All paediatricians are complicit in delivering a racist healthcare service

Cite this article as:
Zeshan Qureshi and Anna Rose. All paediatricians are complicit in delivering a racist healthcare service, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33938

We’re supposed to be the nice ones. The friendly, fun, caring and supportive speciality – right? We’re the ones who have teddies on our stethoscopes and know all the words to Disney songs. In the hospital, we’d like to think we’re the Good Guys – but maybe we’re not when it comes to race. 

The COVID-19 pandemic has been a monumental challenge to the NHS and has, undoubtedly, showcased the everyday heroism of our staff. It has also thrown a sharp light onto the ongoing racial inequalities in our society and healthcare systems. Racial disparities in the pandemic have been widely documented – and make for sobering reading. Analysis of national hospital data suggests that people of black and other minority backgrounds are up to twice as likely to die from the virus, as compared to white Britons – with some groups, such as black African-born men living in Britain, having an even higher risk [1]. Despite this, we have little doubt that the major impetus for the unprecedented emergency measures, national lockdowns, and political obsession was not the deaths of the poor, the ethnic minorities, or those in low and middle-income countries – but the perceived threat to wealthy, predominantly white, Westerners.

In an eerie parallel to the racial inequalities highlighted by the pandemic, the past year has also seen racial tensions in the USA reach boiling point. Following several high-profile incidents of police brutality, there was an eruption of social unrest and protest in America and around the world. The systemic disregard of black lives is not just written in blood on American pavements. It is written into the systems that surround us in our everyday working lives. As a speciality, and in the NHS as a whole, we must confront these engrained systemic inequalities, if we are to provide truly equitable care to all of our patients. 

In this blog series, we will examine how clinical outcomes for common paediatric conditions are worse for children from minority ethnic backgrounds. Stillbirth, low birth weight and preterm birth are all more common in minority groups as compared to white northern European populations [2,3,4 ]. Outcomes for common chronic conditions, such as asthma and type 2 diabetes, are also worse for children within minority groups [5,6]. This could be because care received by children with chronic conditions is worse. Non-white children with renal failure are less likely to pre-emptively receive a renal transplant, for example [7]. There are also complex social and environmental roots to these adverse health outcomes – such as increased poverty in non-White groups [8] — and we will try to investigate these issues in more detail. 

We will also explore how paediatrics has normalized white Northern European genetics, physiology and behaviour, leading to biased clinical decision making. Normalization of one ethnic group has lead to the classification of other normal values (in both the laboratory and social sense) as pathological or inappropriate. In other words – you are only normal if you are white and normal. Neutrophil counts are often lower in black babies [9]. Rather than reporting ethnically normal ranges babies often end up having multiple blood tests due to a lack of awareness of the variation. Parents get told that their neutrophil count is low, but it’s acceptable for a black baby (rather than categorically stating that their count is normal). Worst still, it might be classified as a disease – benign ethnic neutropenia – despite not being associated with increased morbidity or mortality.

Within medical education, we are guilty of peddling irrelevant and outdated racial and religious stereotypes. These hold little educational value, but risk enforcing dangerous bias within our future doctors. Any paediatrician would be able to tell you about the association between Tay-Sachs disease and Ashkenazi heritage, or sickle cell disease and sub-Saharan Black Africans. Such associations are often over-simplified and over-emphasized, to the point of creating a disease-ridden caricature, particularly in exam questions. Most of these stereotyped conditions are very rare, and over-emphasis during medical school risks blinkering us to more common diagnoses. We’ll explore how racial bias is ingrained in medical education in the UK, and try to come up with some ideas on how we can improve MedEd to be more diverse and inclusive in the future. 

There also seems to be a disproportionate concern that those from Muslim backgrounds might be consanguineous, and that we need to ask about this even when it is not relevant to the presenting complaint. Conversely, when genetic testing is being sent off, a detailed family tree needs to be drawn. It should include details of any consanguinity – yet it seems that a white family is less likely to be asked. As first or second cousin marriages are no longer a social norm in the UK, they have become defined by pathological associations with genetic conditions, such as inborn errors of metabolism. And whilst there are, of course, differences in the prevalence of disease alleles in different populations, and an increased risk of recessive disorders in families with intergenerational consanguinity, it does not automatically follow that a child from a Muslim background has a recessive disorder, or that a white British child does not. The same considerations need to be given to other cultural practices that might be different to the social norms of Northern and Western Europe. Putting children on a vegetarian diet is often classed as a ‘restrictive diet’ – despite the fact that it is only restrictive based on traditional Western standards – and might, in fact, hold health benefits [10]. 

