Mark the site campaign

MARK THE SITE
 

A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS

(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery happens 40 times a week in the USA. http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.

Solutions

It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.

MARK THE SITE

This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).

Surgeons

Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.

Anaesthetists

Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.

Nurses

Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)

Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site

Everyone

Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.

MARK THE SITE

©M HEMADRI 

Follow me on twitter @HemadriTweets

Scheduled airlines are safe, just like out patient clinics

There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is.  There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.

In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.

To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.

Variation the enemy of quality

People talk about variation of care across hospitals and locations; it is true that there is wide variation and reducing the variation will improve outcomes.

Aviation which is often looked upon as a beacon of safety also has variation. Looking at 2004 accident rates for North American airlines Delta scored 0.30 and Value Jet/Air Tran scored 5.88 – well, you work out the how wide the variation is even in an ultra safe industry. If you start looking at international comparisons the variations are of course much worse. (http://www.airdisaster.com/statistics/) There is also a five times variation of fatalilties per million flight hours with scheduled airlines being lowest compared with general aviation.

When there is human to machine interaction as in aviation, there is such a large degree of variation. Healthcare is human to human interaction so it is hardly surprising that variation exists and could be expected to be more than other industries. Looks like variation in performance is not a problem exclusive to healthcare industry; variation is a human problem or to put it better, variation is a function of human performance.

That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.

Fatalities in Aviation

The human fatality rate is very low indeed in the scheduled airlines part of the aviation industry. The air transport of animals, however has suffered bad press. Airlines are apparently not even required to report animal deaths. The mortality rate of animals in air transport is thought to be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)

The post surgical 30 day mortality for day case surgery in humans which is about 0.01%. In-hospital mortality for day cases is probably as low as the scheduled commercial aviation segment.

CRM and Simulation are of course extremely valuable tools and has a lot to teach us in healthcare. The number of air accidents and the number of fatal air accidents have remarkably decreased over the past few decades. That is truly fantastic. What is interesting though, is that the pilot error rate has been at about 50% since the 1950s to the 2000s, percentage of accidents attributed to pilot errors has not shown a significant decrease. The proportions of various reasons for crashes have also remained more or less the same. This is in a way a tribute to the aviation industry, since the planes have become technologically very superior it would not be surprising if pilot/human error played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?

Survival rates of passengers in aircrafts involved in fatal accidents has not improved (and averages about 25% since the 1930s to 2000s) (http://planecrashinfo.com/cause.htm) Military aircraft, fighter planes, aircraft engaged in warfare and private planes are thought to have much higher accident and fatality rate.

Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others

I suppose in clinical healthcare delivery terms, scheduled airlines are possibly the equivalent of out patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case surgery and obviously the risk increases with emergencies and trauma.

In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.

What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.

There is a fundamental problem with my writing here. I am not comparing like for like, I am comparing apples to pears. In my defense, I did not start that comparison. Comparing aviation to healthcare was not my original idea. There is a second problem with this manner of writing, it may sound like I am being defensive of healthcare and its practices, I am certainly not defending any poor healthcare practice or result. I acknowledge the superior results that aviation has had as a result of dedicated persistent efforts in the field of human transportation in scheduled airlines. I recognise the need for healthcare to learn from every source possible including commercial scheduled airlines. All I am saying is, let us stop comparisons and let us focus on learning. Let us look for clinical adaptations of these techniques rather than attempted direct transfer of airline techniques. Let us recognise the uniqueness and the intimacy of human to human interaction that healthcare involves.

A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Letter to my nieces

A letter to my nieces

Sam (USA)

– who has just joined med school this year

&

Mayank (India)
- who completes med school this year

Dear Sam and Mayank

Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.

I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.

I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.

These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.

As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts.  I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.

We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.

As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.

We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.

Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.

In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.

Nobody will tell you yet that

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above

These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves.  The brilliance of the medical profession is also blinding itself.

