Matt Morgan: Life and how to live it

I still remember the first time I heard the haunting American sound of Michael Stipe, the lead singer of the band R.E.M. I was 10 years old when my dad tried to sing their confusing lyrics from “The Sidewinder Sleeps Tonight.” R.E.M.’s bittersweet combination of melancholy notes with lyrical storytelling spoke to me and has left me helpless ever since. Twenty-five years later, as I was driving back from the hospital, their song “Life and How to Live It” spoke to me again.

This 1985 song describes the bizarre life Brev Mekis, a resident from R.E.M.’s hometown Atlanta, Georgia. Brev lived in a large house divided in two by an internal wall with a single door allowing him to move from one side to the other. He would spend a few weeks living on one side of the wall, wearing certain clothes, reading certain books and eating certain food. He would then move to the other side, eat different food, wear different clothes and watch the television. He flip-flopped back and forth every few weeks until he died. After he died, the housing department cleared out his house and found hundreds of identical books, all neatly stacked in a large, tall cupboard. None of these had been read or even opened. Brev had written and published these books himself. The book was called ‘Life and How to Live it’.

Every time I step through the automatic sliding doors at my hospital entrance, I walk between two sides of my life. I wear different clothes, I eat different food, I read different books. I even wear different aftershave. Unlike Brev, each time I move back to the other side, I take a little baggage with me. When I started as a junior doctor, the two sides of my house were very different. The small amount of baggage I have been bringing back with me ever since has now left the two sides of my life more similar than different. Sometimes this is a good thing, sometimes not. How thick are the walls between your lives?

Matt Morgan is honorary senior research fellow at Cardiff University, consultant in intensive care medicine, Research and Development lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan

Competing interests: None declared 

Read more in Matt’s first book, “Critical – science and stories from the brink of life.” Available to order now www.drmattmorgan.com.

 

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The robot needs a human heart—why AI in medicine brings moral choices into focus

In a crisp, white building deep in the heart of California’s Silicon Valley, teams of people make moral choices on your behalf. The development of self-driving cars may improve global road safety and efficiency, but for individuals, they also transform purely philosophical questions of the past into a harsh reality of today. When self-driving cars need to choose between a head-on collision into a child or swerving into an adult, what should they do? What impact will these dilemmas have for artificial intelligence in medicine?

Described as the “Trolley problem,” a modern version can be traced back to the British philosopher Philippa Foot. [1] She described a runaway trolley heading toward five people who will be killed by the collision. The trolley could be steered onto a different track on which there is only one person by pulling a lever. Intuitively, it seems permissible to turn the trolley to kill one person compared with five. Yet it also doesn’t seem permissible to kill one person to save five in other cases such as organ donation.

Fast forward to 2018, with the first self-driving car fatality, AI collision avoidance systems need a steer on how they should react. Vehicles cannot escape from moral value judgements implicit in their pre-programmed decision rules. What should the humans with hearts tell these inanimate machines to do? Maybe these robots need a human heart?

One way to inform these decisions is to simply ask people. The Massachusetts Institute of Technology ran an online global experiment called the “Moral Machine” where millions of people from over 200 countries took a quiz, resulting in 40 million ethical decisions. The study’s authors describe consistent global preferences in collision avoidance for sparing humans over animals, saving more lives rather than fewer and saving children over adults.

While variation is expected, they also described large shifts in choices made across social, geographic, and demographic groups. In China, Japan, and Saudi Arabia for example, the preference to spare younger rather than older people was far less pronounced.

With AI in medicine consistently described as one of the most important advances in healthcare, the “Trolley problem” is soon coming to a hospital near you. AI models are increasingly promoted for use in diagnostic imaging, risk prediction, and even treating sepsis. Up-front ethical decisions may need to be an integral part of AI modules in healthcare.

When providing care for critically ill patients, predictive AI may help guide who should be admitted to the last critical care bed. This is a close comparator to whether healthcare professionals should “pull the trolley lever” to admit the sick child with leukaemia or else the elderly adult with pneumonia. What should we do?

The first step in managing this problem is appreciating that it exists. Although the hype around AI suggests it is a panacea for improving healthcare, equal focus now needs to be placed on the inherent challenges to humanity as well as the challenges in computing. Social scientists need to be let back into the room, sharing a table with computer scientists, healthcare professionals, politicians and, importantly, patients. Perhaps a medical version of the “Moral Machine” may help gauge the public’s attitude to these ethical dilemmas. We should also consider if healthcare decisions should echo views of people from different geographical areas or simply act as a universal moral compass. Finally, perhaps we should give the owners of self-driving cars the autonomy to make difficult ethical choices themselves in advance as individuals. Some may choose to swerve, some may not. If so, AI in medicine could also be uniquely tuned by individuals to best suit their personal choices and values around health and disease. These decisions could be made in advance before mental capacity was lost as is done through systems of opt-in and opt-out to organ donation. This way, silicone derived artificial intelligence could adjust to the needs of complex organic life.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, Research & Development lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania His first book Critical will be published in May 2019.

Paul Dark,Consultant in Critical Care Medicine, NIHR Clinical Research Network National Specialty Lead for Critical Care and Chair in Critical Care Medicine, University of Manchester. He is on twitter: @DarkNatter

Competing interests: none declared.

References:

1] Philippa Foot, The Problem of Abortion and the Doctrine of the Double Effect in Virtues and Vices Oxford: Basil Blackwell, 1978, originally appeared in the Oxford Review, Number 5, 1967.

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Is TED dead?—a return to good-old fashioned conversation

We two authors used to attend medical conferences that felt more like pathetic gladiator battles. Weapons included poison-tipped USB sticks, monotone delivery, and a complete lack of eye-contact. The audience’s ritualized beating often also included an entirely pointless ten-minute speaker biography, followed by a bludgeoning from 120 slides. The cruellest speakers went further still: “there’s too much information on this slide but let me try anyway;” “I know my time is up but I’ll just go overtime.” In brief, we were tired of the “sage on the stage.”

We paid good money to live (and die) through blurry images and the entire front page of their manuscript stating the blindingly obvious. We endured the speaker delivering the same tedious joke as last year—and it wasn’t funny the first time. For reasons we could never deduce this death-via-powerpoint often included a picture of the presenter’s children. A big question mark on the final slide then indicated that it was time for the chairperson to contrive a gratuitous question. He or she had to, after all the audience was now comatose. Sometimes, we would leave with a morsel of medical insight. More often we would depart with a sore arse, indecipherable notes, and a useless rucksack. That, and during the break there was never enough tea and biscuits!

However, empires crumble and time marches on. In the educational ring, this has meant the explosion of what naysayers call “infotainment” and what we choose to call “about bloody time”. Thanks to the hard graft of @ffolliet, SMACC and the other people’s champions, we believe that the medical conference has changed and will never be the same again. Admittedly, some of these newer events feel like rock concerts, and have ticket prices to match. Faculty may still be a little too pleased with themselves, and likely still trade invites to the next conference. However, increasingly the presentation is geared to the audience’s needs and not the presenter’s ego.

The goal is to disrupt and to inspire via an engaging story that “sticks.” Multimedia is widely applied and no useful emotion is spared. Some presenters have been known to loosen their ties and some to shed a tear. Regardless, we are big fans and occasional contributors. These talks are both celebrated or derided by calling them “TED-style.” This is after the organization that launched conferences around Technology Entertainment and Design in 1984. At the time these talks really were revolutionary, and were eagerly shared via that other wonder of the modern world—the internet.

Importantly, TED has subsequently worked hard to stay current and user-friendly. They understand that a speaker riding a unicycle while performing beat-poetry (we made that up) might be oodles of fun, but not necessarily fit-for-task. Moreover, for everything gained, something may be lost. Bite-sized inspiration is easy to digest, but doesn’t always offer nutritional balance. Before we overdo this dietary analogy, the point is that we still need nuance, detail, thought, and debate. Above all, we need a conversation.

TED releases long form interview podcasts from speakers where the backstory can be further dissected. These complement rather than compete with the flash-bang of the big stage performance. Long-form conversational podcasts include three hour offerings from celebrity-atheist Sam Harris, the polymath Joe Rogan and Canada’s most unapologetic man, Jordan Petersen. Of note, these are hugely popular, and assuming that most-downloaded equals most-influential. Regardless, the popularity of long-form argues that learners do not have the attention span of a goldfish. Moving back to our more comfortable dietary analogy: we all enjoy tapas, but we will also order an entire meal: it just needs to be tasty.

The value of a medical conferences will always be in its unscripted conversations and the discussion afterwards that matters most. It’s that lightbulb moment when we realize we need international coordination and collaborative research. Importantly, these disruptive discussions often occur away from the stage’s twinkling lights. Accordingly, the best conference makes time for breaks, encourages the hoisting of pints, and emphasizes that debate long outlive the event. Notably, the disruptive and marvellous EMCrit Conference no longer promotes speakers, but rather people to speak with. The organisers provide a platform, a relaxing setting, along with time and space to simply talk. Like us they seem eager to celebrate the long-lost art of conversation. After all, some things should never get old.

Matt Morgan is Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, R&D lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania 

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Competing interests: None declared.

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Matt Morgan and Peter Brindley: Some Christmas words of wisdom for today’s medical students

In the seasonal spirit of giving, Matt Morgan and Peter Brindley share what they’ve learnt from their time in medicine

When these authors were medical students—several millennia ago—we faced the difficult challenge of finding a quote to accompany our graduation photos. On the one hand, we had received a marvelous state subsidised education. We had learnt from the best informed teachers and we were truly thankful and humbled and excited for more. But medical school had also been a multi-year arse kicking that included some moody supervisors, persnickety colleagues, and patients who didn’t make it. Accordingly, we were exhausted and bruised and scared.