Finally, in our series, we will examine how systemic racism within the health service tolerates – and sometimes even facilitates –  the unacceptable behaviours demonstrated by some parents. One thing that sets paediatrics apart from adult medicine is that patients are almost never seen alone, and a parent is often required to deliver care. This can present a dilemma to staff when confronted with a racist parent. Any punishment directed towards the parents might directly harm their child. We will explore how guidelines should be developed to help clinicians handle racist parents, whilst minimizing the effect on the clinical care of our patients. 

It can be painful for us – as individuals and as a speciality – to consider that we might be complicit in a racist system that ultimately leads to poorer health outcomes for some children. Just because something is painful, does not mean we shouldn’t do it. We hope that you’ll join us for this series of short articles, as we try to explore how we can begin to move from a white-centric healthcare system to a child-centred one.

James Baldwin quote on racism

Selected references

1) The IFS Deaton Review. Are some ethnic groups more vulnerable to COVID-19 than others? 

2) Gardosi J, et al. (2013). Maternal and fetal risk factors for stillbirth: population-based study. BMJ 346:f108.

3) Kelly Y, et al. (2008). Why does birthweight vary among ethnic groups in the UK? Findings from the Millenium Cohort Study. Journal of Public Health, 31:131–137.

4) Aveyard P, et al (2002). The risk of preterm delivery in women of different ethnic groups. British Journal of Obstetrics and Gynaecology 109:894-899.

5) Asthma UK (2018) On the Edge: How inequality affects people with asthma. Available at www.asthma.org.uk

6) RCPCH (2020) State of Child Health: Diabetes. Available at www.rcpch.ac.uk

7) Plumb LA et al. (2021) Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN. 16:194-203.

8) Office for National Statistics (2020) Child poverty and education outcomes by ethnicity. Available at www.ons.gov.uk.

9) Haddy TB, Rana SR, Castro O. (1999) Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 133:15-22.

10) Kalhoff H. et al (2021) Vegetarian Diets in Children—Some Thoughts on Restricted Diets and Allergy. International Journal of Clinical Medicine. 12:43-60.

Moral injury HEADER

Psychological distress in healthcare workers

Cite this article as:
Gladymar Perez and Rie Yoshida. Psychological distress in healthcare workers, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32653

We know that healthcare workers are at a greater risk of burnout, however you chose to define it. This study takes a look at the impact of COVID on the psychological distress of those on the frontline.

Roberts T, Daniels J, Hulme W, Hirst R, Horner D, Lyttle MD, Samuel K, Graham B, Reynard C, Barrett MJ, Umana E. Psychological Distress and Trauma in Doctors Providing Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A Prospective Longitudinal Survey Cohort Study.

Background

This study aimed to assess the prevalence and extent of psychological distress and trauma of doctors working in the UK and Ireland during the first wave of the COVID-19 pandemic.   

Doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) were asked to complete online surveys at the acceleration, peak and deceleration of the COVID-19 first wave, providing an insight into their psychological well-being at different phases of the pandemic. Exposure to previous infectious disease outbreaks have shown that elevated psychological distress is associated with the development of chronic stress, depression, anxiety, physical health problems, increased sickness rates, emotional exhaustion and impaired performance at work. Given that the COVID-19 pandemic will undoubtedly have a significant impact on the mental health of healthcare workers in the UK and Ireland, this study is important to understand the extent of the pandemic’s impact in these settings. The study also looked at personal and professional factors associated with increased distress in an attempt to identify those who are most at-risk and may benefit from early intervention.  

Methods

The study was carried out using a prospective online three-part longitudinal survey administered at the acceleration, peak and deceleration of the COVID-19 first wave.  Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire for distress and the Impact of Event Scale -Revised for trauma.  These tools have been extensively utilised across different settings and cultures. The survey was distributed to doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) in the UK and Ireland through existing trainee research networks, faculties and Royal Colleges.   Following participation in the first survey, the subsequent surveys were emailed directly to participants.  Survey distribution dates were decided based on public health data on the number of confirmed cases and deaths in the UK and Ireland.   The following dates were used:

  • Acceleration phase UK: 18/03/2020 – 26/03/2020, Ireland: 25/03/2020 – 02/04/2020
  • Peak phase UK: 21/04/2020 – 05/05/2020, Ireland: 28/04/2020 – 12/05/2020
  • Deceleration phase UK: 03/06/2020 – 17/06/2020, Ireland: 10/06/2020 – 24/06/2020

Personal and professional characteristics relating to participants’ current role, and their preparedness and experiences during the pandemic were also collected. 

Results 

Of the estimated 34,188 eligible doctors, the response rate for the initial acceleration survey was 15.9% (n=5440).  Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. (Ed. note- Though you could argue that the peak and deceleration responses were actually 11% and 9% of all eligible doctors). Prevalence of psychological distress was highest during the acceleration phase at 44·7% then declined through peak and deceleration phases of the first wave to a level comparable to pre-pandemic levels, reflecting a degree of natural recovery. The prevalence of trauma was highest at the peak of the pandemic at 23·7%. The figures for both psychological distress and trauma were substantially higher than for the general population.  The most significant personal and professional predictors associated with distress and trauma related to familial safety; personal safety and established mental health conditions.  Whilst ethnicity was not strongly associated with distress, it was a stronger predictor of trauma (R2 = 0·03).   

