Doctors who question and teach us.
(1) The practice of medicine has changed in recent years as described by Atul Gawande. Briefly describe this change and what he proposes to do to make the practice of medicine work better.
Atul Gawande is a surgeon, writer, and public health researcher (1) who talks how medicine has changed over the years and he expresses what he believes would make the practice of medicine better.
Back in the day in the 1920s, medicine and the practice of medicine made no difference to the patients life expectancy (2). Nowadays we have so many different medical treatments for each individual condition and although doctors are certainly more knowledgeable and more specialised than before, there is still much more to discover, learn and improve the lives of patients.
As Atul mentioned, there is evidence that patients are not receiving the required care they need, even nurses have reported poor or fair quality of care, and it is unacceptable that this still occurs today.(3) Patients should not have to die unnecessarily due to poor quality. It is not unusual to find articles about the poor care in the NHS. (4,5,6)
In the talk Atul mentions “we need pit crews for patients”, a team to work cohesively to treat the patient. We need to be able to combine skills of several team members towards success, not just several specialised practitioners, that is not enough. At the end of the day if these highly skilled professionals cannot communicate, understand and work in partnership, it is not possible to complete the tasks at hand.
To reduce deaths in surgery, Atul worked with the World Health Organisation (WHO) on their campaign “Safe Surgery Saves Lives” to find ways that mortality associated with surgery could be reduced. (7) The obvious was to give more training, provide the best technology and specialisation. However there still lacked something to really see improvements in reducing death rates. While looking at the differences between high risk industries and the medical practice, one things that medical care did not have was a checklist. The purpose of a checklist is to minimise failure by ensuring that all tasks are completed and with consistency. WHO decided to apply this tool in different hospitals around the world and saw a considerable amount of deaths reduced, that is by 47% and complications were also reduced by 37%.
Particularly in surgery, there often will be times of intense pressure which can lead to making the wrong decisions, even the smallest mishap can result in disastrous consequences. Checklists are useful because they help surgeons by allowing problems to be identified before hand, problems during and make sure they remember every step. These checklists, although simple can save many lives, evident in the success rate already. (8)
Though, this is not just a simple task. Many people in the medical profession have fixed mindset. In another talk by Matthew Syed, he discusses how common it is for people who work in healthcare to not extend on their talents by improving on themselves which involves identifying failures – many doctors find this difficult to admit and discuss openly. It is not easy for some to come to terms with the fact that the medical system is not good enough to meet patient needs. Furthermore, to go forward with this new method, it requires leadership – to keep everyone on the right track, strong teamwork – where each person is clear on what their role is; enthusiasm – if members view the checklist as a chore, it will be difficult to involve themselves fully in the scheme; and most importantly a positive attitude to learning and engaging in the new tool. Training will be key and there will be good results as the system is put into action around the world.
By identifying failure, solutions can be composed and if this tool can be executed. This is why it is so crucial to give doctors the capacity to discuss failures and have a more open mind to their growth of knowledge, only then, will it be possible to allow checklists to be used globally.
(2) Summarise the talk by Ben Goldacre and propose plausible solutions to the problems he describes that you think he would agree with. What would be necessary to get negative clinical trial results published? Describe why Goldacre felt misled by the published information about reboxitine and why this sort of thing is not a rare occurrence.
Ben Goldacre talks about the publication bias which is involved in medicine and other academic fields today. Ben wants to make it easier for people to be able to publish negative results in public to encourage transparency and make information more accessible.
In 1980, a drug lorcainide, an antiarrhythmic drug was used in clinical trials, 10 of the 50 patients who had the drug died and 1 of the 50 who had the placebo died. They ceased its development after concluding is failure as drug but the data from the trial was not published. The following 10 years had other companies developing antiarrhythmic drugs which was widely prescribed and because the trial of lorcainide was never published, these years saw 100,000 people die. This could have been avoided if that one trial was published.
