30th October 2018, RCPCH London
Dr Chris Course
The RCPCH and the NIHR (National Institute for Health Research) held annual joint study day aimed at promoting and de-mystifying academic training careers. This free study day is fairly new on the RCPCH events calendar, having only been held for the past couple of years, but aims to tackle an area of training which is sometimes perceived as difficult to understand and undertake.
This was my first trip to RCPCH HQ in London, and it was great to actually see the place where its all run from. Despite not being as grand as the Royal College of Surgeons or GPs, it was a modern building with good meeting facilities. I was also a little worried that, not already been on an academic training pathway, I may be a little “out-of-it” or some of the subject matter may not be useful or attainable for me.
Thankfully, I was wrong! There was a really good mix of trainees in attendance with a wide range of backgrounds. Some were already undertaking PhDs, some were nearing the end of their training and looking to build a research career, some were already on an academic training fellowship. Meeting all these colleagues with different backgrounds in the “Networking” session during the morning helped me to put my own current aspirations and difficulties into context and to being finding some solutions to these problems.
The speakers for the day were an eminent bunch and gave some really useful and insightful talks. Professor Anne Greenough started the day with a broad introduction to academic career paths, and how the new progress curriculum is building research and academia into the training domains, aiming to improve our exposure to clinical research, as well as encouraging the Deaneries to facilitate more academic opportunities. Dr Chris Gale then gave his personal experience of his path into an academic career, giving a “how-to” guide too framing a research question, finding the supervisors and mentors to help develop your project and then how to find the grant money. It was encouraging to hear how perseverance is the key to obtaining the funding, and giving hope that somebody wold fund your project if you’ve had a good idea! The morning was rounded off by Professor Paul Dimitri trying to de-mystify the NIHR – not an easy task! It seems to be a very complex structure, and I can’t say I understand how they work completely, but I’ve definitely got a better idea of where to find more information now. There was also good formation on how to further an academic career as a trainee and consultant after completing your initial projects.
The afternoon included workshops from Dr Lauren Kier from the Wellcome trust, covering tips on grant application writing and how to secure that all-important funding, and balancing clinical and academic priorities through your training grades. Following this, there was a presentation covering developing a career in industry, and leaving clinical medicine. I can’t say this talk filled me with inspiration, but it was a interesting to hear the experiences of life outside of clinical medicine with a medical degree. The day was a rounded off with an entertaining talk from Professor Mike Levin, giving an overview of “A journey into research with no plan”, and how an inquisitive mind and a bit of serendipity can help forge an academic career. I’m not sure if the much more structured and formalised training career we have now, with portfolio and ARCP demands, would still allow such a career path, but it was interesting all the same.
I would recommend the Academic Trainees Day to anyone contemplating an academic training path or thinking about taking time out of training to do research. Also highlighted in the day was the RCPCH’s Academic Toolkit www.academictoolkit.org which is another useful resource for anyone wanting to know more about academic careers. The day highlighted the challenges and obstacles to an academic career, and how to start overcoming them, and was a good networking opportunity to learn of other peoples experiences. The day showed that an academic career can be a challenging one to start and maintain, but can be incredibly rewarding.
Dr Rebecca Broomfield
A summary of a year taken out of program to pursue an interest in clinical leadership.
During the last year I have spent my time as a Welsh Clinical Leadership Fellow. While we want to use this blog to promote research and education we also want to highlight opportunities that we have within Wales for trainees. The year as a Leadership Fellow was one of the hardest but most enjoyable of my career. I have blogged on here individually about some of the fantastic opportunities which I was able to attend. I encourage you to look up the posts on the Faculty of Medical Leadership and Management Leaders in Healthcare conference and the blog on the Neuroscience of Leadership course at MIT to name a few. In this summary post I want to give you an overview of why I think clinical leadership is so important and what this year involved
Why do it? Is it even important?
Leadership is everyone’s business. As you go through your career you will be but into leadership positions even if you don’t think that you are. Everybody within medicine is a leader in some way and therefore surely it is important to learn the skills to be a good one? We teach other things, procedures, history taking, interpretation of investigations so why not teach leadership? I believe there is some weight in the argument that leaders are born, not made in that some people will naturally gravitate to and thrive in leadership positions. But every leader can improve, and therefore good leadership can be taught. If as trainees we are given an opportunity to learn these skills then this can only be a good thing for the future of health care.
The Faculty of Medical Leadership and Management Trainee steering group is a fantastic resource for trainees. (https://www.fmlm.ac.uk/about-us/networks-and-groups/trainee-steering-group). They have just published a toolkit which outlines the importance of clinical leadership more eloquently than I can summate in this paragraph. It offers hints and tips to expand your own leadership styles without having to take a year out like I did. This can be found here: https://www.fmlm.ac.uk/members/resources/leading-as-a-junior-doctor
When I started this year, I anticipated that the patient improvement project which I had selected to do would be the complete focus of my attention but actually this was a very small part of the lasting impression I have from this year. My project was based within the medical education department at Cardiff and Vale Health Board. I worked with the simulation team changing the way which we collected feedback from our simulation courses, helping with the development of a new simulation suite, designing and leading new simulation courses and co-ordinating a innovative in-situ simulation program to tackle falls.
My supervisor Dr John Dunne was fantastic, alongside Miss Melanie Cotter they gave me freedom which I have not had in a structured training program to pursue my own interests and develop my project as we went along. Because of this I probably worked harder than I ever have, but also enjoyed work more than I ever did. My project actually became more of a tool in which to try out different leadership styles and the hints and tips we were learning as part of the PGCert in Leadership and management. It was successful and will leave a sustainable change within the medical education department.