Strengths

This is a large-scale longitudinal study that prospectively examined the psychological wellbeing of frontline doctors, using GHQ-12 and IES-R, validated self-report measures for assessing  distress and trauma respectively. These outcome measures have been used in previous infectious disease outbreaks. A pre-specified analysis plan was published and is available online. 

This study included responses from 5440 frontline doctors throughout the UK and Ireland, an impressive response rate given that it was undertaken in the midst of a pandemic and was achieved thanks to the collaboration of multiple Emergency Medicine and Intensive Care research networks. (TERN, PERUKI, RAFT, ITERN, TRIC)  

Due to the extent of data collected, findings from this study offer an essential insight into the mental health of frontline doctors in an infectious disease outbreak.  These can be used to inform policy-makers on the development of interventions in the current pandemic and future outbreaks.  The three phase approach means interventions can be targeted in a timely manner.    

The study identifies ethnicity as a novel, key predictor of trauma.  By including the impact of ethnicity in the study the researchers have recognised the important role that ethnicity has played in this pandemic, given the higher rates of reported mortality in ethnic minority groups.  

Limitations

The surveys were distributed in a specific time frame that was based on the number of cases in both countries as a whole without accounting for the regional variation which occurred. 

As such, the researchers recognise that the variation in regional peaks may have influenced accurate capturing of psychological distress and trauma rates. In addition, pre-pandemic levels of distress and trauma in the cohort included in the study, remain unknown. 

There was a considerable drop-out rate in responses throughout the study with a 56.6% response at the final deceleration phase.  The researchers note that there was no significant difference in either the GHQ-12 or IES-R scores between those who dropped out and those who remained in the study.  However, the reason for participants’ lack of response is unknown and these participants may have been experiencing increased distress. Alternatively, a number of those without any concerns may have felt it no longer necessary to complete the survey, therefore, exaggerating the finding of significant trauma in those who did respond.

What should I wear to work?

Cite this article as:
Jilly Boden. What should I wear to work?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29527

One of the things I enjoy a lot paediatrics training is the generally softer and more informal ‘child friendly’ approach we have. Lots of research has gone into making children’s wards and environments brighter, more fun and appealing. But what about us?

It seemed to me that, for children at least, as healthcare professionals we were strangers, without an obvious, identifiable role. That first impression we give before we even approach the child must be quite confusing. Dr Brown Bear, Doc Mc Stuffins and Dr Ranj all wear white coats, they are always friendly, smiley and make you better. We don’t. Pre-COVID, it was only really our emergency colleagues who wore scrubs

So, in the pre-COVID era, I created a study (yes a real actual research project) where we surveyed 50 children using the images below.

Interestingly, the outcome was not only what I suspected, but also, COVID convenient. The favourite overall (and the most ‘friendly’) outfit chosen by the children was blue scrubs. The outfit I called ‘office attire’, smart trousers/shirt but not formal suit and tie, came out as the least desirable outfit. You may appear more clever in a suit and tie, but not particularly trustworthy or friendly. Individual comments gave a window into their choices, scrubs apparently allowed us to run faster to help them, and allowed us to sleep better so that we would not be tired and ‘be better doctors’. 

As for those in ‘office attire’, unfortunately you are the least trusted, least clever and least friendly, but the most scary

As for the age-old white coat, it’s not scary and actually, those who wear them appear quite trustworthy. Perhaps a reflection of what children see in the modern media, they trust Dr Ranj & Doc Mc Stuffins.

 In summary, I’m sticking to scrubs, and look forward to the day when I can add a (short sleeved of course) white coat.

Ref: The study was published in the EMJ (ok, the supplement but it still counts right?) but annoyingly doesn’t have a DOI, please feel free to email me for a digital copy of it. 

Take a break?

Cite this article as:
Andrew Tagg. Take a break?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29431

We spend a large proportion of our lives at work so it is important that we pay attention to our own wellbeing. A casual stroll through Twitter may reveal any number of wellbeing initiatives – from early morning yoga classes, through communal choirs, to meditation mornings. Whilst, subjectively, many of these appear to work, there is clearly a need for a better measure of wellbeing. Enter the NFR.

What is the NFR?

The Need For Recovery scale measures that subjective feeling of the need to take a break and recuperate from the emotional and physical demands of a day at work.

Originally derived from a sample of 68775 shift workers in the Netherlands, it is comprised of eleven dichotomous Yes/No questions.

