empathy, n.
Pronunciation: /ˈɛmpəθɪ/
The power of projecting one's personality into (and so fully comprehending) the object of contemplation.
Definition from the Oxford English Dictionary
Following on from my recent quality improvement blog, I've been thinking a lot about patient centredness and what patient centred care really means. I stated (probably more than was strictly necessary) that I believed that so long as we aimed to provide high quality patient care, quality improvement would naturally occur. I also used a definition of quality which included the term patient centred. I think, therefore, that it is pretty important to reflect on what patient centredness actually is.
I don't actually think patient centred care is a difficult concept. It's all about providing care which focuses on the patient and what they both want and need. What is trickier is working out how to go about actually doing this.
At this point, I'd like to share a favourite video of mine. It's from the Cleveland Clinic in Ohio and, like many things I am likely to blog about, I was first shown it during my MSc teaching. It is slightly "American" in tone, so for those of you who feel you'd prefer a "British" alternative, there is a very similar version produced by Wrightington, Wigan and Leigh NHS Foundation Trust. Both videos end with a quote: "If you knew how they felt, would you treat them differently?".
I don't know who first said "Everyone you meet is fighting a battle you know nothing about. Be kind, always" - it's been attributed to so many people, from Plato to the Dalai Lama. Regardless, I think it sums up the essence of those videos nicely. It is all too easy see a patient's illness in isolation, without considering what else may be happening in someones life. If you don't at least attempt to understand an illness in the context of a patient's wider life, how can you even attempt to work out what they want and need from their healthcare interaction?
I think that really, empathy is what patient-centred care is all about. The most important person in any healthcare setting is the patient. Empathy is a crucial quality for any healthcare professional to possess. Without it, ascertaining what a patient wants and needs (and therefore providing patient centred care) becomes almost impossible.
I'll end this post with a challenge: next time you're about to get frustrated with a patient who has turned up late to an appointment or not taken their medications as directed, just stop and think about what else could be going on in their lives.
Friday, 22 November 2013
Thursday, 17 October 2013
QI
The two letter acronym QI may refer to several things. One is a television quiz show hosted by a personal hero of mine, Stephen Fry. In this context, QI stands for "quite interesting". In a context closer to my heart, it also stands for "quality improvement".
I was first introduced formally to the concept of quality improvement during my MSc module on "Organising and Delivering High Quality Care", where the motivational and enigmatic Prof Mitch Blair and Dr Bob Klaber (and several of their colleagues) gave us an overview of the concept. Quality Improvement very much does what it says on the tin. It's all about facilitating anything which improves quality. In a healthcare setting (my main focus as that is where I work), this is about ensuring high quality care for all patients. "High quality" may sound a bit fluffy and I was challenged when I suggested at the recent Faculty of Medical Leadership and Management conference that all that we do as healthcare professionals should be underpinned by a desire to provide high quality patient care; it was suggested that we ought to actually focus on delivery of safe care. For clarification, when I refer to the concept of quality in healthcare, I refer to the definition proposed by Don Berwick from the Institute for Healthcare Improvement in the States. He describes high quality care as that which is "safe, effective, patient-centred, timely, efficient, and equitable". As a doctor working in the NHS, that seems like as good a definition as any, and given that it was proposed by one of the world experts in patient safety, I feel relatively justified in saying that providing high quality patient care is not at odds with providing safe patient care!
A worry of mine at the moment is that QI in some establishments is not driven by the desire to improve care. This may sound odd - surely if someone is carrying out a QI project then by definition they wish to improve quality of care? Unfortunately, I fear there is a very real danger that, much like audit (and, to a lesser extent, research), doctors in training see it solely as a tick box exercise which is carried out purely for CV-boosting purposes. I am not alone in holding this concern. I have asked several of my senior colleagues why they feel there is so little drive towards QI amongst my contemporaries, and they have all given me similar replies - we aren't in a competitive deanery, so people don't feel they need to undertake these CV-boosting tasks. To me, this completely misses the point. As healthcare professionals, our motivation should not be solely to get our next job or to pass our ARCP as painlessly as possible. We should be motivated by a desire to provide high quality patient care.