As fellows we were all encouraged to take steps to select a project that was outside our comfort zone. While I did have a previous interest in medical education and simulation I am a paediatrican and a lot of my work this year has been done within adult specialities. The projects which we had very varied and extremely different but all offered the same opportunities and similar enough experiences.
This is the qualification which runs throughout the Leadership Fellow year. It is run by Academi Wales through Trinity St David University. The course gives you a qualification at the end of the year and is a big difference in Wales when compared to the clinical leadership opportunities offered in England, Scotland and Northern Ireland. There were structured sessions spaced throughout the year which were attended by a wide variety of participants outside the fellowship program (clinical directors, speech and language directors and dentistry leaders to mention a few.) These focused on a variety of different areas within clinical leadership. Teaching different leadership styles, exploring coaching qualifications and self reflection with tools such as Myers-Briggs. The best session was the team building session in Elan Valley – again on this site there is a blog post dedicated to this experience.
As a tip to this years Welsh Clinical Leadership Fellows – write your project up before you go back to clinical rotations! Right now, when I’m writing the essays, I wish I’d followed this advise from the year before me 😊
I have been able to develop myself more in this year than in the whole of training so far. I have had the opportunity to analyse my behaviour looking at my preferences, understand when they might not be the best option and how to make them work for me. I have been taught the tools to look at difficult situations from different perspectives and recognise that not everybody thinks like me! – This in itself seems simple, obviously not everybody thinks the same but I was really able to explore just how different other peoples viewpoints were. By being able to see and appreciate these, not necessarily agree, you can avoid a great deal of conflict and confusion. Resulting in, as well as from, poor leadership. But I was also taught how to deal with conflict, how to turn challenge and opposition into a unifying aspect rather than a dividing one. I have learnt to ask for forgiveness, not permission and have been given the confidence to express my opinion. I have explored my own personality and learnt to look after myself. I hope to work in the emergency department and these skills will be invaluable as I go through my career to increase my emotional intelligence and resilience.
It was HARD work.
The first few months finding your feet and trying to work out what direction you wanted your project to go in were really difficult. As trainees we come from very structured environments, rotating from job to job, thinking in 6 month blocks and ticking off targets to pass the ARCP. This year was different, at the start there were no targets, you had to make and develop them yourself. You had to become used to managing your own diary. Not having to clock in and clock out was very liberating but also intense. As a group we handled this either by working every hour never really clocking off, in order to justify our time or by spending a while drifting around not really achieving much with he vast amount of time offered to us. This evened out in the end as we learnt the skills which came with the freedom. It was your responsibility to create opportunities rather than somebody handing them to you. And networking is a skill which can only be achieved through practise and comes easier to some than others.
On a personal note, I was also away for large chucks of time from my family home. I have 2 small children aged 5 and 3 and part of this year was to have the flexibility to see them more frequently. I’m not sure I achieved that, being on a plane to Boston while my daughter was on stage at St David’s Hall in her first ballet show was a particular low point. (Thanks go to my Mum for stepping into that!)
The pros far outweigh the cons. I have learnt so much more about who I am. What is good about my leadership style but also what I need to work on. My biggest learning point from this year is to respond not react, something that I didn’t even recognise I was doing until this year. I have had the opportunity to develop a long lasting quality improvement project, which is sustainable even after I have left my post. But I worked hard, I created my own opportunities and spent less time with my family than I would have liked.
Would I do it all again? … Absolutely!
If you are interested in applying for the Welsh Clinical Leadership Year and want me information please do contact me, I’d be more than happy to chat over coffee.
Guest Blog from Dr Katie Greenwood ST8
Hello! Thank you WREN team for giving me the opportunity to share my experiences over the past few years with you.
Life as a paediatric trainee can be one of considerable stimulation, compassion, challenge and significant reward. The desire to deliver a very high standard of performance and achieve excellence within the workplace, has made me recognise the importance of developing exciting out of hours interests and achievements. Alongside working hard as a senior paediatric trainee, I have developed a passion for competing in triathlons and have participated in a number of challenging races across the world.
Where did it all begin?......…
A friend mentioned joining the Cardiff Triathlon club, apparently the fastest growing club within the UK. I pondered the idea of joining the team. Here are a few initial thoughts which crossed my mind:
- How on earth do people manage to swim/cycle/run within one race?
- Open water swimming in the UK sounded particularly un-exotic!
- How does a busy paediatric trainee fit in the training for this challenging sport?
After joining the club I started my racing career with a low key Cardiff “try-a-tri” triathlon and finished the same season with a race in the French alps….the famous (and brutal!) Alpe D’huez mountain climb. Oh dear!
From these moments on, I haven’t looked back! Over the past few years I have been fortunate enough to win both the Sprint and Standard distance Welsh Champion triathlon titles.
I have also been selected to compete for Great Britain (‘GB Age group Team’) at the 2017 World Triathlon Championships in Rotterdam and European Championships 2018 & 2017 in Estonia and Dusseldorf Germany. I was absolutely delighted to represent team GB and finish in the top 10 in each race.
So what does all this involve?
I would encourage everyone to enjoy a hobby outside of work and if you are interested come and join the triathlon club. Immense enjoyment can be experienced at every level and it is a fantastic way to meet new people and keep fit ready for the workplace!
