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