Wednesday, December 31, 2014

A Tricky Question

This article first appeared in the December 2014 issue of the RACGP Publication Good Practice. I have linked to PubMed for the articles, and included links to full text in the references at the end.

One of the most difficult questions in healthcare may be, “Are you a good doctor?”

I am sure, dear reader, that you are a good doctor. You know everything, and you know the things you need to learn. You can see through the twinkle in a drug rep’s eye faster than you can say Vioxx. You are all much better than average, and, even as you know enough statistics to be able to dismiss this as an impossibility, you also know that it is certainly not you who is below average. 

Now that we are patting each other on the back in mutual admiration, here are some people to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger, who won an Ig Nobel prize in 2000 for their work, in experiments showing those who were the least competent in various tasks were also the most likely to rate themselves highly competent.

They also found the same people are the most self-confident. There’s something about not being very good at something that makes you blind to the areas that you don’t know, or even realise that they exist. It’s a good job nothing like that could happen in medicine.

Except, however, research evidence can sometimes be as disquieting as a mirror in a brightly lit room. In JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. The evidence revealed that we are not very good at assessing our own competence. Meanwhile, two years later In Medical Teacher, another systematic review also shows us that we are not that good at assessing our own learning needs.   

In both situations it is the least skilled of us who are the worst at self-assessing, and who are the most confident. 

And then there’s research that consistently shows we think we’re immune to drug repmarketing, no matter how often it’s shown that we’re not. This evidence is entirely consistent with other sociological and psychological research, which confirms that doctors are part of the human race, no matter how much we want to think our training makes us otherwise.

Apply Dunning and Kruger’s research to our profession, and you can see the danger in asking “Are you a good doctor?” It may be the very areas in which we feel highly confident are just those areas we are worst at. It may be that those of us who think they are expert at seeing through drug rep spin are those most susceptible. 

What if those of us who say they are good doctors are the ones we need to be most wary of?

Of course, you could dispute the evidence. All that stuff about education and drug reps doesn’t apply to you, or to Australia. But that is just what you would say, wouldn’t you, if you were subject to the Dunning-Kruger effect! 

In order to show how competent we are, we might have to admit some uncertainty over our competence. In fact, in real life, I have discovered that the doctors I really admire all feel that they will be tapped on the shoulder and outed as a fraud at any moment.

For any eager regulators out there wanting to put conditions on the registration of anyone admitting they think they are a good doctor, the solution is even simpler. As a profession, with specific knowledge and expertise, self-regulation often means peer review. We need - and should welcome - others around us to help us see our blind spots. Perhaps “Are you a good doctor?” is not such a dangerous question if the answer is “You’re asking the wrong person.”

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121-1134.  

Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA : the journal of the American Medical Association. 2006 Sep;296(9):1094-1102

Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, et al. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical teacher. 2008 Jan;30(2):124-145.

Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003 Jul;290(2):252-255

The Hunger Games

This article first appeared in the July 2014 issue of the RACGP Publication Good Practice. It was written for a GP audience, who I hope would have fond memories of all the food terminology. Perhaps it was just me. The published version was edited slightly, but this is the original.

Being a doctor makes me hungry. Surely, many of us spend a morning clinic thinking about lunch, and an afternoon clinic wondering about dinner. I’m pretty sure it has been the same throughout history. I imagine Hippocrates eating herring, Galen tucking into grapes and Vesalius enjoying veal. However, I think they had stronger stomachs than me. I trained at one of those traditional medical schools that did dissection, and the combination smell of meat and formalin meant I was never hungry. 

This didn’t seem to be true for previous generations of pathologists, though. All those historical types were clearly distracted by their stomachs, as any quick leaf through a medical textbook will tell you. I imagine that as their assiduous students examined yet more examples of pathological body fluids, they’d ask their teachers for adequate descriptions.
“What does this stool look like?”

“Redcurrant jelly.”

“And this one?”

“Rice water. Better wash your hands. It’s supper time.”

There would be no fluid too disgusting to describe in tasty terms, every internal organ was ripe for culinary description.

“Your next patient looks a little unwell. Yeuch, he’s just vomited in the waiting room.”

“So he has. And, my goodness, it looks like coffee grounds. Remarkable.”

“Oh. I thought it looked like soil.”

“Watch and learn, dear pupil.”