In the emergency department, there are a number of extrinsic factors that might impact on our Need For Recovery. These include departmental crowding, lack of resources, and ambulances queuing out of the door. The assumption is that the daily accumulation of such tiring shifts, without a restorative break, can impact on our long-term health and increased occupational stress.

In order to look at how we are doing now, it might be worth taking a snapshot of the adult and paediatric emergency department workforce. PERUKI and TERN combined their might to do just this.

Cottey L, Roberts T, Graham B Trainee Emergency Research Network (TERN) and Paediatric Emergency Research in the UK and Ireland (PERUKI), et al. Need for recovery amongst emergency physicians in the UK and Ireland: a cross-sectional surveyBMJ Open 2020;10:e041485. doi: 10.1136/bmjopen-2020-041485

Population

This study was coordinated through the Trainee Emergency Research Networks (TERN) of UK and of Ireland and Paediatric Emergency Research in UK and Ireland (PERUKI).

A total of 4247 emergency physicians* from 112 emergency departments completed the survey.

For the purposes of this study an emergency physician was defined as any doctor working within the ED, be they seasoned veterans or post-graduate year one doctors completing their six-month term in emergency medicine.

Exposure

Participants were invited to take part in an online version of the Need For Recovery instrument. Although developed for industry it has been piloted in Emergency Department staff. Graham et al. (2020) trialed the survey in a single ED and achieved an 80.3% response rate (168/209). These subjects had to complete the 11 point NFR survey as well as an additional 32 questions. This larger survey upped the ante and added 44 items to the NFR. The quality of the web-based survey was maximized using the CHERRIES checklist.

Snapshot data was collected over a six-week period from 3rd June 2019, long before anybody had even heard of SARS-CoV-2.

Outcomes

Before we look at the Need For Recovery it is interesting to look at the demographic data.

3445 (83.5%) survey respondents worked full time. 609 (14.7%) worked less than or equal to 80% full time equivalents.

2886 (70.3%) worked more than one in four weekends with a shocking 1479 (36%) working every other weekend!

36.2% worked for, at most, four consecutive days, with the majority working between five and seven days in a row. 13.5% (554) had been rostered on for eight days straight.

Emergency physicians score higher than paediatricians, miners, paramedics, everyday folk, nurses, merchant sailors and truck drivers

The median NFR score (remember you want it to be as low as possible) was 70.0 (with 95% confidence intervals ranging between 62.0 and 78.0). It appeared to be higher in the more junior cohort – those that had been in the department for less than a year. This group scored an average of 72.7 with an upper limit of 90.9. Those who had spent more time in the job seemed better at recovery with a median NFR of 63.6. Those lucky individuals that had made a career of emergency medicine and had spent over ten years in post had the lowest score of all, 54.5.

As one might expect, higher scores were associated with a full-time work commitment, a burdensome weekend roster, and a higher number of consecutive days worked.

Lower scores were found in consultants and those that worked less than full time. The ability to access study leave and annual leave was also associated with lower scores. Luckily for those of us who have pursued a career in paediatric emergency medicine, this appeared to be associated with a lower NFR score too.

The authors conclude that there are three modifiable risk factors related to a higher NFR – access to annual leave, to study leave, and the proportion of out of hours work. Non-modifiable factors included things like male gender, seniority, generally good physical health, and working in a Paeds ED.

Risk of bias

So far we have reported the facts, as presented but let’s get a little nerdy, as Ken Milne would say, and look at the paper using Burns and Kho (2015) assessment guide for survey reports.

Was a clear research question posed?

Yes – the researchers wanted to look at Need For Recovery scores in a cohort of doctors working in emergency departments throughout the United Kingdom and Ireland.

Yes but… – the target population was defined as any registered doctor who had a fixed contract position (i.e. not a locum) in an emergency department in the UK and Ireland.

There are 183 Type 1 Emergency Departments in England alone. These are consultant-led, 24 hours a day, 7 days a week, 365 days a year services. The authors asserted that they wanted to have over 50% of their respondents from Type 1 centres but this data is not clear in the data presented. Are the majority of respondents from centres that do not have good consultant support?

According to 2018 data, 26% of advertised UK EM consultant places are unfilled. I would be interested to know if individual departmental data could be pulled out and benchmarked against the national average.

Yes – the technique was clearly outlined in the methods.

Yes – the questionnaire developed was very similar to that used by Graham et al. The only key difference being around some of the ancillary questions, rather than those analysed in this paper

Yes – it was distributed in an appropriate way.

No – though all principal investigators should be applauded for the large number of surveys completed, it is not clear what the denominator is. How many emergency physicians, as defined by the study group) were working during the six week period? Were those doctors who did not even attempt to complete the survey just too exhausted to do so?

