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When Not to be a Doctor

Hayn.2015“Now you know. And knowing is half the battle.” As a child growing up in the 80’s, I heard this line at the end of every G.I. Joe cartoon show. But what if knowing doesn’t really help?

As a urologic oncologist, I (try) to know as much as possible about urology and urologic cancers. I counsel patients about their diagnosis, treatment, and prognosis. I give them facts and statistics, quote predictive nomograms, describe operations, draw pictures, and give them my expert opinion. I would like to think that I am being helpful.

But am I really helping? Do patients and family members really want all of that?

Twenty years ago, my mother-in-law had breast cancer. She had a lumpectomy, chemotherapy and radiation. She “cured” and went on with her life. Her cancer was mentioned occasionally, but only as a remote event. We mostly forgot about it.

Then, 4 years ago, she felt a lump next to her breast. Eventually it was biopsied – recurrent breast cancer. She saw the experts at my hospital. Bad news – the cancer had spread (in a big way) to her liver.

We were all devastated, especially my wife. After 10 years away, she had just moved back to New England. She was looking forward to spending more time with her mom and her family. Cancer had reared its ugly head, and turned that all upside down.

What did I do? I did what I thought would be helpful. Looked up treatment options. Looked up 5-year survival estimates. I gathered information. Lots of information. This turned out to be an unmitigated disaster. It did not help my wife. It made things worse.

In 2014, Paul Kalanithi, then a Neurosurgery resident at Stanford, wrote a great piece in the New York Times about his advanced lung cancer diagnosis.

His basic message – don’t obsess over the numbers. Live your life. Get on.

I had failed my wife in that moment by acting like “a doctor”. She didn’t want numbers or survival estimates. She wanted me to act like a husband and friend. She wanted sympathy, a hug, and a shoulder to cry on. She wanted me to acknowledge how much it sucked that her mom had cancer.

In the end, patients want both, and they need both. They need expert advice and “the numbers”. More importantly, they want and need compassion and empathy. Thankfully, my mother-in-law continues to do well to this day.

Communicating both of these effectively will make me a better doctor, a better husband, and a better person.

 

Dr Matt Hayn

Medical Direction, Genitourinary Cancer Program

Maine Medical Center

Portland, Maine

@matthayn

 

Face to interface

Cast your mind back to college physics and recall that an interface is a boundary between two phases of matter, for example gas and liquid. The interface is where interaction occurs between the disparate parts, there may be an exchange of molecules, or a conversion of molecules from one state to the other such as evaporation. Information, such as light or sound is always upset when it reaches an interface and some of the message may be bounced off while some is transmitted across the interface to the other state. This is why we might see our reflection in a pond, as some of the incident light bounces of the liquid interface and back to our eyes. So far, so dry and irrelevant.

If we think about interfaces between people, the equivalent to phases of matter is two disparate minds attempting to transmit information across the interface of human communication. It seems logical that minds that are more familiar and perhaps similar due to experience and level of sophistication lose less information due to reflection (think of the ease of communication between close family members versus explaining theoretical physics to a three year old).

There is always an interface with communication, be it speech, gestures, semaphore, or Twitter. Our intention is to effectively get across sufficient information to understand and be understood. Each modality has pros and cons, for example a letter allows a distillation of thought and a poetry that is absent in a phone call, while Skype allows you to see a loved one in real time. Due to a lack of vocal inflection, facial expression, and physical gestures, many public figures have claimed a misunderstanding after making inflammatory statements on social media.

We certainly are getting used to communication through physical separation. The ability to keep in touch when you want to while geographically apart is undoubtedly a boon, and in the medical sphere isolated patients are benefiting from teleconferenced and video-linked consultations, along with podcasts, tweets, and YouTube videos that make medical advice more and more accessible.

But here is the problem. The interface between a doctor and a patient has a very high surface tension. That means that information struggles to breach the membrane from doctor to patient and vice versa. Without conscious effort, by default information thoughtlessly spouted will bounce off and be lost. The minds of the doctor and patient are usually disparate, with one an expert in their own experience of a disease, and the other an expert on pathophysiology and evidence based practice. Both are complex subjects, difficult to communicate to the non-expert in the conversation. With the addition of a screen, or phone line to the interface, we have to beware of the surface tension becoming impenetrable. As medicine becomes increasingly electronic, we need to remember that dispensing advice to the internet is different from communicating with a patient. Every communication interface has its weakness, and we need to be aware of avoiding pitfalls that compromise care. Humour often does not work as well in an email as it would in person, accompanied with a cheeky grin. Speech over an internet connection may be distorted, intermittent, and as a result, irritating to listen to, making us want to curtail conversations prematurely. To shamelessly direct you to my other work on the role of technology in medicine and life we need to add value as doctors above what a digital algorithm can provide to justify our work.

Why? The usual arguments (it is good business to keep the client happy, specially if you use Salesforce help, the prestige of being a preferred doctor, the opportunity to expand ones sphere of influence), but also I think most of us sacrificed our youth training in order to make people better, and we cannot do that if patients cannot hear us.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

Article of the week: Surgical safety checklist for robotic surgery

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development and content validation of a surgical safety checklist for operating theatres that use robotic technology

Kamran Ahmed, Nuzhath Khan, Mohammed Shamim Khan and Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, UK

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OBJECTIVES

• To identify and assess potential hazards in robot-assisted urological surgery.