Let's not forget why we went into medicine in the first place - we (mostly) went into this field for the patients. They must still be our focus. Ward rounds, clinics, GPs, ED... They're all there with the aim of providing patient care.
We should *want* to continually improve care, not only to boost our own CVs, but because if providing the best possible care to our patients no longer drives us, we probably need to start thinking about a change of career!
**addendum** It has been pointed out to me that the definition of quality I quoted comes from the Institute of Medicine; this was modified by the IHI when creating their own goals. Apologies for any confusion caused.
I was first introduced formally to the concept of quality improvement during my MSc module on "Organising and Delivering High Quality Care", where the motivational and enigmatic Prof Mitch Blair and Dr Bob Klaber (and several of their colleagues) gave us an overview of the concept. Quality Improvement very much does what it says on the tin. It's all about facilitating anything which improves quality. In a healthcare setting (my main focus as that is where I work), this is about ensuring high quality care for all patients. "High quality" may sound a bit fluffy and I was challenged when I suggested at the recent Faculty of Medical Leadership and Management conference that all that we do as healthcare professionals should be underpinned by a desire to provide high quality patient care; it was suggested that we ought to actually focus on delivery of safe care. For clarification, when I refer to the concept of quality in healthcare, I refer to the definition proposed by Don Berwick from the Institute for Healthcare Improvement in the States. He describes high quality care as that which is "safe, effective, patient-centred, timely, efficient, and equitable". As a doctor working in the NHS, that seems like as good a definition as any, and given that it was proposed by one of the world experts in patient safety, I feel relatively justified in saying that providing high quality patient care is not at odds with providing safe patient care!
A worry of mine at the moment is that QI in some establishments is not driven by the desire to improve care. This may sound odd - surely if someone is carrying out a QI project then by definition they wish to improve quality of care? Unfortunately, I fear there is a very real danger that, much like audit (and, to a lesser extent, research), doctors in training see it solely as a tick box exercise which is carried out purely for CV-boosting purposes. I am not alone in holding this concern. I have asked several of my senior colleagues why they feel there is so little drive towards QI amongst my contemporaries, and they have all given me similar replies - we aren't in a competitive deanery, so people don't feel they need to undertake these CV-boosting tasks. To me, this completely misses the point. As healthcare professionals, our motivation should not be solely to get our next job or to pass our ARCP as painlessly as possible. We should be motivated by a desire to provide high quality patient care.
Let's not forget why we went into medicine in the first place - we (mostly) went into this field for the patients. They must still be our focus. Ward rounds, clinics, GPs, ED... They're all there with the aim of providing patient care.
We should *want* to continually improve care, not only to boost our own CVs, but because if providing the best possible care to our patients no longer drives us, we probably need to start thinking about a change of career!
**addendum** It has been pointed out to me that the definition of quality I quoted comes from the Institute of Medicine; this was modified by the IHI when creating their own goals. Apologies for any confusion caused.
Tuesday, 6 August 2013
FY1 in blog form!
How time flies - I have just got home from my last shift as an FY1! As I mentioned earlier,
I was one of the poor sods who started on nights. This seems to be a
pattern for me - as I started my second job on nights too, and tomorrow I
start my first FY2 job on nights... Despite this run of frankly
appalling luck in the rota department (I also did long day Christmas day
and nights over New Year), I have had a pretty good year. I have no doubt that newly qualified doctors up and down the country are now anxiously preparing for starting work tomorrow, so I thought I'd write down a few survival tips which I've found useful.
In no particular order, my #tipsfornewdocs
- Ask where things are early on. In a difficult/stressful situation with a sick patient, you don't want to be running around like a headless chicken trying to locate the ECG machine/resus trolley/cannulating equipment etc. Hopefully all of the new FY1s will have done some shadowing on the wards they will be working on so should know this, but for future jobs, find out where all useful things are as soon as you possibly can.
- When a consultant/registrar asks you to request an investigation, clarify exactly what they are looking for. You are unlikely to convince radiology to perform a CT scan unless you have a very good reason - and "my consultant asked for it" is not a good reason!
