Friday, 26 December 2014

The Problem with PDSA in healthcare

In healthcare it is now generally understood that using the PDSA cycle is a good and valid method to try to achieve improvement. The PDSA is very widely known in healthcare and often used, though it is thought it ought to be used even more. Yet, when we look at health organisations that are using the PDSA we do not find the improvement at a range or scale or impact that is very often found in other industries who use PDSA.


To resolve the angst around this we need to know what comes before and after any particular individual PDSA cycle.

Before a PDSA

How is the specific individual PDSA cycle conceived? Why was this particular PDSA chosen over many possible PDSAs that could have been done?

Before choosing to do any one particular PDSA there are at least five prior major detailed outlining steps to be completed that involves objective and subjective methods, data analysis, prioritisation, setting aims, measures and interventions. Only after this a PDSA ought to be done by a very small team which has mostly understood the prior steps as a matter of overall context – i.e. the how and the why, the logic that validates your activity, the reason that requires your engagement and the rationale that demands your time and energy.

If you are currently doing a PDSA or soon planning to do a PDSA it is important for you to consider how it was chosen. If you chose it out of an impulse, hunch, suggestion, obligation, instruction that is great for your personal learning of the tool which is of course very important. It may (or may not) show an improvement on that particular cycle or cycles, but you or your organisation should not be under the illusion that this PDSA effort is going to contribute to sustained or widespread improvement. It is important to prove to yourself on where the PDSA fits in within a broader department, division, directorate, organisation context.

One of the ways to identify whether there is any link to anywhere other than to you is to observe if your boss or your boss’ boss is as keen and enthusiastic about your PDSA not because they support you but because your PDSA has an important link to moving the dots in the right direction that they are supposed to move and they can prove it. They should be able to stop further PDSAs that is not working and you should be happy with it.

After a PDSA

What happens to your PDSA after you have completed and you think it shows some positive result? Are you in a position to pilot it further in repeatedly larger areas/scales? Do you have the support for it? Have your bosses confirmed your PDSA cycles have proved as shown by a series of linked organisation wide data that it has led to wider improvement? Eventually after a series of such PDSAs does your intervention, process and outcome become official standard protocol for the area?

The problem with PDSAs as we do it in healthcare right now

Every empowered person does PDSA based improvement activity but there is usually no one to track all of these, guide the people doing PDSA projects, help them do the run or SPC charts, identify where these projects are in the overall organisational improvement effort (say by using a driver diagram), capture and roll out good ideas for the whole organisation's benefit.
I would say that we should stop healthcare employees from doing unsupported PDSAs for at least two reasons a) it wastes individual staff time which could be usefully spent on something more useful b) if the unsupported PDSAs are successful then it leads to small individual areas shining which is usually a drain on resources and general emotion (technically known as sub-optimisation). In theory it is possible to even cause harm by such poorly designed activity.

The issue is Tools vs Philosophy

PDSA has great history and comes from the times of superior masters like Shewhart Juran and Deming. It is a part of an overall philosophy that can be called the QI movement or which after adaptation now more familiarly known as the ‘Lean’ (though some purists, even non-purists will be able to differentiate between the two).

To understand this better, we need to ask ourselves whether the PDSA is used as a tool for individuals or as a part of a philosophy for organisations. Similar to the issue whether Lean is used as a method or philosophy. If you or your organisation are using PDSA (or Lean) as a mere tool or a method – you are designing is poor and destined to fail.

We are at a point in history of improvement healthcare that we are training a large number of people on ‘quality improvement’ and letting them do unsupported PDSAs. We do that under the guise that we do not want to interfere with the freedom of senior and experienced healthcare staff. When these ‘trained’ ‘senior’ people do not see the improvement that the lean system claims that it offers, they then become committed disbelievers in the philosophy while at the same time being obliged to follow the tools and the methods.

We are at the risk of defiling and debunking a well established validated healthcare improvement philosophy because of our unwillingness to adopt it as a philosophy. It will be to the eternal shame of us in healthcare. We are creating proof that lean healthcare does not work, instead of accepting that we do not know how to do lean healthcare properly and we are not doing it as we are supposed to do. We need to act swiftly to avoid this - there is life and limb at risk.


