Medical students’ view about deceiving patients with dementia

Dementia is set to become one of the major challenges of the next 50 years, in both the developed and developing world. In a 2014 paper in Aging and Mental health [Aging & Mental Health, 2014 http://dx.doi.org/10.1080/13607863.2014.967173] students expressed uncertainty as to their ability to make judgments about honest communication with patients with dementia and their families. In this very interesting qualitative study, the researchers found that whilst students recognised the importance of the autonomy of each individual with dementia, they expressed difficulties with determining an individual’s‘best interests’ in isolation. Students commented on the apparent mismatch between rule based ethical ideals, as promoted in formal documents about professionalism, and the complexities that they had seen in practice. They expressed anxiety about their own ability to interpret professional guidelines and act in the best interests of individual patients at all times. This is a great paper for both researchers and as a teaching tool. 

Solving global health problems and healthcare

Do the solutions for global health lie in healthcare? A recent analysis article in the BMJ [BMJ 2014;349:g5457 doi: 10.1136/bmj.g5457] should be sobering reading for all of us. The author Jocalyn Clark reminds us to why putting all our money on healthcare to solve global health problems is doomed to failure. The article does a fine job in arguing why we need to find creative solutions that integrate healthcare into the equation. My own take on the piece is that is has interesting implications for how we train and educate doctors. I will be distributing copies of it to the clinicians that I teach, and exploring their reactions to its implications. 

Safety and quality are not necessarily the same thing!

An excellent article in BMJ Open [Mumford V, et al. BMJ Open 2014;4:e005284. doi:10.1136/bmjopen-2014-005284] reveals how safety and accreditation processes can travel in different directions. The study involved a longitudinal comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. The most interesting aspect of the study was that higher accreditation scores as reflected in hand hygiene rates appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores. Basically, smaller hospitals (with good hand hygiene scores) failed to score well on the accreditation programme due to organizational size. As the authors conclude themselves; “In this study, a focus on the accreditation results would underestimate the successful implementation of the hand hygiene policy by smaller hospitals. Conversely, just using hand hygiene results would underestimate the research and leadership investment in infection control by larger hospitals.”

Disruptive behaviour among physicians; a few bad apples or the whole barrel?

I am reviewing the literature on disruptive behaviour among physicians, and the Leape et al (2012) article stands out as one worth reading [Acad Med. 2012;87:845–852. doi: 10.1097/ACM.0b013e318258338d]

Some of their conclusions are worth repeating;
"We believe, however, that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change. Central to this culture is a physician ethos that favors individual privilege and autonomy—values that can lead to disrespectful behavior."

"Students and residents suffer from disrespectful treatment. “Education by humiliation” has long been a tradition in medical education and still persists."

While other authors in the field are a bit too focused on repeat offenders (which is a worthy topic), Leape et al provide a cogent series of arguments that should force us to look at the system issues that contribute doc's behaving badly.

The implications for patient safety come screaming out at us......

Why do surgery residents want to leave their programmes?

An interesting US study [JAMA Surg. doi:10.1001/jamasurg.2014.935] looking at the reasons why general surgery residents want to leave their programmes reveals how more than half seriously consider leaving the program. Notable among the reasons was an undesirable future lifestyle, which chimes with the research on burnout and work-home conflict. Also, women were more likely to report wanting to leave. Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). Ultimately, the high percentage of residents who express a desire to leave should prompt us to consider how we can rethink residency training. The authors didn’t measure patient outcomes, but one wonders whether those who want to leave treat patients differently?

guides for new docs- what does it say about the culture of medicine?

The BMJ guide for newly qualified doctors is well written and packed with useful information.
It can be downloaded at http://doc2doc.bmj.com/assets/secure/youwillsurvive.pdf
However, if we step back and take a more panoramic view, does it tell us something more interesting about the culture of medicine and the values that it represents?
The guide it titled 'You will Survive', and page 2 starts with the sentence "The first day will always be frightening says junior doctor......."
The overall tone of the guide is that new doctors are going to feel out of their depth and under great levels of stress. The interesting question is to what degree the tone of the guide reinforces the notion that feeling overwhelmed should be considered normal. Preparing doctors to accept that being stressed is the norm and that feeling terrified is acceptable makes it less likely that they will ever question whether healthcare can be delivered in a radically different way.
It's obvious that guide is useful, but does it get the individuals to focus on themselves rather than the system they inhabit?

What kind of doctors have difficulty asking for help?

Doctors who male, older or suffering from addictions have greater difficulties when asking for help from a Physicians’ Health Program. Very interesting study from a team from Barcelona. 
http://bmjopen.bmj.com/content/4/7/e005248.full.pdf+html

Greater professional empathy leads to higher agreement about decisions made in the consultation

Interesting study about empathy in the consultation process.  See the article at http://www.sciencedirect.com/science/article/pii/S0738399114001827
In the study, empathic responses to statements of challenge were found to be a strong predictor of agreement and resulted in both parties reporting and agreeing on more decisions. 
In particular, I liked the fact that empathy can be communicated by simply acknowledging the other. 

The inevitability of physician burnout: Implications for interventions

For physicians, burnout is the inevitable consequence of the way that medical education is organised and the subsequent maladaptive behaviours that are reinforced in healthcare organisations via the hidden curriculum. Thus, burnout is an important indicator of how the organisation itself is functioning. I have written a paper about the issue;
http://www.sciencedirect.com/science/article/pii/S2213058614000084
A central theme of paper is the degree to which the organisational systems are responsible for the disconnect between performance and physician health. Healthcare pays considerable ‘lip-service’ to systems approaches, but in practice it valorises the role of the individual physician in terms of both success and failure. Thus, this contradiction needs to be addressed.