The lack of evidence and the opinion based practice results in hierarchical power games. Those who are unable to play become bad apples initially and ‘poor performers’ later. Now, imagine that, top scores at school graduation, long mind numbing hours of hard work for years, proven success in exams and other challenges, then eventually being called incompetent or poor performer or some other derogatory term by people who practice the art of medicine while imagining it to be based on facts and evidence. Worse still these phenomena perpetuate the wide clinician generated variations in practice. Doctors are intelligent and learned enough to be able to justify their individual practices as evidence based; that is of course true. What is important to understand is that their justification is based on the evidence they choose to base it upon. My evidence is the truth and nothing but the truth but not the whole truth. Simply because firstly the whole truth probably is not already known, secondly the whole truth is too vast to know and thirdly in healthcare the whole truth often has a tendency to contradict itself.

I write this not in despair, not to distract you, but to give you hope. Because the solutions for embracing a world of wrongness and still do good to the maximum number of your patients are already out there. I want to briefly introduce you to that world and I want you to be aware of it. These are the shades that you wear when you are out in the bright sun, it will also make you look cool. It might make you comfortable in a world of contradictory evidence.

In conventional science based research oriented world there is probably nothing that is absolutely true; there is a current hypothesis which we attempt to validate or reject and the hypothesis stands till it is rejected. You will find that most hypothesis in medicine are rejected over a period of time, this gives rise to problems in clinical practise as the research that is good today becomes ‘false’ very soon. However, that is how research and science works. That is how it should work. However, in our routine clinical practice we do not work as researchers, we work as operational practitioners. My suggestion therefore is to look at operational methods for a good clinical practise and use to them to the best benefit for your patients. These derive from the shared baseline approaches devised by Brent James and his team at Utah.

At a basic level, a good shared baseline method looks like this

-         - You agree with your immediate and local colleagues on a protocol for most common problems that are seen in your clinical practise

-         - You track the outcomes over time of some of the process and outcome parameters of the protocol that you have agree

      - You amend your protocol based on the outcome tracking

-         - You show deep and genuine respect for everyone who works with you

-         - You share and learn operational clinical day-to-day practise first and primarily with/from your immediate and local colleagues before you do so with the rest of the world

Intermountain Healthcare does this, they probably discovered this method. IHI recommends it (I suggest you become members of IHI open school), people at Mayo, Virginia Mason, Jonkoping and a few others have their own versions of this. The method though, is not one of a pick and mix buffet, one has to do them all or get no benefits from them.

I suggest that you start exploring this kind of thinking in parallel with your conventional learning, not for fact based subjects but for the rest of them. We are all creatures of habit, attitude and cultures. It will be very difficult to change once certain mindsets are established. The energy and effort required to do it now in parallel is much less than to do it later. Your patients will get remarkably far better results and your systems (your patients, insurance, hospital, yourself) will spend far less on a like for like basis.

Many doctors will understandably be either uncomfortable or unwilling to accept or follow this kind of practice. They will deride it as cook-book medicine run by technical managers interfering in clinical work. Obviously the ignorant will be prone to say what they want, that will be a reason to work to remove the ignorance not to forget the observed truth, unlike conventional healthcare practices and religion with its believed truth, this method is really the observed and demonstrated truth. Of course if you decide to choose conventional scientific research as a career then these methods are not suitable for you but if your life is that of a normal operational clinician then these are entirely relevant. I do not expect you to understand the new method fully, it will be a reason to learn it in due course. Enough for now to be aware that there are plenty of problems and there are proven solutions – just a matter of putting them together at the right time.

The wrongness that exists in medicine will not go away, that can only be solved by scientific research and one day you may in your lifetime find that medicine is based purely on scientific evidence. Till that time, awareness of, learning and practising the shared baseline method will give you superior results despite the wrongness around you.

As you stand on the threshold of entering into a new world, I wish you every success and great happiness in the practise of your profession. There can of course be no greater professional joy for a doctor than to see more of their patients get better.