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Sunday, 30 November 2014

Yo BAPIO - What is that Moral Victory thing?

This article was first published in Sushruta Vol 7 Issue 1 by BAPIO

It is now very well known that BAPIO filed for a judicial review of the MRCGP examination, especially with regards to the CSA component; well there is no point beating about the bush, BAPIO lost the case.

That means that the MRCGP was ruled to be a fair examination, by indirect inference it may be assumed that other examinations were also likely to be fair. BAPIO members, BME doctors, IMGs can be reassured that things are rosy and live in joy. I was just about to do that when I found that Prof Rajan Madhok, Chairman, BAPIO tweeted ‘JR judge says: moral success but not legal victory! So our laws go against our morals? Crazy’ It is true. The judge said BAPIO had a moral victory.

So what is that moral victory thing? It is just a judge being polite?

Pause. Reflect.

To understand this, we have to go back to 7 June 1893. One Mr MK Gandhi who had a first-class ticket and was travelling in a first-class rail compartment was thrown off the train. He had a legal right to be on that train but he still lost his seat in the train; Gandhiji had a moral victory. The rest was history and what a history it was.

The judicial review has set off a number of changes which we are beginning to hear about. The GMC is now considering seriously introducing a common licensing examination for UK graduates and IMGs (similar the concept of USMLE). The GMC is introducing English language competency tests for EU doctors (where there is cause for concern). The time allowed for the AKT MCQ examination of the MRCGP is being increased. There could be changes to the way CSA is conducted and assessed. There are numerous other changes and many Royal Colleges and medical educational establishments are engaging with BAPIO and its partners.

The RCGP and GMC activities considered in the Judicial Review were ruled legal. Yet they and other institutions are making changes that further cause of equality. BAPIO contends that these changes would not have happened at this juncture and at this pace, without the Judicial Review? Are we beginning to understand the concept of a legal loss and a moral victory?

By the way, Gandhiji protested and was allowed to travel the next day by first class. In the continuation of the same journey he was beaten by a driver, banned from hotels and subjected to other forms of abuse.

BAPIO should be under no illusion that things are or soon will be rosy. The path is strewn with thorns and BAPIO should be prepared for its skin to be pricked in this journey. What does BAPIO want? BAPIO wants, what you have always wanted. A level playing field, no bias, high standards, fair assessment and equal opportunity to progress.

Here are some suggestions on the specifics that BAPIO should be asking for

1) Real patients rather than role players
2) Increased number of BME/IMG examiners
3) Two examiners on each station
4) Video recording of the session.
5) Improved training of the candidates.
6) Improved training of the trainers and holding to account of trainers with poor record of success of their trainees.
7) Feedback and mentoring for those who fail
8) Removal of hawk examiners/trainers (especially those who have negative impact on BME/IMG doctors)
9) Removal of dove examiners/trainers (especially those who have a negative impact on BME/IMG doctors)
10) Testing and continued monitoring of sub-conscious bias in examiners/trainers.
11) Examiners with extreme bias not to be selected, examiners with non-extreme bias to be provided training followed by monitoring.
12) Pass-fail threshold and other standard setting (such as ARCP/RITA progress) should be tested for impact on various populations with protected characteristics and where there is no evidence of impact on patient outcomes the thresholds should be adjusted to reduce any possible negative impact on doctors with protected characteristics.
13) Objective assessments/examinations for summative, pass-fail, high-stakes situations/examinations/assessments (with any subjective assessments reserved for formative processes)

There are many more ideas that will benefit the system.

If BAPIO decides to ask for these and more, you can be assured BAPIO will be vilified and denounced. The hope is, after the abuse is done, the changes would happen, even if they were slow.

A couple of thousand of years before Gandhi, we hear of one Jesus Christ, who lost a legal case and was crucified; he seemed to have won the moral case quite convincingly. Time will tell, but BAPIO’s moral victory may turn out to be a very strong force for change.