Dr Chris Course
The European Respiratory Society held their annual Congress for 2018 in Porte de Versailles conference centre, Paris. The European Respiratory Society is a non-profit organisation which aims to promote lung health and drive standards for respiratory medicine globally. In addition to publishing the European Respiratory Journal and educational handbooks, the annual congress is the largest respiratory conference in the world, covering topics on respiratory health and disease from fetal life to old age.
Having registered months ago, (with an excellent discount on the registration fee for the honour of being under 40!) the congress program arrived in my inbox a few weeks ago, and to say it was overwhelming was an understatement. There were numerous concurrent sessions, across three floors of the conference venue, with special seminars and workshops on topics from non-invasive ventilation in adults, to bronchoscopy, lung ultrasound and inhalers for COPD. Having a paediatric/neonatal interest made it much simpler, as once you had filtered out all of the adult program, there was a manageable range of choices!
The whole conference ran across four to five days, with the majority of the paediatric program running across the middle three days. The quality of presentations was high, and the speakers were clearly eminent in their field. Despite being a “European” conference there were speakers from across the world. I had gone with Professor Sailesh Kotecha and members of the research team at the School of Child Health, Cardiff University, and Professor Iolo Doull from the Paediatric Respiratory Medicine team in Cardiff.
The first day we attended sessions on Prematurity and Lung Disease which included work presented by David Gallacher (Neonatal GRID trainee, Wales) from work he conducted with the School of Child Health at Cardiff University looking at pro-inflammatory cascades in the Preterm lung. Presentations also included work on Ureaplasma treatment for Preterms, animal models looking at effects of different durations of mechanical ventilation on long term alveolar structure and the Forced Oscillatory Technique for real-time assessment of preterm baby’s lung mechanics. The afternoon had an excellent Paediatrics Year in Review session looking at the top literature from the last year, the highlight of which was Dr Ian Balfour-Lynn (Royal Brompton, London) presenting the last year’s work on Cystic Fibrosis disease modifying drugs like Ivacaftor and Orkambi.
The second day started with the Paediatric Grand Round where challenging cases and unusual diagnoses were presented and discussed, and this brought a good contrast to some of the talks from the first day on mechanistic and translational science. This as followed later in the day with a Lungs on Fire session where quick fire case presentations and questions were put to a panel of experts and the audience with the opportunity for us to vote along – this gave me confidence that some timers no-one knows what the right answer should be! Another session looked at the infectious causes of wheeze and asthma and our current knowledge in their manipulation. Talks included work on the microbiome of the upper airways, and our current evidence base for the treatment of pre-school wheeze, and it looks like Montelukast is out again! A running theme across the first two days was the quantity of work looking at azithromycin for the treatment of a range of conditions, and although lots of the evidence was convincing, I was occasionally left wondering if it’s the current fashionable treatment or a drug with further unexplored potential.
The second day ended with the paediatric dinner, which started with a boat trip down the Seine, followed by dinner at the foot of the Eiffel Tower. This was a great evening and opportunity to escape the conference venue. As much as I enjoy a good conference, the inside of a presentation hall is pretty much the same wherever you are, and it was nice to get out and see a little of the City of Lights. Dinner was interesting (the starter consisted of a mixture of tuna steak and strawberries…) but so was the opportunity to meet new people from across Europe and the world.
The last day (slightly tired!) we got in nice and early, mainly because our posters had to go up! After a coffee and a croissant, we headed to the first session on Prenatal Origins of Respiratory and Atopic Disorders which included data from the COPSAC (Copenhagen birth cohort) studies and animal models looking at how maternal smoking, and interestingly “vaping” may affect offspring into adult life. It also highlighted the scientific, economic and clinical difficulties in managing such large birth cohort studies and how replicating results can be challenging. Following this, we attended a session on Advances in Primary Ciliary Dyskinesia. This covered pathophysiology of this rare and little understood disease and highlighted how genetic are changing diagnosis. However, it was rightly pointed out after the presentations that, much as with Cystic Fibrosis, the phenotypic variance of these genotypes is still not clearly understood, and the continuing importance of expert interpretation of histological samples and formation of centres of excellence to manage this condition.
We ended the ERS by having a walk through the exhibitors hall. There was a great ‘Game Zone’ where we could play with video laryngoscopes, bronchoscope and thoracic ultrasounds and it was great to have a go with bits of kits that we’d seen or heard about but had little experience with. Tutors were on hand thankfully to guide us through the finer details! We also had a look through the commercial and pharmaceutical exhibition areas, which looked more like a new car show at times (not sure a hologram is really required to advertise an inhaler) and there was a paucity of the free pens, but there were plenty of places to sit and have a quiet five minutes, which was much needed by this point!
Overall, the ERS Congress was a fantastic experience. Definitely the best organised, highest quality, best value meeting I’ve ever been to, and would thoroughly recommend to anyone with a respiratory interest.
Next year the congress is heading to Madrid, check out www.ersnet.org for more information
Faculty of Medical Leadership and Management Wales Regional Conference 2018
13th September 2018
Dr Rebecca Broomfield
While I have completed my year as a Welsh Clinical Leadership Fellow (Blog post teaser … more on that in Novembers posts!) I still very much have an interest in leadership and how we can rise to the current challenges facing the National Health Service. Therefore I was excited to learn that the FMLM were hosting a conference just up the road in Cardiff.
It was a heavily packed program and the day flew by in a flash. The FMLM Chief Executive Mr Peter Lees spoke to us about the aims and targets of FMLM and how they plan to achieve this.