- If inserting a new cannula or taking a gentamicin level at 5am, check whether the patient is due any other bloods in the morning - they'll thank you for taking them off at the same time and avoiding them being stabbed a second time!
- Find time to eat/drink. You may think you're being efficient by working through lunch but if you then end up fainting and having to go home or being admitted to hospital with urosepsis (and yes, those things have happened to F1s I know) things will be a whole lot more behind than if you'd just taken 20 minutes to have a sandwich and a coffee.
- Keep up with your friends and maintain a social life. Sometimes rotas will mean you don't see friends for months at a time, and working nights and weekends means you'll have to turn down invitations to nights out. Make an effort to socialise when you can. Whilst I wouldn't advocate getting horrifically drunk the night before a shift, popping out for an hour or two rather than missing out entirely may just keep you sane.
- Invest in some decent curtains. There is nothing worse than being exhausted between night shifts but not being able to sleep because it's too bright.
- Be nice to the nurses. Sometimes you won't see eye to eye on things, but be polite and friendly anyway. They're the ones who can make your life a misery if they so choose! Also, they're often very experienced and will have a good idea of what particular consultants like doing in certain situations, so befriend them and listen to their suggestions.
- Feed people. Specifically, your senior colleagues. If you become known for bringing in cupcakes or sweets on a regular basis, people tend to look more favourably upon you.
- If you are asking for an urgent review from another specialty, saying you're phoning on behalf of Prof/Dr/Mr Consultant gets you taken a whole lot more seriously than just saying you're the FY1 (once resulted in the grumpy neuro reg sending his consultant to review someone in 20 minutes).
I'm sure I'll think of many more - feel free to leave other suggestions as comments and I'll edit this and add them in (with credit to the author).
Best of luck to everyone in their new jobs tomorrow, but especially the new FY1s - you'll be great!
In no particular order, my #tipsfornewdocs
- Ask where things are early on. In a difficult/stressful situation with a sick patient, you don't want to be running around like a headless chicken trying to locate the ECG machine/resus trolley/cannulating equipment etc. Hopefully all of the new FY1s will have done some shadowing on the wards they will be working on so should know this, but for future jobs, find out where all useful things are as soon as you possibly can.
- When a consultant/registrar asks you to request an investigation, clarify exactly what they are looking for. You are unlikely to convince radiology to perform a CT scan unless you have a very good reason - and "my consultant asked for it" is not a good reason!
- If inserting a new cannula or taking a gentamicin level at 5am, check whether the patient is due any other bloods in the morning - they'll thank you for taking them off at the same time and avoiding them being stabbed a second time!
- Find time to eat/drink. You may think you're being efficient by working through lunch but if you then end up fainting and having to go home or being admitted to hospital with urosepsis (and yes, those things have happened to F1s I know) things will be a whole lot more behind than if you'd just taken 20 minutes to have a sandwich and a coffee.
- Keep up with your friends and maintain a social life. Sometimes rotas will mean you don't see friends for months at a time, and working nights and weekends means you'll have to turn down invitations to nights out. Make an effort to socialise when you can. Whilst I wouldn't advocate getting horrifically drunk the night before a shift, popping out for an hour or two rather than missing out entirely may just keep you sane.
- Invest in some decent curtains. There is nothing worse than being exhausted between night shifts but not being able to sleep because it's too bright.
- Be nice to the nurses. Sometimes you won't see eye to eye on things, but be polite and friendly anyway. They're the ones who can make your life a misery if they so choose! Also, they're often very experienced and will have a good idea of what particular consultants like doing in certain situations, so befriend them and listen to their suggestions.
- Feed people. Specifically, your senior colleagues. If you become known for bringing in cupcakes or sweets on a regular basis, people tend to look more favourably upon you.
- If you are asking for an urgent review from another specialty, saying you're phoning on behalf of Prof/Dr/Mr Consultant gets you taken a whole lot more seriously than just saying you're the FY1 (once resulted in the grumpy neuro reg sending his consultant to review someone in 20 minutes).
