It’s the little things that matter…

There’s a lovely initiative kicking off in the Broome Hospital this year, thanks to my colleague Dr Casey Parker of BroomeDocs.  Have a read of Casey’s latest blog post yourself – the premise is simple – to ensure that junior trainees follow through their patients from admission to ward, not just in terms of their medical management – but in terms of the experience for the patient.  In essence Casey wants to make sure his emergency residents will “Own the Patient”.

  • At some stage in each shift our ED residents will be encouraged to “visit” their patients on the wards.
  • Ten or fifteen minutes during the inevitable lulls.
  • I want them to specifically visit the “standard” patients, e.g.  the ‘mild COPD’ or the ‘RUQ pain for investigation.’
  • When I say “visit”, that is exactly what I mean.  I want them to go to the bedside in the same way a concerned relative might do.
  • They should not check on the progress with their inpatient colleagues first – I want them to go in and get an untarnished patient perspective.
  • When they visit the patient whom they admitted I want them to ask 3 simple questions:
    1. How are the symptoms that lead to their ED presentation going?  Have they been relieved?
    2. Ask them to explain what has happened since admission – ask the patient to explain their understanding of what has happened to them OR what do they understand the treatment plan is going forward.
    3. Ask, “is there anything I can do for you?”
  • After visiting they can then go and do all the usual doctorly things – look at the CT, chase the bloods or get the 30 second thumbnail from the inpatient team.
  • As they walk back to ED I want them to meditate on what they could have done differently to make that patient’s experience easier, less painful or less confusing.

Silo Mentality and Interspecialty Bickering

Medicine is hopelessly siloed – whether between paramedics, nursing, doctors & allied health, or between specialties in each discipline.

Insightful and reflective clinicians will do all they can to break down these silos – Vic Brazil spoke eloquently at smacc13 on the need to break down tribalism as does Dharmaraj Karthikesan on the need for doctors to be kind to each other, a lesson applicable to all healthcare tribes.

I count my lucky stars that I moved into the practice of rural primary care in Australia – not only does it embrace all the ‘best bits’ of medicine, it allows a real sense of purpose within the community, the joy of practicing procedural skills and of course is a job in demand!  It’s also been interesting to view the practice of some of my specialist (or perhaps I should say partialist) colleagues from the perspective of a specialist in rural medicine (FACRRM).  I’ve had occasions to make for ways back into the hospital system to upskill in obstetrics, anaesthetics and prehospital care – and on each occasion was struck how constrained the practice of my specialist colleagues was compared to mine.

Sir Chris Hoy London 2012
The Aggregation of Marginal Gains

Intensive Care ward rounds were a good example – of course the intensivist brings all their knowledge and skill to these critically ill patients – but if a patient came out in a rash, or a skin lesion was noticed, there would be an immediate consult for a dermatology consult (which might take a day or so) and delay the discharge of that patient.  When moonlighting on ICU as a rural doc, I’d enjoy not only the critical care side of patient care, but also managing the more mundane aspects – diagnosing the rash, excising the skin lesion, tidying up their chronic disease, speaking to family etc.  Ditto in prehospital care – skills across emergency, anaesthesia and obstetrics seemed well-suited to this environment, over the skills of say a clinician trained purely in anaesthesia.  Common to these specialties was the fact that the LITTLE things matter – critical care (whether in the ICU or at the roadside) is mostly about doing the basics…but doing them well, consistently and ensuring good clinical governance. People often talk about the British Olympic cycling team and their coach, David Brailsford – leading into a discussion of the ‘aggregation of marginal gains’.  A small improvement of just 1% in any one area, when amplified across the complex system of either elite sport or healthcare, can lead to significant improvements – those 1%s all add up!

To my mind, holistic patient care is the key to those 1%s. And primary care is expert in this.

The Power of Primary Care

THIS is why I think Casey Parker’s notion of #ownthepatient is so important – it’s bringing that longitudinal generalist approach to bear in a hospital environment, breaking across the silos.  More importantly still, this is done with a solid emphasis on the patient perspective…because despite all of the technical brilliance that we aspire to achieve in whichever discipline, this is essentially useless if the patient is not cared for, informed and a fellow traveller in the journey to recovery.

“these outcomes will never be counted in audits, but they matter.  The only way to learn the 1-percenters is to close the loop.  Go and talk to your patients.  Understand their experiences and then try to do better.  This stuff is largely tacit learning – it is unteachable.  One must consciously try to experience the “little” problems in order to prevent them from recurring” – Casey Parker

I like to think that primary care clinicians have something to offer here – to be honest it rankles me somewhat that many tertiary partialists (and even some patients) have the perspective of ‘just a GP’.  Former rural locum Dr Penny Wilson has also written nicely on this (see her post copied in the Huffington Post) and it leads into a wider discussion of the true value of good quality primary care – whether practiced by doctor, nurse or paramedic.  Of course Casey, Minh and I have all made forays into the conference circuit, often talking to audiences of physicians, intensivists or emergency docs about our perspectives as rural docs/GPs (the smacc series is perhaps the best example). I think it’s invaluable to have generalists talking to partialists, rather than the usual ‘specialist-lecturing-to-ill-educated-GPs” education! Of course FOAMed means that knowledge is freely available and readily discussed, similalry breaking down silos and leading to real learning.

This extension of good ‘primary care’ skills into the hospital system, with a patient-centric focus as exemplified by BroomeDocs is fascinating – not only is the paradigm widely applicable from rural hospital to uber-specialised tertiary or quaternary centres, it also gets back to the very essence of why we are all in healthcare – to help the patient, and implicitly, to improve the lot of fellow human travellers.

My question is whether such ventures will translate into measurement of improved health outcomes; current systems of audit and indeed funding rarely measure the impact of such simple interventions. There ARE examples – the UK’s #hellomynameis campaign to ensure introductions between healthcare workers can improve teamwork, patient safety and is just plain courtesy.  But most healthcare funding is focussed on dollar savings and measurement of targets – time in ED, number of procedures, length of bed stay etc

Interestingly there IS evidence of the value of the rural generalist in cutting health costs (see this fascinating keynote from Professor Richard Roberts at the RMA15 conference – and forward to Health Minister Sussan Ley who needs to be reminded of the value of an effective primary care system).  Such care is characterised by patient-centredness, minimising inappropriate investigations and procedures and having an absolute focus on what is right for THIS patient, at THIS time in THIS place.

Whether the ‘Own the Patient’ paradigm will be taken up by other institutions and translate into improved patient outcomes remains to be proven – intuitively I think it is a good thing….I hope you will too.

References

Dear Doctors – Be Kind to Each Other from Dharmaraj Karthikesan http://dharmarajkarthikesan.com/2015/05/09/dear-doctors-be-kind-to-each-other/

Myths About General Practitioners – Penny Wilson writes on why she’s ‘not just a GP’ http://www.huffingtonpost.com/penny-wilson/myths-about-general-practitioners_b_3937618.html

Own the Patient – Brilliance from Casey Parker of BroomeDocs http://broomedocs.com/2016/01/own-the-patient-clinical-case-126/

Tribes, Timing & STEMIs – Vic Brazil at smaccGOLD (2013) lifeinthefastlane.com/timing-tribes-stemis

 

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