He was followed by Wales' very own Chief Medical Officer Dr Frank Atherton who opened with "If we don't seize the opportunity as medical leaders …. who will?" He emphasised the need for whole system change not jus on an individual level and that as an NHS in Wales we do not simply need more. We need to harness ideas and bring them together. We need to keep patient safety at the centre of everything we do and bring those who resist change with us through the changes which need to occur.
Following the CMO is always a tough gig but it was managed superbly by Dr David Samuel (A fellow Leadership Fellow Alumni) and Dr Sian Lewis. They reminded us of the need for diversity in the workplace and within medical leadership teams. They asked us to do a tabletop exercise to emphasise this point. Each member of the team picked a O or a X card. We were not able to tell each other which symbol we were. Then everybody shut their eyes and the X's were instructed to open their eyes and read the instructions. The task was to plan a holiday but to do so without giving any value or time to the O members of your table. Then the O's reopened their eyes and the task of organising a holiday was given to the table. I was an X. It was incredibly difficult to ignore and not give value to peoples suggestions. It felt awkward and non productive to an effective team working environment. The O's felt undervalued, and eventually gave up suggesting things and went off into their own discussion, effectively planning a whole other holiday. The exercise was trivial but raised a good point - are you really inclusive in your leadership? Do you consciously or unconsciously bias against somebody and importantly how does that effect the team.
Post a quick coffee stop we heard from Mr Nigel Edwards (Chief executive, Nuffield Trust) about integrated care and Dame Clare Marx (Current Chair of FMLM, former President of the Royal College of Surgeons, soon to be Chair of the GMC and a dynamic powerful woman) She spoke about the importance of clinical leadership and the fact that we need to change. She suggested that we need to exchange hierarchy for connectivity and that clinical leadership can impact to increase quality, social performance and make financial gains. She believes that positivity has a big impact on your team and that we have a responsibility to coach clinical leaders and help people to develop themselves.
Following this we had the unique opportunity to have a panel discussion on current leadership challenges and how we can embrace them and continue to move forward within Wales. We asked for their key Leadership message:
Dr Frank Atherton - To use management experience from outside of Medicine and promote interdisciplinary working.
Dame Clare Marx - The only thing you can control in life is yourself, the way you work and the way you behave. Understand what it is you have the ability to control.
Mr Nigel Edwards - Connect what feels real, we are missing a narrative "tell a story"
After lunch we were encouraged by Ms Katie Laugharne (Head of Welsh affairs at the GMC) and Dr Madhu Kannan (Current Welsh Clinical Leadership Fellow within the GMC) to think about Leadership expectations and impact. How the things you do day to day have an impact and how small things, like tea!, can really matter. We were encourage to think about how our leadership style was viewed by members of our teams and if that was the way we wanted it to be.
After a quick coffee break we learnt from Mr Christian Servini about what the future generations act was enabling people to do in Wales and the impact this was having on Well-being. Then to end the day a quick fire 5 minute presentation round where we heard about improvement projects which were having an impact around Wales. My project (poster below) was one of those presented.
If you are at all interested in Clinical Leadership I would encourage you to take a look at the FMLM website and consider going to the annual conference. Leaders in Healthcare details of this can be found here: https://www.fmlm.ac.uk/events/leaders-in-healthcare-2018
Dr Annabel Greenwood ST3
This is the first (hopefully of many!) of a new blog feature entitled ‘a day in the life of….’
Rebecca and I thought the blog would provide an excellent platform to share experiences of various opportunities and achievements, including paediatric speciality medicine posts, and out-of-programme experiences, both academic and non-medicine related, inspiring readers to explore something new to enhance and enrich their paediatric training.
It gives me great pleasure to debut this new blog feature by sharing my experiences of paediatric oncology. Having just completed my 6-month ST3 post, there is absolutely no question that I would recommend it to my fellow trainees! I hope by the end of reading this blog some of the misnomers associated with the world of paediatric oncology will have been dispelled.
Now, I’ll be completely honest with you…when I was first given ‘paediatric oncology’ as my ST3 rotation, I was a little apprehensive to say the least. My previous exposure to oncology had been only brief encounters during out-of-hours speciality cover, treading water until handover. The complexity of the patients, the mind-field of chemotherapy regimens, and the ‘sick’ potential of the febrile neutropaenia patients is enough to induce a resting tachycardia just thinking about it right?! Let alone managing such situations!
Fast forward 6 months, and my feelings as I walk onto the ward each morning couldn’t be further from that overwhelming uncertainty at the outset. And these are just some of the reasons why;
1. Teamwork: The MDT on the paediatric ward is truly wonderful and you feel part of the ‘family’ in no time. The nurses and nurse specialists know everything about their patients and chemotherapy regimens, and are always happy to help, the play specialists have an incredible way of boosting morale and making what can sometimes feel impossible, possible, and the consultants are very ‘hands-on,’ supportive and approachable. I sometimes don’t know where I’d be without the knowledge and advice of the pharmacists, not to mention to the wonderful physios, dieticians, and psychologists.
2. Variety: There is no denying that paediatric oncology is one of the busiest jobs in the hospital. The days can be relentless and sometimes it feels like you spend hours sorting the smallest of tasks, yet it’s often the smallest things that can make the biggest difference to both patients and their families. No two days are the same, from daybed reviews to the ward management of both haematology and oncology inpatients…every day brings new challenges and experiences.