Each site PI did provide an best-guess estimate of the number of potential respondents (accounting for sick leave, sabbaticals, annual leave etc.). This number was then used as the departmental denominator, with each site aiming for a 70% response rate. The actual response rate is not mentioned in the paper.

Sort of – there were actually 5107 unique visits to the survey site but only 4247 eligible for analysis. The NFR scores were then calculated as long as a minimum of 8 of the 11 questions were answered. The authors do not mention how they handled the missing data. If only 8/11 answers were provided, how would the addition of 3 further data points affect the results?

The demographic data was clearly reported, barring a few items, as described above, and the rest of the results were presented neatly.

Although I agree with the majority of the authors conclusions I am not so sure I would agree with the assertion that NFR score is unrelated to hours worked. It would seem from the data provided in table 2. those working less than full-time had a lower score.

Where to from here?

The ability to bounce back after a hard day at work is a marker of our general wellbeing. Whilst not everyone can swap over to working in PEM, these data from Cottey et al. would suggest that there are modifiable factors that would improve one’s ability to recover. Interestingly, none of these are within the junior doctors’ locus of control – access to study or annual leave, and better rostering. They are fully in the hands of others. This lack of autonomy can also lead to a lack of motivation.

The term, Need for Recovery, suggests that the onus is on the individual as if they were an elite athlete resting between races. It is not. It is the system that needs to change.

The authors note, in their limitations, that this is just a data snapshot, taken at one moment in time. There is little, in the medical sphere, to benchmark this data against. A similar survey could be carried out, in a different setting, in different geography or at a different time. Are these ratings typical of all areas of the hospital in the NHS or is it just the NHS? Do different craft groups score as highly? Are Need for Recovery scores as high in Australia and New Zealand (Editors note: I’ll work on that one) or are they a product of just working in the ED, regardless of the temperature outside? Are these scores a product of the time? The survey was carried out in the Northern hemisphere summer of 2019. What would those scores be like now, in a COVID ravaged world?

One more thing

There is one non-modifiable risk factor that we have not discussed – gender. Male and female respondents were equal in number but men had a much lower NFR than women – 65.6% (CI 60.8 – 66.5) vs 72.7% (70.5 – 75). But, women are much more likely to be the primary caregiver, you might argue. And you would be right, but even if this is taken into account, women seem to have a higher need for recovery. This seems to hold true in other studies that have looked at gender differences and fatigue.

References:

Burns KE, Kho ME. How to assess a survey report: a guide for readers and peer reviewers. Cmaj. 2015 Apr 7;187(6):E198-205.

Eysenbach, G., 2004. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Journal of medical Internet research6(3), p.e34.

Graham B, Cottey L, Smith JE, et al Measuring ‘Need for Recovery’ as an indicator of staff well-being in the emergency department: a survey study. Emerg Med J  Published Online First: 2020. doi: 10.1136/emermed-2019-208797

Van Veldhoven, M.J.P.M. and Broersen, S., 2003. Measurement quality and validity of the “need for recovery scale”. Occupational and environmental medicine60(suppl 1), pp.i3-i9.

Winwood, P.C., Winefield, A.H. and Lushington, K., 2006. Work‐related fatigue and recovery: the contribution of age, domestic responsibilities and shiftwork. Journal of Advanced Nursing56(4), pp.438-449.

Wood, M., 2005. Bootstrapped confidence intervals as an approach to statistical inference. Organizational Research Methods8(4), pp.454-470.

Playing by the rules – and getting it wrong

Cite this article as:
Tony Long. Playing by the rules – and getting it wrong, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29840

Ethics is based in philosophy – the critical evaluation of arguments and assumptions – and therefore is the activity of philosophical reflection about norms and values; right and wrong; good and bad; what ought and ought not to be done. Bluffer’s Guide tip: ethics is Greek and moral is Latin. Talking about ethics and morals is like referring to renal kidneys or cardiac hearts.

Theoretical positions

Two main theories guide ethical behaviour. The most commonly espoused is that of deontology: a principles – or rules-based approach. This has nothing to do with gods (Latin “deus”). It is from the Greek “deon” for duty. Immanuel Kant (1724-1804)not-a-recent-reference defined the Categorical Imperative, a supreme over-riding principle that is never context-dependent, which rules humans absolutely, and which is felt even when defied. It’s like Pinocchio’s Jiminy Cricket. For Kant, the foundation of morality was duty. Acts should be considered good or bad of their own right, regardless of the outcome.