One of these authors eventually landed on the first line of a Tale of Two Cities as his quote: “It was the best of times, it was the worst of times.” Given that he didn’t have a “Dickens” what to write, it seemed as good—or as bad—as any one liner. Twenty years on, that quote still causes a wince. It was trite, self-congratulatory, and pretentious. Fortunately, that same doctor had no “great expectations” of being anything else.

As these aging medics move from Christmas past to Christmas present, we still struggle to dispense wisdom to the latest recruits. This is a problem as our trainees are just as bewildered as us. Likely it is selective memory, but, as junior doctors, we recall being given a hard time left and right. The instructors are gentler now but the students are no less hard on themselves. Their hours are less sadistic but the world sure is. We were unsure what kind of  doctors we wanted to be but this rarely found purchase in our sleep deprived brains. We simply assumed that “when we grew up” people would tire of reprimanding us, and we would emerge somewhat clinically competent and moderately valued. Contrast this with today’s medical student: up to their necks in worry.

Instead of focusing on teaching young doctors life saving clinical pearls of wisdom, academic instruction seems to veer more and more into “how you can maximise your future.” Students feel pressured to regard university as little more than time to buff the CV and outflank the competition. In this solipsistic pursuit they are robbed of the opportunity to expand horizons, nourish neurons, meet soulmates, quaff pints, and cut parental cords. Both because it’s the holiday season, and because it truly sucks, we want to say “sorry.” We still have time, and so do you.

The talk that welcomed our classes to medical school focused less on “you are the chosen ones,” and more on “I hope you weren’t a mistake.” Just in case we weren’t “motivated” enough, we were introduced to classmates who had won Olympic medals, sung in major choirs, and run successful companies. However, as a coda, we later learnt that if we hadn’t been singled out that they still saw something in us: our job was to discover it and nourish it. We graduated bruised but ready to go.

We fell into intensive care—or maybe it chose us instead—because we wanted to think and to do. More latterly, we understand that above all we wanted to communicate. We (wrongly?) felt confident that regardless of our hours or the cash, we would never work more than our parents or earn less. We didn’t know that workaholism would likely increase our risk of premature death, and that our dark humour could reach a point of no return. Hopefully, today’s graduates will navigate this better.

We now know that we want our days to include not only “head and hands” but also “hearts.” For these two doctors, true happiness has become about “making connections” whether with patients, colleagues, or even academic ideas. It means that we stop to talk and listen far more than we used to. We just wish we had known and believed this years ago.

Back to Charlie Dickens for a sec. He also wrote that we should maintain “a heart that never hardens, a temper that never tires, and a touch that never hurts.” A much more useful quote for doctors, but equally likely to make eyes roll in this best and worst of times. Fortunately, it’s Christmas so we don’t have to worry how corny it sounds: “God bless us all, everyone.”

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @Matrix_Mania

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared. 

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Matt Morgan: What can Bridget Jones can do for medicine?

As we enter Christmas party season, solving the mystery of an unconscious patient will be repeated across emergency departments around the country on countless occasions. The Holy Trinity of legal drug excess, illicit drug use, or organic disease will be explored through endless scans and blood tests.

When looking after critically ill patients, the most effective diagnostic aid is often stolen from right underneath our noses. The Greeks first encouraged taking a “medical history” 300 BC and as Jesus turns over two thousands years old, it is surprising how little has changed. The Hippocratic ancient text would not feel out of place in the paper notes found in my hospital today:

“One should pay attention to the first day the patient felt weak; one should inquire why and when it began. These are the key points to keep in mind. After these questions have been cautiously considered, one should ask the patient how his head feels, or if he has any pain or if he feels heavy.”

— Littre’s Translation of Hippocrates, 2, 436–40: Regimen in Acute Disease. Appendix #9 quoted by Siegel, RE. Clinical observation in Hippocrates: an essay on the evolution of the diagnostic art. J Mount Sinai Hosp 1964;31, 285–86.

What has changed is our insight that even a primary source of information can be mistaken. This can be true when asking patients about their symptom timeline as it can when asking a witness to describe the perpetrator of a crime. A wealth of research now suggests that even eyewitness identification can be unreliable, with the American Psychological Association issuing a warning to courts and juries to be cautious evaluating eyewitness testimony.

When even this primary source is incapacitated, we extend our investigation to family and friends who try their best to fill in the gaps. However, wouldn’t it be fantastic to have a contemporaneous record of events written by the very patient who is now unconscious? There are surprising benefits to regular journal keeping including reduced anxiety and even improved cardiovascular variables. The explosion of social media has silenced the paper-based Bridget Jones inside some of us, although 1 in 4 adults still keep a diary of their life. Peering inside the pages of a patent’s inner Adrian Mole while they have crushing chest pain is unlikely to instil confidence in the medical profession and the personal nature of journalising means it is unlikely to be acceptable to patients to share their diaries.

But would a palatable alternative be to look at the public outpourings found across the social media world? Open access “journals” including Twitter and Instagram may be an acceptable alternative, allowing health professionals to expand their envelopes of history taking, especially in cases where patients are unable to contribute themselves. A colleague recently told me how an unconscious patient’s diagnosis was only revealed after a family member showed them the patient’s Twitter timeline. Should we therefore adapt the “Social History” section of our medical clerking into “Social Media History”? Would this be acceptable to patients, the profession, and how would it affect the doctor-patient relationship?

Thanks to Dr Nick Stallard for inspiration.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Competing interests: None declared

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Matt Morgan: Buying toilet rolls and writing rotas—is this really the best use of clinicians’ time?

Quality improvement schemes have so far been aimed at solving clinical and logistical problems, but have forgotten about the most important assetstaff

 

I’m staring at a screen filled with different coloured boxes, endless numbers and characters fighting for attention. As one number changes, another flashes to life. Although this has similarities to the patient monitors in the intensive care unit where I work, I am actually sitting at my desk. I’m writing yet another rota for twenty people spanning the next six months.

Teenagers across the land are not told when ticking “medicine” as a career that an in-depth knowledge of Excel macros is a key requirement for a doctor. Fifteen years of medical training seldom prepares you for the first time you tell a colleague that they are going to work Christmas Day this year. The truth is that I actually like my role of writing a complicated consultant rota. There is a simple satisfaction when all of the cells turn green after matching fifty different study leave requests in the same month to the clinical needs of a unit. Yet a part of me worries about whether this is really the best use of my time. Is it good for the NHS that hundreds of front line clinicians are doing what non-medical others could do better?

The NHS is the world’s fifth biggest employer spending over £2 billion every week. It employs 1.3 million people with a budget more than New Zealand’s entire gross domestic product. If it were a company, the competition commission would soon be knocking at its doors. Yet this shear scale which should be a winning factor, is often a weakness.

Before improvements in central procurement, even buying toilet rolls was devolved to individual hospitals leading to hundreds of different suppliers. Even my family of four people exploit economy of scale and bulk buy ours together. Yet the NHS was doing the equivalent of popping to the corner shop every day to buy a single roll. One hospital may pay £32 for 100 rolls while another £66 for the very same item. Although procurement is now slowly getting into gear, there are more pressing aspects of scale that should be developed.

Richard Branson said “if you look after your staff, they’ll look after your customers.” There is now finally appreciation of the negative effects that shift work, poor rostering, and disturbed sleep have on the health of healthcare staff. As the NHS spends 40% of its costs on staff, it makes sense to put staff wellbeing and efficient working at the centre of what it does. This in turn will lead to profound benefits for patients.

Why then, am I reinventing the wheel, making bespoke rotas for our staff, just like thousands of other doctors are doing every day wedged between their clinical work? Although, as a computer geek, I feel I am skilled at this task, I can never be as skilled as the combined knowledge of millions of staff delivered through a software package designed for a specific purpose. Why can’t we learn the lessons of efficient rostering that promotes good health and apply them across the biggest employer in Europe? This would in-turn promote better patient care.

It seems quality improvement schemes have so far been aimed at solving clinical and logistical problems, but have forgotten about the most important assetstaff. Using the sheer scale of the NHS to automate, improve, and offload these important tasks from front line clinicians will give them more time and energy to do what they do bestbe on the front line helping patients.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Competing interests: None declared

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Matt Morgan and Peter Brindley: Doctors are not d**kheads, but they are human beings

Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare

The recent trending Twitter hashtag, #DoctorsAreDickheads, started after Stevie Boebi posted a YouTube video describing the time it had taken to reach a diagnosis of her medical condition. The resultant social media response became, as it so often does, an unruly dogpile. In this case, it was the medical profession squashed at the bottom. Next time it could be any convenient target group: nurses, teachers, policemen, lollipop ladies. In this particular iteration, what followed were hundreds of stories describing wrongful diagnoses, erroneous treatments, missed opportunities, and especially how the white coat brigade were individually and irrevocably to blame.

We do not for one moment question the sincerity of Ms Boebi’s frustration, or that many others have suffered from medicine’s imperfections. What we take umbrage with is the overly convenient cause and effect. It is rarely an individual doctor’s inadequacies that cause such problems: it takes a village, after all.

Moreover, has any situation ever improved by calling someone a dickhead? Instead, this sort of language leads to an arms race of finger pointing, excessive shouting, and inadequate listening. Dismissing somebody as a “dickhead” is also virtually tailor made to encourage backlash. Some doctors took the bait and argued back, pointing out that some patients fail to give a clear history or understand the diagnosis even when it is fully and compassionately explained, or even fill their prescription. This blame game should not be tolerated from either side of the erstwhile healthcare partnership. This is why we would all be rightly appalled if there was, for example, an equivalent hashtag about patients.

“My doctor is a dickhead” represents the perfect get out of jail card for the 21st century. Welcome to the age of “it’s not my fault, it’s yours,” “I’m great but you suck,” and “if I don’t understand then you didn’t explain.” Welcome to a world where insulting somebody has morphed into empowerment. These two authors are not only tired of this, we are also scared by how easily patients and providers inexorably drift apart.  