Affectionately

HEMADRI

August 2012

©M HEMADRI 

Follow me on twitter @HemadriTweets

Recurring 'errors', learning and some fundamental issues

Recurring errors

Many of you could be familiar with the Elaine Bromiley case where a young lady for a routine ENT procedure died due to intubation difficulty (http://www.chfg.org/resources/07_qrt04/Anonymous_Report_Verdict_and_Corrected_Timeline_Oct_07.pdf). There it was found that there was lack of situational awareness, poor decision making and poor leadership. This happened in 2005.The Harmer report on the tragedy is dated July 2005, the coroner inquest in October 2005. Marin Bromiley, Elaine's husband, an airline pilot, chairs the CHFG to promote human factors with a view to reducing avoidable errors.

Gordon Ewing died in May 2006 and the Scottish Sherriff’s fatal accident enquiry determination has been published (http://www.scotcourts.gov.uk/opinions/2010FAI15.html). I recommend that all of us read all the 108 pages patiently. Here the patient was scheduled for open reduction and internal fixation of terminal phalanx of little finger and died due to airway related difficulty.

Again, similar factors such as poor decision making and poor leadership has come up along with a host of other factors. The unwillingness to stop has been a common factor in both cases. I suspect it is just not these cases.


The link below is about 3 post cholecystectomy deaths in a 3 month period in 2006

http://www.scotcourts.gov.uk/opinions/FAI13%2014%2015.html



I feel that recurrence is probably an essential feature of an error, my guess is that there are no errors that have ever happened only once. It might have happened only once to a person or a location but the error itself would have happened a number of times. Vincristine and nuclear leaks come to mind.


Who should learn?

In meetings where we discuss morbidity, mortality and learning from SUIs, a phrase you might often hear is 'for the benefit of the juniors/residents/trainees', as though 'seniors' do not commit 'errors' or have nothing to learn from the discussion. Well, all the above cases are about very senior and experienced doctors; so these reports are not for ‘the benefit of the trainees’ or ‘for the benefit of the juniors’. It is for everyone, specifically for senior post holders. Also, though the specific examples are about anaesthetics, surgery, etc; these cases are not about anaesthetists, surgeons, etc; the lessons are for all of us clinicians and non-clinicians; the generic issues are relevant as lessons for everyone. Techniques are speciality specific and person specific, errors and learning are generic.

Learning

Elaine Bromiley's case is well known and is full of learning which have been described by many before.


In the Ewing case, the Sheriff says:

‘While the lead clinician has the over all responsibility to ensure safe use of equipment, individual clinicians have a professional responsibility to use only equipment with which they are familiar and competent to use. This is particularly so where the piece of equipment is rarely used.’

There are many gems in the Gordon Ewing report.

In the gall bladder surgery cases, the report speaks about:

Tunnel vision

Damaged confidence from an incident preventing speaking up at a subsequent incident, potentially causing harm.

Poor notes, missing notes

Breast surgeon doing cholecystectomy

Consultant surgeon not attending

Consultant radiologist refusing to do scans at night

Consultant surgeon who does not do lap cholecystectomy dealing with complications of cholecystectomy

The repeated failure that patients post operative problems could result from the surgical procedure

The report is very recent. The incidents happened not too long ago either. They are from a normal hospital with normal people like you and me working in it and dealing with typical/usual patients.


The learning is profound, not new - many of us would have faced these situations a number of times; errors are recurrent. The impact of errors are horrendous for the people involved in it especially for patients and families (see previous blog on impact of complications http://successinhealthcare.blogspot.co.uk/2012/02/complications-or-harm-and-their-impacts.html)


Fundamental issues

It is very heartening to note that courts and authorities who write the reports use a very respectful language towards doctors. They limit themselves to investigating and reporting event, post-event and agree with the given wisdom in practise as acceptable standards. I wonder whether this prevents an exploration of some fundamental issues.


Let me ask an awkward question. Why is a general anaesthetic even an option to deal with the terminal phalanx of the little finger? The report says that there was no record of non-GA options. My point is not that, my question is why was GA ever an option. Some of you are going to leap up and say 'patient choice' meaning that patients have to be offered a choice or patient choice to have a GA must be agreed with. Patients choices are mainly guided by their clinicians views, supplier induced demand, often felt to be well meaning, is alive and well in healthcare.