• To develop a comprehensive checklist to be used in operating theatres with robotic technology.

METHODS

• Healthcare Failure Mode and Effects Analysis (HFMEA), a risk assessment tool, was used in a urology operating theatre with innovative robotic technology in a UK teaching hospital between June and December 2011.

• A 15-member multidisciplinary team identified ‘failure modes’ through process mapping and flow diagrams.

• Potential hazards were rated according to severity and frequency and scored using a ‘hazard score matrix’.

• All hazards scoring ≥8 were considered for ‘decision tree’ analysis, which produced a list of hazards to be included in a surgical safety checklist.

RESULTS

• Process mapping highlighted three main phases: the anaesthesia phase, the operating phase and the postoperative handover to recovery phase.

• A total of 51 failure modes were identified, 61% of which had a hazard score ≥8.

• A total of 22 hazards were finalised via decision tree analysis and were included in the checklist.

• The focus was on hazards specific to robotic urological procedures such as patient positioning (hazard score 12), port placement (hazard score 9) and robot docking/de-docking (hazard score 12).

CONCLUSIONS

• HFMEA identified hazards in an operating theatre with innovative robotic technologies which has led to the development of a surgical safety checklist.

• Further work will involve validation and implementation of the checklist.

 

Read Previous Articles of the Week

 

Editorial: Sergeant, do you copy?

In the Institute of Medicine report published in 1999, it was estimated that 44 000–98 000 patients died annually from preventable medical errors. It was further reported that the annual burden on economy due to preventable medical errors was anywhere between 17–29 billion American dollars. In the USA federal budget 2000–2001, the entire federal resources devoted to general science, space and technology was 19.2 billion American dollars: ≈10 billion less than the cost of medical errors (Fig. 1).

Figure 1. The magnitude of problem caused by medical errors. USDs, American dollars.

On root cause analysis of the errors identified in the Joint Commission on Accreditation and Certification database (2011), it was reported that most of these errors are non-technical, i.e. human factors (72%), leadership (65%), communication breakdown (61%), etc. Furthermore, Greenberg et al. studied the patterns of communication breakdown on the Malpractice Insurers’ Medical Error Prevention Study (MIMEPS) database and concluded that breakdown patterns were similar preoperatively (38%), intraoperatively (30%) and postoperatively (32%). Most errors were due to miscommunication within a single department (78%), as compared with across departments (19%) or institutions (3%). In 49% of the cases, the information was never relayed and in 44% the information relayed was not comprehended appropriately. In all, 29% of these errors involved a surgery attending at transmitting end and 56% at the receiving end of information. In all, 85% of these communications were verbal.

In this issue of BJUI, Ahmed et al. have used the Healthcare Failure Mode and Effect Analysis (HFMEA) model to design a safety checklist specifically for robotic procedures. Checklists have been heavily used in high-risk environments that involve complex technology, e.g. aerospace and nuclear engineering. Robotic surgery is another such high-risk environment, where intraoperative communication is critical. When a surgeon performs a robotic surgery, (s)he is not standing next to the patient (and occasionally not even in the same room!) and relies heavily on his/her assistant. Additionally, the bulky robot takes most of the space around the patient. Small movements of the instruments can cause abrupt and exaggerated movements of the robotic arms, which might injure the bedside assistant, anaesthesiologist, or the patient himself. Last, but not the least, there is a memory clutch on the robotic arms, and its purpose is to ‘remember’ the position of the arms while exchanging the instruments. However, if this clutch is pressed by mistake, all memory is lost and careless insertion of an instrument at this time, making an assumption of memory, can be dangerous and can cause serious injury. The safety checklist described by Ahmed et al. is one of the first checklists specific to robotic surgery. In parallel to this, the Fundamentals of Robotic Surgery (FRS) inter-disciplinary consortium led by Dr Richard Satava has also developed a checklist, specifically for robotic surgery. It will be interesting to study the actual impact of these checklists on prevention of medical errors in robotic surgery. Similar checklists have been validated showing significant clinical correlation using in situ simulation for obstetric emergencies.

Although checklists do help to a certain extent to prevent serious errors, the basics of communications must not be forgotten while communicating to a colleague about patient care. There should be no ambiguity about who is the ‘transmitter’ and who is the ‘receiver’ of information. Both the ‘transmitter’ and ‘receiver’ should have a shared mental model about the purpose of communication (‘transmitter’ is seeking guidance, giving orders, asking for an opinion, referring a case, etc.). Finally, closed-loop communication should be a part of protocol where both the ‘receiver’ and ‘transmitter’ acknowledge the receipt of information, e.g.

Console Surgeon: ‘Please replace the scissors in the right arm with the needle driver’.

Assistant: ‘OK, I am replacing the scissors in your right arm with a needle driver’.

Console Surgeon: ‘Go ahead’.

Assistant: ‘Needle driver coming in’.

Console Surgeon: ‘Perfect. Thank you’.

 

Sanket Chauhan and Robert M. Sweet
Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA

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