Specious accusations are all too easily heaped on anyone in authority or with a tough job to do. It is just that the result of medical mistakes is that much more critical than in many other professions, and being sick is that much more rotten to begin with. Medical errors—or what can be better understood as human errors in a medical environment—can be truly awful and sometimes lethal. To wrongly attribute the root cause to a fallible individual, however, is to squander the opportunity to meaningfully improve. Although we get the human need for blame, more important is what is the collective plan going forward? This should start by accepting how complicated healthcare can be. Next let’s encourage behaviour that builds rather than tramples.

We have previously discussed how, even deep within the whizz bang world of intensive care medicine, arriving at the correct diagnosis is difficult and imperfect work. Even where no expense is spared, no test is skipped, and no consult foregone, we do not always pinpoint a treatable condition. Humans and their myriad of presentations are eye wateringly complex. This is why up to half of our medical diagnoses may be ultimately wrong or incomplete. Moreover, more testing can make it more wrong as well as more right. After all, those tests are as imperfect as humans; false positives and false negatives abound. Medicine is as much a philosophy for dealing with uncertainty and managing probabilities as it is anything else. It is not, however, an exact science.

Regardless, to get closer to the correct answer, all of us should recognise and overcome ingrained cognitive biases, and we will name (and shame) only the top two. There is the anchoring bias (i.e. the patient with “sepsis” who actually has acute gallstone pancreatitis) and the confirmation bias (“ah yes, it does look like pneumonia on the chest x-ray” in the patient, for example, with systemic lupus erythematosus related diffuse alveolar haemorrhage). These biases are why the good doctor does not rest on their assumptions, their laurels, or their backside. Instead, we must challenge (and rechallenge and rechallenge) ourselves and our co-workers to search for alternatives. We must be similarly energised when it comes time to treat. We must attack and soothe on all fronts: therapeutically, psychologically, and compassionately.

Clearly this is hard. Just as clearly, it doesn’t get any easier if our patients really do think we are “dickheads.” Moreover, overtaxed and under-resourced systems encourage error. Similarly, human brains look for comfortable and familiar patterns whether they be patient or practitioner. All of this means that what we needed is not the soothing comfort that comes from individual blame, but rather the hard graft that comes with accepting collective responsibility. Our systems need checkpoints, fail safes, and predictability, but above we all need to commit to making things better not worse. In an effort to remove emotions from medicine, we could all—doctor, nurse, patient, caregiver—learn a thing or two by following Dr Atul Gawande, and joining his “Checklist Manifesto.” Good checklists can free our attention from the mundane and make sure that important steps are never missed. Unfortunately, bad checklists can make us unthinking and automatic.

There is an assumption that doctors should just tolerate these insults, but what is less well understood is the profound and harmful nature of rudeness. Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare. We should all get more comfortable with life’s hardest sentence: “I don’t know.” Nobody gains by leveling harsh accusations at fallible humans, regardless of their proximity or salary. Doctors are not dickheads, we are just heads, and, like our patients, these heads are connected to hearts.

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @Matrix_Mania

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared. 

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Matt Morgan: Time to stop serving the “shit sandwich”

If you have attended an Advanced Life Support course, you will be familiar with the so-called “shit sandwich.” Despite electrocuting yourself with the defibrillator, tripping over the ECG cables and giving your assistant a needle-stick injury, the feedback will inevitably start with “Right everyone, what did they do well?” A lone voice will respond with “I like the way they introduced themselves to the patient” which would be fine had the patient not been having a cardiac arrest. Once the bottom slice of motivation has been laid, next will come the filling of errors you made, each delivered with a sympathetic facial expression. Finally, you are left with that top buttered slice of “Well done! You can do this! What do you think you could do better next time?” “Read the manual,” you think to yourself. And so the “shit sandwich” is served, whereby criticism is couched in positive feedback. 

I had been happily eating this staple diet throughout my medical education until I met an extraordinary person. Gary Thomas amazed me from the moment I met him. A talented clinical teacher, he could take you on a journey from fundamental physics to caring for a sick child in the blink of an eye. While revising for an anaesthetic exam, he offered viva practice, which I was strangely looking forward to. I had passed my written exams, felt confident about my knowledge base, and hoped that I could impress him. Days before Christmas, I stepped into Gary’s office for our first session. The next hour was a blur. Perhaps I have mentally blocked out the pain. The memory I have retained is responding to a question on the risks of thermometers with “Well, they might explode!” Not only had I performed terribly, but there was no comfort of a shit sandwich to chew on. “That’s not good enough to pass. You have to do more work and in a different way if you want to pass.” “Happy Christmas to me,” I thought.

But Gary was right. I worked hard, changed the way I was revising, and passed. Increasingly, I realise that Gary’s response was so much richer than a shit sandwich. It would have been easy for him to start his feedback with “Well you were good at remembering your name.” What he gave me instead was an honesty wrap. The filling was my inadequate ability at that time to pass an exam. But this was wrapped in something powerful—a choice. He gave me a choice to improve my ability—work harder and in a different way then you can pass. Sometimes it is not your ability, but the choices you make in medicine that are important. A great teacher knows that. A good student should be told.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Competing interests: none declared.

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Matt Morgan and Peter Brindley: Time for tough talk with the NHS—equality or longevity?

It may be time for different salaries for different specialties in different locations to plug extreme rota gaps, say Matt Morgan and Peter Brindley

 

Happy 70th Birthday, NHS. We are proud of you and we love you. As a septuagenarian, in theory, you can now spend your days travelling the bus for free and sneaking into afternoon movies. Instead, Britain still needs you working, and harder than ever. As such, please excuse these two young whippersnappers, but we think it is time for “the talk.” What do you want going forward? What are you prepared to give up? And what sort of legacy do you wish to continue? We know that this is a tough discussion, and we know we’d all rather ignore it. We only bring it up because we care. We put it off as long as we could.

We wholeheartedly stand behind your principle of equality of access despite socioeconomics or postal code. Alongside education, healthcare is a magnificent way to provide opportunity, and these two middle class lads were grateful beneficiaries of your hard graft. However, you have been struggling to keep the lights on for some time. This is in part due to the rapid inflation of available treatments and diagnostics. With the risk of stating the bloody obvious, things have changed a tad since 1948. Back in the day, your doctors battled the inevitability of death with a scalpel, a brace of antibiotics, and a trusty stethoscope. You now confront 60 000 different conditions, offer 4000 procedures, and stock 6000 drugs. This was hardly what you signed up for. You look tired.

You are also one of the country’s largest employers, and if one thing has remained constant it is that British workers are often unhappy. You need, and we need, a workforce that is fit for purpose. Not only the right numbers, but in the right specialties, and in the right places. Both town and country have problems: smaller, rural hospitals struggle to provide comprehensive services, while so called ivory towers are drowning in volume. We have a suggestion, and this is where it gets awkward. After all, if there’s one thing you don’t usually do in Britain, it is talking about money. Here goes . . .

Sometimes you are penny wise and pound foolish. Please do not wait for a crisis before you spend. Sometimes you are just too generous. Please do not expect to be all things to all folk. Regardless, this is tough stuff, so let’s narrow the conversation to where we feel slightly more qualified to comment. Among other issues, it is time to review the one size fits all model of NHS consultant pay. The NHS is unlike many other countries, including those with a single payer system. It pays the same to a consultant cardiac surgeon, a consultant in wound healing, a forensic psychiatrist, and an occupation health doctor. Or at least you claim you do. You are a bit sneaky.

Part of your strategy to attract people lies in what is euphemistically called creative job planning. With all respect, this system is already a bit Animal Farm, where “everyone is equal, but some are more equal than others.” For example, you offer posts with a high number of sessions attached. You also try to tempt folks with those on-again, off-again pay awards. A few are making “loads of money,” while others collect the minimum. We suggest that this strategy to deal with market forces could be more transparent. Simply accept that, where extreme shortages are impacting the NHS’s ability to deliver safe care to all, you could pull the salary lever. Like our medical cousins around the world, it may be time for different salaries for different specialties in different locations. There, we said it, and now we can’t take it back.

Before the outrage begins, let’s be very clear. This is in no way to argue that different specialties have different worth. Moreover, each specialty has equal potential to enhance or mess up a patient’s life. Pay is not delivered according to moral or health worth in any sphere of life. If it was then bankers would be handing their Porsche keys over, and teachers would be driving them away. Also, we are not saying that pay is determined by “rarity”; otherwise a small specialty such as cardiac surgery would be paid far more than larger groups such as psychiatry.

Perhaps we need the courage to contemplate the contrary. In specific geographical areas, where psychiatry is in dire straits due to staff shortages, psychiatrists could be paid more than cardiac surgeons. We shall pause to let you gasp. However, this general idea of geographic incentives approximates what they do in Canada and Australia in hopes of caring for the North and the Outback, respectively. Admittedly, it hasn’t fully solved their problems, but the extra costs it incurs may be offset by reducing treatment delays and locum costs.

You might argue that “tiering” professionals breeds resentment and false incentives. However, you have lived with this system all your days. Two tiered UK healthcare means that you already have private medicine, and to a far greater extent than other countries. Moreover, London pay is sometimes weighted, just as the Highlands and Islands can get special allowances. Regardless, this may help level out the playing field where those in specialties with long waiting lists find themselves with less private work. This is because public staff shortages can be mitigated using differential pay.

Presumably what is good and bad for doctors applies for nurses too. Presumably, we need to get that thorny conversation sorted in short order. After all, next comes that even more contentious subject: what services should be covered and what should not. This is the part in the conversation where we typically all look at our shoes.

