Matt Morgan's Blog, page 3

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 asset—staff

 

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 asset—staff. 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 best—be 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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