3. Organisational/management skills: New patients often need investigations and procedures sorting quickly, involving liaison with the anaesthetists, surgeons and radiologists. There is a weekly ‘lines list’ to be coordinated for insertion/removal of portacaths/hickmann lines, and there is a weekly ‘planning meeting’ to discuss and arrange patients to be admitted for chemotherapy, investigations or procedures.
4. Practical procedures: There is a small theatre room on the ward for the weekly list of bone marrow aspirates, lumbar punctures and intrathecal chemotherapy. This is primarily led by the consultants and registrars.
5. The management of sick kids: Oncology and haematology patients have the potential to get really sick, quickly. Neutropaenic patients on chemotherapy can become profoundly septic, and sickle cell patients can present in an acute crisis. Coordinating the management of such patients although stressful, is excellent preparation for transitioning to middle grade training. There are protocols for the management of various situations, and as mentioned previously, there is always support provided by the consultant.
6. Emotional aspect: One of my principal anxieties before starting the rotation was how to handle the emotional aspect of the job. Of course, there can be devastating situations where treatment is unsuccessful, however, the kids are incredible, so resilient and courageous, and certainly serve to put things into perspective. Many of the children return to the ward on a regular basis for reviews and chemotherapy, so you really get to know the children and their families, and play a significant part along their treatment ‘journey.’
Of course like most jobs there can be days where there is no spring in my step along the ward, however, the positives far outweigh the negatives, and I am so grateful for the opportunity to experience such a truly wonderful job.
If you've done a unique job and want to share your experiences as a blog post then email either Rebecca or Annabel to share different experiences.
‘The Palliative Care Journey: Managing Uncertainty’
Guest blogger Dr Tim Warlow
All Wales Paediatric Palliative Care Network
Following the success of last years All Wales Paediatric Palliative Care Network Conference, the team are excited to introduce the much anticipated 2018 conference. This year we will be exploring the palliative care journey from the perspective of the child and family. Hearing from the families themselves, the day will follow their journey from diagnosis through to bereavement. Some of the questions we will be asking include:
• When should palliative care be introduced and how do I raise the issue with families?
• How do I support families whilst making difficult decisions about their child’s care?
• What are the spiritual needs of families at the end of their child’s life?
• How do I manage difficult and unfamiliar symptoms at the end of life?
• How do I approach uncertainty and grief?
• How can Ty Hafan Children’s Hospice help me to provide holistic care to families?
When working with families of sick children, many of the most challenging issues we face are also the most rewarding when done well. This day aims to unveil those daunting aspects of care, provide ample opportunity for discussion, and hearing from the expert parents and professionals as to how we can serve our families better.
The morning will focus on introducing palliative care and decision making, especially relevant in light of recent high-profile media cases. We will consider how we can involve children better in decisions relating to their care, collaborating with families to ensure they feel listened to and valued whilst navigating legal and ethical uncertainties.
Next we will hear from families of children with life limiting conditions themselves. What were the most challenging times, and what actions of professionals were key to their palliative care journey? What was helpful, what was harmful? We will consider how each professional on their journey played a key role in ensuring excellent holistic palliative care and what we can learn from one another.
Finally, the afternoon will include a series of breakout groups to provide opportunity to really get stuck in exploring an aspect of the palliative care journey that is a priority for you. There will be time to discuss and ask questions in a smaller group setting. Topics include supporting children and families at the end of life, managing difficult symptoms, supporting grief, bereavement and spiritual care, and how to support staff including debriefing.
Last year’s conference was booked up quickly and over 100 delegates had a fantastic day. Now in its fourth year we have built on the lessons of previous years, responded to your feedback, and produced a day which promises to be challenging, rewarding, and a fascinating insight into the lives of our patients and families through their own eyes.
Here is some feedback from last year’s conference as a taster of what delegates took away:
“Learnt many new things. Was challenged on preconceptions and pre-existing myths of Palliative Care. Enjoyed the professional, but personal element for some speakers / discussions.”
“ Excellent day from start to finish, sessions we interesting, informative and thought provoking.”
“I was hooked from start to finish”
“The case studies/discussion groups with the panel of different professionals involved with the neonate and their families’ journey were excellent and thought provoking. These were great for learning about how processes can work well and can adapt along the way.”
We look forward to you joining us in October
Date: 18th October 2018
• Location: Park Inn by Radisson Hotel, Cardiff City Centre
• Cost: £32 per person (£16 subsidised tickets available for students and upon individual request)
• Bookings and information: email@example.com
9th-10th July 2018
Dr Rebecca Broomfield
The Patient Safety Congress aims to transform the UK’s approach to delivering high quality care. It champions patient safety as the organising principle of a healthcare system which is truly efficient, effective and able to offer the best experience to patients and carers.
I was lucky to be able to attend the Conference in Manchester in July. Prior to attending I had minimal experience with the Health Service Journal who sponsor the event and although clearly focusing my training and clinical work on optimising patient safety I knew very little about this movement within healthcare. The HSJ run awards and publish a journal purely focusing on and publishing patient safety initiatives and ways which can all make out practice patient focused and as safe as possible.
The conference was busy and if I am completely honest the timetable when I first looked at it was completely overwhelming. There was key note lectures which drew the participants together and then 5 streams running throughout the 2 days which you could dip in and out of to cover the sessions which most interested you and met your personal learning needs. Along with an exhibition centre and poster presentations focusing on 9 different topic areas.
