How to be… a conference chair

Cite this article as:
Ian Summers. How to be… a conference chair, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12545

You check your in-box and there it is, another e-mail from one of those pesky conference organizers. You make sure it is not just a repeat of the one about being a Twitter moderator but this time  the tag line is different.  “Dear X, would you be interested in being a chairperson for a session at our upcoming conference?” Again it is time to hit up some friends for their words of wisdom.

DFTB go to Berlin – #SMACCmini

Cite this article as:
Tagg, A. DFTB go to Berlin – #SMACCmini, Don't Forget the Bubbles, 2017. Available at:
https://dontforgetthebubbles.com/dftb-go-to-berlin-smaccmini/

Having flown 16,893 kilometres to visit family, a short hop over the Berlin was nothing. This year Tessa and I were honoured to be able to help out with SMACCmini – the paediatric workshop before the main event.  DasSMACC is the second-most* anticipated conference of the year and we wanted to make sure the delegates left better able to look after critically unwell children.

Supervision

Cite this article as:
Henry Goldstein. Supervision, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12157

I’ve been lucky enough to be one of the few paediatric registrars allocated to an Adolescent Inpatient Mental Health ward for a 6 month rotation. Although I’d worked in (adult) Psych wards before, I had few well formed ideas about psychiatric theory or practice past how to “do a takedown”. In Shem’s House of God, the future psychiatrist repeatedly states that “Good medicine as doing as much nothing as possible”. Until this term, I wasn’t entirely sure what that was, and knew even less about what to expect when it came to the care of young people.

As this opportunity is becoming rarer by the year and the rarefied air of Inpatient Adolescent Psychiatry is far removed from most paediatric practice; this is the second post in a series aiming to help understand the work (and underpinning theories) seen on the inpatient unit. 

Several months in advance of my rotation through Adolescent Psychiatry, there was much made of term supervisor allocation. I was pleasantly surprised on arrival into psych that the approach to mentoring and clinical supervision is quite different from that in paediatric training.

It’s worth pausing to reflect on the origins of medical training; until Osler introduced the intern/resident medical officer – style system we use today, much of medicine was a 1 on 1 apprenticeship. Some, including Dornan, have argued in favour of a “new apprenticeship model”; but for most trainees, as we change rotations, roles or hospitals on a regular basis, a longstanding, whole-of-training supervisor might feel like a pipe-dream. In this respect, psychiatry was not particularly different to paediatrics, but, in general, the approach to supervision was quite apart from what I’d previously experienced.

What happens?

Each member of the team, from case manager to consultant psychiatrist is allocated a senior supervisor. The pair is scheduled one hour of protected one-on-one time on a weekly basis. This is enshrined in the RANZCP program, which stipulates “Of [the 4 hrs/wk clinical supervision], a minimum of 1 hour per week must be individual supervision of a trainee’s current clinical work.” I can’t think of any other clinical job I’ve done where there is this kind of opportunity, let alone mandatory requirement!

 

What is this mean?

This tremendously augmented my education and overall experience from what could easily have been a paediatrics trainee “just muddling through” to being a functional member of the team, able to work independently in clinically challenging situations. Although I’m speaking of my experience, the general principles that this kind of supervision fosters, include establishing and maintaining an active/mentoring role, frequent contact, open dialogue, identifying opportunities for learning and discussion about multiple domains of practice.

A good mentor and active supervisor means much more than reducing the likelihood of the awkward end-of-term assessment most of us have endured in our junior years. By it’s nature, my experience of supervision in psychiatry was more immediate and active. The supervisor and trainee would see several patients together each week and discuss the clinical interaction.

I believe it possible to parallel this in medical specialities, as it is a key part of a consultant ward round. It is, however, something that must be actively held in mind by the supervisor, in addition to patient care. Interestingly, in 2004, a Danish group published a validated checklist assessing ward round performance in internal medicine. Although this kind of tool, along with other standardised forms, undoubtedly have their place for objectively measuring skill attainment and improvement, the many aspects of medicine that are learned from mentoring are often numerically elusive.

Frequent contact leads to both the supervisor having a better handle on how the trainee is going, and running counter to this, the trainee establishing a greater chance of understanding the supervisor’s philosophies of practice, and hopefully the opportunity to humbly question and challenge them!

This increased overall fidelity (rather than one tired afternoon as a chore), enables the opportunity to discuss not only clinical work but also system issues, learning points and more grand theories of practice and professionalism.

Much has been written in recent weeks about physician well-being, and I’d speculate regular meetings might also enable a supervisor to become both aware and active at an earlier stage for a doctor struggling with burnout or overwork, rather than picking up the pieces of an upset, overburdened registrar mid-term, or much worse. Supervision is a key part of a culture of care.

Barriers?