Sunday, 19 October 2014

Innovations in a small hospital

Have you heard of Goole Hospital? If you have not heard of it, that is not surprising. We generally don’t want you to hear about it/us.  It is a small hospital with about 30 beds and we do not do brain transplant.

We have a minor injuries unit, some medical in-patients, elective services in ophthalmology, orthopaedics, general surgery. There are outpatients and other services – you can check out the website

What fascinates me is the number of innovations that have happened in Goole. Why it happens could be the subject of another blog post.

I am defining innovation as, ‘use of a better and, as a result, novel idea or method’ (Wikipedia).

Goole Innovations

Here I write about a dozen innovations that I have seen or been involved in at Goole.

1)      No clinic letter Clinic notes faxed to GPs as is

This when the general surgery clinic’s doctors’ handwritten notes are faxed to the general practitioner (mostly within 24 hours) instead of a letter first dictated then typed and then cross checked before signing and sending. Saves a load of secretarial time and money.

2)      Tests before OPD (USS OGD Flex Sig)

When we know by reading a general practitioner’s letter that the patient would undoubtedly need a particular test, such as an ultrasound scan, gastroscopy or a flexible sigmoidoscopy the doctor who vets the letter orders the test so that the result of the test is available for discussion at the patient’s first out-patient clinic consultation. Allows sensible discussion, often gives answers.

3)      Same day pre-assessment for general surgery and endoscopy patients

When the doctor tells the patient ‘you need a surgical procedure’, the patient if they have the time are pre-assessed at the same first surgical clinic visit. A kind of a one-stop service. Saves a lot of time for patients. We try to do this as often and as many patients as we practically can.

4)      Single Visit General Surgery

For general surgery patients who are suitable for day case surgery the Goole Single Visit pathway offers for suitable patients the option of visiting the hospital just once. Consultation and operative surgical procedure (occasionally some smaller additional investigations) all done in the same visit. Lumps and bumps right up to gall bladders.

See this link that blogs about the single visit service

5)      Laser Haemorrhoidectomy

Formal surgical operation for piles done with local anaesthesia and laser with patients discharged in two hours. We have been doing this for a few years now. Brief blog about that can be found at

6)      Entonox for colonoscopy

Entonox, also known as gas & air can be used instead of sedation for colonoscopy. That is neither special nor surprising. In Goole, at the last look, we found approximately 35% of our colonoscopy patients opted for Entonox when the general published number is 17%. All I can say is our patients and staff are very special.

7)      Straight to test two week wait colo-rectal cancer referrals

Overwhelming majority of patients referred as two week wait cancer referrals end up having a colonoscopy. We have a system where suitable patients have their first consultation and colonoscopy at the same visit.

8)      Own reporting software for endoscopy

External software involves purchase cost, maintenance cost and annual licensing costs. We have created our own reporting software with Microsoft Infopath which was already available in trust computers. We have been using this for a few years. Spending your money responsibly, eh?

9)      Single length endoscopic accessories (0 error)

We use the colonoscopy length accessories for colonoscopy and gastroscopy. This has resulted in zero error hence zero waste (since there is no possibility of opening a gastroscope length accessory for a colonoscopy procedure)

10)  Home enemas

Patients who are for flexible sigmoidoscopy need an enema. To have someone unknown administer an enema in an unfamiliar environment and then have to use the unfamiliar toilet can be bothersome. We ask patients if they want to administer the enemas themselves in the comfort of their own homes.

11)   In-situ simulation training

First in-situ simulation training with two scenarios, two trainers, one volunteer ‘patient’ and a professional actor, in our organisation with three hospitals. Even before our nearest tertiary hospital could do it (they have since done it)

12)  Local Anaesthesia option for most inguinal and umbilical hernia repairs

Once the patient is considered suitable the patient has the choice to go for local anaesthesia (with or without sedation) or a general anaesthetic. A large number go for local anaesthetic repairs.