I know a general anaesthetic is routinely one of the anaesthetic options for any surgical procedure; but so was Halstead's mastectomy for any breast cancer in the past. Would we offer it as a choice now? Hypothetically if a patient wanted a Halstead when a local excision would suffice, would we do it? When an easier, safer, quicker, better, cheaper method is available is it still valid to offer potentially high risk complex procedure as an option?


Here is another awkward question. Why are breast surgeons, colo-rectal surgeons and all surgeons doing gall bladders and hernias when hernia surgeons do not do breast or colo-rectal surgery? I do not mind good old style of general surgery where everyone did everything - at least that is what they were supposed to do.  But that is not the world we live in these days (even in 2006) at least in the western world in the era of sub-specialisation. The situation of anyone doing the so called 'simple' things, still persists in many hospitals. Toe nail problems are as profound as any other 'major' medical problems for that given day for that given patient; it is not a matter of scale or judgement.

I wish the various authorities recognise the need to ask very deep and fundamental questions. Such as was this really indicated in the first place? Were the right people dealing with issues to begin with? I wish they would not accept given wisdom based on pacts of convenience as acceptable. Not with a view to punishing but with a view to improving clinical quality.

I wish they recognise and point out that these are massive system and leadership failures.

©M HEMADRI 

Follow me on twitter @HemadriTweets

CLINICAL WRONGOLOGY

CLINICAL WRONGOLOGY©

M. HEMADRI

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence

Substantial activity in clinical medicine cannot after care delivery find evidence to back it

Substantial clinical care is delivered incompletely

Substantial amount of errors are found in the delivery of care

Substantial numbers of clinicians are either unable or unwilling to accept the above

In effect there is plenty or wrongness in theory, plenty of wrongness in practice and blindness to wrongness in clinical medicine. The wrongness is affecting patients by causing poor experience of healthcare, avoidable complications and avoidable deaths. Clinical wrongness is also affecting doctors and other clinicians causing variations in practice, restriction in the ability to practice appropriately and punishments for poor clinical performance.

There will be a day in the future when clinical medicine will practiced on the basis of proven science. We will truly rejoice on that day. Till that day arrives clinicians will need an approach that will help in appreciating, understanding and coping with the wrongness that is prevalent. The study of that approach is Clinical Wrongology.

Clinical Wrongology will remove the blindness to wrongness. It will make clinicians appreciate that there is wrong, wrongness and errors everywhere and these are normal to general life and clinicians are not exempt from this. Clinical wrongology will then encourage clinicians to cope with the wrongness around them and will show some methods to practice within the wrongness atmosphere with a view to increasing safety, quality and decreasing cost.
  
Clinical  Wrongology, the new specialty in healthcare is now declared open.

Watch this blog as there will be more on this subject.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: While there are philosophers who are masters on the subject of wrongness and great experts in the study of error, my inspiration for thinking about wrongology and clinical wrongology was from 'Being Wrong', Kathryn Schulz's brilliant book. Kathryn if you are reading this blog I hope you do not mind me calling myself a Clinical Wrongologist, (perhaps the worlds first and only one till date); having vainly given myself that title I could be motivated to live up to it; unless I am totally wrong on that!

NB: Persons in healthcare who want to be involved and contribute to this effort, please leave a comment with a means of contacting you or send a direct message to me on twitter.

EWTR - Sleepy Tired Doctors are Unsafe Doctors

A major newspaper ran a campaign last year in association with one of the surgical royal colleges against the European Working Time Regulation for doctors especially for surgeons. I am finding it uneasy that we seem to have lost balance on this issue and chosen to take the campaign mode. We learn that the Government could ask for an exemption from EWTR for British doctors. Having done training posts in the pre-EWTD era and regularly worked more than 80 hour weeks in surgery, I welcome the European Working Time Regulation especially for doctors in training; but it not just a matter of opinion.