With some months of hindsight, I perceive the main barriers for this kind of supervision in paediatric training are threefold:-

Firstly, and most profoundly, the culture of making time, and the will to include this as paid work. Many departments battle to have protected teaching time, reasonable hours and a safe clinical workload. Non-clinical time is at a premium for everyone in a service and, in this context, supervision might strike many as an inefficient, unproductive use of time to have both a trainee and a consultant unavailable for an hour each week. There is strong argument to the contrary; as Bradfield observes “[t]here is overwhelming evidence that closer clinical supervision of junior doctors results in better patient outcomes, in the same way that double-checking reduces medication errors in a nursing context.

Secondly, the immediacy of supervision may be heavily diluted. I’ve alluded to check-box supervision above, but additionally, one or two sessions in a three-month rota often equates to a global impression that is simply too diluted to utilise pragmatically. I imagine it quite frustrating to know an observed ward round is more likely to terminate with the consultant dashing off to clinic, rather than a thoughtful, timely discussion about the morning’s caseload.

Thirdly, the goodness of fit between the supervisor and trainee probably plays a role. It’s understandable that not everyone gets on with everyone. Not all physicians are, by their nature, extroverts, teachers or energised by their work; qualities which may be more or less helpful for mentoring. This isn’t something to modify aggressively, but more an observation of personality, culture and the world, and bears consideration as a barrier to close supervision.

This topic isn’t a new one, having been more comprehensively reviewed in Bradfield’s take on the 2008 Garling Report into the provision and governance of Acute Care Services in New South Wales Public Hospitals.

Taussig & Blalock; senior peers.

What about senior staff?

Everyone benefits from senior supervision, irrespective of experience. The consultants in the Adolescent Unit also had supervision on a weekly basis. As a junior observing, this seemed to evolve with a clinician’s experience; from the outside, depending on the experience differential, this appeared as either a grandparent-parent interaction, and, as the age and experience of the pair narrowed, two older professional siblings discussing their work thoughtfully and with joy.

The further I extend this metaphor, the more supervision strikes me as being about communication between generations of clinicians. That is, interns (consciously or subconsciously) model their thinking and behaviour on their immediate peers and seniors, often those whom they have the most contact.

Within this framework, registrars are the adolescents of the medical world; they have developed sufficiently as clinicians to think and act, and are often looking for guidance about the transition to (clinical) adulthood.

Having senior peers effectively in the role of parents and grandparents are indispensable in guiding, modelling and nurturing the “adolescent” clinician through these tricky years. Further, the parallel key roles of the consultant and the parent; to be bigger, wiser, stronger and kind, are equally applicable in mentoring. Like parenting, the most important thing to have someone who is willing and able to supervise and hold the younger in mind.

References and Further Reading:

Dornan T., Osler, Flexner, apprenticeship and ‘the new medical education’ J R Soc Med. 2005 Mar; 98(3): 91–95.

Nørgaard K, Ringsted C, & Dolmans D., Validation of a checklist to assess ward round performance in internal medicine. Medical Education 2004; 38: 700–707

Bradfield, O.M. “Ward rounds: the next focus for quality improvement?” Australian Health Review, 2010, 34, 193–196 

Garling P . Final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 27 November 2008. https://www.dpc.nsw.gov.au/?a=34194 Accessed June 2017.

Royal Australian and New Zealand College of Psychiatrists (RANZCP), Supervisor Manual. 2012. https://www.ranzcp.org/Files/Resources/Assessor-Supervisor/Supervisor-Manual.aspx Accessed Feb 2017

Pelling, N., Barletta, J. and Armstrong, P. The practice of clinical supervision. Bowen Hills, Qld. : Australian Academic Press, 2009.

 

 

Caring for children with disabilities

Cite this article as:
Lori Chait-Rubinek. Caring for children with disabilities, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.12145

`I recently completed my first rotation as a doctor in the Emergency Department. Prior to entering the medical workforce, I had spent most of my employed life as a respite carer looking after and assisting children with developmental disabilities. I thought about these kids and how difficult an Emergency Department (ED) environment would be for them, as it is a place of hyper-sensory overload – noisy, bright lights and with constant movement. Yet when I looked at the literature I found limited qualitative data describing this patient groups experience in this setting.

A gentle nudge…

Cite this article as:
Tessa Davis. A gentle nudge…, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11516

Children have a right to receive healthcare regardless of the decisions made by their parents. This week, the RACP released a further statement citing refusal to treat patients for non-vaccination as ‘unethical coercion’. Whilst the majority of paediatricians are clear on the benefits of vaccinations, parents can choose not to vaccinate their children. Under the No Jab No Pay policy, this choice can lose them their right to Child Care Rebate. However, it should not lose them their right to receive healthcare. A poll by the Royal Children’s Hospital in Melbourne found that 17% of children who were not fully vaccinated had been refused healthcare by a provider. But what does ‘refused’ actually mean? And does the RACP’s statement leave us confused rather than providing clarity?