13)  Synchronised test-opd

When routine follow up ultra-sound scans are needed to monitor a situation, we used to get them done a couple of hours earlier than the clinic appointment time. Latest information available. One visit instead of two for the patient. We used to do this typically for patients who were being monitored for abdominal aortic aneurysms.

I said a dozen things done differently at Goole but have listed 13; that would be typical of Goole, we try and often tend to over deliver.

There are a number of innovations from our colleagues in orthopaedics, ophthalmology and other departments.

You will not hear too much from Goole, the people there are a bit shy of fame, a bit skeptical about awards, a shade reluctant to talk about themselves; it is a unique micro-culture - more on that later. There are very specific reasons why innovation happens at Goole (though I do not have too high a regard for CQC ratings you may be interested to know that Goole Hospital scores all greens ‘good’  for its services, we at Goole are neither bothered nor surprised about this).

At this point I have to say that I am one of the very few variant ones for Goole, talking and blogging about these things, I suspect my team often wonders why I am so vain.

Many hospitals in the country could be doing one or more of the above, but I do wonder if all these things happen in a small hospital.

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PS: We follow Noble prize winner's Kahneman's methods to improve our patients' experience, I have already blogged about this

Tuesday, 14 October 2014

Power words to avoid in healthcare

On words such as 'intelligence', 'insight' and 'discretion' used as tools in demonstrating power.........................

A colleague had an email from a clinical director asking to ‘acknowledge that CT Cologram is a scarce resource to be used intelligently’.

When we got talking about this we wondered how one was supposed to respond, react or put this into action. What did that mean? Does it mean that they as a department they were using the resource like a bunch of idiots? Is this saying that they were a part of a group of people with not such a high intelligence? They were talking about doctors most of whom had at least two degrees and many years of training and experience - generally thought of as abundant proof of intelligence.

You can see this has raised my hackles. What is really interesting is this comes from a hospital which had one of the highest utilisation of CT scans in the country. If they were abusing CT facilities already, why would a cologram (colonography) be an exception? 

The issue is not the CT use intelligent or otherwise. The issue is the lack of understanding of how clinical management works and the use of operational management language. It is the lack of analysis and lack of definition behind these statements that are the problem. Of course no manager who imagines he/she is worth his/her salt will ever agree that this type of communication is grossly deficient. In fact the managers will insist that ‘intelligent use of resources’ is essential. And they can prove it. They will prove it by letting others use the resource and then using their higher hierarchical authority by making a post-event, ad hoc individual judgement on others who used the resource intelligently. You can see how it massages the ego of individual managers and riles up everyone else.

There are many other terms which lack analysis or definition yet used very liberally by everyone. Insight is one. Discretion is another.

Many doctors in trouble are accused of lack of insight. A GMC related official described insight as breathtaking arrogance in the face of overwhelming evidence.....  So, it is safe to assume that when evidence is presented to a doctor that he/she is no good and yet the doctor maintains that he/she was good would probably classed as lack of insight. At this point, it may look acceptable.
The point is, the use of ‘lack of insight’ as a reason and sanctions that follow often comes from a people with higher authority and directed against people with lower authority. In medical practice there is none or very little evidence for many things we do. In such a situation evidence becomes the view of a group of people in power who are then not inclined to look at the evidence presented by the weaker party. Insight becomes a power game. 

Let us look at discretion. Let us say that your boss in clinical medicine says that all patients are not the same and you must use your discretion according to the given situation. You are likely to think that your boss has given you a lot of freedom. What you are actually being set up for is another power game where your boss retains the right to question your discretion, pitch your discretion with others discretion and to override your discretion. Now you might think that is why you have bosses. But what actually happens is a clear recipe for failure and conflict. 

There are better ways of dealing with these. At a simple level as a starting point is to stop using such words which have the potential to confuse and cause harm; words such as discretion, insight and intelligence in day to day operational activity. I am not saying these words or their implications are not important, of course they are; I am questioning if they should be used in day to day operational management especially in healthcare. 

