Quality Education

excellent piece from BMJ Q&S concerning education and training in healthcare quality and safety. The authors make a number of valid points.

There is a lack of suitably qualified experts in the area of health Quality and Safety to provide education
The traditional approach o education imposes an artificial barrier between clinical and improvement work; the two must be seen to be two sides of the same coin.
A consequence of this barrier is that front line staff fail to understand the true significance of quality improvement
This last point is one that has not previously occurred to me; the traditional method of teaching, asking questions, implies to the learner that every question and every problem has a solution, which is patently not the case.

The authors provide a framework to transform the way such training is delivered.

QI becomes an integral part of clinical practice and training
Students and teachers become co-learners, along with patients, families, and non clinical staff
QI is seen to result not from "great individuals", but from a team approach to problem solving
The end result is not judged by answering questions correctly, but how effectively a problem is solved.

Hot off the press

Just published, a supplement to BMJ Quality and safety, all open access, looks like some great stuff.

Tonsillectomy

I am currently reading John Wennbergs "Tracking Medicine". There are some great insights, and I cannot recommend it enough. One of the most striking pieces I came across relates to the belief, now vanished, that tonsillectomy was critical for a healthy childhood:

"The American Child Health Association’s research design used a random sampling of 1,000 New York City school children. On examination by a school physician, 60% were found to have already had a tonsillectomy, and of the remaining 40%, nearly half were deemed in need of the operation. To make sure that no one in need of a tonsillectomy was left out, the association arranged for the children not selected for tonsillectomy to be reexamined by another group of physicians. The second wave of physicians recommended that 40% of these children have the operation. Still not content that unmet need had been adequately detected, the association arranged for a third examination of the twice-rejected children by another group of physicians. On the third try, the physicians produced recommendations that another 44% should have the operation. By the end of the three-examination process, only 65 children of the original 1,000 emerged from the screening examination without a recommendation for tonsillectomy. If the association had put those 65 children through additional rounds of examination, it seems likely that virtually every last one would have been recommended for surgery, a thought that gives new meaning to the phrase “no child left behind.”

While we may laugh at such a practice, are we really that different? Look at the variation you practice yourself, let alone the variation amongst your colleagues, and then remember that the variation within an institution is far less than variation between hospitals. As Wennberg says,

"Thus regions have characteristic “surgical signatures” and regions with high rates of a surgery in the early 1990s still tend to have high rates today, and the cumulative effect is to expose large numbers of patients to surgical interventions that they may or may not have wanted." 

To screen or not to screen? That is the question.

Screening arouses great passion, well greatish. Sticking to prostate cancer, there has been a back and forth argument for many years. There is no doubt that using prostate specific antigen testing detects many cancers; however the key question remains whether finding these cancers impacts survival. In other words, would many of these men die with rather than because of their prostate cancer. According to Wennberg, if 1000 men are screened for 10 years, 1 cancer will be found and treated successfully, 4 men will die of their cancer regardless and 50 men will be over-diagnosed and over-treated.
A study just published finds that over a 20 year period, there is no differnece in death rate form prostate cancer between those screened and unscreended.
Again, this points to the potential for reducing variation and reducing costs in healthcare.

Simulation

There is increasing interest in the benefits of simulation to ensure improved outcomes in healthcare. A piece in the Economist piqued my interest in this area. They describe a story I had never heard before, involving the role of former US President Jimmy Carter in dealing with a reactor meltdown in Canada in 1952. Carter led a 23 man team to disassemble a reactor near Ottawa that partially melted down. Such was the radiation exposure that each person was limited to 90 seconds at the core. To ensure that the process went as smoothly as possible in such adverse conditions,

"The team built an exact replica of the reactor on a nearby tennis court, and had cameras monitor the actual damage in the reactor's core. "When it was our time to work, a team of three of us practised several times on the mock-up, to be sure we had the correct tools and knew exactly how to use them. Finally, outfitted with white protective clothes, we descended into the reactor and worked frantically for our allotted time," he wrote. "Each time our men managed to remove a bolt or fitting from the core, the equivalent piece was removed on the mock-up."

The take home message is no surprise, simulation to be successful must be as realistic as possible, with real time feedback. A paper published in January in PCCM reports that with increasing use of simulation of cardiac arrest in a children's hospital, survival post cardiac arrest increased to 50%, substantially above the national average.