Acute sleep deprivation has been shown to result in more errors, longer time to complete tasks, slower reaction times resulting in a deterioration in clinical performance. This is the case in both In simulated and real time environment. There are important consequences for chronic sleep deprivation as well. The issue is not just about the duration of sleep but also the importance of quality of sleep, which is indirectly reflected in some of the rules of the EWTR regarding continuous uninterrupted rest periods. Healthcare claims to be learning from the airline industry, the airline industry recognised the issue of working hours and rest and has very strict rules for the pilots regarding flying hours; it is well known that scheduled commercial airlines rank very high in safety.

Since the gradual implementation of the working time directive, now a regulation, this country has not seen any objective worsening of clinical standards such as mortality or complications; in fact most parameters have shown an improvement in standards of care, obviously there is no implication of cause and effect here. However, surveys showing perception that patient care has possibly become unsafe are not really borne out by objective evidence; as a profession based on science we must be aware of both the power and limitations that perceptions can have. Further, I am not aware of even a single consultant level doctor appointed in recent times who has stopped being a consultant and gone back to training due to any recognition that the EWTD allowed poor training. 


If indeed, as a country we wanted to act on a survey perception that EWTR is affecting training, instead of putting patients at potential risk by asking doctors to work longer hours, the powers in charge of training should have addressed the issue by prolonging the period required to complete the training. Part-time trainees do this all the time while providing equal quality of care and with the changing gender profile of the medical profession this becomes even more relevant.

Europeans, in consideration of a better quality of life have taken a societal direction to work lesser hours and for British doctors to some how claim that we are very different from the society we live in, is an attitude incompatible with modern life. Doctors are not super human, though it may seem some of us ardently wish to be so.

There is no scientific, operational or societal reasons to oppose the EWTR. I think it is time to recognise this before the society begins to wonder if there were considerations other than these in the medical profession's decision making; that would damage the image of the profession. There have also been recent suggestions that we can ignore the law, such a thinking does not bode well for a profession held in high esteem by the public. The issue is about safer healthcare, longer duration of working which is highly likely to result in sleep deprivation impacts adversely on safety. 


If I had the opportunity to choose my doctor I would obviously opt for a well qualified and experienced one who is not tired, I am not sure anyone would choose otherwise. Is it unreasonable to ask the government to ensure the same for me through the NHS?

Duty of candour: Voluntary or statutory?

Duty of candour: Voluntary or statutory?

Candour is the quality of being honest and telling the truth, especially about a difficult or embarrassing subject[1]. When things go wrong and especially when patients are harmed whether it is due to natural circumstances or due to error by individuals or systems candour becomes very important. One of the components of such candour is to offer an apology to the patients and their families. It is important to understand that as clinicians we may not be apologise for in a ‘conventional’ sense when there is no individual error is involved; what we would be apologising for in all cases is for the fact that the patients’ expectations were unable to be fulfilled on that occasion.

Compensation Act 2006 states: ‘An apology, offer of treatment or other redress shall not of itself amount to an omission of negligence or breach of statutory duty. The medical indemnity providers have always held a similar view that apologising does not put a clinician at risk of being accused of anything in the future – it is not an admission of liability.

In the document ‘The Coalition: our programme for government’[2] it says "We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong".  The words ‘will’, ‘require’ and ‘always’ seems to indicate that the government is inclined towards introducing  statutory candour or some version of it.

The CMO has been recommending a statutory duty of candour for a good few years and there are currently deliberations including the GMC on this subject. There has been parliamentary health select committee recommendation to consider this subject.

Understandably patient groups especially the AvMA are in full support of a legal duty of candour; understandable because of the powerful case studies[3] they use where a statutory duty could have either avoided prolonged and vexatious interactions with authorities involved in those case studies or would have helped to bring events to a closure quickly. 

The MDU does not support the consideration of a statutory duty of candour based on the argument that there is already an ethical duty backed up by adequate GMC sanctions.[4] The MPS also seems to take a similar view. The NPSA’s new ‘being open’ policy (as opposed to its ‘open disclosure’ policy) is based on the premise that doctors apologising would prevent many unnecessary complaints and possibly some of the litigation that follows. There is international evidence that litigation occurs less often when an apology is offered and accepted upfront.