Instead clear definitions agreed as a group, in the form of specific and detailed protocols with further second and third order protocols defined when the first one does not fit might be a better way in operational management in healthcare. There will be a situation when these definitions will not work in which case a variation made after very quick group consultation which is then analysed later may be needed.

The main issues are that you will not like this since you might feel your autonomy is being reduced; your boss won’t like it since he/she may feel that his/her power is being reduced. Finally the chances are you, your colleagues and your boss will not agree on most things at an operational level; well you see this is not your fault as clinicians are taught only how to make individual decisions implemented according to a power based hierarchical scale. 

Clinicians have never been taught on how agreements are reached and never experienced the power of agreements between them.
There are clear ways to achieve this. That is when you will find Success in Healthcare.


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PS: If you would like to get away from the conventional use of terms such as discretion, insight, intelligence and move to a different approach; if you would like to know what agreement actually means and would like help to achieve it – you are welcome to get in touch with me mr.hemadri at gmail dot com

Sunday, 21 September 2014

Bullying - a personal story and some strategies

This is my personal story, only a small story.   

In the early 1990s, in Ancoats Hospital, Manchester I was a Senior House Officer in Orthopaedics. I was warned when I joined about one of the consultants, Mr X, who had a habit of hitting junior doctors assisting him at surgery with instruments when the going got a little difficult. That was the most useful informal induction that I could have ever had. It was bound to happen. I could attempt to prepare for it. 

My options, when it happened, were a) to lodge a formal complaint with the hospital - as though that often did any good to anyone b) to lodge an assault complaint with the police - which may or may not have got any result but the career would have ground to a halt. So possibly option 'a' was better. Hmm.... Time to think, time to plan... I had a plan. 

Then one day, it happened, it was bound to. I was assisting Mr X and his forceps rapped my knuckles. Use some imagination to visualise the scene that I describe next. The instrument I was holding flies off in one direction, I leap sideways and backwards and slump down the theatre wall, wailing and shaking my hand. The theatre nurses go red, Mr X goes pale. I immediately start apologising 'sorry Mr X that must have caught a sensitive nerve or something'. I proceed to take off my gloves and gown; I say 'I will be back soon' and walk off to the coffee room. It was an intermediate type of operation, no harm to patient occurred. 

Very soon Mr X finishes the operation, walks camly across to the coffee room has an arm around my shoulder and says 'Are you okay son?'. I simply mumbled some meaningless neutral words. A few days later, same theatre coffee room, I had a request for Mr X. It was not a busy job, my colleagues were excellent and willing. My main interest was surgery (not orthopaedics) Hence, I wanted to attend Sir Miles Irving's unit at Salford Hospital for half of the week. As a young surgeon in training, preparing for examinations and the unknown future, hungry for every morsel of surgical knowledge and exposure - that was exactly what I wanted then. Mr X's answer, immediately and as expected was 'of course you can'. Apparently Mr X was never so easily convinced to agree to a request. 

It was a trade off. I knew that it would happen. I worried about conventional approaches not benefiting anyone. I was young and proud, I could not simply let it go. So I planned the scenario to get the best benefit for me under the circumstances. What was done to me was illegal, it was assault. Acting as per law would have put my career at risk. We can choose not to press on according to law. That is what I did. I also used intelligence, planning and emotion to use the situation and get what I wanted, my own compensation method. What I asked for was not illegal, it was discretionary and the discretion was used for my benefit. Since then........ I have got older and wiser. Was it ethical? Was it moral? I do not know, the reader can make up his/her own mind about it.

What is bullying?

Bullying carries on. Sometimes bullying these days takes the form of using 'clinical governance', 'patient safety', 'mandatory' issues, 'job planning', 'appraisal', 'pay progression', 'revalidation', in fact the most noble and most benign of tools can become a weapon in the hands of the unworthy.  At the extreme there can be threats of 'disciplinaries', 'NCAS referrals', 'GMC referrals', etc.

Bullying exists when there is a threat present in an atmosphere when it should not be present. 