I'm sure I'll think of many more - feel free to leave other suggestions as comments and I'll edit this and add them in (with credit to the author).
Best of luck to everyone in their new jobs tomorrow, but especially the new FY1s - you'll be great!
Sunday, 23 June 2013
The Impact Factor
As a budding academic, I hear all too often about the importance of the 'impact factor'; that is, how likely articles from a journal are to be referenced in a later article. It's a somewhat controversial measure of how "good" a journal is, but the journals with the biggest reputations (eg Science, Nature) do seem to have the highest impact factors anyway. Frankly, at my stage, I'm still happy enough if anyone seems interested in publishing something I've been involved in writing so it doesn't particularly bother me if the impact factor is 0.01, but no doubt if things progress then at some point I'll probably have to start choosing to submit to higher impact journals.
Despite just writing a paragraph about it, this blog entry wasn't meant to be about the impact of journals and articles. It was about the impact we have on patients. Sometimes, I think it's easy to get wrapped up in the numbers and figures. A busy day of surgical receiving becomes 4 query appendicitis, 6 diverticulitis, a renal colic, the stab wound in A&E and 3 from GP still to be seen. Another 5 blood results awaited, 3 abdominal films to chase and would radiology please hurry up and report that CT scan. Yes, we care about our patients deeply, but sometimes what we do becomes so routine that we may forget that although this is our 24th acute abdomen, for the patient it's the first time in hospital or the most terrifying thing they've ever experienced. Even for those patients who we see regularly - the chronic pancreatitis after another alcohol binge, the poorly controlled Crohn's disease desperate to avoid a stoma - their interaction with the health service is likely to have a significantly greater impact on them than it does on us.
I was recently in a bar with a colleague when a lady approached us. "I know you" she said to him. He looked momentarily embarrassed and I assumed he had no idea who she was. Her next sentence took me (although I suspect not him) by surprise. "You're the doctor who saved my husband's life". I didn't go into details with him about what had happened, but it was clear that in the course of going about his daily work he had made a huge difference to this family (and, I suspect, many others). She was very pleasant, updated him with how things were, wished us a good night (and said it was great to see that doctors were humans who you saw drinking in pubs in town like normal people - but that's definitely a different topic...) and went on her way. I was surprised by how very uncomfortable my colleague seemed with this. He muttered something about "just doing my job" to me and returned to his pint.
The "just a job" attitude is an incredibly difficult one to get right. After more and more guidelines about what we can say on Twitter or the photos we shouldn't put on Facebook, many doctors have become fed up with the constant attempts to control our out of work lives. This has resulted in many of us (myself included) taking the staunch position of "it's only a job". I don't think that this is wrong. I go to work, do my job and hopefully do it well, and then I go home to the kind of social life I choose. I don't believe that drinking more than my recommended alcohol intake or (god forbid) having a cheeky cigarette makes me less competent at what I do. Where this attitude falls down, though, is that it makes us more likely to forget how important what we do is. We're privileged enough to be involved in some of the most important times of families' lives. Let's not forget the impact each of our interactions will have on a patient and their loved ones.
Sunday, 7 April 2013
2 Out Of 3 Ain't Bad...
Or so Meatloaf would have us believe.
Despite what my blog would have you believe, I have actually really enjoyed my first 8 months of working.
My first job, which was in medicine, was tough as there wasn't a lot of senior support and out of hours there was sometimes noone to call other than the consultant if I had concerns - something quite intimidating for a newly qualified junior. However, I worked with mostly lovely people, learned absolutely loads and felt like I really developed as a doctor.
My second job (the one I finished last week) was also medical, and was fantastic. There were a few issues, mostly with other juniors not pulling their weight, but that aside I loved it. I got on especially well with one of the registrars and 2 of the SHOs, but all of my seniors were fantastic. Again, I learned lots and am definitely much more confident in my abilities than I was before I started. I also had chance to get involved with some research, which is great given my academic ambitions.
