Matt Morgan and Peter Brindley: Meetings⁠—where minutes are kept and hours lost

It is estimated that meetings add less than 5% to productivity, are mostly about status management, and contribute to 70% of workers feeling disengaged. [1] Oh well, no time for such thoughts: it’s off to the monthly medical meeting. You’re not working clinically, but are dragged back to the hospital. At least you can sport your latest hipster t-shirt rather than those crumpled scrubs. Others dress in Lycra bike shorts that leave nothing to the imagination. Regardless, it’s time to ingest stale coffee, squint at a blurry screen, and balance on a wipeable chair: Let the predictable pantomime begin! But will everyone remember their lines?

Act one

Scene one: The mandatory IT delay

The organiser fumbles with a broken remote control, and cycles through countless menus: “VGA1,” “VGA2,” “AUX,” “Laptop,” “HDMI”. The screen stays as black as the coffee. Attendees mutter awkwardly as wires are un-plugged, blown on, and returned to the same hole. The organiser becomes increasingly red-faced; enter the IT saviour. You worked in Dixons at age 16 and know the dark arts of video projection. You move in, pop a battery in the remote control, and, voila, the screen is resuscitated to a bright white light. You believe you are a hero. Others silently disagree; after all this meeting was close to being cancelled. Ten minutes in, nothing yet achieved.

Scene two: For those calling in from home

An iPhone is balanced on the table and its volume turned to max. Battery power might be at 5%, but let’s give it a go. Multiple passwords are tried, before a picture of a dog eventually appears. At this point the script is as familiar and it is farcical:

“We see you but can’t hear you” 

“Try logging out and logging back in”

“Is the Wifi better in the kitchen?”

Finally, the video becomes clear, and the sound becomes ear-shatteringly loud. An important point is made right as the video connection dies. Twenty minutes in; surely there is more to life than this. 

Scene three: This will never work

It’s time to hear from “the voice.” Namely, that person who has worked more shifts that you have had hot lunches, has saved lives using nothing but a rusty spoon, and even remembers life before flat whites. With both eyes on retirement, he has little time for new initiatives that are really just recycled old ones. Nowadays, he takes delight in saying things that would get new hires struck off yet he receives admiration and the odd bottle of wine in return. 

Act two

Scene one: Why is he even here?

Our next protagonist cares more about the Wifi code and little about the agenda. His power cord is stretched across the entire floor and he has commandeered the room’s only socket. He noisily taps computer keys, and repeatedly checks his beloved phone. He might be studiously taking notes, but is likely just shopping on Amazon. Forty minutes in: if only we had arranged to be paged out. 

Act three

Scene one: Not so fast

Discussion about the clinical rota has concluded, and that contentious checklist has been okayed. A détente is reached that would impress the UN security council. “Onto the second agenda item” says the organizer at which point several actors burst into song: “uhm, just returning to the last topic, am I right in thinking that . . .?” No, dear colleague, you’re wrong, dead wrong, and you would know that if you had been listening. “Perhaps we’ll move on” states the frazzled organizer, “well I think this needs more discussion” the others reply. Fifty minutes in; thank goodness there are no sharp objects nearby. 

Scene two: Crisis averted 

Near the end of our play a villain enters in a cloud of paper and to a cacophony of pages. He collapses into the last empty seat, and is passed the agenda that he has clearly not pre-read. He tries unsuccessfully to obtain a few drips of coffee, and is just about to bite into the last stale muffin when he remembers another meeting he needs to be at. Everyone breathes a sigh of relief that they will be spared his attempt to highjack the agenda. He leaves and likely won’t be heard from for months. The meeting has now reached its allotted 60 minutes: time to conclude the performance.

Closing scene

 “Right, the next meeting is during half term, shall we meet anyway?”

“YES!” is the unanimous reply.

“Any future agenda items?”

“Can we talk about whether these meetings are truly useful” says a quiet voice in the back.

“Sorry, there’s simply no time”. 