The analogies continued. As they probed deeper, medicine became like a banquet. The main course was cauliflower ear, with subtle flavouring found in livers that looked like nutmeg. The cheese course was supplied by chest granulomas described as caseating. No-one could resist the chocolate cysts on the ovaries. After the food had settled, the skin was eagerly examined for port wine stains and café-au-lait spots.
It appears we might now be running out of foods to use. Arguments break out, amid confusing errors as to precisely which diseased organ looks like a strawberry. 

“Wasn’t it that strawberry naevus?”

“No, I thought it was a strawberry cervix.”

“Actually, I was talking about the strawberry tongue. I’m not sure how you missed it!”

I’m not sure I believe they really could see these things. Perhaps all they were cooking were the books.

And back to reality. If the thought of all that pathology puts me off my next meal, this is reinforced by my next patients who bring with them the strangest of menus. The first person tells me he has a frog in his throat. The next person has butterflies in her stomach. She’s worried, she tells me. Something is eating away at her. Up next is someone who knows something is wrong from her gut instinct. It’s quite a relief to find my next patient is so hungry she could eat a horse, but she is pleased as the treatment seems to be bearing fruit. My final patient has a few lumps in various places, which I carefully examine and document their sizes – a grain of rice, a pea, and, most surprisingly, a grapefruit. 

I reach the end of my surgery, running particularly late. After this procession of unpalatable symptoms, all I have the appetite for now is my apple, which is successful at keeping the doctor away from his lunch.

As my afternoon patients start arriving and peeling off their coats in the waiting room, I anticipate the feast to come. I reassure myself that, running late, slow food is healthier for all of us. Feeling better, my appetite for the work is not diminished. I look forward to the afternoon with relish.

Sunday, March 30, 2014

My Personalised Digital Learning Space Thingummybob

Recently, I made my way down the beautiful escarpment to Wollongong to the Coast City Country (CCCT) GP Supervisors' Professional Development weekend. I was giving my personal experience of creating a "Personalised Digital Learning Space. I didn't realise that this is what I had done - essentially it was about how you use interactive social tools on the internet to enhance your own learning and teaching.

This post will summarise the talk I gave and some of the discussion that took place. Please use the comments to continue the discussion, and feel free to catch up with me on Twitter. You'll notice that the process of putting up this blog, and sharing our Prezis, is a demonstration of the content of the talk - as is commenting!

Sharon Flynn, the CEO of CCCT, opened with an outline of the background and theory, such as it is. You can find her Prezi here, and mine is embedded below.

It's quite possible to feel completely overwhelmed by online tools. There are so many people, and so many websites, apps and tools for so many devices. It can be like getting to grips with the size of the galaxy. In the same way that we don't have detailed knowledge of every drug available on the PBS (but we know where to find it), we can use three or four tools well, and not worry too much about all the others.

Here I'll describe how I use social media, and which tools I use. I don't want you to feel that this is the way of doing it. This is just a way (and probably not even close to the best way.

I was asked to cover the following questions:

  • How do I find stuff?
  • How do I know it’s accurate?
  • How do I share content?
  • How do I filter content?
  • How do I keep up with all the news?
  • How do I organise content?
  • How do I categorise content?

My system is very simple. It's based around Twitter and Blogger. Mostly...

How do I find stuff?

You already find stuff! Most people already find stuff through colleagues in rel life, and through Google. Popular medical magazines like Australian Doctor and Medical Observer are widely used. I still look at textbooks, too - I shall never grow tired of Balint, and while Trish Greenhalgh writes books, I shall read them! So online isn't the be all and end all.

I'd add Google Scholar and PubMed (especially Clinical Queries, which adds search filters to help you find systematic reviews and randomised controlled trials). I routinely check out the Tables of Contents (eTOCs) (login required) issued by the RACGP library and the PHCRIS e-bulletin.Some people used the subscription services Up To Date or Dynamed (also available through the RACGP library). These offer evidence reviews supposed to be used at the point of care, though they are not quite succinct enough for this.

The social nature of the web means that you can extend the circle of people you call upon from those you know personally to (potentially) anyone, including leaders in the field. Watching out for accounts on Twitter who regularly point out interesting research and articles is really valuable. For me, Trish Greenhalgh, Ash Paul, Jonathan Tomlinson, Annmarie Cunningham, Melissa Sweet and WePublicHealth would be examples where much of what they tweet I find interesting and relevant. It's much more useful (and fun) to see tweets containing opinions, not just headlines, too.