And now, I have most to general surgery. Eugh. Despite not wanting to be a surgeon, I had thought I would enjoy this rotation. Numerous friends who are medics through and through had told me how much they'd loved their FY1 surgical post. I don't think I will be jumping on that bandwagon though.
A few months ago, I was chatting on Twitter about how I felt I needed to revise some surgery, as after 8 months working in medicine I was a bit rusty. A surgeon on there, who I get on with pretty well, had said I didn't need to know any surgery. I totally unintentionally upset him but saying that I wanted to be able to suggest differentials for emergency admissions so I could order appropriate investigations. I was genuinely confused when he was so angered by my comment that surely I ought to be ordering targetted investigations to confirm or refute a diagnosis and not just going on a fishing trip for information. After all, that's what we were repeatedly taught throughout medical school and it was definitely the case in my medical jobs. It appears that things are slightly different in the surgical world. At induction for this job, we were told that everyone gets the same set of tests ordered and we shouldn't try to work out which were indicated and which weren't - and then I realised that my comment on Twitter had unwittingly criticised the way huge numbers of surgeons expect their juniors to behave (and by implication, criticised them I suppose). It's a big change in the way I think.
I am struggling with the mindlessness involved in this job. A few days in, and I have already discovered that "chase the bloods" literally means "write the results down in a folder". In my previous jobs, I would have been criticised for not acting on results. Now, I'm not expected to act on anything. Yesterday I was chastised for prescribing further NaCl for a patient who had already received several bags. No-one cared that my reason for doing so was that the patient was (still) borderline hyponatraemic and I had checked the blood results before deciding which fluids to write up. It seems I shouldn't try to use my brain, I should just write everyone up for Hartmans, Hartmans, Hartmans.
Of course, there is the distinct possibility that my seniors are just being super-cautious because I have only just started working there. Maybe I will discover that, actually, I am quite happy doing this repetitive kind of work once I adjust to the change. I could settle in and find that actually I love my new job. If not, I've enjoyed 2 of my 3 FY1 jobs. And 2 out of 3 ain't bad.
Despite what my blog would have you believe, I have actually really enjoyed my first 8 months of working.
My first job, which was in medicine, was tough as there wasn't a lot of senior support and out of hours there was sometimes noone to call other than the consultant if I had concerns - something quite intimidating for a newly qualified junior. However, I worked with mostly lovely people, learned absolutely loads and felt like I really developed as a doctor.
My second job (the one I finished last week) was also medical, and was fantastic. There were a few issues, mostly with other juniors not pulling their weight, but that aside I loved it. I got on especially well with one of the registrars and 2 of the SHOs, but all of my seniors were fantastic. Again, I learned lots and am definitely much more confident in my abilities than I was before I started. I also had chance to get involved with some research, which is great given my academic ambitions.
And now, I have most to general surgery. Eugh. Despite not wanting to be a surgeon, I had thought I would enjoy this rotation. Numerous friends who are medics through and through had told me how much they'd loved their FY1 surgical post. I don't think I will be jumping on that bandwagon though.
A few months ago, I was chatting on Twitter about how I felt I needed to revise some surgery, as after 8 months working in medicine I was a bit rusty. A surgeon on there, who I get on with pretty well, had said I didn't need to know any surgery. I totally unintentionally upset him but saying that I wanted to be able to suggest differentials for emergency admissions so I could order appropriate investigations. I was genuinely confused when he was so angered by my comment that surely I ought to be ordering targetted investigations to confirm or refute a diagnosis and not just going on a fishing trip for information. After all, that's what we were repeatedly taught throughout medical school and it was definitely the case in my medical jobs. It appears that things are slightly different in the surgical world. At induction for this job, we were told that everyone gets the same set of tests ordered and we shouldn't try to work out which were indicated and which weren't - and then I realised that my comment on Twitter had unwittingly criticised the way huge numbers of surgeons expect their juniors to behave (and by implication, criticised them I suppose). It's a big change in the way I think.