Antidepressants is another type of drug that is commonly used today. Ben was prescribed reboxetine and found data published to state that this drug was similar to taking any other antidepressant. Digging deeper however, led to him finding further trials of which 6 were negative and never published. These trials contained information which exposed reboxetine as a worse off drug. Ben was right to have felt misled. The information available to the public told one story but the information that took more work to discover, revealed that it was the total opposite. The information available did not reflect the full extend of the trial (9) , but why is nobody held accountable for this?Depression is a serious mental illness and to withhold information from doctors and patients can prevent them from getting the best treatment or even worse suffer from severe side effects due to undisclosed information. How can people trust in pharmaceutical companies who lead these clinical trials and sell to the public when they cannot be fully transparent with the information they have. Perhaps it is not the best idea to publish all information from clinical trials including negative results, particularly if the public are able to access it. Being able to view such data may reduce patient compliance to their medication. Fear can arise in the public, and even though people do realise side effects can occur, a mass of negative results from clinical trials will cause patients to abandon the medication completely. Why would they risk the negative effects? On the other hand it is crucial for negative results to be published so that deaths from the antiarrhythmic drugs can be avoided. Medical staff would have more knowledge on drugs, the possible complications and be prepared to deal with it if necessary. It is unethical to keep this from people working and under the care of health organisations. Furthermore it is an educational tool to help others conducting clinical trials, and pharmaceutical companies to improve and develop better drugs.
There is a serious problem on publication bias, and it is known that positive trials (favourable results) are 2 times as likely to be published as negative findings. (9) Companies go as far as manipulating results by asking misleading questions which in their favour creates good results (10) Even finding information through the Freedom of Information Act, for Tamiflu resulted in a load of different results and not even being able to access the clinical study reports which is usual for negative data. (11)
Now the FDA Amendment Act requests all trials conducted after 2008 to be published, which is
ridiculous to practice medicine based on trials only conducted a few years ago when we have so much information of older trials and more recent ones withheld because there is no legislation to force people to do so. Due to the fact that there is no law holding these companies accountable for their responsibility in publishing such data they feel no need to publish. It’s unethical to leave patients and doctors in the dark and suffer the consequences of unpublished data. There needs to be a system where it is the law to register a trial and publish all information regarding that trial without fail. If punishment was made clear to those who do not publish this information then companies will start to publish all data, otherwise they will not do it. WHO has made a statement for all clinical trials to be published in the present and past however they cannot take legal action to make this happen so it is down to the healthcare industry to appeal for this to happen.
(3) Summarise the talk by Siddhartha Mukherjee. Explain, with evidence from the talk, your views about whether you agree or disagree with his view about the future of medicine.
Siddhartha Mukherjee is an author, editor, assistant professor of medicine at Columbia University, a cancer physician and researcher. (http://siddharthamukherjee.com/about-siddhartha/) He talks about the simple model for illness and treatment and summarises in six words: have disease, take pill, kill something. This applied particularly to antibiotics. The discovery of antibiotics was a revolution, a once life threatening disease could be cured by a taking a pill and science has attempted to replicate this model of a “lock and key” over the past hundred years for non infectious disease. He also mentions how only 0.025% of all chemical reactions are targeted in this lock and key model. He discusses how the natural world is organised in hierarchically upwards. From a cell to tissues to organs and ultimately a human – he suggests that this is an alternative way of applying our thinking in medicine.
http://www.eurostemcell.org/what-diseases-and-conditions-can-be-treated-stem-cells
https://www.worldhealth.net/news/are-stem-cells-future-medicine/
http://www.lifeextension.com/Magazine/2006/12/awsi/Page-01
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744935/
https://www.nature.com/news/stem-cells-take-root-in-drug-development-1.10713
https://www.nature.com/nature/journal/v441/n7097/full/nature04960.html
In theory, there’s no limit to the types of diseases that could be treated with stem cell research. Given that researchers may be able to study all cell types via embryonic stem cells, they have the potential to make breakthroughs in any disease. (https://www.cirm.ca.gov/patients/power-stem-cells)
(4) A and E doctors have very challenging jobs. What are your views about Brian Goldman’s talk? Why do healthcare professionals find it so difficult to talk about their mistakes? What can be done to address the issues that Goldman discusses within the wider healthcare professions?