Curtain drops, exit stage left. 

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

References:
[1]  Bruce Daisley is the European VP for Twitter. He hosts the podcast Eat Sleep Work Repeat ad has authored the book “The Joy of Work”.

The post Matt Morgan and Peter Brindley: Meetings⁠—where minutes are kept and hours lost appeared first on The BMJ.

Hospital doctors should step outside BMJ 2019

https://doi.org/10.1136/bmj.l4914 (Published 06 August 2019) Cite this as: BMJ 2019;366:l4914

Last year I did something I found difficult, unsettling, and risky. Yet, in many ways, it was a simple act that community health workers do every day. It didn’t involve a complex procedure or a new treatment. I even wore a pair of jeans while I did it.

Last year I stepped into the home of a patient I’d cared for while he was critically ill many years before. I left the safe neon confines of “my” hospital and entered “his” softly lit world of home. I was the visitor, the guest in his life rather than he in mine. That experience changed me. It was a powerful way to navigate the fog of medicine that surrounds us in hospitals.

Until then, my “patient follow-up” had involved seeing an empty bed in the intensive care unit. This meant that the patient had either died or got better. Occasionally I’d expand this window further, by visiting people on the ward after leaving intensive care or by looking at their date of discharge on the hospital computer. To my colleagues, a “did not attend” at an outpatient clinic may represent something similar: the patient didn’t come, presumably having got better or perhaps worse.

This binary view of the future is, of course, not real life. While survival is good, it’s not always good enough, and we should strive towards what’s important to patients. What better way to frame these hopes than to see patients living their own life? Before I saw the other side of that journey I was ill prepared to advise on what route to take. This form of follow-up may be a rare concept in hospital medicine, but it’s one we need to learn about from our community colleagues, who have known this for decades.

As I stood in that person’s home—seeing the adapted shower, hearing the children playing in the garden, smelling the home cooked food—I was reminded of what medicine’s really about. Not a ward discharge, not a hospital discharge, but life returning.

I’ve come to think of this as “deep follow-up,” and I believe that it may help combat nihilism when treating conditions such as traumatic brain injury or cardiac arrest. I later visited a family where life could not return, where the patient had died. But this, too, may give us the humanity to have difficult conversations about survivorship earlier and may help shared decision making about life sustaining treatments.

Of course, this kind of follow-up needs to be done safely, with support for all parties. It may not be suitable for all patients, all families, or all staff. It isn’t practical for every encounter. But perhaps we can occasionally flip the narrative and, instead of patients booking an outpatient appointment with us, book a walk in the park with them.

Matt Morgan and Peter Brindley: Why it’s time we all woke up to the importance of sleep

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep, say Matt Morgan and Peter Brindley

Lauren Connelly was delighted when she landed her ideal job. After years of proving her mettle through hard study she stepped enthusiastically onto the medical ladder. She was now a doctor, and would hone her craft at a rural Scottish hospital. Fast forward a few weeks and Lauren was exhausted, both physically and mentally, after yet another 100 hour-week. Undaunted she readied herself for seven consecutive night shifts. This may have been her dream job, but the truth is that the rota rarely allowed for adequate sleep. Her death occurred on 17 September 2011 on Scotland’s busiest motorway, after falling asleep at the wheel. 

Following Lauren’s death, her dad, Brian [1], suffered his own insomnia, albeit for different reasons. Alongside grief, Brian Connelly was angry and in disbelief. After all, we—the supposedly sensible and all knowing medical profession—had blithely ignored decades of its own research. We know that lack of sleep kills. Data have consistently shown how it kills slowly and silently by increasing the likelihood of cancer, heart disease, immunosuppression, and weight gain. Poor sleep also kills suddenly and loudly through motor vehicle crashes and workplace trauma. If insomnia was a drug we would ban it immediately. If sleep was a drug we would prescribe it to all. Brian is right to speak up, is right to ask questions, and deserves our full support. The answer is seemingly simple: more and better sleep for all. The question remains: do we care enough to do the right thing? 