The difficulty in dealing with bullying is about feeling, perceptions of various parties in the mix such as the victim, perpetrator or investigator. In my view it is not about feelings. There should be a threat, tangible, palpable, hopefully something can be proven, something that has a previous record. For any given person, when observed, measured data shows performance/behaviour within an acceptable band and yet others around this person use their power based on opinions to set or impose conditions when none should be set or imposed then bullying exists. 

TYPES of Bullying and Dealing with it

Bullying due to Pressure: Normal persons can show expressed behaviours of a bully when there are excessive pressures e.g. shortage of resources such as staff, equipment, money or an excess of work such as too many patients or too much regulation. These can be resolved without reference to the bully; simply by providing the right resources and systems. Here, the management becomes responsible for bullying and even more responsible for solving the problem. My personal opinion as an observer of work environment is that expressed bullying behaviour due to work pressures is responsible for about 40% to 50% of all cases of bullying.

Bullying due to personal deficiency of knowledge: People express bullying behaviour expressed initially as aggressiveness and eventually abusive behaviour to camouflage their personal deficiencies of knowledge and the consequent lack of confidence. This sometimes happens consciously but often without people even realising it. Operational data will often identify proof of deficiencies in these individuals; this evidence may not be in the outcomes but in process data. It will be ideal if the individuals are able to recognise this by themselves often they need a little pointer from friendly colleagues. In this case, resolution takes the form of additional development of the individual concerned. Technical development or non-technical development, often both will be needed. Team training could be a route to accomplish this. Again, my personal opinion as an observer of these issues is that this kind of bullying accounts for 40% to 50% of bulliers.

Bullying due to inherent pathological behaviour: A small number of individuals have bullying as a psychological personality trait. These individuals will not recognise themselves or accept the view of others that they have personality issues. These individuals may even often have excellent medical/clinical outcomes. These people often are mis-recognised as excellent performers with an assertive personality and are actually promoted up the hierarchy – they will shine till the day they burn the whole edifice down. We need a mature special method of dealing with these people. These people need to be put in a space with a small group of mature trusted people (staff who are trusted by the individual and by the organisation) so that they can carry on their clinical work without affecting wider morale of the organisation. That would be possible; but it will require immense managerial effort to do so. These individuals should never be given positions of power. A smaller number will play up at the end of all this, they will need to be taken up through formal systems.

Instead of dealing with bullying as above, we currently either ignore it or when we are not able to ignore we deal with it through rules and law. Both are inappropriate.

Individuals coping with bullying

Those of us who are not in a position to implement the above methods will need personal mechanisms to cope. Since the dated example described above, I have been of course bullied. Sometimes I have ignored, sometimes I have suffered it (on one occasion nearly 2 years) for obtaining long term gains, sometimes I have confronted the bully. I have never had to write in an official bullying and harassment complaint; will not hesitate to do that if the circumstances were right. Also never hesitated to wage personal campaigns to make everyone aware of the bully, bullying and mechanisms to cope – never hesitated to retaliate by damaging the image or reputations of bullies; I never do it lightly, only after significant evidence and deep thought. 

In the personal mechanism to cope with bulliers it is important to think, plan and practice extensively on how and when to confront the bully, when done right bullies stop bothering you. I have in my personal capacity helped one or two persons do so. It is sad that we may have to do this to protect ourselves when the systems let us down. Sadly this method only protects us and the bully moves on to someone else.

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I have already blogged about some of the organisational principles to resolve bullying titled 'Fearless Healthcare is what we want'

Tuesday, 26 August 2014

QuizUp and the dangers of Unconscious Competence

I have recently been playing QuizUp. It is an online quiz which you can play real time against other people from all parts of the world. There are innumerable topics and categories with thousands of people playing it.

I chose a topic that was familiar and another one which was not familiar. What I learned was something many of us may already know. But are we applying what we already know? Are we harming people by not recognising and applying what we know in a proper manner?