Brian Goldman shares his experience in practice and how his mistakes affected him as a doctor. Doctors are not able to communicate their failures because they work in an environment that indulges in the blame culture and as a result they hold back important information, and hinder their growth in their profession.
We get so caught up in the idea that doctors are like superheroes and can do everything that we forget they are also human and that mistakes can occur. People expect so much from those in the medical department that there is so much pressure to not fail and when they do fail, they cannot accept the responsibility due to the attitude of healthcare organisations.
Over the course of his profession Brian made many mistakes. His first was sending a patient home too early. She returned, but this time she was near death and she did die unfortunately. Brian was ashamed, he felt “alone” and “isolated”. Unable to speak to his colleagues about his mistakes, he beat himself over the woman who died. There were many other situations where he felt ashamed and was unable to talk to anyone and the sad thing is he’s not the only one. https://www.rd.com/health/healthcare/doctors-confess-their-fatal-mistakes/
Between 2000 and 2003 there were 3 doctors prosecuted due to medical negligence. http://careers.bmj.com/careers/advice/Should_doctors_always_admit_mistakes%3F While taking legal action may help a patient get the justice they need, this is a reason why doctors find it so difficult to report their mistakes. Not only that they fear facing the criticism from others, the punishment and other consequences. This results in naming and shaming, underreporting of data and undermines patient safety. http://careers.bmj.com/careers/advice/Should_doctors_always_admit_mistakes%3F If there were support and people had more realistic expectations, perhaps we would have better care for patients.
Doctors are only human and mistakes do happen, we can’t just accept that this is it and that there is not more that can be done. Patients still die of avoidable medical errors, not only that medical knowledge is always expanding, it is difficult for one person to keep up with so much in an unsupportive environment. http://onlinelibrary.wiley.com.libproxy.ucl.ac.uk/doi/10.1111/j.1365-2753.2012.01831.x/full Brian was on “White Coat, Black Art” where he talked abut his worst mistake and asked the healthcare professionals there what their worst mistake was. He described their reaction and though it was difficult for them to talk about their own experiences, they really did want to share their story. We need to learn and accept that we all make mistakes and that includes doctors. The medical organisations need to be able to give healthcare profession the space to do this and the encouragement to report and teach others so they can learn from other people's mistakes. Not being able to share these stories is like living in your own prison. It is difficult to imagine how horrible it must be to keep something in which matters so much.
To combat this serious issue of silence, hospitals and other organisations alike need to have a more supportive system in which healthcare professionals are encouraged to report (From a blame culture to a just culture in health care). By doing this it will encourage conversations and better communication between staff members, because at the end of the day mistakes are normal. Giving doctors a space to talk about their experiences will allow people to learn from these mistakes opposed to making the same mistakes and brushing it off. Only then will doctors be able to improve and give better patient care.
Brian is extremely brave in sharing his stories to such a large audience. He contributes to a system that has the ability to change and is commendable for that. It takes one person to talk and encourage others to take the same steps to liberate themselves from their own prisons. His talk allows people to think deeply into an organisation which we all will come across one way or another and so encourages conversation to make the industry better.
(5) Please summarise Matthew Syed’s comparative analysis about high performance in two safety critical professions: aviation and healthcare. Describe what is necessary for learning in a complex world and the limitations of a fixed mind-set (and blame) culture. What are the characteristics of a growth mind-set culture and the implications in healthcare?
Matthew Syed is an author, journalist and once a champion of table tennis. In this Ted talk about the mindset of individuals and how this leads to our behaviours to achieve success. Generally speaking, he sug
gests that there are two groups of people, ones who believe high performance is achieved through talent called the “fixed mindset” on the other hand there are people who believe while talent plays a part, “hard work, practice, persistence, resilience and perseverance” plays a bigger role in going further and beyond the talent that one may already have.
He compares the aviation industry and the healthcare industry and the differences between their mindsets and how this affects the performance of growth of both industries.