The GMC guidance on good medical practice[5] states ‘‘if a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened and the likely short-term and long-term effects’’. However, a 2008 survey by the MPS[6] showed that while more than 90% of professionals believed that patients are less likely to litigate after errors if they received an explanation and an apology but only 68% were willing to be open when something went wrong. Clearly the issue of liability and blame still plays in the minds of doctors.

This raises the question whether the duty of candour should be statutory or mandatory.

Clinicians especially doctors really would not want statutory duty of candour as they would like to think that they are doing the right thing because it is the right thing and not because it is simply required by law. The GMC and other bodies, regulatory or not, take a very poor view of lack of transparency. Actioning after an event of low transparency is like many other triggers may turn out to be subjective, discretionary and inconsistent. However, in practice once the issue reaches the 'authorities' there are significant consequences which inevitably follow. Therefore a culture change route is preferable for clinicians.

The next issue to consider is how we design a response to the call of ‘duty of candour’. What the profession needs to understand is whether there was a rising trend that doctors and other clinicians are getting less transparent, if there is no such trend whether there are frequent examples of lack of candour. There seems to be no general trend that doctors are getting less transparent. Hence, a culture change approach using the voluntary duty supported by a strong view from the GMC and other bodies would certainly make a difference from the perspective of clinical professionals; with aberrant doctors dealt with strongly by using the full force of current systems. 

There are however, very frequent examples of outliers. This is when we have to recognise that institutional candour is a different situation. While individuals are all for openness, the current system of risk, clinical governance, complaints and legal actions inevitably raises doubts on the relevance of the extent of candour and its impact on future action against organisations. Further, often in inefficient and overspent circumstances or in situations of poor organisational vision, what is not required by the force of law or the force of higher authority is actively prevented from happening. This is understandable from an organisation's perspective but would be unacceptable to patients. There are examples of individual clinical candour followed by organisational resistance that happen in sequence. This is obviously unsatisfactory.

On balance, it seems that under current moral mores of our society a statutory duty of candour is probably going to be inevitable.  The question is of course is whether individual clinicians or the organisation would be legally responsible for the statutory duty of candour. It would make sense for the organisation to be responsible for such a statutory duty. The issue of candour after serious untoward incidents has extremely personal and wide ramifications at the same time, that it becomes clearly outside the remit of individual personal clinical responsibility. Further, organisations and organisational responsibility is likely to cover everyone in the organisation which would include doctors - any aberrations on the grounds of candour by doctors would therefore be dealt with by their organisation and by the GMC.

There might be a case for parallel dual responsibility (which has the risk of diluting responsibility) or for purely individual responsibility (where it could become 'fault', 'witch-hunt'  and 'scape goating' usual suspects). In a broad sense since the responsibility for quality moved from consultants to chief executives in the mid 80s, candour as such should therefore be an organisational responsibility delivered by individuals rather than individual responsibility enforced by personally applicable law.


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The department of health has launched a consultation on duty of candour: http://www.dh.gov.uk/health/2011/10/candour-consultation/ Please respond to it.

 

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[1] Cambridge Advanced Learner’s Dictionary

[2] The Coalition: Our programme for government: http://www.direct.gov.uk/prod_consum_dg/groups/dg_digitalassets/@dg/@en/documents/digitalasset/dg_187876.pdf

[3] http://www.avma.org.uk/pages/legal_duty_of_candour_-_robbies_law.html 

[4] http://www.the-mdu.com/section_medical_students/topnav_News_3/hidden_Article.asp?articleID=2011&contentType=Media+release&articleTitle=MDU+supports+apologies+to+patients+but+says+no+need+for+duty+of+candour

[5] http://www.gmc-uk.org/guidance/good_medical_practice/relationships_with_patients_open_and_honest.asp

[6] http://www.medicalnewstoday.com/articles/127194.php