Speaking six years after his daughter’s death, you can still hear gritty determination mixed through his Scottish accent. He intends to wake up the government and the medical profession, and like all good parents, he just won’t quit. There is legislation to limit working hours, but Brian will tell you how it is commonly exploited and stretched. For example, we often tabulate average working hours. This sleight of hand allows 100 grueling hour weeks to be hidden within a rota, as long as that rota includes less hours over subsequent months. Brian is clearly smarter than the lot of us when he reminds us that: “Sleep cannot simply be banked and averaged over time.” We simply don’t believe that any doctor should be worked to death. 

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep. Regardless of whether insomnia is limited to medicine or is, instead, a society wide issue, we can likely all agree that we need a cultural shift. This starts by senior folks speaking up and standing side by side with junior colleagues. 

We should not, cannot, and need not stand by as doctors work hours that we would never condone for pilots or bus drivers. Lessons must be heeded. Fortunately, these are lessons that we have known for decades, and lessons that Lauren and her dad are shouting on our behalf. Patient safety matters, and so does practitioner safety. 

Brian is a professional working in the information technology industry. As such, both his advocacy and his day job could save more lives than any single doctor. This is because many of the greatest patient safety initiatives have been spearheaded not by highly qualified doctors, but rather by remarkable and tenacious people who had to respond to tragedy and refused to wait for us to do the right thing. Brian’s campaign mirrors another magnificent non-medical professional, the airline pilot Martin Bromiley, whose wife Elaine died unexpectedly after a minor operation. Inability to manage her airway should not have ended her life, but it did. Elaine died because while the doctors and nurses had all of the individual skills they had insufficient team skills. She died because of her team’s spiral of indecision, deferred responsibility, and its collective failure to act. She died because a team of experts is not the same thing as an expert team. This death was no one person’s fault, instead it was everybody’s fault. Accordingly, making things better is everyone’s responsibility. [2]

Like Brian, Martin Bromiley threw his energy into improving the system even while battling grief. They simply could not just stand by and let it happen again. Using decades old lessons learnt from the aviation industry, Bromiley’s Clinical Human Factors Group may well save more lives than you and I ever will. We suspect Brian’s campaign to reduce deaths from medical tiredness will be equally revolutionary and necessary and therapeutic. We medical practitioners have a lot of work to do. We need to wake up, and this starts by ensuring everyone is properly rested. We owe it to Lauren, Brian, Martin and Elaine…and many many others.

Matt and Peter would like to thank Brian Connelly for his bravery and time.

Matt Morgan is an honorary senior research fellow at Cardiff University, a consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter: @dr_mattmorgan
Competing interests: None declared

Peter Brindley is a professor of critical care medicine, medical ethics, anesthesiology at the University of Alberta, Canada. 
Twitter: @docpgb
Competing interests: None declared

References

[1]https://www.dailyrecord.co.uk/news/scottish-news/worked-to-death—exhausted-young-1084348

[2] https://qualitysafety.bmj.com/content/24/7/425

Critical thinking Matt Morgan: Fixing our broken wards BMJ 2019; 366 doi:

As I reach the top of the staircase a faded sign reads, “Block A, Tower 3, Wards 7F and 6G.” Nobody really knows what these characters mean or how they help to navigate the twists of an ever changing, expanding hospital. A patient looks up and down at a clutched paper letter, wondering if they’re going the right way. A hospital porter senses their disorientation and points them back towards the way they’ve already come.

As I approach the door of the ward, I see a line of relatives huddled around a buzzer with “ONLY PRESS ONCE” taped over its scratched buttons. Once a minute, once an hour, once a day? A busy nurse, looking after patients and supporting families, hears the buzzer’s call but can’t answer it. As I open the door with my access card, the opportunity is seized and families flow in. Through that one door come meals, x ray machines, dirty linen, nurses, doctors, patients, and dead bodies.