The aviation industry have improved and grown over the years through accepting failures, investigating them and finding solutions to these failures so that they can be avoided in the future. It’s really important to know that this industry does not cover up their mistakes but instead uses their mistakes as a learning tool to continually improve and that is what makes the industry achieve an accident rate of one crash per eight point three million take offs, among the major airlines, from being one of the riskiest forms of travel back in 1912. Matthew mentions how pilots volunteer to submit reports after near miss events which is then analysed to figure out where it has gone wrong. In addition, planes now have flight recorders also known as black boxes which are manufactured to retain data be recovered in the event of a disaster. https://www.google.com/patents/US5742336 The first one records the electronic data from the instruments used on the panel and the second is to record the voices of the flight crew. This is important to reveal the causes of a crash if it were to occur. Matthew gives an example where two switches were identical for the landing wheel and wing adjustments which resulted in the 1940s b-17 Boeing planes to often crash. A psychologist was hired to identify the problem and came to a solution to add a wheel shaped tab and a flap shaped tab to each switch so they can be differentiated more easily and to no surprise this problem diminished. He believes that this is “cultural and psychological achievement” due to the mindset of the industry which makes it possible for the growth of aviation.
Unfortunately it is not the same for the healthcare industry and in fact many other industries share the same fixed mindset. Fixed mindsets involve having just the talent, avoiding or giving up on challenges due to the risk of failure, not putting in 100% effort and being unable to take criticism or feedback and being defensive when given that. People who have this mind set cannot change because they believe that their personal traits are fixed therefore they cannot get any better. This limits them from achieving more which differs to the growth mindset where people can achieve more because they allow themselves to.
In healthcare, often when doctors make a mistake rather than discussing and using it as an opportunity to identify the problem and find a solution to learn for themselves and for others to learn, these situations are usually covered up. The fear of criticism, the consequences, looking untalented, and the blame culture is the reason which fuels this behaviour of hiding away and overlooking problems instead of facing them. (From a blame culture to a just culture in health care
) Blame culture is where people in an organisation are not willing to take the responsibility for their actions due to the fear of criticism and punishment. It is heavily embedded in healthcare and many clinicians are reluctant to open up about their experiences because they do not have the space to do so. They are being punished instead of being given the support they need to better themselves. http://onlinelibrary.wiley.com.libproxy.ucl.ac.uk/doi/10.1111/j.1365-2753.2012.01831.x/full By being honest and open would make them vulnerable to a claim and the possibility of being sued even though it is not often that patients do so (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628492/ ). Why would people in the healthcare industry want to be open about their medical errors if that is the case? This is a serious problem which hinders patient safety because clinicians are more concerned about covering their mistakes up instead of sharing and learning. The worse thing about this is that the consequence of this fixed mindset is the unnecessary deaths due to medical errors which are avoidable. http://onlinelibrary.wiley.com.libproxy.ucl.ac.uk/doi/10.1111/j.1365-2753.2012.01831.x/full Matthew states in the US that 400,000 patients die every year in hospitals alone which he compared it to two jumbo jets crashing every day.
Another example was given by Matthew where Virginia Mason Hospital continued to grow and make them one of the safest hospitals in the world. Mistakes at this hospitals were investigated and the hospital continually faced different problems but the difference is they solved these problems instead of covering them up. Even the little things like similar labels can have detrimental effects to a patient which they discovered and rectified, resulting in patients lives being saved.
Simply being able to recognise that there is the the ability to develop skills and grow, take on challenges, persevere even during the most difficult of times, taking feedback and turning that into a positive – all of this inspires a person to encourage themselves to be better and keep at the process of getting stronger. Rather than focusing on the goal people of this mindset focus on the process of getting to their goal, resulting in progression opposed to regression. https://michaelgr.wordpress.com/2007/04/15/fixed-mindset-vs-growth-mindset-which-one-are-you/
In the field of healthcare, all members must be able to accept failure and move forward from that by learning and improving. They already have the talent which has put them where they are but having an open mind is what makes a person have a growth mindset and going beyond their talents making them the best person they can be. They need to have that supportive frame to be able to adopt this alternative mindset and until that happens we cannot expect progression in the industry.