Following the rules

The Beauchamp and Childress schema of respect for autonomy, beneficence, non-maleficence and justice is often adopted. Patients should not smoke (no-one should): it’s hazardous to their health and 50% of smokers will die from a smoking-related illnessinsert-reference-of-your-choice. (This includes the fictitious lady who smoked only 19 a day.) Beneficence requires that we act in patients’ best interests and stop them smoking: confiscating cigarettes and frisking visitors for contraband. At the same time, non-maleficence requires us to prevent the effects of withdrawal that we enforce. If patients refuse to use them, we might have to sneak nicotine patches in under the dressings. Justice requires that we treat all patients equally, not spending too much time stopping the smoking because obese patients need to get on the treadmills and time must be allocated to preventing cake-smuggling. Then respect for autonomy requires that patients decide for themselves whether or not to smoke (or eat too much). There’s the rub.Hamlet, nd.

Rules-based approaches are difficult because the rules or principles conflict. Increasingly more conditions (formally known as “ifs and buts”) have to be introduced to make it work. Ifs and buts bring with judgements based on circumstances, so the rules are no longer universal and rigid. Judging what action to take based on guidance (rules that have to be interpreted) and on circumstances is more often known as a consequentialist stance. Discworld fans might recognise this as Commander Vimes’ “dealing with what is in front of you” approach:try “Night Watch” something that will be familiar to all senior clinicians.

Considering the outcome

An alternative, also not without its critics, justifies actions by expected outcomes. Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873) were the classic sources of consequentialist or utilitarian theory: that to act morally, we should try to bring about the best consequences. Sometimes, telling lies is right (“Is this spot really noticeable?”), and sometimes, judgement is needed to decide between opposing actions. In health care, possible outcomes are often not clear-cut. Complexity and differing viewpoints make judgements difficult.


Ethical decisions in research

Ethical decision-making in research is just as difficult. When to stop a trial because of side effects or because the results are obviously fabulous, whether we can deceive participants for the greater good, and how informed participants need to be can all be problematic. The opt-out article is a discussion of a decision made about informing potential participants and ensuring that they have given valid consent for data to be collected in a research study in paediatric urgent care departments. 

Since the bureaucracy never retreats, the content of participant information sheets (PIS) continues to grow. Required items are added, but nothing is ever removed. A 20-page PIS is perfectly normal for a drug trial. Four pages will often be required even for an innocuous survey. GDPR regulations have added one or two pages of the densest and opaque text for those of standard (ie: low) reading age. You don’t read two pages of small print before signing a new mobile phone contract.No-you-don’t! There is evidence that participants don’t read PIS, either, so they are not informed before signing up. There is something odd, too, about requiring the person who is to be protected to sign the researcher’s consent form. The participant’s signature actually protects the researcher by evidencing that consent was sought.

In the study, we adopted opt-out consent in which brief information (one side of A4 in large print and low reading age) was provided, and parents or young people would sign only to indicate a refusal to participate. (This last sentence has a Gunning-Fog readability index of 21.5. Anything above 12 is hard for most people to read!)Years of experience in research with young people has taught us that they will not read more than a paragraph before making a decision, and they will decide immediately, refusing a cooling-off period.

Since that study, incorporation of GDPR into English law has led (in good faith and with appropriate professional concern) to the banning of opt-out consent in NHS research by the Health Research Authority and therefore by the National Institute for Health Research, applying the rule that “active consent” is compulsory. We argue that this is based on the false assumption that opt-out consent implies a lack of information and lack of a decision by participants. The brief information that we supplied had a better chance of being read than a standard PIS, so participants may have been better informed than usual. Parents made a decision for their child’s clinical data to be included and did so by not completing the contact details on the reverse of the form. 


Applying a blanket rule like this can damage recruitment to very large studies, may lead to participation without effective information, and places a greater burden of time on participants which is not commensurate with the risks of participation. The law must be obeyed, but what if the law has been misinterpreted? What if the rule brings about worse outcomes? See what you think.

Emotional Contagion: Andrew Tagg at DFTB19

Cite this article as:
Andrew Tagg. Emotional Contagion: Andrew Tagg at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22095

I’ve always had an affinity for John Carter, as played by Noah Wyle, from the TV series ER. The night ER premiered on UK television happened to be my very first ED shift as a medical student at the Chelsea and Westminster Hospital.  I remember sneaking away to the lounge to watch it. My first ED experience was nothing like Carters but I was hooked.

I went to Chicago to do my elective and saw them filming in the snow in between shifts at Northwestern and when I returned to England to prepare for finals we would gather around the TV trying to make the diagnosis before the medicos on the television. We called it revising, but really it was escaping from the textbooks for a short time.

My interest wained nearer the end of the run. Carter had been through many trials, as had I, but one thing has stuck with me more than anything else. It was something passed down from David Morgenstern (William H. Macy) to Mark Greene (Anthony Edwards), and then more importantly from Greene to Carter. That is the basis for this talk. You can read the background here.

 

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.