Overall, we are not arguing that any new system would be perfect. We’re not even arguing that it is more “right” or “moral.” Moreover, in your seven decades you’ve probably heard every overly simplistic solution to every overly complex problem; we wouldn’t be surprised if you’ve had it up to here. Like you we are just fighting to remain true to your vision of healthcare for all. The NHS is a beloved national treasure. We want to keep you around while also keeping patients safe and staff engaged. Life is getting tougher, and you are looking frail. It’s time to have a tough chat about pounds and pence and common sense. We’d like to wish you another 70 years, but right now that seems hard to imagine. Perhaps not what you wanted to hear on your birthday, but it really is because we care.

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @Matrix_Mania

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared. 

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Peter Brindley and Matt Morgan: Burnout in healthcare workers—are we surprised?

There is a picture of a vending machine that went viral. This is because a note was placed on the glass that describes how many of us feel: “the light inside has broken, but I still work.” Sure, there are “lies, damn lies, and statistics,” but approximately half of healthcare workers appear to be struggling against psychological burnout. Melodrama aside, when we come to work we are battling for more than just our patient’s health. The diagnostic criteria for burnout are woefully imprecise, but usually encompass exhaustion, depersonalization, and loss of meaning. Given that much of modern society recognizes those same symptoms in themselves we ought not to be surprised. Along with everyone else, we healthcare workers are tired of being asked to do more with less. Please just allow us to put on our own oxygen mask before assisting others.

Healthcare workers are not asking for special consideration, or even fawning praise, but a bit more give and take would help. Let’s be clear, many days are great and many patients are lovely, but certainly not all. Call us old-fashioned but we are growing weary of being pelted with expletives and threats. Of course, terrible stuff doesn’t happen everyday, but the cumulative effect takes a toll. As outlined, doctors and nurses are not special. Therefore it is informative to paraphrase the UK policeman John Sutherland who wrote a moving memoir entitled “Blue: Keeping the peace and falling to pieces.” He points out that the bobby’s maxim “every contact leaves a trace” applies to coppers not just crime scenes. Back in our medical world, resuscitation can be difficult, and end of life issues can be draining, but it’s being treated like crap that is the most exhausting. With that in mind, just a friendly word to the medical brass: keeping up with clinical advances is a walk in the park compared with accommodating computers and administrative edicts.

Modern life is tough for all of us. It is stressful and stress-filled, and algorithms are replacing humans at a terrifying rate. Accordingly, perhaps we’re not even surprised at the tsunami of drug abuse, or that suicide is one of the Western world’s commonest causes of death. Many of us are all exhibiting varying levels of despair. Doctors and nurses are not immune, but we are famously bad at seeking help. The rate of death by suicide among healthcare workers is 2-3x the rate of the general population. Clearly, we have a problem, but so does the public that relies upon us. These abstract statistics mean the very real loss of 500 doctors per annum in the United States alone. Expressed another way that is an entire medical school each year, or more than one doctor per day.

When a doctor or nurse suffers from that euphemistic state called “compassion fatigue,” and the job has been squeezed of all its juice, then the public probably doesn’t want us as their state appointed professional. Fortunately, there is a simple cost-free way of improving morale. It is no panacea, but a genuine “thank you” is often all we need; well, that and occasional baked goods. In contrast, studies are showing what common sense would otherwise intuit: if rudeness were a drug it would come with warnings on the label.

During resuscitation, rudeness has been shown to worsen performance both at the individual and team level. This might seem intuitive; what is fascinating and terrifying is the extent of its harm. Rudeness may affect outcome more than fatigue and it cannot be conquered with technology. Early rudeness studies involved nothing more than a doctor phoning into a resuscitation simulation. The physician actor merely told the healthcare professionals that “they did not know what they were doing”, and that “he would not want his loved-one in their hospital.” Follow up studies looked at the impact of families being rude to healthcare professionals, and showed a similar detrimental effect. In short, rudeness is not only unnecessary, it can be dangerous.

Of course, we professionals sometimes simply need to “suck it up”. We also need to bring our best self to work, and to remember that patients and families are often having the worst experience of their lives. Equally patients and families should speak up when care is insufficiently delivered and inadequately communicated. But there is never an excuse for rotten behaviour. Remember that “hurt people hurt people”, and that behaviour might be as contagious as the common cold. The expression can also apply to the likelihood of medical errors. Hurt people don’t mean to hurt people although unknowingly they probably do.

As doctors and nurses we fear burnout like patients fear that conversation when the test results come back. The term “burnout” is currently carrying the load for emotions ranging from everyday frustration to clinical depression. As such, let’s not unfairly apportion blame, or offer platitudes and bromides. Adversity presents each of us with a choice to be the best or worst version of ourselves. These authors have both been the victims and perpetrators of rudeness, and we offer a belated though sincere apology. Much like that vending machine we all need to keep on working. Going forward, we politely suggest that we all pull together so that the light remains on.

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada @docpgb

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

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Nick Wilson and Matt Morgan: Is the “bench to bedside” broken?

Over recent decades, the UK has been a key innovator in medicine. The UK ranked 2nd overall between 1996-2017 in the number of medical publications (1,059,287). [1] The benefits of research are obvious, for example, the development of new treatments, diagnostic tools, and changes in patient management. But research also helps patients directly, with hospitals and departments involved in research producing better patient outcomes. [2] With these benefits to be enjoyed and in a changing and strained healthcare system, we need to think hard about how research is carried out.

The term “translational science” was first coined in the 1980s, but is not really a new concept. Simply, it is the practice of taking scientific discoveries and research and applying them in clinical practice to generate new therapeutics and treatments. [3] A dramatic example of this process is the development of monoclonal antibody therapies, where a molecular target (e.g. TNFα for Infliximab) must first be identified and implicated in a disease process. Only then can an antibody be produced followed by rigorous drug trials before reaching the clinic door.

Carrying out research and drug development has become more costly and complex with many barriers. In 2016, it was estimated that large pharmaceutical companies spent approximately US$2.56 billion to bring a drug to market. [4] This monumental figure also took into account the low clinical success rate, with 88% of drugs having their development abandoned. This low success rate, combined with the high cost of development, would seem to make the complete development of a new drug an almost impossible feat for non-commercialised ventures. Applicants slaving over research grant forms for a “bench to bedside” project are surely stretching the truth to what the funders may want to hear.

Taking research from a lab all the way to the clinic is not only costly, but also a lengthy process. To identify a target implicated in a disease, understand its biology fully, develop a treatment, and then to enter lengthy drug trials will mostly take decades and countless numbers different professionals. All of these factors are barriers to cohesive translational research projects. The attractiveness of a complete translational research project to a grant awarding body is also questionable. The time taken for these projects, as well as their unpredictability, would make a single grant unfeasible. As would applying for a grant for a conceptual treatment based on limited evidence from early lab work.

Another criticism of the model of translational research is the sheer unpredictability of medicine. Many medical discoveries have been completely by chance as opposed to being due to an understanding of the science underpinning the practice. Sildenafil (Viagra), a drug previously developed for hypertension, when launched by Pfizer in 1988 became the leading drug for erectile dysfunction and doubled Pfizer’s share price overnight. [5] The fortuitous discovery of its potency in erectile dysfunction was only noticed however, during phase I trials to assess its benefit in angina as the original “bench to bedside” application form would have read. They just didn’t know at the time it would literally be from bench to bedside. 

The switching and assessment of already clinically approved and safe drugs for the treatment of different conditions is now termed “drug repositioning” and companies like NovaLead Pharma and Numedicus are entirely set-up around this concept. [6] Drug repositioning shortcuts translational research, using drug screening technology to assess different functions of drugs. An example is the use of itraconazole (an anti-fungal medication) for its action as an inhibitor of blood vessel growth. Itraconazole had shown promise in cancer models and recently showed positive results in Phase II trials in lung and prostate cancer. [7]

There will still however, always be a requirement for new therapeutics for still unmet clinical needs. These needs include many degenerative neurological conditions (e.g. Alzheimer’s and Parkinson’s disease), chronic untreatable diseases (e.g. pulmonary hypertension and pulmonary fibrosis) and rare diseases. These needs will have to be met by translational research in some form or another. And while the process of translational research may have become more fragmented, allowing researchers into the clinic and engaging with scientific research could be a small step towards redeveloping a culture which can again support the practice of translational research and again reap the benefits. Grant calls should embrace this uncertainty and allow longer-term, more explorative research or else remove the promise in short-term funding to deliver patient benefit in that area in an unrealistic timescale.

Special thanks to Dr Matthias Eberl, Cardiff University for his input and support.

Nick Wilson, Medical Student, Cardiff University.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

References:

[1] Scimago Journal & Country Rank. SJR – International Science Ranking. Scimagojr.com. 2018. [accessed 3 Jul 2018] Available from: https://www.scimagojr.com/countryrank.php?area=2700

[2] Ozdemir BA, Karthikesalingam A, Sinha S, Poloniecki JD, Hinchliffe RJ, Thompson MM, Gower JD, Boaz A, Holt PJ. Research activity and the association with mortality. PLoS One. 2015 Feb 26;10(2):e0118253.Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342017/

[3]Emmert-Buck MR. Translational research: From biological discovery to public benefit (or not). Advances in Biology. 2014;2014.Accessed from: https://www.hindawi.com/journals/ab/2014/278789/

[4] DiMasi JA, Grabowski HG, Hansen RW. Innovation in the pharmaceutical industry: new estimates of R&D costs. Journal of health economics. 2016 May 1;47:20-33. Accessed from: https://www.sciencedirect.com/science/article/pii/S0167629616000291?via%3Dihub

[5] Jacque Wilson C. Viagra: The little blue pill that could – CNN. CNN. 2018. [accessed 20 Jun 2018] Available from: https://www.cnn.com/2013/03/27/health/viagra-anniversary-timeline/index.html

[6] Nosengo N. Can you teach old drugs new tricks?. Nature News. 2016 Jun 16;534(7607):314. Accessed from:https://www.nature.com/news/can-you-teach-old-drugs-new-tricks-1.20091

[7] Sun W, Sanderson PE, Zheng W. Drug combination therapy increases successful drug repositioning. Drug discovery today. 2016 Jul 1;21(7):1189-95. Accessed from: https://www.sciencedirect.com/science/article/pii/S1359644616301866

 

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Matt Morgan and Peter Brindley: Doctor does not always know best

For centuries, old white men have argued about whether medicine is more of a science or an art. That is until, belatedly, some smart Alec—or some smart Alexa—realised that patient safety and medical predictability mattered too. Accordingly, we now spout language as recognisable to engineers as to Osler. We talk about standard operating procedures, and fail-safes, and checklists. However, what determines patient outcome is as much about old-fashioned relationships, rather than new-fangled whizz-bang. Without getting too “Oprah”, it really does take a village to help a patient. Doctor, you are in the “relationship business”; are you fit for task?