It's also useful to keep your eye out on some hashtags. Hashtags are search terms attached to tweets which allow you to find information you are interested in from poeple you don't know exist. #FOAMed #FOAM4GP #MedEd and #SoMeGP would be good places to start. As you get more connected, people will learn your interests and direct things to you that they think you will be interested in. For example, some recent tweets I received:

@NACCHO_CEO Aboriginal Health reform Justin Mohamed - @Informa_Oz… @WePublicHealth @croakeyblog @timsenior @qaihc

— Aboriginal Health (@NACCHOAustralia) March 25, 2014

A #publichealth perspective on the RDA… FYI @warrenmundine @GreenJ @NACCHOAustralia @timsenior @LowitjaInstitut

— Melissa Sweet (@croakeyblog) March 24, 2014

How do I know it's accurate?

This is no different to other parts of life! Do I trust the writer? Do I trust the tweeter? Do I trust the publisher/journal/website? There's no reason to suspend you critical judgement. Things on the internet are no more or less reliable than our daily newspapers. Make of that what you will!

How do I share content?

Simple answer: I tweet it. I usually tweet links to things I find interesting, usually with a comment about why it's interesting or useful. Where I want to say more than 140 characters, or want to say something with more thought behind, I'll blog about it (on for Aboriginal health stuff, and on for anything else). It's very easy just to use Twitter and a blog as a basis for sharing.

There are other tools that can be helpful. Storify for bringing together a series of tweets and links into a story; Slideshare or Prezi for sharing presentations; Youtube or Vimeo if you fancy making and sharing videos.

So you see I've managed to embed a Prezi to share on the blog. On this post, I've embedded a Storify.

How do I filter content?

I use 2 questions, essentially:

Is it useful – will it change my practice?

Is it interesting?

If the answer to both of these is no, then I won’t bother.

Sometimes when I am really busy, something has to be really really useful or really really interesting for me to worry about it.

How do I keep up with all the news?

I used to try! Now I don’t worry. If it’s important enough, it’s will be tweeted several times through my network. If it’s not, I won’t miss out. You can’t know everything. Remember that it's social media and not social media - your network will find stuff for you! (It’s why you should share interesting or useful stuff you find.)

How do I organise content?

If I see a tweet with interesting info in (for checking out later) I will favourite it. (You can see what I've favourited here).

If I see a journal article worth reading, I will save it to my CiteuLike library. (Incidentally, if you have access to a University Library, see if there is a version of the LibX toolbar you can install...)

If I see a website or some other bit of information, I will save it to my Evernote notebook which is accessible from my computer and phone. This is useful for websites, articles, meeting notes, pictures, tweets, sounds, drawings etc. (I used to use Pocket, too.)

How do I categorise content?

Citeulike and Evernote both use tags. I attach key words of my choosing to interesting articles, and can then find them later. So, for example, these are all my Citeulike articles tagged Education

Some of the discussion

My observation that the development of theory was playing catch-up to the ways people were using social media for education provoked the useful clarification that the educational theory hasn't changed, and that the challenge is to make the most effective use of these tools intelligently. We can't ignore what we already know about educational effectiveness, but neither can we just translate lectures, seminars, workshops, tutorials across to an online environment and expect them to work. (Which incidentally, is why my Prezi here may not be very useful on it own!)

The other interesting discussion was about the use of social media by registrars. Some GP Supervisors were concerned about the use of mobile phones and social media during clinic sessions, especially the distraction of this while seeing a patient. It would be interesting to hear from others about their experience with this. Our discussion thought about using video to see the impact on the consultation, and asking the registrar what they thought the patient might be thinking seeing the registrar checking their phone when it buzzed. (Any doctor not able to put themselves in the patient's shoes at this point probably has bigger problems than just the use of social media!) Where students are engrossed in an electronic device, there is scope to use this as a teaching moment for all concerned, and ask the student to get specific information relating to that consultation.

I'm fully aware that there are many other tools and strategies out there that you will use. Please tell us in the comments below.

Friday, February 21, 2014

There’s no such thing as minor illness – three scenarios

Where you'd rather be than the doctors... until...

Sometimes commentary about health systems seems to view the people who use them as a nuisance. “If only they wouldn’t come with their minor problems.” “Let’s charge them so they think twice about coming.” We are made to imagine a health systemclogged up with people who shouldn’t be there with all those self-limiting illnesses. Leave the room for those who are properly ill, thank you very much.

It may be surprising to learn that there is no such thing as minor illness. That’s not to say that there’s no such thing as self-limiting illness, but that by trying to keep people out of the health system, we lose opportunities to get them in. Here are three scenarios. 