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Culture Cataclysm in modern medicine: Helen Bevan at DFTB19

Cite this article as:
Team DFTB. Culture Cataclysm in modern medicine: Helen Bevan at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22588
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Helen Bevan is the Director of Service Transformation for the National Health Service Institute for Innovation and Improvement. The NHS is one of the biggest employers in the world. When it was established in 1948 the average life expectancy for men was 66 and 71 for women. As science has advanced and the population becomes more medically complex so the challenges of meeting increased demand have become more apparent.

As Chief Change Office Helen talks about the clash between old and new power and the ability of super-connectors to drive change.

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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COVID anxiety

Cite this article as:
Ana Waddington. COVID anxiety, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24478

Working in healthcare is never easy, but working through the COVID-19 pandemic takes all the usual stresses, strains, and anxieties, and amplifies them by a factor of ten.

The mood in my A&E department is very emotional. Above all, we’re worried about the impact of the coming (or already arrived) tsunami of COVID-19 patients, which feels like it’s been looming for months now. But we’re also affected by the uncertainty and the deferral of plans and hopes which had been the only things keeping us going in the ever-strained atmosphere of A&E. Two weeks ago, a nurse I’d never met before broke down in the changing room, after having a much-needed break canceled by an airline. “I really needed this holiday”, she said. “I’ve been saving up for a whole year”. All I could do was hug her, which didn’t feel like enough. Our most used methods of coping have been stripped from us, and we’re having to find different ways to manage.

Many people are worried about spreading the virus to others, and these fears are particularly acute for healthcare workers. A friend texted me to say that she’s so scared that she will kill people in her household. She’s constantly disinfecting surfaces and feels like she spends most of her free time cleaning. And she’s not the only one – I’m not looking forward to receiving my next water bill, given the amount of time I now spend washing my clothes and showering. There’s also the feeling that we should be constantly working, permanently manning the barricades. A colleague told me she feels “helpless” on her days off: she wants to come into the hospital to support. I feel the same way, but I know, if I’m able to think clearly about it, that preserving myself and taking the time to recharge is more important. We can’t afford to burn ourselves out. I’ve just canceled my bank shifts.

 

One positive thing that I hope comes out of this is a tightening of the bonds of solidarity that hold the NHS workforce together. Watching how the entire workforce is uniting to help patients during this time is inspiring. Every time I walk through our ‘clean area’ and see groups of people gathered together, teaching one another new skills, reminds me how much we are doing to ensure we are prepared for what is to come – or what has already come, depending on when you read this.

 

I’ve written in the past about the issue of night shift anxiety, and the sense of isolation and disconnect from the wider society that comes with working nights. Over the past few weeks, I’ve found these feelings are more acute than ever. And it’s not just night shifts that are causing this: as healthcare workers, we are now living totally different lives to most. The patterns of working life continue as normal for us, even as the world around us dramatically alters. The experience is jarring: it feels like I’m living in a different timezone to everybody else, or like I’m a ghost of the world we inhabited a couple of weeks ago. Some colleagues have even said that they feel guilty that they get to go to work, and that we should consider ourselves lucky that we’re able to get out of the house. And they’re right to an extent, we are lucky to be able to see our colleagues and friends face-to-face – but it’s small consolation for having to face this pandemic as frontline staff.

 

I have struggled with my own rollercoaster of emotions. Some of my non-healthcare friends haven’t been taking the precautions they should, insisting they have nothing to worry about. I know that I should be more understanding – the advice provided by the government has been confusing and ambiguous, so it’s no wonder that people have different opinions on what’s appropriate – but I find it hard to understand their mindset. A friend of mine feels the same way: “my ability to cope with other [non-NHS] people’s emotions is low”, she tells me, adding: “I feel extremely guilty about this”. For healthcare workers at present, it feels a bit like the world is a Rorschach test, and we’re seeing and experiencing things differently to everybody else.

 

Nevertheless, the generosity of others is extremely precious in these times – the organized clap last Thursday moved me to tears. But I feel guilty receiving such kindness: I don’t feel like I’ve earned it yet. The worst, we are constantly being told, is yet to come. The looming doom is hard to handle. Colleagues are also concerned that we’re letting our normal responsibilities slide, forgetting about our other duties as nurses and doctors. “What happens to everyone who doesn’t have COVID?”, a colleague asks, “I’m worried about all the social cases that are being missed”.

 

We also know that, as healthcare professionals, we’ll have to make difficult decisions that we haven’t had to make before. Horror stories from Italy, or from our own ITU wards, are spreading across hospitals. As recently discussed in the New York Times, we may be forced to take actions that go against our moral judgment, such as breaking bad news without present family or making agonizing calls on access to ventilators. As a result, we run the risk of ‘moral injury’ – harm to the conscience due to being forced to violate our own moral values. The kinds of decisions we’ll have to make are similar to those faced by soldiers/aid workers in warzones, and there are likely to be cases of post-traumatic stress when this is all over. I’m already all too aware of such scenarios playing out – just yesterday, faced with an adult COVID-19 patient crying because she was too scared to die alone, I could only smile behind my facemask and offer her a gloved hand to calm her down: giving her a hug was not an option, even though it felt like the right thing to do.