This medical job is, and has always been, “relationship before task.” This is true whether within harmonious specialties or across embittered hospitals. To truly “get stuff done” means knowing the booking clerks, thanking the porters, and not forgetting the secretary’s birthday. It’s about the relationships between those that buy sutures and those that tie the knots. It’s even about the ergonomic relationship between your hands and your beloved pieces of kit. Obviously, the relationship that matters most is the one between patient and provider, especially in chronic disease, and especially as we transition care. This can be tricky stuff.

It has been estimated that admission to Intensive Care comes with approximately 180 steps per-patient per-day. While clichéd there really is no “I in ICU” and “teamwork really does make the dreamwork”. We do not so much look after patients as conduct a large skilled orchestra. This comes with the side effect of pharmacists interrogating our antibiotic choices, physiotherapists advocating for early mobilisation, and the dietician suggesting a few calories might not be a miss. It can also be the social worker arguing for more time to get support in place and a family member reminding us discharge includes more than whether we need the bed. It is good that we have many eyes on the prize. Our decisions are regularly questioned. We appreciate this, even if our facial expressions sometimes suggest otherwise.

Sign-over and discharge-planning may be exasperating but keeps us all honest. These medical procedures also happen thousands of times per day. They are therefore as necessary as hand-washing, but have received far less attention. Get it wrong and we lose the plot. However, get it right and we can challenge assumptions and confront cognitive bias. Sign-over can be as tedious and discharge can be tiresome. However, it is also a much needed second opinion in a system that doesn’t otherwise encourage descent. We want you to speak up and we want you to prove us wrong. We really don’t want to be incorrect a moment longer than necessary.

We have gnashed their teeth through more team meetings than post-night shift breakfasts. This is because we are impatient buggers. It is also because there is a clear and present danger that time will be wasted, nuisance will be missed, details will be morphed, and hard-fought relationships will be scuppered. These risks are real. However, a “second” opinion” is often the best first strategy. This is the case when we do not know what to do and even when we are certain that we do. We do not always have the humility to admit that doctor does not always know best. Thank you for disagreeing, we know it takes effort and resolve. Thank you, in turn, for accepting that we may disagree right back.

Our brand of acute care medicine comes with built-in second opinions. The danger is that these opinions lie unmolested in the chart (the Ninja consult, anyone?). Some opinions are also little more than repetition of the blindingly obvious. Regardless, we are the lucky ones. We have ready access to the hospital’s hive mind. In contrast, other inpatients and outpatients are exposed to the same weary assumptions for weeks and months and sometimes decades. Perhaps the benefits of the relationship built-up over years of chronic disease outpatient clinics can be outweighed by a regular rotation through fresh eyes? Without this, it may mean one-doctor, one-opinion, and one-direction. Nobody needs to hear more from One Direction. There are great advantages to fresh eyes, new ideas, and good old-fashioned differences of opinion. Maybe medicine is not just art or science, or even engineering. Maybe medicine is a branch of the social sciences. That’s just our opinion; you are welcome to disagree, or ask a colleague for their thoughts.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada @docpgb

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Matt Morgan and Paul Twose: Efficient, fragmented holistic care

It is a familiar situationsitting on the ward, long after your shift has finished, waiting for the phone to ring so you can clarify a patient treatment plan.

Was that conversation really essential at that very moment? Maybe not. Will the overstretched junior doctor even be able to answer your question? Probably not. Was that efficient use of your time? Definitely not! In hindsight, the last time the authors made such a call was because everyone was being so efficient in “their” aspect of patient care that the holistic plan became fragmented and anything but efficient.

We are certainly not alone in putting extra time to deliver more holistic care. The nurse who helps a patient’s wife find the car park, the physio that holds a patient’s hand whilst blood is taken, the doctor helping to roll a patient. These happen every minute of every day. Yet we seem to get more recognition when we are successful at making “efficiency savings.” We argue that sticking to individualised, fragmented work streams actually result in more work not less. Maybe not for the one being efficient, but for the next healthcare professional involved, or those trying to orchestrate good care.

Modern healthcare is often compared with industry, especially car production, with Toyota’s lean manufacturing system leading the charge in the boardroom. Within this process, each employee knows their precise role and how to achieve their task in the most efficient way. You wouldn’t want the welder to suddenly help out the windscreen installer on the production line just because they needed to go to the toilet.

Of course, service improvement is important including the need for efficiency savings. However, this cannot lose a sense of holistic care which often is not, and must not, be efficient. Sometimes the welder simply needs to hold the glass. So please excuse us if we are not 100% efficient all of the time.

Paul Twose, Lead Physiotherapist, Adult Intensive Care, University Hospital of Wales. @PaulTwose

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

 

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Matt Morgan and Jade Cole: Research matters

It has been a very long, unforgiving winter. Although the Welsh daffodils outside of the window are blooming, hospital beds around the country remain full to the brim with patients with flu, acute-on-chronic health conditions, and newly diagnosed illnesses that will be nursed for weeks to come. The “Winter Crisis” is now simply “The Crisis” as countless newspaper articles report. In these times of patient-a-plenty, why am I sitting at home, planning our next research study? Why are we using valuable nursing staff to randomise patients into clinical trials? Why is scarce money being spent on placebo pills that do nothing? Because research matters. It matters to patients, it matters to staff, and it matters to healthcare.

It is easy to think that under such conditions of pressure, medical research is simply a nice bolt-on to have only when a system is performing well. An additional sheen to be applied only when the machinery of healthcare is running smoothly. It is not. It is as fundamental to good care as any other essential component of healthcare. It it not an optional extra, it is a necessity.

It has been shown that patients in clinical trials have a higher survival rate that those not in trials, even if they are in the control arm. Units that do research have better outcomes than those that do not. Hospitals that do research have better outcomes that those that do not. Fostering research fosters good relationships between specialities, and leads to better staff satisfaction with better recruitment and retainment rates. If research were a pill, the number needed to treat may be lower than many other medical interventions we deliver to patients every day.

Of course, it has to be good research, well designed, asking important questions, and conducted in the correct manner. Even when this is the case, there seems to be a tension between money spent on “front-line” healthcare, public awareness, quality improvement measures, and research. I have even been told by a senior university leader that medical research is simply “money in, money out”. It seems even some of the institutions founded to advance knowledge have been captured by the businessology of education. The impact of an extra nurse on the ward is easier to quantify than that same nurse working on a medical trial which will result in better care for countless future patients. Similarly, there is emphasis, rightly so, on public awareness and quality improvement in conditions such as early cancer diagnosis and recognition of sepsis. However, public awareness is one pillar that needs to be reinforced with treatments and diagnostics that actually work.

The highly publicised media campaign to help identify meningococcal meningitis using a glass tumbler on a skin rash is both memorable and important. However, the 190 deaths due to meningococcal disease in 1999 compared with just 10 cases in 2016 is not due to this alone. The dramatic plummet in the year immediately following the introduction of a successful vaccine was gained through hard, expensive, and time consuming research. Research matters. Especially now.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania 

Jade Cole, Critical Care Research Nurse Specialist, University Hospital of Wales.

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Peter Brindley and Matt Morgan: Advice to medical school applicants—be average

Despite a darn cold winter, well-scrubbed medical school applicants in Canada are currently sweating in interview chairs. This is despite knowing most of the questions they will receive, and despite having prepared assiduously in the bathroom mirror. “What strengths do you possess?” a world-weary interviewer will underarm bowl. “Well, let me think about that” the candidate might reply as they feint surprise at this delivery. They are then likely to hit it to the boundary with a statement about “leadership” and “perspicacity.” When the interviewer tries to explore their “weaknesses” they are just as likely to dispatch this predictable Yorker, “Well, people say I’m a perfectionist”. And so it continues: day after weary day.

Many wonderfully talented people apply to medical school, and most have noble intentions. However, every system produces the results it is designed to. Instead of your- or my– ability to trample the competition we really need to explore what makes you, and me, decidedly average. Moreover, what do you intend to do about your “unremarkableness” with a state subsidized training and enviable job security. How about we focus less on the leader you will become and more about the follower you will need to be. This gets short shrift, raised eyebrows, and air-sucked-through-teeth. After all, we live in a society that equates service with passivity and the failure to “be all you can be”. These beliefs are as pervasive, solipsistic, and daft. Firstly, lets accept that the lowly toilet has saved more lives than any doctor ever could. Secondly, not everybody leads, and even titular leaders do not lead all the time. Everybody is an assistant during most of their life. This is true in the hospital, just as when these authors head home and become decidedly “second-in-charge” to the domestic general, be it behind your child, your spouse, or your dog.

Being a follower does not automatically make you a “sheep,” just as being a leader does not automatically make you an all-conquering hero. You would never know this from the medical and business literature. It is awash in books and pamphlets extolling the champion. It is largely mute when it comes to the larger and less vocal majority. Modern workers are rarely passive subordinates. Instead, we/they are all educated, expected to problem solve, and able to influence or to disrupt. These roles matter, and therefore warrant just as much reflection and tenacity. Perhaps it is more comforting to cut ribbons and raise champagne flutes outside of so called “centres of excellence.” In contrast, why don’t we celebrate those who deliver unglamorous help to those most in-need. How often do we ask: “what is needed of me?”, rather than “what do I need?”