When I start playing QuizUp even for very familiar topics such as medicine or healthcare I had to read the questions slowly because the style and format of the question is different for each question. Some are direct, some are linked with directly topic related pictures, some are related with general pictures from news and social media that relate to the topic, some have humour, others have pun and so on. Then comes the answers there are very technical answers from some questions, lay answers for some, humorous answers for others and so on. So even when I understood the question perfectly well and knew AN answer which was right, THE answer that was right for QuizUp took time to learn. Of course there is the issue of learning the answers that I did not know before. 

Now, once these were learned, the issue became one of speed, because even if I knew all the answers if I did not answer them fast enough I would lose. At this point, I began winning a number of matches/plays/games. But also loosing a number of them because the speed itself caused errors due to many reasons including the jumbling of answers and the pressure involved in a fast recall and response to a touch screen.

At this stage, there is enough knowledge, memory, recall and speed which then moves on to pattern recognition. Most often there was no need to read the questions or the answers the responses came automatically, fast and correctly. It was on auto-pilot and very successful.

My scores were soaring, the whole thing was getting a bit monotonous, repetitive and pointless. This is when QuizUp decided to update the questions so there were a number of new questions thrown in. Obviously I had to go through the sequence described above for these new questions. That is when I discovered that I not only had trouble with the new questions in terms of knowledge, speed etc. Because the new questions had been interspersed with the older/original ones I was struggling with the older ones as well.

I was struggling to answer questions that I used to answer automatically and correctly within a second. I was getting them either slow or wrong. I was UK top ten for a particular month in the topic and was getting stuff wrong. Interestingly, because I was already way up top ten it really did not matter, I did not drop too many ranks if at all. Mind you, I am talking about marginal differences here. The nature of the game and my overall rank meant I was still winning but not as efficiently as before.

The worrying thing was that the minute I stopped pattern matching my scores fell.

The last point I wish to draw your attention to is this. I was concerned about the efficiency of my wins and started reviewing my questions by reading the question and answer in detail after playing each game. I was surprised that I was neither fully aware of the wordings of the question nor the logic of the answers; I knew what the question was and what the answer was that is knowledge but while answering them repeatedly my knowledge formed the basis of pattern matching but as the pattern matching became dominant potential and/or real drops in awareness of knowledge and on some occasions of knowledge itself happened.

Pondering on the above gave rise to some worrying thoughts and certain concepts which may be negatively affecting some of us.

Many of you with some knowledge about education and learning methods will recognise the model where we are

Unconsciously incompetent

Consciously incompetent

Consciously competent

Unconsciously competent

These are called the four stages of learning or four stages of competence and linked with the concepts around the Johari window.

Is there a risk with Unconscious Competence?

You would have noticed from my above description that like any learning or skill my QuizUp journey moved from Unconsciously Incompetent to Unconsciously Comptent. Educationalists and trainers want us to be unconsciously competent, it is supposed to be the highest in the hierarchy of learning and competence.

Here is the worry or the risk.

Many senior experienced older doctors are unconsciously competent, i.e. where we actually want them to be. When we want them to incorporate something new into their routines we are pushing them back to conscious competence. We are aware for that for the new skill there is a learning curve, we accept that. I am not sure if whether while the new skill is being incorporated their performance with their established skills fall, even temporarily; and if it were to fall whether we even notice it as it is likely to be subsumed in the averages of their overall numbers/performance which had a good baseline to start with.

But, here is the more worrying aspect. Due to some unfortunate reason if any of the senior established busy doctors were referred for an assessment of their knowledge and competence (say to an agency such as NCAS) these doctors are tested for their conscious competence when their daily practice is in the domain of unconscious competence. Add the pressure and stress of going through the formal assessments that decide the fate of their careers, these doctors often unsurprisingly come out as lacking in knowledge and skills, i.e. incompetent.

I have no empirical research or data to show this. I can only hypothesise based on my observation of my play of QuizUp that I really enjoy and am good at to some extent. Also, this phenomenon of slipping back into conscious competence may be limited only to me and not the rest of the world (though I doubt it) and so this whole concept may be relevant only to me.