Unfortunately due to childcare compromises (working parent problems!) I wasn’t able to travel up to Manchester until the Monday morning so missed the opening keynote speakers which I was reliably informed were excellent and predicted the exit of The Right Honourable Jeremy Hunt from his health secretary post, but unfortunately the predicted replacement Dr Kevin Fong turned out to be less accurate!
When I arrived I set up shop in the Human Factors stream. The streams for day 1 were: Human factors, Delivering quality improvement on the frontline, Driving a culture of patient safety, Improving patient safety through governance and compliance and finally Bridging the gap: policy and clinical Practice. The human factors stream was chaired by Martin Bromiley OBE (@MartinBromiley) of medical “Just a routine operation” fame https://www.youtube.com/watch?v=JzlvgtPIof4 – if you don’t know who he is or his story as a healthcare professional then you really should so click on the youtube link and learn about it.
What is human factors?
As defined by NHS England Human Factors for healthcare are: “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”.
Essentially it is about
Making it easy to do the right thing
The stream started well and I very much enjoyed hearing from 3 speakers talking about how they had introduced human factors within their areas or work and outlining the importance of doing do. Dr Shelly Jeffcott (@drjeffcott) spoke first about the importance of human factors and outlined some goals.
She emphasised designing the systems so that it is easy to do the right thing and the importance of integrating human factors training in the medical workforce. Education for Scotland have developed an e-learning package on human factors. It is easy to create an account and access this at:
Next up in this session was Mr Simon Paterson-Brown (@spbsurgery) he spoke about the use of training within a surgical environment to develop non technical skills. His sessions Non-Technical Skills for Surgeons have international acclaim and have been widely published. Finally the session ended with Professor George Youngson (@ggyrach) whop focused on thE impact of bullying and discrimination in care systems. Bullying is a huge problem in the NHS and this was outlined during this session Professor Youngson identified that it is still a problem and has done work proving its detrimental effect on patient safety. He encouraged us to speak up for safety and ensure that bullying was addressed in our departments.
The stream then moved onto the nudge theory and how we can use this within the NHS.
Helping people to make the right decision at the right time thus improving patient safety. During this session there was talk about the noble prize winning book “Thinking fast and slow” by Daniel Kahneman looking at the way people make decisions and how the nudge theory exploits this. By understanding how people behave we can design better policies and systems to improve patient safety. The EAST framework was suggested here: Easy, Attractive, Social and Timely. Any change in behaviour should fit into this framework. And where there is variation in practice it offers a good target for change.
After lunch I remained in the Human Factors stream and the session delivered by Abbie Coutts and Professor Bryn Baxendale (@gasmanbax) focusing on situational awareness. During this session it was the first time in this conference that I was exposed to a patient story being used to demonstrate a learning point. This is something which was utilised through the conference, across many different streams and had a truly powerful impact. Abbie Coutts presented her father’s case and observations on why errors occurred.
She has used the errors in care which happened to her father to teach the health board which cared for him about human factors. She suggests that this should be taught by people doing the job and understand why errors happen in order to address them rather than just how they happened. Professor Bryn Baxendale then spoke about balancing acts and how to embedded key skills and behaviours into practice. Both speakers focused on normalising excellence and doing the simple things well.
The fourth session in the human factors stream again used a patient story presented by Kathryn Walton https://www.youtube.com/watch?v=r7gk1AvZKZA We heard from the patient, the healthcare worker and what happened afterwards. I would encourage everybody to follow the link about and listen to the story. This was an exceptionally emotive story and emphasised.
The final breakout session I attended was delivered by The GMC within the Driving a culture of patient safety stream who presented a discussion on the GMC survey and understanding this data in relation to patient safety. The keynote to end day one was delivered by Professor Alison Leary (@alisonleary1) and focused on the fact the “Hope is not a plan” and within medicine what we can learn from other safety critical industries. Professor Leary presented an the fact that the very structure of the NHS is significantly different to other safety critical industries in that we place our most junior inexperienced staff at the front line closest to the operational risk, with the experienced workforce behind the scenes. This is in contrast to other industries who use their experienced work force next to the operational risk and use them to allocate selected work to the junior teams. In the NHS we need to be focusing on rewarding frontline experts to stay where they are on the shop floors rather than moving them further and further away into managerial positions. We need to use good policy and education where the expectations are clear and safety is mandated alongside clear credible leadership. Her closing statement was particularly poignant and a quote from Dr Tracy Dillinger NASA “People defer to hope, but when failure is not an option, hope is not a plan”
We went out for dinner in Manchester as a group of leadership fellows and I can 100% recommend The Alchemist for cocktails because they are fantastic, and for those based in South Wales one has just opened in Cardiff (yay!).
Back to the conference ...!
Day 2 opened with the prize giving for the poster competition. I entered 2 posters and this one won its category of ‘Education and Training’ Proof that if you do an interesting improvement project then it’s always worth popping it into a conference because you never know how far it might go.
The keynotes opened with Dr Bill Kirkup presenting themes which happen when things go wrong and how we should use these to make sure that as organisations we do not get into situations where things go wrong. He identified the follow themes:
- Failure to learn
He ended with 5 key points for maintaining patient safety:
- Listen to the patient, they are telling you the answer
- Honesty not reputation management
- Investigate and learn – not suppressing bad news and learning from others mistakes
- Dismissing and denial leads to a slippery slope which is harder to stop
- Do NOT think “It will never happen here”
The second keynote was also focused on investigations but from the Healthcare Safety Investigation Branch and what we can learn from the investigations which they have already processed. It is worth reading the summary documents of these investigations as it is different from a root cause analysis which will take place internally. They look at the route cause but also ask “why?”