It has been wryly observed that the closest a person gets to perfection is the night they write their resume. Moreover, success has 1000 parents, whereas failure is an orphan. Fortunately, some scientists are fighting back and wearing failures on the sleeve of their lab coats. They have posted “failure CVs” in which they list degrees that they did not get, programs that shunned them, and papers that were summarily executed. 

In fact, quitting should be heartily encouraged to maximize opportunity costs if you can psychologically accept the sunk costs.

This is not false modesty. If less than 20% of grants and fellowships are accepted, then good scientists know to get immunised against failure, and fast. Modern parenting and the consumer society are unlikely to help in this regard.

We wish applicants all the luck that they deserve during this interview season. We also understand that the Buddhist gift of “not getting what you want, but rather what you need” may sound obnoxious coming from two old chubby white men. However, we can tell you that most of the best doctors failed to get in the first time, and that adversity can be a terrible thing to waste. We also believe that great medicine is about doing the right thing when nobody is watching, and will often make you unpopular. As one of our famous philosophers once said, “It is our choices that show what we truly are, far more than our abilities.” (Albus Dumbledore).

In contrast, interviews and oral exams are more about theatre and omniscience. We look forward to welcoming you to this marvellous and difficult profession. We look forward even more to you pointing out our deficiencies. Please help us to be, if not great then, exactly the type of average that our patients need.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on twitter: @docpgb

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Matt Morgan and Peter Brindley: Medicine in the “Age of Anger”

Matt Morgan and Peter Brindley encourage us to take a deep breath

 

Anger rarely solves anything, it builds virtually nothing, and can destroy almost everything. With the risk of being trite, anger is also one letter short of danger. The film “Love Actually” starts by claiming that “love is all around.” In contrast, author Pankai Mishra makes a compelling argument that we are now living in an “age of anger” and experiencing “a pandemic of rage.” [1] Recent clinical weeks have suggested to us that many of our hospitals are no different. In case you think we are pointing fingers, we assure you that we are, and at every darn one of us: patients, families, administrators, clinicians, and most assuredly, these two authors. As intensivists, we prescribe the following: lets ALL take a deep breath.

There are no simple explanations, nor simple solutions. Mishra talks about “ressentiment”. This is a complex French idea that translates as a psychological state arising from suppressed hatred and envy that cannot be acted upon. However, rather than focusing on pathophysiology, let’s talk about symptom control. Perhaps it starts by diagnosing communication as healthcare’s most dangerous “procedure” and understanding that “verbal dexterity” matters as much as manual dexterity. Then counsel yourself that words, once said, might be forgiven, but are rarely forgotten. Then self-administer regular boluses of self-reflection: perhaps we enjoy self-righteous anger a little too much; perhaps we find comfort by playing the victim. Perhaps the games people play help bring meaning; hopefully they do not prevent clarity.

We were taught that hurt people hurt people. Less time was spent teaching us that this need not be inevitable. Despite living through the holocaust, the physician Victor Frankl was able to believe: “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” He was just as adroit when stating: “when no longer able to change a situation, we are challenged to change ourselves.” Unfortunately, though, this level of compassion can seem unattainable if you feel immersed in daily anger; in the same way that it is impossible to swim without getting wet. Regardless, a wise mentor taught us that there are only three emotions that matter: fear, greed, and fear (sic). As such, let’s start by sharing what we are scared of. Perhaps for doctors it’s the loss of autonomy. Perhaps for patients it’s loss of certainty as much as loss of health. Let’s find time for a cup of tea and some bilateral empathy.

Violence is still a disproportionately male response, but blame and anger are common regardless of gender or demographic. Humans are built such that the “adrenal” can easily dominate the “cerebral.” The result is that “anger“ hogs our bandwidth, and leaves less room for “acceptance” and “compromise” and “compassion.” Mishra’s book offers no easy excuses. Mishra also believes that reasonableness can only flourish when there is widespread optimism. He also believes that the current state is the culmination of replacing traditional beliefs with consumerism and disconnectedness. We want to (politely) disagree, but are finding it hard. We want to do better, and we know we must. For now, we will just take that deep breath.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on twitter: @docpgb

References:

  1. Pankaj Mishra. The Age of Anger. 2017. Farrar, Straus, and Giroux publishing. New York

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Matt Morgan and Peter Brindley: Medical conference emojis—which one are you?

Matt Morgan and Peter Brindley have been studying human doctors in their native conference environment

While there is always a medical conference on the horizon, this fallow time of year allows for respite and reflection. We can put our tiny tube of toothpaste away, we can forego removing our shoes for airport security and we can focus on the important stuff: which colourful lanyard to wear for the remainder of the year. While you were, no doubt, studiously absorbing the latest advances in your field, we took a different, albeit distracted, approach. We were the two folks sitting in the back, studying the human doctor in his/her native conference environment. Think of us like Desmond Morris or David Attenborough but without their charm, erudition, or intelligence. We wish to summarize our findings, and in a format relevant to the modern learner: which conference emoji are you?

The human sponge

You arrive early, get the best seat, and sharpen your metaphorical pencil. Before you know it, you have filled a whole notepad with at least 200 essential take home messages. You have a carefully constructed schedule, timed to perfection to catch the best sessions: often you colour code. You race from session to session, you soak up knowledge, and file it neatly: you are a conference hero! You return home eager to share it on your next ward round. Nobody listens.

The social butterfly

For you, the value of a conference lies not in its content but its people and its receptions. You meet old friends and make new ones, you don’t miss a single social event and you spend the bright conference days rehydrating from the night before. Your clothing reflects your personality: loud, lively, and designed to attract attention. You hug dear friends farewell and make all kinds of plans to catch up. None of these follow-up meetings occurs until next year’s conference. You wish to call in sick for your next shift, as you are rather too exhausted for clinical work.

The ultra-tweeter

The first question from your lips is “how fast is the wifi?”, followed breathlessly by “and the hashtag?”. You tirelessly tweet every moment—poignant or mundane, you don’t care. You spend more time with your screen than any flesh or blood human. You have hundreds of “conference friends” but wouldn’t recognize any of them in three dimensions. You return home, holding your head high as the most trending tweeter. No one can take that away from you. Surprisingly, you receive little public adulation.

The niche celeb

Nobody knows more than you about less. You are the don of the anterior mitral valve leaflet. People flock and queue to hear your latest musings: as long as one person constitutes a queue? You laugh loudly at your own jokes, and you are the smartest person you have ever met. For that brief conference moment, you feel like Justin Bieber: just with fewer tattoos, and without the Lamborghini. During the conference you get to taste the high life by guzzling free soft drinks in the speaker’s area. You spend most of the conference trying to get invited back. Before you know it, you are back on the 14h15 train to Slough: ready to take out the bins and to clean up after the dog.

The hopeless wanderer

You never seem to be in the right place at the right time. You wander from one empty lecture hall to the next. Why do you always miss that keynote that everyone is talking about? You walk down a long corridor to use the toilet, only to face a locked fire exit. You are tired of getting stuck in stairwells. When you arrive for lunch, there is one remaining sandwich, or more accurately a piece of wrinkled bread stuck to a sweaty lettuce leaf. You swear you’re done with conferences. We will see you next year.

The irrelevant question asker

At the microphone during question time, you recount your own interpretation of the speaker’s talk. But first, a six-part comment that starts with an irrelevant anecdote from 20 years ago. The audience needs to understand that you are “a frontline doc” and not one of these “ivory tower eggheads” and not a “pinhead administrator”. When asked what your question is, you sheepishly admit that you don’t have one. In fact, it’s just a statement really, and was fully addressed in the opening slide. People fidget in their seats and eye the clock. Next question please.

The vacationer

You’ve always fancied visiting this city and have unused conference leave. You might even submit a poster, but won’t be standing by it at the appointed hour. Instead of attending the sessions, you realize that there are bikes to be rented, slopes to be skied, and museums in which to loiter. How do we know you had a better time than us? Don’t worry you will tell us.  

The naysayer

It’s all rubbish, it’s all been said before, and none of this is relevant to practice. You harrumph your way through three days. You do your best to catch people’s eyes with your world-weary expressions. You seem personally offended that the p-value was greater than 0.05 and you can’t believe the taxpayer is supporting this bush-league research. Surprisingly, you are invited to present the following year. You have a change of heart: what a terrific conference.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on twitter: @docpgb

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Matt Morgan and Peter Brindley: Why negative trials are usually positive

There are many benefits to patients from negative trial results

We’re going to let you in on a secret. Although intensive care medicine often looks complex, usually it is not. In fact, it is likely one of the simplest medical specialties. Despite a myriad of journals, shockingly expensive therapies, and all the latest shiny machines, we have a meagre four evidence-based curative interventions: antibiotics, steroids, surgery, and most importantly, time. Thus, when a large clinical trial comes along that examines any one of these four pillars it is a big deal. The ADRENAL trial justifies the hype and is, to quote Kathy Rowen, “a wow moment. ADRENAL is the world’s largest trial examining the putative role of corticosteroids in fighting the scourge of critical illness: sepsis. The researchers deserve unfettered praise and a well-earned rest. The researchers also signalled how information dissemination has changed by releasing the data in Belfast, away from the mega-conference circus, but streamed live worldwide thanks to Rob McSweeney. While the trial’s intimate details will be dissected ad nauseum by the Critical Care Medicine community, there are three general themes of relevance for the wider medical community.