 

What can we do to keep ourselves functioning and healthy in these trying times? Many of the normal tricks, used to confront the usual anxieties associated with healthcare work, can’t be applied to COVID-related anxiety. Eating well, for instance: it’s hard to do when the only dried food left in the shop when you finish your shift is bulgur wheat. Seeing friends in anything but a virtual context is ruled out for now. And suddenly every film you watch has an unexpected pandemic-related subtext.

 

My sister Dr. Emma Waddington, a clinical psychologist, says that teaching your mind not to become preoccupied with “wandering” thoughts is important. She recommends making a concerted effort not to focus on the negatives, absences, and perceived failings: not to let your mind drift to the things you aren’t doing, the social bonds you aren’t able to maintain, the news and information you aren’t keeping up with. Instead, try to focus on what you are doing, which is, as she and many others insist, amazing. She has a simple message which she wants us to keep in mind: “You are doing enough. You are enough.

Of course, focusing on our achievements and positive contribution to the fight against COVID-19 is easier said than done. One mechanism that Emma recommends to help with this is “thought stopping techniques”. These techniques help us to “pause, reappraise, and reframe”, to stop our minds becoming preoccupied with negative thoughts.

 

At work, finding new methods of coping has become key. We now cover our faces with masks and mostly work in cubicles on our own. Ensuring we take time to ask each other if we are okay is crucial. With expressions obscured by masks, it’s become a vital new healthcare skill to be able to tell what emotions people are going through solely by looking at their eyes. I’ve found out that no one can tell if I am smiling or not, I’m trying to achieve more expressions with my eyebrows now. Checking up on each other has been really important, and I’m particularly enjoying the new ways of being affectionate at work – elbow tap here, toe tap there.

 

With the help of friends and colleagues, I’ve added a few other techniques to the toolkit I’m using to help deal with COVID-19 anxiety. Firstly, I’ve bought an alarm clock so that when I go to sleep, I can leave my phone in a different room. That way I’m more fully disconnected from the world when I’m resting, and less tempted to catch up on things if I wake up in the middle of the night. And when I do get up, I don’t open my eyes to a bombardment of push-up notifications, emails, and frenzied messages. Secondly, I make sure I do some form of exercise once a day – even if this means following a pre-recorded boxing class via a choppy video stream. And finally, I make sure to properly relax during my time off by penciling in some time for indulging in my greatest passion (besides nursing): sprawling on the sofa and watching rubbish TV. Just make sure that the new Netflix series doesn’t have a pandemic-related sub-plot before you get stuck into it.

For some extra resources:

Watch out Clinician Care webinar

Managing mental health injury during pandemic

Podcast on moral injury

Good Netflix binges (not sponsored) that aren’t pandemic related:

  • Stranger things
  • The Stranger
  • Sinner
  • Sex education
  • Good girls
  • Frankie and grace
  • Working moms
  • The Fyre festival
  • Russian Doll
  • Ozark
  • Call the midwife

Good Instagram workouts

  • kobox
  • The jab
  • Melissawoodhealth
  • Joewicks

Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Top 10 Tips for NHS Consultant Interviews

Cite this article as:
Tessa Davis. Top 10 Tips for NHS Consultant Interviews, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21861

I’m finally settling into some job security after 16 years of changing jobs every six months. One advantage of not being in run-through training has been the frequency of job interviews (and the consequent interview experience I’ve gained). The consultant interview involved another level of preparation. Facing this is a challenge, particularly for trainees who will not have had an interview for 6-8 years. My approach was to throw everything into it. I worked extremely hard to prepare, practice, and research – essentially leaving no stone unturned so that if I didn’t get the job at least I would know I’d done my best.

Be productive and indistractible

Cite this article as:
Tessa Davis. Be productive and indistractible, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21430

I love my phone (iPhone X) and I love my laptop (MacBook Pro 13″). But their aim is to enhance my productivity and not to detract from it. As apps, tech, and the way we communicate have evolved over the last 5 years, have we (or have I) evolved to handle them?

Change against the grain: Shweta Gidwani at DFTB19

Cite this article as:
Team DFTB. Change against the grain: Shweta Gidwani at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20875

Shweta Gidwani graduated from Seth G.S. Medical College, Mumbai, India in 2002. S. She has been involved in the development of emergency care service delivery and training programs in India for several years and was invited to join the International Emergency Medicine section at George Washington University as Adjunct Asst Professor in 2013 where she works on the India programs.

This talk, the opening talk proper after Mary set the scene, is a stark reminder of just how the world really works.

 

©Ian Summers

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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