admit / discharge?

…

These are three haiku, one story.

In setting suns and

In rising moons, ebbing tides,

Shaped clay is fired

In misted dreams and

In lambent grace, gathered close,

Hardened hearts soften

Opened and opened,

Wide, yielding, deep, enfolding,

One falls into grace

HBS Response: What do readers think May 2006

 

What are worker benefits? We all strive for health, wealth and fulfilling leisure.

 

Technological developments drive higher quality living: life in 2006 is orders of magnitude better than life in 1906 – for the wealthiest and the poorest.

 

Paid work supports health, allows for the accumulation of wealth and is generally a prerequisite for fulfilling leisure. It also promotes social gender equality, reduces the number of children women have, and improves women’s health and longevity.

 

Higher employment drives consumption which drives technological development which improves quality of life.

 

Regarding social sector effects it is to be remembered that for most of us, in our striving for health, wealth and fulfilling leisure, we do not do the small things that need to be done consistently. It is the complex cumulative of individual actions and omissions that produce individual health, wealth and fulfilling leisure not the actions of large corporates.

 

Before criticising, we should examine carefully the social sector effects of wage deflation and higher productivity. In all ecologies things are not simple.

a haiku

After chrysalis -

samadhi, love, satori

-Lepidoptera

Excellence

We are what we repeatedly do.

Excellence, then,

is not an act, but a habit.

- Aristotle

"Ever tried. Ever failed. No matter. Try Again. Fail again. Fail better."

Samuel Beckett

An open letter to South African policy makers

The standard of medical care is now global: this means that the expertise, the skill, the consideration expected of a medical practitioner in South Africa is the same as would be expected of one in the USA, Australia, Canada and the UK. True, levels of litigation and liability differ but the expected levels of care do not.

South African doctors are good and are welcome in the countries abovementioned.

Professional fees in South Africa are not determined by market forces because the government believes, correctly, that market forces would price most consumers out of receiving necessary care. However, most medical expenditure does not go to heath care providers: a larger proportion is spent on administrative costs in the industry than on doctors’ fees.

Given the small proportion of people capable of being doctors, doctors in South Africa are paid considerably less than their counterparts elsewhere whereas business people are paid considerably more. This says a great deal about what South African society values and how little political capital doctors in South Africa have.

The NHRPL has one purpose, to drive down the cost of medical care: it seeks to broaden access rather than fairly remunerate health care providers. Access is a laudable goal as is fair remuneration. However, these two are mutually exclusive. So, trade-offs are necessary and expected and not objectionable. My point, made repeatedly, is that healthcare providers should not be expected to bear such societal costs disproportionately as they currently do. That is inequitable and unsustainable and drives emigration.

The HPCSA’s primary remit is to protect the public not serve the interests of health care providers. The only body charged with acting in the interests of health care providers is the SAMA.

As a doctor, I believe that doctors in South Africa get a raw deal and I know that that will not change for a number of reasons and that it arouses very little sympathy. I also know that it is short-sighted because good health is the base of the human capital pyramid. Good health is the base of all economic measures including Gross National Happiness.

To the law of unintended consequences!

A Letter to The Editor, EMJ

It is a wonderful circumstance that when a professional publication will not publish something, one can always self-publish. It may not have as wide a readership as a professional publication but time is a factor that could change that considering that web publishing is not ephemeral.

Admittedly, the letter below was part rant and part therapy, it still raised an issue that is generally important. (IMNSHO)

The Editor,

I was to sit the SAQ (Part B) on Monday 18^th December. I didn't because I arrived (18 minutes) late.

I left home at 0515 to take the 0700 BA flight from Manchester to Heathrow. The flight boarded timeously but departed late (0731). From Heathrow I took the next Heathrow Express (0848), arrived Paddington 0904 and immediately took a taxi to the Barbican.

After several consultations amongst the invigilators I was told that the 15 minute rule could not be relaxed because to do so would set a precedent.

I stayed outside the doors until 1043 when the first candidate left.

I reflected.

The exception discussed could in no way be binding on any future invigilators. "Precedent" was contextually a malapropism. The exception would have done no harm and would have benefited me tremendously.

Beneficence, too, as an observed principle was conspicuously lacking.

For a professional speciality tasked primarily with the urgent, the emergent and the critical, an inflexible adherence to the letter is a cause for concern.

A society's resilience is entirely dependent on the initiative and flexibility of its constituent members....

My disappointment and frustration are salved somewhat by this letter, but the issues I raise above are material to the profession (sic) of Emergency Medicine.

Sincerely,

E. Hassen

HBS Response: What do readers think September 2005

Two things come to mind. Plans are nothing; Planning is everything! And, the right people on the right vehicle before you select the right destination.

 

The rate of change accelerates and the number of disasters are only going to increase (natural and otherwise). Events cannot be predicted with a long lead time.

 

Every organisation needs to be more flexible, more modular, more adaptable. Large organisations especially, need to be reconfigured.

 

Lessons: The future is unpredictable; trust and credibility are crucially dependant on time to response - respond promptly.