Should doctors share their notes with patients?

The answer seems to be yes for patients, but no for some doctors, according to a recent study in the Annals of Internal Medicine [Ann Intern Med. 2011;155:811-819]. The most interesting part of the study was the fact that patients expressed considerable enthusiasm and few fears about sharing notes. However doctors who had declined to participate in the pilot worried about frightening and confusing patients; recording their thoughts candidly; and writing about such issues as mental health, substance abuse, cancer, and obesity. The sample in the study was US primary health care physicians. 

Physicians Vs professional managers? Who should be running the hospital?

The idea that physicians should be better hospital managers is deeply embedded in medicine. Put simply, the folks that have “walked the walk” should be able to lead by example and should instil more confidence in their medical colleagues. A recent study in Social Science & Medicine [doi:10.1016/j.socscimed.2011.06.025 ] suggests that  Physicians, compared with non-physician leaders,  with  do make better leaders. Data were collected on the top-100 U.S. hospitals in 2009, as identified by a widely-used media-generated ranking of quality, in three specialties: Cancer, Digestive Disorders, and Heart and Heart Surgery. Three areas of healthcare performance are reflected within the Index Health Quality scores: structure, process, and outcomes. For example, the researchers looked at metrics such as availability of key technologies, mortality rates and diagnostic tests ordered. The authors caution us that the study is cross-sectional and doesn’t improve that doc’s are better leaders. The most interesting aspect of the paper relates to the unanswered questions. For example, top hospitals maybe more likely to seek out top physicians as leaders, or the mere presence of a physician leader may attract more talented medical staff. The authors acknowledge that they didn’t evaluate actual leader behaviour, which would give us a better insight as to mechanisms of successful leadership. We don’t have information on the type of individual who are leaders in hospitals, but don’t have traditional medical backgrounds. Finally, performance metrics are important, but it would be interesting to assess the experience of staff in the two different regimes.

Dirty clothes and doctors!

As if healthcare professionals did not already have enough to worry about, it seems as though their clothes may be working against them. In a recent study where cultures were obtained from the uniforms of nurses and physicians, up to 60% of hospital staff’s uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. As noted by the authors, the maximal contamination occurs in areas of greatest hand contact (ie, pockets and cuffs), allowing recontamination of already washed hands. The authors acknowledged that the scope of the research was limited and it remained to be determined whether these bacteria could be transferred to patients and cause clinically relevant infection.

Study: Am J Infect Control 2011;39:555-9.)doi:10.1016/j.ajic.2010.12.016

Are GPs better at communication?

GP observers and patient observers performed quality assessments of Dutch General Practice consultations on hypertension videotaped in 1982-1984 and 2000-2001 [Butalid L, Verhaak PFM, Tromp F, et al. BMJ Open (2011). doi:10.1136]. GPs, although more task-orientated (according to the authors) seem to be getting better. Both GPs and patients rated the 2000-2001 consultations as better, in terms of medical technical quality, psychosocial quality and the quality of interpersonal behaviour. Great study and interesting data. The authors admit that the GP ratings may have suffered from a ‘halo effect’ and they don’t have a complete answer for why the patient ratings agreed with the GPs, given one would expect patients would prefer a more affective style communication. However, the authors don’t discuss the possibility that being a patient and judging a consultation externally may prompt different evaluation needs. It would of been useful to also have data from the actual patients involved in the research.

GPs as medical leaders

The following video http://www.youtube.com/watch?v=JmQaCZufBtQ contains an excellent interview with Prof. Aidan Halligan. He talks about his views regarding medical education. Near the end of the video, his discusses an experience he had  in Afghanistan where a GP was leading a NHS field hospital team. He admits this went against the grain, but talks about how it has influenced his work in the NHS.

Is self-treatment an occupational hazard among physicians and medical students?

When it comes to their own health, doctors may behave irrationally and paradoxically. The medical profession expect patients to seek appropriate medical help when they encounter significant problems with their health and yet doctors do not behave in this way when it comes to their own health. There is a culture within medicine that doctors do not expect themselves or their colleagues to be sick. Thus, the associated complexities of self-diagnosis, self-referral and self-treatment among physicians are significant and may have repercussions for both their own health and, by implication, for the quality of care delivered to patients. In a recent review of the literature [Occupational Medicine doi:10.1093/occmed/kqr098], the authors found that self-treatment was strongly embedded within the culture of both physicians and medical students as an accepted way to enhance/buffer work performance. Although numbers are likely to be small, the implication of potentially impaired doctors treating patients is serious.

Physicians as “second victims”

Critical incidents and medical mistakes have serious psychological and health related impact on patients and their families. This is for sure. However, a recently published review of the impact of critical incidents provides interesting insights on how such incidents can also impact on healthcare professionals [Best Practice & Research Clinical Anaesthesiology 25 (2011) 169–179]. The second victim label refers to the way that healthcare professionals can be adversely affected by critical incidents.

The paper reviews lots of interesting work and provides useful directions for future research and interventions. For me, three points from the review stood out;

1.    Some health-care providers report symptoms of post-traumatic stress disorder, such as sleep disturbance, nightmares, irritability and problems concentrating that may even lead to inability to work. However, even without these symptoms (especially) physicians frequently suffer from feelings of incompetence, anxiety about future errors and professional isolation, all of which were associated with higher job-related stress making it harder to continue working clinically

2.    Long term impacts included increased burnout, symptoms of depression and reduced quality of life

3.    A major motivation for taking legal action is the lack of reliable information and a perceived lack of respect and feelings of abandonment.