Bertrand Russell on the scientific method

"Aristotle maintained that women have fewer teeth than men; although he was twice married, it never occurred to him to verify this statement by examining his wives' mouths"

Dr Yoda & the Pirates of the Caribbean

Rather than review some health related news stories, I thought Dr ZDogg would do a better job.
Have a great weekend.

Angry Bird Medicine

A wonderful title to a great blog entry on the BMJ blogs site. Talking about reducing medicine to an App that can be downloaded to ones phone. He has a fantastic quote, “6 years of medical school and 10 years of training can now be put onto an App and sold for a few dollars – where did I go wrong?”

I dont think a 99 cent app on your phone is going to take the place of a doctor just yet, but the natural progression is that knowledge becomes a commodity, it moves down the value chain, and it no longer becomes cost effective for a particular expert to broker that knowledge. So for example, there is no reason why someone with hypertension cant be monitored at home, blood pressure readings relayed by phone to a central station and feedback given around diet, medications etc, all without the person ever leaving home.

Disruptive Innovation & healthcare education

One of the great difficulties in bringing safety and quality to the fore in healthcare is that although it impacts everyone, no specialty sees it as their responsibility to take the lead, itself a damning sign of the inability of the profession to see the critical merits of teamwork and systems thinking. The IHI set up its Open School some years ago in an attempt to bring this knowledge directly to healthcare students. My impression is that it is certainly proving successful, but it is the nature of such developments to take many years to fully bear fruit. But bear fruit it will. The message is too compelling and students will naturally ask why they are not being exposed to this area by their own teachers. It's all part of a bottom up approach to change. As an example, I suggest you check out this video, part of the course materials for the Open School.

Learned Helplessness

It has struck me repeatedly that there is a huge degree of learned helplessness in the public sector around the world. I am unsre why this should be the case. Does it reflect a risk averse culture? An overly bureaucratic one in which every action must be backed by a memo? Who knows? The great pity is that one of the great motivating forces for skilled professionals is to have pride and autonomy on their work. See the video, (thanks John F) for a great example of the phenomenon.

Public Reporting of Surgical Outcomes

In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.

In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.

While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted. 

See also this post from Paul Levy.

Trends in youth mortality around the world

Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.

Statistics for dummies.

For anyone who love data, check this out. Rosling is magnificent and can summarise in 4 minutes of pictures what may are unable to do in a book. Wealth increases health.
Also see his website. www.gapminder.org

Reduced work hours for doctors

In both Europe and the US, there has been a push to reduce the hours worked by doctors. This has been based on the belief that tired doctors make more mistakes. An article in this weeks BMJ points out that to date there is no evidence that these measures have brought about an improvement in safety. Why should this be? There are many possible explanations, but in my view, these reductions in working hours have been implemented without taking a fundamental look at how doctors work. in other words, a dramatic change in work hours should have been accompanied by a radical restructuring of shifts, handovers, continuity and so on. It is likely that this has not occured. The other problem is that junior doctors work hour and patterns evolved to match those of senior physicians. The work patterns of these senior doctors also needs to be considered and modified.

Thank you for the music

Falls are an major problem for the elderly. An interesting piece in this weeks Archives of Internal Medicine reports that using music to in effect co-ordinate walking substantially reduces the risk of falls in a community based elderly population.

How to wash your hands properly in hospital

Great video from NEJM, free to view. Obligatory for all healthcare staff, (and also patients, families, kids so they can be sure their carers are doing it the right way.)

Immunisation

I was going to do a piece on immunization. These guys do a far better job than I ever could. Check out zdoggmd.com

How not to deal with the media

St Stephens Green, Dublin

Overdiagnosis

A fantastic piece in the Archives of Internal Medicine, about incidental findings (incidentalomas) picked up while testing for something else. This opens up a whole Pandoras box. A great line about a New York Times columnist who believed he had survived a brush with death following the finding of one such incidentaloma. No, the authors say, he survived a brush with overdiagnosis.
This is very important. The fundamental issue is that each patient will feel they have been saved and each becomes an advocate for more and more testing. However, there is no evidence that many of these findings, even if malignant, will ever pose a threat to health. The authors provide some practical suggestions as to how best to approach these matters.