The ADRENAL trial could be called another “negative” trial. After all, the primary end point—mortality at 90 days—was no different in the steroid group compared with placebo. For a trial that consumed millions of pounds and a comparable number of research hours, this could be described as a disaster. We would argue instead for more salutary words: important, exciting, provocative. Medics are biased towards positive trials and may assume that these are more beneficial. Importantly, however, negative trials allow interventions NOT to be used. This translates into time savings, cost savings, and time focused on interventions likely to work rather than unlikely to work. Moreover, despite all the resources available to medicine in general, “time” is often our most precious resource. Time is, after all, both a great healer, and a reliable prognosticator. Removing interventions with no proven benefit limits distractions, and focuses our energies. This also obviates harmful side effects. Given the publication bias towards “positive” trials—especially those with pharmaceutical backing—negative trials may actually be a better reflection of scientific truth. If you agree with our logic then perhaps you will accept our conclusion: overall negative trials may actually be more beneficial: to professionals, to health systems, and most importantly to our patients.

ADRENAL interrogated many important secondary outcomes, several of which reached statistical significance. On average, the steroid recipients spent less time hooked up to mechanical ventilators, had less blood transfused, and spent less time in the intensive care unit. However, secondary outcomes and surrogate measures have been treated with disdain in the medical literature for at least twenty years. Scepticism is appropriate, but cynicism is not. Nor is intransigence in the face of large study data. The danger is that the “secondary outcome excuse” can also be a way to hold on to unscientific hunches or unsupported biases. Interestingly, in a holistic way, secondary outcome measures tend to be far more patient focused than raw, binary outcomes: dead versus not dead. For the patient, less time in a scary critical care environment, or fewer days attached to an annoying ventilator, may be personally hugely meaningful. Furthermore, reducing costly or dangerous interventions, such as blood transfusions, is  prudent medicine. Reducing costs could also allow funds to be reinvested. Sometimes, the endless striving towards a p value showing small improvements in death can hide noteworthy benefits that have a positive impact on a patient’s life.

Finally, and perhaps most importantly, the ADRENAL trial casts a jaundiced eye towards trial safety monitoring. Trials are stopped early when interim analyses show strong signals of either harm or benefit. On first blush this seems appropriate as it both safeguards participants, while allowing early dissemination. However well intentioned, interim analyses can also be premature and therefore wrong. Had the ADRENAL trial been stopped during the interim analysis, we might have lost the major take home point: no proven benefit. This begs the question of how many other trials have been stopped before their best-by date, and how often have we landed on an “alternative truth”. Perhaps this “early warning system” is not as safe as finding the enduring truth, which will benefit a far greater number of future patients. In short, in addition to congratulating the researchers, we wish to emphasize that this negative trial was actually extremely positive. The search continues…

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania 

Peter Brindley, professor of Critical Care Medicine, Anesthesiology and Pain Medicine, and Health Ethics, University of Alberta, Edmonton, Canada@docpgb

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Matt Morgan: “Running a hospital is a bit like running a . . .”  

Medicine needs to make, adapt, and find its own strategies

Anyone who has listened in on hospital boardroom meetings will be familiar with the increasing number of strategies borrowed from other industries. Waterfall and agile methods have been plucked from their software home in Silicon Valley and dropped into small rural hospitals. Lean management, from the automotive industry, has been wrenched from the iron of Post-war Japan and left in the revolving door of an outpatient clinic. Six Sigma unplugged from the neon glow of the high-end electronic scene and left in theatre five.  

Similarly, clinicians at the coal-face have borrowed techniques from safety conscious industries including crew resource management, checklists, and human factor approaches. We take these tasty morsels of experience, apply them to medicine and say “Running a hospital is a bit like the *replace the blank* industry”. Of course, it is not.   

Methods borrowed from production industries may be useful for increasing the numbers of hernia operations done per year or outpatient clinic visits each quarter. However, they do not tell the story of how palliative care should be compassionately delivered at 1am on a snowy New Year’s Day.  

Lean design may argue that we can increase throughput in day surgery, but this was designed in a world where a numerical output was the measure of most significance. Honda would be delighted with a doubling of production of it’s new engine blocks, yet your mum may be distraught if her mastectomy was scheduled to happen at 10pm on Easter Sunday to achieve this target.  

What these adoptions often fail to capture is the importance of experience in the production of a good. Anyone who has sat on the other side of healthcare as a patient will remember the things that hit home most. That uncomfortable broken seat that you sat on for 4 hours, the vending machine that was out of order, the way your name may have been mispronounced. These are vital experiences that shape our interactions with healthcare, yet cannot be counted in a bean machine. We need the beans, but we should aim for better beans.  

Perhaps medicine needs to look more towards industries that focus instead on experience as well as production. The book “If Disney Ran Your Hospital” started this U turn. It recognises that one element you would least expect is actually at the heart of Disney’s customer mission—safety. Yes, they also can focus on a great experience, but their main focus is actually safety.

Experience, safety and efficiency can, and should, coexist. This is when they thrive. Ultimately, medicine needs to make, adapt, and find its own strategies. We need to aim for the next hospital CEO to proudly announce in his welcome address that “Running a hospital is a bit like, running a hospital.”

Matt Morgan is an Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

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Matt Morgan and Peter Brindley: Everybody’s Free (To Be Kind)

The commencement address that nobody asked for

These two middling authors have long hoped somebody would ask them to deliver a commencement. The fact that this is unjustified has not stopped them from writing one. The following is based upon “Everyone’s Free (to wear sunscreen)”, attributed to Mary Schmich. We encourage everyone to reflect, to refine, and to rebut.

Ladies and gentlemen: be kind. If we could offer only one tip for the future, “kindness” would be it. The long-term benefits of sunscreen may be supported by more scientific evidence, but kindness is required at all times of day and in every medical location. Admittedly, these ideas of “kindness” are based on our own meandering experiences as much as empiric evidence. Regardless, whether doctor or nurse, allied health worker, giddy trainee, or burnout curmudgeon, we humbly dispense this advice.

Enjoy the incredible opportunities to learn, and to grow, even if you feel scared about what is ahead, or are counting the days to blessed retirement. Oh never mind, most of us are too sleep-deprived to truly understand how lucky we are. Trust us, you will look back at how much possibility lay before you and what a unique ride you went on; especially, if your pension still exists and the children still talk to you. You are not the imposter you imagine. You are good enough.

Don’t worry about the future, or if you do worry, know that constant worrying is as effective as trying to reverse terminal illness with CPR. The real troubles in your life are apt to be things that never crossed your distracted mind: Like those things that blindside our trauma patients at 4am on some idle Tuesday. Be grateful and find meaning in just being present. You do make a difference.

Do (more than) one thing every day that challenges you. Speak-up, but also be mindful. Don’t be reckless with other people’s hearts…or lungs or kidneys. Don’t put up with others who are callous or have lost the plot. Don’t waste time on jealousy: Sometimes you’re ahead, sometimes you’re behind, and often you’re underappreciated. Good healthcare professionals are simply good people, and ultimately, you only compete against yourself. Realise that you are more than just your job.

Remember compliments and forgive the insults. If you succeed in doing this, share how you did it. Keep your thank-you letters, and sit on angry emails. Laugh often but not at others expense. Don’t feel guilty if you don’t know what to do next with your career. The most interesting registrars didn’t know at thirty what they wanted to do. Some of the most interesting professors still don’t. Get enough rest. Build teams, and respect senior nurses, you will miss them when they’re gone.

Sometimes you win, sometimes you’ll learn.

Maybe you’ll become a clinical director, maybe you won’t.

Maybe you’ll publish in the New England Journal, probably you won’t.

Maybe you’ll finally tell administration where they can stick it.

Whatever you do, don’t congratulate yourself too much, or berate yourself either. Good choices include lots of dumb luck and teamwork. Bad choices require compassion from others and from yourself.

Enjoy your ability to influence the future. Write. Create. Don’t be afraid of what other people think of your ideas. Your mental dexterity is as important as your procedural dexterity. Accept that people cannot know what you are thinking unless you tell them, but understand nobody will listen unless you are respectful.

Exercise: even if you have nowhere to do it but your own office. Listen as actively as you speak. Celebrate the team even if you did all the work. Read complex journals not just easy tweets and blog posts. Remember that we still need proper science, and it still needs us.

Get to know your patients as people first: they need to know you care. Be nice to your teachers, they are your best link to your past, and they have lived much of your future. Accept that clinical fads will come and go (and come again), but patients will always need doctors and nurses who give a damn. Work hard to bridge the gaps between privileged staff and vulnerable patients. After all, the older you get, the closer you move from bedside to bed. Work in a University Hospital but leave if it makes you aloof. Work in a rural centre, but leave if you stop advocating.

Accept certain inalienable truths: None of us fully embrace changes, “it” is rarely entirely pointless or amazing, and none of us is irreplaceable. When you do retire you will fantasise that when you were young: change was easy, common sense reigned, and you were unique. Say “thank you” and learn the names of the cleaning staff. Be known as the person who delivers tea and empathy. Be a custodian of values not just a janitor. Create a legacy but don’t expect one.

Enjoy diagnostic challenges, but don’t expect patients to be interesting for your benefit. Maybe you will invest your money well, and maybe you will marry well. Regardless, you never know when either one will run out. Don’t tell people to leave you alone because they might do exactly that. Be careful whose advice you co-sign, but be respectful with those who offer it. Advice is an easier drug to prescribe than to swallow…but trust us on the “kindness.”

Acknowledgement: Our wives who support our goals and tolerate our hypocrisy.

Peter Brindley, professor of Critical Care Medicine, Anesthesiology and Pain Medicine, and Health Ethics, University of Alberta, Edmonton, Canada@docpgb

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania 

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Peter Brindley and Matt Morgan: All I want for Christmas…is to slow down

Digital addiction is a real barrier to patient centred care

As another frantic holiday season approaches, we are reminded of the three stages of life: First you believe in Santa, then you don’t believe in Santa, then you are Santa. We are both willing actors in stage-three, and along with this came acceptance of an inconvenient truth: our parents were right all along. We had both spent four decades rolling our collective eyes as our mums delivered the same advice: “Just slow down.” Mum was right of course, mum is always right: right about parenthood, just as right about “doctorhood.”