On the ward the relatives peer into different wings, looking for “bed 9 in the 4 bedder,” without knowing what that means. As an overflowing catheter bag is quickly carried to the sluice, the dinner trolley is manoeuvred to make room. The height of the desk at the nurses’ station is an awkward compromise—too low for my knees to fit underneath and too narrow to house a set of paper notes. As I squeeze in, the computer mouse falls to the floor, hanging helplessly by the wire and swinging like a pendulum. I feel the same.

I want to speak to the patient and her family. I think that the patient is going to die. The cloth curtains around the bed are too thin to contain this news from the well wishers next door, so I look for a more private area. (“Just use the office, it should be empty.”) I don’t want to use the office. This is a hospital ward. It should be the perfect environment to do all of this—for conversations to be spoken, for food to be eaten, for patient care to happen, and for medicine to work.

Yet the many hospital wards I’ve visited all over the world have a design that’s changed little since the late 18th century. It’s time to reimagine it. The general ward should have as much consideration as a shiny new operating theatre or boardroom.

Wards need separate entrances for utilities and families—even a circular design with dividing walls. Natural light and noise reduction technology would aid sleep, and communal areas would encourage socialising, rather than eating in a chair next to the bed. We need separate areas where intimate examinations, treatments, and even difficult conversations can happen. These should be large enough to house a hospital bed and a supportive family. We should replace faded signs and use floor maps, with directions to toilets and exits, that are shown to nudge human behaviour.

Think too about staff. Central workspaces should encourage thoughtful work with additional areas close to patients, for individualised care. Zoned areas could indicate different levels of need and safe “wander paths,” allowing movement even when patients are unwell. And ageing posters that fail to change behaviour could be replaced with art that encourages reflection and has been shown to aid recovery. Hospital needs to be a place that promotes healing, not one that simply delivers it.

Read the full article here.

Expanding neverland —applying never events management to hospital infrastructure

It had been a tough weekend for our colleagues. They had to deal with a complex patient in cardiac arrest. Yet the response team took days to get to them. This decline was hardly a surprise, the warning signs were there in the notes months before. Chronic ill health, previous missed opportunities to intervene with a failure to engage with difficult palliative care conversations. Had the case been examined in detail, a DNAR decision would probably have been in their best interests. Yet instead, there was a mad scramble to treat all reversible causes while the team tried to keep blood flowing through the system at short notice.

This may sound a sadly familiar story, but we are not talking about a patient. We are not even talking about a human. We are talking about a sudden break in the critical physical infrastructure of a hospital that was predictable, should have been prevented and responded to without the necessary skills nor urgency. As the NHS creaks into its 71st year, hospitals up and down the country will echo these events. Cables will break, pipes will burst, and lifts will stop. These are all predictable events. The important thing is that prevention can work and a rapid response should be rehearsed. The day of the week, the time of night or the hospital manager on duty should not matter just as it does not for patients when they are sick. A sick hospital means that all patients are at risk and a proportionate response should be elicited.

In 2009 the NHS implemented a “never events” policy to improve patient safety. The list of never events included wrong site surgery, in-patient suicide, and wrong route medications. It was hoped that this list would allow focus on detection, investigation and action with reports shared with care commissioners. It has long been taught that before offering help, you should first “check the scene is safe”. The physical structure of a system is a core component of safety for both patients and staff. It is about time that never events are extended to organisational events and non-clinical staff. 

We propose that the never events list should include:

  • Malfunctioning safety systems during an event such as fire detectors, sprinklers and circuit breakers.
  • An inadequate or untimely response to critical infrastructure systems failure including water, electricity and transport.
  • Serious injury to staff from known, predictable risks including asbestos exposure, non-compliant building regulations or structural damage.
  • Failure to address staffing gaps that are known about that result in patient or staffing harm.

If it is right to call proximal patient harms events that should never happen, then surely it is right to apply these same standards to the wider hospital structures that endanger the many as well as the few.

Tom HolmesConsultant in Intensive Care Medicine.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Competing interests: None declared