So, some healthcare professionals can suffer just as much as patients from critical incidents, they may (understandably) fail to perform adequately in terms of disclosure, and not surprisingly some patients want to take legal action.

Using drama to explain medical errors and medical mistakes!

 I recently attended a conference about organisational culture and job burnout in hospitals (April 2011-Thessaloniki, Greece). I delivered a paper at the conference. However, I was very impressed by the presentation from a group of final year medical students (from Aristotle Medical School, Thessaloniki, Greece). The students used drama as a way to highlight the impact that medical mistakes have on both healthcare professionals and patients. It`s difficult to convey their approach without showing a video, but basically, they dramatised personal interviews from physicians as a series of short plays. In addition, they used clever technology to overlay the Hippocratic oath throughout the performance. Thus, we the audience, were prompted to reflect via the use of different modalities. Very innovative, very interesting and difficult to forget! Drama and medicine in Greece, very fitting!

Preventing job burnout in medical students

Treating burnout in physicians can be difficult and the evidence to date is mixed and patchy. However, a recent paper in Medical Education [Med Educ. 2010 Oct;44(10):1016-26. doi: 10.1111/j.1365-2923.2010.03754.x] provides some interesting insights on how we can try to prevent burnout in medical students. The researchers followed medical students prospectively and categorised students in three major groups; (1) no burnout (the resilient group), (2) initial burnout, but no burnout on follow-up (recovering group), (3) burnout continuously (chronic burnout group). Roughly, a third of students were classified in the resilient group. The researchers found that modifiable individual factors and learning climate characteristics including employment status, stress level and perceptions of the prioritising of student education by faculty members related to medical students’ vulnerability to burnout. The authors do not name it as such, but in my opinion, the factors identified by the authors all relate to organisational/educational climate. On the plus side, the fact that the identified factors are modifiable provides hope, and more importantly, the opportunity for us to test their hypotheses.

The reason why doctors don`t fly planes!

 

The following study is from 2000 [BMJ 2000;320:745–9], but it`s worth reading if you missed it!

In a study comparing attitudes to work, fatigue and error among healthcare professionals and pilots; researchers found that 70% consultant surgeons claimed to perform effectively when fatigued, compared with 24% among pilots. Additionally, healthcare professionals (compared to pilots) were less likely to disagree with the statement that junior team members should not question the decisions made by senior team members.  The research also showed that error was difficult to discuss in medicine. Ultimately, healthcare professionals seem to be denial about the impact that stress and fatigue can have on their performance.

Rain and selecting medical students

In a very interesting and novel piece of research, Redelmeier and Baxter [CMAJ 2009. DOI:10.1503/cmaj.091546] found that bad weather significantly influenced scores at admission interviews at a Canadian medical school. Potential medical students received lower scores from interviewers on bad weather days. The difference in scores was equivalent to about a 10% lower total mark on the Medical College Admission Test.

Interesting study, that shows how mood can influence our ratings of others!

Irish Doctors, performance and Lifelong learning

From May 1^st 2011, Irish doctors seeking to renew their professional registration will be required to complete an annual declaration that they have enrolled in and are complying with the requirements of a specific competence scheme. The new rules will require doctors to “systematically acquire, understand and demonstrate the substantial body of knowledge that is at the forefront of the field of learning in their speciality, as part of a continuum of lifelong learning”.

 [http://www.irishtimes.com/newspaper/health/2011/0412/1224294468256.html]

Obviously, encouraging doctors to continuously update knowledge is desirable, but one wonders whether such efforts can significantly influence behaviour and attitudes? Skills are important, but will such rules contribute positively to real behaviour change among doctors?

What happens if you have to bring a family member to the doctor?

 A recent meta-analysis on this subject [Social Science & Medicine; 2011;doi:10.1016/j.socscimed.2011.01.015] found that accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. The heterogeneity of studies reviewed made broad conclusions difficult, but one result stands out in terms of physician behaviour. Physicians were found to provide more biomedical information to patients when a companion was present, and results suggest that they were also less apt to engage in social conversation. The studies reviewed did not systematically address patient outcomes, but there was no evidence to suggest that accompanied patient outcomes were inferior. However, outcomes were consistently favourable among accompanied patients when family companions were more verbally active suggesting that wasn’t not simply the presence of family companions, but the roles they assume that have a bearing for patient outcomes.

Psychology works, but it takes time!

Psychological interventions can help healthcare professionals working in hospitals, but it takes time and the participation of the healthcare professionals themselves!  A 2010 study [Occup Environ Med doi: 10.1136/oem.2010.055202] found that a participatory intervention team, meaning the intervention involved people working in the target hospital, helped to reduce adverse psychosocial work factors and improve mental health. The interesting aspect of the intervention was that it involved 8 meetings (for 3 hours) over a four month period, and the actual follow-up was 3 years after the intervention. So, helping hospital workers takes an investment of time and the results may not be seen for quite some time!

Are doctors learning?

One would think that work-based assessment would be a useful tool for doctors. Ideally, we would hope that doctors assess their performance and use this as a tool to improve. We can imagine that continuously updating their education and performance would be especially desirable for doctors. However,  a  recent review [BMJ 2010;341:c5064doi:10.1136/bmj.c5064] on the impact of work based assessment on doctors’ education and performance found little evidence that such assessments act as an educational initiative. There was limited evidence for multi-source feedback. Put simply, there was little evidence that assessing work performance was leading to actual behaviour change among doctors.