One of these authors (PB) recently reviewed the book “Distracted Doctoring: Returning to Patient-Centered Care” by Papadakos and Bertman. [1] It offers lessons for both our personal and professional lives that would receive unwavering maternal approval. If you can find time from your other distractions, then you too will be rewarded and admonished in equal order. The book opens by explaining the concept of “digital harm”, and ends by imploring you—and me and us—to simply slow down and to be present. In the medical realm, this book warns cogently about how flesh-and-blood patients have become iPatients. The book also outlines how we are prone, perhaps even wired, to attend to the screen before the human. “Digital addiction” is not only real it is a real barrier to patient centred care. It is also a clear and present danger to our personal lives. Unfortunately, the problem is easier to diagnose than to cure. Moreover, without action it will only get worse.

It is dangerous to outsource deep-thought, to dilute face-to-face contact, and to believe that we can seamlessly multi-task. However, distraction and time pressure has long bedevilled professionals and parents alike. What is novel, and perhaps paradoxical, is the idea that easy-information can promulgate lazy-thinking. In the past, as doctors, we were forced to head to the library, to radiology, and to medical records. Late at night, it was worse still, as we likely had to waylay a security guard. These were major distractions—no doubt about it—but these limits forced us to prioritize, to rationalize, to think, and to think again. Now we reach for the phone in our pocket and our prefrontal cortex is given a bye. Like the holiday season we receive sack loads of stuff, but not necessarily meaning. It may be easy to inhabit “app-y” valley, but it is not without risk.

In the “attentional economy,” engineers and psychologists are actually incentivized to distract us. It is likely that companies and politicians wish to do the same. Regardless, it appears that we get a squirt of dopamine with each electronic diversion. This in turn primes our primate neural circuitry to desire more, and a vicious cycle ensues. Hyperbole aside this means that medical problem-solving and interpersonal relationships are under-siege from pocket dopamine machines. Even if it is not our fault, it is still our responsibility to control our attention. These authors believe we have reached the point where we need to redefine what it means to be a medical professional, an attentive parent, and an empathic partner. We must not use these “weapons of mass distraction” longer than is necessary or helpful. The computer and the phone must be our servant not our master.

We acknowledge that no physician, parent, or partner can know everything, and that we need data that is readily accessible and legible. However, we also believe it is time to see increased screen time as a relative failure, and to move past the specious idea that the computer is automatically mightier than the pen. You are not a Luddite is you forgo the latest in favour of the reliable. Moreover, our technology should pass a new digital test: does this deliver usable information quicker than erstwhile methods, does it encourage better documentation, and does it illuminate rather than obfuscate the human story? Above all, does it help me to focus on what matters most? If it fails these tests then it is not “fit for task.”

These two authors are issuing a Christmas challenge and a New Year’s resolution. During medical rounds—just as with family time—we will leave our phones behind and forego the comforting pocket vibration. We will prepare beforehand and we will read after. We shall maximize time with humans and downgrade the iPatient and iFamily. We will think until it hurts, and we will communicate face-to-face. In short, we will strive to be the doctors and family members that our patients need and our mothers expect. These two Santa-wannabes also wish you the gift of a restorative holiday, a digital reset, and a less distracted 2018.

Peter Brindley, professor of Critical Care Medicine, Anesthesiology and Pain Medicine, and Health Ethics, University of Alberta, Edmonton, Canada@docpgb

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

References:

[1] Distracted Doctoring: Returning to Patient-Centered Care” by Papadakos and Bertman. (publication pending Anesthesia and Analgesia 2018)

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Matt Morgan: WhatsApp Doc?

Restricting the use of WhatsApp is fine, but there must be a viable alternative provided

The pager buzzes in my pocket. It’s lucky I noticed because the battery is nearly dead and the screen display only just visible through the sticky tape holding it together. Next starts the hunt for a phone. I’m walking down an empty corridor on my way to speak to a patient’s family so I pop into the nearest ward only to find all three phones in use. The bleep goes again. I walk in the opposite direction back up the corridor and lean over a reception desk to borrow the first free phone I can find. I call the number displayed on the pager’s screen—engaged. My bleep goes again as the same number flashes up. I call again and this time it is answered.

“Hi, this is Matt one of the ICU consultants” I say.

Silence.

“Um, ok. How can I help you?” says the perplexed voice on the other side.

“Someone paged me.”

“Oh, I’m not sure who that was, hold on . . .”

I hear a sound of the receiver being bumped around on the desk as a conversation between doctors is audible in the background.

“ANYONE PAGED ICU!?” shouts a voice.

“YES! It was me, give me a minute I’m just dealing with a patient” I hear.

A few minutes pass.

“Hi Matt, the family of bed 3 have arrived. They said they were due to speak to you five minutes ago.”

“I’m on my way . . .” I say.

I retrace my steps along the corridor to speak to that same family that I was originally walking towards five minutes ago.

In my pocket, I have a device one million times more powerful than the computers that delivered the Apollo moon landing. On this device is a piece of software with encryption that the CIA are unable to crack—WhatsApp. A recent paper has shown that over one third of doctors have used mobile software to share confidential clinical information. A simple question about the use of WhatsApp in the NHS posed on Twitter by our very own David Oliver spawned over 500 replies within twelve hours such is the gap in a service that allows quality, confidential transfer of information within a healthcare setting.

There are huge incremental benefits to using current technological solutions including WhatsApp and other commercial platforms. They all also bring important risks. Although end-to-end encryption allows message content to remain secure in transit, unlocked devices may still allow information leak. This is a risk equally present using the current ratified means. My NHS email is similarly secure in transit, but not if I leave my computer turned-on when I go to the toilet. In fact, the commonly used security method of writing hospital username and passwords underneath a keyboard can hardly compare with fingerprint access to my iPhone. All communication means have risks, and must be matched to benefits and viable alternatives.

The advice from the NHS is clear. Do not use WhatsApp to transfer confidential information. However, there seems to be a growing tension between patient safety and patient confidentiality. The doctors who use WhatsApp do so to improve communication and deliver better healthcare. In my day job, I use fax machines, Windows 98, 1980s pagers, and landlines. As I cross the hospital exit, I use mobile data, WhatsApp, secure banking apps, and iPads. It is right and proper for the NHS to recognise the risks in these technologies, but they also need to recognise the risks of sticking with the status quo. Restricting their use is fine but there must be a viable alternative provided. Until then people will continue to use fax machines on open wards, paper lists that fall out of the pocket, and conversations in corridors that can be readily overheard. These come with similar if not greater risks. It would be useful to embrace incremental benefits whilst working towards perfection.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

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Matt Morgan: Poor hospital design has an impact on staff, patients, and healthcare

Simply the presence of a good physical environment signals organisational respect and care

I try my best to indoctrinate my children into liking the things that I do. This is of course doomed to fail, which is a good thing. Thus far tastes in food, music, and books can be added to the “Dad you are so embarrassing” list. However, one thing we all can agree on as a family is Mr Bean. Whilst watching the 25-year-old series recently, it struck me how dated the physical environment and everyday objects appeared. The cars looked unrecognisably ancient, as did the clothes, the street signs, and even the food. The muffins were small and shrivelled and the coffee was all instant. However, there was one scene that didn’t look at all dated. In one particular episode, Mr Bean attends the local emergency department after getting his hand stuck in a kettle. The physical layout of the department, the colour scheme, the signage, and even the technology all looked remarkably familiar. It could have been filmed in many NHS hospitals in 2017.

Many hospitals in which I have worked have struggled with finances over the last 5 years. There has often been a ban on capital investment on new physical infrastructure projects even extended to repairs in some circumstances. Only spending on direct patient care was permitted. However, divorcing the environment from care is fundamentally flawed. The physical environment has been shown to influence not only behaviour, but also physical and mental wellbeing.

One hospital in which I have worked has a large, bowl-like commercial area filled with shops, staff, patients, and the occasional pigeon. Access from this bustling area to the entirety of the hospital is via a single, narrow, small corridor. At the start of this corridor is of course a steep flight of stairs. After this first obstacle, the thin corridor continues with multiple sharp exits on both the right and lefthand sides. Patients with walking frames, sticks, and wheelchairs bump into staff rushing to clinics, wards, and meetings. People stop suddenly mid-stride as they look for directions on the walls. They zig-zag across the corridor, in and out of doors.

I am unsure if the architect had ever stepped into a hospital or encountered an ill person before they considered this design as a good idea. With the inability to move in anything but a single file, I often think that installing traffic lights may help ease the daily congestion. Combine this with a lift system that is prone to malfunction then late arrivals at outpatients, delays in theatre start times, and problematic patient movement is a certainty. And don’t get me started on car parking.

I do understand the emphasis on prioritising spending on direct patient care. Each of us goes to work with patient care at the heart of our concerns. Delivering excellent patient care however depends on a lot of factors. Having safe, healthy, motivated staff is one essential piece of this puzzle. Even the design of an office building impacts directly on our health. “Sick building syndrome” was described in the same year as the first Mr Bean series in 1991. It relates poor design with increased levels of employee sickness, physical ill health, and lower job satisfaction. Combine these findings with a physical infrastructure designed to treat patients and deliver healthcare care then the implications are more profound.

One of the greatest improvements in my professional life that has led to increased job satisfaction over the last 12 months has been the installation of a new hospital canteen. Having well cooked, healthy, hot food, served in a nice environment goes a long way to help staff and patient morale. This is even the case if I cannot actually get there to eat. Simply the presence of a good physical environment signals organisational respect and care. Ultimately the reason we all go to work is to help patients. I hope that financial planners and healthcare organisations recognise the impact that the physical environment has on staff, on patients and on healthcare.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

from Matt Morgan – The BMJ http://ift.tt/2hz5npJ