Again day 2 was split into streams. The 6 streams on day 2 were: Collaborating to achieve patient safety, Delivering improvement on the frontline, Using research to solve the big challenges, Prioritising safety for vulnerable people, workforce the crucial ingredient for safety and Bridging the gap: Policy and the clinical practice. I attended Leading from the top: New research on trust level leadership under the using research to solve the big challenges stream. I left this session feeling quite negative. The panel presented learning which they felt had happened since the Frances Report. Which seemed to be, in their opinions, very little. They appeared to feel that this was a continuing problem with variability in quality and consistency of leadership practises. I feel (esp. as a current leadership fellow) that the Wales deanery is actively promoting and encouraging learning about clinical leadership. And I would signpost anybody to the FMLM website if they want more information on clinical leadership. https://www.fmlm.ac.uk/
I then attended the LEDER program, http://www.bristol.ac.uk/sps/leder/, focusing on what needs to change for people with a learning disability in order to ensure their safety, under the Prioritising safety for vulnerable people. Again this focused on a patient story presenting the experience of the family of Oliver McGowan. (@PaulaMc007) They are campaigning for mandatory training for healthcare professional in how to adapt for patient with autism and learning difficulties. They want to work on preventing these stories and raise awareness for people to make reasonable adjustments. They encourage communication, an overriding theme from this year, with the patients, and their families as they know the patient best.
Then, before lunch I moved into the Workforce stream to hear from Leigh Kendall (@leighakendall) Again this presentation focused on a patient story presenting Hugo’s story focusing on preventable harm within a maternity setting. Hugo was born after Leigh suffered from HELLP syndrome at 24 week gestation and lived for 35 days. She is working on improving bereavement information and including bereaved families in the quality improvement processes, alongside communication between healthcare professionals. She again encouraged communication and stated something which will stick with me “You can’t upset us anymore because the worst has already happened” Don’t be afraid to speak to bereaved families they can give you vital information and want to have a voice. Mr Edward Morris then presented the work of the Royal College of Obstetricians and Gynaecologists on Each baby counts (@EachBabyCounts) again focusing on patient stories and human factors to encourage a focus on communication and preventing harm. https://www.rcog.org.uk/eachbabycounts
After lunch the conference was again brought back together for keynote sessions. The CQC Chief inspector of Hospitals, Professor Ted Baker, presented an evidence based argument for how Inspections can help us with patient safety. He encouraged us to engage and empower frontline staff to really focus on patient safety and put patients at the centre of what we do. He reminded us to “relentlessly focus on leadership and culture” but also to recognise that healthcare is a high risk area and we have to accept the implications of that fact. He believes that with backing the inspection process can be used to drive forward a culture of patient safety.
The Right Honourable Jeremy Hunt MP was due to present next in his role of Secretary of State for Health and Social care, but as he had been relocated and Matt Hancock (@MattHancock) had been in the job for less than 24 hours Professor Bruce Keogh and Dr Aidan Fowler from 1000 Lives stepped up to be part of a panel for the next steps for patient safety.
The conference closed hearing from a panel about how their organisations overcame safety challenges. The overriding themes were again all about culture, communication and mindset. If you can get this right then you seem to be on the right track!
The Patient Safety Congress was a fantastic, engaging conference and if you get a chance to go I really would. The use of patient stories to focus the attendees was a really useful tool and one which I will take forward with other presentations in the future. It was a really important reminder that we do have the opportunity even as trainees to focus on patient safety and improve outcomes.
Guest Blogger Dr Jordan Evans
N Engl J Med 2018;378:2275-87.
If there’s one thing we all know about manging diabetic ketoacidosis (DKA), it’s the importance of being extremely cautious with fluid management due to the risk of causing iatrogenic cerebral oedema right?...Wrong! Once again, like John Snow, we unfortunately ‘know nothing!’. When will the childhood lies end, Father Christmas isn’t real, the Easter bunny’s not real and now this, the most painful blow yet.
In this PECARN (Pediatric Emergency Care Applied Research Network) study, published in the New England Journal of Medicine, Nathan Kuppermann et al investigated the influence of intravenous fluid administered on the rates of neurological injury in children with DKA.
What was the reason for the study?
Brain injury occurs in the region of 0.5% - 1% of DKA presentations. It presents with sudden neurological deterioration. Patients without a marked neurological deterioration may have more mild neurological impairments e.g. memory / cognitive impairment. As all of us were likely taught, brain injury in DKA has long been thought to be iatrogenic, secondary to fluid administration causing cerebral oedema due to osmotic gradients. The evidence for this school of thought is however lacking and evidence has emerged actively disputing it. Alternative explanations have been proposed that there may be something about being particularly unwell with DKA that leads to the neurological injury, possibly inflammatory or vascular changes. The more unwell the patient is the more likely they are to require fluid resuscitation and therefore an association between severe DKA with brain injury and fluid administration could be mistaken as causation. Remember that association is not proof of causation! Oedema may develop secondary to the brain injury itself as it does in other mechanisms of injury such as trauma.
Where did the study take place?
The study was conducted across 13 centres in the United States.
Who did they include ?
Children aged 0 – 18 years with a diagnosis of DKA (pH < 7.25, glucose > 16.7 mmol/L. Children with GCS <12 were excluded two years into study (due to concerns of treating clinicians).