 

What was the poll?

The Australian Child Health Poll team at RCH is led by Dr Andrea Rhodes. It runs a quarterly poll on contemporary child health issues by conducting national surveys across Australia. The latest poll, released earlier this week, looked at vaccination perspectives of Australia families.

Data was collected from 1945 parents (with 3492 children). They were asked questions relating to the vaccination status of their children and attitudes to vaccinations.

 

What were the key findings on refusal of care?

  • 95% of the children were fully up to date with their vaccinations
  • 30% of parents had some concerns about vaccination
  • 9% of parents did not agree that “…it was important to vaccinate their child to protect the community (herd immunity)”
  • Of those not up-to-date, 17% had been refused healthcare (29 children)

 

Why are children not up-to-date with their vaccinations?

24% had delayed some vaccinations due to to minor illnesses, and there were misconceptions about when to delay.  36% thought that vaccines should be delayed in child with a runny nose but no temperature, and 47% thought they should be delayed if the child was on antibiotics. 22% thought vaccines should be postponed due to a local reaction from a previous vaccination.

18% had a preference against vaccinations, and perhaps worryingly 10% thought that vaccinations were linked to autism and a further 30% felt unsure about the link.

22% had delayed because of barriers to education and access. Half of these struggled to attend for vaccination and the other half had questions about vaccinations that they were unable to get answered. This emphasises the importance of our role. This sizeable group needs our input as paediatricians – to offer information, be open to discussion and assist with making vaccinations accessible.

 

What can we take from this?

This is the first poll in Australia providing information about refusal to provide healthcare.

Our role as paediatricians is to provide healthcare for each child regardless of their circumstances and certainly regardless of any actions of their parents. This poll makes it clear that there is a sizeable group of parents with uncertainty about vaccination who are interested in engaging and accessing services. We would be doing them a disservice by refusing to treat their children. And even where parents have made a specific decision not to vaccinate, we still have a duty to provide healthcare for their children. It is only by keeping the channels open that we can support, educate, and engage.

The RACP has released a clear statement on this which reinforces their Immunisation Position statement.

It is inappropriate to refuse to treat unvaccinated children, firstly because it represents unethical coercion and secondly because the children will be further disadvantaged.

Yes, we know that vaccinations are beneficial. And yes, we want to increase vaccination rates and ensure our patients are vaccinated. However, by denying unvaccinated children healthcare we are disadvantaging them even further. The RACP goes as far as to call this ‘unethical coercion’. We need to provide healthcare and not use it as bargaining chip.

However, the concept of refusal may not be clear cut. This poll did not collect data on the circumstances of refusal so we do not know which provider has refused treatment or how that refusal has occurred. It is possible that parents perceive that healthcare professionals are not happy to treat them and classify this as outright refusal.

Research in the US has shown that providers worry that unvaccinated children will pose a risk to young babies in their waiting rooms, or that the unvaccinated child themselves is at risk of catching a serious infection. These are reasonable concerns and therefore steps may need to be taken to minimise these risks. If unvaccinated children need to sit separately, could this constitute refusal in the eyes of parents? If the parents have to engage in an awkward 10 minutes of discussion with the paediatrician about the benefits of vaccination, could this constitute refusal in the eyes of the parents?

So the answer is not as clear cut as the RACP’s statement makes it seem. Of course we should not refuse to treat a child because their parents didn’t vaccinate them. But it is also our role to encourage vaccinations and to engage in discussion about the benefits of vaccination. This engagement may make vaccine-refusers feel uncomfortable and affect their perception of our willingness to provide healthcare. This is not the same as refusal to treat.

 

Phone a Friend

Cite this article as:
Andrew Tagg. Phone a Friend, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11413

As supervisor for the latest batch of interns that come through our emergency department I get to nurture them straight out of medical school, before the cynicism of the ward service sets in. It’s never the medicine that is a challenge, but the hidden curriculum that they are not taught in medical school. This time I’m going to focus on a piece of technology that I use every day at work but have never once been taught how to use – the telephone.

Coping with errors

Cite this article as:
Tessa Davis. Coping with errors, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11227

When you lie in bed at night and have moments of reflection about your work, what do you think about? The patient whose abnormal blood result you didn’t spot? The time you prescribed the wrong drug dose for a patient? The child who died unexpectedly and you wonder what you should have done differently?

That’s Entertainment

Cite this article as:
Andrew Tagg. That’s Entertainment, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.10997

As a birthday treat (mine not hers) my five year old daughter took me to see Operation Ouch Live! It’s one of the few television shows we watch as a family in our house so I thought I’d share you some (non-clinical) lessons I have learnt from Dr Chris and Dr Xand.