However, my concerns are two fold. First, in teaching new skills to the old dogs we may be negatively impacting on their overall competence at least temporarily (while their new skill competence gradually improves – learning curve) and while this may be happening we may not be able to recognise it. Secondly, once these doctors are in difficulty, we may be testing the skills of race car driving with a normal driving test template and failing them in both.

Whether this is purely theoretical or not, it is worth putting some research into this. It may be beneficial to both patients and doctors.


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Wednesday, 16 July 2014


Last year (2013) as my thank you for the BAPIO Award for “Outstanding contribution to the health services in the NHS and abroad” I had put together the compendium of my reflective writings over the last 25 years in the NHS (download here It contains my writings on various aspects of health services (not my research publications) and range from a one pager to very substantial documents like the Milroy Lecture. Now it was not until much later, years after I started writing, that I realised that what I was doing was reflection – the term reflective practice was not much in use then and indeed even now. I sort of fell into it, mainly as a way of improving my writing skills which were (are) essential for public health practice, and once I got the ‘bug’ I kept going and tackled increasingly complex subjects including my observations on medical leadership and about my time as the GMC Council member. I had discovered that writing made me think and make sense of what I had observed or done and most importantly how I could improve. 

The publication of the compendium has provided further impetus and I now want to find out more about reflective practice. I realised that I had approached the subject back to front. Until very recently I had very limited knowledge of the theory of reflective practice and I basically did what I felt like! I did not know ‘Reflection on Action’ from ‘Reflection in Action’. 

The definition that I find useful now is from Boud et al who define reflection as ‘‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’’ (p. 19). Schon introduced the concept of the ‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. (from 1) 

Simply put, critical reflection is the process of analysing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice). (2)

Now, you must wonder why I am being so self-indulgent, and what does it mean for clinicians.

In this regard, this analysis probably sums it up

“If we take the example of a medical mistake, a superficial, educationally ineffective reflection will consist of a description of the events or a description accompanied by reasons such as the team/clinic was busy and other people failed in their responsibilities. A more useful and deeper reflection would include consideration of how and why decisions were made, underlying beliefs and values of both individuals and institutions, assumptions about roles, abilities and responsibilities, personal behavioural triggers, and similar past experiences (‘‘when pressed for time, I . . . ’’), contributing hospital/clinic circumstances and policies, other perspectives on the events (frank discussion with team members, consultation of the literature or other people who might provide alternative insights and interpretations), explicit notation of lessons learned and creation of a specific, timely, and measurable plan for personal and/or system change to avoid future similar errors. Effective reflection, then, requires time, effort and a willingness to question actions, underlying beliefs and values and to solicit different viewpoints. This ‘‘triple loop’’ approach moves beyond merely seeking an alternate plan for future similar experiences (single loop) or identifying reasons for the outcome (double loop) to also questioning
underlying conceptual frameworks and systems of power.” (2)

In essence, reflection is the basis of patient safety and is about learning from mistakes and putting things right. It is a bit like the “5 Whys’ approach to investigating incidents whereby one keeps asking why at each stage of questioning until you understand the root cause. 

Now, look at your, and others, practice- how far up this triple loop scale are you? When you make notes after CPD are you being critical/reflective enough? Is revalidation in danger of becoming a tick box exercise? Are we really doing enough for patient safety – do we know the root causes in our settings and are we addressing them, and why not? Are we ‘learners’ and able to constantly innovate and improve?

These are some fundamental questions facing us as doctors. We have to provide the leadership in these challenging times in the NHS, and central to being a leader is insight, self-awareness and ability to reflect and learn. In any case, the future of medicine is self- and life-long learning, and without a good grounding in reflection it will be difficult to cope with increasingly demanding jobs. 

So what could/should we do – can we do something together? Do you think we need more reflective practice in the NHS? Can you help me in my journey? Can I help you? Shall we form a group – virtual or real – to develop this further?
I will be very interested to hear from you- contact me at

16 JULY 2014

  1) Mann K, Jill AE, Macleod A. Reflection and reflective practice in health professions education: a systematic review. Adv in Health Sci Educ (2009) 14:595–621
 2) Aronson, L. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher 2011; 33: 200–205