What did the investigators do?
Children presenting to study centres with DKA were randomly assigned to one of the following four groups;
1) 0.9% saline fast administration
2) 0.9% saline slow administration
3) 0.45% saline fast administration
4) 0.45% saline slow administration
The fast group were given a 20ml/kg bolus which was then followed with replacement of a 10% fluid deficit with the first half of the deficit volume being replaced over 12hrs and the rest over the next 24 hrs.
The slow group were given a 10ml/kg bolus which was then followed by replacement volume for a 5% deficit which was given over 48hrs.
The primary outcome was a decline in mental status (GCS <15 on two occasions within first 24 hours of treatment. Patients and parents were blinded but not the clinician.
Secondary outcomes; clinically apparent brain injury (neurological deterioration leading to clinical decision to treat for raised ICP, intubation or death), short term memory, memory & IQ at 2 months and 6 months.
What were the results?
4912 patients met the inclusion criteria. Due to the complexities of the study of these there were a total of 1389 episodes of DKA included in the study (from 1255 different children). There was a fall in GCS in 3.5% of these epsiodes (48 episodes). There was clinically apparent brain injury in 0.9% (12 episodes). There was no difference between the two groups for any of the outcomes. (Some of the raw results favoured the fast fluid administration group although none of these results reached a statistically significant level).
Kupperman et al. rightly concluded that ‘Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis’.
Take home message for practice in Wales
1. We no longer need to be as anxious about giving fluid too fast in DKA
2. If you need to give a bolus for shock do so without fear of causing cerebral oedema, this study provides evidence that it’s not harmful.
3. With regards to the fluid deficit replacement although this study shows we could safely give it a little faster stick to current practice of the Wales DKA protocol as it doesn’t show any improvement in outcomes for the faster administration of IV fluids.
4. It’s worth remembering that there is good evidence for using 0.9% saline for maintenance IV fluids in children (to prevent hyponatraemia) so it’s not clear why they chose to have arms in this trial with both 0.9% saline and 0.45% saline.
Guest blogger Dr Sandheeah Ramdeny
Over The Wall, is an amazing activity camp which is free for children, teenagers and family who are living with serious health challenges. It is a national charity which provide support to kids who are faced with seious health challenges through transformational residential camps across the UK. There are different camps which take place at different times of the year some of the camps focused mainly on the kids living with serious health problems some on the siblings and some on the families. These kids who lives with their health problems are mostly affected by their illness and are unable to participate in fun activities normally enjoyed by their friends and peers. Consequently, these kids then have a reduced self-esteem and self-confidence which can negatively impact on their growth and their development.
The main purpose of Over the Wall, is to tackle these issues to allow a transformational change to occur in a safe environment with medical professionals being around to provide the medical care that they need so that the campers return with a new sense of their abilities and ambitions and improved self-confidence.
I choose to take part in the health challenge camp which was mainly focused on the kids with serious health challenges which took place in Strathallan, a really nice boarding school located in Perth, Scotland with breath taking landscapes. The medical team were named the ‘Beach Patrol’, which consisted of 5 paediatric Spr, on GP, one paramedic, two nurses. The camp lasted for a week and the first few days were mainly centred around simulation scenarios to deal with the different cases which could arise whilst in camp as well as becoming familiar with the medical condition of the campers and to learn about their individual management plan. There were around 60 campers with a wide range of medical condition ranging from Type 1 diabetic, ALL, sickle cell disease, cerebral palsy, medical condition requiring bowel washout, Haemophilla, Marfan syndrome, Noonan’s syndrome, DiGeorge syndrome, kids with heart failure, patients on daily chemotherapy. Our normal day would start at 07 30 am in the morning and end around 2230 with 2 of us taking turns to do a night shift to provide cover each night. As the medical team, we were involved in giving the campers their medication before breakfast, during lunch and dinner time and accompanying the campers whilst they were carrying out their activities such as ensuring the young Type 1 diabetic would have their blood sugar level monitored and insulin administered accordingly. Each one of us would be closely attached to a camper who could potentially become sick so that we would be able to keep a close eye on them and we would accompany them to all the activities.
Most of the activities were based on the campus of the boarding school. For instance, each day would have activities planned such as archery, music, drama, swimming, arts and crafts. These activities would be focused to allow them to realise their potential and us trying to make them believe in themselves and go beyond what they can do. The evenings were based mainly on Talent night where the campers would do an interesting act, play, dance or music to demonstrate each of their talent.
There was one day, when the whole team went to Edinburgh to go to the international climbing arena. This was an excellent opportunity to allow campers to reach beyond their capabilities. For instance, on the camper in my group, a lovely 8 year old girl, who was afraid of heights and did not want to attempt any climbing. However, when she saw the other kids having so much fun and me being by her side telling her that I would be here and she could just attempt to climb and that she didn’t have to go too far. She was initially reluctant but the finally agreed. When she started climbing., she realised that she wasn’t scared anymore and was able to climb. When she got down, she was very emotional as she was now able to do something that she could not do. She said that she would never forget this experience.
Some of the statements of the campers from Over The Wall, “It is no exaggeration to say that my experience with OTW was on the best weeks of my life. It Is true what they say.”
To me, I do believe that Over The Wall provides an amazing opportunity to allow seriously ill children to go beyond the boundaries of their illness and have a positive impact for the rest of their life.
For more information go to www.otw.org.uk
Dr Rebecca Broomfield