I am struggling with the mindlessness involved in this job. A few days in, and I have already discovered that "chase the bloods" literally means "write the results down in a folder". In my previous jobs, I would have been criticised for not acting on results. Now, I'm not expected to act on anything. Yesterday I was chastised for prescribing further NaCl for a patient who had already received several bags. No-one cared that my reason for doing so was that the patient was (still) borderline hyponatraemic and I had checked the blood results before deciding which fluids to write up. It seems I shouldn't try to use my brain, I should just write everyone up for Hartmans, Hartmans, Hartmans.
Of course, there is the distinct possibility that my seniors are just being super-cautious because I have only just started working there. Maybe I will discover that, actually, I am quite happy doing this repetitive kind of work once I adjust to the change. I could settle in and find that actually I love my new job. If not, I've enjoyed 2 of my 3 FY1 jobs. And 2 out of 3 ain't bad.
Sunday, 24 February 2013
Workingman's Blues
"You can hang back or fight your best on the front line
Sing a little bit of these workingman's blues"
Ok, so technically I'm a working woman rather than a working man, but I like to think that "man" can be considered to mean "man or woman" in those lyrics.
Working is tough, really tough. I didn't go into medicine completely blind. I've worked at least part time pretty much constantly since I turned 16. I've done my fair share of menial jobs and I'm not unaccustomed to 13 hour shifts or 80+ hour weeks. I suppose, then, I was naive when I thought that that would have prepared me somewhat for the life of a junior doctor.
I was raised with a pretty strong work ethic. My parents drilled the "if you want nice things you need to work hard for them" mantra into me from the moment I was old enough to know what it meant, or possibly before. I distinctly remember my Dad being off sick from work when I was about 4. He hasn't had a sick day since; if he can get out of bed, he goes to work. Even in my £3 an hour job when I was 16, I was aware that I was being paid to do something and therefore I ought to do it properly.
All of this has contributed to my utter shock that some days I really struggle to cope with working. It isn't the job - that's pretty straightforward although it can be busy. It isn't really the people - my seniors are generally very supportive. It's me. I cannot escape the feeling that I make an absolutely terrible doctor. I accept that all juniors feel pretty rotten about their ability at some time or other, but this is totally consuming my mind. I can't escape the feeling that I'm utterly useless. The slightest criticism leaves me close to tears and I'm deaf to any praise or compliments I receive. Even if I'm not terrible right now, it's probably a self-fulfilling prophecy that if I believe I'm awful, I'll slip into despondency, stop trying and really be dreadful.
I'd better start working harder. Not at my job. But at my self esteem. And I'm that only one who can do that.
Sing a little bit of these workingman's blues"
Ok, so technically I'm a working woman rather than a working man, but I like to think that "man" can be considered to mean "man or woman" in those lyrics.
Working is tough, really tough. I didn't go into medicine completely blind. I've worked at least part time pretty much constantly since I turned 16. I've done my fair share of menial jobs and I'm not unaccustomed to 13 hour shifts or 80+ hour weeks. I suppose, then, I was naive when I thought that that would have prepared me somewhat for the life of a junior doctor.
I was raised with a pretty strong work ethic. My parents drilled the "if you want nice things you need to work hard for them" mantra into me from the moment I was old enough to know what it meant, or possibly before. I distinctly remember my Dad being off sick from work when I was about 4. He hasn't had a sick day since; if he can get out of bed, he goes to work. Even in my £3 an hour job when I was 16, I was aware that I was being paid to do something and therefore I ought to do it properly.
All of this has contributed to my utter shock that some days I really struggle to cope with working. It isn't the job - that's pretty straightforward although it can be busy. It isn't really the people - my seniors are generally very supportive. It's me. I cannot escape the feeling that I make an absolutely terrible doctor. I accept that all juniors feel pretty rotten about their ability at some time or other, but this is totally consuming my mind. I can't escape the feeling that I'm utterly useless. The slightest criticism leaves me close to tears and I'm deaf to any praise or compliments I receive. Even if I'm not terrible right now, it's probably a self-fulfilling prophecy that if I believe I'm awful, I'll slip into despondency, stop trying and really be dreadful.
I'd better start working harder. Not at my job. But at my self esteem. And I'm that only one who can do that.
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