Scenario 1 – People only walk out with minor illness.

One of the common set of symptoms that people come to the doctor with is things like a cough, sore throat, runny nose, perhaps fevers. It’s really only possible to say this is minor illness at the end of a consultation. These symptoms can be the early symptoms of conditions like meningitis, pneumonia or a septicaemia. Usually they are not, but the headlines make the front page of the newspaper when they are missed. These diseases progress very quickly.
Much of the pressure not to go to the doctor with these symptoms forgets that these are not just an isolated and independent collection of physical occurrences. They are accompanied by feelings – usually worry and anxiety. The decision to come to adoctor is rarely taken lightly. Most people discuss their symptoms with friends and family beforehand and ask for advice on what to do. Some people will consult Dr Google. The decision to see a doctor is driven by anxiety – anxiety for themselves, often anxiety for a child, sometimes anxiety for a partner. (The main exception to this is a request for a medical certificate for time off work – this won’t change while workplaces require certificates for minor illnesses.) People don’t really come in for an antibiotic. That might be the request, but people want their anxiety reduced. That’s why with good listening and careful explanations which get at the reason they are worried, almost everyone is happy not to have antibiotics if they are not required. This is also an opportunity to speak with people face to face about how they make the decision to seek further medical help - probably much more useful than providing written information,

Scenario 2 - …And another thing

About 40% of people bring more than one problem at a time to their GP. (PDF) The minor illness might be a ticket in through the door – the reason they can give the receptionist and their workmates, but there are often more profound concerns that people come with. These might be the chest pain they’ve been having that they’re worried might be serious. Or it might be symptoms of depression or anxiety, or the worry over episodes of hearing voices. Often this is the real problem people come with, but it won’t be raised unless the person feels they can relate to the doctor they are seeing. Sometimes it will come up in the same consultation. All GPs know those final moments in a consultation, with the door about to open, when…”there was just one other thing, doctor.” It doesn’t always happen like this. I am aware that I have had people try me out over something fairly trivial for two, three or more consultations before feeling that I can be trusted enough to tell me about the thing that is really worrying them. If I don’t develop a rapport, I’ll never even know there was something else.
Both scenario 1 and scenario 2 are opportunities for the preventive healthcare that often gets talked about. 85% of the Australian population see a GP each year, which is a lot of opportunity to make sure screening and preventive activities happen, without needing any health check policy. It’s one good reason why we have excellent guidelines about what preventive activities work. And why many of the conceptual models we work with in general practice talk about something akin to “The Doctor’s Agenda” recognising that there are things that the patient needs to be done in a consultation, and there are things the doctor would also like to achieve. 

Scenario 3 - The Perhaps scenario…

Often people do come in with what turns out to be, when they leave, a minor illness. Sometimes these are people who rarely see a doctor at all. They may be young men (who’s consultations are usually shorter, do less preventive activities and deal mainly with physical symptoms) or they may be people whose first language is not English, or they may be people unused to navigating complex health systems, and a bit intimidated by health professionals. Or they may be people who see a range of different doctors. It doesn’t really matter. Everyone at some point is at risk of succumbing to a serious physical or mental illness. If that time comes, people want to see someone they can trust. If, having seen a doctor who treated the person with compassion and respect, and didn’t make them feel like they were wasting their time for something minor, then that will be remembered. And if it is remembered a few months down the line when that breast lump appears, or those suicidal thoughts keep entering the mind unbidden, the question “Who can I turn to?” comes up. One option for the answer should always be “I remember that nice doctor I saw with my cough.”
The seeds are sown in those consultations for minor illness for tougher times ahead, the investment made in the trust that is required to tell of your most worrying, perhaps shameful, secrets when it is required. Most experienced GPs know this, and put time in during those minor illness consultations to develop the trust. General Practice is, after all, a specialty built on relationships over time with patients, rather than a series of one-off information gathering exercises.
There are obviously challenges in funding and workforce. But if we forget that in consultations for minor illness, we are doing so much more than just seeing a collection of trivia, then we are building a health care system which is impersonal, anonymous and foreboding.We don’t just stop people attending their GPs now. We stop them attending in the future, too, perhaps when it really matters.
I should emphasise that this applies particularly to GPs and Primary Care. Emergency Departments are not set up to provide this sort of care, where GPs are. I also include non-medical staff in this description of a GP’s work. Nurses would clearly be involved in developing relationships, too. I am most familiar with the way this plays out for GPs, and know that GPs have been researching and teaching this core part of their role for decades.

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